**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident, staff, and Medical Director interviews the facility failed to protect a resident's right to be free from the misappropriation of controlled medication for 1 of 2 residents (Resident #40) reviewed for misappropriation. Findings included: A review of the facility's policy titled Abuse, Neglect, or Misappropriation of Resident Property dated last revised on 3/10/2017 revealed in part The facility believes that our residents have the right to be free from abuse, neglect, involuntary seclusion, exploitation or misappropriation of property. The facility will do whatever is in it's control to prevent mistreatment, neglect, exploitation, and abuse of our residents or misappropriation of their property. Resident #40 was admitted to the facility on [DATE] with a diagnosis of chronic pain. A physician's order for Resident #40 dated 5/17/24 indicated to administer oxycodone (a narcotic pain medication) 10 milligrams (mg)/acetaminophen (a non-narcotic pain medication) 325 mg one tablet by mouth to Resident #40 four times daily for chronic pain. A review of Resident #40's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and on a scheduled pain medication regime. She received as needed medication for pain. Resident #40 had pain of an 8 on a 0 to 10 scale almost constantly with 0 being no pain and 10 being the most pain imaginable. A review of a pharmacy packing slip dated 6/20/24 revealed the facility received 120 doses of oxycodone 10 mg/acetaminophen 325 mg tablets for Resident #40. Two nurse signatures appeared on the bottom of the packing slip acknowledging that the medication was received. The same two nurse signatures appeared at the top of the controlled substance count records for the medication which were labeled one of four, two of four, and three of four. The controlled substance count sheet four of four was missing. A review of Resident #40's Medication Administration Record (MAR) for June 2024 revealed documentation oxycodone 10 mg/acetaminophen 325 mg one tablet was administered to Resident #40 four times a day on 6/20/24 through 6/30/24 at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM as ordered by her physician. A review of Resident #40's Medication Administration Record (MAR) for July 2024 revealed documentation oxycodone 10 mg/acetaminophen 325 mg one tablet was administered to Resident #40 four times a day on 7/1/24 through 7/6/24 at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM as ordered by her physician. A review of the Shift Change Controlled Substances Count Check dated 7/3/24 at 7:00 AM revealed the off-going Nurse #5's and the oncoming Nurse #4's signature on the log verifying there were 23 controlled substance count sheets present. On 7/3/24 at 3:00 PM the off-going Nurse #4's and oncoming Nurse #3's signatures were present on the log verifying that there were 23 controlled substance count sheets present. On 7/3/24 at 11:00 PM the off-going Nurse #3 and the oncoming Nurse #2's signature were present on the log indicating there were 23 controlled substance count sheets present. On 7/4/24 at 7:00 AM the off-going Nurse #2's and the oncoming Nurse #4's signatures were present on the log, but the number 23 was crossed out and the number 22 was written indicating there were 22 controlled substance count sheets present with a note that the count was verified. On 11/12/24 at 2:24 PM an interview with Resident #40 indicated she had a history of chronic pain. She stated she received medication in the facility for her pain that helped her. She stated she did not recall ever not receiving the pain medication she needed to control her pain. On 11/15/24 at 12:39 PM an interview with Central Supply Clerk #1 indicated on 7/3/24 after 3:00 PM he needed to check the medication room to see what supplies needed to be restocked. He stated normally, the nurse would open the door to the medication room and be present while he did this, but on this occasion Nurse #3 gave him the keys, he used them to open up the medication room door. He went on to say he propped the door open with his cart while he restocked the supplies, and when he turned around to give Nurse #3 back her keys, she was gone. He reported he had not been in the medication room with the keys for very long, he thought maybe about 30 seconds. Central Supply Clerk #1 recalled he saw Nurse #4 and the Unit Nurse Manager at the nurses' station, and when he attempted to give the keys to the medication room to the Unit Nurse Manager, Nurse #4 reached out her hand, said I'll take them and took the keys from him. Central Supply Clerk #1 stated Nurse #4 told him she would give the keys to Nurse #3 when Nurse #3 got back from the bathroom. He went on to say approximately 3 to 5 minutes later he saw Nurse #3 in the hallway, asked her if she had gotten her keys back, and she told him she had. On 11/15/24 a review of a written witness statement by Nurse #3 dated 7/8/24 revealed on 7/3/24 at the start of her 3:00 PM to 11:00 PM shift Nurse #3 completed the controlled substance reconciliation count with the off going Nurse #4. This was her first time working at the facility. Although there had been only 22 controlled medication cards in the medication cart and there were 23 listed on count sheet, when she asked Nurse #4 about it, Nurse #4 had given her an explanation for it, and so she signed the count sheet for 23 controlled medications and sheets. Nurse #3 remembered giving Central Supply Clerk #1 the keys to the medication room and leaving the medication cart at the nurse's station while she went to the bathroom. When Nurse #3 returned from the bathroom, Nurse #4 gave these keys back to her. On 11/15/24 at 10:19 AM, 12:42 PM and 3:07 PM attempts to reach Nurse #3 for a telephone interview were unsuccessful. Nurse #3 no longer worked at the facility, and no other method of contact for her was available. On 11/15/24 at 10:18 AM a telephone interview with Nurse #4 indicated she was assigned to care for Resident #40 on 7/3/24 from 7:00 AM until 3:00 PM. Nurse #4 explained Nurse #3 was new to the and she had taken Nurse #3 around the facility, given her report on the residents, and done the controlled medication reconciliation with Nurse #3 before giving Nurse #3 the keys to the controlled substances and the medication cart at about 3:30 PM on 7/3/24. Nurse #4 reported she recalled there being 23 controlled medications and 23 controlled substance count record sheets present. She stated she stayed for a while after her shift ended that day and was at the nurses' station at about 3:45 PM on 7/3/24 when Central Supply Clerk #1 came up to the nurses' station where she was seated looking for Nurse #3. Nurse #4 reported Central Supply Clerk #1 had the keys to the medication cart which included the keys to the controlled substances and wanted to return them to Nurse #3. She went on to say she had not seen Nurse #3 give the keys to the medication cart to Central Supply Clerk #1. She reported the medication cart had been in the hallway next to the nurses' station where she was seated. Nurse #4 indicated she had not seen Central Supply Clerk #1 access the medication cart or use the keys to access the locked medication room which was about 3 doors down from the nurse's station, although she could see both the cart and the room from where she was seated. Nurse #4 stated she told Central Supply Clerk #1 that Nurse #3 was in the bathroom, and that he could lay the keys on the counter at the nurses' station, which he did. Nurse #4 reported that she could see the keys to the medication cart lying on the counter at the nurse station the entire time until Nurse #3 came out of the bathroom and picked them up a few minutes later. The interview further revealed when she returned to the facility on 7/4/24 for her 7:00 AM to 3:00 PM shift and was reconciling the controlled medication in the medication cart with Nurse #2, she noticed Resident #40 was missing a card of 30 doses of oxycodone 10 mg/acetaminophen 325 mg and the controlled substance count record sheet that went with the medication. She reported the shift change controlled substance count check sheet indicated there should be 23 count sheets and 23 narcotic medications in the cart, but there had only been 22. She went on to say Nurse #2 asked her how she knew Resident #40 was missing a card of 30 doses of oxycodone 10 mg/acetaminophen 325 mg and the controlled substance count record sheet for this medication before they had finished reconciling the controlled medication, and she told her she knew what was supposed to be in the cart because she was very familiar with that medication cart and was the regular nurse for that hall. Nurse #4 indicated she did not know what happened to the medication or the sheet and she and Nurse #2 had immediately reported the discrepancy to the Unit Nurse Manager. On 11/15/24 at 9:25 AM a telephone interview with Nurse #2 indicated she was assigned to care for Resident #40 on 7/3/24 from 11:00 PM until 7/4/24 at 7:00 AM. She stated when she counted the controlled narcotic medication on 7/4/24 at 11:00 PM with the off going Nurse #3 who was assigned to care for Resident #40 on 7/3/24 from 3:00 PM until 11:00 PM she noticed the number of controlled medications and the number of the controlled substance count record sheets did not match what was on the shift-change controlled substance count check log. She stated the shift change controlled substance count check log indicated there should be 23 controlled medication cards and 23 controlled substance count records but there had only been 22. Nurse #2 reported she had asked Nurse #3 why this was, and Nurse #3 informed her Nurse #4, who had been assigned to care for Resident #40 on 7/3/24 from 7:00 AM until 3:00 PM, had instructed her that the 2 cards of a narcotic medication in a bag were supposed to be counted as 2. Nurse #2 stated she had been working at the facility for the past 3 years, and she didn't think this was correct, but if she counted the medication in the bag as 2 then there would have been 23 controlled medications. She went on to say the pharmacy had come to deliver medications while she was performing the controlled substance reconciliation with the off going Nurse #3 on 7/3/24, and she had accepted the keys to the medication cart without completing the controlled substance reconciliation and signed the shift change controlled substance count check log to indicate there were 23 medication cards present. Nurse #2 reported she thought she would figure out why the narcotic count seemed to be incorrect later on in her shift, but she had gotten busy and had not. She went on to say the next morning, on 7/4/24 at 7:00 AM when she and the oncoming Nurse #4 began to perform the narcotic reconciliation, she asked Nurse #4 whether or not she instructed Nurse #2 to count the narcotic medication in the bag as 2 and Nurse #4 told her she had not said this. Nurse #2 stated before she and Nurse #4 finished the controlled medications reconciliation, Nurse #4 told her Resident #40 was missing a whole card of 30 doses of oxycodone 10 mg/acetaminophen 325 mg. Nurse #2 went on to say she thought this was strange, because she and Nurse #4 had not even finished reconciling the controlled medications when Nurse #4 said this. Nurse #2 reported she had asked Nurse #4 how she knew what was missing, and Nurse #4 told her she knew how much of this medication Resident #40 was supposed to have because she was Resident #40's regularly assigned nurse. Nurse #2 indicated she did not know what happened to the missing medication or the record sheet. She stated the discrepancy had been reported to the Unit Nurse Manager on 7/4/24. On 11/15/24 at 8:35 AM an interview with the Unit Nurse Manager indicated on 7/3/24 after 3:00 PM she was in the hallway and heard Central Supply Clerk #1 ask Nurse #4 for assistance with getting into the medication room. The Unit Manager stated she heard Nurse #4 ask Central Supply Clerk #1 to wait a moment and she would help him. She reported a few minutes later that Central Supply Clerk #1 attempted to give her some keys, but Nurse #4 offered to take the keys from him. She reported she saw Central Supply Clerk #1 give the keys to Nurse #4. The Unit Nurse Manager did not discuss why she allowed Central Supply Clerk #1 to give the keys to Nurse #4, or why she had not questioned the situation on 7/3/24. She went on to say on 7/4/24, Nurse #2 and Nurse #4 reported to her that there was a card of 30 doses of Resident #40's oxycodone 10 mg/acetaminophen 325 mg and the controlled substance count record sheet that went with the medication missing from the medication cart. She reported she verified the medication, and the record sheet were missing, and immediately reported the medication discrepancy to the Director of Nursing. The Unit Nurse Manager stated Nurse #4 should not have had the keys to the medication cart and the controlled substances after she passed the keys to Nurse #3 at the end of her shift on 7/3/24, and Central Supply Clerk #1 should never have been allowed to have these keys or access to the areas where medications were kept unsupervised. On 11/15/24 at 11:47 AM a telephone interview with the Pharmacy Manager indicated on 6/20/24 the pharmacy dispensed 120 doses of oxycodone 10 mg/acetaminophen 325 mg to the facility for Resident #40. He stated Resident #40 took one dose of this medication 4 times daily. He went on to say the 120 doses should have been a 30 day supply of the medication for Resident #40. The Pharmacy Manager reported on 7/10/24, the pharmacy had to reissue a 10 day supply of the medication early, billed to the facility and not to Resident #40, because of diversion of the medication by someone at the facility. On 11/15/24 at 1:18 PM an interview with the Director of Nursing (DON) indicated a full card of 30 doses of Resident #40's oxycodone 10 mg/acetaminophen 325 mg medication and the controlled substance count record sheet for the medication had gone missing by the Unit Nurse Manager on 7/4/24 between 7:00 AM and 8:00 AM. She stated she had been involved in the investigation. The DON reported there should always be clarification immediately prior to accepting the keys to the medication cart as soon as there was any question about the accuracy of the controlled substance reconciliation. She stated she had not been made aware of any concern with the controlled substance reconciliation count until 7/4/24. The DON stated the nurse should never pass the keys to their medication cart to anyone after they had counted the narcotic medications and accepted responsibility for the medication cart. She reported Nurse #4 should not have had access to the medication cart keys after she performed the controlled substance reconciliation with Nurse #3 at the end of her shift on 7/3/24. The DON stated although these were things that she felt should just be basic nursing knowledge, since this incident the facility had done in-service education with all nurses and medication aides, and it was included in the facility's orientation process. She went on to say a corrective action plan for the incident had been implemented. She reported the follow-up audits had not revealed any additional concerns. The DON stated she continued to periodically monitor and reconcile the controlled substances in the medication carts. On 11/15/24 at 1:57 PM an interview with the Administrator indicated the facility had confirmed that Resident #40's 30 doses of oxycodone 10 mg/acetaminophen 325 mg medication and the controlled substance count record sheet for the medication had gone missing on 7/4/24. He stated an investigation had been competed, replacement medication had been ordered from the pharmacy and billed to the facility, and Resident #40 had not missed any doses of the medication. He reported Nurse #4 had been hired at the facility in August 2023, and the facility had been aware that she had a reprimand on her nursing license from the North Carolina Board of Nursing (NCBON) related to concerns about missing narcotic medications and the documentation of controlled substances by Nurse #4 when she was hired. He stated Nurse #4 had not had any restrictions on her nursing license and had been allowed to handle and administer controlled substance medications. He went on to say although he could not prove it, he believed Nurse #4 was responsible for Resident #40's missing medication. The Administrator stated Nurse #4 no longer worked at the facility, and he had reported the incident to the NCBON. He reported an initial and 5 day investigation report had been submitted to the State Agency, Adult Protective Services and the Medical Director had been notified of the incident, and a report to law enforcement had been made. He went on to say the missing controlled medication had been reported to the Drug Enforcement Agency. The Administrator stated the facility completed an investigation of the incident and implemented a performance improvement plan. He went on to say there had been no additional concerns on their follow-up audits. He stated this incident, and the follow-up audits had been discussed in the Quality Assurance and Performance Improvement meetings. On 11/15/24 at 11:49 AM an interview with the Medical Director indicated she had not been the Medical Director for the facility when the incident occurred. She went on to say the previous Medical Director no longer worked for the company, and no contact for him was available. She stated the positive thing was that Resident #40 had not missed any doses of her oxycodone 10 mg/acetaminophen 325 mg medication and had not suffered any negative outcome. The facility provided the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; - On 7/4/2024, the Administrator and Director of Nursing (DON) were notified of missing medication from the medication cart for a resident. The Administrator and Director of Nursing initiated an investigation regarding missing medications. - The resident was assessed by nursing staff for signs and symptoms of pain on 7/4/2024. No significant findings noted from the assessment. The resident was able to receive pain medication from remaining doses on the medication cart. The resident and the Resident Representative (RR) were made aware of the missing medication. The medication was reordered from the pharmacy. - Initial allegation report was submitted to Division of Health Service Regulation (DHSR) on 7/4/2024 by the Administrator. - The local law enforcement agency was made aware of the missing medication on 7/4/2024 by the Administrator. A report was completed for the missing medication. - The facility Medical Director and the resident's RR were made aware of the missing medication on 7/4/2024 by the Administrator and Director of Nursing. The Medical Director had no new orders. - The Drug Enforcement Agency was notified of the missing medication on 7/5/2024 by the Administrator. - NCBON was notified of the missing medication on 7/8/2024 by the Director of Nursing. - APS made aware of the investigation on 7/4/2024 by the Administrator. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; - On 7/4/2024 the Unit Managers completed an audit of the last 30 days of ordered narcotic medications to ensure the medications were in the medication cart, administered, or returned to pharmacy per protocol. No concerns were noted during the audit. - On 7/4/2024, the Director of Nursing reviewed packing slips for the past 30 days to ensure all narcotic medications were checked in appropriately and accounted for. No concerns were noted from the audit. - On 7/4/2024, the Director of Nursing completed an audit of 100% of all resident's Controlled Substance Count sheets in comparison to the narcotic medication blister packs in the medication cart to ensure there were no discrepancies in the count of the medications. No concerns were noted from this audit. - On 7/4/2024, the Unit Managers inspected the narcotic blister pill packages for any tampering of medications. No concerns with tampering were noted. - On 7/4/2024, the Unit Managers and Assistant Director of Nursing initiated assessment of all residents for pain. The Director of Nursing will address will initiate non-pharmacological interventions, pain medication, and/or physician notification for any identified areas of concern during the audit. The audit was completed by 7/5/2024. No concerns were noted from this audit. - On 7/5/2024, the Accounts Payable completed an audit of all nurses and medication aides' license verification and HCPI checks. No concerns were noted from this audit. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; - On 7/4/2024, the Staff Development Coordinator initiated an in-service with all nurses and medication aides regarding Controlled Substance Diversion to include: the definition, implications, the process for returning narcotic medications, and not removing the declining count sheet from the controlled substance book until the end of the shift to ensure it is signed by 2 nurses. The in-service also will discuss reporting discrepancies immediately to the nurse manager, not accepting a medication cart until the discrepancy is investigated and not allowing any other nurse to have access to the medication cart if it is not their assigned medication cart. The in-service was completed by 7/5/2024. After 7/5/2024, any nurse or medication aide that had not worked or received the in-service will complete it upon the next scheduled work shift. All newly hired nurses or medication aides will be educated during orientation by the Staff Development Coordinator regarding Controlled Substance Diversion. On 7/5/24, the Administrator notified the Director of Nursing her responsibility to monitor and to ensure all in-services are completed per the plan of correction. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and - 100 % of all ordered narcotic medications will be reviewed by the Assistant Director of Nursing weekly x 4 weeks and compared to the Controlled Substance Count Sheets, medication administration record, and/or return of drug slips to ensure the narcotic medications are being administered or have been returned to pharmacy as required per policy and there are no signs of drug diversion utilizing a Controlled Substance Audit tool. All areas of concern will be addressed during the audit including re-educating nurses. The DON will review and initial the audits weekly x 4 weeks then monthly x 1 month to ensure all areas of concern were addressed appropriately. - The Administrator or DON will present the findings of the Audit Tools to the Quality Assurance Performance Improvement (QAPI) Committee monthly for 2 months. The QAPI Committee will meet monthly for 2 months and review the audit tools to determine trends and/or issues that may need further interventions and the need for additional monitoring. Include dates when corrective action will be completed. - Corrective action was completed on 7/6/2024. Onsite validation of the facility's Plan of Correction was completed on 11/15/24. The initial audit results were reviewed. The in-service education record dated 7/5/24 was reviewed. Interviews with nurses and medication aides indicated they attended and/or received in-service training on misappropriation of controlled substances and handling of the medication cart and controlled substance medications. The follow-up audit results were reviewed. The QAPI meeting minutes were reviewed. The facility's completion date of 7/6/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews the facility failed to provide nail care for a dependent resident for 1 of 7 residents reviewed for activities of daily living (ADL) (Resident #18). The findings included: Resident #18 was readmitted to the facility on [DATE] with diagnoses that included dementia, Parkinson's disease, and early onset cerebellar ataxia (lack of voluntary coordination of muscle movement beginning at the cerebellum of the brain). A review of a care plan dated 5/5/22 revealed Resident #18 had activities of daily living and personal care deficit with interventions which included Resident #18 was totally dependent on staff for bathing and preferred bed baths. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was moderately cognitively impaired and was not coded for rejection of care. Resident #18 required total dependence with bathing and grooming An observation and interview with Resident #18 were conducted on 11/12/24 at 11:54 AM. Resident #18 was observed to have approximately half-inch long fingernails with jagged nails on both thumbs. Resident #18 could only respond with head movements to questions, and he nodded affirmatively that he wanted them trimmed. A review of the Electronic Health Record shower documentation from 11/10/24 until 11/12/24 revealed Resident #18 received bed baths on each day from Nurse Aide (NA) #1. An interview was conducted on 11/13/24 at 2:39 PM with NA #1. NA #1 stated Resident #18 was totally dependent on staff during bathing. She indicated she had given him a bath in the morning of 11/13/24 and cleaned his nails. NA #1 stated that Resident #18's nails were not at a length where they needed to be trimmed. An observation and follow-up interview with NA #1 were conducted on 11/13/24 at 2:48 PM. Resident #18 was observed to have half inch-long fingernails with thumbnails jagged at either side. She stated she would cut his nails today. An observation and interview were conducted with Nurse #1 on 11/13/24 at 2:52 PM. Nurse #1 stated Resident #18's nails should have been cut due to a few jagged edges on the thumbnails. The Director of Nursing (DON) was interviewed on 11/14/24 at 12:36 PM. She stated she expected nails to be checked every time care was provided. The DON indicated nails should be cut/trimmed as needed, especially if they were jagged. She stated that Resident #18's nails should have been cut previously when observed to be jagged. During an interview with the Administrator on 11/14/24 at 2:46 PM, he revealed that if Resident #18's nails needed to be cut, then they should have been cut in a timely manner.

Based on observations and staff interviews the facility failed to discard expired medication that remained on the medication cart available for use. This was for 1 of 4 medication carts (Upper 300 Hall) reviewed for medication storage. Findings included: On 11/14/24 at 4:11 PM an observation of the Upper 300 Hall medication cart and interview with the Unit Manager occurred. The observation of the medication cart revealed an opened 355 milliliter (ml) bottle of Antacid Liquid medication with an expiration date of July 2024. The bottle contained liquid medication. An interview with the Unit Manager at that time indicated there was liquid medication remaining in the bottle. She reported this Antacid Liquid medication was expired and should not have been on the medication cart available for use. She stated she checked this medication cart weekly for expired medications and had last checked it on 11/11/24 or 11/12/24. She went on to say she must have missed this bottle. On 11/15/24 at 1:18 PM an interview with the Director of Nursing (DON) indicated the medication carts were monitored weekly by the Unit Manager for expired medications and these were discarded. She stated there should not be any expired medications on any medication carts available for use. On 11/15/24 at 1:57 PM an interview with the Administrator indicated there should not be expired medication on a medication cart available for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. Review of Resident #18's medical record revealed the Resident was readmitted to the facility on [DATE] with diagnoses that included dementia, Parkinson's disease, and cardiovascular disease. The review revealed a full code status was care planned on 5/20/23. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. c. Review of Resident #51's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, and hypertension. The review revealed a full code Physician order dated 11/5/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. d. Review of Resident #84's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included a history of a stroke and diabetes. The review revealed a full code Physician order dated 11/5/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. An interview was completed on 11/13/24 at 11:15 AM with the facility's Admissions Director. She revealed that either she or the Social Worker discussed only code status with residents. A further discussion about advance directives did not take place, and there is no documentation to show the Resident's understanding beyond code status. An interview was completed on 11/13/24 at 11:50 AM with the facility's Social Worker #1. Social Worker #1 stated she only discussed code status with the Resident and/or their responsible party (RP). An interview was completed with the facility's Administrator on 11/13/24 at 2:15 PM. He revealed SW #1 documented the code status discussion in the medical record, but there was not a form for advance directives with an explanation that was signed by the Resident or the RP. The Administrator stated the only document that went into the chart was the Do Not Resuscitate (DNR) form itself and the order verification form that the physician signed. Based on record review and resident and staff interviews, the facility failed to ensure a copy of the resident's advanced directive was included in the resident's record (Resident #10) and failed to provide written advance directive information and/or an opportunity to formulate an advance directive (Residents #18, #51, and #84). This was for 4 of 17 residents reviewed for advance directives. The findings included: a. A review of the facility's policy titled Documentation of Advanced Directives dated 2/2007 revealed in part It is the policy of the facility to document in the residents' medical record whether or not the resident has executed an advanced directive. If the resident or resident's family or representative indicates that the resident has executed an advanced directive, facility staff will request that a copy of the advanced directive be provided to the facility for inclusion in the resident's record as soon as possible. Resident #10 was admitted to the facility on [DATE] with a diagnosis of respiratory failure. A review of Resident #10's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. On 11/14/24 at 12:47 PM an interview with Resident #10 indicated her family member was her Power of Attorney (POA) and that family member had the written paperwork for this. She stated she did not recall anyone asking her if she had a POA when she was admitted to the facility or asking her to provide a copy of the document. On 11/14/24 at 1:00 PM a review of Resident #10's medical record did not reveal evidence of Resident #10's POA document. On 11/15/24 at 1:03 PM an interview with the Admissions Director indicated she was aware that Resident #10 had a POA document when Resident #10 was admitted to the facility. She stated she had spoken with the Social Worker at another facility, who informed her that Resident #10 had one. She went on to say she had not asked Resident #10 or her family member to provide a copy of the POA or documented this in Resident #10's medical record. On 11/15/24 at 1:57 PM an interview with the Administrator indicated typically the facility's Business Office Manager requested copies of the Living Will and/or the POA, if the resident had these, during the financial interview upon admission. He stated the Business Office Manager had been out on leave. He reported he felt a copy of Resident #10's POA had not been obtained for Resident #10's medical record because the Business Office Manager normally did this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #117 was admitted to the facility on [DATE], and her diagnoses included acute cerebrovascular insufficiency, vascular dementia, hypertension, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117 was moderately cognitively impaired. Review of Resident #117's care plan revealed it had been reviewed and revised on 9/12/24 and 10/23/24 by the interdisciplinary team. Review of the care plan meeting signature sheet dated 9/12/24 showed those in attendance were the Social Worker, Activity Director and Resident #117's Representative (via telephone). Resident #117 had not attended the care plan meeting. Review of the care plan meeting signature sheet dated 10/23/24 showed those in attendance were the Social Worker, Activity Director, and a registered nurse who worked on the hall. Resident #117's Representative attended via telephone. Resident #117 had not attended the care plan meeting. Attempts were made to reach Resident #117's Representative to obtain an interview via telephone with no return call. The Social Worker was interviewed on 11/12/24 11:00 AM, and stated if the resident was alert and oriented, she verbally notified the resident of a care plan meeting. She had not invited Resident #117 to care plan meetings because she did not consider the resident to be alert and oriented. An interview with Resident #117 was held on 11/13/24 at 2:45 PM, during which she stated she would like to be invited and involved in the planning of her care. The Assistant Administrator was interviewed on 11/14/24 at 9:12 AM. She revealed that the Social Worker initiated the care plan meeting. If a resident was not alert and oriented the resident representative was invited to attend the meeting. The Assistant Administrator explained that the Social Worker referenced the Brief Interview for Mental Status (BIMS) in the MDS assessment to determine if a resident was alert and oriented. The Social Worker verbally notified residents of the upcoming care plan meetings. If the BIMS of a resident was 12 or higher the Social Worker invited them to participate in the planning of care. An interview with the Administrator on 11/15/24 at 1:27 PM revealed his expectation was that the resident was invited to care plan meetings and that written invitations were given to both the resident and resident representative. Based on record review, resident, Resident Representative (RR) and staff interviews, the facility failed to conduct care plan meetings or invite residents to their care plan meetings for 4 of 9 residents reviewed for care plans (Residents #39, #40, #100, and 117). Findings included: 1. Resident #39 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and aphasia (unable to speak). The quarterly Minimum Data Set assessment dated [DATE] indicated that Resident #39 was severely cognitively impaired. An interview on 11/12/24 at 11:13 AM with Resident #39's Resident Representative (RR) revealed she had not been invited to a care plan meeting since Resident #39's admission. She stated she would like to attend a care plan meeting. An interview on 11/13/24 at 1:21 PM with the Social Worker (SW) #1 revealed that based on Resident #39's record, it appeared she had not had a care plan meeting since 4/5/2018. The SW indicated he was aware of the requirement to hold care plan meetings quarterly. An interview on 12/13/24 at 2:55 PM with the Administrator revealed he was unaware that Resident #39 had not had a care plan meeting since 2018. He stated SW #1 made the care plan meeting schedule and sent the invitations by mail to residents' RRs, or hand delivered them to residents who were their own responsible party. 2. Resident #100 was admitted to the facility on [DATE]. A review of Resident #100's care plan revealed it was last updated on 10/6/24. A review of Resident #100's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired. On 11/12/24 at 1:35 PM an interview with Resident #100 indicated he did not recall ever being invited to attend a care plan meeting. He stated he would like to be invited to attend. On 11/13/24 a review of Resident #100's medical record did not reveal any documentation that a care plan meeting was conducted since Resident #100's admission to the facility. On 11/13/24 at 11:03 AM an interview with MDS Nurse #1 indicated Resident #100's Social Worker (SW) was responsible for sending the invitations and for arranging Resident #100's care plan meetings. She reported a care plan schedule calendar was generated based on the MDS assessment dates and provided to the SW. She further indicated Resident #100 would have been scheduled for a care plan meeting in accordance with his 10/25/24 MDS assessment. On 11/13/24 at 12:42 PM an interview with SW #2 indicated Resident #100 was due for a care plan meeting around the time of the 10/25/24 MDS assessment. He stated he was responsible for providing the invitation to the meeting, and for maintaining the documentation of the meeting including those who attended. SW #2 stated care plan meetings included the resident and their Representative if this applied, a Nurse, a Nurse Aide, Activities, Dietary, and Therapy if this applied. He reported he had been Resident #100's SW since Resident #100's admission to the facility. SW #2 stated he had not invited Resident #100 to a care plan meeting and had no documentation that a meeting occurred. He went on to say care plan meetings were important and should be held at least quarterly and as needed. SW #2 stated he did not have a reason why a care plan meeting for Resident #100 had not been held. On 11/13/24 at 1:42 PM an interview with the Director of Nursing (DON) indicated care plan meetings should be held at specific intervals for residents. She stated she did not have any documentation that a care plan meeting had been held for Resident #100 since his admission to the facility. On 11/15/24 at 11:57 AM an interview with the Administrator indicated care plan meetings were required for residents. He stated the resident needed to be invited to the meetings, and all disciplines needed to be represented at the meeting. The Administrator stated care plan meetings should be held on admission, quarterly, and any time there was a significant change with the resident. 3. Resident #40 was admitted to the facility on [DATE]. A review of Resident #40's quarterly MDS assessment dated [DATE] revealed she was cognitively intact. A review of Resident #40's care plan revealed it was last revised on 10/22/24. On 11/12/24 at 2:24 PM an interview with Resident #40 indicated she did not recall being invited to a care plan meeting. She stated she would like to be invited to attend. On 11/12/24 a review of Resident #40's medical record did not reveal any documentation that a care plan meeting was conducted for Resident #40 since her admission to the facility. On 11/13/24 at 11:03 AM an interview with MDS Nurse #1 indicated Resident #40's SW was responsible for sending the invitations and arranging Resident #40's care plan meetings. She reported a care plan schedule calendar was generated based on the MDS assessment dates and provided to the SW. She further indicated Resident #40 would have been scheduled for a care plan meeting in accordance with her 10/18/24 MDS assessment. On 11/13/24 at 12:42 PM an interview with SW #2 indicated Resident #40 was due for a care plan meeting around the time of the 10/18/24 MDS assessment. He stated he had been Resident #40's SW since her admission to the facility. SW #2 reported he was responsible for providing the invitation to the meeting, and for maintaining the documentation of the meeting including those who attended. SW #2 stated care plan meetings included the resident and their Representative if this applied, a Nurse, a Nurse Aide, Activities, Dietary, and Therapy if this applied. He reported he had not invited Resident #40 to a care plan meeting and had no documentation that a meeting occurred since Resident #40's admission to the facility. He went on to say care plan meetings were important and should be held at least quarterly and as needed. SW #2 stated he did not have a reason why a care plan meeting for Resident #40 had not been held. On 11/13/24 at 1:42 PM an interview with the Director of Nursing (DON) indicated care plan meetings should be held at specific intervals for residents. She stated she did not have any documentation that a care plan meeting had been held for Resident #40 since her admission to the facility. On 11/15/24 at 11:57 AM an interview with the Administrator indicated care plan meetings were required for residents. He stated the resident needed to be invited to the meetings, and all disciplines needed to be represented at the meeting. The Administrator stated care plan meetings should be held on admission, quarterly, and any time there was a significant change with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure advanced directive information matched throughout the medical record for 1 of 1 resident (Resident #67) reviewed for advanced directives. Findings included: Resident #67 was admitted to the facility on [DATE]. Resident #67's electronic medical record revealed an active physician's order dated [DATE] that read DNR (Do Not Resuscitate). A review of Resident #67's paper medical chart revealed there was no advanced direction information in the paper medical chart. The facility did not have an additional notebook with resident DNRs at the nursing station. Resident #67's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively intact. An interview was conducted on [DATE] at 8:38 A.M. with Resident #67. Resident #67 indicated she was unable to recall when, but she told someone at the facility she did not want her chest pumped or someone to breathe for her if her body stopped working. She stated she was unable to remember what it was called or who asked her about her code preference. An interview was conducted on [DATE] at 12:11 P.M. with Nurse #1. During the interview, Nurse #1 stated she was unfamiliar with Resident #67's code status. Nurse #1 explained if something happened and Resident #67's code status was needed, she would look in Resident #67's paper medical chart at the nurse's station to determine if CPR (Cardiopulmonary Resuscitation) was required to be administered. Nurse #1 looked in Resident #67's paper medical chart and stated there was no DNR paperwork on file. Nurse #1 stated if Resident #67's code status was needed, she would check Resident #67's paper medical chart at the nurse's station and without seeing an advanced directive, she would have started CPR (cardiopulmonary resuscitation) on Resident #67. An interview was conducted on [DATE] at 12:14 P.M. with Unit Manager #1. The Unit Manager looked in Resident #67's paper medical chart at the nurse's station and stated Resident #67's DNR form was not in the medical chart. During the interview, the Unit Manager stated DNR forms were kept at the nurse's station in the resident's paper medical chart. Unit Manager #1 explained Resident #67 had signed a DNR form and the form was placed in Resident #67's paper medical chart. She stated Resident #67 may have had an outside medical appointment and the DNR form was not returned to Resident #67's paper medical chart when she returned from the appointment. The Unit Manager stated Resident #67 had several appointments and she was unable to determine when the DNR form was misplaced. An interview was conducted on [DATE] at 12:45 P.M. with the Director of Nursing (DON). During the interview, the DON stated Resident #67's DNR form should be in her paper medical chart located at the nurse's station. The DON stated she was unsure why Resident #67's DNR was not located in her paper medical chart and explained the form may have been misplaced when Resident #67 had a medical appointment, and the form was removed to be transferred with her to the outside medical appointment. The DON further explained the assigned nurse when Resident #67 returned from her appointment was responsible to ensure the DNR was received and returned to Resident #67's paper medical chart. The DON was unsure when Resident #67's DNR form was misplaced, or which nurse was assigned Resident #67 when the form was misplaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure a resident with a mental disorder had received a Preadmission Screening and Resident Review (PASRR) prior to admission to the facility for 1 of 4 residents reviewed for PASRR (Resident #100). Findings included: Resident #100 was admitted to the facility on [DATE] from another nursing home with a diagnosis of bipolar disorder. Resident #100 was discharged to the hospital on 3/18/2023 and was readmitted on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #100 was not considered by the state Level II PASRR process to have a serious mental illness. There were no Level II PASRR conditions marked for serious mental illness. The MDS indicated Resident #100's diagnoses included bipolar disorder. Resident #100 was noted as receiving an antipsychotic (treatment for mental health conditions) medication daily. Resident #100's care plan dated 4/22/2023 included a focus for the use of psychotropic drugs for diagnosis of bipolar disorder, and interventions included evaluating the effectiveness and side effects of psychotropic medications. The care plan did not include PASRR information. A psychiatric evaluation progress note dated 5/9/2023 recorded Resident #100 with a long history of bipolar disorder and treatment included administration of lurasidone, an antipsychotic medication used to treat mental health conditions like bipolar disorder. Physician orders dated 7/25/2023 included lurasidone hydrochloride 20 milligram tablet at bedtime for bipolar disorder. On 8/29/2023 at 2:33 p.m. the Administration provided a copy of Resident #100's PASRR Level II determination notification letter dated 3/15/2023. Resident #100's physical and mental needs had been evaluated and deemed nursing facility placement was appropriate for Resident #100. There was no end date or limitation unless Resident #100 had a change in her condition. On 9/1/2023 at 11:00 a.m. during an interview with the admission Coordinator, she reviewed emails and information received from the transferring facility and stated they did not share any information indicating a new diagnosis for Resident #100 or submission of a Level II PASRR screening prior to her admission. She explained she ensured new admissions had a Level I PASRR, and Level II PASRR screenings were submitted by the Social Workers. On 9/1/2023 at 8:47 a.m. in an interview with MDS Nurse #1, she stated according to Resident#100's FL2 (Medicaid form) information, she had a Level I PASRR determination. She explained she had not received any information that Resident #100 had a Level II PASRR determination. On 9/1/2023 at 9:54 a.m. in an interview with Social Worker #1, she explained she was the assigned social worker for Resident #100 and did not have a Level II PASRR determination for Resident #100. She stated Resident #100 was admitted from another nursing home with a Level I PASRR noted on the FL2 form. Therefore, she did not think Resident #100 needed a Level II PASRR evaluation submitted for her diagnosis of bipolar disorder. She stated this was the first time she was seeing the Level II PASRR Determination Notification letter provided to the surveyor by the Administration on 8/29/2023. In a follow up interview with Social Worker #1 on 9/1/2023 at 11:04 a.m., she stated she was new to the position, and they were responsible for submitting Level II PASRR information for determination. She explained since Resident #100 had a diagnosis of bipolar disorder, she thought the transferring facility had completed the Level II PASRR screening process, and the Level I PASRR was current. She stated she should have checked the North Carolina Medicaid Uniform Screening Tool (NC MUST) system to confirm Resident #100 had been screened for a Level II PASRR determination. On 9/1/2023 at 10:51 p.m. in an interview with Social Worker #2, he stated based on the NC MUST report, the transferring facility submitted Level II PASRR information for Resident #100 on 3/9/2023 due to a change in condition. The report noted the Level II PASRR screening was completed and listed the start date as 3/15/2023. He explained the PASRR information printed on 8/29/2023 was different from information received from the transferring facility for Resident #100. He stated Resident #100's FL2 form recorded a Level I PASRR with a diagnosis of bipolar disorder on admission and a Level II PASRR evaluation should have been submitted. On 9/1/2023 at 10:00 a.m. in an interview with the Administrator, he explained the new Level II PASRR Determination Notification letter for Resident #100 was printed from the NC MUST program on 8/29/2023 by Social Worker #2. He explained it was after the PASRR information was requested they became aware of Resident #100's Level II PASRR status. He explained the transferring facility only provided Level I PASRR information for Resident #100. They thought since Resident #100 was being admitted from another nursing home she had been screened for Level II PASRR by the other facility and remained a Level I PASRR. He stated Resident #100 had arrived on 3/15/2023 at 1:00 p.m. and he understood the transferring facility received the Level II PASRR information at 3 p.m. on 3/15/2023 but did not call or email the facility to share the information. He said the facility was not aware of the Level II PASRR for Resident #100 until 8/29/2023. In a follow up interview on 9/1/2023 at 11:10 a.m., the Administrator stated residents' diagnoses warranting Level II PASRR screening were discussed in the interdisciplinary morning meetings. He explained if Resident #100 had transferred in from the hospital initially, her diagnosis of bipolar disorder would have triggered a Level II PASRR screening, but because she transferred from another nursing home facility, a Level II PASRR was not triggered for initiation. He stated the transferring nursing home failed to share the information about Resident #100's Level II PASRR Screening results with them and this facility did not verify Resident #100's Level II PASRR status in the NC MUST program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop and implement an individualized person-centered baseline care plan that included the use of an indwelling urinary catheter for elimination for 1 of 2 residents reviewed for urinary catheters (Resident #240). Findings included: Resident #240 was admitted to the facility on [DATE] and diagnoses included fracture right femur. The nursing admission assessment dated [DATE] at 10:37 p.m. recorded Resident #240's indwelling urinary catheter was draining clear yellow urine. Physician orders dated 2/2/2023 included providing urinary catheter care with soap and water every shift. Physician progress notes dated 2/3/2023 recorded use of the indwelling urinary catheter was due to Resident #240's inability to sit up and use a urinal after surgery of to the right femur. The baseline care plan dated 2/3/2023 for Resident #240 did not address the use of an indwelling catheter for urine elimination. On 9/01/2023 at 9:30 a.m. in an interview with Nurse #2, he stated the unit manager or assigned admission nurse on evenings and weekends started residents' electronic baseline care plans within forty-eight hours of admission. In a follow up interview on 9/1/2023 at 12:53 p.m., Nurse #2 explained Resident #240 was admitted to the facility late in the evening of 2/2/2023 and admission assessments were completed the following morning on 2/3/2023. He stated baseline care plans were based on items triggered on the admission assessment, and the indwelling urinary catheter should had been addressed on Resident #240's baseline care plan. Nurse #2 stated unit managers were responsible for checking the admission checklist which included the baseline care plan for completion of all items and stated asthe unit manager, he dropped the ball with Resident #240's baseline care plan. On 9/01/2023 at 12:00 p.m. during an interview with the Director of Nursing, she stated after Resident #240's admission process was completed, the unit manager was to check that the baseline care was started within forty-eight hours and included the use of the indwelling urinary catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to discard a resident's unlabeled opened Humalog insulin vial from 1 of 3 medication storage rooms observed (Specialized Programming for Alzheimer's Related Care [SPARC] unit). Findings included: Resident #119 was admitted to the facility on [DATE]. Physician orders dated 7/25/2023 included an order for Humalog solution 100unit/ml (Insulin Lispro (Human) inject as per sliding scale subcutaneously before meals for diabetes mellitus: if 0-150=0 units, 151-200= 2 units, 251-250=4 units, 251-300=6 units, 301-350=8 units, 351-400 =10 units; 401+ =12 units or above. Call MD if patient symptomatic. The order stated to discard the medication 28 days after opening and to check the expiration date. The order for Humalog insulin was started on 7/25/23 and was discontinued on 7/31/23. A review of Resident #119's Medication Administration Record for July 2023 indicated blood glucose monitoring was conducted three times a day and blood glucose levels were recorded less than 150 requiring no Humalog insulin administration to Resident #119. On 8/30/2023 at 11:40 a.m. during observation of the medication storage area for the SPARC unit with Nurse #2, a vial of Resident #119's Humalog insulin was observed open in a medication bottle with no vial cap located on top of the vial in the medication storage area refrigerator. The manufacture's expiration date on the vial of Humalog insulin read 3/13/2026. A label on the Humalog insulin vial read to discard in twenty-eight days, and there was no open date indicated on the label. The label on the outside of the medication bottle indicated the vial of Humalog Insulin was dispensed from the pharmacy on 7/27/2023. On 8/30/2023 at 11:40 a.m. in an interview with Nurse #2, she stated she was unsure when Resident #119's vial of Humalog insulin was opened and based on the date the pharmacy dispensed the medication (7/27/2023), the vial of Humalog insulin was expired and discarded the vial of Humalog insulin into the sharp's container on the SPARC's medication cart. She said Resident #119 had not received any of the Humalog insulin and explained refrigerated medications in the SPARC unit medication storge area were checked weekly for expiration date. In a follow up phone interview with Nurse #2 on 9/1/2023 at 1:15 p.m., she stated on 8/30/2023 she was assigned to the SPARC unit medication cart and had not had a chance to check the medication refrigerator on the SPARC unit for expired medications. On 8/30/2023 at 11:42 a.m. in an interview with the Director of Nursing (DON), she explained Resident #119's vial of Humalog insulin should have been discarded when the physician's order was written on 7/31/2023 to discontinue Resident #119's order for Humalog insulin and stated medications in the medication storage areas were to be checked daily for expired medications. In a follow up interview with the DON on 9/1/2023 at 11:57 a.m., she explained there was no reason for Resident #119's vial of Humalog insulin to be opened because Resident #119 had not required the use of Humalog insulin since ordered. She stated they were unable to determine when and why the cap was removed from Resident #119's vial of Humalog insulin and open vials of Humalog insulin expired in twenty-eight days after opening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident interivew and staff interviews, the facility failed to honor food preferences for 1 of 2 residents reviewed for food preferences (Resident #100). Findings included: Resident #100 was admitted to the facility on [DATE]. Resident #100's care plan dated 4/25/2023 included a focus for nutrition with actual weight loss due to cardiac disease. Interventions included providing diet as ordered and referencing dietician evaluations and recommendations. Physician orders dated 5/2/2023 included an order for a regular texture no added salt diet and to encourage fluids and offered hydration periodically every day for hydration. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #100 was moderately cognitively impaired and independently fed herself after the meal tray was set up. Dietary documentation dated 7/18/2023 indicated Resident #100 was receiving a regular textured no added salt diet with thin liquids and was consuming 50-100% on her dietary meals. The dietary note warranted no nutrition concerns although Resident #100 had experienced a 11.3% weight loss in last 90 days because Resident #100's weight had stabilized in the last 30 days. There were no recommendations for dietary changes. On 8/30/2023 at 12:45 p.m., Resident #100 was observed sitting up in wheelchair eating lunch. Resident #100's meal ticket read regular diet, eight-ounce water, two eight-ounce teas and wants some kind of fruit every meal. There was no eight-ounce water and no fruit observed on the meal tray. There was only one eight-ounce tea observed on the meal tray. Resident #100 stated she had her own water pointing to her water container and requested two teas for her meal trays. She explained she usually only received one tea and stated instead of receiving fruit on the lunch tray, she received a cookie. On 8/30/2023 at 1:17 p.m. in an interview with Dietary Aide #1, she stated she was responsible for informing the dietary staff on the lunch serving line of the preferences listed on Resident #100's meal ticket. She explained she forgot and did not call out to the dietary staff for Resident #100 to get two glasses of tea and fruit for the lunch meal tray. O 8/30/2023 at 1:13 p.m. in an interview with Dietary Supervisor, she stated residents should receive requested items on the meal tickets unless the food items are not available and stated fruit and teas were available for lunch meal trays. She explained dietary staff on the serving line were informed fruit for the lunch tray was bananas, and there were plenty of teas to provide Resident #100 two teas because there were cups of tea left at the completion of the lunch meal trays. She said Resident #100 not receiving tea eight-ounce teas and fruit on the meal tray as indicated on the meal ticket was an error on the serving line. She explained there was new dietary staff members on the serving line, and she would re-educate the dietary staff on granting resident's preferences and checking resident meal trays against the meal ticket for accuracy. On 9/01/2023 at 11:17 a.m. in an interview with the Administrator, he stated Resident #100 should had received items listed as preferences on the meal ticket on the lunch meal tray. He stated he had not received any dietary concerns from Resident #100's family or the Resident Council with the dietary department not honoring resident preferences.

Based on record review, observations, resident interview and staff interviews, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint survey of 4/8/2022. This was for two recited deficiencies on the current recertification and complaint investigation survey of 9/01/23. The deficiencies included Baseline Care Plan (F655) and Resident Allergies, Preferences and Substitutes (F806). The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross-referenced to: F-655 Based on record review and staff interviews, the facility failed to develop and implement an individualized person-centered baseline care plan that included the use of an indwelling urinary catheter for elimination for 1 of 2 residents reviewed for urinary catheters (Resident #240). During the recertification and complaint survey of 4/8/2022, the facility was cited for failure to complete a baseline care plan within 48 hours for a newly admitted resident. In an interview with the Administrator on 9/1/2023 at 1:13 p.m., he stated baseline care plans were added to the admission checklist for unit managers to ensure baseline care plans were started on new admissions. He explained the admission checklist was sent to Quality Assurance Performance of Improvement (QAPI) to review for completion of tasks on the admission checklist. He stated all nurses were trained on how to initiate a baseline care plan, and care plans were reviewed in interdisciplinary (IDT) meetings. He reported since November 2022, there had been no issues identified with the initiation of a baseline care plan for new admissions. F-806 Based on record review, observations, resident interview and staff interviews, the facility failed to honor food preferences for 1 of 2 residents reviewed for food preferences (Resident #100). During the recertification and complaint survey of 4/8/2022, the facility was cited for failure to provide resident's food preferences as listed on the meal tray ticket for a resident. In an interview with the Administrator on 9/1/2023 at 1:13p.m., he stated there had been no concerns identified with residents not receiving their dietary preferences in Quality Assurance Performance of Improvement (QAPI) meetings. He explained due to the Dietary Manager being out of work for medical reasons and employment of some new staff members in the dietary department, he had assigned the Assistant Administrator to oversee the operations of the dietary department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews with the resident and facility staff the facility failed to honor a resident ' s preference for time of day to receive a shower for 1 (Resident #39) of 3 reviewed for choices. The findings included: Resident#39 was admitted to the facility on [DATE]. The care plan initiated on 6/10/19 revealed Resident #39 required assistance for bathing related to impaired mobility and documented he preferred showers about 11:00 AM. The care plan again documented Prefers shower at around before lunch. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #39 was cognitively intact. He required extensive assistance with most activities of daily living and was totally dependent for bathing. On 4/4/22 at 1:22 PM Resident #39 stated his shower schedule changed to the 3:00 PM to 11:00 PM shift because they did not have time on the 7:00 AM - 3:00 PM shift to give him a shower. Resident #39 also said his shower schedule was changed but he still does not get a shower when he wants one. On 4/8/22 at 9:13 AM Resident #39 said they changed his shower schedule about 3 months ago and he had been very unhappy since that happened. He stated he was never told why his shower schedule changed but he told the nurse aide he did not like it. He added he did not remember which nurse aide it was. Resident #39 said he felt he had to go with what they say. On 4/8/22 at 12:13 PM Nurse #4 stated he was unsure why the shower schedule changed but the schedule was based on the resident ' s room number, and he thought Resident #39 ' s shower schedule changed when he moved to his current room. On 4/8/22 at 2:20 PM the Director of Nursing stated she was unaware Resident #39 ' s shower schedule was changed, and she was not aware he preferred to have a shower on the 7:00 AM to 3:00 PM shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility neglected to provide requested assistance as directed in the resident's plan of care for 1 of 10 residents reviewed for activities of daily living (Resident #217). Findings included: Resident #217 was admitted to the facility 3/30/22. Her active diagnoses included contusion of unspecified forearm, repeated falls, and dependence on renal dialysis. Resident #217 did not have a completed Minimum Data Set assessment. Review of the completed Brief Interview for Mental Status (BIMS) signed 3/31/22 revealed she was assessed as cognitively intact. Resident #217's care plan dated 3/31/22 revealed she was care planned for activities of daily living care. The interventions included to provide one-person guidance and physical assistance with transfers and provide one-person physical extensive assistance for safety with toileting, adjusting clothing, washing hands, and pericare. During an interview on 4/4/22 at 3:06 PM Resident #217 stated early that morning she had to go to the bathroom. She rang the call bell around 6:00 AM. She stated she was previously told not to get out of bed herself by therapy and the staff in the facility. After she had waited thirty minutes, she was able to reach her wheelchair and transferred herself to the wheelchair. She reported she went to the door to the hall in order to turn the light on and a male nurse aide (NA #1) opened the door and said, What do you need? The resident told him she needed to use the restroom and she had rung, and no one answered. He told her, well go. She informed him she was not supposed to transfer alone. She said NA #1 pushed her briskly into the bathroom and left without assisting her on to the toilet. He was gone before she could say anything to him. She transferred herself to the toilet and went to the bathroom but she could not transfer herself back to the wheelchair as the wheelchair was higher than the toilet seat and she was not supposed to transfer herself. She turned on the call light in the bathroom. She sais she pulled the call light three or four times, but no one came. She started yelling from the bathroom for help and banging the wall. After about fifteen minutes of shouting for help she started to cry, and NA #1 came in and asked sharply What's wrong? She told him she could not get off the toilet. NA #1 then attempted to assist her by her left arm but her left arm was swollen and painful due to a dialysis shunt issue, so she told him not to use her left arm for transfers. She said NA #1 then took ahold of her nightgown by her right shoulder in his hand and pulled her up by the night gown. It was uncomfortable but enough support to help her transfer to the wheelchair. He pushed her in her wheelchair out of the bathroom into the room and put her beside the bed. Resident #217 stated NA #1 did not transfer her to the bed or assist with her transfer. He left the room quickly before she could ask for assistance back to the bed. She knew at that point she was not going to get help back to bed so she attempted herself. She said she was able to transfer herself to her bed and by that point her legs were shaking. She concluded it made her feel deeply concerned she was not going to get the care and assistance she needed in the facility and it caused her to cry. Resident #219 resided across the hall from Resident #217 and a review of her Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. During an interview on 4/4/22 at 2:44 PM Resident #219 stated that morning for about 15 minutes a resident was shouting for help across the hall. The resident was shouting for someone to help her, banging on the walls, and crying. Eventually a staff member must have responded because the noise ended after 15 to 20 minutes. Review of the assignment sheet for the 11 PM to 7 AM shift for 4/3/22 through 4/4/22 revealed NA#1 was assigned Resident #217. During an interview on 4/7/22 at 4:52 PM NA#1 stated the morning of 4/4/22 Resident #217 had turned her call light on and he went to her room. She asked for assistance to the bathroom. He stated she was still in the bed, and he asked her how she needed assistance as it was his first time working with her. She asked him to guide her by her left arm to her wheelchair and then she could go to the bathroom. NA #1 stated he assisted her by her left arm into the wheelchair and then they entered the bathroom he then assisted her by her left arm to the toilet and told her to ring the call bell when she was done, and he would give her privacy. He stated he then left.NA #1 stated about 5 minutes later the resident rang the call bell from the bathroom and he returned when he saw the light turn on over her room. He stated she had transferred herself back to the wheelchair and was in her room. He stated while trying to transfer the resident back to bed, she indicated she was too weak, so he got assistance from NA#5. Together they were able to transfer the resident to her bed. During an interview on 4/7/22 at 5:33 PM NA#5 stated she did work on 4/3/22 through 4/4/22 and never assisted NA #1 with Resident #217. She further stated she did not like working with NA#1 because he would clock in to work and then disappear. NA #5 stated NA #1 did not answer his call lights and would have a bad attitude in order to avoid work. NA #5 concluded she would spend the shift working with NA#1 answering his call lights and providing care in order to assure his residents as well as her own received care. During an interview on 4/8/22 at 7:58 AM Nurse #4 stated NA#1 was always late and always had complaints from his residents about him. Nurse #4 filed grievances about NA#1 on behalf of the residents. NA#1 was fired from the facility a long time ago and came back with an agency staff person. Nurse #4 said NA#1 was then identified as do not return to the facility with his agency but when the Administrator changed, NA#1 would return through an agency. The nurse would inevitably have to file a grievance about NA#1 for a resident and the nurse aide would be labeled as do not return again. This had happened multiple times. During an interview on 4/8/22 at 9:34 AM the Director of Nursing stated nurse aides should assist with transfers and activities of daily care in accordance with their plan of care. Nurse aides were expected to answer and engage with residents to promote dignity and provide the assistance they needed. Based on the information provided she understood this was a concern for Resident #217 and she would follow up with Resident #217 and the nurse aide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to identify and complete a significant change in condition assessment after the resident was admitted to Hospice services for 1 of 2 residents reviewed for Hospice (Resident #21). Findings included: Resident #21 was admitted to the facility on [DATE] with multiple diagnoses that included malignant neoplasm. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively intact. A Physician's order dated 2-10-22 revealed Resident #21 was placed on hospice services. Resident #21's care plan dated 2-10-22 revealed a goal that he would not experience pain without appropriate nursing intervention. The interventions for the goal were in part spiritual care consult, consult with hospice and physician regarding pain management. During an interview with MDS Nurse #1 on 4-6-22 at 2:55pm, MDS Nurse #1 confirmed there was not a significant change MDS completed after Resident #21 was placed on hospice. She also confirmed a significant change MDS should have been completed on 2-10-22 when Resident #21 was placed on hospice. The MDS Nurse stated she had missed completing the significant change assessment. The Administrator was interviewed on 4-8-22 at 12:30pm. The Administrator stated he expected the MDS to be accurately documented when a significant change had occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of functional limitation in range of motion (Resident #75), Preadmission Screening and Resident Review (Resident #91), and tobacco use (Resident #97). This was for 3 of 29 resident's MDS assessments reviewed. Findings included: 1. Resident #75 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disturbance. A review of the 03/14/2022 quarterly MDS assessment for Resident #75 revealed she had no functional limitation in the range of motion of her lower extremities. It further revealed she received physical therapy (PT) for a total of 169 minutes in the last 7 days beginning on 03/08/2022. A review of the PT Daily Treatment Note for Resident #75 dated 03/08/2022 revealed the treatment diagnosis of contracture (a permanent tightening of the muscles, tendon, skin, and nearby tissues that causes the joints to shorten and become very stiff) of the left knee. On 04/06/2022 at 1:45 PM an interview with Resident #75's Physical Therapist (PT #1) indicated Resident #75's treatment began on 03/08/2022 because of a contracture of her left knee. She stated this meant Resident #75 did not have full functional range of motion in her left knee and could not straighten it all the way. PT #1 went on to say Resident #75 continued to have this knee contracture on 03/29/2022 when Resident #75 was discharged from PT services. On 04/07/2022 at 8:47 AM an interview with MDS Nurse #1 indicated she coded Resident #75's quarterly MDS assessment dated [DATE] to reflect Resident #75 had no functional limitation in the range of motion of her lower extremities. She stated Resident #75 could not follow instructions. She went on to say she had not wanted to touch Resident #75 during the assessment because Resident #75 was easily agitated. She further indicated she observed Resident #75 moving her lower extremities in bed during the look back period for this assessment. On 04/07/2022 at 9:06 AM an interview with the Director of Nursing (DON) indicated Resident #75's MDS assessment should be an accurate reflection of her status. 2. Resident #91 was admitted to the facility on [DATE]. His active diagnoses included schizophrenia. Resident #91's most recent Preadmission Screening and Annual Resident Review (PASARR) Level II determination notification dated 1/26/22 revealed he was assessed to be level II PASARR. Resident #91's MDS assessment dated [DATE] revealed he was assessed to not have a level II PASARR. During an interview on 4/6/22 at 10:09 AM MDS Nurse #2 stated the MDS dated [DATE] was incorrectly coded and was an error. She concluded she would complete a modification immediately. During an interview on 4/6/22 at 9:52 AM the Administrator stated PASARR status should be accurately reflected in resident MDS assessments. 3. Resident #97 was admitted to the facility on [DATE], Her diagnoses included chronic obstructive pulmonary disease and nicotine dependence. The annual MDS dated [DATE] indicated Resident #97 was moderately cognitively impaired and was not a current tobacco user. On 4/5/22 at 2:17 PM Resident #97 was observed outside in a designated smoking area with other residents and a staff member. She was observed smoking a cigarette. On 4/5/22 at 2:17 PM Resident #97 stated she had been a smoker since admission to the facility. On 4/8/22 at 12:34 PM an interview with MDS nurse #1 was conducted. She stated Resident #97 was a smoker and tobacco use had been coded incorrectly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident, staff and Physician interviews, the facility failed to provide wound care treatment as ordered for 1 of 3 residents (Resident #106) reviewed for pressure ulcers. Findings included: Resident #106 was admitted to the facility on [DATE] with multiple diagnoses that included pressure ulcer of the left heel stage 3. Resident #106's care plan dated 2-27-22 revealed a goal that her current pressure ulcer would not worsen or show signs/symptoms of infection. The interventions for the goal were in part treatment as ordered by the Physician. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #106 was cognitively intact and was coded for 1 unstageable pressure ulcer. Physician order dated 3-8-22 read to clean wound with wound cleanser, apply Medi-honey, foam dressing and wrap with gauze. Review of Resident #106's Treatment Administration Record (TAR) for March 2022 revealed there was no documentation of wound care completed on the following dates, March 12, 13. and 27. During an interview with Resident #106 on 4-4-22 at 12:00pm, the resident stated when the wound care nurses were not working, her dressings to her left heel were not changed. Documentation of Resident 106's heel wound revealed the wound measured 5 centimeters long and 2.6 centimeters wide on 3-30-22. Observation of Resident #106's wound care occurred on 4-6-22 at 9:43am. The wound was noted to be partially covered with eschar (dead tissue) and had moderate bloody drainage. There was no odor or signs and symptoms of an infection. The peri wound was observed to be pink. Resident #106's wound measured 5 centimeters long by 3.5 centimeters wide with no depth. The wound care nurse was observed to provide wound care per the Physician's order maintaining a clean field. A telephone interview was conducted on 4-7-22 at 12:37pm with Nurse #1. The nurse confirmed she worked on 3-12-22 and 3-13-22 with Resident #106. She stated she was aware the resident had a wound, but she did not complete the wound care. Nurse #1 said she thought the wound care nurses would complete the wound care and was not informed there was not a wound care nurse working on 3-12-22 and 3-13-22. Wound Care (WC) Nurse was interviewed on 4-7-22 at 2:43pm. The WC nurse stated she was aware wound treatments were being missed when she was not available and explained the floor nurses were responsible for the residents' wound care when there was not a WC nurse available. She also discussed sharing with the facility's Physician the status of Resident #106's wound and had received new treatment orders when necessary. During a telephone interview with Nurse #7 on 4-7-22 at 4:43pm, the nurse confirmed she was assigned to Resident #106 on 3-27-22. The nurse stated she thought she had completed the wound care to Resident #106's heel but said she did not document that the care was completed because the TAR was in a separate binder, and she forgot to look in the TAR binder. The facility Physician was interviewed on 4-7-22 at 1:21pm. The Physician explained he did not perform wound care but spoke with the WC nurses about residents' wounds and would adjust treatment as needed. He stated he was not aware the wound care was not being completed at times and expected staff to complete wound care as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, facility staff and Physician interviews the facility failed to administer medications as ordered by the physician resulting in 7 missed doses of Neurontin (pain medication) for 1of 5 residents (Resident #82) reviewed for unnecessary medication. Findings included: Resident #82 was admitted to the facility on [DATE] with multiple diagnoses that included chronic pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #82 was cognitively intact. Resident #82's care plan dated 4-5-22 revealed a goal that she would be pain free. The interventions for the goal were in part administer pain medication as ordered by the Physician and note the effectiveness. A Physician order dated 3-7-22 read Neurontin (pain medication) 300mg (milligram) twice a day for pain. Review of the Pharmacy documentation for March 2022 and April 2022 revealed no documentation for a dose reduction of Resident #82's Neurontin. Resident #82's printed Medication Administration Record (MAR) for April 2022 was reviewed and revealed the order for Neurontin 300mg twice a day had the word twice scratched out and the evening dose time scratched out so Resident #82 was receiving her Neurontin once a day from 4-1-22 through 4-8-22. During an interview with Nurse #3 on 4-8-22 at 8:00am, the nurse confirmed on Resident #82's MAR, the medication Neurontin had the word twice scratched out and the evening dose time was scratched out. She stated she was not aware of who scratched out the information and thought it had been scratched out due to a transcription error. The nurse reviewed the Physician's orders and confirmed there was no order to decrease Resident #82's Neurontin from twice a day to once a day. Observation of Resident #82 occurred on 4-8-22 at 8:50am. The resident was receiving pain medication and was observed not to inquire about what she was taking or how often her medication was prescribed. The facility Physician was interviewed by telephone on 4-8-22 at 9:00am. The Physician confirmed he had not changed Resident #82's Neurontin order from twice a day to once a day. He also stated Resident #82 would not show signs of increased pain from the decreased dose of Neurontin for 3 weeks to a month. An interview with the Director of Nursing (DON) occurred on 4-8-22 at 9:10am. The DON stated she could not comment on the error because she had not known the MAR had been changed. The facility's Nurse Practitioner (NP) was interviewed by telephone on 4-8-22 at 9:16am. The NP confirmed she had not decreased Resident #82's Neurontin from twice a day to once a day. She stated she had given a verbal order today (4-8-22) to decrease the Neurontin dose to once a day due to Resident #82's blood work.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews with facility staff and the Registered Dietitian the facility failed to provide resident's food preferences as listed on the meal tray ticket for 1 (Resident #26) of 3 residents reviewed for food preferences. The findings included: Resident #26 was admitted to the facility on [DATE]. His diagnoses included severe protein calorie malnutrition, diabetes, and adult failure to thrive. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #26 was cognitively intact. He had no behaviors. He was independent with eating. The care plan updated 1/27/22 indicated Resident #26 had diabetes and was not compliant with diet and medications. The interventions included obtain resident's likes and dislikes and to incorporate as many likes as possible that are compatible with dietary restrictions. The care plan also revealed he was resistive to care and treatment. The intervention for this focus was to honor resident's choices, preferences and wishes regarding care and services. The diet order dated 3/19/22 was consistent carbohydrate, no added salt diet, regular texture. On 4/5/22 at 8:41 AM Resident #26 stated They did it again. He said he received 2 individual prepackaged bowls of cereal but no milk for them. He noted there was a sausage patty, grits, toast, and apple juice on the breakfast tray. Resident #26 stated he does not eat those items, and he just wanted his cereal with milk. He then stated How can I eat cereal with no milk? Who eats cereal with no milk? A review of the breakfast meal tray ticket for 4/5/22 revealed a notes section which read; Send two cheerios .& two milks only per resident request. In the section titled Standing orders the meal tray ticket read; 4 oz (ounces) assorted juice, 8 oz coffee, hot cereal, 2 X 8 oz milk 2%. An observation of the meal tray line was conducted on 4/6/22 from 12:00 PM - 12:20 PM. It was noted the dietary aide who was putting on the lid did not review the meal tray ticket to make sure the requested foods were on the trays. On 4/7/22 at 2:20 PM the Assistant Dietary Manager stated the dietary aide who put the lid on the tray was also responsible to check the tray for accuracy and food preferences. She said she did not remember which dietary aide was working in the tray checker position at breakfast on 4/5/22. On 4/7/22 at 2:30 PM the Registered Dietitian stated residents should receive foods as written on the meal tray ticket.

Based on record review and staff interviews the facility failed to provide effective oversite to ensure 100% of staff were fully vaccinated or granted medical/non-medical exemptions per Centers for Medicare and Medicaid Services (CMS) requirements. The findings included: This tag is cross-referenced to: CFR 483.80 (F888) - Based on observation, record review, and staff interviews the facility failed to implement an effective process for tracking COVID-19 vaccinations status to achieve 100% vaccination rate which resulted in 8.2% of staff partially vaccinated. This was for 8 of 11 staff reviewed for COVID-19 Vaccination Status (Nurse Aide (NA) #11, NA #12, NA #13, NA #14, Nurse #9, Dietary Aide #1, Housekeeper #1, and Housekeeper #2). The facility was not in outbreak status and had no positive cases for COVID-19 among the residents. During an interview on 4/8/22 at 10:11 AM the Corporate Clinical Director stated Administration should have been monitoring the staff vaccination requirements and enforced the 100% COVID-19 vaccination or approved exemption of staff requirement.

Based on observation, record review, and staff interviews the facility failed to implement an effective process for tracking COVID-19 vaccinations status to achieve 100% vaccination rate which resulted in 8.2% of staff partially vaccinated. This was for 8 of 11 staff reviewed for COVID-19 Vaccination Status (Nurse Aide (NA) #11, NA #12, NA #13, NA #14, Nurse #9, Dietary Aide #1, Housekeeper #1, and Housekeeper #2). The facility was not in outbreak status and had no positive cases for COVID-19 among the residents. Findings included: A review of the COVID-19 Guideline on Staff Vaccine Requirement dated 11/9/21 revealed all employees were required to become fully vaccinated with some limited exceptions. Vaccination under this policy is a mandatory condition of employment unless a request for reasonable accommodation was approved. Healthcare workers were to become fully vaccinated for COVID-19 prior to 1/4/22. Applicants for employment were required to be vaccinated at the time of hire. Applicants who had received one dose of a two dose series would be considered for employment contingent on their agreement to receive the second dose at the appropriate time. All documents were to be provided to the Administrator. Review of the COVID-19 Staff Vaccination Status Matrix revealed 8 staff members of 98 total facility staff were partially vaccinated resulting in 91.8% of staff being fully vaccinated. Review of the vaccination documentation of the 8 staff members provided by the facility revealed NA #11 received the first dose on 12/13/21 and had not received the second dose. NA #12 received the first dose on 12/3/21 and had not received the second dose. NA #13 received the first dose on 1/28/22 and had not received the second dose. NA #14 received the first dose on 12/3/21 and had not received the second dose. Nurse #9 received the first dose on 12/3/21 and had not received the second dose. Dietary Aide #1 received the first dose on 11/21/21 and had not received the second dose. Housekeeper #1 received the first dose on 10/5/21 and had not received the second dose. Housekeeper #2 received the first dose on 1/12/22 and had not received the second dose. NA #12, Nurse #9, Dietary Aide #1, and Housekeeper #1 were unable to be interviewed. During observation on 4/4/22 at 3:39 PM Nurse #9 was observed in the facility working a floater. Nurse #9 was one of the 8 partially vaccinated staff. During an interview on 4/7/22 at 4:23 PM the Scheduler stated Nurse #9 worked as a floater on 4/4/22 which meant she assisted nurses with residents throughout the building where she was needed. During an interview on 4/7/22 at 2:07 PM NA #14 stated she had received only one dose of the COVID-19 vaccine on 12/3/21 and had not received her second dose. She concluded she had been working with residents up through 4/2022 while she was partially vaccinated, had been told she needed a second dose, but had forgotten. During an interview on 4/7/22 at 2:59 PM NA #13 stated she was hired towards the end of 10/2021. At that time, they were told vaccinations would become mandatory for COVID-19 at the facility and she would be required to receive the vaccine. She stated at the beginning of 2022 the facility offered the vaccine to staff but she was sick and unable to get it so she told them she would get it from somewhere else. The nurse aide stated she did not receive the vaccine on 1/28/22 as the facility documentation indicated. The facility did not have anyone following up with staff or enforcing the vaccine requirement and it slipped her mind to get the vaccine and she had not thought about it until she was at her doctor's office on 3/28/22 and received it that date. During an interview on 4/7/22 at 3:19 PM Housekeeper #2 stated she received her first dose of the COVID-19 vaccine 1/12/22. She further stated she had not thought about getting the second dose and no one from the facility had asked her about the second dose until this week and she had been working through 4/2022. During an interview on 4/7/22 at 3:28 PM NA #11 stated she had gotten the first vaccine dose on 12/3/21 and had not received a second dose. She had just returned from having an extended leave and had worked a few days at the end of 3/2022 and beginning of 4/2022. She concluded she had not been told by the facility she needed to get the second dose, and no one had been enforcing vaccination requirements at the facility. During an interview on 4/7/22 at 12:56 PM the Administrator stated he had multiple staff members who had the first vaccine dose of a multi-dose vaccine, were eligible for the second dose, but had not received it. He stated he was aware of the new requirements from the Centers for Medicare and Medicaid Services (CMS) for staff to be either 100% fully vaccinated or granted an exemption. He concluded he had no explanation as to why the staff were not 100% fully vaccinated or granted an exemption.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #43 was admitted to the facility on [DATE] with a diagnosis of dementia without behavioral disturbance. A review of the quarterly MDS assessment for Resident #43 dated 02/10/2022 revealed she was severely cognitively impaired. She required the extensive assistance of two people for bed mobility and extensive assistance of one person for dressing. It further revealed Resident #43 required the total assistance of one person for toileting, personal hygiene, and bathing. A review of her medical record revealed no evidence of care plan meetings or care plan meeting attendance signature sheets. On 04/04/2022 at 4:41 PM a telephone interview with Resident #43's family member revealed he was her Representative (RP). He stated although the facility kept him informed of any falls or other issues with Resident #43, he had not received any invitation to or participated in any care plan meetings. On 04/07/2022 at 9:46 AM an interview with SW #1 indicated Resident #43 had not previously been assigned to him. He stated he took over the assignments for all residents in February 2022. He went on to say normally care plan meetings were held based on a calendar the MDS Nurse sent out. SW #1 indicated he would send out the invitation letters to the scheduled care plan meetings to residents and their RPs. He went on to say he did not have any record of Resident #43's scheduled care plan meetings and had not sent her RP any invitation letters. On 04/07/2022 at 10:08 AM an interview with MDS Nurse #1 indicated she sent out the care plan schedule to the SW based the day a resident's MDS assessment was due. She stated Resident #43's 02/10/2022 MDS assessment date would have been on this care plan schedule but she did not keep any records of this. On 04/7/2022 at 5:43 PM an interview with the facility Corporate Clinical Director indicated the facility had no record of any care plan meetings or care plan meeting attendance sheets for Resident #43. She stated if a care plan meeting was held, there should have been documentation in the progress notes or a care plan meeting signature sheet to indicate who attended the meeting. On 04/08/2022 at 8:10 AM an interview with the facility's Mobile Administrator indicated she was the facility's previous Administrator and now served as a Mobile Administrator. She stated she thought she recalled a care plan meeting for Resident #43 in December 2021, although she could not recall the exact date. She stated she did not recall the names of the people who attended and there was no documentation of this and no care plan meeting signature sheets in Resident #43's record. She further indicated care plan meetings for residents should be held at least every 3 months and occur after any change in condition. She went on to say she was not aware of any other care plan meetings for Resident #43. On 04/08/2022 at 3:19 PM an interview with the Administrator indicated Resident #43 did not have care plan meetings as required. He stated due to the transition of administration and the loss of the social worker who arranged the meetings they had not happened. Based on record review and staff, resident, and resident representative interviews the facility failed to invite a resident or resident representative to participate in the development or revision of the care plan for 5 of 8 residents reviewed for care plan meetings (Resident #91, Resident #16, Resident #46, Resident #97, and Resident #43). Findings included: 1. Resident #91 was admitted to the facility on [DATE]. His active diagnoses included schizophrenia, type 2 diabetes mellitus, hyperlipidemia, ischemic cardiomyopathy, stage 4 kidney disease, and heart failure. Resident #91's Minimum Data Set assessment dated [DATE] revealed the resident was assessed as cognitively intact. During an interview on 4/4/22 at 11:43 AM Resident #91 stated he had never had a care plan meeting but was not entirely sure what a care plan meeting was. During an interview on 4/6/22 at 8:15 AM Social Worker #1 stated Resident #91 was admitted [DATE] and there were two social workers who worked at the facility until early 2/2022. Resident #91 was on Social Worker #2's caseload, and he was unable to find any documentation of any care plan meetings with the resident. There was also no documentation of the resident being invited to any care plan meetings. He concluded he was unaware of any reason the resident did not have any care plan meetings or invitations to care plan meetings documented and could not speak to if a care plan meeting ever happened for Resident #91 due to lack of documentation. He stated when Social Worker #2 left in 2/2022 the facility began looking for another social worker and in the interim, he was keeping up with the whole building. Social Worker #1 concluded he was unaware the resident had not been having his routine care plan meetings. During an interview on 4/6/22 at 9:52 AM the Administrator stated in early 3/2022 they had identified care plan meetings as an issue due to the loss of a staff member. The facility was hiring for a new social worker and the current social worker had not completed the backlog of care plan meetings that had been missed. He stated currently they have letterheads they had implemented to invite residents and resident representatives to care plan meetings and had implemented a weekly calendar and the letters were sent out on Mondays. The Administrator concluded Resident #91 should have had a care plan meeting and been invited. Social Worker #2 was unavailable for interview. 2. Resident #16 was admitted to the facility on [DATE]. His active diagnoses included malnutrition, peripheral vascular disease, chronic venous hypertension with ulcer of left and right lower extremity, anemia, adult failure to thrive, dysphagia, personal history of malignant neoplasm of prostate, and type 2 diabetes. Resident #16's Minimum Data Set assessment dated [DATE] revealed he was assessed as severely cognitively impaired. During an interview on 4/4/22 at 1:58 PM Resident #16's responsible party stated he was not aware of ever being involved in or invited to a care plan meeting. During an interview on 4/6/22 at 8:15 AM Social Worker #1 stated Resident #16 was admitted [DATE] and there were two social workers who worked at the facility until early 2/2022. Resident #16 was on Social Worker #2's caseload, and he was unable to find any documentation of any care plan meetings with the resident's responsible party as the resident was severely cognitively impaired. There was also no documentation of the resident's responsible party being invited to any care plan meetings. He concluded he was unaware of any reason the resident did not have any care plan meetings documented or invitations of the resident's responsible party to care plan meetings documented. He could not speak to if a care plan meeting ever happened for Resident #16 due to lack of documentation. He stated when Social Worker #2 left in 2/2022 the facility began looking for another social worker and in the interim, he was keeping up with the whole building. Social Worker #1 concluded he was unaware the resident had not been having his routine care plan meetings. During an interview on 4/6/22 at 9:52 AM the Administrator stated in early 3/2022 they had identified care plan meetings as an issue due to the loss of a staff member. The facility was hiring for a new social worker and the current social worker had not completed the backlog of care plan meetings that had been missed. He stated currently they have letterheads they had implemented to invite residents and resident representatives to care plan meetings and had implemented a weekly calendar and the letters were sent out on Mondays. The Administrator concluded Resident #16 should have had a care plan meeting and been invited. Social Worker #2 was unavailable for interview. 3. Resident #46 was readmitted to the facility on [DATE] with diagnoses which included congestive heart failure, atrial fibrillation, and hypertensive heart disease. The most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS indicated Resident #46 was cognitively intact. During an interview with Resident #46 on 4/5/22 at 10:54 AM she stated she had not attended a care plan meeting and had never heard of a care plan meeting or what it was for. On 4/6/22 at 8:59 AM Social Worker (SW) #1 stated he reviewed the documentation and there was no record of a care plan meeting for Resident #46. SW #1 said the care plan meeting should be scheduled after each MDS assessment was completed. He said the last MDS for Resident # 46 was dated 2/11/22 so there should have been a care plan meeting within 14 days of that MDS. SW #1 said SW #2 was responsible for this resident prior to 2/2022 when SW #2 was no longer employed by the facility. On 4/6/22 at 11:30 AM the Administrator reported the facility had identified care plan meetings were not being conducted since one of the two social workers left employment. He said the current social worker had not completed the backlog of care plan meeting that had been missed. This included resident #46. The Administrator stated care plan meeting should be scheduled and the residents or their responsible party should be invited to attend. 4. Resident #97 was admitted [DATE]. Her diagnoses included atrial fibrillation and obstructive pulmonary disease. The most recent MDS an annual MDS dated [DATE] indicated Resident #97 was moderately cognitively impaired. She was able to make herself understood and she was able to understand others with clear comprehension. On 4/5/22 at 2:03 PM Resident #97 stated she had not attended a care plan meeting. On 4/6/22 at 8:55 AM SW #1 stated there was no documentation of a care plan meeting for Resident #97. He said he review her medical record back to June 2021 and there were no notes about any care plan meetings. SW #1 stated the other SW left in February 2022 and SW #1 thought SW #2 had completed her assignments. He reported he just started conducting care plan meetings that were previously assigned to SW #2. SW #1 stated Resident # 97 must have been missed. On 4/6/22 at 11:35 AM the Administrator reported the facility had identified care plan meetings were not being conducted since one of the two social workers left employment. He said the current social worker had not completed the backlog of care plan meeting that had been missed. This included resident #97. The Administrator stated care plan meeting should be scheduled and the residents or their responsible party should be invited to attend.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #106 was admitted to the facility on [DATE] with multiple diagnoses that included spinal stenosis, chronic pain and diabetes. Resident #106's care plan dated 2-27-22 revealed a goal that she would be neat, clean and odor free. Maintain good oral hygiene. The interventions for the goal were in part bathing required total dependance with one person, provide intermittent supervision, repetitive cues, aid with set up of oral/dental supplies. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #106 was cognitively intact and required extensive assistance with 2 people for bed mobility, total assistance with one person for transfers, bathing and toileting, extensive assistance with one person for personal hygiene. Review of the March 2022 ADL documentation revealed there was no documentation of baths/showers being provided for the following dates, March 3, 19, 20, 22, 24, 27. Resident #106 was interviewed on 4-4-22 at 12:00pm. The resident discussed not receiving a bath on a regular basis and stated her baths were not provided mostly on the weekends. During an interview with NA #10 on 4-7-22 at 1:30pm, the NA confirmed she was assigned to Resident #106 most of the days in March. She stated if the missing documentation for a bath/shower was on a weekend (March 19, 20, & 27) she did not provide a bath or shower to Resident #106 due to not having enough staff. NA #10 said on March 3, 22 and 24 she probably had provided a bath/shower and forgot to document. The Director of Nursing (DON) was interviewed on 4-8-22 at 11:20am. The DON stated ADL care not being provided to the residents was a problem and she was aware the nurses were not assisting the NA's when there were not enough NA's present to complete ADL care. The DON discussed the facility trying to hire more staff to alleviate the care issue. 7. Resident #77 was admitted to the facility on [DATE] with multiple diagnoses that included fracture of the upper end of the left humerus (long bone from the shoulder to the elbow). Resident #77's care plan dated 2-7-22 had a goal of ADL/personal care would be completed with staff support. The interventions for the goal were in part bathing extensive assistance with one person. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was cognitively intact and required extensive assistance with one person for bed mobility, transfers, dressing, toileting and personal hygiene and total assistance with one person for bathing. Review of Resident #77's ADL documentation for March 2022 revealed no documentation the resident received a bath/shower on the following dates, March 3, 10, 15, 19, 20, 24, 27. Resident #77 was interviewed on 4-4-22 at 11:35am. The resident stated she felt the facility was short staffed because there were many days, she did not get a bath or shower and the NA would tell her there were not enough staff to give everyone a bath. During an interview with NA #3 on 4-6-22 at 8:35am, the NA stated she may have been assigned to Resident #77 on one of the dates in March but could not remember. She said if there was not any documentation of a bath or shower provided, she probably was not able to complete the task because there were not enough staff. During an interview with NA #10 on 4-7-22 at 1:30pm, the NA confirmed she was assigned to Resident #77 most of the days in March. She stated if the missing documentation for a bath/shower was on a weekend (March 19, 20, 27) she did not provide a bath or shower to Resident #77 due to not having enough staff. The DON was interviewed on 4-8-22 at 11:20am. The DON stated ADL care not being provided to the residents was a problem and she was aware the nurses were not assisting the NA's when there were not enough NA's present to complete ADL care. The DON discussed the facility trying to hire more staff to alleviate the care issue. 8. Resident #21 was admitted to the facility on [DATE] with multiple diagnoses that included muscle weakness and dementia with behavioral disturbance. The quarterly MDS dated [DATE] revealed Resident #21 was cognitively intact and required extensive assistance with one person for toileting and personal hygiene and physical help with one person for bathing. Resident #21's care plan revealed a goal that he would bath safely and appropriately. The interventions for the goal were in part requires set up help provided by staff. Review of Resident #21's ADL care documentation for March 2022 revealed there was no documentation of Resident #21 had received a bath on the following dates, March 3, 6, 9, 12, 17, 19, 20, 24, 25, 27. An interview occurred with Resident #21 on 4-4-22 at 12:15pm. Resident #21 discussed being mostly independent with his bathing but required help with set up and washing some parts of his body. He stated he had not received the help necessary to have a bath on a regular basis. During an interview with NA #3 on 4-6-22 at 8:35am, the NA stated she may have been assigned to Resident #21 on one of the dates in March but could not remember. She said if there was not any documentation of a bath provided on the weekend, she probably was not able to complete the task because there were not enough staff. During an interview with NA #10 on 4-7-22 at 1:30pm, the NA confirmed she was assigned to Resident #21 most of the days in March. She stated if the missing documentation for a bath/shower was on a weekend (March 12, 19, 20, 27) she did not provide a bath or shower to Resident #21 due to not having enough staff. The DON was interviewed on 4-8-22 at 11:20am. The DON stated ADL care not being provided to the residents was a problem and she was aware the nurses were not assisting the NA's when there were not enough NA's present to complete ADL care. The DON discussed the facility trying to hire more staff to alleviate the care issue. 9. Resident #114 was admitted to the facility on [DATE] with multiple diagnoses that included muscle weakness and dementia without behavioral disturbance. The quarterly MDS dated [DATE] revealed Resident #114 was moderately cognitively impaired and required total assistance with one person for dressing, toileting personal hygiene and bathing. Resident #114's care plan dated 3-22-22 revealed a goal that Activities of ADL/personal care would be completed with staff support. The interventions for the goal were in part bathing total dependance with one person. Review of Resident #114's ADL documentation for March 2022 revealed there was no documentation Resident #114 received a bath/shower on the following dates, 1, 2, 3, 5, 6, 7, 9, 10, 14, 16, 19, 25, 26, 27, 28. Resident #114 was interviewed on 4-4-22 at 10:53am. The resident stated she did not receive a bath daily and emphasized especially on the weekends. During an interview with NA #3 on 4-6-22 at 8:35am, the NA stated she may have been assigned to Resident #114 on one of the dates in March but could not remember. She said if there was not any documentation of a bath provided on the weekend, she probably was not able to complete the task because there were not enough staff. During an interview with NA #10 on 4-7-22 at 1:30pm, the NA confirmed she has been assigned to Resident #114 in March 2022. She stated if the missing documentation for a bath/shower was on a weekend she did not provide a bath or shower to Resident #114 due to not having enough staff. NA #1 was interviewed on 4-7-22 at 5:10pm. NA #1 stated he had been assigned to Resident #114 in March 2022 but could not remember which days. He stated if there was not documentation of a bath/shower being provided then he had forgotten to document. The NA also stated if he had worked on a weekend, it was possible, he did not provide a bath or shower due to the number of residents he was assigned. The DON was interviewed on 4-8-22 at 11:20am. The DON stated ADL care not being provided to the residents was a problem and she was aware the nurses were not assisting the NA's when there were not enough NA's present to complete ADL care. The DON discussed the facility trying to hire more staff to alleviate the care issue. Based on observations, record review, and staff interviews the facility failed provide assistance with transfers and assistance with toileting (Resident #217), failed to keep dependent residents' fingernails clean (Resident #16, Resident #82, Resident #97, and Resident #88), and failed to provide baths (Resident #77, Resident #21, Resident #114, and Resident #106) for 9 of 10 resident reviewed for activities of daily living (ADL) care. Findings included: 1. Resident #217 was admitted to the facility 3/30/22. Her active diagnoses included contusion of unspecified forearm, repeated falls, and dependence on renal dialysis. Resident #217 did not have a completed Minimum Data Set (MDS) assessment. Review of the completed Brief Interview for Mental Status (BIMS) signed 3/31/22 revealed she was assessed as cognitively intact. Resident #217's care plan dated 3/31/22 revealed she was care planned for activities of daily living care. The interventions included to provide one-person guidance and physical assistance with transfers and provide one-person physical extensive assistance for safety with toileting, adjusting clothing, washing hands, and pericare. During an interview on 4/4/22 at 3:06 PM Resident #217 stated early that morning she had to go to the bathroom. She rang the call bell around 6:00 AM. She was previously told not to get out of bed herself by therapy and the staff in the facility. After she had waited thirty minutes, she was able to reach her wheelchair and transferred herself to the wheelchair. She went to the door to the hall in order to turn the light on and a male nurse aide (NA #1) opened the door and said, What do you need? Resident #217 told NA #1 she needed to use the restroom and she had rung, and no one answered. He told her, well go. She informed him she was not supposed to transfer alone. She stated NA #1 then pushed her briskly into the bathroom and left without assisting her on to the toilet. He was gone before she could say anything to him. REsidnet #217 stated she transferred herslef to the toilet and went to the bathroom but could not transfer herself back to the wheelchair as the wheelchair was higher than the toilet seat and she was not supposed to transfer herself. Resident #217 said she turned on the call light in the bathroom. She pulled the call light three or four times, but no one came. She started yelling from the bathroom for help and banging the wall. After about fifteen minutes of shouting for help she started to cry, and NA#1 came in and asked sharply What's wrong? She told him she could not get off the toilet. He then attempted to assist her by her left arm but her left arm was swollen and painful due to a dialysis shunt issue, so she told him not to use her left arm for transfers. NA #1 then took ahold of her nightgown by her right shoulder in his hand and pulled her up by the night gown. Resident #217 said it was uncomfortable but enough support to help her transfer to the wheelchair. He brought her in the room and put her beside the bed and did not transfer her to the bed or assist with her transfer. Resident #217 stated NA #1 left the room quickly before she could ask for assistance back to the bed. She knew at that point she was not going to get help back to bed so she attempted herself. She was able to transfer herself to her bed and by that point her legs were shaking. She concluded it made her feel deeply concerned she was not going to get the care and assistance she needed in the facility and it caused her to cry. Resident #219 resided across the hall from Resident #217 and a review of her Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. During an interview on 4/4/22 at 2:44 PM Resident #219 stated that morning for about 15 minutes a resident was shouting for help across the hall. The resident was shouting for someone to help her, banging on the walls, and crying. Eventually a staff member must have responded because the noise ended after 15 to 20 minutes. Review of the assignment sheet for the 11 PM to 7 AM shift for 4/3/22 through 4/4/22 revealed NA#1 was assigned Resident #217. During an interview on 4/7/22 at 4:52 PM NA#1 stated the morning of 4/4/22 Resident #217 had turned her call light on and he went to her room. She asked for assistance to the bathroom. He stated she was still in the bed, and he asked her how she needed assistance as it was his first time working with her. She asked him to guide her by her left arm to her wheelchair and then she could go to the bathroom. He assisted her by her left arm to the wheelchair and then they entered the bathroom he then assisted her by her left arm to the toilet and told her to ring the call bell when she was done, and he would give her privacy. He stated he then left. About 5 minutes later the resident rang the call bell from the bathroom and he returned when he saw the light turn on over her room. He stated she had transferred herself back to the wheelchair and was in her room. He stated while trying to transfer the resident back to bed, she indicated she was too weak, so he got assistance from NA#5. Together they were able to transfer the resident to her bed. During an interview on 4/7/22 at 5:33 PM NA#5 stated she did work on 4/3/22 through 4/4/22 and never assisted NA #1 with Resident #217. She further stated she did not like working with NA#1 because he would clock in to work and then disappear. She stated he did not answer his call lights and would have a bad attitude in order to avoid work. The nurse aide concluded she would spend the shift working with NA#1 answering his call lights and providing care in order to assure his residents as well as her own received care. During an interview on 4/8/22 at 7:58 AM Nurse #4 stated NA#1 was always late and always had complaints from his residents about him. Nurse #4 filed grievances about NA#1 on behalf of the residents. NA#1 was fired from the facility a long time ago and came back with an Agency. NA#1 was then identified as do not return to the facility with his agency but when the Administrator changed, NA#1 would return through an agency. The nurse would inevitably have to file a grievance about NA#1 for a resident and the nurse aide would be labeled as do not return again. This had happened multiple times. During an interview on 4/8/22 at 9:34 AM the Director of Nursing stated nurse aides should assist with transfers and activities of daily care in accordance with their plan of care. Based on the information provided she felt this was an activities of daily living concern for Resident #217 and she would follow up with the resident and the nurse aide. 2. Resident #16 was admitted to the facility on [DATE]. His active diagnoses included malnutrition, peripheral vascular disease, anemia, hypertension, and diabetes mellitus. Resident #16's quarterly minimum data set assessment dated [DATE] revealed he was assessed as severely cognitively impaired. He had no moods and no behaviors. He was totally dependent on one staff member for personal hygiene. A review of Resident #16's care plan dated 2/16/22 revealed he was care planned for activities of daily living care. The interventions included to provide extensive physical assistance with personal hygiene. During observation on 4/4/22 at 12:24 PM Resident #16 was observed to have black debris caked under his fingernails. During observation on 4/5/22 at 10:00 AM Resident #16 was observed to still have black debris caked under his fingernails. During an interview on 4/5/22 at 10:09 AM NA #6 stated Resident #16's fingernails were very dirty and did have black debris caked under the nails and should have been cleaned. She stated she had never known Resident #16 to refuse care and she would clean them that morning when she provided his bed bath. During observation on 04/05/22 10:10 AM NA #6 was observed to ask Resident #16 if his nails needed to be cleaned and if he would let her. Resident #16 nodded and smiled. During an interview on 4/5/22 at 10:14 AM Nurse #4 observed Resident #16's fingernails and stated they should have been cleaned before now as they had black debris caked under the nails. He concluded Resident #16 never refused care in his experience. During an interview on 4/5/22 at 10:15 AM the Director of Nursing, upon observing Resident #16's nails, stated his nails should have been cleaned prior to now as they had black debris caked under the fingernails. During an interview on 4/5/22 at 10:52 AM the Cooperate Clinical Director stated cooperate staff had rounded this morning on 4/5/22 and identified multiple residents with nail concerns and Resident #16 was one of the residents identified to have not received proper nail care. She concluded staff had not gotten around to cleaning his nails yet. 3. Resident #82 was admitted to the facility on [DATE] with diagnoses which included diabetes and hemiplegia of the left nondominant side. The quarterly MDS dated [DATE] indicated Resident #82 was cognitively intact. She had no behaviors. She required extensive to total assistance with activities of daily living. The care plan focus area of bathing last updated 9/15/20 and indicated Resident #82 was totally dependent on staff for bathing. On 4/4/4/22 at 2:30 PM Resident #82 was observed to have dirty fingernails on both hands. The fingernails were caked with dark brown and black debris. On 4/4/22 at 2:30 PM Resident #82 stated she did not know when her fingernails were last cleaned. She reported she had received her bed bath this morning and the previous morning. On 4/5/22 at 11:00 AM Resident #82's fingernails continued to contain dark brown and black debris. On 4/5/22 at 11:05 AM NA #2 observed Resident #82's fingernails. NA #3 stated the fingernails were dirty and needed to be cleaned. On 4/5/22 at 11:15 AM Nurse #11 observed Resident #82's fingernails. She stated the Residents' fingernails were dirty and also needed to be trimmed because they had jagged edges. Nurse # 11 then said the NA can clean the fingernails and should report to the nurse if the fingernails need to be trimmed since Resident #82 had a diagnosis of diabetes. On 4/5/22 at 2:29 PM the Director of Nursing (DON) said she expected resident's fingernails to be kept clean even if the resident only received a bed bath. She added NAs and nurses should notice if fingernails are dirty or long and clean and trim them as soon as possible. 4. Resident #97 was admitted to the facility on [DATE], Her diagnoses included atrial fibrillation, chronic obstructive pulmonary disease and nicotine dependence. The annual MDS dated [DATE] indicated Resident #97 was moderately cognitively impaired. She had rejection of care 1-3 days. She required extensive assistance for dressing, toilet use and personal hygiene. She was totally dependent on staff for bathing. On 4/5/22 at 10:34 AM Resident #97 was observed to have brown and black debris under her fingernails. On 4/7/22 at 12:04 PM Resident #97 stated she received a bath last night and her hair was washed. She said her nails were not cleaned during her bath and an observation during the interview revealed her fingernails continued to contain brown and black debris. On 4/8/22 at 12:06 PM an observation of Resident #97's fingernails revealed they continued to contain brown and black debris. The fingernails were now noted to be jagged. On 4/8/22 at 12:49 PM NA #15 stated she had enough time to give residents a bath but often did not have time to clean or trim a resident's fingernails. On 4/5/22 at 2:29 PM the Director of Nursing (DON) said she expected residents' fingernails to be kept clean even if the resident only received a bed bath. She added NAs and nurses should notice if fingernails are dirty or long and clean and trim them as soon as possible. 5. Resident #88 was admitted to the facility on [DATE] with diagnoses which included diabetes, coronary artery disease, and arthritis. The annual MDS dated [DATE] indicated Resident #88 was moderately cognitively impaired. She required extensive assistance with activities of daily living except she was totally dependent on staff for toileting and bathing. On 4/4/22 at 12:56 PM Resident #88 was observed to have brown and black debris under the fingernails of both hands. Her fingernails were noted to be more than ¼ inch in length. On 4/5/22 at 11:08 AM NA #2 observed Resident #88's fingernails. NA #3 stated the fingernails were dirty and needed to be cleaned. She stated Resident #88 had diabetes so she the nurse was responsible to trim her fingernails. On 4/5/22 at 11:18 AM Nurse #11 observed Resident #88's fingernails. She stated the Residents' fingernails were dirty and also needed to be trimmed because they were long. Nurse #11 then said the NA can clean the fingernails and should report to the nurse if the fingernails need to be trimmed since Resident #88 had a diagnosis of diabetes. On 4/5/22 at 2:29 PM the DON said she expected residents' fingernails to be kept clean even if the resident only received a bed bath. She added NAs and nurses should notice if fingernails are dirty or long and clean and trim them as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff and physician interviews the facility failed to apply a left knee brace as recommended by physical therapy (PT) services (Resident #75) and failed to apply a hand roll and elbow brace (Resident #9) for 2 of 2 Residents reviewed for positioning and mobility. This placed Resident #75 and Resident #9 at risk for a decrease in range of motion. Findings included: 1. Resident #75 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disturbance. A review of the 03/14/2022 quarterly Minimum Data Set (MDS) assessment for Resident #75 revealed she was severely cognitively impaired. She rejected care on one to three days of the seven day look back period of the assessment. Resident #75 required extensive 2 person assistance for bed mobility. She required the extensive assistance of one person for dressing. She did not walk. She had no functional limitation in the range of motion of her lower extremities. It further revealed Resident #75 received physical therapy (PT) for a total of 169 minutes in the last 7 days beginning on 03/08/2022. A review of the PT Daily Treatment Note for Resident #75 dated 03/08/2022 revealed the treatment diagnosis of contracture (a permanent tightening of the muscles, tendon, skin, and nearby tissues that causes the joints to shorten and become very stiff) of the left knee. She was discharged from therapy services on 03/29/2022. A review of a Functional Maintenance Recommendations form dated 03/29/2022 for Resident #75 revealed recommendations by PT to encourage range of motion (ROM) to bilateral lower extremities during activities of daily living (ADL) care and for Resident #75 to wear her left knee extension brace up to 6 hours. The form was signed by Nurse Aide (NA) #7, NA #8, and the Therapy Director on 03/29/2022 indicating in-service training related to the application of Resident #75's left knee brace was provided to NA #7 and NA #8 on that date. On 04/04/2022 at 2:39 PM Resident #75 was observed in bed. She was not wearing a left knee brace. No brace was observed in Resident #75's room. On 04/06/2022 at 8:53 AM Resident #75 was observed in bed. She was not wearing a left knee brace. No brace was observed in her room. On 04/06/2022 at 1:09 PM an interview with the Therapy Director indicated Resident #75 was discharged from therapy services on 03/29/2022 with the recommendation for her to continue wearing her left knee extension brace for up to 6 hours daily as tolerated. She went on to say she provided training to NA #7 and NA #8 on 03/29/2022 and the Functional Maintenance Recommendation form was provided to Unit Manager (UM) #1 either that day or the following day. The Therapy Director indicated she normally would train the NAs and Nurse regularly assigned to Resident #75 but NA #7 and NA #8 were the only people available to train that day. She indicated NA staff were to apply Resident #75's knee brace. She went on to say UM #1 was to place the recommendation on Resident #75's care plan for the NAs to carry out. On 04/06/2022 at 1:22 PM an observation of Resident #75 revealed she did not have her left knee brace on. An interview with NA #9 indicated she was regularly assigned to Resident #75 at least five days weekly and familiar with her care. She stated Resident #75 did have a left knee brace, but she had not seen it on her lately. She stated therapy staff applied Resident #75's brace. NA #9 went on to say the knee brace was kept in Resident #75's closet. She further indicated she had not been trained or instructed to apply it. She stated if NA staff were to apply a resident's brace it would appear on the resident's care plan which NAs had access to. On 04/06/2022 at 1:26 PM an interview with Nurse #6 indicated she was regularly assigned to Resident #75 five days weekly. She stated Resident #75 had been receiving therapy services but they had been discontinued. She went on to say Resident #75 had a left knee brace that therapy staff applied. She indicated she had not been instructed to apply Resident #75's left knee brace. Nurse #6 stated it was not on Resident #75's care plan. She stated she had not seen the brace on Resident #75 lately. On 04/06/2022 at 1:29 PM an interview with Unit Manager (UM) #1 indicated she received the Functional Maintenance Recommendation form for Resident #75 but could not recall when. She stated therapy staff normally gave these to her after residents were discharged from therapy and NA staff were trained. She went on to say Resident #75's form had been on her desk. She further indicated she tried to enter the recommendations onto care plans as soon as she got them but she had gotten behind on therapy recommendations and had not entered Resident #75's. A review of the comprehensive care plan for Resident #75 revealed a focus area initiated on 11/25/2021of activities of daily living (ADL). The goal last updated on 12/15/2021 was for Resident #75 to receive ADL care with staff support as required to maintain or achieve her highest practicable level of function through the next review. A goal initiated on 04/06/2022 was mobility functional maintenance, left knee extension brace up to 6 hours as tolerated. On 04/06/2022 at 1:36 PM an interview with MDS Nurse #2 indicated the Therapy Manager called her a few minutes ago and told her about Resident #75's left knee brace so she just added it to Resident #75's care plan. On 04/06/2022 at 1:45 PM an interview with Resident #75's Physical Therapist (PT #1) indicated Resident #75's PT treatment began on 03/08/2022 because of a contracture of her left knee. She stated this meant Resident #75 did not have full functional range of motion in her left knee and could not straighten it all the way. PT #1 went on to say Resident #75 continued to have this knee contracture on 03/29/2022 when Resident #75 was discharged from therapy services. She indicated Resident #75 was discharged from therapy with instructions to nursing staff to begin applying Resident #75's left knee extension brace for up to 6 hours a day five days a week as tolerated to prevent Resident #75's contracture from worsening. PT #1 stated she would expect NA staff to begin applying the knee brace as recommended the day they were instructed or the next day. She went on to say she would not expect it to take eight days for this to happen. PT #1 further indicated going that long without the application of her left knee brace put Resident #75 at risk for worsening of the contracture and further decrease in the range of motion of her left knee. On 04/26/2022 at 2:06 PM an interview with NA #7 revealed she did recall being instructed on the application of Resident #75's left knee brace by therapy staff although she could not recall the exact date. She stated she had not been instructed to pass this information onto anyone and had not done so. She stated she was rarely assigned to Resident #75 and had not applied her knee brace again since being trained. On 04/06/2022 at 2:21 PM an interview with NA #8 revealed she did recall being instructed on the application of Resident #75's left knee brace by therapy staff although she could not recall the exact date. She stated she was not instructed to pass this information on to anyone and had not done so. She went on to say she had not been assigned to Resident #75 since being instructed and had not applied Resident #75's left knee brace again since being trained. On 04/06/2022 at 2:47 PM an interview with the Director of Nursing (DON) indicated when Resident #75 was discharged from therapy services with the recommendation for nursing staff to continue the application of her left knee brace, UM #1 should have made sure this information was placed on Resident #75's care plan. She stated placing the information on the care plan would ensure NA staff caring for Resident #75 had access to the recommendation. She stated when the information was entered on the care plan it would then be available for the NAs to know they needed to apply the brace. The DON went on to say NA staff who were trained on the application of Resident #75's brace should have passed the information on in report to ensure continuity of care. She further indicated she did not feel eight days was a reasonable amount of time for this to happen. On 04/06/2022 at 2:56 PM a follow up interview with the Therapy Director indicated she assessed Resident #75's left knee contracture and there had been no decrease in her range of motion. She went on to say she also instructed Nurse #6 in the application of Resident #75's knee brace. 2. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses that included hemiplegia affecting right dominant side. The quarterly MDS dated [DATE] revealed Resident #9 was moderately cognitively impaired. Resident #9's care plan dated 3-24-22 revealed a goal that activities of daily living/personal care will be completed with staff support to maintain or achieve highest level of functioning. The interventions for the goal were in part encourage resident to allow passive range of motion during care and encourage the resident to wear right elbow splint up to 3 hours and right hand roll up to 8 hours. A review of the NA care guide revealed instructions to the NA to apply a right elbow extension splint and a hand roll as tolerated. Resident #9 was interviewed on 4-4-22 at 10:55am. The resident stated she did not have any braces for her arm or anything for her hand. Resident #9 clarified she had not had any brace or hand roll applied. Observation of Resident #9 on 4-5-22 at 1:00pm revealed she did not have a hand roll or brace applied to her right upper extremity. On 4-6-22 at 12:50pm, Resident #9 was observed and revealed no brace or hand roll had been applied to her right upper extremity. During an interview with the Therapy Director on 4-6-22 at 4:05pm, the Therapy Director stated Resident #9 was supposed to have an elbow splint and a hand roll for her right upper extremity that was contracted. She discussed Resident #9 having difficulty wearing the elbow splint and would wear it for 3 hours at a time and the hand roll the resident would wear up to 5 hours. The Therapy director explained Resident #9's therapy ended in January 2022 and the NAs were educated on how to apply the elbow splint and hand roll. An interview with NA #3 occurred on 4-6-22 at 4:40pm. The NA confirmed she was familiar with Resident #9 but stated she was not aware the resident was supposed to have an elbow splint or hand roll applied. NA #3 stated she did see the instructions on Resident #9's care guide but thought therapy was applying the splint and hand roll. NA #4 was interviewed on 4-7-22 at 3:35pm. The NA stated she was familiar with Resident #9 but was unaware the resident was supposed to have an elbow splint or hand roll applied. She stated she had received training by one of the therapists today (4-7-22) on how to apply the elbow splint and hand roll. The facility Physician was interviewed on 4-7-22 at 1:21pm. The Physician stated applying the elbow brace and hand roll to Resident #9 was a low priority and explained due to the length of time the resident had hemiplegia he would not expect to see much improvement.

Based on record review, resident and staff interviews the facility failed to provide sufficient staffing to assist with Activities of Daily Living (ADL) care for residents (Resident #106, Resident #77, Resident #21 and Resident #114) who were dependent on facility staff for ADL care. This affected 4 of 42 residents reviewed for staffing. Findings included: Review of the working schedules for March 2022 revealed there were 2 Nursing Assistance (NA) scheduled on the 7:00am to 3:00pm shift for approximately 44 residents on the following dates, March 19 and 27. The working schedules for March 2022 also showed there were 3 NAs scheduled for approximately 44 residents on the following dates, March 6 - 7:00am to 3:00pm, March 19 - 3:00pm to 11:00pm and March 25 - 7:00am to 3:00pm. During an interview with NA #10 on 4-7-22 at 1:39pm, the NA stated She had been assigned to Resident #106, Resident #77, Resident #21 and Resident #114 during the month of March. She discussed on the weekends there were usually only 2 NAs for approximately 44 residents, and she was unable to provide baths to all the residents assigned to her. NA #10 also said when there were only 2 NAs present, the nurses were supposed to help with ADL care but that did not occur. NA #1 was interviewed on 4-7-22 at 5:10pm. The NA stated he was unable to document or provide scheduled showers on the weekends due to only 2 NAs scheduled for the shift. He also discussed the 11:00pm to 7:00am shift stating he worked the night shift and there were usually only 2 NAs for approximately 44 residents. An interview with the facility scheduler occurred on 4-8-22 at 10:06am. The scheduler discussed trying to over staff each shift because she was aware there would be staff call outs. She discussed if the call outs occurred before 5:00pm, she would ask staff to stay over to work an extra shift and she would call the agency to see if there were staff available. The scheduler stated if the call outs occurred after 5:00pm, the nurse on call would be responsible for arranging coverage. She confirmed, if the facility was unable to arrange coverage, each staff present would be expected to care for up to 20-22 residents. The scheduler discussed March 19 and 27 and confirmed only 2 NAs were scheduled but stated the floor nurses were expected to assist the NAs in providing ADL care. During an interview with the Director of Nursing (DON) on 4-8-22 at 11:20am, the DON stated the facility was in the process of trying to hire more staff. She discussed care not being completed was a problem and she was aware the floor nurses were not assisting the NAs in providing ADL care. The DON said she was working with staff to work together as a team. The Administrator was interviewed on 4-8-22 at 12:30pm. The Administrator stated financially the facility was over staffed and there were enough staff to provide care to the residents.