**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with resident, staff, Nurse Practitioner (NP), and the Medical Director (MD), the facility failed to notify the NP and MD that a resident was completely out of her narcotic pain medication resulting in her missing 14 consecutive doses for 4 ½ days for 1 of 3 residents reviewed for notification (Resident #17). The findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses which included debility, arthritis, and chronic pain. The physician's order dated 10/25/23 revealed Resident #17 had an order to receive one tablet of oxycodone-Acetaminophen oral tablet 5-325 milligrams (mg) (oxycodone with acetaminophen) or Percocet (a type of opioid analgesic consisted of oxycodone/acetaminophen that acted on the central nervous system to relieve pain) by mouth three times a day for pain. The medication was scheduled to be given at 8:00 AM, 2:00 PM and 8:00 PM. The Medication Administration Record (MAR) for August 2024 revealed Resident #17 had not received her medication the following dates and times: - August 1 8:00 AM, 2:00 PM and 8:00 PM - August 2 8:00 AM, 2:00 PM and 8:00 PM - August 3 8:00 AM, 2:00 PM and 8:00 PM - August 4 8:00 AM, 2:00 PM and 8:00 PM - August 5 8:00 AM and 2:00 PM for a total of 14 doses missed. The August 2024 MAR revealed on the following dates and times, Agency Nurse #3 had taken care of Resident #17 and had not administered her Percocet: - August 1 at 8:00 AM and 2:00 PM - August 3 at 8:00 AM, 2:00 PM and 8:00 PM - August 4 at 8:00 AM and 2:00 PM A telephone interview was attempted with Agency Nurse #3 on 10/10/24 at 3:15 PM; however, the number had been disconnected and Nurse #3 was no longer employed through the Agency. The August 2024 MAR revealed on the following dates and times, Nurse #2 had taken care of Resident #17 and had not administered her Percocet: - August 2 at 8:00 AM and 2:00 PM - August 5 at 8:00 AM and 2:00 PM A telephone interview on 10/10/24 at 4:00 PM with Nurse #2 revealed she couldn't recall the specifics but said generally if a resident does not have their medication, she typically contacts the pharmacy and then if a script was needed, she contacted the NP to send an electronic script to the pharmacy for the medication. Nurse #2 stated she couldn't recall if they had oxycodone with acetaminophen in their narcotic Emergency Kit but stated she felt like if they had she would have given it from the Emergency Kit. She further stated she could not recall notifying the NP or MD that the resident was completely out of her pain medication. The August 2024 MAR revealed on August 4 at 8:00 PM Agency Nurse #4 had taken care of Resident #17 and had not administered her Percocet on that day and time. A telephone interview was attempted several times with Agency Nurse #4 without success. Review of Resident #17's significant change MDS dated [DATE] revealed she was cognitively intact and received scheduled pain medication and no as needed pain medication. The assessment also revealed the resident had almost constant pain at a level of 10 out of 1-10. An interview on 10/10/24 at 10:03 AM with Resident #17 revealed she had gone 4 ½ days the first of August without receiving her pain medication as ordered. She stated during that time she had an increase in her pain level to an 8 on a scale of 1-10, instead of her usual pain level of 0 to 3 with her pain medication. She stated the staff (couldn't remember names) kept telling her it was on order and had not come from the pharmacy and said one nurse (couldn't remember name) finally told her it was too soon to refill her prescription for her pain medication. An interview on 10/10/24 at 4:35 PM with the MD revealed she was not aware Resident #17 had completely ran out of her pain medication. The MD stated she or the NP should have been notified the resident was completely out of her pain medication so they could have ordered pain medication to cover her while awaiting her order from the pharmacy. She further stated she was familiar with Resident #17 and her chronic pain and her concern with her not receiving her pain medication for over 4 days would have been her increased intensity in pain. A telephone interview on 10/11/24 at 2:04 PM with the NP revealed she was not aware that Resident #17 had completely ran out of her pain medication. The NP stated had she known she could have ordered additional pain medication and potentially other modalities such as heat to help with her pain. The NP further stated her concern with Resident #17 not receiving her pain medication would have been her increased intensity in pain making it difficult to get the pain back under control. An interview on 10/11/24 at 6:10 PM with the Director of Nursing (DON) revealed it her expectation that residents received their medications as ordered by the providers. The DON stated the nurses or Unit Manager #2 should have contacted the NP or MD to obtain orders for pain medication and utilized other modalities such as heat to assist the resident in managing her pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, residents and staff interviews, the facility failed to invite residents to participate and provide input in care planning for 2 of 3 sampled residents (Residents #82 and #13). Findings included: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses that included gout (type of arthritis that causes severe pain, swelling, redness and tenderness in joints), hypertension, severe protein-calorie malnutrition, and osteoarthritis of knee. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had intact cognition. Review of Resident #82's electronic medical record revealed no evidence he was invited to attend a care plan meeting to discuss and provide input regarding his plan of care following the completion of the admission MDS assessment dated [DATE]. Review of the facility's Care Plan Meeting Schedules for the period August 2024 - October 2024 revealed a care plan meeting with Resident #82 was not listed on the schedules. During an interview on 10/07/24 at 4:18 PM, Resident #82 did not recall being invited to participate in any care plan meetings since being admitted to the facility. During interviews on 10/09/24 at 12:02 PM and 10/10/14 at 10:27 AM, the Social Worker (SW) verified a care plan meeting had not been held with Resident #82 following the completion of his admission MDS assessment dated [DATE]. The SW explained when she started her employment in October 2023, the previous SW had not wanted to train her and there was a lot that she did not know or was trained to do. The SW explained at the time, she really didn't have a process for ensuring care plan meetings were scheduled which resulted in care plan meetings falling through the cracks. She stated now, the process was for the receptionist to schedule the meeting and the SW would keep track of the meetings on a monthly calendar and facilitate the care plan meeting. The SW stated that sometimes the families of residents did not want the resident to attend the meeting so she did not invite the resident at the families' request. The SW stated she was unaware that residents should be invited and provided the opportunity participate in their care plan meeting but she would make sure she invited residents going forward. During an interview on 10/11/24 at 5:52 PM, the Administrator stated the SW was responsible for keeping track of the care plan meeting schedule and he expected the initial care plan meeting to be conducted within 72-hours of a resident's admission to the facility and then completed quarterly. The Administrator stated the care plan meetings should be conducted with the entire Interdisciplinary Team (IDT) present to provide information related to the resident's progress with each discipline. If the IDT member was not able to attend the care plan meeting, he expected the IDT member to provide the information to the SW for her to review with the resident and/or their representatives during the care plan meeting. 2. Resident #13 was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis (breakdown of muscle tissue), hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition. Review of Resident #13's electronic medical record revealed no evidence he was invited to attend a care plan meeting to discuss and provide input regarding his plan of care following the completion of the admission MDS assessment dated [DATE]. Review of the facility's Care Plan Meeting Schedules for the period August 2024 - October 2024 revealed no care plan meeting was scheduled for Resident #13 until October 24, 2024. During an interview on 10/07/24 at 12:28 PM, Resident #13 stated that he had not been invited to participate in any care plan meetings since being admitted to the facility. During interviews on 10/09/24 at 12:02 PM and 10/10/14 at 10:27 AM, the Social Worker (SW) verified a care plan meeting had not been held with Resident #13 following the completion of his admission MDS assessment dated [DATE]. The SW explained when she started her employment in October 2023, the previous SW had not wanted to train her and there was a lot that she did not know or was trained to do. The SW explained at the time, she really didn't have a process for ensuring care plan meetings were scheduled which resulted in care plan meetings falling through the cracks. She stated now, the process was for the receptionist to schedule the meeting and the SW would keep track of the meetings on a monthly calendar and facilitate the care plan meeting. The SW stated that sometimes the families of residents did not want the resident to attend the meeting so she did not invite the resident at the families' request. The SW stated she was unaware that residents should be invited and provided the opportunity participate in their care plan meeting but she would make sure she invited residents going forward. During an interview on 10/11/24 at 5:52 PM, the Administrator stated the SW was responsible for keeping track of the care plan meeting schedule and he expected the initial care plan meeting to be conducted within 72-hours of a resident's admission to the facility and then completed quarterly. The Administrator stated the care plan meetings should be conducted with the entire Interdisciplinary Team (IDT) present to provide information related to the resident's progress with each discipline. If the IDT member was not able to attend the care plan meeting, he expected the IDT member to provide the information to the SW for her to review with the resident and/or their representatives during the care plan meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, family member, and staff interviews, the facility failed to clean and trim nails on both hands of a dependent resident and failed to shave chin hairs on a dependent resident for 1 of 3 dependent residents reviewed for activities of daily living (Resident #43). The findings included: Resident #43 was readmitted on [DATE]. Her diagnoses included diabetes mellitus type II, osteoporosis, and dementia. Resident #43's Care Area Assessment for activities of daily living (ADL) dated 07/14/24 revealed she needed assistance from staff with all activities of daily living due to her diagnoses of dementia, hemiplegia following a stroke affecting her left non-dominant side and osteoporosis. Resident #43's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired but was able to make her needs known. The assessment also revealed Resident #43 required substantial to maximal assistance with showering and bathing and required partial to moderate assistance with personal hygiene. The resident had no behaviors of rejection of care. Review of Resident #43's care plan last revised on 10/05/24 revealed she had a focus area for requiring assistance with activities of daily living (ADL) related to left sided hemiplegia from previous stroke. The interventions included in part, bed mobility required substantial to maximal assistance, showers/bathing required substantial to maximal assistance and personal hygiene required partial to moderate assistance from staff. An observation on 10/07/24 at 3:43 PM revealed Resident #43 resting in her bed eating crackers with her nails noted to be ¼ inch beyond the end of her fingers with brown debris under all the nails on both her hands. Resident #43 was also noted to have visible white chin hairs that were ¼ inch long on her chin. An interview with the resident revealed she did not like her nails to be long and would like for them to be trimmed and cleaned on both hands and said she didn't like having chin hairs and would like for someone to trim them off her chin for her. Resident #43 stated her family member usually had to trim her nails and the chin hair off her chin because the staff at the facility didn't offer to do it for her. She further stated her family member had not been able to come to the facility to visit her because she had fallen and broken her arm. A telephone interview on 10/11/24 at 3:55 PM with Agency Nurse Aide (NA) #8 revealed she had taken care of Resident #43 on 10/07/24 during the 7:00 AM to 3:00 PM shift and had given her a complete bed bath. Agency NA #8 stated she knew Resident #8 had long nails, but she was not used to taking care of her, so she didn't trim her nails. She further stated she had not reported to Unit Manager #2 that her nails were long and needed trimming. Agency NA #8 said she did not usually trim chin hairs on women and said she had not asked Resident #43 if she wanted her chin hairs trimmed and had not reported to Unit Manager #2 that her chin hairs needed to be trimmed. She indicated she was not aware she was expected to trim chin hairs on women. An observation on 10/08/24 at 4:32 PM revealed Resident #43 resting in her bed and her nails were still long with brown debris under them and she still had visible white chin hairs on her chin. She stated she had received a bed bath on 10/07/24 but her nails had not been trimmed and she had not had her chin hairs shaved during her bath. Review of the shower schedule revealed Resident #43 was scheduled for showers/bed baths on Monday and Thursday on 2nd shift (3:00 PM to 11:00 PM). An interview on 10/09/24 at 3:15 PM with Nurse Aide (NA) #11 revealed she had taken care of Resident #43 on 10/08/24 and 10/09/24 during the 7:00 AM to 3:00 PM shift and stated she had not noticed Resident #43's nails being long or being dirty on both her hands. NA #11 stated she had not given her a bath on the days she had cared for her and had not paid attention to her nails or the hair on her chin. She stated usually resident's nails are trimmed and they are shaved on their shower days, and she had not provided Resident #43's shower when she cared for her on 10/08/24 and 10/09/24. NA #11 further stated she believed Resident #43 was diabetic and her nails would have to be trimmed by the nurse but said she had not reported her nails needing to be trimmed to Unit Manager #2. An observation on 10/09/24 at 3:03 PM revealed Resident #43 lying in bed with her family member at her bedside. Her nails were trimmed and cleaned, and her chin hairs had been shaved. The family member stated she had trimmed and cleaned the brown debris from under Resident #43's nails and shaved her chin hairs because the staff at the facility would not do it even though she had requested the resident's nails to be trimmed and kept clean and her chin hairs shaved from her face. The family member further stated she had not been able to visit for 3 weeks because she had fallen and broken her arm and had to heal herself. She indicated to her knowledge the facility staff had never offered to trim Resident #43's nails or shave the chin hairs from her face, so she tried to do it, but it had been difficult today with her broken arm. An interview on 10/10/24 at 2:54 PM with Unit Manager #2 revealed she was not aware, and no one had told her that Resident #43's nails were long and needed to be trimmed. She stated her nails would have to be trimmed by a nurse since she was diabetic but the NAs caring for her should keep them clean and they shouldn't have brown debris under the nails. Unit Manager #2 further stated that shaving residents both male and female was part of their routine when giving residents bed baths or showers and said Resident #43 should have been shaved on Monday when she received her bed bath. She indicated she was not aware the resident's family member had requested the resident be shaved and her fingernails trimmed but said it should be part of her routine ADL care and her family member should not have to trim her fingernails or shave her chin hairs. She further indicated that should be done by the facility staff. An interview on 10/11/24 at 6:10 PM with the Director of Nursing (DON) revealed she expected residents to have their nails trimmed and cleaned and be shaved as part of their bed bath or shower. She stated the NAs should report to the nurses or Unit Managers any diabetic residents with nails that needed to be trimmed, and they should be trimming the other resident's nails. The DON further stated all residents that wanted to be shaved male or female should be shaved as part of their ADL care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews the facility failed to apply compression wraps daily per the physician's order for 1 of 1 resident (Resident #57) reviewed for edema (swelling). Findings included: Resident #57 was admitted to the facility on [DATE] with diagnoses that included lymphedema (chronic condition that causes swelling, most often in the arms or legs, due to a buildup of lymph fluid). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had intact cognition. She required substantial/maximum staff assistance with lower body dressing and received application of nonsurgical dressings other than to feet. It was further noted that Resident #57 had not rejected care during the MDS assessment reference period. An active physician's order dated 08/23/24 for Resident #57 read in part, apply compression garments (wraps) in the morning daily for 8 to 12 hours. Remove at night and elevate legs. Every shift for lymphedema of bilateral lower extremities. Review of the staff progress notes for October 2024 revealed no entries related to Resident #57 refusing application of the compression wraps. An observation and interview was conducted with Resident #57 on 10/07/24 at 4:08 PM. Resident #57 was sitting up in her motorized wheelchair, there was swelling noticed to both lower legs and she had no compression wraps applied. A rolling walker was placed at the end of Resident #57's bed and lying on the seat of were two compression wraps. Resident #57 stated she was supposed to wear the compression wraps on her lower legs due to edema and never refused to have them applied. Resident #57 explained she couldn't put them on herself and staff did not consistently apply them for her. Resident #57 stated staff did not apply the compression wraps on Thursday (10/3/24) or Friday (10/04/24) and had yet to apply them today (10/07/24). Review of Resident #57's Treatment Administration Record (TAR) for October 2024 revealed the compression wraps were initialed as applied daily except for 10/03/24 and 10/04/24. Further review revealed Nurse #5 initialed the TAR as applying the compression wraps on 10/07/24. During an interview on 10/11/24 at 10:04 AM, the Wound Nurse revealed he worked the medication cart on 10/03/24 when he was on-call and could not recall if he had offered to apply Resident #57's compression wraps. He stated if he had, it would not have been until late in the afternoon. The Wound Nurse stated Resident #57 had told him that her compression wraps were not applied last Thursday (10/03/24) or Friday (10/04/25) and typically didn't get applied when he or the weekend Wound Nurse were not working. During a telephone interview on 10/11/24 at 12:54 PM, Nurse #5 revealed she had offered to apply Resident #57's compression wraps on 10/04/24 but she had refused. Nurse #5 stated she had meant to document the refusal on Resident #57's TAR but she must have got distracted and forgot. During a telephone interview on 10/11/24 at 1:43 PM, Nurse #6 revealed she was assigned to do treatments on 10/07/24 but did not have Resident #57 on her list of treatments completed that day. Nurse #5 confirmed it was her initials that were noted on Resident #57's TAR for 10/07/24 and explained it was initialed as completed by mistake because she did not apply Resident #57's compression wraps that day. During an interview on 10/11/24 at 4:25 PM, the Director of Nursing (DON) stated Resident #57 did not typically refuse to have her compression wraps applied by staff, she might delay having them put on until after her shower but not refuse completely. The DON was unaware Resident #57's compression wraps were not applied by staff on 10/3/24, 10/04/24 or 10/07/24. She stated she would expect for the physician order to be followed and if the treatment nurse was not doing treatments, hall nurses were responsible for checking the TAR and completing treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews the facility failed to secure an indwelling urinary catheter tubing to prevent tension or trauma for 1 of 3 residents reviewed for urinary catheter (Resident #63). The finding include: Resident #63 was admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia (enlarged prostate which can cause urinary obstruction). The admission Minimum Data Set assessment dated [DATE] revealed Resident #63's cognition was moderately impaired and had an indwelling urinary catheter. Review of Resident #63's care plan revised 07/10/24 that addressed the use of an indwelling urinary catheter related to benign prostatic hyperplasia. The goal that he would be free of urinary tract infections would be attained by utilizing interventions that include following catheter care policies and procedures and abiding by enhanced barrier precautions. Review of Resident #63's physician order dated 08/20/24 indicated indwelling urinary catheter due to benign prostatic hyperplasia. On 10/07/24 at 12:56 PM during an observation and interview with Resident #63 while sitting up in his wheelchair, the Resident wore pants, and the catheter tubing was threaded down his left pant leg and the catheter bag was contained in a catheter bag holder which was hooked to the wheelchair bars. When the Resident was asked if the catheter tubing had a stabilizing device attached to his leg to prevent pulling on the tubing he replied, sometimes but not now, I don't always have one. On 10/08/24 at 10:42 AM Nurse Aide (NA) #1 and Medication Aide (MA) #1 was in Resident #63's room to provide morning care. Before providing catheter care it was noted that there was no stabilizing device in place to prevent pulling or trauma related to the catheter. The MA located the Wound Nurse who came into the Resident's room and applied a sure lock tape on the Resident's left thigh and secured the catheter tubing during the observation. During interviews with the Wound Nurse and MA #1 on 10/08/24 at 10:42 AM the MA explained that sometimes the staff remove it when they give him a shower and when the MA was asked if Resident #63 had a shower that morning the MA indicated he had not. The MA and Wound Nurse stated there should be a stabilizing device in place for every indwelling urinary catheter. An interview was conducted with the Director of Nursing (DON) on 10/11/24 at 10:11 AM. The DON explained that every catheter should have a stabilizing device in place to prevent trauma caused by pulling on the catheter tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident and staff interviews, the facility failed to provide the resident's preference of showers for 3 of 3 residents reviewed for choices (Resident #17, Resident #189 and Resident #64). The findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses which included debility, arthritis, and chronic pain. Resident #17's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required substantial to maximal assistance with showering and bathing. The assessment also revealed Resident #17 had no rejection of care behaviors and according to the assessment, it was very important to the resident to choose between a tub bath, shower, bed bath or sponge bath. The shower schedule for the middle hall revealed Resident #17 was scheduled for showers on Tuesday and Friday on 1st shift (7:00 AM to 3:00PM). The documentation of showers in the electronic medical record for Resident #17 for 08/13/24 through 10/11/24 revealed she received showers as scheduled on 08/13/24, 08/16/24, 08/20/24, 08/27/24, 09/03/24, 09/10/24, 09/17/24, 09/20/24, and 09/24/24. On the other days she was scheduled for showers the following was documented: Friday 08/23/24 no shower provided Friday 08/30/24 partial bath provided Friday 09/06/24 no shower provided Friday 09/13/24 no shower provided Friday 09/27/24 no shower provided Tuesday 10/01/24 no shower provided Friday 10/04/24 no shower provided Tuesday 10/08/24 no shower provided Friday 10/11/24 no shower provided An observation and interview on 10/08/24 at 9:23 AM revealed Resident #17 sitting up in her wheelchair and dressed for the day. The Resident's skin was visibly dry and flaky. Resident #17 stated she was not getting her showers two times a week as scheduled and stated she preferred to take showers because the hot water felt good to her arthritis. Resident #17 further stated she had not refused any of her showers and had not been offered showers two times per week, every week and had sometimes gone two weeks without a shower. On 10/10/24 at 4:00 PM a Resident Council Meeting was held, and Resident #17 was in attendance and again she and others complained about not getting showers during the meeting. She stated that she was not getting her showers two times per week as scheduled. A telephone interview was attempted several times with agency NA #13 who cared for Resident #17 on 08/23/24 during the 7:00 AM to 3:00 PM shift with voicemail messages left for return call with no response. A telephone interview on 10/11/24 at 3:55 PM with agency NA #8 revealed she had cared for Resident #17 on 08/30/24 during the 7:00 AM to 3:00 PM shift. She stated she usually tried to give all her showers or bed baths but said sometimes their schedule changed during their shift and showers sometimes got missed. Agency NA #8 further stated the scheduled changed frequently and it was difficult to keep up with showers when changes were made mid-day. A telephone interview on 10/10/24 at 12:07 PM with Agency Nurse Aide (NA) #3 revealed she had cared for Resident #17 on 09/06/24 during the 7:00 AM to 3:00 PM shift. She stated she couldn't remember why she had not given Resident #17 a shower on that day but said sometimes their assignments were changed during the shift and residents may have missed their showers. Agency NA #3 stated she usually gave all her showers and bed baths unless the schedule was changed and said that happened a lot because staff worked different hours. She further stated the staff worked 4, 8, 12 and 16-hour shifts. A telephone interview was attempted several times with agency NA #12 who cared for Resident #17 on 09/13/24 and 10/11/24 during the 7:00 AM to 3:00 PM shift with voicemail messages left for return call with no response. An interview on 10/11/24 at 4:42 PM with Unit Manager #2 revealed she was not aware, and no one had told her that Resident #17 was not receiving her showers as scheduled. She stated the NAs should be reporting not getting showers done to the nurse or to her so they could have adjusted the schedule to accommodate the residents. Unit Manager #2 further stated she could have moved NAs around or added them to an assignment to get the resident showers done if she had been told they were not done. An interview on 10/11/24 at 6:10 PM with the Director of Nursing (DON) revealed she expected residents to have their bed baths or showers as scheduled. She stated the NAs should report to the nurses or unit managers any residents refusing care or who didn't receive their bed bath or shower as scheduled so they could be accommodated on the next shift or next day. The DON further stated there were changes sometimes to the schedule because they had staff working 4, 8, 12 and 16-hour shifts. She indicated they were trying to cover the schedule with agency staff as they hired their own staff, and it was difficult with using so many agencies to get dependable staff to cover the schedule. The DON further indicated they needed to interview the residents and make sure their preferences were documented correctly. 2. Resident #64 was admitted to the facility on [DATE] with diagnoses which included hemiparesis due to cerebrovascular accident (CVA) or stroke. Resident #64's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired and required partial to moderate assistance with showering and bathing. The assessment also revealed Resident #64 had no rejection of care behaviors and according to the assessment, it was somewhat important to the resident to choose between a tub bath, shower, bed bath or sponge bath. The shower schedule for the middle hall revealed Resident #64 was scheduled for showers on Wednesday and Saturday on 2nd shift (3:00 PM to 11:00 PM). The documentation of showers in the electronic medical record for Resident #64 for 08/05/24 through 10/09/24 revealed she received showers on 08/20/24 which was not a scheduled shower day (Tuesday), 09/04/24, 09/11/24, 10/02/24 and 10/07/24 which was not a scheduled shower day (Monday). On the other days she was scheduled for showers the following was documented: Wednesday 08/07/24 partial bath provided Saturday 08/10/24 partial bath provided Wednesday 08/14/24 no shower provided Saturday 08/17/24 complete bed bath Wednesday 08/21/24 no shower provided Saturday 08/24/24 no shower provided Wednesday 08/28/24 partial bath provided Saturday 08/31/24 complete bed bath provided Saturday 09/07/24 no shower provided Saturday 09/14/24 complete bed bath provided Wednesday 09/18/24 no shower provided Saturday 09/21/24 complete bed bath provided Wednesday 09/25/24 no shower provided Saturday 09/28/24 partial bath provided Saturday 10/05/24 no shower provided Wednesday 10/09/24 no shower provided An observation and interview on 10/07/24 at 3:30 PM with Resident #64 revealed her lying in bed and said she had a shower today but prior to that it had been a while since she had one. Resident #64 stated she only got one shower about every 2 weeks and would like to get 2 showers a week as scheduled. She further stated she preferred a shower because the warm water felt good to her, and she felt cleaner after a shower than when she received a bed bath. A telephone interview was attempted several times with Nurse Aide (NA) #6 who cared for Resident #64 on 08/14/24 and 08/28/24 during the 3:00 PM to 11:00 PM shift with voicemail messages left for return call with no response. A telephone interview on 10/10/24 at 11:22 AM with agency NA #4 revealed she had cared for Resident #64 on 08/21/24 (along with agency NA #5), 08/31/24, and 09/18/24 during the 3:00 PM to 11:00 PM shift. She stated she usually tried to get all her showers done but sometimes their assignments changed 2 hours into the shift, and she may have been switched to other residents and not gotten her shower done before the assignment changed. Agency NA #4 stated there seemed to be a scheduling problem at the facility because assignments were constantly being changed during the shift. A telephone interview on 10/10/24 at 11:50 AM with agency NA #5 who cared for Resident #64 on 08/21/24 (along with agency NA #4), and 09/25/24 during the 3:00 PM to 11:00 PM shift revealed if they were fully staffed, she was able to get her showers done on 2nd shift but if not, she was not able to get all the showers done as scheduled. She stated there were times that staff would just not show up for their shift and would not call and that left them short and on those shifts it was difficult to get all the showers done. An interview on 10/11/24 at 4:42 PM with Unit Manager #2 revealed she was not aware, and no one had told her that Resident #64 was not receiving her showers as scheduled. She stated the NAs should be reporting not getting showers done to the nurse or to her so they could have adjusted the schedule to accommodate the residents. Unit Manager #2 further stated she could have moved NAs around or added them to an assignment to get the resident showers done if she had been told they were not done. An interview on 10/11/24 at 6:10 PM with the Director of Nursing (DON) revealed she expected residents to have their showers as scheduled. She stated the NAs should report to the nurses or unit managers any residents refusing care or who didn't receive their shower as scheduled so they could be accommodated on the next shift or next day. The DON further stated there were changes sometimes to the schedule because they had staff working 4-, 8-, 12- and 16-hour shifts. She indicated they were trying to cover the schedule with agency staff as they hired their own staff, and it was difficult with using so many agencies to get dependable staff to cover the schedule. The DON further indicated they needed to interview the residents and make sure their preferences were documented correctly. 3. Resident #189 was admitted to the facility on [DATE] with diagnoses which included hemiplegia due to cerebrovascular accident (CVA) or stroke. Resident #189's annual Minimum Data Set (MDS) dated [DATE] revealed it was very important to the resident to choose between a tub bath, shower, bed bath or sponge bath. Resident #189's quarterly MDS dated [DATE] revealed she was moderately cognitively impaired but could make her needs known and required setup with showering and bathing. The assessment also revealed Resident #189 had no rejection of care behaviors. The shower schedule for the middle hall revealed Resident #189 was scheduled for showers on Monday and Thursday on 2nd shift (3:00 PM to 11:00 PM). The documentation of showers in the electronic medical record for Resident #189 for 08/05/24 through 09/05/24 revealed she received no showers as scheduled during this time. On the days she was scheduled for showers the following was documented: Monday 08/05/24 no shower provided Thursday 08/08/24 no shower provided Monday 08/12/24 complete bed bath provided Thursday 08/15/24 no shower provided Monday 08/19/24 no shower provided Thursday 08/22/24 partial bath provided Monday 08/26/24 partial bath provided Thursday 08/29/24 partial bath provided Monday 09/02/24 complete bed bath provided Thursday 09/05/24 no shower provided Documentation for 09/06/24 through 10/09/24 was not provided for this resident. An observation and interview on 10/07/24 at 12:38 PM with Resident #189 revealed her sitting up in her wheelchair in her room dressed for the day. The Resident's skin that was visibly dry and flaky. Resident #189 stated she was not getting her showers two times a week as scheduled and stated she preferred to take showers because the hot water felt good to her, and she felt cleaner after a shower and getting her hair washed. A telephone interview was attempted several times with Nurse Aide (NA) #6 who cared for Resident #189 on 08/08/24, 08/12/24 and 08/26/24 during the 3:00 PM to 11:00 PM shift with voicemail messages left for return call with no response. A telephone interview on 10/10/24 at 12:07 PM with Agency NA #3 revealed she had cared for Resident #189 on 08/05/24 and 09/05/24 during the 3:00 PM to 11:00 PM shift. She stated she couldn't remember why she had not given Resident #189 a shower on those days but said sometimes their assignments were changed during the shift and residents may have missed their showers. Agency NA #3 stated she usually gave all her showers and bed baths unless the schedule was changed and said that happened a lot because staff worked different hours. She further stated the staff worked 4, 8, 12 and 16-hour shifts. A telephone interview on 10/10/24 at 11:57 AM with agency Nurse Aide (NA) #2 revealed she had cared for Resident #189 on 08/19/24 during the 3:00 PM to 11:00 PM shift. She stated she was not sure why she had not given Resident #189 a shower on that day but said sometimes their assignments were changed during the shift. She further stated it could have been that she originally had the resident and then was reassigned to another set of residents. Agency NA #2 indicated she always tried to give her showers and if she was not able to it was because the assignments were changed or there was not enough time during her shift to get it done. She also indicated there were times when staff called out or didn't show up and there was not enough time in the shift to give showers because of the increased workload. A telephone interview on 10/10/24 at 11:22 AM with Agency NA #4 revealed she had cared for Resident #189 on 08/22/24 during the 3:00 PM to 11:00 PM shift. She stated she usually tried to get all her showers done but sometimes their assignments changed 2 hours into the shift, and she may have been switched to other residents and not gotten her shower done before the assignment changed. Agency NA #4 stated there seemed to be a scheduling problem at the facility because assignments were constantly being changed during the shift. A telephone interview was attempted several times with agency NA #15 who cared for Resident #189 on 08/29/24 during the 3:00 PM to 11:00 PM shift with voicemail messages left for return call with no response. A telephone interview was attempted several times with agency NA #7 who cared for Resident #189 on 09/02/24 during the 3:00 PM to 11:00 PM shift with voicemail messages left for return call with no response. An interview on 10/11/24 at 4:42 PM with Unit Manager #2 revealed she was not aware, and no one had told her that Resident #189 was not receiving her showers as scheduled. She stated the NAs should be reporting not getting showers done to the nurse or to her so they could have adjusted the schedule to accommodate the residents. Unit Manager #2 further stated she could have moved NAs around or added them to an assignment to get the resident showers done if she had been told they were not done. An interview on 10/11/24 at 6:10 PM with the Director of Nursing (DON) revealed she expected residents to have their preferred showers as scheduled. She stated the NAs should report to the nurses or unit managers any residents refusing care or who didn't receive their shower as scheduled so they could be accommodated on the next shift or next day. The DON further stated there were changes sometimes to the schedule because they had staff working 4-, 8-, 12- and 16-hour shifts. She indicated they were trying to cover the schedule with agency staff as they hired their own staff, and it was difficult with using so many agencies to get dependable staff to cover the schedule. The DON further indicated they needed to interview the residents and make sure their preferences were documented correctly.

Based on record review, resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns and/or suggestions voiced by residents during Resident Council meetings for 6 of 10 months reviewed (January 2024, March 2024, April 2024, June 2024, July 2024, and August 2024). Findings included: Review of the Resident Council Minutes for the period 09/25/23 through 09/20/24 revealed the following: a. The Resident Council meeting minutes dated 01/31/24 revealed under New Business there were noted resident concerns about not receiving showers, staff turning off call lights and not providing care, ice not being passed daily, and better customer service. b. The minutes from the Resident Council meeting held on 02/16/24 were not available for review. c. The Resident Council meeting minutes dated 03/22/24 revealed the section for old business noted resident concerns with showers not being given or in a timely manner, staff turning off call lights and not answering them, and better customer service. There was no indication of the facility's response to these concerns listed under old business. Under New Business there were noted residents were unhappy with certain pictures being taken down, nursing assistants being disrespectful, not changing sheets, or making resident beds, not picking up trays or telling residents their names, and not receiving showers on time. d. The Resident Council meeting minutes dated 04/19/24 revealed no indication that the minutes from the Resident Council meeting held on 03/22/24 were read, approved, revised and/or resolved. Further review revealed the section for old business noted residents were unhappy with certain pictures being taken down, nursing assistants being disrespectful and not changing their sheets or making their beds, not picking up their trays, not telling residents their names, and not receiving showers on time. There was no indication of the facility's response to these concerns. Under New Business there were noted resident concerns with showers, staff not picking up resident trays, wipes not being replaced in resident rooms, resident beds not being made, 3rd shift staff turning off call lights and not coming back in a timely manner for care, and dietary not providing correct utensils. e. The minutes from the Resident Council meeting held on 05/19/24 were not available for review. f. The Resident Council meeting minutes dated 06/21/24 revealed section for old business noted about showers given on time and call lights answered in a timely manner. There was also no indication of the facility's response to concerns voiced during the 05/19/24 resident council meeting. g. The Resident Council meeting minutes dated 07/19/24 revealed no indication that the minutes from the Resident Council meeting held on 06/21/24 were read, approved, revised and/or resolved. Further review revealed the section for old business noted no improvements to prior complaints. Under New Business there was noted resident concerns of housekeeping throwing away cups with herbs in them and giving plants too much water, nursing assistants were changing air conditioning temperatures in resident rooms and residents were cold, dietary concerns of correct food for diets, receiving utensils on tray, ice cream being served melted, and facility staff not being friendly. h. The Resident Council meeting minutes dated 08/19/24 revealed no indication that the minutes from the Resident Council meeting held on 07/19/24 were read, approved, revised and/or resolved. Further review revealed, the section for old business noted the complaints that were staff related have somewhat improved. Under New Business there was noted resident concerns of medications being passed late, resident not receiving their pain medication for 4 days, nursing assistants talking too much, resident bed linens not being changed more than once a month and their beds not being made daily, and missing clothing items. A Resident Council group interview was conducted on 10/09/24 at 4:00 PM. During the interview, Residents #3, #17, #38, #45, #57, and #66, who attend Resident Council meetings regularly, all stated they felt facility staff did not really address their concerns or suggestions because the only response they typically received from staff, if they received one at all, was we are working on it, it has been addressed, or we spoke with staff but never any satisfactory resolution and some of the issues continued to happen. Resident #45, who was the Resident Council President, added they understood some of the concerns they voiced couldn't be fixed right away but it would be nice to receive some form of communication back as to what was being done. The residents all agreed they would like to know they were being heard and receive feedback from the administration on the efforts that had been made or attempted to resolve their concerns and/or suggestions. During an interview on 10/09/24 at 4:45 PM, the Activity Director (AD) confirmed she attended and recorded the minutes for the Resident Council monthly meetings. The AD explained she had been told by the previous Administrator that when residents voiced concerns and/or suggestions during the monthly meetings, to write them under new business on the Resident Council minutes and inform him or the previous Director of Nursing (DON) of the concerns and they would look into them. She stated she never received an actual response back from the previous Administrator or the previous DON as to how the concerns had been resolved other than being told it had been addressed or they were working on it. She revealed most of the same concerns were mentioned during the meetings each month and she continued to document those concerns in the Resident Council minutes and inform the current Administrator and DON. The AD stated the previous DON attended some of the Resident Council meetings prior to her leaving and during those meetings the residents addressed their concerns with nursing staff directly to her. The previous DON stated she would take care of those concerns but never informed the AD if or how those concerns were addressed or resolved. The AD revealed moving forward she would prefer to write any concerns or suggestions from Resident Council meetings on a grievance form so she could have some form of a paper trail showing the concerns had been reviewed and were being addressed. A telephone interview with the previous Director of Nursing (DON) on 10/10/24 at 11:11 AM revealed she had been employed at the facility from April 2024 until the first week of September 2024. She stated during her employment at the facility she had attended Resident Council meetings but could not recall which dates she had attended, or any specific resident concerns or resolutions discussed during the meetings. The former Administrator was unable to be interviewed. During an interview on 10/11/24 at 4:30 PM, the current Administrator revealed he began his employment at the facility around the middle of August 2024. He stated that he could not speak to the process of former Administration, but his preference would be for the AD to complete grievance forms for any concerns/suggestions brought up during Resident Council meetings. The Administrator revealed once the grievance forms from Resident Council meetings were completed, they would be given to him as he was the grievance officer and he would distribute them out to the responsible departments for their review. He stated once the grievances were resolved, the departments would write out their resolution on the grievance form and those would be distributed back to the AD for review at the following Resident Council meeting. He also stated that moving forward with this process would help with making sure any grievances or suggestions from Resident Council were being addressed and the departments responsible were being held accountable.

Based on record review and staff interviews, the facility failed to notify the Regional Ombudsman when residents discharged or transferred from the facility for 6 of 6 months (April 2024, May 2024, June 2024, July 2024, August 2024, and September 2024). Findings included: Review of the facility's Admission/Discharge report for the period 04/01/24 to 09/30/24 revealed there were 149 residents who were discharged home, transferred to the hospital, or transferred to another nursing facility. During an interview on 10/09/24 at 12:03 PM, the Social Worker (SW) revealed since starting her employment in October 2023, she had not sent notifications to the Regional Ombudsman when residents discharged or transferred from the facility and wasn't aware that she needed to do so. During an interview on 10/09/24 at 10:16 AM, the Administrator revealed he had spoken with the SW and she had not been contacting the Regional Ombudsman to notify them of any resident discharges or transfers. The Administrator stated both he and the SW had no excuse as to why notifications were not sent to the Regional Ombudsman but they should be done anytime a resident discharged or transferred from the facility and there would be a process moving forward.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident, family and staff interviews, the facility failed to have a discharge planning process in place that incorporated the resident in the development of a discharge care plan that addressed the resident's discharge goals and post-discharge needs for residents who wished to discharge to the community for 3 of 4 sampled residents (Residents #82, #13 and #137). Findings included: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses that included gout (type of arthritis that causes severe pain, swelling, redness and tenderness in joints), hypertension, severe protein-calorie malnutrition, and osteoarthritis of knee. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had intact cognition with a discharge goal to return to the community. The MDS noted an active discharge plan was in place for Resident #82. The Social Service admission assessment dated [DATE] noted Resident #82's discharge goal was to return to the community. Review of Resident #82's comprehensive care plan, last reviewed/revised 10/09/24, revealed no discharge care plan. During an interview on 10/07/24 at 4:18 PM, Resident #82 expressed his goal was to return home as soon as he was able. Resident #82 revealed that since being admitted to the facility, he did not recall having a discussion with facility staff regarding his discharge goals, plans or rehab progress. During an interview on 10/09/24 at 12:03 PM, the Social Worker (SW) explained when residents were first admitted to the facility, she met with the resident and/or Responsible Party (RP) to introduce herself, complete the initial assessment and then held a 72-hour care plan meeting with the resident/RP to discuss their goals. The SW stated after the initial 72-hour care plan meeting, she tried to visit with the resident weekly but didn't document the conversations. The SW stated she had not developed a discharge care plan for Resident #82 or any other resident. She stated care plans were completed by the MDS Coordinator. During an interview on 10/09/24 at 12:20 PM, the MDS Coordinator explained the development of a resident's comprehensive care plan was an Interdisciplinary Team effort and discharge care plans normally fell on the SW to complete. The MDS Coordinator stated she had not developed or completed any resident's discharge care plan. During an interview on 10/09/24 at 3:50 PM and follow-up interview on 10/11/24 at 5:52 PM, the Administrator stated for residents who admitted to the facility for short-term rehab, the discharge planning process should begin upon admission, updated based on the resident's progress and remain ongoing until the resident discharged . In addition, he expected the initial care plan meeting to be held with the resident/RP within 72-hours to discuss the resident's overall goals. The Administrator explained that a discharge care plan should be developed as part of the discharge planning process that incorporated the resident's goals and wishes and updated based on the resident's therapy progress, goals and care needs. 2. Resident #13 was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis (breakdown of muscle tissue), hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition with a discharge goal to return to the community. The MDS noted an active discharge plan was in place for Resident #13. Review of Resident #13's comprehensive care plan, last reviewed/revised 08/26/24, revealed no discharge care plan. During an interview on 10/07/24 at 12:28 PM, Resident #13 stated he wanted to return home but was not sure when that would be. Resident #13 stated no one at the facility has talked with him about his discharge goal, plans or needs. During an interview on 10/09/24 at 12:03 PM, the Social Worker (SW) explained when residents were first admitted to the facility, she met with the resident and/or Responsible Party (RP) to introduce herself, complete the initial assessment and then held a 72-hour care plan meeting with the resident/RP to discuss their goals. The SW stated after the initial 72-hour care plan meeting, she tried to visit with the resident weekly but didn't document the conversations. The SW stated she had not developed a discharge care plan for Resident #13 or any other resident. She stated care plans were completed by the MDS Coordinator. During an interview on 10/09/24 at 12:20 PM, the MDS Coordinator explained the development of a resident's comprehensive care plan was an Interdisciplinary Team effort and discharge care plans normally fell on the SW to complete. The MDS Coordinator stated she had not developed or completed any resident's discharge care plan. During an interview on 10/09/24 at 3:50 PM and follow-up interview on 10/11/24 at 5:52 PM, the Administrator stated for residents who admitted to the facility for short-term rehab, the discharge planning process should begin upon admission, updated based on the resident's progress and remain ongoing until the resident discharged . In addition, he expected the initial care plan meeting to be held with the resident/RP within 72-hours to discuss the resident's overall goals. The Administrator explained that a discharge care plan should be developed as part of the discharge planning process that incorporated the resident's goals and wishes and updated based on the resident's therapy progress, goals and care needs. 3. Resident #137 was admitted to the facility on [DATE] with diagnoses that included right pubis fracture (one of the bones in the pelvis), multiple myeloma (cancer of the plasma cells) and chronic pain. The Nursing admission Assessment completed on 09/27/24 revealed that Resident #137 was able to communicate her needs and be understood. Resident #137 required supervision or touching assistance with eating and substantial/maximal assistance with all other self-care tasks, bed mobility and transfers. The Social Service admission assessment dated [DATE] noted Resident #137's discharge goal was to return to the community. An interview was conducted with Resident #137 and her family member on 10/07/24 at 3:50 PM. Both Resident #137 and her family member stated that her goal was to receive therapy services and discharge home as soon as possible. Both Resident #137 and the family member expressed that staff had not met with them to discuss Resident #137's discharge goals, plans or treatment needs. Both Resident #137 and the family member stated the only discussion they have had with staff thus far was regarding her insurance right after Resident #137 first admitted to the facility. An interview was conducted with Resident #137's Responsible Party (RP) on 10/09/24 at 9:25 AM with Resident #137 and her family member present. The RP stated no one had met with him or Resident #137 to discuss her discharge plans and voiced frustration over the lack of communication regarding Resident #137's therapy progress. The RP stated he received a call from facility staff about a week ago and a care plan meeting was scheduled for 10/24/24 which would be almost a month since she was admitted to the facility. The RP explained Resident #137's rehab stay was covered for the first 20 days and starting day 21, she would have to start paying a copay and they had planned on her returning home before that. During an interview on 10/09/24 at 12:03 PM, the Social Worker (SW) explained when residents were first admitted to the facility, she met with the resident and/or RP to introduce herself, complete the initial assessment and then held a 72-hour care plan meeting with the resident/RP to discuss their goals. The SW stated she did not conduct a 72-hour care plan with Resident #137 or her RP and was not sure what happened, it just fell through the cracks. The SW stated she had not developed a discharge care plan for Resident #137 or any other resident. During an interview on 10/09/24 at 3:50 PM and follow-up interview on 10/11/24 at 5:52 PM, the Administrator stated for residents who admitted to the facility for short-term rehab, the discharge planning process should begin upon admission, updated based on the resident's progress and remain ongoing until the resident discharged . In addition, he expected the initial care plan meeting to be held with the resident/RP within 72-hours to discuss the resident's overall goals. The Administrator explained that a discharge care plan should be developed as part of the discharge planning process that incorporated the resident's goals and wishes and updated based on the resident's therapy progress, goals and care needs.

Based on record reviews and staff interviews, the facility failed to maintain accurate Treatment Administration Records (TAR) for 1 of 4 residents reviewed for pressure ulcers (Resident #238). The findings include: a. Review of Resident #238's medical record revealed a physician order dated 02/17/2024 to cleanse sacral pressure ulcer with wound cleanser and pat dry then apply non-adhesive pad then cover with foam dressing every day and as needed. Review of Resident #238's 02/2024 TAR revealed there was no documentation on 02/27/2024 to indicate the treatment was completed as ordered. An interview was conducted with former Wound Nurse #1 on 10/09/2024 at 7:01 AM who was assigned to perform pressure ulcer treatments on 02/27/2024. Wound Nurse #1 explained that she remembered Resident #238 and when she performed the Resident's admission skin assessment on 02/16/2024 the Resident had a stage II pressure ulcer on her sacrum. Wound Nurse #1 reported she worked Monday through Friday, but she was also responsible to take call which meant if she was called into work during the week after her first shift, she was scheduled off the following day and the pressure ulcer treatments were left up to the nurse on the hall to perform. Wound Nurse #1 stated she could not verify whether 02/27/2024 was one of those days she was off or whether she forgot to initial for the treatment. She indicated it was possible that she overlooked initialing it. Review of Resident #238's 03/2024 TAR revealed there was no documentation on 03/15/2024, 03/20/2024, 03/25/2024 and 03/29/2024 to indicate the treatment was completed as ordered. An interview was conducted with former Wound Nurse #1 on 10/09/2024 at 7:01 AM who was assigned to perform pressure ulcer treatments on 03/15/2024. Wound Nurse #1 explained that she could not confirm whether she was scheduled to perform the treatments on 03/15/2024 and stated it was possible she forgot to initial for the treatment. An interview was conducted with Nurse #8 on 10/10/2024 at 2:31 PM who worked on 03/20/2024 and 03/29/2024 first shift. Nurse #8 explained she vaguely remembered Resident #238 and did not recall whether she performed the pressure ulcer treatment or not. The facility was unable to identify the initials of the nurse who worked the hall on 03/25/2024 first shift in order to obtain an interview. Review of Resident #238's 04/2024 TAR revealed there was no documentation on 04/10/2024 to indicate the treatment was completed as ordered. An interview was conducted with Nurse #8 on 10/10/2024 at 2:31 PM who worked on 04/10/2024 first shift. Nurse #8 explained she vaguely remembered Resident #238 and did not recall whether she performed the pressure ulcer treatment or not. b. Review of Resident #238's medical record revealed a physician order dated 04/24/2024 to cleanse sacral pressure ulcer with wound cleanser and apply crushed metronidazole (antibiotic) and collagenase ointment (used to debride) then cover with a silver fortified dressing and an island dressing every day. Review of Resident #238's 04/2024 TAR revealed there was no documentation on 04/25/2024 to indicate the treatment was completed as ordered. An interview was conducted with Nurse #8 on 10/10/2024 at 2:31 PM who worked on 04/25/2024 first shift. Nurse #8 explained she vaguely remembered Resident #238 and did not recall whether she performed the pressure ulcer treatment or not. c. Review of Resident #238's medical record revealed a physician order dated 05/03/2024 to cleanse sacral pressure ulcer with wound cleanser and apply calcium alginate and cover with dry dressing every day. Review of Resident #238's TAR for 05/2024 revealed there was no documentation that indicated the treatment was completed on 05/09/2024. An interview was conducted with Nurse #8 on 10/10/2024 at 2:31 PM who worked on 05/09/2024 first shift. Nurse #8 explained she vaguely remembered Resident #238 and did not recall whether she performed the pressure ulcer treatment or not. An interview was conducted with the Director of Nursing (DON) on 10/11/2024 at 11:28 AM. The DON explained that if it is not documented, then it was not done because when staff initialed for the treatment it indicated the treatment was done. She indicated if the treatment was not completed for whatever reason, then there should be documentation to support the reason why the treatment was not done.

3. Review of the facility's policy on Enhanced Barrier Precautions (EBP) revised 06/14/24, indicated EBP are used in conjunction with Standard Precautions to reduce the risk of Multi Drug Resistant Organism (MDRO) transmission during high-contact resident care activities. Includes use of both gown and gloves. EBP are meant to be in place for the duration of the resident's stay or until resolution of a wound or discontinuation of an indwelling medical device. Review of the facility's policy on Handwashing revised 04/2023, indicated personnel are required to wash their hands after each direct or indirect resident contact for which handwashing is indicated by acceptable standards of practice. Personnel should wash their hands: After contact with blood, bodily fluids, secretions, excretions, & equipment or articles contaminated by them. After removing gloves before performing procedures in which a normally sterile part of the body is entered. a. On 10/08/25 at 10:15 AM an observation was made of Nurse #9 who went into Resident #139's room to administer an intravenous (IV) antibiotic through a central venous catheter (CVC, a long flexible tube inserted into a vein in the neck, chest, arm or groin that leads to the large vein which empties into the heart). Posted on the Resident's door was a sign for Enhanced Barrier Precautions that indicated all healthcare personnel should don gloves and gowns when providing care of high contact resident care activities that included device care or use including central lines. Nurse #9 applied gloves and gathered the IV antibiotic, normal saline flush syringe and alcohol pads before she entered Resident #139's room. The Nurse proceeded to sanitize the catheter tip and flushed the normal saline into the CVC before she connected the IV antibiotic to the catheter. b. An observation was made on 10/08/24 at 11:20 AM of Nurse #9 disconnecting Resident #139's IV antibiotic from her central venous catheter. The Nurse sanitized her hands and donned gloves and gathered a normal saline syringe and alcohol pads before she went into the Resident's room. Nurse #9 sanitized the catheter tip then removed the IV antibiotic and flushed the normal saline then sanitized the catheter tip a second time. An interview was conducted with Nurse #9 on 10/08/24 at 2:39 PM. While standing outside of Resident #139's door the Nurse was asked to explain the EBP sign posted on the Resident's door. Nurse #9 explained that Resident #139 had multiple wounds on her coccyx and heels and had to be under EBP. The Nurse was asked if having a central venous catheter warranted being under EBP and Nurse #9 stated no. The Nurse was asked to read the sign, and she then stated yes, I guess it does. Nurse #9 stated she usually wore the gown, but she had not worn the gown with Resident #139. When asked why not, the Nurse stated she really had no reason to offer. An interview was conducted with the Weekend Supervisor on 10/08/24 at 3:11 PM. The Supervisor explained she had only been employed by the facility for three weeks and was still learning her duties. She continued to explain that if Resident #139 had a CVC, then Nurse #9 should have followed the EBP sign on the door. She indicated Nurse #9 might need further education on infection control. c. On 10/08/24 at 10:42 AM an observation was made of Nurse Aide (NA) #1 and Medication Aide (MA) #1 going into Resident #63's room to provide urinary catheter care. It was noted that there was no Enhanced Barrier Precaution sign or Personal Protective Equipment (PPE) posted on the Resident's door. The two staff donned gloves but did not don gowns. After the MA noticed Resident #63 did not have a stabilizing device in place for his urinary catheter, she removed her gloves and left the room to inform the Wound Nurse about the Resident needing a stabilizing device. The MA never returned to the room. In the meantime, NA #1 emptied Resident #63's catheter bag and disposed of the urine in the commode. NA #1 then removed her gloves and without sanitizing or washing her hands she donned another pair of gloves. At this time the Wound Nurse entered the room wearing only gloves and proceeded to attach the stabilizing device on Resident #63's left thigh. The Wound Nurse removed his gloves, washed his hands and left the room. NA #1 then proceeded to perform catheter care on the Resident and when she was finished, she removed her gloves and washed her hands before she left the Resident's room. An observation was made on 10/08/24 at 3:00 PM of the Enhanced Barrier Precaution sign and PPE tower was posted on Resident #63's door. An interview was conducted with NA #1 on 10/08/24 at 3:02 PM as she stood outside Resident #63's door. NA #1 explained she had been at the facility for about 6 months and received infection control training when she was hired. When asked how she knew if a resident was on any kind of infection control precaution, she responded the precaution sign should be posted on the door. The NA pointed at the EBP sign on Resident #63's door and stated that sign was not on the Resident's door earlier when she rendered care to him because if the sign had been on the door, she would have donned the appropriate PPE meaning a gown as well as the gloves because the Resident had a catheter. The NA was asked if she should have done anything different during the morning care of Resident #63 the NA explained she should have washed her hands after she emptied his urinary bag and removed her gloves and before she donned another pair of gloves. An interview was conducted with the Weekend Supervisor on 10/08/24 at 3:11 PM. The Supervisor explained that anytime you remove gloves you should wash your hands before donning more gloves so NA #1 should have washed or sanitized her hands after she removed her gloves and before she donned new gloves. She stated a resident who had a urinary catheter should be on EBP which indicated to use the PPE of gown and gloves. The Supervisor reported she did not know who was responsible for posting the precaution signs and PPE, but the Director of Nursing was responsible for the infection control program. On 10/08/24 at 3:48 PM during an interview with the Medical Supply Clerk, she explained that she posted the EBP sign and PPE on Resident #63's door earlier that afternoon and was asked to post them by Nurse #10. During an interview with the Wound Nurse on 10/08/24 at 4:29 PM the Nurse explained that he had only been doing the wound treatments for a few months. When asked about if Resident #63 was on EBP he stated he could not remember if the precaution sign was on the door, but he should have worn a gown and gloves because the Resident had a urinary catheter. When asked what he wore when he applied the stabilizing device to Resident #63 the Wound Nurse explained he only wore gloves and not the gown because he was told if the reason you were coming in contact with the resident did not last longer than 15 minutes then you did not have to wear the gown. The Wound Nurse implied he was told that by the Director of Nursing. An interview was conducted with Nurse #10 on 10/08/24 at 7:47 PM who explained that she just started back to work at the facility that week. The Nurse stated she was asked by the Director of Nursing earlier in the afternoon (10/08/24) to have the Medical Supply Clerk post the EBP sign and PPE on Resident #63's door. d. An observation was made of the Wound Nurse applying a stabilizing device for Resident #60's indwelling urinary catheter on 10/08/24 at 4:24 PM. The door was open to the Resident's room which had an EBP sign posted, and the PPE tower mounted on the Resident's door. The Wound Nurse was noted to be wearing gloves and no gown during the procedure. An interview was conducted with the Wound Nurse on 10/08/24 at 4:29 PM. The Wound Nurse was asked about what kind of precautions was posted on Resident #60's door and he replied EBP which meant he should have worn gloves and a gown. When asked why he did not wear a gown the Nurse explained that he was told that if the reason he was coming in contact with the resident did not last longer than 15 minutes then you did not have to wear a gown. The Wound Nurse implied he was told that by the Director of Nursing. During an interview with the Director of Nursing (DON) who was also the Infection Preventionist on 10/08/24 at 4:50 PM the DON explained that she had only been employed at the facility for about 4 weeks and had not yet put any new systems into place regarding infection control nor had she conducted any education on infection control. The DON remarked that you would think that Nurse #9 wound follow the directions of the EBP sign posted on Resident #139's door before she administered medication to Resident #139's CVC. She reported that she conducted an audit for the precaution signs and found that Resident #63 had an indwelling urinary catheter and did not have an EBP sign or PPE posted on his door, so she instructed Nurse #10 to have a sign placed on the Resident's door. The DON stated she did not have a routine monitoring for handwashing but indicated NA #1 should have washed her hands after she removed her gloves and before she donned new gloves after she emptied Resident #63's catheter. She stated both NA #1 and the Wound Nurse should have worn a gown when they worked with Resident #63 and Resident #60 because the residents had an indwelling urinary catheter. The DON voiced that she did not inform the Wound Nurse that if the encounter with the resident lasted no longer than 15 minutes then they did not have to wear gowns that the Wound Nurse must be getting it confused with COVID contact time. She stated it looked like she would need to educate on infection control sooner than later. Based on observations, record reviews, and resident and staff interviews, the facility failed to implement infection control policies and procedures when the Wound Nurse did not follow the procedure for dressing change for a wound (Resident #25). In addition, Nurse Aide (NA) #11 failed to remove soiled gloves and perform hand hygiene after incontinence care and before she touched the resident, bed linens and the bed control (Resident #25), the Wound Nurse did not follow enhanced barrier precautions (EPB) while applying stabilizing devices to indwelling catheters for two residents (Resident #60 and Resident #63), Nurse #9, failed to follow enhanced barrier precautions while administering intravenous antibiotics into a central venous catheter (Resident #139) and NA #1 did not follow EPB when providing catheter care (Resident #63). The deficient practice occurred for 4 of 5 staff observed for infection control practices (Wound Nurse, Nurse Aide (NA) #11, Nurse #9, and NA #1). The findings included: 1. Review of the facility's policy and procedure on clean dressings last revised on 10/31/18 revealed the following procedure: - Provide for clean field on overbed table by using wax paper, paper towel, etc. - Place clean supplies on the clean field. - Place trash receptacle within easy reach. - [NAME] gloves, remove, and dispose of old dressing in the trash receptacle. - Cleanse the wound. Cleanse from the inside working out. If additional cleaning is needed, use another 4 x 4 gauze. Never use the same 4 x 4. - Discard sponges used for cleaning the wound in the trash receptacle/bag. - Remove and dispose gloves in trash receptacle/bag. - Wash your hands. - [NAME] clean gloves. Apply clean dressing. - Secure dressing with tape. - Date and initial the dressing. - Remove and dispose of gloves in trash receptacle/bag. - Wash hands. - Remove supplies and trash from the resident's room. - Dispose of removed trash properly. An observation of wound care was made on 10/09/24 at 09:50 AM. The Wound Nurse washed his hands with soap and water, donned a clean gown and gloves and placed a barrier down on the overbed table that had not been cleaned. After placing all the supplies on the barrier, he doffed his gloves, sanitized his hands, and donned clean gloves. He assisted Nurse Aide (NA) #11 with turning Resident #25 on his side and the resident had a large amount of stool between his buttock cheeks and there were smears of stool on the brief underneath the resident. The Wound Nurse removed the old dressing and discarded the dressing in the trash bag. He doffed his gloves, sanitized his hands, and donned new gloves and cleaned the outer portion of the wound with normal saline (NS). He then proceeded to clean the wound bed with NS. He doffed his gloves, sanitized his hands, and donned new gloves and proceeded to apply an antifungal and a corticosteroid cream to the outer edges of the wound. The Wound Nurse then applied moisture barrier cream (used to treat minor skin irritations) to the wound edges and peri wound area. He doffed his gloves, sanitized his hands and donned clean gloves and applied a hydrogel that helps maintain a moist wound environment conducive to healing to the wound bed and packed it with a solution-soaked gauze used to prevent and treat infection. As the Wound Nurse was packing the solution-soaked gauze in the wound the end of the gauze fell out of the wound onto the stool smeared brief and the Wound Nurse proceeded to pack it back into the wound. The Wound Nurse applied the bordered gauze dressing to the wound and Resident #25 was turned onto his back. An interview on 10/09/24 at 11:41 AM with the Wound Nurse revealed he had been doing wound care at the facility for 4 months and did all the wound care in the building both pressure and non-pressure wounds. He stated he had forgotten to clean the overbed table prior to placing his wax paper down and he forgot to put a clean chuck pad under Resident #25 prior to providing the wound care. The Wound Nurse further stated he realized that he should have tossed the gauze when it fell out of the wound onto the resident's brief but was nervous about being observed and just continued with the wound care. An interview on 10/11/24 at 6:34 PM with the Director of Nursing (DON) who was also the Infection Preventionist revealed it was her expectation for the Wound Nurse to follow infection control guidelines and wound care guidelines while providing wound care. She stated they were auditing staff to ensure they were following infection control guidelines and procedures and said she would be adding the Wound Nurse and wound care to the auditing tool. The DON/IP further stated she thought the Wound Nurse was nervous about being observed doing wound care. 2. Review of the facility's policy on Handwashing revised 04/2023, indicated personnel are required to wash their hands after each direct or indirect resident contact for which handwashing is indicated by acceptable standards of practice. The policy read in part: Personnel should wash their hands: - After contact with blood, bodily fluids, secretions, excretions, & equipment or articles contaminated by them. - After removing gloves before performing procedures in which a normally sterile part of the body is entered. - Before and after touching wounds. - When otherwise indicated to avoid transfer of microorganisms to other residents and environments. - When indicated between tasks and procedures to prevent cross contamination of different body sites. An alcohol-based hand sanitizer may be used for handwashing unless the hands are visibly soiled. The hands should be free of dirt and organic material when using an alcohol-based hand sanitizer. The hands should be washed with soap and water after exposure to blood or body fluids. An observation of incontinence care was made on 10/09/24 at 10:13 AM and revealed Nurse Aide (NA) #11 wearing a gown and gloves proceeded to clean stool from Resident #25's buttocks and made sure he was thoroughly clean. With the same gloves on, she adjusted the resident in bed, touching his linens and pillow under his legs and bed controls. She then touched his catheter bag, clean pants and pushed his catheter bag through his pants. In the meantime, his top sheet had fallen on the floor behind his bed, and she walked behind the bed and lifted the sheet up off the floor and placed it on his bed. After getting his pants pulled up on him, she placed the sheet that had fallen on the floor over the resident and then touched his bed controls again with the same gloves to put his bed in low position. NA #11 doffed her gown and gloves without sanitizing her hands and put on a single glove, collected the trash bag and left the room. An interview on 10/09/24 at 3:12 PM with NA #11 revealed she had only taken care of Resident #25 a couple of times. NA #11 stated she realized after she left the room that she should have doffed her gloves after cleaning the resident, sanitized her hands and donned clean gloves prior to touching him and anything in his environment. She further stated she was nervous about being observed providing care and just forgot to change her gloves. NA #11 indicated she should have gotten the resident a clean sheet as well since his had fallen onto the floor. An interview on 10/11/24 at 6:34 PM with the Director of Nursing/Infection Preventionist (DON/IP) revealed she expected all staff to follow the infection control procedures and guidelines when providing incontinence care and any care to residents. She stated she would be providing additional education to the NAs on infection control procedures and guidelines and would likely be monitoring them to ensure they are following the guidelines while providing care to the residents. The DON/IP further stated they would provide additional one on one training as the need was identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review, the facility failed to provide a dignified dining experience by standing while providing assistance with feeding for 1 of 5 residents (Resident #123) reviewed for assistance with dining. Findings included: Resident #123 was admitted to the facility on [DATE] with diagnoses that included, in part, dementia and gastro-esophageal reflux disease. The admission Minimum Data Set assessment dated [DATE] was in progress. The assessment revealed Resident #123 had severely impaired cognition. The baseline care plan dated 2/15/22 indicated the resident needed assistance with eating. On 2/21/22 at 12:40 PM Resident #123 was observed in her bed in an upright seated position. She was being fed by Nurse Aide (NA) #1. The meal tray was located on the overbed table at the foot of the resident's bed. NA #1 was observed as she walked to the foot of Resident #123's bed, scooped up a serving of food, then walked back to the head of the bed where the resident was, stood above eye level of Resident #123 and fed her. NA #1 then returned to the meal tray and obtained another scoop of food and walked back to the resident and fed her. NA #1 continued to walk back and forth with each bite of food and stood above eye level of Resident #123 for the duration of the meal while she fed the resident. At 12:58 PM Resident #123 indicated she was finished eating and NA #1 removed the lunch tray from the overbed table and exited the room. An interview was completed with NA #1 on 2/21/22 at 12:59 PM, during which she stated Resident #123 had confusion and needed to be fed her meal. She said she typically stood up when she fed residents, including Resident #123. NA #1 shared the facility hadn't specifically educated staff whether they should be seated or stand when they fed a resident. The Staff Development Coordinator (SDC) was interviewed on 2/24/22 at 9:10 AM. She explained staff were to be seated in a chair when they fed a resident. She stated staff positioning during meals was covered in the nurse aide skills training. The SDC added NA #1 was from a nurse staffing agency and although the SDC hadn't done skills training with the nurse aide, she expected agency staff to know the right things to do with resident care. During an interview with the Administrator on 2/24/22 at 2:43 PM, she said NA #1 was new to the facility and did not know why she stood when she fed Resident #123. She explained staff were to be seated when they provided assistance to a resident during meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and record reviews the facility failed to provide activities based on individual interest to include 1:1 activities for 1 of 1 sampled for activities (Resident # 59). Findings included: Resident #59 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included obstructive pulmonary disease, presence of a cardiac pacemaker, peripheral vascular disease, and acquired absence of the right leg. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had cognitive impairment for decision making and required extensive assistance of staff for activities of daily living with transfers, locomotion, bed mobility and dressing. A review of the comprehensive care plan dated 2/18/2022 revealed a focused area for activities that read, Resident #59 can make his own choice of whether or not he would like to participate in group activities. Resident #59 will participate in 1:1 activity with the activities staff a couple of times a week to engage in mental stimulation. Resident #59 will be able to identify at least 2 activities that he would like to participate in whether it be in the room, 1:1 or out of the room. If he can identify 1:1 activities that he would like then he will be offered those a couple of times a week. Interventions included: Arrange for the activity aide to visit and encourage Resident #59 to observe or participate in an activity out of the room so that he can be social with other residents. Assist Resident #59 in planning his own leisure time activities and remind him that his wife comes to visit which will help with his being mentally stimulated and engage in conversation. Sustain contact with Resident #59 by visiting in the room frequently and remind him that 1:1 activities are also an option. An observation was conducted of Resident #59 on 2/21/22 at 10:18 AM lying in bed with his eyes shut, without a book, magazine, or music. There was no item for entertainment on the nightstand. An interview was conducted with Resident #59 on 2/21/22 at 10:29 AM and he stated he gets bored sitting in this room. An observation was conducted on 2/22/22 at 3:23 PM of Resident #59 and he was lying in bed with no books, magazines, or items for entertainment, staring at the wardrobe with no music and no television. An observation was conducted on 2/23/22 at 11:19 AM of Resident #59 lying in bed sleeping. An interview was conducted on 2/23/2022 at 2:11 PM with the Activities Director and she revealed that she had been out of the facility from 2/15/2022 through 2/21/2022 and during this time the Assistant Activities Director was managing all activities programs and the one-on-one activities that took place in the facility. She revealed that documentation of one-on-one activities had not been completed during the past few months. An interview was conducted on 2/23/2022 at 2:31 PM with the Assistant Activities Director and she revealed she managed the activities that had been conducted from 2/15/2021 through 2/23/2022 and these activities did not include any one-on-one activities with Resident #59. She added that she had not documented any one-on-one activities for any residents for the last few months. An interview was conducted with the Administrator on 2/23/2022 at 2:54 PM and she revealed she was unaware Resident #59 had not received 1:1 activities over the last week, per his care plan, and she planned to meet with the Activities Director to provide education regarding 1:1 documentation and participation and this would be conducted immediately.