Based on interview and record review it was determined the facility failed to ensure resident representatives were informed in writing of changes in financial coverage for 1 of 4 sampled residents (#340) reviewed for advance beneficiary notification. This placed residents and their representatives at risk for unknown financial liabilities and lack of knowledge regarding the right to appeal the decision. Findings include: Resident 340 was admitted to the facility for skilled care in 2/2023 with diagnoses including Alzheimer's disease. Resident 340's 3/2/23 Psychosocial History and Discharge Plan revealed the resident's family assisted her/him with decision-making and the resident was unable to make serious medical decisions for her/himself. Resident 340's 3/10/23 admission MDS revealed the resident was severely cognitively impaired. Resident 340's undated admission Record (a document in a patient's electronic health record that summarizes important details, including patient identification, allergies and contact information) identified Witness 2 (Family Member) as the resident's Emergency Contact #1, Care Conference Person, Power of Attorney (POA) and Representative Payee (a person or organization who receives Social Security or SSI [supplemental security income] benefits for anyone unable to manage his/her own benefits). Although Resident 340 was identified as severely cognitively impaired in assessments, a Notice of Medicare Non-Coverage (NOMNC) form was provided by facility staff and signed by the resident on 3/28/24. The form indicated the resident's covered services were scheduled to end on 3/30/23. According to the resident's health record, Resident 340 remained in the facility after 3/30/23 as a private pay resident after that date. No evidence was found in the resident's health record to indicate Witness 2 was provided with a NOMNC, her right to appeal the determination or notification of any other financial liabilities, including an advanced beneficiary notification. On 6/25/24 at 2:51 PM Witness 2 stated she informed Staff 12 (Social Services Director) on 2/27/23 she was Resident 340's POA and was responsible for making all medical and financial decisions for the resident. Witness 2 stated the facility never provided her with a NOMNC for Resident 340. Witness 2 stated she found out months later that the resident signed the form per request of the facility and accrued a bill ever since. On 6/26/24 at 3:00 PM Staff 12 (Social Services Director) stated Witness 2 was involved in Resident 340's care and was her/his POA. On 6/26/24 at 3:44 PM Staff 1 (Administrator) stated he issued Resident 340 the NOMNC and was present when the resident signed the form. Staff 1 stated he typically did not have a resident with a diagnosis of dementia sign the form but he did it in this case in the essence of time. Staff 1 stated he did not notify Witness 2 he had Resident 340 sign the form.

Based on interview and record review it was determined the facility failed to provide residents with a written notice of the facility's bed hold policy at the time of transfer to the hospital for 1 of 3 sampled residents (#40) reviewed for hospitalization and discharge. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: Resident 40 was admitted to the facility in 12/2023 with diagnoses including dementia and heart disease. Resident 40's 2/26/24 Discharge MDS indicated the resident was discharged to an acute care hospital. Review of Resident 40's health record revealed no documentation to indicate the resident was notified of or provided a copy of the facility's bed hold policy prior to her/his 2/26/24 discharge. On 7/1/24 at 9:54 AM Staff 2 (DNS) confirmed a bed hold policy was not provided to Resident 40 when she/he transferred to a hospital.

Based on interview and record review it was determined the facility failed to revise and update a care plan intervention for clothing preferences and call light use for 1 of 2 sampled residents (# 45) reviewed for care planning. This placed residents at risk for unmet of care needs. Findings include: Resident 45 admitted to the facility in 11/2023 with diagnoses including paralysis and infection. Resident 45's 2023 comprehensive care plan indicated she/he preferred to get dressed in a shirt even when she/he stayed in bed. Resident 45's comprehensive care plan further indicated her/his call light was to be within reach and Resident 45 was encouraged to use it. Observations made from 6/24/24 through 6/27/24 revealed Resident 45 wore a hospital gown throughout the day. On 6/27/24 at 9:29 AM Staff 26 (CNA) and Staff 27 (LPN) stated Resident 45 rarely used her/his call light. When Resident 45 wanted something she/he yelled for assistance. Staff 26 stated Resident 45 preferred to wear a hospital gown. Staff 26 stated Resident 45 did not seem to have a preference between shirt or gown. On 6/28/24 at 10:57 AM Staff 28 (CNA) stated 2 years ago Resident 45 used her/his call light consistently and showed a preference for shirts. Staff 28 stated currently she did not see her/him use a call light and stated Resident 45 did not have a preference of clothing. On 6/28/24 at 11:00 AM Staff 29 (CNA) and Staff 30 (CNA) stated Resident 45 rarely ever used her/his call light. Staff 29 and Staff 30 stated she/he called out for assistance. Staff 29 and Staff 30 stated Resident 45 did not express a preference for wearing a shirt or hospital gown. On 6/28/24 at 11:52 AM Staff 25 (RN) Stated Resident 45 wore a shirt or one of the hospital gowns. Staff 25 stated Resident 45 did not really use her/his call light. Staff 25 stated when Resident 45 really needed something she/he yelled. Staff 25 confirmed Resident 45's care plan was not updated for her/his changed needs.

Based on observation and interview it was determined the facility failed to ensure residents were aware of the right to review survey results for 2 of 2 floors and failed to make survey results were readily accessible for 1 of 2 floors reviewed for resident rights. This placed residents and the public at risk for not being informed of the facility's survey history. Findings include: On 6/27/24 at a resident meeting at 2:00 PM residents asked if they were allowed to know the results of the current survey when it was completed. None of the 8 residents attending were aware there was a copy of the survey results located on the first floor near the elevator. Residents further stated most second floor residents could not easily access the first floor without assistance from staff. On 6/28/24 at 2:00 PM no accessible survey results were observed on second floor. On 6/28/24 at 2:00 PM Staff 14 (Activities Director) stated there used to be a place by the nurses station on the second floor where the results of the survey were available in the past, but she believed it disappeared during a remodel. Staff 14 stated she did not think most residents were aware there were results of the survey available to residents. On 6/28/24 at 2:35 PM Staff 1 (Administrator) stated survey results were available by the first-floor entrance, which everyone uses for admission, appointments, outings. Staff 1 stated there was no copy on the second floor in the past six years. Staff 1 also stated if residents on the second floor wanted to see a copy of the survey results, They can ask staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 16 was admitted to the facility in 6/2024 with diagnoses including a right foot wound. Resident 16's 6/6/24 admission MDS revealed the resident was cognitively intact. On 6/25/24 at 9:46 AM Resident 16 was observed in her/his room in bed with a blanket covering the length of her/his body. Resident 16 stated her/his room was freezing and her/his children brought extra comforters because the room was so cold. Resident 16 stated she/he complained to facility staff that the room was too cold on the day she/he admitted to the facility. Resident 16 stated an unidentified staff member blocked the vent in the room approximately five to seven days after she/he reported the temperature issue but the room was still cold. Resident 16 further stated she/he did not shower in the bathroom because it was excessively cold. On 6/26/24 at 9:22 AM Resident 16 was observed in her/his room in bed with a blanket covering the length of her/his body and wearing a hat. Resident 16 stated she/he often wore a hat in her/his room to keep warm and she/he preferred to keep the door to the bathroom closed at all times so the cold air would not blow into [her/his] room. The Surveyor entered the resident's bathroom and felt cold air blowing. On 6/26/24 at 9:59 AM Staff 23 (CNA) stated Resident 16 complained about her/his room being cold a couple of times, and when the resident did, Staff 23 stated she added the resident's concern to the maintenance book and offered the resident an extra blanket. Staff 23 stated Resident 16's room was known to be really bad when it came to temperatures. Staff 23 stated Resident 16's room temperatures fluctuated a lot and the room was sometimes really, really hot and sometimes really, really cold. On 6/26/24 at 10:09 AM Staff 6 (Maintenance Director) stated it was his practice to continue checking the temperatures of rooms with temperature complaints even after he felt the issue was addressed in order to ensure that the concern was resolved. Staff 6 stated Resident 16's room had a long history of temperature complaints but he did not take regular temperature readings of Resident 16's room. Staff 6 stated he was not aware Resident 16 complained that her/his room and bathroom were cold. At that time, Staff 6 took temperature readings of the resident's room and bathroom. The temperature reading to the left of the resident's head of bed was 69 degrees and the temperature in the resident's bathroom was 65 degrees. On 6/26/24 at 11:23 AM Staff 1 (Administrator) acknowledged the findings and stated resident room temperatures were determined according to resident preferences. Based on observation and interview it was determined the facility failed to maintain a homelike and comfortable environment for 2 of 3 halls reviewed for environment. This placed residents at risk for living in an unkempt and uncomfortable environment. Findings include: 1. Observations of the facility's general environment and residents' rooms from 6/24/24 through 7/1/24 identified the following issues: -room [ROOM NUMBER] had wall damage behind the bed with missing paint and exposed drywall; -room [ROOM NUMBER] had wall damage behind the bed with missing paint, exposed drywall, several brown spots on the ceiling and a fan with dirty blades; -room [ROOM NUMBER] had wall damage on the right side of the bed with missing paint and exposed drywall; -room [ROOM NUMBER] had damage to the lower portion of the door with sharp/jagged edges; -room [ROOM NUMBER] had wall damage to the left of the door with missing paint and exposed drywall; -room [ROOM NUMBER] had lower wall damage on two walls including behind the bed with missing paint/drywall and a stained/dirty privacy curtain; -room [ROOM NUMBER] had wall damage behind the bed with missing paint and exposed drywall; -The 300 hall had a broken picture frame on the wall with sharp/jagged edges; -An overhead light was burned out in the dining room, as well as between rooms 27-28 and between rooms 39-40. On 7/1/24 at 9:26 AM Staff 1 (Administrator) and Staff 6 (Maintenance Director) acknowledged the identified concerns needed to be addressed.

3. Resident 339 was admitted to the facility in 6/2024 with diagnoses including congestive heart failure. A 6/17/24 Progress Note indicated Resident 339 was sent to the hospital. No evidence was found in Resident 339's health record to indicate a copy of the resident's transfer notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for the hospitalization. On 7/1/24 at 10:35 AM Staff 13 (Social Services Director) stated she was unaware a representative of the Office of the State Long-Term Care Ombudsman was to be notified when a resident was hospitalized . On 7/1/24 at 11:02 AM Staff 1 (Administrator) confirmed the facility did not send a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman for Resident 339's hospitalization. 2. Resident 87 was admitted to the facility in 5/2024 with a diagnosis of spinal cord compression. A 5/23/24 Nursing Note indicated Resident 87 was sent to the hospital. No evidence was found in the resident's clinical record to indicate the Office of the State Long Term Care Ombudsman was notified of Resident 87's hospitalization. On 7/1/24 at 10:35 AM Staff 13 (Social Services) stated she was unaware the Office of the State Long Term Care Ombudsman's office was to be notified when a resident was sent to the hospital. On 7/1/24 at 10:46 AM Staff 1 (Administrator) stated the facility did not send out written hospital notifications to the Office of the State Long Term Care Ombudsman. Based on interview and record review it was determined the facility failed to ensure the Office of the State Long Term Care Ombudsman was notified of resident hospitalizations for 3 of 3 sampled residents (#s 40, 87 and 339) reviewed for hospitalization. This placed residents at risk for lack of advocacy by the Ombudsman's office. Findings include: 1. Resident 40 was admitted to the facility in 12/2023 with diagnoses including dementia and heart disease. Resident 40's 2/26/24 Discharge MDS indicated the resident was discharged to an acute care hospital. Review of Resident 40's health record revealed no documentation to indicate the state/local Ombudsman was notified Resident 40 was discharged to a hospital. On 7/1/24 at 11:02 AM Staff 1 (Administrator) stated the facility did not notify the Ombudsman of discharged residents.

Based on observation, interview and record review it was determined the facility failed to ensure foods were labeled and stored in a way to minimize food spoilage and cross contamination for 1 of 1 kitchen and 1 of 3 snack/resident refrigerators reviewed for sanitary food storage. This placed residents at risk for potential infections related to foodborne pathogens. Findings include: Review of the US FDA 2022 Food Code revealed: -food prepared and held cold must be clearly marked with date prepared or by day which the food shall be consumed or discarded with a maximum of seven days. Observation on 6/24/24 at 9:12 AM of the following items placed on the dishwashing station by Staff 21 (Cook): -An undated plastic container of macaroni with red meat sauce. -A container of whipped topping dated 6/7. -A container of undated gelatin. Observation of the kitchen on 6/24/24 at 9:12 AM revealed the following: Freezer: -An open plastic bag with three waffles dated 4/16/24. -An undated open plastic bag of five garden burgers with freezer burn. -A box of undated garlic bread sticks. - A large piece of wrapped meat with no date. Walk-in refrigerator: -A box of individually wrapped Danish rolls dated 3/30. The box instructions directed if frozen, thaw overnight and serve. -A partially open plastic container of whipped topping dated 5/25. -An open undated plastic bag of five white slices of cheese. On 6/24/24 at 9:39 AM Staff 21 confirmed the items she placed on the dishwasher station were removed from the refrigerator and should have been removed from the refrigerator prior to that day. On 6/24/24 at 9:40 AM Staff 16 (Dietary Manager) confirmed the items in the freezer and refrigerator where not stored or labeled correctly and were past the date to serve. Staff 16 threw away items. Staff 16 stated the box of Danish rolls were frozen but did not know when they were pulled from the freezer. Observation on 6/27/24 at 8:33 AM of the station two snack/resident refrigerator with an undated or labeled plate with a blue lid of an uneaten lunch meal from 6/24/24 (baked pasta, broccoli and a roll). On 6/27/24 at 8:40 AM Staff 1 (Administrator) removed the undated and unlabeled plate of food from the station two snack/resident refrigerator. Staff 1 acknowledged he expected all food in the refrigerator to be labeled and dated. Staff 1 acknowledged the finding of the kitchen observations and stated he expected all food to be labeled, dated and discarded by the expiration date.

2. Resident 21 was admitted to the facility in 2021 with diagnoses including aftercare following surgical amputation and diabetes. A 3/7/23 revised care plan indicated Resident 21 was cleared to transfer to and from the toilet with limited assist of one staff. No additional details regarding her/his toilet use were provided. The 4/2023 Documented Survey Report indicated from 4/1/23 through 4/18/23 Resident 21 was continent and independent for toileting during evening and night times for 31 of 36 opportunities. On 4/17/23 at 2:57 PM Resident 21 stated she/he transferred herself/himself on and off the toilet from her/his wheelchair so she/he wanted her/his own option to clean the common bathroom/shower room toilet independently before use. Resident 21 stated she/he bought herself/himself a toilet brush which often disappeared from the bathroom and also utilized an alternative bathroom if the shower/bathroom near her/his room was occupied. On 4/19/23 at 9:49 AM the shower/bathroom near Resident 21's room was observed to have a shower chair in front of the sink with no available paper towels or toilet paper for resident use. On 4/19/23 at 9:50 AM Staff 5 (CNA) stated Resident 21 chose to use the toilet independently and did not use the call light to ask for any assistance in the shower/bathroom. Staff 5 stated she often cared for Resident 21 and knew the resident was particular about germs but unaware of her/his intent to clean the bathroom or her/his need for toileting supplies. Staff 5 revealed the bathroom was routinely cleaned only after showers but she and other CNAs were capable to assist Resident 21 with the cleaning of the toilet if informed. On 4/19/23 at 10:20 AM Staff 25 (Housekeeper) stated she supplied Resident 21 with toilet paper because paper products often went missing from the shower/bathrooms due to a resident who liked to take them. Staff 25 stated she did not believe anyone else knew she supplied Resident 21 with her/his own supply of toilet paper and provided it for about five months. On 4/19/23 at 1:47 PM Staff 6 (LPN) stated she was aware Resident 21 needed to carry her/his own toilet paper because of another resident who removed them from the shower/bathroom. Staff 6 stated she was surprised that not all CNAs were aware of Resident 21's toileting needs. On 4/19/23 at 2:18 PM Staff 26 (CNA) observed with the surveyor an alternate shower/bathroom near Resident 21's room where shower chairs impeded access to the sink and toilet. Staff 26 stated she was unaware residents ever needed to use the toilet independently in that room and extra shower chairs were often stored in that location. On 4/19/23 at 4:53 PM Staff 24 (CNA) stated she was aware Resident 21 needed a clear walkway in the shower/bathroom for toileting. On 4/21/23 at 10:09 AM Staff 2 (DNS) stated the shower room/bathroom cleaning was a process and the room may be dirty if any independent resident needed to use the toilet. Staff 2 also stated because of the current demolition of a storage area extra shower chairs were stored in the shower/bathroom. Staff 2 stated she was unaware of missing toilet paper and paper towels in the shower/bathrooms and confirmed Resident 21 needed toilet paper with her/him to use toilet. Based on observation, interview and record review it was determined the facility failed to accommodate resident needs for 2 of 6 sampled residents (#s 21 and 77) reviewed for environment. This placed residents at risk for lack of accommodation of needs and preferences. Findings include: 1. Resident 77 was admitted to the facility in 2022 with diagnoses including muscle wasting, falls and edema. Resident 77's care profile indicated Resident 77 was her/his own responsible party. An 10/15/22 care plan indicated Resident 77 was a high fall risk. The care plan indicated she/he had edema to both legs with interventions including to elevate her/his legs. An 4/3/23 Alert Note indicated the family came in to visit with Resident 77 and her/his family member stated the physician recommended Resident 77 sleep in the bed at an angle. Resident 77 was currently using the recliner to sleep. Resident 77 stated she/he would try to sleep in the bed. An 4/3/23 Skilled Services Note indicated the family wanted Resident 77 back in bed. Maintenance was aware and planned to remove the recliner and replace it with a bed on 4/4/23. An 4/4/23 Quarterly MDS indicated Resident 77's BIMS score was 13 which indicated she/he was cognitively intact. 4/12/23 and 4/13/23 Skilled Service Notes indicated Resident 77 was supposed to sleep in the bed and keep her/his lower extremities elevated. Resident 77 was non-compliant with this and slept in her/his wheelchair. On 4/20/23 at 6:01 AM Staff 19 (CNA) stated Resident 77 slept in her/his wheelchair at night. On 4/20/23 at 5:59 AM Resident 77 was observed in her/his wheelchair with eyes closed and a blanket on her/his lap. Multiple medical supplies and other items were on Resident 77's bed. On 4/20/23 at 11:17 AM Resident 77 stated she/he loved the recliner but was told the physician ordered the bed. Resident 77 stated she/he tried the bed once, but it was very painful to be in, so she/he slept in the wheelchair. On 4/20/23 at 10:42 AM Staff 11 (Patient Care Coordinator) stated the facility encouraged Resident 77 to use her/his bed and Resident 77's family member requested removal of the recliner. On 4/21/23 at 11:02 AM Staff 2 (DNS) indicated the facility would speak with the therapy department to see if it was okay for Resident 77 to use her/his recliner to sleep in.

Based on interview and record review it was determined the facility failed to ensure a resident's missing personal property was adequately addressed for 1 of 2 sampled residents (#67) reviewed for personal property. This placed residents at risk for loss of personal items. Findings include: Resident 67 was admitted to the facility in 2022 with diagnoses including stroke. A 3/28/23 Quarterly MDS revealed Resident 67 had a BIMS of 15 and was cognitively intact. A 5/18/21 Resident's Personal Property Record indicated Resident 67 had two pairs of jeans. On 4/17/23 at 3:04 PM and 4/19/23 at 4:47 PM Resident 67 stated almost one year ago she/he had four pairs of jeans, but now only had two pairs of jeans for some time. Resident 67 stated all CNAs knew about the missing jeans, there was no follow-up to her/his concern and she/he was never shown a Grievance Form or Missing Item Report form to complete. On 4/19/23 at 4:53 PM Staff 24 (CNA) stated for about three months she was aware of Resident 67's missing jeans, thought the process was already documented and as a result provided no follow-up or additional reporting for lost items. On 4/20/23 at 3:19 PM Staff 3 (Patient Care Coordinator) stated around nine months ago Resident 67's brother bought two new pairs of jeans for the resident. Staff 3 stated Resident 67 indicated around that time the jeans went missing but Staff 3 immediately found the jeans, labeled them, but did not update the resident's inventory. Staff 3 stated she was unaware Resident's 67 jeans were still missing. Staff 3 confirmed Resident 67's inventory should have been updated to include four pairs of jeans, CNAs should have offered Resident 67 a Grievance Form or Missing Item Report form and inform Staff 3 the missing jeans issue continued. On 4/21/23 at 8:55 AM Resident 67 stated Staff 2 (DNS) found one additional pair of jeans in her/his room yesterday (three total) but still wanted the fourth pair of jeans found. Resident 67 stated no Missing Item Report was completed at that time and Staff 2 indicated she would follow up with the missing fourth pair of jeans.

Based on observation, interview and record review it was determined the facility failed to provide ADL care for 1 of 6 sampled residents (#55) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 55 was admitted to the facility in 2021 with diagnoses including stroke with right sided hemiparesis (paralysis). The 3/23/23 care plan indicated Resident 55 was totally dependent on one staff for personal hygiene. Observations on 4/17/23 through 4/19/23 during day and evening shifts revealed Resident 55 had dried dark brown and tan substances under her/his left hand fingernails and whiskers on her/his chin. On 4/18/23 at 10:36 AM Resident 55 stated staff did not offer to clean her/his nails or shave her/his chin. Resident 55 stated she/he did not appreciate the whiskers on her/his face and had to wait until shower day to have them shaved. On 4/19/23 at 12:08 PM Staff 2 (DNS) acknowledged Resident 55's nails were dirty and needed to be cleaned and there were whiskers on her/his chin.

Based on interview and record review it was determine the facility failed to follow physician's orders and implement timely interventions after an injury for 1 of 2 sampled residents (#21) reviewed for abuse. This placed residents at risk for lack of adequate care. Findings include: Resident 21 was admitted to the facility in 2021 with diagnoses including aftercare following surgical amputation and diabetes. A 1/23/23 physician Discharge Instructions After Shoulder Surgery indicated Resident 21 was to wear her/his sling at all times except when showering, dressing and when doing her/his exercises. Resident 21's arm was also non-weight bearing with no lifting, pushing or pulling with the operative arm and her/his arm was to be kept at her/his side when the sling was not worn. A 2/3/23 Nursing Note indicated Resident 21 did not wear her/his sling because she/he believed the physician gave her/him different orders. A 2/8/23 Nursing Note indicated Resident 21 complained of increased right shoulder pain after Staff 4 (CNA) turned her/him using her/his right shoulder. The 2/2023 MAR indicated twice on 2/8/23 and once on 2/9/23 oxycodone (narcotic pain medication) was requested by Resident 21 due to elevated pain. Prior to 2/8/23 oxycodone was requested only once on 2/1/23. A 2/13/23 Incident Report indicated Resident 21 stated Staff 4 did not know not to touch her/his shoulder during turning and a voicemail was received on 2/9/23 to confirm the physician wanted Resident 21 to wear the sling at all times except for bathing, dressing and exercises. A 2/16/23 initiated care plan (seven days after the facility received clarification of physician orders) indicated Resident 21 was to have her/his right arm in a sling at all times unless bathing, dressing or during exercise per physician orders (there was no indication in the care plan related to no pulling or pushing of the resident's arm since orders received on 1/23/23). On 4/19/23 at 10:40 AM Staff 4 stated he assisted Resident 21 with turning because her/his call light was on but did not look at Resident 21's care plan prior to providing her/his care. On 4/19/23 at 1:47 PM Staff 6 (LPN) stated she evaluated Resident 21 at the time of the 2/8/23 incident and started alert charting for three days on 2/14/23 after speaking to Staff 3 (Patient Care Coordinator). Staff 6 stated Staff 4 was an agency staff at the time of the incident so viewing a care plan prior to providing care would be a nursing standard and even more important. On 4/20/23 at 3:50 PM Staff 3 (Patient Care Coordinator) confirmed she initiated, followed up and completed the investigation dated 2/13/23 and all information on the dates of the 2/8/23 incident came from Resident 21. On 4/21/23 at 11:28 AM Staff 28 (RNCM) confirmed care plans should be updated timely according to physician orders.

Based on observation, interview and record review it was determined the facility failed to provide respiratory care and services for 1 of 3 sampled residents (#13) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs. Findings include: 1. a. Resident 13 was admitted to the facility in 2023 with diagnoses including respiratory failure and sleep apnea. A 2/27/23 care plan indicated Resident 13 had alteration of respiratory status with interventions including provide oxygen therapy as physician ordered and provide oxygen via nasal cannula at two to four liters per minute with a goal to keep oxygen levels above 92 percent. A review of the TAR from 4/1/23 through 4/21/23 instructed staff to monitor Resident 13's oxygen saturation (how much oxygen in the blood) as needed and to keep oxygen saturations above 92 percent PRN. There was no documentation on the TAR Resident 13 was administered oxygen or how many liters per minute were provided. An O2 Sats Summary report revealed from 4/1/23 through 4/21/23 Resident 13 was on oxygen via a nasal cannula 44 instances and on room air 13 instances when her/his oxygen saturation levels were checked. A 4/7/23 Nurse Practitioner's Encounter Note indicated Resident 13 was on two liters per minute of oxygen. On 4/21/23 at 7:44 AM Resident 13 was in her/his room and was observed with a nasal cannula in place receiving oxygen. On 4/21/23 at 9:14 AM Staff 18 (CNA) stated Resident 13 sometimes wore her/his oxygen in bed during the day. On 4/21/23 at 10:55 AM Staff 2 (DNS) stated the liters per minute should be indicated on the TAR and she expected staff to document when Resident 13 was administered oxygen. b. A review of the 3/13/23, 4/7/23 and 4/11/23 Nurse Practitioner's Encounter Notes indicated for Resident 13 to use a CPAP (Continuous Positive Airway Pressure) machine nightly. A 4/4/23 Secure Conversations Note indicated Resident 13 mentioned she/he used a Bipap (Bi-level Positive Airway Pressure) machine at home and when she/he was at the hospital and it was care planned for her/him to be on droplet precautions when she/he was using her/his CPAP machine, but there was no CPAP machine. Observations from 4/17/23 through 4/21/23 revealed no CPAP machine in Resident 13's room. On 4/17/23 at 11:50 AM and 4/21/23 at 7:44 AM Resident 13 was in her/his room and reported she/he wore oxygen at night, she/he used to use a CPAP machine at home, but did not know why the facility did not give her/him a CPAP machine. On 4/21/23 at 10:55 AM Staff 2 (DNS) stated if a resident did not actively have a CPAP machine, they had to get another sleep study completed. Staff 2 stated she did not know if Resident 13 had a CPAP machine previously or if the facility could obtain the CPAP machine for her/him.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 3 of 6 sampled residents (#s 197, 203 and 297) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 197 was admitted to the facility in 2022 with diagnoses including heart failure, weakness and difficulty walking. A 5/30/22 admission MDS indicated Resident 197 had a BIMS of 15 indicating she/he was cognitively intact. Resident 197 required extensive assistance from one person with toileting. A Documentation Survey Report from 6/1/22 through 6/25/22 revealed out of 25 opportunities on evening shift Resident 197 did not receive toileting assistance eight instances. A [NAME]-Care Report (call light time log) for Resident 197's room from 6/1/22 through 6/15/22 revealed the following call light wait times over 20 minutes: -6/1/22: 4:23 PM 50 minutes, 5:56 PM 31 minutes. -6/2/22: 1:03 AM 26 minutes, 1:58 am 23 minutes, 4:48 AM 21 minutes. -6/5/22: 10:37 AM 29 minutes. -6/11/22: 5:39 AM 45 minutes. -6/12/22: 2:34 AM 21 minutes, 12:57 PM 42 minutes. -6/15/22: 6:37 AM 39 minutes. Review of Direct Care Staff Daily Reports from 6/1/22 through 6/25/22 revealed the facility did not meet the state minimum CNA staffing ratios on the following days: -6/10/22 day shift. -6/11/22 night shift. -6/12/22 day shift and evening shift. -6/18/22 night shift. -6/19/22 day shift. -6/24/22 day shift and night shift. -6/25/22 day shift. On 4/18/23 at 8:27 AM Witness 4 (Complainant) reported call light times were long throughout the day in 6/2022 and Resident 197 had incontinent episodes because of waiting too long. On 4/21/23 at 10:46 AM Staff 2 (DNS) stated she did not receive reports the residents had concerns with call light wait times. Staff 2 stated she expected call light wait times to be under 15 minutes and in general did not remember staffing concerns in 6/2022. 2. Resident 203 was admitted to the facility in 2022 with diagnoses including muscle wasting and a history of falling. Review of Direct Care Staff Daily Reports from 9/15/22 through 10/1/22 revealed the facility did not meet the state minimum CNA staffing ratios on the following days: -9/15/22 day shift. -9/21/22 day shift. -9/25/22 night shift. -9/26/22 day shift. -10/1/22 day shift. A [NAME]-Care Report (call light time log) for Resident 203 from 9/28/22 through 10/1/22 revealed the following call light wait times over 20 minutes: -9/30/22: 4:33 AM night shift 28 minutes, 10:17 PM 24 minutes. -10/10/22: 6:40 AM 20 minutes. On 4/18/23 at 12:44 PM Witness 6 (Complainant) stated Resident 203 reported concerns with staffing and had to wait for call lights to be answered timely. On 4/21/23 at 10:46 AM Staff 2 (DNS) stated she did not receive reports residents had concerns with call light wait times. Staff 2 stated she expected call light wait times to be under 15 minutes. 3. Resident 297 was admitted to the facility in 2022 with diagnoses including fracture to the right leg and muscle weakness. An 8/8/22 admission MDS indicated Resident 297 had a BIMS of 15 indicating she/he was cognitively intact. Resident 297 required extensive assistance with two persons assist with toileting. Review of Direct Care Staff Daily Reports from 9/15/22 through 10/1/22 revealed the facility did not meet the state minimum CNA staffing ratios on the following days: -9/15/22 day shift. -9/21/22 day shift. -9/25/22 night shift. -9/26/22 day shift. -10/1/22 day shift. A [NAME]-Care Report (call light time log) for Resident 297's bed from 9/28/22 through 10/1/22 revealed the following call light wait times over 20 minutes: -9/30/22: 10:06 AM 27 minutes, 6:54 PM 24 minutes, 8:00 PM 39 minutes -10/1/22: 12:41 AM 54 minutes, 9:56 AM 24 minutes. On 4/18/23 at 12:44 PM Witness 6 (Complainant) stated on 10/1/22 she and Resident 203 returned to the facility and Resident 297 (Resident 203's roommate) was agitated. Resident 297 reported she/he had to wait for staff to assist with incontinent care which was an ongoing concern. The facility told Resident 297 there was not enough staff. On 4/21/23 at 10:46 AM Staff 2 (DNS) stated she did not receive reports the residents had concerns with call light wait times. Staff 2 stated she expected call light wait times to be under 15 minutes.

Based on interview and record review it was determined the facility failed to provide written information to residents concerning the right to formulate an advance directive for 5 of 6 sampled residents (#s 30, 41, 55, 59 and 399) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: Records reviewed for Residents 30, 41, 55, 59 and 399 revealed no documentation of an advance directive or documentation to indicate the residents were informed of or provided written information concerning their right to formulate an advance directive. On 4/20/23 at 12:35 PM Staff 27 (Social Services Coordinator) stated she asked about a POLST (Physician Orders for Life Sustaining Treatment) upon admission but not advance directives. Staff 27 stated the facility had no process for discussing advance directives upon admission and was unable to provide documentation to verify residents were notified of their right to formulate an advance directive or to ensure a copy was obtained if a resident had an advance directive. On 4/20/23 at 2:11 PM Staff 1 (Administrator) confirmed Staff 27 did not follow through with assisting residents to formulate an advance directive.

3. Resident 49 was admitted to the facility in 2020 with diagnoses including dementia. A care plan revised 10/5/21 revealed Resident 49 spoke Ukrainian and Russian only, understood some English words, staff were to use a communication board to help with communication and were to provide a translator as necessary. The care plan did not indicate how to contact a translator for Resident 49. On 4/21/23 at 8:08 AM Staff 32 (CNA) stated she occasionally worked with Resident 49 because she was able to speak Russian with her/him. Staff 32 stated the other facility staff did not have a way to communicate with Resident 52. On 4/21/23 at 8:41 AM Resident 49 was in bed, a communication board or information about a translator tool was not observed in the room. Resident 49 did not respond when spoken to. On 4/21/23 at 8:43 AM Staff 33 (CNA) stated she spoke slowly to Resident 49, she/he understood sometimes and the facility did not have a translation tool to use to communicate with Resident 49. On 4/21/23 at 10:07 AM Staff 28 (RNCM) stated Resident 49 could understand some English, some facility staff were able to speak to Resident 49 in Ukrainian and the facility utilized a translator tool, but the staff were required to get approval from the administrator prior to each use. On 4/21/23 at 10:07 AM Staff 1 (Administrator) stated the facility had translation services to communicate with Resident 49, but this was not included in the care plan and he was going to distribute information regarding the service to the staff. Staff 1 also stated some facility staff spoke Resident 49's native language and were able to speak with the resident. Resident 49's care plan was reviewed with Staff 1 and he confirmed there was nothing related to the translation services, that family was available to assist in translating and the care plan did not include staff who were able to communicate with Resident 49. 4. Resident 52 was admitted to the facility in 1/2023 with diagnoses including stroke. Resident 52's communication care plan revised 1/12/23 revealed Resident 52 had aphasia (inability to speak) following a stroke and staff were to speak to her/him on an adult level, speak clearly and slower than normal and anticipate the resident's needs. On 4/19/23 at 11:30 AM Resident 52 was interviewed and was able to respond appropriately to questions. Resident 52 spoke slowly but was able to convey her/his message using simple words. On 4/20/23 at 4:20 PM Staff 31 (CNA) stated Resident 52 was able to speak but needed time to respond. On 4/21/23 at 8:48 AM Staff 33 (CNA) stated Resident 52's communication improved significantly since she/he admitted to the facility. Staff 33 stated Resident 52's improved communication was not addressed on the care plan and updates were not added to the care plan. On 4/21/23 at 10:11 AM Staff 28 (RNCM) reviewed Resident 52 and stated her/his communication improved since she/he admitted to the facility. Staff 28 reviewed the care plan and confirmed the care plan was not revised to indicate how Resident 52's communication changed and did not include information on how to communicate with her/him. Based on observation, interview and record review it was determined the facility failed to revise care plans for 4 of 13 sampled residents (#'s 21, 28, 49 and 52) reviewed for communication, environment and ADLs. This placed residents at risk for lack of person-centered care. Findings include: 1. Resident 21 was admitted to the facility in 2021 with diagnoses including aftercare following surgical amputation and diabetes. A 3/7/23 revised care plan indicated Resident 21 was cleared to transfer to and from the toilet with limited assist of one staff. No additional details regarding her/his toilet use was provided. The 4/2023 Documented Survey Report indicated from 4/1/23 through 4/18/23 Resident 21 was continent and independent for toileting during evening and night times for 31 of 36 opportunities. On 4/17/23 at 2:57 PM Resident 21 stated she/he transferred herself/himself on and off the toilet from her/his wheelchair so she/he wanted her/his own option to clean the common bathroom/shower room toilet independently before use. Resident 21 stated she/he bought herself/himself a toilet brush which often disappeared from the bathroom and also utilized an alternative bathroom if the shower/bathroom near her/his room was occupied. On 4/19/23 at 9:49 AM the shower/bathroom near Resident 21's room was observed to have a shower chair in front of the sink with no available paper towels or toilet paper for resident use. On 4/19/23 at 9:50 AM Staff 5 (CNA) stated Resident 21 chose to use the toilet independently and did not use the call light to ask for any assistance in the shower/bathroom. Staff 5 stated she often cared for Resident 21 and knew the resident was particular about germs but unaware of her/his intent to clean the bathroom or her/his need for toileting supplies. Staff 5 revealed the bathroom was routinely cleaned only after showers but she and other CNAs were capable to assist Resident 21 with the cleaning of the toilet if informed. Staff 5 stated the care plan was not updated for Resident 21's needs or wants related to toileting. On 4/19/23 at 10:20 AM Staff 25 (Housekeeper) stated she supplied Resident 21 with toilet paper because paper products often went missing from the shower/bathrooms due to a resident who liked to take them. Staff 25 stated she did not believe anyone else knew she supplied Resident 21 with her/his own supply of toilet paper and provided it for about five months. On 4/19/23 at 1:47 PM Staff 6 (LPN) stated she was aware Resident 21 needed to carry her/his own toilet paper because of another resident who removed them from the shower/bathroom. Staff 6 was surprised not all CNAs were aware of Resident 21's toileting needs, acknowledged the information was not on the resident's care plan and stated residents' care plans were updated by the Resident Care Manager. On 4/19/23 at 2:18 PM Staff 26 (CNA) observed with the surveyor an alternate shower/bathroom near Resident 21's room where shower chairs impeded access to the sink and toilet. Staff 26 stated she was unaware residents ever needed to use the toilet independently in that room and extra shower chairs were often stored in that location. On 4/19/23 at 4:53 PM Staff 24 (CNA) stated she was aware Resident 21 needed a clear walkway in the shower/bathroom for toileting but the information was not in the care plan. On 4/20/23 at 3:50 PM Staff 3 (Patient Care Coordinator) stated she completed some care plan updates but an RN was responsible for the oversight of the care plan. Staff 3 acknowledged Resident 21 often provided her/his own care by her/his choice including independent toileting in the shower/bathroom and her/his care plan should be updated to be more person-centered. 2. Resident 28 was admitted to the facility in 2015 with diagnoses including end stage renal disease (kidney failure) and diabetes. The 1/13/23 Annual MDS and Nutrition CAA indicated Resident 28 received dialysis and was at risk for nutritional deficits related to renal dialysis which occurred three times per week. A 3/6/23 Order Summary indicated Resident 28's dialysis appointment time was for 11:30 AM and pick-up time was from 10:32 AM until 11:02 AM with a return time of 4:15 PM. A care plan printed on 4/18/23 indicated to send meals or snacks with Resident 28 to dialysis. On 4/18/23 at 11:10 AM and 4/19/23 at 9:32 AM Resident 28 stated she/he often did not eat breakfast and food was not sent with her/him to dialysis due to increased precautions at dialysis over the last three years. Resident 28 stated sometimes she/he had lower blood sugar in the afternoon because she/he missed lunch due to the dialysis schedule. Resident 28 stated she/he often had to wait for food when she/he returned in the afternoon from dialysis. On 4/19/23 at 1:47 PM Staff 6 (LPN) confirmed no food was sent with Resident 28 to dialysis and at breakfast the resident received extra food because of the dialysis schedule. On 4/21/23 at 10:09 AM Staff 2 (DNS) confirmed food was no longer allowed at dialysis and acknowledged Resident 28's care plan needed to be updated to meet her/his individual needs.

Based on observation, interview and record review it was determined the facility failed to maintain cleanliness of a positioning harness for 1 of 1 sampled residents (#18) reviewed for dignity. This placed residents at risk for loss of dignity. Findings include: Resident 18 was admitted to the facility in 7/2017 with diagnoses including multiple sclerosis (chronic autoimmune disorder affecting movement). The 9/14/18 Enabler Review indicated Resident 18 used a chest harness while in her/his wheelchair. Random observations during a three day period were made from 4/29/19 through 5/1/19 between the hours of 8:00 AM and 2:30 PM. During these observations, Resident 18 was in her/his wheelchair in the dining room and common areas. Resident 18's chest harness was soiled with the same large patches and smears of dried food and beverage. On 5/01/19 at 8:42 AM Staff 2 (CNA) stated she was unsure if Resident 18's harness was soiled. She stated Resident 18 used the chest harness while in her/his wheelchair throughout the day. Staff 2 stated if the chest harness was soiled, it would get sent to laundry at night. On 5/1/19 at 8:49 AM Staff 3 (RNCM) confirmed Resident 18's chest harness was soiled. Staff 3 stated her expectations included the harness be wiped clean after meals and should not be soiled for days.

Based on interview and record review it was determined the facility failed to ensure reports of missing funds were thoroughly addressed for 1 of 2 sampled residents (#24) reviewed for personal property. This placed residents at risk for unresolved concerns. Findings include: Resident 24 was re-admitted to the facility in 9/2018 with diagnoses including repeated falls. Resident 24's 2/2019 Annual MDS revealed the resident had a Brief Interview of Mental Status score of 11 out of 15 (moderately impaired). The Trust-Transaction History revealed on 1/11/19 and 1/18/19 the resident withdrew 50 dollars on each occasion. The 1/25/19 Missing Item Report revealed the following: -The resident reported she/he was missing 20 dollars on either 1/19/19 or 1/20/19 and was missing 45 dollars on 1/24/19; -The items were not listed on the resident's personal inventory; -The follow up stated the money was not found, and staff were unable to verify there was lost money. In an interview on 4/29/19 at 2:01 PM Resident 24 stated she/he was missing 20 dollars and 40 dollars and nothing was done. In an interview on 5/1/19 at 3:05 PM Staff 22 (Social Services Director) stated the resident made a grievance in 1/2019 and the facility was unable to verify the funds were lost and the response to the grievance was to make an effort to secure future funds. In an interview on 5/2/19 at 9:11 AM Staff 23 (Business Office Manager) stated the resident reported missing funds in 1/2019. Staff 23 stated Resident 24 withdrew larger amounts of money in 1/2019 and she tried to explain the facility would not replace funds if lost or missing. Staff 23 stated she asked the resident to take out less money because she/he could access additional funds at any time at the nurses' station. In an interview on 5/6/19 at 12:15 PM Staff 19 (Administrator) stated she expected staff to bring grievances to her so they can be addressed appropriately. Staff 19 stated when Resident 24's money went missing the facility should of replaced it.

2. Resident 39 re-admitted to the facility in 5/2018 with diagnoses including inflammatory disorders. Resident 39's 3/2019 Quarterly MDS revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (cognitively intact). Resident 286 re-admitted to the facility in 2/2019 with diagnoses including a dislocated hip. Resident 286's 2/2019 Annual MDS coded the resident had a BIMS score of 15 out of 15 (cognitively intact). The 2/10/19 Resident/Resident incident report revealed the following: *Incident Description: - Resident 286 and Resident 39 were in a physical altercation; - Resident 286 punched Resident 39 and Resident 39 returned punches; - Resident 286 had a 3.5 cm by 2 cm puffy area to her/his left eye, a 2 cm by 1 cm bump to the left side of her/his head and a 1 cm by 0.5 cm red area under the right eye; - Resident 39 had a bruise on the top of her/his hand that was 7.5 cm by 3.5 cm and a 5.5 cm by 2 cm red area to the front right shin; *Witness statements: - Staff 27 (RN) stated when she returned from lunch Staff 34 (CNA) waved to her for help and that was when she saw Resident 286 and Resident 39 punching each other. Staff 27 stated she tried to separate them and Staff 7 (CMA) also came to help separate the residents. Staff 27 stated she called 911 because they could not separate the two and while on the phone to 911 the two residents stopped fighting. - Staff 7 stated she was not present at the beginning of the fight but saw the residents fighting. Resident 39 was behind Resident 286 and was hitting her/him in the head. Staff 7 stated she and Staff 27 could not get them separated and Staff 27 called the police. The residents stopped fighting on their own. - Staff 34 stated she was at the nurses' station when she heard Resident 286 say to Resident 39 ok fat boy what are you going to do now? and Resident 286 came toward Resident 39 and swung at her/him. Staff 34 stated she waved for help and Staff 27 came to help and they could not separate the two. Staff 27 called the police. The residents stopped fighting on their own. Staff 34 stated she heard Resident 286 cussing loudly earlier when she/he was talking to Resident 10. - Resident 10 stated Resident 286 and Resident 39 started arguing during smoke break related to waiting for pain medications. Resident 39 complained about Resident 286 and Resident 10 went and told Resident 286. Resident 286 cursed loudly at Resident 39 and Resident 10 reported she/he left and did not witness any additional interactions. Staff 34 was unable to be reached for an interview. Resident 286 was no longer a resident at the facility. On 5/2/19 at 10:20 AM Resident 10 refused to be interviewed. In an interview on 5/2/19 at 10:22 AM Resident 39 stated she/he and Resident 286 got into a fight due to a spontaneous issue. Resident 39 stated she/he was under a lot of stress due to unrelated issues and the fight just happened. Resident 39 stated she/he and Resident 286 had a verbal exchange and then hit each other. Resident 39 stated staff came immediately and staff could not have stopped them from fighting. In an interview on 5/2/19 at 4:07 PM Staff 1 (DNS) stated Resident 286 and Resident 39 were both alert, oriented and mobile. Staff 1 stated she learned from Resident 10 that Resident 286 and Resident 39 exchanged words during smoke break on 2/10/19. Later on 2/10/19 Resident 286 and Resident 39 engaged in a physical altercation, staff responded immediately but were unable to separate them and the police were called. The residents self-separated and the police took no action. In an interview on 5/3/19 at 8:50 AM Staff 7 verified the statement she provided in the incident report. Staff 7 also stated Resident 286 and Resident 39 had no prior history of fighting. In an interview on 5/6/19 at 12:15 PM Staff 19 (Administrator) stated she expected residents to be free from abuse. Based on interview and record review it was determined the facility failed to ensure resident safety for 3 of 6 sampled residents (#s 39, 285, 286) reviewed for abuse. This placed residents at risk of being abused. Findings include: 1. Resident 285 was admitted to the facility in 12/2018 with diagnoses including dementia with behaviors and delusional disorders. A 2/3/19 facility investigation revealed Resident 285 was in the main dining room when she/he became agitated. Resident 285 hit Resident 85 three times before staff intervened. While staff moved Resident 285 to her/his room, she/he reached out and hit Resident 48 in the hallway and called her/him a derogatory name. The investigative report revealed Resident 85 indicated she/he was not hurt but never wanted to speak to Resident 285 again. The report revealed Resident 48 indicated she/he was not hurt and did not want to be near Resident 285. A physician order for Ativan (medication used for Resident 285's agitation) was obtained and administered. Resident 285 was provided with 1:1 monitoring after the incident. Resident 285's 12/2018 admission MDS Assessment Section C: Cognitive Pattern coded her/him to have a Brief Interview for Mental Status (BIMS) score of 05 out of 15 (severe cognitive impairment). Resident 85's 1/2019 Quarterly MDS Assessment Section C: Cognitive Pattern coded her/him to have a BIMS score of 14 out of 15 (cognitively intact). Resident 285 was care planned with interventions for physical aggression towards others. The interventions included: - Administer medications as ordered; - Provide rest, toileting assistance, pain medication, favorite snack or activities of interest when behaviors occur; - Removing resident from the situation to a quiet setting, resident should not be left unattended, keep her/him in the line of sight prior to meals. A 2/3/19 progress note revealed Resident 48 denied pain as a result of the altercation, but she/he would not dine with Resident 285. Resident 48's 3/2019 Quarterly MDS Assessment Section C: Cognitive Pattern coded her/him to have a BIMS score of 15 out of 15 (cognitively intact). On 5/1/19 at 11:01 AM Resident 48 stated she/he was hit by Resident 285 while in the hallway. Resident 48 acknowledged the incident occurred on 2/3/19. Resident 48 indicated she/he was not hurt from being hit but her/his feelings were hurt when Resident 285 called her/him mean things. Resident 48 stated she/he stayed away from Resident 285 after the incident and indicated she/he did not want to be hit or called names in her/his home. Resident 85 was discharged in 3/2019. On 5/2/19 at 4:46 PM Staff 18 (CNA) stated Resident 285 had a history of hitting others and indicated although 1:1 staffing was needed to support her/him, 1:1 staffing was not always available. Staff 18 stated Resident 48 indicated she/he did not want to be near Resident 285 after the incident on 2/3/19. On 5/3/19 at 2:22 PM Staff 10 (RN) acknowledged Resident 285 hit and made obscene comments to Residents 48 and 85 on 2/3/19. Staff 10 indicated Residents 48 and 85 were not physically hurt and neither wanted to be around Resident 285 anymore. On 5/6/19 at approximately 10:00 AM Staff 35 (RCM) acknowledged Resident 285 had a history of physically aggressive behaviors. Staff 35 indicated Resident 48 was not injured when she/he was hit but she/he did not want to be in the same room or around Resident 285 after the incident. Staff 35 stated Resident 48 was afraid she/he would be hit again. On 5/6/19 at 12:23 PM Staff 1 (DNS) was informed of surveyor investigative findings regarding the incident on 2/3/19. Staff 1 requested additional staff interviews be conducted. On 5/6/19 at 3:12 PM Staff 28 (CNA) stated Resident 285 had it out for anyone who was overweight. Staff 28 acknowledged the incident on 2/3/19 and indicated Resident 285 called Resident 48 a derogatory name and told her/him to feed your face more. Staff 28 stated she witnessed Resident 48's face become bright red with embarrassment as she/he looked around the dining room which was full of residents.

Based on observation, interview and record review it was determined the facility failed to implement the comprehensive care plan for 1 of 3 sampled residents (#14) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 14 admitted to the facility in 7/2013 with diagnoses including oropharyngeal phase dysphasia (abnormalities of swallowing) and dementia. The care plan initiated on 10/19/17 and in use on 4/29/19 revealed the following: -The resident was totally dependent on staff for eating; -One-on-one assistance while eating, sips of liquids between bites to clean oral cavity and small bites; -Position upright in her/his wheelchair at all meals. On 4/29/19: -Observed at 12:11 PM a tray was delivered to Resident 14 in her/his room. The resident was alone and started eating independently without staff present; -Obsevered at 12:23 PM Staff 25 (CNA) entered the room, stopped the resident from eating and removed the tray from her/his bedside; -In an interview at 12:23 PM Staff 25 stated it was not safe for Resident 14 to eat alone. Resident 14 had no observed distress or concerns while eating alone on 4/29/19. On 5/1/19 and 5/2/19 the resident was observed eating in the dining room in her/his wheelchair with one-on-one assistance and was encouraged by the attending CNA to cough to clear secretions. In an interview on 5/2/19 at 1:40 PM Staff 26 (Registered Dietitian) stated when residents, including Resident 14, were charted as dependent on staff for eating it meant residents would receive one-on-one assistance. Staff 26 stated staff should not drop off a tray and let Resident 14 eat alone because she/he needed help at all times and should not be left alone. In an interview on 5/2/19 at 4:18 PM Staff 1 (DNS) stated she expected staff to follow the resident's care plan. In an interview on 5/6/19 at 12:15 PM Staff 19 (Administrator) stated she expected staff to follow the care plan.

Based on observation, interview and record review it was determined the facility failed to provide restorative services at the frequency ordered to maintain or prevent a decline in range of motion for 1 of 3 sampled residents (#8) reviewed for range of motion. This placed residents at risk for worsening contractures. Findings include: Resident 8 was admitted to the facility in 8/2016 with diagnoses including stroke, hemiplegia (paralysis of half of the body) and hemiparesis (weakness of one side of the body) of the right dominant and left non-dominant sides of the body. A 4/7/18 OT assessment noted worsening contractures of the right hand. A 4/12/18 physician order directed staff to discontinue PT services as therapy goals were met and refer to restorative program. A 6/20/18 physician order directed staff to discontinue OT due to meeting goals and refer to RNP (Restorative Nursing Program) for bilateral upper extremity passive range of motion to reduce risk of further joint contractures. The 1/29/19 Quarterly MDS Section G: Functional Status, indicated Resident 8 had impairments on both sides of upper body extremities and one side of the lower body. The Section O: Special Treatments, Procedures and Programs, indicated Resident 8 had seven days of active and passive range of motion (AROM and PROM) for restorative nursing during the look back period. The 3/4/19 Restorative Evaluation and Summary indicated Resident 8 received restorative services for ambulation and range of motion with goals to maintain current functional level and prevent decline of bilateral upper extremities. The 4/29/19 Contracture Screening indicated Resident 8 had contractures of the right shoulder, elbow, wrist, fingers and thumbs. On 4/29/19 Resident 8 was observed to have contractures of all five fingers on her/his right hand and stiff appearing arm and fingers on the left side. She/he was in a wheelchair and used her/his legs for locomotion. Resident 8's current Restorative Care Plan included: - Ambulation within parallel bars (minimal assist) as tolerated up to two times per week; - Active ROM (range of motion) legs, Omnicycle (a lower body exercise device) two times per week for 15 minutes; - PROM of bilateral upper extremities all joints/planes two sets of 10 up to three times per week. The April 2019 Restorative Tracking Form lacked any documentation for the following interventions. - April 1-6: Ambulation in parallel bars; - April 7-13: AROM legs, Omnicycle and PROM to bilateral upper extremities; - April 14-20: AROM legs, Omnicycle; - April 21-28: AROM legs, Omnicycle. On 5/3/19 at 11:24 AM, Staff 20 (RA) reported the blank areas on the Restorative Tracking Form indicated Resident 8 did not receive restorative services or a resident refusal was not documentated. She was unable to recall if resident received or refused services. On 5/3/19 at 11:25 AM, Staff 21 (RA) could not recall if Resident 8 received services on the blank dates on tracking form. An interview on 5/3/19 at 12:07 PM with Staff 3 (LPN/resident care manager) revealed restorative aides were employed seven days per week and CNAs do not provide restorative therapy. If there were blank areas on the tracking form, the resident did not receive services or the services were not documented as refused.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 1 sampled residents (#287) identified with a medication error. As a result, Resident 287 received an antipsychotic medication on 10/28/18 and required admission to the hospital for monitoring. The facility identified the noncompliance and immediately initiated a plan of correction which resulted in staff awareness and education to ensure accurate identification of residents and no further medication errors occurred. This incident was identified as meeting the criteria for past noncompliance. Findings include: The facility General Dose Preparation and Medication Administration policy, last revised 1/2013, included the following: -Staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Resident 287 admitted to the facility in 10/2018 with diagnoses including aftercare following left knee surgery. Resident 287 discharged from the facility in 10/2018. On 10/28/19 at 6:00 PM Staff 16 (CMA) erroneously administered Geodon (an antipsychotic medication) 100 mg to Resident 287. Staff 16 realized her mistake and immediately reported the error to Staff 11 (LPN). Staff 11 evaluated Resident 287 and notified the physician, the resident and Resident 287's family. The physician directed Staff 11 to monitor Resident 287 for adverse effects and send the resident to the hospital for any change of condition. Resident 287 later became sleepy and Staff 11 sent the resident to the hospital for evaluation. In an interview on 4/30/19 at 3:40 PM Staff 11 (LPN) stated on 10/28/18 Staff 16 erroneously administered Geodon 100 mg to Resident 287. Staff 11 stated she immediately evaluated Resident 287 and notified the physician, the resident and the resident's family. Staff 11 stated Resident 287 became less responsive and appeared sleepy and was sent to the hospital for evaluation. In an interview on 5/1/19 at 1:58 PM Staff 16 (CMA) stated on 10/28/18 she administered incorrect medication to Resident 287. She stated she realized her error and immediately reported to Staff 11 (LPN). Staff 16 stated Resident 287 was a new admit and a picture was not available and she identified Resident 287 by the room number. Staff 16 stated it was a mistake not to identify the resident by name and date of birth . Staff 11 stated she did not pass medications after the incident until she received two weeks of one on one training with Staff 37 (RN) and attended a four hour competency class for certified medication aides. Interviews conducted from 4/30/19 through 5/2/19 between the hours of 8:00 AM and 5:00 PM with Staff 4 (LPN), Staff 5 (LPN), Staff 6 (CMA), Staff 7 (CMA), Staff 8 (CMA), Staff 9 (CMA), Staff 10 (LPN), Staff 11 (LPN), Staff 12 (CMA), Staff 13 (CMA), Staff 14 (LPN), Staff 15 (RN) and Staff 16 (CMA) identified all staff interviewed were aware of the five rights of medication administration. All staff stated it was expected and proper procedure to identify the resident with a picture, name band, name and date of birth before administering medications. On 5/2/19 at 10:49 AM and 3:39 PM Staff 1 (DNS) confirmed the medication error occurred and Resident 287 was sent to the hospital for evaluation. Staff 1 stated a Quality Assurance process was immediately implemented which included placement of identification wrist bands on newly admitted residents. Additionally, a four hour CMA training course was offered and Staff 38 (Staffing Coordinator/CMA) conducted skills audits to ensure medication pass competency of CMA and LPN staff. Staff 1 reported there were no further medication errors since the 10/28/18 incident. This situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance at F760. 2. The noncompliance occurred after the exit date of the last standard recertification survey (10/6/17) and before the date of this survey (5/6/19). 3. There was sufficient evidence the facility corrected the noncompliance and was in substantial compliance with F760 as evidenced by: -No deficient practice found at F760 with additional sampled residents -Evidence the deficient practice was identified by the facility, brought to quality assurance and a plan of correction was implemented on 10/29/18 to place a name band on newly admitted residents and educate and reinforce protocol to accurately identify residents. -DNS, RN, LPN and CMA interviews indicated knowledge and awareness of expectations and protocol to accurately identify residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 2 was admitted to the facility in 1/2019 with diagnoses including gastric bypass revision (stomach surgery), paraplegia (paralysis) and hypothyroidism (underactive thyroid gland). admission orders dated 1/4/19 indicated Resident 2 was to receive a regular diet which included her/his food preferences of cottage cheese at lunch and one hard boiled egg at dinner. Dietary Profiles dated 1/4/19 and 4/4/19 indicated Resident 2 reported disliking fish. Resident 2's diet meal card dated 5/6/19 listed cottage cheese and hard boiled egg as food preferences. In an interview on 4/30/19 at 10:16 AM Resident 2 reported weight loss because she/he preferred not to eat certain foods. Resident 2 reported the kitchen served her/him cottage cheese at lunch every day but she/he had not received hard boiled eggs with dinner as one of her/his requested food preferences. On 4/30/19 at 12:15 PM Resident 2 was served a plate of food which included fish. In an interview on 5/2/19 at 11:00 AM Staff 39 (CNA) reported the CNAs were responsible to ensure residents food requests and food preferences were communicated to the kitchen but the kitchen did not always have the food. On 5/2/19 at 12:04 PM Staff 40 (CNA) delivered a meal tray with fish as a main coarse to Resident 2. Resident 2 told Staff 40 she/he only wanted the cottage cheese and a beverage. Resident 2's meal card did not identify fish as a dislike. In an interview on 5/6/19 at 2:25 PM Staff 30 (Dietary Manager) reported the CNAs were responsible for submitting residents food requests and stated she was new and just learning the computer system. 2. Resident 26 was admitted to the facility in 1/2019 with diagnoses including kidney disease and gout. Upon admission, a therapeutic diet was ordered to address Resident 26's kidney disease. The diet order was revised on 2/1/19 to include Resident 26's preference to receive soy milk over regular milk. A 4/24/19 Dietary Profile indicated Resident 26 reported liking fruit, but did not like fish. Resident 26's care plan and [NAME] (CNA care plan) did not include resident food preferences. On 4/30/19 at 12:06 PM, Resident 26 was observed with an untouched plate of food that included fish. Resident 26 stated she/he told the facility she/he did not eat fish and was tired of rice. Resident 26 ate a bag of candy and stated she/he would not ask for an alternative meal. Resident 26's meal card did not identify fish as a dislike. On 5/2/19 at 11:58 AM, Staff 33 (CNA) delivered a meal tray to Resident 26's room. Staff 33 reported Resident 26 received fish as the main dish. On 5/2/19 at 12:02 PM, Resident 26 was observed dining in her/his room. Resident 26's meal included fish, cooked zucchini, cooked corn, a dessert, a glass of soy milk. When asked about the meal, Resident 26 complained about having fish again and did not like the zucchini. Resident 26 ate the corn and took two bites of the fish, made a disapproving sound and pushed the plate away. Resident 26 proceeded to eat the dessert and drink the soy milk. Resident 26's meal card did not identify fish as a dislike. 5/3/19 at 3:59 PM, Staff 31 (CNA) reported if a resident had a food preference, it would be on the resident's meal card and sometimes on the [NAME]. Staff 31 reported Resident 26 had not mentioned food preferences to him. 5/6/19 at 9:42 AM, Staff 32 (CNA) stated if a resident had a food preference, she/he would tell the nurse or the dietitian. Staff 32 reported the preference had to be on the meal card, because it was used to prepare the resident's tray and if it was not on there, it would not get done. 5/6/19 at 1:02 PM, Staff 30 (Dietary Manager) reported food preferences must be transferred to the meal card and verified this was not done for Resident 26. Based on observation, interview and record review, it was determined the facility failed to honor food preferences for 3 of 9 sampled residents (#2, 26, 48) reviewed for food concerns. This place residents at risk for unintended weight loss and decreased quality of life. Findings include: 1. Resident 48 was admitted in 12/2017 with diagnoses including major depressive disorder and diabetes. An 11/9/18 Dietary Profile Assessment noted the resident did not like cooked vegetables. The 12/20/18 Cognitive Loss/Dementia CAA identified the resident was able to verbally communicate with others and made her/his needs known. Resident 48 advocated for her/himself and was involved in care decisions. A 3/13/19 Dietary Profile Assessment identified the resident received chef salads each lunch, but had no food items which she/he disliked. At the time of the survey, the resident's meal card (which identified diet orders and resident preferences on the meal tray) showed Resident 48 received a controlled carbohydrate diet with no added salt and no allergies identified. The card further identified the resident received chef salads at lunch per preference and had no dislikes. In interviews on 4/30/19 at 11:52 AM and 5/6/19 at 11:16 AM, Resident 48 stated she/he hated cooked vegetables but was getting tired of the chef salads she/he had requested. The resident also voiced concerns about the small portions served of the main course which left her/him unsatisfied with the meal. When interviewed on 5/2/19 at 9:08 AM, Staff 36 (Kitchen Staff) stated staff did not always have sufficient food ingredients to serve all residents the same menu or to provide additional servings when residents requested. Frequent food substitutions were made. In a 5/6/19 interview at 9:36 AM, Staff 28 (CNA) stated Resident 48 often asked for more food. Staff 28 could generally offer cottage cheese, sandwiches or if available, more of the main course. The resident complained about the small main course portion the previous night which consisted of two small pieces of meat and onions. When interviewed on 5/6/19 at 12:28 PM, Staff 30 (Dietary Manager) stated when a resident identified a food dislike during the Dietary Profile Assessment, it would be reflected on the assessment and added to the meal card. Staff 30 was unaware of Resident 48's dislike of cooked vegetables and stated new dinner menus had resulted in small portions at the previous night's dinner. Additional vegetables and rice were going to be added to the dinner recipe in the future.