**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that Resident (R)3 was free from misappropriation by Certified Nursing Assistant (CNA)1, for 1 of 3 residents reviewed for misappropriation or property. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating last revised on September 2022, revealed All reports of resident abuse (including injuries of unknown origin, neglect, exploitation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. The Administrator or individual making the allegation immediately reports his or her suspicion to the following persons or agencies; the state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, the resident's representative, law enforcement officials, the resident's attending Physician and the facility Medical Director. Review of the undated facility policy titled Resident Rights revealed, Employees shall treat all residents with kindness, respect, and dignity. Federal and state law guarantee certain basic rights to all residents of this facility, these rights include a dignified existence, be treated with respect, kindness, and dignity. To be free from abuse, neglect, misappropriation of resident property, and exploitation. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE], with diagnoses including but not limited to: Type 2 Diabetes without complications, hypertension, protein calorie malnutrition, and muscle spasm. Review of R3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/25, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that R3 was cognitively intact. Review of a Grievance dated 06/02/25, revealed, [R3] had theft from her bank account after allowing [CNA1] to borrow her phone. Social Worker met with [R3] to interview, law enforcement notified. Review of an Incident/Investigation Report dated 06/02/25 at 11:31 AM, revealed, Crime Incident - Wire Fraud; value $21.05; On 06/02/25 this unit responded to the incident located in reference to wire fraud. The Administrator informed this unit that a Resident [R3] had made a complaint in reference to larceny of money by an employee [CNA1]. [R3] stated that [CNA1] borrowed her cellphone for approximately 30 minutes to find her personal cellphone. [R3] stated that [CNA1] returned her phone and told the resident that she located her cellphone in the grass, however [R3] stated she received notifications from Cash App informing her that someone accessed her account and attempted to transfer two separate transactions totaling $700 to [CNA1] account but they were decline by [R3's] bank. A single transaction for $10.00 did go through but the funds were returned to fraudulent activity. She also stated her Shien Account was accessed, and a $21.05 order was placed. Additionally, another order was placed for $96.26 but was declined. This unit provided [CNA1] with her [NAME] rights prior to interviewing her, [CNA1] stated that on 05/29/25 she borrowed R3's cellphone for approximately five minutes and utilized it to locate her cellphone. [CNA1] advised [R3] she located her cellphone in her vehicle and returned [R3's] cellphone to her. When questioned in reference to the three Cash App transactions made from [R3's] account to hers she denied the $600 and $100 attempt but stated that she must have used the wrong phone to send her son $10.00, [CNA1] denied knowledge of the two transactions made towards the Shien account. Ultimately [R3] declined prosecution, Administrator informed this unit the facility was required to report the incident to the state agency. She also stated that [CNA1] would be placed on suspension while the facility completed an investigation. During an interview on 06/23/25 at 10:05 AM, R3 revealed that on 05/29/25 they received a text message from their bank related to a $600 authorization from Cash App to send to CNA1. R3 further stated that she replied to the text message no and then called her bank and was informed by a Fraud Investigator about other potentially fraudulent activities which included requests through Cash App for $100 which was also denied by the residents financial institution. The fraud investigator informed R3 that two successful transactions were completed by CNA3, the first was $10 which were later credited back to the residents account and a $21.05 through an online shopping website ([NAME]). R3 stated that she would often let CNA1 and other staff members charge their phones because they often have the same type of phone (iPhone). R3 was able to recall CNA1 borrowed her phone because CNA1 told the resident that she had misplaced her personal phone and needed to call it so she can locate it. R3 stated that CNA1 borrowed her phone for about 30 minutes and then returned it to her, R3 then later received the fraudulent text messages from her bank. R3 stated that they spoke with law enforcement about the incident but declined to press charges on CNA1, she always so kind to me and I didn't want her to get into trouble with the law. R3 stated she was disappointed. During review on 06/23/25 at 10:05 AM, of R3's cellphone, revealed text messages from her financial institution alerting her of potential fraud on 05/29/25 at 3:58 PM. R3 also showed her bank statement from May 2025, which revealed CNA1's name making an attempt to send $10.00 to herself and a $21.05 order for [NAME] Clothing which the resident denies attempting herself. During a phone interview on 06/23/25 at 11:21 AM, R3's Resident Representative (RR) revealed that he was disappointed and frustrated that a staff member would take money from his mother. R3's RR further stated that he didn't know much about the incident and could not recall if the facility notified him about the incident. During a phone interview with CNA1 on 06/23/25 at 3:19 PM, revealed that they denied misappropriating any funds from R3 or any other residents. CNA1 stated, One time by accident [R3] sent her $10.00 through Cash App but they denied the transaction and sent the resident back the money. CNA1 further stated they were unsure of how R3 knew their personal Cash App identification. R3 stated that they are currently suspended from the facility due to the allegation of misappropriation of resident property and has been suspended for approximately 2 weeks and are unsure when they will be able to return to the facility. During an interview on 06/23/25 at 3:53 PM, the Social Services Director (SSD) revealed they were informed by the Activities Director (AD) that R3 wanted to speak with her because she had received notification from her finical institution that detected fraudulent activity with her account, after allowing a staff member (CNA1) to borrow her phone. The SSD and the AD went to go speak with R3 regarding her concern. The SSD stated that R3 said that she allowed CNA1 to use her phone because CNA1 told the resident that she misplaced her phone and she needed to call to it to locate it. R3 told staff that CNA1 took her phone outside of her room to call her own phone. The SSD further stated that during interview with the resident she was able to show text messages from her bank notifying R3 of the potentially fraudulent activity through Cash App and [NAME] (online clothing store). While interviewing R3 she stated that she did not approve these transactions and was notified as well. During an interview on 06/24/25 at 11:17 AM, the Director of Nursing (DON) and the Administrator revealed that they were notified of this incident by the SSD and Activities Director. CNA1 was at work when the resident reported the misappropriation, and she was immediately pulled from the unit and interviewed by facility staff and law enforcement. CNA1 denied misappropriating from the resident however, due to law enforcement having R3's text messages and bank statement they wanted to arrest her for theft. R3 did not want to press charges against CNA1 therefore law enforcement could not arrest CNA1. CNA1 was placed on suspension on 06/02/25 and was later terminated from the facility on 06/06/25 after the investigation was completed and the substantiation of the allegation of misappropriation of property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to develop a Care Plan for Resident (R)163, related to Advance Directives, for 1 of 2 residents reviewed. Findings include: Review of the facility policy titled Care Plan, Comprehensive Person Centered last revised on March 2022, documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 1. The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 7. The comprehensice, person-centered care plan: a. includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident excersing his or her rights, including the righ to refuse treatment; Review of R163's Face Sheet revealed R163 was admitted to the facility on [DATE], with diagnoses including but not limited to: encounter for orthopedic aftercare, dementia with psychotic disturbance, muscle weakness, hypertension, major depressive disorder, and anemia. Review of R163's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/24, revealed R163 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated that R163 had severe cognitive impairment. Review of R163's Care Plan, last revised on 11/04/24, revealed that R163 was not care planned for Advanced Directives. An interview on 11/04/24 at 3:20 PM with Licesned Practical Nurse (LPN)2 revealed that they were unable to locate interventions in R163 Electronic Medical Record (EMR) related to Advanced Directives. An interview on 11/05/24 at 6:03 PM with the Administrator and Director of Nursing (DON) revealed that R163 was not care planned for Advanced Directives while a resident in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, interview, and record review, the facility failed to ensure Resident (R)52, who was dependent on staff for activities of daily living (ADLs), received the necessary services to maintain personal hygiene, for 1 of 6 residents reviewed. Findings include: Review of the facility policy titled, Activities of Daily Living (ADL), Supporting with a date of 2001, documented, Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support with assistance with: a. hygiene (bathing, dressing, grooming, and oral care) . Review of R52's admission Record revealed R52 was admitted to the facility on [DATE], with diagnoses including but not limited to: Parkinson's Disease, chronic kidney disease, muscle weakness, acquired absence of right leg above knee, and acquired absence of left leg above knee. Review of R52's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/24, indicated R52 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R52 had intact cognition. Review of R52's Task Documentation revealed no showers were documented for the months of June through November 2024, indicating R52 did not receive showers during that time frame. During an observation on 11/03/24 at 12:46 PM, R52 was observed laying in bed, with no shirt and laying underneath a sheet. R52's face was unshaven, and a crusty discharge was in the corners of both eyes. During an observation on 11/04/24 at approximately 12:20 PM, R52 was observed laying in bed without a shirt, face still unshaven. During an interview on 11/03/24 at 12:46 PM, R52 stated he has not had a shower since his admission into the facility in June 2024. R52 further stated he does not know his shower days and he is dependent on staff to take him for his showers. R52 concluded that he does not refuse showers. During an interview on 11/04/24 at approximately 12:20 PM, R52 stated he had not received a shower or bed bath today. During a follow up interview on 11/05/24 at 10:52 AM, R52 stated staff provided him with a bed bath earlier, but he still was not offered a shower or received one. R52 verified that he does not refuse showers, and he has not had a shower since he has been in the facility. During an interview on 11/05/24 at 11:19 AM, Certified Nursing Aide (CNA)2 revealed she is familiar with R52. CNA2 stated, To be honest I had never put him in the shower. [R52] usually received a bed bath by staff on the previous shift. CNA2 further stated that most of the time he has already had a bed bath on the previous shift. CNA2 concluded that she has never offered R52 a shower. During an interview on 11/05/24 at 3:28 PM, Unit Manager Licensed Practical Nurse (LPN)4 revealed she is the unit manager for [NAME]-100 wing where R52 resides. LPN4 stated R52's shower days are Monday, Wednesday and Friday. Residents shower schedules are charted, and refusals are documented in the system. LPN4 further stated, it is the expectation that staff will offer residents showers on their scheduled days. The days that are not shower days; residents receive bed baths. If residents refuse showers, the CNA notifies the nurse, and the nurse will reapproach residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observations and interviews, the facility failed to ensure biologicals were stored appropriately in 3 of 3 Medication Treatment Carts. Findings include: Review of the facility policy, copyright 2001 Med-Pass, Inc, titled, Medication Labeling and Storage documents, the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Medication Storage 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. During an observation on [DATE] at 12:23 PM, of the [NAME] Treatment Cart revealed the following: -Gentell rolled gauze bandage (4.5 x 4.1 YDS (11cm x 3.7m) Lot # 240217 exp 2027 02 16 Sterile and opened. -Silvercel Non-adherent antimicrobial Alginate Dressing with Easy Lift 10/4 1/4 in x 4 1/4 in (11cm x 11cm) Manufacturer Sustagenix Lot # 55760V001 Expired 2024 09 30 Manufacturer Sustagenix X6 was expired. During an interview on [DATE] at 12:51 PM, Licensed Practical Nurse (LPN)5 stated, The wound nurse and unit managers check the expiration dates. The wound nurse changes the dressings except on the weekends and nights. All the nurses are responsible for changing dressings. LPN5 discarded the items. During an observation on [DATE] at 1:07 PM, of the Riverside Treatment Cart revealed the following: -Medline Extra Absorbent Abd Pad single use Sterile Ref # PRM 21453 Lot # 6052406001 Sterile and opened. -Xeroform Gauze Dressing 5 in x 9in (13cm x 23 m) Manufactured for HealQu LLC exp 2026 08 24 Sterile and opened. -Wound Closure Strip 1/8 x 3 Manufacturer [NAME] Skin Closure Strips non reinforced sterile MRF # 3000 AirLife Ref Al4109k Lot T22N32 exp 2024 12 01 Sterile and opened. During an interview on [DATE] at 1:25 PM, LPN2 stated, We usually check the treatment carts. LPN2 discarded the open items into the trash. During an observation on [DATE] at 1:59 PM, of the Palmetto [NAME] Treatment Cart revealed, Nystatin Cream USP (1000, 000 USP) Nystatin units Manufacturer Padagis R 34321766 exp 08/2024 and was opened. During an interview on [DATE] at 2:08 PM, LPN6 stated the wound nurse checks the treatment cart. During an interview on [DATE] at 3:25 PM, the Director of Nursing (DON) stated, Both wound nurse and floor nurse should check the treatment cart for expirations.

Based on observations and interviews the facility failed to ensure that the ice machine in 1 of 1 kitchen was kept clean and sanitized. Findings include: A facility policy regarding the ice machine was requested on 11/05/24 at 3:22 PM. At 5:15 PM, the Administer advised that a policy was not available. During the initial tour of the Kitchen on 11/03/24 at 9:55 AM, the ice machine was observed, in the presence of the Kitchen Manager (KM), to have a black moldlike substance around the ice dispenser. During an interview on 11/03/24 at 9:55 AM, the KM verified the the black moldlike substance in the ice machine and stated that it is her expectation that the ice machine is cleaned daily, at the end of the day. Attempted review of the kitchens cleaning logs, revealed there were no cleaning logs of the ice machine available. During an interview on 11/05/24 at 3:22 PM, the Administrator stated that it is expected that all equipment is maintained in a clean and sanitized manner.

Based on review of the facility policy, record review, and interviews, the facility failed to notify Resident (R)1's responsible party (RP) of a change in skin condition when an unstageable wound was discovered for 1 of 3 records reviewed for quality of care. Findings include: Review of the facility policy, with a revision date of 2001, titled, Change in a Residents Condition or Status revealed under policy, Unless otherwise instructed by the resident, a nurse will notify the resident's representative when, there is a significant change in the residents physical status. Review of R1's Face Sheet revealed the facility admitted R1 on 12/25/2020 with diagnoses including, parkinsonism, chronic obstructive pulmonary disease and type 2 diabetes. Review of R1's treatment administration record (TAR) dated 05/17/2024, revealed a treatment order to, cleanse left trochanter with wound cleanser, and apply hydrogel, cover with bordered foam gauze daily for unstageable every shift. Review of the TAR revealed the signatures began on 05/17/2024, signed as treatment administered. Review of R1's physician orders dated 05/13/2024 revealed an order to refer to QSM for evaluation and treatment of left hip. Record review of R1's wound notes dictated by an outside provider dated 05/15/2024 revealed a note, left hip recorded as in house pressure ulcer as unstageable and new. An interview with R1's RP on 06/14/2024 at 10:27 AM revealed she was not notified timely of R1's wound to her left hip. She said she came from out of state to visit and then met with the Director of Nursing (DON), the Social Worker (SW) and the Wound Nurse on 05/20/2024. She said it was in this meeting when she learned about the wound. An interview with the Wound Nurse on 06/14/2024 at 11:30 AM revealed she notifies the residents responsible parties of all wounds. She said she remembered telling R1's RP in the meeting with the DON and SW present, when they were visiting. She confirmed she had notified R1's RP in the meeting, not before. An interview with the DON on 06/14/2024 at 12:39 PM revealed, The family member should have been notified before they came to visit, after the wound developed.

Based on review of the facility policy, record review, and interview, the facility failed to ensure a written grievance was filed for Resident (R)1 regarding care concerns for 1 of 3 residents reviewed for quality of care. Findings include; Review of the facility policy, revised April 2017, titled, Grievances/Complaints Filing revealed under policy, Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. Record review of the facility Resident Grievance Log dated May 2024, does not record any concerns for R1. An interview with R1's Personal Representative on 06/14/2024 at 10:27 AM revealed, I visited about a month ago and had care concerns. I asked to speak to the head of nursing and the social worker, but they were both off, it was on Friday the 17th. I returned Monday, the 20th of May and met with the head of nursing, the social worker and the wound nurse. I had a lot of concerns about the care, the odors, R1's fall, and her hip wound, which I was surprised about and the state of her room. They told me they would take care of it. An interview with the Social Worker (SW) on 06/14/2024 at 11:11 AM revealed, If I had received a concern, it would have been noted as a concern on the grievance. When I was coming into the conference room, I entered the conference room and I was brought into a conversation with R1's Personal Representative (PR) and the Director of Nurses (DON). I was asked about hospice services, and I explained to the PR about hospice and so we did initiate hospice services soon after. If it had been brought to my attention as a grievance, I would have written it. Anyone can write out a grievance. We have the forms posted on each bulletin board. I would present the grievance in the AM meeting, and I would then log it. I will also follow up on it as well. An interview with the DON on 06/14/2024 at 12:39 PM revealed she was not the DON at the time of the grievance, but any care issues or concerns should have been written and presented as a grievance for all her concerns. An interview with the Wound Nurse on 06/14/2024 at 12:55 PM revealed, The SW, the DON and I were in the meeting with R'1s PR and she had a lot concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were submitted within the 14-day period for 1 of 1 Resident (R)1, reviewed for resident assessments. Findings include: Review of the facility's policy titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/19, indicated Entry: Transmission date no later than entry date +14 calendar days; Comprehensive assessment: Transmission date no later than care plan completion date +14 calendar days; Discharge assessment: Transmission date no later than MDS completion date +14 calendar days. Review of the MDS with an Assessment Reference Date (ARD) of 04/27/22 revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated R1 had severely impaired cognition. This MDS revealed R1 was admitted on [DATE]. Review of the MDS transmission logs provided by the MDS coordinator revealed: Entry MDS date 04/20/22; Submitted and accepted 05/27/22. Comprehensive MDS date 04/27/22; Submitted and accepted 05/27/22. 5-Day MDS assessment date 04/27/22; Submitted and accepted 05/27/22. Discharge MDS assessment date 05/06/22; Submitted and accepted 05/27/22. During an interview on 10/08/22 at 10:55 AM, the MDS Coordinator verified the Entry MDS assessment was due 05/03/22 but was not completed until 05/27/22, the comprehensive assessment was due 05/03/22 but was not completed until 05/27/22, the 5-day assessment was due on 05/03/22 but was not completed until 05/27/22, and the discharge assessment was due on 05/19/22 but was not completed until 05/27/22. The MDS coordinator stated she started at the facility in May and completed the assessments at that time. She stated the facility was in-between MDS coordinators when she started the MDS position.

Based on review of the facility policy, record review, and interview, the facility failed to ensure insulin was provided according to the sliding scale the Physician ordered for 1 (Resident (R)17) of 1 resident reviewed for insulin administration. Findings include: Review of the facility's policy titled Insulin Administration, reviewed 05/27/22, indicated Purpose: to ensure medication is given as ordered by the physician to the resident. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/27/22 revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated R17 had severely impaired cognition. Review of the physician order provided by the Director of Nursing (DON) revealed Novolog Flexpen U-100 Insulin aspart: Before meal and at bedtime: 170 thru 200 give 2.0 units; 201-250 give 4.0 units; 251 thru 300 give 6.0 units; 301 thru 350 give 8.0 units; 351 thru 400 give 10.0 units. Start date 09/07/22. Review of the electronic medication administration record (eMAR) provided by the DON, dated 10/22 revealed: On 10/01/22: HS (bedtime) accucheck- 210 with 3-units insulin marked as given. On 10/04/22: HS accucheck- 200 and 6-units insulin marked as given. On 10/04/22: AC (before meal) Supper accucheck- 245 and 6-units insulin marked as given. During an interview on 10/06/22 at 2:03 PM, the DON confirmed R17 should have received four units instead of the three units documented on 10/01/22; two units instead of the six units documented 10/04/22 HS; and four units instead of the six units as documented 10/04/22 AC. During an interview on 10/07/22 at 1:19 PM, the DON stated she had talked to the nurses involved in the discrepancy and they felt like it was an accidental error, and they felt the residents received the appropriate insulin amount.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed accurately for 3 of 3 residents (Resident (R)77, R17, and R60) reviewed for PASRR. Findings include: Review of the facility's policy titled, Resident Assessment-Coordination with PASARR [preadmission screening and resident review] Program, dated 2022, indicated All applicants will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with State Medicaid rules for screening. PASARR level I- initial screening that is completed under admission .The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority .Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. 1. Review of R77's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 09/15/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R77 had intact cognition. The resident was admitted on [DATE] with a readmission date of 09/09/22. The resident was documented with bipolar disorder under psychiatric/ mood disorder. The resident received an antipsychotic seven times over the seven days look back period. Review of the Profile Face Sheet provided by the facility, undated, revealed R77 had diagnoses which included bipolar disorder documented at two separate times (dated 11/10/20 and 03/30/22). Review of the physician orders provided by the facility, dated 10/2022, revealed R77 was receiving Aripiprazole (antipsychotic medication) 5 milligram (mg)- 1 tab by mouth at bedtime for bipolar disorder (start date 3/30/22). Review of R77's PASARR Level 1 screening form, dated 03/30/22 revealed: Section all diagnosis: missing the diagnosis for bipolar disorder. Section II: Diagnosis for mental illness marked as no. Section III: List all psychotropic drugs- blank. The PASARR form did not include the diagnosis of bipolar or the psychotropic medication R77 was receiving. 2. Review of R17's MDS with an ARD of 09/27/22 revealed a BIMS score of 7 out of 15, which indicated R17 had severely impaired cognition. The resident was admitted on [DATE] with a readmission date of 09/21/22. R17 was documented with bipolar disorder and anxiety under psychiatric/ mood disorder. R17 received an antipsychotic and antianxiety, antidepressant, and hypnotic six times over the seven days look back period. Review of the Profile Face Sheet provided by the facility, undated, revealed R17 had diagnoses which included bipolar disorder (dated 02/18/22); anxiety disorder (dated 11/27/13), and major depression disorder (dated 11/27/13). Review of the physician orders provided by the facility, dated 10/2022, revealed R17 was receiving Aripiprazole 5 milligram (mg)- 1 tab by mouth once a day for bipolar disorder (Start date 10/05/20); Divalproex (anticonvulsant) SOD ER 500mg - take 1 tablet by mouth once a day for other bipolar disorder (Start date: 02/18/21); Lorazepam (antianxiety) 0.5 mg tablet- 1 tablet twice daily for anxiety (Start date 02/18/22); and Venlafaxine (antidepressant) HCL ER 150 mg- 2 caps every day for other bipolar disorder (Start date 02/19/22). Review of R17's PASARR Level 1 screening form, dated 10/17/13 revealed: Section all diagnosis: missing the diagnosis for major depression. Section II: Diagnosis for mental illness marked as no. Section III: List all psychotropic drugs- Xanax. No other psych medications documented. The PASARR form did not include the diagnosis of bipolar and major depression and was missing some of the psychotropic medication the resident was receiving. 3. Review of R60's MDS with an ARD of 08/30/22 revealed a BIMS of 15 out of 15, which indicated R60 had intact cognition. R60 was admitted on [DATE] with a readmission date of 08/12/22. The resident was documented with bipolar disorder, anxiety, and schizophrenia under psychiatric/ mood disorder. The resident received an antipsychotic and antianxiety seven times and an antidepressant four times over the seven days look back period. Review of the Profile Face Sheet provided by the facility, undated, revealed R60 had diagnoses which included schizophrenia (dated 09/17/20), bipolar disorder (dated 09/17/20); anxiety disorder (dated 09/17/20), and major depression disorder (dated 09/17/20). Review of the physician orders provided by the facility, dated 10/2022, revealed the resident was receiving Risperidone (antipsychotic) 2 mg, take 1 tablet by mouth twice a day for Schizophrenia (Start date 04/12/21), Alprazolam (antianxiety) 0.5 mg tablet, 1-tab by mouth at bedtime for anxiety disorder (Start date 02/15/21), Alprazolam 0.5 mg tablet- take 1-half tablet twice a day and one whole tablet at bedtime for anxiety disorder (Start date 01/05/21) Review of R60's PASARR Level 1 screening form, dated 08/22 revealed: Section all diagnosis: missing the diagnosis for bipolar disorder. Section II: Blank and not filled out. Section III: Blank and not filled out. The PASARR form did not include the diagnosis of bipolar and section III was not completed as required. During an interview on 10/05/22 at 2:58 PM, the Social Worker (SW) stated the residents came in with PASARR on admission. The SW stated The SW stated the admission staff received the PASARR, the physician was the one who made change requests for the PASARR, and no one was monitoring the accuracy of the PASARR. During an interview on 10/06/22 at 10:54 AM, the admissions staff member stated she received the PASARR from the hospital and scanned them into the computer system. She stated she checked to ensure the PASARR was signed and dated, but did not monitor for accuracy. She stated she was taught that PASARR was under the SW department.

Based on record review and interviews, the facility failed to provide the required documents when the facility decided to end Medicare Part A Services for two (2) of three (3) residents sampled, Resident #247 and Resident #248. Findings include: 1. Review of Resident #247's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review, completed by the facility revealed the resident started Medicare A Skilled Services on 5/5/21 and ended services on 6/12/21. The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Review of the Discharge List revealed Resident #247 discharged from the facility on 6/13/21. Further Review revealed the facility did not provide the Notice of Medicare Non-Coverage or the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) form as required. 2. Review of Resident #248's SNF Beneficiary Protection Notification Review completed by the facility revealed the resident started Medicare A Services on 6/15/21 and ended services on 7/1/21. The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Review of the Discharge List revealed Resident #248 discharged from the facility on 7/2/21. The facility provided to Resident #248's Responsible Party the Notice of Medicare Non-Coverage on 6/28/21 stating the facility would be ending Medicare A services on 7/1/21. Further review revealed the facility did not provide the SNF ABN Form as required. Interview with the Administrator on 9/2/21 at 12:11 p.m. revealed he/she had called the Social Worker and found out the Business office provided the SNF ABN form to the resident and/or Responsible Party and the Social Worker provided the Notice of Medicare Non-Coverage form to the resident and/or Responsible Party. The Administrator confirmed the facility had no additional documents to reveal the resident and/or Responsible Party received the required information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of facility policy, the facility failed to assess for the use of full side rails for one (1) resident of the sample. The sample was 97 residents. Resident #38 Findings include: Review of the policy titled, Restraint Free Environment dated 8/15/17 revealed the purpose was to ensure each resident attained and maintained his/her highest practicable well-being in the facility that prohibited the use of restraints for discipline or convenience and limited restraint use to circumstance in which the resident had medical symptoms that warranted the use of restraint. The procedure included, providing a restraint free environment and resident, family and interdisciplinary team involvement in the care planning, implementation, and decision-making process to alternatives to restraint use. Review of the policy titled, Side or Bed Rails, dated 8/1/17 revealed, side or bed rails within this facility would be utilized only after: 1) a comprehensive individualized assessment of each resident's medical condition, ability to use side or bed rails, medications, risk for falls and cognition by an interdisciplinary team. 2) A physician's order indicating side or bed rails appropriate for mobility and transfer assist. 3) Addressed in the individualized resident's care plan with the risk and benefits for each individual resident addressed during quarterly reviews of the resident assessment. 4) Appropriate alternative to bed or side rails usage had been explored and exhausted. 5) Family and or representative education was provided to explain potential risk and benefits of the side or bed rail usage. Review of Resident #38's clinical record revealed an admission date of 6/23/21 and the diagnoses included: Encephalopathy, Acute Kidney Failure, Osteoarthritis, Dementia, Subluxation of the Left Hip, and Cerebral Infarction. Review of Resident #38's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, (with a score of eight (8) to 12 indicating moderately impaired cognition). The resident displayed no signs/symptoms of delirium and no behaviors. The MDS revealed the resident required limited assistance with bed mobility and transfers, did not walk, and required extensive assistance of one (1) person with dressing, eating, toilet use, personal hygiene, and bathing. The resident had a decrease in range of motion (ROM) on one (1) side of the lower extremity, utilized a walker or wheelchair and did not receive therapy or restorative services. The resident had experienced a fall in the last month prior to admission, unable to determine if the resident fell in the two (2) to six (6) months prior to admission and sustained a fracture in the last six (6) months prior to admission. The MDS did not document if the resident had a restraint. The Care Area Summary (CAA) revealed physical restraints did not trigger based on the admission MDS. Review of the Cognition Care Plan dated 7/14/21 listed the intervention, Avoid use of restraints. Further review of the Care Plan lacked intervention(s) for the use of side rails. Review of the Nurse's Note dated 7/11/21 at 12:53 a.m. revealed the Certified Nurse Assistant (CNA) observed the resident on the floor in a fetal position. The resident was unable to state how he/she ended up on the floor. The resident was transferred to bed with siderails per the family request. Review of the Nurse's Note dated 7/27/21 at 2:06 a.m. revealed the resident was alert and oriented to self, in no acute distress, and was unaware of safety needs. The resident often made attempts to get up without assistance. Review of the Physician's Orders on 8/31/21 at 4:36 p.m. lacked an order for the use of side rails. Review of the clinical record lacked an assessment for the use of the full side rails/physical restraint. Observation on 8/30/21 at 9:41 a.m. revealed Resident #38 lying in bed and the full side rails raised. Observation on 8/31/21 at 12:47 p.m.,12:57 p.m. and 1:37 p.m. revealed the resident lying in bed and the full side rails in the raised position. Observation on 9/1/21 at 10:27 a.m. and 2:40 p.m. revealed the resident lying in bed and the full side rails in the raised position. Interview with the Director of Therapy on 8/31/21 at 1:54 p.m. revealed the therapy department was not involved in the assessment for the use of side rails. Interview with the MDS Coordinator on 9/2/21 at 10:50 a.m. revealed when completing the care plan, he/she looked at the diagnoses, assessments, and physician orders. The MDS Coordinator stated he/she did not know Resident #38 had full side rails. Interview with CNA #9 on 9/1/21 at 12:00 p.m. revealed when the resident first entered the facility, he/she would try to get out of bed, so we added the full side rails. CNA #9 also stated Resident #38 placed his/her legs over the side rails trying to get out of bed. Interview with the Director of Nursing (DON) on 9/1/21 at 2:10 p.m. revealed prior to using siderails the facility first assessed to see if the side rails would be safe for the resident. We would use side rails if the resident had a fall or per the resident's family request. The DON stated he/she did not know if the facility completed an assessment prior to the use of the full side rails for Resident #38. Interview with Resident #38's Physician's Nurse #17 on 9/2/21 at 12:33 p.m. revealed he/she made rounds with the Physician at this facility. He/she further stated the facility usually just called to report the resident had fallen and if they needed additional orders i.e., send to hospital. The nurse further stated they were not aware Resident #38 had a physical restraint consisting of full side rails. Attempted interview with the responsible party on 9/2/21 was unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy it was determined for four (4) of 37 sampled residents (Resident #38, Resident #53, Resident #84, and Resident #91) the facility failed to develop and implement a comprehensive person-centered care plan to address desired outcomes to meet each resident's needs. Resident #38 had siderails in use when in bed and a Care Plan had not been developed to address the siderail use. Residents #53 and #91 had a decrease in ROM and a Care Plan was not developed and/or implemented to increase or maintain their ROM. Resident #84 was discontinued from skilled therapy services with recommendations for nursing to continue with implementing a program to maintain mobility. A care plan was not developed or implemented to maintain the resident's functional mobility status. Findings include: Review of a facility policy titled Care Plans for the Resident & RAI (Resident Assessment Instrument) dated 2/26/21 revealed a policy purpose statement To develop an individualized holistic and comprehensive care plan for each resident that includes measurable and realistic goals/objectives and time frames to meet a resident's medical, functional, psychosocial, and cognitive needs that are identified in the comprehensive resident assessment completed by inter-disciplines. Policy procedures indicated the facility will develop and implement a person-centered Care Plan that would describe the services to attain/maintain the resident's highest practical physical, mental, and psychosocial well-being. Additionally, policy procedures specified direct care staff would be able to describe the care, services, and expected outcomes of the care they provide. They will have a general knowledge of the care and services being provided by therapists and have a general knowledge of the expected outcomes. 1. Review of Resident #38's clinical record revealed an admission date of 6/23/21 and the diagnoses included: Encephalopathy, Acute Kidney Failure, Osteoarthritis, Dementia, Subluxation of the Left Hip, and Cerebral Infarction. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, (with a score of eight (8) to 12 indicating moderately impaired cognition). The MDS revealed the resident required limited assistance with bed mobility and transfers, did not walk, and required extensive assistance of one (1) person with dressing, eating, toilet use, personal hygiene, and bathing. The resident was not steady and only able to stabilize with staff assistance with moving from a seated to standing position, moving on and off the toilet and surface to surface transfers. The activity of walking and turning around did not occur. The resident had a decreased in range of motion (ROM) on one (1) side of the lower extremity, utilized a walker or wheelchair and did not receive therapy or restorative services. The resident had experienced a fall in the last month prior to admission, staff were unable to determine if the resident fell in the two (2) to six (6) months prior to admission and sustained a fracture in the last six (6) months prior to admission. The MDS did not document if the resident had a restraint. Review of the Fall Care Plan dated 7/14/21 listed the interventions, give resident verbal reminders not to ambulate/transfer without assistance as needed, provide resident with safety device/appliance as indicated, provide an environment free of clutter, keep call light in reach at all times, 6/30/21 - observe frequently and place in supervised area when out of bed as needed, 7/10/21 - bed in low position, 7/11/21 - fall mats as ordered, 7/21/21 - encourage the resident to sit by the nurses' station as tolerated. Review of the Cognition Care Plan dated 7/14/21 listed the intervention, Avoid use of restraints. Further review of the Care Plan lacked intervention(s) for the use of side rails. Review of the Nurse's Note and Facility Investigation dated 7/10/21 at 6:53 a.m. revealed the resident was observed at 6:30 a.m. lying on the floor on the right side of the bed in a fetal position. The resident's bed was in the lowest position at the time of the fall. Bed and chair alarms would be placed as an intervention. The Care Plan did not list the interventions for the bed and chair alarms. Review of the Nurse's Note and Facility Investigation dated 7/11/21 at 12:53 a.m. revealed the Certified Nurse Aide (CNA) found the resident on the floor in a fetal position. The resident could not state how he/she ended up on the floor. The resident was transferred to a bed with siderails per the family's request. The investigation lacked evidence if the bed or chair alarm sounded and if the resident was in the bed or chair prior to the fall. The Care Plan did not include the use of full side rails. Review of the Risk Management Meeting notes dated 7/13/21 at 10:30 a.m. revealed a floor mat was placed on the right side of the lowered bed with the call light within reach. The resident was started on 30-minute checks to monitor the resident throughout the shifts to prevent further falls. A clipboard with Log to be placed in the resident's room to monitor services provided throughout the day. Review of the Nurse's Note and Facility Investigation dated 7/21/21 at 1:57 p.m. revealed the CNA reported the resident was on the floor at 1:00 p.m. The resident was sitting up in a chair with non-skid socks and the bed was in the lowest position. The resident sustained a small laceration above the right eyebrow and staff applied steri-strips. The staff added the intervention to keep the resident up in a chair close to the Nurses' Station so staff could monitor the resident. The investigation lacked evidence if the bed or chair alarm sounded at the time of the fall and when the staff last checked the resident. Review of the Physician's Orders on 8/31/21 at 4:36 p.m. lacked an order for the use of side rails. Review of the clinical record lacked an assessment for the use of the full side rails/physical restraint. Observation on 8/30/21 at 9:41 a.m. revealed Resident #38 lying in bed and the full side rails raised. There were fall mats on both sides of the bed, but the bed was not in a low position. Observation on 8/31/21 at 11:47 a.m. revealed the resident was in his/her room yelling out, I want to lay down, I'm sick. The resident was sitting in the wheelchair by the closet door and not able to be observed from the door. Observation on 8/31/21 at 12:47 p.m.,12:57 p.m. and 1:37 p.m. revealed the resident lying in bed and the full side rails in the raised position. There were fall mats on both sides of the bed, but the bed was not in a low position. Observation on 9/1/21 at 10:27 a.m. revealed the resident lying in bed with the full side rails in the raised position, fall mats were on both sides of the bed and the bed was not in a low position. Observation on 9/1/21 at 11:10 a.m. revealed the resident sat in a wheelchair on the opposite side of the bed from the room door. No one was with the resident. Observation on 9/2/21 at 9:52 a.m. revealed the resident lying in bed, the bed was lowered to the floor with no side rails. The resident had a floor mat on the right side of the bed and on the left side of the bed. The floor mat on the left side of the bed was positioned at the head of bed and angled out to 48 inches away from the bed at the bottom of the floor mat. Interview with the Director of Nursing (DON) on 9/1/21 at 2:10 p.m. revealed prior to using siderails the facility first assessed to see if the side rails would be safe for the resident. We would use side rails if the resident had a fall or per the resident's family request. The DON stated he/she did not know if the facility completed an assessment prior to the use of the full side rails for Resident #38. Interview with the MDS Coordinator on 9/2/21 at 10:50 a.m. revealed when completing the care plan, he/she looked at the diagnoses, assessments, and physician orders. The MDS Coordinator stated he/she did not know Resident #38 had full side rails. 2. Review of Resident #53's clinical record revealed an admission date of 11/11/19 and the diagnoses included: Adult Failure to Thrive; Diabetes; Major Depressive Disorder; Dementia; Cerebral Infarction; and Pruritus. Review of Resident #53's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine (9) with a score of eight (8) to 12 indicating modified cognition. The resident displayed no behaviors and required extensive assistance of one (1) staff member for bed mobility, dressing, eating, and toilet use. The resident required total assistance of two (2) staff for transfers and required total assistance of one (1) staff with personal hygiene and bathing. The MDS revealed Resident #53 had no skin issues, received an anticoagulant four (4) of the last seven (7) days and received Hospice services. The MDS revealed the resident had decreased range of motion (ROM) on one (1) lower extremity. The resident did not receive therapy or restorative services. Review of the Skin Conditions Care Plan dated 7/18/21 revealed Resident #53 had chronic pruritis and scratched his/her skin all over. The itching sensation seemed to be internal. The interventions included: body audit conducted by nursing staff per the policy and procedures; keep skin well lubricated; dress the resident in long sleeve clothing during the day hours; staff to dress the resident in pajamas for bedtime; and use geri-sleeves (protective arm sleeves) on bilateral upper extremities to protect the skin. Further review of the Care Plan lacked interventions for the decrease in ROM. Review of Resident #53's Physician Orders revealed an order for protective arm sleeves times two (2). Apply to bilateral upper extremities and may remove for bathing and daily skin inspection with the start date of 9/6/2020 and Triple Antibiotic Ointment (TAO) and dry dressing as needed (prn) to scratched areas and change daily and prn with the start date of 2/2/2020. Review of the Interdisciplinary Note dated 8/28/21 at 12:45 p.m. revealed, yesterday around 5:10 p.m. the nurse was made aware the resident had scratched his/herself upper left arm. The nurse assessed the area and noted the resident to have scratch their upper left arm and provided the prn treatment. Review of the 8/2021 Treatment Administration Record (TAR) on 9/1/21 at 6:43 p.m., revealed documented they applied the protective arm sleeves from 8/1/21 to 8/20/21, 8/22/21 to 8/25/21 and 8/27/21 to 8/28/21. Observation of Resident #53 on 8/30/21 at 11:47 a.m. revealed the left arm had three (3) different dressings that basically covered the entire left arm. Further observation revealed no geri-sleeves in place. Observation on 8/30/21 at 1:34 p.m. revealed Resident #53 lying in bed and the legs bent at the knees and drawn upward. Observation on 8/31/21 at 11:50 a.m. revealed Resident #53 had three (3) dressings, dated 8/29/21, basically covering the entire left arm. The resident did not have geri-sleeves on. Further observation revealed no change in the resident's positioning of the legs. Observation on 9/1/21 at 10:41 a.m. revealed the resident had old skin tears and scabs on the left arm. The resident did not have the geri-sleeves on. Interview with CNA #13 on 8/31/21 at 1:45 p.m. revealed when therapy was discontinued for a resident, they would verbally tell the nursing staff if a resident required further restorative care if they had time. Interview with Certified Nurse Assistant (CNA) #11 on 9/1/21 at 11:04 a.m. revealed Resident #53 scratched a lot and over the weekend the resident had one dressing on the left arm. The resident should wear geri-sleeves, but he/she could not find them today. Interview with Licensed Practical Nurse (LPN) #4 on 9/1/21 at 11:30 a.m. revealed, usually the nurse would write a note regarding the skin tears. LPN #4 also stated the resident should have geri-sleeves on. Interview with the Director of Nursing (DON) on 9/1/21 at 2:02 p.m. revealed the staff should put geri-sleeves on the resident. Interview with the MDS Coordinator on 9/2/21 at 10:50 a.m. revealed anytime the CNAs provide activity of daily living (ADL) care they should provide ROM, but he/she would not add it to the Care Plan. 3. Resident #84 was admitted to the facility on [DATE]. Admitting diagnoses included Cerebrovascular Accident (CVA), Hemiplegia following Cerebral Infarction, Chronic Obstructive Pulmonary Disease (COPD), Anxiety Disorder, Depression, Muscle Weakness, Unspecified fall with Subsequent Encounter, Weakness, Unspecified Abnormalities of Gait, Age-related Osteoporosis, Abnormal Posture, and Other Lack of Coordination. Review of an admission Minimal Data Set (MDS) assessment, dated 4/14/21 revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was independent in cognitive skills for daily decision making. The resident was assessed in functional status for Activities of Daily Living (ADL) to require the limited assistance of one (1) staff person with transfers, and the activity of ambulation did not occur. Resident #84 had experienced no falls during the assessment review period. Physical Therapy (PT) services had been provided on four (4) days, starting on 4/9/21 and continuing at the time of the MDS assessment. ADL Functional Rehabilitation potential and a risk for falls were each care areas triggered on the Care Area Assessment (CAA) and a decision made to continue to the Care Plan to address each area. Review of a PT Evaluation and Plan of Treatment document dated 4/9/21 revealed Resident #84 was evaluated and started receiving Pt services. A short-term goal was established for the resident to ambulate 150 feet using a four-wheel walker (FWW). A long-term goal was established for Resident #84 to ambulate 300 feet with a FWW. The frequency of PT services was to be five (5) times per week, daily, for four (4) weeks. Review of a PT Discharge (DC) Summary revealed PT services were discontinued for Resident #84 on 4/30/21. The DC Summary indicated Resident #84 could ambulate 50 feet when PT services were initiated on 4/9/21. The resident could ambulate 200 feet at the time of discharge from PT services on 4/30/21. The PT Discharge Summary noted Resident #84's prognosis to maintain current level of function was good with consistent staff follow-through. PT discharge recommendations included for staff to continue assisting the resident with ambulation as needed to maintain the current level of function and prevent decline. Review of a Care Plan dated 4/8/21 revealed a problem deficit for Resident #84 that stated the resident had impaired mobility. A goal was established for the resident to not develop any complications related to decreased ADL self-performance through next review period. Interventions planned to address the impaired physical mobility deficit included: 1) PT, OT evaluation as indicated. 2) Provide appropriate level of assistance to promote safety. 3) Modify environment as needed to enhance mobility. 4) Provide assistive device as indicated. The Care Plan was not updated to include interventions recommended by PT for staff to continue an ambulation program for Resident #84 to maintain and prevent decline in the resident's functional mobility status. Review of Activities of Daily Living (ADL) charting by Certified Nursing Assistants (CNAs) revealed Resident #84 was not being provided with an ambulation program to maintain and prevent decline in functional mobility status. ADL documentation reflected after the resident was discontinued from PT services on 4/30/21, Resident #84 was assisted with ambulation in his/her room eight (8) days and was assisted with ambulation in the hallway three (3) days, in May 2021. Resident #84 was not documented as having received any assistance with an ambulation program during the month of June 2021. The ADL charting for July 2021 and August 2021 revealed the resident was assisted with ambulating one (1) day during each of the months. Review of a Quarterly MDS assessment dated [DATE] revealed Resident #84 continued to have a BIMS score of 13, indicating independence in cognitive skills for daily decision making. The assessment of ADL functional status identified Resident #84 as not walking in room or in the hallway during the assessment review period. The assessment of special treatments provided indicated Resident #84 had received PT services from 4/9/21 to 4/30/21. Resident #84 was observed on 8/30/21 at 12:18 p.m. to be up in a wheelchair positioned in his/her room. There was a four-wheel walker (FWW) in the resident's room, leaning against a wall and not within reach of the resident. An interview was conducted on 8/31/21 at 11:45 a.m. with Resident #84. The resident stated he/she had received PT services when first admitted to the facility and had been able to walk at that time. Resident #84 stated after being discharged from PT services the resident could no longer walk. Resident #84 stated he/she had not been offered assistance with walking by the nursing staff after the PT services were discontinued. An interview was conducted on 9/2/21 at 12:00 p.m. with the Minimum Data Set Coordinator (MDSC). The MDSC confirmed Resident #84's Care Plan should have been updated to include the PT recommendations for nursing to continue with a mobility program, after being discontinued from PT services. The MDSC reviewed the ADL daily charting by direct care staff for the months following Resident #84 being discharged from PT. The MDSC noted mobility assistance was occasionally documented for the resident. However, acknowledged there had been no consistent ambulation program provided to maintain the resident's mobility status as recommended by PT. The MDSC stated he/she did not know if Resident #84 was currently able to ambulate at the level of function he/she had been doing when discharged from PT. An interview was conducted on 8/31/21 at 1:30 p.m. with Certified Nursing Assistant (CNA) #12, who provided care for Resident #84. The CNA stated the resident could self-propel in a wheelchair but could not stand up and walk. The CNA was not aware of a requirement to provide ambulation assistance to the resident. An interview was conducted on 8/21/21 at 1:40 p.m. with CNA #13. The CNA did recall Resident #84 receiving PT services during the first month after the resident was admitted (April 2021). CNA #13 did not remember Resident #84 walking after PT services were discontinued. According to the CNA the resident propelled him/herself in a wheelchair in the hallway. An interview was conducted on 9/1/21 at 12:08 p.m. with the Director of Nursing (DON). The DON stated when PT services were discontinued with recommendations made for nursing services to continue to provide restorative services for mobility, the resident's Care Plan should have been updated. The DON stated the Care Plan should reflect the recommended therapy interventions and Resident #84 should not have stopped receiving mobility assistance when PT services ended. The DON did not know if Resident #84 had continued to maintain the level of function in mobility he/she had displayed at the time of discharge from Pt services. 4. Review of Resident #91's clinical record revealed an admission date of 5/11/21 and the diagnoses included: Fracture of the Left Femur, Diabetes, Muscle Weakness, Fibromyalgia, Abnormality of Gait, Major Depressive Disorder and Lack of Coordination. Review of Resident #91's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eight (8) with a score of eight (8) to 12 indicating modified cognition. The resident displayed no behaviors and required extensive assistance of one (1) person with bed mobility, dressing, toilet use, and personal hygiene. The resident required extensive assistance of two (2) people with transfers and required total assistance of one (1) person for bathing. The MDS revealed the resident did not walk or move about the room or corridor. The resident had decreased range of motion (ROM) in the lower extremities bilaterally and did not receive therapy or restorative services. Review of the Care Plan updated on 8/25/21 listed the intervention for Therapy per Physician's order with the start date of 5/11/21. Review of the Nurse's Note dated 5/12/21 at 5:27 p.m. revealed Resident #91 was admitted on [DATE] for rehab. Review of Therapy Note dated 6/25/21 at 11:15 a.m. revealed the Director of Rehab spoked with the Responsible Party (RP) to discuss therapy discharge date secondary to plateau. RP reported he/she would come to the facility to discuss long term care with Resident #91. Review of OT and PT Discharge Summaries revealed therapy was discontinued on 6/29/21. Observation and interview with Resident #91 on 8/30/21 at 9:51 a.m. revealed he/she was not receiving therapy now because his/her insurance would not cover it, but Resident #91 stated he/she need to get back to it. The resident complained of right ankle pain and the right ankle was elevated while the resident laid in bed on his/her back. Observation on 8/31/21 at 11:48 a.m. revealed the resident sat in his/her wheelchair with a Hoyer lift pad under him/her. Observation on 8/31/21 at 1:36 p.m. revealed staff did not change the position of the resident. Interview with Certified Nurse Assistant (CNA) #9 on 9/1/21 at 11:56 a.m. revealed there was no formal restorative program, but he/she liked to work the resident's legs. CNA #9 stated he/she did not document the ROM anywhere. Interview with the Director of Nursing (DON) on 9/1/21 at 1:54 p.m. revealed there was not a restorative program at the facility. The CNAs and the nurses know that if they see a decline in a resident, they should fill out a therapy form. When asked if the facility was doing anything to prevent a decline the DON stated, the nurses would do some ROM if they noticed some stiffness and then notify therapy. Interview with the MDS Coordinator on 9/2/21 at 10:50 a.m. revealed anytime the CNAs provide activity of daily living (ADL) care they should provide ROM, but he/she would not add it to the Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy it was determined the facility failed to ensure care plans were updated/revised to meet the psychosocial needs for one (1) of 37 sampled residents, Resident #21. Resident #21 had been roommate with his/her spouse since admission to the facility, 18 months prior. The resident's spouse had recently expired, and the resident was expressing grief and loneliness. The facility failed to update the resident's care to address the grief the resident was experiencing due to loss of spouse/roommate. The findings include: Review of the facility policy, Care Plan Revisions Upon Status Change, with revision date [DATE] revealed the purpose of the policy is to provide a consistent process for reviewing and revising the care plan for residents experiencing a status change. Care plans will be updated with new or modified interventions by the Minimum Data Set (MDS) Coordinator or other designated staff member. Review of Resident #21's clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included legal blindness, glaucoma, depression, anxiety, osteoarthritis, hypertension, gastroesophageal reflux disease with gastrostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] determined the resident's hearing and speech was adequate, vision was severely impaired, and the Brief Interview for Mental Status (BIMS) score was 12, indicating moderate cognitive impairment. According to the assessment the resident required limited one (1) person assist for bed mobility, locomotion and dressing, supervision with personal hygiene, eating required one (1) person extensive assistance (tube feeding) and was totally dependent on staff for bathing and toileting. The resident received antianxiety and antidepressant medications for seven (7) days of the assessment period. Review of the resident's Care Plan for Psychosocial Well-Being implemented on [DATE] and was documented as resolved on [DATE]: Resident has a potential for a psychosocial well-being problem related to sharing a room with spouse. The goal of the care plan was for resident to not experience any adverse effect from sharing room with spouse through next review date. Interventions listed on the care plan included encourage resident to verbalize feelings, monitor for anxiety, discomfort, tension between resident and spouse, and to de-escalate any tensions between residents before it escalates. Review of the Interdisciplinary Notes revealed the following: - [DATE] 3:29 p.m. the resident's physician reviewed medications related to spouse being in hospital and is not expected to live much longer. The resident is aware of spouse's condition and have been yelling out and experiencing much more anxiety. The physician increased Lorazepam 0.5 milligram to three (3) times per day. - [DATE] 11:42 a.m. the resident was provided with psychosocial support related to spouse being in the hospital terminally ill. - [DATE] 2:30 p.m. Resident's family at bedside and resident was made aware of spouse's passing. Resident crying out off and on and was comforted by family and staff. - [DATE] 5:03 p.m. Resident noted to have periods of grieving this shift. - [DATE] 9:49 a.m. Resident speaks of decreased spouse from time to time. Observation on [DATE] at 11:15 a.m. revealed Resident #21 was lying in low bed supine position with head of bed up 45 degrees. The resident stated at this time that he/she wished people could spend more time in his/her room because he/she gets lonely. An observation on [DATE] at 11:15 a.m. the resident was lying in low bed supine position. During an interview with the resident at this time the resident stated he/she was blind and cannot walk and needs help. The resident said he/she had to be fed with a tube because was not able to swallow safely. The resident further stated he/she had experienced blindness due to a left eye implant that had moved and could not see out of the left eye due to a stroke. The resident concluded his/her only concern with care at the facility was that of being lonely and wanted staff to come in to see him/her more often. During an interview with the resident on [DATE] at 1:45 p.m. the resident stated he/she had been married to his/her spouse for 27 years and the spouse had recently died Resident #21 stated he/she gets lonely because he/she was used to having someone to talk to and wished more people would come visit in his/her room. On [DATE] at 1:35 p.m. Certified Nursing Assistant (CNA) #15 stated during an interview that Resident #21's spouse had recently passed away and the resident was still grieving. He/she said the resident was legally blind and staff had to do everything for the resident. She stated staff encouraged the resident to get out of bed, but the resident was refusing. An interview with LPN #2 on [DATE] 3:00 p.m. revealed the resident and his/her spouse would argue at times, but there were never any arguments that could be considered abusive. The LPN stated since the resident's spouse had died, that he/she attempted to spend as much time as possible in the resident's room because the resident was grieving for the loss of roommate/spouse. During an interview with the Unit Manager (UM) on [DATE] at 10:30 AM, he/she stated Resident #21, and spouse were roommates and would argue at times like many couples do. He/she stated the resident's spouse had recently died and the resident was still grieving. The UM said the resident had anxiety and does takes antianxiety meds, but no further services/treatments had been provided to the resident since his/her spouse had expired. After reviewing the resident's care plan the UM stated the resident's care plan should have been updated after the loss of spouse with interventions in place to address ongoing grief. An interview with Social Services (SS) on [DATE] at 9:05 a.m., he/she stated had begun employment at the facility on [DATE], that the SS Director had been on leave since the beginning of [DATE]. He/she said it was his/her understanding that the previous administrator had been acting as temporary SS Director until he/she started in current position and had discontinued Resident #21's psychosocial care plan. SS said he/she is still learning job duties and had just learned SS was responsible for revising psychosocial care plans. After reviewing Resident #21's psychosocial care plan he/she stated the resident's care plan should not have been resolved but should have been updated with specific interventions addressing the grief process. On [DATE] at 9:50 a.m. the Administrator stated Resident #21's care plan should have been updated to address the grieving process related to the loss of spouse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of facility policy, the facility failed to assess the skin and provide interventions as planned for the prevention of skin breakdown for one (1) of one (1) resident sampled for non-pressure related skin issues. (Resident #53) Findings include: Review of the policy titled, Wound Documentation Guidelines dated 10/3/16 revealed, the facility will maintain clinical records on each resident with accepted professional standards and practices. Documentation would provide a picture of the resident's progress including response to treatment, change in condition and changes in treatment. The Treatment Documentation Guidelines included the type of wound (pressure injury, surgical, etc., measurements, description of wound characteristics, and current treatment). Review of Resident #53's clinical record revealed an admission date of 11/11/19 and the diagnoses included: Adult Failure to Thrive; Diabetes; Major Depressive Disorder; Dementia; Cerebral Infarction; and Pruritus. Review of Resident #53's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine (9) with a score of eight (8) to 12 indicating modified cognition. The resident displayed no behaviors and required extensive assistance of one (1) staff member for bed mobility, dressing, eating, and toilet use. The resident required total assistance of two (2) staff for transfers and required total assistance of one (1) staff with personal hygiene and bathing. The MDS revealed Resident #53 had no skin issues, received an anticoagulant four (4) of the last seven (7) days and received Hospice services. Review of the Skin Conditions Care Plan, dated 7/18/21, revealed Resident #53 had chronic pruritis and scratched his/her skin all over. The itching sensation seemed to be internal. The interventions included: body audit conducted by nursing staff per the policy and procedures; keep skin well lubricated; dress the resident in long sleeve clothing during the day hours; staff to dress the resident in pajamas for bedtime; and use geri-sleeves (protective arm sleeves) on bilateral upper extremities to protect the skin. Review of Resident #53's Physician Orders revealed an order for protective arm sleeves times two (2). Apply to bilateral upper extremities and may remove for bathing and daily skin inspection with the start date of 9/6/2020 and Triple Antibiotic Ointment (TAO) and dry dressing as needed (prn) to scratched areas and change daily and prn with the start date of 2/2/2020. Review of the Interdisciplinary Note, dated 8/28/21 at 12:45 p.m., revealed, yesterday around 5:10 p.m. the nurse was made aware the resident had scratched his/herself upper left arm. The nurse assessed the area and noted the resident to have scratch their upper left arm and provided the prn treatment. Review of the 8/2021 Treatment Administration Record (TAR) on 9/1/21 at 6:43 p.m., revealed the order for TAO and dry dressing prn and initialed as completed on 8/27/21 and 8/28/21. Further review of this TAR revealed the order for protective arm sleeves times two (2), apply to bilateral upper extremities. Staff documented they applied the protective arm sleeves from 8/1/21 to 8/20/21, 8/22/21 to 8/25/21 and 8/27/21 to 8/28/21. Observation of Resident #53 on 8/30/21 at 11:47 a.m. revealed the left arm had three (3) different dressings that basically covered the entire left arm. Further observation revealed no geri-sleeves in place. Observation on 8/31/21 at 11:50 a.m. revealed Resident #53 had three (3) dressings, dated 8/29/21, basically covering the entire left arm. The resident did not have on geri-sleeves. Observation on 9/1/21 at 10:41 a.m. revealed the resident had old skin tears and scabs on the left arm. The resident did not have the geri-sleeves on. Interview with the Wound Nurse (WN) on 9/1/21 at 9:45 a.m. revealed the nurse that initiated the skin tear treatment should document the assessment of the skin tears. Interview with Certified Nurse Assistant (CNA) #11 on 9/1/21 at 11:04 a.m. revealed Resident #53 scratched a lot and over the weekend the resident had one dressing on the left arm. The resident should wear geri-sleeves, but he/she could not find them today. Interview with Licensed Practical Nurse (LPN) #4 on 9/1/21 at 11:30 a.m. revealed it was normal practice for the nurse would write a note regarding the skin tears. LPN #4 also stated the resident should have geri-sleeves on. Interview with the Director of Nursing (DON) on 9/1/21 at 2:02 p.m. revealed if a resident developed a new skin issue, the nurse should document it in the nurse's notes and complete an incident report. The DON also stated the staff should put geri-sleeves on the resident. The surveyor requested the skin assessments and the incident reports regarding the three areas on the left arm. As of 9/2/21 at 1:20 p.m. the DON had not provided the requested skin assessments or incident reports.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide restorative services to maintain or improve range of motion (ROM) for two (2) residents and mobility for one (1) resident of a sample of 37 residents. Residents #53 and #91 had a decrease in ROM and were not provided services to increase or maintain their ROM. Resident #84 was discontinued from skilled therapy services with a recommendation for nursing to continue an ambulation program. The facility failed to provide an ambulation program to maintain the resident's maximum level of independence with ambulation. Findings Include: Interview with the facility Administrator on 9/1/21 at 2:45 p.m. revealed the facility had no policy related to the provision of services regarding residents requiring ROM or mobility assistance. The Administrator indicated the facility followed the Resident Assessment Instrument (RAI) and resulting Care Plan development for addressing each resident's ROM and mobility status. 1. Review of Resident #53's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine (9), with a score of eight (8) to 12 indicating modified cognition. The resident required extensive assistance of one (1) person for bed mobility, dressing, eating, and toilet use. The resident required total assistance of one (1) person with personal hygiene and bathing and required total assistance of two (2) people with transfers. The MDS revealed the resident did not walk and only one (1) time in the past seven (7) days move about the room and/or corridor. The MDS revealed the resident had decreased range of motion (ROM) on one (1) lower extremity that had not changed. The resident did not receive therapy or restorative services and was on Hospice services. Review of the Care Plan updated on 7/18/21 lacked interventions for the decrease in ROM. Review of current Physician's Orders lacked an order for therapy. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment revealed the Resident #53 received only an evaluation and no further treatment required from OT. Review of the Physical Therapy (PT) notes revealed Resident #53 received PT in May 2021 for sitting and ROM. Observation on 8/30/21 at 1:34 p.m. revealed Resident #53 lying in bed and the legs bent at the knees and drawn upward. Observation on 8/31/21 at 11:50 a.m. revealed no change in the resident's positioning of the legs. Interview with Certified Nursing Assistant (CNA) #13 on 8/31/21 at 1:45 p.m. revealed when therapy was discontinued for a resident, they will verbally tell the nursing staff if a resident required further restorative care if we have time. Interview with CNA #11 on 9/1/21 at 11:04 a.m. revealed the CNAs were not responsible for doing any ROM or restorative services with the residents. Interview with the Director of Nursing (DON) on 9/1/21 at 1:54 p.m. revealed there was not a restorative program at the facility. The CNAs and the nurses know that if they see a decline in a resident, they should fill out a therapy form. When asked if the facility was doing anything to prevent a decline the DON stated, the nurses would do some ROM if they noticed some stiffness and then notify therapy. Further interview with the Director of Nursing on 9/1/21 at 2:02 p.m. revealed he/she would expect the staff to do gentle ROM, but probably since Resident #53 was a hospice resident they probably do not. 2. Resident #84 was admitted to the facility on [DATE]. Admitting diagnoses included Atrial Fibrillation (A Fib), Hypertension (HTN), Cerebrovascular Accident (CVA), Hemiplegia following Cerebral Infarction, Chronic Obstructive Pulmonary Disease (COPD), Anxiety Disorder, Depression, Muscle Weakness, Unspecified fall with Subsequent Encounter, Weakness, Unspecified Abnormalities of Gait, Age-related Osteoporosis, Abnormal Posture, and Other Lack of Coordination. Review of an admission Minimal Data Set (MDS) assessment, dated 4/14/21 revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was independent in cognitive skills for daily decision making. The resident was assessed in functional status for Activities of Daily Living (ADL) to require the limited assistance of one (1) staff person with transfers, and the activity of ambulation did not occur. An assessment of the resident's Functional Rehabilitation Potential identified both Resident #84 and Direct Care Staff as believing the resident was capable of increased independence in at least some ADLs. The resident was assessed to have experienced no falls during the MDS assessment review period. The MDS assessment indicated Resident #84 received four (4) days of Occupational Therapy (OT) and four (4) days of Physical Therapy (PT), with both skilled services starting on 4/9/21. The assessment identified both skilled therapy services to be on-going for the resident. The care areas of ADL Functional/Rehabilitation Potential and Falls triggered to require further evaluation. Review of the Care Area Assessment (CAA) summary documentation addressing ADLs and risk for falls revealed Resident #84's physical functioning had declined due to medical condition and weakness post hospitalization. The resident triggered for a risk for falls based on the decreased functional mobility and a history of multiple falls prior to admission. The CAA summary indicated Resident #84 was receiving skilled therapy services and assistance as needed. A decision was made to proceed to the Care Plan to address the resident's physical functioning decline, including a decreased functional mobility. Review of a Quarterly MDS assessment dated [DATE] revealed Resident #84 continued to have a BIMS score of 13, indicating independence in cognitive skills for daily decision making. The assessment of ADL functional status identified Resident #84 as not walking in room or in the hallway during the assessment review period. The assessment of special treatments provided indicated Resident #84 had received PT services from 4/9/21 to 4/30/21. Review of a Care Plan dated 4/8/21 revealed a problem deficit for Resident #84 that stated the resident had impaired mobility. A goal was established for the resident to not develop any complications related to decreased ADL self-performance through next review period. Interventions planned to address the impaired physical mobility deficit included: 1) PT, OT evaluation as indicated. 2) Provide appropriate level of assistance to promote safety. 3) Modify environment as needed to enhance mobility. 4) Provide assistive device as indicated. Continued review of Resident #84's Care Plan dated 4/8/21 revealed the resident had a potential for injury related to fall risk. A goal established to address the problem deficit stated the resident would remain free of falls or injury through the next review period. Interventions planned included: 1) Give resident verbal reminders not to ambulate/transfer without assistance. 2) Provide resident with safety device/appliance as indicated. 3) Provide resident an environment free of clutter. 4) Keep call light in reach at all times. 5) Keep personal items and frequently used items within reach. 6) Keep bed in lowest position with brakes locked. A review of the medical record revealed a physician's order dated 4/9/21 for skilled PT to evaluate Resident #84 and treat as indicated. Review of a PT Evaluation and Plan of Treatment document revealed Resident #84 was evaluated for the receipt of physical therapy services on 4/9/21. The PT evaluation determined Resident #84 would receive skilled PT services from 4/9/21 through 5/8/21. Short-term goals established included Resident #84 would safely ambulate on level surfaces 150 feet using four-wheel walker (FWW) with standby assistance (SBA) and occasional verbal cues for proper sequencing, for task segmentation, and for correct use of assistive device (AD) in order to return to prior living and supervision levels. A target date of 4/22/21 was established. A long-term goal for Resident #84 was to safely ambulate on level surfaces 300 feet using FWW with modified independence and 0% verbal cues for proper sequencing, for task segmentation and for correct use of AD in order to return to prior living and supervision levels. A target date of 5/8/21 was established. The frequency of PT services was to be five (5) times per week, daily, for four (4) weeks. The evaluation included Resident #84's goals of going home and indicated the potential of achieving goals, stating Patient demonstrates excellent rehab potential as evidenced by high PLOF (prior level of function), recent onset, low number of comorbidities and motivation to return to PLOF. The evaluation indicated the resident and caregivers participated in establishing the Plan of Treatment (POT). Review of a PT Discharge Summary revealed PT services were discontinued for Resident #84 on 4/30/21. The short-term goal established on 4/9/21 for the resident to ambulate 200 feet had been met. The summary documentation reflected on 4/9/21 Resident #84 had ambulated 50 feet with CGA (contact guard assistance) and 10% verbal cues. On 4/30/21 the resident was discharged being able to ambulate 200 feet with CGA and occasional verbal cues. The PT Discharge Summary indicated the resident and caregivers were provided training and instructed in safety sequencing techniques and safe transfer techniques in order to increase safety and decrease need for assistance, preserve current level of function and prevent decline from current level of skill performance. Resident #84 was noted to have made progress towards goals as a result of skilled PT and is now at baseline. Resident completes bed mobility and transfers with SBA (stand by assistance) and ambulates 200 feet with FWW and CGA for improved safety awareness. Resident is also able to ascend/descend 12 steps with CGA and both siderails. Resident #84's final prognosis to maintain current level of function (CLOF) was good with consistent staff follow-through. PT discharge recommendations included recommending staff to continue assisting resident as needed to maintain current level of function and prevent decline. A review was conducted of Activities of Daily Living (ADL) charting by Certified Nursing Assistants (CNAs) for the months following Resident #84 being discharged from PT skilled services. The ADL documentation for May 2021 revealed the resident had received support from staff with ambulating in his/her room on eight (8) days during the 31 day timeframe. Resident #84 had received support from staff with ambulating in the hallway on three (3) days during the 31 day timeframe. The ADL documentation for June 2021 revealed Resident #84 had not ambulated in his/her room or in the hallway during the month. The ADL charting for July 2021 and August 2021 reflected Resident #84 had received assistance one (1) day with ambulating in his/her room and in the hallway, for a total of two (2) days during the two (2) month timeframe. The ADL charting for each of the months following the resident being discharged from PT services did not include documentation of the distance the resident was assisted in ambulating or the level of support the resident required. The PT discharge recommendation for staff to continue assisting Resident #84 with an ambulation program, as needed to maintain current level of function and prevent decline was not being followed. An observation on 8/30/21 at 12:18 p.m. of Resident #84 revealed the resident was in his/her room, seated in a wheelchair. A four-wheel walker (FWW) was observed to be leaning against the wall of the resident's room and was not within reach of the resident. The resident stated he/she had been able to walk prior to coming to the facility. The resident stated he/she had received physical therapy services when first admitted to the facility in April 2021, but he/she no longer received the skilled service. Resident #84 stated he/she could weight bear with staff assistance but could no longer walk. Observation and interview on 8/31/21 at 11:45 a.m. with Resident #84 revealed the resident was in his/her room, seated in a wheelchair. When questioned regarding receiving assistance with ambulating the resident reiterated his/her previous statement regarding having been able to walk with Pt services when first admitted to the facility. The resident stated after PT quit walking with him/her, he/she was no longer able to do it (ambulate). Resident #84 stated after PT services were discontinued no one had discussed with him/her the need for a restorative program or for nurses to continue walking with him/her. The resident stated he/she just went from being able to walk to no longer getting help with walking. The resident stated he/she was able to self-propel the wheelchair up and down the hallway. An interview was conducted on 8/31/21 at 12:32 p.m. with the Therapy Director (TD). The TD stated the facility did not have a Restorative Nursing Program. According to the TD nursing had the understanding that when a resident was discontinued from a therapy program they can pick up and continue a walking or exercise program. The TD stated Resident #84 had received a skilled therapy program. When the therapy program was discontinued the Unit Manager (UM) and Director of Nursing (DON) would have been notified of any recommendations for a specific program. The TD stated there were Screen Forms kept on each unit. If any nurse felt a resident had experienced a decline or change in function, the nurse should submit a completed Screen Form which would alert the therapy department to conduct a screening of the resident. If the therapy screen determined, a resident would benefit from therapy services, a request would be made for physician's orders to treat. The TD stated staff had not completed, a Screen Form and the therapy department was not aware of a decline in Resident #84's ability to ambulate. Interview conducted on 8/31/21 at 1:30 p.m. with Certified Nursing Assistant (CNA) #12 revealed Resident #84 was able to weight bear during transfers. CNA #12 stated the resident was provided stand by assistance only during transfers from bed to chair or chair to bed. The CNA stated Resident #84 could propel his/herself up and down the hallway in a wheelchair but could not stand up and walk down the hallway. An interview was conducted on 8/21/21 at 1:40 p.m. with CNA #13. The CNA did recall Resident #84 receiving PT services during the first month after the resident was admitted (April 2021). CNA #13 stated two (2) therapy staff would walk down the hallway with the resident, one (1) staff person beside the resident, and one (1) staff person pushing a wheelchair behind the resident. CNA #13 did not remember Resident #84 walking after PT services were discontinued. According to the CNA the resident propelled him/herself in a wheelchair in the hallway. Interview on 9/1/21 at 12:08 p.m. with the Director of Nursing (DON) revealed he/she had not been the facility DON in April 2021, when Resident #84 was admitted and received skilled PT services. However, the DON stated when PT services were discontinued with recommendations made for nursing services to continue to provide restorative services for mobility, the resident's Care Plan should have been updated. The DON stated the Care Plan should reflect the recommended therapy interventions and Resident #84 should not have stopped receiving mobility assistance when PT services ended. The DON stated he/she was aware the resident could weight bear and could pivot for transfers without assistance. An interview was conducted on 8/31/21 at 2:15 p.m. with the facility Administrator. The Administrator stated the facility had employed many new direct care staff employees to work on the units and the new employees might not have knowledge of residents and their past histories. The Administrator stated the new direct care staff employees should be looking at each resident's Care Plan to determine the care needs of residents they were assigned to care for. 3. Review of Resident #91's clinical record revealed an admission date of 5/11/21 and the diagnoses included: Fracture of the Left Femur, Diabetes, Muscle Weakness, Fibromyalgia, Abnormality of Gait, Major Depressive Disorder and Lack of Coordination. Review of Resident #91's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eight (8) with a score of eight (8) to 12 indicating modified cognition. The resident displayed no behaviors and required extensive assistance of one (1) person with bed mobility, dressing, toilet use, and personal hygiene. The resident required extensive assistance of two (2) people with transfers and required total assistance of one (1) person for bathing. The MDS revealed the resident did not walk or move about the room or corridor. The resident had decreased range of motion (ROM) in the lower extremities bilaterally (present on admission) and did not receive therapy or restorative services. Review of the Care Plan updated on 8/25/21 listed the intervention for Therapy per Physician's order with the start date of 5/11/21. Review of the Nurse's Note dated 5/12/21 at 5:27 p.m. revealed Resident #91 was admitted on [DATE] for rehab. Review of Therapy Note dated 6/25/21 at 11:15 a.m. revealed the Director of Rehab spoke with the Responsible Party (RP) to discuss therapy discharge date secondary to plateau. RP reported he/she would come to the facility to discuss long term care with Resident #91. Review of the Nurse's Note dated 7/22/21 at 2:32 a.m. revealed Physical Therapy (PT) and Occupational Therapy (OT) continued, see therapy notes for progress and tolerance. Review of OT and PT Discharge Summaries revealed therapy was discontinued on 6/29/21 with no further treatment requested. The clinical record lacked evidence the facility provided range of motion services after therapy was discontinued. Observation and interview with Resident #91 on 8/30/21 at 9:51 a.m. revealed he/she was not receiving therapy now because his/her insurance would not cover it, but Resident #91 stated he/she need to get back to it. The resident complained of right ankle pain and the right ankle was elevated while the resident laid in bed on his/her back. Observation on 8/31/21 at 11:48 a.m. revealed the resident sat in his/her wheelchair with a Hoyer lift pad under him/her. Observation on 8/31/21 at 1:36 p.m. revealed staff did not change the position of the resident. Interview with Certified Nurse Assistant (CNA) #9 on 9/1/21 at 11:56 a.m. revealed there was no formal restorative program, but he/she liked to work the resident's legs. CNA #9 stated he/she did not document the ROM anywhere. Interview with the Director of Rehab (DOR) on 9/1/21 at 12:03 p.m. revealed, when the resident stopped getting therapy, the therapy staff would talk with nursing about what they could do with the resident but not necessarily a plan. The DOR stated nursing had access to their therapy notes. The DOR stated the facility did not have a restorative program in the facility. Interview with the Director of Nursing (DON) on 9/1/21 at 1:54 p.m. revealed there was not a restorative program at the facility. The CNAs and the nurses know that if they see a decline in a resident, they should fill out a therapy form. When asked if the facility was doing anything to prevent a decline the DON stated, the nurses would do some ROM if they noticed some stiffness and then notify therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and review of facility policy, the facility failed to provide fall interventions as care planned for one (1) resident of the 37 sampled. (Resident #38.) Findings include: Review of the facility policy titled, Falls dated 2/24/16 revealed, on admission, the nurse would do a Fall Risk Assessment which would document the resident's risk factors and potential for a fall. Depending on the risk score, the nurse may collaborate with other disciplines to initiate steps to prevent a future fall. The nurse will collaborate with the physician and obtain orders. For a resident who had a fall, the staff would attempt to define the possible cause(s) within 24 hours of the fall. The staff will evaluate the resident to see if the fall could have been prevented. After a fall, therapy would evaluate the individual and make recommendations. The staff and the physician would monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If the resident continued to fall, the staff and physician would re-evaluate the situation and consider other possible reasons for the resident's falling and re-evaluate the continued relevance of current interventions. Falls would be added to the care plan with interventions and updated as need. Review of Resident #38's clinical record revealed an admission date of 6/23/21 and the diagnoses included: Encephalopathy, Acute Kidney Failure, Osteoarthritis, Dementia, Subluxation of the Left Hip, and Cerebral Infarction. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, (with a score of eight (8) to 12 indicating moderately impaired cognition). The resident displayed no signs/symptoms of delirium and no behaviors. The MDS revealed the resident required limited assistance with bed mobility and transfers, did not walk, and required extensive assistance of one (1) person with dressing, eating, toilet use, personally hygiene and bathing. The resident was not steady and only able to stabilize with staff assistance with moving from a seated to standing position, moving on and off the toilet and surface to surface transfers. The activity of walking and turning around did not occur. The resident had a decreased in range of motion (ROM) on one (1) side of the lower extremity, utilized a walker or wheelchair and did not receive therapy or restorative services. The resident had experienced a fall in the last month prior to admission, staff were unable to determine if the resident fell in the two (2) to six (6) months prior to admission and sustained a fracture in the last six (6) months prior to admission. The Care Area Summary (CAA) for falls dated 6/29/21 revealed the resident was at risk for falls related to his/her recent fall that led the resident to the hospital. The resident had fall precautions in place for his/her safety and the resident required assistance with activities of daily living (ADLs). Review of the Fall Care Plan dated 7/14/21 listed the interventions to include give resident verbal reminders to not to ambulate/transfer without assistance as needed, provide resident with safety device/appliance as indicated, provide an environment free of clutter, always keep call light in reach. As of 6/30/2, observe frequently and place in supervised area when out of bed as needed. As of 7/10/21, bed in low position. As of 7/11/21, place fall mats as ordered. As of 7/21/21, encourage the resident to sit by the nurses' station as tolerated. Review of the [NAME] Fall assessment dated [DATE], the resident scored a 33. A score between 16 to 35 would place the resident at a moderate risk for falls. Review of the [NAME] Fall assessment dated [DATE] scored the resident at a 37. A score of 36 and over placed the resident at a significant risk for falls. Review of the Nurse's Note and Facility Investigation dated 7/10/21 at 6:53 a.m. revealed the resident was observed at 6:30 a.m. lying on the floor on the right side of the bed in a fetal position. The resident's bed was in the lowest position at the time of the fall. Bed and chair alarms would be placed as an intervention. Review of the Nurse's Note and Facility Investigation dated 7/11/21 at 12:53 a.m. revealed the Certified Nurse Aide (CNA) found the resident on the floor in a fetal position. The resident could not state how he/she ended up on the floor. The resident was transferred to a bed with siderails per the family's request. The investigation lacked evidence if the bed or chair alarm sounded and if the resident was in the bed or chair prior to the fall. Review of the Risk Management Meeting notes dated 7/13/21 at 10:30 a.m. revealed a floor mat was placed on the right side of the lowered bed with the call light within reach. The resident was started on 30-minute checks to monitor the resident throughout the shifts to prevent further falls. Additional intervention for a clipboard with Log to be placed in the resident's room to monitor services provided throughout the day. Review of the Nurse's Note and Facility Investigation dated 7/21/21 at 1:57 p.m. revealed the CNA reported the resident was on the floor at 1:00 p.m. The resident was sitting up in a chair with non-skid socks and the bed was in the lowest position. The resident sustained a small laceration above the right eyebrow and staff applied steri-strips. The staff added the intervention to keep the resident up in a chair close to the Nurses' Station so staff could monitor the resident. The investigation lacked evidence if the bed or chair alarm sounded at the time of the fall and when the staff last checked the resident. Observation on 8/30/21 at 9:41 a.m. revealed Resident #38 lying in bed and the full side rails raised. There were fall mats on both sides of the bed and the bed was not in a low position. Observation on 8/31/21 at 12:47 p.m.,12:57 p.m. and 1:37 p.m. revealed the resident lying in bed and the full side rails in the raised position. There were fall mats on both sides of the bed and the bed was not in a low position. Observation on 8/31/21 at 11:47 a.m. revealed the resident was in his/her room yelling out, I want to lay down, I'm sick. The resident was sitting in the wheelchair by the closet door and not able to be observed from the door. Observation on 9/1/21 at 10:27 a.m. revealed the resident lying in bed with the full side rails in the raised position, fall mats were on both sides of the bed and the bed was not in a low position. Observation on 9/1/21 at 11:10 a.m. revealed the resident sat in a wheelchair on the opposite side of the bed from the room door. No one was with the resident. Observation on 9/2/21 at 9:52 a.m. revealed the resident lying in bed, the bed was lowered to the floor and no side rails in position. The resident had a floor mat on the right side of the bed and on the left side of the bed. The floor mat on the left side of the bed was positioned at the head of bed and angled out to 48 inches away from the bed at the bottom of the floor mat. Interview with CNA #9 on 9/1/21 at 12:00 p.m. revealed when the resident first entered the facility, he/she would try to get out of bed, so we added the full side rails. CNA #9 also stated this morning Resident #38 placed his/her legs over the side rails trying to get out of bed. Interview with the Director of Nursing (DON) on 9/1/21 at 2:10 p.m. revealed he/she would have to check to see if the facility had a Fall Program. At the time of a fall the nurse was expected to put a fall intervention in place. The facility discussed all falls in the clinical meeting held Monday through Friday and during the Risk Meeting every Tuesday. During these meetings the fall was reviewed for the causative factors and the intervention(s) the nurse put in place to see if they were appropriate. Interview with Unit Manager II on 9/2/21 at 9:10 a.m. revealed the facility did not do the 30-minute checks or the Clipboard with a Log but implemented a better solution, to put the resident in a wheelchair and bring him/her to the Nurses' Station. Unit Manager II stated the facility did not do a Fall Investigation unless the resident had an injury such as a fracture. He/she also stated he/she expected the staff to document what was in place at the time of the fall and where the resident was located at prior to the fall, i.e., bed or chair. Interview with Resident #38's Physician's Nurse #17 on 9/2/21 at 12:33 p.m. revealed he/she made rounds with the Physician at this facility. He/she further stated the facility usually just called to report the resident had fallen and if they needed additional orders i.e., send to hospital. The nurse stated him/herself and the doctor were not involved in deciding on interventions for the prevention of falls. Attempted interview with the responsible party on 9/2/21 was unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure psychosocial services were provided to one (1) of 37 sampled residents, Resident #21. Resident #21 had resided in the facility for 18 months with spouse as roommate since admission. The resident's spouse had expired, and the facility failed to ensure the resident's psychosocial needs were met related to the grieving process. The findings include: Review of Resident #21's clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included Legal Blindness, Glaucoma, Depression, Anxiety, Osteoarthritis, Hypertension, Gastroesophageal reflux disease with Gastrostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] determined the resident's hearing and speech was adequate, vision was severely impaired, the Brief Interview for Mental Status (BIMS) score was 12, indicating moderate cognitive impairment. The resident's mood score was zero indicating no signs/symptoms of depression and no behaviors were exhibited during the assessment period. According to the assessment the resident required limited one (1) person assist for bed mobility, locomotion and dressing, supervision with personal hygiene, eating required one (1) person extensive assistance (tube feeding) and was totally dependent on staff for bathing and toileting. The resident received antianxiety and antidepressant medications for seven (7) days of the assessment period. Review of the resident's Care Plan for Psychosocial Well-Being implemented on [DATE] and was documented as resolved on [DATE]: Resident has a potential for a psychosocial well-being problem related to sharing a room with spouse. The goal of the care plan was for resident to not experience any adverse effect from sharing room with spouse through next review date. Interventions listed on the care plan included encourage resident to verbalize feelings, monitor for anxiety, discomfort, tension between resident and spouse, and to de-escalate any tensions between residents before it escalates. Review of the Interdisciplinary Notes revealed the following: - [DATE] 3:29 p.m. the resident's physician reviewed medications related to spouse being in hospital and is not expected to live much longer. The resident is aware of spouse's condition and have been yelling out and experiencing much more anxiety. The physician increased Lorazepam 0.5 milligram to three (3) times per day. - [DATE] 11:42 a.m. The resident was provided with psychosocial support related to spouse being in the hospital terminally ill. - [DATE] 2:30 p.m. Resident's family at bedside and resident was made aware of spouse's passing. Resident crying out off and on and was comforted by family and staff. - [DATE] 5:03 p.m. Resident noted to have periods of grieving this shift. - [DATE] 9:49 a.m. Resident speaks of decreased spouse from time to time. Observation on [DATE] at 11:15 a.m. revealed Resident #21 was lying in low bed supine position with head of bed up 45 degrees. The resident stated at this time that he/she wished people could spend more time in room because he/she gets lonely. An observation on [DATE] at 11:15 a.m. the resident was lying in low bed supine position. During an interview with the resident at this time the resident stated he/she was blind and cannot walk and needs help. The resident said he/she had to be fed with a tube because was not able to swallow safely. The resident further stated he/she had experienced blindness due to a left eye implant that had moved and could not see out of the left eye due to a stroke. The resident concluded his/her only concern with care at the facility was that of being lonely and wanted staff to come in to see him/her more often. A further observation on [DATE] 1:45 p.m. revealed the resident was administered bolus tube feeding of Jevity 1.5 eight (8) ounces and 175 milliliters of water per gravity per gastrostomy tube by Licensed Practical Nurse (LPN) #2 as per physician orders. The resident spoke with LPN #2 and surveyor during this time and stated he/she had been married to spouse for 27 years and spouse had recently died. Resident #21 stated he/she gets lonely because was used to having someone to talk to and wished more people would come visit in room. On [DATE] at 1:35 p.m. Certified Nursing Assistant (CNA) #15 stated during an interview that Resident #21's spouse had recently passed away and the resident was still grieving. He/she said the resident was legally blind and staff had to do everything for the resident. She stated staff encouraged the resident to get out of bed, but the resident was refusing. An interview with LPN #2 on [DATE] 3:00 p.m. revealed the resident and his/her spouse would argue at times, but there were never any arguments that could be considered abusive. The LPN stated since the resident's spouse had died, that he/she attempted to spend as much time as possible in the resident's room because the resident was grieving for the loss of spouse/roommate. During an interview with the Unit Manager (UM) on [DATE] at 10:30 a.m. he/she stated Resident #21, and spouse were roommates and would argue at times like many couples do. He/she stated the resident's spouse had recently died and the resident was still grieving. The UM said the resident had anxiety and does takes antianxiety meds, but no further services/treatments had been provided to the resident since his/her spouse had expired. He/she said the facility has been working on getting psychiatric services to provide to the residents. He/she said the facility had in the past attempted tele-health for psychiatric services, but it did not work out. The UM said the facility needs to ensure residents get psychiatric services, that someone from psychiatric services is needed to review psychiatric meds to ensure they are being monitored effectively. An interview with the Administrator on [DATE] at 9:50 a.m. revealed he/she had been at the facility for two (2) weeks. He/she said the facility did not have a policy to address the psychosocial needs of residents and did not have a contract to provide psychiatric services to the residents of the facility, if needed residents were to a local psychiatrist's office. The administrator stated it was his/her understanding that the facility had attempted tele-health for psychosocial services and that it did not work out. He/she said the facility was currently looking for Psychiatric services contract to provide for the psychosocial needs of residents. The administrator concluded that psychiatric services were needed to address Resident #21's needs as well as other residents needs, and to ensure psychiatric medications are monitored as prescribed by primary care physicians.

Based on observation, record review, interviews and review of facility policy, the facility failed to administer two (2) out of 34 medications observed, as ordered for one (1) resident. (Resident #244.) The error rate was 5.88 percent. Findings include: Review of the policy titled, Drug Administration, undated, revealed, the label on each medication bottle or unit dose package shall be read three (3) times, 1) when taking it from the drug bin, 2) read Medication Administration Record (MAR), and 3) before administering to the resident. To assure administration accuracy, the nurse shall cross check these reference points: 1. Physician's Orders and Medication Record, 2. Medication Record and label on Drug Container and 3. Label on Drug Container and Physician's Orders. Observation on 8/31/21 beginning at 9:30 a.m. and ending at 10:30 a.m. revealed Licensed Practical Nurse (LPN) #6 prepared the medication for Resident #244 while LPN #7 observed. LPN #6 prepared the resident's medication including, mixing one (1) capful of MiraLAX (laxative) in a four (4) ounce glass of water and administered Glimepiride (used to treat diabetes) two (2) milligrams. Review of Resident #244's Physician Orders revealed an order to administer the MiraLAX in eight (8) ounces of water with the start date of 8/11/21 and the Glimepiride was discontinued on 8/18/21. Interview with the Unit Manager (UM) II on 9/2/21 at 9:07 a.m. confirmed the staff should mix the MiraLAX in eight (8) ounces of water as ordered by the physician. He/she also confirmed the Glimepiride was discontinued on 8/18/21. Upon request by the surveyor, Resident #244's medication packaging on the medication cart was observed. The Glimepiride was still present in the packaging system that also contained other medications given at that time. The UM II stated when a medication was discontinued the facility sent the packaging back to the pharmacy and the pharmacy would send out a new multi pack of medications minus the medication that was discontinued. Interview with the Pharmacist on 9/2/21 at 10:40 a.m. revealed the facility received multi mediation packaging on a 14-day cycle. When a medication was discontinued during the 14-day cycle the facility had red flag stickers that they should place on each package containing the discontinued medication. When the new 14-day cycle started the discontinued medication would not be in the packaging. The Pharmacist further stated they never received the order to discontinue the Glimepiride.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of facility policy, the facility failed to label Insulin when opened, failed to discard a multi dose vial of Tuberculin 30 days after being opened, failed to label two (2) multi dose vials of Lidocaine when opened and failed to discard one (1) multi dose vial of Lidocaine when expired. Findings include: Review of the policy titled, Proper Storage and Expiration of Insulin, with no date, revealed, all vials of insulin should be dated on the first date opened using the stickers provided by the pharmacy. Observation on 8/31/21 at 9:24 a.m. of one (1) of the medication carts on [NAME] Unit revealed: Multi dose vial of Tuberculin opened on 7/28/21; multi dose vial of Admelog Insulin opened and multi dose vial of Semglee Insulin opened for Resident #245; 50 milliliter (ml) vial of Lidocaine opened for Resident #246; 50 ml vial of Lidocaine opened but expired on 5/21/21 for Resident #31; and multi dose vial of Admelog Insulin opened for Resident #96. These medications were not dated when opened. Observation on 8/31/21 at 9:45 a.m. of the other medication cart on [NAME] Unit revealed: Lispro Insulin opened and not dated, and Lantus opened and not dated for Resident #40; multi dose vial of Senglee Insulin opened and not dated for Resident #33; and Lispro Insulin injectable pen opened and not dated for Resident #33. Interview with Licensed Practical Nurse (LPN) #7 on 8/31/21 at 11:46 a.m. revealed the staff should date the Insulin vials and pens when opened and staff should also date the Tuberculin vial and Lidocaine vials when opened. LPN #7 stated he/she did not know how long the Tuberculin and Lidocaine vials were good for after opened but would check and let the surveyor know. Further interview with LPN #7 on 8/31/21 at 12:42 p.m. revealed revealed, the Pharmacist told him/her it was okay to put the date the insulin was dispensed from the pharmacy as the opened date for the insulins reviewed. LPN #7 also stated the Director of Nursing (DON) told him/her the Tuberculin was good for 30 days. Interview with the Pharmacist on 9/1/21 at 2:33 p.m. revealed a Pharmacy Technician (P Tech) came to the facility one (1) time a month and checked the medication carts for expired medications and unlabeled medications. The P Tech would then give a written report of his/her findings to the Pharmacist. The Pharmacist stated he/she included that report with his/her monthly report. The Pharmacist stated he/she had received reports that the facility was not dating the insulin vials when opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of facility policy, the facility failed to provide isolation procedures for one (1) of the 37 residents sampled. (Resident #35) Findings include: Review of the Quick Guide for COVID-19, Putting on (donning) personal protective equipment (PPE) for aerosol generating procedures (AGPs), revealed staff should wear a gown, mask, eye protection and gloves Review of Resident#35's clinical record revealed an admission date of 6/21/21 and a readmission date of 8/23/21. The diagnoses included: Parkinson's Disease, End Stage Renal Disease, Anxiety Disorder, Dementia; Chronic Respiratory Failure with Hypoxia, Lupus Erythematosus and Congestive Heart Failure. Review of Resident #35's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 with a score of eight (8) to 12 indicating modified cognition. The resident required limited assistance with bed mobility, transfers, eating, dressing, and personal hygiene and required extensive assistance of one (1) staff with walking, locomotion, and bathing. Review of the revised 7/28/21 Care Plan lacked interventions for isolation. Observation on 8/30/21 at 11:39 a.m. revealed a sign on Resident #35's door that identified the staff should wear full Personal Protective Equipment (PPE) (gown, mask, gloves) when they went into the room and a three (3) drawer isolation cart was by the resident's door. Further observation at that time revealed a staff member went into Resident #35's room to get the resident for a window visit with only a mask on. Staff at that time was observed leaving the resident's room carrying a bag of dirty laundry and not wearing gloves. Observation on 8/30/21 at 12:12 p.m. revealed a housekeeper brought the trash can out of Resident #35's room and placed a new trash bag and then returned the trash can to the resident's room. The housekeeper then dusted and cleaned the resident's room and swept the floor. The housekeeper then left the room and placed the used dust mop on his/her cart and proceeded to the next room without changing the mop head. Further observation revealed the housekeeper did not wear gloves, or a gown and only wore a mask while cleaning the room. Observation on 8/30/21 at 12:48 p.m. revealed staff brought the lunch tray to the resident's room and placed it on the overbed table without wearing gloves or a gown. Observation on 8/30/21 at 12:51 p.m. revealed staff brought the resident a glass of iced tea and placed it on the overbed table without wearing gloves or a gown and then went to the next room without cleansing his/her hands. Observation on 8/30/21 at 2:00 p.m. of the three (3) drawer isolation cart revealed no gloves or face shields on the cart. The gloves were noted on the wall by the resident's bed and the trash can was by the wall across from the bed and not near the door of the room. Additionally, there was no hand sanitizer on the cart or outside of the room. Observation on 8/31/21 at 11:52 a.m. revealed no gloves on the three (3) drawer isolation cart. Observation on 9/1/21 at 10:33 a.m. revealed Certified Nurse Assistants (CNAs) #10 and #11 wheeled Resident #35 from his/her room and one (1) of the CNAs carried a trash bag out of the room. CNAs #10 and #11 only had on a mask. Observation on 9/1/21 at 10:59 a.m. revealed CNA #11 wheeled the resident back to his/her room and transferred the resident back to his/her bed with no gloves or gown on. Interview with CNA #8 on 8/30/21 at 1:30 p.m. revealed Resident #35 was not on isolation. Interview with LPN #6 on 8/30/21 at 1:36 p.m. stated Resident #35 had gone to the hospital and when he/she came back, they were placed on isolation for 14 days. LPN #6 further stated the resident would be off isolation on 8/31/21 (eight (8) days after readmission). Interview with CNA #10 on 9/1/21 at 10:35 a.m. stated the resident was on isolation but could not state what type of isolation when asked. When asked what type of PPE he/she should wear when providing care for Resident #35, CNA #10 stated gown, gloves, and mask. Interview with CNA #11 on 9/1/21 at 11:01 a.m. revealed Resident #35 was on isolation and staff should wear a gown, mask and gloves when bathing the resident or providing peri-care and wear gloves and a mask for all other cares. Interview with LPN #4 on 9/1/21 at 11:25 p.m. revealed Resident #35 should be on droplet isolation and staff should wear a mask, gown and gloves when providing direct care, bathing, perineal care, etc. Interview with the Housekeeping Manager on 9/1/21 at 1:27 p.m. revealed the housekeeping staff should wear a mask, gown and gloves when they clean Resident #35's room. He/she also stated the housekeeping staff should change everything out before going to the next room after cleaning Resident #35's room. Interview with Director of Nursing (DON) on 9/1/21 at 1:42 p.m. revealed when a resident was admitted or readmitted the resident was put on droplet isolation for 14 days. The staff should wear a mask, gown and gloves when entering the room and should wear a face shield when providing wound or perineum care. The DON stated the isolation drawers were stocked by the Unit Manager and he/she checked them weekly. The isolation drawers should contain gowns, gloves, masks, face shields, biohazard bags and melt away laundry bags. Further interview with the DON on 9/2/21 at 1:11 p.m. revealed Resident #35 had not been vaccinated for COVID. Interview with the Facility RN Consultant (RNC) on 9/2/21 at 2:16 p.m. revealed if the resident was readmitted from the hospital and was unvaccinated the staff should wear gowns, gloves, masks, and face shields every time they go in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility policies and records, the facility failed to ensure food was stored and prepared and served in a safe manner that would prevent food borne illness by failing to clean and maintain storage and cooking equipment and failing to ensure the chemicals in the sanitizing sink met manufacturers guidelines. The findings included: On 8/30/21 at 10:45 a.m. during initial tour of the kitchen with the Assistant Kitchen Manager (AKM) observation of the walk-in freezer temperature log revealed blank areas where temperatures were not documented on 8/17/21-p.m.; 8/18/21-p.m.; 8/19/21 a.m. and p.m.; 8/20/21-a.m. and p.m.; 8/21/21-a.m. and p.m.; 8/22/21-a.m. and p.m.; 8/23/21-a.m. and p.m.; 8/24/21 p.m.; 8/25/21-p.m.; 8/28/21-p.m.; 8/29/21-p.m.; 8/30/21-p.m.; 8/31/21-a.m. Observation of the walk-in freezer door revealed the door would not close. There was a buildup of ice around the door frame and on boxes just inside the freezer door. The Assistant Kitchen Manager attempted to slam the door, causing ice particles to fall on the floor and food storage shelving. S/he stated the door had been that way for a couple of weeks and a new seal was needed. The initial tour continued accompanied by the Certified Dietary Manager (CDM). Observation of the three (3)-compartment sink revealed dirty dishes in the first compartment, the second compartment was empty, and the third compartment contained dirty water. The CDM tested the sink with a strip, and it tested at zero (0) parts per million (ppm) indicating there was no sanitizer in the sink. S/he stated the Oasis machine that dispenses the sanitizer was empty and the facility was waiting on a shipment. S/he stated in the interim, the kitchen staff was using Steramine tablets for a substitute. S/he stated the staff must have forgotten to add the tablets. Review of the instruction on the bottle of Steramine tablets stated to use one (1) to two (2) tablets per gallon to obtain the required level of sanitizer at 150-200 ppm. When asked how many gallons the sink was, s/he stated s/he didn't know. S/he stated there used to be a line on the inside wall of the sink, but it had gotten rubbed off. When asked how the staff would determine how many tablets to use, s/he showed a line on the outside of the sink and filled the sink to that line, added eight (8) tablets of Steramine, stirred the water (turning it blue) and tested with a strip with the results of 200 ppm. Review of the log for the three (3) compartment sink revealed staff documented every time it was tested during the month of August, it tested at 400 ppm. When asked why s/he only got 200 ppm and the kitchen staff documented 400 ppm three times a day for the month of August 2021, s/he stated because they probably didn't put as much water in the sink which would make the level of sanitizer more concentrated. S/he stated the automatic sanitizer had been empty since the week prior. Observation of the deep fryer revealed the covers were bent and did not fit well. The top of the fryer and the top edges and the back splash were covered in dried food build up and a white powdery substance which the CDM stated was probably flour. The gas cook top stove was dirty with white powdery substance and dried food buildup around the burners and the space between the burners. The overflow tray in the oven below the burners was covered with aluminum foil and had dried brown food particles. The CDM stated the equipment was original to the building and was over [AGE] years old. Observation of the double oven revealed a dried brown substance on the frame and the oven doors. Inside the lower oven, there were loose food particles and food buildup. The CDM confirmed the deep fryer, the stove top and the ovens needed to be cleaned. On 8/30/21 at 12:13 p.m. observation on the hallway for rooms 402-419, the food cart was observed to have a dirty frame with a dried brown substance on the handles. At 12:28 p.m., observation on the hallway for rooms 420-438, the food cart was observed to have a dirty frame with a dried brown substance on the handles, dried food drippings on the front of the doors, a dried brown substance on the back of the cart and the end of the cart had a build-up of dried brown substance at the seam. On 8/30/21 at 10:50 a.m. while completing the initial tour, the CDM stated during an interview that the fryer, the stove top and the oven were being cleaned in the afternoon. S/he stated per the cleaning schedule, the fryer is to be cleaned weekly when the staff changed the vat of grease. S/he stated that should have happened last week on Friday, which s/he said clearly did not happen. Observation on 9/1/21 at 10:30 a.m. revealed the ice buildup around the walk-in freezer door was still present. Review of an undated facility policy titled, Monitoring of Cooler/Freezer Temperature, revealed in the section titled, Policy Explanation and Compliance Guideline: 1. Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. a. Temperatures will be checked and logged at least twice per day by designated personnel. b. Logs will be changed out and filed each month. Review of an undated facility policy titled, Manual Ware Washing-3 Compartment Sink revealed, a section titled, Sanitizing procedures for the three-compartment sink are as follows: Third Sink Sanitizing-Fill with hot water (171 degrees F) or use chemical sanitizer: Iodine at 12.5 ppm; QAC ammonia at 150-200 ppm or chlorine at 50-100ppm. Confirm appropriate temperature or concentration prior to washing and record on sanitation control log. Review of an undated facility policy titled, Policy: Cleaning Schedule-1. Cleaning schedule will be posted weekly for morning and afternoon shifts. 2. Each employee will check the cleaning schedule to determine what tasks are to be completed during their shift. 3. Employees are to complete task(s) during their shift and initial the cleaning schedule once task is complete. 4. Supervisor(s) will check behind employees periodically to ensure tasks are completed. Review of the AM Shift Cleaning Schedule and the PM Shift Cleaning Schedule revealed an employee was assigned to clean the cooking equipment in the morning and the afternoon. The CDM stated the persons assigned to clean the oven, stove top and deep fryer had not completed their tasks as assigned. Review of the facility policy dated 11/14/16 and titled, Maintenance Work/Service Orders revealed the Procedures: 1. Maintenance is responsible for maintaining the building in compliance with current federal, state and local laws, regulations and guidelines. 2. A maintenance logbook is located on every nursing unit where staff will complete a maintenance work order to communicate to the maintenance department there is a maintenance need. 3. The maintenance department will check each unit for any work/service orders. 4. The maintenance supervisor will establish a priority of maintenance service when work/service orders are received. 5. Emergency request will be given priority in making necessary repairs. The policy does not address work/service orders received from the kitchen. On 8/31/21 at 9:20 a.m. the CDM stated during an interview the freezer had been having an ice buildup for a couple of weeks. S/he stated maintenance had been notified and were working to receive estimates for repair. S/he stated s/he did not know the status of the work order. On 8/31/21 at 11:50 a.m., the CDM acknowledged the kitchen cooking equipment (oven, stove top and fryer were old. S/he stated the staff had cleaned them the best they could but due to the age of the equipment, they were not able to remove all the buildup. The lower oven had buildup on the ledge inside the door. The upper oven had buildup on the bottom of the oven. The stove top had a buildup of dried brown substance. The overflow tray on the stove top had aluminum foil covering it with food drippings on the foil. The aluminum foil had not been removed after staff finished cooking lunch. The grill between the stove top and the fryer had a buildup of brown substance. The fryer lids remained bent and ill fitting. The fryer doors were covered with food buildup and a white powdery substance. The exhaust openings to the fryers were rusty on the inside. The CDM stated the equipment was over [AGE] years old and the dietary staff was not able to get it any cleaner than what it was observed at that time. The CDM confirmed after reviewing the walk-in freezer temperature log, that it was incomplete and missing multiple temperatures during the month of August 2021. The CDM confirmed the sanitizer for the automatic dispenser used in the three (3)-compartment sink had come in and was in use. This was observed at 1:00 p.m. on 8/31/21 in the kitchen. The CDM stated the sanitizer dispenser had been empty for a few days but was now in stock and being used. On 8/31/21 at 11:55 a.m., the assistant kitchen manager stated s/he got busy and did not record all the freezer temperatures for the month of August 2021. On 9/1/21 at 12:20 p.m. during an interview with the Maintenance Director (MD), s/he stated a work order to repair the seal on the walk-in freezer had been received from the kitchen. S/he stated the facility had received and estimate for repair, but the repair had not been completed. S/he was not able to locate the work order or provide a date in which the kitchen had requested the repair. S/he was also not able to locate the estimate received from the repair company. The MD stated the request was to be given to the Maintenance Supervisor (MS), who is the maintenance person in charge of the skilled facility. On 9/1/21 at 1:30 p.m. during an interview with the MS, s/he stated the procedure for work order is the department should complete a work order request and turn it in to him. S/he stated all work orders are turned in to the MD at the end of the day. Work orders that were not completed should be redistributed the next day and completed work orders were filed. S/he stated a work order for the freezer had been received by him/her, but s/he was not able to locate the work order. S/he was not able to provide a date but stated he received an email reminder two days ago on 8/30/21. S/he stated the repair had not been completed as it should have and the repair request, fell through the cracks. On 9/1/21 at 2:00 p.m., the owner of the facility reported s/he had checked on the walk-in freezer and confirmed an ice buildup around the door opening. S/he stated s/he had spoken with the maintenance department to contact the repair company for completion of the repair before the survey team would exit on 9/2/21. On 9/2/21 at 9:45 a.m. the CDM confirmed the repairs to the freezer had not been completed. On 9/2/21 at 10:00 a.m., the Administrator stated the repairs to the freezer would not be completed on 9/2/21 prior to the end of survey. S/he stated the MD had ordered parts which were due to be delivered to the facility on 9/3/21. S/he stated the MD would complete the repairs when the parts were received.