**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, Resident Assessment Instrument (RAI) Manual 3.0 review, medical record review, and interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 1 resident (Resident #1) of 3 residents reviewed for MDS assessments. The findings include: Review of the facility's policy titled, Certification of Accuracy of the MDS, reviewed 9/05/2024, revealed .the assessment must accurately reflect the resident status . Review of the RAI Manual 3.0 dated 10/2024, revealed .Section M .Skin Conditions . Document the risk, presence, appearance, and change of pressure ulcers as well as other skin ulcers, wounds or lesions . Medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnosis including Dementia, Delusional Disorders, Malignant Neoplasm of Skin, Diabetes Mellitus with Chronic Kidney Disease, Stage 5 Chronic Kidney Disease, Peripheral Vascular Disease, and Dependence on Renal Dialysis. Review of the Nursing Progress Notes for Resident #1 dated 12/10/2024, revealed .[name of resident son] notified of right heel pressure wound, tx [treatment plan] and interventions in place . Review of the Nursing Progress Notes for Resident #1 dated 1/4/2025, revealed .Nurse Aide notified this nurse that resident has an open wound to his left heel which she found when bathing him this morning . Review of an Annual MDS assessment for Resident #1 dated 1/28/2025, revealed the right and left heel wounds were not documented in Section M for skin conditions of the MDS. During an interview on 2/13/2025 at 11:48 AM, the Director of Nursing (DON) confirmed the Annual MDS assessment for Resident #1 dated 1/28/2025 was not an accurate assessment and did not note the wounds on Resident #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 2 residents (#56 and #84) of 38 residents reviewed for dignity. The findings include: Review of the facility's policy titled, Safeguarding Posted PHI, revised on 4/15/2022, showed .Protected health information (PHI) is not posted or displayed in a public location .A resident or his/her personal representative may make a request to have PHI posted in the room. It is acceptable to accommodate this request; the request should be documented in the medical record .PHI intended for viewing by staff involved in resident care is not displayed by any means that might be viewed by visitors or staff who would normally not have access to the protected information . Review of the facility's policy titled, Resident Rights, reviewed on 10/6/2022, showed .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life .The resident has a right to personal privacy and confidentiality of his or her personal and medical records .The resident has a right to secure and confidential personal and medical records . Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Persistent Vegetative State, Contracture to Right and Left Wrist, Other Lack of Coordination, Chronic Pain, Osteoarthritis, Anxiety Disorder, Anoxic Brain Damage, Gastrostomy, Seizures, and Muscle Weakness. Review of Resident #56's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #56 had severely impaired cognitive skills for daily decision making. Review of Resident #56's Comprehensive Care Plan showed no documentation that Resident #56 or Resident #56's family had requested for the sign to be posted in the resident's room. During observations on 3/27/2023 at 12:42 PM, 3/27/2023 at 3:26 PM, and 3/28/2023 at 8:54 AM, a sign was posted on the wall across from Resident #56's bed which read, .[Resident #56's room number and bed location] .Has a cushion that needs to be put into chair when up in Chair on (Monday), (Wednesday), (Friday) + [and] (Saturday) .Thanks . The sign was visible to anyone who entered the room. During an interview on 3/28/2023 at 2:48 PM, the Director of Nursing (DON) stated it was the expectation of the facility that resident care needs were communicated to staff on the Care Plan or [NAME]. The DON stated signage which contained resident care information was not to be posted in resident rooms unless requested by the resident or family and approved by the Interdisciplinary Team. Signage approved to be posted was to be documented on the Care Plan. The DON stated signage posted in resident rooms that contained information about the resident's care was a dignity concern. During an observation and interview on 3/28/2023 at 2:53 PM with the DON, in Resident #56's room showed a sign posted on the wall across from Resident #56's bed that read, .[Resident #56's room number and bed location] .Has a cushion that needs to be put into chair when up in Chair on (Mon, Wed, Fri + Sat .Thanks) . The DON confirmed the signage was visible to anyone who entered the room. Resident #56's roommate had a visitor in the room at the time of the observation. During a telephone interview on 3/28/2023 at 3:47 PM, Resident #56's responsible party stated she had not requested any signage to be posted in Resident #56's room. Resident #56's responsible party stated someone from the facility .called today . and asked for permission to post the sign. Resident #84 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Nontraumatic Subarachnoid Hemorrhage From Basilar Artery, Osteoarthritis, Dementia, Contracture of Muscle of Left Thigh Muscle, Left Ankle and Foot, Left Lower Leg, Left Hand, Left Forearm, and Left Upper Arm. Review of Resident #84's significant change MDS assessment dated [DATE], showed Resident #84 scored a 5 on the Brief Interview for Mental Status (BIMS), indicating the resident was severely cognitively impaired. Review of Resident #84s Comprehensive Care Plan showed no documentation that Resident #84 or Resident #84's family had requested for the sign to be posted in the resident's room. During observations on 3/27/2023 at 12:30 PM and 3/28/2023 at 8:58 AM, a sign was posted on the mirror across from Resident #84's bed which read, .Splint to be worn 6-8 (hours) a day .Carrot splint when splint removed + at Night .Thanks .Rehab . The sign was visible to anyone who entered the resident's room. During an interview on 3/27/2023 at 12:30 PM, Resident #84 stated she did not request for the sign to be posted. During an observation and interview on 3/28/2023 at 2:55 PM, in Resident #84's room, there was a sign posted on the mirror across from Resident #84's bed that read, .Splint to be worn 6-8 hrs a day .Carrot splint when splint removed + at Night .Thanks .Rehab . The DON confirmed the sign was visible to anyone who entered the resident's room. During a telephone interview on 3/28/2023 at 3:52 PM, Resident #84's emergency contact stated she did not request any signage be posted in the Resident #84's room. Resident #84's emergency contact stated .they called me today . and asked if it was ok for the sign to be posted. During an interview on 3/28/2023 at 4:09 PM, the DON confirmed after surveyor inquiry the facility had contacted Resident #56 and #84's families today (3/28/2023) for permission for the signs to be posted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation and interview, the facility failed to obtain the most recent Hospice plan of care for 1 resident (Resident #319) of 3 residents reviewed for Hospice services. The findings include: Review of the facility's policy titled, Hospice Coordination of Care, reviewed 8/18/2022, showed, .Each LTC [long term care] facility .designate a member of .interdisciplinary team .to coordinate care to the resident .Obtaining the following .from the hospice .most recent hospice plan of care .Each LTC facility providing hospice care .must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #319 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Alzheimer's Disease and Congestive Heart Failure. Review of physician's orders showed Resident #319 was admitted to Hospice care on 3/18/2023. Review of a care plan dated 3/22/2023 showed the resident had dehydration or potential fluid deficit related to a decline in health and resident was placed on hospice. Record review on 3/27/2023 at 4:27 PM, showed a hospice tab was available for Hospice staff to record interactions with the resident on Resident 319's chart. The record did not have documentation of hospice or a Hospice care plan in Resident #319's chart. During an interview on 3/28/2023 at 3:42 PM, the Assistant Director of Nursing (ADON) confirmed there was no hospice documentatoin or hospice care plan in Resident #319's medical record. The ADON stated hospice communication was to be documented between the Hospice provider and the facility, and she a copy of the hospice care plan for facility staff to reference in the resident's medical record to provide care needs.

Based on facility policy review, observations, and interview the facility failed to maintain a sanitary kitchen which had a potential to effect 114 of 116 residents of the facility. The findings include: Review of the facility policy titled, Sanitation and Maintenance, revised 11/4/2022, showed .Director of Food and Nutrition Services is responsible for ensuring that the department is maintained according to the standards of sanitation and in compliance with federal, state and local requirements . All dishes, pots and pans must be air dried after sanitizing and should not be stored wet to prevent wet nesting. During an observation of the kitchen on 3/28/2023 at 11:09 AM, showed the following cooking pans were stacked and stored wet: -6 full size pans, -4 1/3 size pans -8 1/6 size pans. During an interview on 3/28/2023 at 11:09 AM, the Certified Dietary Manager (CDM) confirmed the washed pans had been stacked and stored wet in a unsanitary manner in the facility kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to obtain laboratory tests as ordered by the physician for 1 resident (Resident #37) of 5 residents reviewed for laboratory tests. The findings include: Review of the facility's policy titled, Diagnostic Services, last reviewed 4/15/2019, showed .Ensure that the residents receive laboratory .services as ordered by the attending physician . Resident #37 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction, Muscle Weakness, Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Hypothyroidism, Polyneuropathy, and Fibromyalgia. Review of a physician's Order Summary Report dated 6/10/2019 showed .for Hgb A1C [Glycated Hemoglobin, a laboratory test used to measure blood sugar] .every 6 month(s) .starting on the 17th [6/17/2020] Lipid panel [a laboratory test used to measure cholesterol level] .every 6 month(s) .starting on the 17th .TSH [a laboratory test to measure the thyroid stimulating hormone] Free T3 [a laboratory test to measure thyroid hormones] .every 6 month(s) .starting on 6/17/2019 . Review of Resident #37's medical record showed no documentation the Hgb A1C, the Lipid panel, the TSH level, or the Free T3 was completed on 6/17/2019. Further review revealed no documentation the Lipid panel or the Free T3 was completed on 12/17/2019. During an interview and review of the medical record on 2/19/2020 at 1:10 PM, Licensed Practical Nurse #3 confirmed the laboratory tests were not done. During an interview on 2/19/2020 at 1:15 PM, the Assistant Director of Nursing confirmed the laboratory tests were not done.

Based on facility policy review, observation and interview, the facility failed to provide a safe environment for residents on 1 hall (North hall) of 3 halls observed in the facility. The findings include: Review of the facility's policy, Maintenance, not dated, stated .The facility must provide a safe, functional, sanitary, and comfortable environment for the residents .The facility must: Equip corridors with firmly secured handrails . Observations made during the survey on 2/18/2020 through 2/20/2020 showed a partially detached handrail with 4 screws visibly exposed on the North hall. During an interview on 2/20/2020 at 11:17 AM, the Maintenance Director stated he first became aware of the partially detached handrail on the morning of 2/18/2020 and was aware the handrail was a safety hazard. During an interview on 2/20/2020 at 11:31 AM, Certified Nursing Assistant #1 stated there was 1 ambulatory resident and 11 residents who self-propelled in a wheelchair on the North hall who used the handrails.

Based on facility policy review, observation, and interview, the facility failed to dispose of expired medications and supplies in 2 medication storage rooms (South Wing and [NAME] Wing) of 3 medication storage rooms observed. The findings include: Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biological, Syringes and Needles, revised 4/5/2019, showed .Facility should destroy or return all .outdated/expired .medications .Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis . During an observation of the South wing medication storage room and interview with Licensed Practical Nurse (LPN) #1 on 2/20/2020 at 9:42 AM, showed 7 wound culture swabs with an expiration date of 12/27/2019, 98 urine chemistry test strips (used to test the urine for possible infection) with an expiration date of 12/31/2019, and 5 unopened 5 milliliter vials of influenza vaccine with an expiration date of 5/31/2019. LPN #1 confirmed the above items were expired and were available for resident use. Observation of the [NAME] wing medication storage room and interview with LPN #2 on 2/20/2020 at 10:14 AM showed 4 colostomy flanges (device used to hold a colostomy bag) with an expiration date of 12/2018, 100 blunt plastic cannulas (needle free device used with intravenous injections) with an expiration date of 12/2019, and 42 tuberculin syringes with an expiration date of 4/2019. LPN #2 confirmed all above items were expired and were available for resident use. During an interview on 2/20/2020 at 10:27 AM the Director of Nursing stated it is his expectation for the medication storage rooms to be checked routinely and for all expired items to be discarded immediately.