Based on record review and interview, the facility failed to notify the physician of a resident leaving AMA for 1 (#4) of 1 sampled resident reviewed for leaving the facility AMA. The administrator identified 62 residents resided in the facility. Findings: Resident #4 had diagnoses which included alcohol abuse, other psychoactive abuse with intoxication, chronic heart failure, anxiety, depression, and anemia. A late entry progress note, dated 11/25/24, showed Resident #4 left the facility under the care of their friend and all medications were in the resident's possession. There was no documentation Resident #4's physician was notified the resident left AMA. On 03/04/25 at 4:14 p.m., the administrator was asked if Resident #4's physician was notified the resident left AMA, or if there was any documentation the physician was notified. The administrator stated there was no documentation. On 03/04/25 at 4:20 p.m., corporate nurse consultant #1 was asked if the facility had a policy or procedure for a resident leaving AMA. They stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a significant change assessment for a resident with declines in ADLs for one (#48) of two sampled residents reviewed for ADLs. The administrator identified 66 residents resided in the facility. Findings: An annual MDS, dated [DATE], documented Res #48 had no functional impairments in range of motion. The MDS documented Res #48 required setup/cleanup assistance with upper body dressing. The MDS documented Res #48 required supervision with walking 10 feet. The MDS documented Res #48 required partial/moderate assistance with lower body dressing and applying and removing footwear. A quarterly MDS, dated [DATE], documented Res #48 had declined in range of motion and had impairments of upper and lower extremities on both sides. The MDS documented Res #48 had declined in their ability to perform toileting hygiene, and showering/bathing self and required partial/moderate assistance. The MDS documented Res #48 was newly dependent with upper and lower body dressing, and applying/removing footwear. The MDS documented Res #48 was newly dependent with walking 10 feet. On 03/13/24 at 2:03 p.m., corporate MDS coordinator #1 stated the significant change had been missed and should have been completed.

Based on record review and interview the facility failed to update a care plan with smoking interventions for one #57) of one sampled resident reviewed for smoking. The Administrator identified 66 residents resided in the facility and the list of smoking residents documented eleven residents smoked. Findings: A Smoking Policy and Procedure revised 02/24/20, read in part .To offer the resident the ability to smoke free of danger to self and others .The resident may choose to utilize an electronic cigarette .physicians should be notified to appropriately update care plan and set goals for residents regarding smoking habits . Resident #57 had diagnoses which included, heart failure and type two diabetes mellitus. Resident #57's care plan did not have any interventions or safety measures implemented for smoking. On 03/11/24 at 12:59 p.m., Resident #57 was asked if they smoked. They stated that they were and was able to smoke when they wanted. On 03/12/24 12:44 p.m., the Administrator was asked if Resident #57 was a smoker. They stated the resident had signed a smoking contract, had started smoking cigarettes and had used electronic cigarettes vaped when they admitted . On 03/14/24 11:55 a.m., the corporate nurse was shown the care plan and asked if there were any interventions for smoking. They stated No. They were asked if the care plan should identify the resident as a smoker. They stated if the resident is a smoker it should be care planned. On 03/12/24 12:45 p.m. the corporate nurse was shown the smoking assessment ,dated 02/02/24, and stated the assessment documented the resident was a smoker and it should have been care planned.

Based on record review and interview, the facility failed to ensure a medication regimen review was responded to timely for one (#9) of five sampled residents reviewed for unnecessary medications. The administrator identified 66 residents resided in the facility. Findings: Res #9 had diagnoses which included bipolar disorder, insomnia, and depression. A physician order, dated 09/07/23, documented to administer Zoloft oral tablet 50 mg one time per day for depression. A physician order, dated 09/07/23, documented to administer Abilify oral tablet 2 mg one time per day for bipolar disorder. A physician order, dated 10/18/23, documented to administer Trazodone HCL oral tablet 300 mg at bedtime for bipolar disorder. A monthly medication review, dated 12/18/23, documented the pharmacist request to attempt a gradual dose reduction of the residents Zoloft, Abilify, or trazodone. The medication review was not documented as responded to until 02/12/24 in which the physician declined the GDR. On 03/14/24 at 2:51 PM, Corporate consult RN #1 stated if there is not a response within 30 days to a monthly medication review the facility must go to the medical director.

Based on record review and interview the facility failed to notify the physician when fingerstick blood sugar results were greater than 501 for one (#57) of one sampled resident reviewed for change in condition. The Administrator identified 66 residents resided in the facility. Findings: A Resident's Family or Physician Notification of Change Guideline policy dated 12/01/09, read in part .The facility will .consult with the resident's physician .of the following events .A need to alter treatment significantly. (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) . Resident #57 had diagnoses which included, heart failure and type two diabetes mellitus. A physician order, dated 01/10/24, documented to administer Humalog Insulin subcutaneously before meals and at bedtime per sliding scale. Resident #57's January and February 2024 MAR documented the resident was to be administered the following insulin on a sliding scale: .Humalog Injection inject per sliding scale: If 0-60 = 0 units, Give glucose recheck in 15 mins if still below 60 call MD; 61-149 = 0 units; 150-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401-450 = 12 units; 451-500 = 14 units; 501-999 = 16 units Call MD, subcutaneously before meals and at bedtime . The clinical health record did not contain documentation the physician had been notified of the fingerstick blood sugar results on the following days; a. On 01/27/24 FSBS was 528, b. On 01/28/24 FSBS was 501 at 11 am, and 545 at 9 pm, c. On 02/1/24 at 4 p.m. FSBS was 556, d. On 02/5/24 at 4:00 p.m., FSBS was 501, and e. On 02/10/24 at 11:00 a.m., FSBS was 544. On 03/14/24 01:46 p.m., LPN #2 was asked where would the documentation be if the physician had been notified regarding an elevated fingerstick blood sugar. They stated it should generate a progress note. On 03/14/24 02:27 p.m. the Corp Nurse Consult #1 was shown the January MAR and asked if there was any documentation the physician had been notified regarding the results greater than 501 on the following days: 01/27/24 FSBS was 528, and on 01/28/24 FSBS was 501 at 11 am, and 545 at 9 pm. The corporate nurse stated there was no documentation the physician had been notified. On 03/14/24 02:28 p.m., the Corp. Nurse Consult #1 was shown the February 2024 MAR and asked if there was any documentation the physician had been notified regarding the results greater than 501 on the following days: On 2/1/24 at 4 p.m. FSBS was 556, on 2/5/24 at 4:00 p.m., FSBS was 501, and on 2/10/24 at 11:00 a.m., FSBS was 544. They stated they did not see any nursing documentation the physician had been notified.

Based on observation, record review, and interview, the facility failed to prevent development of new pressure ulcers for one (#15) of one sampled residents reviewed for pressure ulcers. Corporate consult RN #1 identified six residents resided in the facility with pressure ulcers. Findings: Res #15 had diagnoses which included quadriplegia, pressure induced deep tissue damage of left heel, and pressure ulcer of sacral region stage IV. A physician order, dated 02/12/24, documented heel lift boots in place every shift for wound prevention. A care plan, reviewed 02/13/24, documented Res #15 was to have heel lift boots in place every shift, and staff were to float heels with pillows while in bed. A weekly skin evaluation, dated 03/11/24 at 11:08 a.m., documented Res #15 had no new skin issues. On 03/12/24 at 9:15 a.m., Res #15 was observed in bed on their back. Both feet were observed without any pressure relieving devices in place. The resident's bare feet were observed pressed into the footboard of the bed. The right great toe, second toe, and third toe were observed curling under from pressure/contact with the footboards. No offload or pressure reducing devices were observed in the resident's room. On 03/12/24 at 12:15 p.m., Res #15 was observed during medication administration. The resident's bare feet continued to be pressed against the footboard without any offload/pressure reduction devices in place. A nurse progress note, dated 03/12/24 at 5:10 p.m., documented a post-wound assessment of the sacral wound. The note documented the left heel deep tissue injury was stable. The note did not document any new discoloration or pressure injuries. On 03/13/24 at 9:53 a.m., wound nurse #1 was observed providing ordered wound care for Res #15. The resident was observed to have a new purple area to right great toe. The nurse was made aware and stated they would have to contact the provider. A nurse progress note, dated 03/13/24 at 10:22 a.m., documented a new purple discoloration was noted to left great toe. The note documented the resident also had a new purple area to the right heel. On 03/13/24 at 11:33 a.m., CNA #3 stated the resident was supposed to wear offload boots daily. They stated if they were not in place they were to notify the nurse. They stated they could not recall if they were in place yesterday. On 03/13/24 at 11:37 a.m., LPN #1 stated the nurses and aides were responsible for ensuring the pressure reduction devices were in place. They stated they had noticed yesterday the boots were not in place and had not located them in the room. They stated they meant to go get them and place them on the resident but did not. They stated they did not notify anyone the offload boots were not in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to obtain orders for continuous oxygen and failed to ensure oxygen tubing was changed and dated per physician orders for two (#1 and #9) of two sampled residents reviewed for oxygen administration. Corporate consult RN #1 identified 13 residents received oxygen in the facility. Findings: 1. Res #1 had diagnoses which included COPD. A physician order, dated 11/17/22, documented to administer oxygen at 2 liters per minute as needed to maintain oxygen saturation above 89%. A physician order, dated 11/17/22, documented to change oxygen tubing and humidifier bottle monthly on the 15th on night shift. The order documented to date tubing. A quarterly MDS, dated [DATE], documented Res #1 was cognitively intact. On 03/11/24 at 12:22 p.m., Res #1 was observed in bed with oxygen being administered via nasal cannula from a concentrator. The tubing was observed without a date indicating when it was last changed. The humidification bottle on the concentrator was observed without a date indicating when it was last changed. The oxygen was observed to be set at 2 liters per minute. The resident stated they required oxygen most of the time to ensure their levels remained up. They stated they felt they needed the oxygen continuously. They stated they were unsure the last time the tubing and humidification bottle was changed. On 03/12/24 at 11:41 a.m., Res #1 was observed in bed with oxygen being administered via nasal cannula. The oxygen concentrator was set at 4 liters per minutes. On 03/12/24 at 3:16 p.m., LPN #1 was asked to accompany the surveyor to Res #1's room. The LPN stated the oxygen concentrator was set at 4 liters per minutes. The LPN reviewed the resident's orders and stated there was not an order for continuous oxygen. They stated the as needed order was for 2 liters per minute. 2. Res #9 had diagnoses which included COPD. A physician order, dated 09/06/23, documented to administer oxygen via nasal cannula at 2 liters per minute as needed. A physician order, dated 11/15/23, documented to change oxygen tubing and humidifier bottle monthly on the 15th on night shift. The order dated to date the tubing. A significant change MDS, dated [DATE], documented Res #1 was cognitively intact. On 03/11/24 at 12:56 p.m., Res #1 was observed seated in bed. The resident was observed with oxygen being delivered via nasal cannula from a concentrator. The concentrator was observed set at 3 liters per minute. A portable oxygen tank on the resident's wheelchair was observed set at 3.5 liters per minute. The tubing attached to the concentrator was not dated. The humidifier bottle on the concentrator was not dated. The tubing attached to the portable bottle on the wheelchair was not dated. The resident stated they required oxygen all the time. They stated their oxygen tubing had never been changed. They removed the tubing from their nose and pointed out the cannula was discolored. The cannula was observed with a slight yellow tinge to the tubing. A physician order, dated 03/13/24, documented to administer oxygen at 3 liters per minute continuously. On 03/13/24 at 1:18 p.m., Res #9 was observed transferring self from wheelchair to bed. The resident's portable oxygen was observed set at 2 liters per minute. The bedside concentrator was observed set at 2 liters per minute. On 03/14/24 at 10:35 a.m., LPN #1 stated the order for continuous oxygen was obtained after they had noted the resident only had orders for as needed oxygen. The LPN stated the resident had recently been requiring the oxygen all the time. The LPN stated the oxygen was ordered at 3 liters per minute.

Based on record review and interview, the facility failed to ensure there was ongoing assessment of a resident on dialysis for one (#54) of one sampled resident reviewed for dialysis services. The administrator identified two residents received dialysis services. Findings: A Guidelines for Dialysis After Care policy and procedure, dated 07/11/12, read in part, .Inspection of the AVF .access and entire access extremity including hands or feet .Presence/absence or thrill and/or bruits .Signs and Symptoms of infection .Bruising and/or bleeding .Peripheral Pulses .Erosion of Skin or Sores over access site .Post dialysis dressing removal includes .Dressing should be removed 4 hours after dialysis treatment . Res #54 had diagnoses which included ESRD. Physician orders, dated 02/02/24, documented, dialysis Tuesday, Thursday, and Friday; check AVF for thrill and bruit every shift. If absent notify the physician; monitor AVF for s/s of trauma and/or infection every shift; and remove AVF dressing four hours after dialysis treatment. The February and March 2024 dialysis communication forms and skilled nurses' notes were reviewed. There was no documentation 20 out of 58 opportunities the AVF was checked for thrill and bruit, monitored for s/s of trauma, and/or infection every shift. There was no documentation seven out of 13 opportunities the AVF dressing was removed four hours after dialysis treatment. On 03/12/24 at 12:46 p.m., the ADON was asked where it was documented when a resident on dialysis had physician orders for ongoing assessment. They stated it would be documented on the TAR. They stated they would check the TARs for Res #54. On 03/12/24 at 12:58 p.m., the ADON stated they used the dialysis communication form consistently to document everything. They were made aware the form did not document the resident being checked for thrill and bruit each shift, monitored for s/s of trauma and/or infection each shift, or the dressing changed after dialysis. On 03/12/24 at 1:04 p.m., the ADON stated the daily skilled nurses' notes documented they monitored for dialysis management. They were asked what it indicated when the dialysis management box was checked. They stated it meant they assessed the resident. On 03/12/24 at 1:17 p.m., corporate nurse consultant #1 stated they had daily skilled nurses notes documenting dialysis management. They stated they followed policy for monitoring, but not for following physician orders to monitor each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure medications were administered according to physician orders for one (#12) of five sampled residents reviewed for unnecessary mediations. The administrator identified 66 residents resided in the facility. Findings: Res #12 had diagnoses which included diabetes, coronary artery disease, and hypertension. A physician order, dated 09/14/23, documented to administer insulin glargine subcutaneous solution 20 units subcutaneously two times a day for diabetes at 6:00 a.m. and 9:00 p.m. A physician order, dated 09/14/23, documented to administer insulin aspart subcutaneous solution per sliding scale: if 0 - 150 = 0; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401 - 450 = 12; 451 - 999 = 12 For FSBS greater than 450, give 12 units and notify MD for further instructions before meals and at bedtime related to diabetes. A physician order, dated 11/23/23, documented to administer Victoza subcutaneous solution 1.2 mg one time per day at 6:00 a.m. for diabetes. A physician order, dated 12/09/23, documented to administer amlodipine besylate oral tablet 10 mg one time per day for hypertension. The order documented to hold the medication if the systolic blood pressure was below 110, the diastolic blood pressure was below 60, or the pulse was below 60. A physician order, dated 12/09/23, documented to administer losartan potassium oral tablet 50 mg one time per day for hypertension. The order documented to hold the medication if the systolic blood pressure was below 110, or the diastolic blood pressure was below 60. A physician order, dated 12/09/23, documented to administer carvedilol oral tablet 6.25 mg two times per day for hypertension. The order documented to hold the medication if systolic blood pressure was below 110, diastolic blood pressure below 60, or pulse below 60. A quarterly MDS, dated [DATE], doucmented the resident was cognitively intact. A MAR for January 2024 documented Res #12's blood pressure was 128/57 on 01/04/24, 125/57 on 01/08/24, 163/50 on 01/10/24, and 139/49 on 01/20/24. The MAR documented Res #12 received their amlodipine on 01/08/24, 01/10/24, and 01/20/24. The MAR documented Res #12 received their losartan on 01/20/24. The MAR documented Res #12 received the carvedilol on 01/04/24, 01/10/24, and 01/20/24. An insulin administration record for January 2024, documented Res #12's Victoza was administered greater than one hour after the prescribed administration time on 01/24/24 and 01/28/24. The administration record documented the insulin glargine was administered greater than one hour after the prescribed time for the 6:00 a.m. dose on 01/10/24, and 01/28/24. The administration record documented the 4:00 p.m. dose of insulin aspart was administered greater than one hour after prescribed time on 01/04/24. The record documented the 6:00 a.m. dose was administered greater than one hour after the prescribed time on 01/05/24. The insulin aspart 01/05/24 4:00 p.m. dose was blank. A MAR for February 2024 documented Res #12's blood pressure was 139/49 on 02/10/24. The MAR documented Res #12 received the carvedilol on 02/10/24. An insulin administration record for February 2024, documented Res #12 Victoza was administered greater than one hour after the prescribed administration time on 02/01/24, 02/07/24, and 02/17/24. The administration record documented the insulin glargine was administered greater than one hour after the prescribed time for the 6:00 a.m. dose on 02/07/24, and 02/17/24, and the 9:00 p.m. dose was administered greater than one hour after the prescribed administration time on 02/13/24. An insulin administration record for March 2024, documented Res #12's Victoza was administered greater than one hour after the prescribed administration time on 03/03/24, 03/09/24, and 03/10/24. The administration record documented the insulin glargine was administered greater than one hour after the 6:00 a.m. prescribed time on 03/03/24 and 03/09/23. The administration record documented the 9:00 p.m. dose of insulin glargine on 03/10/24 was not administered. On 03/11/24 at 11:45 a.m., Res #12 was observed in their room in the bed. The resident stated they often received their medications late. On 03/14/24 at 9:59 a.m. CMA #2 stated the blood pressure medications should have been held on the above dates because the blood pressure was out of parameters. On 03/14/24 at 10:09 a.m. LPN #1 stated insulin can be administered an hour before to an hour after the prescribed time. They were shown the above dates and stated the insulin was administered late. They stated the blanks on the MAR meant the medication was not given.

Based on record review and interview the facility failed to monitor for side effects related to the use of Warfarin for one (#62) of one sampled resident reviewed anticoagulant use. The Administrator identified 66 residents resided in the facility. Findings: Resident #62 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction. September, October, November, December and January MAR's documented Resident #62 had been administered Warfarin as ordered by the physician. The clinical health record did not document Resident #62 had been monitored for side effects related to the use of Warfarin from 09/08/23 through 01/22/24. Resident #62's TAR, dated 01/22/24, read in part .Monitor: Nose/gum bleeding, coughing or bloodtinged sputum, hematuria, black/tarry stools, vomiting of blood or coffee ground-like material, abnormal or excessive bruising, low b/p, Change in cognition, cyanosis, every shift for anti-coagulation therapy Warfarin . On 03/12/24 at 02:21 p.m. the Corp. Nurse Consultant #1 was asked if Resident #62 had been monitored for side effects in the months of September, October, November, and December 2023. They stated there were no orders to monitor for side effects until January 2024.

2. Res #9 had diagnoses which included anxiety disorder. A physician order, dated 04/13/23, documented to administer Ativan oral tablet 0.5 mg every 12 hours as needed for anxiety. A monthly medication review, dated 05/01/23, documented the pharmacist's request to add a stop date to the as needed Ativan order per regulations. There was no documented stop date to the order until 08/05/23. A MAR for May 2023 documented Res #9 received the as needed Ativan 33 times. A MAR for June 2023 documented Res #9 received the as needed Ativan 25 times. A MAR for July 2023 documented Res #9 received the as needed Ativan 29 times. A MAR for August 2023 documented Res #9 received the as needed Ativan four times. The order was discontinued on 08/05/23. On 03/14/24 at 3:00 p.m. Corporate consult RN #1 stated a 14 day stop date was not added to the order. Based on record review and interview, the facility failed to ensure: a. behavior and side effect monitoring was conducted for the use of psychotropic medications for one (#127), and b. PRN antianxiety medications were limited to 14 days for one (#9) of five sampled residents reviewed for unnecessary medications. Corporate Nurse Consultant #1 identified 11 residents had orders for routine psychotropic medications and six residents had orders for PRN antianxiety medications. Findings: A Medications Requiring Behavior and Effect Monitoring policy, dated 10/25/21, read in part, .Antipsychotics .required monitoring .Targeted Behaviors, Side Effects .quetiapine . 1. Res #127 had diagnoses which included dementia with other behavioral disturbance. A physician's order, dated 03/04/24, documented quetiapine fumarate (antipsychotic medication) 100 mg. Give one tablet by mouth at bedtime. End date 03/06/24. A physician's order, dated 03/06/24, documented quetiapine fumarate 150 mg. Give 0.5 tablet by mouth bedtime for three days. End date 03/09/24. A physician's order, dated 03/10/24, documented quetiapine fumarate 50 mg. Give one tablet by mouth bedtime for three days. End date 03/13/24. There was no documentation behaviors and side effect were monitored 03/04/24 through 03/12/23. On 03/14/24 at 11:24 a.m., the administrator was asked to provide behavior and side effect monitoring for 03/04/24 through 03/12/24 for the use of quetiapine fumarate. On 03/14/24 at 12:25 p.m., the administrtaor stated there was no documentation behaviors and side effects were monitored. They stated they should have been monitored. They stated it was overlooked.

Based on record review and interview the facility failed to obtain laboratory studies as ordered for one (#5) of five sampled residents reviewed for unnecessary medications. The administrator identified 66 residents resided in the facility. Findings: Res #5 had diagnoses which included hypokalemia. A lab result, dated 06/20/23, documented Res #5 had a low potassium level. A handwritten note on the result documented the nurse practitioner was notified, and a new order was received to administer potassium 10 meq and repeat CMP on 6/26/23. A nurse progress note, dated 6/23/2023 at 12:33 p.m., documented a focused assessment related to labs. CBC, CMP and lipid panel sent to nurse practitioner for review. New orders to give KCL 20 meq now and repeat CMP on Monday 06/26/23. On 03/12/24 at 4:08 p.m., the missing labs were requested from the ADON. On 03/15/24 at 9:14 a.m., the administrator stated it was their understanding that the facility was unable to locate documentation for the repeat lab on 6/26/23.

Based on record review, observation, and interview, the facility failed to ensure resident call lights were in reach for one (#23) of 24 residents observed for call lights. The Resident Census and Conditions of Residents form documented 73 residents resided in the facility. Findings: Res #23 had diagnoses which included sequelae of unspecified cerebrovascular disease, pressure ulcer of sacral region, chronic pain, quadriplegia C1-C4 incomplete, collapsed vertebra cervical region sequelae of fracture, and neuropathy. A significant change assessment, dated 01/19/23, documented the resident had moderately impaired cognition, required two person assist with bed mobility, had an indwelling catheter, was incontinent of bowel, and received opioid medication. On 01/24/23 at 10:12 a.m., Res #23's call light was observed clipped to his sheet above his shoulder. At that time the resident stated he wanted to be moved because he was hurting and his nose itched. The resident was asked if he could use his call light. He looked over at it and shook his head no. At that time the surveyor initiated the call light for the resident. On 01/24/23 at 10:20 a.m., CNA #1 entered the resident's room and asked the resident what he needed. The resident stated he was hurting and wanted to be moved. At that time the CNA was asked about the resident's call light location and if the resident could reach it. She stated the resident could not reach it where it was. She stated the call light should be under his right hand. The CNA at that time put the call light disc under the resident's hand. On 01/27/23 at 3:02 the DON was made aware of the resident not being able to reach the call light and having to wait close to 30 minutes to be repositioned. She stated the staff were re-educated on where to place the resident's call light.

Based on record review, observation, and interview, the facility filed to ensure an allegation of abuse was reported to the State Survey Agency no later than two hours after the allegation was made for one (#21) of one resident reviewed for abuse. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility. Findings: The Resident Abuse, Neglect and Misappropriation of Property policy and procedure, revised 11/01/22, read in part, .C. Director of Nursing/Administrator do initial state report, send in any staff to Nursing/CNA Board Immediately but no later than 2 hours* - If the alleged violation involves abuse or results in serious bodily injury .'' Res #21 had diagnoses which included diabetes mellitus, depressive disorder, and anxiety disorder. A quarterly assessment, dated 01/11/23, documented the resident was intact with cognition and required extensive assistance with bed mobility and total assistance with toilet use and bathing. An incident report, dated 07/17/22 at 4:45 a.m., documented an allegation of neglect. The initial report fax cover page dated 07/17/22 at 10:11 a.m., of when the allegation was faxed to OSDH. On 01/23/23 at 4:17 p.m., Res #21 was observed laying in her bed. Res #21 had on her call light. The resident stated the staff do not come quickly to answer the call lights in the facility. Res #21 stated she had been left on a bed pan for three to four hours before she was assisted off the bed pan. She stated she had laid in shit for eight hours, but that incident happened a while ago. Res #21 stated a few months ago she had called the police and they came to the facility. Res #21 stated CNA #3 would not answer her call light. Res #21 stated CNA #3 did not come in her room now and she would not tell anyone else to answer the call light, she waited hours to do it. Res #21 stated after she called the police a CNA came and took care of her. On 01/26/23 at 10:10 a.m., the administrator stated reporting an allegation of abuse/neglect should be sent in within two hours of the incident. On 01/26/23 at 11:31 a.m., the DON stated she had worked the night the incident happened with Res #21. She stated she was working as charge nurse and did not fill out a reportable incident report and send into the state office, but the incident report should have been sent in within two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure a resident received adequate supervision and/or failed to implement interventions to prevent wandering into other resident rooms for one (#11) of one resident reviewed for wandering. The Resident Census and Conditions of Residents report documented 73 residents residing in the facility. Findings: 1. Res #11 was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, dementia with behavioral disturbance, bipolar disorder, and unspecified anxiety disorder. A quarterly assessment, dated 12/03/22, documented the resident was cognitively impaired, had behavioral disturbances, was independent with walking, and had wandering behaviors which occurred daily. A care plan, last reviewed 12/12/22, was completed and there was no care plan for wandering. On 01/23/23 at 1:00 p.m., Res #11 was observed wandering throughout the facility. On 01/24/23 at 7:48 a.m., Res #11 was observed wandering in room [ROOM NUMBER] and pilfering through another resident's personal belongings. On 01/24/23 at 10:00 a.m., Res #11 was observed wandering throughout the facility. On 01/26/23 at 4:53 p.m., an interview with CNA #5 stated Res #11 did go in other resident rooms, and when he did the staff would redirect him. On 01/26/23 at 5:00 p.m., an interview was conducted with the DON. She stated that the care plan did not include wandering for the resident and it should have.

2. Res #26 was admitted to the facility with diagnoses of generalized muscle weakness, recurrent depressive disorder, anxiety disorder, and schizophrenia. An admission assessment, dated 01/09/23, documented resident #26 was cognitively intact and was independent with eating. On 01/23/23 at 5:10 p.m., an observation was made of Res #26 asking the kitchen staff for a grilled cheese sandwich while seated in the dining area. The kitchen staff refused to give Res #26 a grilled cheese sandwich, stating Res #26 had already had two grilled cheese sandwiches. Res #26 informed the kitchen staff he only had one grilled cheese sandwich, not two. The kitchen staff continued to argue with Res #26, stating he had two. Another kitchen staff spoke up and stated Res #26 had only one grilled cheese sandwich because he had given the second grilled cheese to another resident. On 01/24/23 at 10:20 a.m., an interview was conducted with Res #26. Res #26 stated that he asked for a second grilled cheese sandwich because one grilled cheese sandwich was not enough. The kitchen staff was observed to refuse to give him another sandwich. The resident stated that he did get another grilled cheese sandwich after another kitchen staff spoke up for him. On 01/26/23 at 12:00 p.m., an interview was conducted with the dietary manager. He stated Res #26 should have been given a second grilled cheese sandwich without hesitation. He also stated that the kitchen staff should never argue with any resident at any time. Based on record review, observation and interview, the facility failed to ensure residents were treated with respect and dignity, and care in a timely manner for two (#23 and #26) of 24 residents reviewed for dignity and respect. The Resident Census and Conditions of Residents form documented 73 residents resident in the facility. Findings: 1. Res #23 had diagnoses which included sequelae of unspecified cerebrovascular disease, pressure ulcer of sacral region, chronic pain, quadriplegia C1-C4 incomplete, collapsed vertebra cervical region sequela of fracture, and neuropathy. A significant change assessment, dated 01/19/23, documented the resident had moderately impaired cognition, required two person assist with bed mobility, had an indwelling catheter, was incontinent of bowel, and received opioid medication. The resident's current care plan documented to assist with turning and repositioning frequently. On 01/24/23 at 10:12 a.m., Res #23's call light was observed clipped to their sheet above their left shoulder. At that time the resident stated they wanted to be moved because they were hurting and their nose itched. The resident was asked if they could use their call light. They looked over at it and shook their head no. At that time the surveyor initiated the call light for the resident. On 01/24/23 at 10:20 a.m., CNA #1 entered the resident's room and asked the resident what they needed. The resident stated they were hurting and wanted to be moved. At that time the CNA was asked about the resident's call light location and if the resident could reach it. She stated the resident could not reach it where it was. She stated the call light should be under their right hand. The CNA at that time put the call light disc under the resident's hand. The CNA then left the room without repositioning the resident and without verbalizing her intent. Immediately after the CNA left the resident's room LPN #3 and LPN #4 entered the room with a tray which contained wound supplies. LPN #4 turned off the call light. The two nurses had a discussion between themselves, picked up the tray from the bedside table, then left the room. On 01/24/23 at 10:30 a.m., the administrator was walking down the hall, saw the surveyor near the door, came in the room, and ask the resident if they needed anything. The resident asked her to scratch their head. The administer scratched the resident's head then left the room. On 01/24/23 at 10:32 a.m., the DON came in the resident's room. The resident told the DON they were hurting and their face itched. The DON talked to the resident then left the room. On 01/24/23 at 10:36 a.m., CMA #1 came in the resident's room. The CMA stated she was giving the resident a liquid antianxiety medication and had already given the resident a pain medication at 9:00 a.m. On 01/24/23 at 10:41 a.m., LPN #3 and LPN #4 came in the room with the wound supplies. The nurses were observed conducting incontinent care and wound care. On 01/27/23 at 3:02 p.m., the DON was made aware of the resident not being able to reach the call light and having to wait close to 30 minutes to be repositioned. She stated the staff were re-educated on where to place the resident's call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to maintain a safe, clean, comfortable, homelike environment regarding wheelchair maintenance and air temperatures. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility. Findings: 1. On 01/23/23 at 4:02 p.m., Res #13 stated she stayed cold all the time and had to wear multiple layers of clothing to stay warm. Res #13 was observed to have on two coats, two sock hats, the hood from one of her jackets, and a pair of gloves. The temperature was taken in the resident's bathroom and it was 68.2 degrees F. The temperature at the resident bed was 68.0 degrees F. There was a white blanket observed folded up on the window ledge but a draft was still felt coming through the window. On 01/24/23 at 11:44 a.m., Res #13's room temperature at the bed was 59.5 degrees and in the bathroom it was 63.1 degrees. On 01/25/23 at 10:40 a.m., the temperature in Res #13's room was 66.7 degrees at the bed and the bathroom was 65.7 degrees. On 01/25/23 at 10:45 a.m., room [ROOM NUMBER] was 67.8 degrees. In the middle of Hall 100 by the thermostat it was 69.9 degrees. The thermostat was set on 74 and the temperature on the thermostat read 74 degrees. On 01/25/23 at 10:49 a.m., the temperature in room [ROOM NUMBER] was 70.8 degrees. Res #49 stated he got cold at night. The resident had a jacket on and several blankets on his bed. On 01/25/23 at 11:05 a.m., the maintenance man stated he did the air and water temperatures every week randomly. A review of the air temperature logs reveled resident room temperatures were not documented on the log. On 01/25/23 at 4:29 p.m., CNA #2 stated Hall 200 is the warmer hall and Hall 400 was the colder hall. She said the shower rooms in the facility were really cold. She stated Hall 400 had a heater in the shower room and the other hall shower rooms did not. CNA #2 stated the residents have to load up with blankets then they have a hard time getting in and out of bed. On 01/25/23 at 5:59 p.m., the maintenance man obtained the temperature in room [ROOM NUMBER], it was 61.7 degrees. He stated the temperature in the room was chilly. He said there were vents in the shower rooms on all the halls. On 01/25/23 at 6:08 p.m., the maintenance man checked the temperature in Hall 100 shower room. He stated at the window the temperature was 62 degrees. He stated the temperature in the upper corners of the shower room were 66 degrees. On 01/27/23 at 8:37 a.m., the maintenance man stated some rooms were colder around the windows and there was a draft around some of the windows, so it was colder in some of the rooms. 2. Res #6 was admitted to the facility on [DATE] and had diagnoses which included dementia, Parkinson's disease, and seizures. The admission MDS, dated [DATE], documented the resident's cognition was severely impaired, required assistance with ADLs, and used a W/C for a mobility device. On 01/23/23 at 3:55 p.m., Res #6 was observed in her room in bed. The resident's W/C was near the bed. The W/C was missing the entire arm pad on the left side and the right side pad cover had multiple cracks and tears in the material and was rough to the touch. The resident stated it was the facility's W/C and it had been given to her to use upon admittance to the facility. On 01/23/23 at 3:59 p.m., the DON answered the resident's call light. At that time she was asked about the W/C arms missing and in disrepair. She stated the W/C should have been put on the maintenance log to be fixed. 3. Res #124 was admitted to the facility on [DATE] and had diagnoses which included a hip fracture. The admission MDS assessment, dated 12/08/22, documented the resident's cognition was intact and the resident required assistance with ADLs. On 01/23/23 at 5:23 p.m., Res #124 was observed sitting in their W/C. The W/C arm pad on the left was torn and had foam hanging out over the side of the arm pad. The right side pad had multiple cracks and tears and was rough to the touch. The resident stated the chair belonged to the facility and it was like that when they gave it to her to use. On 01/27/23 at 2:19 p.m., the DON stated she had noticed the resident's W/C yesterday and had it sent to maintenance to be repaired. 4. Res #42's admission MDS assessment, dated 11/01/22, documented the resident was cognitively intact and required assistance with ADLs. On 01/24/23 at 12:09 p.m., the resident's RM [ROOM NUMBER] had a temperature of 66.5 degrees F. The resident stated his room was always cold and even colder at night. The resident was observed in bed covered with blankets. 5. Res #63's quarterly MDS assessment, dated 12/01/22, documented the resident's cognition was moderately impaired and required assistance with ADLs. The assessment documented the resident's diagnoses included CVA and hemiparesis. On 01/25/23 at 11:15 a.m., the resident's RM [ROOM NUMBER] had a temperature of 63.7. The resident had a T-shirt on and stated he was not cold. On 01/25/23 at 11:17 a.m., CMA #2, came in the room while the temperature was being measured. The CMA was asked if the residents had complained of their rooms being too cold. The CMA stated residents had complained about their rooms being cold. The CMA stated they were supposed to log the concern in the computer system for maintenance to address. On 01/25/23 at 11:18 a.m., an observation was made of the Hall 400 thermostat with a reading of 74 degrees. 6. Res #40's quarterly MDS assessment, dated 10/11/22, docuented the resident's cognition was intact and was independent with set-up help only. On 01/25/23 at 11:21 a.m., the resident's RM [ROOM NUMBER] had a temperature of 68.3 degrees F. The resident was lying in bed with a coat on which was zipped up and a large thick blanket over her. The resident stated she was the resident council president. She stated residents had complained about cold rooms. She stated she had to dress warm and use blankets to keep warm while in her room. 7. Res #16's quarterly MDS assessment, documented the resident was cognitively intact and required assistance with ADLs. On 01/25/23 at 11:24 a.m., the resident's RM [ROOM NUMBER] had a temperature of 69.8 degrees F. The resident stated her room was chilly and even gets colder at night sometimes. 8. Res #37's quarterly MDS assessment, dated 11/18/22, documented the resident was cognitively intact and was independent with ADLs except for bathing. On 01/25/23 at 11:28 a.m., the resident's RM [ROOM NUMBER] had a temperature of 71.3. She stated her room stayed cold and got cooler at night. She stated there was a draft by the window. On 01/25/23 at 5:50 p.m., the maintenance man stated he did not document what room he obtained the temperatures in on the halls. He stated he obtained the temperatures in about four rooms on each hall. He stated he was having issues with the heat for two weeks in room [ROOM NUMBER] and he did what he could, then he called the heat and air repair yesterday. He stated when he had a complaint of temperature, he would get the temperature in that room or where the complaint was about. He stated he tried to keep the temperature at 74 to 75 degrees. He stated Hall 200 was the coldest hall in the whole building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the OHCA was notified after a resident received a significant mental health diagnoses for two (#17 and #37) of three residents reviewed for PASRR. The Resident Census and Conditions of Residents report, documented 72 residents who reside in the facility. Findings: 1. Res #17 was admitted to the facility on [DATE] with diagnoses which included recurrent depressive disorder and anxiety disorder. On 02/28/19, a new diagnosis of psychotic disorder with delusions due to known physiological condition was documented in the resident's diagnoses in the medical record. On 01/27/23 at 10:15 a.m., the DON and corporate nurse consultant #1 stated the OHCA should have been called after the new diagnoses was added on 02/28/19. 2. Res #37 admitted to the facility on [DATE] with diagnoses which included recurrent depressive disorder and anxiety disorder. On 12/03/21, a new diagnosis of delusional disorder was documented in the resident's record. On 01/27/23 at 10:16 a.m., the DON and corporate nurse consultant #1 stated the OHCA should have been called after the new diagnoses was added on 12/03/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #11 was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, dementia with behavioral disturbance, bipolar disorder, and unspecified anxiety disorder. A quarterly assessment, dated 12/03/22, documented the resident was cognitively impaired; had behavioral disturbances; and required assistance with activities of daily living; and had no impairment in the upper and lower extremities. On 01/23/24 at 1:00 p.m., Res #11 was observed wandering throughout the facility. On 01/24/23 at 10:00 a.m., Res #11 was observed wandering throughout the facility. A record review of the resident's care plan was completed and there was no care plan for wandering. On 01/26/23 at 5:00 p.m., an interview was conducted with the DON. She stated that the care plan did not include wandering, but should have. . Based on record review, observation, and interview, the facility failed to develop a comprehensive person-centered care plan for two (#6 and #11) of 23 residents whose care plans were reviewed. The facility failed to develop a care plan: a. related to wandering behaviors for Res #11 and b. related to ADL care including refusals to bathe for Res #6. The Resident Census and Conditions of Residents form documented 73 residents resided at the facility. Findings: 1. Res #6 was admitted to the facility on [DATE] and had diagnoses which included dementia, Parkinson's disease, and seizures. The admission MDS, dated [DATE], documented the resident's cognition was severely impaired, required assistance with ADLs, had not bathed in the last seven days, and had no rejection of care behaviors. On 01/23/23 at 3:53 p.m., Res #6 was observed in her room in bed. The resident was asked if they were getting their baths as scheduled. The resident stated they had not had a bath in five weeks. The resident's bathing record documented the resident was scheduled for a bath on Tuesday, Thursday, and Saturday on the evening shift. The bathing record for the last 30 days documented the resident refused eight showers, received seven showers, and missed two showers out of 14 opportunities. The resident's current care plan was reviewed and did not contain a care plan for ADL care, bathing, or rejection of care behaviors. On 01/25/23 at 4:41 p.m., CNA #2 stated the resident did refuse showers often. On 01/27/23 at 12:22 p.m., the corporate MDS nurse stated the resident should have had a care plan for ADL care and for rejection of care.

4. Res #17 had diagnoses which included cervical spina bifida with hydrocephalus, recurrent depressive disorder, psychotic disorder with delusions, and anxiety disorder. A quarterly assessment, dated 11/08/22, documented the resident was cognitively intact and required moderate to extensive assistance with ADLs. The resident's bathing record, from 12/21/22 to 01/20/23, documented the resident had a bath/shower two times. On 01/24/23 at 7:46 a.m., Res #17 stated she had gone two weeks without a bath and/or shower. The resident stated it took too long for the aides to answer the call lights. On 01/25/23 at 5:33 p.m., LPN #1 stated the resident would only allow certain females to give her a bath. On 01/25.23 at 4:11 p.m., CNA #4 stated she worked day shift and most of the time there was not enough staff to finish everything. She stated there needed to be two aides on each hall but at this time there was only one on each hall and an aide that floats between halls. Based on record review, observation, and interview, the facility failed to ensure bathing was provided to dependent residents for six (#2, 17, 21, 23, 30, and #124) of six residents reviewed for ADL care. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility. Findings: 1. Res #2 had diagnoses which included COPD, dementia, and depressive disorder. A care plan, last revised 11/11/22, documented bathing Tuesday, Thursday, Saturday on the 3-11 shift. Res #2 required one to two staff participation with bathing. Provide Res #2 with a sponge bath when a full bath or shower cannot be tolerated. Res #2 will often refuse showers. A five day assessment, dated 01/03/23, documented the resident was intact with cognition and required extensive assistance with bathing. The EHR bathing documentation for the last 30 days documented the resident was scheduled for bathing on Tuesday, Thursday, and Saturday on the 3-11 shift and PRN. The resident should have received 13 baths during the 30 day time frame. There were two documented baths, six refused baths, and five scheduled baths that were not documented for the resident. On 01/23/23 at 2:38 p.m., Res #2 stated the facility did not have enough staff with only one aide on the hall and they were run ragged. She stated she had to wait an hour for some one to get her water. She stated she did not get any baths last week. Resident #2 stated she was dependant on staff for her care. On 01/24/23 a skin monitoring shower review sheet, documented the resident refused a bath. This form was signed by the charge nurse that she was aware the resident refused a bath on 01/24/23. There were no other shower sheets that documented the resident had a shower or refused a bath. On 01/25/23 at 3:56 p.m., Res #2 stated she had refused bathing because she had one staff member she liked to bath her. Res #2 stated she did not think the staff had asked six times to bath her in the past 30 days. Res #2 stated she really did not like bed baths and preferred a staff member to take her to the shower. On 01/25/23 at 4:11 p.m., CNA #4 stated the facility did not have enough staff to get everything done. CNA #4 stated the facility needed two CNAs per hall. CNA #4 stated if someone called in no one else usually took their place. CNA #4 stated the baths were not getting done because there was not enough staff. CNA #4 stated they did try to get to the call lights as quick as they could, 10 to 15 minutes was the standard time. The CNA stated it was a struggle when we had to use the lift because another staff had to help. CNA #4 stated Res #2 will refuse a bath most of the time, but the staff can usually talk her into taking a bed bath most of the time. On 01/25/23 at 4:24 p.m., CNA #2 stated when a resident refused a bath the staff should give the resident another option or wait a little while and go back and ask again. CNA #2 stated if they still refuse a bath they are to tell the charge nurse and the nurse will go talk to the resident to see if the resident will take a bath. She stated resident #2 refused baths very frequently. She was pretty hit or miss on taking a bath. CNA #2 stated if the resident's sister did not want a bath then Res #2 would say no also. CNA #2 stated the staff member the resident wanted to bath her probably could get the resident to bathe, she worked evening and weekend shifts. 2. Res #21 had diagnoses which included respiratory failure with hypercapnia, neuropathy, and chronic pain. A quarterly assessment, dated 01/11/23, documented the resident was intact with cognition and required total assistance with bathing. The assessment documented the resident had rejected care during the look back period. A care plan, last reviewed 01/17/23, documented if the resident refused care, staff should re-attempt care at a different time if possible with a different staff member. Res #21 required total assistance for bathing when the resident wanted to bathe. Baths were scheduled Monday, Wednesday, and Friday on the 3-11 shift. The EHR bathing documentation for the last 30 days had the resident scheduled for bathing on Monday, Wednesday, Friday on the 3-11 shift and PRN. Two baths were documented as refused and one day was documented the resident was not available. From 12/27/22 to 01/24/23 the resident was scheduled for 12 baths. The resident had no documented baths during these dates. On 01/24/23 at 11:00 a.m., Res #21 stated they did not get baths as scheduled. Baths were few and far between. Res #21 stated she would rather get up and go to the shower than get a bed bath. On 01/25/23 at 4:17 p.m., CNA #4 stated when CNA #2 worked, she would make sure Res #21 was bathed. On 01/25/23 at 4:35 p.m., CNA #2 stated Res #21 would let her bathe the resident. Res #21 was very modest and had a lot of pain. CNA #2 stated when the resident had her pain medication she was more up for taking a bath and was a two person assist with her bathing. CNA #2 stated the staff also should complete a shower sheet besides documenting in the EHR. She stated the shower sheets where then turned in to the charge nurse. On 01/25/23 at 4:55 p.m., LPN #1 stated the CNA should fill out a skin monitoring shower review. If a resident refused a bath the CNA should document refused and then let the charge nurse know. LPN #1 stated the form then goes in the skin wound book until the corporate nurse took them out. 3. Res #30 had diagnoses which included CHF, angina pectoris, and hypertensive heart disease with heart failure. An annual assessment, dated 12/21/22, documented the resident was intact with cognition and required extensive assistance with bathing. A care plan, last reviewed 12/27/22, documented the nurse was to ensure the resident was taking showers as scheduled. If the resident refused for the CNA, the nurse was to attempt. The EHR bathing documentation for the last 30 days had the resident scheduled for bathing on Tuesday, Thursday, and Saturday on the 3-11 shift and PRN. Res #30 had 13 scheduled baths and none were documented as given. The bathing record documented four unscheduled baths as refused. On 01/27/23 at 2:15 p.m., LPN #1 stated she was not able to find any bathing shower sheets for Res #30. On 01/27/23 at 2:20 p.m., the DON stated she was not aware of all the resident refusals regarding bathing.5. Res #124's admission MDS assessment, dated 12/08/22, documented the resident was cognitively intact, required the assistance of two people with bathing, and had no rejection of care behaviors, The resident's bathing record documented the scheduled times for bathing were Tuesdays, Thursdays, and Saturdays. The record documented for the last 30 days, the resident had 14 opportunities for bathing. The record documented the resident received three showers, refused eight times, and missed three showers. On 01/23/23 at 5:27 p.m., the resident was asked if she received her baths as scheduled. The resident stated sometimes they skip her. She stated she has not had a bath in two weeks. The resident's hair was observed to be greasy and separated. On 01/25/23 at 4:15 p.m., the resident was asked if she ever refused to take her baths. The resident stated the only time she had refused was when they came to take her to the shower at 8:30 in the evening. She stated she did not want to go to bed with her hair wet. She stated most of the time no one had ever asked her if she wanted a bath. The resident's hair still observed greasy as earlier in the week. On 01/25/23 at 4:30 p.m., LPN #2 stated she just learned this week that the resident had been refusing baths. She stated she was not sure why she was refusing. On 01/27/23 at 2:16 p.m., LPN #1 stated CNAs the process was for the CNA's to fill out a bath sheet for a resident on their bath when they had a shower or when they refused. The LPN could not find any bath sheets for Res #124. On 01/25/23 at 4:41 p.m., CMA #2 stated the resident was easy going with showers and usually would not refuse, but she had not worked her hall recently. On 01/27/23 at 2:19 p.m., the DON stated she was not aware of refusals of bathing and residents not getting bathed as scheduled. 6. Res #23 had diagnoses which included sequelae of unspecified cerebrovascular disease, pressure ulcer of sacral region, chronic pain, quadriplegia C1-C4 incomplete, collapsed vertebra cervical region sequela of fracture, and neuropathy. A significant change assessment, dated 01/19/23, documented the resident had moderately impaired cognition, required two person assist with bed mobility, had an indwelling catheter, was incontinent of bowel, and received opioid medication. The resident's current care plan documented to assist with turning and repositioning frequently. On 01/24/23 at 10:12 a.m., Res #23's call light was observed clipped to their sheet above their left shoulder. At that time the resident stated they wanted to be moved because they were hurting and their nose itched. The resident was asked if they could use their call light. They looked over at it and shook their head no. At that time the surveyor initiated the call light for the resident. On 01/24/23 at 10:20 a.m., CNA #1 entered the resident's room and asked the resident what they needed. The resident stated they were hurting and wanted to be moved. At that time the CNA was asked about the resident's call light location and if the resident could reach it. She stated the resident could not reach it where it was. She stated the call light should be under their right hand. The CNA at that time put the call light disc under the resident's hand. The CNA then left the room without repositioning the resident and without verbalizing her intent. Immediately after the CNA left the resident's room LPN #3 and LPN #4 entered the room with a tray which contained wound supplies. LPN #4 turned off the call light. The two nurses had a discussion between themselves, picked up the tray from the bedside table, then left the room. On 01/24/23 at 10:41 a.m., LPN #3 and LPN #4 came in the room with the wound supplies. The nurses were observed conducting incontinent care and wound care. On 01/27/23 at 3:02 p.m., the DON was made aware of the resident not being able to reach the call light and having to wait close to 30 minutes to be repositioned. She stated the staff were re-educated on where to place the resident's call light.

8. Res #17 had diagnoses which included cervical spina bifida with hydrocephalus, recurrent depressive disorder, psychotic disorder with delusions, and anxiety disorder. A quarterly assessment, dated 11/08/22, documented the resident was cognitively intact and required moderate to extensive assistance with ADLs. The resident's bathing record, from 12/21/22 to 01/20/23, documented the resident had a bath/shower two times. On 01/24/23 at 7:46 a.m., Res #17 stated she had gone two weeks without a bath and/or shower. The resident stated it took too long for the aides to answer the call lights. On 01/25/23 at 5:33 p.m., LPN #1 stated the resident would only allow certain females to give her a bath. On 01/25.23 at 4:11 p.m., CNA #4 stated she worked day shift and most of the time there was not enough staff to finish everything. She stated there needed to be two aides on each hall but at this time there was only one on each hall and an aide that floats between halls. 9. The Resident Council minutes, dated 08/15/22, documented the residents voiced slow call light response times. The Resident Council minutes, dated 10/20/22, documented a resident voiced the call light response times on Hall 100 were too long. The facility's OHCA Quality of Care Monthly Report, for November 2022, documented staffing hours which did not meet the minimum requirement for the resident census for six 24 hour days. The Resident Council minutes, dated 12/30/22, documented the residents voiced they were waiting too long for a response to their call lights. The facility's OHCA Quality of Care Monthly Report, for December 2022, documented staffing hours which did not meet the minimum requirement for the resident census for two 24 hour days. On 01/27/23 at 1:36 p.m., the administrator stated the facility had been looking at hiring and staff retention in their quality assurance program. She stated they had started a peer mentoring program in which she hoped would help with the staffing issue. 3. Res #2 had diagnoses which included COPD, dementia, and depressive disorder. A care plan, last revised 11/11/22, documented bathing Tuesday, Thursday, Saturday on the 3-11 shift. Res #2 required one to two staff participation with bathing. Provide Res #2 with a sponge bath when a full bath or shower cannot be tolerated. Res #2 will often refuse showers. A five day assessment, dated 01/03/23, documented the resident was intact with cognition and required extensive assistance with bathing. The EHR bathing documentation for the last 30 days documented the resident was scheduled for bathing on Tuesday, Thursday, and Saturday on the 3-11 shift and PRN. The resident should have received 13 baths during the 30 day time frame. There were two documented baths, six refused baths, and five scheduled baths that were not documented for the resident. On 01/23/23 at 2:38 p.m., Res #2 stated the facility did not have enough staff with only one aide on the hall and they were run ragged. She stated she had to wait an hour for some one to get her water. She stated she did not get any baths last week. Resident #2 stated she was dependant on staff for her care. On 01/24/23 a skin monitoring shower review sheet, documented the resident refused a bath. This form was signed by the charge nurse that she was aware the resident refused a bath on 01/24/23. There were no other shower sheets that documented the resident had a shower or refused a bath. On 01/25/23 at 3:56 p.m., Res #2 stated she had refused bathing because she had one staff member she liked to bath her. Res #2 stated she did not think the staff had asked six times to bath her in the past 30 days. Res #2 stated she really did not like bed baths and preferred a staff member to take her to the shower. On 01/25/23 at 4:11 p.m., CNA #4 stated the facility did not have enough staff to get everything done. CNA #4 stated the facility needed two CNAs per hall. CNA #4 stated if someone called in no one else usually took their place. CNA #4 stated the baths were not getting done because there was not enough staff. CNA #4 stated they did try to get to the call lights as quick as they could, 10 to 15 minutes was the standard time. The CNA stated it was a struggle when we had to use the lift because another staff had to help. CNA #4 stated Res #2 will refuse a bath most of the time, but the staff can usually talk her into taking a bed bath most of the time. On 01/25/23 at 4:24 p.m., CNA #2 stated when a resident refused a bath the staff should give the resident another option or wait a little while and go back and ask again. CNA #2 stated if they still refuse a bath they are to tell the charge nurse and the nurse will go talk to the resident to see if the resident will take a bath. She stated resident #2 refused baths very frequently. She was pretty hit or miss on taking a bath. CNA #2 stated if the resident's sister did not want a bath then Res #2 would say no also. CNA #2 stated the staff member the resident wanted to bath her probably could get the resident to bathe, she worked evening and weekend shifts. 4. Res #21 had diagnoses which included respiratory failure with hypercapnia, neuropathy, and chronic pain. A quarterly assessment, dated 01/11/23, documented the resident was intact with cognition and required total assistance with bathing. The assessment documented the resident had rejected care during the look back period. A care plan, last reviewed 01/17/23, documented if the resident refused care, staff should re-attempt care at a different time if possible with a different staff member. Res #21 required total assistance for bathing when the resident wanted to bathe. Baths were scheduled Monday, Wednesday, and Friday on the 3-11 shift. The EHR bathing documentation for the last 30 days had the resident scheduled for bathing on Monday, Wednesday, Friday on the 3-11 shift and PRN. Two baths were documented as refused and one day was documented the resident was not available. From 12/27/22 to 01/24/23 the resident was scheduled for 12 baths. The resident had no documented baths during these dates. On 01/23/23 at 4:17 p.m., Res #21 was observed laying in her bed. Res #21 had on her call light. The resident stated the staff do not come quickly to answer the call lights in the facility. Res #21 stated she had been left on a bed pan for three to four hours before she was assisted off the bed pan. She stated she had gone unassisted while soiled in feces for for eight hours before, but that incident happened a while ago. Res #21 stated a few months ago she had called the police and they came to the facility because CNA #3 would not answer her call light. Res #21 stated CNA #3 did not come in her room now and she would not tell anyone else to answer the call light, she waited hours to do it. On 01/24/23 at 11:00 a.m., Res #21 stated they did not get baths as scheduled. Baths were few and far between. Res #21 stated she would rather get up and go to the shower than get a bed bath. On 01/25/23 at 4:17 p.m., CNA #4 stated when CNA #2 worked, she would make sure Res #21 was bathed. On 01/25/23 at 4:35 p.m., CNA #2 stated Res #21 would let her bathe the resident. Res #21 was very modest and had a lot of pain. CNA #2 stated when the resident had her pain medication she was more up for taking a bath and was a two person assist with her bathing. CNA #2 stated the staff also should complete a shower sheet besides documenting in the EHR. She stated the shower sheets where then turned in to the charge nurse. On 01/25/23 at 4:55 p.m., LPN #1 stated the CNA should fill out a skin monitoring shower review. If a resident refused a bath the CNA should document refused and then let the charge nurse know. LPN #1 stated the form then goes in the skin wound book until the corporate nurse took them out. 5. Res #30 had diagnoses which included CHF, angina pectoris, and hypertensive heart disease with heart failure. An annual assessment, dated 12/21/22, documented the resident was intact with cognition and required extensive assistance with bathing. A care plan, last reviewed 12/27/22, documented the nurse is to ensure resident is taking showers as scheduled. If the resident refused for the CNA, the nurse was to attempt. The EHR bathing documentation for the last 30 days documented the resident was scheduled for bathing on Tuesday, Thursday, and Saturday, on the 3-11 shift and PRN. Res #30 had 13 scheduled baths and none were documented as given. The bathing record documented four unscheduled baths as refused. On 01/23/23 at 1:50 p.m., Res #30 stated CNA #3 took a long time to answer the call lights and sometimes the lights did not get answered. Res #30 stated CNA #3 told him to get his own coffee. Res #30 stated he was on the toilet an hour and 1/2 this past weekend, and did not know why it took so long. Res #30 reported they were so busy they shut the light off and did not come back. Res #30 stated the staff aggravated him because they think he does not need assistance. On 01/27/23 at 2:15 p.m., LPN #1 stated she was not able to find any bathing shower sheets for Res #30. On 01/27/23 at 2:20 p.m., the DON stated she was not aware of all the resident refusals regarding bathing. 6. Res #49 had diagnoses which included HTN, depression, and Alzheimer's disease. An annual assessment, dated 01/16/23, documented the resident was moderately impaired with cognition and was independent with most activities of daily living. On 01/23/23 at 1:46 p.m., Res #49 stated the staff did not come when you use the call light. Res #49 stated he did a lot for himself. 7. Res # 13 had diagnoses which included COPD, chronic pain syndrome, and seizures. A quarterly assessment, dated 12/20/22, documented the resident was intact with cognition and required extensive assistance with bathing. On 01/23/23 at 3:55 p.m., Res #13 stated the facility did not have enough CNAs. Res #13 stated her call light stayed on for an hour and 1/2 before. She stated the staff tell her she is independent and did not want to help her. She stated she had requested assistance getting to the shower room but the staff would not push her down there. Based on record review, observation, and interview, the facility failed to ensure there was sufficient nursing staff to provide care in accordance with resident care plans for eight (#2, 13, 17, 21, 23, 30, 49, and #124) of 24 residents reviewed for staffing. The Resident Census and Conditions of Residents form documented 73 residents resided at the facility. Findings: 1. Res #124's admission MDS assessment, dated 12/08/22, documented the resident was cognitively intact, required the assistance of two people with bathing, and had no rejection of care behaviors, The resident's bathing record documented the scheduled times for bathing were Tuesdays, Thursdays, and Saturdays. The record documented for the last 30 days, the resident had 14 opportunities for bathing. The record documented the resident received three showers, refused eight times, and missed three showers. On 01/23/23 at 5:27 p.m., the resident was asked if she received her baths as scheduled. The resident stated sometimes they skip her. She stated she has not had a bath in two weeks. The resident's hair was observed to be greasy and separated. On 01/25/23 at 4:15 p.m., the resident was asked if she ever refused to take her baths. The resident stated the only time she had refused was when they came to take her to the shower at 8:30 in the evening. She stated she did not want to go to bed with her hair wet. She stated most of the time no one had ever asked her if she wanted a bath. The resident's hair still observed greasy as earlier in the week. On 01/25/23 at 4:30 p.m., LPN #2 stated she just learned this week that the resident had been refusing baths. She stated she was not sure why she was refusing. On 01/27/23 at 2:16 p.m., LPN #1 stated CNAs the process was for the CNA's to fill out a bath sheet for a resident on their bath when they had a shower or when they refused. The LPN could not find any bath sheets for Res #124. On 01/25/23 at 4:41 p.m., CMA #2 stated the resident was easy going with showers and usually would not refuse, but she had not worked her hall recently. On 01/27/23 at 2:19 p.m., the DON stated she was not aware of refusals of bathing and residents not getting bathed as scheduled. 2. Res #23 had diagnoses which included sequelae of unspecified cerebrovascular disease, pressure ulcer of sacral region, chronic pain, quadriplegia C1-C4 incomplete, collapsed vertebra cervical region sequela of fracture, and neuropathy. A significant change assessment, dated 01/19/23, documented the resident had moderately impaired cognition, required two person assist with bed mobility, had an indwelling catheter, was incontinent of bowel, and received opioid medication. The resident's current care plan documented to assist with turning and repositioning frequently. On 01/24/23 at 10:12 a.m., Res #23's call light was observed clipped to their sheet above their left shoulder. At that time the resident stated they wanted to be moved because they were hurting and their nose itched. The resident was asked if they could use their call light. They looked over at it and shook their head no. At that time the surveyor initiated the call light for the resident. On 01/24/23 at 10:20 a.m., CNA #1 entered the resident's room and asked the resident what they needed. The resident stated they were hurting and wanted to be moved. At that time the CNA was asked about the resident's call light location and if the resident could reach it. She stated the resident could not reach it where it was. She stated the call light should be under their right hand. The CNA at that time put the call light disc under the resident's hand. The CNA then left the room without repositioning the resident and without verbalizing her intent. Immediately after the CNA left the resident's room LPN #3 and LPN #4 entered the room with a tray which contained wound supplies. LPN #4 turned off the call light. The two nurses had a discussion between themselves, picked up the tray from the bedside table, then left the room. On 01/24/23 at 10:41 a.m., LPN #3 and LPN #4 came in the room with the wound supplies. The nurses were observed conducting incontinent care and wound care. On 01/27/23 at 3:02 p.m., the DON was made aware of the resident not being able to reach the call light and having to wait close to 30 minutes to be repositioned. She stated the staff were re-educated on where to place the resident's call light.

Based on record review, observation, and interview, the facility failed to obtain blood pressures for one (#30) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report documented 73 residents resided in the facility. Findings: Res #30 had diagnoses which included CHF, angina pectoris, and hypertensive heart disease with heart failure. A physician order, dated 05/29/20, documented prazosin 5 mg at bedtime related to hypertensive heart disease with heart failure. Hold if systolic BP <110. A physician order, dated 05/25/21, documented metoprolol ER 50 mg one time a day related to hypertensive heart disease with heart failure. Hold if systolic BP is <110, diastolic BP <60, or pulse <60. A physician order, dated 06/03/21, documented isosorbide 10 mg two times a day related to angina pectoris. Hold for systolic BP <110, diastolic BP <60, or pulse <60. A physician order, dated 11/24/21, documented ranolazine ER 500 mg two times a day related to angina pectoris. Hold if systolic BP < 110 or diastolic BP < 60. An annual assessment, dated 12/21/22, documented the resident was intact with cognition and was independent with most activities of daily living. A care plan, last reviewed 12/27/22, documented to obtain blood pressure readings before giving medications and PRN. The care plan documented to take blood pressure readings under the same conditions each time. The January 2023 MAR documented metoprolol with three days where BP and heart rate were not documented and medication was held. The January 2023 MAR documented for prazosin there was four days the BP was not documented, of those four days, three days the medication was held and one day the medication was administered. The MAR documented there were two other times there were BP's of 127/52 and 116/44 and the medication was held. The order only addressed the systolic blood pressure. The January 2023 MAR documented for isosorbide there were nine times the resident's BP and heart rate were not documented. Seven times the medication was held, one time the medication was refused, and one time the medication was given. The January 2023 MAR documented for ranolazine there were nine times the resident's BP was not documented, was held eight times, and refused one time. On 01/23/23 at 1:52 p.m., Res #30 was observed in his bed. He reported he got dizzy when he got up. On 01/27/23 at 10:17 a.m., the IP stated the BP should be documented on the MAR. She stated if the medication was held there should be documentation of why it was held. On 01/27/23 at 11:48 a.m., the DON stated the resident went out to the hospital quite frequently for chest pains. The DON stated the BP should be documented on the MAR. On 01/27/23 at 12:33 p.m., the DON stated the CMA should let the nurse know when holding a medication. The DON stated the facility did not have a policy on notifying the physician when a medication was held.

Based on interview and record review, it was determined the facility failed to notify the physician and the family in a timely manner after a fall for one (#68) of two sampled residents who were reviewed for falls. The resident census and condition report documented 76 residents resided in the facility. Findings: Resident #68 had diagnoses which included dementia. A quarterly assessment, dated 09/05/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required limited assistance of one staff with transfers and extensive assistance of one person for toileting. The resident was frequently incontinent of bowel and bladder. She had one fall without injury prior to the assessment. The care plan, last revised on 09/23/19, documented a focus related to falls due to confusion. The goal was for staff to evaluate all falls and intervene as needed to reduce the potential of significant injury through the review date. Interventions included to toilet and provide incontinent care frequently. On 10/08/19 at 8:35 a.m., the resident's responsible party stated he had been informed by the resident's roommate that morning that the resident had fallen in the bathroom on 10/07/19 during the second shift. He stated she was found in the bathroom by herself. He stated he had not been informed of the fall by staff. Review of the clinical record from 10/07/19 through 10/08/19 at 12:59 p.m. did not include documentation of a fall. A nurse's note, dated 10/08/19 at 1:00 p.m., documented, .Incident Note .Initial- Resident's roommate reports that [resident name deleted] fell in her bathroom last night on the 3-11 shift. Resident is oriented to self only and does not recall falling. Nurse working yesterday evening contacted with no return. Aide working hall contacted and states that the resident did in fact fall at around 1930 [7:30 p.m.] and the nurse was notified. Resident was noted sitting on floor in between toilet and wall. Charge nurse working assessed resident for injuries. No apparent unjuries [sic] noted upon assessment by this nurse. ROM is wnl for her. Neuro checks initiated and are wnl. Denies pain. VS:116/68, 82, 97.9, 95%, 18. Husband [name deleted] notified. Dr [name deleted] notified. On 10/09/19 at 1:22 p.m., CNA #1 was asked the process when a resident fell. She stated she informed the nurse. At 2:09 p.m., LPN #2 was asked what the process was when a resident fell. She stated she assessed the resident, documented the fall and notified the family, director of nursing and physician. She was asked when she reported to the family, director of nursing and the physician. She stated, Immediately afterwards. LPN #2 was asked when the staff had notified the family of the fall. She stated on 10/08/19 at 1:00 p.m. LPN #2 was asked if the fall had been reported in a timely manner. She stated, No. At 2:34 p.m., the DON was asked when the staff notified the family after a fall. She stated they should immediately notify the family and physician after they assessed the resident. The DON was asked when the family and physician had been notified of the fall. She stated on 10/08/19. The DON was asked if the staff had followed the facility protocol for assessment, notification and documentation related to a fall. She stated, No.

Based on record review and interview, it was determined the facility failed to develop a care plan related to smoking for one (#33) of four sampled residents who smoked. The facility identified 15 residents who smoked. Findings: Resident #33 had diagnoses which included end stage renal disease and type 2 diabetes mellitus. A progress note, dated 09/12/19 at 5:19 p.m., documented the SSD was notified by a CMA that the resident had been smoking in the resident's room. When the SSD went to the resident's room, the pack of cigarettes was observed next to the resident and the lighter was on the bedside table. The resident was reminded of the smoking policy and the SSD requested the staff keep the cigarettes and lighter but the resident refused. According to the admissions coordinator the resident was caught smoking earlier in the day. A behavior note, dated 09/16/19 at 4:05 p.m., documented the resident had been smoking two times that day in the resident's room during the day shift. The resident was informed that smoking in the facility was not ever allowed. There was no care plan developed or implemented to identify the resident smoked or the resident's needs related to smoking. On 10/09/19 at 11:04 a.m., the DON was asked if resident #33 was a smoker. She stated, yes. She was asked if the resident's care plan had been developed to include the resident smoked. The DON reviewed the clinical record and stated no, it should have been included.

Based on interview and record review, it was determined the facility failed to assess a resident in a timely manner after a fall for one (#68) of two sampled residents who were reviewed for falls. The resident census and condition report documented 76 residents resided in the facility. Findings: Resident #68 had diagnoses which included dementia. A quarterly assessment, dated 09/05/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required limited assistance of one staff with transfers and extensive assistance of one person for toileting. The resident was frequently incontinent of bowel and bladder. She had one fall without injury prior to the assessment. The care plan, last revised on 09/23/19, documented a focus related to falls due to confusion. The goal was for staff to evaluate all falls and intervene as needed to reduce the potential of significant injury through the review date. Interventions included to toilet and provide incontinent care frequently. On 10/08/19 at 8:35 a.m., the resident's responsible party stated he had been informed by the resident's roommate that morning that the resident had fallen in the bathroom on 10/07/19 during the second shift. He stated she was found in the bathroom by herself. He stated he had not been informed of the fall by staff. Review of the clinical record from 10/07/19 through 10/08/19 at 12:59 p.m. did not include documentation of a fall. A nurse's note, dated 10/08/19 at 1:00 p.m., documented, .Incident Note .Initial- Resident's roommate reports that [resident name deleted] fell in her bathroom last night on the 3-11 shift. Resident is oriented to self only and does not recall falling. Nurse working yesterday evening contacted with no return. Aide working hall contacted and states that the resident did in fact fall at around 1930 [7:30 p.m.] and the nurse was notified. Resident was noted sitting on floor in between toilet and wall. Charge nurse working assessed resident for injuries. No apparent unjuries [sic] noted upon assessment by this nurse. ROM is wnl for her. Neuro checks initiated and are wnl. Denies pain. VS:116/68, 82, 97.9, 95%, 18. Husband [name deleted] notified. Dr [name deleted] notified. On 10/09/19 at 1:22 p.m., CNA #1 was asked the process when a resident fell. She stated she informed the nurse. At 2:09 p.m., LPN #2 was asked what the process was when a resident fell. She stated she assessed the resident, documented the fall and notified the family, director of nursing and physician. LPN #2 was asked when the resident had been assessed after the fall on 10/07/19. She stated on 10/08/19 at 1:00 p.m. She was asked when the fall had occurred. She stated on the 3-11 shift on 10/07/19. At 2:34 p.m., the DON was asked when the staff assessed a resident after a fall. She stated as soon as they were aware of the incident. The DON was asked when the staff had assessed the resident after the fall on 10/07/19. She stated she did not know. She stated the resident's responsible party had informed the day shift staff of the fall on the morning of 10/08/19. The DON was asked if the staff had followed the facility protocol for assessment, notification and documentation related to a fall. She stated, No.

Based on interview and record review, it was determined the facility failed to document a fall in the clinical record in a timely manner for one (#68) of two sampled residents who were reviewed for falls. The resident census and condition report documented 76 residents resided in the facility. Findings: Resident #68 had diagnoses which included dementia. A quarterly assessment, dated 09/05/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required limited assistance of one staff with transfers and extensive assistance of one person for toileting. The resident was frequently incontinent of bowel and bladder. She had one fall without injury prior to the assessment. The care plan, last revised on 09/23/19, documented a focus related to falls due to confusion. The goal was for staff to evaluate all falls and intervene as needed to reduce the potential of significant injury through the review date. Interventions included to toilet and provide incontinent care frequently. On 10/08/19 at 8:35 a.m., the resident's responsible party stated he had been informed by the resident's roommate that morning that the resident had fallen in the bathroom on 10/07/19 during the second shift. He stated she was found in the bathroom by herself. He stated he had not been informed of the fall by staff. Review of the clinical record from 10/07/19 through 10/08/19 at 12:59 p.m. did not include documentation of a fall. A nurse's note, dated 10/08/19 at 1:00 p.m., documented, .Incident Note .Initial- Resident's roommate reports that [resident name deleted] fell in her bathroom last night on the 3-11 shift. Resident is oriented to self only and does not recall falling. Nurse working yesterday evening contacted with no return. Aide working hall contacted and states that the resident did in fact fall at around 1930 [7:30 p.m.] and the nurse was notified. Resident was noted sitting on floor in between toilet and wall. Charge nurse working assessed resident for injuries. No apparent unjuries [sic] noted upon assessment by this nurse. ROM is wnl for her. Neuro checks initiated and are wnl. Denies pain. VS:116/68, 82, 97.9, 95%, 18. Husband [name deleted] notified. Dr [name deleted] notified. On 10/09/19 at 1:22 p.m., CNA #1 was asked the process when a resident fell. She stated she informed the nurse. At 2:09 p.m., LPN #2 was asked what the process was when a resident fell. She stated she assessed the resident, documented the fall and notified the family, director of nursing and physician. She was asked when she documented a fall. She stated as soon as she could. She was asked if she documented a fall before the end of her shift. She stated, Oh yeah, definitely. LPN #2 was asked when the fall had occurred. She stated on the 3-11 shift on 10/07/19. She was asked if the nurse who was on duty at the time of the fall had documented the incident. She stated no. She was asked when the fall had been documented. She stated on 10/08/19 at 1:00 p.m. LPN #2 was asked if the fall had been documented and reported in a timely manner. She stated, No. At 2:34 p.m., the DON was asked when the staff assessed a resident after a fall. She stated as soon as they were aware of the incident. She was asked when the staff notified the family after a fall. She stated they should immediately notify the family and physician after they assessed the resident. The DON was asked when they should document a fall. She stated as soon as everyone was notified and the resident was safe. The DON was asked when the staff had assessed the resident after the fall on 10/07/19. She stated she did not know. She stated the resident's responsible party had informed the day shift staff of the fall on the morning of 10/08/19. The DON was asked when the staff had documented the fall on 10/07/19. She stated on 10/08/19 at 1:00 p.m. The DON was asked if the staff had followed the facility protocol for assessment, notification and documentation related to a fall. She stated, No.

Based on record review and interview, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated for one (#15) of two sampled residents who were reviewed for thorough investigations. The resident census and condition report identified 76 residents resided in the facility. Findings: Resident #15 had diagnoses which included schizophrenia. A quarterly assessment, dated 07/05/19, documented the resident was moderately impaired in cognitive skills for daily decision making, required limited assistance from staff for ambulation and was independent with transfers. A care plan, dated 07/12/19, documented the resident had impaired cognition, due to schizophrenia and his behaviors and mood could fluctuate. He used psychotropic medications related to behavior management. Interventions included to offer the resident reassurance, redirection and one to one supervision as needed. Staff was to monitor and record behaviors of refusing care, hoarding and anxiety exhibited by restlessness. A nurse's note, dated 08/29/19 at 3:03 p.m., documented the resident was sitting inside the dinning room and starting rubbing on the inside of a females thigh until he was asked to stop. The resident was placed on one on one supervision. An incident report form, dated 08/29/19, documented the staff observed resident #15 rubbing the inside of resident #61's thigh and advancing toward the genital area. Staff intervened and the residents were separated. Resident #15 was placed on one on one observation until sent for a geropsychiatric evaluation. It was further documented an investigation was conducted which included staff interviews, resident interviews and resident focused assessments. Upon completion of the investigation, the facility concluded resident #15 needed a geropsychiatric evaluation. There was no documentation of the staff interviews conducted during the investigation. There was no documentation of the resident interviews or focused assessments conducted during the investigation. There was no documentation to indicate a geropsychiatric evaluation was conducted for resident #15. A progress note, dated 09/20/19 at 2:25 p.m., documented a medication review, which included changes in the medication regimen, was conducted due to previous behaviors. The resident had been removed from one on one supervision. An incident report form, dated 09/22/19, documented several residents observed resident #15 rubbing the abdomen of resident #61 and advancing toward the genital area when stopped by staff. The residents were separated. Interviews were conducted with staff. Residents were assessed and interviewed. Resident #15 was placed on one on one observation until sent for a geropsychiatric evaluation. There was no documentation of the staff interviews, resident interviews or resident assessments conducted during the investigation. On 10/10/19 at 12:27 p.m., the DON was asked if documentation could be provided of the interviews and assessments which were documented as part of the investigations. She stated she had no other documentation. The DON was asked if the incidents were thoroughly investigated. She stated, No. She was asked if thorough investigations should have been conducted to ensure the safety of the residents and prevent further occurrence. The DON shook her head yes.

Based on observations, record review and interview, it was determined the facility failed to ensure assistance with activities of daily living was provided in a timely manner for three (#44, #59 and #61) of three sampled residents who were reviewed for activities of daily living. The facility identified 69 residents who required assistance with bathing and 49 residents who required assistance with toileting. Findings: 1. Resident #59 had diagnoses which included transient cerebral ischemic attack and overactive bladder. A quarterly assessment, dated 08/26/19, documented the resident was independent in cognitive skills for daily decision making. She required extensive assistance of one person for toileting and bathing. The resident was always incontinent of bowel and bladder. The care plan, last revised on 09/14/19, documented a focus related to having bowel and bladder incontinence due to overactive bladder. The goal was to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included to check the resident frequently for incontinence and provide incontinent care as needed. On 10/07/19 at 10:13 a.m., the resident was observed self-propelling in the hallway. She was asked how she was doing. She stated, I am good, but yesterday I had to lay in my shit for four hours before they changed me. At 10:24 a.m., the resident's call light was observed to be on. The light was observed to remain on until 10:48 a.m. At 10:48 a.m., CNA #2 was observed to enter the resident's room. She informed the resident she would get CNA #1 and the call light was turned off. No care was provided to the resident. At 10:49 a.m., CNA #1 was observed to enter the resident's room. She told the resident to give her about 15 minutes. At 10:53 a.m., the resident was asked if her needs had been met from when she had called for assistance. She stated, No. She was asked what assistance she required. She stated, My bath. She stated she had not received a bath Friday, Saturday or Sunday. At 11:01 a.m., the resident was observed sitting in her wheelchair in the hallway outside her room. At 11:07 a.m., the resident was in the hallway and stated she was going to the noon meal. She stated, I guess they will just have to smell me. She stated she had still not received her bath. At 2:41 p.m., the resident was asked if she received the care she needed with activities of daily living without having to wait a long time. She stated, They only help me when I can catch them. She stated she had waited up to three to four hours to get help going to bed and to receive incontinent care. She was asked when she had received the bath she had requested and waited on staff assistance for before the noon meal today. She stated, After lunch. The resident explained she had to ask the staff again for assistance with her bath after lunch and it took them one hour to get to her. On 10/08/19 at 8:31 a.m., the resident asked CMA #1 for assistance with incontinent care. CMA #1 stated, Not right now, I am in the middle of med pass. The resident's call light was observed to be on. At 8:36 a.m., CNA #1 walked past the resident and stated to the resident, Give me a minute. The resident's call light was observed on. At 8:41 a.m., the resident's call light was observed to still be on. At 8:45 a.m., the resident told CNA #1 she had an exercise activity to attend at 9:30 a.m. CNA #1 was observed to turn the resident's call light off and exit the room. No care was provided to the resident. At 9:01 a.m., CNA #1 asked the resident if she was ready for her. At 9:05 a.m., two staff were observed to enter the resident's room with supplies to perform incontinent care. At 10:33 a.m., the resident was asked when she had been provided assistance with incontinent care prior to 9:05 a.m. She stated, They changed me at 5 a.m. and took me down to breakfast. On 10/10/19 at 1:59 p.m., CNA #1 was asked when she provided incontinent care for the resident. She stated she made rounds with the night shift staff when she arrived to work for the 7:00 a.m. to 3:00 p.m. shift. She stated the last two days the resident had already been up in the dining room when she came on shift, so she had assisted with incontinent care after breakfast. She stated the resident got up at about 5:30 a.m. to 6:00 a.m. The CNA was asked if the resident was already in the dining room when she arrived to work at 7:00 a.m. She stated, Yes. At 2:03 p.m., LPN #3 was asked how she monitored to ensure the resident's received timely incontinent care. She stated she observed the residents as she performed her treatments and made her rounds. She was asked how often incontinent care was provided for dependent residents. She stated at least every two hours. She was asked if they had enough staff to meet the needs of the residents in a timely manner. She stated, Most of the time, sometimes we need more help than we have. At 2:09 p.m., the DON was asked how often incontinent care was provided for dependent residents. She stated they checked them every two hours. She was asked how she monitored to ensure resident's received timely incontinent care. She stated the managers for each hall checked the residents and made sure the care was completed. The DON was asked what an acceptable time period was for a dependent resident to go without incontinent care. She stated, No longer than two hours. 2. Resident #61 had diagnoses which included dementia. A quarterly assessment, dated 08/28/19, documented the resident was severely impaired in cognitive skills for daily decision making. She required extensive assistance of two staff for toileting. The resident was always incontinent of bowel and bladder. The care plan, last revised on 09/15/19, documented a focus related to bladder incontinence. The goal was to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included to check frequently and as needed for incontinent care. On 10/08/19 at 8:21 a.m., the resident was observe to self-propel at the end of the hall near the nurse's station. The resident was not observed to have been in her room from 8:21 a.m. through 9:47 a.m. At 9:48 a.m., CNA #4 was observed pushing the resident in her wheelchair down the hall. She pushed the resident into her room and left her. No care was observed to be provided to the resident. The resident was observed in the same position in her wheelchair from 9:48 a.m. through 11:32 a.m. in her room. No care was observed to have been provided to the resident. At 11:32 a.m., CNA #2 was observed to walk past the resident's doorway and look in at the resident. She was not observed to enter the resident's room or provide care to the resident. The resident was observed in the same position in her wheelchair from 11:32 a.m. through 11:42 a.m. in her room. No care was observed to have been provided to the resident. At 11:42 a.m., the ADON was observed telling CNA #2 to be sure to change the resident. CNA #2 asked the ADON if she should wait on CNA #1 to return to the hall because she did not want to transfer the resident with one person. The ADON stated she could assist her if needed. The ADON left the hallway. The resident was observed in the same position in her wheelchair in her room. No care had been provided to the resident. At 11:44 a.m., CNA #2 was observed to enter the resident's room with a brief and wipes in hand. She placed a trash can liner in the trash can and exited the room. The resident was observed in the same position in her wheelchair. No care was observed to have been provided to the resident. The resident was observed in the same position in her wheelchair from 11:44 a.m. through 11:49 a.m. in her room. No care was observed to have been provided to the resident. At 11:49 a.m., CNA #2 was observed leaving the hall to assist on another hall. She stated, I don't know where [staff name deleted] is. The resident was observed in the same position in her wheelchair from 11:49 a.m. through 12:00 p.m. in her room. No care was observed to have been provided to the resident. At 12:14 p.m. the resident was still observed to have been in the same position in her room, sitting in her wheelchair. At 12:24 p.m., LPN #2 looked in the resident's room. She was not observed to enter the room or provide care to the resident. At 12:26 p.m., the DON looked in the resident's room. The DON talked to LPN #2 at the medication cart. LPN #2 stated, Yes, I know. At 12:29 p.m., LPN #2 was observed in the resident's room. She told the resident, I will be right back. She was observed to exit the room without providing care to the resident. The resident was observed to remain in the same position in her wheelchair. The resident was observed in the same position in her wheelchair from 12:29 p.m. through 12:42 p.m. in her room. No care was observed to have been provided to the resident. At 12:42 p.m., CNA #1 was asked when the last time the resident had been provided incontinent care. She pointed to CNA #4 and stated, She did it. At 12:43 p.m., CNA #4 was asked if she had provided incontinent care to the resident on this shift. She stated, No. At 12:44 p.m., CNA #1 was asked when the last time she had provided incontinent care for the resident. She stated they had changed her before breakfast at about 8:00 a.m. At 12:51 p.m., CNA #1 and CNA #2 were observed providing incontinent care to the resident. The resident was observed to have blanching of the skin under the brief. At 1:00 p.m., CNA #1 was asked how often they provided incontinent care to the dependent residents. She stated every two hours. She was asked if the resident was considered a dependent resident. She stated, Yes. CNA #1 was asked if they had enough staff to meet the needs of the residents in a timely manner. She stated no, they needed to always have two nurse's aides on this hall and they only had one from 7:00 a.m. until 11:00 a.m. She was asked if any tasks go undone during her shifts. She stated no. She stated the incontinent care did not get done every two hours, but it eventually got done. 3. Resident #44 had diagnoses which included cerebrovascular disease and hemiplegia. A quarterly assessment, dated 08/12/19, documented the resident was independent in cognitive skills for daily decision making. She required extensive assistance of two staff for toileting. The resident was always incontinent of bowel and bladder. The care plan, last revised on 08/31/19, documented a focus related to bladder and bowel incontinence. The goal was to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included the resident required extensive assistance of one to two staff for peri care and changing clothing and to check frequently and provide incontinent care as needed. On 10/08/19 at 8:30 a.m., the resident was observed laying in her bed. The resident was observed from 8:30 a.m. through 9:30 a.m. No staff was observed to provide incontinent care to the resident. At 9:31 a.m., the resident was observed laying in her bed. CNA #1 was observed to enter the resident's room. She asked the resident if she could check her and move her. The CNA closed the door. At 9:33 a.m., CNA #1 was observed leaving the resident's room. The CNA exited the hallway. The resident was observed laying in her bed from 9:34 a.m. through 11:52 a.m. No staff was observed to provide incontinent care to the resident. At 11:53 a.m., CNA #1 was observed to enter the resident's room. She called for assistance from LPN #2 who never responded. CNA #1 exited the room without providing care to the resident. At 12:00 p.m., CNA #1 and LPN #2 were observed to provide incontinent care to the resident. The brief was observed to be saturated with urine and a large bowel movement. At 1:00 p.m., CNA #1 was asked how often they provided incontinent care to the dependent residents. She stated every two hours. She was asked if the resident was considered a dependent resident. She stated, Yes. She was asked when was the last time she had provided incontinent care for the resident prior to 12:00 p.m. She stated it was around 10:30 a.m. to 10:40 a.m., it was just before she had went to lunch at about 11:15 a.m. She stated the resident was not wet at the time, but she had a small bowel movement and she changed her. The CNA was informed the resident had been observed to receive no care from 9:34 a.m. through 12:00 p.m.

Based on observation, record review and interviews, it was determined the facility failed to ensure: ~ supervision was provided to prevent elopements for one (#33) of one sampled resident who was reviewed for eleopements; ~ smoking assessments were completed and supervision was provided to ensure residents did not smoke in their rooms for one (#3) of one sampled resident who smoked; and ~ safe transfers with a lift were provided with the assistance of two staff members for one (#23) of one sampled resident who was reviewed for transfers using a lift. The facility identified 15 residents who smoked and 76 residents who resided in the facility. Findings: 1. Resident #33 had diagnoses which included end stage renal disease and type 2 diabetes mellitus. An admission elopement assessment, dated 07/30/19, documented the resident was a low risk for elopement. An admission assessment, dated 08/08/19, documented the resident was moderately impaired in cognition for daily decision making skills and required limited assistance from staff with activities of daily living. A behavior note, dated 08/19/19 at 2:24 a.m., documented the resident was confused and wandering down the hallway and into an empty room. The resident was difficult to redirect. An incident note, dated 08/22/19 at 4:20 p.m., documented during shift change the resident was not observed in the room. A search was conducted and the resident was found at a convenience store. Upon return to the facility, the resident was placed on one on one supervision and lab work was to be drawn. An elopement assessment, dated 08/22/19, documented the resident was a moderate risk for elopement. A care plan, inititated on 08/22/19 documented, [Resident] is at risk for leaving the facility due to confusion r/t ESRD. He needs staff to monitor his where abouts .Interventions .Show him his room .Wanders around facility and on occasion attempts to leave to go by [sic] cigarettes and snacks . A progress note, dated 09/12/19 at 5:19 p.m., documented the SSD was notified by a CMA that the resident had been smoking in the resident's room. When the SSD went to the resident's room, the pack of cigarettes was observed next to the resident and the lighter was on the bedside table. The resident was reminded of the smoking policy and the SSD requested the staff keep the cigarettes and lighter but the resident refused. According to the admissions coordinator the resident was caught smoking earlier in the day. A behavior note, dated 09/16/19 at 4:05 p.m., documented the resident had been smoking two times that day in the resident's room during the day shift. The resident was informed that smoking in the facility was not ever allowed. A behavior note, dated 09/17/19 at 4:53 p.m., documented the resident went up to the nurse station and stated the resident was walking to the store to buy cigarettes. It was documented the resident was redirected and assisted to the smoking area to smoke cigarettes with no further incident. A behavior note, dated 10/02/19 at 1:20 p.m., documented the resident had behaviors and threatened to leave the facility. The resident was redirected by staff and taken outside for a walk. An incident note, dated 10/06/19 at 6:25 a.m., documented the resident was not found in bed during the 2:00 a.m. rounds. A search was conducted. The resident was found going to the store to buy cigarettes and returned to the facility by the police department. An elopement assessment, dated 10/06/19, documented the resident was a moderate risk for elopement. A progress note, dated 10/07/19 at 4:36 p.m., documented the resident had reported leaving the smoking porch to purchase cigarettes when the elopement occurred on 10/06/19. The intervention which had been put in place was one on one supervision. On 10/09/19 at 11:04 a.m., the DON was asked if any of the residents required supervision to smoke. She stated, no. She was asked if the residents were allowed to smoke in the facility. She stated, no. The DON was asked if resident #33 was a smoker. She stated, yes. She was asked if he kept his cigarettes. She stated no, because he was caught smoking in the facility. She also stated the resident was now supervised due to having eloped. The DON was asked if a smoking assessment had been conducted on the resident. She reviewed the clinical record and stated, no. She was asked if there should have been one. The DON stated, yes. The DON was asked when the resident was removed from one on one supervision after the first elopement incident. She stated when the lab work was finished. She was asked to review the elopement assessments and notes from 09/17/19 and 10/02/19. The DON then stated, so if the elopement assessments were more accurate and a smoking assessment had been done maybe the second elopement would not have occurred. 2. Resident #23 had diagnoses which included cerebral palsy. A care plan, last updated on 01/19/18, documented a focus of potential for falls related to impaired mobility due to cerebral palsy. The goal was to minimize the risk for falls and related injury through the review date. Interventions included the use of a sit to stand lift and assist of two persons for transfers. An annual assessment, dated 07/19/19, documented the resident was independent in cognitive skills for daily decision making. She required extensive assistance of two staff for transfers and toileting. On 10/07/19 at 11:16 a.m., CNA #2 was observed pushing the sit to stand lift into the resident's room. She came out of the room to obtain gloves from the supply closet and re-entered the resident's room. She then closed the door. At 11:20 a.m., CNA #2 was observed in the resident's room. The resident was observed up in the lift with CNA #2 pushing the lift toward the bathroom. No other staff was present in the room. On 10/08/19 at 9:58 a.m., a sign was observed on the wall in the hall. The sign documented, .safety first! 2-person assists . The sign contained a picture of two people assisting a person with transferring from a wheelchair to a walker with the use of a lift. On 10/09/19 at 10:05 a.m., CNA #3 was asked how they performed transfers with the use of a lift. She stated they used two staff for safety and to ensure safe maneuvering of the lift. Two staff transfers with the lift also made sure the resident felt safe. She was asked if it was ever okay to use the lift without another staff member present. She stated, No, there is too many variables. At 1:39 p.m., the resident was observed sitting in her wheelchair in her room with the lift sling underneath her. LPN #2 was observed attaching the lift to the sling. No other staff was observed in the room. LPN #2 was asked what care was being provided. She stated, She has to go to the bathroom. At 1:42 p.m., LPN #2 was observed standing at the doorway of the resident's bathroom. She was asked if the resident had been transferred to the toilet. She stated, Yes. CNA #1 entered the room and asked LPN #2 if she needed assistance. The CNA remained in the room. At 2:06 p.m., LPN #2 was asked what training she had received related to safe transfers. She stated she had been a CNA for thirteen years. She stated she just learned today something she should have already known. She was asked if it was ever okay to only use one staff when using the lift during a transfer. She stated, Probably not, learned the hard way. She was asked if she had ever observed the nursing staff perform a transfer with just one person. She stated, No, usually they have two. She was asked if she had performed the transfer of resident #23 without another staff assisting. She stated yes, she had transferred the resident to the toilet. At 2:32 p.m., the DON was asked how they trained the staff to perform transfers with the use of a lift. She stated they were supposed to do a competency checklist on the staff using the lift. She was asked how many staff were required while using a lift. She stated, Two. She was asked if they required two staff for all types of lifts. She stated, Yes.

Based on observation, record review and interview, it was determined the facility failed to ensure pain medication was administered in a timely manner for one (#27) of three sampled residents who were reviewed for pain. The facility identified 76 residents who resided in the facility. Findings: Resident #27 had diagnoses which included fracture of the tibia. A discharge assessment, dated 08/10/19, documented she was independent in cognitive skills for daily decision making and had frequent pain rated a four on a scale of 0-10. A care plan, last revised on 09/19/19, documented a focus of acute/chronic pain related to fracture to the shaft of the right tibia, wedge compression fractures to thoracic and lumbar vertebra and spinal stenosis of the lumbar region. The goal was to not have an interruption in normal activities due to pain through the review date. Interventions included to administer Percocet every four hours as needed as ordered; respond immediately to any complaint of pain; monitor/record/report to nurse loss of appetite, refusal to eat and weight loss; and monitor/record/report to nurse resident complaints of pain or requests for pain treatment. A physician's order, dated 09/30/19, documented half of a Percocet 10/325 mg tablet was to be administered every four hours as needed for pain rated 0-5. A physician's order, dated 09/30/19, documented Percocet 10/325 mg was to be administered every four hours as needed for severe pain rated 6-10. The narcotics record, dated 10/10/19 at 8:00 a.m., documented the resident had received Percocet 5 mg. On 10/10/19 at 12:13 p.m., SS #1 was observed delivering the noon meal tray to the resident in her room. The resident stated she did not want to eat. She stated, I am hurting too bad. The SS #1 was observed informing LPN #1 in the hallway the resident had declined her tray because she was hurting too bad. LPN #1 stated to SS #1, See if she wants tomato soup. At 12:14 a.m., LPN #1 was observed to ask the resident if she wanted tomato soup and a grilled cheese. The resident declined. LPN #1 stated, Okay. At 12:30 p.m., the housekeeping supervisor was observed to offer the resident a shake and a glass of milk. The resident declined. The housekeeping supervisor stated to the resident, You don't want it? Okay. The narcotics record, dated 10/10/19 at 1:18 p.m., documented the resident had received Percocet 5 mg. The narcotics record, dated 10/10/19 at 2:06 p.m., documented the resident had received Percocet 10 mg. The treatment administration record, dated 10/2019, documented the staff had administered Percocet 5 mg when the resident had rated her pain 6-10. It was documented the staff had administered 10 mg when the resident had rated her pain a two. On 10/10/19 at 2:15 p.m., the resident was asked if she currently had pain. She stated, I am in great pain. She stated her pain was rated a nine and the staff had just administered pain medication. At 2:19 p.m., LPN #1 was asked if the resident had accepted her noon meal tray. She stated, No. She was asked why the resident had declined the tray. She stated she the resident did not want to eat, but she did not know why. She stated the resident had also declined a shake. The LPN stated, I asked her if she wanted tomato soup and she still hasn't wanted it. LPN #1 was asked what medications were ordered for the resident for pain. She stated Percocet 5 mg every four hours for pain rated 0-5 or 10 mg for pain rated 6-10. She stated the resident had rated her pain a five earlier so she gave her Percocet 5 mg at 1:18 p.m., but later she rated her pain an eight so she gave her Percocet 10 mg at 1:58 p.m. She was asked if it was acceptable to administer Percocet 5 mg and Percocet 10 mg in the time frame she had administered the medication. She stated, That is how the order is written. At 2:36 p.m., SS #1 was asked if the resident had accepted her noon meal tray this date. She stated, No. She was asked why the resident had declined the tray. She stated, She said she was in too much pain at that moment. She was asked what she had done when the resident had declined her tray. She stated, I let the nurse know. She was asked when she had informed the nurse. She stated, Right after. At 2:38 p.m., LPN #1 was asked what she had done when SS #1 had informed her the resident had declined her noon tray due to hurting too bad. She stated, I didn't know [SS #1 name deleted] told me she said she was hurting too bad. She stated, [SS #1 name deleted] said she didn't want lunch, so I offered tomato soup. I am so busy. At 2:48 p.m., the DON was asked what time frame she expected staff to administer pain medication when a resident was in pain. She stated five minutes. She was asked if it should take one hour and five minutes. She stated, No. She was asked when the resident had received pain medication this date. She stated at 8:00 a.m., 1:18 p.m. and 2:06 p.m. She was asked when she would expect the nurse to administer pain medication if a resident stated she was in pain at 12:13 p.m. She stated, As soon as she was told. At 3:02 p.m., the DON was asked what the orders were for Percocet. She stated to give five milligrams for pain rated zero to five and to give ten milligrams for pain rated six to ten. The DON was asked to review the treatment administration record. She was asked if the medication had been administered per orders in relation to the pain rating. She stated, No. She was asked how the staff had administered the pain medication. She stated, They are giving the half tab, five milligrams, no matter what the rating and one time it was rated a two and they gave ten milligrams. The DON was asked if the staff should have administered Percocet five milligrams at 1:18 p.m. and ten milligrams at 1:58 p.m. She stated, No, they should not be going off of these orders. She was asked if the staff should have contacted the physician. She stated, Yes.

Based on observation, record review and interview, it was determined the facility failed to provide sufficient nurse staff to ensure care was provided in a timely manner for three (#44, #59 and #61) of 14 sampled residents who were reviewed for staffing. The facility identified 76 residents who resided in the facility. Findings: 1. Resident #59 had diagnoses which included transient cerebral ischemic attack and overactive bladder. A quarterly assessment, dated 08/26/19, documented the resident was independent in cognitive skills for daily decision making. She required extensive assistance of one person for toileting and bathing. The resident was always incontinent of bowel and bladder. The care plan, last revised on 09/14/19, documented a focus related to having bowel and bladder incontinence due to overactive bladder. The goal was to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included to check the resident frequently for incontinence and provide incontinent care as needed. On 10/07/19 at 10:13 a.m., the resident was observed self-propelling in the hallway. She was asked how she was doing. She stated, I am good, but yesterday I had to lay in my shit for four hours before they changed me. At 10:24 a.m., the resident's call light was observed to be on. The light was observed to remain on until 10:48 a.m. At 10:48 a.m., CNA #2 was observed to enter the resident's room. She informed the resident she would get CNA #1 and the call light was turned off. No care was provided to the resident. At 10:49 a.m., CNA #1 was observed to enter the resident's room. She told the resident to give her about 15 minutes. At 10:53 a.m., the resident was asked if her needs had been met from when she had called for assistance. She stated, No. She was asked what assistance she required. She stated, My bath. She stated she had not received a bath Friday, Saturday or Sunday. At 11:01 a.m., the resident was observed sitting in her wheelchair in the hallway outside her room. At 11:07 a.m., the resident was in the hallway and stated she was going to the noon meal. She stated, I guess they will just have to smell me. She stated she had still not received her bath. At 2:41 p.m., the resident was asked if she received the care she needed with activities of daily living without having to wait a long time. She stated, They only help me when I can catch them. She stated she had waited up to three to four hours to get help going to bed and to receive incontinent care. She was asked when she had received the bath she had requested and waited on staff assistance for before the noon meal today. She stated, After lunch. The resident explained she had to ask the staff again for assistance with her bath after lunch and it took them one hour to get to her. On 10/08/19 at 8:31 a.m., the resident asked CMA #1 for assistance with incontinent care. CMA #1 stated, Not right now, I am in the middle of med pass. The resident's call light was observed to be on. At 8:36 a.m., CNA #1 walked past the resident and stated to the resident, Give me a minute. The resident's call light was observed on. At 8:41 a.m., the resident's call light was observed to still be on. At 8:45 a.m., the resident told CNA #1 she had an exercise activity to attend at 9:30 a.m. CNA #1 was observed to turn the resident's call light off and exit the room. No care was provided to the resident. At 9:01 a.m., CNA #1 asked the resident if she was ready for her. At 9:05 a.m., two staff were observed to enter the resident's room with supplies to perform incontinent care. At 10:33 a.m., the resident was asked when she had been provided assistance with incontinent care prior to 9:05 a.m. She stated, They changed me at 5 a.m. and took me down to breakfast. On 10/10/19 at 1:59 p.m., CNA #1 was asked when she provided incontinent care for the resident. She stated she made rounds with the night shift staff when she arrived to work for the 7:00 a.m. to 3:00 p.m. shift. She stated the last two days the resident had already been up in the dining room when she came on shift, so she had assisted with incontinent care after breakfast. She stated the resident got up at about 5:30 a.m. to 6:00 a.m. The CNA was asked if the resident was already in the dining room when she arrived to work at 7:00 a.m. She stated, Yes. At 2:03 p.m., LPN #3 was asked how she monitored to ensure the resident's received timely incontinent care. She stated she observed the residents as she performed her treatments and made her rounds. She was asked how often incontinent care was provided for dependent residents. She stated at least every two hours. She was asked if they had enough staff to meet the needs of the residents in a timely manner. She stated, Most of the time, sometimes we need more help than we have. At 2:09 p.m., the DON was asked how often incontinent care was provided for dependent residents. She stated they checked them every two hours. She was asked how she monitored to ensure resident's received timely incontinent care. She stated the managers for each hall checked the residents and made sure the care was completed. The DON was asked what an acceptable time period was for a dependent resident to go without incontinent care. She stated, No longer than two hours. 2. Resident #61 had diagnoses which included dementia. A quarterly assessment, dated 08/28/19, documented she was severely impaired in cognitive skills for daily decision making. She required extensive assistance of two staff for toileting. The resident was always incontinent of bowel and bladder. The care plan, last revised on 09/15/19, documented a focus related to bladder incontinence. The goal was to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included to check frequently and as needed for incontinent care. On 10/08/19 at 8:21 a.m., the resident was observe to self-propel at the end of the hall near the nurse's station. The resident was not observed to have been in her room from 8:21 a.m. through 9:47 a.m. At 9:48 a.m., CNA #4 was observed pushing the resident in her wheelchair down the hall. She pushed the resident into her room and left her. No care was observed to be provided to the resident. The resident was observed in the same position in her wheelchair from 9:48 a.m. through 11:32 a.m. in her room. No care was observed to have been provided to the resident. At 11:32 a.m., CNA #2 was observed to walk past the resident's doorway and look in at the resident. She was not observed to enter the resident's room or provide care to the resident. The resident was observed in the same position in her wheelchair from 11:32 a.m. through 11:42 a.m. in her room. No care was observed to have been provided to the resident. At 11:42 a.m., the ADON was observed telling CNA #2 to be sure to change the resident. CNA #2 asked the ADON if she should wait on CNA #1 to return to the hall because she did not want to transfer the resident with one person. The ADON stated she could assist her if needed. The ADON left the hallway. The resident was observed in the same position in her wheelchair in her room. No care had been provided to the resident. At 11:44 a.m., CNA #2 was observed to enter the resident's room with a brief and wipes in hand. She placed a trash can liner in the trash can and exited the room. The resident was observed in the same position in her wheelchair. No care was observed to have been provided to the resident. The resident was observed in the same position in her wheelchair from 11:44 a.m. through 11:49 a.m. in her room. No care was observed to have been provided to the resident. At 11:49 a.m., CNA #2 was observed leaving the hall to assist on another hall. She stated, I don't know where [staff name deleted] is. The resident was observed in the same position in her wheelchair from 11:49 a.m. through 12:00 p.m. in her room. No care was observed to have been provided to the resident. At 12:14 p.m. the resident was still observed to have been in the same position in her room, sitting in her wheelchair. At 12:24 p.m., LPN #2 looked in the resident's room. She was not observed to enter the room or provide care to the resident. At 12:26 p.m., the DON looked in the resident's room. The DON talked to LPN #2 at the medication cart. LPN #2 stated, Yes, I know. At 12:29 p.m., LPN #2 was observed in the resident's room. She told the resident, I will be right back. She was observed to exit the room without providing care to the resident. The resident was observed to remain in the same position in her wheelchair. The resident was observed in the same position in her wheelchair from 12:29 p.m. through 12:42 p.m. in her room. No care was observed to have been provided to the resident. At 12:42 p.m., CNA #1 was asked when the last time the resident had been provided incontinent care. She pointed to CNA #4 and stated, She did it. At 12:43 p.m., CNA #4 was asked if she had provided incontinent care to the resident on this shift. She stated, No. At 12:44 p.m., CNA #1 was asked when the last time she had provided incontinent care for the resident. She stated they had changed her before breakfast at about 8:00 a.m. At 12:51 p.m., CNA #1 and CNA #2 were observed providing incontinent care to the resident. The resident was observed to have blanching of the skin under the brief. At 1:00 p.m., CNA #1 was asked how often they provided incontinent care to the dependent residents. She stated every two hours. She was asked if the resident was considered a dependent resident. She stated, Yes. CNA #1 was asked if they had enough staff to meet the needs of the residents in a timely manner. She stated no, they needed to always have two nurse's aides on this hall and they only had one from 7:00 a.m. until 11:00 a.m. She was asked if any tasks go undone during her shifts. She stated no. She stated the incontinent care did not get done every two hours, but it eventually got done. 3. Resident #44 had diagnoses which included cerebrovascular disease and hemiplegia. A quarterly assessment, dated 08/12/19, documented the resident was independent in cognitive skills for daily decision making. She required extensive assistance of two staff for toileting. The resident was always incontinent of bowel and bladder. The care plan, last revised on 08/31/19, documented a focus related to bladder and bowel incontinence. The goal was to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included the resident required extensive assistance of one to two staff for peri care and changing clothing and to check frequently and provide incontinent care as needed. On 10/08/19 at 8:30 a.m., the resident was observed laying in her bed. The resident was observed from 8:30 a.m. through 9:30 a.m. No staff was observed to provide incontinent care to the resident. At 9:31 a.m., the resident was observed laying in her bed. CNA #1 was observed to enter the resident's room. She asked the resident if she could check her and move her. The CNA closed the door. At 9:33 a.m., CNA #1 was observed leaving the resident's room. The CNA exited the hallway. The resident was observed laying in her bed from 9:34 a.m. through 11:52 a.m. No staff was observed to provide incontinent care to the resident. At 11:53 a.m., CNA #1 was observed to enter the resident's room. She called for assistance from LPN #2 who never responded. CNA #1 exited the room without providing care to the resident. At 12:00 p.m., CNA #1 and LPN #2 were observed to provide incontinent care to the resident. The brief was observed to be saturated with urine and a large bowel movement. At 1:00 p.m., CNA #1 was asked how often they provided incontinent care to the dependent residents. She stated every two hours. She was asked if the resident was considered a dependent resident. She stated, Yes. She was asked when was the last time she had provided incontinent care for the resident prior to 12:00 p.m. She stated it was around 10:30 a.m. to 10:40 a.m., it was just before she had went to lunch at about 11:15 a.m. She stated the resident was not wet at the time, but she had a small bowel movement and she changed her. The CNA was informed the resident had been observed to receive no care from 9:34 a.m. through 12:00 p.m.

Based on observation, record review and interview, it was determined the facility failed to ensure a sufficient amount of bedtime snacks were available and offered to residents. The facility identified 75 residents who received meals from the kitchen, and 25 residents were identified as diabetic. Findings: On 10/09/19 at 10:05 a.m., a group meeting with 13 residents was conducted. The residents stated snacks had been available at the nurse's station for those who were capable to help themselves. They stated snacks were not passed on a regular basis to the dependent residents. The residents stated the staff had not been putting out enough snacks for all the residents and some residents would take multiple snacks if they were able to get to the tray first. At 1:50 p.m., the dietary staff was observed preparing the bedtime snacks. DA #1 was asked what was being prepared. He stated 20 bologna and cheese sandwiches were made and cut in half to make 40 servings. The staff would then wrap the half sandwiches individually for the bedtime snacks. The DA stated they would also set out fruit, cereals and extra deserts for the bedtime snacks. At 4:10 p.m., the DM was asked what the procedure was for providing the snacks at bedtime. He stated a tray was delivered to the nurse's station between 6:30 p.m. and 7:00 p.m. He stated the staff was supposed to pass the snacks to the residents at 8:00 p.m. The DM stated a smaller tray was prepared for emergency diabetic needs, which included six half sandwiches and orange juice. These were delivered directly to the nurses to be kept if needed. On 10/10/19 at 1:45 p.m., LPN #1 was asked what the procedure was for ensuring the residents received bedtime snacks. She stated the kitchen staff delivered the snacks to the nurse's station and they were kept until it was time to be passed to the residents. At 2:00 p.m., the DON was asked what the procedure was for ensuring the residents received bedtime snacks. She stated the kitchen staff prepared the snacks and put them out at the nurse's station before they left for the day. She stated she was unaware of the type or number of snacks prepared. She was asked if 40 half sandwiches were sufficient for 75 residents. She stated, No. She was asked if six half sandwiches and three orange juices were sufficient for the 25 diabetics. She stated, No.