Based on interview and record review, the facility failed to ensure one resident's (Resident #3's) representative/power of attorney was able exercise his/her rights to refuse medical treatment on behalf of the resident. The sample was four. The census was 44. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/15/25, showed: -Diagnoses included Parkinson's disease (brain disorder causing unintended or uncontrolled movements), anxiety, and unspecified lump in left breast; -Brief Interview for Mental Status (BIMs) should not be conducted. Resident is rarely/never understood. Review of the resident's care plan, dated 5/20/25, showed: -Focus: The resident has a terminal prognosis and admitted to hospice care; -Goal: The resident's comfort will be maintained through the review date; -Interventions: Adjust provision of activities of daily living (ADLs) to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Work cooperatively with hospice team to ensure the resident' spiritual, emotional, intellectual, physical and social needs are met. Work with nursing staff to provide maximum comfort for the resident. Review of the resident's progress notes, showed: -A note, dated 5/8/25, written by a Nurse Practitioner (NP) for an outside wound management company showed: -Patient presents today for evaluation and treatment of open wound/skin lesion. I certify the following reasons meet medical necessity for this encounter procedure(s) performed at this encounter that is outside the scope of practice of an licensed practical nurse (LPN) or registered nurse (RN) to perform. Prescription medication was ordered/recommended at this visit. Further diagnostic testing or examination was performed or ordered at this encounter. Education/counseling was provided to the patient regarding compliance and adherence with treatment plan. Bedside nurse was instructed on proper dressing changes or dressing change techniques to enhance wound healing; -Minor Procedures: Surgical incision and drainage of left breast: Verbal consent was obtained before procedure. Education given on benefits and risks that can occur with incision and drainage. Resident acknowledged understanding and has no further questions; -Procedures: 22 blade scalpel was used for incision of mass to wound bed. Lidocaine 2% (local anesthetic) used for anesthetic prior to sharps debridement (procedure to remove dead, damaged, or infected tissue from a wound). Betadine (topical antiseptic) was used for cleansing purposes of wound bed before any insertion of sharps into tissue. Anticoagulant (blood thinner) use was reviewed prior to procedure. Heavy purulent (thick yellow/green) drainage during procedure, pressure dressing applied with successful coagulation. Post procedural pain: 0/10 per patient report. Post procedure measurements: 9 x 3 x 8.6 centimeter (cm) incision, Surface area incised: 27 cm². Will follow up in one week; -Time spent today with resident was 35 minutes. Preparing to see the client, reviewing lab(s) or other test results, receiving report from the client and/or family and/or other caregiver, evaluating and assessing wounds and/or skin issues, educating bedside nurse on wound conditions and/or skin issues and/or dressing changes, educating client on condition and/or reinforcement of plan of care, ordering medications and/or tests and/or procedures, documenting clinical information in the health record. During an interview on 5/30/25 at 12:06 P.M., the resident's adult child said that neither he/she nor his/her sibling, who is the resident's power of attorney (POA), were informed that the wound management company staff were coming to the facility to perform a procedure on the resident's left breast on 5/8/25. The family was not informed by the facility that the procedure was done. They were informed on 5/9/25 by the hospice employee who came to the facility that the procedure was done on 5/8/25. The resident was unable to consent to the procedure himself/herself and would not have wanted the procedure done according to his/her power of attorney. The resident's POA would not have consented to the procedure had he/she been made aware in advance. After the procedure on 5/8/25, the resident was in pain, requiring morphine, and stopped eating. During an interview on 5/30/25 at 2:12 P.M., the Hospice Admission's Nurse said the resident's hospice team was not informed the resident was to have a procedure done on the resident's left breast by the wound management company on 5/8/25. On 5/9/25, a hospice nurse came to the facility to provide services and was notified that the procedure was done. The family was not informed of the procedure and would not have consented. The resident was not cognitively able to make his/her own decisions, and his/her POA was making medical decisions on his/her behalf. The resident was in more pain than normal after the procedure and required morphine. During an interview on 5/30/25 at 2:30 P.M., the Administrator and Director of Nursing (DON) said they did not get permission from the resident's power of attorney prior to the wound management team coming to the facility and performing the lancing on the resident's left breast. They said the family signed a consent form on 5/24/24 giving permission for wound management to provide services to the resident. They did not consider the lancing to be a procedure but normal care. MO00254669

Based on observation, interview and record review, the facility failed to ensure staff oversight of one resident in the shower, resulting in the resident falling (Resident #1). The sample was four. The census was 44. The Administrator was notified on 5/30/25, of the past non-compliance. The facility gave certified nursing assistant (CNA) C a written warning and educated him/her on the importance of not leaving residents alone in the shower and gathering needed supplies before the shower. Maintenance staff audited all shower chairs to ensure they were in working order. Nursing staff were in-serviced on not leaving staff alone in the shower. The deficiency was corrected on 4/24/25. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/31/25, showed: -Diagnoses of diabetes, epilepsy (seizures), and acquired absence of left and right leg above the knee; -Cognitively intact. -Substantial/maximum assistance from staff needed with transferring in and out of the shower. Review of the resident's progress notes, showed a note, dated 4/7/25, called to resident's room by resident's roommate who stated resident was on the floor. Upon entering the room, resident was sitting up with his/her buttocks on the floor next to the bed. The bed was noted to be in the lowest position. Resident stated he/she was self-transferring and fell. Resident stated he/she did not hit his/her head, arm, back or buttocks. Resident given call-light and educated on use and asking for assistance. Resident stated understanding, range of motion done with no loss, call placed to emergency contact, physician, and Director of Nursing (DON) made aware of fall. Neurological checks in progress, plan of care ongoing. Review of the resident's care plan, in use at the time of the investigation,showed: -Focus: The resident has had an actual fall with no injury on 4/22/25 due to above knee amputations, anxiousness, poor balance, and poor communication/comprehension; -Goal: The resident will resume usual activities without further incident through the review date; -Interventions: Per resident request, to have assist times one at all times while showering. Also request staff member remains in the shower room the entire time. Review of the facility's fall scene investigation report, dated 4/22/25, showed: -Date of fall: 4/22/25; -Time of fall: 10:50 A.M.; -Fall description details: Factors at the time of fall indicated equipment malfunction; -Fall summary: Found on the floor in the resident's shower, unwitnessed fall; -Resident stated he/she was just taking a shower when the chair fell apart. The shower chair has arms that are removable; -Neurological checks attached were completed after the fall. During an interview on 5/30/25 at 9:56 A.M., the resident said on 4/22/25, he/she was in the shower chair in the shower in his/her room when CNA C told him/her that he/she was going to go get more towels. He/She said while alone in the shower, the shower chair broke and he/she fell onto his/her back and hit his/her head on the wall. He/She was not injured, but the fall was painful. Staff came right away and assessed him/her before getting him/her off the floor. During an interview on 5/30/25 at 7:43 A.M., CNA D said he/she was working on the resident's floor but was not assigned to the resident on 4/22/25. He/She said the shower chair had been moved to the spa room because it was broken. He/She said CNA C used the shower chair anyway, even though he/she knew it was broken. CNA C got the shower chair from the spa room and took it to the shower in the resident's room and put the resident on it. CNA C left the resident to go get towels and while he/she was gone, the resident fell. During an interview on 5/30/25 at 11:27 A.M., Housekeeper B said he/she was working on the resident's hallway when the fall occurred on 4/22/25. He/She saw CNA C leave the resident in his/her room in the shower and told him/her that he/she should not be leaving the resident alone. CNA C ignored him/her and left to go get towels. Housekeeper B went to the nurse and reported that CNA C had left the resident alone. CNA C was aware that the shower chair used was broken, prior to the resident's fall, and the chair had been placed in the spa to prevent it from being used. CNA C went to the spa room and got the shower chair to use it, knowing it was broken. Housekeeper B did not witness the fall. Since the incident, the shower chair was removed by maintenance and fixed. During an interview on 5/30/25 at 1:41 P.M., CNA C said on 4/22/25, he/she was giving the resident a shower, and the resident had a bowel movement (BM). CNA C left the room to go get towels and while he/she was gone, the shower chair broke resulting in the resident's fall. The resident was assessed and neurochecks were initiated. The resident did not have any injuries. CNA C did get the shower chair from the spa room but was unaware that it was broken. The resident should not have been left alone, and CNA C was given a warning by the Administrator and educated on gathering supplies before bringing residents into the shower. During an interview on 5/30/25 at 1:53 P.M., the Administrator and DON said the resident's fall was a result of the shower chair breaking while the resident was on it. They said the shower chair was fixed and maintenance staff checked other shower chairs to ensure no other chairs were broken. CNA C was given a verbal warning and educated on not leaving residents in the shower alone. They would expect staff to gather towels and supplies before bringing the resident into the shower. They would expect staff to ensure the shower chair is not broken before using it. MO00253458

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure the pharmacist completed the monthly medication reviews (MRR) in a timely manner for one of five sampled residents (Resident (R) 20) reviewed for unnecessary medications. Findings include: 1. Review of R20's undated Resident Face Sheet, found in the electronic medical record (EMR) under the Profile tab indicated the resident was initially admitted to the facility on [DATE] with diagnoses including major depression, Alzheimer's, mood disorder and dementia. R20's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/06/24, indicated a Brief Interview for Mental Status (BIMS) of 14 out of 15 which indicated that R20's cognition was intact. The assessment indicated the resident was exhibiting delusions during the assessment period. Review of R20's Physician Order Report in the EMR under the Orders tab, indicated, Quetiapine Fumarate oral tablet 25 Milligram (MG) (Quetiapine Fumarate) ordered 08/21/24 give 25 mg by mouth at bedtime for mental health; Donepezil HCl oral tablet 10 MG (Donepezil Hydrochloride) ordered 05/17/24 give 10 mg by mouth in the morning for dementia; and Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) ordered 03/06/24 give 1 tablet by mouth at bedtime for depression. Review of R20's EMR indicated the facility's pharmacist had not completed the MMR since 01/22/24. During an interview on 09/12/24 at 1:26 PM, the Director of Nursing (DON) confirmed that the pharmacist completed R20's last MMR on January 2024. She stated the pharmacist was not linked to the resident's chart to be able to review R20's medications monthly. During an interview on 09/12/24 at 4:44 PM, the Administrator stated her expectation was for the pharmacist to complete the residents' MMR. During an interview on 09/12/24 at 4:49 PM, the pharmacist stated she received a call on 09/11/24 about R20's MMR. She stated that she didn't have access to R20's EMR to complete the MMR. Review of the Medication Regimen Reviews policy Revision date January 2024 provided by the facility documented, 1. The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. 2. Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See event ID LK0M12 This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies dated 7/28/23. Based on observation, interview, and record review, the facility failed to ensure each resident receives care and assistance to prevent accidents for two of two residents observed to be transferred without the use of a gait belt (Residents #75 and #301). The census was 45. Review of the facility's undated Safe Lifting and Movement of Residents policy showed: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 1. Review of Resident #75's medical record, showed: -Diagnoses included Alzheimer's disease, age-related osteoporosis (thinning of the bones), history of falls, and muscle weakness. Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/14/23, showed: -Sit to stand and chair/bed-to-chair transfer: Supervision or touching assistance - helper provides verbal cues or touching/steadying assistance as resident completes activity; -Toilet transfer: Partial/moderate assistance. Helper does less than half of the effort. Review of the resident's care plan, in use at the time of the investigation, showed: -Focus: At risk for self-care deficit: Bathing, dressing, feeding, toileting, and transfers; -Goal: Resident will be able to perform self-care needs; -Interventions included: Evaluate resident's ability to perform activities of daily living (ADLs). Provide assistance with ADLs as needed; -The care plan failed to identify the level of assistance required for transfers. Observation on 10/19/23 at 7:01 A.M., showed Certified Nursing Assistant (CNA) FF completed rounds on the floor. He/She said the residents who are still in need of morning care all require two staff assistance for care, so he/she has to wait for help. At 7:04 A.M., CNA GG said the resident was ready to get up and entered the room with CNA FF. CNA GG placed non-skid socks on the resident's feet. CNA GG assisted the resident to sit on the edge of the bed and moved the wheelchair near the bed. One CNA stood on the resident's left side and one CNA stood on the resident's right side. Both CNAs grabbed the resident under his/her arms and told the resident to stand as they pulled him/her up. The resident's arms and shoulders raised as staff pulled up on the resident. Staff assisted the resident to pivot and sit in the wheelchair. CNA GG propelled the resident into the bathroom near the toilet. Both CNAs assisted the resident to stand from the wheelchair as on CNA stood behind the resident and reached over the back of the wheelchair and the other CNA stood to the residents left side. Staff instructed the resident to stand and pulled up on his/her arms. His/Her arms and shoulders raised as staff pulled up on the resident. Staff assisted the resident to turn and pivot, and then sit on the toilet. The resident appeared unsteady. Once the resident was ready, both CNAs stood in front of the resident, and used their arms to assist the resident to stand and pivot to the wheelchair. The resident's shoulders made a shrugging motion as staff pulled up on his/her arms. CNA GG provided morning care as the resident sat in his/her wheelchair in front of the sink, as CNA FF made the resident's bed. CNA FF exited the room with the soiled linen. CNA GG stood behind the resident at the sink and put his/her arms under the resident's under arms and attempted to stand the resident. The resident's arms went up, but the resident remained seated. CNA GG said he/she needed to wait for CNA FF, because the resident is not able to stand. He/She needs two staff and will need to wait for CNA FF to come back so the resident does not slip and slide. CNA FF entered the resident's room. Both staff stood behind the resident's wheelchair, one to the left and one to the right, and placed their arms under the resident's arm pits. Staff pulled up on the resident's arms. The resident moaned. His/Her arms raised up, but he/she did not stand. The CNAs released the resident's arms. Repositioned the wheelchair a little further away from the sink and attempted to stand the resident again. The resident stood, his/her arms and shoulders were raised as the CNAs pulled up on his/her arms. Staff completed morning care one handed as they held onto the residents arms. The resident appeared unsteady. When done providing care, staff pulled up the resident's pants and assisted the resident to sit in his/her wheelchair. Observation showed CNA FF wore a gait belt around his/her waste that was not used to assist the resident to transfer. During an interview on 10/19/23 at 8:45 A.M., with CNA FF and CNA GG, they said they learned resident care needs when they were in training and did rounds with the staff who trained them. At that time, staff showed them how to care for residents and how residents transfer. They learn the resident's care needs as they provide care. During an interview on 10/19/23 at 4:10 P.M., with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), they said staff should use a gait belt when assisting a resident to transfer. Resident #75 required one to two staff assistance with transfers and a gait belt should be used. Staff should know a residents transfer status by reviewing the electronic medical record. The care plan should clearly indicate a resident's transfer status. 2. Review of Resident #301's medical record showed: -Diagnoses included hemiplegia (paralysis on one side of the body) affecting left non-dominant side, stroke, muscle weakness, and need for assistance with personal care. Review of the resident's annual MDS, dated [DATE], showed sit to stand, chair/bed-to-chair transfer, and toilet transfer: Substantial/maximal assistance - helper does more than half of the effort. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: At risk for falls related to left sided weakness; -Goals: Be free from falls; -Interventions included: Assist with ambulation and transfers utilizing therapy recommendations. Observation on 10/19/23 at 6:05 A.M., showed CNA Q entered the resident's room. CNA Q assisted the resident with morning care and then moved his/her electric wheelchair to the bedside. The resident's left arm appeared to be contracted (loss of range of motion caused to rigidity of the tendons and joints) and flaccid (paralyzed). The resident used his/her right arm to hold his/her left arm. CNA Q stood at the resident's side and pulled up on his/her left arm to assist the resident to stand. The resident leaned to the right as the CNA pulled on his/her left side. Once standing, the resident then pivoted and sat in his/her wheelchair. He/She said ouch as he/she pinched his/her arm between the wheelchair and his/her body as he/she sat down. The resident use his/her right hand, grabbed his/her left arm to reposition the arm. CNA Q did not use a gait belt. During an interview on 10/19/23 at 4:10 P.M., with the DON and ADON, they said the resident was seen by therapy, but they were not sure what the recommendations for transfer were. The resident can be a two or one person assist with transfers. He/She has one sided weakness. The care plan should clearly indicate the resident's transfer status. A gait belt should have been used.

See event ID LK0M12 Based on observation, interview, and record review, the facility failed to ensure each resident's bedside was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for two of nine call lights checked (Residents #19 and #306). The census was 45. 1. Review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/7/23, showed: -Cognitively intact; -Partial/moderate assistance required for toileting hygiene, showers/baths, upper and lower body dressing, putting on/taking off footwear, positioning from left to right, sit to lying, lying to sitting, sitting to standing, chair/bed-to-chair transfer, and toilet transfers. During an interview on 10/19/23 at 6:30 A.M., the resident said his/her call light had been broken for a while. He/She reported it but it had not been fixed. Observation and interview on 10/19/23 at 6:36 A.M., of the resident's call light, located at his/her bedside, showed the call light pressed. No light indicator was available outside of the room door. Registered Nurse (RN) II sat at the nurse desk and said the call light worked by alarming at the nurse's desk on the panel. The panel then showed which room had a light going off. Observation of the panel, showed no audible alarm and no indication a call light had been pressed. RN II verified the panel did not show any call lights activated and added there are some issues with the call light panel. Sometimes when a call light was pressed, staff could not get it to turn off. They had to unplug and then plug in the panel to reset it. He/She was not aware of any call lights that did not work when pressed, just issues with them not turning off. Observation and interview on 10/19/23 at 12:20 P.M., showed the call light panel on the resident's floor showed ready. The call light in the resident's was room pressed. Observation of the panel, showed no audible alarm and no indication that a call light had been pressed. RN HH said the resident's roommate's call light stuck and could be difficult to turn off. He/She was aware of an issue with the resident's call light, but maintenance had been in last week to fix it. He/She was not sure if it was fixed. 2. Observation and interview on 10/19/23 at 9:15 A.M., showed Resident #306 sat in a recliner in his/her room and ate breakfast. The resident's call light hung between the foot board of the bed and the arm rest of the recliner. The resident said the call light did not work sometimes. The call button was pressed and a red light on the connection plate illuminated. No sound could be heard inside or outside the room. Observation on 10/19/23 at 9:23 A.M., showed the call light connection plate in the resident's room remained illuminated red. No sound could be heard inside or outside the resident's room. During an interview on 10/19/23 at 9:23 A.M., CNA MM said there was a call light panel at the nurse's desk which displayed a red light and alarmed when a call light was on. CNA MM said the light on the box was green indicating no call lights were on. Observation of the resident's room at 9:24 A.M., showed the red light on the connection plate remained red. The call light panel at the nurse's desk showed a green light and ready. Observation on 10/19/23 at 12:20 P.M., showed the call light panel on the resident's floor showed ready. The call light in the resident's was room pressed. Observation of the panel at the nurse's desk, showed no audible alarm and no indication a call light had been pressed. 3. During an interview on 10/19/23 at 4:10 P.M., with the Director of Nursing and Assistant Director of Nursing, both said they were aware one call light did not work about a week ago, but thought it was fixed. The Maintenance Supervisor resigned just the day before, so they would not be able to verify. If a call light was not working, staff were expected to fill out a sheet and give it to the Maintenance Supervisor. They had an electronic system that it could be reported to, but the Maintenance Supervisor preferred paper sheets be handed to him.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See event ID LK0M12 This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies dated 7/28/23. Based on interview and record review, the facility failed to encode resident assessment data within 7 days after a facility completed a resident's assessment and transmit the assessment timely, for three out of 11 residents investigated for resident assessment (Residents #306, #302, and #303). The census was 45. Review of the Minimum Data Set (MDS, a federal mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) user manual, showed: -For all non-admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the admission assessment, the MDS completion date must be no later than 13 days after the entry date; -Encoding data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). 1. Review of Resident #306's medical record showed: -admitted [DATE]; -An admission MDS in progress. 2. Review of Resident #302's, medical record showed: -admitted [DATE]; -No MDS records in progress or completed. 3. Review of Resident #303's, medical record, showed: -admitted [DATE]; -No MDS records in progress or completed. 4. During an interview on 10/19/23 at 11:20 A.M., the Administrator said the facility does not have an MDS coordinator and is using the corporate MDS coordinator that was being used during the annual survey. 5. During an interview on 10/19/23 at 4:10 P.M., with the Director of Nursing and Assistant Director of Nursing, they said MDS should be encoded and transmitted timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See event ID LK0M12 This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies dated 7/28/23. Based on observation, interview, and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address specific needs of the residents for five of 19 sampled residents (Residents #75, #301, #308, #307, and #13). The census was 45. 1. Review of Resident #75's medical record showed: -Diagnoses included Alzheimer's disease, age-related osteoporosis (thinning of the bones), history of falls, and muscle weakness. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 7/14/23, showed: -Sit to stand and chair/bed-to-chair transfer: Supervision or touching assistance - helper provides verbal cues or touching/steadying assistance as resident completes activity; -Toilet transfer: Partial/moderate assistance. Helper does less than half of the effort. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: At risk for self-care deficit: Bathing, dressing, feeding, toileting, and transfers; -Goal: Resident will be able to perform self-care needs; -Interventions included: Evaluate resident's ability to perform activities of daily living (ADLs). Provide assistance with ADLs as needed; -The care plan did not identify the level of assistance required for transfers. Observation on 10/19/23 at 7:01 A.M., showed Certified Nursing Assistant (CNA) FF completed rounds on the floor. He/She said the residents who were still in need of morning care all required two staff assistance for care, so he/she had to wait for help. At 7:04 A.M., CNA GG said the resident was ready to get up and entered the room with CNA FF. CNA GG assisted the resident to sit on the edge of the bed and moved the wheelchair near the bed. One CNA stood on the resident's left side and one CNA stood on the resident's right side. Both CNAs grabbed the resident under his/her arms and told the resident to stand as they pulled him/her up. The resident's arms and shoulders raised as staff pulled up on the resident. Staff assisted the resident to pivot and sit in the wheelchair. CNA GG propelled the resident into the bathroom near the toilet. Both CNAs assisted the resident to stand from the wheelchair as one CNA stood behind the resident and reached over the back of the wheelchair and the other CNA stood to the resident's left side. Staff instructed the resident to stand and pulled up on his/her arms. His/Her arms and shoulders raised as staff pulled up on the resident. Staff assisted the resident to turn and pivot and then sit on the toilet. The resident appeared unsteady. Once the resident was ready, both CNAs stood in front of the resident and used their arms to assist the resident to stand and pivot to the wheelchair. The resident's shoulders made a shrugging motion as staff pulled up on his/her arms. CNA GG stood behind the resident at the sink and put his/her arms under the resident's under arms and attempted to stand the resident. The resident's arms went up, but the resident remained seated. CNA GG said he/she needed to wait for CNA FF, because the resident was not able to stand. He/She needed two staff and would need to wait for CNA FF to come back so the resident did not slip and slide. CNA FF entered the resident's room. Both staff stood behind the resident's wheelchair, one to the left and one to the right, and placed their arms under the resident's arm pits. Staff pulled up on the resident's arms. The resident moaned. His/Her arms raised up, but he/she did not stand. The CNAs released the resident's arms, repositioned the wheelchair a little further away from the sink and attempted to stand the resident again. As the resident stood, his/her arms and shoulders were raised as the CNAs pulled up on his/her arms. Staff completed morning care one handed as they held onto the resident's arms. The resident appeared unsteady. After care was provided, staff pulled up the resident's pants and assisted the resident to sit in his/her wheelchair. Observation showed CNA FF wore a gait belt around his/her waist, but it was not used to assist the resident to transfer. During an interview with CNA FF and CNA GG on 10/19/23 at 8:45 A.M., both said they learned resident care needs when they were in training and did rounds with the staff who trained them. At that time, staff showed them how to care for residents and how residents transferred. They learned the resident's care needs as they provided care. During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 10/19/23 at 4:10 P.M., both said staff should have used a gait belt when assisting a resident to transfer. Resident #75 required one to two staff assistance with transfers with a gait belt. Staff should have known a resident's transfer status by reviewing the electronic medical record. The care plan should have clearly indicated the resident's transfer status. 2. Review of Resident #301's medical record showed: -Diagnoses included hemiplegia (paralysis on one side of the body) affecting left non-dominant side, stroke, muscle weakness and need for assistance with personal care. Review of the resident's annual MDS, dated [DATE], showed sit to stand, chair/bed-to-chair transfer, and toilet transfer: Substantial/maximal assistance - helper does more than half of the effort. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: At risk for falls related to left sided weakness; -Goals: Be free from falls; -Interventions included: Assist with ambulation and transfers utilizing therapy recommendations. -Review showed it did not include the resident's transfer status. Observation on 10/19/23 at 6:05 A.M., showed CNA Q entered the resident's room. CNA Q assisted the resident with morning care and then moved his/her electric wheelchair to the bedside. The resident's left arm appeared to be contracted (loss of range of motion caused to rigidity of the tendons and joints) and flaccid (paralyzed). The resident used his/her right arm to hold his/her left arm. CNA Q stood at the resident's side and pulled up on his/her left arm to assist the resident to stand. The resident leaned to the right as the CNA pulled on his/her left side. Once standing, the resident then pivoted and sat in his/her wheelchair. He/She said ouch after he/she pinched his/her arm between the wheelchair and the resident's body when he/she sat down. The resident used his/her right hand to grab his/her left arm and repositioned the arm. Staff did not use a gait belt. During an interview with the DON and ADON on 10/19/23 at 4:10 P.M., both said the resident was seen by therapy, but they were not sure what the recommendations for transfer were. The resident could be a one or two person assist with transfers. He/She had one sided weakness. The care plan should have clearly indicated the resident's transfer status. A gait belt should have been used. 3. Review of Resident #308's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Required limited staff assistance for transfers, personal hygiene and dressing; -Diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements). -Mobility: Wheelchair. Review of the resident's progress notes showed: -On 9/27/23 at 7:11 P.M., Resident was noted on floor by another resident laying on right side on his/her elbow. Nurse did a head to toe assessment, there was injury to his/her right side of face, purple bruising and a skin tear. This nurse asked resident what he/she was trying to do and he/she said I was trying to pick something up off the floor, that's when I tipped over. This nurse reminded resident to call for help before trying to bend over; -On 9/27/23 at 10:38 P.M., Noted right side of face slightly discolored, had a fall earlier this evening, discoloration was not observed at time of incident. Review of the resident's care plan, last revised on 9/29/23 and in use during the survey, showed: -Focus: Resident is at risk for falls due to decreased cognition. Actual fall on 9/27/23, no injury; -Interventions did not include any new interventions put in place to address how the resident fell and hit her face on the floor. -The care plan did not show the resident sustained an injury to his/her head when he/she fell on 9/27/23; -The care plan did not provide new interventions specific to the fall on 9/27/23. Observation and interview of the resident on 10/19/23 at 9:30 A.M., showed the resident with a crescent-shaped bruise under his/her right eye. The resident said he/she fell about a week ago. He/She was bending over to pick something up off the floor and fell out of his/her wheelchair. The resident said he/she forgot to lock the wheels before he/she bent over. The resident said staff constantly reminded him/her to lock the wheels. During an interview on 10/19/23 at 4:05 P.M., the DON said falls and interventions were reviewed every morning at the Risk meeting. The care plan should have been accurate and updated with new interventions specific to the incident. 4. Review of Resident #307's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Behaviors observed in the last 4-6 days: Delusions and wandering; -Independent with bed mobility, transfers and walking; -Diagnoses included Alzheimer's disease. Review of the resident's October 2023 physician order sheet (POS) showed an order, dated 6/28/23, to make sure Wanderguard (a monitoring device) is in place on the left ankle, every shift. Observation of the resident on 10/19/23 at 12:37 P.M., showed the resident wore a Wanderguard bracelet on his/her left ankle. Review of the resident's care plan, in use during the survey, showed: -Focus: The resident was a wanderer related to Alzheimer's disease; -Goal: The resident's safety would be maintained through the review date; -Interventions included: Identify pattern of wandering. Intervene as appropriate; -The care plan did not address the use or location of the Wanderguard bracelet. During an interview on 10/19/23 at 12:35 P.M., RN HH confirmed the resident wore a Wanderguard bracelet. 5. Review of Resident #13's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Wandering behavior exhibited; -Walks independently in room and corridor; -Diagnoses included dementia, Parkinson's disease, anxiety and depression. Review of the residents October 2023 POS showed: -An order, dated 6/8/23, to ensure Wanderguard in place on left ankle, every shift; -An order, dated 8/14/23, to check Wanderguard placement, and function every night shift. Observation on 10/19/23 at 12:35 P.M., showed the resident wore a Wanderguard on his/her left ankle. Review of the resident's care plan, in use during the survey, showed: -Focus: The resident was a wanderer related to Alzheimer's disease; -Goal: The resident will not leave the facility unattended. The resident's safety would be maintained; -Interventions included: Identify pattern of wandering. Intervene as appropriate; -The care plan did not address the use or location of the Wanderguard bracelet. During an interview on 10/19/23 at 4:05 P.M., the DON said the care plan should include the use of a Wanderguard to show staff what interventions were in place. She expected the care plans to be revised as needed. The DON, ADON and MDS nurse updated care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See event ID LK0M12 This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies dated 7/28/23. Based on observation, interview and record review, the facility failed to ensure side rails were assessed as a necessary device and ensure the side rails fit properly to reduce the risk of entrapment prior to instillation and use, for two of seven residents reviewed for side rail assessments (Residents #33 and # 13). The census was 45. Review of the facility's undated Bed Safety and Bed Rails policy showed: -The use of bed rails is prohibited unless the criteria for use of bed rails have been met; -The resident's sleeping environment is evaluated by the interdisciplinary team; -Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -The use of bed rails or side rails (including temporarily raising the side rails for episodic care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment and informed consent; -The resident assessment to determine risk of entrapment includes, but is not limited to: -Medical diagnosis, conditions, symptoms, and/or behavioral symptoms; -Size and weight; -Sleep habits; -Medications; -The resident assessment also determines potential risks to the resident associated with the use of bed rails including: -Accident hazards; -Restricted mobility; -Psychosocial outcomes. Review of the residents with side rails list, provided by the facility on 10/19/23, showed Resident #33 and #13 were not on the list. 1. Review of Resident #33's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/14/23, showed: -No cognitive impairment; -Independent with bed mobility, required staff set up/clean-up for transfers; -Diagnoses included diabetes and seizures. Review of the resident's October 2023 physician order sheet showed an order, dated 11/29/22, for quarter side rails x 2 for transfers, bed mobility, and positioning. Review of the resident's care plan, in use during the survey, showed: -Focus: Impaired physical mobility; -Goals: Resident will perform physical activity within prescribed mobility restrictions. Resident will use adaptive techniques to safely transfer and ambulate; -Interventions included utilize repositioning devises in bed, may use quarter rails on bed for bed mobility and positioning. Review of the resident's medical record showed no assessment for side rail appropriateness and safety. Observation and interview on 10/19/23 at 3:53 P.M., showed two half side rails secured to the head of the resident's bed. The resident said he/she always used the side rails for repositioning in bed. 2. Review of Resident #13's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Bed rail used daily; -Required staff assistance for transfers; -Diagnoses included dementia, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), anxiety and depression. Review of the residents October 2023 POS showed an order, dated 11/29/22, for quarter side rails x 2 for transfers, bed mobility and positioning. Review of the resident's care plan, in use during the survey, showed: -Focus: Resident is at risk for impaired physical mobility; -Goal: Resident will be able to perform activity within physical limits to fullest extent; -Resident uses quarter side rails x 2 for transfers, bed mobility and positioning. Review of the resident's medical record showed no assessment for side rail appropriateness and safety. Observation of the resident's bed on 10/19/23 at 12:35 P.M., showed the two quarter side rails secured to the head of the resident's bed. 3. During an interview on 10/19/23 at 1:56 P.M., RN JJ said his/her responsibility is to call the physician and obtain an order if it is determined side rails are needed. He/She will check the side rail assessment to ensure that side rails are appropriate. He/She is not sure who is responsible to complete the side rail assessments or how this is done. 4. During an interview on 10/19/23 at 4:10 P.M., with the Director of Nursing and Assistant Director of Nursing said in August 2023, a facility wide audit was completed to see which residents had side rails. Any residents identified to have side rails were assessed for appropriateness and safety for use of the side rails. The maintenance director, who resigned yesterday, was the only one who could apply side rails to the bed and it was expected the side rail assessment be completed prior to the side rails being applied to the bed. Side rails were also assessed quarterly. It was important to make sure side rails were safe and appropriate prior to being placed on the bed. The use of side rails should be on the care plan.

See event ID LK0M12 This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies dated 7/28/23. Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 27 opportunities, four errors occurred resulting in a 14.81% error rate (Residents #302, #23, and #304) The census was 45. Review of the facility's undated Administering Medications policy showed: -Medications are administered in a safe and timely manner, and as prescribed; -Medications are administered in accordance with prescriber orders, including any required timeframes; -The individual administering the medication checks the label three times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication. 1. Review of the undated Humalog insulin pen manufacturer's information showed: -Push the capped needle straight onto the pen; -Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the pen is working correctly; -If you do not prime before each injection, you may get too much or too little insulin; -To prime your pen, turn the dose knob to select 2 units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding the pen with needle pointing up. Push the dose knob until it stops and 0 is seen in the dose window; -Select your dose to administer. Review of Resident #302's medical record showed: -No diagnoses listed; -An order, dated 8/23/23, for Humalog (short acting insulin). Inject 11 units subcutaneously (under the skin) before meals for diabetes. Observation on 10/19/23 at 7:37 P.M., showed Registered Nurse (RN) JJ checked the resident's blood sugar level and said no sliding scale insulin was required, but routine insulin was ordered to be administered. RN JJ obtained a Humalog insulin pen from the medication cart for the resident, applied the needle tip, and set the pen to administer 12 units of insulin. He/She said that he/she sets the pens for one extra unit so one unit can prime the needle. This is a technique he/she had learned at a different job. RN JJ administered the 12 units of insulin to the resident. 2. Review of Resident #23's medical record showed: -Diagnoses included diabetes; -An order, dated 12/28/22, for Tradjenta (oral medicine used to treat diabetes) 5 milligrams (mg). Give one tablet by mouth one time a day. Scheduled administration time 9:00 A.M.; -An order, dated 1/2/23, for omeprazole (used to treat heart burn) delayed release 20 mg. Give one tablet by mouth one time a day. Scheduled administration time 9:00 A.M. Observation on 10/19/23 at 7:56 A.M., showed Certified Medication Technician (CMT) KK administered the resident's 8:00 A.M. and 9:00 A.M. medications. Omeprazole 20 mg and Tradjenta 5 mg were not administered. Review of the resident's medication administration record (MAR), showed omeprazole 20 mg and Tradjenta 5 mg scheduled to be administered at 9:00 A.M., daily. Both documented as administered as ordered on 10/19/23. During an interview on 10/19/23 at 12:18 P.M., CMT KK said he/she had not needed to go back to administer the resident any other medications since the observed administration in the morning. 3. Review of Resident #304's medical record showed: -Diagnoses included anemia (low levels of red blood cells); -An order, dated 9/11/22, for folic acid (a vitamin that helps the body make red blood cells) 1 mg (1 mg is equivalent to 1000 micrograms (mcg) of the same medication). Give one tablet by mouth one time a day. Scheduled administration time 8:00 A.M. Observation on 10/19/23 at 8:27 A.M., showed CMT H administered the resident's medication. He/She administered folic acid 400 mcg (equivalent to 0.4 mg of the same medication). 4. During an interview on 10/19/23 at 4:10 P.M., with the Director of Nursing and Assistant Director of Nursing, they said medications should be administered as ordered. This includes the correct ordered dose. Insulin pens should be primed using manufacturers recommendations. MO00224866

Based on interview and record review, the facility failed to distribute interest (money paid regularly to depositors of money at a financial institution a particular rate) for residents who allowed the facility to manage their resident funds during the months of January 2023 through July 2023. In addition, the facility failed to ensure the resident trust was in an interest-bearing account during the month of January 2023. This practice potentially affected five residents who allowed the facility to manage their funds. The census was 43. Review of the facility's undated resident personal funds policy, showed: -If the resident chooses the facility to manage funds, proper account and monitoring of such funds will be made; -Facility shall deposit any resident's personal funds in excess of $50.00 ($100 for Medicare) in an interest-bearing account or account that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. Review of the resident trust account, showed: -January 2023: Bank statement showed a balance of $1,527.73, in a non-interest bearing account. Review of the facility's monthly balance sheet, dated February 2023 through June 2023, showed: -No interest was credited to each resident's trust account; -A separate page for interest only showed: -2/28/23 for $.32; -3/31/23 for $0.48; -5/31/23 for $0.47; -6/30/23 for $0.42. -No documentation of interest credit to each resident trust account. During an interview on 7/26/23 at 2:24 P.M. and on 7/27/23 at 7:48 A.M., the Business Office Manager (BOM) said the resident trust account was not in an interest-bearing account when the new account opened in January 2023. It was originally set up incorrectly, so the funds were not in an interest-bearing account. The Administrator was responsible for reconciling the resident trust. Interest is divided annually based on average balances and pro rata. The interest is applied to the account because it is in an interest-bearing account.

Based on observation, interview and record review, the facility failed to reconcile the petty cash (a small amount of cash that is kept in a facility's business office to dispense to residents who have a resident trust account) on a monthly basis. In addition, the facility failed to provide bank statements with reconciliation sheets for the months of July 2022 through December 2022. This practice potentially affected five residents who had resident trust accounts. The census was 43. Review of the facility's undated resident personal funds policy, showed: -A resident may choose to have the facility manage personal funds; -If the resident chooses the facility to manage funds, proper accounting and monitoring of funds such funds will be made. Review of the facility's monthly reconciliation sheet, showed: -Monthly reconciliation sheet not provided for July 2022 through December 2022; -January 2023, an ending balance of $1,527.73. Petty cash was not included; -February 2023, an ending balance of $1,528.05. Petty cash was not included; -March 2023, an ending balance of $1,346.18. Petty cash was not included; -April 2023, an ending balance of $1,346.59. Petty cash was not included; -May 2023, an ending balance of $1,284.06. Petty cash was not included; -June 2023, an ending balance of $1,284.48. Petty cash was not included. Review of Resident #1's trust account, showed: -On 11/14/19, a starting balance of $250.00; -On 7/27/23, a balance of $722.38. Review of Resident #14's trust account, showed: -On 9/19/19, a starting balance of $70.00; -On 7/27/23, a balance of $70.00. Review of the facility's funds close-out report, dated 6/22/22, showed: -Resident #1, a balance of $667.73; -Resident #14, a balance of $70.00. During an interview on 7/26/23 at 2:24 P.M., the Business Office Manager (BOM) said the facility opened a new account in January 2023. She was not aware if there were statements or an account for resident funds prior to January 2023. The Administrator was responsible for reconciling the accounts. The BOM was not responsible for petty cash. The Receptionist is responsible for dispersing the money when residents want cash. Prior to 2023, there was no resident trust account so there are no bank statements. During an interview on 7/27/23 at 7:55 A.M. and 8:09 A.M., the BOM said prior to January 2023, the previous owners of the facility had resident funds. The BOM said Residents #1 and #14 had transactions prior to January 2023. Those accounts were closed in 2022. The residents who had a resident trust account prior to January 2022 were non-Medicaid residents. The account was closed and those funds were sent out to families. At 8:09 A.M., the BOM said the previous owners have the funds information prior to January 2023. There were no Medicaid residents with a trust account prior to January. Observation and interview on 7/27/23 at 7:43 A.M., showed Receptionist/Activity Aide W counted the petty cash. There was $27.50 in the petty cash box. He/She is responsible for disbursing the funds and to get signatures from the residents who requested cash.

Based on observation, interview and record review, the facility failed to protect the resident's right to privacy during personal care and medical treatments for one resident exposed to the hall when a non-nursing staff member entered the room, stood in the doorway, and asked about a different resident. In addition, one resident had their blood sugar checked in the dining room with other residents present (Residents #7 and #23). The census was 43. Review of the facility's resident's rights poster, posted on the resident floors, showed: Your rights as a resident in a long-term care facility: -Every facility must inform residents of these upon being admitted and must protect and promote these rights for all residents; -To privacy and respect: You have the right to privacy in medical treatment, personal care, telephone and mail communications, visits and meetings of family and of resident groups. You shall be treated with consideration, respect and full recognition of your dignity and individuality. You may not be required to do things against your will. 1. Review of Resident #7's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 5/2/23, showed: -Rarely/never understood; -Primary medical condition category: Debility, cardiorespiratory conditions; -Extensive assistance required for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder. Observation on 7/25/23 at 12:27 P.M., showed Registered Nurse (RN) E entered the resident's room. He/She and Nurse in Training T assisted the resident to his/her right side to observe a sacral (buttocks area) wound. RN E said he/she was going to change the resident because he/she was wet. He/she assisted the resident to his/her right side, unsecured his/her brief, wiped the resident, then released the resident to allow him/her to roll onto his/her back. He/She pulled the brief down in the front to expose the resident's genitals and applied A&D cream to groin. At 12:36 P.M., there was a knock on the door. RN E said nursing and Receptionist/Activity Aide W entered anyway and stood in the doorway with the door open, while the resident was exposed. Receptionist/Activity Aide W started asking about a different resident who was transferred out, and asking where they went. RN E told him/her several times to step out, but he/she stayed in the doorway and kept asking. RN E then said I don't know, I will come get you later. Receptionist/Activity Aide W left the room and closed the door. RN E identified the staff person as the receptionist. 2. Review of Resident #23's care plan, in use at the time of the survey, showed: -Focus: The resident has diabetes; -Goal: Be free from signs and symptoms of hypo/hyperglycemia (low and high blood sugar); -Interventions: Administer sliding scale insulin as ordered by the physician. Review of the resident's physician order sheet, showed an order dated 1/3/23, for insulin apart (short acting insulin) FlexPen solution. Inject as per sliding scale, subcutaneously (under the skin) before meals. Observation on 7/24/23 at 4:23 P.M., showed RN A gathered the supplies needed to check residents' blood sugar levels and walked into the dining room, where the resident sat in a wheelchair with five other resident's present. RN A wiped the resident's finger off, stuck the resident's finger to obtain a blood sample, and then measured the results. RN A then said out loud the resident's blood sugar result of 317 before returning to the medication cart. 3. During an interview on 7/27/23 at 1:44 P.M., the Director of Nursing (DON) said residents have the right to privacy during care. This includes both personal care and blood sugar checks. Blood sugar levels should not be obtained in the dining room if there are other resident's present. If staff are providing care, a non-nursing staff member knocks, and the staff providing care say nursing that means the non-nursing staff should not enter. It is not acceptable to open the door with the resident's genitals exposed and stand in the doorway with the door opened while talking about a different resident.

Based on observation, interview and record review, the facility failed to ensure each resident was free from neglect when Registered Nurse (RN) E willfully neglected to provide goods and services to a resident that are necessary to avoid physical harm. RN E failed to compete the treatment of a pressure ulcer (injury to the skin and/or underlying tissue, as a result of pressure or friction) as ordered, for two days in a row, yet said the dressing was changed and documented the dressing as changed. When asked about the treatment not being done, RN E created a physician order to make it appear the dressing was not due to be changed. This was done without calling the physician or assessing the wound to see the appropriateness of changing the order. RN E failed to administer a resident's medications as ordered. When asked about the medications being due, RN E said they were administered and documented the administration. Review of the video footage and direct observation, showed RN E never administered the medications (Resident #7). This failure had to potential to affect all resident's under RN E's care. The census was 43. Review of the facility's Abuse prevention, Reporting and Investigation policy, effective 2015 and last revised on 10/2022, showed: -Objective: Residents, staff, and visitors to the facility have the right to be free form abuse, neglect, misappropriation of property and exploitation. This shall include freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition; -The facility will provide a safe and home-like environment that ensures the right of each resident to be free of abuse, neglect, misappropriation of property and exploitation; -Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress; -Person-centered care, as defined by the Institute of medicine, is providing care that is respectful and responsive to the individual resident preferences, needs, and values, and ensuring that the resident's values guide all decisions related to care and services. Review of the facility's undated Pressure Ulcers/Skin Breakdown- Clinical Protocols policy, showed: -The nurse staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s); -In addition, the nurse shall describe and document/report the following: -Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates (drainage) or necrotic (dead) tissue; -The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement (removal of dead tissue) approaches, dressings, and application of topical agents. Review of the facility's undated Administering Medications policy, showed: -Medications are administered in a safe and timely manner, and as prescribed; -Medications are administered in accordance with prescriber orders, including any required timeframe; -Medications are administered within one hour of their prescribed times, unless otherwise specified (for example, before and after meal orders); -The individual administering the medication checks the label three times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication; -For residents not in their rooms or otherwise unavailable to receive medication on the pass, the medication administration record (MAR) may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication; -The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of Resident #7's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 5/2/23, showed: -Rarely/never understood; -Primary medical condition category: Debility, cardiorespiratory conditions; -Diagnoses included stroke, dementia, and hemiplegia and hemiparesis (hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body); -At risk for pressure ulcers; -Extensive assistance required for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder; -Had a feeding tube (gastric tube (g-tube), a tube inserted into the stomach to provide food, fluid and medications). Review of the resident's care plan, in use at the time of the survey, showed: -Focus revised on 9/21/22: Self-care performance deficit for activities of daily living (ADLs) and requires one to two assist as needed for bathing, dressing, feeding, and mobility: -Goal: The resident will participate in self-care activities to be as independent as possible; -Interventions included provide assistance with ADLs as needed; -Focus revised on 12/14/22: The resident has altered neurological status: -Goal: Resident will maintain baseline mental status; -Interventions included evaluate level of consciousness and mental status; -Focus revised on 12/14/22: At risk for impaired physical mobility: -Goal: Skin will remain intact; -Interventions included assist resident in performing movements/tasks. Utilize pressure relieving devices on appropriate surfaces; -Focus revised on 6/26/23: At risk for impaired skin integrity: -Goal: Skin will remain intact; -Interventions included evaluate skin and monitor skin for moisture, apply barrier product as needed. Review of the resident's electronic physician order sheet (ePOS), reviewed on 7/24/23, showed: -An order dated 5/20/23, for the wound nurse to evaluate and treat; -An order dated 5/24/23, for famotidine (used to treat heart burn) 20 milligram (mg). Give one tablet via g-tube one time a day: -Scheduled administration time: 9:00 A.M.; -An order dated 5/24/23, for Florastor (probiotic). Give one capsule via g-tube one time a day: -Scheduled administration time: 9:00 A.M.; -An order dated 6/10/23, for Baclofen (muscle relaxer) 10 mg. Give one tablet via g-tube, three times a day: -Scheduled administration time: 9:00 A.M., 3:00 P.M., and 9:00 P.M.; -An order dated 6/10/23, for guaifenesin (cough medication) 100 mg/5 milliliter (ml). Give 10 ml via g-tube every 6 hours: -Scheduled administration time: 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -An active order dated 6/29/23, for calcium alginate (used in the treatment of moderately to heavily draining wounds), apply to sacrum (tailbone area) topically one time a day for wound care. Cleanse area with wound cleanser, apply alginate and dry dressing daily, and as needed. Review of the resident's treatment administration record (TAR), reviewed on 7/26/23 at 11:02 A.M., showed the order for calcium alginate apply to sacrum topically one time a day for wound care, scheduled daily at 9:00 A.M., and documented as completed as ordered by RN E on July 24 and 25, 2023. Review of the facility's wound reports for July 2023, showed the following for Resident #7: -On 7/7/23, onset date (no date listed), location sacrum, wound description and measurements: 0.5 x 0.4 x 0.3 (unit of measurement not identified), injury/condition background: unstageable (full thickness tissue loss in which the actual depth of the ulcer is obscured by slough (yellow, tan, gray, green, or brown dead tissue) and/or eschar (tan, brown, or black dead tissue) in the wound bed), treatment prescribed: Alginate and dry dressing, next dressing change date: Daily, no odor present, healing; -On 7/19/23, onset date (no date listed), location sacrum, wound description and measurements: 1.0 x 0.3 x 0.1 (unit of measurement not identified), injury/condition background: unstageable, treatment prescribed: Alginate and dry dressing, next dressing change date: Daily, no odor present, healing. During an interview on 7/25/23 at 7:08 A.M., RN E said he/she will complete the resident's morning g-tube medication administration at 9:00 A.M. At 8:50 A.M., RN E said a different resident had a medical emergency, the resident's medications will be rescheduled for noon. Continuous observation of the RN E on 7/25/23 from 9:03 A.M. through 11:48 A.M., showed RN E never left foyer or dining/living room area to administer medications. During an interview on 7/15/23 at 11:48 A.M., RN E said the resident got up in his/her chair for a while today, so he/she will have to wait until after the resident is put back to bed, after lunch is served. Observation, showed RN E sat at the nurse's desk and talked with another staff person. During an interview on 7/25/23 at 11:48 A.M., Certified Medication Technician (CMT) H said he/she had concerns about the care provided to the resident. RN E does not feed the resident his/her tube feeding and his/her treatments are only done on Wednesdays when the wound nurse is in. RN E is good at completing his/her paperwork, but does not provided the treatments or administer medications. Observation on 7/25/23 at 12:06 P.M., showed a call light went off. The audible indicator right next to where RN E and Nurse in Training T sat. Neither responded to the call light and both continued to sit at the desk. Observation on 7/25/23 at 12:10 P.M., showed Certified Nursing Assistant (CNA) J, RN E, and Nurse in Training T transferred the resident to bed using a mechanical lift. Observation on 7/25/23 at 12:22 P.M., showed RN E stood at the medication cart, and poured guaifenesin 10 mg per 5 ml, 10 ml into a medication cup. At 12:27 P.M., RN E entered the resident's room and administered the medication via the resident's g-tube. No other medication besides the guaifenesin administered. RN E asked the surveyor if there was anything else the surveyor needed to see. When asked about the pressure ulcer treatment, RN E said the dressing was changed this morning when they got the resident up in his/her chair. The surveyor asked to observe the dressing. RN E and Nurse in Training T assisted the resident his/her right side, to observe the sacral area. The dressing was dated 7/23/23 and looked very soiled. Before the surveyor could view the initials documented on the dressing, RN E quickly released the resident, causing him/her to roll over on his/her back. The surveyor asked to view the dressing again. RN E rolled the resident to his/her left side, but not far enough that the dressings could be seen. RN E released the resident and the resident rolled to his/her back. The surveyor again asked to see the dressing. RN E and Nurse in Training T assisted the resident to his/her right side and exposed the dressings on the resident's sacral area. Observation showed, in addition to the date of 7/23/23, it was labeled with initials which were not those of RN E. When asked whose initials they were, RN E said Nurse Y, who worked Monday over nights. RN E then said I will have double check when due referring to the dressing. The nurse was asked if he/she had changed the dressings before getting the resident up, why is it still labeled from two days earlier. RN E said he/she thought night shift did the dressings changes. When asked if the dressing needed to be done now, RN E said he/she needed to check the order. He/She assisted the resident to be covered, washed his/her hands and exited the room at 12:49 P.M. The surveyor asked RN E to pull up the order and verify the order. RN E walked to the desk as the surveyor pulled up the order on the surveyor's computer. RN E went out to the desk and logged onto his/her computer. At 12:54 P.M., RN E said he/she checked the order, then he/she proceeded to read the order out load, verbatim, with the exception to where the surveyor saw the order to read daily RN E said every 3 days. RN E then said the treatment was not due. At no time did RN E call the physician during this observation. Review of the resident's ePOS, showed: -RN E added an order on 7/25/23 at 12:50 P.M. (during the time the surveyor stood and waited for RN E to look up the wound treatment order), for calcium alginate, apply to sacrum topically for wound care. Cleanse area with wound cleanser, apply alginate and dry dressing every three days. RN E documented the order was obtained via a phone call to Physician AA; -On 7/25/23 at 12:51 P.M. (during the time the surveyor stood and waited for RN E to look up the wound treatment order) RN E discontinued the order for the resident's calcium alginate, apply to sacrum topically one time a day for wound care. RN E documented the order was obtained via a phone call to Physician AA. Reason for the discontinued order: Updated. Review of the resident's medication audit report, for the date of 7/25/23, showed: -Famotidine 20 mg documented as given by RN E at 9:46 A.M.; -Florastor documented as given by RN E at 9:46 A.M.; -Baclofen 10 mg documented as given by RN E at 9:46 A.M. During an interview on 7/25/23 at 1:05 P.M., Nurse in Training T said he/she did not administer the resident's morning medication and did not see RN E administer the morning medications. During an interview on 7/25/23 at 1:11 P.M., RN E said he/she gave the resident his/her AM medications. The original time of 9:00 A.M., that was pre-arranged, did not work because he/she had to send a resident to the ER and that messed with the time. He/She went in and gave the medications after the other resident went out to the ER and before Resident #7 got up in his/her chair. During an interview on 7/25/23 at 2:10 P.M., CNA J said he/she got the resident up at around 9:45 A.M. He/she was waiting to get him/her up, because he/she knew RN E said he/she was going to be watched by state. He/she thought state was going to watch the resident be transferred and his/her wound treatment, but RN E never came in, so CNA J got someone else up and came back to get the resident up because he/she was just lying there. He/She then got the resident up and took him/her to the TV room. RN E and Nurse in Training T never got up from the desk. CNA J was actually watching them and he/she never saw the nurses get up to give medication. During an interview on 7/25/23 at 3:05 P.M., the Director of Nursing (DON) said she would expect staff to provide care as ordered. Staff should not say they provided care and document they provided care if they did not. She defined neglect as being neglectful of the resident's needs. She will start an investigation into RN E's actions to determine if there was neglect, and will follow the facility abuse and neglect policy. The facility does have cameras and she will check to see if she can access the camera footage. Observation on 7/25/23 at 3:30 P.M., RN F, the nurse for a different floor at the facility, entered the resident's room to complete the resident's treatment. The dressing continued to be dated 7/23/23 with the initials of Nurse Y. RN F completed the treatment as ordered. During an interview on 7/28/23 at 10:48 A.M., the DON and Assistant Director of Nursing (ADON) said it is very hard to get ahold of Physician AA or other physicians at that practice. Physician AA is currently on vacation and the calls are being covered by a different physician. The ADON verified the initials on the resident's treatment record for the dates of 7/24 and 7/25/23 as those of RN E. The DON said RN E admitted he/she changed the treatment order without a physician's order. This is also reflected in the statement he/she wrote. When RN E discontinued the daily treatment and changed it to every three days, the every three day order had to then be discontinued and it was re-ordered for daily. Review of the facility's investigation, showed: -A statement dated 7/25/23, written and signed by RN E regarding Resident #7, showed regarding the resident's wound care, when providing care for the resident, the state representative asked to see the treatment site on the resident's sacral area. While the resident was turned over, the representative and him/herself looked at the dressing and noted it was dated for 7/23. He/She realized that he/she did not get around to changing it the previous day, like he/she signed out he/she had done. This is not a normal occurrence, as evidenced by the continued improvement in the wounds status. He/she intended the previous day to speak to the physician to change the schedule of the treatment and when questions about the schedule, he/she made the mistake and spoke of the schedule he/she was seeking instead of the schedule that still existed; -A statement dated 7/25/23 at 4:00 P.M., written and signed by RN E regarding Resident #7, showed upon RN E's arrival today, he/she was asked by a state representative to watch medication administration of the resident via g-tube. We planned to administer/observe at 9:00 A.M. A little later, the representative came to the unit and I spoke with him/her about rescheduling this medication pass/observation because he/she was dealing with a provider and other urgent needs on the unit. The state representative agreed to a noon medication administration. While having a little down time between other needs, RN E went to the resident's room with his/her AM medications and to change his/her tube feeding. Later, when the state representative came up, we went to the room with the resident and he/she observed him/her administer the resident's noon medication; -A follow-up investigation report, provide by the DON on 7/27/23 at 11:49 A.M., showed: -RN E did not change the resident's dressing to his/her bottom as ordered by the physician. He/she changed the order without notifying the physician from daily to every three days. RN E also had the resident up in a chair in the common area for 4 hours with no continuous tube feeding running. No physician order to discontinue the feeding. He/she did not have an order to discontinue the tube feeding for 4 hours; -RN E confirmed that he/she had not changed the dressing and documented that he/she did in the medical record. Observation of the facility's camera footage, on 8/2/23 at 1:42 P.M., reviewed for the date of 7/25/23 from 8:28 A.M. through 9:43 A.M., of the second floor lobby area, showed the following: -At 8:28 A.M., RN E and Nurse in Training T sat at the desk in the second floor lobby. The medication cart sat in view of the camera; -At 9:19 and 18 seconds A.M., Emergency Medical Services (EMS) arrived to the floor, exiting the elevator into the second floor lobby. RN E stood up and walked into the dining room/living room area, out of view of the camera; -At 9:19 and 58 seconds A.M., RN E re-entered the camera view from the dining room/living room area and propelled a resident in their wheelchair over to the EMS gurney, which sat in view of the camera; -From 9:19 A.M. through 9:25 A.M., RN E and Nurse in Training T assisted EMS by providing paperwork, assisting with the resident and talking with EMS; -At 9:25 A.M., RN E and Nurse in Training T sat back down at the desk; -At 9:43 A.M., CNA J brought the resident in his/her medical reclining chair from down the hall and into the dining/living room area; -RN E never left the desk any other time during the footage reviewed. During an interview on 8/2/23 at 1:42 P.M., the Administrator verified RN E never left the desk during the recorded observation outside of when he/she was assisting a different resident to be sent out with EMS. During a telephone interview on 8/3/23 at 8:53 A.M., RN E was informed that the video footage from the day in question was reviewed and was asked if he/she gave the resident his/her 9:00 A.M. morning medications, RN E said he/she did give the medications. He/she said the Baclofen was being given due to the resident's contractures and to help him/her relax. It was for discomfort, because he/she was having pain during therapy. The risk of not receiving the baclofen would be pain and stiffness during therapy. Regarding the order to change the treatment to every 3 days, he/she made a poor decision. He/She was seeking orders for every 3 days dressing changes. When he/she went in to do the treatment with the surveyor, he/she was not sure if the order was changed yet or not. He/She would define neglect as not doing something for the resident that causes harm. The nurse was again asked about the medications and reminded a second time that the video was reviewed. RN E said he/she disagrees with what the video shows. He/She gave the medications when the surveyor was in there. RN E was informed that the person he/she was talking to was the surveyor in the observation and he/she only gave the guaifenesin. RN E then said he/she did go and give the medications earlier that day. RN E said the nurse in training was with him/her when he/she went and gave them. RN E was informed that the video footage was reviewed, the med cart was in view the entire time, and he/she was never observed to get out any medicines, he/she was in view of the camera with the exception of going into dining room to get the resident to send to the ER, the nurse in training was interviewed and said he/she never saw RN E administer the medications. In addition, a surveyor was positioned on the floor with the assignment of observing to see when/if the medications were given and they were not given. RN E said he/she gave the medications and disagrees with the video and what other people say. MO00222094

Based on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition for one resident who was not assisted in an upright position for breakfast and not assisted to eat breakfast, resulting in the resident's food ending up on his/her lap and the floor (Resident #74). The sample was 12. The census was 43. Review of the facility's undated Activities of Daily Living (ADL) Supporting policy, showed: -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Dining (meals and snacks); -A resident's ability to perform ADLs will be measured using clinical tools, including the Minimum Data Set (MDS, a federally required assessment instrument completed by facility staff). Functional decline or improvement will be evaluated in reference to the assessment reference date and the following MDS definitions: -Independent: Resident completed activity with no help or staff oversight; -Supervision: Oversight, encouragement or cuing provided; -Limited assistance: Resident highly involved in activity and received physical help in guided maneuvering of limbs or other non-weight bearing assistance; -Extensive assistance: While resident performed part of activity, staff provided weight bearing support; -Total dependence: Full staff performance of an activity with no participation by the resident for any aspect of the ADL activity; -Interventions to improve or minimize a resident's functional abilities will be in accordance with the residents' assessed needs, preferences, stated goals and recognized standards of practice. Review of Resident #74's medical record, showed: -Diagnoses included hemiplegia and hemiparesis (hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body) following a stroke affecting the right dominate side, aphasia (loss of ability to understand or express speech, caused by brain damage), dementia, and depressive disorder; -A care plan, in use at the time of the survey, showed risk for self-care deficit: Bathing, dressing, feeding, toileting, and transfers: Evaluate functional abilities. Provide meal support per resident's needs. The resident has an alteration in musculoskeletal status related to contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the right arm related to a stroke: Staff to assist with feedings; -An order dated 3/8/23, for a regular diet with super cereal with breakfast and Boost with dinner. Observation on 7/24/23 at 7:04 A.M., showed the resident sat in a Broda chair (medical wheeled reclining chair) in the third floor dining room. His/Her right leg hung down to the ground, off of the side of the chair and his/her head tilted to the left and over the side of the chair. The resident grimaced as he/she tried to reposition him/herself. At 8:27 A.M., staff brought breakfast to the third floor on a wire rack and staff began to pass out trays. Staff placed Resident #74's food on the table in front of him/her. The food was still covered with a lid. The resident sat in his/her chair, not assisted to eat, and slouched down in his/her chair. Both legs were on the reclined leg rests, but his/her buttocks slid down causing the bend in the chair to line up with his/her lower back and not his/her hips. At 8:33 A.M., Certified Nursing Assistant (CNA) B positioned the resident's chair up closer to the table and sat the chair up rapidly. This caused the residents to be jerked forward rapidly. The resident then fell back into the chair and slid down further into the chair. His/her feet pressed against the legs of the table and the bend of the chair was near the resident's mid back. The resident leaned to the left side. CNA B started to cut up the resident's food. Staff served the resident oatmeal, cheesy eggs, two sausage links, Boost, orange juice, pancakes, milk, and another unidentified drink in a cup. The resident reached to the table and took a drink of his/her juice. CNA B said sit up now, take your hand from your shirt so you can eat. CNA B then adjusted the resident's right sleeve, that had slipped down over his/her hand, but he/she did not assist the resident to sit up. CNA B stood over the resident on the left side and gave the residents two bites of food, then walked to a different resident. The resident still slouched in his/her chair. At 8:34 A.M., the resident struggled to reach for his/her food and his/her position in the chair appeared unsafe for eating and uncomfortable. CNA B exited the dining room as the resident struggled to reach for his/her food, using his/her hands to grab at the food. Registered Nurse (RN) A walked over to the resident, put a clothing proctor on him/her, then offered him/her a straw. The resident remained slouched, and no staff assisted him/her to sit up or be positioned in the chair. RN A returned with straws and put them in his/her drinks. The resident's feet continued to be press against the legs of the table. After adding a straw in the resident's drinks, RN A walked away. The resident struggled to reach for his/her food. He/she grabbed a piece of sausage, took a bite then reached to set his/her sausage down. The resident reached for his/her eggs, stuck his/her fingers into the eggs, and then licked his/her fingers. He/She reached for the bowl that contained oatmeal and tried to drink from it like a cup, his/her left hand shook significantly. At 8:43 A.M., the resident continued to struggle to reach his/her food. The resident leaned to one side and slouched, making it hard for him/her to reach anything on the tray. Two staff stood near the resident while assisting other residents. No staff offered positioning assistance to the resident. At 8:47 A.M., the resident was able to reach his/her fork and then dropped the fork on his/her lap. There were several pieces of pancake and several pieces of egg on his/her lap. The resident grabbed a drink from the tray, struggled to take a drink, and began to cough. He/She spilled his/her drink all over his/her tray. The resident attempted, but was not able to reach any other drinks on the tray, so he/she attempted to reach for the cup that lay on its side. Only a scant amount of drink remained in the cup. At 8:49 A.M., the resident dropped his/her cup on the floor. He/She then picked up the sausage from his/her lap, attempted to bring it to his/her mouth, and then dropped the piece of sausage on the floor. The resident was able to reach his/her second piece of sausage. He/She took one bite and then the sausage dropped to the floor. He/She ended up only being able to take one bite of each piece of sausage before dropping them. The resident reached over and pulled his/her tray closer and reached with his/her hands into the eggs but was not able to get any. CNA B walked over to the resident, picked up the fork from his/her lap, said I can help you, stood next to the resident and fed the resident a bite of food. CNA B then took the resident's plate and took it to the microwave. As CNA B stood at the microwave, the resident grabbed the bowl of oatmeal and drank from it like a cup. As he/she drank, some spilled on his/her clothing protector. CNA B returned to the resident's side, stood over the resident, and placed a bite in the resident's mouth. The resident said too hot. The resident continued to be slouched and leaned in his/her chair. CNA B scooped up random bites of food and put them in the resident's mouth. At 9:02 A.M., only a few minutes after starting to feed the resident, CNA B walked away from the resident suddenly and stopped feeding him/her. The resident began to reach for his/her food with his/her bare hands and almost dumped the whole tray on floor when his/her hand began to shake suddenly. He/She was able to pull the tray close enough to get to his/her orange juice. Approximately half of the food that was on the tray was now gone, but half of that amount lay on the floor or the resident's lap. The resident appeared to be exhausted and stopped attempting to feed him/herself. At 9:14 A.M., two staff walked over to the resident and pulled him/her up in the chair. One of the CNAs then stood over the resident and gave another bite of food, then walked away. During an interview on 7/26/23 at 8:53 A.M., RN A said he/she has been provided education on proper feeding and eating techniques. He/She is a CNA instructor. Staff should check the resident's diet and make sure their food is cut up. The proper technique is to give four or five bites of food then something to drink. Take time while feeding. Sit while feeding and not stand. Proper positing for residents is at least 90 degrees, not flat. If a resident is fed when slouched or scooted down in the chair or bed, there is a risk of choking or aspiration. To know which resident's require assistance with eating, he/she walks around and observes or checks the care plan. During an interview on 7/26/23 at 8:57 A.M., CNA B said he/she knows how to provide care because he/she has been working with and knows the residents. He/She has been provided training on techniques and dignity. Residents should be sitting up when eating. They can choke if slouched or laying. The technique training provided was when he/she was in school to be a CNA, not provided by the facility. He/she just knows the residents and knows which ones are feeders. During an interview on 7/27/23 at 1:44 P.M., the Director of Nursing said when staff are feeding residents, the residents should be sitting upright. Staff should assist with meals if needed.

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction) receives necessary treatment and services, consistent with professional standards of practice when the nurse failed to apply the treatment as ordered for two days, yet documented the treatment as completed. As a result, a different nurse had to leave their assigned floor to complete the ordered treatment (Resident #7). In addition, the facility failed to ensure the resident's medical record contained documentation of the resident's pressure ulcers staging, measurements, and appearance per acceptable standards of practice. The facility identified one resident with pressure ulcers on their Resident Matrix and Resident #7 was not the resident identified. The census was 43. Review of the facility's undated Pressure Ulcers/Skin Breakdown- Clinical Protocols policy, showed: -The nurse staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s); -In addition, the nurse shall describe and document/report the following: -Full assessment of pressure core including location, stage, length, width and depth, presence of exudates (drainage) or necrotic (dead) tissue; -The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement (removal of dead tissue) approaches, dressings, and application of topical agents. Review of Resident #7's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 5/2/23, showed: -Rarely/never understood; -Diagnoses included Stroke, dementia, and hemiplegia and hemiparesis (hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body); -At risk for pressure ulcers; -No pressure ulcers identified as being present; -Extensive assistance required for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, in use at the time of the survey, showed: -Focus revised on 9/21/22: Self-care performance deficit for activities of daily living (ADLs) and requires one to two assist as needed for bathing, dressing, feeding, and mobility: -Goal: The resident will participate in self-care activities to be as independent as possible; -Interventions included provide assistance with ADLs as needed; -Focus revised on 12/14/22: At risk for impaired physical mobility: -Goal: Skin will remain intact; -Interventions included assist resident in performing movements/tasks. Utilize pressure relieving devices on appropriate surfaces; -Focus revised on 6/26/23: At risk for impaired skin integrity: -Goal: Skin will remain intact; -Interventions included evaluate skin and monitor skin for moisture, apply barrier product as needed; -Focus revised on 5/23/23: The resident has a pressure ulcer to the coccyx (tailbone area), development related to immobility; -Goal: The resident's pressure ulcer will show signs of healing and remain free from infection; -Intervention, reposition every two hours; -The care plan provided conflicting information about the resident's skin status. Review of the resident's electronic physician order sheet (ePOS), showed: -An order dated 5/20/23, for a skin assessment weekly, every evening shift, every Thursday; -An order dated 5/20/23, for the wound nurse to evaluate and treat; -An order dated 6/29/23, for calcium alginate (used in the treatment of moderately to heavily draining wounds), apply to sacrum (tailbone area) topically one time a day for wound care. Cleanse area with wound cleanser, apply alginate and dry dressing daily, and as needed. Review of the resident's treatment administration record (TAR), showed the order for calcium alginate apply to sacrum topically one time a day for wound care, scheduled daily at 9:00 A.M., and documented as completed as ordered by Registered Nurse (RN) E on July 24 and 25, 2023. Review of the resident's skin observations tools, for July 2023, showed: -On 7/6/23, no new skin concerns noted at this time; -On 7/13/23, no new areas; -On 7/20/23, no new skin issues noted. Review of the resident's medical record, showed no documentation of the resident's pressure ulcer measurements, staging, appearance, or drainage. Review of the facility's wound reports (facility document that lists multiple residents on one report and therefore cannot be part of the individual resident's medical records) for July 2023, showed the following for Resident #7: -On 7/7/23, onset date (no date listed), location sacrum, wound description and measurements: 0.5 x 0.4 x 0.3 (unit of measurement not identified), injury/condition background: unstageable (full thickness tissue loss in which the actual depth of the ulcer is obscured by slough (yellow, tan, gray, green, or brown dead tissue) and/or eschar (tan, brown, or black dead tissue) in the wound bed), treatment prescribed: Alginate and dry dressing, next dressing change date: Daily, no odor present, healing; -On 7/19/23, onset date (no date listed), location sacrum, wound description and measurements: 1.0 x 0.3 x 0.1 (unit of measurement not identified), injury/condition background: unstageable, treatment prescribed: Alginate and dry dressing, next dressing change date: Daily, no odor present, healing. During an interview on 7/25/23 at 7:08 A.M., RN E said he/she will complete the resident's treatment at 9:00 A.M. During an interview at 8:50 A.M., RN E said a different resident had a medical emergency, the resident's treatment will be rescheduled for noon. At 11:48 A.M., RN E said the resident got up in his/her chair for a while today, so he/she will have to wait to do the treatment until after the resident is put back to bed, after lunch is served. Observation, showed RN E sat at the nurse's desk and talked with another staff person. Observation on 7/25/23 at 12:27 P.M., showed RN E entered the resident's room and administered a medication to the resident. RN E asked the surveyor if there was anything else the surveyor needed to see. When asked about the pressure ulcer treatment, RN E said the dressing was changed this morning when they got the resident up in his/her chair. The surveyor asked to observe the dressing. RN E and Nurse in Training T assisted the resident to his/her right side, to observe the sacral area. The dressing was dated 7/23/23 and looked very soiled. Before the surveyor could view the initials documented on the dressing, RN E quickly released the resident, causing him/her to roll over on his/her back. The surveyor asked to view the dressing again. RN E rolled the resident to his/her left side, but not far enough that the dressings could be seen. RN E released the resident and the resident rolled to his/her back. The surveyor again asked to see the dressing. RN E and Nurse in Training T assisted the resident to his/her right side and exposed the dressings on the resident's sacral area. Observation showed the dressing labeled with the date of 7/23/23 and initials which were not those of RN E. When asked whose initials they were, RN E said Nurse Y, who worked Monday over nights. RN E then said I will have double check when due referring to the dressing. RN E was asked if he/she said he/she had changed the dressings before getting the resident up, then why is it still labeled from two days earlier. RN E said he/she thought night shift did the dressings changes. When asked if the dressing needed to be done now, RN E said he/she needed to check the order. He/She assisted the resident to be covered, washed his/her hands and exited the room at 12:49 P.M. As RN E walked to his/her computer, the surveyor pulled up the resident's treatment order on his/her computer. The surveyor asked RN E to pull up the order on his/her computer to verify the order. RN E went out to the desk and logged onto his/her computer. At 12:54 P.M., RN E said he/she checked the order, then he/she proceeded to read the order out load, verbatim, with the exception to where the surveyor saw the order to read daily RN E said every 3 days. RN E then said the treatment was not due. Observation on 7/25/23 at 3:30 P.M., showed RN F, the nurse for a different floor at the facility, entered the resident's room to complete the resident's treatment. The dressing continued to be dated 7/23/23 with the initials of Nurse Y. RN F completed the treatment as ordered. During an interview on 7/25/23 at 3:05 P.M., the Director of Nursing (DON) said she would expect staff to provide care as ordered. Staff should not say they provided care and document they provided care if they did not.

Based on observation, interview and record review, the facility failed to adequately provide assistance to promote good nutrition and to maintain acceptable parameters of nutritional status by failing to ensure one resident (Resident #7) with nutritional needs received enteral feeding (method of feeding that uses the gastrointestinal (GI) tract to deliver nutrition and calories) via gastrostomy tube, (g-tube, a surgically placed device used to give direct access to one's stomach for supplemental feeding) as ordered. The sample size was 12. The census was 43. Review of the facility's undated Enteral Nutrition policy, showed: -Policy Statement; -Adequate nutritional support through enteral nutrition provided to residents as ordered; -Policy Interpretation and Implementation; -The interdisciplinary team, including the dietician, conducts a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings. The assessment includes: -Evaluation of the resident's current clinical and nutritional status; -Relevant functional and psychosocial factors; -The recommendation to initiate the use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice, the resident's advance directives, treatment goals and facility policies; -The dietician, with input from the provider and nurse: -Estimates calorie, protein, nutrient and fluid needs; -Determines whether the resident's current intake is adequate to meet his or her nutritional needs; -Recommends special food formulations; -Calculates fluids to be provided; -Enteral nutrition is ordered by the provider based on the recommendations of the dietician. If a feeding tube is ordered, the provider and interdisciplinary team document why enteral nutrition is medically necessary. Review of Resident #7's care plan, in use during the time of the investigation, showed: -Focus: Revised 12/14/22. The resident is at risk for impaired nutrition; -Goal: Resident will consume adequate caloric intake through the next review; -Interventions: Consult a dietician, per order; -Focus: The resident is at risk for malnutrition; -Goal: Resident intake of nutrients will meet metabolic needs; -Interventions: If mini nutritional (assessment) results indicate risk and malnutrition, consult dietician. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/2/23, showed: -Rarely/Never understood; -Exhibited no behaviors; -Required total dependence of one staff for eating; -Diagnoses included heart failure and a stroke; -Use of a feeding tube while a resident. Review of the resident's Mini Nutritional Assessment, dated 6/15/23, showed: -Malnourished; -Bed or chair bound; -Has suffered psychological stress or acute distress in the past three months; -Severe dementia or depression. Review of the resident's physician's orders, dated 7/19/23 through 8/18/23, showed an order, dated 5/20/23, for Enteral Tube Feeding order: Isosource/Jevity/Osmolite 1.5 Cal (therapeutic nutrition that provides complete, balanced nutrition for feeding tubes), Continuous feed at 65 milliliters per hour with free water flush of 100 milliliters every two hours. Observations on 7/25/23 at 9:43 A.M. through 12:09 P.M., showed Certified Nursing Assistant (CNA) J brought the resident in his/her medical reclining chair from the resident's room and into the dining/living room area. The resident's feeding tube was not attached to the resident. At 12:09 P.M., the resident remained in the same spot, in front of the television. The feeding tube was not attached to the resident. During an interview on 7/25/23 at 1:16 P.M., Nurse E said the resident was supposed to receive continuous tube feeding and the order had been in place for about two months. Nurse E will disconnect the feeding tube to allow the resident a break. He/She will give the resident a break, here and there for about two hours at a time. During an interview on 7/27/23 at 8:08 A.M., the Registered Dietician (RD) said she was familiar with the resident and he/she was losing weight and went to the hospital around May of 2023. When the resident returned, he/she had an order for continuous feeding with water flushing every two hours. She expected the resident to remain on the feeding tube continuously for nutritional needs. It was not appropriate to take him/her off the feeding tube. If the resident was to be taken off the feeding tube, the nurse should have obtained an order. During an interview on 7/27/23 at 9:06 A.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said the resident should receive tube feeding for 24 hours and if he/she were to be taken off for an extended amount of time, there should have been an order. Review of the facility's follow-up investigation report, provided by the DON on 7/27/23 at 11:49 A.M., showed Nurse E had the resident up in a chair in the common area for four hours with no continuous feeding running. No physician order to discontinue the tube feeding for four hours.

Based on observation, interview, and record review, the facility failed to ensure each resident's bedside was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for two of nine call lights checked (Residents #19 and #306). The census was 45. 1. Review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/7/23, showed: -Cognitively intact; -Partial/moderate assistance required for toileting hygiene, showers/baths, upper and lower body dressing, putting on/taking off footwear, positioning from left to right, sit to lying, lying to sitting, sitting to standing, chair/bed-to-chair transfer, and toilet transfers. During an interview on 10/19/23 at 6:30 A.M., the resident said his/her call light had been broken for a while. He/She reported it but it had not been fixed. Observation and interview on 10/19/23 at 6:36 A.M., of the resident's call light, located at his/her bedside, showed the call light pressed. No light indicator was available outside of the room door. Registered Nurse (RN) II sat at the nurse desk and said the call light worked by alarming at the nurse's desk on the panel. The panel then showed which room had a light going off. Observation of the panel, showed no audible alarm and no indication a call light had been pressed. RN II verified the panel did not show any call lights activated and added there are some issues with the call light panel. Sometimes when a call light was pressed, staff could not get it to turn off. They had to unplug and then plug in the panel to reset it. He/She was not aware of any call lights that did not work when pressed, just issues with them not turning off. Observation and interview on 10/19/23 at 12:20 P.M., showed the call light panel on the resident's floor showed ready. The call light in the resident's was room pressed. Observation of the panel, showed no audible alarm and no indication that a call light had been pressed. RN HH said the resident's roommate's call light stuck and could be difficult to turn off. He/She was aware of an issue with the resident's call light, but maintenance had been in last week to fix it. He/She was not sure if it was fixed. 2. Observation and interview on 10/19/23 at 9:15 A.M., showed Resident #306 sat in a recliner in his/her room and ate breakfast. The resident's call light hung between the foot board of the bed and the arm rest of the recliner. The resident said the call light did not work sometimes. The call button was pressed and a red light on the connection plate illuminated. No sound could be heard inside or outside the room. Observation on 10/19/23 at 9:23 A.M., showed the call light connection plate in the resident's room remained illuminated red. No sound could be heard inside or outside the resident's room. During an interview on 10/19/23 at 9:23 A.M., CNA MM said there was a call light panel at the nurse's desk which displayed a red light and alarmed when a call light was on. CNA MM said the light on the box was green indicating no call lights were on. Observation of the resident's room at 9:24 A.M., showed the red light on the connection plate remained red. The call light panel at the nurse's desk showed a green light and ready. Observation on 10/19/23 at 12:20 P.M., showed the call light panel on the resident's floor showed ready. The call light in the resident's was room pressed. Observation of the panel at the nurse's desk, showed no audible alarm and no indication a call light had been pressed. 3. During an interview on 10/19/23 at 4:10 P.M., with the Director of Nursing and Assistant Director of Nursing, both said they were aware one call light did not work about a week ago, but thought it was fixed. The Maintenance Supervisor resigned just the day before, so they would not be able to verify. If a call light was not working, staff were expected to fill out a sheet and give it to the Maintenance Supervisor. They had an electronic system that it could be reported to, but the Maintenance Supervisor preferred paper sheets be handed to him.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity when staff stood over residents who required assistance with eating as the residents were fed, fed residents bites of food and drinks without communicating with the residents, and complained about their workload in front of residents (Residents #72 and #20). In addition, staff ignored a call light for a resident who had a spill (Resident #173). The census was 43. 1. Review of the facility's resident's rights poster, posted on the resident floors, showed: Your rights as a resident in a long-term care facility: -Every facility must inform residents of these upon being admitted and must protect and promote these rights for all residents; -To privacy and respect: You have the right to privacy in medical treatment, personal care, telephone and mail communications, visits and meetings of family and of resident groups. You shall be treated with consideration, respect and full recognition of your dignity and individuality. You may not be required to do things against your will. 2. Review of Resident #74's medical record, showed: -Diagnoses included hemiplegia and hemiparesis (hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body) following a stroke affecting the right dominate side, aphasia (loss of ability to understand or express speech, caused by brain damage), dementia, and depressive disorder; -A care plan, in use at the time of the survey, showed risk for self-care deficit: Bathing, dressing, feeding, toileting, and transfers: Evaluate functional abilities. Provide meal support per resident's needs. The resident has an alteration in musculoskeletal status related to contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the right arm related to a stroke: Staff to assist with feedings. Review of Resident #20's medical record, showed: -Diagnoses included dementia, dysphagia (difficulty swallowing), anxiety, and age related physical debility; -A care plan, in use at the time of the survey, showed nutritional problem or potential for nutritional problem related to dementia: Monitor/document/report signs and symptoms of dysphagia: Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appears concerned during meals. Observation of the breakfast meals service in the third floor dining room, on 7/24/23 at 8:27 A.M., showed breakfast arrived to the floor on a wire rack and staff began to pass out the food trays. Staff placed Resident #72's food on the table in front of him/her. At 8:33 A.M., Certified Nursing Assistant (CNA) B propelled Resident #72 in his/her Broda chair (medical wheeled reclining chair) up to the table and sat the chair up. CNA B started to cut up the resident's food as he/she complained to the resident that there is too much going on and too much going on every day. He/She stood to the residents left side and stood over him/her to feed the resident. A chair positioned right next to CNA B was not in use. He/She gave the resident two bites of food without communicating with the resident what food was being served, then without communicating with the resident, walked to a different resident and propelled the other resident closer to the table. At 8:34 A.M., CNA B then walked over to Resident #20 and stirred his/her food. He/She then moved the tray closer to the resident and gave him/her a bite of food, as he/she stood over the resident, not communicating with the resident. Registered Nurse (RN) A walked up to Resident #20 and told CNA B that he/she would feed the resident. CNA B wiped his/her hands off on Resident #20's clothing protector then walked to the meal cart, then down the hall out of the dining room. RN A stood over Resident #20 and fed him/her bites of food. Two dining room chairs sat unused and available for use in the dining room. At 8:43 A.M., the phone rang, and without communicating with the resident, RN A walked away to answer the phone. After taking the call, RN A returned and again began to feed the resident as he/she stood over him/her. At 8:54 A.M., CNA B walked up to Resident #72, picked up the fork that had fallen on the resident's lap and said he/she would help the resident. He/she stood over the resident and fed the resident a bite of food, then without warning CNA B took the resident's plate and walked away with it. He/she walked to the microwave and placed it in the microwave. He/She then returned and placed the plate back down, stood over the resident, and placed a bite of food in the resident's mouth. The resident said too hot. CNA B continued to stand over Resident #72 and scooped up bites of food and put it in the resident's mouth without conversation or communication of what food he/she was getting. The resident asked CNA B where is the desert at, and while the resident was in mid-sentence, CNA B put a straw in the resident's mouth, which caused the resident to appear startled. CNA B said this is breakfast, no desert. At 9:02 A.M., CNA B walked away from the resident suddenly and stopped feeding him/her. He/She did not communicate with the resident prior to walking away. The resident reached for food with his/her bare hands and almost dumped the whole tray on the floor. Approximately half of Resident #72's food was gone from the plate, but about half of what is gone, lay on the floor or on the resident's lap. At 9:09 A.M., RN A walked away from feeding Resident #20, walked up to another resident, stood over the other resident, and fed him/her breakfast. Observation of breakfast meal service on the third floor, on 7/25/23 at 8:07 A.M., showed CNA B entered the dining room and told Resident #20 to wait a minute. He/she then went over to the resident, stood over the resident, and began to assist him/her to eat. He/She stood over the resident and scooped food into his/her mouth without communicating with the resident. Several unused chairs available for the staff to sit to assist residents, were not in use. Further observation at 8:44 A.M., showed Resident #72 in his/her room in bed. CNA B entered the room with a food tray, stood over the resident and placed bites of food in the residents' mouth. During an interview on 7/26/23 at 8:53 A.M., RN A said it is best to sit by residents when feeding them because they feel more comfortable with staff sitting at their level. During an interview on 7/26/23 at 9:41 A.M., RN F said he/she has been told both to sit while feeding residents and to stand while feeding residents, but staff should be at eye level. Staff should sit to feed residents. During an interview on 7/26/23 at 9:54 A.M., CNA J said staff should sit to feed residents. During an interview on 7/27/23 at 1:44 P.M., the Director of Nursing (DON) said staff should sit at a resident's side when feeding them and engage with the resident. It is not acceptable to put food or drink in a resident's mouth without communicating with them. If staff need to walk away, they should communicate this to the resident. Staff should not complaint about their workload to the residents. 3. Review of Resident #173's care plan, revised on 10/12/22, in use during the time of the survey, showed: -Focus: At risk for self-care deficit for bathing, dressing, and feeding; -Goal: Resident will be able to perform self-care needs to fullest potential through next review; -Interventions: Provide assistance with activities of daily living and provide meal support per resident's need. Review of the resident's admission MDS, dated [DATE], showed: -Cognitively intact; -Exhibited no behaviors; -Diagnoses included malnutrition, fractures and depression. During an observation and interview on 7/25/23 at 12:02 P.M., showed the resident sat in his/her room in a recliner. His/her lunch tray sat on the night stand and a health shake spilled onto the lunch tray. The resident said he/she pushed the call light about 10 minutes ago and waited for a response. He/she wanted someone to assist with cleaning the lunch tray so he/she could eat. Observation on 7/25/23 at approximately 12:03 P.M., showed Nurse E and Nurse in Training (NIT) T sat at the desk at the nursing station. The call light system located behind the desk, next to where Nurse E sat. The call light system gave a loud sound, indicating a resident's call light was turned on. Nurse E talked with NIT T and did not acknowledge the call light. During an interview on 7/25/23 at 12:06 P.M., Certified Medication Technician (CMT) H said if a resident pressed the call light, it would alert at the nurse's station and staff was expected to go to the nurse's station to see where the call light was coming from. CMT H went to the nurse's station to check the call light and said it was coming from Resident #173's room. Nurse E and NIT T sat at the nurse's station and sat behind the desk and did not acknowledge the call light. CMT H said he/she would check on the resident. During an interview on 7/27/23 at 9:06 A.M., the DON and Assistant Director of Nursing said Nurse E should have acknowledged the resident's call light and should not have continued to sit behind the desk as the call light continued to go off.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to encode resident assessment data within 7 days after a facility completes a resident's assessment for 19 of 20 residents who resided on the third floor, which was newly certified on 7/1/23, as indicated by the MDS showing as in progress (Residents #29, #36, #24, #28, #30, #33, #23, #34, #32, #35, #20, #27, #75, #31, #26, #73, #76, #77 and #74). In addition, the facility failed to ensure three additional residents who resided on the second floor had their MDS transmitted timely, as indicated by them showing completed in the facility's medical record but not accepted (Residents #19, #20 and #21). The sample was 12. The census was 43. Review of the facility's Centers for Medicare and Medicaid Services (CMS) Certification and Transmittal, showed effective July 1, 2023 the section for long-term care regulations recommends approval for a skilled nursing facility (SNF) license and Medicaid certified (24) bed increase on floor 3. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the admission assessment, the MDS Completion Date must be no later than 13 days after the entry date; -Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). 1. Review of Resident #29's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 2. Review of Resident #36's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 3. Review of Resident #24's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 4. Review of Resident #28's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 5. Review of Resident #30's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 6. Review of Resident #33's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 7. Review of Resident #23's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 8. Review of Resident #34's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 9. Review of Resident #32's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 10. Review of Resident #35's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 11. Review of Resident #20's medical record, showed: -The resident resided on the third floor on 7/1/23; -A quarterly MDS, dated [DATE], in progress. 12. Review of Resident #27's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 13. Review of Resident #75's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 14. Review of Resident #31's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 15. Review of Resident #26's medical record, showed: -The resident resided on the third floor on 7/1/23; -A quarterly MDS, dated [DATE], in progress. 16. Review of Resident #73's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 17. Review of Resident #76's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 18. Review of Resident #77's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 19. Review of Resident #74's medical record, showed: -The resident resided on the third floor on 7/1/23; -An admission MDS assessment, dated 7/14/23, in progress. 20. Review of Resident #19's medical record, showed: -The resident admitted on [DATE]; -A significant change MDS assessment, dated 3/8/23, completed; -A quarterly MDS assessment, dated 4/22/23, completed. 21. Review of Resident #20's medical record, showed: -The resident admitted on [DATE]; -A quarterly MDS assessment, dated 5/10/23, in progress. 22. Review of Resident #21's medical record, showed: -The resident admitted on [DATE]; -A quarterly MDS, dated [DATE], completed; -A significant change MDS, dated [DATE], in progress. 23. During an interview on 7/27/23 at 9:56 A.M., MDS Coordinator X said he/she had been completing the resident's MDS since June 2023. He/She tried to come to the facility once a week. He/She goes through the assessments and verifies the documentation from staff to determine if he/she had the most accurate information. He/She reviews the medical record and physician's orders. He/She is the one person that completes the MDS and is responsible for transmitting the MDS. He/She was unaware of resident MDS' that were not transmitted. The system automatically transmits the MDS assessments. He/She did not know the reason why it was not transmitted. The quarterly, significant change, and annual MDS are expected to be encoded within 14 days. The third floor just became certified and the MDS are in progress. If an MDS shows in progress it means it was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address specific needs of the residents for six of 12 sampled residents (Residents #74, #7, #13, #8, #173 and #174). The census was 43. 1. Review of Resident #74's medical record, showed: -Diagnoses included hemiplegia and hemiparesis (hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body) following a stroke affecting the right dominate side, aphasia (loss of ability to understand or express speech, caused by brain damage), dementia, and depressive disorder; -A care plan, in use at the time of the survey, showed: -Focus revised on 3/29/23: At risk for falls. Have been known to purposely throw shelf on the floor when wanting something and when seeking attention; -Goal: Fewer episodes of putting self on the floor; -Interventions: Keep bed in lowest position. Ensure call light is available to resident; -Focus revised on 10/14/22: Psychosocial well-being problem (potential) related to COVD pandemic restrictions; -Goal: Have no indications of psychosocial wellbeing problems; -Interventions: Allow the resident time to answer questions and verbalize feelings, perceptions, and fears; -The care plan did not address any concern of the resident becoming restless when out of bed, the need for one on one activities for social interactions, or interventions to prevent isolation. Observation on 7/24/23 at 7:04 A.M., in the third floor dining room, showed the resident sat in a Broda chair (reclining wheeled medical chair). His/Her right leg hung down to the ground and his/her head tilted to the left and over the side of the wheelchair. The resident appeared restless and had a grimace on his/her face as he/she tried to reposition him/herself. Observation on 7/24/23 at 2:43 P.M. and 4:05 P.M., showed the resident in his/her room in bed. Observation on 7/25/23 at 9:55 A.M., showed the resident lay in bed. At 10:09 A.M. and 10:39 A.M., the resident in bed, his/her legs hung off the side of the bed. At 11:20 A.M., the resident lay in bed. Certified Nursing Assistant (CNA) B said the nurse told him/her not to get the resident up today. At 1:06 P.M., the resident lay in bed. During an interview on 7/25/23 at 11:20 A.M., Registered Nurse (RN) F said the resident hallucinates and puts his/herself at risk of falling out of the chair. The resident did get up yesterday, but when in the chair, he/she tries to swat at a hallucinated dog or cat and reaches out to get it. He/She ends up only falling out of the chair. Observation on 7/26/23 at 11:32 A.M., showed the resident in his/her room in bed. Observation on 7/27/23 at 6:33 A.M., showed the resident in his/her room in bed. At 9:32 A.M., the resident lay in bed with his/her blanket partially off and moving around in the bed. During an interview on 7/28/23 at 11:23 A.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said they would expect activities to meet the needs and interests of the residents. This includes residents who cannot attend group activities. For the resident, he/she would benefit from activities. He/She prefers to be in bed, but would benefit from one on one in room activities, music, or something. When he/she gets up in the day, he/she gets anxious. They do not think this would need to be part of the care plan. 2. Review of Resident #7's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 5/2/23, showed: -The resident is rarely/never understood; -Diagnoses included heart failure, stroke, aphasia and dementia; -At risk for pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction); -No pressure ulcers identified as being present; -Extensive assistance required for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Total dependence on staff for eating; -Use of a feeding tube (a tube inserted into the stomach to provide food, fluid, and medications); -Exhibited no behaviors. Review of the resident's care plan, in use at the time of the survey, showed: -Focus revised on 12/14/22: At risk for impaired physical mobility: -Goal: Skin will remain intact; -Interventions included assist resident in performing movements/tasks. Utilize pressure relieving devices on appropriate surfaces; -Focus revised on 6/26/23: At risk for impaired skin integrity: -Goal: Skin will remain intact; -Interventions included evaluate skin and monitor skin for moisture, apply barrier product as needed; -Focus revised on 5/23/23: The resident has a pressure ulcer to coccyx (tailbone area) development related to immobility; -Goal: The resident's pressure ulcer will show signs of healing and remain free from infection; -Interventions, reposition every two hours; -Focus: Revised 12/14/22. The resident is at risk for impaired nutrition: -Goal: Resident will consume adequate caloric intake; -Interventions: Consult a dietician per order. Evaluate oral cavity and mucous membranes, evaluate resident's physical ability to eat, and perform frequent oral care; -Focus: The resident is at risk for malnutrition: -Goal: Resident intake of nutrients will meet metabolic needs; -Interventions: If mini nutritional evaluation results indicate risk or malnutrition, consult dietician; -The care plan failed to address the resident's use of a feeding tube; -The care plan provided conflicting information about the resident's skin status. Review of the resident's electronic physician order sheet (ePOS), showed: -An order dated 5/20/23, for Enteral Tube Feeding Isosource/Jevity/Osmolite (different types of feeding formulas) 1.5 calorie, Continuous feed at 65 milliliters (ml) per hour with free water flush of 100 ml very two hours; -An order dated 5/20/23, for a skin assessment weekly, every evening shift, every Thursday; -An order dated 5/20/23, for the wound nurse to evaluate and treat; -An order dated 6/29/23, for calcium alginate (used in the treatment of moderately to heavily draining wounds), apply to sacrum (tailbone area) topically one time a day for wound care. Cleanse area with wound cleanser, apply alginate and dry dressing daily, and as needed. Review of the resident's medical record, showed no documentation of the resident's pressure ulcer measurements, staging, appearance, or drainage. Review of the facility's wound reports for the July 2023, showed the following for Resident #7: -On 7/7/23, onset date (no date listed), location sacrum, wound description and measurements: 0.5 x 0.4 x 0.3 (unit of measurement not identified), injury/condition background: unstageable (full thickness tissue loss in which the actual depth of the ulcer is obscured by slough (yellow, tan, gray, green, or brown dead tissue) and/or eschar (tan, brown, or black dead tissue) in the wound bed), treatment prescribed: Alginate and dry dressing, next dressing change date: Daily, no odor present, healing; -On 7/19/23, onset date (no date listed), location sacrum, wound description and measurements: 1.0 x 0.3 x 0.1 (unit of measurement not identified), injury/condition background: unstageable, treatment prescribed: Alginate and dry dressing, next dressing change date: Daily, no odor present, healing. Observations on 7/24/23 at approximately 7:15 A.M., 7/25/23 at 7:01 A.M. and 7/26/23 at 9:42 A.M., showed the resident lay in bed on his/her back. The resident's feeding tube formula infused at 65 ml per hour. Observation on 7/25/23 at 3:30 P.M., showed RN F entered the resident's room to complete the resident's pressure ulcer treatment. RN F completed the treatment as ordered. During an interview on 7/27/23 at 9:06 A.M., the DON said nursing is responsible for skin assessments. The use of a feeding tube should have been addressed on the resident's care plan. The DON and ADON are responsible for updating care plans. Care plans are updated quarterly. 3. Review of the Resident #13's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, non-Alzheimer's dementia, Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), seizure disorder, anxiety, and depression; -Required extensive assistance with dressing, toileting, and personal hygiene. Review of the resident's care plan, revised 10/12/22, and in use at the time of the survey, showed: -Problem: The resident has a psychosocial well-being problem (potential) related to COVID; -Goal: The resident will have no indications of psychosocial well-being problem by/through review date; -Intervention: Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears. Encourage participation from resident who depends on others to make own decisions. Provide opportunities for the resident and family to participate in care. When conflict arises, remove residents to a calm safe environment and allow to vent/share feeling; -The care plan did not address the resident's diagnosis of depression, use of medication to treat depression, and diagnosis of dementia. Review of the resident's ePOS, showed: -An order dated 1/20/23, for Donepezil HCL (used to treat Alzheimer's disease) 10 milligram (mg) tablet. Give one tablet by mouth in the morning for dementia; -An order dated 2/16/23, for Trazodone HCL (anti-depressant) 50 mg tablet. Give 25 mg by mouth at bedtime for depression. Observation on 7/24/23 at 9:08 A.M., 7/25/23 at 9:22 A.M. and 12:34 P.M., and 7/27/23 at 9:23 A.M., showed the resident in the dining room. He/She sat at a table. The resident did not interact or speak with other residents. During an interview on 7/26/23 at 12:44 P.M., Receptionist/Activity Aide W said the resident cannot handle activities. He/She stays on the second floor. When staff attempt to interact with him/her, he/she put his/her hands over his/her ears. 4. Review of Resident #8's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high blood pressure, kidney failure, heart failure, high cholesterol, Alzheimer's disease, non-Alzheimer's dementia, anxiety, and depression; -Required extensive assistance with transfers, dressing, and toileting. Review of the resident's care plan, dated 11/20/22, and in use at the time of the survey, showed: -Problem: Resident uses anti-anxiety medications related to generalized anxiety disorder: -Goal: Resident will be free from discomfort or adverse reactions related to anti-anxiety therapy; -Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Monitor the resident for safety. The resident is taking anti-anxiety medications which are associated with an increased risk of confusion, amnesia (forgetting), loss of balance, and cognitive impairment that looks like dementia, and increases risk of falls, broken hips and legs; -Problem: Resident has a psychosocial well-being problem (potential) related to COVID pandemic restrictions: -Goal: Resident will have no indications of psychosocial well-being problem by/through review date; -Interventions: Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears. Encourage participation from resident who depends on others to make own decisions. Provide opportunities for the resident and family to participate in care. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings; -The care plan did not address the resident's history of auditory hallucination symptoms or use of medications for auditory hallucinations. Review of the resident's ePOS, showed an order dated 6/22/23, for Quetiapine Fumarate (anti-psychotic) tablet 25 mg. Give one table by mouth at bedtime for auditory hallucinations. During an interview on 7/25/23 at 10:45 A.M., the resident said he/she hallucinated since he/she was in his/her 30's. It is auditory hallucinations. He/she hears buzzing or music. It is not music or a song that is in his/her head. It is similar to when music is playing and he/she tried to figure out where it is coming from. 5. Review of Resident #173's care plan, in use during the time of the investigation, viewed on 7/25/23 at 10:12 A.M., showed: -Focus: Revised on 4/8/23. Impaired nutrition; -Goals: Resident intake of nutrients will meet metabolic needs; -Interventions: Provide education to resident/representative regarding proper nutritional intake. Review of the resident's nutrition/dietary note, dated 4/12/23 at 10:20 A.M., showed Registered Dietician (RD) followed up for weight loss. Spoke to the resident about on-going gradual weight decrease since last visit. Per speech therapist, resident has reduced swallow and is afraid to eat some things and recommended soft foods. Resident continues to state he/she is full and cannot eat. On regular/mechanical soft diet with Boost (a nutritional drink) with meals. Suggest a small amount of Two Cal (a nutritional supplement) with medication three times a day should stop gradual weight loss. Review of the resident's weight summary report, showed on 1/9/23, the resident weighed 114 pounds. On 7/6/23, the resident weighed 105 pounds, indicating a 7.89 percent weight loss over a six month period. Review of the resident's physician orders, dated 7/19/23 through 8/18/23, showed: -An order dated 4/17/23, for a regular diet with a mechanical soft texture and Boost supplement with all meals; -An order dated 6/15/23, for Two Cal supplement, three times a day with medication pass. Review of the resident's care plan, in use during the time of the investigation, viewed on 7/25/23 at 10:12 A.M., showed no further information regarding the resident's nutritional status. During an interview on 7/27/23 at 9:06 A.M., the DON and ADON said the resident had a significant weight loss and the interventions to decrease weight loss should have been included in the resident's care plan. 6. Review of Resident #174's care plan, in use during the time of the investigation, viewed on 7/25/23 at 10:51 P.M., showed: -Focus: Revised 9/27/22. The resident has an activities of daily living (ADL) self-care deficit related to terminal illness of sepsis (systemic infection); -Goal: The resident will maintain current level of function with staff oversight and dignity maintained; -Interventions: Bed mobility; the resident required extensive assistance by staff to turn and reposition in bed. Transfers; the resident is totally dependent on one to two staff for transferring with the use of a lift for safety and fall risk measures; -The care plan did not address the resident's use of bed rails. Review of the resident's admission MDS, dated [DATE], showed: -Cognitively intact; -Exhibited no behaviors; -Required extensive assistance of one staff for bed mobility; -Required total dependence of two staff for transfers; -Diagnoses included heart failure, kidney disease, diabetes and arthritis. Review of the resident's physician orders, dated 7/19/23 through 8/18/23, showed no order for the use of bed rails. Observations on 7/24/23 at approximately 7:15 A.M., 7/25/23 at 6:59 A.M. and 7/26/23 at 9:41 A.M., showed the resident lay in bed on his/her back, asleep. One quarter length bed rail was raised on both sides of the bed. During an interview on 7/27/23 at 9:06 A.M., the DON and ADON said the resident used quarter length side rails for repositioning. The use of side rails should be addressed on the care plan. 7. During an interview on 7/28/23 at 11:23 A.M., the DON and ADON said care plans were updated quarterly and as needed. Nursing staff was responsible for updating care plans. The care plans should be individualized and specific to resident needs.

Based on observation, interview and record review, the facility failed to provide an ongoing activity program based on resident preferences, to support residents in their choice of activities and meet the needs of the residents. The facility failed to provide adequate organized activities in the evenings and on the weekends. The resident council representatives reported activities to be insufficient. In addition, residents observed and interviewed reported concerns with the activity program ( Residents #74, #18, #7, #173 and #174). The census was 43. Review of the facility's undated activities program policy, showed: -Objective: To provide a Resident-centered activities program that incorporates the residents' interests, hobbies, and cultural preferences; -Policy: Daily events and activities will be planned and conducted in a manner that is consistent with individual resident assessments and care plans and in accordance with state and federal laws and regulations; -Procedure: Plan daily events consistent with individual assessments and group preferences that support dignity, independence and a positive self-image for all residents; -Encourage and support the development of new interests, hobbies, and skills (e.g., training on using the Internet); -Promote person-appropriate activities; -Design group activities that represent shared interests; -Assist residents with transportation to activities; -Provide functional assistance, adaptive equipment and supplies as necessary; -Schedule individual and group events in cooperation with other departments, such as nursing, dining/dietary, social services and therapy; -Assign volunteers and activities staff to facilitate events as applicable; -Provide opportunities for residents to connect with the community by scheduling activities involving organizations such as places of worship, veterans' groups, volunteer groups, support groups, wellness groups, athletic, musical and theatrical or educational connections (via outings or invitations to such groups to visit facility). 1. During an interview on 7/25/23 at 6:55 A.M., the Director of Nursing (DON) said the Administrator was the Activity Director and Receptionist/Activity Aide W helps out with activities. They did not have an official Activities Director or no activities staff. 2. During an interview on 7/27/23 at 8:11 A.M., Receptionist/Activity Aide W provided the July activity documentation for all residents. Review showed some of the documents were titled visitor sign in. Receptionist/Activity Aide W said this was when the residents had visitors. He/She will log it on their activity sheet as a visitor activity. 3. Review of the July, 2023 activity calendar, showed: -Activities scheduled on Saturdays were a resident discussing animals in the television room; -Activities scheduled on Sunday were religious services and a resident who did exercises on his/her own, and discussing medical questions with the facility nurse. -Activities scheduled Monday through Friday ended at 3:00 P.M. 4. Review of Resident #74's medical record, showed: -Diagnoses included hemiplegia and hemiparesis (hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body) following a stroke affecting the right dominate side, aphasia (loss of ability to understand or express speech, caused by brain damage), dementia and depressive disorder; -No activity assessment completed; -No activity participation notes in the electronic medical record. Review of the resident's care plan, in use at the time of the survey, showed: -Focus revised on 3/29/23: At risk for falls. Have been known to purposely throw self on the floor when wanting something and when seeking attention; -Goal: Fewer episodes of putting self on the floor; -Interventions: Keep bed in lowest position. Ensure call light is available to resident; -Focus revised on 10/14/22: Psychosocial well-being problem (potential) related to COVID pandemic restrictions; -Goal: Have no indications of psychosocial wellbeing problems; -Interventions: Allow the resident time to answer questions and verbalize feedings, perceptions, and fears; -The care plan did not address any concern of the resident becoming restless when out of bed, the need for one on one activities for social interactions, or interventions to prevent isolation. Review of the resident's June, 2023 activity log, showed: -A family/friend visited on seven of the 30 days; -No group activity participation; -No one on one activities provided by the facility. Review of the organized activity participation sign in sheets, for July 2023, reviewed on 07/27/23 at 8:45 A.M., showed no documented activities. Observation on 7/24/23 at 7:04 A.M., in the third floor dining room, showed the resident sat in a Broda (reclining medical chair). His/Her right leg hung down to the ground and his/her head tilted to the left and over the side of the chair. The resident appeared restless and had a grimace on his/her face as he/she tried to reposition him/herself. At 2:43 P.M. and 4:05 P.M., the resident was in his/her room in bed. Observation on 7/25/23 at 9:55 A.M., showed the resident lay in bed. At 10:09 A.M. and 10:39 A.M., the resident was in bed, and his/her legs hung off the side of the bed. At 11:20 A.M., the resident lay in bed. Certified Nursing Assistant (CNA) B said the nurse told him/her not to get the resident up today. At 1:06 P.M., the resident lay in bed. During an interview on 7/25/23 at 11:20 A.M., Registered Nurse (RN) F said the resident hallucinates and puts him/herself at risk of falling out of the chair. The resident did get up yesterday, but when in the chair, he/she tries to swat at a hallucinated dog or cat and reaches out to get it. He/She ends up only falling out of chair. Observation on 7/26/23 at 11:32 A.M., showed the resident in his/her room in bed. Observation on 7/27/23 at 6:33 A.M., showed the resident in his/her room in bed. At 9:32 A.M., the resident lay in bed with his/her blanket partially off and moving around in the bed. During an interview on 7/26/23 at 12:44 P.M., Receptionist/Activity Aide W said the resident is incapable of doing a lot, but the facility does have music. They could bring him/her down. Any residents with Broda chairs, they bring down to music. During an interview on 7/28/23 at 11:23 A.M., the DON and Assistant Director of Nursing (ADON) said the resident would benefit from activities. He/She prefers to be in bed, but would benefit from one on one in room activities, music or something. When he/she gets up in the day, he/she gets anxious. They do not think this would need to be part of the care plan. 5. Review of Resident #18's medical record, showed: -Diagnoses included depression, kidney failure and high blood pressure; -No activity assessment completed; -No activity participation notes in the electronic medical record. Review of the resident's care plan, in use during the time of the investigation, showed: -Focus: Revised 12/14/22. The resident has the potential for psychosocial well-being problem related to being in a new environment and history of depression; -Goal: The resident will have minimal indications of psychosocial well-being problem by the next review date; -Interventions: Encourage participation from the resident. Provide opportunities for the resident and family to participate in care and when conflict arises, remove the resident to a calm environment to share feelings. Review of the resident's June, 2023 activity log, showed; -A family and friend visited on one of the 30 days; -No group activity participation; -No one on one activities provided by the facility; Review of the facility's organized activity participation sheets for July 2023, showed no documented activities. During an interview on 7/24/23 at approximately 7:15 A.M., the resident said he/she was chair and bed bound and did not get up often. He/she wanted to attend activities but the facility did not offer many activities. He/she would attend activities when they are offered. During an interview on 7/26/23 at 12:43 P.M., the business office manager (BOM) and Receptionist/Activity Aide W said the resident was bed bound and could not attend activities, but received one on one activities. The activity aide said he/she read stories to the resident and will go in his/her room and smile. Smiling at a resident was considered an activity. The resident also received visits from family. 6. Review of Resident #7's medical record, showed: -Diagnoses included heart failure, paralysis of right side following a stroke, muscle weakness and dementia; -No activity assessment completed; -No activity participation notes in the electronic medical record. Review of the resident's care plan, in use during the time of the investigation, showed: -Focus: Revised 12/14/23. The resident is at risk for activity intolerance; -Goal: Resident will maintain an optimum activity level to fullest extent possible through the next review; -Interventions: Encourage resident to set small obtainable activity goals. Review of the resident's June, 2023 activity log, showed; -A family and friend visited on 10 of the 30 days; -No group activity participation; -No one on one activities provided by the facility; Review of the facility's organized activity participation sheets for July 2023, showed no documented activities. Observations on 7/24/23 at 7:12 A.M., 7/25/23 at 8:39 A.M., and 7/26/23 at 9:42 A.M., showed the resident lay in bed on his/her back in his/her room. The television remained on. During an interview on 7/26/23 at 12:43 P.M., the BOM and Receptionist/Activity Aide W said the resident was bed bound and could not attend activities, but received one on one activities. The activity aide said he/she read stories to the resident about two weeks ago but had not provided any other activities. 7. Review of Resident #173's medical record, showed: -Diagnoses included depression, osteoporosis and mild cognitive impairment; -No activity assessment completed. Review of the resident's care plan, in use during the time of the investigation, showed: -Focus: Revised 10/12/22. The resident has a psychosocial well-being problem related to COVID pandemic restrictions; -Goals: The resident will have no indicators of psychosocial well-being problem by the next review date; -Interventions: Encourage participation from resident who depends on others to make own decisions. When conflict arises, remove resident to a calm safe environment to allow to share feelings. Review of the resident's June 2023 activity log, showed; -A family and friend visited on 15 of the 30 days; -Religious services one of the 30 days; -Rosary two of the 30 days; -Sensory activity one of the 30 days. Review of the facility's organized activity participation sheets for July 2023, showed: -7/6/23: Participation in Mass; -7/21/23: Piano concert. During an interview on 7/24/23 at 7:11 A.M., the resident said the facility does not offer many activities. In the month of July, he/she only attended two activities. He/She would attend activities if the facility offered them. During an interview on 7/26/23 at 12:43 P.M., the BOM and Receptionist/Activity Aide W said the resident attended Rosary once a week and attended the piano concert. The resident attends activities when they are offered. 8. Review of Resident #174's medical record, showed: -Diagnoses included insomnia, diabetes, heart failure and muscle weakness; -No activity assessment completed; -No activity participation notes in the electronic medical record. Review of the resident's care plan, in use during the time of the investigation, showed: -Focus: The resident relies on staff for meeting emotional, intellectual, physical and social needs related to immobility; -Goal: The resident will participate in activities of choice three to five times weekly through the next review date; -Interventions: Invite the resident to attend activities. Provide the resident with an activity calendar. Thank the resident for attending activities and resident needs assistant/escort to all activity functions. Review of the resident's June 2023 activity log, showed; -A family and friend visited on 12 of the 30 days; -No group activity participation; -No one on one activities provided by the facility; Review of the facility's organized activity participation sheets for July 2023, showed no documented activities. During an interview on 7/26/23 at 12:43 P.M., the BOM and Receptionist/Activity Aide W said the resident received one on one activities. He/She was bedridden and staff will take him/her to medical appointments. The resident also received mail delivered to him/her. Appointments and mail delivery was considered an activity. 9. During a group interview on 7/26/23 at 11:05 A.M., six residents, who the facility identified as alert and oriented, attended the group meeting. The residents said the facility used to offer organized activities but activities had not been offered in a while. The residents do their own activities. Nothing is offered during the weekends or evenings. Receptionist W will bring board games to the units for residents to play with. 10. During an interview on 7/25/23 at 11:48 A.M., Certified Medication Technician (CMT) H said they did not have an activity's aide and activities were not provided for residents. There were no one on one activities offered. Nursing staff will bring the residents to the dining/living room so they can listen to music and watch television. 11. During an interview on 7/26/23 at 12:44 P.M., the BOM said for individual activity needs, the facility based it on the nursing documentation and their interests to some degree. Some residents are very into crafts, some would rather have music. A couple weeks ago they did bubble blowing and ate doughnuts. It was based on the interests of the residents. The activity assessment is pulled from nursing. She was not sure what pulled from nursing means. Activity participation documentation is hand written, but the facility is getting set up for documentation in the electronic medical record. Receptionist/Activity Aide W does the majority of activities. Receptionist/Activity Aide W said they recently realized the need to fine tune activities, and set up a good program to move forward. The BOM said beginning in August, the facility will have a daily chronicle delivered to the resident's doors. There will be a monthly gazette starting in August, to encourage participation in activities. The facility does need more one on one activities. She did not think the facility was doing anything wrong with activities, but feels the scope needs to be broadened. They need to do some one on one activities. She does not think the one on one activities provided are as encompassing as desired. The BOM said she walks around and talks with residents on the floors. The Administrator is the Activity Director. There are activity carts on the floors for the CNAs to pull from, for activities in the evening. The Ombudsman group has been coming and spending time with residents. That is a partnership that has seemed to blossom and was considered an activity. Receptionist/Activity Aide W said for residents not able to get to activities or cannot verbalize, residents in wheelchairs, etc., he/she will get the residents or staff to bring them down. The ones that are not capable, he/she will try to go in and read/talk to them. They seem to like that. There are a lot of residents who have no visitors. Those are the ones who he/she feels he/she should go and talk to. There are quite a few residents he/she would like to get closer to and talk to them. 12. During an interview on 7/28/23 at 11:23 A.M., the DON and ADON said they expected activities to meet the needs and interests of the residents. This includes residents who cannot attend group activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents for one resident with a diagnosis of difficulty swallowing who was left alone in the dining room while eating (Resident #20). One resident was propelled in a wheelchair with his/her feet dragging the ground (Resident #73). One resident was propelled in a Rollator (a four wheeled walker with a seat) while seated in the Rollator (Resident #75). One resident with a risk of falls from bed was in bed without the use of the ordered fall mat (Resident #74). One staff member attempted to stand a resident by pulling their pants and pulling at their arm, resulting in the resident leaning off the side of the chair (Resident #76). In addition, the facility failed to have a process to ensure a resident's wander guard (device that prevents the user from exiting doors that are wander guard protected by causing the door to lock or alarm) was in working order for one resident who used a wander guard (Resident #13). The sample was 12. The census was 43. 1. Review of the facility's undated Activities of Daily Living (ADL) Supporting policy, showed: -Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: -Hygiene (bathing, dressing, grooming, and oral care); -Mobility (transfer and ambulating, including walking); -Elimination (toileting); -Dining (meals and snacks); -Communication (speech, language, and any functional communication systems); -A resident's ability to perform ADLs will be measured using clinical tools, including the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff). Functional decline or improvement will be evaluated in reference to the assessment reference date and the following definitions: -Independent: Resident completed activity with no help or staff oversight; -Supervision: Oversight, encouragement or cuing provided; -Limited assistance: Resident highly involved in activity and received physical help in guided maneuvering of limbs or other non-weight bearing assistance; -Extensive assistance: While resident performed part of activity, staff provided weight bearing support; -Total dependence: Full staff performance of an activity with no participation by the resident for any aspect of the ADL activity; -Interventions to improve or minimize a resident's functional abilities will be in accordance with the residents' assessed needs, preferences, stated goals and recognized standards of practice. 2. Review of Resident #20's admission Minimum Data Set, dated [DATE], showed: -Cognitive skills for daily decision making severely impaired- never/rarely made decision; -Inattention and disorganized thinking continuously present, does not fluctuate; -Extensive assistance of one person required for eating; -Diagnoses included non-traumatic brain dysfunction, Alzheimer's disease, dementia, and anxiety disorder. Review of the resident's medical record, showed: -Diagnoses included dysphagia (difficulty swallowing) and age related physical debility; -A care plan, in use at the time of the survey, showed nutritional problem or potential for nutritional problem related to dementia: Monitor/document/report signs and symptoms of dysphagia: Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appears concerned during meals. During a meal service observation on 7/25/23 at 8:00 A.M., Registered Nurse (RN) F placed a clothing protector on the resident and set up his/her tray as the resident sat in a specialty high back wheelchair in the dining room. After RN F finished setting up the meal tray, he/she walked away. At 8:02 A.M., all staff left the dining room, leaving the dining room unattended. RN F got on the elevator and left the floor. The resident fed him/herself what appears to be oatmeal with his/her hands. The dining room remained unattended and the resident ate breakfast until 8:07 A.M., when Certified Nursing Assistant (CNA) B entered the dining room and told the resident to wait a minute, then he/she went over, stood over the resident and began to assist him/her to eat. During an interview on 7/26/23 at 8:57 A.M., CNA B said he/she knows how to provide care because he/she has been working with the residents and knows the residents. He/She has been provided training on techniques and dignity. The technique training provided was when he/she was in school to be a CNA, not provided by the facility. He/She just knows the residents and knows which ones are feeders. During an interview on 7/27/23 at 1:44 P.M., the Director of Nursing (DON) said staff should be present in the dining rooms if meal service is in progress. This is in case of choking, and some residents require assistance. 3. Review of the facility's undated Safe Lifting and Movement of Residents policy, showed: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 4. Review of Resident #73's medical record, showed: -Diagnoses included Alzheimer's disease, age related physical debility, need for continuous supervision, and need for assistance with personal care; -A care plan, in use at the time of the survey, showed focus: At risk for self-care deficit: Dressing, feeding, toileting, transfers, revised on 10/14/23. Interventions: Evaluate the resident's ability to performed ADLs. Provide assistance with ADLs as needed. Provide meal support per resident's need. Observation on 7/25/23 at 7:44 A.M., showed a staff member propelled the residing down the hall, around a corner, and into the dining room at a fast pace as the resident sat in a wheelchair and his/her feet drug the floor. During an interview on 7/26/23 at 8:57 A.M., CNA B said when transferring residents in a wheelchair. Staff should sit the resident up straight and tell them to hold their knees up so they will not drag. The risk of their feet dragging is breaking ankles or toes, or having falls. Foot pedals are available for use. During an interview on 7/27/23 at 1:44 P.M., the DON said when propelling a resident down the hall in a wheelchair, their feet should not drag the ground. The risk of dragging the feet is injury. 5. Review of Resident #75's medical record, showed: -Diagnoses included Alzheimer's disease, osteoporosis (thinning of the bone), age related physical debility, and muscle weakness; -A care plan, in use at the time of the survey, showed: -Focus: At risk for falls related to history of falls. Interventions included ensure the resident is wearing appropriate footwear when ambulating or mobilizing in the wheelchair; -Focus: At risk for self-care deficit. Interventions included evaluate functional abilities. Provide assistance with ADLs as needed. Review of the Rollator user instruction manual, showed: -The lightweight 4-wheeled Rollator is designed to aid the user to walk, and as an option, carry items such as shopping; -Ensure that the brakes are locked on when sitting on the seat. Observation on 7/25/23 at 7:14 A.M., showed CNA B walked besides the resident towards the dining room as the resident used a Rollator. The resident walked slowly. CNA B told the resident to sit on the seat of the Rollator. The resident turned slowly and sat on the seat. The CNA then pushed the resident backwards into the dining room and assisted him/her to a dining room table. During an interview on 7/26/23 at 8:57 A.M., CNA B said when using a Rollator, staff count to three and stand the resident, tell the resident to put their hands on both handles of the Rollator, unlock it and make sure the resident is close to the walker. Staff can propel residents in the Rollator if the resident is tired, but not doing it properly could cause the resident to fall. Staff can get hurt too. During an interview on 7/27/23 at 1:44 P.M., the DON said the proper way to use a Rollator is to have the resident standing in front of it and walk with it. Staff should not propel a resident on the Rollator. The risk of propelling a resident in a Rollator is injury. 6. Review of Resident #74's care plan, showed: -Focus revised on 3/29/23: At risk for falls. Have been known to purposely throw shelf on the floor when wanting something and when seeking attention; -Goal: Fewer episodes of putting self on the floor; -Interventions: Keep bed in lowest position. Ensure call light is available to resident; -Focus revised on 7/10/23: Risk for self-care deficit: -Goal: Resident will be able to perform self-care needs to fullest potential; -Interventions: May use ¼ rails times two on the bed to assist with mobility and repositioning. Review of the resident's medical record, showed: -Diagnoses included hemiplegia and hemiparesis (hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body) following a stroke affecting the right dominate side, aphasia (loss of ability to understand or express speech, caused by brain damage), dementia, and depressive disorder; -An order dated 3/8/23, for low bed, floor mat in place while resident is in bed. Observation on 7/25/23 at 10:09 A.M. and 10:39 A.M., showed the resident lay in bed, his/her legs hung off the side of the bed. The fall mat leaned against the wall on the far side of the room, not next to the bed. At 10:51 A.M., CNA B entered the room and said he/she was just checking on the resident. He/She assisted the resident to place his/her legs in the bed and covered the resident. CNA B then exited the room without placing the floor mat down on the floor. At 1:06 P.M., the resident lay in bed. The floor mat leaned against the wall, on the far side of the room. On 7/26/23 at 11:32 A.M., the resident lay in bed. The floor mat leaned against the wall, on the far side of the room. During an interview on 7/27/23 at 1:44 P.M., the DON said she would expect the resident's fall mat be next to the resident's bed when she is in bed. 7. Review of Resident #76's care plan, in use at the time of the survey, showed: -Focus revised on 10/14/22: Risk for self-care deficit: Bathing, dressing, feeding, toileting, and transfers: -Goal: Resident will be able to perform self-care needs to fullest potential; -Interventions: Evaluate functional abilities. Evaluate resident's ability to perform ADLs. Provide assistance with ADLs as needed; -Focus revised on 10/14/22: At risk for falls: -Goal: be free from falls; -Assist resident with ambulation and transfers, utilizing therapy recommendations. Determine resident's ability to transfer; -The care plan did not identify the resident's transfer status. Review of the resident's medical record, showed: -Diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), osteoporosis (thinning of the bones), age related physical debility, and dementia; -A physician order sheet, showed no transfer status identified; -No therapy notes. The resident's [NAME], showed two person assist for transfers. Observation on 7/25/23 at 1:37 P.M., showed CNA U entered the resident's room. The resident sat in his Broda chair (reclining wheeled chair). CNA U propelled the resident's Broda chair into the bathroom and said he/she was going to try to stand the resident up. If the resident cannot stand, then he/she will use the lift. CNA U guided the resident's hands to the handrails then grabbed the resident's pants by the waist band and pulled. The pants pulled up, but the resident did not stand. CNA U made a second attempt and a third attempt to pull the resident up using his/her waist band. He/She then then pulled up on the resident's right arm. The resident's arm and shoulder went up, but the resident still did not stand. A second attempt was made to stand the resident by grabbing his/her arm under the armpit area. Observation of the resident's feet, showed they were pressed up against the wall, both angled and faced to the left, and not flat on the ground. The CNA made another attempt to stand the resident by pulling up on his/her right arm. The resident's feet continued to be crooked and pressed against the wall. At this time, CNA U said he/she was going to get the lift. He/She pulled the resident's chair back. The resident leaned far to the left and crooked in his/her chair. At 1:43 P.M., CNA U returned with Certified Medication Technician (CMT) I and a sit-to-stand lift (mechanical lift) and they assisted the resident to stand. During an interview on 7/26/23 at 11:23 A.M., the Director of Rehab said the resident had never been seen by therapy. Therapy has made no recommendations for the resident's transfer status. During an interview on 7/26/23 at 11:35 A.M., CNA V said he/she is the resident's CNA. He/She knows his/her transfer status based on the care plan and nurse report. He/She has not cared for the resident in a while, so he/she asked the nurse today what his/her transfer status was, and he/she said the resident is now a Hoyer lift (full body mechanical lift). During an interview on 7/26/23 at 11:36 A.M., RN A said the resident requires a Hoyer lift. His/Her condition has gone down. He/She has Parkinson's disease. He/She had a condition changed. The CNAs get verbal report from him/her at the start of their shift. During an interview on 7/26/23 at 11:40 A.M., CNA V returned, followed by CMT I. CMT I stood behind CNA V and nodded to him/her. Then CNA V said I mean, he/she is a sit to stand. During an interview on 7/27/23 at 1:44 P.M., the DON said the resident is a two person transfer with a gait belt. It is not acceptable to attempt to pick up a resident out of their chair by their pants or arm. If a resident is not able to stand or struggling to bear their own weight, a sit-to-stand may be appropriate. 8. Review of the facility's undated resident elopement risk policy, showed: -All residents are to be assessed for wandering behaviors and risk of elopement at admission and with any significant change in condition. Residents identified as having wandering behaviors and/or being at risk for elopement are to have specific care plan and/or service plan actions defined to prevent elopement; -All door and wander guard/individual alarms are to be checked routinely for proper functioning; -Disabling and/or disarming alarms is prohibited and considered to be a serious safety violation that may result in immediate termination without additional warning; -Alarms that have engaged are not be turned off until management has verified awareness and that the source of the alarm is being appropriately managed. Review of Resident #13's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included non-Alzheimer's dementia, seizure disorder, anxiety, and depression; -Required supervision with transfers, bed mobility, and eating; -Required extensive assistance with dressing, toileting, and personal hygiene; -Has the resident wandered: Behavior of this type occurred 1 to 3 days; -Does the wandering place the resident at significant risk of getting to a potentially dangerous place: blank; -Does the wandering significantly intrude on the privacy of activities of others: blank. Review of the resident's medical record, showed: -Diagnoses included dementia, mood disturbance and anxiety, Parkinson's disease, need for continuous supervision, and need for assistance with personal care; -An order, dated 6/8/23, to ensure wander guard is in place on left ankle every shift; -A care plan, revised on 12/14/22, and in use during the survey, showed no documentation of history of wandering or rationale for the use of a wander guard; -No wandering or wander guard assessment. Observation on 7/24/23 at 9:08 A.M., 7/25/23 at 9:22 A.M. and 12:24 P.M. and 7/27/23 at 9:26 A.M., showed a wander guard on the resident's left ankle. During an interview on 7/24/23 at 9:55 A.M., a resident observed with a stop sign that was Velcroed across his/her door said Resident #13 used to go into his/her room, but not too much anymore. During an interview on 7/27/23 at 9:32 A.M., CMT H said he/she did not know anything about a wander guard tester. It might be checked by social services. It does alert when they get to the elevator. He/She did not know who checks the wander guard every shift or where the wander guard tester is located. RN BB said he/she was an agency nurse. Usually the nurses would check the wander guard, but the other nurses would know more about it. During an interview on 7/27/23 at 9:37 A.M., CMT H and CMT CC said there is another resident that has a wander guard and it will alert if he/she goes on the elevator. They was not sure about Resident #13, but was aware that Resident #13 did not go onto the elevator until the other resident with the wander guard arrived. Resident #13 usually wanders around the floor and goes into the resident rooms. He/She will walk around and he/she will get tired and sit down. CMT H had never seen anyone check the residents wander guard. During an interview on 7/27/23 at 9:44 A.M., RN BB said he/she called the Assistant Director of Nursing (ADON) and asked about checking wander guards. He/She was told that the ADON would call him/her back about it. During an interview on 7/27/23 at 10:09 A.M., the DON and ADON said maintenance is responsible for checking the wander guards. There was someone that had a wander guard sheet, it is has been a month since they left. They were not sure if the current maintenance director is aware that they are responsible for checking them. Maintenance has the wander guard tester. Nursing staff determines if a resident requires a wander guard. Resident #13 came from assisted living with the wander guard. They checked the wander guard when the resident moved down. The assessments are completed quarterly. The DON would expect assessments to be completed for the use of a wander guard. She would expect there to be documentation to reflect why the resident has a wander guard. Resident #13 would sit in the dining room or the couch. The DON would expect the resident's history of wandering and use of wander guard to be care planned. During an interview on 7/28/23 at 11:42 A.M., Maintenance director said he did not have a device to check the wander guards. It can be checked via the elevator. If nursing has an issue with it malfunctioning, they will notify him.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who is incontinent of bowel and bladder received appropriate treatment and services after an incontinent episode. One resident was left without personal care for over 8 hours, resulting in the resident's brief being saturated with urine (Resident #76). One resident had stool remain on his/her skin for an 8 hour shift when the evening shift failed to cleanse all areas of the skin after a bowel movement and the night shift did not cleanse the skin until the end of their shift the next morning. This resulted in the stool being dried and had to be scrubbed and not all stool was removed from the skin (Resident #174). One resident was provided incontinence care with not all areas of the skin cleaned. In addition, a dressing soiled due to the incontinence was not changed and was allowed to remain on a wound (Resident #7). One resident with a brief saturated with urine was cleansed with water but no soap or other approved product (Resident #13). This affected four of five observations of personal care. The census was 43. Review of the facility's undated Perineal (area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum) Care policy, showed: -The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -Review the resident's care plan to assess for any special needs of the resident; -Assemble the equipment and supplies as needed; -The following equipment and supplies will be necessary when performing this procedure: Wash basin, towels, washcloth, soap (or other authorized cleansing agent, and persona protective equipment (e.g. gloves, etc.); -Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached; -Wash and dry your hands thoroughly; -Put on gloves; -Was the perineal area; -Wash the rectal area; -Remove gloves and discard. Wash and dry your hands. Review of the facility's undated Activities of Daily Living (ADL) Supporting policy, showed: -Resident's will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the pan of care, including appropriate support and assistance with: -Hygiene (bathing, dressing, grooming, and oral care); -Mobility (transfer and ambulating, including walking); -Elimination (toileting); -A resident's ability to perform ADLs will be measured using clinical tools, including the Minimum Data Set. Functional decline or improvement will be evaluated in reference to the assessment reference date and the following definitions: -Independent: Resident completed activity with no help or staff oversight; -Supervision: Oversight, encouragement or cuing provided; -Limited assistance: Resident highly involved in activity and received physical help in guided maneuvering of limbs or other non-weight bearing assistance; -Extensive assistance: While resident performed part of activity, staff provided weight bearing support; -Total dependence: Full staff performance of an activity with no participation by the resident for any aspect of the ADL activity; -Interventions to improve or minimize a resident's functional abilities will be in accordance with the residents' assessed needs, preferences, stated goals and recognized standards of practice. 1. Review of Resident #76's care plan, in use at the time of the survey, showed: -Focus revised on 10/14/22: Risk for self-care deficit: Bathing, dressing, feeding, toileting, and transfers: -Goal: Resident will be able to perform self-care needs to fullest potential; -Interventions: Evaluate functional abilities. Evaluate resident's ability to perform ADLs. Provide assistance with ADLs as needed. Review of the resident's medical record, showed: -Diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), osteoporosis (thinning of the bones), age related physical debility, and dementia; -An order dated 12/6/22, resident to be toileted every 2 hours for incontinence. Observation on 7/25/23 at 5:15 A.M., showed the resident up and dressed, sat in his/her Broda chair (medical reclining chair) in the dining room. During an interview on 7/25/23 at 5:45 A.M., Certified Nursing Assistant (CNA) Q said he/she got the resident cleaned up around 5:00 A.M. and up in his/her chair around 5:00 A.M. or 5:30 A.M. Observation on 7/25/23 at 6:49 A.M., showed day shift arrived to the resident's floor, completing rounds. The resident remained in the dining room. Continuous observation maintained by the surveyor. At 8:57 A.M., the resident remained in the dining room, at a table, after being assisted with breakfast. At 9:44 A.M., staff propelled the resident from the table in the dining room to the TV area of the dining room. At 10:40 A.M. and 11:10 A.M., the resident remained in the TV area of the dining room. At 11:29 A.M., the resident in the TV area of the dining room in his/her chair, asleep. At 1:05 P.M., the resident remained up in his/her chair in the dining room after the lunch meal service. During an interview on 7/25/23 at 1:16 P.M., CNA B said residents should be changed every 2 hours or as needed. Observation on 7/25/23 at 1:24 P.M., showed a visitor arrived to see the resident and propelled him/her to his room. He/she asked if staff could provide care. During an interview on 7/25/23 at 1:37 P.M., when asked when the resident would be provided care, CNA U said he/she was headed that way now. He/she entered the resident's room and attempted to assist the resident to the bedside commode, but the resident was not able to stand. He/She left to get help. At 1:43 P.M., CNA U returned to the room with Certified Medication Technician (CMT) I. Staff assisted the resident to stand with the use of a sit to stand lift (mechanical lift). As the resident stood, the brief appeared to sag. Staff unsecured the brief, the brief was saturated with urine from the front to the back. CNA U tossed the brief into the trash can. The resident sat on the bedside commode. CNA U put a clean brief on the resident, between the resident's legs, and secured it at the knee level. Staff raised the lift, raising the resident, as CNA U stood behind the resident. CNA U wiped up the resident's anal area with a disposable wipe, tossed the wipe, obtained a new wipe and again wiped up the anal area. He/She then pulled up the residents brief. Neither the buttock cheeks nor genitals were washed. Staff placed the resident over his/her Broda chair and lowered him/her into the chair. The visitor returned to the room to visit. 2. Review of Resident #174's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 1/10/23, showed: -Cognitively intact; -Extensive assistance required for bed mobility, dressing, toilet use, and personal hygiene; -Has an indwelling urinary catheter (a tube inserted through the urinary opening into the bladder to drain urine); -Frequently incontinent of bowel; -Diagnoses include heart disease, heart failure, and debility. Review of the resident's care plan, in use at the time of the survey, showed: -Focus revised on 9/27/22: The resident has an ADL self-care performance deficit related to terminal illness of sepsis (systemic infection); -Goal: Maintain current level of function with staff oversight and assistance, dignity maintained; -Interventions included: The resident is totally dependent on staff to provide bath/shower. The resident requires extensive assistance by staff to turn and reposition in bed. The resident requires extensive assistance by staff with personal hygiene and oral care. The resident requires skin inspections weekly and as needed. The resident requires total assistance for toileting needs including catheter care. During an interview on 7/25/23 at 5:56 A.M., CNA O said he/she worked the night shift and last checked the resident at 4:30 A.M. He/She has a catheter, but he/she checks him/her for bowel movements and turns him/her. Observation on 7/25/23 at 6:18 A.M., showed CNA O entered the resident's room. An odor of stool permeated the room. CNA O assisted the resident to his/her left side. The resident had an indwelling urinary catheter in place and the bag was full and bulging. CNA O uncovered the resident and revealed an area of stool in the shape of finger prints on his/her right outer knee. Stool was visible all over the incontinence pad located under the resident. No stool was on the resident's buttocks. CNA O said the bowel movement on the pad was still there from the shift prior, because the resident did not have a bowel movement on his/her shift. Observation in the resident's bathroom, showed a pad on the floor in the bathroom with bowel movement all over it. CNA O said that was from prior to his/her shift. He/She did not put it there. The resident did not have a bowel movement on night shift and he/she was only night CNA working that night. CNA O wiped the resident's right butt cheek with a wet, but not soapy rag. No bowel movement visible in the buttocks fold or rectum area. CNA O did not clean the finger print shaped stool on the resident's leg. He/She positioned the resident to the right side. The resident had a large area of dried stool on his/her left buttock cheek. No bowel movement in the gluteal fold or rectum area. CNA O scrubbed the skin hard to get the dried bowel movement off. When done, there were a few speckles of dried bowel movement that remained on the resident's skin. CNA emptied the resident's indwelling urinary catheter. Dark amber urine, 1000 milliliters (ml) drained from the bag. CNA O said he/she worked from 10:30 P.M. last night and gets off at 7:00 A.M. 3. Review of Resident #7's quarterly MDS, dated [DATE], showed: -The resident is rarely/never understood; -Diagnoses included stroke, dementia, and hemiplegia and hemiparesis (hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body); -At risk for pressure ulcers (injury to the skin and underlying tissues as a result of pressure or friction); -No pressure ulcers identified as being present; -Extensive assistance required for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, in use at the time of the survey, showed: -Focus revised on 12/14/22: At risk for impaired physical mobility: -Goal: Skin will remain intact; -Interventions included assist resident in performing movements/tasks. Utilize pressure relieving devices on appropriate surfaces; -Focus revised on 6/26/23: At risk for impaired skin integrity: -Goal: Skin will remain intact; -Interventions included evaluate skin and monitor skin for moisture, apply barrier product as needed; -Focus revised on 5/23/23: The resident has a pressure ulcer to the coccyx (tailbone area) development related to immobility; -Goal: The resident's pressure ulcer will show signs of healing and remain free from infection; -Interventions, reposition every two hours; -The care plan provided conflicting information about the resident's skin status. Observation on 7/25/23 at 12:27 P.M., showed Registered Nurse (RN) E entered the resident's room to administer medication. After administering medication, he/she completed a skin assessment of the resident's buttocks. The resident had a dressing on the buttocks that appeared to be very soiled with urine and a brown substance. The resident was wet with urine. RN E said he/she is going to change the resident because he/she is wet. He/She got a wipe and assisted the resident to his/her right side. RN E unsecured the resident's brief and completed a single wipe of the resident's buttocks. He/She did not clean the left or right buttocks, or genital area. He/She took his/her gloves off and placed new gloves on. He/She pulled the brief down in the front to expose the resident's genitals and applied A&D cream to groin. RN E unsecured the right side of the brief and instructed Nurse in Training T to pull the brief out on the right side. Nurse in Training T removed the soiled brief. RN E assisted the resident to be covered, washed his/her hands and exited the room. 4. Review of Resident #13's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Extensive assistance required for dressing, toilet use, and personal hygiene; -Frequently innocent of bowel and bladder; -Diagnoses included dementia, Parkinson's disease, anxiety, and depression. Review of the resident's care plan, in use at the time of the survey, showed: -Focus revised on 12/14/22, at risk for self-care deficit: bathing, dressing, feeding, and toileting; -Goal: Be able to perform self-care needs to the fullest potential; -Intervention included: Encourage resident to participate in planning day to day care. Evaluate resident's ability to perform ADLs. Provide assistance with ADLs as needed. Observation on 7/25/23 at 6:05 A.M., showed CNA O entered the resident's room. He/She assisted the resident to sit on the edge of the bed, then assisted him/her to stand, and walked into the bathroom. The resident's brief so wet it sagged to the resident's mid thighs. Once to the sink, CNA O removed the resident's brief and put it in the trash. It made a loud thud sound when it hit the trash can. CNA O wet a hand towel with water from the sink, no soap used. He/She then cleaned the resident's arm pits, back, then buttocks. He/she then used the same rag and wiped the resident's genitals. No soap or approved incontinence wipes used, and both were located in the bathroom. CNA O did not dry the resident's skin. CNA O placed a brief on the resident and then assisted the resident to get dressed. 5. During an interview on 7/26/23 at 8:53 A.M., RN A said staff received in-servicing on providing incontinence care in March 2023. Proper technique is to clean the genitals from front to back. All areas potentially soiled should be cleaned because if not, it could cause a skin tear or break. Resident's should have a skin assessment. All soil should be removed. Gloves are changed as need when soiled. Take them off off after touching the resident and between different procedures, then wash hands and place new gloves on. Hand hygiene is performed before and after a procedure. Hand sanitizer is used up to four times with four different residents, then hands should be washed. Residents are checked every two hours. 6. During an interview on 7/26/23 at 9:41 A.M., RN F said the proper technique for personal care is to wash hands and clean from front to back. Use different towels when cleaning from front to back. Use water, towels and wipes. Pat dry. He/she was last in-serviced on this in September 2022 at a different job. All soil should be removed from the skin. Gloves are changed between dirty to clean. Hand hygiene is performed before, during, and after care. Residents are checked and changed every 2 hours or as needed. 7. During an interview on 7/26/23 at 9:54 A.M., CNA J said when providing care, residents are cleaned from front to back. The last time he/she was in-serviced on providing care was last year. All areas potentially soiled should be cleaned and all soil should be removed. Gloves are changed at least four times during care. Hand hygiene is performed before and after care. Residents are checked every 2 hours and as needed. 8. During an interview on 7/26/23 at 8:57 A.M., CNA B said the proper technique for providing personal care is to wash hands, put gloves on, wash front to back, apply soap, and wash until soap is gone. He/She has not had in-servicing on personal care that he/she can remember, but had in-servicing on hand washing a month ago. During care, all areas potentially soiled should be cleaned and soil should be removed. Gloves are changed twice, hands washed with glove changes. Residents are checked every 2 hours. 9. During an interview on 7/27/23 on 1:44 P.M., the Director of Nursing said when providing perineal care, all areas potentially soiled should be cleaned. Resident's should be cleaned with soap and water, or wipes. Residents are checked for incontinence every 2 hours, 8 hours is too long. The risk of not properly cleaning a resident or leaving a resident wet for extended periods of time is the risk of getting a urinary tract infection or skin break down.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure side rails were assessed as a necessary device and ensure the side rails fit properly to reduce the risk of entrapment prior to instillation and use for the residents, for six residents (Residents #74, #77, #8, #7, #18 and #174) of 12 sampled residents. The census was 43. Review of the facility's undated Bed Safety and Bed Rails policy, showed: -Policy statement: Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met; -Policy Interpretation and Implementation: -The resident's sleeping environment is evaluated by the interdisciplinary team; -Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -Additional safety measures are implemented for residents who have been identified as having a higher than usual risk for injury including bed entrapment (e.g., altered mental status, restlessness, etc.); -The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment; -The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent; -The resident assessment to determine risk of entrapment includes, but is not limited to: -Medical diagnosis, conditions, symptoms, and/or behavioral symptoms; -Size and weight; -Sleep habits; -Cognition; -Risk of falling; -The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following: Accident hazards, restricted mobility, and psychosocial outcomes; -Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. 1. Review of Resident #74's care plan, in use at the time of the survey, showed: -Focus revised on 3/29/23: At risk for falls. Have been known to purposely throw shelf on the floor when wanting something and when seeking attention; -Goal: Fewer episodes of putting self on the floor; -Interventions: Keep bed in lowest position. Ensure call light is available to the resident; -Focus revised on 7/10/23: Risk for self-care deficit: -Goal: Resident will be able to perform self-care needs to fullest potential; -Interventions: May use ¼ rails times two on the bed to assist with mobility and repositioning. Review of the resident's medical record, showed: -Diagnoses included hemiplegia and hemiparesis (hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body) following a stroke affecting the right dominate side, aphasia (loss of ability to understand or express speech, caused by brain damage), dementia, and depressive disorder; -An order dated 3/8/23, for ¼ side rail times one for transfers, bed mobility and positioning; -No side rail assessment completed. Observation on 7/24/23 at 2:43 P.M. and 4:05 P.M., 7/25/23 at 7:11 A.M., 11:20 A.M., and 1:06 P.M., and 7/27/23 at 6:33 A.M., showed the resident in his/her room in bed with one quarter side rail up on the right side of the bed near the head of the bed. 2. Review of Resident #77's care plan, in use at the time of the survey, showed: -Focus revised on 10/14/22: Risk for self-care deficit; -Goal: Be able to perform self-care needs to fullest potential; -Interventions: May use ¼ rails times two on the bed to assist with bed mobility and transfers. Review of the resident's medical record, showed: -Diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and morbid obesity; -An order dated 11/29/22, for ¼ side rails times two for transfers, bed mobility and positioning; -No side rail assessment completed. Observation on 7/24/23 at 2:00 P.M., showed the resident in his/her electric wheelchair in his/her room. A quarter side rail up on the top of both the left and right side of the bed. The resident said his/he legs come off the bed when asleep. He/She wants full rails but the facility told him/her that he/she cannot have full rails because state does not allow it. 3. Review of Resident #8's care plan, revised 11/10/22, and in use during survey, showed: -Focus: Resident is at risk for falls and requires a Hoyer lift (full body mechanical lift) for transferring; -Goal: Resident will be free of falls and from major injury; -Interventions: Resident requires ¼ side rails x 2 for transfers, bed mobility, and positioning. Review of the resident's medical record, showed: -Diagnoses included fracture of lower end of left tibia (the larger of the two shin bones), subsequent encounter for open fracture type I or II with routine healing, and fracture of upper and lower end of left fibula (the smaller of the two shin bones); -An order dated 11/29/22, for ¼ side rails x 2 for transfers, bed mobility, and positioning; -No side rail assessment. Observation and interview on 7/25/23 at 10:45 A.M., showed ¼ side rails on the resident's bed. The resident said he/she used the side rails to help sit up and put his/her feet on the ground when he/she is attempting to get out of bed. 4. Review of Resident #7's care plan, in use during the time of the investigation, showed: -Focus: Revised 9/21/22. The resident has a self-care deficit for activities of daily living and requires one to two assist as needed for bathing, dressing, feeding and mobility; -Goal: The resident will participate in self-care activities to be independent; -Interventions: The resident uses one half length bed rails on either side for mobility only. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 5/2/23, showed: -Rarely/never understood; -Exhibited no behaviors; -Required extensive assistance of one staff for bed mobility; -Required extensive assistance of two staff for transfers; -Diagnoses included heart failure and stroke. Review of the resident's physician's orders, dated 7/19/23 through 8/18/23, showed an order, dated 5/20/23, for one half length side rails times two side rails for bed mobility and positioning only, secondary to stroke. Review of the resident's medical record, reviewed on 7/27/23 at 9:31 A.M., showed no side rail assessment. Observations on 7/24/23 at approximately 7:14 A.M., 7/25/23 at 7:01 A.M., and 7/26/23 at 9:42 A.M., and 2:34 P.M., showed the resident lay in bed on his/her back. One half length side rails were raised on both sides of the bed. 5. Review of Resident #18's care plan, in use during the time of the investigation, showed: -Focus: The resident is at risk for impaired physical mobility related to debility; -Goal: The resident will be free of complications of immobility by completing tasks to fullest extent through the next review; -Interventions: The resident has one quarter length side rails times two for mobility and positioning. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Exhibited no behaviors; -Required extensive assistance of one staff for bed mobility; -Required extensive assistance of two staff for transfers; -Diagnoses included kidney failure, traumatic brain injury and depression. Review of the resident's physician's orders, dated 7/19/23 through 8/18/23, showed an order dated 3/14/23, for one quarter length side rails times two for transfers, bed mobility and positioning. Review of the resident's medical record, reviewed on 7/27/23 at 9:32 A.M., showed no side rail assessment. Observations on 7/24/24 at 7:11 A.M., 7/25/23 at 7:03 A.M., and 7/26/23 at 9:44 A.M., showed the resident lay in bed on his/her back with quarter length side rails raised on both sides. 6. Review of Resident #174's care plan, reviewed on 7/25/23 at 10:51 P.M., showed: -Focus: Revised 9/27/22. The resident has an activities of daily living self-care deficit related to terminal illness of sepsis (systemic infection); -Goal: The resident will maintain current level of function with staff oversight; -Interventions: Bed mobility; the resident required extensive assistance by staff to turn and reposition in bed. Transfers; the resident is totally dependent on one to two staff for transferring with the use of a lift for safety and fall risk measures; -The care plan did not address the resident's use of bed rails. Review of the resident's physician orders, dated 7/19/23 through 8/18/23, showed no order for the use of bed rails. Observations on 7/24/23 at approximately 7:15 A.M., 7/25/23 at 6:59 A.M. and 7/26/23 at 9:41 A.M., showed the resident lay in bed on his/her back asleep with one quarter length bed rails raised on both sides. 7. During an interview on 7/26/23 at 9:54 A.M., Certified Nursing Assistant (CNA) J said side rails are used for residents who are a fall risk and for mobility. Mostly for safety. The Director of Nursing (DON) and maintenance are responsible to assess a resident's need for side rails. 8. During an interview on 7/26/23 at 8:57 A.M., CNA B said side rails are used to keep residents from falling off the bed. 9. During an interview on 7/26/23 at 8:53 A.M., Registered Nurse (RN) A said side rails are used for safety and not for restraints. The doctor writes an order for the side rails, but the use of side rails is at the nurse's discretion. The intake coordinator does a side rail assessment on a side rail form. 10. During an interview on 7/26/23 at 9:41 A.M., RN F said side rails are used for positioning and safety. Family will bring it to the staff's attention if side rails are needed. 11. During an interview on 7/27/23 at 1:44 P.M., the DON said residents who have side rails in use should have had their side rail assessment completed prior to now. The side rail assessment is used to determine if they are appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide services by sufficient numbers of nursing personnel on a 24-hour basis to provide nursing care to all residents, when the nurse assigned to the second floor was also responsible for oversight of residents in the sister facility located on the fourth floor in the same building. In addition, the nurse on the third floor was also responsible for oversight of residents on the unlicensed independent living apartments located in the same building on the fifth floor. The census was 43. Review of the Facility Assessment Tool, dated February 2023, showed: -Indicate the number of residents you are licensed to provide care for: -Floor 2: Skilled Nursing- 24; -Floor 3: Intermediate Nursing- 24; -Floor 4: Assisted Living Memory Care- 23; -Floor 5: Independent Living- 23; -Staffing Plan: Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time: At least one Registered Nurse (RN) for direct care including the Director of Nursing (DON). Licensed nurses available 24/7. 1. Review of the facility's Centers for Medicare and Medicaid Services (CMS) Certification and Transmittal, showed: -Effective July 1, 2023 the section for long-term care regulations recommends approval for a skilled nursing facility (SNF) license and Medicaid certified (24) bed increase on floor 3; -The facility is Medicaid certified on the second and third floors. During an interview on 7/24/23 at 9:59 A.M., the DON said the skilled nursing facility (SNF) is on the 200 and 300 floors. 2. Review of the staffing assignment sheet, dated 7/24/23, showed: -RN E assigned the 200 and 400 halls on the 7:00 A.M. thorough 7:00 P.M. shift; -RN A assigned the 300 and 500 halls on the 7:00 A.M. thorough 7:00 P.M. shift; -Licensed Practical Nurse (LPN) C assigned the 200 and 400 halls on the 7:00 P.M. thorough 7:00 A.M. shift; -RN R assigned the 300 and 500 halls on the 7:00 P.M. thorough 7:00 A.M. shift; -On the Certified Nursing Assistant (CNA) assignment for the 11:00 P.M. through 7:00 A.M. shift, a note written Aide from 3 go assist with rounds RM [ROOM NUMBER]. During an interview on 7/24/23 at 6:59 A.M., RN A said he/she just arrived for his/her shift. He/She is the nurse on the third floor and fifth floor. The nurse on the second floor is also responsible for the fourth floor. The fifth floor CNA also helps out on the third floor. During an interview on 7/25/23 at 5:22 A.M., RN R said he/she was the nurse overnight last night. He/She is headed up to the fifth floor to do what he/she needs to do up there. In addition to the third floor, he/she is also responsible for the fifth floor. RN R then headed to the fifth floor. At 5:46 A.M., RN R returned to the third floor. During an interview on 7/25/23 at 6:01 A.M., LPN C said he/she is the nurse for the second and fourth floor. 3. Review of Resident #77's care plan, in use at the time of the survey, showed: -Focus: Risk for self-care deficit; -Goal: Resident will be able to perform self-care needs to fullest potential; -Interventions included evaluate functional abilities. Maintain consistent schedule with daily routine. Provide assistance with activities of daily living as needed. During an interview on 7/24/23 at 11:20 A.M., the resident said the drawback is that they have nurses and medication technicians handling two floors. Sometimes there is a time element that affects when you get medications. If they are on a different floor, residents have to wait. 4. During an interview on 7/28/23 at 11:23 A.M., the DON said the second floor nurse will run the independent floor on five, there are some medications that need to be given on the fifth floor. Fourth floor has an assist manager on day shift. Night shift, the facility will try to have three nurses in the building. The second floor nurse helps with any needs they have on the fifth floor. The third floor nurse will take care of any needs on the fourth floor. There is now a float nurse that floats on all floors. The nurses do 12 hour shifts. There are no CNA or Certified Medication Technician (CMT) shared duties on the fourth and fifth floor. The fourth floor is the assisted living facility. The fifth floor is the independent living apartments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nursing staff had the appropriate competencies and skill sets, and were able to demonstrate those competencies during care for residents. The facility failed to ensure nursing staff were able to demonstrate competency in skills and techniques necessary to care for residents, by failing to provide adequate perineal care (cleansing of the area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum) for five of five observations, failed to be knowledgeable of the facility's supplies and what they are to be used for, and failed to be demonstrate competency for safe positioning during meals. The census was 43. Review of the Facility Assessment Tool, dated February 2023, showed: -Staff training/education and competencies: Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population. Including staff certification requirements as applicable. Potential data sources include hiring, education, training, competency instructions, and testing policies; -Competencies: (This is not an inclusive list): -Person-centered care- this should include but not be limited to person centered care planning, education of resident and family/resident representatives about treatments and medications, documentation of resident treatment preferences, end of life care, and advance care planning; -Activities of daily living- bathing, bed making, bedpan, dressing, feeding, nail and hair care, perineal care, mouth care, providing resident privacy, range of motion, transfers, using gait belts, using mechanical lifts; -Infection control- hand hygiene, isolation, standard universal precautions including use of personal protective equipment, environmental cleaning; -Measurements: blood pressure, body temperature, height and weight, respirations, pulse, urine tests for glucose (sugar); -Specialized care- catheterization (inserting an indwelling urinary catheter to drain urine) insertion/care, tube feedings, wound care/dressings. 1. Review of the facility's Hand Hygiene Competence Assessment and Monitoring tool, showed: -Knows when to perform hand hygiene with soap and water: When hands are visibly dirty or visibly soiled with blood or other body fluids; before eating and after using the restroom; After approximately 10 uses of alcohol-based hand gel or hands feel tacky from use of hand gel; -Knows when to perform hand hygiene with either alcohol-based hand gel: Before and after patient contact; before and after glove use; after body fluid exposures, manipulation of a urinary catheter device, or contact with other inanimate objects; before and after computer use. Review of the facility's undated Perineal Care policy, showed: -The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -Assemble the equipment and supplies as needed; -The following equipment and supplies will be necessary when performing this procedure: Wash basin, towels, washcloth, soap (or other authorized cleansing agent), and persona protective equipment (e.g. gloves, etc.); -Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached; -Wash and dry your hands thoroughly; -Put on gloves; -Was the perineal area; -Wash the rectal area; -Remove gloves and discard. Wash and dry your hands. 2. Review of Resident #13's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 5/9/23, showed: -Severe cognitive impairment; -Extensive assistance required for dressing, toilet use, and personal hygiene; -Frequently innocent of bowel and bladder; -Diagnoses included dementia, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), anxiety, and depression; Review of Resident #174's admission MDS, dated [DATE], showed: -Cognitively intact; -Extensive assistance required for bed mobility, dressing, toilet use, and personal hygiene; -Has an indwelling urinary catheter; -Frequently incontinent of bowel; -Diagnoses included heart disease, heart failure, and debility. Observation on 7/25/23 at 6:05 A.M., showed Certified Nursing Assistant (CNA) O entered Resident #13's room. He/She assisted the resident to sit on the edge of the bed, then assisted him/her to stand, and walked into the bathroom. The resident's brief was so wet it sagged to the resident's mid thighs. Once to the sink, CNA O placed gloves on, removed the resident's brief and put it in the trash. It made a loud thud sound when it hit the trash can. CNA O took a hand towel, wet it in the sink, and wiped the resident's face with same gloves used to remove the soiled brief. He/She then used the towel and cleaned the resident's arm pits, back, then buttocks. After wiping the resident's buttocks, he/she used the same part of the towel used to wipe the resident's buttocks and wiped the resident's genitals. No soap used and the resident was not dried. The CNA placed a brief on the resident as he/she stood at the sink. The brief was secured, and CNA O pulled up the resident's pants while wearing the same soiled gloves. CNA O removed his/her gloves, did not wash or sanitize his/her hand. He/She placed deodorant on the resident, got a shirt from a chair in the room, brought it to the resident, and placed the shirt on the resident. CNA O then got a hair brush and brushed the resident's hair. He/She then grabbed the resident's hands and while walking backwards, led the resident to the bedroom. CNA O made the resident's bed and walked out of room as the resident followed. CNA O grabbed the resident's hand and walked with the resident to the dining room. Observation on 7/25/23 at 6:18 A.M., showed immediately after assisting Resident #13 to the dining room and without washing his/her hands, CNA O entered Resident #174's room. He/She picked up trash from the floor, next to the resident's bed and threw it away. He/She obtained gloves from the bathroom and placed them on, without washing or sanitizing his/her hands. CNA O assisted the resident to his/her left side. The resident had an indwelling urinary catheter in place. CNA O uncovered the resident and revealed an area of stool in the shape of finger prints on his/her right outer knee. Stool was visible all over the incontinence pad located under the resident. No stool on the resident's buttocks. CNA O said the bowel movement on the pad was still there from the shift prior, because the resident did not have a bowel movement on his/her shift. Observation in the resident's bathroom, showed a pad on the floor in the bathroom with bowel movement all over it. CNA O said that was from prior to his/her shift. He/She did not put it there. The resident did not have a bowel movement on night shift and he/she was the only night CNA working that night. CNA O wiped the resident's right buttock with a wet, but not soapy rag. No bowel movement visible in the buttocks fold or rectum area. CNA O did not clean the finger print shaped stool on the resident's leg. He/She positioned the resident to the right side. The resident had a large area of dried stool on his/her left buttock. No bowel movement in the gluteal fold or rectum area. CNA O scrubbed the skin hard to get the dried bowel movement off. When done, there were a few speckles of dried bowel movement that remained on the resident's skin. With the same soiled gloves, CNA O emptied the resident's indwelling urinary catheter. Dark amber urine, 1000 milliliters (ml), was in the bag. CNA O said he/she worked from 10:30 P.M. last night and gets off at 7:00 A.M. He/She picked up the stool soiled linen from the bathroom floor, looked at the bowel movement and said gross and set it back down. He/She then returned to the resident's side, positioned his/her legs in the bed, covered him/her with a blanket, handed him/her the call light, all with soiled gloves on. The resident asked for a cup, so CNA O handed him/her a cup with his/her soiled, gloved thumb inside the inner rim of the cup. CNA O then picked up the soiled linen from the bathroom floor and emptied the trash. He/She exited the room, touching the door handle, and entered the soiled utility room, touching the door handle with the soiled gloves on. 3. Review of Resident #74's medical record, showed: -Diagnoses included hemiplegia and hemiparesis (hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body) following a stroke affecting the right dominate side, aphasia (loss of ability to understand or express speech, caused by brain damage), dementia, and depressive disorder; -A care plan, in use at the time of the survey, showed risk for self-care deficit: Bathing, dressing, feeding, toileting, and transfers: Evaluate functional abilities. Provide meal support per resident's needs. The resident has an alteration in musculoskeletal status related to contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the right arm related to a stroke: Staff to assist with feedings. Observation on 7/25/23 at 5:31 A.M., showed CNA N entered the room of Resident #74, gathered supplies, picked the fall mat up off of the floor, and said he/she is waiting for the other CNA, CNA Q. CNA Q entered the room and both CNAs put gloves on. Neither staff washed or sanitized their hands prior to placing gloves on and after entering the room. Staff raised the resident's bed. The CNAs unsecured the resident's brief. The resident's perineal area was reddened. CNA Q obtained a personal wipe and wiped the resident from front to back and said he/she is pretty chapped. The resident's brief was completely saturated and bowel movement was visible. The CNAs assisted the resident to his/her right side. CNA Q wiped the resident's buttocks. The resident's buttocks reddened. CNA N squirted barrier cream into CNA Q's gloved hand, the same gloved hand used to clean up the stool. The barrier cream was applied. The resident again started to have a bowel movement. CNA Q removed one glove and without sanitizing his/her hands, placed one new glove on, wiped up the bowel movement, obtained a new wipe and repeated the process. CNA Q placed a clean pad, then clean brief under the resident with the same gloves used to wipe the bowel movement. CNA Q, while wearing the same soiled gloves, assisted the resident to his/her other side, and placed a hand on the resident's leg. CNA Q removed one glove and secured the resident's brief. CNA N left the room with the soiled linen and trash. CNA Q removed his/her gloves and tossed them in the trash in the room, he/she did not wash or sanitize his/her hands. 4. Review of Resident #76's medical record, showed: -A care plan, in use at the time of the survey, showed: -Focus revised on 10/14/22: Risk for self-care deficit: Bathing, dressing, feeding, toileting, and transfers: -Interventions: Evaluate functional abilities. Evaluate resident's ability to perform activities of daily living (ADLs). Provide assistance with ADLs as needed; -Diagnoses included Parkinson's disease, osteoporosis (thinning of the bones), age related physical debility, and dementia. Observation on 7/25/23 at 1:37 P.M., showed CNA U entered the resident's room and attempted to assist the resident to the bedside commode, but the resident was not able to stand. He/She left to get help. At 1:43 P.M., CNA U returned to the room with Certified Medication Technician (CMT) I. Staff assisted the resident to stand with the use of a sit to stand lift (mechanical lift). As the resident stood, the brief appeared to sag. Staff unsecured the brief, which was saturated with urine from the front to the back. CNA U tossed the brief into the trash can. The resident sat on the bedside commode. CNA U put a clean brief on the resident, between the resident's legs, and secured it at the knee level. Staff raised the lift, raising the resident, as CNA U stood behind the resident. CNA U wiped up the resident's anal area with a disposable wipe, tossed the wipe, obtained a new wipe and again wiped up the anal area. He/She then pulled up the residents brief. Neither buttock cheeks nor genitals were washed. Staff placed the resident over his/her Broda chair (reclining wheeled chair) and lowered him/her into the chair. 5. Review of Resident #7's quarterly MDS, dated [DATE], showed: -The resident is rarely/never understood; -Diagnoses included stroke, dementia, and hemiplegia and hemiparesis (hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body); -At risk for pressure ulcers; -Extensive assistance required for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder. Observation on 7/25/23 at 12:27 P.M., showed Registered Nurse (RN) E entered the resident's room to administer medication. After administering medication, he/she completed a skin assessment of the resident's buttocks. The resident had a dressing on the buttocks that appeared to be very soiled with urine and a brown substance. The resident was wet with urine. RN E said he/she is going to change the resident because he/she is wet. He/She got a wipe and assisted the resident to his/her right side. RN E unsecured the resident's brief and completed a single wipe of the resident's buttocks He/She did not clean the left or right buttocks, or genital area. He/She took his/her gloves off and placed new on. He/She pulled the brief down in the front to expose the resident's genitals and applied A&D cream to groin. RN E unsecured the right side of the brief and instructed Nurse in Training T to pull it out on the right side. Nurse in Training T removed the soiled brief. RN E assisted the resident to be covered, washed his/her hands and exited the room. 6. During an interview on 7/27/23 at 1:44 P.M., the Director of Nursing (DON) said when providing perineal care, all areas potentially soiled should be cleaned. Staff should use either soap or personal wipes. Gloves should be changed when going from soiled to clean. Hand hygiene is performed after gloves changes, after every resident, and before leaving a room. It is not ok for staff to touch the resident or clean surfaces with a soled glove or unclean hands. Dirty linen is put in bags, tied, and taken out. Trash is taken directly to the soiled utility room. Soiled linen should not be placed directly on the floor. Soiled linen should not be allowed to sit in a resident's room overnight if care was done on the evening shift. 7. During an interview on 7/26/23 at 9:54 A.M., CNA J said when providing perineal care, the proper technique is to cleanse front to back. The last time he/she was in-serviced on this was last year. All areas potentially soiled should be cleansed. All soil should be removed. Gloves are changed when soiled, so at least four times during care. Hand hygiene is performed both before and after providing care. 8. During an interview on 7/26/23 at 8:57 A.M., CNA B said when providing care, staff should go in, wash their hands, and put on gloves. Staff should wash from front to back, apply soap and wash until the soap is gone. He/she has not had in-servicing on providing perineal care that he/she can remember, but did have in-service training on hand washing a month ago. All potential areas should be cleaned and soil should be removed. Gloves are changed twice during care because he/she pours water out to get fresh, so he/she takes his/her gloved off and washes his/her hands, then new gloves are applied. 9. During an interview on 7/26/23 at 8:53 A.M., RN A said staff received in-servicing on providing incontinence care in March 2023. Proper technique is to clean the genitals from front to back. All areas potentially soiled should be cleaned because if not, it could cause a skin tear (a skin tear is a tear in the skin caused by pulling or rubbing, not a type of skin break down caused by moisture or incontinence) or skin break. Resident's should have a skin assessment. All soil should be removed. Gloves are changed as needed when soiled. Take them off after touching the resident and between different procedures, then wash hands and place new gloves on. Hand hygiene is performed before and after a procedure. Hand sanitizer is used up to four times with four different residents, then hands should be washed. 10. During an interview on 7/26/23 at 9:41 A.M., RN F said the proper technique for personal care is to wash hands and clean from front to back. Use different towels when cleaning from front to back. Use water and towels and wipes. Pat dry. He/She was last in-serviced on this in September 2022 at a different job. All soil should be removed from the skin. Gloves are changed between dirty to clean. Hand hygiene is performed before, during, and after care. 11. Review of the facility's undated Cleaning and Disinfection of Resident-Care Items and Equipment policy, showed: -Resident care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standards; -Reusable items are cleaned and disinfected or sterilized between residents; -Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions; -Durable medical equipment is cleaned and disinfected before reuse by another resident. Review of the facility's undated Insulin Administration policy, showed: -Purpose: To provide guidance for the safe administration of insulin to residents with diabetes; -Cleanse the injection site with an alcohol wipe and allow to air dry. Review of Resident #23's medical record, showed: -Diagnoses included diabetes; -An order dated 1/3/23, for insulin aspart (short acting insulin) FlexPen solution. Inject as per sliding scale subcutaneously (under the skin) before meals. Review of Resident #24's medical record, showed: -Diagnoses included diabetes; -An order date 12/16/22, for Humalog (short acting insulin) solution. Inject 5 units subcutaneously before meals for diabetes. Review of Resident #25's medical record, showed: -Diagnoses included diabetes; -An order dated 7/4/23, for Humalog. Inject per sliding scale before meals. During an interview on 7/24/23 at 4:15 P.M., RN A said the CMT that was supposed to be work starting at 3:00 P.M. never showed up. He/She does have blood sugar checks to do. At 4:22 P.M., RN A sent another staff person to get alcohol wipes from the other floors because they were out on the floor. The staff person returned a few min later and said the second floor had no alcohol wipes, but handed RN A a box of skin prep (barrier wipes that create an invisible layer on the skin to protect it. It has no cleansing properties and can leave a tacky reside that could cause bacteria to stick to the site). The nurse looked at the box and said this will work, these are the same thing. At 4:23 P.M., the CMT, who just arrived to work, said he/she is not insulin certified, so RN A said he/she would get the blood sugar readings. Observation on 7/24/23 at 4:23 P.M., showed RN A grabbed skin prep and called them alcohol wipes. He/She gathered supplies and went to the treatment cart. He/She had one alcohol prep pad left. He/She washed his/her hands with soap and water, placed gloves on, and walked over to Resident #23, who sat in the dining room. RN A wiped the resident's finger with the last alcohol wipe, obtained a blood sugar sample, then wiped the excess blood from the resident's finger with the alcohol wipe. RN A then wiped the blood sugar machine off with a skin prep wipe, and not a wipe approved to kill the Hepatitis B virus (bloodborne virus). At 4:35 P.M., RN A washed his/her hands with soap and water, placed new gloves on and obtained a skin prep wipe from his/her pocket. Supplies were gathered and taken to the room of Resident #24. The resident sat on the edge of the bed. RN A set up the supplies, wiped the resident's finger with skin prep, and obtained a blood sample. There was insufficient blood, so the measurement could not be obtained. RN A went to the medication cart and set down supplies. He/She gathered more supplies and returned to the resident's room. He/She placed gloves on and a skin prep wipe was used to wipe a different finger. A blood sample was obtained. RN A then wiped the excess blood off the resident's finger with skin prep. Supplies were disposed. He/She returned to the medication cart, removed his/her gloves and washed her hands with soap and water. She placed the blood sugar machine directly on the treatment cart. At 4:46 P.M., RN A returned to the treatment cart and wipe down the machine with skin prep. Supplies were gathered, and he/she went to the room of Resident #25. The resident sat in a reclining wheel chair. RN A wiped the resident's finger with skin prep. A blood sample was obtained. There was not enough blood. The resident refused any further attempts for blood. During an interview on 7/24/23 at 5:13 P.M., the DON said during blood sugar checks, staff should cleanse the blood sugar machine between residents with Sani-wipes (a cleansing wipe approved to kill the Hepatitis B virus and approved for cleaning shared medical equipment that could potentially be contaminated with blood, such as a blood sugar testing machine). Alcohol wipes should be used to wipe off the resident's fingers before and after obtaining the sample. Skin prep is not the same thing as alcohol wipes and is not okay to use in place of an alcohol wipe or Sani-wipe. She will get some alcohol wipes for the floor. 12. Review of the facility's undated Activities of Daily Living (ADL) Supporting policy, showed: -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the pan of care, including appropriate support and assistance with: Dining (meals and snacks); -A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the assessment reference date and the following definitions: -Independent: Resident completed activity with no help or staff oversight; -Supervision: Oversight, encouragement or cuing provided; -Limited assistance: Resident highly involved in activity and received physical help in guided maneuvering of limbs or other non-weight bearing assistance; -Extensive assistance: While resident performed part of activity, staff provided weight bearing support; -Total dependence: Full staff performance of an activity with no participation by the resident for any aspect of the ADL activity; -Interventions to improve or minimize a resident's functional abilities will be in accordance with the residents' assessed needs, preferences, stated goals and recognized standards of practice. Review of Resident #74's medical record, showed: -Diagnoses included hemiplegia and hemiparesis following a stroke affecting the right dominate side, aphasia, dementia, and depressive disorder; -A care plan, in use at the time of the survey, showed risk for self-care deficit: Bathing, dressing, feeding, toileting, and transfers: Evaluate functional abilities. Provide meal support per resident's needs. The resident has an alteration in musculoskeletal status related to contractures to the right arm related to a stroke: Staff to assist with feedings; -An order dated 3/8/23, for a regular diet with super cereal with breakfast and Boost with dinner. Observation on 7/24/23 at 7:04 A.M., showed the resident sat in a Broda chair (medical reclining chair) in the third floor dining room. His/Her right leg hung down to the ground off of the side of the chair and his/her head tilted to the left and over the side of the chair. The resident grimaced as he/she tried to reposition him/herself. At 8:27 A.M., staff brought breakfast to the third floor on a wire rack and staff began to pass out trays. Staff placed Resident #74's food on the table in front of him/her. The food was still covered with a lid. The resident sat in his/her chair, not assisted to eat, and slouched down in his/her chair. Both legs now on the reclined leg rests, but his/her buttocks slid down causing the bend in the chair to line up with his/her lower back and not his/her hips. At 8:33 A.M., CNA B positioned the resident's care up closer to the table and sat the chair up rapidly. This caused the resident to be jerked forward rapidly. The resident then fell back into the chair and slid down further into the chair. His/her feet pressed against the legs of the table and the bend of the chair near the resident's mid back. The resident leaned to the left side. CNA B started to cut up the resident's food. The resident served oatmeal, cheesy eggs, two sausage links, Boost, orange juice, pancakes, milk, and another unidentified drink in a cup. The resident reached to the table and took a drink of his/her juice. CNA B said sit up now take your hand from your shirt so you can eat. CNA B then adjusted the resident's right sleeve, that had slipped down over his/her hand, but he/she did not assist the resident to sit up. CNA B stood over the resident on the left side and gave the residents two bites of food, then walked to a different resident. The resident still slouched in his/her chair. At 8:34 A.M., the resident struggled to reach for his/her food and his/her position in the chair appeared unsafe for eating and uncomfortable. CNA B exited the dining room as the resident struggled to reach for his/her food, and used his/her hands to grab at the food. RN A walked over to the resident and put a clothing proctor on him/her then offered him/her a straw. The resident remained slouched, and no staff assisted him/her to sit up or be positioned in the chair. RN A returned with straws and put them in his/her drinks. The resident's feet continued to be press against the legs of the table. After adding a straw in the resident's drinks, RN A walked away. The resident struggled to reach for his/her food. He/She grabbed a piece of sausage, took a bite then reached to set his/her sausage down. The resident reached for his/her eggs, stuck his/her fingers into the eggs, and then licked his/her fingers. He/she reached for the bowl that contained oatmeal and tried to drink from it like a cup, his/her left hand shook significantly. At 8:43 A.M., the resident continued to struggle to reach his/her food. The resident leaned to one side and slouched, making it hard for him/her to reach anything on the tray. Two staff stood near the resident while assisting other residents. No staff offered positioning assistance to the resident. At 8:47 A.M., the resident was able to reach his/her fork and then dropped the fork in his/her lap. There were several pieces of pancake and several pieces of egg on his/her lap. The resident grabbed a drink from the tray, struggled to take a drink, and began to cough. He/She spilled his/her drink all over his/her tray. The resident attempted, but was not able to reach any other drinks on the tray, so he/she attempted to reach for the cup that lay on its side. Only a scant amount of drink remained in the cup. At 8:49 A.M., the resident dropped his/her cup on the floor. He/She then picked up a piece of sausage from his/her lap, attempted to get the sausage to his/her mouth, and then dropped the piece of sausage on the floor. The resident was able to reach his/her second piece of sausage. He/She took one bite and then the sausage dropped to the floor. He/She ended up only being able to take one bite of each piece of sausage before dropping them. The resident reached over and pulled his/her tray closer and reached with his/her hands into the eggs but was not able to get any. CNA B walked over to the resident, picked up the fork from his/her lap, said I can help you, stood next to the resident and fed him/her a bite of food. CNA B then took the resident's plate and took it to the microwave. As CNA B stood at the microwave, the resident grabbed the bowl of oatmeal and drank from it like a cup. As he/she drank, some spilled on his/her clothing protector. CNA B returned to the resident's side, stood over the resident, and placed a bite in the resident's mouth. The resident said too hot. The resident continued to be slouched and leaned in his/her chair. CNA B scooped up random bites of food and put them in the resident's mouth. At 9:02 A.M., only a few minutes after starting to feed the resident, CNA B walked away from the resident suddenly and stopped feeding him/her. The resident began to reach for his/her food with his/her bare hands and almost dumped the whole tray on the floor when his/her hand began to shake suddenly. He/She was able to pull the tray close enough to get to his/her orange juice. Approximately half of the food that was on the tray now gone, but half of that amount lay on the floor or the resident's lap. The resident appeared to be exhausted and stopped attempting to feed him/herself. At 9:14 A.M., two staff walked over to the resident and pulled him/her up in the chair. One of the CNAs then stood over the resident and gave another bite of food, then walked away. During an interview on 7/26/23 at 8:53 A.M., RN A said he/she has been provided education on proper feeding and eating techniques. He/She is a CNA instructor. Staff should check the resident's diet and make sure their food is cut up. The proper technique is to give four or five bites of food then something to drink. Take time while feeding. Sit while feeding and do not stand. Proper positioning for residents is at least 90 degrees, not flat. If a resident is fed when slouched or scooted down in the chair or bed, there is a risk of choking or aspiration. To know which residents require assistance with eating, he/she walks around and observes or checks the care plan. During an interview on 7/26/23 at 8:57 A.M., CNA B said he/she knows how to provide care because he/she has been working with the residents and knows the residents. He/she has been provided training on techniques and dignity. Residents should be sitting up when eating. They can choke if slouched or laying. The technique training provided was when he/she was in school to be a CNA, not provided by the facility. He/she just knows the residents and knows which ones are feeders. During an interview on 7/27/23 at 1:44 P.M., the Director of Nursing said when staff are feeding residents, the residents should be sitting upright. Staff should assist with meals if needed.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, 13 errors occurred resulting in a 43.33% error rate (Residents #76, #7, #23, #24 and #8). The census was 43. Review of the facility's undated Administering Medications policy, showed: -Medications are administered in a safe and timely manner, and as prescribed; -Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so; -Medications are administered in accordance with prescriber orders, including any required timeframe; -Medications are administered within one hour of their prescribed times, unless otherwise specified (for example, before and after meal orders); -The individual administering the medication checks the label three times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication; -For residents not in their rooms or otherwise unavailable to receive medication on the pass, the medication administration record (MAR) may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication; -The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 1. Review of Resident #76's medical record, showed: -Diagnoses included depressive disorder, diabetes, and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination); -A medication start date of 9/12/22, for Metamucil capsule (stool softener) 0.52 grams. Give three capsules by mouth two times a day for constipation, scheduled administration time, 8:00 A.M. and 5:00 P.M.; -A medication start date of 9/12/22, for metformin HCL (used to treat diabetes) 500 milligram (mg). Give half a tablet by mouth two times a day, scheduled administration time 7:30 A.M. and 5:00 P.M.; -A medication start date of 9/12/22, for pyridostigmine bromide (used to increase muscle strength) 60 mg. Give half a tablet by mouth two times a day, scheduled administration time 8:00 A.M. and 8:00 P.M.; -A medication start date of 9/12/22, for carbidopa-levodopa (medication used to treat Parkinson's disease) 25-100 mg. Give one tablet by mouth with meals, scheduled administration time 7:30 A.M., 12:30 P.M., and 5:30 P.M.; -A medication start date of 9/13/22, for multivitamin tablet, administer one tablet one time a day for supplement, scheduled administration time, 9:00 A.M.; -A medication start date of 9/13/22, for Sertraline HCL (antidepressant) 50 mg. Give one tablet one time a day, scheduled administration time, 9:00 A.M.; -A medication start date of 10/1/22, for Tylenol extra strength 500 mg. Give 1000 mg by mouth two times a day, scheduled administration time, 9:00 A.M. and 5:00 P.M.; -An order dated 11/30/22, make sure medications have been given out of the medication planner; -An order dated 6/26/23, all medications are filled by the VA and the residents spouse is handling everything. During observation and interview on 7/25/23 at 9:03 A.M., Certified Medication Technician (CMT) I said the resident's spouse prepares the resident's medications, then staff give them. Observation in the medication room, showed CMT I opened the medication cart and removed a zip lock bag that contained a weekly pill divider with four different time slots available. CMT I said the different time slots are for the 8:00 A.M., noon, 5:00 P.M., and bedtime pills. He/She opened the 8:00 A.M., pill slot. There were 8 pills/capsules. Six were tablets that were all different and two capsules which appeared to be the same medication, he/she dumped them into a medicine cup. The CMT prepared the medications and administered them to the resident. The CMT did not verify the identity of any of the medications in the cup prior to administration or clarify the discrepancies when comparing the medications in the pill divider with what was ordered. This included the discrepancy of administering Tylenol 500 mg tablets to equal 1000 mg and three capsules of Metamucil. During an interview on 7/26/23 at 8:53 A.M., Registered Nurse (RN) A said all medication containers should be labeled and dated. Labeling includes the drug name, dose, resident's name, the medication dose, rout and doctors name. Medications cannot be administered by someone who did not pull them from the original container because staff would not know what they are giving. If staff did not pull it, it could be anything. During an interview on 7/26/23 at 9:41 A.M., RN F said medications cannot be administered if they were prepared by someone else because staff would not know what was being put in the cup. During an interview on 7/26/23 at 9:48 A.M., CMT H said medications cannot be administered if they were prepared by someone else. 2. Review of Resident #7's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 5/2/23, showed: -The resident is rarely/never understood; -Diagnoses included stroke, dementia, and hemiplegia and hemiparesis (hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body); -Had a feeding tube (gastric tube (g-tube) a tube inserted into the stomach to provide food, fluid and medications). Review of the resident's electronic physician order sheet (ePOS) and MAR, showed: -An order dated 5/24/23, for famotidine (used to treat heart burn) 20 milligram (mg). Give one tablet via g-tube one time a day: -Scheduled administration time: 9:00 A.M.; -An order dated 5/24/23, for Florastor (probiotic). Give one capsule via g-tube one time a day: -Scheduled administration time: 9:00 A.M.; -An order dated 6/10/23, for Baclofen (muscle relaxer) 10 mg. Give one tablet via g-tube, three times a day: -Scheduled administration time: 9:00 A.M., 3:00 P.M., and 9:00 P.M.; -An order dated 6/10/23, for guaifenesin (cough medication) 100 mg/5 milliliter (ml). Give 10 ml via g-tube every 6 hours: -Scheduled administration time: 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. During an interview on 7/25/23 at 7:08 A.M., RN E said he/she will complete the resident's morning g-tube medication administration at 9:00 A.M. At 8:50 A.M., RN E said a different resident had a medical emergency, the resident's medications will be rescheduled for noon. At 11:48 A.M., RN E said the resident got up in his/her chair for a while today, so he/she will have to wait until after he/she is put back to bed, after lunch is served. Observation, showed RN E sat at the nurse's desk and talked with another staff person. Observation on 7/25/23 at 12:22 P.M., showed RN E stood at the medication cart and poured guaifenesin 10 mg per 5 ml, 10 ml into a medication cup. At 12:27 P.M., RN E entered the resident's room and administered the medication via the resident's g-tube. During an interview on 7/25/23 at 1:05 P.M., Nurse in Training T said he/she did not administer the resident's morning medication and did not see RN E administer the morning medications. During an interview on 7/25/23 at 1:11 P.M., RN E said she gave the resident his/her AM medications. The original time of 9:00 A.M., that was pre-arranged, did not work because he/she had to send a resident to the ER and that messed with the time. He/She went in and gave the medications after the other resident went out and before the resident got up. During an interview on 7/25/23 at 2:10 P.M., Certified Nursing Assistant (CNA) J said he/she got the resident up at around 9:45 A.M. He/she was waiting to get him/her up, because he/she knew RN E said he/she was going to be watched by state. He/she thought state was going to watch the resident be transferred and his/her wound treatment, but RN E never came in, so CNA J got someone else up and came back to get the resident up because he/she was just lying there. He/she then got the resident up and took him/her to the TV room. RN E and Nurse in Training T never got up from the desk. CNA J was actually watching them and he/she never saw the nurses get up and give medication. Observation of the facility's camera footage, on 8/2/23 at 1:42 P.M., reviewed for the date of 7/25/23 from 8:28 A.M. through 9:43 A.M., of the second floor lobby area, showed the following: -At 8:28 A.M., RN E and Nurse in Training T sat at the desk in the second floor lobby. The medication cart sat in view of the camera; -At 9:19 and 18 seconds A.M., Emergency Medical Services (EMS) arrived to the floor, exiting the elevator into the second floor lobby. RN E stood up and walked into the dining room/living room area, out of view of the camera; -At 9:19 and 58 seconds A.M., RN E re-entered the camera view from the dining room/living room area and propelled a resident in their wheelchair over to the EMS gurney, which sat in view of the camera; -From 9:19 A.M. through 9:25 A.M., RN E and Nurse in Training T assisted EMS by providing paperwork, assisting with the resident and talking with EMS; -At 9:25 A.M., RN E and Nurse in Training T sat back down at the desk; -At 9:43 A.M., CNA J brought the resident in his/her medical reclining chair from down the hall and into the dining/living room area; -RN E never left the desk any other time during the footage reviewed. 3. Review of Resident #23's medical record, showed: -Diagnoses included diabetes; -An order dated 1/3/23, for insulin aspart (short acting insulin) FlexPen solution. Inject as per sliding scale subcutaneously (under the skin) before meals. For a blood sugar level of 301 through 350, administer 6 units. Review of Resident #24's medical record, showed: -Diagnoses included diabetes; -An order date 12/16/22, for Humalog (short acting insulin) solution. Inject 5 units subcutaneously before meals for diabetes. During an interview on 7/24/23 at 4:15 P.M., RN A said the CMT that was supposed to work never showed up. He/She will obtain the blood sugar checks. At 4:23 P.M., the CMT arrived to the floor and said he/she is not insulin certified. RN A said he/she would have to administer the insulin. Observation on 7/24/23 at 4:23 P.M., showed RN A obtained a blood sugar result for Resident #23 of 317. No insulin administered at this time. At 4:35 P.M., RN A obtained a blood sugar result for Resident #24 of 107. No insulin administered at this time. Observation on 7/24/23 at 5:36 P.M., showed meal service on the floor completed. At 5:46 P.M., RN A sat at the desk and had not administered any insulin to any of the residents. During an interview on 7/24/23 at 6: 10 P.M., the surveyor asked RN A if he/she had any insulin to administer. RN A said yes, since the CMT is not insulin certified he/she will go ahead and administer it now. At 6:23 P.M., RN A entered the room of Resident #23. The resident in bed with the lights off, asleep. RN A administered Resident #23 his/her Novolog 6 units of sliding scale insulin and said he/she had no other insulin to administer to any of the residents. He/She did not administer Resident #24's routine insulin. 4. Review of Resident #8's medical record, showed -A diagnoses of coronary artery disease (heart disease); -An order dated 9/10/22, for aspirin chewable 81 mg. Give one tablet one time a day, scheduled administration time, 9:00 A.M. Observation on 7/27/23 at 7:27 A.M., showed CMT H administered the resident's medications. He/she administered aspirin enteric coated (EC, a coating that dissolves slowly) 81 mg, one tablet and not the aspirin chewable tablet as ordered. 5. During an interview on 7/27/23 at 1:44 P.M., the Director of Nursing (DON) said medications should be administered as ordered. If a medication, such as insulin, is ordered to be administered before meals, it should be administered before meals. Staff cannot administer medications that were prepared by someone else. Medications should not be pre-pulled. Resident #76's spouse had been pulling his/her medication for years. The facility needs to correct this.

Based on observation, interview and record review, the facility failed to ensure drugs used in the facility are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions for one resident when staff allowed the residents family to prepare the medications for a week at a time, and store the medications in a pill divider with no medication names, dose, or instructions labeled (Resident #76). The facility failed to store all drugs and biologicals at the proper temperature controls when the medication refrigerator in the third floor medication room was inside a cubby hole that did not allow the door to close all the way. In addition, the facility failed to ensure drugs were stored in locked compartments and permit only authorized personnel to have access to the medications when the medication rooms on both the second and third floor were observed to be opened with no staff present. The census was 43. 1. Review of the facility's undated Storage of Medications policy, showed: -The facility stores all drugs and biological in a safe, secure, and orderly manner; -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications; -Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers; -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manor; -Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing; -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended; -Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurse's station or other secured location. Medications are stored separately from food and are labeled accordingly. 2. Review of Resident #76's medical record, showed: -Diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and dementia; -An order dated 11/30/22, make sure medications have been given out of the medication planner; -An order dated 6/26/23, all medications are filled by the VA and the residents spouse is handling everything; -Medications scheduled to be administered at 7:30 A.M., 8:00 A.M., 9:00 A.M., 12:30 P.M., 5:00 P.M., 5:30 P.M., 8:00 P.M., 9:00 P.M., and as needed. During observation and interview on 7/25/23 at 9:03 A.M., Certified Medication Technician (CMT) I said the resident's spouse prepares the resident's medications, then staff give them. Observation in the medication room, showed CMT I opened the medication cart and removed a zip lock bag that contained a weekly pill divider with four different time slots available. CMT I said the different time slots are for the 8:00 A.M., noon, 5:00 P.M., and bedtime pills. He/She opened the 8:00 A.M., pill slot. There were 8 pills, two which appeared to be the same medication, and he/she dumped them into a medicine cup. The CMT prepared the medications and administered them to the resident. 3. Observation on 7/24/23 at approximately 4:25 P.M., showed Registered Nurse (RN) A entered the third floor medication room. A medication refrigerator was located on the floor pushed inside a cubby hole under the counter. The refrigerator door was not completely closed and the top shelf inside the refrigerator was visible without opening the refrigerator. The door to the refrigerator stuck on the side of the cabinet. Observation inside the refrigerator, showed the temperature inside measured 60 degrees Fahrenheit (F). The safe temperature range for refrigeration on the thermometer identified as 32 degrees F through 40 degrees F. Any temperature above 40 degrees F identified as warm. The top ice/freezer area with a thick buildup of ice and the ice melted and dripped down onto the medications. RN A said it is the night shift's responsibility to check the refrigerator temperatures. RN A then exited the medication room without fixing the medication refrigerator door. During an interview on 7/24/23 at 5:03 P.M., the Director of Nursing (DON) said the Assistant Director of Nursing (ADON) checks medication room temperatures daily. Observation of the third floor medication refrigerator on 7/24/23 at 5:06 P.M., showed the refrigerator contained 53 insulin pens for several different residents. The insulin pens were a mix of Novolog (short-acting insulin) and Levemir (long-acting insulin). In addition, a bin that contained suppositories was stored at the bottom of the refrigerator. A puddle of melted ice on the bottom shelves and the boxes that held the insulin were wet and soggy. During an interview at this time, the DON said the temperature logs are kept downstairs in her office, she will call the ADON to get them. Observation at this time, showed the refrigerator in the red warm zone and measured 55 degrees F. The DON walked to the nurse's desk and asked the nurse on third floor where the refrigerator temperatures are kept. The nurse said he/she did not know. The DON flipped through a binder at the nurse's station and found the temperature log in it. Review of the log, showed the last temperature documented on 7/23/23 and measured 40 degrees F. The DON said the high temperature must be a new thing that just started today. Review of the medication refrigerator temperature log for the third floor, for the month of July 2023, showed on July 1, 2023, the temperature documented as 50 degrees F with a comment defrosted freezer. Observation on 7/25/23 at 5:22 A.M., of the third floor medication refrigerator, showed it was pulled out of the cubby hole, just enough so the door could close. The temperature measured at an acceptable 40 degrees F. RN R said he/she was the person who documented the temperature on July 1st and had to defrost the refrigerator because someone left that door open and the ice overgrew. It took 2 days to defrost. He/She had to take all the medications and store them on a different floor. He/She has told management that they need to do something to keep people from pushing the fridge all the way back into the cubby, because then the fridge will not close. 4. Observation on 7/25/23 at 7:34 A.M., of the third floor medication room, showed the door opened and leaned against the door frame. No staff were present in the area. Observation inside the medication room, showed no staff present. The medication cart sat in the medication room, unlocked. The medication cart contained all of the third floor resident's medications. 5. Observation on 7/27/23 at 11:53 A.M., of the second floor medication room, showed the door closed, but not locked. No staff were present in the medication room or in the area of the medication room. Three black plastic bins full of medication cards were present. During an interview with the nurse on the floor, she said the door needs to be closed fully to lock. It was pulled closed and is now locked. 6. During an interview on 7/26/23 at 8:53 A.M., RN A said medication should be locked in a medication cart. Medications should be stored at the proper temperature. There is a normal range visible on the thermometer inside the refrigerator. All medication containers should be labeled and dated. Labeling includes the drug name, dose, resident's name, and the medication dose, rout and doctors name. Medications cannot be administered by someone who did not pull them form the original container because staff would not know what they are giving. If staff did not pull it, it could be anything. 7. During an interview on 7/26/23 at 9:41 A.M., RN F said pharmacy provides stickers for open dates of medications. Pills are placed in each resident's individual slot in the medication cart. Staff are to check the labels and expiration dates. Medications should be stored at the proper temperature. The thermometer in the refrigerator specifies these settings. Medication containers should be labeled. The label should include the drug name, strength, dose, doctors name, date dispensed, expiration date and lot number. Medications cannot be administered if they were prepared by someone else because staff would not know what was being put in the cup. 8. During an interview on 7/26/23 at 9:48 A.M., CMT H said medications should be stored in the correct container, marked and dated with labels and dates they were opened. They are kept in a locked cart. They should be stored at the proper temperature. There is a thermometer that should be checked daily. All medication should be labeled to include the drug name, dose, room, resident, and rout. Medications cannot be administered if they were prepared by someone else. 9. During an interview on 7/27/23 at 1:44 P.M., the DON said medication rooms should be locked when staff are not present. Medications should be stored at the proper temperature. Staff cannot administer medications that were prepared by someone else. Medications should not be pre-pulled. Resident #76's spouse had been pulling his/her medication for years. The facility needs to correct this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility to maintain appropriate infection control practices when staff failed to demonstrates proper use of gloves with hand hygiene during personal care. Soiled gloves were used to touch the resident, resident surfaces, and resident personal belongings. Staff failed to demonstrate proper use of gloves with hand hygiene after providing care to one resident and before providing care to a different resident. Staff failed to provide proper perineal care (cleansing the surface area between the thighs, extending from the pubic bone to the tail bone) when staff cleansed the rectal area of a resident and then use the same area of the rag to cleanse the genitals, for three of five residents observed during perineal care and one additional resident who had their personal belongings touched after staff provided care to a different resident (Residents #13, #174, #74, and #26). Staff failed to use proper infection control practice when handling soiled linen and trash, when staff placed soiled linen directly on the floor in resident rooms and in the halls and stored trash in the halls on the floor. In addition, staff failed to follow proper infection control practices during blood sugar checks when staff used a product with no cleansing properties to wipe off the resident's skin prior to drawing blood and to wipe off a blood sugar machine between resident use, for three of three residents observed for blood sugar checks (Residents #23, #24, and #25). The census was 43. Review of the facility's Hand Hygiene Competence Assessment and Monitoring tool, showed: -Knows when to perform hand hygiene with soap and water: When hands are visibly dirty or visibly soiled with blood or other body fluids; before eating and after using the restroom; After approximately 10 uses of alcohol-based hand gel or hands feel tacky from use of hand gel; -Knows when to perform hand hygiene with either alcohol-based hand gel: Before and after patient contact; before and after glove use; after body fluid exposures, manipulation of a urinary catheter device, or contact with other inanimate objects; before and after computer use. Review of the facility's undated Perineal Care policy, showed: -The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -Review the resident's care plan to assess for any special needs of the resident; -Assemble the equipment and supplies as needed; -The following equipment and supplies will be necessary when performing this procedure: Wash basin, towels, washcloth, soap (or other authorized cleansing agent, and persona protective equipment (e.g. gloves, etc.); -Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached; -Wash and dry your hands thoroughly; -Put on gloves; -Was the perineal area; -Wash the rectal area; -Remove gloves and discard. Wash and dry your hands. 1. Review of Resident #13's medical record, showed: -A quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/9/23, showed: -Severe cognitive impairment; -Required extensive assistance for dressing, toilet use, and personal hygiene; -Frequently innocent of bowel and bladder; -Diagnoses included dementia, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), anxiety and depression; -A care plan, in use at the time of the survey, showed: -Focus revised on 12/14/22, at risk for self-care deficit: bathing, dressing, feeding and toileting; -Goal: Be able to perform self-care needs to the fullest potential; -Intervention included: Encourage resident to participate in planning day to day care. Evaluate resident's ability to perform activities of daily living (ADLs). Provide assistance with ADLs as needed. Review of Resident #174's medical record, showed: -An admission MDS, dated [DATE], showed: -Cognitively intact; -Required extensive assistance required for bed mobility, dressing, toilet use and personal hygiene; -Has an indwelling urinary catheter (a tube inserted through the urinary opening into the bladder to drain urine); -Frequently incontinent of bowel; -Diagnoses include heart disease, heart failure, and debility -A care plan, in use at the time of the survey, showed: -Focus revised on 9/27/22: The resident has an ADL self-care performance deficit related to terminal illness of sepsis (systemic infection); -Goal: Maintain current level of function with staff oversight and assistance, dignity maintained; -Interventions included: The resident is totally dependent on staff to provide bath/shower. The resident requires extensive assistance by staff to turn and reposition in bed. The resident requires extensive assistance by staff with personal hygiene and oral care. The resident requires skin inspections weekly and as needed. The resident requires total assistance for toileting needs including catheter care. Observation on 7/25/23 at 6:05 A.M., showed Certified Nursing Assistant (CNA) O entered Resident #13's room. He/She assisted the resident to sit on the edge of the bed, then assisted him/her to stand, and walked into the bathroom. The resident's brief was so saturated, it sagged to the resident's mid thighs. Once to the sink, CNA O placed gloves on, removed the resident's brief and put it in the trash. It made a loud sound when it hit the trash can. CNA O took a hand towel, wet it in the sink, and wiped the resident's face with the same gloved hand used to remove the soiled brief. He/She then used the towel and cleaned the resident's underarms, back, then buttocks. After wiping the resident's buttocks, he/she used the same part of the towel used to wipe the resident's buttocks and wiped the resident's genitals. No soap was used and the resident was not dried. The CNA placed a brief on the resident as he/she stood at the sink. The brief was secured, and CNA O pulled up the resident's pants, while still wearing the same soiled gloves. CNA O removed his/her gloves, and did not wash or sanitize his/her hands. CNA O placed deodorant on the resident, got a shirt from a chair in the room, brought it to the resident, and placed the shirt on the resident. CNA O then got a hair brush and brushed the resident's hair. He/She then grabbed the resident's hands and while walking backwards, led the resident to the bedroom. CNA O made the resident's bed and walked out of room as the resident followed. CNA O grabbed the resident's hand and walked with the resident to the dining room. At 6:18 A.M., immediately after assisting Resident #13 to the dining room and without washing his/her hands, CNA O entered Resident #174's room. He/She picked up trash from the floor, next to the resident's bed and threw it away. He/She obtained gloves from the bathroom and placed them on, without washing or sanitizing his/her hands. CNA O assisted the resident to his/her left side. The resident had an indwelling urinary catheter in place. CNA O uncovered the resident and an area of stool on his/her right outer knee. Stool was visible all over the incontinence pad located under the resident. No stool was on the resident's buttocks. CNA O said the bowel movement on the pad was still there from the shift prior, because the resident did not have a bowel movement on his/her shift. Observation in the resident's bathroom, showed a pad on the floor in the bathroom with bowel movement all over it. CNA O said that was from prior to his/her shift. He/She did not put it there. The resident did not have a bowel movement on the night shift and he/she was the only night CNA working that night. CNA O wiped the resident's right buttuck with a wet, but not soapy rag. No bowel movement was visible in the gluteal fold or rectum area. CNA O did not clean the stool on the resident's leg. He/She positioned the resident to the right side. The resident had a large area of dried stool on his/her left buttock. CNA O scrubbed the skin hard to get the dried bowel movement off. When done, there were a few specks of dried bowel movement that remained on the resident's skin. With the same soiled gloves, CNA O emptied the resident's indwelling urinary catheter, which showed dark amber urine, approximately1000 milliliters (ml) in the bag. CNA O said he/she worked from 10:30 P.M. last night and gets off at 7:00 A.M. He/She picked up the stool soiled linen from the bathroom floor, looked at the bowel movement and said gross and set it back down. He/She returned to the resident's side, positioned his/her legs in the bed, covered him/her with a blanket, handed him/her the call light, all with the soiled gloves on. The resident asked for a cup, so CNA O handed him/her a cup with his/her soiled, gloved thumb inside the inner rim of the cup. CNA O then picked up the soiled linen from the bathroom floor and emptied the trash. He/She exited the room, touching the door handle, and entered the soiled utility room, touching the door handle with the soiled gloves on. 2. Observation on 7/25/23 at 5:47 A.M., showed a bag of trash, and soiled linen which was not in a bag, on the floor in the hall, outside rooms 201, 224 and 221. A bag of trash was outside room [ROOM NUMBER]. Soiled linen lay directly on the floor, just inside room [ROOM NUMBER]. A bag of trash lay outside rooms [ROOM NUMBERS]. A strong odor of stagnant urine was noted throughout the hall. On 7/25/23 at 5:52 A.M., CNA O threw linen directly onto the floor, outside room [ROOM NUMBER] and then reentered the room. 3. Review of Resident #74's medical record, showed: -Diagnoses included hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body) following a stroke affecting the right dominate side, aphasia (loss of ability to understand or express speech, caused by brain damage), dementia and depressive disorder; -A care plan, in use at the time of the survey, showed risk for self-care deficit: Bathing, dressing, feeding, toileting and transfers: Evaluate functional abilities. Provide meal support per resident's needs. The resident has an alteration in musculoskeletal status related to contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the right arm related to a stroke: Staff to assist with feedings. Review of Resident #26's admission MDS, dated [DATE], showed: -Severely impaired cognition; -Required extensive assistance for bed mobility, toilet use, and personal hygiene; -Diagnoses include seizure disorder and anxiety. Observation on 7/25/23 at 5:31 A.M., showed CNA N entered the room of Resident #74, gathered supplies, picked the fall mat up off of the floor, and said he/she is waiting for the other CNA, CNA Q. CNA Q entered the room and both CNAs put gloves on. Neither staff washed or sanitized their hands prior to placing gloves on and after entering the room. Staff raised the resident's bed. The CNAs unsecured the resident's brief. The resident's perineal area was reddened. CNA Q obtained a personal wipe and wiped the resident from front to back and said he/she is pretty chapped. The resident's brief was completely saturated and bowel movement was visible. The CNAs assisted the resident to his/her right side. CNA Q wiped the resident's buttocks. The resident's buttocks reddened. CNA N squirted barrier cream into CNA Q's gloved hand, the same gloved hand used to clean up the stool. CNA Q applied the barrier cream. The resident started to have a bowel movement. CNA Q removed one glove and without sanitizing his/her hands, placed one new glove on, wiped up the bowel movement, obtained a new wipe and repeated the process. CNA Q placed a clean pad and a clean brief under the resident with the same gloved hands used to wipe the bowel movement. CNA Q, while wearing the same soiled gloves, assisted the resident to his/her other side, and placed a hand on the resident's leg. CNA Q removed one glove and secured the resident's brief. CNA N left the room with the soiled linen and trash. CNA Q removed his/her gloves and tossed them in the trash in the room. He/She did not wash or sanitize his/her hands. CNA Q entered Resident #26's room and started moving his/her wheelchair around, said he/she was going to assist him/her to get up and closed the door. 4. During an interview on 7/26/23 at 9:54 A.M., CNA J said when providing perineal care, the proper technique is to cleanse front to back. The last time he/she was in-serviced on this was last year. All areas potentially soiled should be cleansed and all soil should be removed. Gloves are changed when soiled, so at least four times during care. Hand hygiene is performed both before and after providing care. 5. During an interview on 7/26/23 at 8:57 A.M., CNA B said when providing care, staff should go in, wash their hands, and put on gloves. Staff should wash from front to back, apply soap and wash until the soap is gone. He/She has not had in-servicing on providing perineal care that he/she can remember, but did have in-service training on handwashing a month ago. All potential areas should be clean and soil should be removed. Gloves are changed twice during care because he/she pours water out to get fresh water, so he/she takes his/her gloves off and washes his/her hands, then new gloves are applied. 6. During an interview on 7/26/23 at 8:53 A.M., Registered Nurse (RN) A said staff received in-servicing on providing incontinence care in March 2023. Proper technique is to clean the genitals from front to back. All areas potentially soiled should be cleaned because if not, it could cause a skin tear or break. All soil should be removed. Gloves are changed as needed when soiled. Staff should take gloves off after touching the resident and between different procedures, then wash hands and place new gloves on. Hand hygiene is performed before and after a procedure. Hand sanitizer is used up to four times with four different residents, then hands should be washed. 7. During an interview on 7/26/23 at 9:41 A.M., RN F said the proper technique for personal care is to wash hands and clean from front to back. Staff shoudl use different towels when cleaning from front to back, and use water and towels and wipes, then pat dry. He/She was last in-serviced on this in September 2022 at a different job. All soil should be removed from the skin. Gloves are changed between dirty to clean. Hand hygiene is performed before, during and after care. 8. During an interview on 7/27/23 at 1:44 P.M., the Director of Nursing (DON) said when providing perineal care, all areas potentially soiled should be cleaned. Staff should use either soap or personal wipes. Gloves should be changed when going from soiled to clean. Hand hygiene is performed after gloves changes, after every resident, and before leaving a room. It is not ok for staff to touch the resident or clean surfaces with a soiled glove or unclean hands. Dirty linen is put in bags, tied, and taken out. Trash is taken directly to the soiled utility room. Soiled linen should not be placed directly on the floor. Soiled linen should not be allowed to sit in a resident's room overnight. 9. Review of the facility's undated Cleaning and Disinfection of Resident-Care Items and Equipment policy, showed: -Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standards; -Reusable items are cleaned and disinfected or sterilized between residents; -Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions; -Durable medical equipment is cleaned and disinfected before reuse by another resident. Review of the facility's undated Insulin Administration policy, showed: -Purpose: To provide guidance for the safe administration of insulin to residents with diabetes; -Cleanse the injection site with an alcohol wipe and allow to air dry. Review of Resident #23's medical record, showed: -Diagnoses included diabetes; -An order dated 1/3/23, for insulin aspart (short acting insulin) FlexPen solution. Inject as per sliding scale subcutaneously (under the skin) before meals. Review of Resident #24's medical record, showed: -Diagnoses included diabetes; -An order date 12/16/22, for Humalog (short acting insulin) solution. Inject 5 units subcutaneously before meals for diabetes. Review of Resident #25's medical record, showed: -Diagnoses included diabetes; -An order dated 7/4/23, for Humalog. Inject per sliding scale before meals. During an interview on 7/24/23 at 4:22 P.M., RN A sent another staff person to get alcohol wipes from the other floors because they were out on the floor. The staff person returned a few minutes later and said the second floor had no alcohol wipes, but handed RN A a box of skin prep (barrier wipes that create an invisible layer on the skin to protect it. It has no cleansing properties and can leave a tacky residue that could cause bacteria to stick to the site). The nurse looked at the box and said this will work, these are the same thing. Observation on 7/24/23 at 4:23 P.M., showed RN A gathered supplies and went to the treatment cart. He/She had one alcohol prep pad left. He/She washed his/her hands with soap and water, placed gloves on, and walked over to Resident #23, who sat in the dining room. RN A wiped the resident's finger with the last alcohol wipe, obtained a blood sugar sample, then wiped the excess blood from the resident's finger with the alcohol wipe. RN A then wiped the blood sugar machine with a skin prep wipe (not approved to kill the Hepatitis B virus (bloodborne virus)). At 4:35 P.M., RN A washed his/her hands with soap and water, placed new gloves on and obtained a skin prep wipe from his/her pocket. Supplies were gathered and taken to the room of Resident #24. The resident sat on the edge of the bed. RN A set up the supplies, wiped the resident's finger with skin prep, and obtained a blood sample. There was insufficient blood, so the measurement could not be obtained. RN A went to the medication cart and set down the supplies. He/She gathered more supplies and returned to the resident's room. He/She placed gloves on and used skin prep to wipe a different finger. A blood sample was obtained. RN A then wiped the excess blood off the resident's finger with skin prep. He/She returned to the medication cart, removed his/her gloves and washed her hands with soap and water. He/She placed the blood sugar machine directly on the treatment cart. At 4:46 P.M., RN A returned to the treatment cart and wiped down the machine with skin prep. Supplies were gathered, and he/she went to the room of Resident #25. The resident sat in a reclining chair. RN A wiped the resident's finger with skin prep. A blood sample was obtained. There was not enough blood. The resident refused any further attempts for blood. During an interview on 7/24/23 at 5:13 P.M., the DON said during blood sugar checks, staff should cleanse the blood sugar machine between residents with Sani-wipes (a cleansing wipe approved to kill the Hepatitis B virus and approved for cleaning shared medical equipment that could potentially be contaminated with blood, such as a blood sugar machine). Alcohol wipes should be used to wipe off the resident's fingers before and after obtaining the sample. Skin prep is not the same thing as alcohol wipes and is not okay to use in place of an alcohol wipe or Sani-wipe.

Based on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed frames, mattresses and bed/side rails as part of a regular maintenance program to identify areas of possible entrapment, for six of 12 sampled residents (Residents #74, #77, #8, #7, #18 and #174). The census was 43. 1. Review of the facility's undated Bed Safety Audit form, showed: -Nursing and maintenance are responsible for conducting bed safety audits; -Audits will be conducted annually and with a change of specialty bed or mattress. During an interview on 7/27/23 at 9:11 A.M., the Plant Director provided the Bed Safety Audit form and said preventative maintenance on side rails is completed every 12 months. This has not yet been done. 2. Review of Resident #74's medical record, showed: -An order, dated 3/8/23, for quarter side rail times one for transfers, bed mobility and positioning; -No side rail assessment. Observation on 7/24/23 at 2:43 P.M. and 4:05 P.M., 7/25/23 at 7:11 A.M. and 11:20 A.M., and on 7/27/23 at 6:33 A.M., showed the resident in his/her room in bed with one quarter side rail on the right side of the bed near the head of the bed. 3. Review of Resident #77's medical record, showed: -An order, dated 11/29/22, for quarter side rails times two for transfers, bed mobility and positioning; -No side rail assessment. Observation on 7/24/23 at 2:00 P.M., showed the resident in his/her electric wheelchair in his/her room. A quarter side rail was up on the top of both the left and right sides of the bed. The resident said his/her legs come off the bed when asleep. He/She wants full rails but the facility told him/her that he/she cannot have full rails because state does not allow it. 4. Review of Resident #8's medical record, showed: -An order, dated 11/29/22, for quarter side rails times two for transfers, bed mobility and positioning; -No side rail assessment. Observation and interview on 7/25/23 at 10:45 A.M., showed quarter side rails on the resident's bed. The resident said he/she uses the side rails to help sit up and put his/her feet on the ground when he/she is attempting to get out of bed. 5. Review of Resident #7's medical record, showed: -An order, dated 5/20/23 for one half-length times two side rails for bed mobility and positioning only, secondary to stroke; -No side rail assessment. Observations on 7/24/23 at approximately 7:14 A.M., 7/25/23 at 7:01 A.M., and on 7/26/23 at 9:42 A.M., and 2:34 P.M., showed the resident lay in bed on his/her back. One half-length side rails were raised on both sides of the bed. 6. Review of Resident #18's medical record, showed: -An order, dated 3/14/23 for one quarter length side rails times two for transfers, bed mobility and positioning; -No side rail assessment. Observations on 7/24/24 at 7:11 A.M., 7/25/23 at 7:03 A.M., and 7/26/23 at 9:44 A.M., the resident lay in bed on his/her back. Quarter length side rails were raised on both sides. 7. Review of Resident #174's medical record, showed: -The care plan did not address the resident's use of side rails; -No order for the use of side rails; -No side rail assessment. Observations on 7/24/23 at approximately 7:15 A.M., 7/25/23 at 6:59 A.M. and 7/26/23 at 9:41 A.M., showed the resident lay in bed on his/her back asleep. One quarter length bed rails were raised on both sides. 8. During an interview on 7/26/23 at 9:42 A.M., the Maintenance Supervisor said he is not aware of a maintenance program regarding side rails. He has been employed at the facility for three months. If a resident is receiving side rails, the only thing he is told is to put them on and to take them off. 9. During an interview on 7/27/23 at 1:44 P.M., the DON said residents who have side rails in use should have had their side rail assessment completed. Maintenance should assess side rails for the risk of entrapment.

Based on observation, interview and record review the facility failed to store food appropriately by failing to label, date, and cover food items and discard outdated items. The facility also failed to ensure areas of the kitchen and storage room were free of food crumbs, dust and debris. These deficient practices had the potential to affect all residents who consumed food from the facility's kitchen. The census was 43. 1. Review of the facility's undated food storage and leftovers policy, showed: -Leftovers: Careful planning shall be practiced at all times to minimize over production which causes leftover food; -Leftovers should be used within 30 hours for use at next meal service day. Freezer space is too limited to tie up with leftovers; -Food products remaining after each day's operation shall be handled and stored so as to prevent contamination. Food items that meet strict food safety standards may be retained and offered for re-service in another meal. Leftovers that do not meet food safety standards will be discarded; -Procedure: All foods leftover after the meal service is finished must be recorded on the daily production record; -Foods that are not suitable for future service should be discarded immediately and recorded on the daily production record as discarded; -Foods that are going to be stored for future service must be returned to safe temperatures as soon as possible; -Both cold and hot foods should be covered and placed in the cooler to speed cool down of internal temperature to 40°F or below; -All leftover foods that are being stored for future service should be marked with a label that lists the food item, and the date prepared; -A perpetual inventory of leftover foods should be maintained to ensure usage as soon as possible. 2. Review of the facility's undated Labeling and Dating policy, showed: -Storage and packaging practices help assure proper ingredient usage and food safety; -In addition to labeling, dating items requires special attention. All foods that require time and temperature control should be labeled with the following: -Common name of the food (ex: macaroni and cheese); -Date the food was made; -Use by date; -The temperature control food can be kept for seven days if it is stored at 41 degrees Fahrenheit or lower. If the temperature control food is not used within seven days, it must be discarded. Remember day one is the day the product was made. 3. Review of the Cook's area cleaning checklist, posted on the wall, on all days of survey from 7/24/23 through 7/28/23, showed: -Cook preparation area which includes grill, stove, fryer, oven are cleaned after every shift. All surfaces and sides of united will be wiped clean and fryer will be checked for grease spillage. 4. Observation on 7/24/23 at 7:07 A.M., 7/25/23 at 6:30 A.M., 7/26/23 at 1:25 P.M. and 3:10 P.M., and 7/27/23 at 8:44 A.M., showed: -Dust, debris, and trash on the floor inside the storage room; -Food crumbs behind the prep table and underneath the microwave and toaster; -Dust/debris and food crumbs behind the large containers of rice and flour; -Buildup of grease on the right side of the fryer; -Buildup of lint around the oven knobs. 5. Observation on 7/24/23 at 7:08 A.M., showed an undated container of fruit, unlabeled and undated wrapped food, undated wrapped lunch meat, and undated sliced cheese in the double refrigerator. Observation on 7/25/23 at 6:30 A.M., showed: -Uncovered tray with 2 uncovered bowls of orange slices, uncovered large tray of Jell-O, uncovered small plate with a brownie, and a large, undated and unlabeled baggie of salad mix in the double refrigerator outside of the storage room; -Large baggie of scrambled eggs, dated 7/21/23, and container labeled breakfast meat dated 7/19/23, in the double refrigerator; -Unidentified food in a container that was unlabeled and dated 7/17/23, in the double refrigerator. Observation on 7/26/23 at 1:25 P.M., showed unidentified food in a container that was unlabeled and dated 7/17/23, in the double refrigerator. Observation on 7/27/23 at 8:44 A.M., showed: -An undated container of tuna in the double refrigerator in the kitchen; -A container of mashed potatoes dated 7/23/23; -An undated container with one hotdog and bun; -Unidentified food in a container that was unlabeled and dated 7/17/23, in the double refrigerator; -An undated container of kitchen salad; 6. During an interview on 7/27/23 at 12:15 P.M., the Dietary Manager said she would expect all food to be labeled with a date and covered. All food should be thrown out after three days. On the 3rd day, staff usually turn the leftovers into a soup. The kitchen is cleaned twice a day at 2:00 P.M. and when they close. Staff are expected to clean underneath and behind the kitchen equipment, dish machine, and tables. The cooks are responsible for cleaning the prep tables. The dish washer is responsible for stock and cleaning the stock room. She would expect it to be cleaned and free of dust/debris and food crumbs. She would expect staff to sweep and mop behind the three large containers of rice and flour. She agreed that it would be an area that would attract bugs.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent roaches and evidence of mice in the kitchen and failed to ensure effective measures were implemented to ensure the potential source was eliminated. The census was 43. 1. Review of the facility's extermination report, dated 7/21/23, showed: -Action Required: Door needs to be rodent proofed. Repair or replace as needed. Opened on 10/29/19; -Action Required: Gaps around pipes and/or fixtures (Kitchen). Repair or replace as needed. Opened on 8/15/22; -Action Required: Grout lines in floor low or missing (Kitchen). Repair or replace as needed. Opened on 08/15/22; -Action Required: Wall coverings loose/peeling (Kitchen). Repair or replace as needed. Holes are in the walls by double sink. Roaches are getting into the wall voids in those areas and are difficult to treat. Opened on 8/15/22; -Action Required: Conducive Condition (Kitchen). Please repair as soon as possible. Major rust under the food line across from the stove underneath the metal plates. Talked to kitchen staff and it is from water damage. It is also where roaches are still being seen by said staff. There is nothing treatment wise I can do until it has been repaired. Roaches are hiding under the layers of rust if they are there. Opened on 11/18/22; -Action Required: Spillage under appliance/machinery/equipment (Kitchen). Clean as needed. Opened on 4/14/23; -Action Required: Employee practices are unsanitary (Kitchen). Recommend that employees be instructed on good practices. Evening staff in kitchen are not cleaning properly and the roaches are feeding on what they leave behind and not my bait. Opened on 4/14/23. Observation and interview on 7/25/23 at 6:40 A.M., showed Dietary Aide DD picked up a trash can lid from the floor that revealed a copious amount of bugs that scattered across the floor, crawling underneath the prep table and other areas in the kitchen. The bugs ranged in size with a couple that were much larger that the other bugs. Dietary Aide DD said they were roaches. There had been roaches for a while, but he/she did not know if the facility had an exterminator. Observation on 7/26/23 at 1:25 P.M., showed: -One dead roach by the trash can; -A dead roach on the floor next to the fryer, surrounded in grease; -One live roach that crawled behind the fryer. Observation on 7/26/23 at 3:10 P.M., showed: -Two dead roaches behind the kitchen equipment; -One dead roach underneath the convection oven; -One dead roach on the floor outside the storage room; -Several dead roaches on the floor on the side of the ice machine; -Dead roaches on the floor behind the large containers of rice and flour. During an interview on 7/26/23 at 3:15 P.M., the Dietary Manager said they have some bugs in the kitchen. An exterminator comes once a week. Observation on 7/27/23 at 8:44 A.M., showed one dead bug on the floor behind the standing mixer. Observation and interview on 7/27/23 at 8:55 A.M., showed a roach crawling on the floor near the freezer. Dietary Aide DD stepped on the roach. He/She said they have someone who comes in and the Dietary Manager would know more about it. There was one roach that crawled in the cracks of the floor near the dish machine. Multiple roaches crawled on the floor under the fryer and convection oven. [NAME] EE said he/she does not see any bugs around the oven or stove. They have someone who comes in for that. Observation and interview on 7/27/23 at 11:04 A.M., showed one roach crawled on the floor, large in size, near the dish machine. The roach was observed to have a capsule-shaped protrusion sticking out of the roach. Dietary Aide DD said the roach looked pregnant and stepped on it. One dead roach was observed on the floor next to staff as they prepped the food cart. Review of a pest control roach reference sheet, showed female roaches will lay anywhere from six to 14 egg capsules their lifetime. Each case holds about 16 eggs, and the female can drop the egg capsule with one day of it being formed. They hold the capsule egg sack to their body until ready to be dropped. Observation on 7/27/23 at 12:11 P.M., showed one roach crawling under the coffee cart near the hand-washing sink. The roach crawled up the wall. Observation and interview on 7/27/23 at 12:15 P.M., the Dietary Manager said the exterminator comes twice a month. The exterminator said there were holes under the sink that needed to be repaired because that was where the roaches were coming from. The Dietary Manager believed the exterminator's report was not accurate because the exterminator wrote the same thing every month. The last time the exterminator was here, he/she brought the supervisor from the exterminating company. The Dietary Manager observed the bug crawling near the hand-washing sink and observed it crawl up the wall. The Dietary Manager said she finds live roaches and dead roaches. The kitchen is cleaned twice a day at 2:00 P.M. and when they close. Staff are expected to clean underneath kitchen equipment, the dish machine, tables, and behind as well. The cooks clean the prep tables. Staff should clean behind containers of flour and rice. Bugs would go to the area where there are food crumbs. The Dietary Manager said the roaches came from holes under the dish machine and the drain underneath it. The cracks in the wall and in the floor are places they will hide. During an interview on 7/27/23 at 12:48 P.M., the exterminator said he/she comes to the facility weekly for over a year. At first, it took a while to get things under control. In November 2022, they did a fog treatment and it helped for a while. The dietary staff said they had not seen anything for a while. After that treatment, bugs were bad again. He/she spoke to the previous Maintenance Director, who received the service reports of what needed to be done. There are holes behind the 3 sink sanitizer and behind the dish machine, but they are bolted to the wall and floor. The roaches could hide in those areas and the exterminator cannot get to those areas. He/she treats or dusts around the areas as best as he/she can. The exterminator said there are unsanitary practices. He/she arrives at 5:00 A.M. or 6:00 A.M., before staff arrives and there is standing water on the floor. Grease is not cleaned up and the bugs prefer the grease. The bugs do not take the bait. If the report says action required, they are still dealing with the issue otherwise the report will say resolved. The exterminator said the date listed on the report is the date of when the issue started. They had a meeting with the current Maintenance Director last month. The previous Maintenance Director did not see eye to eye with the exterminator and there were conflicting issues. The current Maintenance Director made some improvements, such as covering some of the gaps where pipes are. The issues were addressed with the previous and current Maintenance Directors, and the Administrator and was told there is nothing they can do about it because it would require getting new equipment. 2. Observation on 7/24/23 at 7:08 A.M., 7/25/23 at 6:30 A.M., 7/26/23 at 3:10 P.M. and on 7/27/23 at 8:44 A.M., showed mice droppings on the bottom of the cement platform under the shelves in the dry food storage room. 3. During an interview on 7/28/23 at 9:59 A.M., the Maintenance Director said he was not aware of the facility's pest control program or policy, but an exterminator comes to the facility. He had not spoke to the previous Maintenance Director or the Administrator regarding the extermination reports. There is a small bug problem they have been fighting for a while, but he had not seen any bugs in the kitchen. The Maintenance Director does not go into the kitchen unless there are issues that requires him to make repairs. The exterminator always arrives before anyone else is here. The Maintenance Director applied caulk to seal the pipes in the wall because the cut was too wide. It never had caulk around it, so he sealed it to avoid water damage in the walls. There had been no other repairs or changes to help mitigate the bugs. They are trying to find the appropriate materials to stay within compliance. The issue with the report is the only thing that changes are the date and time. Everything else is worded the same. He did not believe the time stamp was accurate because there was no way the exterminator was treating what it said they treated. The exterminator had their supervisor from the company with him/her the last time they were in the facility. They did take more time in the facility, but there was no way the exterminator went to the first, second, and third kitchen. There are no issues with the grout on the floor in the kitchen from what he had seen. There are no issues with pest or mouse droppings found in the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, regarding diagnosis and behaviors for one of one resident reviewed for behaviors (Residents #2). The sample was eight. The census was 24 with nine residents in certified beds. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Brief Interview for Mental Status (BIMS) score of 10 out of 15; -A BIMS score of 10 showed moderate cognitive impairment; -Diagnoses included heart failure, obstructive uropathy (urine obstruction), diabetes and anxiety disorder; -No hallucinations or delusions; -No verbal or physical behaviors; -Diagnosis of dementia not coded; -Verbal behaviors not coded. Review of the resident's care plan, dated 10/14/19, showed: -Problem: Needs supervision for off floor mobility related to some short term memory issues. History of behavior episode treated with Depakote (medication used to treat bipolar disorder and seizures) and psych follow-up; -Goal: Will have skilled therapy for increasing knee function/transfer during the next three months; -Approach: Monitor and report behaviors for treatment need. Review of the resident's long term care notes, dated 1/9/20, showed the resident with Alzheimer's dementia with behavioral disturbance, generalized anxiety disorder, and psychosis; was seen on follow up. He/she is followed by psychiatry for dementia and anxiety and was last seen on 1/7/20. Behaviors increased related to a progression of dementia. He/she had increased outburst and his/her Depakote was increased to 250 milligram (mg) twice a day. During an interview on 2/19/20 at 2:30 P.M., the resident council said the Resident #2 is verbally aggressive. He/she tells the other residents to go to hell. They are afraid to ride the elevator with him/her. During an interview on 2/21/20 at 12:27 P.M., the MDS coordinator said she was aware of the resident's verbal behaviors, but did not document it on the MDS because the resident was not verbally aggressive or display behaviors with her. She was not aware of the resident's diagnosis of Alzheimer's dementia, but would expect it to be coded on the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update resident comprehensive care plans to include behaviors and vision impairments. This affected two (Residents #2 and #9) of eight sampled residents. The census was 24 with nine residents in certified beds. 1. Review of the facility's Comprehensive Care Plan policy, revised 12/2016, showed: -Statement: Comprehensive assessments will be conducted to assist in the developing person-centered care plans; -Interpretation and implementation: The objective of information collection is to obtain, organize and analyses information. Assess the resident and gather information through observation, assessment, condition related assessments, resident and family interview and evaluations from other disciplines. 2. Review of the Resident #2's medical record, showed diagnoses included atrial fibrillation (irregular rapid heart rate), polyneuropathy (nerve disease), edema, diabetes, delirium, congestive heart failure, anxiety and shortness of breath. Review of the resident's care plan, dated 10/14/19, showed: -Problem: Needs supervision for off floor mobility related to some short term memory issues. History of behavior episode treated with Depakote (medication used to treat bipolar disorder and seizures) and psych follow up; -Goal: Will have skilled therapy for increasing knee function/transfer during the next three months; -Approach: Monitor and report behaviors for treatment need; Review of the resident's long term care notes, dated 1/9/20, showed resident with Alzheimer's dementia with behavioral disturbance, generalized anxiety disorder, and psychosis; was seen on follow up. He/she is followed by psychiatry for dementia and anxiety and was last seen on 1/7/20. Behaviors increased related to a progression of dementia. He/she had increased outburst and his/her Depakote was increased to 250 milligram (mg) twice a day. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/15/20, showed: -Moderate cognitive impairment; -Diagnoses included heart failure, obstructive uropathy (urine obstruction), diabetes and anxiety disorder; -No hallucinations or delusions; -No verbal or physical behaviors. Further review of the care plan, showed no documentation of the resident's diagnosis of Alzheimer's dementia, interventions, and goals related to the diagnosis and progression of the disease or increased behaviors and outbursts. 3. Review of Resident #9's quarterly MDS, dated [DATE], showed: -Visual impairment- impaired, sees large print, but not regular print in newspapers or books; -Cognitively intact; -Cataract, glaucoma or macular degeneration: blank; -Diagnoses of dry eye syndrome, osteoporosis and kyphoscoliosis (inward curvature of the spine or hump back appearance). Review of the resident's ophthalmology (eye specialist) visit progress note, dated 2/11/20, showed the resident had a mature cataract of the right eye and surgery would be difficult related to the resident's osteoporosis of the spine. Review of the resident's care plan, reviewed on 2/13/20, showed no assessment of the visual impairments or interventions to address the resident's decline in vision. During an interview on 2/18/20 at 3:38 P.M., the resident said he/she had been to the eye doctor recently and had been told that his/her cataract had gotten worse. He/she could not have surgery because of his/her severe back arthritis. He/she cannot see well and had no glasses. He/she enjoys reading and needs the magnifying glass to read. On 2/20/20 at 1:48 P.M., the resident said he/she needed staff to set up the magnifying glass. It is hard for him/her to see his/her food but he/she will not ask for assistance to eat his/her food. At times, staff forget to assist him/her with the magnifying glass and he/she is not able to read or enjoy past times in his/her room. 4. During an interview on 2/21/20 at 12:25 P.M., the MDS Coordinator said she expected the floor nurses to update the care plans as the residents' care changed. The care plan should be fluid and reflect the current status of the residents and include behaviors and diagnoses. It is important for updates and changes to be entered so staff and family are up to date on the resident's current status and interventions can be initiated. She had been at the facility for several months and had been working on updating care plans. Not all of the care plans had been updated and she had been working on training floor staff to update the care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess and provide language and auditory (hearing) assistive devices for one resident (Resident #60) who communicated in a different language. The facility did not identify any residents who did not speak the primary language used at the facility. The sample was eight. The census was 24 with nine residents in certified beds. Review of the facility assessment, showed the facility's residents identify with their heritage including Italian and German. Review of Resident #60's medical record, showed admitted on [DATE]. Review of the resident's initial social service history, dated 11/22/17, showed the resident's place of birth was Italy. Review of the resident's social service progress notes, showed: -On 5/20/18, he/she tends to speak in Italian, often making communication difficult; -On 8/19/18, continues to have days of anger and aggression but has stabilized somewhat physically and cognitively. States his/her needs are met most of the time. Suggest finding a volunteer to converse in Italian with resident for comfort; -On 11/10/19, resident seems to be functioning about the same. He/she speaks English and Italian. Review of the resident's care plan, dated 1/23/20, showed: -Problem: Resident's ability to complete Activities of Daily Living (ADLs): transfers, walk in room, walk in corridor, dress, toilet, maintain personal hygiene, has deteriorated related his/her dementia; -Problem: Resident has behavioral symptoms not directed to others. He/she will throw food on the floor at meal time. He/she has been noted to yell out; -Problem: He/she is incontinent of bowel and bladder; -Problem: Resident is at risk for pressure ulcer related to his/her decreased mobility; -Problem: Resident is at risk for falls due to his/her dementia and lack of safety awareness; -No documentation of the resident's language, how he/she communicates with staff, devices used to assist with communication, or social history information. Review of the resident's monthly communication summary, showed: -On 8/11/19, doesn't speak English well, understands at times; -On 10/16/19, language barrier, speaks no English; -On 12/4/19, clear but not easily understood due to language barrier; -On 2/11/20, language barrier. Observation and interview on 2/19/20 at 11:03 A.M., showed the resident spoke another language to the certified nurse aides (CNAs) during care. CNA A did not attempt to find ways to explain care to the resident. CNA A said the resident does not make any sense and he/she speaks another language. The resident cannot understand what the staff say to him/her. Staff do not have a way to talk to the resident, but they attempt to use 'yes or no' questions. They do not have any communication board to use or images. The resident has dementia, so there was no way to help them communicate with the resident and upper management has not given them guidance or communication board with photos or any way to translate. During an interview on 2/20/20 at 12:15 P.M., the resident spoke to the surveyor in a different language. The surveyor used an electronic translator to communicate with the resident. The resident continued to point at the electronic device while he/she spoke a different language. Surveyor asked the resident how he/she was feeling, in Italian. The resident continued to speak a different language while he/she rubbed his/her stomach. The electronic device showed the resident said the word pooping in another language. The resident was asked if he/she could speak English; however, the resident continued to speak in another language. The resident held the surveyor's hand and said thank you in English. The words thank you were the only two words the resident said in English. During an interview on 2/21/20 at 12:36 P.M., the Minimum Data Set (MDS) Coordinator said she was responsible for completing the resident's care plan. The resident spoke another language, but she was not sure if it was Spanish or Italian. When she spoke to the resident, she did not know if it was another language or just mumbling due to the resident's diagnosis of dementia. The staff know the resident inside and out and they know his/her verbal and non-verbal cues. The MDS Coordinator did not include the resident's language in the care plan because she was not sure if it was even a language the resident was speaking. During an interview on 2/21/20 at 12:59 P.M., the Director of Nursing (DON) said she was familiar with the resident. He/she speaks English, but it can also be rambling or another language. Sometimes the sentences are not jointed. The DON did not have any difficulty communicating with the resident because the resident spoke to her in English. The resident can become more agitated and confused, so it is more difficult to understand what he/she said. The DON did not know what language the resident speaks and there were no reports from staff that said the resident spoke a different language. The DON would expect staff to reach out to family if they were having trouble communicating with the resident. The Speech Therapist has a communication board that can be utilized. She would expect an assessment to determine what language the resident spoke or if it was the dementia. She would expect the language barrier and communication needs to be in the resident's care plan. During an interview on 2/21/20 at 1:45 P.M., the MDS Coordinator said the resident spoke Croatian. She was told by a housekeeper that the resident was taught by Croatian nuns when he/she was a child. During an interview on 2/21/20 at 2:10 P.M., Registered Nurse (RN) B said he/she heard the resident spoke Croatian. He/she was not sure, but that is what someone said. The resident always said, ciao, ciao and [NAME], [NAME]. RN B confirmed that the resident's initial social history said his/her birth place was Italy and social service notes said he/she spoke Italian. Review of Italian to English translation, showed: -[NAME] translates to beautiful; -Ciao translates to both hello and goodbye.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care and services to ensure resident nails had been cleaned and trimmed. This affected two residents (Residents #4 and #3) of eight sampled residents. The census was 24 with nine residents in certified beds. Review of the facility's undated Nail Hygiene policy, showed all residents will be offered appropriate nail hygiene to decrease the risk of infection. The purpose of this procedure are to clean the nail bed, to keep the nails trimmed and prevent infection. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/15/20, showed: -Severe cognitive impairment; -Total dependence on staff to provide hygiene and bathing needs; -Diagnoses of heart failure, dementia, stroke and paralysis. Review of the resident's care plan, updated on 10/31/19, showed: -Problem: Total staff assistance needed for care needs; -Goal: Staff provide care to keep the resident comfortable and staff observe for the resident's needs. Observations of the resident during the survey, on 2/18/20 at 2:58 P.M. and 4:45 P.M., on 2/19/20 at 6:55 A.M., 1:22 P.M. and at 2:47 P.M., on 2/20/20 at 8:15 A.M., 12:22 P.M. and 3:15 P.M. and on 2/21/20 at 8:15 A.M., showed the resident's finger nails to both hands noted to be long and jagged. A dark brown substance noted under three nails of the right hand and 4 nails of the left hand. During an interview on 2/21/20 at 9:11 A.M., Certified Nurse Aide (CNA) A said that the facility shower aide is responsible to trim resident nails on the residents' shower days. If the shower aide forgot to provide nail care, the floor aides should trim the nails and clean under them. Resident nails should not be untrimmed, jagged or dirty. 2. Review of Resident #3's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Limited staff assistance required for hygiene; -Total staff assistance required for bathing; -Diagnoses of stroke, one sided paralysis, anxiety and depression. Review of the resident's care plan, updated on 12/21/19, showed: -Problem: Total staff assistance needed for care needs; -Goal: Staff provide care to keep the resident comfortable and staff observe for the resident's needs. Observations on 2/18/20 at 3:17 P.M., on 2/19/20 at 7:10 A.M. and 12:57 P.M., and on 2/20/20 at 6:17 A.M., showed the resident had long, jagged finger nails and a dark brown substance under his/her finger nails. During and observation and interview on 2/20/20 at 1:43 P.M., the resident said he/she received his/her scheduled shower on 2/19/20. The shower aide did not trim or clean under his/her fingernails during the shower. He/she would like to have his/her nails cut and cleaned. The facility will have manicure activities monthly but if he/she is out of the building or missed the activity, his/her nails are not cared for. If he/she attended the activity, the activity staff will only file his/her nails and will not clean under the fingernails. He/she is paralyzed on one side of his/her body and cannot trim his/her own nails. The paralysis can cause him/her to have muscle spasms and if he/she had long fingernails at the time a spasm occurred, his/her nails could cut into his/her palm. 3. During an interview on 2/21/20 at 12:50 P.M., the Director of Nursing said that all staff should be checking and cleaning nails at bathing and meal times. Residents should not be having to wait until manicure days to trim nails. The shower aide should provide nail care at least weekly during the resident's shower. The nails are soft and able to be cleaned well at that time.

Based on observation, interview and record review, the facility failed to provide restorative therapy (RT) assessment and evaluation to one resident (Resident #4) of two residents investigated for position/mobility. The sample was eight. The census was 24 with nine residents in certified beds. Review of the facility's rehabilitation service policy, revised 11/2018, showed: -Objective: To make certain that residents receive necessary rehabilitative services; -Policy: The resident will receive specialized rehabilitative services as determined by the comprehensive assessment and care plan, to prevent avoidable physical and mental deterioration and to assist them in obtaining or maintaining their highest practicable level of functional and psychosocial well-being; -Procedure: Restorative services are provided by an outside contract provider based on the comprehensive assessment and according to the plan of care. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/15/20, showed: -Severe cognitive impairment; -Total staff assistance with hygiene, bathing, eating and mobility; -Section G 0400: Functional limitation in range of motion: impairments to both sides of the upper and lower body; -Diagnoses: heart failure, stroke, dementia and paralysis; -Received no therapy or restorative services. Review if the resident's physician order sheet (POS) and treatment administration record (TAR), dated 1/1/20 through 1/31/20, showed an undated order for 7:00 A.M. - 3:00 P.M., the resident to wear a splint on the right hand/arm daily for 3-4 hours. All dates of the month initialed as completed. Review of the resident's monthly summary, dated 2/4/20, showed the resident to receive special treatments of restorative techniques of splint/brace assistance and passive range of motion (PROM, movement of a joint or limb, fully completed by staff, the resident does not assist in the movements). Review of the resident's POS, dated 2/1/20 through 2/29/20, showed an undated order for the resident to wear a splint to his/her right hand/arm for three to four hours daily. Observations on 2/19/20 at 7:34 A.M. and 12:02 P.M., on 2/20/20 at 8:10 A.M. and 11:02 A.M., and on 2/21/19 at 9:10 A.M. and 12:08 P.M., showed the resident in his/her reclining wheelchair. His/her right forearm noted to be secured in a black foam brace on the wheelchair arm. His/her right hand observed to be contracted and hung loosely off the side of the black foam brace. No splint noted to the contracted hand. During an interview on 2/20/20 at 11:02 A.M., Registered Nurse (RN) B said that he/she has been working on the unit for several months and the unit does not have restorative services that he/she had seen. The resident has contractures to the right hand and would probably benefit from extra range of motion. During an interview on 2/21/20 at 8:06 A.M., the Director of Nursing said that therapy services will often come to the unit and discuss any concerns with staff regarding therapy and if any residents may benefit from therapy. Therapy will then evaluate the resident and determine if the resident would benefit from restorative therapy and write the orders. The Certified Nurse Aides (CNA) are responsible to apply braces and provide the ordered RT services. During an interview on 2/21/20 at 9:26 A.M., RN B said the resident's splint order is the black foam pad on the resident's wheelchair arm. Staff Velcro the resident's arm on to the padding but the splint does not help the resident's hand contracture. He/she thought the black foam brace on the resident's wheelchair arm is what is used for bracing and he/she was not aware of any brace or sling for the resident's contracted hand. Since he/she had worked on the floor, the resident had not been assessed by therapy services and would probably benefit from some services. He/she was uncertain how to refer a resident for evaluation. During an interview on 2/21/20 at 10:40 A.M., Physical Therapy Assistant (PTA) C said if a resident is discharged from skilled therapy, the physical therapist will write restorative therapy orders for the resident. The resident has not been assessed by therapy in several months and to his/her knowledge, does not receive any RT services. The therapy department provides the RT to facility residents. Nursing staff can verbally report concerns to the therapy department and the therapist will perform an evaluation, obtain the physician orders and carry out the orders. Residents with contractures should be evaluated to prevent worsening of the contractures. There is a PTA in the building five days a week to provide therapy services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible by failing to ensure medications were secured per facility policy. The census was 24 with nine residents in certified beds. Of the nine residents' in certified beds, four were identified by the facility as being independent with locomotion on the unit. Of those four, the facility identified one with mild cognitive impairment and one with severe cognitive impairment. Review of the facility's medication storage policy, revised 4/2019, showed: -Prescription and over the counter medications are to be administered only by those with appropriate education, credentials for storing medications; -All resident medications must be properly labeled with a resident name and current directions and expiration date. Over the counter medications must have proper labeling consistent with pharmacy standards of practice and as described in the pharmacy policy; -Drugs are to be stored in a secure and orderly manner and accessible only to licensed nursing and pharmacy personnel; -Procedure: Storage of medication: All drugs and non-prescription drugs must be locked and secured. Observations of the shared bathroom of resident room [ROOM NUMBER] during the survey, showed on 2/18/20 at 10:45 A.M. and 5:10 P.M., on 2/19/20 at 7:10 A.M. and 1:03 P.M. and on 2/20/20 at 10:10 A.M., 2:22 P.M. and 3:56 P.M. an unlabeled, and undated four ounce bottle of chlorhexidine gluconate (used as a topical antibiotic and skin cleanser) 4 percent (%) solution unsecured and exposed in a pink bath basin on a wire shelf. The door to the resident's room noted as open for all of the above times and the shared bathroom door ajar. Review of the chlorhexidine gluconate 4 % solution safety data sheet (SDS), showed: -Hazard identification: Causes skin irritation, causes serious eye damage; -Precautionary statements: -If in eyes, rinse cautiously with water for several minutes; -Immediately call a poison center or doctor if skin irritation occurs; -If ingested seek medical attention and do not induce vomiting, maybe harmful if swallowed; -Store locked up. During an interview on 2/21/10 at 12:50 P.M., the Director of Nursing said that all medications should be locked and secured either in the medication room or the medication cart. All medications should be labeled and dated. Exposed medications could allow residents access to medications that are not intended for that resident.

Based on interview and record review, the facility failed to ensure as needed (PRN) psychiatric medications were re-evaluated after 14 days of use for two of six residents reviewed for unnecessary psychotropic medications (Residents #3 and #1). The sample was eight. The census was 24 with nine residents in certified beds. Review of the facility's pharmacy policy, revised 11/2019, showed: -A licensed pharmacist will review the charts for PRN psychotropic medication orders that might be eliminated; -Procedure: The licensed pharmacist will report any irregularities to the attending physician and the Director of Nursing (DON), and these reports will result in corrective action. 1. Review of Resident #3's medical record, showed: -Cognitively intact; -Diagnoses of depression and anxiety. Review of the resident's physician order sheet (POS), dated 2/1/20 through 2/29/20, and reviewed on 2/19/20, showed: -An order dated 2/4/20, for alprazolam (Xanax, used to treat anxiety) 0.5 milligrams (mg), take one tablet at bedtime PRN; -No end date noted for the PRN order. Further review of the medical record, showed no pharmacy review or recommendations. No physician documentation to support the extension of the PRN psychiatric medication. During an interview on 2/20/20 at 2:47 P.M., the DON said PRN medications should have a 14 day end date when the medication order is given. He/she was not sure if the February medication review had been completed by the pharmacist. 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/15/20, showed the following: -Rarely understood; -Received antianxiety medications seven of seven days; -Diagnoses included high blood pressure, kidney failure, Alzheimer's disease, anxiety and depression. Review of the resident's care plan, dated 8/15/19, showed: -Problem: Documented late stage dementia with behavioral disturbance. Late afternoon may have calling out or other behaviors. Stable on current medication of administration of Lorazepam(medication used to treat anxiety). Has disorganized thinking and severely impaired decision making; -Goal: Will have the cueing needed to stay focused on the task at hand and medication as needed for vocalization occurring during the next three months; -Approach: Staff to give cueing to bring resident's attention to the task he/she is currently doing. Use supportive care, especially gentle touch and soothing conversation if the resident does not understand. Family uses conversational reminiscing to distract him/her during his/her vocalizations. Medication as needed if vocalizations occur; -Problem: May have agitated behavior with calling out from time to time especially late afternoon and evening; -Goal: Will have assessment of restless behaviors to determine if related to pain; -Approach: Staff will sit and talk to the resident at same height. Staff will talk to resident in calm manner and attempt to redirect behavior. Staff will offer fluids and/or snacks. Staff will check for incontinence and reposition resident for comfort. Resident enjoys being off the floor for different scenery. Administer scheduled Lorazepam. Monitor for need of PRN Tylenol before giving PRN Lorazepam. Keep physician informed for change in treatment needs. Family visits daily and uses supportive care to relieve anxiety. May respond to gentle touch. Review of the resident's POS, dated 12/1/29 through 2/29/20, showed the following: -An order dated 12/6/19, for Lorazepam concentrate 2 mg. Give 0.5 milliliters (ml) (1 mg) by mouth daily at 4:30 P.M. and 0.5 ml three times a day as needed (PRN) for diagnosis of Alzheimer's disease. Review of the resident's medication administration record (MAR), dated 12/1/19 through 2/21/20, showed: -Lorazepam 0.5 ml, administer three times a day PRN, documented as administered on the following dates and times: -On 12/7/19 at 7:00 P.M., for agitation and yelling; -On 12/26/19 at 10:30 P.M., for agitation and attempting to get up; -On 1/8/20 at 9:00 P.M., for anxiety; -On 1/10/20 at 9:00 P.M., for anxiety, yelling, and attempt to get out of chair; -On 2/7/20 at 9:00 P.M., for increased agitation. Review of the resident's long term care progress notes, dated 1/22/20, showed resident had advanced Alzheimer's dementia with behavioral disturbance and major depressive disorder. (There were no new concerns from nursing staff. No increase in agitation or anxiety reported). During an interview on 2/21/20 at 1:10 P.M., the DON said she would check to see if there was documentation from the physician to show that the order for the Lorazepam PRN was longer than 14 days. At 2:00 P.M., the DON said staff documented the resident's agitation in the progress notes and the long term care progress notes showed no increased agitation, but there was no documentation that showed a rationale for the PRN Lorazepam to be longer than 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an annual assessment or test for tuberculosis (TB) for three out of five residents reviewed (Residents #60, #7, and #2). In addition, the facility failed to ensure two of ten employees reviewed, received their two step TB skin test upon hire per facility policy. The census was 24 with nine residents in certified beds. Review of the facility's policy for TB vaccines for staff and residents, revised April 2017, showed: -Policy Interpretation and Implementation: The facility requires tuberculosis skin test on residents at admission. Will test residents again if they exhibit signs and symptoms; -Nurses will schedule any resident with symptoms of TB for a chest x-ray and evaluation. Symptoms include any of the following that persist for two weeks: productive cough, coughing up blood, weight loss, loss of appetite, lethargy/weakness, night sweats or fever; -Resident with suspected infectious TB will be immediately transferred to hospital. They will be sent by ambulance and no procedures or services will be performed in house. They must be masked and segregated while awaiting transfer. Any employee working in an area where they are waiting transfer must wear a mask. Such segregation rooms will be marked Do not enter without permission from the Director of Nursing (DON); -The policy did not require that all long-term care residents have a documented annual evaluation to rule out signs and symptoms of TB; -Employees are required to have a purified protein derivative (PPD, tests for the TB antibody) at time of hire. Each staff member will receive a Manitoux (PPD) two step TB test upon hire, unless documentation is provided that either the prospective employee has had a previous positive PPD, has been treated with anti-tuberculosis drugs, or can provide written documentation of a previous PPD in the past twelve months. Any employee providing documentation of a previous PPD within 12 months will be given a single step PPD; -Review of the back side of the policy, showed a copy of regulations: All long-term care residents shall have a documented annual evaluation to rule out signs and symptoms of TB. 1. Review of Resident #60's medical record, showed: -admitted to the facility on [DATE]; -No documentation of an annual TB assessment or PPD to show signs and symptoms of TB or exposure. 2. Review of Resident #7's medical record, showed: -admitted to the facility on [DATE]; -No documentation of an annual TB assessment or PPD to show signs and symptoms of TB or exposure. 3. Review of Resident #2's medical record, showed: -admitted to the facility on [DATE]; -No documentation of an annual TB assessment or PPD to show signs and symptoms of TB or exposure. 4. Review of Certified Nurse's Aide (CNA) L's employee file, showed the following: -Hire date of 12/18/18; -No documentation of the first or second step PPD completed. 5. Review of Licensed Practical Nurse (LPN) M's employee file, showed the following: -Hire date of 6/29/19; -No documentation of the first or second step PPD completed. 6. During an interview on 2/21/20 at 12:47 P.M., the DON said the facility does not complete an annual PPD assessment on residents. It was not required. The residents receive a two-step PPD when they are admitted ; however, staff are assessing the resident for TB symptoms when their vitals are checked. On 2/21/20 at 2:00 P.M., the DON said employees should have their PPD upon hire.

Based on interview and record review, the facility failed to ensure certified nurse aides (CNAs) received the required 12 hours of training and have a system in place to track the hours, for nine of the nine employees reviewed who worked at the facility for over a year. The census was 24 with nine residents in certified beds. Review of facility assessment tool, Part Three. Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, showed: -Required in-service training for nurse aides. In-service training must: -Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; -Include dementia management training and resident abuse prevention training; -Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff; -For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired; -Person-centered care- This should include but not be limited to person-centered care planning, education of resident and family/resident representative about treatments and medications, documentation of resident treatment preferences, end of life care and advance care planning; -Activities of daily living, bathing, bed-making, bedpan, dressing, feeding, nail and hair care, perineal care, mouth care, providing resident privacy, range of motion, transfers, using gait belt, using mechanics (lifts); -Disaster planning and procedures-active shoot, elopement, fire, flood, power outage, and tornado; -Infection control-hand hygiene, isolation, standard universal precautions including use of personal protective equipment, and environmental cleaning; -Medication administration-injectable, oral, subcutaneous, topical; -Measurements: blood pressure, orthostatic blood pressure, body temperature, urinary output including urinary drainage bags, height and weight, radial and apical pulse, respirations, recording intake and output, urine test for glucose/acetone; -Caring for persons with Alzheimer's or dementia; -Specialized care; -Caring for residents with mental and psychosocial disorders and implementing no pharmacological interventions. Review of the training records provided by the facility, showed: -CNA D, hired on 4/4/95, number of hours of training as 12 hours; -Further review, showed incomplete documentation of competencies or education, which included names and dates missing on quizzes and training; -CNA E, hired on 5/26/99, number of hours of training as 12 hours; -Further review, showed incomplete documentation of competencies or education, which included names and dates missing on quizzes and training; -CNA F, hired on 1/13/12, number of hours of training as 12 hours; -Further review, showed incomplete documentation of competencies or education, which included names and dates missing on quizzes and training; -CNA G, hired on 6/9/2014, number of hours of training as 12 hours; -Further review, showed incomplete documentation of competencies or education, which included names and dates missing on quizzes and training; -CNA H, hired on 9/3/14, number of hours of training as 12 hours; -Further review, showed incomplete documentation of competencies or education, which included names and dates missing on quizzes and training; -CNA I, hired on 8/18/16, number of hours of training as 12 hours; -Further review, showed incomplete documentation of competencies or education, which included names and dates missing on quizzes and training; -CNA J, hired on 2/6/18, number of hours of training as 12 hours; -Further review, showed incomplete documentation of competencies or education, which included names and dates missing on quizzes and training; -CNA K, hired on 8/23/1, number of hours of training as 12 hours; -Further review, showed incomplete documentation of competencies or education, which included names and dates missing on quizzes and training; -CNA L, hired on 12/18/18, number of hours of training as 12 hours; -Further review, showed incomplete documentation of competencies or education, which included names and dates missing on quizzes and training. During an interview on 2/21/20 at 1:31 P.M., the Director of Nursing said prior to her coming to the facility, she couldn't guarantee staff had their 12 hour training. She doubted she would find the 12 hours on everyone.

Based on observation, interview and record review, the facility failed to maintain food under sanitary conditions by not ensuring food was labeled after opening, protected stored food from cross contamination, and ensuring meat was thawed appropriately. This had the potential to affect all residents who consumed food from the facility kitchen. The census was 24 with nine residents in certified beds. Review of the facility's Food Storage policy, revision date April 2019, showed: -Food items shall be stored, prepared, distributed and served in accordance with professional standards for food safety; -Food storage containers will be dated and identified with the common name of the food. Working containers holding food or food ingredients that are removed from their original packages for use, such as cooking oils, flours, herbs, salt and sugar shall be dated and identified with the common name; -Food shall be protected from contamination by storing food in a clean, dry location where it is not exposed to splash, dust or other contamination and at least six inches off the floor. 1. Observation of the kitchen freezer, located behind the stove, showed: -On 2/18/20 at 11:09 A.M.: -A box with the top flaps opened and contained a clear plastic bag, filled with frozen chicken breast fillets. The clear plastic bag open to air, the box and bag, undated; -A box with the top flaps opened and contained a clear plastic bag, filled with frozen beef patties. The clear plastic bag open to air, the box and bag, undated; -On 2/19/20 at 3:30 P.M.: -A box with the top flaps opened and contained a clear plastic bag, filled with frozen vegetable egg rolls. The clear plastic bag open to air, the box and bag, undated; -A box with the top flaps opened and contained a clear plastic bag, filled with frozen beef patties. The clear plastic bag open to air, the box and bag, undated; -A box with the top flaps opened and contained a clear plastic bag, filled with frozen chicken breast fillets. The clear plastic bag open to air, the box and bag, undated; -On 2/20/20 at 3:04 P.M.: -A box with the top flaps opened and contained a clear plastic bag, filled with frozen beef patties. The clear plastic bag open to air, the box and bag, undated; -A box with the top flaps opened and contained a clear plastic bag, filled with frozen chicken breast fillets. The clear plastic bag open to air, the box and bag, undated. 2. Observation of the kitchen refrigerator, located across from the restrooms, showed: -On 2/20/20 at 3:05 P.M., a box of sliced, uncooked bacon. The box open to air, undated; -On 2/21/20 at 11:25 A.M., a box with the top flaps opened and contained a clear plastic bag filled with frozen sausage. The bag open to air, the box and bag, undated. 3. Observation of the kitchen on 2/21/20 at 7:55 A.M. and 9:00 A.M., showed a large roll of raw hamburger sat in a large square pan, filled with water, at the bottom of the sink. A quarter of the hamburger roll, too large for the pan, hung outside the pan. 4. During an interview on 2/21/20 at 11:31 A.M., the dietary manager said he would expect staff to thaw meat under running water, the hamburger should not have been left in a pan of water in the sink. Food should be stored, and closed to keep safe from possible contamination and should be dated upon opening.