Refer to Event ID U31013 for additional information. Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #3 and #2) were treated with dignity and respect when staff members were unnecessarily rough while providing care. This deficient practice affected two of 6 sampled residents. The facility census was 73.

Refer to Event ID U31013 for additional information. This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 03/03/2025. Based on interview and record review, the facility failed to report an injury of unknown origin to the Department of Health and Senior Services (DHSS) when Resident #1 sustained an open fracture (a bone break with an opening to the skin) to his/her right femur (upper leg bone). The Director of Nursing (DON) assessed the resident and did not report the injury of unknown origin to DHSS and did not immediately report to the Administrator. This deficient practice affected one of one sampled residents. The facility census was 73.

Refer to Event ID U31013 for further information. This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 03/03/2025. Based on interview and record review, the facility failed to initiate an investigation into an injury of unknown origin when Resident #1 sustained an open fracture (a bone break with a skin opening) to his/her right femur (upper leg bone). The Director of Nursing (DON) assessed the resident and did not initiate an investigation to determine the cause of the injury. This deficient practice affected one of one sampled residents. The facility census was 73.

Based on interview and record review the facility failed to protect one resident (Resident #4) of 6 sampled residents, right to be free from verbal and physical abuse when Certified Medication Technician (CMT) A called the resident derogatory names based on his/her body type and abilities and roughly pushed the resident's wheelchair forward. The facility census was 66. Review of the facility policy titled, Abuse Prevention Program, dated 1/20/25 showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish. Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Verbal abuse is defined as the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Review of Resident #4 Significant Change Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 1/28/25 showed: -Brief Interview of Mental Status (BIMS) of 12, indicated minimal cognitive loss; -Verbal behaviors (such as yelling, cursing) towards others for one to three of 7 days; -Moderate assistance on staff for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself); -Use of wheelchair for mobility; -Use of oxygen; - Diagnoses included: Extreme Binge Eating Disorder (is a serious condition involving feeling like one is not able to stop eating, and often involves eating much larger than usual amounts of food.) obesity, and anxiety. Hypertension (high blood pressure), Congestive Heart Failure (CHF: the heart cannot pump blood effectively), Chronic Obstructive Pulmonary Disease (COPD: lung disease that causes air flow obstruction and difficulty breathing). Review of the resident's face sheet showed he/she had a diagnosis of oxygen dependence. Review of the resident's Comprehensive Care Plan 1/28/25 showed: -Need for assistance with ADL's; -Impaired cognitive function. During an interview on 3/13/25 at 10:30 A.M. Resident #4 said: -He/She was fine; -He/She was not afraid of anyone; -No one had been rude, hateful or disrespectful to him/her; -Staff are good to him/her. During an interview on 3/13/25 at 2:00 P.M. HK A said: -He/She was at the D hall housekeeping closet on 3/11/25 around 7:45 A.M. when he/she heard CMT A yell get your ass to the closet three to four times; -HK A walked into the hallway, saw Resident #4 was sitting at the dining room door in his/her wheelchair, then he/she pedaled himself/herself a few feet into the hallway; -CMT A got behind the resident's wheelchair, grabbed the handles, pushed aggressively and said I told you to get your fat ass going as he/she pushed the resident around a corner; -HK A left the hall to notify his/her supervisor. During an interview on 3/13/25 at 3:18 P.M. CMT A said: -On 3/11/25 he/she was passing medications at the dining room; -He/She had told Resident #4 to wheel himself/herself to the oxygen closet; -Resident #4 had pedaled himself/herself a few feet into the hall from the dining room, then would not move; -He/She let his/her frustration get the best of him/her and said get your fat ass rolling to Resident #4; -Resident #4 was almost always out of oxygen in his/her tank in the mornings; -When he/she got the wheelchair he/she gave the resident an energetic push forward; -He/She had Abuse and Neglect education less than a month ago; -He/She knew better, yelling and cursing at the resident was another example of his/her temper getting away from him/her. Review of the facility investigation dated 3/11/25 showed: -8:00 A.M. an allegation of verbal abuse by CMT A to Resident #4 was reported to the Administrator by Housekeeping Aide (HK) A; -8:10 A.M. the resident's physician was notified of the alleged abuse; -8:12 A.M. the resident representative was notified of the alleged abuse; -8:15 A.M. interview with the reporter showed he/she had heard CMT A yell a derogatory term to Resident #4, while pushing the resident's wheelchair roughly; -8:20 A.M. interview with Resident #4 showed he/she was not aware of any derogatory term being used; -8:55 A.M. interview with CMT A showed, he/she was suspended and escorted out of the facility. During an interview on 3/13/25 at 4:10 P.M. the Administrator said: -CMT A's employment had been terminated; -The comments made by CMT A were abuse and unacceptable; -Immediate education was provided for staff; -She would not expect staff to curse or yell at residents. MO250870

A revisit was completed and the facility was found to have continued non-compliance. Refer to Event ID U31012 for federal and state deficiencies cited as a result of this complaint investigation. Based on interview and record review, the facility failed to report an injury of unknown origin, when the facility staff became aware on 2/27/25 that one resident (Resident #1) had a right leg femur fracture. The facility census was 67.

Refer to Event ID U31012 Based on interview and record review, the facility failed to complete a thorough investigation when one resident (Resident #1) sustained a femur fracture of unknown origin and failed to maintain documentation that an alleged violation was thoroughly investigated. The facility census was 67.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #3 and #2) were treated with dignity and respect when staff members were unnecessarily rough while providing care. This deficient practice affected two of 6 sampled residents. The facility census was 73. Review of the facility policy titled Resident Rights, dated 1/30/24, showed the facility staff will treat the resident with respect and dignity. Review of the facility policy titled Perineal Care, dated 1/20/25, showed: - The purpose of the policy was to ensure the residents receive safe and respectful perineal care; - The staff are to uphold the resident's dignity with professional standard in long-term care; - All residents who require assistance with perineal care will be provided with appropriate and person-centered care that promotes their comfort and dignity. 1. Review of Resident #3 admission MDS, dated [DATE], showed: -A BIMS of 15 indicated no cognitive loss; -Dependent on staff for ADLs; -Diagnoses of segmental and somatic dysfunction of the lumbar region (problem with the lower back causing issues with nerves, muscles, joints, or their interaction), muscle weakness, need for assistance with personal care, falls, hypertension, renal disease (damage or disease of the kidneys). Review of the resident's baseline Care Plan, dated 3/28/25, showed need for assistance with personal care. During an interview on 4/3/25 at 3:28 P.M., the resident said: -CNA B had come into his/her room with CNA C to provide care on 4/1/25; -CNA B rolled him/her really hard and fast; -CNA C told CNA B to quit being rough; -CNA B began yelling at CNA C and continued to provide care to him/her; -He/She was not afraid, but he/she did not like the way the staff were yelling over him/her. During an interview on 4/3/25 at 4:29 P.M., Nurse Aide (NA) A said: -CNA B was rough with residents when providing care and throws them around; -He/She reported to the Charge Nurse that CNA B was rough with residents, throwing them around in bed. During an interview on 4/3/25 at 4:53 P.M., LPN A said: -CNA C had reported to him/her CNA B was rough with a resident on 4/1/25; -He/She attempted to call the DON and Assistant DON multiple times without success on 4/1/25; -Resident #3 reported CNA B was really rough throwing him/her around in bed and he/she did not like it; -CNA B was very disrespectful and got into arguments in front of residents before. During an interview on 4/7/25 at 2:15 P.M., the resident said: -He/She needed cleaned up on 4/1/25; -He/She thought CNA B was going to pick him/her up and throw him/her; -CNA B threw him/her side to side and wiped his/her skin really hard and it hurt; -CNA B yelling at CNA C made him/her uncomfortable; -CNA B was excessively rough when providing care; -CNA B completed care hard and fast and it hurt. -He/She told the nurse CNA B turned him/her fast and cleansed his/her perineum with hard pressure. During an interview on 4/18/25 at 11:02 A.M., CNA B said: -He/She had worked with Resident #3: -He/She was moving Resident #3 on 4/1/25, and the resident's leg slipped, he/she grabbed the resident's leg again and pulled him/her over fast, the resident didn't yell out or complain; -CNA C told him/her not to be rough; -He/She told CNA C he/she was not being rough, but had to get the resident moved over to provide care; -He/She would never intentionally hurt a resident. During an interview on 4/3/25 at 5:00 P.M., the Administrator said: -She was aware of the complaint Resident #3 had regarding CNA B; -She felt it was a customer service issue and not abuse; -An investigation was done; -Education was provided to all staff on Abuse and Resident Rights. -She expected staff to be gentle and kind to all residents 2. Review of Resident #2's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 3/8/25, showed: - The resident had a Brief Interview for Mental Statutes (BIMS) score of 11, indicating moderate cognitive impairment; - Diagnoses included: Parkinson's disease (disorder of the central nervous system that affects movement) and anxiety; - The resident was dependent on staff for his/her activities of daily living (ADLs-tasks completed daily to care for oneself); - The resident was incontinent of bowel and bladder. Review of the resident's impaired communication care plan, dated 1/14/25, showed: - The staff was to allow the resident adequate time to respond; - Anticipate the resident's needs; - Minimize environmental stimuli; - Provide clear, simple, and concise instructions for the resident. Observation on 4/5/25 at 8:54 P.M., showed: - CNA A entered the resident's room and put on gloves; - Certified Medication Technician (CMT) B entered the resident's room and put on gloves; - CNA A and CMT B assisted the resident to bed; - CMT B turned the resident to his/her side; - CNA A pulled the resident's pants down while CMT B rolled the resident back to his/her back; - CNA A pushed the resident's knees apart, unfastened the resident's incontinence brief, took a wipe form the package and scrubbed vigorously with an up and down motion along the resident's right side of groin; - CNA A threw the used wipe away and scrubbed vigorously up and down with a clean wipe the resident's left side of his/her groin and perineal area; - CMT B told the resident he/she was going to turn the resident and then turned the resident to the side; - CNA A removed another wipe from the package and scrubbed vigorously back and forth across the resident's; buttocks; - CNA A did not explain the procedure to the resident during this observation; - The CNA A did not verbalize to the resident during the perineal care. During an interview on 4/5/25 at 10:10 P.M., CMT B said: - CNA A was rough when he/she provided perineal care to the resident; - CNA A gets in a hurry to finish resident cares. During an interview on 4/5/25 at 10:56 P.M., Licensed Practical Nurse (LPN) A said: - Residents have complained about CNA A being too rough; - He/She had not witnessed CNA A providing cares to residents; - She would expect CNAs to complete perineal care in a way that was comfortable for the resident; - It was not appropriate to vigorously scrub Residents #2's perineal area, groin, and bottom. During an interview on 4/5/25 at 11:15 P.M., CNA A said: - He/She was trained to provide perineal care with one swipe per wipe; - He/She should not have scrubbed vigorously the resident's groin, perineal area, and bottom. During an interview on 4/5/25 at 11:26 P.M., the Director of Nursing (DON) said: - She expected the staff to treat all residents with dignity and respect; - She did not expect CNA A to be rough when he/she provided perineal care for Resident #2; - She did not expect CNA A to scrub the resident's groin, perineal area, or bottom; - She expected cares to be carried out as gently as possible. MO252298 MO252340 MO251843 MO252096

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect Resident #2's right to be free from sexual abuse by Resident #1, when Resident #1 was observed by staff sitting next to Resident #2, with his/her hand down the front of Resident #2's pants. The facility census was 63. Review of the facility's undated Abuse Prevention Program policy showed: -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish. Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Sexual abuse is defined as non-consensual sexual contact of any type with a resident; -The purpose of this policy is to protect the residents in this facility from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This 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 the residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual. 1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 12/26/24, showed: -The resident had diagnoses of heart disease (heart conditions that include diseased vessels, structural problems, and blood clots), senile degeneration of the brain (a general term for a group of neurological disorders that cause a decline in cognitive function), weakness, chronic fatigue, dementia (a group of thinking and social symptoms that interferes with daily functioning), malaise ( a general sense of being unwell, often accompanied by fatigue, diffuse pain, or lack of interest in activities); -He/She had adequate hearing, clear speech, makes self understood and able to understand others; -He/She scored 3 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates severely impaired cognitive skills; -He/She had displayed no behaviors. Review of the resident's undated comprehensive care plan showed: -The resident had a history of being resistive to cares related to anxiety and dementia; -The resident had a history of behaviors related to dementia and can display physical aggression. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -He/She had diagnoses of spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy, affecting all four limbs, the trunk, and often the face, causing significant muscle stiffness and usually resulting in an inability to walk, often accompanied by other developmental disabilities like speech problems and intellectual impairment), dysphagia (difficulty swallowing), pain, repeated falls, non-traumatic subarachnoid hemorrhage (bleeding that occurs in the brain without trauma), dysarthria (weakness in the muscles used for speech, which often causes slowed or slurred speech), anarthria (loss of control over the muscles used for speaking), convulsions (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), amnesia (memory loss); -He/She had adequate hearing, unclear speech, sometimes is able to make self understood and usually understands others; -He/She scored zero on the BIMS, indicating severely impaired cognitive skills; -He/She had displayed no behaviors. Review of the residents comprehensive care plan, dated 10/24/24, showed: -He/She had a history of exhibiting sexually inappropriate behaviors, such as making inappropriate sexual comments to staff and at times will attempt to lay down in other resident's beds; -Resident #2 was able to answer questions by nodding yes or shaking his/her head no. 3. Review of the facility investigation, dated 1/12/25, showed: -On 1/12/25 at approximately 5:00 P.M., Resident #1 was observed by staff with his/her hand down Resident #2's pants. Certified Medication Technician (CMT) A was at the nurses' desk, counting medications. Resident #3 came to the nurses' desk and told CMT A that Resident #1 had his/her hand down Resident #2's pants. CMT A went to Resident #1 and redirected him/her from Resident #2. CMT A then assisted Resident #2 to the dining room as it was meal time; -During an interview with the Administrator, Resident #1 was unable to recall the incident with Resident #2. He/She denied touching another resident inappropriately; -During an interview with the Administrator, Resident #2 indicated no one had touched him/her inappropriately. He/She also indicated he/she felt safe in the facility; -Resident #1 was placed on 15 minute check observation. He/She was also moved to a private room with a private bath. During an interview on 1/15/25 at 12:17 P.M., CMT A said: -Resident #3 approached CMT A while he/she was at the nurses' station and said Resident #1 had his/her hand down Resident #2's pants. CMT A approached Residents #1 and #2 and observed Resident #1's hand down Resident #2's pants. CMT A asked Resident #1 to remove his/her hand from Resident #2's pants. CMT A then assisted Resident #2 to the dining room. CMT A then informed the charge nurse of the incident; -CMT A had not witnessed Resident #1 be inappropriate with other residents before this incident. During an interview on 1/15/25 at 12:19 P.M., Certified Nurses Assistant (CNA) A, said: -He/She was standing at the nurses desk when Resident #3 approached the desk. Resident #3 stated he/she needed help because Resident #1 had his/her hand down Resident #2's pants. CNA A looked over and observed Resident #1 sitting next to Resident #2 with his/her hand down Resident #2's pants. CMT A then went over to the residents and redirected Resident #1 and assisted Resident #2 to the dining room as it was almost meal time. During an interview on 1/15/25 at 12:21 P.M., Resident #3 said: -He/She was sitting in the front living room area, watching television with other residents. He/She saw movement and looked over and saw Resident #1 with his/her hand down the front of Resident #2's pants. Resident #1 went to the nurses desk and asked CMT A for help. During an interview on 1/15/25 at 12:30 P.M., Resident #1 said: -He/She had no recollection of being inappropriate with another resident; -No one at the facility has been inappropriate with him/her. He/She felt safe at the facility. During an interview on 1/15/25 at 12:45 P.M., the Administrator said it was his/her expectation that residents are safe in the facility and not touched inappropriately by other residents. MO247928

Based on interview and record review, the facility failed to report an injury of unknown origin, when the facility staff became aware on 2/27/25 that one resident (Resident #1) had a right leg femur fracture. The facility census was 67. Review of facility policy, Abuse, Neglect, and Exploitation, revised 1/17/25, showed: -Reporting of all alleged violations to the administrator, state agency, adult protective services, and to all other required agencies within specified time frames: -Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or -Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. -The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 1. Review of Resident #1's Quarterly Minimum Data set (MDS), a federally mandated assessment tool completed by staff, dated 2/9/25, showed: - Cognition severely impaired: - The resident had impaired range of motion on both upper and lower extremities; -Dependent on a wheelchair; -Dependent on staff for all acitivities of daily living, transfers, and mobility. -He/she received scheduled pain medication; -He/she had no falls in last six months; -Diagnoses included: Quadriplegia (paralysis of all four limbs), aphasia (a language disorder that affects a person's ability to communicate), and unspecified pain (pain that did not have clear cause or diagnosis). Review of the residents care plan, dated 1/9/25, showed: -The resident is at risk for impaired circulation; -Staff are to administer pain medications per physician orders; -Staff are to encourage and maintain bed rest, with leg elevated per order; - The reisdent is at risk for falls due to paralysis; - Staff are to use of mechanical lift for transfers; Review of physician's orders, dated 3/3/25, showed: - An order dated 11/22/24, to assess for pain every shift; - An order dated 1/10/25, to wrap legs from toes to knee on in am and off in pm, two times a day for swelling of feet; - An order dated 1/10/25, to administer Acetaminophen oral liquid 160 milligram (MG)/5 milliliter (ML), give 20 ml via gastrostomy tube (g-tube) (a surgically inserted tube that allows direct access to the stomach for feeding, medication administration, and other purposes) every 4 hours as needed for pain or fever; - An order dated 1/10/25, to administer Gabapentin tablet 600 mg, give 1 tablet via peg-tube three times a day for pain in legs and feet; - An order dated 1/10/25, to administer Hydroco/apap 5-325 mg (UD), give 0.5 tablet via G-tube two times a day for pain related to unspecified pain; - An order dated 1/10/25, to administer Hydroco/apap 5-325 mg, give 1 tablet via G-tube as needed for pain related to unspecified pain; - An order dated 1/10/25, to administer Hydrocodone-acetaminophen oral tablet 5-325 mg, give 1 tablet via G-tube every 8 hours as needed for pain / allow adequate time for resident response. Review of progress notes, dated 1/20/25-2/27/25, showed: -On 1/20/25 at 06:30 A.M., Registered Nurse (RN) A wrote - entered room and observed resident laying on floor on mechanical lift pad under resident. CNA reported to RN A the mechanical lift started to tip and CNA lowered resident to floor. No injuries noted and resident denied pain. Assist of three per mechanical lift to wheelchair. -On 2/27/25 at 12:24 A.M., Resident complained of pain in right knee, found on assessment that right knee was swollen and tender to touch. Notified physician, obtained order for radiograph (x-ray) of right knee. While assessing resident found resident was at 84% on room air. Resident was placed on oxygen via nasal cannula and order obtained for chest radiograph. -On 2/27/25 at 1:09 A.M., Resident took oxygen off was sweaty and hard wheezes on expiration. Oxygen saturations were at 82 %. Resident removed oxygen and would not allow nasal cannulas back on. Physician notified and orders obtained to send resident to emergency room. Review of hospital records, dated 2/27/25-3/2/25, showed: -On 2/27/25, patient evaluated in emergency room for right distal femur fracture. Unknown date of injury or mechanism. Resident was agitated and noted to have knee redness and swelling. Radiograph in emergency department revealed distal femur fracture, bicondylar displaced. -On 2/27/25, Review of imaging results of radiograph of right knee, showed: mildly displaced distal right femoral metadiaphyseal fracture; -Plan of closed bicondylar facture of distal femur showed recommended non-operative management, hinged knee brace per ortho, will need frequent skin check near brace due to risk of wounds/skin break down, and pain control. During an interview on 3/3/25, at 3:03 P.M., Certified Nurse Aide (CNA) A said: -The resident recently had been found to have a leg fracture; -Nobody knew how the fracture of resident's leg occurred; -Resident had been fine prior to shower; -Upon return from shower resident had flailed their arms and legs; -The resident kept saying that they hurt; -The resident was always in pain but appeared to have new pain that day; -The residents fracture was discovered that night after their shower; -The resident had swollen area on their leg before they were sent out to hospital. During an interview on 3/3/25 at 3:20 P.M., CNA B said: -The resident had a right broken femur; -No one knew what happened to cause the fracture to resident; -Resident received a shower that morning and had been fine before the shower; -Later after shower resident complained their leg was hurting; -The Director of Nursing (DON) had spoken with them and wanted to know how many times they had touched resident. During an interview on 3/3/25 at 2:37 P.M., Administrator said: -The resident was evaluated in the emergency room on 2/27/25 for a right distal femur fracture; -The injury was from an unknown date or mechanism; -The resident showed signs of agitation and noted to have knee redness and swelling; -A radiograph (a picture or image produced using x-rays) in the emergency department revealed a right distal femur fracture; -The hospital records indicated the fracture was closed so it had to be an old fracture; -On January 27th, 2025 the resident got tangled up in reclining wheel chair during a mechanical lift transfer and staff lowered resident all the way to the ground; -The resident did not fall but was lowered to the ground during the transfer; -There had been no complaints of pain from resident after the mechanical lift incident in January; -The resident experienced frequent pain; -The DON interviewed staff to determine if any abnormal event had happened; -She was unsure why a report regarding the injury of unknown origin was not made; -She had been waiting to get report back from hospital; -She had phoned her corporate contact and was advised to wait for radiology report; -She did not suspect abuse or neglect of resident; -She was not sure if they should have reported the injury of unknown origin. During an interview on 3/3/25 at 3:39 P.M., DON said: -He/She was notified by the nurse on February 26, 2025 that resident was not feeling well and had swelling of leg; -The resident's family notified the facility from the hospital that resident had fracture on February 27, 2025; -The resident's family inquired with facility when they called if the facility was aware of any possible falls for resident; -He/She started investigation by interviewing aids who had worked the floor; -He/She did not find anything from anyone that led to a transpiring event; -He/She did not report injury of unknown origin because they were waiting to hear from the hospital orthopedic doctor; -He/She discussed unknown injury with corporate and administrator and was advised to wait and see what information they received from hospital; -He/She learned resident had a closed fracture on Monday; - The Administrator was responsible for doing facility reporting; -He/She and administrator deferred to corporate and made team decisions prior to making any reports; -The resident had no known injuries to his/her femur in past. MO240279

Based on interview and record review, the facility failed to complete a thorough investigation when one resident (Resident #1) sustained a femur fracture of unknown origin and failed to maintain documentation that an alleged violation was thoroughly investigated. The facility census was 67. Review of facility policy, Abuse, Neglect, and Exploitation, revised 1/17/25, showed: -Possible indicators of abuse included: physical injury of a resident, of unknown source; -An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. -Written procedures for investigations include: -Identifying staff responsible for the investigation; -Exercising caution in handling evidence that could be used in a criminal investigation; -Investigating different types of alleged violations; -Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; -Focusing investigation on determining if abuse, neglect, exploitation, and/or mistreatment had occurred, the extent, and cause; and -Providing complete and thorough documentation of the investigation. 1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by staff, dated 2/9/25, showed: -Cognition Severely Impaired: -They had impaired range of motion on both upper and lower extremities; -Dependent on a wheelchair; -Dependent on staff for all cares, transfers, and mobility; -They received scheduled pain medication; -They had no falls in last six months; -Diagnoses included: Quadriplegia (paralysis of all four limbs), aphasia (a language disorder that affects a person's ability to communicate), and unspecified pain (pain that did not have clear cause or diagnosis). Review of care plan, dated 1/9/25, showed: -The resident was at risk for impaired circulation; -Staff to administer pain medications per order, if non-medication interventions were ineffective; -Encourage and maintain bed rest, with leg elevated per order; -The resident was at risk for falls due to paralysis; -Use of mechanical lift for transfers; Review of nursing progress notes, dated 1/20/25-2/27/25, showed: -On 1/20/25 at 06:30 A.M., Registered Nurse (RN) A wrote- entered room and observed resident laying on floor on mechanical lift pad under resident. CNA reported to RN A that the mechanical lift started to tip and CNA lowered resident to floor. No injuries noted and resident denied pain. Assist of three per mechanical lift to wheelchair. -On 2/27/25 at 12:24 A.M., Resident complained of pain in right knee, found on assessment that right knee was swollen and tender to touch. Notified physician, obtained order for radiograph (x-ray) of right knee. While assessing resident found resident was at 84% on room air. Resident was placed on oxygen via nasal cannula and order obtained for chest radiograph. -On 2/27/25 at 1:09 A.M., Resident took oxygen off was sweaty and heard wheezes while breathing. Oxygen saturations were at 82 %. Resident removed oxygen and would not allow nasal cannulas back on. Physician notified and orders obtained to send resident to emergency room. Review of hospital records, dated 2/27/25-3/2/25, showed: -On 2/27/25, patient evaluated in emergency room for right distal femur fracture. Unknown date of injury or mechanism. Resident was agitated and noted to have knee redness and swelling. Radiograph in emergency department revealed distal femur fracture, bicondylar displaced. -On 2/27/25, Review of imaging results of radiograph of right knee, showed: mildly displaced distal right femoral meta diaphyseal fracture; -Plan of closed bicondylar facture of distal femur showed recommended non-operative management, hinged knee brace per ortho, will need frequent skin check near brace due to risk of wounds/skin break down, and pain control. Review of facility investigation showed a one page typed document showed: -Staff Interview -Resident #1 (investigative event) dated 2/27/25: -Hospital nurse was unable to provide information and confirm fracture until orthopedic doctor confirmed. -CNA C: (Night shift) did not work with resident on that shift. -CNA D: (Night shift) did not notice anything unusual, when caring for Resident #1. -CNA E: (Night shift) did not work on Resident #1's hall. -CNA F: (Night shift) did not work on Resident #1's hall. -CNA B: (Night/Day shift) did not notice anything unusual. The nurse was notified of any discomfort from Resident #1. -CNA G: (day shift/shower aide) resident #1 did not show any signs of pain when showering resident. -CNA H: -did not work on that hall. -No date or times were documented of interview statements; -There was no additional information provided from facility investigation. During an interview on 3/3/25, at 3:03 P.M., Certified Nurse Aide (CNA) A said: -The resident recently had been found to have a leg fracture; -Nobody knew how the fracture of resident's leg occurred; -Facility staff came around and asked if the aides knew anything about how fracture occurred with resident; -He/she did not complete a written statement regarding residents fracture; -He/she would report suspected abuse to charge nurse, administrator, DON, or Assistant DON; -Facility staff always have the aides write a written statement if an event occurred, even if they did not witness event. During an interview on 3/3/25 at 3:20 P.M., CNA B said: -The resident had a broken femur; -He/she nor other staff knew what happened to cause the fracture to resident; -The Director of Nursing (DON) had spoken with him/her and wanted to know how many times he/she had touched resident; -He/she did not complete any written statement of event for the investigation. During an interview on 3/3/25 at 2:37 P.M., the Administrator said: -The resident was evaluated in the emergency room on 2/27/25 for a right distal femur fracture; -The injury was from an unknown date or mechanism; -The residents family mentioned to the DON the possibility of the resident getting hurt when the mechanical lift tipped back in January; -A radiograph (a picture or image produced using x-rays) in the emergency department revealed distal femur fracture; -The DON interviewed staff to determine if any abnormal event had happened leading to the injury; -The DON had completed the investigation; -She does not suspect abuse or neglect of the resident. During an interview on 3/3/25 at 3:39 P.M., the DON said: -He/She was notified by the nurse on February 26, 2025 that resident was not feeling well and had swelling of leg; -The residents family notified her from the hospital that resident had fracture on February 27, 2025; -When the reisdent's family called, they and asked they were aware of any possible falls for resident; -He/She investigated the injury of unknown origin by verbally interviewing aids who had worked with resident; -He/She did not collect written statements from staff as part of her investigation; -He/She did not have any additional documents regarding the investigation. -He/She did not have any documentation of mechanical lift incident that occurred in January other than what was in the progress notes; -He/She did not know what CNA was involved in the lift transfer in January; -He/She did not find anything out during interviews that led him/her to believe there was a transpiring event causing resident's injury of unknown origin; -One shower aid that was interviewed did not witness anything unusual with the resident; -He/She informed the administrator of his/her findings from the interviews. MO250279

Based on interview and closed record review, the facility staff failed to complete a comprehensive discharge summary for one resident (Resident #61) out of three discharged residents. The facility census was 66. The facility did not provide a policy regarding the discharge process. Review of Resident #61 Electronic Medical Record showed: -The resident was admitted to the facility 09/30/2023. - Diagnoses included: Diverticulosis of intestine (small bulging pouches in the digestive tract), Type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), Mild neurocognitive disorder with behavioral disturbance (a decline in function, memory, learning and attention), dementia with psychotic disturbance (a decline in thinking and problem solving skills as well as seeing/hearing things that are not there or belief that something is real when it is not), Alcohol dependence, Acute metabolic acidosis (a condition in which acids build up in your body.), Hallucinations (seeing or hearing something that isn't there). -The Comprehensive Care Plan showed: the resident was to discharge from the facility. The facility was to provide written instructions for care and resources to use in case of emergency; plan for specific resident needs/continuing care needs after discharge; assist the resident and/or support person in locating and coordinating post-discharge services; and ensure access to services. -Progress Notes showed: -2/07/2024 at 3:29 P.M. the resident discharged home with a Home Health agency for nursing, Physical Therapy, and Occupational Therapy. A follow up appointment with the primary care provider was set up and the information was emailed to the resident's family. The resident was discharged home. There was no discharge summary completed. During an interview on 5/9/24 at 3:12 P.M. the Administrator said: -No one is doing discharge summaries. -She is unsure who took over the responsibility when the last Minimum Data Set (MDS) Coordinator left.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care in place to ensure appropriate services to promote the resident's highest level of functioning and psychosocial needs were provided for one resident (Residents #216) out of the seventeen sampled residents. The facility census was 66. The facility did not provide a policy in regards to addressing behaviors or care for residents with dementia. 1. Review of Resident #216's face sheet, dated 5/7/24, showed: -Resident admitted to facility on 4/22/24 -Diagnoses included: neurocognitive disorder with lewy bodies (a type of progressive dementia that leads to decline in thinking, reasoning, and independent function). Review of Resident's Brief Interview Mental Status (BIMS) Assessment, dated 4/26/24, showed: -Resident had severely impaired cognition. Review of Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, showed resident did not have a completed MDS. Review of physician's orders dated 4/8/24 to 5/8/24, showed: -Primary admission diagnosis was Neurocognitive disorder with lewy bodies Review of care plan, dated 5/8/24, showed: -Did not address specific nursing interventions for dementia care; -Did not address specific interventions for activities for a resident diagnosed with dementia care; -Did not address specific behavioral interventions for dementia care. Review of the resident's baseline care plan, dated 4/22/24, showed: -He/She had confused cognition status; -He/She required assist of two staff for bed mobility, transfers, bathing, locomotion, and toileting; -He/She had safety concerns regarding balance and gait, muscle weakness, and fatigue; -He/She required assist of one staff with eating; -He/She used a mechanical lift for transfers; -His/Her bed should be in lowest position; -He/She had as needed, medications for psychosocial interventions; -He/She was always incontinent of bowel and bladder; -He/She preferred to be called J; -He/She displayed behaviors of sad and crying, agitation, and aggression. Review of electronic medical record showed: -4/22/24 3:17 P.M. , Registered Nurse (RN) A wrote resident admitted from hospital via ambulance. Resident was combative unable to obtain weight. Resident was alert to self-confused and yelling. Resident had Lewy body dementia; and hallucinations. -04/23/24 05:48 AM, Licensed Practical Nurse (LPN) E wrote resident continued to be combative and tearful at times of cares. Resident alert to name. -4/23/24 5:58 P.M., RN C wrote resident continued to be combative and tearful at times of cares. Resident alert to name. Resident attempted to hit and bite when moved and turned. Reassurance given. Sister had been at bedside for the whole day. -4/24/24 3:51 A.M., LPN E wrote Resident was combative with cares during rounds. Yelling, biting and hitting staff before changing. When staff approached resident, resident started to scream. Resident yelled so loudly he/she was waking up other residents on the same hall. Nurse attempted to give as needed physician ordered Haldol, which resident spit out at nurse. Nurse then administered as needed Zyprexa IM 2.5mg in Left Glute. -4/25/24, 5:50 A.M., LPN C wrote that resident was in low-fowlers (a position in which patient is seated in semi-sitting position 45-60 degree angle); alert to self. Resident combative with CMT at bedtime medication pass, combative with nurse when attempting assessment; yelling, cursing, hitting, kicking, and biting. -4/27/24, 5:43 A.M., LPN E wrote that resident was extremely combative with cares that morning. It took 3 staff members during bed check to change resident. Nurse attempted to redirect resident and reassure resident but was unsuccessful. Resident was punching, biting and yelling at staff. -4/28/24, 6.00 P.M., RN B wrote that resident was administered Zyprexa after resident was biting and kicking and hitting staff while getting an radiographic image (x-ray). Resident was also noted to be trying to get out of bed, bed repositioned to low and fall mats placed on both sides of bed. -5/1/24 9:20 A.M., LPN A wrote resident was combative, refusing care, yelling at staff and family. resident's son and sister were both visiting. Family requested medication to help calm resident down. PRN Zyprexa given. About 1 hour later he/she was still resistant with cares and yelling at staff, he/she did not get his/her morning medications because she refused. About 2 hours after injection resident was sleeping peacefully. Observation on 5/7/24 at 10:03 A.M., showed resident was sitting in bed with side rails up leaning forward grimacing with eyes closed. Resident mumbling inaudible words and scrunching shoulders and forehead. Certified Nurse Aide (CNA) A came into resident's room to provide cares and change gown, resident began having tears run down cheeks. During an interview on 5/7/24 at 10:44 A.M., Resident representative said: -No care plan meeting has occurred regarding resident's care needs; -He/She had received no phone call or team collaboration from the facility; -Resident is very aggressive and he/she felt facility had not made any effort to learn resident's care needs; -He/She was aware resident can be difficult to care for due to his/her behaviors as family had been providing all his/her care at home prior to long term care placement. During an interview on 5/8/24 at 9:54 A.M., Social Service Designee (SSD) said: -The MDS coordinator wrote most of the care plans, however he/she was terminated and it was unclear who was writing them now; -He/She only wrote code status and trauma sections of care plans; -Comprehensive care plans should be written within 14 days after a resident admits to facility; -He/She leads and schedules care plan meetings; -He/She did the resident's baseline care plan with resident's sister; -Resident did not have a completed comprehensive care plan. During an interview on 5/8/24 at 2:25 P.M., Certified Medication Technician (CMT) B said: -Facility had not provided any dementia training; -He/She had previously worked with dementia patients at another facility; -He/She had no training on how to approach this resident; -He/She did talk to resident's sister and learned interactions went better if staff walked into room and said Hey J instead of resident's name; -He/She noted resident was accepting of cares when approached using hey J; -No other facility staff had told him/her what worked and did not work when interacting with resident; -Resident is often screaming, cussing, and displaying hitting behaviors; -Behaviors should be charted daily; -When resident was provided drinks of water it would helped to calm him/her down as most of time he/she was thirsty; -Facility system to pass along information learned about resident was to share at shift changes with oncoming shifts; -He/She did not have access to update or write in the resident's care plan. During an interview on 5/8/24 at 2:38 P.M., Certified Nurse Aide (CNA) A said: -Resident was a fighter; -Resident would hit, bite, and yell; -He/She had not received any training on how to approach this resident; -There was nothing that worked for resident's behaviors; -Staff talked to resident and he/she would still yell at staff; -He/She did not know resident's diagnosis; -He/She could talk to resident politely and he/she would still yell at him/her; -Nobody had told him/her any tricks that worked when interacting with resident; -He/She had training on dementia care from another facility a few months ago; -He/She did not know of any approaches he/she should take with dementia residents when providing them care. During an interview on 5/9/24 at 11:40 A.M., the Administrator said: -He/She had not done any training with staff on dementia care since he/she became administrator in March; -He/She had no documentation of facility provided dementia care training. During an interview on 5/9/24 at 11:47 A.M., Business Office Manager said: -He/She could not locate any facility information regarding provided dementia training inservices. During an interview on 5/9/24 at 3:12 P.M., Administrator said: -Staff are informed of resident's with dementia care preferences during shift preferences; -Currently facility did not have a MDS person to update care plans; -Social Services Designee had been updating his/her part of care plans -Each department should update their parts of a resident's care plan; -MDS staff should oversee the quality of the care plan; -If there is a change with resident the MDS staff person should document any changed interventions that were implemented; -Any nursing staff can update the care plan; -Staff do not have access to modifying resident care plans; -Staff refer to the resident [NAME] for specific information; -Baseline care plans need to be completed within 48 hours of admission; -Initial comprehensive care plans need to be completed within 7 days of their MDS assessment; -He/She did not provide dementia training to staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Based on observations, interviews and record review, the facility failed to treat each resident with respect and dignity and failed to provide care for each resident in a manner and in an environment that promoted enhancement in their quality of life when staff failed to knock on resident doors prior to entering their room and failed to announce themselves to (Resident #2 and #8), Staff left the bedroom door to the hallway open while providing peri-care to one resident (Resident #35). Additionally, staff failed to answer one resident's call light in timely manner resulting in that resident being incontinent of urine (Resident #21). This affected four residents out of the 17 sampled residents. The facility census was 66. Review of facility policy, Resident Rights, dated 1/30/24, showed: -The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality. -Resident has the right to exercise his/her rights as a resident of the facility and as a citizen or resident of the United States. -Resident has the right to reasonable access to stationary, postage, writing implements (at the resident's expense) as well as the ability to send and receive unopened mail. -When providing resident care, always provide privacy by knocking and announcing self, pulling a curtain around the bed, pulling the drapes to windows, closing the door, and draping the resident's body appropriately; 1. Review of Resident #35's Quarterly MDS, dated [DATE] showed: -Brief Interview of Mental Status of 4, indicated significant cognitive deficit. -Partial to moderate assistance on staff for Activities of Daily Living (ADL's: tasks performed to care for oneself in a day). -Dependent on staff for standing, maximum assistance for transfers -Occasional incontinence of urine -Continent of bowel -Diagnoses of Alzheimer's Dementia (progressive memory loss that interferes with daily life), and disorientation (a state of mental confusion). Review of the resident's comprehensive Care Plan dated 3/1/24 showed: -He/she takes the assist of 2 staff for toileting -He/She experienced bladder and bowel incontinence; use incontinent pads or briefs to protect his/her dignity. -He/She can be confused at times; break tasks into manageable segments, explain all procedures, allow him/her to make simple decisions. During an observation on 5/08/24 at 5:05 A.M. the resident was in his/her bed, Nurse Aide A entered the resident's room leaving the room door open. The privacy curtain was pulled half way, leaving the lower half of the bed and resident visible from the hallway. NA A pulled the resident's blanket and sheet toward the foot of the bed, exposing the resident's incontinent brief and legs to the hallway. The NA then opened the tabs of the resident's incontinent brief, pulled the front of the brief down; exposing the resident's genital folds to the hallway. NA A told the resident he/she was slightly soiled and they would get a clean brief. He/She then pulled the brief back up between the resident's legs, refastened the tabs, covered the resident with a blanket and left the room. Observation on 5/08/24 at 5:15 A.M. showed NA A and NA B entered Resident #35's room. NA B shut the resident's room door, and provided incontinent care to the resident. During an interview on 5/08/24 at 5:27 A.M. NA A said the resident's door should be shut for any care to provide policy. He/she did not realize he/she left the door open. It would be embarrassing to be exposed to a stranger. During an interview on 5/9/24 at 3:12 P.M. the Director of Nursing (DON) said: -The room door should never be left open during incontinent care. During an interview on 5/9/24 at 3:12 P.M. the Administrator said: -Room doors should not be left open during incontinent care. -She expects staff to close the curtain and the door completely. 2. Review of Resident #21's Annual MDS dated [DATE] showed: -BIMS of 14, indicating no cognitive deficits -Partial assistance from staff for ADL's. -Partial to moderate assistance for standing and transfers. -Touch assist for ambulation (walking) -Occasional incontinence of urine and bowel. -Diagnoses of Transient Ischemic Cerebral Attack (a brief blockage of blood flow to the brain), difficulty in walking, dizziness, low back pain, chronic fatigue syndrome, atrial fibrillation, arthritis. -Review of the resident's comprehensive Care Plan dated 3/21/24 showed: -The resident is incontinent of bowel and bladder occasionally. Provide assistance with toileting every two hours and as needed. Check incontinence pads frequently and change as needed. During an observation on 5/07/24 at 3:28 PM resident call light was on. At 3:47 P.M. CNA B entered the resident's room asking what he/she needed. The resident said he/she needed to use the bathroom. CNA B assisted the resident into the restroom, removed the resident's adult brief. The brief was saturated/wet. CNA B assisted the resident in putting on a new brief, pulled up pants and returned to his/her recliner in his/her room. During an interview on 5/07/24 at 3:52 P.M. the resident said: -His/Her light was on since 3:02 P.M. -He/She knows the time because he/she looked at the digital clock on his/her wall. -His/Her call light is rarely answered quickly enough for him/her to make it to the bathroom in time. -He/she is embarrassed when he/she does not make it to the bathroom in time. During an interview on 5/07/24 at 4:00 P.M. CNA B said: -He/she tried to answer the call light in time. -He/she answered as quickly as he/she could, but he/she was busy with another resident. -There is not enough help to answer the call lights immediately. During an interview on 5/9/24 at 3:12 P.M. the Administrator said: -She expects staff to answer lights as soon as possible. -There is not enough staff to meet all the resident's needs, staff do the best they can. 3. Review of Resident #2's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Independent with toilet use, dressing, personal hygiene and transfers; - Occasional incontinence of urine; - Always continent of bowel; - Diagnoses included seizure disorder and depression. Observation and interview on 5/6/24 at 11:05 A.M., showed: - The resident's door was closed and the surveyor was interviewing the resident; - The receptionist did not knock or announce him/herself and opened the resident's door, walked in then said, knock, knock and delivered mail to the resident; - The resident said he/she always entered without knocking; - The resident would prefer he/she knocked before he/she entered but around here you just learned to live without any of your rights and privileges. Observation and interview on 5/6/24 at 11:16 A.M., showed: - The resident's door was closed and the surveyor was interviewing the resident; - Registered Nurse (RN) A did not knock or announce him/herself and opened the door to the resident's room and gave the resident his/her medication; - The resident said-the staff always enter without knocking. 4. Review of Resident #8's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Lower extremity impaired on one side; - Dependent on staff assistance for toilet use, transfers and dressing the lower extremities; - Independent on personal hygiene; - Always continent of bowel and bladder; - Diagnoses included anxiety and depression. Observation and interview on 5/6/24 at 11:16 A.M., showed: - The resident's door was closed and the surveyor was interviewing the resident; - RN A did not knock or announce him/herself and opened the door to the resident's room and gave the resident his/her medication. Observation and interview on 5/6/24 at 12:51 P.M., showed: - The resident's door was closed and the surveyor was interviewing the resident; - The receptionist did not knock or announce him/herself and opened the resident's door, walked in then said, knock, knock and delivered mail to the resident; - The resident said the staff are always just walking into their room and don't knock first. The other thing is they never wear a name tag so you don't know if they are a visitor or if they work there or what their job is. It made him/her feel like he/she did not matter when they don't treat him/her with dignity and respect. During an interview on 5/9/24 at 3:12 P.M., the Administrator and the DON said: - They expected the staff to knock before they entered the residents' rooms and to introduce themselves. During a telephone interview on 5/14/24 at 11:26 A.M., the receptionist said: - He/she should knock before entering the residents' rooms; - He/she should introduce themselves to the residents. During an interview on 5/14/24 at 11:29 A.M., RN A said: - He/she always tried to knock before entering the residents' rooms; - He/she always tries to introduce him/herself to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to create an environment respectful of the rights of a resident to make choices about aspects of his/her life that are significant to them, when the facility failed to allow two out of seventeen sampled residents to go outside unsupervised (Resident #45 and #212). The facility census was 66. Review of the facility's Resident Rights policy, dated 1/30/24., showed: -Residents do not leave their individual personalities or basic human rights behind when they move to a long-term care facility. The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality. -Resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his/her rights and to be supported by the facility and the exercise of those rights. -To receive services with reasonable accommodation of needs and preferences except when to do so would endanger the health and safety of the resident or other residents. -The resident has the right and this facility promotes and supports the right to make choices about aspects of his/her life in the facility that are significant to the resident including: -Choose activities and schedules including sleeping and waking times. -Interact with people from community and participate in community activities both inside and outside the facility. -The resident has the right to, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the state, participate in planning care and treatment or changes in care and treatment. 1. Review of Resident #45's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/12/24, showed the resident: - is cognitively intact; - able to make self-understood, and understand others; -activity preferences- very important to the resident to go outside to get fresh air when the weather allows; -impairment on one side of his/her body; -dependent on walker and wheelchair for mobility; -Diagnoses including anxiety disorder. Review of Resident's medical record showed the resident admitted to the facility on [DATE]. The resident did not have a care plan. During an interview on 5/06/24 at 12:57 P.M. resident said he/she loved to go outside. The facility had a smokers area, but he/she was not a smoker and staff did not do anything to help him/her outside. The resident had to be escorted outside if he/she was offered the opportunity. 2. Review of Resident #212's admission MDS, dated [DATE], showed the resident: -cognitively intact; - has clear speech, able to make self-understood, and clear comprehension of others; -activity preferences- it was very important to go outside to get fresh air when weather allowed; -limited range of motion to both sides of lower extremities. -dependent on walker and cane for mobility; -Diagnoses : , heart failure, high blood pressure, renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), and diabetes. Review of resident's medical record showed the resident admitted to facility on 4/22/24 and primarily responsible for self. The resident did not have a care plan. During an interview on 5/07/24 at 9:35 A.M., Resident said: -He/She could not go outside alone, and that someone had to supervise him/her all the time. -He/She liked to wake up early and has watched the sun come up his/her whole life; -He/She could only smoke one cigarette at one time during scheduled smoke breaks. -He/She was own person (makes his/her own decisions). 3. During a group meeting on 5/7/24 at 1:32 P.M., three of the thirteen residents said: -They were not allowed to go outside unless someone was available to go with them; -Residents who smoke had certain times to go outside. If not a smoker, residents cannot go outside unless they have family available to take them out. -They would like to be able to have the opportunity to go outside. 4. During an interview on 5/9/24 at 10:05 A.M., the Housekeeping Supervisor said: -Residents are allowed to go outside, but have to go out with a staff member present; -Residents are not allowed to be left unattended while outside. During an interview on 5/9/24 at 10:32 A.M., Nurse Aide (NA) C said: -Residents must have a staff member with them when they go outside; -Residents sit outside on the front porch or at one of the ends of the hall with staff. During an interview on 5/9/24 at 3:12 P.M., the Director of Nursing said: -Facility had designated smoke times for residents to go outside; -It was the resident's right to go outside, if they are their own person but the facility was still liable for them. During an interview on 5/9/24 at 3:12 P.M., the Administrator said: -Residents going outside is dependent on staff availability, resident's have to be supervised while outside; -An assessment should be done on whether residents need supervision or could go outside unsupervised; -Facility did not have a courtyard currently available for residents; -He/She had concerns with residents being outside and in front of the building unsupervised; -He/She was concerned with current sloping landscape and providing a safe environment for residents to be outside. -It is the residents rights to go outside, if the resident was safe and did not take off and leave. -If a staff member is available someone will go out with residents; -It is a resident's right to outside, but it has to be done to ensure safety.

Based on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was . Review of the facility maintained Resident Trust Bank Statements for the period 05/2023 through 05/2024, showed an average monthly balance of $27,000.00. Review on 05/07/24, of the Department of Health and Senior Services approved bond list showed the facility had a $1,000.00 approved bond, making the bond insufficient by $22,000.00. During an interview on 05/07/24 at 10:42 A.M., the Business Office Manager said the facility had changed ownership recently and was unaware the bond had not been reassessed since the new company had taken control. During an interview on 05/07/24 at 3:44 P.M., the Business Office Manager said she would expect the bond to be sufficient to cover the resident funds.

Based on observation and interview, the facility failed to protect the resident rights when the facility did not provide accessible information regarding the State Long Term Care Ombudsman program and the State Survey Agency in a location that was readily available and could be read by residents in the facility without assistance. The facility census was 66. Review of facility policy, resident rights, undated, showed: -The resident has the right to receive a list of the names, addresses (mail and email) and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care ombudsman program, the protection and advocacy agency, adult protective services, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit. The resident must also receive a statement that he/she may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with advance directives requirements and requests for information regarding returning to the community. Observation on 5/7/24 at 1:45 P.M. showed ombudsman poster hanging on wall in day room of facility, the poster was not visible to someone sitting in a wheelchair. During a group interview on 5/7/24 at 1:32 P.M., the residents said: -All residents interviewed did not know what an ombudsman was or where information was posted in facility or how to reach the ombudsman. -Twelve residents did not know how to formally file a complaint to state survey agency. During an interview on 5/9/24 at 3:12 P.M., the Administrator said: -Ombudsman contact information was posted in the facility day room; -He/She did not know how residents had been educated on reaching the ombudsman representative or state survey agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #45's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], showed: -Resident was cognitively intact; -He/She had clear speech, was able to make self-understood, and understand others; -Diagnoses included aftercare after joint replacement surgery, and high blood pressure. Review of the electronic medical record on [DATE] at 8:34 A.M. showed the resident had a signed do not resuscitate sheet dated [DATE]; Review of physician's orders, on [DATE] at 8:35 A.M., showed the resident's code status was full code Review of care plan, dated [DATE], showed the residents code status was do not resuscitate. 2. Review of Resident #214's Face Sheet, dated [DATE], showed the resident admitted to facility on [DATE], with diagnoses including rheumatoid arthritis, and generalized muscle weakness. Review of electronic medical record on [DATE], showed the resident had a signed do not resuscitate sheet dated [DATE]. Review of physician's orders, [DATE] at 8:50 A.M., showed the resident's code status as full code. Review of care plan, dated [DATE], showed care staff directed to not resuscitate. 3.) During an interview on [DATE] at 8:57 A.M., Certified Medication Technician (CMT) A said he/she looks for code status in the resident's care plan. If the code status was not in resident's care plan he/she would go to a nurse and ask them. During an interview on [DATE] at 9:19 A.M., Certified Nurse Aide (CNA) C said: -Today was his/her first day working in facility; -He/She believed the sticker on the room doors identified resident's code status; -If there was no sticker on the door he/she would look in resident's electronic medical record. During an interview on [DATE] at 9:39 A.M., Certified Medication Technician (CMT) B said: -He/She knew resident's code status by dot on the resident's door; -If the sticker was not on the resident's door would notify charge nurse and look on the electronic medical record. During an interview on [DATE] at 9:40 A.M., Licensed Practical Nurse (LPN) F said: -Resident's code status was available on the resident's door and in the electronic medical record; -The physician's order and advance directive should match, if they don't then the orders should be clarified. During an interview on [DATE] at 9:54 A.M., Social Service Designee said: -Physician's orders and advance directives should match; -Hard copies of advance directives were kept in his/her office; -He/She wrote code status in care plans. During an interview on [DATE] at 3:12 P.M., Director of Nursing said: -The code status in physician's orders should match the advance directives. During an interview on [DATE] at 3:12 P.M., Administrator said: -Code status should be the same in physician's orders and the resident's advance directives; -When resident admits to the building they are considered full code until the facility has received the resident's advance directive paperwork; -The social service designee is responsible for scanning in the advance directive paperwork. Based on interviews and record review, the facility failed to clarify the code status (whether the resident wished to have cardio-pulmonary resuscitation- CPR) of two of the 17 sampled residents, (Resident #45 and #214), and failed to ensure Resident #16's Durable Power of Attorney (DPOA) for Health Care Decisions was invoked (activated by verifying incapacity of the resident to make decisions) by two physicians. The facility census was 66. Review of the facility's policy for living will/advance directives/life-sustaining treatment orders, dated [DATE], showed, in part: - The purpose is to ensure resident rights are protected when Advance Directives have been executed: - Residents will be given the option of completing a Living Will (a type of advance directive that states the specific types of medical care that a person wishes to receive if that person is no longer able to make medical decisions because of a terminal illness or being permanently unconscious) or Advance Directive if they have not already done so. This option will be presented to a resident on admission to the facility. Advance Directives allows the resident to ask for no lifesaving measures without the need for a terminal diagnosis. The Living Will or Advance Directives will then be noted on the resident's medical record; - A resident who chooses to sign a Living Will or Advance Directive must be of sound mind and competent to make life-directing decisions. 1. Review of Resident #16's Durable Power of Attorney (DPOA) for Health Care Decisions, dated and notarized on [DATE] showed: - Required two physicians to activate the document; - Designated DPOA as his/her agent to make healthcare decisions. Review of the residents capacity verification, dated [DATE] showed: - Only one physician had declared the resident incapacitated. Review of the resident's Outside the Hospital Do Not Resuscitate (OHDNR) order showed; - [DATE]- signed by the resident's DPOA; - [DATE]-signed by the physician. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE] showed: - Cognitive skills moderately impaired; - Upper and lower extremities impaired on both sides; - Dependent on staff for toilet use, showers, dressing, personal hygiene and transfers; - Diagnoses included coronary artery disease (CAD, damage or disease in the heart's major blood vessels causing coronary arteries to narrow, limiting blood flow to the heart), stroke, high blood pressure and diabetes mellitus. Review of the resident's physician order sheet (POS) dated [DATE] showed: - Start date - [DATE] - Do Not Resuscitate (DNR). Review of the resident's face sheet showed: - admit date 12/122; - Current admit date [DATE]; - Code status - DNR. During an interview on [DATE] at 12:14 P.M., the Social Services Designee said: - He/she reviewed the resident's medical record and the resident was a DNR; - The resident had only been declared incapacitated by one physician but it should have been two physicians. During an interview on [DATE] at 3:12 P.M., the Administrator said: - If the DPOA does not specify if it should be one or two physicians to declare the resident incapacitated, then it should be two physicians.

Based on observation, record review and interviews, the facility failed to ensure they maintained a safe, clean, comfortable homelike environment for the residents when staff did not keep all areas of the facility clean and safe; and failed to maintain comfortable temperatures in the common areas of the building between 71 and 81 degrees Fahrenheit (F). Additionally, the facility failed to ensure they provided a sufficient amount of bed linens, towels and wash cloths. The facility census was 66. Review of the facility policy Cleaning Resident Rooms dated 1/30/24 showed: -Ensure rooms are clean and sanitary. The facility did not provide a policy on cleaning hallways, general areas or common areas of the facility. The facility did not provide a policy on Homelike Environment. The facility did not provide a policy for the amount of linens the facility should have on hand. 1. Observations beginning on 5/06/24 at 10:03 A.M., showed: -the ceiling vent, at room C111, had cobwebs and thick coating of dust on the grates; -C hall handrails had chips in the paint and exposed wood; -Ceiling vent, at room C109, had dust and dirt debris on the grates and inside the vent; -the floor behind the C hall fire doors was coated with dust, dirt and debris; -D hall handrails had chips in the paint and exposed wood; and -D hall sheetrock had multiple gouges and scuffs along the lower 1/3 of the wall. Observations on 05/06/24 at 11:38 A.M, showed: -a dining room window had a thick coating of dust, dirt and glitter; -vinyl coating of multiple dining room chairs was cracked, exposing the soft surface underneath; -a large cobweb with dead bugs at the corner of the courtyard exit door; -the baseboard at the exit door was loose and peeling away from the wall; and. -the vinyl surface of the love seat was peeling, exposing the soft surface underneath. Observations on 05/06/24 at 2:45 P.M., showed: - a cubby area by the salon, had broken, misfit floor tiles. The wall was patched with appeared to be cardboard; - a ceiling vent by the soiled linen room had dust, debris and fuzz hanging from it; -the exit door had blue painters tape painted down to the door frame; -cobwebs showed in the exit door corners; -a 12 feet (ft) by 3 ft area of white tile that were cracked with a pitted, rough surface; -ceiling fan at D108 had dirt and debris hanging down; -light fixture outside D108 had no protective cover; -light fixture outside D104 had broken, misshapen metal stay in middle; -cobwebs at corner of fire doors; and -dark brown/black debris, dirt and dust behind fire doors. Observations on 5/06/24 at 4:41 P.M., showed: -B hall temperature of 81.9 degrees F and -E hall temperature of 82.4 degrees F. Observation on 05/07/24 at 7:58 A.M., showed: -dining room temperature of 65.8 degrees F; -dining/activity room temperature of 66.4 degrees F; -E hall temperature of 84.0 degrees F; -TV/sitting area/nurse's station temperature of 84.7 degrees F; -F hall temperature of 81.1 degrees F; -Multiple residents covered in blankets, one resident wearing a stocking cap. -Resident #35 stated he/she was cold and requested a blanket from staff. During an interview on 5/08/24 at 9:21 A.M., the Maintenance Supervisor said: -the air conditioning was not working prior to him/her taking this position; (when was he hired?) -he/she is unsure when it started not working correctly; -it is cold in the dining room; -Heating, Ventalation, Air Conditioning (HVAC) company was scheduled to be in the facility the week of 5/13 for repairs; -maintenance is responsible for the vents and light cleaning; and -vents and lights are to be cleaned monthly. During an interview on 5/8/24 2:25 P.M., Certified Medication Technician B said: -he/she was told by maintenance only two of the air conditioning units worked; -he/she thought it is too hot in the building; -every morning residents complain about the dining room being too cold; - it is usually about 65 degrees in the dining room, and he/she needed a jacket when he/she was in there. During an interview on 5/09/24 at 11:37 A.M., Housekeeping Aide C said: -he/she sweeps the hall as she goes from room to room; -the vents and dusting are housekeeping staff responsibility; -he/she is unsure if housekeeping is responsible for the light fixtures; -staff are assigned to clean the halls and general areas of the facility; -the Supervisor has a deep cleaning list and tells staff daily what is to be deep cleaned for that day; and -windows and sills are cleaned weekly During an interview on 5/09/24 at 1:31 P.M., the Housekeeping Supervisor said: -he/she took over as supervisor about two months ago; -housekeepers are responsible for all dusting; -maintenance is responsible for vent and light cleaning; -deep cleans are done weekly; and -windows and sills are to be cleaned monthly. During an interview on 5/9/24 at 3:12 P.M., the Administrator said: -housekeeping is responsible for all cleaning and dusting of rooms and halls; -maintenance is responsible for the vents and lights; -there is not a cleaning list for daily, weekly or deep cleaning; -the floor is on a list of updates to be completed; -the dining room was cold last summer as well; - they are waiting on someone to fix the main air conditioning unit; and -she is working with staff on ensuring the building is maintained and clean. 2. Review of Resident #8's Quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff, dated 2/3/24 showed: - Cognitive skills intact; - Lower extremity impaired on one side; - Dependent on staff assistance for toilet use, transfers and dressing the lower extremities; - Always continent of bowel and bladder; and - Diagnoses including anxiety and depression. Observation and interview on 5/6/24 at 1:03 P.M., showed: - The resident was covered up with a fitted sheet; - The resident said he/she had asked for a clean top sheet and the staff brought him/her a fitted sheet because they did not have any clean top sheets; - The staff never switch the fitted sheet out for a clean top sheet when they become available. During an interview on 5/7/24 at 1:58 P.M., the Dietary Manager said: - he/she is also the head of laundry; - if they have a machine go down, then it might take longer to get the laundry completed; - they have enough linens, top sheets, fitted sheets, towels, wash cloths and hand towels; - they have one laundry person who may come in either in the morning or in the evening; and - linens were coming up missing, so now they have codes on the doors. The Charge Nurses (CNs) have the door codes. During an interview on 5/8/24 at 5:05 A.M., Nurse Aide (NA) B said they have run out of linens before. During an interview on 5/8/24 at 2:06 P.M., Certified Medication Technician (CMT) B said: - the facility does not have enough linens; - he/she went through all the rooms and pulled any extra linens to give the staff more access to the linens; - they do not have enough top sheets, wash cloths or towels; and - they have enough hand towels because the residents do not use them. During an interview on 5/8/24 at 2:38 P.M., Certified Nurse Aide (CNA) A said: - there are not enough linens in the facility, it's slim pickings; - he/she thought there was supposed to be someone working in laundry in the morning and in the evening; and - the aides are not supposed to know what the codes are to get the supplies and it makes it hard to do your job when you don't have access to what you need. You spend a lot of time going from room to room or hall to hall hunting for supplies when they could be providing care to the residents. During an interview on 5/9/24 at 9:55 A.M., Licensed Practical Nurse (LPN) B said: - we do not have enough lines; - there are codes on all the doors; and - he/she did not think the towels were getting washed as quickly as they should. During an interview on 5/9/24 at 10:29 A.M., CNA D said: - laundry comes in around 11:00 A.M., and starts washing the laundry; - he/she has started showers at 5:00 A.M., and has run out of towels by 10:00 A.M., and has to wait until 1: 00 P.M. before there are more towels ready for him/her to use; and - if the beds are stripped on the resident's shower days, there's not enough linens to make the beds. Observation and interview with the Dietary and Laundry Manager on 5/9/24 at 11:54 A.M., showed: - he/she had taken over laundry and housekeeping two months ago; - he/she checked the room the laundry is stored in after being washed and dried. They had 20 wash clothe, 28 hand towels, 30 towels, four top sheets, 13 fitted sheets and two pillow cases; - the shower room on D hall did not have any linens in it; - the linen cart on C hallway had four fitted sheets; - the shower room on B hallway had approximately 20 wash cloths and six towels; - the linen cart on A hallway had one fitted sheet; - the linen cart on F hallway had nine fitted sheets and six top sheets; and - E hallway did not have a linen cart. During an interview on 5/9/24 at 3:12 P.M., the Administrator and the DON said they do not have enough linens, as they keep disappearing.

Based on interviews and observation, the facility failed to ensure residents knew how to file a grievance. This deficient practice had the potential to affect any resident wanting to file a grievance. The facility census was 66. Review of facility policy, resident rights, undated, showed a resident has the right to voice grievances to this facility or other agency concerning treatment, care, behavior of staff and/or other residents as well as other concerns about his/her stay without discrimination or reprisal. The resident has the right to information on how to file a grievance or complaint as well as to the prompt resolution of grievances. 1. During a group meeting on 5/7/24 at 1:32 P.M., thirteen of thirteen residents said that they did not know how to file a formal grievance or who the grievance officer in the facility was. Observation on 5/9/24 at 10:51 A.M., showed a red folder hanging on the wall at four feet, which is inaccessible to residents in wheelchair position. This folder contained blank grievance forms with no area or information identified of where grievance forms were to be submitted. During an interview on 5/9/24 at 10:05 A.M., the housekeeping supervisor said he/she: -did not know facility grievance process; -did not know where grievance forms are located; and -he/she believed the Dietary Manager had some in his/her office; During an interview on 5/9/24 at 10:17 A.M., Dietary Manager said: -facility grievance forms are available by administrator's door, where a form is available to be filled out; -grievance forms are filled out by the social worker; and -the social worker distributes the grievance to appropriate departments heads and they go back to the administrator. During an interview on 5/9/24 at 10:32 A.M., Nurse Aide (NA) C said: -he/She did not know what the grievance process was for the facility; -he/She had been told to tell residents the Social Service Designee (SSD) would take care of complaints; and -the Social Service Designee would take complaints to managers. During an interview on 5/9/24 at 10:48 A.M., Licensed Practical Nurse (LPN) B said: -he/She did not know what facility grievance process was; -he/She though the SSD would just talk with residents; and -he/She did not know if residents had access to forms to fill out for a formal complaint. During an interview on 5/9/24 at 10:50 A.M., Certified Nurse Aide (CNA) A said a folder of blank grievance forms was hung inside the red folder on the wall near the nurses station. During an interview on 5/9/24 at 3:12 P.M., Administrator said: -the grievance process now included a red folder hanging outside the copier room towards the front of facility, that was available to residents and families; -families are encouraged to fill out grievance form; -grievance forms given to the SSD who reviewed them and decided what department the grievance needed to go to for the department to investigate and remedy the problem; -the grievance should then came back to his/her desk for review; -the grievance folder was not accessible to someone seated in wheelchair; -he/she did not know if there was a way for residents or families to make anonymous complaints; -he/she was aware the facility had a corporate compliance line- but did not know if that information was provided to residents in the facility admission packet; and -he/she did not know how resident's were educated about the grievance process but expected the SSD to educate during the 48 hour care plan meeting.

Based on record review and interview, the facility staff failed to check the Certified Nurse Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected three of ten sampled staff (Certified Medication Technician A, Dietary Aide C, and Licensed Practical Nurse C). The facility census was 66. Review of facility Policy, Abuse and Neglect, dated 1/30/24, showed: -Employee background checks and employment history collection will be done before hire. The facility will not knowingly employ any individual who had been found guilty of abusing, neglecting, exploiting, misappropriating, or mistreating individuals. -The abuse prevention program provides polices and procedures that govern, as a minimum: -Conducting employee background checks. 1. Review of Certified Medication Technician (CMT) A's employee file., showed: - Employee hired on 12/26/23; -No Family Care Registry check had been completed; -No Employee Disqualification List (EDL) check had been completed. 2. Review of Dietary Aide C employee file., showed: - Employee hired on 11/2/23; -Family Care Registry checked 5/7/24, six months after date of hire; -No EDL check had been completed; -No Nurse Aide Registry had been checked. 3. Review of Licensed Practical Nurse (LPN) C employee file., showed: -Employee hired on 12/16/23; -No EDL check had been completed. -No Nurse Aide Registry Check had been completed. During an interview on 5/7/24 at 3:49 P.M., the Business Office Manager said: -He/She started in the Business Office Manager position, on 3/15/24; -Family care registry should be done on employees before they are hired; -Nurse Aide Registry checks are completed on all employees; -Background checks were completed upon hire; -Facility did not do periodic background checks of employees. During an interview on 5/9/24 at 3:12 P.M., the Director of Nursing said: -Background checks should be done on employees prior to start of employment; -Nurse aide registry checks should be completed on all employees. During an interview on 5/9/24 at 3:12 P.M., the Administrator said: -Background checks should be completed prior to hire and as soon as employee has interviewed; -Nurse aide registry checks should be completed before the employee is hired.

2. Review of Resident #14's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/15/24, showed the resident assessed as: -cognitively intact; -has clear speech, able to make self-understood, and has clear comprehension of others; -dependent on wheelchair for mobility; -impairment to both sides of upper and lower extremity range of motion; -dependent on staff for eating, oral care, toileting, bathing, lower body dressing, personal hygiene, rolling left and right, lying to sitting, sitting to stand, chair to bed transfers, and shower transfers; -diagnoses including neurogenic bladder (a condition in people who lack bladder control due to a brain, spinal cord, or nerve problem), pneumonia, septicemia (a blood poisoning by bacteria), urinary tract infection, wound infection, paraplegia (paralysis of the legs and lower body), quadriplegia (symptoms of paralysis that affects all a person's limbs and body from the neck down), anxiety disorder, depression, post traumatic stress disorder, asthma, chronic pain due to trauma, neurogenic bowel (loss of normal bowel function), and pressure ulcers. During an interview on 5/6/24 at 11:18 A.M , the resident said he/she was hospitalized in February for over a week for being septic and had pneumonia. Review of the resident's medical record, dated 2/3/24, showed: -On 2/3/24 at 2:27 P.M., LPN A called the physician at 1:38 P.M. and gave report of decreased oxygen and temperature and obtained orders to send resident to the emergency room. Resident was in agreement. Call made to 911 to transport patient. They arrived at 1:45 P.M. -On 2/3/24 at 2:59 P.M., LPN D gave report to emergency room nurse. -On 2/3/24 at 7:39 P.M., LPN E received call from resident's family who stated resident was in intensive care unit with pneumonia, urinary tract infection, and was septic. -On 2/12/24 at 5:00 P.M., LPN E wrote resident returned via emergency medical support and was on isolation until further notice. The medical record did not have a copy of a transfer or discharge letter issued to the resident or responsible party. Review of census records showed the resident discharged on 2/3/24 and he/she returned to facility 2/12/24. During an interview on 5/9/24 at 11:07 A.M., Administrator said he/she started as administrator in March. The previous Administrator would notify the Ombudsman, however, he/she did not know to do so and so he/she had not done so. The Social Service Designee also did not know he/she was supposed to contact the Ombudsman when a resident was discharged . During an interview on 5/9/24 at 3:12 P.M., Director of Nursing said he/she was new to his/her position as Director of Nursing and did not know about about notice of transfer and discharge. During an interview on 5/9/24 at 3:12 P.M., Administrator said he/she could not find a notice of transfer packet for the facility. He/she would ensure the Ombudsman was notified monthly. Based on interview and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties that included the reason for the transfer, in writing and in a language they understood. The notice should have included the effective date of discharge or transfer, the location to which the resident would be transferred or discharged , and information regarding the resident's appeal rights, including how to file an appeal or obtain assistance in completing and submitting it. The facility also failed to notify the State Long-Term Care Ombudsman of the transfers and discharges. This affected two of 17 sampled residents, (Resident #14 and #27). The facility census was 66. The facility did not provide a policy for transfer/discharge of a resident. 1. Review of Resident #27's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/24 showed: - cognitive skills moderately impaired; - upper and lower extremities impaired on one side; - dependent on staff for toilet use and transfers; and - diagnoses including stroke, Alzheimer's disease ( brain disorder that slowly destroys memory and thinking skills and the ability to carry out the simplest tasks), dementia (the inability to think), anxiety, depression, and hemiplegia (paralysis affecting one side of the body). Review of the resident's medical record dated 3/23/24 at 10:45 P.M., showed the nurse called to the resident's room. The resident was lying face down on the floor under the room mate's bed. The nurse assessed the resident as able to move extremities on the right side of his/her body. Left side unable to move, same as baseline. Resident noted to have large hematoma (localized swelling that is filled with blood outside of a blood vessel) to forehead. Alert and oriented times two as his/her usual baseline. Resident complained of a headache and neck pain. Vital signs obtained. Administration, physician notified. Called Emergency Medical Services (EMS). Review of the resident's medical record on 3/24/24 at 4:27 A.M., showed the resident returned from the hospital via EMS. The residents lab work and scans were negative. The resident had a broken nose. The medical record did not have a copy of a transfer or discharge letter issued to the resident or responsible party. During an interview on 5/9/24 at 9:55 A.M., Licensed Practical Nurse (LPN) B said: - when a resident is sent out to the hospital, he/she sent a transfer sheet (which contained the resident's name, date of birth , and where they were being transferred), the face sheet, physician order sheet, and advance directives; and - he/she did not know about any form with email or mailing address, appeal rights or notifying the State Long-Term Care Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #14's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/15/24, showed the resident: -cognitively intact; -had clear speech, was able to make self-understood and had clear comprehension of others; -dependent on wheelchair for mobility; -with an impairment to both sides of upper and lower extremities; -dependent on staff for all activities of daily living. -Diagnoses including neurogenic bladder (a condition in people who lack bladder control due to a brain, spinal cord, or nerve problem), pneumonia, septicemia (a blood poisoning by bacteria), urinary tract infection, quadriplegia (symptoms of paralysis that affects all a person's limbs and body from the neck down), anxiety disorder, depression, post traumatic stress disorder, chronic pain due to trauma, neurogenic bowel (loss of normal bowel function), and pressure ulcers. During an interview on 5/6/24 at 11:18 A.M., Resident #14 said: -he/she was hospitalized in February for over a week; -he/she was septic and had pneumonia; -he/she did not recall a bed hold notice at time of hospitalization. Review of the resident's medical record, dated 2/3/24, showed: -On 2/3/24 at 2:27 P.M., LPN A called the physician at 1:38 P.M. and gave report of decreased oxygen and temperature and obtained orders to send resident to the emergency room. Resident was in agreement. Call made to 911 to transport patient, whom arrived at 1:45 P.M., and report called to hospital. Resident's family also contacted. -On 2/3/24 at 2:59 P.M., LPN D gave report to emergency room nurse. -On 2/3/24 at 7:39 P.M., LPN E received call from resident's family who stated resident was in intensive care unit with pneumonia, urinary tract infection, and was septic. Review of census records showed the resident discharged [DATE]. The resident returned to the facility 2/12/24. During an interview on 5/9/24 at 3:12 P.M., Director of Nursing said he/she did not know about a bed-hold policy. During an interview on 5/9/24 at 3:12 P.M., Administrator said he/she could not find a discharge packet that included a bed-hold notice. The Social Services Designee also did not know about bed-hold notices. Based on interviews and record review, the facility failed to ensure staff informed the residents and their family/legal representatives of the bed hold policy at the time of the transfer/discharge to the hospital for two of 17 sampled residents, (Resident #14 and #27). The facility census was 66. The facility did not provide a bed hold policy. 1. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/24 showed: - cognitive skills moderately impaired; - upper and lower extremities impaired on one side; - dependent on staff for toilet use and transfers; - frequently incontinent of urine; - always incontinent of bowel; - diagnoses including stroke, Alzheimer's disease ( brain disorder that slowly destroys memory and thinking skills and the ability to carry out the simplest tasks), dementia (the inability to think), anxiety, depression, and hemiplegia ( paralysis affecting one side of the body). Review of the resident's medical record dated 3/23/24 at 10:45 P.M., showed the nurse was called to the resident's room. The resident was lying face down on the floor under the room mate's bed. Nurse assessed the resident, able to move extremities on the right side of his/her body. Left side unable to move, same as baseline. Resident noted to have large hematoma (localized swelling that is filled with blood outside of a blood vessel) to forehead. Alert and oriented times two as his/her usual baseline. Resident complained of a headache and neck pain. Vital signs obtained. Administration, physician notified. Called Emergency Medical Services (EMS). Review of the resident's medical record showed t:he resident was sent to the hospital on 3/23/24 after a fall. There was no documentation in the medical record that the resident or the responsible party was provided provide written information explaining the facility's bed-hold policy. The record did not have have a copy of any bed hold notice/letter that would have been issued to the resident. During an interview on 5/9/24 at 9:55 A.M., Licensed Practical Nurse (LPN) B said: - when a resident is sent out to the hospital, he/she sent a transfer sheet ( which contained the resident's name, date of birth , and where they were being transferred), the face sheet, physician order sheet and advance directives; - he/she was not aware of any bed hold letter/notice that needed to be sent with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview's and record review, the facility failed to complete a Minimum Data Set (MDS) a federally mandated assessment completed by the facility staff within the required time frames, upon the resident's admission for 3 of 17 sampled resident's (Resident #214, #216, and #212). The facility census was 66. The facility did not provide a policy regarding comprehensive assessments. Review of facility policy, Medically Related Social Services, dated 1/30/24, showed: -Facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. -Social services services may include identifying and seeking ways to support resident's individual needs through the assessment and care planning process. 1. Review of Resident #214's Face Sheet, dated 5/7/24, showed: -He/She admitted to facility on 4/19/24; -Diagnoses included rheumatoid arthritis and generalized muscle weakness. Review of MDS showed resident did not have MDS completed. Review of care plan, dated 5/6/24, showed: -He/She had one goal regarding do not resuscitate orders. Review of baseline care plan, dated 4/19/24, showed: -He/She was cognitively intact; -He/She wore glasses; -He/She had verbal communication; -He/She required an assist of one staff for bed mobility, grooming, hygiene, bathing, and locomotion; -He/She required an assist of two staff for transfers and toileting; -He/She needed interventions for skin issues; -He/She needed monitoring for safety and assist while eating and drinking; -He/She had history of falls and was a fall risk; -He/She was dependent on a wheelchair for mobility; -He/She had psychosocial needs and took as needed medications; -He/She was incontinent of bowel and bladder; During an interview on 5/6/24 at 3:16 P.M., resident said: -He/She had a fall prior to arriving to facility; -He/She experienced pain and took pain pills; Review of fall assessment, dated 4/19/24, showed: -He/She was low risk for falls. During an interview on 5/14/24 at 10:34 A.M., State RAI Coordinator said: -Resident's MDS was submitted late and accepted on 5/9/24. 2. Review of Resident #216's face sheet, dated 5/7/24, showed: -Resident admitted to facility on 4/22/24 -Diagnoses included: neurocognitive disorder with lewy bodies (a type of progressive dementia that leads to decline in thinking, reasoning, and independent function), generalized osteoarthritis (a condition in which three or more joint groups are affected when cartilage that cushions end of bones deteriorates), chronic pain syndrome. Review of MDS showed resident did not have MDS completed. Review of care plan, dated 5/8/24, showed: -Resident had one goal regarding full code status. Review of baseline care plan, dated 4/22/24, showed: -He/She had confused cognition status; -He/She required assist of two staff for bed mobility, transfers, bathing, locomotion, and toileting; -He/She had safety concerns regarding balance and gait, muscle weakness, and fatigue; -He/She required assist of one staff with eating; -He/She used a mechanical lift for transfers; -His/Her bed should be in lowest position; -He/She displayed aggression, agitation, and crying; -He/She had as needed medications for psychosocial interventions; -He/She was always incontinent of bowel and bladder. During an interview on 5/14/24 at 10:34 A.M., State RAI Coordinator said: -Resident's MDS was submitted and accepted on 5/9/24; -Facility received an error for the MDS being completed late; -Assessment should have been completed by 5/5/24. 3. Review of Resident #212's face sheet, dated 5/7/24, showed: -He/She admitted to facility on 4/22/24; -Diagnoses included dependence on renal dialysis (a treatment that removed extra fluid and waste products from the blood when kidneys are not able to), diabetes (a condition resulting in too much sugar in the blood, neuropathy (weakness, numbness, or pain from nerve damage), and kidney disease. Review of MDS showed resident did not have MDS completed. Review of care plan showed facility did not provide base line care plan or care plan. During an interview on 5/14/24 at 10:34 A.M., State RAI Coordinator said: -Resident's MDS was submitted and accepted on 5/9/24; -Facility received an error for the MDS being completed late; -admission assessment should have been completed by 5/5/24. 4. During an interview on 5/7/24 at 3:41 P.M., Social Service Designee said: -He/She did some sections of the MDS including sections A, E, and Q; -He/She went to training in August with the regional team; -The MDS process was interdisciplinary within the facility; -The staff member who completed MDS at the facility was fired in February; -The regional staff member who was helping with getting MDS in order was fired last week. During an interview on 5/9/24 at 3:12 P.M., Administrator said: -MDS assessments should be completed on time; -He/She was aware MDS assessments had not been completed; -He/She knew that the previous Regional MDS coordinator had moved a bunch of dates around on the MDS due to him/her going to [NAME] and being out of facility, the facility will have to go back and review time frames to ensure compliance; -Many MDS were not 92 days a part because of the Regional MDS Coordinator changing dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #45's admission minimum data set (MDS), dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood, and understand others; -He/She had impairment on one side; -He/She was dependent on walker and wheelchair for mobility; -He/She required setup or clean-up assistance eating -He/She required substantial/maximal assistance for showers, lower body dressing, sitting to standing, sit to lying, chair to bed transfer, toilet transfer, -He/She required partial/moderate assistance with personal hygiene and rolling left and right. -Diagnoses included aftercare after joint replacement surgery, anemia, high blood pressure, gastroesophageal reflux disease, wound infection, arthritis, anxiety disorder, asthma. Review of physician's orders dated 4/8/24 to 5/8/24 showed: -Order started 4/18/24, Bed rail to assist with getting out of bed and turning unassisted. Review of care plan, dated 5/1/24, showed: -Side rails not care planned; -Shower preferences not care planned; -Activity preferences not care planned; -Pressure ulcer not care planned. -He/She able to move self some in bed but required staff assistance with transfers and bed mobility. Staff to assist him/her with repositioning in bed. He/She had pressure reducing mattress on his/her bed. -He/She was at risk from injury from falls; -Make sure bed was in lowest position with wheels locked; -He/She had fall with a hip fracture prior to admitting to facility, and was on therapy services; -He/She had a lot of anxiety related to fall and impacted ability to transfer his/her self. -Resident is alert and able to communicate his/her needs. Encourage him/her to call for assistance with his/her ADL care. -Resident required assistance of staff with his/her bathing needs. During an interview on 5/6/24 at 1:00 P.M., the resident said: -He/She had a side rail put on to help him/her turn in bed; -He/She slept in recliner now because of swelling in his/her legs and had not used bed rail since it was put on. -He/She last had a shower over a week ago on 4/30/24; -He/She preferred to have showers twice a week on scheduled shower days of Tuesdays and Fridays; -There was not enough activities that he/she enjoyed; -He/She loved to be outside but outside of smoking facility did not do activities for resident's outside; -He/She had cellulitis of his/her legs. Review of electronic medical record, dated 4/18/24 at 12:06 P.M. showed new order was received from physician for bed rail to assist with getting out of bed and turning unassisted. Review of facility matrix showed resident had a pressure ulcer. Review of physician's orders, dated 4/8/24 to 5/8/24, showed: -Order start date 4/12/24, ultra sound to left lower extremity to rule out deep vein thrombosis (DVT) -Order start date 4/12/24, venous ultra sound of left lower extremity to rule out DVT redness and pain in lower left extremity -Order start date 4/15/24 - check skin tear to left lower leg. Keep clean, dry, and covered until healed; -Order start date 4/19/24 - Check and change dry dressing to lower left leg skin tear daily until healed. -Order start date 5/1/24 - Lasix (Furosemide) tablet 20 mg; amt: 1: oral for diagnosis cellulitis of left lower limb once a day in AM; -Order start date 5/1/24, potassium chloride capsule, extended release; 10 mEq; amount: 1 capsule; oral for diagnosis cellulitis of left lower limb, once a day in morning; -Order start date 5/3/24 - nystatin powder; 100,00 unit/gram; amt: apply this layer; topical, special instructions: apply under her breast folds and her abdominal folds twice daily a thin layer. -Order start date 5/3/24 to 5/5/24 - Xeroform petrolatum dressing (bismuth tribrom-petrolatum, wh) bandage; 4x4; amt: 4x4; topical Special instructions: left lower extremity; cleanse area with N/S, apply erform dressing and wrap with kerlix daily for diagnosis of Cellulitis of left lower limb once a day; AM; -Order start date 5/5/24, may have wound care plus diagnosis of cellulitis of left lower limb, -Order start date 5/5/24 to 5/15/24, cephalexin capsule; 500 mg; amt: 500 mg: oral Special instructions: times 10 days for diagnosis cellulitis of left lower limb, three times daily; AM 7:00 AM, 12:00 P.M., 7:00 P.M. -Order start 5/5/24, open ended; Xeroform Petrolatum Dressing (bismuth tribrom-petrolatum, wh) bandage; 4x4' amt: 4x4; topical. Special instructions: lower extremity; cleanse area with N/S, Apply xeroform dressing and wrap with kerlix daily (DX: cellulitis of left lower limb) once a day: am Observation on 5/6/24 at 1:00 P.M. showed resident had side rails on left side of bed only. Review of Side Rail Assessment, dated 4/18/24, showed: -Implemented for bed mobility -Resident had expressed desire to have side rails -Quarter rail will be used to assist in positioning and transfers - Side not indicated. -Use - day and night -Additional interventions: provide frequent staff monitoring at night, visual and verbal reminders to use call light. -Entrapment zones not filled out on the assessment. Review of shower logs from 4/8/24 to 5/8/24 showed: -He/She had 2 of 9 scheduled showers on 4/30/24 and 5/7/24. During an interview on 5/8/24 at 9:54 A.M., Social Service Designee said: -He/She expected side rails to be included in a care plan. 3. Review of Resident #216's face sheet showed: -Resident admitted to facility on 4/22/24 -Diagnoses included: neurocognitive disorder with lewy bodies (a type of progressive dementia that leads to decline in thinking, reasoning, and independent function), generalized osteoarthritis (a condition in which three or more joint groups are affected when cartilage that cushions end of bones deteriorates), chronic pain syndrome. Review of MDS showed resident did not have MDS completed. Review of physician's orders, dated 4/8/24 to 5/8/24, showed: -He/She was taking antipsychotic medications -Order started 5/1/24 rexulti tablet, .5 mg 1 oral tablet for seven days then increase to 1.0 mg; Review of care plan showed resident did not have care plan completed. Review of baseline care plan, dated 4/22/24, showed: -He/She had impaired cognition; -He/She was assist of two staff for bed mobility, transfers, toileting, grooming, hygiene, bathing, and locomotion; -He/She was assist of one for eating; -He/She had safety concerns of balance and gait, muscle weakness, and fatigue/endurance concerns; -He/She had psychosocial concerns of sad and crying, agitation, aggression; -He/She was always incontinent of bowel and bladder. During an interview on 5/7/24 at 10:44 A.M., Resident's representative said: -He/She had not participated in any care plan meeting with the facility; -The facility had provided no team collaboration or phone call regarding resident's care. During an interview on 5/8/24 at 9:54 A.M., Social Service Designee (SSD) said: -He/She did baseline care plan meeting with resident's sister; -Resident did not yet have a regular care plan completed yet. During an interview on 5/8/24 at 12:06 P.M., Resident's sister said: -Resident could not feed themselves. 3. Review of Resident #214's face sheet, dated 5/7/24, showed: -He/She admitted to facility on 4/19/24; -Diagnoses included rheumatoid arthritis and generalized muscle weakness. Review of MDS showed resident did not have MDS completed. Review of physician's orders, dated 4/7/24 to 5/7/24, showed: -He/She was on mechanical soft diet; -He/She had medications for chronic pain; -He/She had as needed medication for generalized anxiety disorder; -He/She had skin prep to right second toe. Review of care plan, dated 5/6/24, showed: -He/She had only do not resuscitate orders care planned. Review of baseline care plan, dated 4/19/24, showed: -He/She was alert and cognitively intact; -He/She used verbal communication; -He/She wore glasses; -He/She was assist of one staff for bed mobility, grooming, bathing, locomotion; -He/She was assist of two for transfers, toileting; -He/She was independent with eating; -He/She was dependent on a manual wheelchair; -He/She had psychosocial concerns of nervousness; -He/She was sometimes incontinent of bowel and bladder. 4. During an interview on 5/8/24 at 9:54 A.M., SSD said: -Care plans should be written 14 days after admission; -He/She led and scheduled care plan meetings; -The writing of care plans was more interdisciplinary; -Care plans are scheduled off the minimum data set (MDS) schedule; -He/She kept a list of upcoming care plans on his/her calendar; -Nursing staff completed the baseline care plans when resident admitted to facility; -He/She did not have families, residents, or care plan participants sign anything when they participated in care plan meetings; -He/She called resident families or representatives for care plan meetings and will make a note in resident's electronic medical record when he/she notified individuals of care plan meetings. -The former MDS Coordinator wrote most of the care plans; -He/She did not know who was responsible for updating the care plans; -He/She usually only completes the code status and trauma section of care plans but had not been trained on doing other areas of the care plans. During an interview on 5/9/24 at 3:12 P.M. the Administrator said: -There was not a MDS coordinator and that position was responsible for checking and updating the care plans. -Nobody has has had formal training on completion of the care plan and the MDS process. -A new MDS/Care plan coordinator started Monday. -Each department should update their part of the care plan with any changes. -The MDS coordinator should oversee the quality of the care plan. -Anyone can update a care plan. Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for three of 16 sampled residents (Residents #162, #45, #216, and #214). The census was 66. Review of the facility provided policy, Comprehensive Care Plan, dated 1/30/24 showed: -Each resident will have a person centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's nursing medical, physical, mental and psychosocial needs identified in the comprehensive assessment. -The comprehensive care plan will be developed within seven days after the completion of the comprehensive assessment. -The comprehensive care plan will be reviewed and revised, based on changing goals, preferences and needs of the resident, and in response to current interventions. 1. Review of Resident # 162 Annual Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 4/12/24 showed: -Brief Interview of Mental Status (BIMS) of 10, indicated cognitive loss. -Dependent on staff for completion of Activities of Daily Living (ADL's: tasks completed to care for oneself in a day) -Indwelling urinary catheter (tube inserted into the bladder to drain urine) -Frequently incontinent of bowel -Hospice services -Use of oxygen (O2) Review of the Physician order sheet for May 2024 showed: -No order for use of side rails/half rails/assist rails Review of the resident's electronic medical record showed: -A neurological assessment completed 4/30/24 with note of unwitnessed fall. -No progress note about a fall. -No indication side rails were in use or placed after the fall. -Review of the comprehensive care plan 5/6/24 showed: -No care plan for need for assistance with ADL's, use of side rails, Hospice services, use of catheter or use of O2. During observation and interview on 5/06/24 at 2:31 P.M. showed half side rails on bed, in the up position. The resident said the rails were up because he/she had rolled out of bed before. During observation on 05/08/24 at 9:10 A.M. showed half rails on bed, in the up position. During an interview on 05/08/24 at 2:33 P.M. Certified Medication Technician (CMT) B said: -Hospice brought the bed in to the resident. -He/She did not know why the resident had them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Resident #45's admission MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood, and understand others; -He/She had impairment on one side; -He/She was dependent on walker and wheelchair for mobility; -He/She required substantial/maximal assistance for showers; -Diagnoses included aftercare after joint replacement surgery and arthritis. Review of care plan, dated 5/1/24, showed -Resident was alert and able to communicate his/her needs. -Encourage him/her to call for assistance with his/her ADL care; -Resident required assistance of staff with his/her bathing needs; -Resident admitted with a hip fracture and was on therapy services. He/She required assistance with mobility of ambulation with a walker and does use a wheelchair for longer distances; -Care plan did not specify resident's shower preferences. Review of baseline care plan, dated 4/8/24, showed: -He/She required assistance of one staff for bathing; -Assist with ADL care as needed to promote health, hygiene, and safety; -He/She was sometimes incontinent of bowel; -He/She was always incontinent of bladder. During an interview on 5/6/24 at 12:49 P.M. Resident said: -He/she had his/her last shower over a week ago on 4/30/24; -He/She preferred to have a shower twice a week; -His/Her shower days were supposed to be on Tuesday and Fridays. Review of shower logs from April 8, 2024 to May 8, 2024 showed: -He/She had two documented showers on 4/30/24 and 5/7/24. During an interview on 5/8/24 at 2:38 P.M., CNA A said: -Shower aide is often pulled to help cover the floor, and did not do showers; -The shower aide worked overnight on 5/7/24 so showers were not getting completed on 5/8/24. 7. Review of Resident #50's Quarterly MDS, dated [DATE] showed: -He/She was cognitively intact; -He/She had impairment on one side of body in upper and lower extremities; -He/She was dependent on wheelchair for mobility; -He/She was dependent for bathing assistance, toileting, upper and lower body dressing; -He/She required substantial/maximal assistance for personal hygiene and mobility; -Diagnoses included stroke, weakness, lack of coordination, difficulty in walking, and need for assistance with personal care. Review of care plan, dated 3/13/24, showed: -Resident required assistance with most activities of daily living due to hemiplegia affecting left dominant side due to status post cerebral vascular accident. -Provide extensive assistance by two staff with personal hygiene, dressing, toileting, bed mobility, and transfers; -Shower preferences not care planned. During an interview on 5/6/24 at 10:31 A.M. Resident said: -He/She had not had a shower in quite awhile because the facility did not have any towels; -His/Her last shower was on a Thursday maybe towards end of March; -He/She would like to have showers two times a week; -Therapy staff gave him/her one of his/her last showers; -He/She had not had any bed baths. Review of shower logs from February 1, 2024 to May 8, 2024 showed: -He/She had sixteen of twenty-eight opportunities for showers; -He/She had showers provided on 2/3, 2/7, 2/10, 2/15, 2/21, 2/28, 3/2, 3/7, 3/9, 3/13, 3/20, 4/1, 4/3, 4/9, 4/15, and 4/19; -His/Her last documented shower was two and half weeks ago. During an interview on 5/8/24 at 2:25 P.M., CMT B said: -Showers did not get done due to shower aide working last night; -There was not enough wash clothes, towels in order to provide showers to every resident; During an interview on 5/8/24 at 2:38 P.M., CNA A said: -There is limited supply on towels, hand towels, and wash clothes; During an interview on 5/9/24 at 3:12 P.M., the Administrator and the Director of Nursing (DON) said: - The resident's showers should be completed per the resident's choice. - Staff should separate and clean all areas of the skin where urine or feces had touched; - Staff should have cleaned the urine from the floor or had housekeeping clean it before they placed the fall mat on the floor; - Staff should have cleaned the seat of the Broda chair; - Staff should not have used the clean incontinent brief once it had fallen on the floor. 3. Review of Resident #35's Quarterly MDS, dated [DATE] showed: -Brief Interview of Mental Status (BIMS) of 4, indicated significant cognitive deficit; -Partial to moderate assistance on staff for Activities of Daily Living (ADL's: tasks performed to care for oneself in a day); -Dependent on staff for standing, maximum assistance for transfers; -Occasional incontinence of urine; -Continent of bowel; -Diagnoses of Alzheimer's Dementia (progressive memory loss that interferes with daily life), disorientation (a state of mental confusion), chronic pain, atrial fibrillation (A-Fib: a type of abnormal heartbeat). Review of the resident's comprehensive Care Plan dated 3/1/24 showed: -He/she takes the assist of 2 staff for toileting; -He/She experienced bladder and bowel incontinence; use incontinent pads or briefs to protect his/her dignity; -He/She can be confused at times; break tasks into manageable segments, explain all procedures, allow him/her to make simple decisions. Observation on 5/08/24 at 5:05 A.M. showed: -Nurse Aide (NA) A and NA B entered the resident's room; NA B closed the resident's bedroom door, removed wipes and removed cream from the resident bedside dresser. NA B uncovered the resident, unfastened the resident's brief and removed the brief from the front of the resident. NA A used one cleansing wipe to wipe the outer skin folds at the thigh and down the middle. The resident said his/her skin was very sore and felt better when cream was applied. The resident was then turned to his/her side. NA A removed another cleansing wipe and with a back and forth motion cleansed the resident's buttocks. NA A then picked up a tube of A&D ointment and applied it to the resident's skin folds. A new incontinent brief was applied and the resident was covered with a blanket. NA A and NA B removed the gloves and left the resident's room. During an interview on 5/8/24 at 5:31 A.M., NA A said: -He/She had been working in facility a couple of months; -He/She would be starting certified nurse aide (CNA) classes soon, but was still waiting to find out; -His/Her training involved staff showing him/her every resident, showing him/her supplies, and what to fill out to help residents, and telling me what he/she can and cannot do. 4. Review of Resident #57 Quarterly MDS dated [DATE] showed: -BIMS of 99, indicated significant cognitive deficit; -Dependent on staff for ADL's; -Always incontinent of bowel and bladder; -Diagnoses of Intracerebral hemorrhage (bleeding into the brain), Aphasia (loss of ability to understand or express speech), hemiplegia (loss of the ability to move one side of the body). Diabetes Mellitus (a health condition that affects how your body turns food into energy), seizures (a condition where you have a temporary, unstoppable surge of electrical activity in your brain) Hypertension (high blood pressure). Review of Resident #57 comprehensive Care Plan, dated 1/24/24 showed: -He/She needed assist of 1-2 staff with ADL's; -Keep his/her call light within reach and answer in a timely manner; -Provide him/her adequate rest periods between activities; -During two hour checks and as needed (PRN: per resident need) please ask the resident if he/she needs any of his/her belongings moved closer so they are within reach; -Frequent checks at night, every one to two hours and prn; -He/she was at risk for pressure ulcers because of incontinent episodes of bowel/bladder; -He/She needs assist with bed mobility; -Keep him/her clean and dry as possible; -Minimize his/her skin exposure to moisture; -Turn and reposition him/her every two hours and PRN; -Encourage toileting before and after meals, before assisting to bed and prn. Continuous observation beginning on 5/08/24 at 5:39 A.M. showed: -The resident was taken to the dining /Activity room by staff. He/she was placed in front of the TV with cartoons on and lights off; - 7:26 A.M. the resident was taken to the dining table for breakfast and assisted with meal; - 9:03 AM he/she remained in the dining/ activity room; he/she was yelling out. MDS Coordinator entered the room and asked the resident if he/she was missing his/her friend. The MDS coordinator assured the resident his/her friend was missing him/her too and walked away. The resident was not offered or taken to the restroom, repositioned or offered food or drinks; - 9:08 AM staff entered the dining/activity room, laid the back of her Broda chair (a tilting, reclining, and wheeled chair) down. The resident was not offered or taken to the restroom, repositioned or offered food or drinks; -9:18 AM the resident was yelling out. LPN A asked the resident why he/she was yelling. The resident said he/she was tired. LPN A asked the resident if he/she wanted to lay down. Resident #57 replied yes. LPN A told the resident he/she would notify CNA staff. The resident began to cry. LPN A asked the resident why he/she was crying. The resident said staff would not come. LPN A asked the resident if he/she was crying because staff had not come to help; the resident responded yes. LPN A then walked away. The resident was not offered or taken to the restroom, repositioned or offered food or drinks. - 9:22 A.M. Nurse Aide C took the resident from the dining/activity room to his/her room. NA C pulled covers back then left room to obtain assistance. The resident was not offered or taken to the restroom, repositioned or offered food or drinks. -9:24 AM NA C returned the resident to the dining/activity room. -9:36 AM the resident remained in the Broda chair in the dining/activity room. NA C had the ice cart, stopped at the resident's chair and covered the resident with a blanket, and left. The resident closed his/her eyes and began snoring. The resident was not offered or taken to the restroom, repositioned or offered food or drinks. - 9:42 AM the resident was dozing off and on, snoring lightly then opening his/her eyes. -10:01 AM the Activity Director (AD) approached the resident, observed the resident with eyes closed, and walked away. The resident was not offered or taken to the restroom, repositioned or offered food or drinks. -10:10 AM Exercise group began in the activity/dining room. The resident remained in his/her Broda chair, reclined, with eyes closed. -10:54 AM staff moved the resident to a dining table. The resident was not offered or taken to the restroom, repositioned or offered food or drinks. During an interview on 05/08/24 at 10:33 A.M. NA C said residents should be moved, toileted, or cleaned up every two hours or as needed. There is not enough help to get everything done that needs to be done. He/she was not aware it had been over two hours that Resident #57 was changed or repositioned. 5. Review of Resident # 162's Annual MDS dated [DATE] showed: -He/she admitted on [DATE]; -BIMS of 10, indicated cognitive loss; -Dependent on staff for completion of ADL's; -Indwelling urinary catheter (tube inserted into the bladder to drain urine); -Frequently incontinent of bowel; -Hospice services; -Use of oxygen (O2). -Review of the comprehensive care plan 5/6/24 showed: -The resident was a do not resuscitate (DNR: a directive to withhold Cardiopulmonary Resuscitation (CPR) if the resident is found deceased ); -No care plan for need for assistance with ADL's, use of side rails, Hospice services, use of catheter or use of O 2. Review of the facility provided shower sheets for April and May 2024 showed no shower sheets for Resident #162. Review of the electronic medical record showed no documented oral care, morning care or bathing. Observation and interview on 05/06/24 at 2:31 PM showed: -The resident had white, stringy, sticky material on his/her teeth and lips; -He/she said his/her teeth had not been brushed and he/she had not had a bath or shower since he/she admitted to the facility; -His /her hair was disheveled and matted at the back of his/her head. Observation and interview on 05/08/24 at 9:10 A.M. showed: -The resident had white, stringy, sticky material on his/her lips, tongue and teeth; -His/her eyes have crusted debris at the corners; -His/her hair is disheveled and matted; -He/she said staff had not brushed his/her teeth, washed his/her face or given him/her a bath since he/she had admitted to the facility. -During an interview on 5/08/24 at 12:06 P,M. CMT B said: -He/she had come in and done 24 showers on his/her day off because none of the residents had one for over a week; -The facility is short staffed; -There is not enough help to get everything done, and things get missed; -They do the best they can to meet the resident's needs. During an interview on 5/08/24 at 3:10 PM CNA A said: -Residents should be repositioned every two hours; -Oral care should be done at least a couple times a shift, more if on 02 because of drying out the mouth; -They do not have enough staff and complete cares when they can. During an interview on 05/09/24 at 9:56 A.M. LPN B said: -Turning, repositioning, incontinent care should be completed every two hours; -Oral care should be completed as needed.Based on observations, interviews and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected three of the 17 sampled residents, (Residents #9, # 35 and #57), as well as failed to ensure showers were completed for four Residents #2, #45, #50 and #162, and additionally the staff failed to reposition Resident #57 who was dependent upon staff for assistance with repositioning. The facility census was 66. Review of the facility's undated policy for shower/tub bath, showed, in part: - The purpose is to promote cleanliness and comfort, relax the resident, stimulate circulation, and facilitate observation of the resident's skin condition. . Review of the facility's policy for perineal care, dated April 2006, showed, in part: - The purpose was to cleanse the perineum (the thin layer of skin between the genitals and anus, and the bottom region of the pelvic cavity) and to prevent infection and odor; - Knock and pause before entering the resident's room; - Introduce yourself; - For the female resident - Use one gloved hand to stabilize and separate the perineal folds, with the other hand wash from front to back; - For the males - follow the above instructions for the female perineal care except wash the skin folds. Pull back the uncircumcised skin fold, wash, dry and replace the skin fold; - Use and new wash cloth and wash around the rectal area. 1. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/3/24 showed: - Cognitive skills intact; - Set up and clean up with showers; - Independent with dressing, personal hygiene and oral hygiene; - Occasionally incontinent of urine; - Diagnoses included seizure disorder and coronary artery disease (CAD, damage or disease in the heart's major blood vessels). Review of the resident's shower sheets for February 2024, showed: - 2/5/24 - the resident had a shower; - 2/13/24 - the resident had a shower; - 2/26/24 - the resident had a shower; - 2/29/24 - the resident had a shower. Review of the resident's care plan, dated 3/4/24, showed: - The resident was at risk for skin breakdown related to lymphedema ( a condition caused by a blockage in the lymphatic system and generally occurs in an arm or leg), in both lower extremities. Showers or baths at least twice weekly or as desired. Review of the resident's shower sheets for March 2024, showed: - 3/11/24 - the resident had a shower; - 3/14/24 - the resident had a shower; - 3/18/24 - the resident refused his/her shower; - 3/21/24 - the resident refused his/her shower due to not feeling well; - 3/25/24 - the resident had a shower; - 3/28/24 - the resident had a shower. Review of the resident's skin attention forms for April 2024, showed: - 4/3/24- the resident had a shower; - 4/4/24 - the resident refused his/her shower; - 4/9/24 - the resident had a shower; - 4/19/24 - the resident had a shower. Requested shower sheets for May, 2024 and none were provided. Observation and interview on 5/6/24 at 11:15 A.M., showed: - The resident was in his/her room; - The resident's hair appeared dull and greasy; - The resident stated he/she has gone two weeks without a shower. It made him/her feel like a filthy pig, nasty and just awful and bad all the way around. He/she was able to give him/herself a shower with staff just helping to set things up. The resident did not understand why he/she didn't get showered twice weekly. During an interview on 5/8/24 at 2:06 P.M., Certified Medication Technician (CMT) B said: - Showers do not always get done because they do not have enough staff; - The facility had a designated shower aide but he/she worked last night so none of the residents would be getting a shower today. During an interview on 5/9/24 at 9:55 A.M., Licensed Practical Nurse (LPN) B said: - When they are short staffed, it is difficult to get the resident's showers completed. During an interview on 5/9/24 at 10:29 A.M., Certified Nurse Aide (CNA) D said: - He/she was the designated shower aide; - He/she gets pulled to work the floor and when that happens, the showers do not get completed; - The other issue with the showers is they do not have enough lines. He/she started showers at 5:00 A.M., and by 10:00 A.M., he/she is out of towels and wash cloths. If Laundry did not come in until 11:00 A. M., then he/she would have to wait until after 1:00 P.M. before he/she could start showers again. 2. Review of Resident #9's Quarterly MDS, dated [DATE] showed; - Cognitive skills severely impaired; - Required substantial to maximal assistance with showers, personal hygiene, toilet use and transfers; - Always incontinent of bowel and bladder; - Diagnoses included non traumatic brain dysfunction (causes damage to the brain by internal factors, such as a lack of oxygen, exposure to toxins, or pressure from a tumor), congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), anxiety, depression, Alzheimer's disease ( brain disorder that slowly destroys memory and thinking skills and the ability to carry out the simplest tasks), and psychotic disorder (a mental disorder characterized by a disconnection from reality). Review of the resident's care plan, dated 3/13/24 showed: - The resident required assistance with activities of daily living (ADL's) due to weakness, decreased cognition related to Alzheimer's disease. Assist the resident with cares. Provide extensive assistance for bed mobility, transfers, locomotion on the unit and off the unit, dressing, toileting, and personal hygiene. The resident is not able to walk. Observation on 5/7/24 at 9:41 A.M., showed: - The resident sat in his/her Broda chair (reclining geri chair) in the assist dining room and was leaning over on the left side of the chair with his/her eyes closed. There was a puddle of urine under the resident's Broda chair; - CNA A took the resident back to his/her room; - CNA A and CNA D did not wash their hands and applied gloves; - CNA A and CNA D used the gait belt (a safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) and transferred the resident from the Broda chair to his/her bed; - There was a puddle of urine under the resident's Broda chair; - CNA A and CNA D removed the resident's wet pants and the saturated and soiled incontinent brief; - CNA A and CNA D turned the resident on his/her side; - CNA D wiped from front to back one time; - CNA D used a new wipe and wiped the rectal area with fecal material noted. CNA D used three different wipes and wiped the rectal area; - The clean incontinent brief fell onto the floor and CNA D picked it up and placed it on the resident and fastened it; - CNA D walked through the urine on the resident's floor and CNA A placed the fall mat over the urine on the floor beside the resident's bed. CNA A and CNA D did not clean the seat of the resident's Broda chair; - CNA D did not provide any peri care to the front perineal folds, did not separate and clean all the perineal folds and did not clean all areas of the skin where urine or fecal material had touched. During an interview on 5/8/24 at 2:38 P.M., CNA A said: - Should separate all the skin folds and clean all areas of the skin where urine or feces had touched; - Should have cleaned the front perineal folds; - Should not have used the brief after it had fallen on the floor; - He/she should have clean the seat of the resident's Broda chair and cleaned the urine from the floor before placing the fall mat on the floor. During an interview on 5/9/24 at 10:29 A.M., CNA D said: - He/she should have separated and cleaned all the perineal folds, especially where the urine had touched; - He/she should have cleaned the front perineal folds; - We should not have used the clean incontinent brief after it had fallen on the floor; - Should have cleaned the urine from the floor and the seat of the resident's Broda chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility staff failed to assure staff used proper techniques to reduce the possibility of accidents and injuries during the use of a gait belt transfer (a safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) for one of 17 sampled residents, (Resident #9) and properly transfer two residents (Residents #21 and #4 ) in a manner to prevent accidents. The facility census was 66. Review of the facility provided policy, Accidents, dated 1/30/24 showed: -The facility must ensure that each resident receives adequate supervision and use of assistance devices to prevent accidents. -All staff will commit to and promote safety. Review of the facility policy, Safe Resident Handling/Transfers, dated 2021 showed: -It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote safe, secure and comfortable experience for the resident while keeping the employees safe accordance with current standards and guidelines. -All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. -Mechanical lifting equipment or other approved transferring aides will be used based on the resident's needs to prevent manual lifting except in medical emergencies. -Handling aids may include gait belt, transfer boards, and other devices. -Resident lifting and transferring will be performed according to the resident's individual care plan. -Two staff members must be utilized when transferring residents with a mechanical lift. 1. Review of Resident #21's Annual MDS dated [DATE] showed: - No cognitive deficits -Partial assistance from staff for ADL's. -Partial to moderate assistance for standing and transfers. -Touch assist for ambulation (walking) -Occasional incontinence of urine and bowel. -Diagnoses of Transient Ischemic Cerebral Attack (a brief blockage of blood flow to the brain), difficulty in walking, dizziness, low back pain, chronic fatigue syndrome, atrial fibrillation, arthritis. -Review of the resident's comprehensive Care Plan dated 3/21/24 showed: -The resident was extensive assistance of one staff with bed mobility, transfers, locomotion on unit, dressing and toileting. -The resident was incontinent of bowel and bladder occasionally. -Provide assistance with toileting every two hours and as needed. -Check incontinence pads frequently and change as needed. -The resident was at risk for falls -Provide individualized toileting interventions based on needs/patterns. Observation and Interview on 5/07/24 at 3:47 P.M. showed: -Resident #21's call light was on, Certified Nurse Aide (CNA) E entered the room, and resident reported he/she needed to use the restroom. -CNA E raised the resident's mechanical lift chair to a partially standing position. -CNA E placed his/her forearms under the resident's armpit, lifting and pulling the resident into a standing position. CNA E then pivoted the resident around and assisted him/her to sit into a wheelchair. -CNA E took the resident into the bathroom, and again placed his/her forearms underneath the resident's armpits, applying pressure and lifting the resident to a standing position then onto the toilet. -The resident used the toilet and requested assistance to go back to his/her recliner. -CNA E placed his/her forearms underneath the resident's armpits, applying pressure and lifting the resident to a standing position then into the wheelchair. -CNA A assisted the resident to the side of the mechanical lift chair. He/she then placed his/her forearms under the resident's armpits lifting and pulling on the resident, standing the resident up and pivoting the resident into the mechanical chair. -The resident then lowered the mechanical chair into a reclined position, CNA E said he/she would get the resident for the evening meal and left the room. -Resident #21 said the transfer did not hurt his/her arms or chest today. There are times when staff do not use a gaitbelt and it pulls his/her pacemaker and that hurts a lot. Sometimes staff twist his/her skin when they do not use a gaitbelt and that hurts. 2. Review of Resident #4's Annual MDS dated [DATE] showed: -Significant cognitive deficits. -Impaired movement on one side of the body, right side. -Substantial to maximum assistance of staff for ADL's. -Frequently incontinent of bowel and bladder. -Diagnoses of spastic quadriplegic cerebral palsy (a disorder of posture and movement that effects the entire body), need for assistance with personal care, major depressive disorder (a persistently low or depressed mood), contractures (a fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement), pain. Review of the resident's comprehensive Care Plan dated 2/15/24 showed: -Limited range of motion, contractures. -At risk for falls. -1 assist with transfers. -Wears a gait belt to assist with transfers/ambulation. -He/she tends to lean to one side, use a gait belt to help distribute weight. Observation on 5/06/24 at 12:12 P.M. showed: -The resident was sitting at the dining room table, eating the noon meal, leaning to his/her left side, with left forearm/elbow on the arm of the chair. -CNA E was standing at the resident's left side. -CNA E placed his/her left forearm under the resident's left armpit, pulled up and to the left, dragging the resident to the left side of the chair and pushing his/her upper body to the right, sitting the resident upright. -The resident grunted loudly. -CNA E then went to the right side of the resident, sat in a chair, and assisted the resident with his/her meal. During an interview on 5/14/24 at 4:55 P.M. CNA E said: -Gait belts or mechanical lifts should be used to move residents, depending on the resident's needs. -For resident #21 and #4 he/she would use a gait belt. -Gait belts are sometimes available on the linen cart, but not always available. -Some staff have their own gait belt, he/she does not. -He/She should not pull on a resident's arms or pants to adjust position. -He/She tried to hurry to get things done and didn't take the time to put a gait belt on. 3. Review of Resident #9's Quarterly MDS, dated [DATE], showed: - Cognitive skills severely impaired; - Required substantial to maximal assistance with showers, transfers, and toilet use; - Always incontinent of bowel and bladder; - Diagnoses included non traumatic brain dysfunction (causes damage to the brain by internal factors, such as a lack of oxygen, exposure to toxins, or pressure from a tumor), congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), anxiety, depression, Alzheimer's disease ( brain disorder that slowly destroys memory and thinking skills and the ability to carry out the simplest tasks), and psychotic disorder (a mental disorder characterized by a disconnection from reality). Review of the resident's care plan, dated 3/13/24 showed: - The resident required assistance with activities of daily living (ADL's) due to weakness, decreased cognition related to Alzheimer's disease; - Transfers: mechanical lift with two person assistance, manual wheelchair for mobility; - Provide extensive assistance for bed mobility, transfers, locomotion on the unit and off the unit, dressing, toileting, and personal hygiene. The resident is not able to walk; - The resident does not walk and can propel self in wheel chair for short distances. He/she is assist of one staff for transfers and toilet use and assist of two staff at times. Observation on 5/7/24 at 9:41 A.M., showed: - The resident was in the assist dining room in his/her Broda chair (a type of reclining geri chair) leaning to the left side with a puddle of urine under his/her Broda chair; - CNA A took the resident to his/her room; - CNA A and CNA D did not wash their hands and applied gloves; - CNA A placed the gait belt around the resident's breasts; - CNA A and CNA D reached under the side of the resident's arms and grabbed the side of the gait belt with one hand and used their other hand and held onto the resident's arm; - When CNA A and CNA D lifted the resident up, the gait belt slid up in the back between the resident's shoulder blades and they transferred him/her to the side of the bed and removed the gait belt and provided incontinent care. During an interview on 5/8/24 at 2:38 P.M., CNA A said: - He/she placed the gait belt under the resident's breasts; - He/she should have placed one hand on the front of the gait belt and the other hand on the back of the gait belt; - The gait belt should not have slid up in the back. During an interview on 5/9/24 at 10:29 A.M., CNA D said: - The gait belt should be placed around the resident's waist under their breasts; - The gait belt should not slide up in the back; - She normally reaches under the resident's arm and grabs the side of the gait belt and uses his/her other hand to grab the back of the gait belt. During an interview on 5/9/24 at 3:12 P.M., the Administrator and the Director of Nursing (DON) said: - The DON thought the gait belt should be place under the resident's arm pit. The Administrator said it should be place below the resident's waist; - Staff should not grab a hold of the resident's arms during the transfer; - The gait belt should not slide up in the back. -Gait belt should be used to reposition residents. -Staff should never pull on a resident's arms/shoulders. -He/she is working with Therapy Director to provide education to staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure staff maintained the hydration status for three of the 17 sampled residents, (Resident #2, #8 and #56), and all residents who attended the group meeting, when staff did not pass fresh ice water to the residents. The facility census was 66. Review of the facility's policy for assisted nutrition and hydration, dated 1/30/24 showed, in part: - The purpose is to ensure each resident maintains, to the extent possible, acceptable parameters of nutritional and hydration status and the facility provides nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment; - Based on a resident's comprehensive assessment, the facility must ensure that each resident is offered sufficient fluid intake to maintain proper hydration and health. 1. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/3/24 showed: - Cognitive skills intact; - Required set up and clean up with eating; - Independent with oral care; - Diagnoses included seizure disorder, depression, and coronary artery disease, (CAD, damage or disease in the heart's major blood vessels). Review of the resident's care plan, dated 3/4/24 showed; - The resident attended activities that he/she enjoyed with encouragement from the staff. Encourage the resident to drink fluids and have a snack during activities; - The resident is at risk for skin breakdown related to lymphedema (caused by a blockage in the lymphatic system causing swelling that generally occurs in an arm or leg) to both lower extremities. Encourage fluids every shift and at meal time; - The resident was at risk for constipation related to psychotropic and Opioid medication use. Encourage fluids every shift and at meal time. Review of the resident's physician order sheet (POS), dated May, 2024 showed: - Start date: 1/9/2024 - regular diet. Observation and interview on 5/6/24 at 11:14 A.M., showed: - The resident said the staff rarely pass fresh ice water each shift; - He/she did not think they had enough staff to pass fresh ice water every shift; - He/she would like to have fresh ice water each shift; - The resident's water pitcher was less than half full and did not have any ice in it; - The resident said it was from yesterday. 2. Review of Resident #8's care plan, revised 12/19/23 showed: - The resident was at risk for constipation related to psychotropic and Opioid medication use. Encourage fluids and high fiber food unless contraindicated; - The resident was at risk for pressure ulcers related to bedfast status and incontinent episodes. Encourage adequate fluid intake daily. Review of the resident's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Lower extremity impaired on one side; - Set up and clean up with eating and oral hygiene; - Diagnoses included anxiety, depression and anemia (a condition in which the blood doesn't have enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). Review of the resident's POS, dated May, 2024 showed: - Start date: 1/9/2024 - regular diet. Observation and interview on 5/6/24 at 1:02 P.M., showed: - The resident said the staff do not pass fresh ice water every shift; - The resident's water pitcher did not have any ice in it and he/she did not know how long it had been there. 3. Review of Resident #56's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Required set up and clean up with eating; - Independent with oral hygiene; - Diagnoses included cancer, anxiety, depression, pneumonia (an infection that affects one or both lungs), anxiety, respiratory failure ( a serious condition that makes it difficult to breathe on your own) and chronic obstructive pulmonary disease (COPD. obstruction of air flow that interferes with normal breathing). Review of the resident's care plan, revised 2/27/24 showed: - The resident attended activities that he/she enjoyed with encouragement from the staff. Encourage the resident to drink fluids and have a snack during activities. Review of the resident's POS, dated May, 2024 showed: - Start date: 1/9/24 - regular diet. Observation and interview on 5/6/24 at 10:42 A.M., showed: - The resident said the staff do not pass fresh ice water every shift; - He/she currently had a water pitcher without a lid on it and said it had been sitting there since yesterday; - The water pitcher was less than half full and did not have any ice in it. 4. During a group interview on 5/7/24 at 1:32 P.M., the residents said: - Two residents said he/she had to ask for fresh ice water; - One resident said facility staff did not pass water at all. During an interview on 5/8/24 at 2:06 P.M., Certified Medication Technician (CMT) B said: - Ice water does not get passed every day because there's not enough staff; - Usually only pass fresh ice water if a resident asks for it. During an interview on 5/8/24 at 2:38 P.M., Certified Nurse Aide (CNA) A said: - Fresh ice water does not get passed every shift. During an interview on 5/9/23 at 3:12 P.M., the Administrator and the Director of Nursing (DON) said: - Staff should be passing fresh ice water every shift and sometimes twice a shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to assure staff provided proper respiratory care for residents, when staff failed to ensure the oxygen concentrator had humidified sterile water which affected two of 17 sampled residents, (Resident #7 and #56), failed to properly clean the oxygen concentrator filter for Resident #56, and additionally failed to date oxygen/ nebulizer tubing for Resident #7 and #56. The facility census was 66. The facility did not provide a policy for respiratory care. 1. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/1/24 showed: - Cognitive skills moderately impaired; - Upper extremities impaired on both sides; - Dependent on staff for personal hygiene, - Diagnoses included traumatic brain injury (TBI, happens when a sudden, external, physical assault damages the brain), chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's care plan, dated 3/13/24 showed: - The resident is at risk for decrease oxygen related to diagnosis of COPD; - Administer medications and oxygen as ordered and monitor for any changes; - Check oxygen saturation (amount of oxygen in the blood) as ordered and as needed; - Oxygen at two liters per nasal cannula (2L/NC) as needed for shortness of breath to keep saturation above 92%. Review of the physician's order sheet (POS) dated May, 2024 showed: - Start date: 10/6/23 - oxygen at 3L/NC as needed for shortness of breath. Observation on 5/6/24 at 10:32 A.M., showed: - The resident had oxygen on at 2L/NC; - The oxygen tubing was not dated; - The humidified water bottle was empty. 2. Review of Resident #56's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Independent with toilet use, showers, dressing, personal hygiene, and transfers; - Diagnoses included cancer, pneumonia (an infection that affects one or both lungs), anxiety, depression, respiratory failure ( a serious condition that makes it difficult to breathe on your own) and COPD. Review of the resident's care plan, dated 2/27/24 showed: - Resident has a diagnosis of COPD and acute or chronic respiratory failure, emphysema ( a disorder that affects the tiny air sacs of the lungs) and shortness of breath and is at risk for decreased oxygen; - Administer oxygen and medication as ordered and monitor for any changes; - Nebulizer treatments and inhalers for wheezing as per orders. Review of the resident's POS dated May, 2024 showed: - Order date: 2/29/24 - Change nebulizer tubing monthly on the first of the month; - Order date: 2/29/24 - Change oxygen tubing monthly on the first of the month; - Order date: 2/29/24 - Oxygen 2L/NC as needed for shortness of breath. Observation and interview on 5/6/24 at 10:49 A.M., showed: - The resident stated he/she had pneumonia twice; - The humidified water bottle was empty; - The oxygen tubing was not dated and was laying on the floor; - The filter was covered in gray lint; - The nebulizer tubing and mask was dated 4/4/24. During an interview on 5/8/24 at 2:38 P.M., Certified Nurse Aide (CNA) A said: - He/she knew the oxygen tubing and nebulizer tubing should be changed but did not know when or how often; - He/she knew the tubing should be dated and placed in a zip lock bag and should not be on the floor. During an interview on 5/9/24 at 9:55 A.M., Licensed Practical Nurse (LPN) B said: - He/she thought the oxygen and nebulizer tubing was changed weekly but it might be monthly; - The tubing should be dated when changed; - The filters on the oxygen concentrators should be cleaned but he/she did not know how or when; - There should be distilled water in the humidified water bottle; - The oxygen tubing should not be on the floor and if it was on the floor it should not be used. During an interview on 5/9/24 at 3:12 P.M., the Administrator and the Director of Nursing (DON) said: - The oxygen and nebulizer tubing should be changed weekly unless it needed to changed earlier; - The oxygen and nebulizer tubing should be dated and initialed when changed; - The filters on the oxygen concentrator should be cleaned; - The oxygen and nebulizer tubing should not be on the floor, they should be placed in a bag; - There should be distilled water in the humidified water bottles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the residents size and weight, failed to complete side rail assessments, and failed to obtain a physician's order prior to installation for five of seventeen sampled residents (Resident #45, #216, #14, #1, and #162). The facility census was 66. Facility did not provide a policy on side rails. Review of facility policy, Bed and Bed Rail Maintenance to Reduce/Prevent Entrapment, dated [DATE], showed: -Ensure that facility beds meet FDA guidance to reduce/prevent resident entrapment. The facility will only utilize beds and bed rails that meet this guidance. -Facility will assess the bed and bed rails for each resident and document such assessment prior to the use of bed rails for every resident. If resident uses a different bed or when bed rails are added, the assessment and subsequent documentation must be repeated. -There are seven areas in a bed system where there is potential for entrapment: -Zone 1: Within the Rail; -Zone 2: Under the Rail, between the rail supports or next to a single rail support -Zone 3: Between the rail and the mattress -Zone 4: Under the Rail, at the ends of the rail -Zone 5: Between split bed rails; -Zone 6: Between the end of the rail and the side edge of the head or foot board; -Zone 7: Between the head or foot board and the mattress end. Review of facility's Accident policy, dated [DATE], showed: -The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. -Evaluating and analyzing hazards and risks. -Implementing interventions to reduce hazards and risks -Monitoring for effectiveness and modifying interventions when necessary. -Individualized, person-centered interventions will be implemented, including adequate supervision and assistive devices, to reduce risks related to hazards in the environment. -Monitoring for effectiveness and modification of interventions, when necessary, will be implemented. 1. Review of Resident #45's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], showed: -Resident was cognitively intact; -He/She had clear speech, was able to make self-understood, and understand others; -He/She had impairment on one side; -He/She was dependent on walker and wheelchair for mobility; -He/She required setup or clean-up assistance eating -He/She required substantial/maximal assistance for showers, lower body dressing, sitting to standing, sit to lying, chair to bed transfer, toilet transfer, -He/She required partial/moderate assistance with personal hygiene and rolling left and right. -Diagnoses included aftercare after joint replacement surgery, arthritis, and anxiety disorder. Review of care plan, dated [DATE], showed: -Resident was able to move self some in bed but required staff assistance with transfers and bed mobility. Staff to assist him/her with repositioning in bed. He/She had a pressure reducing mattress on his/her bed and a cushion in his/her wheelchair. -Care plan did not include use of bed rails Review of physician's orders dated [DATE] to [DATE] showed: -Order started [DATE], Bed rail to assist with getting out of bed and turning unassisted. Review of side rail assessment completed [DATE] at 1:07 P.M. showed: -Implemented for bed mobility; -Resident had expressed desire to have side rails; -Quarter rail will be used to assist in positioning and transfers - Side of rail was not indicated. -Use of side rail during day and night; -Additional interventions: provide frequent staff monitoring at night, visual and verbal reminders to use call light. -Entrapment zones not filled out on the assessment. Review of electronic medical record, dated [DATE], at 12:06 P.M. showed new orders received from the physician for bed rail. To assist resident with getting out of bed and turning unassisted. Observation on [DATE] at 1:00 P.M. showed resident had side rails on left side of bed only. During an interview on [DATE] at 1:00 P.M., The resident said they had the side rail put on to help him/her turn in bed. He/She slept in recliner now because of swelling in his/her legs and had not used bed since railing was put on. During an interview on [DATE] at 2:25 P.M., Certified Medication Technician (CMT) B said: -Resident had a side rail because he/she requested one. During an interview on [DATE] at 2:38 P.M., Certified Nurse Aide (CNA) A said: -Not sure why resident had side rails; -Resident did not sleep in bed, he/she slept in his/her recliner. 2. Review of Resident #216's face sheet showed: -Resident admitted to facility on [DATE] -Diagnoses included: neurocognitive disorder with lewy bodies (a type of progressive dementia that leads to decline in thinking, reasoning, and independent function), generalized osteoarthritis (a condition in which three or more joint groups are affected when cartilage that cushions end of bones deteriorates), and chronic pain syndrome. Review of care plan, dated [DATE], showed: -Side rails not care planned. Review of baseline care plan, dated [DATE], showed: -Bed mobility, transfers, toileting, showed assist of two -Safety concerns included balance and gait unsteady, muscle weakness, fatigue/endurance concerns; -He/She used mechanical lift for transfers; -Bed should be in lowest position; Review of physician's orders, dated [DATE] to [DATE], showed: -No orders for side rails. Review of electronic medical record for the month of April., showed: -No side rail or entrapment assessment completed. Observation on [DATE] at 10:03 A.M. showed resident had side rail on both sides of bed. Observation on [DATE] at 12:06 P.M. showed both resident's side rails were up. resident's bed was not lowered to ground. Observation on [DATE] at 1:29 P.M. showed resident's side rails were up. resident's bed was not lowered to ground. During an interview on [DATE] at 2:25 P.M., CMT B said: -Resident had side rails so he/she did not slide around in his/her bed. During an interview on [DATE] at 2:38 P.M., CNA A said: -Resident had side rails because he/she leans more to right side and would probably fall if side rails were not in place; -He/She had not had falls since coming to facility that he/she was aware of. 3. Review of Resident #14's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and had clear comprehension of others; -He/She was dependent on wheelchair; -He/She had impairment to both sides of upper and lower extremity range of motion; -He/She was dependent on staff for eating, oral care, toileting, bathing, lower body dressing, personal hygiene, rolling left and right, lying to sitting, sitting to stand, chair to bed transfers, and shower transfers. -He/She had no falls since admission; -Diagnoses included paraplegia, quadriplegia, post traumatic stress disorder, chronic pain due to trauma. Review of care plan, dated [DATE], showed: -Provide assistance with bed mobility every 2-3 hours; -He/She was at risk for falling due to quadriplegic; -Keep bed in lowest position with brakes locked; -Keep personal items and frequently used items within reach -Keep call light in reach at all times; -Side rails not care planned. Review of physician's orders, dated -No order for side rails. Review of electronic medical record showed: -No side rail assessment. During an interview on [DATE] at 11:02 A.M., Resident #14 said: -He/She had side rails to help him/her turn; -He/She had nerve damage from neuropathy (sensation of burning pain or loss of feeling in extremities). During an interview on [DATE] at 2:25 P.M., CMT B said: -Resident requested side rails so he/she could move themselves. During an interview on [DATE] at 2:38 P.M., CNA A said: -Resident requested side rails when he/she first moved into facility. Review of Resident #1 Quarterly MDS dated [DATE] showed: - Indicated severe cognitive loss. -Dependent on staff for ADL's and mobility. -Urinary catheter (a tube inserted into the bladder used to drain urine) -Always incontinent of bowel. - Diagnoses of quadriplegia (paralysis of all four limbs) , hypertension (high blood pressure) , seizures (a sudden, uncontrolled burst of electrical activity in the brain, that can cause changes in behavior, movements, feelings and levels of consciousness), intellectual disability (a term used when there are limits to a person's ability to learn at an expected level and function in daily life) , anxiety (a feeling of fear, dread, and uneasiness) contractures ( fixed tightening of muscle, tendons, ligaments, or skin. It prevents normal movement) and hydronephrosis (kidney swelling the does not allow the urine to drain). Review of the resident's comprehensive Care Plan dated [DATE] showed: -Side rails up in use with pads in place for safety/seizure precaution. Review of the resident's skilled note assessment, dated [DATE] showed: -He/She was dependent on staff assistance for mobility Review of the resident's Physician Orders for [DATE] showed: -No order for side rails. Review of the resident's electronic medical record showed: -No assessment for use of side rails -No entrapment assessment or measurements completed. Observation on [DATE] at 10:04 AM showed: -He/she was in bed , leaning to the right side. -His/Her air mattress set to firm. -Bed in low position -Full side rail on right side of bed, in the low position, no padding on rail. Observation on [DATE] at 10:38 A.M. showed: -The resident had a full side rail in the raised position, on the right side of the bed, without any padding, -His/Her bed was in low position. -An air mattress was on the bed. -He/She was in bed leaning to the right side During an interview on [DATE] at 2:32 PM CMT B said: -The resident has a side rail on one side of the bed. -He/She is not sure why the resident has the rail. Review of Resident # 162 Annual MDS dated [DATE] showed: -He/she admitted on [DATE] -Cognition not intact -Dependent on staff for completion of ADL's -Indwelling urinary catheter (tube inserted into the bladder to drain urine) -Frequently incontinent of bowel -Hospice services -Use of oxygen (O2) -Review of the comprehensive care plan [DATE] showed: -The resident was a do not resuscitate (DNR: a directive to withhold Cardiopulmonary Resuscitation (CPR) if the resident is found deceased ) -No care plan to address need for assistance with ADL's, or use of side rails. Review of the resident's electronic medical record showed: -A neurological assessment completed 4/30 with nursing note of unwitnessed fall. -No progress note about a fall. no indication side rails were in use. -Physician orders showed no order for use of side rails. -No side rail assessment or entrapment risk assessment. Observation and interview on [DATE] at 2:31 PM showed: -Half side rails on both sides of the bed, in the up position. -The resident said he/she had the rails because of a fall from the bed. Observation on [DATE] at 9:10 AM showed: -Half side rails on both sides of the bed, in the up position. During an interview on [DATE] at 2:33 PM CMT B said: -He/She thought Hospice brought that bed to the resident. -He/she does not know why the resident has bed rails. During an interview on [DATE] at 9:21 A.M., Maintenance Supervisor said: -He/she did install bedrails; -He/She did not know who authorized bed rails in facility; -He/She did not do any assessments or measurements of side rails; -He/She put side rails on if there was a physician's order on; -He/She made sure side rails were installed good and tight; -He/She would check side rails if he got around to it or was in the area; -He/She did not keep track of side rails or log details of side rails; -He/She did not do any measurements of the bed frames or mattresses; -He/She did not check for entrapment but made sure side rails were on good. During an interview on [DATE] at 3:12 P.M., Administrator said: -He/She felt therapy and nursing should work together to decide when side rails are put on, it was a joint effort; -The nurse does side rail assessment in computer; -Side rail assessments are located in electronic medical record under assessments; -Side rail assessments should be completed upon admission; -There are multiple kinds of side rails used in the building; -Side rail checks are completed by nursing staff; -He/She thinks part of side rail assessment asked for measurements; -Right now there is nobody in facility that is doing bed measurements, measurements of gaps in the mattress or bed frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, the facility failed to provide sufficient nursing staff to meet the resident needs for six of the 17 residents. When staff failed to timely answer resident call lights, failed to provide assistance for one resident to use the bathroom (Resident #21 ), failed to reposition one resident (Resident #57), failed to provide feeding assistance to one resident (Resident #216), failed to have nursing staff available to speak with family (Resident #216), and failed to provide showers twice a week for three residents (Resident #50, #39, #45) of the 17 sampled residents. The facility census was 66. The facility did not provide a policy regarding staffing. Review of facility policy, resident rights, dated 1/3/24, showed: -The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance and enhancement of his/her quality of life and recognizes each resident's individuality. -Resident has a right to live in facility and receive services with reasonable accommodation of needs and preferences except when to do so would endanger the health and safety of the resident or other residents. 1. During a group interview on 5/07/24 at 1:32 PM, The residents said: -Showers are sometimes far and in between; -There had been ten days between some showers and longer; -The facility often ran out of towels, which meant showers would not be completed; -The facility was understaffed; -Weekends were often short of staff; -Call lights could be longer, depending on staffing -On weekends there were longer call light wait times; -They had to ask for fresh ice water, or staff did not pass water at all. 2. Review of Resident #21's Annual MDS dated [DATE] showed: -He/She was cognitively intact; -Partial assistance from staff for ADL's; -Partial to moderate assistance for standing and transfers; -Touch assist for ambulation (walking); -Occasional incontinence of urine and bowel; -Diagnoses of Transient Ischemic Cerebral Attack (a brief blockage of blood flow to the brain), difficulty in walking, dizziness, low back pain, chronic fatigue syndrome, atrial fibrillation, arthritis. Review of care plan, dated 2/5/24, showed: -The resident is incontinent of bowel and bladder occasionally: -Provide assistance with toileting every two hours and as needed; -Check incontinence pads frequently and change as needed. -Resident is at risk for falls due to related to history of falls and unsteady gait. During an interview on 5/6/24 at 2:49 P.M., resident said: -He/She sometimes had to wait an hour or more for his/her call light to be answered; -Weekends are worse with call light response. Observation on 5/7/24 at 3:28 P.M. showed resident's call light was already on, and was answered by Certified Nurse Aide (CNA) E at 3:46 P.M., eighteen minutes after observation started. During an interview on 5/7/24 at 3:47 P.M., Resident said: -Call light was on quite a while, I saw my clock said 3:02 P.M. when I turned it on; -He/She needed to go to the bathroom; -He/She did not make it to the bathroom in time -He/She was embarrassed; -Staff rarely come right away. During an interview on 5/07/24 at 4:00 P.M. CNA E said: -He/she tried to answer the call light quickly. -He/she answered as quickly as he/she could, but he/she was busy with another resident. -There is not enough help to answer the call lights immediately. . Review of Resident #45's admission MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood, and understand others; -He/She had impairment on one side; -He/She was dependent on walker and wheelchair for mobility; -He/She required substantial/maximal assistance for showers; -Diagnoses included aftercare after joint replacement surgery and arthritis. Review of care plan, dated 5/1/24, showed -Resident was alert and able to communicate his/her needs. -Encourage him/her to call for assistance with his/her ADL care; -Resident required assistance of staff with his/her bathing needs; -Resident admitted with a hip fracture and was on therapy services. He/She required assistance with mobility of ambulation with a walker and does use a wheelchair for longer distances; -Care plan did not specify resident's shower preferences. Review of baseline care plan, dated 4/8/24, showed: -He/She required assistance of one staff for bathing; -Assist with ADL care as needed to promote health, hygiene, and safety; -He/She was sometimes incontinent of bowel; -He/She was always incontinent of bladder. During an interview on 5/6/24 at 12:49 P.M. Resident said: -He/she had his/her last shower over a week ago on 4/30/24; -He/She preferred to have a shower twice a week; -His/Her shower days were supposed to be on Tuesday and Fridays. Review of shower logs from April 8, 2024 to May 8, 2024 showed: -He/She had two documented showers one on 4/30/24 and on 5/7/24. During an interview on 5/8/24 at 2:38 P.M., CNA A said: -Shower aide is often pulled to help cover the floor, and did not do showers; -The shower aide worked overnight on 5/7/24 so showers were not getting completed on 5/8/24. 3. Review of Resident #50's Quarterly MDS, dated [DATE] showed: -He/She was cognitively intact; -He/She had impairment on one side of body in upper and lower extremities; -He/She was dependent on wheelchair for mobility; -He/She was dependent for bathing assistance, toileting, upper and lower body dressing; -He/She required substantial/maximal assistance for personal hygiene and mobility; -Diagnoses included stroke, weakness, lack of coordination, difficulty in walking, and need for assistance with personal care. Review of care plan, dated 3/13/24, showed: -Resident required assistance with most activities of daily living due to hemiplegia affecting left dominant side due to status post cerebral vascular accident. -Provide extensive assistance by two staff with personal hygiene, dressing, toileting, bed mobility, and transfers; -Shower preferences not care planned. During an interview on 5/6/24 at 10:31 A.M. Resident said: -He/She had not had a shower in quite awhile because the facility did not have any towels; -His/Her last shower was on a Thursday maybe towards end of March; -He/She would like to have showers two times a week; -Therapy staff gave him/her one of his/her last showers; -He/She had not had any bed baths. Review of shower logs from February 1, 2024 to May 8, 2024 showed: -He/She had sixteen of twenty-eight opportunities for showers; -He/She had showers provided on 2/3, 2/7, 2/10, 2/15, 2/21, 2/28, 3/2, 3/7, 3/9, 3/13, 3/20, 4/1, 4/3, 4/9, 4/15, and 4/19; -His/Her last documented shower was two and half weeks ago. 4. Review of Resident #39's quarterly MDS, dated [DATE], showed: -He/She had mildly impaired cognition; -He/She had clear speech, was usually able to make self-understood and usually understand others; -He/She had impairment to upper and lower extremities on one side causing limited range of motion; -He/She was dependent on a wheelchair for mobility; -He/She required set up or clean up assistance with bathing; -Diagnoses included: stroke, aphasia (disorder that occurs from damage to brain after a stroke that affects ability to communicate), hemiparesis (one sided muscle weakness). Review of care plan, dated 4/24/24, showed: -Resident was limited to transfer self due to right side weakness from stroke; -He/She will transfer with assistance; -He/She was at risk for falls due to weakness on one side related to stroke; -He/She will be free from serious injuries related to falls; -He/She will bathe with assistance; -He/She had impaired vision due to glaucoma; -He/She was at risk for impaired skin integrity and pressure ulcer development due to decreased mobility and incontinent episodes; -Showers and bathes at least twice a week or as requested; -Turn and reposition at least every two hours and PRN when in bed; -Shower preferences not care planned. During an interview on 5/7/24 at 7:45 A.M., Resident #39 said: -He/She did not think facility had enough staff because it took a long time to answer call lights, showers did not get done, and facility did not pass fresh ice water every shift. -He/She said it can take up to five days to get laundry back, and that was not often enough; -Second shift was not good about answering call lights; -He/She had to wait over thirty minutes multiple times to get his/her call light answered; -He/She had waited 1-1.5 hours at least three times in a week for his/her call light to get answered; -He/She received a shower only one time every two weeks which made him/her feel dirty. Review of shower logs, February 1, 2024 to May 8, 2024, showed: -Resident was provided 10 opportunities of 27 scheduled shower days; -He/She had received 8 out of 27 scheduled shower dates on 2/5, 2/13, 2/26, 2/29, 3/11, 3/14, 3/25, and 3/28 -He/She had refused 2 showers on 3/18 and 3/21 5. Review of Resident #216's face sheet showed: -Resident admitted to facility on 4/22/24 -Diagnoses included: neurocognitive disorder with lewy bodies (a type of progressive dementia that leads to decline in thinking, reasoning, and independent function), generalized osteoarthritis (a condition in which three or more joint groups are affected when cartilage that cushions end of bones deteriorates), and chronic pain syndrome. Review of MDS showed resident did not have MDS completed. Review of care plan, dated 5/8/24, showed: -Resident had one goal regarding full code status. Review of baseline care plan, dated 4/22/24, showed: -He/She had confused cognition status; -He/She required assist of two staff for bed mobility, transfers, bathing, locomotion, and toileting; -He/She had safety concerns regarding balance and gait, muscle weakness, and fatigue; -He/She required assist of one staff with eating; -He/She displayed aggression, agitation, and crying; Observation on 5/7/24 at 10:35 A.M. showed food was sitting at beside bed, cover had not been removed, food was cold. Observation on 5/8/24 at 8:39 A.M. showed resident's breakfast was sat on table in front of her, food was covered, resident was not assisted to eat breakfast. Observation on 5/8/24 at 9:32 A.M. showed resident's breakfast was on bedside table in front of her, no staff had assisted him/her to eat breakfast. During an interview on 5/7/24 at 10:56 A.M., The resident's representative said: -Facility did not make attempts to feed resident; -Resident's sister had been going to facility to ensure resident had been fed; -Receptionist told him/her on the phone that there was not a nurse available to talk to him/her on the phone because the nurse was busy and facility was short staffed when he/she called to speak to facility nurse regarding his/her mother. During an interview on 5/8/24 at 2:25 P.M., CMT B said: -Resident did not feed herself; -Most days sister was at facility to feed resident; -Facility did not have enough staff to get resident assistance to eat. During an interview on 5/8/24 at 2:38 P.M., CNA A said: -Resident needed assistance with eating; -Resident's son or sister come in to assist resident with eating. 6. During an interview on 5/8/24 at 2:25 P.M., Certified Medication Technician (CMT) B said: -Ice water did not get passed every day because of staffing; -There was not enough staff to meet the resident's needs; -Today there is one nurse aide, one Certified Nurse Aide (CNA), and myself working; -Showers did not get done because the shower aide worked last night; -Activity of Daily Living charting rarely gets done due to staffing; -He/She did not get to document residents meal intake at meals due to staffing; -There was not enough staff to assist all residents that choose to eat in their rooms; -Three residents did not get served their meal trays served last night. During an interview on 5/8/24 at 2:38 P.M., Certified Nurse Aide (CNA) A said: -Facility did not have enough staff; -He/She had not been able to work in his/her official position as staffing coordinator due to staffing so mostly worked the floor; -Showers do not get done due to staffing; -He/She had to pull staffing aide to cover shifts; -When a nurse aide is working he/she had them pass ice water, but ice water is not always passed; -Staff have to wait for laundry staff to get to the building to do the laundry in order to have supplies needed for showers and other cares; -He/She had transferred patients using gait belt and the mechanical lift by him/herself more often than not due to staffing; -It was hard to get residents repositioned due to staffing. During an interview on 5/9/24 at 9:55 A.M., Licensed Practical Nurse (LPN) B said: -When facility was short staffed it was hard to get showers done; -He/She does not feel have enough staff to meet resident needs; -He/She had a hard time completing treatments, getting showers done, passing fresh ice water, turning, repositioning the residents, call lights will take awhile to get answered; -It may take longer to give pain medications when short staffed. During an interview on 5/9/24 at 10:17 A.M., Dietary Manager said: -He/She was made aware that residents were missed for their meal on 5/7/24's meal due to trays being given to the wrong resident or were lost. -There was a lot of turn over off facility staff. New staff were not aware of the new residents. It was more of a training and orientation issue with staff. During an interview on 5/9/24 at 10:29 A.M., CNA D said: -There was not enough staff; -He/She got pulled from working as a shower aide to cover the floor a lot; -It took longer around lunch time to get call lights answered due to staffing; -Laundry staff come in to work at 11:00 A.M., he/she started showers at 5:00 A.M. and was often out of towels by 10:00 A.M. so he/she cannot continue showers until approximately 1:00 P.M. During an interview on 5/9/24 at 3:12 P.M., Director of Nursing said: -The facility did not even have close to enough staff to meet the resident's needs in the facility. -Timeliness of call lights is a result of being short staffed; -He/She had heard staff are lifting patients by themselves. 7. Review of Resident #57's Quarterly MDS dated [DATE] showed: -BIMS of 99, indicated significant cognitive deficit -Dependent on staff for ADL's. -Always incontinent of bowel and bladder. -Diagnoses of Intracerebral hemorrhage (bleeding into the brain), Aphasia (loss of ability to understand or express speech), hemiplegia (loss of the ability to move one side of the body). Diabetes Mellitus (a health condition that affects how your body turns food into energy), seizures (a condition where you have a temporary, unstoppable surge of electrical activity in your brain) Hypertension (high blood pressure) Review of Resident #57 Comprehensive Care Plan, dated 1/24/24 showed: -He/She needed assist of 1-2 staff with ADL's -Keep his/her call light within reach and answer in a timely manner. -Provide him/her adequate rest periods between activities. -During two hour checks and as needed (PRN: per resident need) please ask the resident if he/she needs any of his/her belongings moved closer so they are within reach. -Frequent checks at night, every one to two hours and prn. -He/she was at risk for pressure ulcers because of incontinent episodes of bowel/bladder. -He/She needs assist with bed mobility. -Keep him/her clean and dry as possible. -Minimize his/her skin exposure to moisture. -Turn and reposition him/her every two hours and PRN. -Encourage toileting before and after meals, before assisting to bed and prn. Continuous observation beginning on 5/08/24 at 5:39 A.M. showed: -The resident was taken to the dining /Activity room by staff. He/she was placed in front of the TV with cartoons on and lights off. - 7:26 A.M. the resident was taken to the dining table for breakfast and assisted with meal. - 9:03 AM he/she remained in the dining/ activity room; he/she was yelling out. MDS Coordinator entered the room and asked the resident if he/she was missing his/her friend. The MDS coordinator assured the resident his/her friend was missing him/her too and walked away. The resident was not offered or taken to the restroom, repositioned or offered food or drinks. - 9:08 AM staff entered the dining/activity room, laid the back of her Broda chair (a tilting, reclining, and wheeled chair) down. The resident was not offered or taken to the restroom, repositioned or offered food or drinks. -9:18 AM the resident was yelling out. LPN A asked the resident why he/she was yelling. The resident said he/she was tired. LPN A asked the resident if he/she wanted to lay down. Resident #57 replied yes. LPN A told the resident he/she would notify CNA staff. The resident began to cry. LPN A asked the resident why he/she was crying. The resident said staff would not come. LPN A asked the resident if he/she was crying because staff had not come to help; the resident responded yes. LPN A then walked away. The resident was not offered or taken to the restroom, repositioned or offered food or drinks. - 9:22 A.M. Nurse Aide C took the resident from the dining/activity room to his/her room. NA C pulled covers back then left room to obtain assistance. The resident was not offered or taken to the restroom, repositioned or offered food or drinks. -9:24 AM NA C returned the resident to the dining/activity room. -9:36 AM the resident remained in the Broda chair in the dining/activity room. NA C had the ice cart, stopped at the resident's chair and covered the resident with a blanket, and left. The resident closed his/her eyes and began snoring. The resident was not offered or taken to the restroom, repositioned or offered food or drinks. - 9:42 AM the resident was dozing off and on, snoring lightly then opening his/her eyes. -10:01 AM the Activity Director (AD) approached the resident, observed the resident with eyes closed, and walked away. The resident was not offered or taken to the restroom, repositioned or offered food or drinks. -10:10 AM Exercise group began in the activity/dining room. The resident remained in his/her Broda chair, reclined, with eyes closed. -10:54 AM staff moved the resident to a dining table. The resident was not offered or taken to the restroom, repositioned or offered food or drinks. During an interview on 05/08/24 at 10:33 A.M. NA C said residents should be moved, toileted, or cleaned up every two hours or as needed. There is not enough help to get everything done that needs to be done. He/she was not aware it had been over two hours that Resident #57 was changed or repositioned. During an interview on 5/9/24 at 3:12 P.M. Administrator said: -He/She did not have enough staff to meet the needs of residents in facility; -Due to staffing shortages there was issues with getting people up and down after meals, repositioning and turning residents, completing bed checks. -Facility had two dedicated shower aides but shower aide gets pulled to the floor to help cover and then showers did not get done; -He/She was aware of five residents who did not receive a meal tray on 5/7/24 due to issues getting people in the kitchen to do their job correctly; -Care plans have not been done because MDS Coordinator had been fired and nobody had been taught how to do them; -No staff currently completing discharge summaries; -He/She had been wearing so many hats he/she had not had time to sit down to train staff -He/She had busted numerous staff completing transfers by themselves or using hoyers by themselves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #34's physician order sheet for May 2024 showed: -Benzotropine 1 mg, give one tablet three times a day for movement disorder. Ordered 6/4/21. -Fluoxetine 20 mg give one capsule with a 40 mg capsule to equal 60 total mg daily for obsessive compulsive disorder (OCD: uncontrollable and recurring thoughts (obsessions), and repetitive behaviors (compulsions) ) Ordered 6/4/21. -Fluoxetine 40 mg give one capsule with one 20 mg capsule to equal 60 total mg daily for OCD. Ordered 6/4/21 -Hydroxizine 10 mg give one tablet daily for anxiety (a feeling of fear, dread and uneasiness). Ordered 6/4/21 -Risperidone 1 mg give one tablet twice a day for schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves.) Ordered 3/9/22 -Carbidopa/levodopa 25 mg/100 mg give one and one half tablets four times a day for Parkinson's disease (A disorder of the central nervous system that affects movement, often including tremors). Ordered 10/14/22 -Vitamin E 400 units give one tablet daily for supplement. Ordered 10/30/23 -Vitamin B 12 500 micrograms (mcg) give two tablets once a day for supplement. Ordered 6/26/21 During observation on 5/08/24 at 7:54 A.M. showed -CMT A removed resident #34's medications from the medication cart. -He/she sat a medication administration cup on top of the medication cart and began popping medication from bubble packs into the medication cup. -He/she popped Benzotropine 1 mg, one tablet, Fluoxetine 20 mg one capsule, Fluoxetine 40 mg one capsule, Hydroxizine 10 mg one tablet and Risperidone 1 mg, one tablet . -CMT A bumped the medication cup with his/her hand knocking it over, Fluoxetine 40 mg capsule fell to the floor, Risperidone 1 mg tablet fell to the floor and Hydroxizine 10 mg tablet fell on the top of the cart. -CMT A picked up the two medications from the floor and laid them on top of the medication cart with the tablet of Hydroxizine. -CMT A popped Carbidopa/levodopa 25 mg/100 mg one and one half tablets into the medication cup, poured Vitamin E 400 units one tablet from the resident specific bottle, into the medication cup and poured Vitamin B 12 500 (mcg) two tablets from the resident specific bottle into the medication cup. -With bare hands CMT A picked up the Fluoxetine 40 mg capsule ,Risperidone 1 mg tablet and Hydroxizine 10 mg tablet from the top of the cart and placed them into the medication cup. -CMT A handed the medication cup and a cup of water to the resident. -Resident #34 placed the medication into his/her mouth and swallowed with water. During an interview on 05/09/24 at 11:59 A.M. CMT A said: -Gloves must be worn if touching a pill. Pills cannot be touched with bare hands. -If a pill falls onto the cart use gloved hands to pick it up, or a something to sweep it into the medication cup. -Medication that falls on the floor must be destroyed and cannot be given to the resident. -There is no five second rule in long term care -He/she did not realize she dropped pills on the floor and cart, picked them up and administered them to the resident. Review of Novo Nordisk (manufacturer of Flex Pen) December 2022 fact sheet showed: -Before each injection, prime your pen by performing an airshot. Turn the dose selector to select 2 units. Holding your pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Press and hold the green push button. Make sure a drop of insulin appears at the needle tip. Review of Resident #56's Quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff) dated 2/16/24 showed: -Brief Interview of Mental Status (BIMS) of 15, indicated no cognitive loss. -Need for set up assistance with Activities of Daily Living (ADL's: tasks performed in a day to care for oneself) -Diagnoses of: Diabetes (disease that affects how your body turns food into energy.) Review of the resident's physician orders dated May 2024 showed: -Novolog U-100 Insulin(medication used to treat diabetes) , 100 units (U) per milliliter (ml) per sliding scale. If blood sugar is : 150 milligrams (mg) / deciliter (dl) to 200 mg/dl give 3 units 201 mg/dl to 250 mg/dl give 5 units 251 mg/dl to 300 mg/dl give 8 units 301 mg/dl to 350 mg/dl give 11 units 351 mg/dl to 400 mg/dl give 14 units 401 mg/dl to 450 mg/dl give 17 units 451 mg/dl to 500 mg/dl give 20 units if greater than 500 mg/dl notify the physician. During an observation on 5/08/24 at 7:24 A.M. showed: -Licensed Practical Nurse (LPN) A obtained a bedside glucose reading of 157 mg/dl -LPN A checked the resident's electronic medical record for his/her insulin order. -LPN A obtained the resident's Novolog flex pen from the cart, removed the cap, cleansed the hub, applied a new needle, turned the dial on the base of the pen to 3 units. -LPN A administered the injection into the resident's abdomen, disposed of the needle, removed his/her gloves, cleansed his/her hands with alcohol hand scrub and charted the administration of the insulin. -LPN A cleansed the insulin pen and returned it to the cart. -LPN A did not prime the insulin pen prior to administration. 2. Review of Resident #47's Annual MDS dated [DATE] showed: -BIMS of 15, indicated no cognitive loss. -Set up assistance for ADL's. -Diagnoses of Diabetes, congestive heart failure (a condition in which the heart cannot pump blood well enough to give the body a normal supply)., cardiac pacemaker (small, battery-powered device that prevents the heart from beating too slowly Review of the resident's comprehensive care plan dated 2/27/24 showed: -The resident is at risk for fluctuating blood glucose levels, administer insulin as ordered Review of the resident's physician order sheet for May 2024 showed: -Insulin glargine (Lantus) Insulin pen (medication used to treat diabetes) ; 100 units per ml, give 10 units subcutaneous (just under the skin) twice a day for diabetes. -Victoza pen injector (medication used to treat diabetes) ; 0.6 mg/0.1 ml give 1.8 mg subcutaneous once a day for diabetes Observations on 05/08/24 at 7:42 A.M. showed: -LPN A obtained the resident's bedside glucose at 160 mg/dl. -LPN A checked the resident's electronic medical record for his/her insulin order. -LPN A obtained the resident's Lantus flex pen and Victoza pen from the cart. -LPN A removed the cap of the Lantus flex pen, cleansed the hub, applied a new needle, turned the dial on the base of the pen to 10 units. -LPN A removed the cap of the Victoza pen, cleansed the hub, applied a new needle, turned the dial to 18 units. -LPN A administered the Lantus injection into the resident's upper left arm. LPN A laid the pen on the top of the cart, -LPN A administered the Victoza injection into the resident's left upper arm. -LPN A disposed of the used needles, removed his/her gloves, cleansed his/her hands with alcohol hand scrub and charted the administration of the insulin. -LPN A cleansed the Lantus and Victoza pen and returned them to the medication cart. -LPN A did not prime the insulin pen prior to administration. During an interview on 05/08/24 at 8:02 A.M. LPN A said: -He/She dials the insulin the correct dose and administers it per the physician order. -He/she does not need to prime the insulin pen. During an interview on 5/9/24 at 3:12 P.M. with the Director of Nursing and the Administrator: -The DON said staff cannot touch medication bare handed. Medication cannot be administered after it has fallen on the floor. -The Administrator said she does not expect staff to touch medication with bare hands or administer medication off the floor. Based on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication rate of less than 5% when facility staff made six medication errors out of 25 opportunities and a medication error rate of 24%, . This affected six of the 17 sampled residents, (Resident #6, #34, #39, #47, #51 and #56). The facility census was 66. Review of the facility's undated policy for medication administration, showed, in part: - Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; - Administer medications as ordered and in accordance with manufacturer specifications. Review of the facility's policy for instillation of eye medication, dated March, 2015, showed: - The purpose is to introduce medication into the eye for treatment or for examination purposes; - Wipe away any secretions present; - Tilt resident's head backward, draw down lower lid. Have resident look up; - To prevent dropper tip from touching eye or lids, nurse should support hand on resident's forehead or bridge of nose. Introduce drop on center of eye lid (outward facing) lower lid (the eye drop must contact the eye for a sufficient period of time before the next eye drop is instilled. The time for optimal eye drop absorption is approximately three to five minutes); - Instruct resident to close eye. Gently press tissue against lacrimal duct (tear duct), (press the tear duct for one minute after eye drop administration or by gentle eye closing for approximately three minutes after the administration). 1. Review of Resident #39's physician order sheet (POS), dated May, 2024 showed: - Start date: 3/9/23 - Dorzolamide-timolol ophthalmic (eye) drops, 22.3-6.8 milligrams per milliliter (mg./ml.), one drop in both eyes twice daily for cataracts (clouding of the normally clear lens of he eye). Review of the resident's medication administration record (MAR), dated May, 2024 showed: - Dorzolamide-timolol ophthalmic (eye) drops, 22.3-6.8 mg./ml., one drop in both eyes twice daily for cataracts. Observation on 5/8/24 at 7:15 A.M., showed: - Certified Medication Technician (CMT) A administered one drop in each eye and did not apply lacrimal pressure. 2. Review of Resident #51's POS, dated May, 2024 showed: - Start date: Polymyxin b sulf-trimethoprim ophthalmic (eye) drops 1 mg./ml., two drops in both eyes four times daily until eye infection is healed. Review of the resident's MAR, dated May, 2024 showed: - Polymyxin b sulf-trimethoprim ophthalmic (eye) drops 1 mg./ml., two drops in both eyes four times daily until eye infection is healed. Observation and interview on 5/8/24 at 7:22 A.M., showed: - CMT A attempted to put one drop in the left eye and missed it then put one drop in the right eye; - The resident informed CMT A he/she missed the left eye; - CMT A placed a drop in the left eye and the tip of the eye dropper touched the resident's eye lashes; - At 7:26 A.M., CMT A placed the second drop in the resident's right eye and touched the tip of the eye dropper to the resident's eye lashes; - CMT A placed a second drop in the resident's left eye and touched the tip of the eye dropper to the resident's eye lashes; - CMT A did not apply lacrimal pressure. During an interview on 5/9/24 at 9:38 A.M., CMT A said: - The tip of the eye dropper should not touch the resident's eye lashes or eye lids; - He/she thought you were supposed to apply lacrimal pressure and thought it might be for 30 seconds. During an interview on 5/9/24 at 3:12 P.M., the Administrator and the Director of Nursing (DON) said: - The tip of the eye dropper should not touch the resident's eye lids or eye lashes; - The DON did not know about applying lacrimal pressure. 3. Review of the facility's policy for instillation of nose drops, dated March, 2015 showed: - The purpose is to relieve nasal congestion; - Assist resident to sitting position with head tilted backward; - Ask the resident to blow his/her nose. Clean secretions from nasal area with tissue wipes prior to instillation of medication; - Instill medication in the amount ordered; - Instruct resident to remain in position for a few minutes and gently inhale. Instruct them not to blow nose. Review of the package leaflet for Flonase nasal spray, revised March, 2016, showed, in part: - Shake the bottle gently; - Blow your nose to clear the nostrils; - Close one side of the nostril. Tilt your head forward slightly and carefully insert the nasal applicator into the other nostril; - Start to breathe in through your nose, and while breathing in press firmly and quickly down one time on the applicator to release the spray; - Repeat in the other nostril; - Wipe the nasal applicator with a clean tissue and replace the cap. 4. Review of Resident #6's POS, dated May, 2024 showed: - Start date: 3/29/24 - Fluticasone (Flonase) nasal spray, 50 micrograms (mcg.), one spray in each nostril twice daily for allergy symptoms. Review of the resident's MAR, dated May, 2024 showed: - Fluticasone (Flonase) nasal spray, 50 mcg., one spray in each nostril twice daily for allergy symptoms. Observation on 5/8/24 at 7:35 A.M., showed: - CMT A did not shake the Flonase bottle, did not have the resident blow his/her nose, did not close either side of the resident's nostril and instilled one spray in each nostril. During an interview on 5/9/24 at 9:38 A.M., CMT A said: - He/should follow the manufacturer's guidelines for the administration of Flonase nasal spray and the prescription (have the resident blow their nose, shake the bottle, close one side of the nostril). During an interview on 5/9/24 at 3:12 P.M., the Administrator and DON said: - Staff should follow the manufacturer's guidelines when administering the nasal sprays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to prime insulin pens for two residents resulting in three significant medication errors out of the 25 sampled medications. The facility census was 66. Review of the facility's undated policy for medication administration, showed: - Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; - Administer medications as ordered in accordance with manufacturer specifications. Review of Novo Nordisk (manufacturer of Flex Pen) December 2022 fact sheet showed: -Before each injection, prime your pen by performing an airshot. Turn the dose selector to select 2 units. Holding your pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Press and hold the green push button. Make sure a drop of insulin appears at the needle tip. 1. Review of Resident #56's Quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff) dated 2/16/24 showed: -Brief Interview of Mental Status (BIMS) of 15, indicated no cognitive loss. -Need for set up assistance with Activities of Daily Living (ADL's: tasks performed in a day to care for oneself) -Diagnoses of: Diabetes (disease that affects how your body turns food into energy.) Review of the resident's physician orders dated May 2024 showed: -Novolog U-100 Insulin(medication used to treat diabetes) , 100 units (U) per milliliter (ml) per sliding scale. If blood sugar is : 150 milligrams (mg) / deciliter (dl) to 200 mg/dl give 3 units 201 mg/dl to 250 mg/dl give 5 units 251 mg/dl to 300 mg/dl give 8 units 301 mg/dl to 350 mg/dl give 11 units 351 mg/dl to 400 mg/dl give 14 units 401 mg/dl to 450 mg/dl give 17 units 451 mg/dl to 500 mg/dl give 20 units if greater than 500 mg/dl notify the physician. During an observation on 5/08/24 at 7:24 A.M. showed: -Licensed Practical Nurse (LPN) A obtained a bedside glucose reading of 157 mg/dl -LPN A checked the resident's electronic medical record for his/her insulin order. -LPN A obtained the resident's Novolog flex pen from the cart, removed the cap, cleansed the hub, applied a new needle, turned the dial on the base of the pen to 3 units. -LPN A administered the injection into the resident's abdomen, disposed of the needle, removed his/her gloves, cleansed his/her hands with alcohol hand scrub and charted the administration of the insulin. -LPN A cleansed the insulin pen and returned it to the cart. -LPN A did not prime the insulin pen prior to administration. 2. Review of Resident #47's Annual MDS dated [DATE] showed: -BIMS of 15, indicated no cognitive loss. -Set up assistance for ADL's. -Diagnoses of Diabetes, congestive heart failure (a condition in which the heart cannot pump blood well enough to give the body a normal supply)., cardiac pacemaker (small, battery-powered device that prevents the heart from beating too slowly Review of the resident's comprehensive care plan dated 2/27/24 showed: -The resident is at risk for fluctuating blood glucose levels, administer insulin as ordered Review of the resident's physician order sheet for May 2024 showed: -Insulin glargine (Lantus) Insulin pen (medication used to treat diabetes) ; 100 units per ml, give 10 units subcutaneous (just under the skin) twice a day for diabetes. -Victoza pen injector (medication used to treat diabetes) ; 0.6 mg/0.1 ml give 1.8 mg subcutaneous once a day for diabetes Observations on 05/08/24 at 7:42 A.M. showed: -LPN A obtained the resident's bedside glucose at 160 mg/dl. -LPN A checked the resident's electronic medical record for his/her insulin order. -LPN A obtained the resident's Lantus flex pen and Victoza pen from the cart. -LPN A removed the cap of the Lantus flex pen, cleansed the hub, applied a new needle, turned the dial on the base of the pen to 10 units. -LPN A removed the cap of the Victoza pen, cleansed the hub, applied a new needle, turned the dial to 18 units. -LPN A administered the Lantus injection into the resident's upper left arm. LPN A laid the pen on the top of the cart, -LPN A administered the Victoza injection into the resident's left upper arm. -LPN A disposed of the used needles, removed his/her gloves, cleansed his/her hands with alcohol hand scrub and charted the administration of the insulin. -LPN A cleansed the Lantus and Victoza pen and returned them to the medication cart. -LPN A did not prime the insulin pen prior to administration. During an interview on 05/08/24 at 8:02 A.M. LPN A said: -He/She dials the insulin the correct dose and administers it per the physician order. -He/she does not need to prime the insulin pen. During an interview on 5/9/24 at 3:12 P.M. with the Director of Nursing and the Administrator ; The Director of Nursing said she would expect staff to follow manufacturers guidelines for medication. The Administrator said insulin pens should be primed every use. She had been taught to prime with 2-3 units every use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure staffing was sufficient to serve residents their meals in a timely manner. This affected three of the 17 sampled residents (Resident #216, #16, and #8). The facility census was 66. Review of facility policy, assistance with meals, dated March 2016, showed: -Residents will receive assistance with meals in a manner that meets the individual needs of each resident. -Nursing staff and or feeding assistants will serve resident trays and will help residents who require assistance with eating. -Nursing staff will remove food trays from food cart and deliver the trays to each resident's room. -Nursing staff and/or feeding assistants will feed those residents needing full assistance. -Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. 1. Review of Resident #216's face sheet showed: -Resident admitted to facility on 4/22/24 -Diagnoses included: neurocognitive disorder with lewy bodies (a type of progressive dementia that leads to decline in thinking, reasoning, and independent function), generalized osteoarthritis (a condition in which three or more joint groups are affected when cartilage that cushions end of bones deteriorates), and chronic pain syndrome. Review of MDS showed resident did not have MDS completed. Review of care plan, dated 5/8/24, showed: -Resident did not have any goals related to eating. Review of baseline care plan, dated 4/22/24, showed: -He/She required one nursing assistant for meals. Review of physician's orders dated 4/8/24 to 5/8/24, showed: -Resident was on regular diet. Observation on 5/7/24 at 10:04 A.M. showed resident's breakfast tray was sitting across the room from resident on bedside over bed table, cover had not been removed from food, food had not been touched and was cold. During an interview on 5/7/24 at 10:56 A.M., Resident Representative said: -Facility did not make attempts to feed resident; -No staff comes to feed resident or assist resident to eat; -Resident's family members had been going to facility to ensure resident had been fed; -Family member tried to get there before breakfast and stay until after dinner to ensure resident was getting to eat. Observation on 5/8/24 at 8:39 A.M. showed resident's breakfast was sat on table in front of her, food was covered and cold, food had not been touched, resident was not assisted to eat breakfast. Observation on 5/8/24 at 9:32 A.M. showed resident's breakfast remained on bedside table in front of her, no staff had assisted him/her to eat breakfast. During an interview on 5/8/24 at 12:06 P.M., Resident's sister said: -He/She had been visiting and feeding resident; -Resident could not feed him/herself. Review of electronic medical record on 5/8/24, showed: -No documentation of resident meal intakes. During an interview on 5/7/24 at 10:08 A.M., Certified Nurse Aide (CNA) B said: -Normally family is at facility to feed resident; -If someone did not feed resident, resident did not eat. During an interview on 5/8/24 at 2:25 P.M., Certified Medication Technician (CMT) B said: -Resident did not feed him/herself, he/she was an assist, most days resident's sister was in facility to feed resident; -For residents that eat their meals in their rooms, facility did not have enough staff to get assistance to residents to help them eat; -He/She tried to ensure that no more than two residents who are assisted diners stay in their rooms to eat; -He/She did not have time to document resident's meal intake due to staffing shortages. -Facility did not have enough staff to meet resident needs. During an interview on 5/8/24 at 2:38 P.M., CNA A said: -Resident required assistance to eat; -The resident's son or sister will come to feed resident a little after breakfast. 2. Review of Resident #16's Quarterly MDS, dated [DATE] showed: -He/She had moderately impaired cognition; -He/She had clear speech, was usually able to make self-understood, and usually able to understand others; -He/She had impairment to range of motion on both sides of lower extremities; -He/She required substantial/maximal assistance with eating; -Diagnoses included: stroke, diabetes (too much sugar in the blood), and osteoarthritis (condition when flexible, protective tissue at the ends of bones wears down). Observation on 5/6/24 at 1:03 P.M. showed Resident #16 received his/her lunch tray at 12:40 P.M., the meal sat on table with lid on it and at 1:03 P.M. staff came in and started assisting resident to eat. Staff did not offer to warm up resident's food that had been sitting in room over 23 minutes. Observation on 5/8/24 at 8:04 A.M. in the kitchen showed last tray was served for breakfast. Observation on 5/8/24 at 9:15 A.M. showed staff attempted to assist resident to eat but he/she did not want anything, 1 hour and 11 minutes after last tray left the kitchen for breakfast service. During an interview on 5/8/24 at 10:45 A.M., Licensed Practical Nurse (LPN) A said: -Something happened to resident's dinner trays last night because he/she did not get anything to eat; -He/She fixed resident a peanut butter and jelly sandwich. During an interview on 5/8/24 at 2:06 P.M., CMT B said: -Twenty-three minutes was not an acceptable time frame for the resident to have waited before staff asked him/her if they wanted to eat their meal. -He/She heard resident did not receive supper tray on 5/7/24. 3. Review of Resident #8's Quarterly MDS, dated [DATE] showed: -He/She had intact cognition; -He/She had clear speech, was able to make self-understood and understand others; -He/She had impaired range of motion of one side of lower extremity; -He/She required set up or clean-up assistance with eating; -Diagnoses included anxiety and depression. During an interview on 5/8/24 at 9:07 A.M., resident said: -He/She did not get any supper last night and there was several other residents that did not receive their trays including Resident #16. -He/She finally told the charge nurse who went and fixed him/her a peanut butter and jelly sandwich. During an interview on 5/8/24 at 10:45 A.M., LPN A said: -Something happened to Resident #16's dinner trays last night because he/she did not get anything to eat; -He/She fixed resident a peanut butter and jelly sandwich. During an interview on 5/8/24 at 2:25 P.M., CMT B said: -He/She was aware resident did not get his/her supper tray passed last night along with two other residents; -He/She was not sure why except maybe the aides just did not get the trays passed. During an interview on 5/9/24 at 10:17 A.M., Dietary Manager said: -He/She was made aware that residents were missed for their meal on 5/7/24's meal due to trays being given to the wrong resident or were lost. -Kitchen staff made an alternate dinner of deli sandwich, chips, fruit, and drink; -Residents were served alternative meal as main meal had already been discarded; -He/She had system in place to ensure room trays were not moved by having a room tray list that is used by staff in kitchen; -There was a lot of turn over off staff, part of problem had new people that had just started and had new residents, and new staff were not aware of the new residents. It was more of a training and orientation issue with staff. During an interview on 5/9/24 at 3:12 P.M., Administrator said: -Residents who require feeding assistance should be assisted in a timely manner; -He/She was aware of five residents who did not get a meal served on 5/7/24 dinner tray pass; -His/Her normal dietary staff took a leave of absence and were out of the country; -He/She had issues with getting people to do their job correctly in the kitchen; -Kitchen staff said they had already put food up; -LPN A was in building and cooked burgers, and make peanut butter and jelly sandwich for those residents; -He/She had a lot to do with educating staff on patient rights. -He/She was aware that insufficient staffing had caused issues with getting residents up and down for meals and meal service. MO233672

Based on 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. This affected all the residents in the facility. The facility census was 66. The facility did not provide a policy for QAPI. During an interview on 5/9/24 at 9:06 A.M., the Administrator said: - She started as the Administrator on 3/14/24; - At this time she was unable to locate any policies and procedures for QAPI; - They have only had one QAPI meeting. Members who attended were all the department heads, the staffing coordinator and the dietary/housekeeping supervisor; - She talked to the Medical Director monthly.

Based on interviews and record review, the facility failed to ensure they developed and implemented appropriate plans of action to correct identified quality deficiencies as part of their Quality Assessment and Assurance (QAA) committee. This affected all the residents in the facility. The facility census was 66. The facility did not provide a policy in regards to their QAA process or committee. The facility was unable to provide record of the the QAA and Quality Assurance/Performance Improvement (QAPI) plan. During an interview on 5/9/24 at 9:06 A.M., the Administrator said: - She started as the Administrator on 3/1424; - She was unable to locate the policy and procedures for QAPI; - They have only had one QAPI meeting. Members who attended were all the department heads plus the staffing coordinator and the dietary/housekeeping supervisor. She talks to the Medical Director monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have an Infection Prevention program to include policies and procedures for infection control. Additionally, the facility staff failed to follow acceptable infection control practices to prevent the spread of infection for three residents (Resident #34, #9 and #35) when staff failed to ensure administered medications did not come in contact with unclean surfaces for one resident (Resident #34), failed to wash hands between areas of clean and dirty when providing personal care, failed to clean up bodily fluids from the floor before walking through it and laying a mat over it, for one resident (Resident #9) and touched medications with bare hands for two residents (Resident #34 and #35). The facility census was 66. The facility did not provide a policy on infection prevention and control. 1. During an interview on 05/08/24 at 2:03 PM the Administrator said: -The facility does not have anyone responsible for infection prevention program at this time. -The Director of Operations was running reports of residents on antibiotics off site. -The Assistant Director Of Nursing will be responsible for doing all the Infection prevention program. -Many policies are missing. She is working with the Director of Nursing and Director of Operations to update and ensure there are policies and procedures put into place. 2. Review of Resident #34 Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 3/8/24 showed: -Brief Interview of Mental Status (BIMS) of 11, indicated some cognitive loss; -Independent to set up assistance for Activities of Daily Living (ADL's: activities in a day to care for oneself); -Diagnoses of Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Schizophrenia (a serious mental health condition that affects how people think, feel and behave), Major Depressive Disorder (a persistently low or depressed mood) , Obsessive Compulsive Disorder (OCD: a long-lasting disorder in which a person experiences uncontrollable and recurring thoughts (obsessions), engages in repetitive behaviors (compulsions), or both) and back pain. Review of the resident's Comprehensive Care Plan dated 3/15/24 showed: -He/She takes psychoactive (substances that effect mental processes) medications medication for anxiety and Parkinson's disease. Administer medications as ordered. Review of Resident #34's physician order sheet for May 2024 showed: -Benzotropine 1 mg, give one tablet three times a day for movement disorder. Ordered 6/4/21. -Fluoxetine 20 mg give one capsule with a 40 mg capsule to equal 60 total mg daily for obsessive compulsive disorder (OCD: uncontrollable and recurring thoughts (obsessions), and repetitive behaviors (compulsions) ) Ordered 6/4/21. -Fluoxetine 40 mg give one capsule with one 20 mg capsule to equal 60 total mg daily for OCD. Ordered 6/4/21 -Hydroxizine 10 mg give one tablet daily for anxiety (a feeling of fear, dread and uneasiness). Ordered 6/4/21 -Risperidone 1 mg give one tablet twice a day for schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves.) Ordered 3/9/22 -Carbidopa/levodopa 25 mg/100 mg give one and one half tablets four times a day for Parkinson's disease (A disorder of the central nervous system that affects movement, often including tremors). Ordered 10/14/22 -Vitamin E 400 units give one tablet daily for supplement. Ordered 10/30/23 -Vitamin B 12 500 micrograms (mcg) give two tablets once a day for supplement. Ordered 6/26/21 During observation on 5/08/24 at 7:54 A.M. showed -Certified Medication Technician (CMT) A removed resident #34's medications from the medication cart. -He/she sat a medication administration cup on top of the medication cart and began popping medication from bubble packs into the medication cup. -He/she popped Benzotropine 1 mg, one tablet, Fluoxetine 20 mg one capsule, Fluoxetine 40 mg one capsule, Hydroxizine 10 mg one tablet and Risperidone 1 mg, one tablet . -CMT A bumped the medication cup with his/her hand knocking it over, Fluoxetine 40 mg capsule fell to the floor, Risperidone 1 mg tablet fell to the floor and Hydroxizine 10 mg tablet fell on the top of the cart. -CMT A picked up the two medications from the floor and laid them on top of the medication cart with the tablet of Hydroxizine. -CMT A popped Carbidopa/levodopa 25 mg/100, mg one and one half tablets into the medication cup, poured Vitamin E 400 units one tablet from the resident specific bottle, into the medication cup and poured Vitamin B 12 500 microgram (mcg) two tablets from the resident specific bottle into the medication cup. -With bare hands CMT A picked up the Fluoxetine 40 mg capsule ,Risperidone 1 mg tablet and Hydroxizine 10 mg tablet from the top of the cart and placed them into the medication cup. -CMT A handed the medication cup and a cup of water to the resident. -Resident #34 placed the medication into his/her mouth and swallowed with water. During an interview on 05/09/24 at 11:59 A.M. CMT A said: -Gloves must be worn if touching a pill. Pills cannot be touched with bare hands. -If a pill falls onto the cart use gloved hands to pick it up, or a something to sweep it into the medication cup. -Medication that falls on the floor must be destroyed and cannot be given to the resident. 3. Review of Resident #9's Quarterly MDS, dated [DATE] showed; - Cognitive skills severely impaired; - Required substantial to maximal assistance with showers, personal hygiene, toilet use and transfers; - Always incontinent of bowel and bladder; - Diagnoses included non traumatic brain dysfunction (causes damage to the brain by internal factors, such as a lack of oxygen, exposure to toxins, or pressure from a tumor), congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), anxiety, depression, Alzheimer's disease ( brain disorder that slowly destroys memory and thinking skills and the ability to carry out the simplest tasks), and psychotic disorder (a mental disorder characterized by a disconnection from reality). Review of the resident's care plan, dated 3/13/24 showed: - The resident required assistance with activities of daily living (ADL's) due to weakness, decreased cognition related to Alzheimer's disease. Assist the resident with cares. Provide extensive assistance for bed mobility, transfers, locomotion on the unit and off the unit, dressing, toileting, and personal hygiene. The resident is not able to walk. Observation on 5/7/24 at 9:41 A.M., showed: - The resident sat in his/her Broda chair (reclining geri chair) in the assist dining room and was leaning over on the left side of the chair with his/her eyes closed. There was a puddle of urine under the resident's Broda chair; - Certified Nurses Aide (CNA) A took the resident back to his/her room; - CNA A and CNA D did not wash their hands and applied gloves; - CNA A and CNA D used the gait belt (a safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) and transferred the resident from the Broda chair to his/her bed; - There was a puddle of urine under the resident's Broda chair; - CNA A and CNA D removed the resident's wet pants and the saturated and soiled incontinent brief; - CNA D provided incontinent care for the resident; - The clean incontinent brief fell onto the floor and CNA D picked it up and placed it on the resident and fastened it; - CNA D walked through the urine on the resident's floor and CNA A placed the fall mat over the urine on the floor beside the resident's bed. CNA A and CNA D did not clean the seat of the resident's Broda chair; - CNA A removed his/her gloves and washed his/her hands; - CNA D removed his/her gloves, did not wash his/her hands and left the room. During an interview on 5/8/24 at 2:38 P.M., CNA A said: - Should not have used the brief after it had fallen on the floor, we should have used a new incontinent brief; - He/she should have cleaned the seat of the resident's Broda chair and cleaned the urine from the floor before placing the fall mat on the floor. - Should wash his/her hands when entering the resident's room, between glove changes and before leaving the room. During an interview on 5/9/24 at 10:29 A.M., CNA D said: - We should not have used the clean incontinent brief after it had fallen on the floor; - Should have cleaned the urine from the floor before we placed the fall mat on the floor and cleaned the seat of the resident's Broda chair; - Should wash hands between glove changes and before leaving the resident's room. During an interview on 5/9/24 at 3:12 P.M., the Administrator and the DON said: - Staff should have cleaned the urine from the floor or had housekeeping clean it before they placed the fall mat on the floor; - Staff should have cleaned the seat of the Broda chair; - Staff should not have used the clean incontinent brief once it had fallen on the floor; - They would expect the staff to wash their hands when they enter the resident's room, should wash their hands during peri care and should wash their hands or sanitize between glove changes. Review of the facility's undated policy for medication administration, showed, in part: - Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; - Administer medications as ordered and in accordance with manufacturer specifications; - Remove medication from source, taking care not to touch medication with bare hands. Review of Resident #35's physician order sheet (POS), dated May 2024 showed: - Start date: 4/25/24 - Linzess 145 mcg, one capsule daily for irritable bowel syndrome (a common digestive disorder that causes abdominal pain and changes in bowel habits); - Start date: 4/19/24 - Rivastigmine tartrate 1.5 mg, one capsule twice daily for Alzheimer's disease ( brain disorder that slowly destroys memory and thinking skills and the ability to carry out the simplest tasks). Review of the resident's medication administration record (MAR), dated May 2024 showed: - Linzess 145 mcg. one capsule daily for irritable bowel syndrome; - Rivastigmine tartrate 1.5 mg. one capsule twice daily for Alzheimer's disease. Observation on 5/8/24 at 6:55 A.M., showed: - CMT A did not wash his/her hands and used her bare hands and pulled the capsules apart and placed them in pudding; - At 7:11 A.M., CMT A administered the medication to the resident. During an interview on 5/9/24 at 9:38 A.M., CMT A said: - He/she should not touch medications with his/her bare hands. During an interview on 5/9/24 at 3:12 P.M., the Administrator and the DON said: - Staff should not handle medications with their bare hands. -Staff should not administer medication that had fallen on the floor. -Medication that fell to the floor should be disposed of and new medication obtained.

Based interview, the facility failed to establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 66. The facility did not provided a policy regarding infection control and prevention. Review of Resident #50 Quarterly Minimum Data Set (MDS:a federally mandated assessment tool completed by facility staff) dated 3/1/24 showed: -Brief Interview of Mental Status (BIMS) of 15, indicated no cognitive deficit. -Dependent for Activities of Daily Living (ADL's: tasks performed in a day to care for oneself) Occasionally Incontinent of bowel and bladder. -Diagnoses of cerebral infarction (loss of blood flow to part of the brain: a stroke), cardiovascular disease (heart disease), muscle spasms. cystitis (urinary tract infection). Review of the resident's comprehensive Care Plan dated 3/13/24 showed: -Report any signs and symptoms of urinary tract infection (urgency, burning, pain, nausea, chills, fever, low back pain, foul odor, blood in urine, concentrated urine). Review of the resident's May Physician Order Sheets showed: -Urgent Urinalysis with culture and sensitivity order date 5/2/24 -Amoxicillin-potassium-clavulanate 875 milligrams (mg)/125 mg tablet, twice a day for seven days for Urinary Tract Infection. Order date 5/7/24. During an interview on 5/08/24 at 2:03 PM the Administrator said: -The Director of Operations was running reports off site of residents on antibiotics -No one was completing the mapping or tracking of infections. -There is no Antibiotic Stewardship Program at this time. -An Assistant Director of Nursing had been hired, had not started, but would be responsible for the IPCP and Antibiotic Stewardship.

Based on record review and interview, the facility failed to ensure they maintained documentation to show they provided training to their staff regarding what constitute abuse, neglect, exploitation and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. The facility census was 66. The facility did not provide documentation to show they provided training to all staff on abuse, neglect, exploitation and misappropriation of resident property when requested. During an interview on 5/8/24 at 5:31 A.M., Nurse Aide (NA) A said: -He/She had worked at facility a couple of months; -He/She had not had any abuse and neglect training at the facility; -His/Her training involved staff showing him around to every resident, showing him/her supplies, learning what he/she needed to fill out, and telling him/her what he/she could and could not do. During an interview on 5/9/24 at 2:25 P.M., Certified Medication Technician (CMT) B said he/she had not had any training at facility. During an interview on 5/9/24 at 2:38 P.M., Certified Nurse Aide (CNA) A said he/she did have training on abuse and neglect as part of his/her training at facility. During an interview on 5/9/24 at 11:40 A.M., Administrator said: -He/She had not done any abuse and neglect training since he/she became administrator in March; -He/She saw that training had been provided in October 2023 but could not locate any inservice sheets showing staff had been trained. During an interview on 5/9/24 at 11:47 A.M Business Office Manager said he/she could not locate inservices on abuse and neglect.

Based on interview and record review, the facility failed to ensure the nurse aides (NA) had a minimum of 12 hours of in-service education (which included abuse, neglect, and dementia care) per year by not providing documentation of these in-services for three of three randomly selected nurse aides. The facility census was 66. Review of facility policy, Abuse Prevention Program, dated 1/30/24, showed: -Mandated staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse, stress management, dealing with violent behavior, or catastrophic reactions, and dementia management. Facility did not provide documentation of abuse and neglect or dementia education. During an interview on 5/8/24 at 5:31 A.M., NA A said: -He/She had not had any abuse and neglect training; -He/She had not received any dementia care training. During an interview on 05/09/24 at 1:29 P.M., NA C said: -He/She has not had any training on Abuse and Neglect at this facility; -He/She had training on dementia care. During an interview on 5/15/24 at 2:31 P.M., NA E said: -He/She did not get any training on abuse and neglect or dementia care. During an interview on 5/9/24 at 11:40 A.M., Administrator said: -He/She could not locate any documentation of inservices or education on abuse and neglect or dementia care. -He/She had not done any training with staff since he/she had become administrator in March. During an interview on 5/9/24 at 11:47 A.M., Business Office Manager said: -He/She could not locate any inservices on abuse and neglect or dementia care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature to seven of the 17 sampled residents (Resident #8, #2, #58, #27, #56, #55, and #212). The facility census was 66. Review of facility policy, food and drink, dated 1/30/24, showed: -Food prepared by methods that provides nutritive value, flavor and appearance; -Food and drink that is palatable, attractive, and served at a safe and appetizing temperature Review of food safety policy, dated 1/30/24, showed: -Facility must store, prepare, distribute, and serve food in accordance with professional standards for food safety. -Ensuring safe food handling once food is brought to facility, including safe temperatures of food and handling of leftovers Review of facility policy, food safety, undated, showed: Holding Hot foods: -To ensure safety, hot foods must be held at 140 degrees Fahrenheit (F) or above. -Place foods in steam table or cabinets designed for holding hot foods immediately after cooking or heating. The maximum length of time that foods can be held on a steam table is a total of 4 hours. -Reheat all food to 165 degrees F for 15 seconds. Food may be reheated only once. -Never heat cold or lukewarm foods in steam tables or other equipment designed to hold hot foods. -Stir the foods frequently to evenly distribute the temperature. The top portion of the foods will cool to room temperature if not stirred. -Cover and protect containers to maintain heat and to protect from contamination. Facility did not provide a policy on food serving temperatures. 1. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/3/24 showed: -He/She had intact cognition; -He/She had clear speech, was able to make self-understood and understand others; -He/She had impaired range of motion of one side of lower extremity; -He/She required set up or clean-up assistance with eating; -Diagnoses included anxiety and depression. During an interview on 5/6/24 at 12:48 P.M., Resident said: -When receiving room tray all his/her foods were sloshed together; -When he/she received a breadstick, it was not separated and put in wax paper, it was placed on his/her plate and became soggy by time he/she was able to eat it; -Food was cold when he/she received it; -Kitchen did not cover drinks that were served; -The drinks spilled all over his/her tray and on his/her food. 2. Review of Resident #2's Quarterly MDS, dated [DATE] showed: -Cognition intact; -He/She had clear speech, was able to make self-understood and understand others; -He/She required set up or clean-up assistance with eating; - Diagnoses included seizure disorder and depression. During an interview on 5/6/24 at 11:03 A.M., Resident said -He/She eats in his/her room and food is cold when he/she received it; -Facility did not cover drinks and they are spilled on his/her tray; -He/She did not receive bread with his/her meal; -Plates are generally uncovered. 3. Review of Resident #58's admission MDS, dated [DATE], showed: -He/She had moderately impaired cognition; -He/She had clear speech, was able to make self-understood and understand others; -He/She required set up or clean up assistance with eating; -Diagnoses included: spinal stenosis of cervical region (neck pain from changes to vertebrae of neck), arthritis (swelling and tenderness of one or more joints), and cognitive communication deficit (difficulty with thinking and how someone uses language). During an interview on 5/6/24 at 10:33 A.M., Resident said: -Food was not good and had no taste; -Food was not hot; -Food was not the right consistency. 4. Review of Resident #27's Quarterly MDS, dated [DATE] showed: -He/She had moderately impaired cognition; -He/She had clear speech, was able to usually make self-understood and usually understand others; -He/She had impaired range of motion of upper and lower extremities on one side; -He/She required supervision or touching assistance with eating; -Diagnoses included stroke, Alzheimer's disease ( brain disorder that slowly destroys memory and thinking skills and the ability to carry out the simplest tasks), dementia (the inability to think), anxiety, depression, and hemiplegia ( paralysis affecting one side of the body). During an interview on 5/6/24 at 3:16 P.M., Resident said: -Food was not good, did not taste good; -Meat was tough. 5. Review of Resident #56's Quarterly MDS, dated [DATE] showed: -He/She had intact cognition; -He/She had clear speech, was able to make self-understood and understand others; -He/She required set up or clean-up assistance with eating; -Diagnoses included cancer, anxiety, depression, pneumonia (an infection that affects one or both lungs), anxiety, respiratory failure (a serious condition that makes it difficult to breathe on your own) and chronic obstructive pulmonary disease ((COPD) obstruction of air flow that interferes with normal breathing). During an interview on 5/6/24 at 10:41 A.M. said: -Food was on cool side; -Meat was tough to chew; -Chicken was dry. 6. Review of Resident #55's Quarterly MDS, dated [DATE], showed: -He/She had moderately impaired cognition; -He/She had clear speech, was able to make self-understood and usually understood others; -He/She was independent with eating; -Diagnoses included: dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life., malnutrition, and generalized muscle weakness. During an interview on 5/7/24 at 3:08 P.M. said: -Food was horrible; -It was served cold; -There was nothing worse than looking forward to something and sticking your finger in it and it being cold; -He/She looked forward to hashbrown at breakfast and it was a grease bomb. 7. Review of Resident #212's face sheet, dated 5/7/24, showed: -He/She admitted to facility on 4/22/24; -Diagnoses included dependence on renal dialysis (a treatment that removed extra fluid and waste products from the blood when kidneys are not able to), diabetes (a condition resulting in too much sugar in the blood, generalized muscle weakness, difficulty in walking, and need for assistance with personal care. During an interview on 5/7/24 at 9:40 A.M. said: -Breakfast is basically cold every time he/she got served. 8. During a continuous observation in the kitchen on 5/8/24 from 6:10 A.M.-8:14 A.M. showed: -At 6:06 A.M. Oatmeal was temperature checked while cooking on stove at 205.6 degrees; -At 6:27 A.M., Sausage patties and links were removed from oven, sausage patties temperature checked at 189.3 degrees and sausage links at 162.0 degrees; -At 6:30 A.M., Sausage patties added to steam table; -At 6:31 A.M., Sausage links placed back in oven; -At 6:32 A.M., Bacon added to steam table; -At 6:34 A.M., Container of leftover ground up mechanical sausage placed in oven. Dietary Manager told Housekeeping Supervisor that they reheated leftovers for mechanical diets and there is some sausage that was always ground up. He/She reheated it and then after that day they throw out the ground up sausage. -At 6:38 A.M., Sausage links removed from oven and temperature checked at 165.6, and was added to steam table; -At 6:44 A.M., Container of eggs removed from oven, temperature checked at 209.6 degrees; -At 6:59 A.M., Mechanical sausage pulled out and temperature checked at 92.0 degrees, placed back in oven; -At 7:02 A.M., boiled eggs temperature checked in pot on stove showed 178.6 degrees, added to steam table; -At 7:22 A.M., Mechanical soft sausage removed from oven and temperature checked 209.8 degrees; -At 7:33 A.M., First breakfast tray served to dining room; -At 8:14 A.M., Last breakfast tray served. Observation of test tray at end of meal service on 5/8/24 at 8:15 A.M., showed: -Oatmeal was 104.5 degrees; -Mechanical soft sausage was 94.7 degrees; -Sausage patty was 119.5 degrees; -Sausage link was 118.4 degrees; -Baked eggs was 102.7 degrees; -Bacon was 87.4 -Mechanical soft sausage was found to be dry and crispy with black hard crunch pieces that tasted burnt -No foods served on test tray was at appropriate serving temperature of 135 degrees. During an interview on 5/8/24 at 2:25 P.M., Certified Medication Technician B said: -Residents have complained about food temperatures a few weeks ago regarding food being cold; -He/She heard kitchen was getting a big plate warmer that can be pushed around; -A resident burned their arms on tomato soup when he/she spilled it on themselves. During an interview on 5/8/24 at 2:38 P.M., Certified Nurse Aide A said: -Sometimes he/she had to go reheat food for residents; -By the time hall trays get served those residents food was cold; -There is no help during morning breakfast past so staff struggled the most to get resident's trays served to them in a timely manner; -He/She tried to get assisted residents meals served first to their rooms. During an interview on 5/9/24 at 9:55 A.M., Dietary Aide B said: -When residents complain about temperature of their foods the kitchen serves them a new tray of food; -Only time he heard food was being served cold was during room tray passes; -Dietary staff covered room trays but if staff did not pass out room trays we do not know how long it takes for food to get to residents on halls. During an interview on 5/9/24 at 10:05 A.M., Housekeeping Supervisor said: -Hot food should be served hot; -Hot food should be served on resident's place no less than 120 degrees; -He/She was not aware of issues of food being served cold; -He/She was just on day two of cross training in dietary department. -Hall trays were an issue as there was a lot of hall trays; -Dietary department was waiting on an extra cart and meal plate covers. During an interview on 5/9/24 at 10:17 A.M., Dietary Manager said: -He/She was made aware from resident council notes that food was going out cold; -Hot food should be served hot, cold food should be served cold; -He/She had completed staff retraining that facility will not dip food onto plate until resident was in dining room; -He/She has ordered insulated domes with metal heat plate insert system that will be used for room trays to help maintain room trays at acceptable serving temperatures;

Based on observation, record review, and interviews the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff with facial hair failed to wear beard coverings, failed to wash hands, failed to date and label all foods, failed to have thermometers in refrigerator and freezer, and failed to maintain a clean and sanitary kitchen. This had the potential to impact all residents in the facility. The facility census was 66 residents. Review of facility policy, food and drink, undated, showed: -Purpose: ensure that the nutritive value of food is not compromised or destroyed because of prolonged: -Food storage, light, and air exposure; -Cooking of foods in a large volume of water or; -Holding on a steam table. -Procedure: -Each resident receives and the facility provides - -Food prepared by methods that provides nutritive value, flavor, and appearance. -Food and drink that is palatable, attractive, and served at a safe and appetizing temperature. -Food is prepared in a form designed to meet individual needs. -Food that accommodates resident allergies, intolerance's, and preferences. -Alternative options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice. -Drinks, including water and other liquids are consistent with resident needs and preferences and sufficient to maintain resident hydration. 1. Review of facility policy, food safety, undated, showed: -Dietary staff must wear hair restraints (example hairnet, hat and/or beard restraint) to prevent hair from contacting food. Observation on 5/6/24 at 9:46 A.M. showed Dietary Aide B who had a beard was not wearing a beard restraint. Observation on 5/8/24 at 6:08 A.M. showed Housekeeping Supervisor was training in the dietary department and was not wearing beard covering. He/She had facial hair. Observation on 5/8/24 at 6:10 A.M. showed dietary aide B entered kitchen and covered hair with a hat. He/She did not apply beard restraint to facial hair. During an interview on 5/9/24 at 9:55 A.M., Dietary Aide B said: -He/She did not wear beard restraints; -Dietary Manager told him/her today that he/she would order beard restraints; -Facility had not had beard restraints in the past. During an interview on 5/9/24 at 10:05 A.M., Housekeeping Supervisor said: -He/She should have wore beard restraint; -He/She did not know if beard nets were available in kitchen; -He/She knew hairnets were available. During an interview on 5/9/24 at 10:17 A.M., Dietary Manager said: -Dietary staff with facial hair should wear beard coverings; -He/She had beard coverings available in the kitchen. During an interview on 5/9/24 at 3:12 P.M., Administrator said: -Dietary staff should wear beard coverings and hairnets; -Hairnets are available in kitchen; -He/She did not know if beard coverings were available to staff. 2. Review of facility policy, Food Safety, dated 1/30/24, showed: -The facility must store, prepare, distribute, and serve food in accordance with professional standards of food service safety. -Employees should never use bare hand contact with any foods, ready to eat or otherwise. -Staff should have access to proper hand washing facilities with available soap (regular or antimicrobial), hot water and disposable towels and/or heat/air drying methods. Antimicrobial gel (hand hygiene agent that does not require water) cannot be used in place of proper hand washing techniques in a food service setting. -The use of disposable gloves is not a substitute for proper hand washing. -Hands must be washed before putting on gloves and after removing gloves as well as between tasks, between handling raw meats and ready to eat foods and between handling soiled and clean dishes, etc. -Staff should maintain nails that are clean and neat, and wearing intact disposable gloves in good condition that are changed appropriately to reduce the spread of infection. Observation on 5/6/24 at 12:02 P.M. showed: -All staff served residents in dining room with gloves on; -Staff did not cleanse hands or change gloves between serving resident lunch trays; -Staff touched cabinets the trays were sat on, touched meal tickets, and helped residents cut up food without sanitizing. Continuous observation in the kitchen on 5/8/24 at 5:37 A.M.-8:14 A.M., showed: -At 6:10 A.M., Dietary Aide A entered kitchen, did not wash hands; -At 6:14 A.M., Dietary Aide A had not yet washed hands, he/she took cereal dispensers out to dining room, grabbed pitcher and started filling coffee to take out to coffee pumps into dining room; -At 6:17 A.M., Dietary Manager washed his/her hands, turned faucet off with his/her clean bare hands, and then dried hands with paper towel; -At 6:19 A.M., Dietary Aide A grabbed washcloth and wiped off prep table, then grabbed premade coffee filter and placed in coffee pot; -At 6:20 A.M., Dietary Aide A placed clean cups on top of cup container, he/she had not washed hands since he/she entered kitchen; -At 6:31 A.M., Dietary Aide A prepped food trays, made himself a cup of coffee and drinking coffee cup, and sat coffee cup on three tiered cart, wheels cart to dining room with clean glasses; -At 6:33 A.M., Dietary Aide A returned to kitchen drinking his/her coffee, did not wash hands; -At 6:36 A.M., Dietary Aide A put away clean pot, he/she had not washed hands since entering kitchen; -At 6:37 A.M., Dietary Aide A and Housekeeping Supervisor leave kitchen; -At 6:42 A.M., Dietary Aide A re-enters kitchen, did not wash hands; -At 6:50 A.M., Dietary Aide A touched face and glasses with bare hands; -At 6:58 A.M., Dietary Aide A spraying off cookie sheet and placed through dishwashing sanitizer machine; -At 7:00 A.M., Dietary Aide A used unwashed and ungloved hands to pull out clean cookie sheet from dishwasher sanitizer; -At 7:01 A.M., Housekeeping Supervisor re-entered kitchen, did not wash hands; -At 7:05 A.M., Dietary Aide A took drink cart out to dining room with two chocolate gallons of milk and one gallon white milk and three drink pitchers; -At 7:29 A.M., Dietary Aide A observed in dining room serving drinks; -At 7:29 A.M., Dietary Aide A re-entered kitchen and observed washing hands for first time; During an interview on 5/9/24 at 9:55 A.M., Dietary Aide B said: -He/She should wash hands before you serve food and after you serve food; -He/She should wash hands when he/she arrived to work and when entering kitchen; -He/She did not was hands when arriving to work on 5/8/24. During an interview on 5/9/24 at 10:05 A.M., Housekeeping Supervisor said: -Hand washing should occur between handling raw food, dirty dishes, and frequently; -He/She should wash hands when entered and exited kitchen, after handling cell phones, after smoking. During an interview on 5/9/24 at 10:17 A.M., Dietary Manager said: -Hand washing in kitchen should happen often; -Hand washing should occur when staff come onto shift and when dietary staff come in and out of kitchen; -He/She should not turn off faucet with bare hands after washing his/her hands; During an interview on 5/9/24 at 3:12 P.M., Administrator said: -Dietary staff should wash their hands prior to serving, during cooking, when entering and exiting the kitchen, and after any contamination of their hands; -Dietary staff should not turn off faucet with their bare cleanly washed hands; -During food service staff should sanitize between serving residents their trays; -It was not appropriate for staff to wear the same set of gloves between residents while serving meal trays. 3. Review of food policy, storage of food in refrigeration, dated 1/30/24, showed: -All containers must be labeled with the contents and date food item was placed in storage; Review of facility policy, food safety, dated 1/30/24, showed: -Store, prepare, distribute, and serve food in accordance with professional standards of food service safety; -Food brought in must be dated and stored; -Food must be discarded after three days; -Facility refrigerators and/or freezers must be in good working condition to keep foods at or below 41 degrees Fahrenheit (F) and the freezer must keep frozen foods in a frozen state; -Cover and date foods. Review of facility policy, food and drink, undated, showed: -Purpose: ensure that the nutritive value of food is not compromised or destroyed because of prolonged: -Food storage, light, and air exposure. Observation in kitchen on 5/6/24 at 10:05 A.M. showed: Walk in cooler: -Undated and opened bag of mild cheddar cheese 5 lb bag; -Undated and opened container of beef base 16 oz; -Undated and opened white sliced cheese wrapped in plastic wrap; -Undated and opened gallon of 1% chocolate milk; Spice Cabinet: -Opened oregano 32 ounces (oz) dated 10/24/2022; -Undated and opened ground pepper 32 oz; -Undated and opened and hand written label of season salt was in a reused bottle; -Undated and opened baking soda 12 oz; -Undated and opened imitation wave 32 oz; -Undated and opened ground allspice 1 pound (lb); -Undated and opened poultry seasoning 10 oz; -Undated and opened imitation almond extract 16 oz; -Undated and opened chicken stock base 1 lb; -Undated and opened oats 42 oz; -Undated and opened powdered sugar; -Undated and opened browned sugar 32 oz; -Undated and opened gelatin dessert 24 oz. During an interview on 5/6/24 at 9:54 A.M., Dietary Manager said: -All cooks have certified food handler license; -Food was dated when opened; -He/She was only supposed to keep spices for thirty days based on county health department guidelines; -He/She did not know when spices should be thrown out for long term care guidelines; During an interview on 5/9/24 at 9:55 A.M., Dietary Aide B said: -Food should be labeled and dated when it was opened. During an interview on 5/9/24 at 10:17 A.M., Dietary Manager said: -Spices should be dated when they are opened; -Spices should be discarded after one year, but the county health department required facility to dispose of spices after 30 days. During an interview on 5/9/24 at 3:12 P.M., Administrator said: -Food should be dated and labeled when it was opened. 4. Review of facility policy, Storage of Food in Refrigeration, dated 1/30/24, showed: -Ensure food needing refrigeration is properly stored to prevent food-borne illness. Review of facility policy, Food Safety, dated 1/30/24, showed: -Store, prepare, distribute, and serve food in accordance with professional standards for food service safety. -Facility's refrigerators and/or freezers must be in good working condition to keep foods at or below 41 degrees F and the freezer must keep frozen foods frozen solid. During an interview on 5/6/24 at 10:23 A.M., Dietary Aide A said: -He/She took temperatures of food when it was done and on steam table and when it was cooked; Observation on 5/6/24 at 10:20 A.M. showed there was no thermometers visible in walk in cooler or freezer. During an interview on 5/6/24 at 10:23 A.M., Dietary Manager said: -He/She did have thermometers in refrigerator and freezer but did not know where they were at. During an interview on 5/6/24 at 10:24 A.M., Dietary Aide A said: -Thermometers were probably towards back of shelf behind boxes, but did not know where thermometers were located. During an interview on 5/9/24 at 3:12 P.M., Administrator said: -There should be thermometers available in freezer and refrigerator. 5. Review of facility policy, food safety, dated 1/30/24, showed: -Facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Facility did not provide a policy on dietary sanitation and cleanliness. Observation in the kitchen on 5/6/24 at 10:05 A.M. showed: -The coils of the fan in the cooler had caked on dust; -Area behind stove had caked on dust on coils, ledges, and cords. Continuous observation of kitchen on 5/8/24 from 5:49 A.M.-8:14 A.M. showed: -Floors in kitchen had not been swept, had crumbs laying all over floor. During an interview on 5/6/24 at 9:54 A.M., Dietary Manager said: -He/She had no cleaning log for kitchen tasks; -Kitchen staff have tasks that are completed every day; -Floors are mopped and trash was taken out; -He/She had deep cleaning days. During an interview on 5/9/24 at 3:12 P.M., Administrator said: -Cleanliness of facility is a work in progress; -Facility did not have cleaning checklists, but they should; -He/She expected the kitchen to be clean and sanitary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff reconciled Schedule II controlled substances (medications with a potential for abuse and dependence) that were stored in the facility's medication cart and the facility's stat safe (emergency drug supply). This effected Resident #1 and Resident #2. The facility census was 59. Review of the facility's Medication Administration policy, dated 2021, showed: -Medications are to be administered in accordance with professional standards of practice; -If a medication is a controlled substance, the narcotic book must be signed; -Correct any discrepancies and report to the nurse manager. Review of the facility's Controlled Substance Administration and Accountability policy, dated 2023, showed: -The facility will have safeguards in place in order to prevent loss and diversion of controlled substances; -All controlled substances will be accounted for each shift; -The charge nurse or designee will conduct a daily visual audit of the required documentation of controlled substances; -Any discrepancy in the count of the controlled substances will be resolved by the end of the shift; -Any discrepancies which cannot be resolved must be reported to the Director of Nursing (DON), the charge nurse and the pharmacy; -An incident report shall be completed detailing the discrepancy; -The DON or designee must report any loss of controlled substances; -If theft is suspected the DON or designee must report to the local law enforcement and the state licensure board. 1. Review of the Nurse's Controlled Substance/Emergency Drug Supply, Shift Change Record, dated December 2023, showed there were no initials for the following dates: -12/4/23 6:00 P.M. on-coming initials; -12/4/23 6:00 P.M. off-going initials; -12/5/23 6:00 A.M. on-coming initials; -12/5/23 6:00 P.M. off-going initials; -12/6/23 6:00 A.M. on-coming initials; -12/6/23 6:00 P.M. on-coming initials and off-going initials; -12/7/23 6:00 A.M. off-going initials; -12/8/23 6:00 A.M. off-going initials; -12/10/23 6:00 A.M. on-coming initials; -12/10/23 6:00 P.M. off-going initials; -12/11/23 6:00 A.M. off-going initials; -12/11/23 6:00 P.M. on-coming initials and off-going initials; -12/14/23 6:00 P.M. on-coming initials; -12/15/23 6:00 A.M. on-coming initials and off-going initials; -12/16/23 6:00 P.M. off-going initials; -12/17/23 6:00 A.M. on-coming initials; -12/17/23 6:00 P.M. off-going initials; -12/20/23 6:00 A.M. on-coming initials and off-going initials; -12/21/23 6:00 A.M. on-coming initials and off-going initials; -12/21/23 6:00 P.M. on-coming initials and off-going initials; -12/22/23 6:00 A.M. on-coming initials and off-going initials; -12/22/23 6:00 P.M. on-coming initials and off-going initials; -12/23/23 6:00 A.M. on-coming initials and off-going initials; -12/23/23 6:00 P.M. on-coming initials and off-going initials; -12/24/23 6:00 A.M. on-coming initials and off-going initials; -12/24/23 6:00 P.M. on-coming initials and off-going initials; -12/26/23 6:00 A.M. on-coming initials and off-going initials; -12/26/23 6:00 P.M. on-coming initials and off-going initials; -12/27/23 6:00 A.M. on-coming initials and off-going initials; -12/27/23 6:00 P.M. on-coming initials and off-going initials; -12/28/23 6:00 A.M. on-coming initials and off-going initials. Review of the F Hall Controlled Substance/Emergency Drug Supply, Shift Change Record, dated December 2023, showed there were no initials for the following dates: -12/2/23 6:00 A.M. off-going initials; -12/5/23 6:00 A.M. off-going initials; -12/5/23 6:00 P.M. on-coming initials and off-going initials; -12/6/23 6:00 A.M. off-going initials; -12/11/23 6:00 P.M. off-going initials; -12/12/23 6:00 A.M. off-going initials. Review of the BCD Halls Controlled Substance/Emergency Drug Supply, Shift Change Record, dated December 2023, showed there were no initials for the following dates: -12/2/23 6:00 A.M. off-going initials; -12/5/23 6:00 A.M. off-going initials; -12/5/23 6:00 A.M. on-coming initials; -12/6/23 6:00 A.M. off-going initials; -12/11/23 6:00 P.M. on-coming initials; -12/12/23 6:00 A.M. off-going initials; -12/14/23 6:00 P.M. off-going initials; -12/16/23 6:00 P.M. off-going initials; -12/17/23 6:00 A.M. off-going initials; -12/18/23 6:00 A.M. off-going initials; -12/19/23 6:00 A.M. off-going initials. 2. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 12/7/23 showed: -Severe cognitive impairment; -Occasionally incontinent of bowel and bladder; -Upper extremity impairment on both sides: -Substantial assistance with transfers; -Receives scheduled pain medication; -Receives medication as needed; -Experiences occasional severe pain; -Diagnoses included, Post-Polio syndrome (a disorder of the nerves and muscles that causes pain in the muscles and joints that occurs years after having Polio-a virus that affect a person's spinal cord, causing paralysis), high blood pressure and anxiety. Review of the resident's care plan dated, 12/19/23, showed: -The resident requires assistance with Activities of Daily Living (ADLs) due to weakness; -Provide assistance with bed mobility, transfers, toileting, and showers; -The resident has chronic pain; -The resident will have pain relief at a tolerable level; -Administer pain medications as ordered. Review of the resident's Physician's Order Sheet (POS) dated, 12/1/23, showed start date 10/16/23: Norco (medication used to treat moderate to severe pain) 5/325 milligrams (mg), take one tab by mouth as needed for pain, every six hours. Review of the receipt from the pharmacy, dated 12/5/23, showed: -60 pills of Norco 5/325 mg were delivered to the facility for the resident; -The pharmacy receipt was signed by Licensed Practical Nurse (LPN) B. Review of the resident's individual narcotic record, dated 10/18/23 through 12/18/23, showed no entry for the 60 pills of Norco 5/325 mg delivered on 12/5/23. During an interview on 12/28/23 at 9:47 A.M., Registered Nurse (RN) B said: -On 12/19/23 he/she counted the narcotics during shift change and the inventory was correct at that time; -He/she gave the DON the keys to the narcotic box when he/she went to lunch; -He/she did not remember giving CMT B the keys to the medication cart; -He/she and LPN B counted narcotics at the end of his/her shift and the resident's individual narcotic record showed seven pills of Norco 5/325 mg remaining; -No pills of Norco 5/325 mg for the resident were found in narcotic lock box; -He/she did not count with the DON when he/she returned from lunch; -He/she reported this to the administrator; -Narcotics should be counted every shift and initialed by the on-coming and off-going shifts. During an interview on 12/28/23 at 10:12 A.M., LPN B said: -He/she put the 60 pills of Norco 5/325 mg into the narcotic lock box on 12/5/23; -He/she added the 60 pills of Norco into the resident's individual narcotic record; -He/she did not know why the record did not show his/her entry of 60 pills; -On 12/19/23 he/she and RN B counted the narcotics at shift change and the resident's individual narcotic record showed seven pills of Norco 5/325 mg remaining; -The resident had no Norco 5/325 mg in the narcotic lock box; -He/she told the DON; -Narcotics should be counted every shift and initialed by the on-coming and off-going shifts. A review of CMT B's written statement, dated 12/19/23, showed: -He/she said he/she had permission from the RN B to get as needed pain medications out of the nurse's medication cart; -RN B was setting at the desk and watched him/her remove the medications from the cart; -The keys were given back to RN B. 3. Review of Resident #2's admission MDS dated [DATE], showed: -No cognitive impairment; -Frequently incontinent of bowel and bladder; -Partial assistance with transfers; -Receives scheduled pain medication; -Receives pain medication as needed; -Experiences occasional severe pain; -Diagnoses included, osteoarthritis, heart failure, respiratory failure and depression. Review of the resident's baseline care plan dated, 12/22/23, showed: -The resident requires assistance with ADLs; -Provide assistance with bed mobility, transfers, toileting, and showers; Review of the residents POS dated, 12/1/23, showed: -Start date 12/23/23: Norco 5/325 mg, take one tab by mouth as needed for pain, every eight hours. Review of the stat safe consolidated delivery sheet from the pharmacy, dated 10/3/23, showed eight pills of Norco 10/325 mg were delivered to the facilty to be added the stat safe. Review of the inventory and access records records from the pharmacy dated 9/30/23 through 12/26/23 showed: -LPN A removed one Norco 10/325 from the stat safe and the remaining inventory was seven pills; -CMT B removed one Norco 10/325 mg from the stat safe but then canceled the removal and the remaining count was seven pills; -No other employees accessed the stat safe for Norco 10/325 mg from the time time the medication was delivered until the time it was reported missing. During an interview on 12/28/23 at 10:12 A.M., RN A said: -At 10:15 P.M. on 12/23/23, he/she went to the stat safe to remove one Norco 10/325 mg for the resident; -The stat safe inventory screen showed seven Norco 10/325 mg were inside the safe; -The stat safe was opened and no Norco was found; -He/she immediately called the administrator; -Narcotics should be counted every shift and initialed by the on-coming and off-going shifts. During an interview on 12/28/23 at 10:25 A.M., CMT A said: -Two staff count the narcotics in the lock box on the medication cart; -The staff counting initial the Controlled Substance/Emergency Drug Supply Shift Change Record every shift; -If there is a discrepancy the DON is notified and no one can leave the facility until it is resolved; -He/she was not aware of any discrepancies when he/she worked; -Narcotics should be counted every shift and initialed by the on-coming and off-going shifts. During an interview on 12/28/23 at 12:50 P.M., the administrator said: -On 12/19/23 the DON contacted him/her to report that seven of Resident #1's Norco 5/325 mg tablets were missing; -The DON had not started an investigation as 12/20/23; -The DON had not conducted any monthly narcotic audits; -He/she has suspended the DON at this time; -No incident reports were filed when the missing narcotics were discovered; -The police were not called after the missing narcotics were discovered; -He/she expects the staff to count all narcotics every shift initial on all shifts to confirm the count has been done and is correct; -The facility investigation is inconclusive with regards to how the medications were removed from the facility. MO00229072 MO00229199 MO00229233

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facilty failed to ensure one cognitively impaired resident (Resident #1) was free from sexual abuse by another cognitively impaired resident (Resident #2) when Resident #1 was found in Resident #2's room with the door closed. The door was opened by staff who observed Resident #2 with his/her hand under Resident #1's shirt while resident #2 had his/her pants to his/her ankles, sitting on the side of the bed and fondling his/her genitals. This deficient practice affected one of five sampled resident. The facility census was 59. Review of the facilities undated abuse and neglect policy showed: - Defines sexual abuse as non-consensual sexual contact of any type with a resident. Review of the undated resident rights policy showed each resident has the right to be free from abuse. 1. Review of Resident #1's record showed: - He/She was admitted to the facility on [DATE]; - Diagnoses included: Dementia (a condition characterized by a progressive loss of intellectual functioning that impairs the memory and reasoning), delirium (a state of mind that causes confusion and disorientation; - Brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment; 2. Review of Resident #2's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff) dated 9/14/23 showed: - He/She had a BIMS score of 6, indicating severe cognitive impairment; - He/She was independent with cares; - Diagnoses included: Dementia and impulsiveness. Review of the resident's behavior care plan dated 8/22/23 showed: - He/She was at risk for aggressive behaviors toward others; - Avoid over stimulation such as noise, crowding and other aggressive residents; - Update on 10/14/23 showed he/she was to receive every 15 minute checks when out of his/her room; - Staff were to monitor the resident's location. 3. During an interview on 10/15/23 at 5:49 P.M. Certified Nurse Aide (CNA) A said: - On 10/14/23 at 10:15 P.M. Resident #1 and another resident was in the day room in their wheelchairs. - CNA A pushed the other resident to his/her room to assist him/her to bed at 10:15 P.M.; - CNA A returned to the day room to assist Resident #1 to bed at 10:30 P.M. and the resident was not in the day room. - CNA A alerted Director of Nursing (DON), who was the charge nurse that night, he/she could not find the resident. - The DON alerted the resident of the staff who began looking for the resident. - At 10:40 P.M. Certified Medication Technician (CMT) A arrived at Resident #2's door and was not able to freely open the door. - CMT A pushed on the door and was able to see into the resident's room, CMT A then yelled no, stop to Resident #2. - CNA A saw Resident #2 pulling his/her pants up. - CNA A and CNA B took Resident #1 to his/her room when they noticed the resident was not wearing the shirt he/she had previously been wearing. - Resident #1 told CNA A and CNA B that Resident #2 had been licking his/her breasts. - CMT A found Resident #1's previous shirt in the bottom of Resident #2's closet. During an interview on 10/15/23 at 5:31 P.M. CMT A said: - CNA A alerted the staff that Resident #1 was not in the day room at 10:30 P.M. - He/She tried to enter Resident #2's room and was not able to easily open the door and he/she got it open enough to see Resident #1 in his/her wheelchair, backed up to the door blocking it from opening. Resident #1's shirt was pulled up to expose his/her chest. Resident #2 was siting on the side of his/her bed with his/her pants around his/her ankles reaching over the foot board of the bed with his/her right hand fondling Resident #1's breast while he/she was fondling his/her genitals with his/her left hand. CMT A yelled for Resident #2 to stop touching Resident #1. - CMT A gained entry into the room; CMT A and CNA A entered the room at the same time, Resident #2 stood up and pulled his/her pants up. - Resident #1 giggled and said Resident #2 was his/her spouse. - Resident #2 did not correct Resident #1. During an interview on 10/15/23 at 5:43 P.M. CNA B said: - He/She was alerted Resident #1 was found in Resident #2's room wearing a different shirt. CNA A and CMT A took Resident #1 to his/her room. The resident's pants were disheveled and the brief was undone. - The resident told him/her that Resident #2 touch him/her on his/her pussy cat and it was ok because Resident #2 was his/her spouse. - CNA A and CMT A helped the resident to bed and did not see any bruises or redness to his/her private area. During an interview on 10/15/23 at 4:45 P.M. the DON said: - He/She was the charge nurse during the night of 10/14/23. - CNA A last saw Resident #1 in the day room at 10:20 P.M.; - CNA A returned at 10:30 P.M. and the resident was not in the day room. - CNA A alerted him/her the resident was not in the day room and the staff began looking for the resident; - Resident #1 was found in Resident #2's room, Resident #1 was in his/her wheelchair backed against the door and Resident #2 was sitting on his/her bed. - CNA A and CMT A took Resident #1 to his/her room and assisted him/her to bed; - He/She assessed the resident's skin and did not find any bruises, red areas or torn skin; - Resident #1 was not able to answer his/her questions due to confusion and Resident #2 denied touching Resident #1. - He/She began an investigation and instructed staff to conduct 15 minute checks for both residents; - He/She assessed Resident #2 BIMS score at a 9, indicating moderate cognitive impairment. Review of the facility investigation dated 10/14/23 showed: - CNA A last saw Resident #1 in the day room at 10:20 P.M.; - CNA A returned at 10:30 P.M. and the resident was not in the day room; - CNA A alerted him/her the resident was not in the day room and the staff began looking for the resident; - Resident #1 was found in Resident #2's room, Resident #1 was in his/her wheelchair backed against the door and Resident #2 was sitting on his/her bed. - Resident #1 was wearing a gray long sleeve shirt prior to being found in Resident #2's room, when he/she was found, he/she wore a sleeveless T-shirt. - CNA A and CMT A took Resident #1 to his/her room and assisted him/her to bed; - The sides of his/her brief was unfastened, but no bruises were noted. - Both resident's were placed on every 15 minute checks. - Law enforcement (LE) was notified. During an interview on 10/15/23 at 4:10 P.M. Resident #2 said: - Resident #1 entered his/her room during the evening; - The resident said his/her back itched and he/she wanted a gown; - He/She did not have a gown for the resident to use but let Resident #1 wear one of his/her T-shirts; - Resident #1 removed his/her shirt and placed the T-shirt on. - He/She scratched the resident's back and side but did not touch the resident's chest area or his/her own genitals; - He/She did not touch the resident's genitals; - The staff entered his/her room and took the resident out. Review of the police report dated 10/14/23 showed: - LE arrived at the facility on 10/14/23 at 11:31 P.M.; - Resident #1 was confused and not interviewable; - Resident #2 reported Resident #1 entered his/her room while he/she was watching television; - Both residents watched television for 30 minutes, Resident #1 asked for a snack and Resident #2 provided him/her with one; - Resident #1 asked Resident #2 for money, he/she did not have any to give the resident; - Resident #2 denied sexual contact; - Resident #1 asked Resident #2 for a gown because his/her shirt was itchy, Resident #2 gave him/her the sleeveless T-shirt to wear because he/she did not have a gown. MO225893 MO225901

Based on observation, interviews, and record review, the facility failed to ensure staff followed their policy for accountability and reconcilation of a Schedule II (narcotics/medications with a potential for abusive use and dependence upon the medication) controlled substance for a medication stored in the facility's locked medication cart. This affected one resident (Resident #1). The facility census was 46. Review of the facility's undated Narcotic Count policy showed: -Purpose is to complete a physical inventory of narcotics at each shift change to identify discrepancies. -Controlled substances are available only to licensed nurses, pharmacists, and certified medical technicians. -One registered nurse (RN), licensed practical nurse (LPN), or certified medical technician (CMT) going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of narcotics supply for each individual resident at the change of each shift. -Narcotic records are reconciled by a physical count of the remaining narcotic supply at each shift change by the incoming and outgoing licensed nurse. Records are to be retained for at least one year. Emergency kits containing narcotics will be checked at the same time to be sure seal has not been broken or will be reconciled if seal is broken. -One prescription for a ontrolled substance is entered on one individual narcotic sheet. -After the supply is counted and justified, the nurse/CMT records the date and his/her signature, verifying that the count is correct. -If the count is not accurate, the nurse going off duty is to remain on duty until the count is reconciled and the Director of Nursing (DON) must be notified for further instruction. -Discrepancies found at any time are to be immediately reported to the DON. The DON will initiate an investigation to determine the cause of the discrepancy and contact the pharmacist for assistance as needed. The facility did not provide a policy regarding medication administration. 1. Review of Resident #1's significant change Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated 4/3/23, showed: -Score of 11 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates moderate cognitive impairment. -Requires supervision to limited assistance with activities of daily living, including dressing, bathing, and personal hygiene. -Diagnoses of pain, dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), history of fracture to lower end right radius (one of the two bones that make up the forearm), palliative care (specialized medical care for people living with a serious illness). -Receives scheduled and as needed pain medication. He/she experiences occasional, moderate pain. Review of the resident's comprehensive care plan, dated 7/17/23, showed: -The resident's pain will be relieved at a tolerable level. Review of the resident's physician order sheet (POS), dated May 24, 2023, showed: -Oxycodone 5milligram (mg) tablet. Two 5mg tablets every four hours as needed for pain. Review of receipt from United Scripts Pharmacy, dated 5/3/23, showed: -One card of 60 tablets of 5mg oxycodone tablets was delivered to the facility on 5/3/23. -The receipt was signed by CMT A. There is no date or time with the signature. Review of the facility's Controlled Substance Log, dated 4/22/23 through 5/21/23 showed: -No entry for the card of oxycodone delivered on 5/3/23 for the resident. Review of the Controlled Substance Shift Change Record, dated May 2023, showed: -5/1/23: 6:00 A.M. No staff members initialed medications were reconciled. Number of medications were not recorded. 6:00 P.M. The offgoing staff did not initial medications were reconciled. Number of medications were not recorded. -5/2/23 6:00 A.M. The oncoming staff did not initial medications were reconciled. Number of medications were not recorded. 6:00 P.M. No staff initialed medications were reconciled. Number of medications were not recorded. -5/3/23 6:00 A.M. No staff initialled medications were reconciled. Number of medications were not recorded. 6:00 P.M. The offgoing staff did not initial medications were reconciled. Number of medications were not recorded. -5/4/23 6:00 A.M. The oncoming staff did not initial medications were reconciled. Number of medications were not recorded. 6:00 P.M. No staff initialled medications were reconciled. Number of medications were not recorded. -5/5/23 6:00 A.M. No staff initialled medications were reconciled. Number of medications were not recorded. 6:00 P.M. The offgoing staff did not initial medications were reconciled. Number of medications were not recorded. -5/6/23 6:00 A.M. The oncoming staff did not initial medications were reconciled. Number of medications were not recorded. 6:00 P.M. The offgoing staff did not initial medications were reconciled. Number of medications were not recorded. -5/7/23 6:00 P.M. Number of medications were not recorded. -5/8/23 6:00 P.M. Number of medications were not recorded. -5/9/23 6:00 A.M. The oncoming staff did not initial medications were reconciled. 6:00 P.M. The offgoing staff did not initial medications were reconciled. -5/11/23 6:00 A.M. Number of medications were not recorded. -5/13/23 6:00 P.M. The offgoing staff did not initial medications were reconciled. -5/14/23 6:00 P.M. Number of medications were not recorded. -5/15/23 6:00 P.M. Number of medications were not recorded. -5/16/23 6:00 P.M. Number of medications were not recorded. -5/17/23 6:00 A.M. The oncoming staff did not initial medications were reconciled. Number of medications were not recorded. 6:00 P.M. The offgoing staff did not initial medications were reconciled. Number of medications were not recorded. -5/19/23 6:00 P.M. Number of medications were not recorded. -5/20/23 6:00 P.M. Number of medications were not recorded. -5/21/23 6:00 P.M. The oncoming staff did not initial medications were reconciled. Number of medications were not recorded. -5/22/23 6:00 A.M. Number of medications were not recorded. 6:00 P.M. Number of medications were not recorded. -5/23/23 6:00 P.M. The oncoming staff did not initial medications were reconciled. Number of medications were not recorded. Review of LPN A's statement, dated 5/7/23, showed: -On May 4th on the early A.M. delivery from pharmacy. CMT A handed me Resident #1's card of oxycodone 5mg, 60 tablets. The resident had been aksing for pain meds so I put the card in the cart and went and gave the resident one tablet around 1:00 A.M. I think I also gave her another one that A.M. as well before I left. I remember in report Thursday A.M. telling LPN B that the resident's oxycodone had finally come in and were in the cart when we counted that A.M. When I counted with the oncoming LPN Friday night 5/5/23, the resident's oxycodones were not in the cart. During an interview on 5/23/23 at 3:24 P.M., RN A said: -He/she alerted the DON on 5/7/23 of the missing medication. -A staff member reported to RN A that the resident was in pain. He/she went to get the resident pain medication, and there were no oxycodones in the cart. -RN A called the pharmacy and was told the card of oxycodone was delivered to the facility on 5/3/23. -RN A did not count and reconcile the medication as he/she was not working as the charge nurse but the supervisor on duty. During an interview on 5/23/23 at 3:30 P.M., LPN B said: -He/she was the oncoming nurse on 5/4/23. -He/she counted the controlled medication with the offgoing staff and all medications were there. -He/she didn't work again until 5/8/23. During an interview on 5/23/23 at 3:45 P.M., the DON said: -The resident's oxycodone was reported missing on 5/7/23 by RN A. -The card of oxycodone was delivered by the pharmacy on 5/3/23 but it was not added to the Controlled Substance Log. -CMT A signed for the medication with the pharmacy delivery. He/she then gave it to LPN A. -CMT should not sign for controlled substances. -Staff are expected to enter controlled substances on the Controlled Substance Log. -Staff are expected to reconcile medications when coming onto a shift and leaving a shift, and initial the Control Substance Shift Change Log. During an interview on 5/23/23 at 4:00 P.M., the Administrator said: -The resident received liquid morphine concentrate on 5/3/23, so he/she did not go without pain relief. -The facility replaced the missing oxycodone. MO218285

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to issue a written discharge notice to two residents (Residents #39 and #38). The facility census was 46. The facility did not provide a policy regarding discharge notices. 1. Review of Resident #39's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 7/29/22, showed: -The resident is able to make self understood and understand others. -The resident scored 15 on the Brief Interview for Mental Status (BIMS), a structured evaluation aimed at evaluating aspects of cognition in elderly patients. This indicates the resident is cognitively intact. -The resident has the diagnoses of anemia (a condition in which a person lacks enough healthy red blood cells to carry adequate oxygen to the body's tissues), heart failure, anxiety, depression, respiratory failure and swallowing difficulty with a feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth or are unable to swallow safely). -He/she requires extensive assistance with activities of daily living, including bathing, dressing, personal hygiene and toileting. He/she is frequently incontinent of bowel and bladder. Review of the resident's progress notes showed: -On 8/5/22, the resident was complaining of abdominal pain and was transferred to the hospital. -No documentation was found regarding a discharge notice was sent with the resident to the hospital. Review of the resident's medical record on 9/14/22 showed: -No record of a discharge notice was sent with the resident. 2. Review of Resident #38's admission MDS, dated [DATE], showed: -The resident is able to make self understood and understands others. -He/she scored seven on the BIMS, indicating severe cognitive impairment. -Diagnoses of anemia, heart failure, renal failure (one or both kidneys does not work as well as they should), Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior), anxiety, depression. -He/she requires extensive assistance with activities of daily living, including bathing, dressing, toileting and personal hygiene. Review of the resident's progress notes showed: -The resident was transferred to a local hospital on 8/9/22. -No documentation was found regarding a discharge notice was sent with the resident to the hospital. Review of the resident's medical record on 9/14/22 showed: -No record of a discharge notice was sent with the resident. During an interview on 9/14/22 at 2:45 P.M., Licensed Practical Nurse (LPN) A said: -He/she does not send a discharge notice with a resident when they are sent to the hospital. -He/she was not aware they needed to be doing this. During an interview on 9/15/22 at 3:30 P.M., the Administrator said: -Staff should try to send the notice with the resident or have the resident sign as they leave. However, this is not being consistently done at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform resident's and their family/legal representatives of the bed hold policy at the time of transfer/discharge to the hospital for two residents. (Residents #39 and #38). The facility census was 46. Review of the facility Bed Hold Policy showed: -The facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given 1. upon admission the the facility, 2. at the time of transfer to the hospital or leave, and 3. at the time of non-covered therapeutic leave. 1. Review of Resident #39's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 7/29/22, showed: -The resident is able to make self understood and understand others. -The resident scored 15 on the Brief Interview for Mental Status (BIMS), a structured evaluation aimed at evaluating aspects of cognition in elderly patients. This indicates the resident is cognitively intact. -The resident has the diagnoses of anemia (a condition in which a person lacks enough healthy red blood cells to carry adequate oxygen to the body's tissues), heart failure, anxiety, depression, respiratory failure and swallowing difficulty with a feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth or are unable to swallow safely). -He/she requires extensive assistance with activities of daily living, including bathing, dressing, personal hygiene and toileting. He/she is frequently incontinent of bowel and bladder. Review of the resident's progress notes showed: -On 8/5/22, the resident was complaining of abdominal pain and was transferred to the hospital. -No documentation was found regarding a bed hold notice was sent with the resident to the hospital. Review of the resident's medical record on 9/14/22 showed: -No record of a bed hold notice was sent with the resident. 2. Review of Resident #38's admission MDS, dated [DATE], showed: -The resident is able to make self understood and understands others. -He/she scored seven on the BIMS, indicating severe cognitive impairment. -Diagnoses of anemia, heart failure, renal failure (one or both kidneys does not work as well as they should), Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior), anxiety, depression. -He/she requires extensive assistance with activities of daily living, including bathing, dressing, toileting and personal hygiene. Review of the resident's progress notes showed: -The resident was transferred to a local hospital on 8/9/22. -No documentation was found regarding a bed hold notice was sent with the resident to the hospital. Review of the resident's medical record on 9/14/22 showed: -No record of a bed hold notice was sent with the resident. During an interview on 9/14/22 at 2:45 P.M., Licensed Practical Nurse (LPN) A said: -He/she does not send a bed hold notice with a resident when they are sent to the hospital. -He/she was not aware they needed to be doing this. During an interview on 9/15/22 at 3:30 P.M., the Administrator said: -Staff should try to send the bed hold notice with the resident or have the resident sign as they leave. However, this is not being consistently done at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene for two residents (Resident #23 and #24) out of 12 sampled residents. The facility census was 46. Review of the facility's undated Activities of Daily Living policy, showed: -It is the policy of this facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of the quality of life, and honor and support these principles for each resident; and that the care and services provided are person centered and honor and support each resident's preferences, choices, values, and beliefs. -A resident who is unable to carry out activities of daily living will receive the necessary services needed to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of Resident #23's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 7/4/22, showed: -The resident is sometimes understood and usually understands others. -He/she was unable to complete a BIMS interview. -The diagnoses of traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain), neurogenic bladder (urinary condition in which people lack bladder control due to a brain, spinal cord or nerve problem), quadripalegia ( a form of paralysis that affects all four limbs), and epilepsy (a central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness). -The resident is totally dependent on staff for all activities of daily living, including dressing, bathing, eating, and personal hygiene. -The resident has limitations in range of motion (ROM, how far a person can move or stretch a part of the body, such as a joint or a muscle) to both upper and lower extremities (a limb of the body, such as the arm or leg). Review of the resident's comprehensive care plan, dated 7/12/22, showed: -The resident requires extensive to total assistance from staff for all activities of daily living, including dressing, bathing, bed mobility, and personal hygiene. -The resident can be combative with cares at times. Observation on 9/13/22 at 9:44 A.M., showed: -The resident is laying in bed, partially covered with a blanket. Resident's left leg is uncovered up to the hip and the incontinent brief is visible. -The resident's hair appeared greasy and unkept. -The resident had beard growth of approximately 1/4 of an inch. Observation on 9/13/22 at 3:47 P.M., showed: -Resident is laying in bed, partially covered with a blanket. The resident's lower legs are uncovered. -The resident's hair appears greasy and is sticking up in many areas. -The resident has beard growth of approximately 1/4 of an inch. Observation on 9/14/22 at 12:14 P.M., showed: -The resident is laying in bed and is covered from the waist down with a blanket. -The resident's hair appears greasy and unkept. -The resident has beard growth of approximately 1/4 of an inch. During an interview on 9/14/22 at 12:14 P.M., the resident indicated: -The resident is unable to speak and answers questions by nodding yes or no. -The resident indicated that he did wish to be shaved and have a shower. -The resident indicated that he had not had a shower, but was unable to indicate how long it has been since the last shower. During an interview on 9/14/22 at 1:13 P.M., Certified Nurse Aide (CNA) A said: -The resident does need total care from the staff. -He/she is unsure when the resident last had a shower. -The resident can be combative and refuse care at times. -He/she agreed the resident needed to be shaved and have his/her hair washed and combed. During an interview on 9/14/22 at 1:57 P.M., Licensed Practical Nurse (LPN) A said: -The resident requires total care from the staff. -He/she does not know much about the resident as he/she is fairly new to the facility. 2. Review of Resident #24's quarterly MDS dated [DATE] showed: -Unable to make decisions; -Total dependence upon two staff for ADL's; -Incontinent of bowel and bladder; -Diagnoses of hypertension and traumatic brain injury (TBI, a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain.) Observation from 9/12/22 through 9/15/22 showed the resident's hands were contracted (A permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff.) with the third and fourth fingers on the right hand curled in with long nails. The nails were pressed into the palm of the resident's hand. The nails on both hands were long with a black substance under the nails. During an interview on 09/14/22 at 1:40 P.M. CNA A said: -He/She does provide care for the resident; -He/She will clean the residents nails; -He/she has not done the residents nails in a while. During an interview on 9/15/22 at 2:48 P.M., the Director of Nursing (DON) said: -Care for resident's who are unable to perform their own activities of daily living includes bathing, shaving, clipping nails and cleaning nails, dressing. -The DON's expectation is that care for dependent residents is completed. However, the DON is aware the care is not always done. -Staffing has been an issue. The facility is no longer using agency staff and has begun hiring their own staff. Staff are still being trained on the expectations in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one residents (Resident #92) when the facility failed to conduct skin assessments and a wound care treatment for Resident #92 upon admission. The facility census was 46. The facility did not provide a policy on skin assessment. The facility did not provide a policy on wound care. 1. Resident #92 was admitted to the facility on [DATE] with the diagnoses of deep vein thrombosis (a medical condition that occurs when a blood clot forms in a deep vein), lymphedema (refers to tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the resident's baseline care plan, dated 9/9/22, showed: -The resident's skin is intact. -The resident requires assistance of 1-2 staff members for bed mobility, transferring, toileting, bathing, and personal hygiene. -No approaches addressing the swelling to the resident's legs, bandages to the heels or open area on the outer right lower leg. During an interview on 9/13/22 at 2:20 P.M., the resident said: -He/she admitted from the hospital. He/she has history of lymphedema and a blood clot in the lower left leg. -There is a bandage on the left heel, dated 9/6/22. The resident came from the hospital with this on. He/she is wearing a tall sock on his/her right foot. -The resident said his/her left lower legs are swollen, pink and warm to the touch. He/she said that he/she arrived from the hospital in this condition. An observation on 9/14/22 at 10:22 A.M., showed: -There is a bandage on the right heel, dated 9/6/22. -There is a bandage on the left heel, dated 9/6/22 -There is an area on the outer side of the right lower leg: open area, indented, scabbed, skin around the scabbed area appears bruised. -The resident's left leg is pink and swollen to above the knee. During an interview on 9/14/22 at 10:15 A.M., Licensed Practical Nurse (LPN) A said: -He/she does not know the resident well, as they have been here a short time. -LPN A has not assessed the resident's legs. -LPN A has not seen any orders for legs/heels or see anything in the baseline care plan about the resident's legs. During an interview on 9/14/22 at 10:22 A.M., the resident said: -He/she came from the hospital with the bandages on both of his/her heels. -He/she came from the hospital with the open area to the outer side of the right lower leg. -He/she came from the hospital with swelling to both lower legs. During an interview on 9/15/22 at 2:48 P.M. the Director of Nursing said:\ -Skin assessments for new admission should done on the shift they are admitted on , full body assessment should be done. -Resident come from the hospital with bandages, the dressings should be removed to assess the skin. The only time a dressing is not removed is a compression dressing; -Skin assessments are done weekly after the initial assessment upon admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #24 Position, Mobility Based on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to maintain or improve mobility when staff did not provide range of motion for two residents or a restorative program for contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) prevention and treatment (Resident #23 and #24). The facility census was 46. Review of the facility Restorative Program policy, dated May 2006, showed: -It is the purpose of this policy to see that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and care plan. -It is the entire staff's responsibility to prevent deterioration and further functional loss of each resident in the facility. The objective is to provide restorative care necessary to meet needs of all residents to enable them to achieve the standard of care. -Restorative Services are to be made available seven days per week, per the resident's assessed needs. -Mechanism for monitoring and on-going evaluation of the restorative program must be established. 1) Review of Resident #23's annual MDS, dated [DATE], showed: -The resident is sometimes understood and usually understands others. -He/she was unable to complete a BIMS interview. -The diagnoses of traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain), neurogenic bladder (urinary condition in which people lack bladder control due to a brain, spinal cord or nerve problem), quadriplegia ( a form of paralysis that affects all four limbs), and epilepsy (a central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness). -The resident is totally dependent on staff for all activities of daily living, including dressing, bathing, eating, and personal hygiene. -The resident has limitations in range of motion (ROM, how far a person can move or stretch a part of the body, such as a joint or a muscle) to both upper and lower extremities (a limb of the body, such as the arm or leg). Review of the resident's Physician Orders, dated September 2022, showed: -No orders for physical or occupational therapy or for restorative nursing. Review of the resident's comprehensive care plan, dated 7/12/22, showed: -No problems or approaches addressing the resident's limited range of motion. -No problems or approaches addressing the resident's hands which are curled into fists, turned into the chest. Observation on 9/13/22 at 9:44 A.M., showed: -Resident's hands are formed into fists and curl inward toward his/her chest. During an interview on 9/15/22 at 2:48 P.M., the Director of Nursing (DON) said: -The facility does not currently have a restorative nursing program, but does have a restorative nursing aide. -An assessment of a residents ROM should be included in the baseline and comprehensive care plans. -Every resident should be screened for appropriateness and need for therapy and restorative program. -Residents with contractures should be identified what the best approaches are for them, such as rolled washed clothes, splints, braces. These approaches should be care planned. -Any resident who has an issue with joint mobility should have a care planning addressing this. 2. Review of Resident #24's quarterly MDS dated [DATE] showed: -Unable to make decisions; -Total dependence upon two staff for ADL's; -No impairment of the upper or lower extremities -No therapy or restorative nursing marked -Incontinent of bowel and bladder; -Diagnoses of hypertension and traumatic brain injury (TBI, a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain.) Observation 9/12/22 at 11:38 A.M. showed: -The both of the resident's fingers were curled in toward his/her palm, both index fingers were bent outward. The third and fourth finger on the right hand was curled in the the nails into the palm; -The resident did not have any splints on or hand rolls in between the fingers and the palm. During an interview on 9/13/22 at 5:17 P.M. Family Member A said: -I have discussed his/her contractures with the facility staff -The resident has not received any therapy that he/she is aware of. Review of the resident's medical record on 9/14/22 at 12:54 P.M. showed: -There was no documentation for Occupational Therapy (OT) or Physical Therapy (PT) -No documentation for Restorative Nursing or any documentation regarding the contractures of both hands. During an interview on 9/14/22 at 1:15 P.M. the Occupational Therapist said: -The resident has never been evaluated for therapy. No one has requested an assessment for the resident. During an interview on 9/14/22 at 1:30 P.M. the Restorative Aide said: -He/she works with the residents 3 times a week, Monday through Friday. -He/she provides restorative care for 13-14 residents; -He/she does not work with either resident. During an interview on 09/14/22 at 1:40 P.M. Certified Nurse Aide (CNA) A said: -He/she does not do anything with the residents hands that is contracted because of his/her last two fingers being contracted. -He/she is not aware as to whether the resident is receiving therapy or ROM. -He/she does not do ROM. During an interview on 9/14/22 at 1:47 P.M. LPN A said: -The resident does have contractures of both his/her hands and has a hard time moving/raising his/her shoulders. -He/she is not aware of any restorative nursing for the resident. During an interview on 9/14/22 at 02:00 P.M. the DON said: -The resident was admitted with contractures -The CNA's are to try and do ROM with cares. They are to documented in Point Of Care (a tool used by the nursing staff to document cares in the electronic medical record). -The resident should have ROM for contractures. -She had not thought about splinting or an assessment for the use of splints

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call lights were within the reach of residents and accessible for use within the residents room for two residents (Resident #24 and #28). The facility also failed to provide all residents with home-like dinnerware during meal service, and failed to give Resident #31 a wheelchair that properly fits him/her, in a timely manner. The facility census was 47. The facility did not provide a policy regarding call light accessibility. The facility does not have a policy pertaining to proper dinnerware. 1. Observation and interviews of the Dining Room on 9/12/22 at 12:10 P.M. showed: -The salad was served out of a styrofoam bowl and dessert was on a paper plate. The salad fork was plastic. -Numerous residents within the dining room and in their rooms said that they have been served on plastic plates and in styrofoam containers. They do not know why and wondered if the facility did not have enough dishes to serve food on. During an interview on 9/15/22 at 11:51 A.M. with Dining Room Supervisor (DRS) states: -Salad bowls and dessert plates are either styrofoam or plastic as the facility currently does not have any regular bowels or dessert plates. Hall trays get hinged styrofoam containers as they do not get returned in a timely manner to be cleaned or even returned sometimes at all. During an interview on 9/15/22 at 2:12 P.M. with the Registered Dietician (RD), he/she stated: -Everything should be on regular plates as this is the resident's home; it should be homelike. Residents should not be eating off of styrofoam or paper. 2. Review of Resident #31's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by staff, dated 7/21/22 showed: -The resident was admitted to the facility on [DATE]; -Alert and oriented and able to answer questions; -Limited assistance of one staff member for transfers, dressing, toilet use and personal hygiene; -Wheelchair for mobile device; During an observation on 9/13/22 at 9:33 A.M. showed: -The resident sat in a wheelchair with the metal bars at mid thigh height pushing into the residents skin. During an interview on 9/13/22 at 8:55 A.M. with the Director of Nursing (DON), it was said: -He/she talks to Therapy to make sure they have the proper size wheelchair to give to a resident. During an interview on 9/15/22 at 11:27 A.M. the resident said: -His/her tail bone hurts while sitting in wheelchair. He/she could use a bigger wheelchair. He/she has been asking for months for a bigger wheelchair. -Therapy brought one down last week to try out, but has not been back since. -The sides of the wheelchair cuts into his/her thighs and hurts the back of his/her legs. During an interview on 9/15/22 at 10:29 A.M. Occupational Therapist (OT) said: -Another chair was tried, but that trialwheelchair needed adjustments. It was also too tall for the resident to use. -Another resident is currently using the trialed wheelchair as his/her power chair broke down, but Therapy will give the new wheelchair to the resident once it is available. -There had been a wheelchair given to the resident before his/her room move and it fit him/her better, but it had disappeared. -Therapy has been busy and has only been able to do a visual assessment and has no entered the measurement on paper or the computer yet. measured resident for proper wheelchair. 3. Review of Resident #24's quarterly MDS dated [DATE] showed: -Unable to make decisions; -Dependent upon staff for Activities of Daily living (ADL's); -Diagnoses of hypertension, traumatic brain injury (TBI - usually results from a violent blow or jolt to the head or body.) Observations on 9/12/22 at 11:37 A.M. and 9/13/22 at 1:17 P.M.,. during resident cares showed: -The residents pressure pad call light was on the over bed table and not within reach of the resident. -And on the floor, not within reach of the resident. During an interview on 9/14/22 at 9:55 A.M. Certified Nurse Aide (CNA) A said: - Call lights should be answered within a timely manner - Staff are alerted to call lights at the nurses desk and above residents doors - Resident has a sensitive call light, the pressure pad. - He/she will clip the call light to blanket, wrap around chair/bed. - He/She would place within reach of resident. During an interview on 9/14/22 at 10:04 A.M. CBA B said: - The resident is capable to push his/her call button. - He/she will clip on blanket or shirt During staff interviews on 9/14/22 at Licensed Practical Nurse (LPN) B said: - Call lights should be within reach of resident. If resident is sitting in recliner or chair, will place next to them. If in bed, will wrap around bed rail or attach to resident's chest. - Response time should be within 1-2 minutes at least to acknowledge. - Would bring staff to the room and educate staff or play, what's wrong with this picture. - The resident is capable of pushing his/her call light. 4. Review of Resident #35's quarterly MDS dated [DATE] showed: -Unable to make decisions; -Supervision to limited assistance of one staff member for ADL's; -Diagnoses of hypertension, peripheral vascular disease (PVD-a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel can cause PVD. PVD may affect any blood vessel outside of the heart including the arteries, veins, or lymphatic vessels), seizure disorder, and anxiety. During observation on 9/12/22 at 2:43 PM showed the residents call light was at foot of the bed with the cord wrapped up in comforter and not in reach of resident. -The Resident was wanting water. Residents lips were very dry. Water cup was sitting on residents dresser out of reach. During observation on 9/14/22 at 10:40 AM showed: -The resident stating he/she needed to to have a bowel movement. -The call light was not visualized on the bed or within the resident's reach; - LPN A asked the resident if he/she needed to go to the bathroom. The resident was observed shaking his/her head yes. LPN A could not locate the call light and pushed the call light on the wall. During an interview on 9/14/22 at 9:55 A.M. CNA A said: - Call lights should be answered within a timely manner - Staff are alerted to call lights at the nurses desk and above residents doors - 9 times out of 10, the resident will holler out or if he/she is having a good day, he/she will push the call light button. - He/she will clip the call light to blanket, to them or wrap around chair/bed. - He/she would place within reach of resident if it was not. During an interview on 9/14/22 at 10:04 AM, CNA B said: -The resident confused is not sure he/she knows why he/she pushes the button - He/she would clip the call light on blanket or shirt During an interview on 9/14/22 at 10:11 A.M. LPN B said: - Call lights should be within reach of resident. If resident is sitting in recliner or chair, will place next to them. If in bed, will wrap around bed rail or attach to resident's chest. - Response time should be within 1-2 minutes at least to acknowledge. - Would educate staff or play, what's wrong with this picture. - The resident sometimes will push call light but will the will yell out. During an interview on 9/15/22 at 2:48 P.M. the Director of Nursing said: -Call lights should be accessible at all times. They should be clipped to divider curtain . The call lights should not be on the floor and not accessible to the resident -Call lights should be answered within 5 minutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to clarify the status of the advanced directives of two residents (Residents #6 and #35) of 12 sampled residents. The facility census was 47. The facility did not provide a policy on advanced directives. 1. Review of resident #6's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated [DATE] showed: -admitted to facility on [DATE] with a Brief Interview for Mental Status (BIMS) of an 8 out of a possible 15. A score of 8 indicates resident is considered to be mildly impaired. -Review of the Annual MDS dated [DATE] resident has a BIMS of 6 equals very severe impairment. Review of resident #6's medical record on [DATE] at 2:18 P.M. showed: - An incapacitation letter (A letter of incompetency is a statement from a physician certifying that a person is incapable of making informed decisions about their health care, finances, and estate.) and Durable Power Of Attorney (DPOA) were on file. -The incapacitation letter showed that he/she was declared incapacitated on [DATE] in which only one physician's signature was signed. -Per the state statue: Unless the patient expressly authorizes otherwise in the power of attorney, the powers and duties of the attorney in fact to make health care decisions shall commence upon a certification by two licensed physicians based upon an examination of the patient that the patient is incapacitated and will continue to be incapacitated for the period of time during which treatment decisions will be required and the powers and duties shall cease upon certification that the patient is no longer incapacitated. -The DPOA form was signed on [DATE] by himself/herself when he/she was already deemed incapacitated. During an interview on [DATE] 10:36 A.M. the Social Services Designee (SSD) stated: -Before ever having someone become incapacitated, staff are to get DPOA forms in place and notarized. It is not the procedure to have the resident become incapacitated first, then get DPOA forms in place and notarized. There are no other DPOA forms on file before [DATE]. His/her original admission date was [DATE] with a re-admission date of [DATE] from a local hospital. 2. Review of Resident #35's Face Sheet showed the resident was admitted to the facility on [DATE] with a Do Not Resuscitate (DNR) code status. Review of resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated [DATE] showed: - A BIMS (Brief Interview for Mental Status) of 6, (which indicates very severe impairment); - There is no evidence of an acute change in mental status from the residents baseline. - Quarterly review assessment dated [DATE] does not show a change in mental status. Review of resident's care plan for DNR code status, dated [DATE] showed staff included the following: - The resident has a DNR code status - Goal: Consent to withhold Cardiopulmonary Resuscitation (CPR) (An emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) will be honored for the next 90 days. Review of resident's physician orders dated [DATE] indicted the resident's code status as DNR. During record review on [DATE] at 12:31 P.M., records showed: - DNR signed by resident on [DATE] and a physician was appointed as Durable Power of Attorney/Power of Attorney (DPOA/POA) for health care. - Out of Hospital DNR signed by DPOA on [DATE]. - There were no letter of incapacitation on file. During interview on [DATE] at 9:33 A.M., the Social Services Designee (SSD) said: - Resident had not been deemed incapacitated at this time. - His/her DPOA or the psychiatrist, would have to give the doctor authorization to examine him/her to determine if he/she is incapacitated. - The POA will say how many signatures are needed for incapacitation. During an interview on [DATE] at 2:48 P.M., the DON said: - Her expectations are for staff to ask questions as part of the admission process to obtain an advanced directive upon admission and will give the DNR form or POA form. - Throughout residents stay, the SSD, Administrator and DON talk with residents about advanced directives. - They read the advanced directive to determine how many MD's are needed for incapacitation letter; -A resident cannot be declared incapacitated then sign a DNR.

**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 care plan with the resident's specific conditions, needs, and risks to provide effective person centered care for two residents ( Resident #23 and Resident #24) out of the 12 sampled residents. The facility census was 47. Facility's care plan comprehensive policy provided from their nursing guideline manual states: - Purpose: An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well -being. - Guidelines: The interdisciplinary care plan team with input from the resident, family, and or legal representative, will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to the MDS (Minimum Data Set- A federally mandated assessment completed by facility staff). A well developed care plan will be oriented to: Prevention, Risk Factors, Preservation, Assessing, Addressing, Managing, and Approaches to end of life care. A periodic review by the interdisciplinary team when a significant change in condition as occurred, or quarterly, when changes occur that impact the residents care. 1. Review of Resident #23's annual MDS, dated [DATE], showed: -The resident is sometimes understood and usually understands others. -He/she was unable to complete a BIMS interview. -The diagnoses of traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain), neurogenic bladder (urinary condition in which people lack bladder control due to a brain, spinal cord or nerve problem), quadriplegia ( a form of paralysis that affects all four limbs), and epilepsy (a central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness). -The resident is totally dependent on staff for all activities of daily living, including dressing, bathing, eating, and personal hygiene. -The resident has limitations in range of motion (ROM, how far a person can move or stretch a part of the body, such as a joint or a muscle) to both upper and lower extremities (a limb of the body, such as the arm or leg). Observation on 9/13/22 at 9:44 A.M., showed: -Resident's hands are formed into fists and curl inward toward his/her chest. Review of the resident's comprehensive care plan, dated 7/12/22, showed: -No problems or approaches addressing the resident's limited range of motion. -No problems or approaches addressing the resident's hands which are curled into fists, turned into the chest. 4. Review of Resident #24's quarterly MDS dated [DATE] showed: -Unable to make decisions; -Totally dependent upon two staff members for Activities of Daily Living (ADL's) -No limitations or impairments of the shoulder, wrist or hands on either side; -No therapies or Restorative Nursing. Review of the resident's care plans showed no care plan for the contractures of the hands. Observation on 9/12/22 at 11:38 A.M. showed the resident lying in bed with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and both index fingers. During an interview on 9/13/22 at 5:17 P.M. Family Member (FM) A said: - During the resident's admission and care plan meetings we have discussed his/her contractures; -The resident was in a car accident which caused them. -He /she is not aware of any therapy for the contractures. During an interview on 9/14/22 at 1:15 P.M Occupational Therapist (OTR) A said: -The resident has never been evaluated for therapy. No one has requested an assessment for the contractures. During an interview on 9/15/22 1:30 P.M. the MDS coordinator said: -He/she is aware that the care plans are not up to date with the resident's condition, the facility is not having risk management meetings, interventions are not being put in place due to not having meetings and discussing the concerns. -He/she will look at electronic medical record for charting from nursing staff and look at progress notes, review new orders, look at facility report which will show last 24 hours for any changed. During an interview on 9/15/22 at 2:48 P.M. the Director of Nursing said: -Care plan should be accurate and revisions should be made as the resident's condition changes. -The facility does not currently have a restorative nursing program, but does have a restorative nursing aide. -An assessment of a residents ROM should be included in the baseline and comprehensive care plans. -Every resident should be screened for appropriateness and need for therapy and restorative program. -Residents with contractures should be identified what the best approaches are for them, such as rolled washed clothes, splints, braces. These approaches should be care planned. -Any resident who has an issue with joint mobility should have a care planning addressing this. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #24's admission MDS dated [DATE] showed: - The resident was admitted to the facility on [DATE]; - Alert and oriented and able to answer questions and complete interview; - Activity Preference Assessment was not completed; - Functional Status: - Total dependence for full staff dependence every time during entire 7 day period with 2+ persons physical assist for bed mobility and transfer. - Total dependence for full staff dependence every time during entire 7 day period with 1 person physical assist for eating, toileting, hygiene and bathing. - Extensive assistance for full staff dependence every time during entire 7 day period with 2+ persons physical assist for dressing. - Extensive assistance for full staff dependence every time during entire 7 day period with 1 person physical assist for location on unit and location off unit. - Wheel chair for mobile device; - Dependent for mobility; - Frequently incontinent; - Diagnoses of Hypertension, Gastroesophageal Reflux Disease (GERD) (a digestive disorder that affects the ring of muscle between your esophagus and your stomach) or Ulcer, Neurogenic Bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition), Urinary Tract Infection (UTI) (Last 30 days), Traumatic Brain Injury (TBI) (an injury that affects how the brain works). Review of resident's care plan, dated 4/1/22 showed nothing to address activities. Observation on 9/12/22 at 2:43 P.M. showed: - Resident was observed laying in bed with radio and TV on in his/her room. - Resident shares a room with another resident. - One television was centered in the room in view of both residents however the television was turned off. - Privacy curtain was pulled shut and room was dark. - No staff to resident interactions were observed. - No activity calendar was observed in residents room. - No activities were observed or posted in the facility; - No activities were listed on the large activity calendar board near the Dining Room. The last month it showed was for the month of May. -Observation from 9/12/22 to 9/15/22 at various times of the day showed the resident was not seen participating in any activities and was observed either laying in bed or laying in wheelchair in his/her room throughout each day. During observation on 9/14/22 atn10:29 A.M. showed: -The resident was dressed in a gray long sleeve shirt, purple pants and tennis shoes. -Licensed Practical Nurse (LPN) A, would be taking resident up in his/her wheelchair to the lobby area. Resident was never brought out of room this entire day. Review of activity attendance sheet dated for 9/13/22 showed: - Ice Cream Social held before lunch at 11:00 A.M. showed resident did not attend. - Paint with [NAME] held at 2:00 P.M. showed resident did not attend. Review of activity attendance sheet dated for 9/14/22 showed: - Exercise at 9:00 A.M. showed resident did not attend. - Halloween Bingo at 10:30 A.M. showed resident did not attend. - Birthday Party at 11:00 A.M. Review of the resident's medical record showed no documentation of activity participation or activity interests. During an interview 9/13/22 at 5:17 P.M., Family Member (FM) A said: - Staff has been requested to have resident moved out of his/her bed at least once a day, placed in wheelchair and taken to lobby area to interact with other residents. 4. Review of Resident #35's care plans, dated 4/29/22 showed: - Focus of psychosocial well-being: Lifestyle change resulting in admission to facility. - Short Term Goal with a target date of 11/10/22: Resident to verbalize verbalize feelings related to placement in facility throughout the next 90 days. - Interventions: Staff will allow time for resident to verbalize his/her feelings and assist in facilitating development of new friends; discuss problem solving methods with resident and encourage resident to attend activities out of her room. -Focus of activities: I attend activities that I enjoy with encouragement from staff. - Short Term Goal with target date 11/10/22: I will continue to attend activities that I enjoy as long as I am able. - Interventions: Discuss with me the activities offered while visiting with me; Encourage me to drink fluids and have a snack during activities; Encourage me to socialize during group activities and give me an activity calendar and remind me of upcoming activities. -Focus of communication: Resident is Alert and Oriented (A&O) times two. However at times resident is disorientated to places, time, or other events. He/she can become confused at times. - Short Term Goal with target date of 11/10/22: Resident will be free from any injury/harm related to (r/t) any disorientation and/or confusion that he/she may experience throughout the next 90 days. -Interventions: Allow resident to make simple decisions r/t care such as what activities to attend, what to eat within dietary guidelines, what time of day to take a shower, etc.; breakdown activities/ADL's (activities of daily living) into manageable segments prn (as needed); Encourage resident to attend activities as offered and provide him/her with an activity calendar for his/her room. Review of the admission MDS dated [DATE] showed: - The resident was admitted to the facility on [DATE]; - Alert and oriented and able to answer questions; - Activity Preference Assessment was not completed; - Limited assistance of one staff member for transfers, dressing, toilet use and personal hygiene; - Wheel chair for mobile device; - Partial to moderate assistance for mobility; - Diagnoses of Hypertension, Peripheral Vascular Disease (a slow and progressive circulation disorder) or Peripheral Arterial Disease (the narrowing or blockage of the vessels that carry blood from the heart to the legs), Seizure Disorder or Epilepsy, Anxiety and Asthma, Chronic Obstructive Pulmonary Disease or Chronic Lung Disease (a group of diseases that cause airflow blockage and breathing-related problems). Observation on 9/12/22 at 2:43 P.M., showed: - Resident was observed laying in bed. - Resident shares a room with another resident. - One television was centered in the room in view of both residents however the television was turned off. - Privacy curtain was pulled shut and room was dark. - No staff to resident interactions were observed. - No activity calendar was observed in residents room. Review of residents physician order dated 4/29/22 showed: - Order has an open end date. - ACTIVITY: May participate in activities as tolerated. Review of activity attendance sheet dated for 9/13/22 showed: - Paint with [NAME] held at 2:00 P.M. showed resident did not attend. Review of activity attendance sheet dated for 9/14/22 showed: - Exercise at 9:00 A.M. showed resident did not attend. - Halloween Bingo at 10:30 A.M. showed resident did not attend. - Birthday Party at 11:00 A.M. showed the resident did not attend. Review of the residents medical record showed no documentation for the residents activity interests or the residents activity participation. 5. Review of Resident #39's MDS dated [DATE], showed: -The resident is able to make self understood and understand others. -The resident scored 15 on the Brief Interview for Mental Status (BIMS), a structured evaluation aimed at evaluating aspects of cognition in elderly patients. This indicates the resident is cognitively intact. -The resident has the diagnoses of anemia (a condition in which a person lacks enough healthy red blood cells to carry adequate oxygen to the body's tissues), heart failure, anxiety, depression, respiratory failure and swallowing difficulty with a feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth or are unable to swallow safely). -He/she requires extensive assistance with activities of daily living, including bathing, dressing, personal hygiene and toileting. He/she is frequently incontinent of bowel and bladder. -He/she is interested in books, newspapers, following the news, going outside and religion. Review of the residents comprehensive care plan, dated 8/5/22, showed: -The resident requires assistance to attend activities. -Inform the resident of activities, assist the resident to activities of interest. During an interview on 9/13/22 at 10:14 A.M., the resident said: -He/she does not know of any activities that are given in the building. -No one brings any activities to his/her room. 6. Review of Resident #38's admission MDS, dated [DATE], showed: -The resident is able to make self understood and understands others. -He/she scored seven on the BIMS, indicating severe cognitive impairment. -Diagnoses of anemia, heart failure, renal failure (one or both kidneys does not work as well as they should), Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior), anxiety, depression. -He/she requires extensive assistance with activities of daily living, including bathing, dressing, toileting and personal hygiene. -He/she is interested in books, newspapers, magazines, music, pets, following the news, going outside and religion. Review of the residents comprehensive care plan, dated 8/22/22, showed: -He/she would like to attend activities and remain active. -The resident requires assistance to attend activities. -Inform the resident of activities, assist the resident to activities of interest. During an interview on 9/13/22 at 9:53 A.M., the resident said: -He/she is not aware of any activities offered in the facility. 7. Review of Resident #23's annual MDS, dated [DATE], showed: -The resident is sometimes understood and usually understands others. -He/she was unable to complete a BIMS interview. -The diagnoses of traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain), neurogenic bladder (urinary condition in which people lack bladder control due to a brain, spinal cord or nerve problem), quadriplegia ( a form of paralysis that affects all four limbs), and epilepsy (a central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness). -The resident is totally dependent on staff for all activities of daily living, including dressing, bathing, eating, and personal hygiene. -The resident has limitations in range of motion (ROM, how far a person can move or stretch a part of the body, such as a joint or a muscle) to both upper and lower extremities (a limb of the body, such as the arm or leg). -He/she is interested in books, newspapers, music, following the news, going outside, and religion. Review of the residents comprehensive care plan, dated 8/12/22, showed: -The resident requires assistance to attend activities. -Inform the resident of activities, assist the resident to activities of interest. Observation on 9/13/22 at 9:44 A.M., showed: -The resident is laying in bed, partially covered with a blanket. -There is no television or radio on. Observation on 9/13/22 at 3:47 P.M., showed: -Resident is laying in bed, partially covered with a blanket. The resident's lower legs are uncovered. -There is no television or radio on. Observation on 9/14/22 at 12:14 P.M., showed: -The resident is laying in bed and is covered from the waist down with a blanket. -There is no television or radio on. During an interview on 9/13/22 at 9:41 A.M., the resident indicated: -There are no activities offered. -Indicates he/she spends time in bed, activities are not brought to his/her room. During interview on 9/15/22 at 9:05 A.M., the Director of Nursing said: - The Activity aide was recently put back into housekeeping position. - The Business office manager helps with activities. - They did have an activity schedule. - Activities Director is supposed to get a calendar. - Activities are not a 5 day a week program. - Her expectations are for activities to be done 2 times a day but admits this had not been happening. - Was not able to provide activity assessments for the resident and admitted on e was not completed. - Was not able to provide activity participation sheets for the residents, and admitted that participation sheets have not been done; - The last calendar of activities they had created was in May of 2022. During interview on 9/15/22 at 9:40 A.M., the Activities Director said: - He/she as been employed at the facility for 5 months. - He/she he has started an online activity class 2-3 months ago. - He/She does activities on Monday, Tuesdays and Wednesdays. - He/She does not do activities on Thursdays, Friday's and Saturdays as he/she works housekeeping. - Does 1 on 1 with residents sometimes and will have those residents write what they want to do. - Wednesdays are free days for residents to do whatever the resident wants to do. - Have group activities 2 times a month which includes music and more hands on activities. - He/She does not document activity attendance in computer as he/she does not have access to a computer. She keeps track on paper which is in his/her office. - Will have volunteers come in for different activities: piano, talent show, pets and books from the library. - Social Services/admission Nurse types up activities calendar since he/she does not have access to the computer to print off. During interview on 9/15/22 at 11:00 A.M., the Business Office Manager said: - He/she has helped with activities 3-4 times since starting work at the facility in March of this year; -He/she held an exercise class today from 9:00 A.M. to 9:20 A.M. and also had Halloween Bingo from 10:00 A.M. to 10:45 A.M. Yesterday the residents painted pumpkins and there was an ice cream social. This is the first time he/she has done activities in a long time - He/she gave the attendance sheets to the facility administrator. During interview on 9/15/22 at 11:20 A. M., the Social Services/admission Nurse said: - If the activities director asks for help, she will help out but does not do hands on. -He/she has not done any activities. During interview on 9/15/22 at 3:30 P.M. the Administrator said: - Activities are to be meaningful and conducting. - He would expect activities should be done every day, do self directed activities and unable, do one on one with the activities director. - Currently do not have a full time activities director. - Is aware activities have been lacking and is of concern. - Currently working on team building. Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the resident's interests for seven residents (Resident #6 #39, #38, #23, #31, #35 and #24) out of 12 sampled residents. The facility census was 47. Review of Resident Activities Policy on 9/15/22 at 1:52 P.M. showed: -An activity program is planned for each resident as part of their total resident care by the Activity Director, in cooperation with Nursing and with Physician approval. Residents shall be encouraged, but not forced, to participate in activities of choice. -An individualized program will be implemented for residents unable to participate in or attend. 1. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by staff, dated 9/12/22 showed: -Brief Interview for Mental Status (BIMS It is a screen used to assist with identifying a resident's current cognition ) was a 10 out of 15 which showed moderately impaired decision making. -Alert and oriented and able to answer questions; -Limited assistance of one staff member for transfers, dressing, toilet use, and personal hygiene; -Wheelchair for mobile device; -The Activity Section was not completed. Review of the medical record showed no Activity Preferences Assessment completed or any documentation of participation in activities Observation on 9/12/22. 9/13/22, 9/14/22 and 9/15/22 showed no Activity calendar in the resident's room. There was no Activities listed on the large activity board in the hall way by the main dining room. During an interview on 9/12/22 at 11:49 A.M. Resident #6, he/she said: -No activities are offered. He/she would like something to do. 2. Review of Resident #31's quarterly MDS dated [DATE] showed: -The resident was admitted to the facility on [DATE]; -Alert and oriented and able to answer questions; -Limited assistance of one staff member for transfers, dressing, toilet use and personal hygiene; -Wheelchair for mobile device; -The activity assessment was blank. Review of the medical record showed no Activity Preferences Assessment completed or any documentation of participation in activities. Observation on 9/12/22. 9/13/22, 9/14/22 and 9/15/22 showed no Activity calendar in the resident's room. During an interview on 9/13/22 at 11:33 A.M. the Resident said: -He/she is not aware of any activities; -He/she is not told of any activities, there is no activity calendar -He/she was unaware of the ice cream social and would have liked to have known in advance so that he/she could attend. -Resident plays games on his/her phone.

Based on observations, interviews, and record review the facility failed to prepare and serve foods that were attractive and palatable to residents. The facility census was 47. Review of Test Meals policy dated April 2011 states: The test meals will be tested at point of delivery to residents. 1. The meal tested should vary (All meals should be examined.). 2. The destination of the tray will also vary. 3. The diets that are tested will be regular and pureed. 4. The test tray will be the last tray on the cart and is tested after all other trays have been served. 5. The Dining Services Manager is responsible for these guidelines. 6. Hot foods should be delivered to the resident at least 120 degrees Fahrenheit (F). 7. Cold foods should be delivered to the resident at 40 degrees F or below. Review for Refrigerator and Freezer Temperatures policy dated April 2011 states: 1. Temperature of refrigerators should be 33-40 degrees F. 2. There should be a thermometer in all refrigerators and freezers. Thermometers should be located in front of the unit. 3. Temperatures should be checked regularly in refrigerators, at least every morning and evening. Observation and tasting of pureed food on Wednesday 9/14/22 at 12:20 P.M. showed: -The carrots, mashed potatoes, pureed meat and gravy were served in bowls; all three bowls were left on the counter without a cover . -Carrots were at 101.5 degrees -Mashed potatoes were at 147.6 degrees -Pureed meat and gravy was at 87 degrees -Pureed carrots were not carrots as what was on the menu, but sweet potatoes from lunch on 9/13/22. -Mashed potatoes were bland and stiff (too thick). -Pureed beef was stringy and gritty. Temperature was cold. -There was not any pureed bread and butter or dessert. During an Interview on 9/14/22, at 3:17 P.M. [NAME] A stated: -Pureed consistency should be like mashed potatoes. -Food on steam table should not be below 165 degrees. -Pureed temperature is at 170 degrees. -At times, he/she does try the pureed food for taste, consistency, and temperature. During an Interview on 9/15/22, at 8:46 A.M. the Dietary Manager (DM) said: -Hot food temperatures are expected as such: eggs 165 degrees, meat 165 degrees or higher, oatmeal 170 degrees or higher. Puree consistency is to be like baby food-smooth and easy to swallow. During an Interview on 9/15/22 at 2:12 P.M. the Registered Dietician (RD) said: - Pureed food should be like a light whipped potato. A spoon should not stand straight up while put in. Hot food should be at least 135 degrees or higher before serving.

Based on observation, interview and record review, the facility failed to ensure dietary staff served hot foods hot when they did not take temperatures of pureed foods prior to meal service and did not follow their policy to serve food at least 120 degrees Fahrenheit. The facility census was 47. Review of the undated facility policy for Food storage showed 1. Proper labeling and dating of all foods. All foods will be considered as leftovers unless in the original container with an expiration date. Leftovers will be discarded after third (3rd) storage day. 2. All food will be stored in appropriate containers. 3. Resident foods will be stored in a designated specific storage area, unless resident has a personal refrigerator in their room. 4. Resident food storage areas will be identified. Monitoring Temperatures: 1. Refrigerator temperatures will be monitored on a routine and consistent basis. 2. Thermometers will be intact and maintained. Test Meals: The test meals will be tested at point of delivery to residents. 1. The meal tested should vary (All meals should be examined.). 2. The destination of the tray will also vary. 3. The diets that are tested will be regular and pureed. 4. The test tray will be the last tray on the cart and is tested after all other trays have been served. 5. The Dining Services Manager is responsible for these guidelines. 6. Hot foods should be delivered to the resident at least 120 degrees F. 7. Cold foods should be delivered to the resident at 40 degrees F or below. Refrigerator and Freezer Temperatures: 1. Temperature of refrigerators should be 33-40 degrees F. 2. There should be a thermometer in all refrigerators and freezers. Thermometers should be located in front of the unit. 3. Temperatures should be checked regularly in refrigerators, at least every morning and evening. 4. Temperature of freezers should be 0 degrees or below. 5. Refrigerator and freezer temperatures should be logged twice daily. Dishwasher Temperatures: 1. High temperature machines (three cycles): A. Pre-wash: 0-110 degrees F. B. Wash cycle: 150 degrees F. C. Final rinse: 180 degrees F. 2. High temperature machine-single temperature: 165 degrees F. 3. Chemical sanitizer machine: Range to be effective- 75-120 degrees F. 4. The dish machine temperatures will be recorded for the wash and rinse cycle daily for chemical sanitized (in addition to a sanitizer test strip), or each meal for high temperature sanitized or as directed by the Consultant Dietitian. Observation on 9/13/22 at 1:28 P.M. showed: -Freezer temperature of 2 degrees. -Open salami in cooler with a date of 9/4/22. -Pitcher of tea with no lid and no date. -Orange juice had a made by date, but no use by date. -Open bag of onion buns without date or label. -Bag of frozen tortellini sitting on counter top thawing. -Open bag of rice crispy cereal has use by sticker on it, but not dated. -Open bag of Cheerios without date or label. Review of the dietary food and dishwasher temperature logs from 9/1/22 to 9/11/22 showed: -No food temperatures were documented for 9/5/22 for breakfast or lunch; for breakfast, lunch or dinner for Tuesday 9/6/22, for lunch or dinner on 9/8/22, no temperatures documented for breakfast, lunch or dinner for 9/11/22; -No dish machine temperatures for all day of 9/7/22 and no temperatures for lunch or dinner on 9/8/22. Observation on 9/14/22 at 8:30 A.M. showed: -Open bag of salad without date or label. -Open bag of donuts without date or label. -Open bag of hot dogs in freezer without date or label. -A bag of chunks on meat in the freezer without date or label. -Milk crate on freezer floor with food in it. -Flour and corn tortillas opened without date or label. Observation on 9/14/22 during the noon meal service: -Six staff members were observed in the kitchen for the noon meal service, only one staff member was observed sanitizing their hands before serving the noon meal; -Staff did not sanitized their hands between serving each meal tray. -Dining Room Supervisor (DRS) tossed dirty gloves onto back counter and did not wash hands at 12:31 P.M. continued serving food after tossing gloves onto back counter. Observation on 9/14/22 at 12:33 P.M. of the noon meal showed: -Pureed carrots, mashed potatoes, and pureed meat and gravy; all three bowls were left on the counter without a cover -Carrots were at 101.5 degrees -Mashed potatoes were at 147.6 degrees -Pureed meat and gravy was at 87 degrees -Pureed carrots were not carrots as what was on the menu, but sweet potatoes from lunch on 9/13/22. -Mashed potatoes were bland and stiff (too thick). -Pureed beef was stringy like canned tuna. Temperature is cold. Did not receive pureed bread and butter or dessert. During an interview on 9/14/22 at 3:17 P.M. with [NAME] A said: -Pureed consistency should be like mashed potatoes. -Food on steam table should not below 165 degrees. -Puree temperature should be 170 degrees. -At times, he/she tries the pureed food for taste, consistency, and temperature. During an interview on 9/15/22 at 8:46 A.M. with Dining Room Supervisor (DRS) said -Hot food temperatures are expected as such: eggs 165 degrees, meat 165 degrees or higher, oatmeal 170 degrees or higher. -Puree consistency is to be like baby food-smooth and easy to swallow. During an interview on 9/15/22 at 11:51 A.M. with DRS states: -Salad bowls and dessert plates do not currently have plastic substitutes. -Hall trays get hinged containers as they do not get returned in a timely manner to be cleaned or even returned sometimes at all. During an interview on 9/15/22 at 2:12 P.M. with Dietician (D) said: -Pureed food should be like a light whipped potato. A spoon should not stand straight up while put in. -Hot food should be at least 135 degrees or higher before serving. -When staff are serving food and not touching residents then no hand washing needed, but if staff are helping cut food or touching the resident then most definitely wash hands. -All staff should wash their hands for 20 seconds.

Based on interview and record review, the facility failed to inform two additional residents (Residents #12 and #51) when changes were made to his/her Medicare coverage prior to the end of service date.The facility census was 55. 1. Review of the facility's Form instructions for the Notice of Medicare Non-Coverage poicy, dated 12/31/11, showed: - A Medicare provider or health plan must give in advance a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees recieving skilled nursing, home health, comprehensive outpatient rehabilitation facility, and hospice services no later that two days before the termination of services. 2. Review of Resident #12's NOMNC service notice showed: - Skilled nursing services ended 1/11/19. - The notice was signed by the resident's Durable Power of Attorney and dated 6/24/19. 3. Review of Resident #51's Advanced Beneficiary Notice of Noncoverage (ABN) notice showed: - Last covered day for skilled services was 4/12/19. - The notice was signed by the resident and dated 6/21/19. During an interview and record review on 7/25/19, at 8:53 A.M., the Social Services Director said she did not have the ABN and NOMNC for the residnt who transferred home and did not provide the residents who discharged off of Medicare Part A skilled nursing services notification within 48 hours because she had just started the job and did not know how to properly complete the forms and the time frames required for the forms.

Based on interview and closed record review, the facility failed to ensure staff completed a comprehensive discharge summary for one of three residents selected for closed record reviews (Resident #64) to include appropriate information about the resident's diagnoses, course of illness/treatment or therapy, a post discharge plan of care to assist the resident to adjust to his/her new living environment when applicable. The facility census was 66. The facility did not provide transfer/discharge policy. 1. Review of Resident #64's closed medical record showed the resident discharged to another facility on 5/17/19. The staff did not complete a nurse's note or a discharge summary. During an interview on 7/25/19, at 3:34 P.M., the Director of Nurses (DON) said, there was not a discharge summary or nurses' note for the resident's discharge information. She did not know why the discharge summary was not completed. She expected staff to complete a discharge summary for all discharged residents.

Based on observation, interview and record review, the facility failed to provide and care plan for restorative services (RS) to assist residents to attain or maintain their highest practicable level of functioning for two residents (Residents #5 and #46), who had limited range of motion (ROM) and/or other physical limitations, of 17 sampled residents. The facility census was 66. Review of the facility's restorative program policy, dated May 2006, showed: - The purpose of the facility see that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. - It is the entire staff's responsibility to prevent deterioration and further functional loss of each resident in the facility. 1. Review of Resident #5's quarterly Minimum Data Set (MDS) assessment, a federally mandated assessment completed by facility staff, dated 4/30/19, showed: - No cognitive impairment. - Required supervision and/or set-up help with activities of daily living (ADLs). - Used wheelchair for mobility and locomotion. - Diagnoses included: paraplegia. Review of the resident's July physician order statement (POS) showed: - Restorative Aide (RA) program three times a week, order dated 3/26/19. Review of the resident's care plan, last reviewed 5/7/19, showed: - Therapy or RA program per order, approach start date 2/21/19. Review of the facility's restorative program tracking forms for, May through June 2019, showed: -Start of rehab nursing program 3/27/19, three times a week for twelve weeks. Review of the facility's restorative program tracking forms for May 2019 showed staff documented they provided services on Mondays, Tuesdays and Thursdays. - Staff documented they provided services on the following days: 5/6/19, 5/7/19,5/9/19,5/14/19, 5/16/19, 5/23/19,5/28/19. - Staff did not document that services were provided on 5/2/19, 5/27/19 or 5/30/19. - Staff documented the services were withheld on 5/20/19. Review of the facility's restorative program tracking forms for June 2019 showed staff documented services provided on Mondays, Wednesdays and Fridays. Staff documented the following: - Services provided on 6/1/19 and 6/18/19 - Staff documented services were withheld on 6/3/19, 6/5/19, 6/7/19, 6/10/19, 6/12/19, 6/14/19, 6/21/19, 6/24/19, 6/26/19, and 6/28/19. Review of the facility's restorative program tracking forms showed for the month of July, staff documented services provided on Mondays, Wednesdays and Fridays and documented the following: - Staff documented they provided services on 7/5/19 and 7/12/19. - Staff documented services were withheld on 7/1/19, 7/3/19, 7/8/19, 7/15/19, 7/24/19. - Staff did not document they provided services on 7/10/19, 7/17/19, 7/19/19, or 7/22/19. During an interview on 7/24/19 at 3:00 PM, Resident #5 said: - He/she was supposed to receive restorative services three times a week, but staff had not provided services last week and had missed several sessions since services began; - He/she did not know why staff were not providing the services three times a week. - He/she felt frustrated that he/she was not receiving the services because the exercises made him/her feel better; - He/she was worried his/her mobility would decrease if he/she was not able to participate in the program. 2. Review of Resident #46's annual MDS assessment, dated 6/19/19, showed: - No cognitive impairment; - Required limited to extensive assistance with ADLs; - Impaired ROM to upper and lower extremities on one side; - Used walker for mobility; - Diagnoses included: kidney disease, hemiplegia, type II diabetes, history of cerebral infarction and thrombosis. Review of the resident's July 2019 POS showed: - RA program; - Start order date 4/12/19. Review of the resident's care plan, last revised 6/29/19, showed: - Therapy or RA program per order. Review of the facility's Restorative Program tracking forms showed: -Start of rehab nursing program 4/5/19, three times a week for twelve weeks. -Staff did not provide documentation for services provided in April or May. Review of the facility's Restorative Program tracking form for June, 2019, showed they provided services on Tuesdays, Wednesdays, and Thursdays: - Staff documented they provided services on 6/19/19, 6/26/19, and 6/27/19. - Staff documented services were withheld on 6/4/19, 6/5/19, 6/6/19, 6/11/19, 6/12/19, 6/13/19, 6/18/19, 6/20/19, and 6/25/19. Review of the facility's Restorative Program tracking form for June, 2019, showed they provided services on Tuesdays, Wednesdays, and Thursdays and documented the following: - Staff documented services were provided 7/4/19, 7/9/19, 7/17/19, 7/22/19, and 7/23/19. - Staff documented services were withheld on 7/2/19, 7/3/19, 7/16/19 and 7/24/19. - Staff did not documented services were provided on 7/10/19, 7/11/19, or 7/18/19. 3. During an interview on 7/25/19, at 1:20 P.M., the Restorative Aide said: - Resident #5 and #46 were on her restorative services caseload. - She documented a W (witheld) on the dates she was not able to provide restorative services; - She could not provide services was because she was pulled to the floor to work. -The blank dates on the calendar signified that services were not provided on those dates.

Based on observation, interview and record review, the facility failed to follow their policy and failed to provide care to prevent urinary tract infections (UTIs) for a resident with a supra-pubic catheter (a urinary catheter that is inserted into the abdominal wall and into the bladder), when staff failed to clean the catheter with soap and water as their policy directed and staff used disposable wipes that did not belong to the resident as staff provided the disposable wipes which they carried in their pockets using the same package of disposable wipes on multiple residents. This affected one of 17 sampled residents (Residents #52). The facility census was 68. 1. Review of the facility policy on supra-pubic catheter care, dated March 2015, showed: - Purpose: To prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. - Clean area around catheter well with soap and warm water. - The catheter should be wiped away from insertion site down two to three inches and not back and forth. - Clean any crusted material from the catheter insertion site. - Do not pull on catheter or advance catheter into the bladder. - The policy did not instruct staff to hold the catheter at the insertion site. 2. Review of Resident #52's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 7/2/19, showed: - Moderate cognitive impairment; - Totally dependent on two staff for activities of daily living (ADL's); - Diagnoses included quadriplegia (paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs) and neurogenic bladder (inability to pass urine from the bladder). Review of the resident's care plan, revised on 7/4/19, showed: - Supra-pubic catheter related to a diagnosis of neurogenic bladder; - Catheter care every shift and as needed; - Staff to monitor for signs and symptoms of infection and report findings. Review of the physician's order sheet (POS), dated July 2019, showed the following orders: - Supra-pubic catheter care every shift; - The order did not include what staff should use to cleanse the catheter. Observation on 7/23/19, at 2:08 P.M., showed Certified Nurse Aide (CNA) A and CNA B did the following after they transferred the resident from his/her chair using the mechanical lift to his/her bed: - Both staff entered the room with a package of disposable wipes in the pocket of their pants; - Both staff washed their hands and put on clean gloves; - The resident did not have a gauze dressing around his/her supra- pubic catheter or a leg strap on to prevent the catheter from pulling; - CNA B pulled the soiled brief from between the resident's legs and discarded it into the trash; he/she did not remove his/her gloves and wash his/her hands; - With dirty gloves CNA B removed the package of disposable wipes from his/her pocket and continued to hand CNA A disposable wipes and he/she cleaned the resident's frontal perineal skin folds and inner thighs removing a moderate amount of fecal material; - Without removing his/her gloves and washing hands, CNA A continued to hold and separate the resident's frontal perineal skin folds removing fecal material; - CNA A removed his/her gloves, used hand sanitizer and put on clean gloves; - With dirty gloves, CNA B handed CNA A additional disposable wipes which he/she used to clean around the supra-pubic catheter then he/she used one wipe to wipe the supra-pubic catheter from the insertion site on the abdomen down to the connector to the urinary drainage bag; - CNA A did not hold the catheter at the insertion site to prevent it from pulling; - CNA A did not cleanse the supra-pubic catheter with soap and water as the facility policy directed; - After cleaning the supra-pubic catheter, CNA A did not remove his/her gloves and wash his/her hands before he/she removed the catheter drainage bag from between the resident's leg, hung it on the side of the bed and covered the resident with a sheet; - Both staff removed their gloves, washed their hands and exited the resident's room. During an interview on 7/23/19, at 2:47 P.M., CNA A and CNA B said: - Frequently, they will use disposable wipes to cleanse supra-pubic catheters; - They have been instructed to inspect their gloves for visible soiling and if they do not see any fecal material it is acceptable to continue with care; - Resident # 52 should have a leg strap on to prevent the catheter from pulling; - Staff should hold the catheter at the insertion site when cleaning to prevent it from pulling; - Staff should not touch clean items with dirty hands; During an interview on 7/24/19, at 3:00 P.M., the Director of Nursing (DON) said: - Staff should anchor a supra-pubic catheter by holding it at the insertion site with a clean glove to prevent it from pulling when cleaning; - Facility staff should follow the catheter care policy; - Resident #52 should have a catheter leg strap on; - She was unaware staff were visually inspecting their gloves; - If there is a question of the possibility of visibly soiled, staff should remove their gloves and wash their hands; - Staff should not touch clean items with dirty hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff treated residents in a manner to maintain their dignity when staff did not pull the privacy curtain and left two of 17 sampled residents (Resident #24 and #30) exposed while providing incontinent care while their roommates remained were in the room in their beds; when staff failed to ensure one sampled resident's catheter drainage bag was placed in a dignity bag (protective covering), that was secured under the resident's chair and failed to ensure this resident's preferences were followed when staff would push him/her from the main television area to the dining room during meal times when this resident was unable to eat, and he/she had a feeding tube for resident (Resident #52), and failed to sit and engage with residents that required staff assistance with eating for two sampled resident (Resident #24 and #64), and staff failed to effectively communicate with each other when assisting residents to smoke which affected one sampled resident (Resident # 60). The facility census was 66. Review of the facility's policy titled Resident Rights revised on October 2017, showed: - Treating residents with dignity and respect is not only the policy of this facility; it is also the law. - Staff should treat all residents with consideration, respect and dignity at all times. - Residents have the right to privacy during medical treatment and during personal care. Review of the facility's policy titled Wound Care and Treatment, dated July 2015, showed: - Privacy must be provided during treatment, the door should be closed and curtains pulled. Review of the facility's policy titled Smoking, dated December 2016, showed: - The facility shall establish and maintain safe resident smoking practices; - Anyone who provides smoking supervision to residents shall be advised of any restrictions/concerns and the plan of care related to smoking; - Suggested times for breaks vary with each facility, suggest four to six breaks each day, each ten to fifteen minutes in length; - The administrator and department heads need to set up the times, post the time and make sure breaks are conducted timely for the residents. 1. Review of Resident #52's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 7/2/19, showed: - Moderate cognitive impairment; - Totally dependent on two staff for activities of daily living (ADLs); - Feeding tube; - Indwelling catheter; - Diagnoses included quadriplegia (paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs) and neurogenic bladder (inability to pass urine from the bladder). Review of the resident care plan, revised on 7/4/19, showed: - The resident is totally dependent on staff to assist with transferring, mobility, eating (tube feedings), dressing, hygiene, bathing, and toileting related to quadriplegia; - Nothing by mouth (NPO), Percutaneous Endoscopic Gastrostomy (PEG, an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall) tube feedings for all intake; - At risk for falls related to behaviors of the resident throwing his/her body causing the chair to tip over; - Suprapubic catheter (a urinary catheter that is inserted into the abdominal wall and into the bladder), related to a diagnosis of neurogenic bladder. Observation on 7/22/19, at 11:23 A.M., showed the resident reclined back in his/her geriatric chair (chairs with wheeled bases, and are designed to assist seniors with limited mobility) in the main television room watching television with his/her catheter drainage bag hooked under his/her chair, not in the dignity bag, half full of urine. Observation on 7/22/19, at 12:53 P.M., showed the resident reclined back in his/her geriatric chair in the main dining room watching television with his/her catheter drainage bag hooked under his/her chair, not in the dignity bag, half full of urine. The television screen was not clear and appeared fuzzy. Observation on 7/22/19, at 2:19 P.M., showed the resident reclined back in his/her geriatric chair in the main television room watching television with his/her catheter drainage bag hooked under his/her chair, not in the dignity bag, 3/4 full of urine. Observation on 7/22/19, at 2:38 P.M., showed the resident in his/her bed with his/her catheter drainage bag in a dignity bag tied to his/her bed. Observation on 7/23/19, at 12:58 P.M., showed the resident reclined back in his/her geriatric chair in the main dining room watching television. The picture was not clear and appeared fuzzy. During an interview on 7/23/19, at 3:00 P.M., CNA A and CNA B said: - Resident #52 should be pushed in the main dining room during meal times so he/she can be monitored. Observation on 7/24/19, at 12:48 P.M., showed the resident reclined back in his/her geriatric chair in the main dining room watching television. The picture was not clear and appeared fuzzy. During an interview on 7/24/19, at 2:18 P.M., as the resident lay in his/her bed, this surveyor asked the resident several questions to indicate his/her responses and he/she answered by nodding his/her head up and down to indicate a yes response and side to side to indicate a no response. When asked if he/she liked staff to push him/her to the dinning room during meal times, the resident began to repeatedly move his/her head back and fourth and started to breath faster to indicate a no response. During an interview on 7/25/19, at 9:48 A.M., Registered Nurse (RN) B said: - Resident #52 can answer yes and no questions by nodding his/her head; - The resident is unable to eat by mouth and all nutritional intake is provided through tube feedings; - If, and when, the resident is up during meal times, staff push the resident to the dinning room for his/her safety, to keep an eye on him/her; - He/she had not asked the resident if he/she would prefer to not be in the dinning room during meal times; - He/she had not noticed the clarity of the television in the main dining room; - A resident's catheter drainage bag should be inside a dignity bag. 2. Review of Resident #30's annual MDS, dated [DATE], showed: - Severe cognitive impairment; - Extensive assistance of two staff for ADLs; - Diagnoses included moisture associated skin damage (MASD), (is caused by prolonged exposure to various sources of moisture, including urine or stool and pressure ulcer (PU), (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) care. Review of the resident's care plan, revised on 6/6/19, showed: - At risk for PU, wound noted to buttock and history of MASD. Observation on 7/22/19, at 3:20 P.M., RN A and Certified Nurse Aide (CNA) C entered the resident's room to provide a dressing change to the resident's buttock and did the following: - CNA C shut the door but neither staff pulled the privacy curtain as the resident's roommate lay awake in the same room in his/her bed; - RN A removed the blanket from the resident exposing the resident's bare buttock as the resident was laying on his/her right side; - RN B asked CNA C to provided incontinent care as the resident had a bowel movement; - CNA C used the disposable pad that was under the resident and he/she wiped the resident's buttock to remove fecal material; - CNA C removed his/her gloves, washed his/her hands, put on clean gloves then he/she pulled the privacy curtain between the two residents; - After CNA C provided incontinent care, RN A provided wound care for the resident. During an interview on 7/22/19, at 4:00 P.M., RN A said: - Staff should ensure privacy during treatments and he/she should have pulled the privacy curtain prior to removing the blanket from Resident #30. 3. Review of Resident #24's annual MDS, dated [DATE], showed: - Severe cognitive impairment; - Totally dependent on two staff for ADLs; - Diagnosis included Alzheimer's disease. Review of the resident's care plan, revised on 6/6/19, showed: - Provide incontinent care after each incontinent episode, use briefs when out of bed to protect dignity; - Extensive staff assistance with eating. Observation on 7/22/19, at 11:25 A.M., showed CNA A and CNA B pushed the resident to his/her room to provide incontinent care, transferred him/her from the chair to the bed with a mechanical lift and did the following: - Both staff entered the room, washed their hands, put on clean gloves and shut the resident's door; - Did not pull the privacy curtain as the resident's roommate lay in the same room in his/her bed; - Both staff removed the resident's pants and CNA B removed the resident's soiled brief exposing the resident's frontal perineal skin folds; - CNA B used disposable wipes to wipe the resident's frontal perineal skin folds; - Staff then assisted the resident to roll onto his/her side - CNA B cleansed his/her buttock and rectal areas; - Staff did not pull the privacy curtain or cover the resident as they provided incontinent care. Observation on 7/22/19, from 12:00 P.M. to 1:00 P.M., showed the resident leaning to his/her left side with his/her feet pulled upwards in his/her broda chair (a chair that tilts) in the dinning room resting with his/her eyes closed the entire time. Observation on 7/23/19, from 12:15 P.M. to 12:45 P.M., showed the resident sitting in his/her broda chair in the dining room and CNA B did the following: - While standing, CNA B provided a bite of food for the Resident #24 then he/she would assist other residents with eating; - He/she continued feeding residents in this manner for the meal while standing the entire time; - CNA B did not inform the resident prior to putting the spoon to his/her mouth; - CNA B did not talk with the resident at all while he/she provided assistance with eating. During an interview on 7/23/19, at 3:00 P.M., CNA A and CNA B said: - The privacy curtain should have been pulled when he/she provided incontinent care for Resident #24; - Resident #24 frequently sleeps through meal times; - They do not sit when feeding the residents at the assist table because there is not enough chairs; 4. Review of Resident #64's entry tracking MDS assessment, dated 7/18/19, showed: - No ADL or diagnoses information. Review of the resident July POS showed: - Diagnoses included vascular dementia and prostate cancer. - End of life hospice services for end stage prostate cancer. Review of the resident's care plan, dated 7/19/19, showed: - New admission, baseline care plan completed; - Did not include ADL goals and approaches. Observations on 7/22/19, starting at 12:40 P.M., showed: - Resident #64 sat in his/her Broda chair at the assist-to-dine tables; - RN A stood next to Resident #64's Broda chair and fed the resident several bites of food and held his/her glass for drinks. 5. Review of Resident #60's 14- Day MDS, dated [DATE], showed: - No cognitive impairment; - Independent with ADLs; - Current tobacco use not indicated; - Diagnoses included depression and anxiety. Review of the resident's care plan updated on 7/2/19, showed: - Staff assistance with smoking. Observation on 7/24/19, at 8:58 A.M., showed Resident #60 walked down the hall with his/her walker, pulled the seat down on the walker, and sat on the seat near the door that exits to the designated smoking area. Observation on 7/24/19, at 9:11 A.M., showed: - Resident #60 continued to sit on the seat of his/her walker and two department heads walked right past him/her. - Neither staff spoke to the resident. - Both staff exited the door and started smoking; - The resident continued to look out the door as staff were smoking; - At 9:13 A.M., an unknown staff said to the resident I will take you out, and the resident exited the door with the staff to smoke. During an interview on 7/24/19, at 10:00 A.M., Resident #60 said: - At 9:00 A.M., today dietary staff was unable to assist him/her with smoking; - Some staff will take him/her out to smoke when he/she is waiting at the door and some will not; - An aide assisted him/her for the 9:00 A.M., smoke break; - He/she has observed staff arguing about who is responsible for the designated smoke times; - This makes him/her feels like he/she is an inconvenience to the staff. During an interview on 7/24/19, at 2:08 P.M., the Dietary Manager said: - Today, his/her department was unable to cover the 9:00 A.M., smoke break; - Often staff have said assisting residents with smoking is not my job; - In the past, Resident #60 has voiced concerns to him/her related to issues with the designated smoking times and staff not being available. 6. During an interview on on 7/25/19, at 3:30 P.M., the Director of Nurses (DON) said: - She was unaware that the clarity of the television in the dinning room was an issue and the facility plans to assess pushing Resident #54 into the dinning room during meal times; - A resident's catheter drainage bag should always be inside a dignity bag when a resident is out of their room; - Staff are expected to provide privacy for residents during care; this includes pulling privacy curtains, and covering resident's during care; - The dining experience should be a positive experience and staff should be conversing with the residents; - When staff are assisting residents that require feeding, staff should be sitting down and engaging with them; - It is not acceptable for a resident to sleep in the dining room; Resident #24 should have been taken from the dining room on 7/22/19, and laid in his/her bed; - The smoking schedule is posted at the nurses' desk and various departments are responsible for the designated times; - If a department is unable to cover their designated smoke time, they should communicate the conflict so that a different department can accommodate the scheduled time; - If a resident is waiting at the door to smoke, it is not acceptable for staff to walk right past them; anyone can take a resident out to smoke.

Based on observation, interview and record review, the facility failed to regularly check refrigerator temperatures that contained residents' medications located in the medication room; failed to regularly check refrigerator temperatures that contained residents' food; failed to ensure staff dated insulin when they opened it for one of 17 sampled residents (Resident #51), and failed to ensure the refrigerator located in the medication room that contained residents' food contained food that was dated when opened, clean, and did not contain food that was spoiled. The facility census was 66. Review of the facility's policy titled Labeling Drugs and Medications, dated March 2015, showed: - All drugs and biological's must be properly labeled and legible at all times; - Any drug label that is soiled, incomplete, illegible, worn, or makeshift must be returned to the issuing pharmacy for replacement for individual drug containers must contain expiration date, date of issue, and other appropriate information. Review of the website, https://www.rapidactinginsulin.com/novolog, showed to use an opened Novolog (fast acting insulin) insulin vial up to 28 days after opened. Review of the facility's policy titled Refrigerators And Freezers, dated May 2015, showed: - All food, including bulk items, should be tightly sealed with an identifying label and date. - Refrigerators and freezers should be cleaned per cleaning schedule. - Spills should be wiped up immediately. Review of the facility's policy titled Safe Food Handling, dated May 2015, showed: - Cold food must be kept at 40 degrees Fahrenheit (F). 1. Review of Resident #51's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 6/27/19, showed: - No cognitive impaired; - Independent for activities of daily living (ADLs); - Diagnoses included: Diabetes; - Daily insulin injections. Review of the physician's order sheet (POS), dated July 2019, showed the following orders: - Accucheck before meals and at bedtime; - Novolog inject 5 units (U) subcutaneous (under the skin) before meals for a diagnosis of diabetes. Observation and interview on 7/22/19, at 12:25 P.M., Registered Nurse (RN) A performed an accucheck and insulin administration on Resident #51 and then did and said the following: - Said he/she was unable to read the date written on the insulin box because staff had written it with a black sharpie pen and it was not legible; - He/she took a black marker and wrote 7/22/19, 12:25 on the vial of Novolog insulin and then he/she placed the insulin vial back into the box and placed it in the medication cart. did she administer it? yes see above If so, add that to your example. During an interview on 7/22/19. at 12:35 P.M., RN A said: - Insulin is good for 28 days after opening; - Insulin should be dated when opened and he/she should not have written today's date on the bottle. 2. Observation on 7/24/19, at 11:38 A.M., of the medication refrigerator showed: -No temperature log sheet taped to the door; so you observed the log sheet, but there was not a log sheet? No I am sorry -The thermometer secured inside the door read 50 F degrees. Observation on 7/24/19, at 11:45 A.M., of the residents' food refrigerator located in the medication room showed: - Dried food particles and a dried, red colored substance on the shelf; - Two soft brown bananas; - Three opened partial containers of boost supplement drinks; - Two opened containers of yogurts with the foil lid partially pulled off; - A divided Tupperware container with a lid that contained a dark furry substance; - An opened bag of potato chips; - Two plastic soda bottles, 1/4 full; - An opened bottle salad dressing that was almost empty; - A Styrofoam Sonic cup of ice cream with a spoon sticking out of it; - None of the items in the refrigerator were labeled with resident names or an open date. Observation on 7/24/19, at 11:55 A.M., of the residents' food refrigerator located in the medication room showed a temperature log sheet taped to the front of the door with the following: - 7/1/19 and 7/2/19: no temperature recorded which indicated staff did not document that they checked the temperature; - 7/5/19 thru 7/7/19: no temperature recorded; - 7/10/19 and 7/11/19: no temperature recorded; - 7/15/19 and 7/16/19: no temperature recorded; - 7/19/19 thru 7/21/19: no temperature recorded; - Staff failed to record the temperature for a total of 12 days, out of a possible 24 days for the month of July. During an interview on 7/24/19, at 12:00 A.M., Licensed Practical Nurse (LPN) A said: - Refrigerator temperatures should be documented every day and this is usually done by the a night shift charge nurse; - The dates not recorded indicate that staff did not record the refrigerator temperature; - He/she thinks the thermometer in the medication refrigerator is broken. During an interview on 7/24/19, at 3:00 P.M., the Director of Nursing (DON) said: - She observed the refrigerator in medication room that contained resident food and it was unacceptable; - The night shift charge nurse is responsible for checking the temperature in all the refrigerators located in the medication rooms and staff is expected to document the temperature on the log sheet; - If there is not an entry on the log sheet, this would indicate that staff did not check or record the temperature; - Insulin is good for 28 days once opened and should only be dated when opened; - If staff are unable to read a date that another staff recorded, they should never change the date to the date of usage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided care in a manner to prevent infections or the possibility of infection when the facility did not provide disposable wipes and staff purchased their own disposable wipes and used the same package on multiple residents going from room to room; staff failed to clean glucometers between residents; failed to removed gloves and wash their hands between dirty and clean tasks while providing resident care. This affected three out of 17 sampled residents (Resident #24, #51, and #52). The facility census was 66. Review of the facility's Handwashing Policy, dated March 2015, showed: - The purpose of handwashing is to reduce transmission of organisms from resident to resident, staff to resident, and resident to staff. Review of the facility's Gloves Policy, dated March 2015, showed: - REMEMBER: Gloves are not a cure-all. - They should reduce the likelihood of contaminating the hands. - Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to the skin on your hands. - Handling medical equipment and devices with contaminated gloves is not acceptable. - Gloves must be changed between residents and between contacts with different body sites of the same resident. Review of the facility's policy titled Wound Care and Treatment, dated July 2015, showed: - Clean equipment with bleach wipes. The facility did not provided a policy for cleaning glucometer machines. 1. Review Resident #24's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 5/31/19, showed: - Severe cognitive impairment; - Totally dependent on two staff for activities of daily living (ADLs); - Diagnosis included Alzheimer's disease. Review of the resident's care plan, revised on 6/6/19, showed: - Provide incontinent care after each incontinent episode, use briefs when out of bed to protect dignity. During an observation on 7/22/19, at 11:25 A.M., Certified Nurse Aide (CNA) A and CNA B pushed the resident to his/her room to provide incontinent care, transferred him/her from the chair to the bed with a mechanical lift and did the following: - Both staff washed their hands, put on clean gloves, and both staff removed the resident's pants; - CNA B removed the resident's soiled brief and discarded the brief; - CNA B removed his/her gloves; CNA A squirted hand sanitizer onto CNA B hands then he/she put on clean gloves; - With clean gloves, CNA B reached into his/her pant pocket, obtained a package of disposable wipes, and handed the package of disposable wipes to CNA A; - CNA A pulled disposable wipes from the package and handed the wipes to CNA B who then wiped the resident's frontal perineal skin folds removing fecal material; - CNA B removed his/her gloves as they contained fecal material; CNA A obtained the hand sanitizer from his/her pocket and squirted it on CNA B hands then CNA B put on clean gloves without washing his/her hands; - CNA A continued to hand CNA B disposable wipes from the package who used additional disposable wipes and wiped the resident's frontal perineal skin folds removing fecal material; - CNA B held his/her gloves out in front of him/her to visually inspect them and with dirty gloves, he/she assisted CNA A to roll the resident onto his/her side; - CNA B used multiple disposable wipes to cleanse the resident's buttock, and rectal area to remove the fecal material; - CNA B removed his/her gloves, did not use hand sanitizer or wash his/her hands before he/she pulled his/her pants up, placed the package of disposable wipes into his/her pant pocket, bagged the trash, then he/she picked up the roommate's fall mat that was leaning against the wall and placed it next to the roommate's bed; - CNA A removed his/her gloves and both staff washed their hands and exited the resident's room. Observation from the hall on 7/22/19, at 12:08 P.M., showed CNA A came out of Room # 104 which is Resident #24's roommate and walked down the hall and said I need the wipes and CNA B reached into his/her pocket and handed the package of disposable wipes to CNA A and he/she re-entered room [ROOM NUMBER] and shut the door. 2. Review of Resident #51's quarterly MDS, dated [DATE], showed: - No cognitive impaired; - Independent for ADLs; - Diagnoses included: Diabetes; - Daily insulin injections. Review of the physician's order sheet (POS), dated July 2019, showed the following orders: - Accucheck before meals and at bedtime; - Novolog (fast acting insulin) inject 5 units (U) subcutaneous (under the skin) before meals for a diagnosis of diabetes. Observation on 7/22/19, at 12:25 P.M., showed Registered Nurse (RN) A performed an accucheck and insulin administration on Resident #51 as follows: - He/she used hand sanitizer and applied gloves; - Cleansed the glucometer with one alcohol swab, did not clean the machine with the recommended wipes and did not let the machine dry to complete the disinfection process; - Removed his/her gloves, did not use hand sanitizer, put on clean gloves and completed the accucheck; - Placed the machine on the medication cart on a Kleenex; - Removed his/her gloves and used hand sanitizer then picked up the used machine and set it back down on the Kleenex, did not remove his/her gloves and sanitize his/her hands; - With dirty gloves, he/she opened the medication cart, obtained a vial of the resident's insulin and administered Novolog 5 U in the resident's left arm; - Removed his/her gloves and used hand sanitizer. During an interview on 7/22/19. at 12:35 P.M., RN A said: - He/she cleaned the accucheck machine with an alcohol swab because the facility is frequently out of bleach wipes; - Currently, the facility is not out of bleach wipes; - Hands should be washed or sanitized every time gloves are removed; - Staff should not touch clean items with dirty hands. 3. Review of Resident #52's annual MDS, dated [DATE], showed: - Moderate cognitive impairment; - Totally dependent on two staff for activities of daily living (ADL's); - Diagnosis included quadriplegia (paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs) and neurogenic bladder (inability to pass urine from the bladder). Review of the resident's care plan, revised on 7/4/19, showed: - Supra-pubic catheter related to a diagnosis of neurogenic bladder; - Catheter care every shift and as needed; - Staff to monitor for signs and symptoms of infection and report findings. Review of the POS, dated July 2019, showed the following orders: - Supra-pubic catheter care every shift; - The order did not include what staff should use to cleanse the catheter. Observation on 7/23/19, at 2:08 P.M., showed Certified Nurse Aide (CNA) A and CNA B did the following after they transferred the resident from his/her chair using the mechanical lift to his/her bed: - Both staff entered the room with a package of disposable wipes in the pocket of their pants; - Both staff washed their hands and put on clean gloves; - Both staff opened the resident's soiled brief which contained a large amount of fecal material; - Both staff rolled the resident onto his/her side then CNA B pulled the soiled brief from between the resident's legs and discarded it into the trash; - CNA B held his/her hands out in front of him/her to visually inspect them, did not remove his/her gloves and wash his/her hands after discarding the brief that contained fecal material; - With dirty gloves, CNA B removed the package of disposable wipes from his/her pocket, pulled wipes from the package and handed them to CNA A to provide incontinent care; - CNA A used two disposable wipes to clean the resident's buttock and rectal area, removing a large amount of fecal material; - CNA A held his/her gloves out in front of him/her to visually inspect them then he/she continued with removing fecal material from the resident's buttock and rectal area; - CNA A removed his/her gloves as they contained fecal material, washed his/her hands and put on clean gloves then continued to remove fecal material from the resident's buttock and rectal area; - CNA A held his/her gloves out in front of him/her to visually inspect them and with dirty gloves CNA A touched the resident's catheter bag moving it as he/she assisted CNA B to roll the resident on to his/her back; - With dirty gloves, CNA B continued to hand CNA A disposable wipes so he/she could clean the resident's frontal perineal skin folds and inner thighs, removing a moderate amount of fecal material; - Without removing his/her gloves and washing his/her hands, CNA A continued to hold and separate the resident's frontal perineal skin folds removing fecal material; - CNA A removed his/her gloves, used hand sanitizer and put on clean gloves; - With dirty gloves, CNA B handed CNA A an additional disposable wipe and he/she cleaned around the supra-pubic catheter then he/she used one wipe to wipe the supra-pubic catheter from the insertion site on the abdomen down to the connector to the urinary drainage bag; - CNA A did not cleanse the supra-pubic catheter with soap and water as the facility policy directed; - After cleaning the supra-pubic catheter, CNA A did not remove his/her gloves and wash his/her hands before he/she removed the catheter drainage bag from between the resident's leg and hung it on the side of the bed and covered the resident with a sheet; - Both staff removed their gloves, washed their hands and exited the resident's room. 4. During an interview on 7/23/19, at 2:47 P.M., CNA A and CNA B said: -The facility does not provide disposable wipes; -The facility provides washcloths but they prefer to use disposable wipes; - They purchase the disposable wipes and use the same package of disposable wipes for multiple residents; - Frequently, they will use disposable wipes to cleanse supra-pubic catheters; - They have been instructed to inspect their gloves for visible soiling and if they do not see any fecal material it is acceptable to continue with care; - Hands should be washed after glove removal; - Staff should not touch clean items with dirty hands. During an interview on 7/24/19, at 3:00 P.M., the Director of Nursing (DON) said: - She was not aware that staff were purchasing disposable wipes and using the same package of disposable wipes on multiple residents; -Staff should be using washcloths when providing peri-care; - This is not an acceptable practice and is an infection control issue; - If staff touched the package of disposable wipes with dirty gloves, the entire package of disposable wipes would be considered contaminated; - Hand washing should be performed after glove removal and when going from a dirty tasks to clean tasks; - She was unaware staff were visually inspecting their gloves; - If there is a question of the possibility of visibly soiled, staff should remove their gloves and wash their hands; - Staff should not use an alcohol swab to clean a glucometer; a bleach wipe should be used, and staff should allow the glucometer to air dry; - Staff should not touch clean items with dirty hands.