Based on observation, interview and record review the facility failed to ensure the resident had a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident # 31) reviewed for medical record confidentiality.The facility failed to ensure RN D kept Resident # 31's medical information confidential.This failure could place residents at risk of their medical information being provided to unauthorized personnel, other residents, or visitors.Findings include: Observation on 08/20/2025 from 9:08 AM until 9:12 AM revealed RN D was not at the medication cart. The computer screen was left open and facing the hallway which exposed Resident confidential medical information which included name and medications. Interview on 08/20/2025 at 9:14 AM, RN D stated resident name and monitoring were on the open screen; however, he could not remember if his diagnosis was on the screen. He stated he received in-service to always lock the computer screen when not standing at the medication cart. He stated he did not recall the date he received the in-service on HIPPA. He stated he did not follow HIPPA protocol. RN D stated a visitor, another resident or anyone not an employee at the facility had access to a resident's medical information if they passed by the medication cart. He stated if another resident saw any information and shared with Resident #31, this may be embarrassing to the resident for other residents to see the resident's medical information. Interview on 08/21/2025 at 1:30 PM, the Administrator stated her expectation was for confidentiality of the residents to be protected. She stated computer screens should have been closed when not in use and any paperwork with the resident information should have been covered. She stated that was protected confidential information and it could have been a HIPAA violation.In an interview on 08/21/2025 at 2:50 PM, the DON stated resident information should be kept confidential and if it were not, it would be a HIPAA violation. She stated all computer screens were expected to be locked if a nurse was not viewing a resident's information. She said because if the screen is left open with the resident's information anyone could get that residents information. Record review of the facility's, undated, Policy on Protected Health Information, Safeguarding Electronic, reflected Electronic protected health information is safeguarded by administrative, technical, and physical means to prevent unauthorized access to protected health information. All workstations are protected from unauthorized access by physical barriers that discourage attempts to tamper with or violate security rules, including:a. Placing computer terminals and workstations away from high- traffic areas of the facility.Automatically locking computer screens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a new resident was not admitted with mental illness unless the state mental health authority determined, based on independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission for 1 of 12 residents (Resident #17) reviewed for PASRR services. The facility failed to ensure a PASRR screening was completed for Resident #17. This deficient practice could place residents at risk for not obtaining the services needed to treat their mental health diagnoses.The findings include: Record review of Resident #17's admission sheet, dated 08/19/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included cystitis without hematuria (inflammation of the bladder), somatization disorder (tendency to experience and express psychological distress as physical symptoms), fusion of the spine (surgical procedure that connect two or more parts in the spine), muscle weakness, congenital malformation of nervous system (birth defect that affects the structure and development of the brain and spinal cord), lack of coordination, anxiety disorder (feeling of uneasiness or worry) and hypertension (high blood pressure). Record review of Resident #17's admission MDS assessment, dated 06/23/2025, revealed Resident #17 had a BIMS score of 13, which indicated intact cognitive response. Resident #17's mood indicators were present which included little interest or pleasure in doing things, feeling down, depressed, or hopeless. The MDS also documented somatization disorder (tendency to experience and express psychological distress as physical symptoms), and anxiety disorder (feeling of uneasiness or worry) as active diagnoses. Record review of Resident #17's care plan, dated on 07/01/2025, noted the resident used an anti-anxiety medication r/t anxiety. The goal was Resident #17 would be free from discomfort or adverse reactions related to anti-anxiety therapy. The interventions were Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucination. Record review revealed Resident #17 did not have a PASRR completed. During an interview with Resident #17 on 08/21/2025 at 11:02 a.m., Resident #17 said she was diagnosed with her mental disorders when she was [AGE] years old. She said she was taking anxiety medication. She said the only other service she was getting for her mental illness was seeing the psychiatrist. She said she did not know if there were other services she might want. During an interview with Marketing on 08/21/2025 at 11:30 p.m. revealed she had not been completely trained on PASRR. She said she was responsible for making sure the resident had a PASRR when they entered the facility. She said the only training she got on PASRR was the PASRR needed to be filled out. She said she could not answer the question of the process, or referrals. She also said she did not know when the PASRR should be done. She said all she knew was the resident needed a PASRR when the resident admitted to the facility for skilled. She said she did not know she needed a PASRR for long term care. She said she was confused on that part. She said she did not know what to do if a resident had a positive PASRR. She said her job was to go out and educate the community about the facility's services. She said when a referral came in, she would send an email the nursing team with the resident's clinical records. She said she did not know what could happen to the residents if they did not have a PASRR. She said she did not know why Resident #17 did not have the PASRR on admission. During an interview with the SW on 08/21/2025 at 2:38 p.m. revealed she had not been trained on PASRR. She also said she did not have anything to do with the PASRR's. During an interview with the MDSN on 08/21/2025 at 2:20 p.m. revealed she was trained on PASRR. She said she did not know what the policy was for PASRR. She said she knew she must have a PASRR before a resident was admitted . She also said if the resident was coming from the community a PASRR needed to be done prior to admission. She said marketing was responsible for ensuring each resident had a PASRR prior to admission. She also said she would ask for the PASRR level one to see if the resident had a qualifying diagnosis. She said if the resident had a qualifying diagnosis, she would submit to the portal so the mental health case worker could come do an assessment on the resident. She said the purpose of the PASRR was to make sure the resident got the services they required and were in the least restrictive environment. She said the facility would have an IDT meeting if the resident had a positive PASRR. She said in the IDT meeting it would discuss the services for the resident and did the referral for the services the resident wanted. She said if the PASRR was not done the facility could not bill Medicaid. She said she monitored the PASRRs on admission and looked at all referrals when she did an admission, and the resident had a qualifying diagnosis, she would do another PASRR. Said she did not know who ensured competency. She said she did not know why Resident #17 did not have a PASRR at admission. During an interview with the ADM on 08/21/2025 at 11:40 a.m., revealed she was trained on PASRR. She said the SW was responsible for doing PASRRs. She also said the SW was responsible for ensuring all residents had a PASRR. She said she did not have a policy for PASRR. She said the facility would get the PASRR for the resident from the hospital and if the resident were coming from the community, the facility would have the family fill the PASRR out. She said all residents were to have a PASRR completed prior to admission into the facility. She said the facility would identify residents with possible MI or ID through the PASRR screening. She said the resident with a qualifying diagnosis should be referred to the PASRR person and a meeting set up with PASRR people. She said the facility did not have anyone who ensured staff competency in PASRR. She said if a resident did not have a PASRR, the facility would not recognize if the resident were positive or not, and the resident could be missing services. She said Resident #17 did not have a PASRR because Marketing did not get the PASRR on admission. During an interview with the ADM on 08/21/2025 at 9:21am the ADM said the facility did not have a PASRR policy. Record review of, undated, Form 1012 Policy and Procedure with Instructions revealed the following: Purpose: Form 1012 assists nursing facilities (NF) in determining whether a resident with a negative Preadmission Screening and Resident Review (PASRR) Level I Screening form submitted into the Long-Term Care (LTC) Portal, needs further evaluation for Mental Illness (Ml). This form is used to determine whether the individual has a primary dementia diagnosis or if the individual has a mental illness diagnosis. This form also serves as the NF's documentation for the individual's medical record as to why further evaluation was or was not completed. Only a physician, which includes a psychiatrist, can complete Section D this form. A Nurse Practitioner or Physician's Assistant cannot complete Section D. Procedure When to Prepare The NF completes Form 1012 following: A determination that a resident with a negative PASRR level 1 screening form submitted into the LTC Portal needs further evaluation for Ml. An individual's diagnosis is changed. The PL 1 on file remains negative. The resident does not need a new PL 1 or further evaluation at this time. A new PL 1 is needed at this time. A full PASRR Evaluation will be conducted after the NF submits a new positive PL 1. After form submission on the LTC Online Portal, include the date of submission and the positive PL 1 document locator number (DLN) on this form. The NF staff completing Form 1012 will complete this section with their name, title, signature, and the date the form was signed. Maintain the completed 1012 form in the individual's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for one of three residents (Resident # 29) reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission for Resident #29. This failure could place residents at risk for not receiving care and services to meet their needs. Findings include: Record review of Resident #29's face sheet, dated 08/21/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses which included tracheostomy status ( a resident's condition of having a surgically created opening in their windpipe with a tube inserted to help them breathe), nontraumatic intracerebral hemorrhage, unspecified (bleeding within the brain tissue that is not caused by a physical injury or trauma), and unspecified convulsions (involuntary spasms and contractions). Record review of Resident#29's admission MDS Assessment, dated 08/13/2025, reflected it was in progress. Record review of Resident #29's Baseline Care Plan, dated 08/07/2025, reflected the following sections were not completed: therapy services- physical therapy, occupational therapy, speech therapy, restorative therapy (the comment section under therapy was blank), and social services: social service provided, mental health needs, behavioral concerns, PASARR Level II ( a comprehensive assessment conducted after a positive Level I screening in the Preadmission Screening and Resident Review process) recommendations, social service goals, and depression screening. The section where the resident's preference for being notified of updates to Plan of Care was blank. The signature of the resident and Representative were not obtained for the baseline care plan. Signed by: Treatment Nurse. Interview on 08/21/2025 at 1:30 PM, the Administrator stated she expected the baseline care plan to be completed including the section on therapy and social services. She stated it was important for the staff to know any interventions needed if a resident had behaviors. She stated if a resident had triggers such as using certain words the staff would need to know this to prevent the resident from having anxiety or depression. She stated she expected the baseline care plan to be signed by the resident or family. The administrator stated therapy information needed to be documented on the baseline care plan and if the resident did not need therapy the staff was expected to document this information in the comment section. The Administrator stated the nurse supervisor who received the resident upon admission was responsible to begin the baseline care plan and it was to be completed within 48 hours upon admission date. She stated the DON, or the Treatment Nurse was responsible to review the baseline care plan after completion to ensure accuracy and completion within 48 hours. Interview on 08/21/2025 at 1:59 PM, the MDSN stated the charge nurse was responsible for the new admission and was in charge of completing the baseline care plan. She stated all the baseline care plans were to be completed in its entirety within 48 hours of the resident's admission date. The MDSN stated the social service section needed to be completed especially if a resident had any type of emotional or psychosocial needs the staff needed to be aware of to give care to the resident. She stated if a resident needed to be assessed by therapy the nurse completing the baseline care plan was expected to document this information within 48 hours of the admission date. Interview on 08/21/2025 at 2:24 PM, the Treatment Nurse, RN stated she did assess Resident # 29 upon admission. She stated she completed Resident #29's baseline care plan. She stated the social service section was vital information to provide to the staff. The Treatment Nurse, RN stated if a resident had any type of behaviors and needed special interventions the staff would not know how to care for the resident if the resident exhibited behaviors. She also stated a resident may have PTSD (post-traumatic stress disorder) and the staff would need to know the residents' triggers to prevent any type of anxiety or depression. The Treatment Nurse stated the resident, or family was expected to sign the baseline care plan, and she did not review the baseline care plan with Resident #29's family or with Resident #29. She stated therapy information was expected to be documented on the baseline care plan to ensure the staff knew the resident would need to be assessed by therapy. She stated she did not recall the reason she did an incomplete baseline care plan on Resident #29. The Treatment Nurse stated it was her responsibility or the Director of Nurses responsibility to ensure all the baseline care plans were completed. She stated all baseline care plans were to be completed within 48 hours of the admission date. She stated if a charge nurse completed the baseline care plan, either she or the Director of Nurses would review the baseline care plan to ensure it was completed and accurate within 48 hours. Interview on 08/21/2025 at 2:50 PM, the Director of Nurses stated baseline care plans were to be completed within 48 hours of the resident's admission date. She stated it was the nurse in charge of the resident's responsibility to complete baseline care plan. The Director of Nurses stated it was reviewed by her or the treatment nurse once the baseline care plan was completed within 48 hours. She stated if a resident's social section and therapy section were not completed, there was a potential a resident may be depressed or have emotional issues. She stated the therapy section and social service section of the baseline care plan was pertinent information to ensure residents received the correct therapy and met their psychosocial needs. She stated if a resident had PTSD, their triggers would need to be added to the baseline care plan. Record review of facility's Baseline Care Plan Policy, dated 12/2016, reflected A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The Interdisciplinary Team will review the healthcare practitioner's orders (dietary needs, medications, routine treatments) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to:a. Initial goals based on admission orders.b. Physician orders.c. Dietary orders.d. Therapy services.e. Social Services; andf. PASARR recommendations, if applicable. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop and interdisciplinary person-centered care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure comprehensive care plans were developed within 7 days after completion of the comprehensive assessment for 2 of 7 residents (Resident #78 and Resident #37) reviewed for comprehensive assessments and timing. 1. The facility failed to ensure Resident #78's Comprehensive Care Plan was completed within seven days of the completion of the comprehensive assessment and no more than 21 days after admission. 2. The facility failed to ensure Resident #37's Comprehensive Care Plan was completed within seven days of the completion of the comprehensive assessment and no more than 21 days after admission. These failures could place residents at risk for not receiving necessary care and services or having important care needs identified and met.The findings include: 1. Record review of Resident #78's admission record, dated 08/21/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #78 had diagnoses which included Parkinson's disease (a progressive disorder that affects the nervous system), lack of coordination, muscle weakness, cognitive communication deficit (problems with communication), dementia (memory, thinking, difficulty), hypertensive heart disease (damage to heart due to chronic high blood pressure), depression, and anxiety (feeling of uneasiness or worry). Record review of Resident #78's care plan, undated and last revised 04/01/2025 reflected there was no information regarding self-care and requiring substantial/maximal assistance with putting on/taking off footwear. Record review of Resident #78's Nursing Home Part A PPS Discharge (NPE) MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate impairment. Further review of the MDS reflected the resident required substantial/maximal assistance with putting on/taking off footwear. Record review of Resident #78's care plan dashboard, dated 08/21/2025, reflected the care plan was generated for start date of 08/28/2025 with a target completion date of 09/10/2025. 2. Record review of Resident #37's admission record, dated 08/21/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #37 had diagnoses which included local infection of the skin, chronic kidney disease stage 4 (a serious condition where the kidneys are severely damaged), anemia (not enough healthy red blood cells), irritable bowel syndrome (a group of symptoms that occur together including repeated pain in your abdomen and changes in your bowel movements), and muscle weakness. Record review of Resident #37's admission assessment MDS, dated [DATE], reflected a BIMS score of 14, which indicated cognition was intact. Record review of Resident #37's initial baseline care plan, undated with date initiated 07/10/2025 and last revised 08/19/2025, reflected only one goal and need was implemented for Resident #37's care plan, actual falls. All other needs and goals for Resident #37 were implemented on the care plan on 08/19/2025, which included: full code status, limited physical mobility and requires staff assistance for ADLs, congestive heart failure, altered cardiovascular status, anemia due to chronic blood loss, on antibiotic therapy, potential unintentional weight loss/gain, risk for skin breakdown and pressure ulcer development due to decreased mobility, has occasional bowel and bladder incontinence, and has impaired visual function. During an interview on 08/21/2025 at 2:09 PM, the MDSN stated she did not know the last time she had training regarding care plans. She stated the IDT meeting was opened by the RN and completed the bulk of the care plans. She stated she reviewed the cause section B on the MDS and completed a chart sweep looking for special medication or diagnosis or high-risk medications, followed by a review of progress notes to get family dynamics and would care plan falls, pain, based on this information. She stated the charge nurses had 48 hours to complete the base line care plans, and she had 7 days after to complete the comprehensive care plans. She stated care plans were updated when there was any change to the resident's care, as needed or when the MDS was due. Depending on what needed to be updated on a care plan depended on which staff was responsible for completing. She said she did not know why Resident #78 and Resident #37 care plans were completed. During an interview on 08/21/2025 at 3:50 PM, the ADM stated she last received basic care plan training in January 2025. She stated training covered patient center care, the goal and discharge plan. She stated the IDT team, MDS, therapy, and nursing staff were all responsible for completing the care plans. She stated the baseline care plan was to be completed within 24 hours and comprehensive care plan was due 7 days after. She stated the care plan should be updated quarterly or if there was a significant event. During an interview on 08/21/2025 at 4:17 PM, the DON stated she was knowledgeable of completing care plans from PCC. She stated the RN opened the care plan, the MDS Coordinator followed up and the DON reviewed the care plan. She stated the care plan information included skin integrity, medication, if they refused medications, any chronic conditions, advance directives, and infections. She stated she was not sure of the timeframes to complete care plans, but the baseline care plan was to be completed within 48 hours. She stated the care plans should be updated quarterly and the MDS nurse was responsible for updating them. During an interview on 08/21/2025 at 6:15 PM, the MDSN stated she started employment on 07/7/2025 at the facility. She stated she was familiar with Resident #78's comprehensive assessments and care plans. She stated as she came on board recently into the MDS position, she worked through the resident care plans and discovered Resident #78's care plan was not developed and completed the initial one on 07/10/2025. She stated the quarterly care plan was now being worked on for him. She stated she was familiar with Resident #37's comprehensive assessments and care plans. She stated she revised Resident #37's care plan on 08/19/2025 to reflect all care areas as it was brought to her attention that it had yet to be completed. She stated she was not sure why the previous staff did not complete the entire care plans or within the required timelines, but she was now keeping track of these dates. She stated by not completing care plans could affect the resident as the direct care staff would not know what care was required for the resident. Record review of the facility's, undated, policy titled Care Plans, Comprehensive Person-Centered revealed 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. Policy Interpretation and Implementation: 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 12 residents (Resident #38) reviewed for Activities of Daily Living. The facility failed to ensure Resident #38 was provided her showers 3 times a week as scheduled. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.Findings include: Record review of Resident #38's admission record, dated 08/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #38 had diagnoses which included hypertensive heart disease without heart failure (changes in the heart due to long term high blood pressure), hyperlipidemia (abnormally high level of fats in the blood), depression (a mood disorder with persistent feeling of sadness and loss of interest), and generalized muscle weakness. Record review of Resident #38's Quarterly MDS, dated [DATE], reflected a BIMS score of 13, which indicated cognition was intact. Section GG - Functional Abilities reflected Resident #38 required Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for showers/bathing self. Record review of Resident #38's care plan, dated 09/16/2022 and last revised 12/02/2024, reflected the following I have an ADL self-care performance deficit r/t decline in cognition. Interventions reflected Personal Hygiene: I require assistance by 1 staff with personal hygiene and oral care. Record review of the, undated, shower schedule reflected the room/bed Resident #38 occupied on 08/21/2025 was scheduled for a shower on Tuesday/Thursday/Saturday. Record review of the task list in the electronic health record for the dates 07/22/2025-08/21/2025 reflected she was scheduled for ADL - Bathing (T-TH-Sat 6p to 6a). She was provided the following showers:07/24/2025,07/29/2025, 08/12/2025, 08/19/2025, and08/21/2025. Showers were scheduled but not documented as given on:07/22/2025,07/26/2025, 07/31/2025, 08/02/2025, 08/05/2025, 08/07/2025 (documented as refused), 08/09/2025, 08/14/2025, and08/16/2025 (documented as refused). Record review of Resident #38's nurses' notes, dated 07/22/2025-08/22/2025, reflected no documentation of refusal of care. Interview and observation on 08/19/2025 at 09:41 AM, Resident #38 stated she had not received a shower in weeks. Resident #38 appeared clean and well-groomed. Interview and observation on 08/21/2025 at 08:10 AM revealed Resident #38 propelled herself in her wheelchair, her hair was standing up in the back and appeared not brushed. Resident #38 stated she had not received her shower in 4 weeks. She stated she was unsure of her shower day, just that they [the staff] would come at night around 09:30 PM to give her a shower and she did not want to go to bed with her hair wet, so she refused. Interview on 08/21/2025 at 03:55 PM, CNA J stated he was working the hallway Resident #38 resided on. He stated he typically did not work the floor and was unable to access the electronic health record. CNA J stated Resident #38 was supposed to get showers in the morning despite her bed assignment. He stated the staff should know though shift report, but he did not know if it was documented anywhere. CNA J stated if a resident refused a shower, then the CNA should notify the nurse. He stated Resident #38 should get 3 showers a week. He stated if a resident did not get their showers, then the resident could become sad, embarrassed, and dirty. Interview on 08/21/2025 at 04:15 PM, CNA H stated she was responsible for the hallway Resident #38 resided on. She stated showers were given per the residents' room assignment. She stated if a resident wanted a different schedule for their showers, then the CNA was responsible for reporting it to the nurse and the nurse would fix the schedule in the computer. CNA H stated if a resident refused a shower, then the CNA was responsible for reporting it to the nurse and completing a shower sheet that indicated the resident refused the shower. She stated she gave Resident #38 a shower during the day shifts a couple of weeks ago, but Resident #38 was scheduled for evening showers. CNA H stated all residents should be getting a shower three times a week. She stated if a resident did not get their shower, then they may feel sad or dirty. Interview on 08/21/2025 at 04:49 PM, the TN stated she was appointed to monitor shower sheets on 08/18/2025. She stated the policy for giving showers was three times a week and the CNAs were to follow the schedule on the handout. She stated if a resident wanted a shower other than what was listed on the handout then it should be documented in their electronic health record. The TN stated, if a resident were to refuse a shower, she expected the CNA to notify the nurse and the nurse to attempt to get the resident to take a shower. She stated if the resident continued to refuse then she expected the nurses to document the refusal in the resident's electronic health record and to notify the responsible party. The TN stated shower sheets should continue to be completed with a refusal documented on it. The TN stated if a resident did not get the showers they were scheduled, then the resident could end up with a fungal infection, moisture associated skin damage, or redness to their skin. Interview on 08/21/2025 at 05:18 PM, RN D stated he was responsible for the hall Resident #38 resided on. He stated policy was for residents to get showers 2-3 times a week according to their schedule in their electronic health record. RN D stated if a resident refused a shower, then the CNA needed to tell the nurse, and the nurse must attempt. He stated the policy was to attempt three times for any refusal of care. He stated if a resident requested a shower at any time, then they were to provide the shower at that time. RN D stated he was aware Resident #38 had refused showers in the past, but he was unsure as to the reason for the refusal. He stated the lack of charting for showers was due to a communication barrier with the CNAs being able to read the electronic health record and they were unable to click the correct box. RN D stated if a resident did not get their scheduled showers, then they could incur skin issues. Interview on 08/21/2025 at 05:36 PM, the DON stated she took over as DON approximately one month prior. She stated the policy for giving showers was the residents were scheduled for getting showers every other day. The DON stated the residents had the right to refuse, but the policy was for at least two different staff members attempt to provide the resident a shower. She stated if the resident continued to refuse a shower after two staff approached them, then the nurse was to notify the responsible party and document the refusal and notification in the resident's electronic health record. The DON stated if a resident requested to have a shower in the morning rather than the evening time, then staff were to attempt to find someone to switch with that resident, but the resident's preference was always honored. The DON stated if a resident was not getting their showers as scheduled, then they could have skin breakdown, they could become dirty and/or smelly and that could affect their psychosocial status. The DON stated, after a record review, Resident #38 received 3 showers from 07/22/2025-08/18/2025. She stated Resident #38 refused a shower 3 times during that same period according to her record review. The DON stated there was no documentation in the nurses' notes related to refusal of care. Interview on 08/21/2025 at 06:02 PM, the ADM stated she had worked at the facility for approximately 2 months. She stated the policy for a shower was, the residents were to get a shower every other day, unless specially requested or extenuating circumstances occurred (for example: diarrhea). The ADM reviewed the shower schedule and stated residents may miss their showers due to CNAs being stressed for time and she was in the process of making a shower aide position. She stated if a resident refused their shower, she expected the CNA to notify the nurse and the nurse to attempt again. She stated, if the resident continued to refuse their shower, she expected the nurse to notify the resident's responsible party and document in the nurses' notes. The ADM stated, if a resident missed their showers, then they may incur impaired skin integrity, they could start to smell, also it could affect their psychosocial status and cause sadness. Record review of the facility's, undated, policy titled, Activities of Daily Living (ADLs), Supporting reflected: Policy StatementResidents will provide with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).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 and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) .4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. Record review of the facility's in-service titled Showers, dated 06/09/2025, reflected: -All residents are to be showered unless resident refuses.-If resident refuses to shower the nurse must be notified-The nurse must make an attempt to get the resident to shower-If resident still refuses to shower, the nurse must contact the resident's RP of the refusal-The nurse must document of the attempt make and that the RP was notified-The nurse must inform the DON; ADON; or WCN of the refusal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments, under proper temperature controls, and labeled in accordance with currently accepted professional principles for 1 of 1 medication storage room refrigerator and 1 of 3 (200 hall) medication carts reviewed for medication storage. 1. The facility failed to ensure the 200-hall medication cart was locked and medications were secured and not accessible to other staff, residents, or visitors. 2. The facility failed to ensure the refrigerator maintained the adequate temperature to store medications (35 - 40 degrees Fahrenheit) that required refrigeration prior to opening. These failures could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missed medications.Findings included: Observation on 08/20/2025 at 9:08 AM revealed an unlocked medication cart beside room [ROOM NUMBER]. The medication cart was between room [ROOM NUMBER] and room [ROOM NUMBER]. The front of the medication cart was facing toward the end of the hall. The locking mechanism was protruding outward on the medication cart. The state surveyor opened drawers and captured pictures. RN D was in room [ROOM NUMBER] with the door closed. Observation on 08/20/2025 at 9:12 AM RN D exited room [ROOM NUMBER] and went to the unlocked medication cart. Interview on 08/20/2025 at 9:14 AM RN D stated the medication cart was to always be locked except when he was dispensing medications from the medication cart. He stated it was his responsibility to ensure the medication cart was locked and secure. RN D stated the key to the medication cart was in his pocket. He stated if residents had accessed the medication cart they could have overdosed, taken wrong medication, had an allergic reaction, and could require admission to the hospital. He stated he had previously been in-serviced on locking the medication carts and could not recall the specific date. He stated he was aware the medication cart should have been locked. He stated the narcotics were locked and were not accessible. RN D stated there was PRN medications and some medical equipment such as blood pressure and glucometer that were not locked. Interview on 08/20/2025 at 9:30 AM the DON stated her expectation was for all medication carts to be locked when the nurse was not administering medications. She stated the staff had been in-serviced on securing the medication carts when not in use. The DON stated she did not know the exact date of the in-service. She stated residents, other staff, and visitors would have access to the medications in the unlocked medication cart. She stated if a resident ingested medications not prescribed to them, there was a potential the resident may have an allergic reaction or may need to be admitted to the hospital. She stated it was the nurse's responsibility to ensure the medication cart was locked when not dispensing a resident's medication. The DON stated she was responsible for monitoring the nurse supervisor. Interview on 08/22/2025 at 1:30 PM the ADM stated her expectations was for the medication carts to be locked when the nurses were not administering medications from the carts. She stated there was a possibility a resident may get medications out of the medication cart. The ADM stated if a resident did take the medications by mouth there was a possibility a resident may have an allergic reaction. She stated it depended on the medication the resident ingested. She stated the nurse assigned to the medication cart was responsible for locking the medication cart after administering medications to a resident. The ADM stated the DON was responsible to monitor the nurse supervisor. Observation and interview on 08/21/2025 at 10:14 AM in the medication storage room with the TN revealed the one medication storage refrigerator with 2 thermometers sitting on the top shelf, one thermometer read 51 degrees, and the other thermometer read 47.5 degrees. The log on the refrigerator door did not have a reading for that day, at the bottom of the log page was handwritten Refrigerator temp 35 F - 40 F. The TN stated the temperature in the refrigerator should be lower and turned the dial inside the refrigerator to adjust the temperature. The medication refrigerator contained multiple medications including: Lantus Solostar (an insulin for diabetes), Insulin Lispro, Insulin Glargine, Wegovy (a medication used for diabetes or weight loss), Humulin 70/30 Kwikpen (an insulin for diabetes), Trulicity (a medication used for diabetes), Acetaminophen suppositories (a medication used for fever and pain when medication cannot be taken by mouth), Glycerin suppositories (a medication used for constipation), Bisacodyl Suppositories (a medication used for constipation), Brimonidine-Timolol (an eye drop used to decrease eye pressure), Latanoprost (an eye drop used to decrease eye pressure), a vaccine for the respiratory syncytial virus (a common respiratory virus that is highly contagious), and Acidophilus (a probiotic). The refrigerator was not at correct temperature. Observation on 08/21/2025 at 10:28 AM revealed the medication storage room one of one refrigerator thermometers with temperature readings of 49.3 degrees and 55 degrees. The TN then notified the ADON, and another medication storage refrigerator was immediately brought into the medication storage room by the ADON. Interview on 08/21/2025 at 10:37 AM with the ADON, he stated all medications would be destroyed.Observation on 08/21/2025 at 10:40 AM revealed the ADON on the phone attempting to reorder all the medications that were stored in the refrigerator in the medication storage room. Interview on 08/21/2025 at 02:49 PM the CP stated she had been informed about all the medication in the refrigerator being outside of the recommended storage range. She stated each different manufacturer would need to be contacted to determine each medication's excursion range (the amount of time and at what temperatures each medication can tolerate). She stated all medications that were in the medication storage room's refrigerator had been destroyed and all medications had been reordered at the facility's expense. The CP stated she was unable to say how the medication would be affected because it varied depending on the medication and manufacturer. She stated the nurses were responsible for completing the temperature monitoring log daily. The pharmacist stated she had visited the facility a week ago and the temperature log was completed at that time and no temperatures were out of range. She stated she was scheduled to visit the facility monthly, and she reviewed the refrigerator during her visits. Interview on 08/21/2025 at 04:49 PM the TN stated the nurses that worked the night shift were responsible for checking the temperature in the medication refrigerator. She stated the DON monitored the temperature log form to ensure it is being completed each day. The TN stated if medications were outside of the recommended storage temperature, then the medication may lose potency.Interview on 08/21/2025 at 05:18 PM RN D stated the nurses that worked the night shift were responsible for checking the temperature in the medication refrigerator. He stated if medications were stored outside of the recommended temperature ranges, then the potency of the medication may be affected, and the resident may not get the intended dose of the medication.Interview on 08/21/2025 at 05:36 PM the DON stated she had been the DON for about a month. She stated she expected the night shift nurses to check the medication storage refrigerator and document the temperature. She stated she monitored to ensure the temperature log was completed daily. The DON stated if medication was not kept within the manufacturers recommended range, then the use of the medication could be affected. Interview on 08/21/2025 at 06:02 PM the ADM stated the temperature of the medication room refrigerator was checked daily by the charge nurse. She stated if the medications in the medication room refrigerator were stored out of range, then the medication could lose its effectiveness. Record review of the facility's Policy on Storage of Medications, not dated, reflected the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Unlocked medication carts are not left unattended.Record review of the facility's, undated, Policy titled Medication Storage and Administration Quick Reference Guide reflected Med carts are locked when not visible to nurse or qualified staff. Temperature of refrigerator should consistently be maintained at 36-46 F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 of 15 residents (Resident #17, Resident #35, and Resident #80) reviewed for resident rights. The facility failed to ensure CNA A and LVN B knocked on Resident #17, Resident #35, and Resident #80's doors when going into the residents' rooms. The deficient practice could place residents at risk of poor self-esteem and feeling like their privacy was being invaded or the facility was not their home.Findings include: 1. Record review of Resident #17's admission sheet, dated 08/19/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included cystitis without hematuria (inflammation of the bladder), somatization disorder (tendency to experience and express psychological distress as physical symptoms), fusion of the spine (surgical procedure that connect two or more parts in the spine), muscle weakness, congenital malformation of nervous system (birth defect that affects the structure and development of the brain and spinal cord), lack of coordination, anxiety disorder (feeling of uneasiness or worry) and hypertension (high blood pressure). Record review of Resident #17's admission MDS assessment, dated 06/23/2025, revealed Resident #17 had a BIMS score of 13, which indicated intact cognitive response. Observation of hall meal tray pass on 08/19/2025 at 12:07 p.m., revealed CNA A did not knock on Resident #17's door before entering her room. During an interview with Resident #17 on 08/19/2025 at 11:01 AM revealed staff did not always knock on the door before entering. She said she would like for them to knock all the time before they entered her room. She said she did not get upset when they did not knock. 2. Record review of Resident #35's admission sheet, dated 08/19/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included muscle wasting, muscle weakness, glaucoma (eye disease), hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), gastritis (swelling of the lining of the stomach), dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), lack of coordination, abnormalities of gait and mobility, and cognitive communication deficit (problems with communication). Record review of Resident #35's admission MDS assessment, dated 05/09/2025, revealed Resident #35 had a BIMS score of 13, which indicated intact cognitive response. Observation of hall meal tray pass on 08/19/2025 at 12:12 p.m., revealed LVN B did not knock on Resident #35's door before entering her room. During an interview with Resident #35 on 08/19/2025 3:45 PM revealed staff did not knock on the door all the time. She said she would like the staff to knock all the time. She said it bothered her when staff did not knock because it startled her. 3. Record review of Resident #80's admission sheet, dated 08/19/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #80 had diagnoses which included dementia (memory, thinking, difficulty), unsteadiness on feet, paroxysmal atrial fibrillation (irregular heartbeat that comes and goes), chronic obstructive pulmonary disease (chronic progressive lung disease), anxiety (feeling of uneasiness or worry), kidney disease, hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), hyperlipidemia (high cholesterol), abnormalities of gait and mobility, insomnia (difficulty sleeping) and cognitive communication deficit (problems with communication). Record review of Resident #80's Quarterly MDS assessment, dated 06/14/2025, revealed Resident #80 had a BIMS score of 15, which indicated intact cognitive response. Observation of halls on 08/20/2025 at 10:45a.m., revealed CNA A did not knock on Resident #80's door before entering her room. During an interview with Resident #80 on 08/19/2025 at 3:35 PM revealed staff did not always knock on the resident's door before entering. She said it bothered her when staff did not knock. She said she would like for staff to knock all the time before entering. During an interview with CNA A on 08/21/2025 at 1:16 PM revealed he was trained on resident rights. He stated the policy was to knock and introduce yourself before entering the resident's room because it was there home. CNA A stated staff should always knock on the door. He said anybody who wanted to go into the resident's room should be knocking. He said the residents did not like staff not knocking. He said it would be like just walking into the resident's house and that was not ok. He said no one monitored to ensure staff were knocking. He said they just had an in-service on knocking this week. He said he did not know why he did not knock on the residents' doors. During an interview with LVN B on 08/21/2025 at 1:30 PM revealed she was trained on resident rights. She said the policy was to knock and introduce yourself to the resident for dignity. She said staff did not just enter. Every time staff wanted to enter the resident's room staff should knock. There was no time staff did not have to knock. She said the resident may feel disrespected if staff did not knock. She said the team watched each other through observations. She said the staff would let each other know if someone forgot to knock. She said she did not know why she did not knock. She also said maybe the door was open but even then, she would have to knock. During an interview with the ADM on 08/21/2025 at 3:37 PM, revealed she and staff were trained on resident rights. She said the policy was staff should knock, announce themselves and let the resident know why the staff member was there. She said all staff were to always knock before going into the resident's room. She said if staff did not knock before entering the room the resident may feel scared or not know who is coming in the room. She said there was never a time when staff did not have to knock on the door before entering. She said knocking was monitored by the charge nurses and administration. She said knocking was monitored through observations and doing rounds. She said she did not know why staff did not knock on Resident #17, Resident #35, and Resident #80's door before entering. During an interview with the DON on 08/21/2025 at 3:40 p.m., revealed she and staff were trained on resident rights. She said the policy for knocking was staff should knock before entering, wait for a response, and let the resident tell the staff to come in. She said staff should knock any time they went into the residents' rooms. She said if staff did not knock on the resident's door the resident may feel bad because the facility was the resident's home. She said there was never a time staff did not have to knock on the resident's door. She said the charge nurses and the managers were responsible for monitoring to ensure staff were knocking. She said knocking was monitored by observations. She said she did not know why staff did not knock on Resident #17, Resident #35, and Resident #80's door before entering. Record review of the facility's, undated, Resident Rights Policy revealed employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 3 residents (Resident #48, Resident #68, and Resident #93) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #48's admission MDS, dated [DATE], accurately reflected his smoking status.2. The facility failed to ensure Resident #68's quarterly MDS, dated [DATE], accurately reflected her smoking status. 3. The facility failed to ensure Resident #93's quarterly MDS, dated [DATE], accurately reflected her smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment for smoking status. Findings include: 1. Record review of Resident #48's face sheet, dated 08/20/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #48 had a diagnosis which included hemiplegia (paralysis and weakness on one side of the body that can affect the arms, legs, and facial muscles). Record review of Resident #48's admission MDS, dated [DATE], revealed Resident #48 had a BIMS of 14, which indicated intact cognitive response. The MDS also revealed current tobacco use was not checked. Record review of Resident #48's care plan, dated 8/14/2025, revealed Resident #48 was a smoker. The goal in place was the resident will not suffer injury from unsafe smoking practices through the review. Interventions were instructing resident about smoking risks and hazards and about smoking cessation aids that were available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Smoking assessment per facility Policy. Record review of Resident #48's Smoking Assessment, dated 8/15/2025, revealed Resident #48 required partial physical assistance with mobility and supervision during smoke break. 2. Record review of Resident #68's face sheet, dated 08/19/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #68 had diagnoses which included cerebral infraction (stroke), major depressive disorder (mental health disorder characterized by persistent depressed mood), lack of coordination, viral hepatitis C (a bloodborne virus that causes liver inflammation), Parkinson's disease (a progressive disorder that affects the nervous system), anxiety (feeling of uneasiness or worry), muscle weakness and morbid obesity. Record review of Resident #68's quarterly MDS, dated [DATE], revealed Resident #68 had a BIMS of 15, which indicated intact cognitive response. The MDS also revealed current tobacco use was not on the MDS. Record review of Resident #68's care plan, dated 07/29/2025, revealed Resident #68 did not have her smoking status on the care plan. Record review of Resident #68's Smoking Assessment, dated 06/02/2025, revealed Resident #68 required supervision and one-on-one assistance. The resident needed to be supervised due to contractions. 3. Record review of Resident #93's face sheet, dated 08/20/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #93 had diagnoses which included lack of coordination, anemia (not enough healthy red blood cells), Schizophrenia (mental disorder that affects a person's ability to think, feel and behave clearly), bipolar (extreme mood swings), anxiety (feeling of uneasiness or worry), depressive disorder (mental health disorder characterized by persistent depressed mood), hypertension (high blood pressure), insomnia (difficulty sleeping), muscle wasting, muscle weakness, and lack of coordination. Record review of Resident #93's admission MDS, dated [DATE], revealed Resident #93 had a BIMS of 15, which included intact cognitive response. The MDS also revealed current tobacco use was not checked on the MDS. Record review of Resident #93's care plan, dated 08/14/2025, revealed Resident #93 did not have her smoking status on the care plan. Record review of Resident #93's Smoking Assessment, dated 08/17/2025, revealed Resident #93 required supervision when smoking. The resident could light her own cigarette, but the facility would follow policy and have the resident supervised. During an interview with the MDSN on 08/21/2025 at 2:02 p.m., revealed she was trained on the MDS but not at the facility. She said the IDT was responsible for the MDS, but she completed most of the MDS's. She said information that was on the MDS were assessments, pain, and data collection from a resident's medical records. She said the MDS should be updated when there was a significate change, or a regulatory requirement. She said she had fourteen days from admission to complete the MDS. She said there was a question on the MDS about the resident's tobacco use and if the resident were a smoker, it would be checked yes. She said if the resident's smoking status were not coded correctly it would not get addressed. She said staff may not know who needs supervision. She said she was never told who smokers were did not answer why she did not know. She said the reason Resident #48, Resident #68, and Resident #93's smoking status was not on the MDS, was because she did not know who the smokers were. She also said she assumed there was not a list available or a clear way of knowing who the smokers were. During an interview with the SW on 08/21/2025 at 2:38 p.m., revealed she had not had any formal training on MDS's or care plans. She said she did not have anything to do with the MDS. Said then said she entered behavior notes and she did sections B, C, D, E and Q (section B covered hearing, vision and speech, section C covered cognitive patterns, section D covered mood, section E covered behavior and Q covered participation in assessment and goal setting). She said every department would have a part on the MDS and care plan. She also said she did not put the smoking status on the MDS. She said the MDS would make a list of things that needed to be done on the MDS, or care plan and staff would go through it daily. She said if a resident did not have their smoking status on the MDS the resident may not get the proper supervision. She said she did not know why Resident #48, Resident #68, and Resident #93's smoking status was not on the MDS. During an interview with the ADM on 08/21/2025 at 3:44 p.m., revealed she had not been trained on MDS's. She said the MDS nurse was responsible for doing the MDS. She said the resident's current smoking status was to be on the MDS. She said if the resident's smoking status were not on the MDS the information would be inaccurate and staff would not know the resident was a smoker. She said staff would not know if the resident needed an apron or supervision. She said she did not know why Resident #48, Resident #68, and Resident #93's smoking status was not on the MDS. During an interview with the ADM on 08/20/2025 at 4:17p.m., the MDS Policy and Accuracy of Assessments Policy was requested from the ADM and was not received on exit. Record review of the Smoking Residents provided on 08/19/2025 revealed that Resident #48, Resident #68, and Resident #93 were all smokers. Record review of the Smoking Residents list provided on 08/19/2025 revealed Resident #48, Resident #68, and Resident #93 were all smokers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 8 of 16 (Resident #7, Resident #10, Resident #17, Resident #21 Resident #31, Resident #65, Resident #68 and Resident #86) reviewed for care plans. 1. The facility failed to ensure Resident #7's comprehensive care plan was updated after the code status was changed from full code to DNR on [DATE]. 2. The facility failed to ensure Resident # 10, Resident #17 and Resident #21's comprehensive care plan was updated with Resident #10, Resident #17, and Resident #21's in room activity needs. 3. The facility failed to ensure Resident #31's comprehensive care plan was updated with Resident #31's advance directive when the care plan was completed on [DATE].4. The facility failed to ensure Resident #65 and Resident #86's comprehensive care plan was updated to include contact isolation.5. The facility failed to ensure Resident #68's comprehensive care plan was updated with her smoking status when the care plan was completed on [DATE]. This deficient practice could place residents at risk of not being provided with the necessary care or services and the implementation of personalized plan of care developed to address their specific needs. The findings include: 1. Record review of Resident #7's face sheet, dated [DATE], revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (paralysis and weakness on right side after stroke), muscle weakness, dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), lack of coordination, adjustment disorder, hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), repeated falls, cerebral infraction (long term effects of a stroke), and protein-calorie malnutrition (inadequate intake of both protein and calories). Record review of Resident #7's quarterly MDS, dated [DATE], revealed Resident #7 had a BIMS of 08, which indicated moderate impairment. The MDS did not document Resident #7's code status. Record review of Resident #7's care plan, dated [DATE], revealed Resident #7 was a full code. The Goal was Resident #7 would be provided with necessary resuscitative measures. Interventions were to advise MD, RP & family of any changes in condition per facility policy. Educate and discuss with resident/family about Full Code status versus OOHDNR code status on an annual basis or as needed. Review Advanced Directives with resident/family annually, upon change in condition andas needed. Record review of Resident #7's Advance Directive Order, dated [DATE], revealed Resident #7 was a DNR. Record review of Resident #7's OOHDNR, dated [DATE], had all the required signatures (doctor signature, RP signature and witness signatures). 2. Record review of Resident #10's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident#10 had a diagnosis which included depression (when a person experiences a persistent sad mood), cognitive communication deficit (communication skills that results from impaired memory, attention, reasoning, and problem-solving which are necessary for effective communication), and generalized anxiety disorder (excessive, persistent, and unrealistic worry about everyday things). Record review of Resident#10's admission MDS Assessment, dated [DATE], reflected Resident #10 had a BIMS score of 15, which indicated her cognition was intact. The following activities were very important to Resident #10: reading, music, being around animals, keep up with the news, going outside for fresh air and participating in religious practices. Record review of Resident#10's Comprehensive Care Plan, revised on [DATE], did not reflect Resident #10's activity plan. 3. Record review of Resident #17's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had a diagnosis which included somatization disorder (a mental health condition characterized by excessive focus on physical symptoms, causing significant distress and functional impairment. Intense worry and preoccupation with these symptoms), congenital malformation of nervous system, unspecified (a birth defect affecting the structure or function of the brain, spinal cord, or other parts of the nervous system, but the specific type of malformation is not known), and anxiety disorder ( a mental health condition characterized by excessive and persistent fear, worry or tension that interferes with daily life causing distress). Record review of Resident #17's admission MDS Assessment, dated [DATE], reflected Resident #15 had a BIMS score of 13, which indicated her cognition was intact. The following activities were important to Resident#17: listening to music, being around animals, keep up with the news, go outside when the weather was good and participate in religious services and practices. Record review of Resident #17's Comprehensive Care Plan, dated [DATE], reflected the resident's current activity plan was not documented. 4. Record review of Resident # 21's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #21 had a diagnoses which included cognitive communication deficit (communication skills that results from impaired memory, attention, reasoning, and problem-solving which are necessary for effective communication), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ( it is a group of symptoms that can affect thinking, memory, and reasoning without behaviors), and adult failure to thrive ( a syndrome of general decline in an older adult's physical and functional capabilities, marked by symptoms like weight loss, poor appetite, and decrease in physical activity). Record review of Resident #21's admission MDS Assessment, dated [DATE], reflected Resident #21 had a BIMS score of 15, which indicated her cognition was intact. The following activities were very important to Resident #21: reading, listen to music, being around animals, keep up with the news, going outside to get fresh air when weather permits. Record review of Resident #21's Quarterly MDS Assessment, dated [DATE], reflected Resident #21 had a BIMS score of 11, which indicated her cognition was moderately impaired. Record review of Resident #21's Comprehensive Care Plan, dated [DATE], reflected Resident #21 did not have an activity care plan. 5. Record review of Resident #31's face sheet, dated [DATE], revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included muscle weakness, neurocognitive disorder with Lewy bodies (type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), vascular dementia (lack of blood that carries oxygen and nutrients to a part of the brain), anxiety (feeling of uneasiness or worry), hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), hyperlipidemia (high cholesterol), fall and anemia (not enough healthy red blood cells). Record review of Resident #31's quarterly MDS, dated [DATE], revealed Resident #31 had a BIMS of 12, which indicated moderate impairment. The MDS also did not have Resident #31's code status. Record review of Resident #31's care plan, dated [DATE], revealed Resident #31 did not have a code status documented on his care plan. Record review of Resident #31's Advance Directive Order, dated [DATE], revealed Resident #31 was a DNR. Record review of Resident #31's OOHDNR, dated [DATE], had all the required signatures (doctor signature, RP signature and witness signatures). 6. Record review of Resident #65's face sheet, dated on [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #65 had diagnoses which included local infection of the skin and subcutaneous tissue, unspecified (a bacterial or fungal infection affecting a specific, limited area of the outer skin layers and the tissue beneath it), non-pressure chronic ulcer of skin of other sites limited to breakdown of skin (an open ,non-healing sore on the skin, not caused by prolonged pressure), and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (hemiplegia refers to paralysis- complete inability to move and hemiparesis - weakness). Record review of Resident # 65's admission MDS Assessment, dated [DATE], reflected Resident #65 had a BIMS score of 10, which indicated her cognition was moderately impaired. Resident #65 had stage 4 pressure ulcer. Record review of Resident #65's Comprehensive Care Plan, dated [DATE], reflected Resident #65 had stage 4 pressure ulcer to sacrum. The pressure ulcer was present upon admission. The care plan did not reflect Resident #65 required contact precautions. 7. Record review of Resident #68's face sheet, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #68 had diagnoses which included cerebral infraction (stroke), major depressive disorder (mental health disorder characterized by persistent depressed mood), lack of coordination, viral hepatitis C (a bloodborne virus that causes liver inflammation), Parkinson's disease (a progressive disorder that affects the nervous system), anxiety (feeling of uneasiness or worry), muscle weakness and morbid obesity. Record review of Resident #68's quarterly MDS, dated [DATE], revealed Resident #68 had a BIMS of 15, which indicated intact cognitive response. The MDS also revealed current tobacco use was not on the MDS. Record review of Resident #68's care plan, dated [DATE], revealed Resident #68 did not have her smoking status on the care plan. Record review of Resident #68's Smoking Assessment, dated [DATE], revealed Resident #68 required supervision and one-on-one assistance. The resident needed to be supervised due to contractions. 8. Record review of Resident # 86's face sheet, dated on [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #86 diagnoses which included infection following a procedure, superficial incision surgical site, subsequent encounter (a bacterial or other microorganism infection that develops in the top layers of skin at a surgical wound site, rather than a deep one, for a resident receiving later follow-up medical care for the infection), methicillin resistant staphylococcus aureus infection, unspecified site (a common bacteria enter the body through a cut or wound , causing symptoms like red, painful, swollen areas, possibly with pus. Methicillin resistant- the bacteria has developed a resistance to certain antibiotics which are normally used to kill staph), and chronic pain (a long lasting, continuous, or recurring pain that persists for at least three months, beyond the normal healing time). Record review of Resident #86's Quarterly MDS Assessment, dated [DATE], reflected Resident #86 had a BIMS score of 15, which indicated her cognition was intact. Resident #86 had open lesions and skin tears. She received treatment for skin and ulcer/ injuries (non-surgical dressings and ointments) Record review of Resident #86's Comprehensive Care Plan, dated [DATE], reflected Resident #86 was at risk for skin breakdown and pressure ulcer development due to decreased mobility and obesity. Resident #86 comprehensive care plan did not reflect Resident #86 being on contact isolation. During an interview on [DATE] at 1:00 PM the Activity Director did not respond why Resident #21, Resident#17, and Resident #10's activities plan for the next quarter was not documented on the comprehensive care plan. She did not respond why it was important to have the residents in room activities on their care plan. During an interview on [DATE] at 1:59 PM, the MDSN stated infection control protocol was to be followed especially if someone was on contact isolation. She stated touching anything with contaminated gloves was considered cross contamination. The MDS RN stated any time someone was on contact isolation it was expected to be care planned. She stated she would need to review Resident #86 and Resident # 65's care plan to determine if contact isolation were care planned and she would inform the state surveyor with the information she gathered from their medical records. She said that she was responsible for updating the care plans and the IDT developed the care plan. She never reported any information to the state surveyor prior to exit. During an interview with the MDSN on [DATE] at 2:14 p.m., revealed she was trained on care plans. She said IDT was responsible for doing the care plan. She said the care plan had to be opened by the RN, but she did most of the care plan. She said smoking could be nursing or social services. She said the SW was responsible for doing the advance directives. She said she looked for special medication, diagnosis, and high-risk medication. She said she would also put the family dynamics on the care plan. She said the facility had 7 days to complete the care plan. She said the care plan should be updated when there was a change to the resident's care. She said the care plans were updated as needed or when the MDS was due. She said depending on the issue with the care plan depended on who was responsible. She said a resident's advance directive went on the care plan. She said if a resident changed their advance directive the care plan should be updated immediately. She also said smoking went on the care plan. She said if the advance directive and smoking status were not correct on the care plan the person looking at the care plan would not have the appropriate information. She said she assumed the SW did not update the care plans for Resident #7, Resident #31, and Resident #68. During an interview on [DATE] at 2:24 PM, the Treatment Nurse stated Resident #65, and Resident #86 were on contact isolation. She stated both residents had MRSA but in different areas. She stated she would need to review their medical charts and would give the areas on both residents (Resident #65 and Resident #86) and would report to state surveyor. The Treatment Nurse never reported this information to state surveyor prior to exit. She stated both residents were on contact isolation. The Treatment Nurse stated both residents required for gowns and gloves to be worn when giving care. She stated contact isolation was expected to be care planned. She stated if it was not care planned the staff would not have the information, they needed to know why the residents were on contact isolation. The Treatment Nurse stated if the staff had contaminated gloves on, picked up the call light, and placed it on the bed, the call light may become contaminated. She stated if a staff or family member visited the resident and had an open area on their fingers or hand the person may become contaminated with MRSA. he stated if there was a hole in the clear plastic bag and the staff carried the bag down the hall there was a potential if another resident had an open area on their arm and touched the contaminated gowns/gloves in the plastic bag, the resident may become contaminated with MRSA. She stated she had been in-service on infection control, and she was the infection control preventionist. She did not recall the date of her training. During an interview with the SW on [DATE] at 2:38 p.m., revealed she had not been trained on care plans. She said she did not know what the policy was for the care plans. She said she did not know who was responsible for updating the advance directives and smoking status. She said the code status was in the care plan. She said the resident's smoking status was also in the care plan. She said she was not responsible for put a resident's smoking status in the care plan. She said she did not know who put smoking status on the care plan. She also said if a resident changed their code status she would wait until she got the completed DNR back before she would update the care plan. She said she had two weeks to update the care plan. She said if the code status were not updated a resident who was a DNR could possibly be given CPR. She said she did not know why Resident #7's code status was not updated. She said she did not know why Resident #31's code status was not in the care plan or why Resident #68's smoking status was not in the care plan. During an interview on [DATE] at 2:50 p.m. The Director of Nurses stated anytime residents were on contact isolation this was required to be care planned. She stated anytime a resident had any type of infection the care plan was to reflect all interventions required to heal the infection. The Director of Nurses did not respond to other questions related to why it was important for infection and contact isolation needing to be care planned. During an interview with the ADM on [DATE] at 3:50 p.m., revealed she was trained on care plans. She said the IDT team, MDS nurse, therapy and nursing were responsible for doing the care plan. She said all the resident's information, goals, focus for the resident and the resident's discharge plans were on the care plan. She said the care plan had to be completed in 7 days and were updated quarterly. She said the care plan would also be updated in the event of a significate change. She said she thought nursing was responsible for putting a resident's smoking status on the care plan. She said the SW was responsible for updating the advance directives. She said the advance directives were to be updated immediately. She said if the care plan were not updated or did not have a resident's advance directive it could affect the outcome if something happened to the resident. She said if the smoking status was not on the care plan staff would not be able to identify the resident as a smoker. She said she did not know why Resident #7's advance directive was not updated. She also said she did not know why Resident #31's advance directive was not on the care plan. She said she did not know why Resident #68's smoking status was not on the care plan. During an interview with the DON on [DATE] at 4:17p.m., revealed she had not been trained on care plans. She said she was knowledgeable from working in PCC and knew how to do the care plans. She said the RN opened the care plan, the MDS followed up and the DON reviewed the care plan. She said the care plan had the resident's skin integrity, medication, if the resident refused medication, any chronic conditions, advance directives, and infections. She said she did not know how long the facility had to complete the care plan. She said the care plan was updated quarterly or as soon as a significate change happened. She said advance directives and smoking status went on the care plan. She said if a resident went from a full code to DNR the facility had to do a document and uploaded it. She said then the code status needed to be changed in the care plan. She said if an advance directive was not correct on the care plan, staff may do CPR on a resident who should not be getting CPR. She said if the smoking status were not on the care plan there was a possibility the resident would not be monitored or a new issue with smoking identified. She said she did not know why Resident #7's advance directive was not updated. She also said she did not know why Resident #31's advance directive was not on the care plan. She said she did not know why Resident #68's smoking status was not on the care plan. Record review of the facility's, undated, Care Plans, Comprehensive Person-Centered Policy reflected 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. The comprehensive, person-centered care plan 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. Record review of the facility's, undated, Advance Directives Policy reflected the plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The Interdisciplinary Team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record. The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Attending Physician will not be required to write orders for which he or she has an ethical or conscientious objection. Record review of the facility's Activity Director Job Description, dated [DATE], reflected this person provides for an ongoing program of activities designed to meet, following the comprehensive assessment, the interests, and the physical, mental, and psycho-social well-being of each resident. Contribute to facility efforts to maintain and/or improve quality of care through participation in care plan meetings. Assess resident needs and develop resident activities goals for the written care plan. Signed by: Activity Director on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed, to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three of six residents ( Resident #10, Resident #17, and Resident #21) reviewed for activities. The facility failed to provide Resident # 3, Resident #10, Resident #17, and Resident #21 in room activities during July 2025 and August 1st thru August 22, 2025.This failure could place residents at risk for boredom, depression, and a diminished quality of life.Findings include:Record review of Resident #10's face sheet, dated 08/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10 had diagnoses which included depression (when a person experiences a persistent sad mood), cognitive communication deficit (communication skills that results from impaired memory, attention, reasoning, and problem-solving which are necessary for effective communication), and generalized anxiety disorder (excessive, persistent, and unrealistic worry about everyday things). Record review of Resident#10's admission MDS Assessment, dated 05/19/2025, reflected Resident #10 had a BIMS score of 15, which indicated her cognition was intact. The following activities were very important to Resident #10: reading, music, being around animals, keep up with the news, going outside for fresh air and participating in religious practices. Record review of Resident#10's Comprehensive Care Plan, revised on 08/28/2025 did not reflect Resident #10's activity plan. Record review of Resident #17's face sheet, dated 08/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included somatization disorder (a mental health condition characterized by excessive focus on physical symptoms, causing significant distress and functional impairment. Intense worry and preoccupation with these symptoms), congenital malformation of nervous system, unspecified (a birth defect affecting the structure or function of the brain, spinal cord, or other parts of the nervous system, but the specific type of malformation is not known), and anxiety disorder (a mental health condition characterized by excessive and persistent fear, worry or tension that interferes with daily life causing distress). Record review of Resident #17's admission MDS Assessment, dated 06/23/2025, reflected Resident #17 had a BIMS score of 13 which indicated her cognition was intact. The following activities were very important to Resident#17: listening to music, being around animals, keep up with the news, go outside when the weather was good and participate in religious services and practices. Record review of Resident #17's Comprehensive Care Plan, dated 07/01/2025 reflected Resident current activity plan was not documented. Record review of Resident # 21's face sheet, dated 8/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #21 had diagnoses which included cognitive communication deficit (communication skills that results from impaired memory, attention, reasoning, and problem-solving which are necessary for effective communication), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety (it is a group of symptoms that can affect thinking, memory, and reasoning without behaviors), and adult failure to thrive (a syndrome of general decline in an older adult's physical and functional capabilities, marked by symptoms like weight loss, poor appetite, and decrease in physical activity). Record review of Resident #21's admission MDS Assessment, dated 04/24/2025, reflected Resident #21 had a BIMS score of 15, which indicated her cognition was intact. The following activities were very important to Resident #21: reading, listen to music, being around animals, keep up with the news, going outside to get fresh air when weather permits. Record review of Resident #21's Quarterly MDS Assessment, dated 07/25/2025, reflected Resident #21 had a BIMS score of 11, which indicated her cognition was moderately impaired. Record review of Resident #21's Comprehensive Care Plan, dated 08/08/2025 reflected Resident #21 did not have an activity care plan. Record review of in room activity participation records, dated July 2025 and August 1, 2025, thru August 22, 2025, reflected Resident # 10, Resident #17 and Resident #21 did not receive in room activities. Record review of residents to receive in room activities for the month of July 2025 and August 2025 reflected Resident #10, Resident #17, and Resident #21 names were on the in-room record. During an interview with Resident #17 on 08/19/2025 at 10:27 AM, revealed that she does not get any activities. She said staff do not give her any books, puzzles, or anything else. She said she is bed bound and her roommate does not like to talk so she felt like she was just lying there to die.Interview on 08/21/2025 at 1:00 PM, the Activity Director stated Resident #3 did not receive in room activities from 07/03/2025 thru 08/11/2025. The Activity Director stated she was expected to ensure all residents received activities based on their preferences and their physical abilities. She stated if residents were not coming out of their room, the residents were to be provided in room activities. The Activity Director stated she provided in room activities at least twice a week. She stated there was not an excuse why Resident #10, Resident #17 or Resident #21 did not receive in room visits. The Activity Director stated if a resident was not receiving activities on a consistent basis there was a potential a resident may become bored, depressed, or have a decline in their quality of life. She stated she was responsible for ensuring all residents received their activity needs including in room activities. Interview on 08/21/2025 at 1:30 PM, the Administrator stated she expected in room activities be provided to the residents needing these types of activities. She stated if a resident was not receiving in room activities there was a possibility a resident may become depressed, bored, and isolated. She stated the Activity Director was responsible for all activities in the facility. She stated she was responsible for monitoring the Activity Director. The Administrator stated it was very important for all residents to receive the activities they needed to enhance their overall quality of life. Record review of the facility's Activity Documentation Policy, not dated, reflected the Activity Director shall coordinate and supervise all documentation and be ultimately responsible for all areas of documentation, according to required timeframes and practice guidelines. The following areas are considered documentation responsibilities of the Activity Director and staff and should be completed in a comprehensive and timely manner such as: resident participation records. All documentation is completed in a manner consistent with health care center policy and applicable state and federal laws.Record review of the facility's Activity Director Job Description, dated 01/30/2025, reflected this person provides for an ongoing program of activities designed to meet, following the comprehensive assessment, the interests, and the physical, mental, and psycho-social well-being of each resident. Provide an activities program daily including evenings and weekends. Provide a plan of activities appropriate to the needs of the residents that includes but is not limited to one-to one attention. Encourage resident participation in activities and document outcomes. Signed by: Activity Director on 01/30/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment for 4 (Residents #17, #37, #3, and #73) of 20 residents reviewed for sufficient staffing. The facility failed to ensure that the facility had sufficient staffing to meet the needs of Residents #17, #37, #3, and #73. This failure could affect and diminish the resident's quality of life by potentially placing the residents at risk of not receiving timely care or receiving nursing interventions to meet the resident's needs, risk of injury, risk of safety, and/or it can make the resident feel neglected affecting their mental health and overall psychosocial well-being not being met by facility staff.Findings include: Record review of Resident #17's admission record, dated 08/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included acute cystitis without hematuria (inflammation of the bladder), other benign neoplasm of uterus (noncancerous tumor in women and people assigned female at birth), somatization disorder (mental health condition characterized by significant distress and impairment related to physical symptoms that may not have a clear medical explanation), fusion of spine, muscle weakness, congenital malformation of nervous system (birth defects that affect the structure and function of the brain and spinal cord), lack of coordination, anxiety disorder, and aftercare following joint replacement surgery. Record review of Resident #17 admission MDS, dated [DATE], reflected a BIMS score of 13, which indicated cognition was intact. Section GG - Functional Abilities reflected Resident #17 required Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for toileting hygiene and chair/bed-to-chair transfer. Record review of Resident #17's care plan, dated 06/20/2025, reflected the following clean peri-area with each incontinence episode. Record review of Resident #37's admission record, dated 08/21/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #37 had diagnoses which included local infection of the skin and subcutaneous tissue, chronic kidney disease, stage 4 (severe), iron deficiency anemia, irritable bowel syndrome, and muscle weakness. Record review of Resident #37's admission MDS, dated [DATE], reflected a BIMS score of 14, which indicated cognition was intact. Section GG - Functional Abilities reflected Resident #37 Needed Some Help - Resident needed partial assistance from another person to complete any activities for self-care and Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for showers/bathing self. Record review of Resident #37's initial baseline care plan, undated with date initiated 07/10/2025 and last revised 08/19/2025 reflected the following, Resident #37 has limited physical mobility and requires staff assistance for ADLs. Interventions reflected Provide supportive care, assistance with mobility as needed. Further review of Resident #37's initial baseline care plan reflected the following, Resident #37 has occasional bowel and bladder incontinence r/t impaired mobility and IBS (common condition that affects the stomach and intestines). Interventions reflected Clean peri-area with each incontinence episode. Record review of Resident #3's admission record, dated 08/20/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with readmission on [DATE]. Resident #3 had diagnoses which included chronic obstructive pulmonary disease, unsteadiness on feet, cognitive communication deficit, pain in right shoulder, mild cognitive impairment, difficulty in walking, major depressive disorder, insomnia, muscle weakness, heart failure, sleep apnea, morbid obesity. Record review of Resident #3's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated cognition was intact. Section GG0115. Functional Limitation in Range of Motion reflected Resident #3 required Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half.the effort for toileting hygiene. Record review of Resident #3's care plan, dated 04/27/2021 and last revised 02/14/2025, reflected the following I have an ADL self-care performance deficit r/t lack of safety awareness and muscle weakness. Interventions reflected TOILET USE: requires assistance by (1) staff for toileting. Record review of Resident #73's admission record, dated 08/21/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #73 had diagnoses which included other sequelae of cerebral infarction (condition of brain swelling, blood clots, trouble swallowing, pneumonia, bladder and bowel problems, seizures, and headaches), muscle weakness, lack of coordination, depression, anxiety disorder, insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep), polyneuropathy (condition characterized by damage to multiple peripheral nerves, leading to symptoms such as pain, weakness, and sensory loss), acute embolism (blood clot that blocks and stops blood flow to an artery in the lung) and thrombosis (condition that involves the formation of a blood clot in blood vessels) of unspecified deep veins, heart failure, obesity, and type 2 diabetes mellitus (condition that happens because of a problem in the way the body regulates and uses sugar as fuel). Record review of Resident #73's admission MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Section GG - Functional Abilities reflected Resident #73 required Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for toileting hygiene and chair/bed-to-chair transfer. Record review of Resident #73's care plan, dated 07/25/2025 and last revised 07/31/2025 reflected the following Resident #73 requires assistance from staff with ADLs such as Bed mobility, Transfers, Locomotion, Dressing, Toileting, Personal hygiene, and Bathing. Interventions reflected facility would Provide devices for mobility and assist as indicated. Staff will encourage resident to participate with ADLs as able. Staff to assist with/provide ADLs as needed. Further review of Resident #73's care plan reflected Resident #73 has bowel and bladder incontinence r/t CVA. Interventions reflected Check resident every two hours and assist with toileting as needed. During an interview and observation on 08/19/2025 at 3:40 PM, Resident #73 stated there was not enough staff and he stays wet often and must call his wife to call up to the nurse's station to get staff to answer his call light. He stated he wants staff to figure out to help him get up as he was supposed to be up and out of bed daily. He stated he presses the call light and at times will come into his room to turn it off and leave and do not return. Resident #73's wife was observed reaching behind his bed on the floor to pick up the call light that was out of reach for resident.During an interview on 08/19/2025 at 4:10 PM, Resident #37 stated call light response depends on the day, and at night he must wait 3 hours for a brief change. He stated he is concerned with having to lay in filth for so long. During an interview on 08/20/2025 at 8:40 AM, Resident #17 stated that staff do not answer the call light and when they do, they will come in and turn it off and not come back. During an interview on 08/20/2025 at 9:41 AM, Resident #3 stated call light response time depends on who is working on the shift. She stated call light response times can take more than 30 minutes during the overnight shifts. She stated she does not like to make waves so she would not speak up about the problem and would wait for staff. In an observation on 08/20/2025 at 10:27 AM revealed Resident #17 pressed the call light to ask for assistance with peri care. At 10:53 AM staff responded to call light, shut it off, and asked Resident #17 if she needed assistance. Resident #17 informed her that she needed to be changed. Staff stated she would get the supplies and return. At 10:58 AM, 31 minutes after the call light was originally pressed, staff returned with peri care supplies and stated she was back to change Resident #17. During an interview on 08/21/2025 at 3:30 PM, CNA J stated he has been in-serviced on resident rights and call lights are to be answered by available staff on the hall. He stated call lights are to be answered within a reasonable timeframe of less than 5 minutes. He stated if staff did not answer call lights in a reasonable timeframe this could cause the residents to become upset and could cause them to feel bad. During an interview on 08/21/2025 at 3:42 PM, CNA G stated she receives continuous in-services on resident rights and call lights. She started the expectation of call lights is to be answered right away, with a reasonable timeframe of 2 minutes or less. She stated if a staff cannot provide care immediately then a reasonable time to return is within 5 minutes to provide the necessary care. She stated 20 minutes or more to answer a call light would make the resident feel neglected. She stated that rounding, peri-care and change motion, rotation should be every 2 hours. She stated if rounding and peri-care is not provided for a resident they can develop bed sores. During an interview on 08/21/2025 at 6:31 PM, CNA I stated she has been in-serviced on call light response times and staff should respond within 1-5 minutes. She stated if staff is unable to provide care immediately the reasonable time to return would be 5-10 minutes. She provided an example requiring 2 staff for transfer, the coordination of staff can take time. She stated 20 minutes or more to answer a call light is unreasonable, and anything could happen in this time. She stated unreasonable response times could cause the residents to feel frustrated and neglected or mad. She stated staff are to provide rounding and per-care every two hours and to ensure resident is clean, as that area is a danger area and needs to stay clean, as resident can develop an infection. During an interview on 8/21/2025 at 6:55 PM, LVN K stated he has been employed one month with this facility and was in-serviced on neglect during orientation and it addressed call lights. He stated call lights are expected to be answered within a reasonable time and are not to be ignored. He believes ASAP is reasonable. He stated call lights should not take more than 10-15 minutes to answer and provide care. He stated 15 minutes is usually when staff is with another resident providing care. He stated not answering call lights is neglectful to residents can cause them mental distress. He stated the expectations for rounding and peri-care is to be thorough, make sure area is clean, brief fits, make sure resident is comfortable before, after, and during the change of their brief. He stated if the resident were not provided rounding and peri-care it could affect their wellbeing and can cause infections, infection control concerns if not staying clean and comfortable. He stated he was unfamiliar with Resident #73 and Resident #3's care as he is new to the facility, but he is working on it. Review of facility policy, undated titled Routine Resident Checks & Call Lights Revised July 2013 revealed Staff shall make routine resident checks to help maintain resident safety and well-being. 1. To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least every 2 hours. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc.4. The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check. (Note: CNAs may also record this information and provide it to the Nurse Supervisor/Charge Nurse.)5. This also includes answering the call light in a timely manner. Review of facility policy, undated, titled, Resident Rights revealed Employees shall treat all residents with kindness, respect, and dignity: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence.b. be treated with respect, kindness, and dignity.c. be free from abuse, neglect, misappropriation of property, and exploitation.f. communication with and access to people and services, both inside and outside the facility.

Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. 1. The two test tray for lunch meal included foods that were bland, and unappealing. 2. The lunch meal trays being delivered to 300 hall residents were unappealing with small side portions. 3. The meal delivery cart doors left open during delivery of hallway meals and reducing the food temperatures. 4. Watery and mushy vegetables served to residents on 08/20/2025. These failures could place residents at risk of decreased food intake, hungry, unwanted weight loss, and diminished quality of life. Findings included: Observation on 08/19/2025 at 12:00 PM revealed unappealing meal trays with poor arrangement of food and small portions of okra being delivered to hallway 300.Food test tray #1 was received at 12:29 PM on 08/19/2025 and was well-presented and arrangement of food was appealing. The tray contained a large white serving plate with an adequate portion of fried okra placed in a small bowl for appearance, corn bread, chili with beans was arranged in a bowl, 2 portions of shredded cheese, donut holes, tea, water, salt, pepper, butter, and utensils wrapped in napkin.Observation and interview on 08/20/2025 at 11:15 AM revealed the broccoli was sitting in a large steal pan filled with water. CK L was observed monitoring food temperatures and stated the broccoli and water remain in the deep pan until meal service and it is drained before serving.Observation on 08/20/2025 at 11:42 AM revealed CDM instructing CK M to drain out as much water from the steal pan of broccoli. CK M used a perforated portion spoon to remove water from the broccoli pan in a slow pace. He was then instructed to stop and to drain as much water when portioning on plate. Broccoli was served on resident plates.Observation on 08/20/2025 at 12:15 PM revealed the meal delivery cart transporting resident meals to hallway 100 was left wide open. The meal delivery cart doors were left open for several minutes exposing resident meal trays and reducing the food temperatures.Food test tray #2 was received at 1:03 PM on 08/20/2025 and the boiled broccoli was mushy and watery. Surveyor tested the tray, and the broccoli was overcooked, soft and squashy, without any seasoning, and dull. The food was warm.During an interview on 08/21/2025 at 10:00 AM, ADM stated the CDM was responsible for maintaining hot, appealing, and flavorful food. She stated she had not heard of complaints regarding food and would ensure the DM was aware of complaints and working with the dietician to improve meals. During an interview on 08/21/2025 at 3:57 PM, CK L stated that vegetables should not sit in water until they were served. She stated she does not leave water in her vegetables and will drain them. She stated if the vegetables remained in water for too long, she would throw it away, because they become mushy. CK L stated this is not the common practice in the kitchen; however, CK M is a new cook in training, and she is trying to teach him good practices as she knows the residents do not like mushy and flavorless foods and would complain about it. CK L stated she hears a lot of complaints when other cooks prepare food as there is no flavor, and limited seasoning of only salt and pepper is used. She stated residents want meals to look forward to. CK L stated using the correct measuring scoops and spoons for serving is necessary for residents to maintain weight and nutrition. She stated following recipes and seasoning required is necessary for meals to be flavorful.During an interview on 08/21/2025 at 4:18 PM, CDM stated she has received complaints from the resident council regarding food being served cold. She stated she believes food may be cold if not delivered to table immediately or to the resident's room in a reasonable time. She stated she does not understand why food becomes cold quickly but will look into this. She stated the broccoli left in water should have been drained before putting the tray on the serving steam table. She stated she was distracted with training a new cook that she overlooked the broccoli staying in water too long and becoming mushy. She stated vegetables are the last food cooked for any meal as they require less time. She stated residents receiving unflavored and mushy vegetables could affect the resident by reducing their nutrition as they may not eat. CDM stated cooks are expected to use the correct portion sized serving tools when serving plates as anything less could affect the residents with weight loss. She stated that all plates served either in the dining room or in the resident rooms should all be uniformed and be appealing so the resident will want to eat it.Review of facility policy undated, titled Food and Nutrition Services revealed Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. 6. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 4 of 6 residents (Resident #29, #65, #70 and #86) reviewed for infection control. 1. The facility failed to ensure CNA C doffed gloves after giving care to Resident #65 and #86 disposed of PPE properly on 08/19/2025. 2. The facility failed to ensure staff wore PPE while providing high contact resident care (transfers and medication administration through a gastrostomy tube) to Residents #29 and #70 on 08/21/2025. These failures could place residents at risk for infection, hospitalization, or death.Findings included: 1. Record review of Resident #65's face sheet, dated on 08/21/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included local infection of the skin and subcutaneous tissue, unspecified (a bacterial or fungal infection affecting a specific, limited area of the outer skin layers and the tissue beneath it), non-pressure chronic ulcer of skin of other sites limited to breakdown of skin (an open ,non-healing sore on the skin, not caused by prolonged pressure), and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (hemiplegia refers to paralysis- complete inability to move and hemiparesis - weakness). Record review of Resident # 65's admission MDS Assessment, dated 07/31/2025, reflected Resident #65 had a BIMS score of 10, which indicated her cognition was moderately impaired. Resident #65 had stage 4 pressure ulcer. Record review of Resident #65's Comprehensive Care Plan, dated 08/04/2025 reflected Resident #65 had stage 4 pressure ulcer to sacrum. The pressure ulcer was present upon admission. The care plan did not reflect Resident #65 being on contact precautions. 2. Record review of Resident # 86's face sheet, dated on 08/21/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident #86 had a diagnoses which included infection following a procedure, superficial incision surgical site, subsequent encounter (a bacterial or other microorganism infection that develops in the top layers of skin at a surgical wound site, rather than a deep one, for a resident receiving later follow-up medical care for the infection), methicillin resistant staphylococcus aureus infection, unspecified site (a common bacteria enter the body through a cut or wound, causing symptoms like red, painful, swollen areas, possibly with pus. Methicillin resistant- the bacteria has developed a resistance to certain antibiotics which are normally used to kill staph), and chronic pain (a long lasting, continuous, or recurring pain that persists for at least three months, beyond the normal healing time). Record review of Resident #86's Quarterly MDS Assessment, dated 07/26/2025, reflected Resident #86 had a BIMS score of 15 which indicated her cognition was intact. Resident #86 had open lesions and skin tears. She was receiving treatment for skin and ulcer/ injuries (non-surgical dressings and ointments) Record review of Resident #86's Comprehensive Care Plan, dated 08/08/2025, reflected Resident #86 was at risk for skin breakdown and pressure ulcer development due to decreased mobility and obesity. Resident #86 comprehensive care plan did not reflect Resident #86 being on contact isolation. 3. Record review of Resident #29's admission record, dated 08/21/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included acute and chronic respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood), tracheostomy status (a surgical opening in the neck directly to the breathing tube/trachea), hypotension (low blood pressure), gastrostomy status (a surgical opening directly to the stomach through the abdomen), nontraumatic intracerebral hemorrhage (bleeding within the brain without any external injury), and hemiplegia and hemiparesis (weakness and inability to move half of the body). Record review of Resident #29's medical record on 08/21/2025 reflected no submitted and accepted MDS due to Resident #29's recent admission on [DATE]. Record review of Resident #29's care plan, dated 08/19/2025, did not mention Enhanced Barrier Precautions Record review of Resident #29's order summary, dated 08/21/2025, reflected, Enhanced Barrier Precaution: PPE required for high resident contact care activities. Indication: TRACHEOSTOMY AND G-TUBE. 4. Record review of Resident #70's admission record, dated 08/21/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included spina bifida (a birth defect that occurs when the neural tube, which forms the spine and spinal cord, does not close completely during early development in pregnancy), syndrome of inappropriate secretion of antidiuretic hormone (a condition where the body makes too much antidiuretic hormone causing water retention and low sodium levels), elevated white blood cell count (diagnosis can indicate infection, inflammation, or immune system disorders), hypertension (high blood pressure), pressure ulcer of sacral region, stage 4 (a wound that extends through all layers of skin, exposing underlying muscle, tendon, or bone caused by pressure to the lower triangular area of the spine), neuromuscular dysfunction of bladder (when there is a problem with the brain, nerves, or spinal cord that affects bladder control), and colostomy status (a surgical opening for the colon through the abdomen). Record review of Resident #70's comprehensive admission MDS, dated [DATE], reflected a BIMS score of 15, which indicated no cognitive impairment. It reflected she had an indwelling catheter, an ostomy, and a pressure ulcer/injury. Record review of Resident #70's care plan, dated 08/15/2025, reflected [Resident #70] has a documented Pressure Ulcer that was present on admission. Care plan also reflected [Resident #70] is at risk for infection related to foley catheter. Care plan had no mention of Enhanced Barrier Precautions. Record review of Resident #70's order summary dated 08/21/2025 reflected, Enhanced Barrier Precaution: PPE required for high resident contact care activities. Indication: open wounds, catheter, colostomy every shift.Observation on 08/19/2025 at 9:39 AM Resident #65 and Resident #86's room (room [ROOM NUMBER]) had signs outside the door reflecting contact isolation signs. The signs had the proper PPE to wear when giving care and how to don (place gowns and gloves on prior to giving care) and doff (removing gowns and gloves after giving care) the PPE. There was a container outside the room with red bags for disposing PPE, gowns, and gloves. Observation and interview in Resident #86's room on 08/19/2025 at 9:45 AM revealed CNA C doffed her gown and placed it in a clear plastic bag. She was wearing same gloves after giving care to Resident# 65. CNA C pulled back the privacy curtain to speak to Resident # 86. CNA C picked up the call light off the floor and placed it on Resident # 86's bed sheets. Resident #86 stated she accidently knocked it off the bed. CNA C touched Resident #86's left hand while wearing same gloves. CNA C picked up the clear plastic garbage bag with several gowns and gloves in the bag. There was a hole to the right side of the clear plastic garbage bag. CNA C placed the contaminated gowns and gloves in the clear plastic bag on the seat of Resident #86's wheelchair. Interview on 08/19/2025 at 9:58 AM CNA C stated she did not follow the infection control rules. She stated she was to doff the gloves and wash her hands prior to touching the call light and Resident #86's arm. She stated if another staff or visitor came into the room and had a scratch or open area on their fingers or hand, there was a possibility they may become contaminated with MRSA if they touched the call light. She stated the wheelchair was also contaminated after she placed the clear plastic bag in the wheelchair. CNA C stated there was a hole to the right side of the bag and she was going to hold it together as she carried the bag to the dirty utility room. She stated she had been in-serviced on contact isolation and infection control. CNA C stated she did not recall the exact date or time of the in-service.Observation on 08/21/2025 at 09:32 AM revealed LVN E did not wear a PPE gown when administering medication through Resident #29 gastrostomy tube. Observation outside of the room revealed a 3-drawer tote filled with PPE and 2 signs that indicated the use of EBP precautions was needed for Resident #29. Interview on 08/21/2025 at 09:51 AM, LVN E stated she forgot to wear a gown to give medications to Resident #29. She stated EBP were to protect the resident from infection. She stated by not wearing a gown during medication administration through a gastrostomy tube then the resident could be exposed to bacteria and contract an infection. Observation on 08/21/2025 at 12:57 PM revealed CNA F and CNA G transferred Resident #70 using a mechanical lift from the wheelchair to the bed, but the CNAs did not wear a gown for EBP PPE. Observation outside of the room revealed a 3-drawer tote filled with PPE and 2 signs that indicated the use of EBP precautions was needed for Resident #70.Interview on 08/21/2025 at 01:33 PM, CNA G stated resident #70 required PPE including a gown for any direct patient care including transfers with a mechanical lift. She stated she forgot to wear a gown when providing care to Resident #70. She stated the resident could be exposed to bacteria and get an infection if EBP PPE was not used when providing direct resident care. Interview on 08/21/2025 at 01:36 PM, CNA F stated he did not wear PPE including a gown while providing direct care during a mechanical lift transfer for Resident #70. He stated he did not normally work with Resident #70 and did not know she required EBP. CNA F stated he did not see the drawers with PPE or the signs outside the door. He stated he was unsure why a resident would require EBP, but he stated by not wearing PPE he could make the resident sick by transmitting bacteria. Interview on 08/21/2025 at 1:59 PM the MDSN stated infection control protocol was to be followed especially if someone was on contact isolation. She stated touching anything with contaminated gloves was considered cross contamination. The MDSN stated any time someone was on contact isolation it was expected to be care planned. She stated she would need to review Resident # 86 and Resident # 65's care plan to determine if contact isolation were care planned and she would inform the surveyor with the information she gathered from their medical records. She never reported any information to surveyor prior to exit. Interview on 08/21/2025 at 2:24 PM the Treatment Nurse stated Resident #65, and Resident #86 was on contact isolation. She stated both residents had MRSA but in different areas. She stated she would need to review their medical charts and would give the areas on both residents (Resident #65 and Resident #86) and would report to surveyor. The treatment nurse never reported this information to surveyor prior to exit. She stated both residents were on contact isolation. The treatment nurse stated both residents required for gowns and gloves to be worn when giving care to both residents. She stated contact isolation was expected to be care planned. She stated if it was not care planned the staff would not have the information, they needed to know why the residents was on contact isolation. The treatment nurse stated if a staff had contaminated gloves on, picked up call light, and placed it on the bed the call light may become contaminated. She stated if a staff or family member visited the resident and had open area on their fingers or hand the person may become contaminated with MRSA. She stated the staff was not to place clear garbage bag full of contaminated gowns and gloves in a wheelchair. She stated the wheelchair would be considered contaminated. She stated if there was a hole in the clear plastic bag and the staff carried the bag down the hall there was a potential if another resident had open area on their arm and touched the contaminated gowns/gloves in the plastic bag, the resident may become contaminated with MRSA. She stated she had been in-serviced on infection control and she was the infection control preventionist. She did not recall the date of her training. Interview on 08/21/2025 at 2:50 the DON stated the staff was to doff gloves and wash hands prior to doing anything for a resident. She stated the staff did contaminate the call light and possibly the resident's hand. She stated if another staff or visitor touched the call light and had an open area on their hand there was a possibility the staff or visitor may become contaminated with MRSA. She stated Resident #65 and Resident #86 both had MRSA. The DON stated the staff was expected to follow infection control protocol. She stated the staff did not follow infection control protocol when she did not remove her gloves when she picked up the call light. She also stated the staff was not to place the clear plastic bag of gowns and gloves in a resident's wheelchair. She stated this was cross contamination. The DON stated anytime residents were on contact isolation this was required to be care planned. She stated anytime a resident had any type of infection the care plan was to reflect all interventions required to heal the infection. The DON did not respond to other questions related to why it was important for infection and contact isolation needed to be care planned. Interview on 08/21/2025 at 04:49 PM, the TN (who is also the infection preventionist) stated she had worked at the facility for 3 weeks. She stated the purpose of EBP was to prevent transmission of bacteria from staff to the resident who may be immunocompromised (their immune system was not functioning properly). She stated that all residents who have any open wounds or surgical/artificial openings, including a foley catheter and gastrostomy tube, required EBP. The TN stated she expected anyone, including staff and family, to wear PPE, including a gown, when providing direct care to residents with indications for EBP. She stated there were signs up and PPE in drawers outside of the residents' rooms that required EBP. The TN stated staff that were administering medication through a gastrostomy tube or using a mechanical lift to transfer a resident with a catheter or wound to wear a gown when they provided the care. She stated not wearing a gown while providing care to the residents that required it could lead to infection, deterioration of condition, sepsis (a severe infection), or even death. The TN stated she had just taken the role that week to monitor for compliance among staff. She stated she provided monthly in-services and quarterly checkoffs related to infection prevention.Interview on 08/21/2025 at 05:18 PM, RN D stated PPE was used when providing direct care to residents who have a gastrostomy tube or foley catheter. He stated EBP required the use of gown and gloves. RN D stated using such precautions protected the resident from getting an infection. He stated anyone who provided care to the resident was responsible for wearing gown and gloves. Interview on 08/21/2025 at 05:36 PM, the DON stated she took over as DON on 07/21/2025. She stated residents that had open wounds, tracheostomies, catheters, or other invasive lines required EBP. The DON stated she expected anyone who provided direct care to residents with those conditions to wear PPE, which included gown and gloves, when they provided care to the resident. She stated that the charge nurses, the ADON and herself were responsible for monitoring for compliance with using the correct PPE. The DON stated not wearing PPE for the residents that required it could introduce infection to those residents. Interview on 08/21/2025 at 06:02 PM, the ADM stated she took over as ADM approximately 2 months prior. She stated residents that have a catheter, a colostomy, a tracheostomy, or a gastrostomy tube required EBP. She stated that any staff that provide direct care for those residents are required to wear a gown and gloves. The ADM stated nursing management monitored proper usage of EBP during their quality-of-life rounds. She stated not using the correct PPE while providing direct care to those who require it could introduce infection to the resident. Record Review of facility's Policy on Isolation- Initiating Transmission- Based Precautions, dated October 2018, reflected Transmission- Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or had a laboratory confirmed infection; and is at risk for transmitting the infection to other residents. Transmission - Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission-Based Precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. Record review of, undated, facility policy titled, Monitoring Compliance with Infection Control reflected: Policy StatementRoutine monitoring and surveillance of the workplace will be conducted to determine compliance with infection prevention and control policies and practices.Policy Interpretation and Implementation1. The infection preventionist or designee shall monitor the effectiveness of our infection prevention and control work practices and protective equipment. This includes, but is not limited to: .f. Effective use of disposable gloves and other personal protective equipment to prevent spread of infection. Record review of facility in-service titled Enhance Barrier Precaution, dated 06/09/2025, reflected: Enhanced Barrier Precautions (EBP) are an infection control intervention that expands the use of gowns and gloves, beyond standard precautions, during high-contact resident care activities to prevent the spread of multi drug-resistant organisms (MDROs). Use gown and glove specific examples of high-contact activities requiring EBP.TransferringDevice care or use (central line, urinary catheter, feeding tube, tracheostomy) .

Based on observations, interviews, and record review the facility failed to maintain essential kitchen equipment in safe operating conditions and according to manufacturers' specifications for the facility's one walk-in refrigerator and one walk-in freezer. 1. The facility failed to ensure that the walk-in freezer temperature was in safe operating conditions of 0 . 2. The facility failed to ensure the walk-in refrigerator's cooling fans were in safe operating conditions. These failures could place residents at risk for health complications, foodborne illnesses, and decreased quality of life. Findings include: Observation in the kitchen on 08/19/2025 at 4:37 PM revealed the walk-in freezer thermometer panel mount temperature was reading 3 . Observation in the kitchen on 08/20/2025 at 10:59 AM revealed the walk-in freezer thermometer panel mount temperature was reading 3 . Observation and interview in the kitchen on 08/20/2025 at 11:00 AM revealed a slow steady water leak from the bottom of the refrigerator cooling fans dripping into a large black plastic bin positioned directly underneath. CDM stated this was a new leak that has been reported to the maintenance staff for immediate repairs. She stated the black plastic bin is to keep the water from leaking onto the food stored on the shelf. She stated all packaged food was removed from this shelf temporarily awaiting repairs. She stated she believes the walk-in freezer temperature is above 0 as staff have been in and out of it this morning prepping foods for the day and organizing frozen foods. During an interview on 08/20/2025 at 1:13 PM, MAIN stated kitchen work orders are managed by him and one other staff. He stated he will reach out to 3rd party contractors if unable to make a repair himself, such as the walk-in refrigerator and walk-in freezer. He stated the leak was reported to him last week some time, the refrigeration contractor visited the facility last week to look at it. He stated there was a delivery last week and staff had the refrigeration doors open, and a lot of condensation was building up when the contractor was assessing. He stated the contractor recommended for him to look at adding some fans to the refrigerator, so it does not create condensation. He stated he also believed since the freezer doors were open for delivery it caused the temperature to rise. He stated kitchen staff are emptying the black plastic bin during morning and night shifts. He stated he has been researching how to run fans for the condensation build up, and he will have to put in electrical system to install the fans. He stated he looked at the inside of the refrigerator not draining. He said he was not sure about the water build up. He said he was looking getting air curtains for the doors. He stated he has requested invoices and estimates for this work. MAIN stated if water were to leak onto the stored food staff should not use as this could affect the residents and make them sick. Surveyor requested work orders submitted for temperatures and water leak concerns, invoices, and estimates from contractors regarding recommendations and repairs and recommended plan to repair the refrigeration systems. These items were not provided prior to exit. Observation on 08/21/2025 at 9:00 AM revealed the walk-in freezer thermometer panel mount temperature was reading 15 and the 2 dial freezer thermometer located in the walk-in freezer was reading 30 . Observation on 08/21/2025 at 9:07 AM revealed the walk-in freezer thermometer panel mount temperature was reading 15 and the 2 dial freezer thermometer located in the walk-in freezer was reading 18 . Observation and interview on 08/21/2025 at 9:11 AM revealed the large black plastic bin positioned directly underneath the cooling fans in the walk-in refrigerator was filled with dirty water that has leaked into it. CDM stated the black bin fills throughout the day and is dumped out every morning and evening shift. She removed the plastic bin to drain water, and the piping of the refrigerator was exposed and had rust and black tape wrapped around the hinges. Observation and interview on 08/21/2025 at 9:12 AM revealed the left side of the cooling fans also had a very slow leak and had dripped into the black large plastic bin that contained cheese blocks. The CDM stated the leak had not been a concern to the left side of the cooling fans and she was not aware of any additional leaks. During an interview on 08/21/2025 at 9:12 AM KH N stated she has been employed a year at this facility and the black plastic bin has been there the entire time and staff have been tasked with emptying out daily. She stated MAIN has been notified numerous times of this concern. She stated residents can become ill if the food is contaminated with leaking water. She stated all staff are responsible for reporting any faulty equipment to the CDM to submit work orders for repairs. During an interview on 08/21/2025 at 9:12 AM, CDM stated she has been employed at the facility since March 2025. She stated the MAIN has been notified numerous times of the walk-in refrigerator leak and walk-in freezer temperatures. She stated she has entered work orders in TELS (software to manage work orders), and MAIN would have access to these workorders. She stated this was a concern that the dietician had addressed with her during her last visit and quality assurance evaluation on 08/08/2025. She stated she is aware this malfunction can be harmful to residents and insisted she has notified the MAIN and ADM of the concerns. During an interview on 08/21/2025 at 9:30 AM, KH O stated that she has been aware of the walk-in refrigerator leak for 2-3 months now. She stated the CDM is aware of the problem. She stated foods can become dangerous for residents if water drips onto it. During an interview on 08/21/2025 at 9:38 AM, CK L stated the leak in the walk-in refrigerator has been ongoing for some time and has not been repaired. She could not recall timeframes but believes a few months. She stated maintenance has assessed the issue and has tried to repair a few times now, but no success. She stated the leak could damage the food stored in the walk-in refrigerator and could make residents sick if water is leaking onto the food. She stated the freezer temperatures have also been reported to CDM and MAIN. She stated MAIN will come in and check the temperature and state the freezer door remains open too long and causes the temperature to go above 0 . She stated the dietitian also addressed this concern a few times during visits. During an interview on 08/21/2025 at 9:53 AM, MAIN stated he talked to a contractor for an estimate to repair the walk-in refrigerator. He stated the parts were not ordered as he had mentioned in an earlier interview. He stated parts have yet to be ordered as the contractor has yet to provide him with an estimate and timeframe to repair the walk-in refrigerator. He stated if the leaking water were to get onto the food stored in the refrigerator it could become contaminated and can cause the residents to become ill. During an interview on 08/21/2025 at 10:00 AM, ADM stated that she was aware of the walk-in refrigerator leak and freezer temperature gauge was having adjustment concerns that were brought to her attention around the 7th or 11th of August 2025. She stated the dietician visited the facility for her monthly evaluations and this concern was discussed and a work order was submitted immediately. She stated KH N is a disgruntled employee and told staff she would be getting people in trouble with the State and is giving an inaccurate timeframe of the walk-in refrigerator leak concerns. She stated her MAIN has been on top of these repairs and it seems to have reached the pinnacle and now needs a contractor that is knowledgeable in repairing refrigeration systems. She stated the MAIN was working on this work order and was trying to get the contractor to provide an estimate for repairs. She stated she was not sure why the delay in getting this estimate to begin the repairs. She stated she will be contacting the contractor herself today to let him know their walk-in refrigerator is a priority and he needs to be here today to repair the leaking refrigerator and the temperature gauge for the walk-in freezer or she would be canceling his contract with the facility. Observation on 08/21/2025 at 12:22 PM revealed two 2 dial freezer thermometers were reading 2 and the other reading 36 . Review of Work Order #1930 created on 08/11/ 2025 titled, Condensation walker in cooler revealed it was submitted for the kitchen and requested by CDM with a medium priority. Status was set to in-progress by MAIN. No details as to the work order progress. Review of third-party contractor email, 08/20/2025 1:32 PM, titled WIC (walk in cooler) revealed correspondence from contractor to MAIN, Per our recent conversation about our site visit last week, I am still working with the manufacture on upgrading the drainage system and installing additional ventilation. I will reach back out for an update and circle back to you shortly. Review of third-party contractor email, 08/21/2025 10:35 AM, titled Walk in cooler and Freezer revealed correspondence from contractor to MAIN, Touching base again, I was able to produce a resolution with the manufacturer on your Walk In cooler Issues. I have a tech that will be on site today between 3-5, He will also be addressing any temporary issues with your freezer while on site also. Review of facility report, 08/20/2025, titled Work Order revealed closed work orders submitted for repairs from 05/15/2025 to 08/20/2025: Work order #1811 submitted on 06/26/2025 by CDM, summary request adjust temperature of freezer. Work order #1933 submitted on 08/13/2025, no staff listed, summary request sealed cooler cracks. Review of facility reports, 06/10/2025 to 08/08/2025, titled QA I Monitor revealed the kitchen underwent monthly quality assurance evaluations conducted by the facilities' licensed dietician and results were reviewed and shared with the CDM and ADM. Areas of non-compliance and comments provided by dietician include: 08/08/2025 Section 5: Food Storage: Refrigerators (32-41 ) and freezers (0 or lower) at proper temperature; logs complete, internal thermometers present in each cooler/freezer.Foods free from freezer burn, dried out appearance, or other signs of quality change. Shelves, interior fans, gaskets, floors, walls clean and in good repair, shelves not lined with paper. Section 8: General Comments and Progress from Last Report: condensation continues with fresh produce continually stored beneath despite RD encouragement to relocate - this is significant contamination risk. 07/10/2025 Section 5: Food Storage: Coolers and freezers not overstocked to promote air circulation.Foods free from freezer burn, dried out appearance, or other signs of quality change. Section 8: General Comments and Progress from Last Report: significant condensation in fridge dripping into pan but also outside onto RTE foods - RD encouraged placing in TELS (software to manage work orders) and removing open RTE food from the area. Review of facility spreadsheet, undated, untitled, revealed dietician outlined problem areas in the kitchen, goals to correct, and specific tasks to successfully meet goals: 08/08/2025 Condensation leakage continues onto ready to eat foods despite RD encouragement for relocation of high-risk foods; interior of refrigerators/freezers are clean, and parts are in good repair; REMOVE ALL OPEN/READY TO EAT FOODS FROM BELOW CONDENSER. Comments: ensure storage of ready to eat items are free from condensation - no changes in last 3 visits with this issue. Review of facility policy undated, titled Refrigerators and Freezers revealed, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Refrigerators and/or freezers are maintained in good working condition. 4. The supervisor takes immediate action if temperatures are out of range. Actions necessary to correct the temperatures are recorded on the tracking sheet, including the repair personnel and/or department contacted. 8. Maintenance will inspect refrigerators and freezers for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. Review of facility policy, undated, titled Maintenance Service revealed, 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: f. Establishing priorities in providing repair service. h. Providing routinely scheduled maintenance service to all areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles, for 2 of 3 (SW, and Marketing) staff reviewed for training in Care Plans and PASRR services in that:The facility failed to train the Social Worker in the assigned SW areas in the PASRR, and updating the Care Plans for advance directives. The facility failed to train the Marketing person about ensuring a PASRR was received at admission.This failure could place residents at risk for harm by not having a complete and accurate care plan or having a PASRR completed to support the residents needs and preferences. The finding included:Resident #7 Review of Resident #7's face sheet dated [DATE] revealed an [AGE] year-old male who was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (paralysis and weakness on right side after stroke), muscle weakness, dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), lack of coordination, adjustment disorder, hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), repeated falls, cerebral infraction (long term effects of a stroke), and protein-calorie malnutrition (inadequate intake of both protein and calories). Review of Resident #7's quarterly MDS dated [DATE] revealed Resident #7 had a BIMS of 08 indicating moderate impairment. The MDS also did not have Resident #7's code status. Record review of Resident #7's care plan dated [DATE] revealed Resident #7 revealed that Resident #7 was a full code. Goal was Resident #7 would be provided with necessary resuscitative measures. Interventions were to advise MD, RP & family of any changes in condition per facility policy. Educate and discuss with resident/family about Full Code status versus OOHDNR code status on an annual basis or as needed. Review Advanced Directives with resident/family annually, upon change in condition andas needed. Record review of Resident #7's Advance Directive Order dated [DATE] revealed Resident #7 was a DNR. Record review of Resident #7's OOHDNR dated [DATE] had all the required signatures. Resident #17 Record review of Resident #17's admission sheet, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cystitis without hematuria (inflammation of the bladder), somatization disorder (tendency to experience and express psychological distress as physical symptoms), fusion of the spine (surgical procedure that connect two or more parts in the spine), muscle weakness, congenital malformation of nervous system (birth defect that affects the structure and development of the brain and spinal cord), lack of coordination, anxiety disorder (feeling of uneasiness or worry) and hypertension (high blood pressure). Record review of Resident #17's admission MDS assessment, dated [DATE], revealed Resident #17 had a BIMS score of 13, indicating intact cognitive response; mood indicators were present including little interest or pleasure in doing things, feeling down, depressed, or hopeless. The MDS also had somatization disorder (tendency to experience and express psychological distress as physical symptoms), and anxiety disorder (feeling of uneasiness or worry) as active diagnoses. Record review of Resident #17's care plan, dated on [DATE] noted the resident used an anti-anxiety medication r/t anxiety. The goal was that Resident #17 would be free from discomfort or adverse reactions related to anti-anxiety therapy. The interventions were Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucination. Record review revealed that Resident #17 did not have a PASRR completed. Resident #31 Review of Resident #31's face sheet dated [DATE] revealed an [AGE] year-old male who was admitted on [DATE] with diagnoses including muscle weakness, neurocognitive disorder with Lewy bodies (type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), vascular dementia (lack of blood that carries oxygen and nutrients to a part of the brain), anxiety (feeling of uneasiness or worry), hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), hyperlipidemia (high cholesterol), fall and anemia (not enough healthy red blood cells). Review of Resident #31's quarterly MDS dated [DATE] revealed Resident #31 had a BIMS of 12 indicating moderate impairment. The MDS also did not have Resident #31's code status. Record review of Resident #31's care plan dated [DATE] revealed Resident #31 revealed that Resident #31 did not have a code status on his care plan. Record review of Resident #31's Advance Directive Order dated [DATE] revealed Resident #31 was a DNR. Record review of Resident #31's OOHDNR dated [DATE] had all the required signatures. During an interview with the SW on [DATE] at 2:38p.m., revealed that she had not been trained on care plans. She said that she did not know what the policy was for the care plans. She said that she did not know who was responsible for updating the advance directives. She said the code status is in the care plan. She also said that if a resident changed their code status she would wait until she got the completed DNR back before she would update the care plan. She said she had two weeks to update the care plan. She said if the code status were not updated a resident who was a DNR could possibly be given CPR. She said she did not know why Resident #7's code status was not updated. She also said she did not know why Resident #31's code status was not in the care plan. She also stated that she did not have anything to do with PASRR. During an interview with Resident #17 on [DATE] at 11:02 a.m., Resident #17 said that she was diagnosed with her mental disorders when she was [AGE] years old. She said that she is taking anxiety medication. She said that the only other service that she is getting for her mental illness is seeing the psychiatrist. During an interview with Marketing on [DATE] at 11:30pm revealed that she had not been completely trained on PASRR. She said that she was responsible for making sure that the resident had a PASRR when they entered the facility. She said the only training she got on PASRR was that the PASRR needed to be filled out. She said she could not answer the question of the process, or referrals. She also said she did not know when the PASRR should be done. She said all she knew was that the resident needed a PASRR when the resident admitted to the facility for skilled. She said she did not know that she needed a PASRR for long term care. She said she was confused on that part. She said she did not know what to do if a resident had a positive PASRR. She said that her job was to go out and educate the community about the facility's services. She said when a referral came in, she would just send an email with the resident's clinical records. She said she did not know what could happen to the residents if they did not have a PASRR. She said she did not know why the Resident #17 did not have the PASRR on admission. During an interview with the ADM on [DATE] at 11:40 a.m., revealed that she had been trained on PASRR. She said that the SW was responsible for doing PASRRs. She also said that the SW was responsible for ensuring all residents had a PASRR. She said she did not have a policy for PASRR. She said that the facility would get the PASRR for the resident from the hospital and if the resident were coming from the community the facility would have the family fill the PASRR out. She said all residents were to have a PASRR completed prior to admission into the facility. She said the facility would identify residents with possible MI or ID through the PASRR screening. She said the resident with a qualifying diagnosis should be referred to the PASRR person and a meeting set up with PASRR people. She said the facility did not have anyone who ensured staff competency in PASRR. She said if a resident did not have a PASRR the facility would not recognize if the resident were positive or not and the resident could be missing services. She said Resident #17 did not have a PASRR because Marketing did not get the PASRR on admission. During an interview with the ADM on [DATE] at 3:50p.m., revealed that she had been trained on care plans. She said the IDT team, MDS nurse, therapy and nursing were responsible for doing the care plan. She said all the resident's information, goals, focus for the resident and the resident's discharge plans were on the care plan. She said the care plan had to be completed in 7 days and was updated quarterly. She said the SW was responsible for updating the advance directives. She said the advance directives were to be updated immediately. She said if the care plan is not updated or did not have a resident's advance directive it could affect the outcome if something happened to the resident. She said that the SW knew that she was supposed to update the Advance directives. She said she did not know why Resident #7's advance directive was not updated. She also said she did not know why Resident #31's advance directive was not on the care plan. During an interview with the DON on [DATE] at 4:17p.m., revealed she had not been trained on care plans. She said she was knowledgeable from working in PCC and knew how to do the care plans. She said that the RN opened the care plan, the MDS followed up and the DON reviewed the care plan. She said the care plan had the resident's skin integrity, medication, if the resident refused medication, any chronic conditions, advance directives, and infections. She said she did not know how long the facility had to complete the care plan. She did say that the baseline care plan had to be updated within 48 hours. She said that the care plan was updated quarterly or as soon as a significate change happened. She said advance directives did go on the care plan. She said if a resident went from a full code to DNR the facility had to do a document and uploaded. She said then the code status needed to be changed in the care plan. She said if an advance directive was not correct on the care plan staff may do CPR on a resident who should not be getting CPR. She said she did not know why Resident #7's advance directive was not updated. She also said she did not know why Resident #31's advance directive was not on the care plan. Record review of Marketings employee training dated [DATE] revealed she did not have any documentation for PASRR training. Record review of SW employee training dated [DATE] revealed she did not have any documentation of training for PASRR or Care Plans. Staff Training Policy was requested from the ADM on [DATE] at 11:13am. The policy was not provided upon exit.

Based on observations, interviews, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen and the facility's only nourishment room reviewed for food and nutrition services. 1. The facility failed to label and date food items in the only walk-in refrigerator. 2. The facility failed to label and date food items in the only nourishment refrigerator.3. The facility failed to maintain the proper temperature of the refrigerator in the nourishment room.4. The facility failed to ensure that the walk-in freezer was maintained at acceptable temperatures which resulted in frozen foods thawing out and then re-freezing without being discarded. 5. The facility failed to ensure that foods were stored away from leaks of malfunctioning cooling fans in the walk-in refrigerator. 6. The facility failed to ensure food products are discarded on or before the expiration date. 7. The facility failed to maintain temperature logs to monitor the nourishment refrigerator to ensure that it is functioning properly. These failures could place residents at risk for health complications, weight loss, foodborne illnesses, and decreased quality of life. Findings include: Observation and interview on 08/19/2025 at 4:30 PM revealed a large metal tray containing opened cooked ham with lid and label of prepared date 08/10/2025 and use by date 08/17/2025 stored in the walk-in refrigerator. The CDM stated the discard date for this food item should be within 7 days of prepared date. She stated it was now 9 days after prepared date and should not be in the refrigerator. She was observed removing the metal tray from the refrigerator to discard food item. Observation on 08/19/2025 at 4:37 PM revealed the walk-in freezer thermometer panel mount temperature was reading 3 . Observation on 08/20/2025 at 10:59 AM revealed the walk-in freezer thermometer panel mount temperature was reading 3 . Observation and interview on 08/20/2025 at 11:00 AM revealed a slow steady water leak from the bottom of the refrigerator cooling fans dripping into a large black plastic bin positioned directly underneath. CDM stated this was a new leak that has been reported to the maintenance staff for immediate repairs. She stated the black plastic bin is to keep the water from leaking onto the food stored on the shelf. She stated all packaged food was removed from this shelf temporarily awaiting repairs. She stated she believes the walk-in freezer temperature is above 0 as staff have been in and out of it this morning prepping foods for the day and organizing frozen foods. Observation on 08/20/2025 at 11:33 AM revealed salad plates with plastic wrap and plastic salad bowls with lids unlabeled and undated in the walk-in refrigerator. CDM immediately grabbed food items and went to add labels to them. During an interview on 08/20/2025 at 1:13 PM, MAIN stated kitchen work orders are handled by him and one other staff. He stated he will reach out to 3rd party contractors if unable to make a repair himself, such as the walk-in refrigerator and walk-in freezer. He stated the leak was reported to him last week some time, the refrigeration contractor visited the facility last week to look at it. He stated there was a delivery last week and staff had the refrigeration doors open, and a lot of condensation was building up when the contractor was assessing. He stated the contractor recommended for him to look at adding some fans to the refrigerator, so it does not create condensation. He stated he also believed since the freezer doors were open for delivery it caused the temperature to rise. He stated kitchen staff are emptying the black plastic bin during morning and night shifts. He stated he has been researching how to run fans for the condensation build up, and he will have to put in an electrical system to install the fans. He stated it would be best if he looked at the inside of the refrigerator, not draining, not sure about the water build up, and look at air curtains for the doors. He stated he has requested invoices and estimates for this work. MAIN stated if water were to leak onto the stored food, staff should not use it as this could affect the residents and make them sick. Surveyor requested work orders submitted for temperatures and water leak concerns, invoices, and estimates from contractors regarding recommendations and repairs and recommended plan to repair the refrigeration systems. These items were not provided prior to exit. Observation on 08/21/2025 at 9:00 AM revealed the walk-in freezer thermometer panel mount temperature was reading 15 and the 2 dial freezer thermometer located in the walk-in freezer was reading 30 . Observation on 08/21/2025 at 9:07 AM revealed the walk-in freezer thermometer panel mount temperature was reading 15 and the 2 dial freezer thermometer located in the walk-in freezer was reading 18 . Observation and interview on 08/21/2025 at 9:11 AM revealed the large black plastic bin positioned directly underneath the cooling fans in the walk-in refrigerator was filled with dirty water that has leaked into it. CDM stated the black bin fills throughout the day and is dumped out every morning and evening shift. She removed the plastic bin to drain water, and the piping of the refrigerator was exposed and had rust and black tape wrapped around the hinges. Observation and interview on 08/21/2025 at 9:12 AM revealed the left side of the cooling fans also had a very slow leak and had dripped into the black large plastic bin that contained cheese blocks. The CDM stated the leak had not been a concern to the left side of the cooling fans and she was not aware of any additional leaks. She stated the cheese is unopened and did not leak into it but believes it would be best to discard. She was observed removing the cheese from walk-in refrigerator. During an interview on 08/21/2025 at 9:14 AM KH N stated she has been employed a year at this facility and the black plastic bin has been there the entire time and staff have been tasked with emptying the water out daily. She stated MAIN has been notified numerous times of this concern. She stated residents can become ill if the food is contaminated with leaking water. She stated all staff are responsible for reporting any faulty equipment to the CDM to submit work orders for repairs. During an interview on 08/21/2025 at 9:16 AM, CDM stated she has been employed at the facility since March 2025. She stated the MAIN has been notified numerous times of the walk-in refrigerator leak and walk-in freezer temperatures. She stated she has entered work orders in TELS (software to manage work orders), and MAIN would have access to these workorders. She stated this was a concern that the dietician had addressed with her during her last visit and quality assurance evaluation on 08/08/2025. She stated she is aware this malfunction can be harmful to residents and insisted she has notified the MAIN and ADM of the concerns. During an interview on 08/21/2025 at 9:30 AM, KH O stated labeling and dating food items are required for every food opened or stored in the walk-in refrigerator and freezer. She stated if food is not labeled it can be expired, be no good and can cause residents to become ill if used. She stated that she has been aware of the walk-in refrigerator leak for 2-3 months now. She stated the CDM is aware of the problem. She stated foods can become dangerous for residents if water drips onto it. During an interview on 08/21/2025 at 9:38 AM, CK L stated she has been employed for 1 year and 8 months at this facility and she has many different duties which include the CDM's right hand as she is new. She stated kitchen labeling and dating training occurred a few months back. She stated the purpose of wrapping and labeling food is to know if the food is good. She stated food can go bad if not labeled, not sure if expired and could make the residents sick if used. CK L stated the leak in the walk-in refrigerator has been ongoing for some time and has not been repaired. She could not recall timeframe but believes a few months. She stated maintenance has assessed the issue and has tried to repair a few times now, but no success. She stated the leak could damage the food stored in the walk-in refrigerator and could make residents sick if water is leaking onto the food. She stated the freezer temperatures have also been reported to CDM and MAIN. She stated MAIN will come in and check the temperature and state the freezer door remains open too long and causes the temperature to go above 0 . She stated the dietitian also addressed this concern a few times during visits. During an interview on 08/21/2025 at 9:53 AM, MAIN stated he talked to a contractor for an estimate to repair the walk-in refrigerator. He stated the parts were not ordered as he had mentioned in an earlier interview. He stated parts have yet to be ordered as the contractor has yet to provide him with an estimate and timeframe to repair the walk-in refrigerator. He stated if the leaking water were to get onto the food stored in the refrigerator it could become contaminated and can cause the residents to become ill. During an interview on 08/21/2025 at 10:00 AM, ADM stated that she was aware of the walk-in refrigerator leak and freezer temperature gauge was having adjustment concerns that were brought to her attention around the 7th or 11th of August 2025. She stated the dietician visited the facility for her monthly evaluations and this concern was discussed and a work order was submitted immediately. She stated KH N is a disgruntled employee and told staff she would be getting people in trouble with the State and is giving an inaccurate timeframe of the walk-in refrigerator leak concerns. She stated her MAIN has been on top of these repairs and it seems to have reached the pinnacle and now needs a contractor that is knowledgeable in repairing refrigeration systems. She stated the MAIN was working on this work order and was trying to get the contractor to provide an estimate for repairs. She stated she was not sure why the delay in getting this estimate to begin the repairs. She stated she will be contacting the contractor herself today to let him know their walk-in refrigerator is a priority and he needs to be here today to repair the leaking refrigerator and the temperature gauge for the walk-in freezer or she would be canceling his contract with the facility. Observation and interview on 08/21/2025 at 11:34 AM, CNA F stated the kitchen staff deliver snacks to the only nurse's station three times a day (10 AM, 2 PM, 6 PM). He stated snacks that are not eaten after 2 hours are returned to the kitchen or discarded. He stated the evening snacks are stored behind a locked door in a small refrigerator. He stated without labels the snacks could be expired, but staff would not know. He stated this could cause the residents to become sick. Observation of the locked nourishment room containing the resident snack refrigerator revealed the refrigerator contained a tray of milk cartons without a label or date, cottage cheese with label with date of 8/12/2025 AM Snack for a specific resident, cartons of Mighty Shakes, Vanilla with label and date of 8/12/2025, pitcher with tape label nectar H2O without date, orange juice with lid without label or date. Also stored in the refrigerator was an unlabeled gallon of ice cream, birthday cake, bag of sodas, and bag of juices. All resident items were unlabeled. The refrigerator did not have a thermometer gauge, there was no temperature log in site, and the refrigerator needed cleaning and to discard expired food. CNA F stated the snack refrigerator stores all resident snacks and items brought in by family to store for a resident. He stated there is no temperature log for the refrigerator that he is aware of, and housekeeping is responsible for cleaning out the refrigerator and getting rid of the expired snacks not eaten. Observation of the freezer on 08/21/2025 at 12:22 PM revealed two 2 dial freezer thermometers were reading 2 and the other reading 36 . During an interview on 08/21/2025 at 3:30 PM, CNA J stated he is the staffing coordinator, he purchases central supplies and is responsible for updating the staffing board daily. He stated he is not aware of a specific staff assigned to the resident snack refrigerator. He believes maintenance is responsible for the temperature logs and housekeeping would be responsible for the upkeep of the refrigerator, and the kitchen staff would be responsible for labeling food. During an interview on 08/21/2025 at 4:40 PM, MAIN stated he is not aware of a temperature log for the resident refrigerator and was not aware that it required one. He stated there is no policy for the nutrition refrigerator specifically. He stated facility staff usually will clean out and discard food items from the nutrition refrigerator but no assigned staff. Review of Work Order #1930 created on 08/11/ 2025 titled, Condensation walker in cooler revealed it was submitted for the kitchen and requested by CDM with a medium priority. Status was set to in-progress by MAIN. No details as to the work order progress. Review of third-party contractor email, 08/20/2025 1:32 PM, titled WIC (walk in cooler) revealed correspondence from contractor to MAIN, Per our recent conversation about our site visit last week, I am still working with the manufacture on upgrading the drainage system and installing additional ventilation. I will reach back out for an update and circle back to you shortly. Review of third-party contractor email, 08/21/2025 10:35 AM, titled Walk in cooler and Freezer revealed correspondence from contractor to MAIN, Touching base again, I was able to produce a resolution with the manufacturer on your Walk In cooler Issues. I have a tech that will be on site today between 3-5, He will also be addressing any temporary issues with your freezer while on site also. Review of facility report, 08/20/2025, titled Work Order revealed closed work orders submitted for repairs from 05/15/2025 to 08/20/2025: Work order #1811 submitted on 06/26/2025 by CDM, summary request adjust temperature of freezer. Work order #1933 submitted on 08/13/2025, no staff listed, summary request sealed cooler cracks. Review of facility reports, 06/10/2025 to 08/08/2025, titled QA I Monitor revealed the kitchen underwent monthly quality assurance evaluations conducted by the facilities' licensed dietician and results were reviewed and shared with the CDM and ADM. Areas of non-compliance and comments provided by dietician include: 08/08/2025 Section 5: Food Storage: Refrigerators (32-41 ) and freezers (0 or lower) at proper temperature; logs complete, internal thermometers present in each cooler/freezer.All other food items covered, labeled, and dated. Received dates present on all items. Foods free from freezer burn, dried out appearance, or other signs of quality change. Shelves, interior fans, gaskets, floors, walls clean and in good repair, shelves not lined with paper. Section 8: General Comments and Progress from Last Report: Fridge/freezer temperatures prefilled for PM; condensation continues with fresh produce continually stored beneath despite RD encouragement to relocate - this is significant contamination risk. Improvement on labeling/dating, must remember to place open dates on all opened items both fridge/dry stock. 07/10/2025 Section 5: Food Storage: Coolers and freezers not overstocked to promote air circulation.Foods free from freezer burn, dried out appearance, or other signs of quality change. Section 6: Meal Service Observation Recipes followed.Nourishment room: clean, not out of date foods, temporary logs in use; N/A Section 8: General Comments and Progress from Last Report: significant condensation in fridge dripping into pan but also outside onto RTE foods - RD encouraged placing in TELS (software to manage work orders) and removing open RTE food from the area. Encouraged organizing freezer and labeling and dating items appropriately. 06/10/2025 Section 5: Food Storage:All other food items covered, labeled, and dated. Received dates present on all items. Food not expired or spoiled. Section 6: Meal Service Observation Nourishment room: clean, not out of date foods, temporary logs in use; N/A Section 8: General Comments and Progress from Last Report: Items addressed with CDM. RD to provide In-services on glove use, labeling and dating. Review of facility spreadsheet, undated, untitled, revealed dietician outlined problem areas in the kitchen, goals to correct, and specific tasks to successfully meet goals: 08/08/2025 Condensation leakage continues onto ready to eat foods despite RD encouragement for relocation of high-risk foods; interior of refrigerators/freezers are clean, and parts are in good repair; REMOVE ALL OPEN/READY TO EAT FOODS FROM BELOW CONDENSER. Comments: improvements in labeling/dating, ensure storage of ready to eat items are free from condensation - no changes in last 3 visits with this issue. Review of facility policy undated, titled Refrigerators and Freezers revealed, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Refrigerators and/or freezers are maintained in good working condition. 4. The supervisor takes immediate action if temperatures are out of range. Actions necessary to correct the temperatures are recorded on the tracking sheet, including the repair personnel and/or department contacted. 5. All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and ''use by dates are indicated once food is opened. 7. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan 7 days after each comprehensive assessment and no more than 21 days after admission for 2 of 5 residents (Residents #1 and Resident #2) reviewed for care plan revision and timing. 1. The facility failed to updated Resident #1's care plan to reflect Resident #1's foley catheter was removed in 2023. 2. The facility failed to implement a comprehensive care plan for Resident #2. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. Findings include: Review of Resident #1 face sheet reflected an [AGE] year-old man admitted on [DATE] with diagnoses of unspecified dementia (group of symptoms affecting memory, thinking, and social abilities), depression (mood disorder that causes persistent feelings of sadness and loss of interest in activities), dysphagia (difficulty swallowing), and type 2 diabetes (chronic condition where the body doesn't properly use insulin to regulate blood sugar). Review of Resident #1's care plan dated 09/27/2023 reflected Resident #1 had an indwelling foley catheter. Goal included catheter would be removed, when possible, over next 90 days with target date of 11/25/2025. Further review of care plan dated 09/26/2023 reflected Resident #1 was a new admission to SNF with goal to adjust to facility with target date of 11/25/2025. Review reflected Resident #1 had impaired cognitive function and required 1:1 staff assistance with toileting and hygiene. Review of Resident #1's orders reflected an order for catheter care every shift was discontinued on 10/02/2023. Review of Resident #1's NP progress note dated 10/05/2023 reflected foley catheter was discontinued. Review of Resident #1's quarterly MDS dated [DATE] reflected Resident #1's BIMS was not conducted as he was rarely or never understood. Review of MDS section H reflected none of the above was selected for bowel and bladder appliances. Indwelling catheter was not selected. Review of Resident #1's orders reflected an order for catheter care every shift was discontinued on 10/02/2023. Review of Resident #1's NP progress note dated 10/05/2023 reflected foley catheter was discontinued. Observation and attempted interview on 08/04/2025 at 11:16 AM revealed Resident #1 sat in the dining room with no foley bag observed on his wheelchair or leg. Resident #1 was unable to answer questions and mumbled as residents approached him. Review of Resident #2's face sheet reflected a [AGE] year-old man admitted on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage in brain stem (stroke where bleeding occurs within the brain stem), malignant neoplasm of prostate (prostate cancer), alcoholic cirrhosis of liver (breakdown of the liver due to alcohol use) and type 2 diabetes (chronic condition where the body does not properly use insulin to regulate blood sugar). Review of Resident #2 quarterly MDS dated [DATE] reflected a BIMS score of 11 which indicated a moderate cognitive impairment. Review of Resident #2's baseline care plan reflected a date of 05/24/2025. Review reflected Resident #2 was always incontinent of bowel and bladder. Review of Resident #2's chart on 08/05/2025 reflected he had no comprehensive care plan created. Resident #2 comprehensive care plan should have been created 21 days after admission on [DATE]. During an interview on 08/05/2025 at 3:01 PM, LVN A stated that cares are generated by an RN and include any devices a resident had and had information to care for the resident. During an interview on 08/05/2025 at 3:28 PM, the DON stated that for the comprehensive care plan, each discipline completed their section and stated that wounds were care planned by the wound nurse, antibiotics by the MDS coordinator and room information by the social worker. The DON stated that the MDS coordinator was responsible to start the comprehensive care plan. The DON stated that she expected every resident to have a care plan in place. The DON stated that the importance of the care plan was to monitor any changes and the resident's condition. The DON stated it showed the residents' baseline at admission and evaluates their status quarterly. The DON stated the care plan was updated quarterly. The DON stated that she did not think there was a definitive person that audited that care plans were updated or completed behind the MDS coordinator, but the DON reviewed care plans sporadically. During an interview at 08/05/2025 at 5:17 PM, LVN B stated that a care plan included general needs of the resident, behaviors, ADL needs and bowel and bladder information. LVN B stated that a care plan has the residents needs to be cared for. During observation and interview on 08/05/2025 at 3:47 PM, the MDS coordinator stated that her role for the comprehensive care plan was to open up or create the care plan if the resident was a new admission. The MDS coordinator stated that she updated the care plan with triggers from the MDS. The MDS coordinator stated that the care plan was also a working document and can be updated as things come up such as dietary changes or behaviors. The MDS coordinator stated that at the latest the care plan had to be completed 21 days after admission but could be completed sooner. The MDS coordinator stated that the importance of the care plan was that it was based on assessment and discovered potential problems, situation or things that needed to be addressed. The MDS coordinator was observed viewing Resident #2's care plan and stated there was no care plan in place and was blank. The MDS coordinator stated she was not in the role at that time and started at the facility on 07/07/2025 and had not reviewed all of the care plans. During an interview on 08/05/2025 at 5:22 PM, the ADM stated the purpose of the care plan was to create a plan of care for the resident upon admission through discharge. The ADM stated she expected the comprehensive care plan to be completed within 21 days of admission. The ADM stated that the care plan was updated every 90 days. The ADM stated she expected the catheter or treatment to be discontinued on the care plan when it occurred. The ADM stated each department was responsible for updating the care plan. The ADM stated there was not any process in place to follow up that care plans were updated behind the MDS coordinator, but there was an audit being completed and all care plans were being reviewed. Review of the facility policy titled Care Plans, Comprehensive Person-Centered with revision date of December 2016, reflected the comprehensive person-centered care plan was completed within seven days of the completion of the comprehensive assessment. The policy reflected that the IDT should review and update the care plan where there has been a significant change in the resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for seven (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) of 10 residents reviewed for pharmaceutical services. 1. The facility failed to ensure Resident #1 , Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7 received their medications scheduled at 5:00 pm on 05/25/25. Findings included: 1. Review of Resident #1's face sheet dated 06/02/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease, retention of urine, anxiety disorder, age-related physical debility, cognitive communication deficit, hypertensive heart disease and muscle weakness. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, indicating her cognition was intact. Review of Resident #1's care plan, dated 05/15/25 reflected Resident #1 was at risk for stomach discomfort related to s/s of GERD, chronic pain r/t osteoarthritis(degenerative joint disease) and spinal stenosis(spinal canal narrows) and decreased cardiac tissue perfusion related to history of CAD and HTN. The relevant intervention was administering medications as ordered by MD. Review of Resident #1's physician's order reflected: 1. Pepcid Oral Tablet 20 MG (Famotidine) :Give 1 tablet by mouth two times a day related to gastro esophageal reflux disease. 2. Artificial Tears Solution 1.4 % (Polyvinyl Alcohol): Instill 1 drop in both eyes two times a day for Dry Eyes 3. Gabapentin Oral Capsule 100 MG: Give 1 capsule by mouth two times a day for Neuropathy. 4. Carvedilol Oral Tablet 12.5 MG (Carvedilol): Give 1 tablet by mouth two times a day for HTN . Hold if SBP less than 100 or HR less than 60. Review of Resident #1's MAR reflected on 05/08/25 Resident #1 had not received Carvedilol Oral Tablet 12.5 MG , Gabapentin Oral Capsule 100 MG, Artificial Tears Solution, and Pepcid Oral Tablet 20 MG scheduled at 5:00pm. During an observation and interview on 06/02/25 at 10:10 am, Resident #1 stated she remembered she had not received her 5:00 pm medications on 05/08/25. She stated she reminded the staff she had not received her 5:00 pm medication and the staff responded to her that it was past 6:00 pm, and she would not be able to provide those medications as the medication administration window time was passed. Resident #1 stated this was not fair as she had crucial medications for her condition, and it was the responsibility of the staff to administer medications on time. During a telephone interview on 06/02/25 at 1:15pm, the FM of Resident #1 stated there were numerous occasions of evening medications that were not provided as reported by Resident #1. He stated providing medications on time was the responsibility of the facility and they were supposed to do this without the reminders by the residents. He stated he had to believe that there was no monitoring system to ensure the nurses were providing medications to residents on time, as scheduled, without any excuses. 2. Review of Resident #2's face sheet dated 06/02/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus , hypertensive heart disease without heart failure, morbid obesity , depression, muscle weakness, unsteadiness on feet, lack of coordination and cognitive communication deficit. Review of Resident #2's quarterly MDS assessment, dated 02/14/25, reflected a BIMS score of 12, indicating his cognition was moderately impaired. Review of Resident #2's care plan, dated 05/15/25 reflected he had bladder incontinence, at risk for skin breakdown and infection and nutritional imbalance . The relevant interventions were monitor/document for s/sx UTI and monitor and dietary/nutritional intake. Encourage adequate food/fluid intake. Review of Resident #2's physician's order reflected: 1. Cipro Oral Tablet 250 MG (Ciprofloxacin HCl): Give 1 tablet by mouth two times a day for UTI for 7 Days. -Start Date-05/22/2025. 2. Ferrous Sulfate Oral Tablet 325 (65 Fe): MG (Ferrous Sulfate): Give 1 tablet by mouth two times a day for Iron deficiency anemia. Monitor for constipation. -Start Date-05/22/2025. 3. Vitamin C Oral Tablet 500 MG(Ascorbic Acid): Give 1 tablet by mouth two times a day for Wound Healing. -Start Date-12/24/2024. 4. Magnesium Oxide Oral Tablet 400 MG (Magnesium Oxide): Give 1 tablet by mouth two times a day for supp -Start Date-04/16/2025 Review of Resident #2's MAR reflected, on 05/26/25 and 05/27/25 Resident #2 had not received Cipro Oral Tablet 250 MG, Magnesium Oxide Oral Tablet 400 MG, Vitamin C Oral Tablet 500 MG and Ferrous Sulfate Oral Tablet 325 MG, scheduled at 5:00pm 3. Review of Resident #3's face sheet dated 06/02/25 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, chronic obstructive pulmonary disease, type 2 diabetes mellitus, hypertensive heart disease, weakness and unsteadiness on feet Review of Resident #3's quarterly MDS assessment, dated 03/21/25, reflected a BIMS score of 7, indicating his cognition was moderately impaired. Review of Resident #3's care plan, dated 05/15/25 reflected Resident #3 used antidepressant medications to treat depression and anxiety . The relevant intervention was administering antidepressant medications as ordered by physician. Review of Resident #1's physician's order reflected: 1. Cymbalta Oral Capsule Delayed Release Particles30 MG (Duloxetine): Give 1 capsule by mouth two times a day for depression/neuropathy. -Start Date-05/09/2025. Review of Resident #3's MAR reflected on 05/12/25, 05/13/25 and 05/26/25 Resident #3 had not received Cymbalta Oral Capsule Delayed Release Particles 30 MG, scheduled at 5:00pm. 4. Review of Resident #4's face sheet dated 06/02/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease with heart failure, alcohol abuse, unspecified protein-calorie malnutrition, age-related physical debility, muscle weakness , unsteadiness on feet, cognitive communication deficit and depression. Review of Resident #4's quarterly MDS assessment, dated 04/17/25, reflected a BIMS score of 9, indicating his cognition was moderately impaired. Review of Resident #4's care plan, dated 05/15/25 reflected he had hypertension and at risk for hyper/hypotensive episodes. The relevant intervention was administering medication and ordered and monitoring blood pressure and notify MD if pressure is not WNL . Review of Resident #4's physician's order reflected: 1. Coreg Oral Tablet3.125 MG(Carvedilol): Give 1 tablet by mouth two times a day for HTN. Hold for SBP <110 or HR <55. -Start Date-03/29/2025. Review of Resident #4's MAR reflected, on 05/12/25, 05/26/25 and 05/27/25 Resident #4 had not received Coreg Oral Tablet 3.125 MG and the blood pressure measurement, scheduled at 5:00pm . 5. Review of Resident #5's face sheet dated 06/02/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including epilepsy(seizure), schizoaffective disorder ( a type of mental illness) bipolar type, muscle weakness, lack of coordination, abnormalities of gait and chronic pain syndrome. Review of Resident #5's initial MDS assessment, dated 03/15/25, reflected a BIMS score of 09, indicating her cognition was moderately impaired. Review of Resident #5's care plan, dated 03/14/25 reflected she had seizure disorder. The relevant intervention was administering medications as ordered by physician and monitoring for side effects and effectiveness Q-shift. Review of Resident #1's physician's order reflected: 1. Divalproex Sodium Oral Tablet Delayed Release 500 MG(Divalproex Sodium): Give 500 mg by mouth two times a day for seizure. -Start Date-03/11/2025. 2. Levetiracetam Oral Tablet 1000 MG(Levetiracetam): Give 1000 mg by mouth two times a day for seizure. -Start Date-03/11/2025. Review of Resident #5's MAR reflected, on 05/13/25 Resident #5 had not received Levetiracetam Oral Tablet 1000 MG and Divalproex Sodium Oral Tablet Delayed Release 500 MG, scheduled at 5:00pm. 6. Review of Resident #6's face sheet dated 06/02/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Wernicke's encephalopathy, chronic obstructive pulmonary disease(breathing difficulty) , heart disease, muscle weakness, cognitive communication deficit, unsteadiness on feet, chronic pain, and need for assistance with personal care. Review of Resident #6's quarterly MDS assessment, dated 03/10/25, reflected a BIMS score of 12, indicating his cognition was moderately impaired. Review of Resident #6's care plan, dated 03/20/25 reflected Resident #6 had Wernicke's encephalopathy ( Type of brain disorder caused by vitamin B1 deficiency) . The relevant intervention was providing care as ordered to ensure resident's safety. Review of Resident #6's physician's order reflected: 1. Lactulose Encephalopathy Oral Solution 10GM/15ML (Lactulose Encephalopathy):Give 30 ml by mouth one-time a day for elevated ammonia level. 2. Buspirone HCl Oral Tablet 7.5 MG (Buspirone HCl): Give 1 tablet by mouth two times a day for anxiety. -Start Date- 05/10/2025. Review of Resident #6's MAR reflected, on 05/12/25, 05/26/25 and 05/27/25 Resident #6 had not received Lactulose Encephalopathy Oral Solution 10 GM/15ML and Buspirone HCl Oral Tablet 7.5 MG, scheduled at 5:00pm. 7. Review of Resident #7's face sheet dated 06/02/25 reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia behavioral disturbance, chronic kidney disease, pain in right hip, pain in right knee, muscle weakness, and anxiety. Review of Resident #7's initial MDS assessment, dated 03/21/25, reflected a BIMS score of 10, indicating her cognition was moderately impaired. Review of Resident #7's care plan, dated 03/13/25 had not included pain management. Review of Resident #7's physician's order reflected: 1.Tylenol Oral Tablet 325 MG (Acetaminophen) : Give 2 tablet by mouth two times a day for pain management. -Start Date-03/04/2025 Review of Resident #7's MAR reflected, 0n 05/8/25, 05/26/25 and 05/27/25 Resident #7 had not received Tylenol Oral Tablet 325 MG and the pain level assessment, scheduled at 5:00pm. During an interview on 06/02/26 at 11:20 am, MA A stated she worked at the facility as an MA for few years and her working schedule was from 6:00 am to 2:00 pm shift, Monday to Friday. MA A stated she was diligent to make sure all the medications ordered were administered on time without fail. MA A stated she did not notice any omission of 5:00 pm medications as she worked only in the morning shifts. She added, MA s should be diligent to administer all the medications ordered within the time frame and any concerns related to medications should be reported to the nurse in charge as soon as possible. During an interview on 06/02/25 at 1:45pm MA B stated she was working at the facility in the morning shift as MA , that began at 6:00am and end at 2:00pm. She stated she started working at the facility from December 2024 and always worked in the morning shift (6am to 2pm) and occasionally did overtime hours as well. MA B stated she ensured that all the medications were administered on time during her shift. MA B stated she was not aware of any omissions, however at times, there was a possibility the MAs administered medications and forgot to document. MA B stated she always make it sure administering medications on time and document the medication administration on the MAR in a timely manner. During a phone interview on 06/02/25 at 2:10pm, the NP stated she visited the facility once a week. The NP stated she never received any communication regarding missed doses of medications scheduled at 5:00 pm on any day , from the facility. She added, as per protocol, any missed doses must be communicated with physicians so that compensatory interventions could be addressed, if necessary. The NP stated there were no residents at the facility who were in danger if they missed one or two doses of any of their medications, however, the seriousness of the consequences depended on many factors. The NP stated she was under the impression that the medications were administered promptly as nobody from the facility talked about missed doses even in meetings . She stated the administrative staff at the facility, including the DON, were new and hopefully they would fix the problem. The NP stated it was mandatory to administer medications exactly as ordered and any changes needed, were to be discussed with the NP or MD . She said any drug errors including omission of medication administration was to be reported in a timely manner. During an interview on 06/02/25 at 2:35 pm, the DON stated she started working at the facility a month ago. She said she noticed there were many issues at the facility and was in the process of fixing them. The DON said she identified the staff who worked on Hall 500 on 05/08/25 in the evening shift (2pm to 10pm) , who was responsible for administering medications in the hall where Resident #1 resided. The DON added that specific MA was terminated from service recently due to her poor performance and other irregularities. When the investigator pointed out that there was a pattern of medication omission in all the halls specifically for the medications scheduled at 5:00 pm, the DON responded that the issue concerned her, and she wanted to find out the root cause. When the investigator asked how she ensured the medications ordered were administered appropriately by the MAs and Nurses, the DON stated she used to do daily MAR auditing in her previous jobs as DON and had the plan to introduce the same system at this facility. Record review of the facility's policy administering Medications revised in April 2019 reflected: Policy statement: Medications are administered in a safe and timely manner, and as prescribed Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 3. Medications are administered in accordance with prescriber orders including any required time frame . 7. Medications are administered within one (1) hour of their prescribed time unless otherwise specified (for example, before and after meal orders)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure the correct the resident and their family members had sufficient preparation and orientation to ensure safe and orderly discharge from the facility to home for 1 (Resident #1) of 3 resident's reviewed for discharge rights. The facility failed to ensure Resident #1 had the correct medications that were prescribed to her upon discharge on [DATE]. Resident #1 was discharged on 12/15/2024 with a blister card of Furosemide 40mg tablets, that were prescribed to Resident #3. Resident #1 was prescribed Furosemide 20mg tablets upon discharge. This failure could put the resident at risk for adverse reactions to a medication not prescribed to her including worsening kidney function, low blood pressure, and hospitalization. Findings included: Review of Resident #1's face sheet dated 1/8/2025, revealed an [AGE] year-old female admitted on [DATE] and discharged on 12/15/2024. Her Diagnoses include metabolic encephalopathy (a change in how the brain works causing confusion, memory loss and loss of consciousness), malignant neoplasm of breast (breast cancer), dementia (a progressive degenerative disorder of the brain causing memory loss and confusion), aphasia (a difficulty in speech), dysphagia (difficulty swallowing), acute kidney failure (the kidneys inability to function properly), depression, gastro-esophageal reflux disease (a chronic digestive disease where the liquid content of the stomach refluxes into the throat), and hypertensive heart disease (chronic high blood pressure that puts a strain on the heart and makes it harder for it to pump your blood). Review of Resident #1's discharge MDS assessment, dated 12/14/2024, reflected a BIMS of 15 indicating her cognition was intact. Review of Resident #1's care plan date initiated on 10/15/2024 reflected: 1. Focus: Dx of hypertension and at risk for hyper/hypotensive (high/low blood pressure) episodes, medication side effects with interventions: Provide medications as ordered. Review of Resident #1's Resident Drug Release dated 12/14/2024 revealed Resident #1 discharged with Furosemide 40mg tablet quantity of 13. Record review of Resident #1's order summary dated 01/07/2025 revealed an order for Lasix(furosemide) 20mg 1 tablet by mouth one time a day for HTN. Review of Resident #3's face sheet, dated 01/08/2025, revealed a [AGE] year-old male admitted on [DATE] and discharge on [DATE]. His diagnoses include fracture of shaft of right tibia (break in the lower right leg), malignant neoplasm of bladder(cancer), peripheral vascular disease (decreased circulation in the legs), hypertensive heart disease with heart failure (inability for the heart to adequately pump blood throughout the body due to damage sustained by high blood pressure), and diabetes mellitus (inability to regulate blood sugar). Review of Resident #3's discharge MDS assessment, dated 12/31/2024, reflected a BIMS of 15 indicating his cognition was intact. Review of Resident #3's care plan date initiated on 12/26/2024 reflected: 1. Focus: At risk for fluid deficits due to taking diuretics for HTN and CKD with interventions: Provide medications as ordered Record review of Resident #3's Order Summary dated 01/08/2025 revealed an order for furosemide 40mg Give 1 tablet by mouth one time a day for Edema. Record review of Incident and Accident Reports dated 01/07/2025 for dates 07/07/2024 to 01/07/2025 had no mentions of Resident #1 or Resident #3. During an interview and observation on 01/07/2025 at 11:09 AM, family member stated when Resident #1 was discharged she got a blister card of Resident #3's medications. She stated that the error was discovered after leaving the facility but before administering any medication. The family member provided a picture of the blister card of medication Resident #1 was provide by the facility during the interview. Observed across the top of the blister card was Resident #3's name, the name of the medication was furosemide 40mg tablet, instructions for use state Give 1 tablet by mouth one time a day for edema. The blister card appears to have 2 pills missing from blister #14 and blister #15. During an interview on 01/08/2025 at 2:30 PM with NP, she stated that the wrong medication was sent home with Resident #1 in the past. She stated the furosemide was a larger dose than was originally ordered though she couldn't recall the exact dosage. She stated that potential negative impacts if the resident would have taken the medication include worsened kidney function and a HIPAA breach. During an interview on 01/08/2025 at 3:26 PM with the DON, he revealed he had been filling in as the interim DON for the past couple months. The DON stated his expectations for discharging a resident with medication were checking the medications against their chart prior to dispensing them out. Make sure the resident was getting the medications that were prescribed to them. He stated a potential negative impact for residents not getting the medication that was prescribed to them could be and adverse effect, a HIPAA violation, but I would hope that the family would read the names on the card. During an interview on 01/08/2025 at 4:24 PM, the ADM stated her expectations for discharging a resident was to ensure the resident has their medications. She stated she believed the name and quantity was documented in the chart when a resident was discharged with medications. She stated they found out the day after the resident was discharged and told the family member of the resident to bring back in the incorrect card of medications and they would give her the correct one, but the family member never returned. She stated they also sent a prescription for furosemide over to the pharmacy. She stated the Resident #3 got his scheduled medication from the E-kit. The ADM stated the potential negative impact on a resident would depend on circumstances. It is difficult to say. It depends. When questioned about possible HIPAA violation she stated, The only thing I can think of it was just the resident's name and the name of the medication.

Based on interview, observation, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 8 (1/1/25, 1/2/25, 1/3/25, 1/4/25, 1/5/25, 1/6/25, 1/7/25, and 1/8/25) of 9 days reviewed for RN coverage. The facility failed to ensure they had an RN charge nurse on duty for 8 days 01/01/2025 through 01/08/2025. This failure could place residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Review of hand written nursing hours for December 31, 2024, to January 8, 2025, by the DON, reflected zero hours worked by an RN charge nurse on the following days: 01/02/2025, 01/06/2025, and 01/07/2025, And less than 8 hours worked by an RN charge nurse on the following days: 01/01/2025, 01/03/2025, 01/04/2025, 01/05/2025, and 01/08/2025. During an observation on 01/07/2025 at 11:35 AM and 01/08/2025 at 11:42 AM the staffing sign in sheet revealed 12-hour shifts for charge nurses. There were no RNs listed as charge nurses on the sign in sheet for 01/07/2025 and one nurse was listed on the sign in sheet for 01/08/2025 to work from 6:00 PM- 6:00 AM filling only 6 of the required 8 hours. During a confidential interview a concern was mentioned about the number of nurses that worked on January 1, 2025. They stated that there was only one nurse providing care to all the residents on the morning of January 1, 2025. During an interview on 01/08/2025 at 3:26 PM with the DON, he stated he was the only registered nurse scheduled to work and that most days he was the registered nurse schedule to work. He stated there was not a registered nurse dedicated as charge nurse today. The DON stated he was typically at the facility throughout the week and if they need a registered nurse when he isn't in the building then they utilize an outside telehealth service for triage. During an interview on 01/08/2025 at 4:24 PM with the ADM, she stated they do their best to ensure there was a registered nurse in the building for 8 consecutive hours a day every day. She stated that all the floor nurses in this building are referred to as charge nurses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including timely administration of all drugs and biologicals to meet the needs for 2 (Resident #1 & #2) of 5 residents reviewed for pharmaceutical services. 1. The facility failed to ensure Resident #1's scheduled medications were administered in a timely manner in accordance with professional standards. Resident #1 was not given her carvedilol (a medication to lower blood pressure and regulate the heart rate) a total of 3 times, her hydralazine (a medication to lower blood pressure) a total of one time, isosorbide dinitrate (a medication to lower blood pressure) a total of one time and ciprofloxacin (an antibiotic) a total of one time. Resident #1 was given the following medications outside of the one hour before and one hour after window that meets professional standards: sodium bicarbonate (for acid indigestion) seven times, carvedilol (to lower blood pressure), Abilify (a mood stabilizer) eight times, sertraline (an antidepressant) eight times, amlodipine besylate (to lower blood pressure) eight times, lisinopril (to lower blood pressure) ten times, hydralazine (to lower blood pressure) thirteen times, isosorbide dinitrate (to lower blood pressure) sixteen times, ciprofloxacin (an antibiotic) five times, Acidophilus (a probiotic) four times, Vitamin D3 (a supplement) one time, Mirtazapine (an antidepressant) two times, and Med pass (a calorie supplement) one time from October 15, 2024 to October 31, 2024 2. The facility failed to ensure Resident 2's scheduled medications were administered in a timely manner in accordance with professional standards. Resident #2 was not given his armodafinil (a medication to treat excessive daytime sleepiness) a total of 2 times and Omeprazole (a medication for acid indigestion) a total of one time. Resident #2 was given the following medication outside of the one hour before and one hour after window that meets professional standards: Jardiance (a medication for diabetes) seven times, Toprol XL (a medication to lower blood pressure) five times, Cholecalciferol (a supplement) five times, Vitamin C (a supplement) six times, senna-docusate (a stool softener) five times, torsemide (a medication to decrease fluid retention and lower blood pressure) 5 times, citalopram (an antidepressant) five times, lactulose (a medication given for constipation) a total of five times, ferrous sulfate (an iron supplement) five times, potassium chloride ER (a supplement) a total of five times, Rivaroxaban (a medication to prevent blood clots because of an abnormal heart rhythm) a total of two times, metformin (a medication to lower blood sugar) a total of four times, and diltiazem (a medication to lower blood pressure and prevent chest pain) one time within the first eight days of January 2025. This failure could place residents at risk of not receiving their scheduled medications in an accurate and timely manner to promote healing and to meet the needs and care of the residents. Findings included: 1. Review of Resident #1's, face sheet dated 1/8/2024, revealed an [AGE] year-old female admitted on [DATE] and discharged on 12/15/2024. Her Diagnoses include metabolic encephalopathy (a change in how the brain works causing confusion, memory loss and loss of consciousness), malignant neoplasm of breast (breast cancer), dementia (a progressive degenerative disorder of the brain causing memory loss and confusion), aphasia (a difficulty in speech), dysphagia (difficulty swallowing), acute kidney failure (the kidneys inability to function properly), depression, gastro-esophageal reflux disease (a chronic digestive disease where the liquid content of the stomach refluxes into the throat), and hypertensive heart disease (chronic high blood pressure that puts a strain on the heart and makes it harder for it to pump your blood). Review of Resident #1's discharge MDS assessment, dated 12/14/2024, reflected a BIMS of 15 indicating his cognition was intact. Review of Resident #1's care plan date initiated on 10/15/2024 reflected: 1. Focus: I use antidepressant medication to treat depression and poor appetite with interventions that include: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. 2. Focus: I use psychotropic medications in conjunction with my antidepressant to control my depression symptoms with an intervention: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness q shift. 3. Focus: Dx of hypertension and at risk for hyper/hypotensive episodes, medication side effects with interventions: Provide medications as ordered. Review of Resident #1's Active order summary report dated 1/7/2025 revealed: Abilify 15mg Give 1 tablet by mouth one time a day for depression Acidophilus 100mg Give 1 capsule by mouth one time a day for GI health Amlodipine Besylate 10mg Give 1 tablet by mouth one time a day for HTN Hold for SBP < 110, HR < 60 Carvedilol 25mg Give 1 tablet by mouth two times a day for HTN Hold for BP <110, HR <60 Hydralazine 100mg Give 1 tablet by mouth three times a day for HTN Hold for SBP <110, HR <60 Isosorbide Dinitrate 20mg Give 1 tablet by mouth every 8 hours for HTN Hold for SBP <110, HR <60 Lisinopril 10mg Give 1 tablet by mouth one time a day for HTN Hold for SBP <100, HR <60 Mirtazapine 15mg Give 2 tablet by mouth at bedtime for depression Sodium Bicarbonate 650mg Give 2 tablet by mouth two times a day for acid indigestion Vitamin D3 5000 unit Give 1 capsule by mouth one time a day for supplement/ vitamin D deficiency. Sertraline 50mg Give 1 tab by mouth one time a day related to depression Record review of Medication Admin Audit Report for Resident # 1 for the month of October 2024 revealed late, and missing doses as follows: 1. Sodium Bicarbonate Oral Tablet 650mg Give 2 tablets by mouth twice daily for acid indigestion. Due 10/15/2024 17:00(5:00PM) administered at 18:15(6:15PM) Due 10/16/2024 09:00(AM) administered at 10:20(AM) Due 10/18/2024 09:00(AM) administered at 10:31(AM) Due 10/19/2024 09:00(AM) administered at 10:13(AM) Due 10/20/2024 09:00(AM) administered at 12:08(PM) Due 10/25/2024 21:00(09:00PM) administered on 10/26/2024 at 04:45(AM) Due 10/26/2024 09:00(AM) administered at 12:12(PM) 2. Carvedilol Tablet 12.5mg give 1 tablet by mouth two times daily for HTN hold for SBP 100, HR 60, take with meals. Due 10/15/2024 17:00(05:00PM) administered at 18:18(6:18PM) Due 10/16/2024 09:00(AM) administered at 10:24(AM) Due 10/18/2024 09:00(AM) administered at 10:36(AM) Due 10/19/2024 09:00(AM) administered at 10:24(AM) Due 10/20/2024 09:00(AM) administered at 12:07(PM) Due 10/24/2024 17:00(05:00PM)-missed dose Due 10/25/2024 17:00(05:00PM)-missed dose Due 10/26/2024 09:00(AM) administered at 12:19(PM) Due 10/29/2024 17:00(05:00PM)-missed dose 3. Abilify 15mg give 1 tablet by mouth one time a day for depression. Due 10/16/2024 08:00(AM) administered at 10:20(AM) Due 10/18/2024 08:00(AM) administered at 10:31(AM) Due 10/19/2024 08:00(AM) administered at 10:13(AM) Due 10/20/2024 08:00(AM) administered at 12:07(PM) Due 10/21/2024 08:00(AM) administered at 09:56(AM) Due 10/26/2024 08:00(AM) administered at 12:12(PM) Due 10/27/2024 08:00(AM) administered at 09:06(AM) Due 10/28/2024 08:00(AM) administered at 09:08(AM) 4. Sertraline HCl Tablet 100mg Give 1 tablet by mouth one time a day for depression Due 10/16/2024 at 08:00(AM) administered at 10:20(AM) Due 10/18/2024 at 08:00(AM) administered at 10:36(AM) Due 10/19/2024 at 08:00(AM) administered at 10:13(AM) Due 10/20/2024 at 08:00(AM) administered at 12:07(PM) Due 10/21/2024 at 08:00(AM) administered at 09:57(AM) Due 10/26/2024 at 08:00(AM) administered at 12:12(PM) Due 10/27/2024 at 08:00(AM) administered at 09:06(AM) Due 10/28/2024 at 08:00(AM) administered at 09:08(AM) 5. Amlodipine Besylate tablet 10mg Give 1 tablet by mouth one time a day for HTN hold for SBP 110, HR 60 Due 10/16/2024 at 08:00(AM) administered at 10:24(AM) Due 10/18/2024 at 08:00(AM) administered at 10:35(AM) Due 10/19/2024 at 08:00(AM) administered at 10:24(AM) Due 10/20/2024 at 08:00(AM) administered at 12:06(PM) Due 10/21/2024 at 08:00(AM) administered at 09:57(AM) Due 10/26/2024 at 08:00(AM) administered at 12:18(PM) Due 10/27/2024 at 08:00(AM) administered at 09:08(AM) Due 10/28/2024 at 08:00(AM) administered at 09:08(AM) 6. Lisinopril tablet 5 mg Give 1 tablet by mouth one time a day for HTN hold for SBP 100, HR 60 Due 10/16/2024 at 08:00(AM) administered at 10:24(AM) Due 10/18/2024 at 08:00(AM) administered at 10:36(AM) Due 10/19/2024 at 08:00(AM) administered at 10:24(AM) Due 10/20/2024 at 08:00(AM) administered at 12:07 Due 10/21/2024 at 08:00(AM) administered at 09:56(AM) Due 10/26/2024 at 08:00(AM) administered at 12:19 Due 10/27/2024 at 08:00(AM) administered at 09:06(AM) Due 10/28/2024 at 08:00(AM) administered at 09:09(AM) Due 10/29/2024 at 06:30(AM) administered at 07:36(AM) Due 10/30/2024 at 06:30(AM) administered at 07:53(AM) 7. Hydralazine HCl 50mg give 1 tablet by mouth three times a day for HTN Hold for SBP 110, HR 60 Due 10/17/2024 at 22:00(10:00PM) administered on 10/18/2024 at 05:48(AM) Due 10/19/2024 at 06:00(AM) administered at 10:22(AM) Due 10/20/2024 at 06:30(AM) administered at 12:05(PM) Due 10/20/2024 at 14:30(02:30PM) administered at -16:55(04:30PM) Due 10/21/2024 at 06:30(AM) administered at 09:56(AM) Due 10/21/2024 at 14:30(02:30PM) administered at 16:15(04:15PM) Due 10/22/2024 at 06:30(AM) administered at 08:30(AM) Due 10/24/2024 at 14:30(02:30PM) missed dose Due 10/25/2024 at 06:30(AM) administered at 07:51(AM) Due 10/26/2024 at 08:00(AM) administered at 12:19(PM) Due 10/26/2024 at 14:00(02:00PM) administered at 17:38(05:38PM) Due 10/26/2024 at 20:00(08:00PM) administered at 21:25(09:25PM) Due 10/27/2024 at 08:00(AM) administered at 09:06(AM) Due 10/28/2024 at 08:00(AM) administered at 09:08(AM) 8. Isosorbide Dinitrate 20mg Give 1 tablet by mouth every eight hours for HTN hold for SBP 100, HR 60 Due 10/17/2024 at 22:00(10:00PM) administered on 10/18/2024 at 05:48(AM) Due 10/19/2024 at 06:00(AM) administered at 10:23(AM) Due 10/20/2024 at 06:30(AM) administered at 12:06(PM) Due 10/20/2024 at 14:30(02:30PM) administered at 16:56(04:56PM) Due 10/21/2024 at 06:30(AM) administered at 09:57(AM) Due 10/21/2024 at 14:30(02:30PM) administered at 16:15(04:15PM) Due 10/22/2024 at 06:30(AM) administered at 08:30(AM) Due 10/24/2024 at 14:30(02:30PM) missed dose Due 10/25/2024 at 06:30(AM) administered at 07:51(AM) Due 10/25/2024 at 22:30(10:30PM) administered on 10/26/2024 at 04:45(AM) Due 10/26/2024 at 06:30(AM) administered at 12:17(PM) Due 10/26/2024 at 14:30(02:30PM) administered at 17:39(05:39PM) Due 10/27/2024 at 06:30(AM) administered at 09:07(AM) Due 10/29/2024 at 22:30(10:30PM) administered on 10/30/2024 at 00:20(12:20AM) Due 10/30/2024 at 06:30(AM) administered at 07:52(AM) Due 10/30/2024 at 22:30(10:30PM) administered on 10/30/2024 at 20:04(08:30PM) Due 10/31/2024 at 06:30(AM) administered at 08:20(AM) 9. Ciprofloxacin HCl Tablet 250mg Give 1 tablet by mouth twice a day for UTI for 7 days Due 10/25/2024 at 09:00(AM)-missed dose Due 10/26/2024 at 09:00(AM) administered at 11:04(AM) Due 10/27/2024 at 09:00(AM) administered at 10:50(AM) Due 10/28/2024 at 09:00(AM) administered at 13:17(01:17PM) Due 10/29/2024 at 09:00(AM) administered at 11:10(AM) Due 10/30/2024 at 09:00(AM) administered at 10:48(AM) 10. Acidophilus Capsule 100mg Give 1 capsule by mouth one time a day for GI health Due 10/26/2024 at 06:30(AM) administered at 12;12(PM) Due 10/27/2024 at 06:30(AM) administered at 09:06(AM) Due 10/29/2024 at 06:30(AM) administered at 07:34(AM) Due 10/30/2024 at 06:30(AM) administered at 07:46(AM) 11. Vitamin D3 capsule 5000units Give 1 capsule by mouth one time a day for supplement/Vitamin D deficiency Due 10/26/2024 at 09:00(AM) administered at 12:12(PM) 12. Mirtazapine 15mg 1 tablet by mouth at bedtime for depression Due 10/15/2024 at 21:00(09:00PM) administered at 22:56(10:56PM) Due 10/25/2024 at 21:00(09:00PM) administered on 10/26/2024 at 04:45(AM) 13. Med Pass 2.0 at bedtime for supplement for 6 weeks 120ml Due 10/25/2024 at 21:00(09:00PM) administered on 10/26/2024 04:45(AM) 2. Review of Resident #2's face sheet, dated 01/08/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses encephalopathy (a change in how the brain works causing confusion, memory loss and loss of consciousness), atrial fibrillation (a abnormal hearth rhythm), dysphagia (difficulty swallowing), heart failure (the heart is unable to pump blood to the body effectively), depression, diabetes mellitus (the inability to regulate blood sugars), edema (swelling), and hyperlipidemia (high cholesterol). Review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS of 12 indicating he had mild cognitive deficits. Review of Resident #2's care plan, date initiated on 09/23/2024 reflected: 1. Focus: I have Congestive Heart Failure and at risk for SOB, fluid overload, and weight gain with interventions that include Give cardiac medications as ordered. 2. Focus: I have transient ischemic attacks (mini strokes) with interventions that include Give medication as ordered by physician. Monitor/document side effects and effectiveness. 3. Focus: I have a DX of Hyperlipidemia with interventions that include Provide medications as ordered. 4. Focus: I have DX of A-fib and take an anticoagulant to treat it. I am at risk for easy bruising and prolonged bleeding with interventions that include Provide medications as ordered. 5. Focus: I have DX of Depression and at risk for adverse reaction side effect with interventions that include Provide medications as ordered. 6. Focus: I have a DX of Hypertension and at risk for hyper/hypotensive (high/low blood pressure) episodes, medication side effects with interventions that include Provide medications as ordered. 7. Focus: At risk for GI upset due to DX of GERD with interventions that include Provide medications as ordered. Review of Resident #2's Active order summary report dated 01/08/2025 revealed: Jardiance 10mg Give 1 tablet by mouth one time a day for DM2 Toprol XL 50mg Give 1 tablet by mouth one time a day for Afib Hold for SBP <110, HR<60 ***DO NOT CRUSH MEDICATION*** Cholecalciferol 125mcg Give 1 tablet by mouth one time a day for supplement Vitamin C 500mg Give 1 tablet by mouth two times a day for wound healing Senna-Docusate Sodium 8.6-50mg Give 1 tablet by mouth two times a day for constipation Torsemide 20mg Give 1 tablet by mouth one time a day for fluid retention Citalopram 20mg Give 1 tablet by mouth one time a day for depression Lactulose 10Gm/15ml Give 30ml by mouth two times a day for constipation. Hold for loose stools. Ferrous Sulfate 325mg Give 1 tablet by mouth one time a day for iron deficiency anemia. Monitor for constipation Potassium Chloride 20meq Give 1 tablet by mouth two times a day for hypokalemia (low potassium in the blood) Metformin 1000mg Give 1 tablet by mouth two times a day for DM2 Armodafinil 150mg Give 1 tablet by mouth one time a day for excessive daytime sleepiness Diltiazem ER 180mg Give 1 capsule by mouth at bedtime for high blood pressure. Hold for BP<110, HR <60 ***DO NOT CRUSH OR OPEN THIS MEDICATION*** Omeprazole Delayed Release 20mg Give 1 capsule by mouth two times a day for GERD (reflux of liquified stomach contents into the throat) ***DO NOT CRUSH OR OPEN MEDICATION*** give 30 to 60 min before bkfst & HS Record review of Medication Admin Audit Report for Resident # 2 for the month of January 2025 revealed late, and missing doses as follows: 1. Jardiance 10mg Give 1 tablet by mouth one time a day for DM2. Due 01/01/2025 06:30(AM) administered at 10:26(AM) Due 01/02/2025 06:30(AM) administered at 08:20(AM) Due 01/03/2025 06:30(AM) administered at 11:11(AM) Due 01/05/2025 06:30(AM) administered at 10:19(AM) Due 01/06/2025 06:30(AM) administered at 11:27(AM) Due 01/07/2025 06:30(AM) administered at 11:29(AM) Due 01/08/2025 06:30(AM) administered at 08:42(AM) 2. Toprol XL tab Extended Release 24-hour 50mg Give 1 tablet by mouth one time a day for A-fib Hold for SBP 110, HR 60 **DO NOT CRUSH MEDICATION** Due 01/01/2025 09:00(AM) administered at 10:26(AM) Due 01/03/2025 09:00(AM) administered at 11:12(AM) Due 01/05/2025 09:00(AM) administered at 10:19(AM) Due 01/06/2025 09:00(AM) administered at 11:27(AM) Due 01/07/2025 09:00(AM) administered at 11:30(AM) 3. Cholecalciferol Tab 125mcg Give 1 tablet by mouth one time a day for supplement Due 01/01/2025 09:00(AM) administered at 10:26(AM) Due 01/03/2025 09:00(AM) administered at 11:11(AM) Due 01/05/2025 09:00(AM) administered at 10:19(AM) Due 01/06/2025 09:00(AM) administered at 11:27(AM) Due 01/07/2025 09:00(AM) administered at 11:29(AM) 4. Vitamin C 500mg Give 1 tablet by mouth two times a day for wound healing Due 01/01/2025 09:00(AM) administered at 10:26(AM) Due 01/01/2025 17:00(PM) administered at 18:29(06:29PM) Due 01/03/2025 09:00(AM) administered at 11:12(AM) Due 01/05/2025 09:00(AM) administered at 10:19(AM) Due 01/06/2025 09:00(AM) administered at 11:27(AM) Due 01/07/2025 09:00(AM) administered at 11:29(AM) 5. Senna-Docusate Sodium 8.6-50mg Give 1 tablet by mouth two times a day for constipation Due 01/01/2025 09:00(AM) administered at 10:26(AM) Due 01/03/2025 09:00(AM) administered at 11:11(AM) Due 01/05/2025 09:00(AM) administered at 10:19(AM) Due 01/06/2025 09:00(AM) administered at 11:27(AM) Due 01/07/2025 09:00(AM) administered at 11:29(AM) 6. Torsemide 20mg Give 1 tablet by mouth one time a day for fluid retention Due 01/01/2025 09:00(AM) administered at 10:26(AM) Due 01/03/2025 09:00(AM) administered at 11:11(AM) Due 01/05/2025 09:00(AM) administered at 10:19(AM) Due 01/06/2025 09:00(AM) administered at 11:27(AM) Due 01/07/2025 09:00(AM) administered at 11:29(AM) 7. Citalopram 20mg Give 1 tablet by mouth one time a day for depression Due 01/01/2025 09:00(AM) administered at 10:26(AM) Due 01/03/2025 09:00(AM) administered at 11:11(AM) Due 01/05/2025 09:00(AM) administered at 10:19(AM) Due 01/06/2025 09:00(AM) administered at 11:27(AM) Due 01/07/2025 09:00(AM) administered at 11:29(AM) 8. Lactulose 10Gm/15ml Give 30ml by mouth two times a day for constipation. Hold for loose stools. Due 01/01/2025 09:00(AM) administered at 10:26(AM) Due 01/03/2025 09:00(AM) administered at 11:11(AM) Due 01/05/2025 09:00(AM) administered at 10:19(AM) Due 01/06/2025 09:00(AM) administered at 11:27(AM) Due 01/07/2025 09:00(AM) administered at 11:29(AM) 9. Ferrous Sulfate 325mg Give 1 tablet by mouth one time a day for iron deficiency anemia. Monitor for constipation Due 01/01/2025 09:00(AM) administered at 10:26(AM) Due 01/03/2025 09:00(AM) administered at 11:11(AM) Due 01/05/2025 09:00(AM) administered at 10:19(AM) Due 01/06/2025 09:00(AM) administered at 11:27(AM) Due 01/07/2025 09:00(AM) administered at 11:29(AM) 10. Potassium Chloride 20meqGive 1 tablet by mouth two times a day for hypokalemia Due 01/01/2025 09:00(AM) administered at 10:26(AM) Due 01/03/2025 09:00(AM) administered at 11:11(AM) Due 01/05/2025 09:00(AM) administered at 10:19(AM) Due 01/06/2025 09:00(AM) administered at 11:27(AM) Due 01/07/2025 09:00(AM) administered at 11:29(AM) 11. Metformin 1000mg Give 1 tablet by mouth two times a day for DM2 Due 01/03/2025 09:00(AM) administered at 11:12(AM) Due 01/05/2025 09:00(AM) administered at 10:19(AM) Due 01/06/2025 09:00(AM) administered at 11:27(AM) Due 01/07/2025 09:00(AM) administered at 11:29(AM) 12. Armodafinil 150mg Give 1 tablet by mouth one time a day for excessive daytime sleepiness Due 01/04/2025 at 08:00AM missed dose Due 01/05/2025 at 08:00AM missed dose 13. Diltiazem ER 180mg Give 1 capsule by mouth at bedtime for high blood pressure. Hold for BP<110, HR<60 ***DO NOT CRUSH OR OPEN THIS MEDICATION*** Due 01/03/2025 21:00(09:00PM) administered at 22:32(10:32PM) 14. Omeprazole Delayed Release 20mg Give 1 capsule by mouth two times a day for GERD ***DO NOT CRUSH OR OPEN MEDICATION*** give 30 to 60 min before bkfst & HS Due 01/06/205 at 05:30AM missed dose Interview on 01/08/2025 at 02:30 PM with the NP revealed she has received complaints from some residents in the past related to late medications. When a resident has brought up any concerns to her, she relayed it to the nurse in charge of the resident at that time. The NP stated to her knowledge there has not been any adverse outcomes at this time due to late or missing medications. She stated a negative impact on residents for missing or late medications depended on the medication in question. There could be a change in vital signs and lab work or even a decline in condition. Interview on 01/08/2025 at 03:26 PM with the DON revealed his expectations for medication administration was medications are to be given within an hour before to an hour after the medication due time. He stated there was a common issue with the internet going down and the medication aide's have gone back to sign off on medications they gave while the internet was down. The DON stated the times may not be accurate. He stated they contacted the internet company, but the issue has not been resolved. He stated the internet was down for sometimes 30 minutes or more and sometimes it was only a few minutes. Interview on 01/08/2025 at 04:25 PM with the ADM revealed his expectations for medication administration was for staff to do everything possible to follow guidelines in the policy. She stated, but I'm sure as we all understand, there are times and circumstances that affect our ability to do that. She stated that the impact to the resident for late or missing medications all depending on the medication and the patient. Facility undated policy titled Administering Oral Medications revealed no specific information in relation medication timing

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that medical records were accurately documented for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for accurate medical records. The facility failed to ensure Residents #1 and #2's facility self-reported incidents were documented in their EMRs and Resident #3's vitals were accurately documented. This deficient practice could result in errors in care and treatment. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including depression, anxiety disorder, epilepsy (seizures), and Alzheimer's disease (a chronic neurodegenerative disease that destroys brain cells). Review of Resident #1's quarterly MDS assessment, dated 11/11/24, reflected a BIMS score of 9, indicating she was moderately cognitively impaired. Review of Resident #1's quarterly care plan, revised 11/18/24, reflected she had impaired cognitive function with an intervention of monitoring/documenting/reporting PRN any changes in cognitive function. Review of facility reported incident, dated 10/18/24, reflected the following: It was reported to the Administrator at approx. 4:15pm by the hospice social worker, that [Resident #1] reported that 2 black females pulled her hair and hit her head on the wall . Review of Resident #1's progress notes for 10/18/24 reflected no entry for the allegation made or plan of action going forward. Review of Resident #2's Face sheet, undated, reflected a [AGE] year-old female with a diagnosis of dementia admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnoses that included dementia and, mood disturbance with anxiety. Review of Resident #2's quarterly MDS assessment, dated 09/05/24, reflected a BIMS of score 8, moderate cognitive impairment. Review of Resident #2's care plan focus dated 09/24/28 and revised on 03/21/22 for ADL self-care performance deficit related to cognitive deficit, debility and required assist from staff for ADL care, mobility and was apt to refuse care from staff. Review of facility reported incident dated 11/14/24 reflected, The resident was noted in hallway seated in wheelchair. As Administrator approached, the resident pointed to a staff member and said, This is the one that beat me. Upon assessment, some discoloration and slight swelling was noted to the tip of the 5th digit of the resident's right hand. The area was tender to touch. The resident denied pain, other than when the area was touched, and the resident was able to actively move the digit. No open areas, bleeding, or other signs of injury were noted. When asked, upon interview, how the injury occurred, the resident offered various conflicting statements including: It was an accident. I don't know how it happened. I had a confrontation in the shower last night with B-E-A-R. When she washed my hair, my finger got in the way somehow. I don't know how this happened to my finger. I could have caught it in my wheelchair (demonstrating placing her hands on the outer rings of the wheels of her wheelchair and self-propelling). Review of Resident #2's progress notes for 11/14/24 reflected no entry for the self-reported injury of an unknown origin. Review of Resident #3's Face sheet, undated, reflected a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] with a diagnosis of arteriosclerotic heart disease (a condition where plaque buildup in the arteries of the heart) and muscle wasting. Review of Resident #3's quarterly MDS assessment, dated 10/11/24, reflected a BIMS score of 15, no cognitive impairment. Review of Resident #3's care plan focus dated 10/27/15 and revision on 10/03/22 reflected Resident #3 was at risk for decreased cardiac tissue perfusion relate history of CAD (coronary artery disease), hypertension (high blood pressure), and hyperlipidemia (abnormally high levels of lipids of fats in the blood). Goal dated 11/26/21, revision, 01/17/24 monitor blood pressure and heart rate as ordered/indicated, notify medical doctor of abnormal findings. Review of #3's order summary, undated, document all vital signs (measures of a person's basic bodily functions, typically including body temperate, pulse rate, respiratory rate (breathing) and blood pressure) complete every shift. Review of Resident #3's treatment administration record for 10/30/24 and 10/31/24 for the first nursing shift reflected blood pressure, temperature, pulse, and respiratory rate N/A (not applicable). During an interview on 11/18/24 at 12:55 PM, the SW stated documentation in general was important to get a clear picture and anyone should be able to go into a resident's chart and see what was going on with them. The ADM stated she expected nurses to document changes in condition, incidents, complains, voiced pain, and unwitnessed injuries. She stated it was the nurses responsibility to ensure incidents were documented in resident charts. The ADM stated a negative outcome of documentation not being thorough could be the failure for communication to get passed on or the staff could fail to assess or follow the resident . During an interview on 11/18/24 at 1:46 PM, the LVN TN confirmed Resident #3's medical administration record reflected N/A (not applicable) for 10/30/24 and 10/31/24 for Resident #3's blood pressure, temperature, pulse, and respiratory rate. She stated if blood pressure readings were not recorded accurately, residents' blood pressure readings could be high, the resident might be agitated, and there might be a non-addressed reason for resident hospitalization. During an interview on 11/14/24 at 2:59 PM, the Corporate RN stated Resident #2's incident of an injury of unknown cause on 11/14/24 should have been entered in a progress note because if things were not documented there could be a lack of follow up care. He stated he did believe that there was follow up care even though the event from 11/14/24 was not documented in Resident #2's progress notes. Review of the facility's undated Charting and Documentation Policy reflected the following: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical chart. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. . 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents, or accidents involving the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the physician prescribed therapeutic diet to 1 of 4 residents (Resident #9) reviewed for therapeutic diets. Resident #9 did not receive a mechanical soft diet as ordered. This failure affected one resident and placed her at risk for choking and causing further health issues. The findings were: Record review of Resident #9's admissions record dated 07/23/2024 revealed that Resident #2 was admitted to the facility on [DATE]. Resident #9's diagnoses included cerebral infraction (long term effects of a stroke), lack of coordination, muscle weakness, dysphagia (difficulty swallowing), atrial fibrillation (abnormal heart rhythm), pressure ulcer of sacral region (wound on boney area on bottom), depression, cardiomyopathy (disease of the heart muscles), anemia (not enough healthy red blood cells), morbid obesity, hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), allergic rhinitis (allergies), obstructive pulmonary disease (chronic progressive lung disease), gastroesophageal reflux disease without esophagitis (reflux), constipation, chronic pain, hemiplegia and hemiparesis following cerebrovascular disease (paralysis and weakness), type 2 diabetes mellitus with other specified complications (high blood sugar), and heart disease. Record review of Resident #9's quarterly MDS dated [DATE] revealed Resident #9's BIMS score was 11 which indicated that Resident #9 could understand and makes self-understood most of the time. The MDS also revealed that the resident needed set up and clean up assistance with eating. Record review of Resident #9's diet orders dated 01/19/2024 revealed the resident was on a regular mechanical soft/ground meats texture thin liquid consistency diet. Observation of dining services on 07/21/2024 at 1:13pm revealed that Resident #9 was given a regular diet tray. The meal was a whole breaded chicken patty, spaghetti noodles, mixed vegetables, and a roll. Resident #9's meal ticket stated, Regular diet mechanical soft/ground meats texture think liquid consistency . An interview with Resident #9 on 07/22/2024 at 9:52am revealed that she was on a regular diet. She stated that she gets a regular diet for all meals. An interview with LVN B on 07/23/2024 at 10:54am revealed that the nurses were supposed to check the meal trays when they came out of the kitchen before it was given to the resident. She stated if the meal tray was not correct the nurse would send it back to the kitchen for the correct meal tray. She stated if a resident got the wrong diet the resident could have an allergic reaction and choke. She stated if there was a change in the resident's diet the nurse would put the change in the computer and take the slip to the kitchen staff. She stated she did not know why the resident was not given a mechanical soft diet and that the nurse should have caught the error. An interview with the DON on 07/23/2024 at 12:59pm revealed that the nurses should be checking the meal ticket with the tray to ensure the meal being served was correct. She stated if a resident had a change in diet the change would go to the dietary manager and the nurse manager. She stated staff could also look in the resident's orders to make sure the resident was getting the proper diet. She also said that if the resident did not get the correct diet the resident could aspirate, choke, or have an adverse reaction. She stated she did not know why Resident #2 did not get the correct diet. An interview with the ADM on 07/23/2024 at 11:54am revealed that nurses were to check the trays before they go out to verify the ticket matches what was on the tray. He stated nursing would put the order in and communicate that to the kitchen. He stated staff could look to see if the resident was getting the proper diet in the computer on the resident's information page. He said if a resident did not get the proper diet, it could cause the resident to choke, or get sick. He stated he did not know why Resident #2 did not get the proper diet. Record Review of Tray Identification Policy dated 04/2007 revealed nursing staff shall check each food tray for the correct diet before serving the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident rights for personal privacy for 5 of 5 residents (Resident #2, Resident #3, Resident #16, Resident #25, and Resident #54) residents reviewed for personal privacy. The facility failed to knock on Resident #2, Resident #3, Resident #16, Resident #25, and Resident #54's door when going into the residents' rooms. The deficient practice could affect all residents right to privacy in the facility and cause the resident to feel like their privacy is being invaded or the facility is not their home. Findings included: Review of Resident #2's Face Sheet dated 07/23/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included atherosclerosis of native arteries of extremities (arteries are blocked), osteoporosis (weak and brittle bones), cognitive communication deficit (problems with communication), anxiety disorder, history of falling, contracture joint (permanently bent), spinal stenosis (spaces inside the bones of the spine get too small), gastroesophageal reflux disease without esophagitis (reflux), irritable bowel, retention of urine, lipoprotein metabolism (particles made of fat and protein that travel through the blood stream), hyperlipidemia (high cholesterol), Arthritis, physical debility, chronic pain, hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), muscle weakness, muscle wasting, and abnormalities with gate and mobility. Record Review of Resident #2's Quarterly MDS dated [DATE] revealed that Resident #2 had a BIMS score of 15, indicating the resident could understand and make self-understood. Review of Resident #3's Face Sheet dated 07/23/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included, dementia (memory, thinking, difficulty), depression, hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), lack of coordination, abnormalities of gait and mobility, unsteadiness on feet, muscle wasting, cognitive communication deficit (problems with communication), dysphagia (difficulty swallowing), hyperthyroidism (excessive production of thyroid hormones), gastroesophageal reflux disease without esophagitis (reflux), iron deficiency, insomnia (difficulty sleeping), hyperkalemia (high potassium levels in the blood), lack of coordination, and protein calorie malnutrition. Record Review of Resident #3's quarterly MDS dated [DATE] revealed that Resident #3 had a BIMS score of 7, indicating the resident could not understand or make self-understood at times. Review of Resident #16's Face Sheet dated 07/23/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #16's diagnoses included dementia (memory, thinking, difficulty), dysphagia (difficulty swallowing), urinary tract infection, depression, gastroesophageal hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), reflux disease without esophagitis (reflux), morbid obesity, muscle weakness, shortness of breath, hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), kidney disease, benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate), obstructive and reflux uropathy (blocked urine flow), neuropathic bladder (bladder issues due to nerve problems), muscle wasting, and anxiety disorder. Record Review of Resident #16's quarterly MDS dated [DATE] revealed that Resident #16 had a BIMS score of 10, indicating the resident could understand or make self-understood at times. Review of Resident #25's Face Sheet dated 07/23/2024 revealed he was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #26's diagnoses included peripheral nervous system (damage to motor nerves), major depressive disorder (mental disorder), Tremors, visual disturbance, anxiety, dry eye, delusional disorder, psychosis, convulsions, pain in right shoulder, constipations, magnesium disorder, muscle weakness, chronic pain, obesity, dysphagia (difficulty swallowing), type 2 diabetes mellitus with unspecified complications (high blood sugar), hypertension (high blood pressure), hyperlipidemia (high cholesterol), paranoid schizophrenia (mental disorder), and bipolar disorder (extreme mood swings). Record Review of Resident #25's quarterly MDS dated [DATE] revealed that Resident #25 had a BIMS score of 15, indicating the resident could understand or make self-understood all the time. Review of Resident #54's Face Sheet dated 07/23/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #54's diagnoses included dementia (memory, thinking, difficulty), urinary tract infection (infection of urine), attention and concentration deficit, encounter of immunization, lack of coordination, weakness, unsteadiness on feet, obstructive pulmonary disease (chronic progressive lung disease), abnormalities of gait and mobility, osteoarthritis (joint disease), dysphagia (difficulty swallowing), pain in right hip, major depressive disorder, hyperlipidemia (high cholesterol), irritable bowel syndrome, insomnia (difficulty sleeping), overactive bladder, iron deficiency, gastroesophageal reflux disease without esophagitis (reflux), type 2 diabetes mellitus without complications (high blood sugar), hypertension (high blood pressure), history of falling, muscle wasting, muscle weakness, and cognitive communication deficit (problems with communication). Record Review of Resident #54's quarterly MDS dated [DATE] revealed that Resident #54 had a BIMS score of 09 indicating the resident could not understand or make self-understood all the time. Observation of hall trays being passed on 07/21/2024 at 12:52pm revealed CNA A not knocking on Resident #3, Resident #16, or Resident #54's doors before entering the room. Observation of hall trays being passed on 07/22/2024 at 12:09pm revealed CNA B not knocking on Resident #2 and Resident #25's doors before entering the room . An interview with Resident #54 on 07/23/2024 at 10:08am revealed that staff do not always knock on her door before entering. She stated she was not sure how often staff did not knock. She stated it would be nice for the staff to knock before entering the room. She said she was not sure how she felt about staff not knocking before entering her room. An interview with Resident #25 on 07/23/2024 at 10:13am revealed that staff sometimes knock and sometimes they do not knock. She stated male staff do not knock on the door before entering. She stated it was not necessary for staff to knock all the time but if she was not dressed, she would want the staff to knock before coming in her room. She stated that if staff do not knock before entering, she gets very upset. An interview with Resident 16 on 07/23/2024 at 10:20am revealed that staff do not always knock. He stated that he would like for the staff to knock before entering his room. He stated in the past a staff member walked in while he was asleep and took covers off him and it startled him. He stated staff walk in without knocking a couple of times a week. He stated it makes him nervous when staff just walk in without knocking because most of the time, he is asleep. An interview with Resident #3 on 07/23/2024 at 10:42am revealed that staff knock on her door unless her door is open. She stated that she did not know how often staff walked into her room without knocking. She stated that it does not bother her if the staff do not knock on her door before entering. An interview with CNA B on 07/23/2024 at 10:31am revealed she had been trained on resident rights and privacy. She stated that staff were supposed to knock and introduce themselves before entering a resident's room. She stated that it was important to knock before entering to give the resident privacy. She stated if you do not knock, it could make the resident feel as if staff were invading their privacy. She stated that she did not know why she did not knock and that she should have. She stated that sometimes it was hard to hold the tray and knock on the door. An interview with the CNA B on 07/23/2024 at 10:39am revealed that she had been trained on resident rights and privacy. She stated that the policy was staff were to knock and announce themselves and what they were there to do for the resident. She stated everyone who was going into the resident's room was supposed to knock. She stated it was important to knock before entering to ensure staff were not invading the resident's privacy. She stated if staff did not knock the resident may be unaware the staff were there, and the resident may feel like staff did not respect them. She stated that she did not knock on the door because it was open. She also stated that she should have knocked. An interview with the DON on 07/23/2024 at 12:59am revealed she had been trained on resident rights and knocking on the resident's door before entering. She said all staff were required to knock on the resident's door before entering their room. She stated it was important to provide them with their privacy and dignity and allow the time for entrance to ensure residents were not exposed. She stated that the facility was the resident's home and that no one would like someone entering their home without knocking. She stated staff could have still knocked on the resident's door before taking the tray out of the cart. An interview with the ADM on 07/23/2024 at 11:54am revealed staff were supposed to knock before entering a resident's room. He stated all staff were supposed to knock before entering a resident's room. He said that it was important to knock before entering because the facility is their home. He stated that if staff did not knock on the door before entering the resident may feel unappreciated or disrespected, because staff were not knocking before going into their home. He stated he did not know why staff did not knock on the resident's door before entering. He also stated the facility did not have a policy for knocking on the resident's door. Record review Residents Rights Policy Statement not dated revealed residents have the right to privacy and confidentiality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the safe handling, humidification, cleaning, storage, and dispensing of oxygen for respiratory care services provided to 3 of 3 residents The facility failed to ensure Resident's oxygen tubing was dated to ensure it was changed weekly for 3 residents (Residents 9, 16, and 25. The facility failed to have a written policy to ensure the safe handling, humidification, cleaning, storage, and dispensing of oxygen on 7/23/24. The facility failed to ensure that the humidifier bottle had water for Resident 25. This failure placed the residents at risk of developing a respiratory infection from contamination of the tubing and humidifier water. Findings included: A review of Resident 9's face sheet dated 7/23/24 reflected she was a [AGE] year-old female with a diagnosis of chronic obstructive pulmonary disease which blocks air flow in the lungs. her other diagnoses were dysphagia (difficulty swallowing), anemia, cerebral infarction (stroke), and congestive heart failure. A review of Resident 9's Quarterly Minimum Data Set, dated [DATE] reflected she had a BIMS (Brief Interview for Mental Status) score of 10 which indicated she was moderately cognitively impaired. A review of Resident 9's Care Plan reflected on 4/10/24, a focus area was initiated for shortness of breath associated with her congested heart failure and chronic obstructive pulmonary disease diagnosis. These diagnoses limit the circulating oxygen in the blood and the amount of oxygen flow in the lungs. The care plan reflected a goal to remain free of respiratory infections and interventions which included oxygen as ordered by the physician. A review of Resident 9's active orders reflected a 1/17/24 order, Apply oxygen as needed at 2-3 liters per minute per nasal canula every 6 hours as needed for shortness of breath or symptoms of respiratory distress. An additional order dated 1/20/24 reflected, Replace humidified water, oxygen tubing, and cleanse filter every night shift every Saturday -label, date, and bag supplies. A review of Resident 16's face sheet dated 7/23/24 reflected he was a [AGE] year-old male with diagnoses of shortness of breath, dementia, hypertensive heart disease, and chronic kidney disease. A review of Resident 16's Quarterly Minimum Data Set, dated [DATE] reflected he has a BIMS (Brief Interview for Mental Status) score of 10 which indicated he was moderately cognitively impaired. A review of Resident 16's Care Plan reflected on 4/10/24, a focus area was initiated for shortness of breath with a goal to remain free of complications related to shortness of breath. A review of Resident 16's active orders reflected a 3/5/24 order to apply oxygen 2-3 liters per minute via nasal canula as needed for hypoxia/maintain oxygen saturation above 92%. No order for cleaning/changing tubing was found in the orders. A review of Resident 25's face sheet dated 7/23/24 reflected she was a [AGE] year-old female with diagnoses of depression, muscle weakness, diabetes, hypertension (high blood pressure), and bipolar disorder. A review of Resident 25's Quarterly Minimum Data Set, dated [DATE] reflected she has a BIMS (Brief Interview for Mental Status) score of 15 which indicated she was cognitively competent. A review of Resident 25's Care Plan reflected on 10/4/22, a focus area was initiated for limited physical mobility related to weakness. A review of Resident 25's Orders reflected an order to change the humidifier water, oxygen tubing, and cleanse filter every night shift every Sunday. Observation on 7/21/24 at 10:45 a.m. revealed Resident 9's oxygen tubing and humidifier bottle was dated 7/14/24. Observation on 7/21/24 at 10:38 a.m. revealed Resident 16's oxygen tubing and humidifier bottle was dated 7/3/24. Observation on 7/21/24 at 10:09 a.m. revealed Resident 25's oxygen tubing and humidifier bottle was dated 6/30/24 and the bottle was empty of water. Observation on 7/22/24 at 9:52 a.m. revealed Resident 9's oxygen tubing and humidifier bottle was still dated 7/14/24. In an interview with the ICP on 7/23/24 at 11:13 am she stated, the policy on changing oxygen tubing and the humidifier bottle was to change on Sunday evening, if empty or if the nasal canula was soiled. She stated that an order was placed on the nurse MAR (Medication Administration Record) that tells nurses to change the tubing weekly. ICP stated an oxygen humidifier bottle should be at least ¾ full and never empty. She further stated, if the doctor does not write an order for changing the tubing, then the staff call the nurse practitioner or the physician to get an order. The ICP stated, it was important to change the tubing so it would work properly and for infection control. She stated, the negative outcome to the residents if the tubing was not changed, would be infections or a drop in oxygen because the tubing may not function properly. In an interview with the DON on 7/23/24 at 11:18 am she stated, the policy on changing oxygen tubing and the humidifier bottle was to change every 7 days and label and date the new tubing. When not in use, the tubing should be placed in a bag. The DON stated an order was placed on the nurse MAR that told the nurses to change the tubing weekly. The DON further stated, an oxygen humidifier bottle should be full up to the level indicated or to the minimum, but it should never be empty. She stated if the doctor does not write an order to change the tubing, then the staff should request an order. She stated it was important to change the tubing for infection control and to prevent bacteria from entering the body. She stated, the negative outcome to residents if the tubing was not changed, would be infections and hospitalizations. She stated that Resident 16 did not have an order to change the tubing because he left the facility and came back. She said the order needed to be added back for that resident. The DON stated the only policy for Oxygen was the Dynasty Health Care Group-Oxygen Administration policy given to the survey team. In an interview with the ADON on 7/23/24 at 11:30 am she stated, the policy on changing oxygen tubing and the humidifier bottle was to change every 7 days, usually on Sunday evenings. She stated that an order was placed on the nurse MAR (Medication Administration Record) that told the nurses to change the tubing weekly. She further stated, an oxygen humidifier bottle should be at least 50% or more full and never empty. She stated, if the doctor does not write an order for changing tubing, then the staff reach out to the nurse practitioner or call the doctor for the order. The ADON stated, it was important to change the tubing so it would not get kinked and to prevent air to flow thoroughly. She also stated, the negative outcome to residents if the tubing was not changed, would be possible infection or lack of oxygen. In an interview with LVN -A on 7/23/24 at 11:26 am she stated, the policy on changing oxygen tubing and the humidifier bottle was to change it once a week on night shift and an order was placed on the nurse MAR that tells nurses to change the tubing weekly. She stated, an oxygen humidifier bottle should be at least ½-2/3 full and never empty. LVN-A stated, if the doctor doesn't write an order for changing tubing, then the staff call and get a clarification order. She further stated, it was important to change the tubing for infection control and because the negative outcome to residents if the tubing was not changed, would be infections. A review of the undated 2-page Oxygen Policy labeled Dynasty Health Care Group-Oxygen Administration revealed that the policy failed to specify the safe handling, humidification, cleaning, storage, or dispensing of oxygen tubing and humidifier bottle, after the initial set-up. The policy did not indicate when tubing should be changed for infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for foods safety for 1 of 1 kitchen reviewed for food safety and sanitation. The facility failed to ensure all food items were labeled and dated. The facility failed to ensure meat was properly thawed to the correct temperature. These failures placed residents at risk of foodborne illness. Findings included: An observation of the walk-in refrigerator on 07/21/2024 at 9:05 a.m. revealed approximately 25 fruit cups exposed to air and not labeled as to when prepped. A pan of ground meat that had been cooked without a label or date. A white bucket of boiled eggs was exposed to air and did not have a label or date as to when opened. Two trays of drinks exposed to air without a label and date on them. An observation of the walk-in freezer on 07/21/2024 at 9:08 a.m. revealed a plastic bag of chicken strips, hamburger patties, and English muffins that did not have a label and date as to when opened. An observation of the kitchen on 07/21/2024 at 9:38 a.m. revealed two long rolls of breakfast sausage were sitting in a pan and were warm when the package was touched. An interview with CK A on 07/21/2024 at 9:41am revealed that he was going to cook the sausage for the next day for breakfast. Observation of CK A on 07/21/2024 at 9:48am of him taking the temperature of the [NAME] Dean sausage rolls revealed that the temperature was 63 degrees. An interview with CK A on 07/21/2024 at 9:48am revealed that the sausage was not at correct temperature and that he was going to throw the sausage away. He stated if he cooked it the residents could get sick because it was not at the correct temperature of 41 degrees or below. He stated he was trained on temperatures when he did his food handlers class. Observation of the kitchen on 07/21/2024 at 12:30pm revealed that CK A did throw the sausage away and did not cook it. An interview with CK B on 07/23/2024 at 9:56am revealed that all kitchen staff were responsible for ensuring food was labeled and dated after opened. He stated that he had just done his food handlers and remembered the temperatures questions. He also stated that the proper temperature of thawed meat was 65 degrees. He stated that when thawing food, the cook was to run water over it in the sink. He stated that if food was not thawed correctly at the proper temperature and the food was not labeled and dated it would put residents at risk for getting sick . An interview with the DM on 07/23/2024 at 10:06am revealed that when the facility would get a truck everything was supposed to be labeled and dated. She stated that the proper temperature for thawing food was 41 degrees. She stated by not thawing food correctly it could cause bacteria to grow. She stated that if food was not labeled and dated it could cause the residents to get sick and possibly die. She stated that staff were trained on temperatures when they get their food handlers cards. She also said that she would go over temperatures with the staff. She stated she did not know why the meat was not at the correct temperature . Record review of kitchen staff files did reveal staff had food handler card. Food handlers class covered temperatures. Record review of Food Storage Policy dated 2018 revealed to ensure freshness, store opened and bulk items in tightly covered container. All containers must be labeled and dated. Date label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Store frozen foods in moisture proof wrap or containers that are labeled and dated. Once frozen food has been thawed it must be maintained at 41 degrees or less prior to cooking. A record review of the FDA's 2022 Food Code reflected the following: 7-209.11 Storage. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents were discharged per facility requirements for one (Resident #1) of 8 residents reviewed for discharge requirements. The facility failed to complete and document in Resident #1's chart her discharge planning and summary upon her discharge on [DATE]. This failure placed residents at risk of improper discharges. Findings included: A record review of Resident #1's undated face sheet reflected a [AGE] year-old female admitted on [DATE] and discharged on 4/12/2024 with diagnoses of benign neoplasm of pituitary gland (abnormal noncancerous growth), gout (excessive uric acid), muscle weakness, hyperlipidemia (high cholesterol), depression, edema (fluid buildup), chronic kidney disease, unspecified convulsions, type 2 diabetes, spinal stenosis (narrowing of spinal column), hypothyroidism (underactive thyroid), morbid (severe) obesity and chronic pain syndrome. A record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 12, which indicated moderately impaired cognition. A record review of Resident #1's care plan last revised on 3/14/2024 reflected the following: My/family's discharge planning will begin on day of admission including preparation for education and/or equipment. A record review of Resident #1's document dated 3/14/2024 titled 30 DAY NOTICE OF TRANSFER/DISCHARGE reflected Resident #1 would be discharged due to non-payment on 4/13/2024. A record review of Resident #1's order dated 4/12/2024, timed 10:48 a.m., and authored by the Nurse Practitioner reflected it was Okay to d/c pt to Group Home. A record review on 4/15/2024 of Resident #1's undated document titled Discharge Planning Review v1.0 reflected her advance directives and that she was not independent prior to admission. The following sections were blank: -Who initiated the discharge -Reason for discharge -Recap of the resident's stay -:Living arrangements prior to admission -Initial discharge goals -Where resident discharged to at time of discharge -Resident's goals of care and treatment preferences -Resident's interest in receiving information regarding returning to the community -Number of times the resident was admitted to the hospital in the past 6 months -Whether resident had a caregiver at time of admission -Whether resident would have a caregiver after discharge -Discharge home services -Discharge goal barriers -Medication reconciliation information -Post-discharge medication list discussion with resident/family -Whether post-discharge medication list was provided to resident/family -Overall summary of discharge -Self-care evaluation and equipment including walking, wheelchair use, transfers, bathing, dressing, using the restroom, preparing meals, eating, grocery shopping, housekeeping, performing home maintenance, obtaining transportation, scheduling medical appointments, getting and taking medications, performing special treatments, procedures, and equipment and supplies Learning and care needs -Contacts and discharge information -Resident signature, resident representative signature, and staff signatures A record review of Resident #1's progress notes from April of 2024 reflected no notes from the SW on discharge planning and preparation. During an interview on 4/15/2024 at 12:52 p.m., Resident #1's family member stated the facility could not find medical necessity for Resident #1 to be eligible for Medicaid and that she went to a boarding home on 4/12/2024. During an interview on 4/15/2024 at 12:55 p.m., the SW stated the facility had worked with Resident #1's family member on making payments but it was not enough for them to not discharge Resident #1 from the facility. The SW stated the process for facility-initiated discharges depended. The SW stated she ensured discharges were safe by making several referrals to other facilities and for Resident #1, she was able find another facility quickly. The SW stated Resident #1 was issued a 30-day notice due to non-payment. During an interview on 4/15/2024 at 1:50 p.m., the Nurse Practitioner stated, All I knew was that [Resident #1] was issued a 30-day notice due to non-payment so they told me she had to be transitioned to a different facility. The Nurse Practitioner stated no she was not involved with Resident #1's discharge planning and said she did not know Resident #1 was being discharged until the day of her discharge, on 4/12/2024. The Nurse Practitioner stated herself or the Medical Director would sign off on discharges. The Nurse Practitioner stated they should complete residents' discharge planning upon discharge and said she felt like it should be done before to anticipate the discharge and know where [Resident #1] was going. In regard to Resident #1's discharge planning and discharge summary not being completed, the Nurse Practitioner stated, that's not appropriate and it should have been done. During an interview on 4/15/2024 at 2:14 p.m., the SW stated she was not in the building when Resident #1 was discharged and said the ADON transported the resident to her new facility. During an interview on 4/15/2024 at 2:16 p.m., the MDS Coordinator stated the SW did all discharge planning for residents and no ma'am she was not involved at all with Resident #1's discharge. During an interview on 4/15/2024 at 2:30 p.m., the ADON stated discharge planning started when you walk in the door. The ADON stated LVN A was the one who took care of Resident #1 the day she was discharged (4/12/2024). The ADON stated the discharge planning task was open prior to residents being discharged and none of us knew where she was going. When asked why that was, the ADON stated, I don't know. The ADON stated not having the discharge summary completed upon a resident's discharge would result in lack of documentation but would not affect care. The Medical Director's contact information was requested on 4/15/2024 at 1:44 p.m. but was not provided before exit. During an interview on 4/15/2024 at 3:47 p.m., the Administrator stated Resident #1's discharge was a little different. The Administrator stated Resident #1 was given two discharge notices, the facility was trying to work with Resident #1's family member, and Resident #1's family member was not using her money correctly. The Administrator stated the SW was responsible for completing the discharge planning and summary. The Administrator stated himself, the SW and the DON were involved with Resident #1's discharge. When asked if failing to document Resident #1's discharge planning in her chart would have the potential to affect her, the Administrator stated, not necessarily if everything was done. During an interview on 4/15/2024 at 3:54 p.m., the DON stated the discharge planning review was supposed to be opened upon admission and closed upon discharge. The DON stated, it's a recap of their stay. The DON stated there as a discharge note they're supposed to do and she was not sure why LVN A did not complete the note . The DON stated the expectation was that the discharge summary was to be completed, which consisted of the discharge planning review and a progress note completed by the nurse. The DON stated, we wouldn't discharge someone who was unsafe. A record review of the facility's undated policy titled Transfer or Discharge, Preparing a Resident For reflected the following: Policy Statement Residents will be prepared for discharge. Policy Interpretation and Implementation . 2. A post-discharge plan is reviewed with the resident, and/or his or her representative (responsible party) upon resident's discharge or transfer from the facility as applicable. 3. Nursing services is responsible for: b. Reviewing the post-discharge plan; d. Providing the resident and/or representative (responsible party) with discharge information. h. Informing appropriate departments of the resident's transfer or discharge

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate timing of notice before transfer for one (Resident #1) of 8 residents reviewed for discharge notices. The facility failed to provide notice at least 30 days before Resident #1 was discharged on 4/12/2024. This failure placed residents at risk of being improperly discharged . Findings included: A record review of Resident #1's undated face sheet reflected a [AGE] year-old female admitted on [DATE] and discharged on 4/12/2024 with diagnoses of benign neoplasm of pituitary gland (abnormal noncancerous growth), gout (excessive uric acid), muscle weakness, hyperlipidemia (high cholesterol), depression, edema (fluid buildup), chronic kidney disease, unspecified convulsions, type 2 diabetes, spinal stenosis (narrowing of spinal column), hypothyroidism (underactive thyroid), morbid (severe) obesity and chronic pain syndrome. A record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 12, which indicated moderately impaired cognition. A record review of Resident #1's care plan last revised on 3/14/2024 reflected the following: My/family's discharge planning will begin on day of admission including preparation for education and/or equipment. A record review of Resident #1's document dated 3/14/2024 titled 30 DAY NOTICE OF TRANSFER/DISCHARGE reflected Resident #1 would be discharged due to non-payment on 4/13/2024. A record review of Resident #1's progress note dated 3/15/2024 authored by the SW reflected the following: on 3/15/2024 the BOM, SW, and ED (Executive Director) had a phone conversation with [Resident #1's family member] to give her updates. The patient will have to DC on 4/13/24. A record review of Resident #1's order dated 4/12/2024, timed 10:48 a.m., and authored by the Nurse Practitioner reflected it was Okay to d/c pt to Group Home. During an interview on 4/15/2024 at 12:52 p.m., Resident #1's family member stated Resident #1's last day was supposed to be 4/13/2024 but they dropped her off at the boarding home Friday (4/12/2024). During an interview on 4/15/2024 at 12:55 p.m., the SW stated the BOM handled 30-day discharge notices and she spoke with Resident #1's family member the day of her discharge on [DATE]. During an interview on 4/15/2024 at 1:50 p.m., the Nurse Practitioner stated, All I knew was that [Resident #1] was issued a 30-day notice due to non-payment so they told me she had to be transitioned to a different facility. The Nurse Practitioner stated she did not know Resident #1 was being discharged until the day of her discharge, on 4/12/2024. The Nurse Practitioner stated, from my understanding, corporate was pushing for her to be gone within 24 hours and said the ADON had asked her to write Resident #1's discharge order on 4/12/2024. The Nurse Practitioner stated she heard from the Administrator that corporate only gave them 24 hours to get [Resident #1] out of the facility. During an interview on 4/15/2024 at 3:47 p.m., the Administrator stated Resident #1's discharge was a little different. The Administrator stated Resident #1 was given two discharge notices , the facility was trying to work with Resident #1's family member, and Resident #1's family member was not using her money correctly. When asked why Resident #1 was discharged on 4/12/2024 when her chart indicated she was to be discharged on 4/13/2024, the Administrator stated because Resident #1's family member would not assist the facility with finding a location . When asked if the facility's corporation gave him 24 hours to discharge Resident #1, the Administrator stated, it's been ongoing for 90 days. A record review of the facility's undated policy titled Transfer or Discharge, Preparing a Resident For reflected the following: Policy Statement Residents will be prepared for discharge. Policy Interpretation and Implementation 1. When a resident is scheduled for transfer or discharge, the facility will coordinate the transfer or discharge so that appropriate procedures can be implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and 2 working days advance notice to the facility to one (Resident#1) of 5 residents reviewed for planning care. As on 03/05/24, the facility failed to provide a copy of the results of the care plan meeting conducted on 01/25/24, as requested by Resident #1 and her representative initially on 02/04/24 and reminded again on 02/16/24. This failure could place the resident at risk for not being a part of the decision making related to their care resulting in decreased quality of care, loss of independence, and decreased psychosocial well-being. Findings include: Review of Resident # 1' s Face Sheet on 03/05/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Gastro-esophageal Reflux Disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), Irritable Bowel Syndrome (cramping, abdominal pain, bloating, gas, and diarrhea or constipation), Retention of Urine, Spinal Stenosis (The narrowing of one or more spaces within your spinal canal), Atherosclerotic Heart Disease of native coronary artery (plaque buildup in the wall of the arteries that supply blood to the heart), History of falling, Anxiety disorder, Recurrent Depressive Disorders, Chronic Pain Syndrome, Cognitive Communication Deficit (difficulty with thinking and how someone uses language.), Hypertensive Heart Disease, Muscle Weakness ,Abnormalities of Gait and Mobility, and Unsteadiness on feet. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 15 indicating she was cognitively intact. Review of Resident # 1' s Face Sheet on 03/05/24 revealed, Resident #1's FM was the responsible party for Resident #1. Review of an the e mail on 03/05/23 from of the FM dated 02/16/24, provided by the SW on 03/05/23 reflected: . [Resident #1] nor I have received a copy of the written 01/25/24 careplan meeting results wherein DON via her 01/26/24 e mail indicated this and that. Are you able to convince DON to release and provide a copy of the 01/25/24 careplan meeting write up report which I on 020/4/24 requested via email from DON? During an interview on 03/05/24 at 11:50 AM with Resident #1, she stated her FM supports her with care plan meetings and he requested for the results of the care plan meeting conducted with her on 01/25/24 in her room by the SW and the DON. Resident #1 said the facility did not provide the outcome of the careplan as on 03/05/24. During a telephone interview on 03/05/24 at 1:15 PM with Resident #1's FM, he stated he was the responsible party for Resident #1. He stated there was a careplan meeting on 01/25/24. He said Resident #1, the SW and the DON participated in the meeting. The FM stated he supports Resident #1 with her plan of care as Resident #1 had difficulty to comprehend what was discussed in care plan meetings. The FM stated he sent an e mail on 02/04/24 to the SW requesting for the outcome of the meeting conducted on 01/25/24, to make sure that the MDT captured all the requests made by Resident #1 in the careplan meeting. He added, since the facility failed to provide the results, on 02/16/24 he sent another e mail as a reminder about his request for the care plan meeting results. The FM stated despite of all these, the were no action from the facility in this matter as on 03/05/24. During an interview on 03/05/24 at 12:00pm the DON stated she was not aware of the request. She said it was the rights of residents at the facility to know about the content of their careplan and was the responsibility of the facility to provide that information. The DON stated, at the facility, the SW had the responsibility to communicate with the family of residents regarding the care plans. During an interview on 03/05/24 at 1:00PM the SW stated she was the responsible person to communicate and address the requests of Resident #1 and her FM. She stated she received an e mail from Resident #1's FM requesting for the results of the monthly care plan meeting conducted on 01/25/24 with Resident #1. The SW explained that the facility agreed with Resident #1 and her FM to have a monthly careplan meeting in addition to the mandatory quarterly careplan meeting. The SW explained to the investigator that she could not furnish the careplan meeting outcome to Resident #1 as requested by Resident #1's FM due to many reasons. The SW stated the printer at the facility was not working in the last week of January 24 and 1st week of February,24. She said after that she was on a vacation for a week and after return from the vacation, she was busy. The SW added, she caught up with other tasks at the facility so that she could not compile and transcribe the points noted down elsewhere, into the careplan conference summary form. The SW also stated, she was not sure if she could disclose the details of the careplan to FM due to HIPAA concerns as FM was not the responsible person for Resident #1. SW remained quiet when investigator pointed out that as per the FM was Resident #1's face sheet dated 03/05/24, FM was the responsible person. Review of the facility's undated policy Resident Rights reflected: Employees shall treat all residents with kindness, respect and dignity . .be informed of, and participates in, his or her care planning and treatment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide comfortable and safe temperature levels at a range of 71 to 81 degrees Fahrenheit for two (Resident #1 and Resident #2) of eight residents reviewed for homelike environment. The facility failed to ensure Resident #1 and Resident #2's room was maintained less than 81 degrees Fahrenheit in that the room reached 88.9 degrees Fahrenheit. This failure could place residents at a major risk of heat exhaustion, dehydration, hospitalization, and death. Findings included: Resident #1 A record review of Resident #1's face sheet dated 9/26/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body) affecting left nondominant side, cerebral infarction (stroke), visuospatial deficit (conditions affecting the ability to perceive, analyze, synthesize, manipulate and transform visual patterns and images), hypertensive heart disease (type of heart disease caused by high blood pressure), muscle weakness, abnormalities of gait and mobility, and generalized anxiety disorder. A record review of Resident #1's annual MDS assessment dated [DATE] reflected a BIMS score of 8, which indicated moderately impaired cognition. A record review of Resident #1's care plan last revised on 9/11/2023 reflected she had impaired visual function and interventions included staff were to assess for potential changes to environment which might improve safety and be acceptable to me. A record review of Resident #'1's physician orders reflected no orders for increased monitoring for heat exhaustion, hydration or ambient room temperature. A record review of Resident #1's progress notes dated 8/27/2023-9/26/2023 reflected no progress notes related to increased monitoring for room temperature, heat exhaustion, or hydration. There were no documented attempts to either move Resident #1 or keep her cool. Resident #2 A record review of Resident #2's face sheet dated 9/26/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of major depressive disorder (depression), unspecified abnormalities of gait and mobility, anxiety disorder, and muscle weakness. A record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated intact cognition. A record review of Resident #2's care plan last revised on 8/02/2023 reflected she had mood and panic disorder and interventions included staff were to coordinate with the Local Mental Health Authority for behavioral services. A record review of Resident #2's physician orders reflected no orders for increased monitoring for heat exhaustion, hydration or ambient room temperature. A record review of Resident #2's progress notes dated 8/27/2023-9/26/2023 reflected no progress notes for increased monitoring for room temperature, heat exhaustion, or hydration. There were no documented attempts to either move Resident #2 or keep her cool. During an observation and interview on 9/25/2023 at 10:29 a.m., Resident #1 was observed wearing a jacket and sitting in a wheelchair in room [ROOM NUMBER]. Resident #1 stated it felt warm in her room, her AC had stopped working a day ago and she needed to get the Maintenance Manager to fix it. LVN A entered Resident #1's room and said she did not know how long the central AC had been out, the facility had ordered a part for it, and just a couple rooms were affected. Resident #1's room contained a portable AC unit and a tower fan, but neither were turned on and running. During an observation and interview on 9/25/2023 at 10:37 a.m., LVN A stated it felt warm in Resident #1's room and she had just realized how hot it was when she came in the room. Observed LVN A turn on portable AC. During an observation and interview on 9/25/2023 at 10:40 a.m., Resident #1's ambient air was measured using a surveyor device accurate +/- 2 degrees Fahrenheit from other temperature monitors and the air temperature read 88.8 degrees Fahrenheit. During an observation and interview on 9/26/2023 at 10:48 a.m., the Maintenance Assistant stated the AC had been down about a week or two in 300 hall and it took them a while to get the part. When asked how the facility kept rooms cool, the Maintenance Assistant stated room [ROOM NUMBER] had a portable unit. Observed the Maintenance Assistant measure the ambient air using a laser thermometer pointed at the middle of an interior wall near Resident #1's head and the thermometer read 88.9 max. The Maintenance Assistant explained that 88.9 degrees Fahrenheit was the maximum temperature measured in the room. The Maintenance Assistant said the vent to the portable AC unit in room [ROOM NUMBER] had been popped off and he was not sure how long it had been that way. During an observation and interview on 9/25/2023 at 10:59 a.m., Resident #2 was observed in room [ROOM NUMBER]. Resident #2 stated it had been hot in her room for a couple weeks and the facility had tried to fix it, stated it wasn't this hot before. Resident #2 said she had a portable AC unit but it should be better. During an interview on 9/25/2023 at 11:53 a.m., the Maintenance Manager stated the compressor in the AC unit on the 300 hall went out and the air conditioning company tried to replace it the previous week, but it was the wrong part; and they planned to replace it that morning. The Maintenance Manager said he put a portable AC unit in room [ROOM NUMBER]. During an interview on 9/25/2023 at 12:44 p.m., LVN A stated she did not know how long the portable AC in room [ROOM NUMBER] had been unplugged but it was not comfortable in her room because it was too hot. LVN A said when she saw Resident #1 that morning, it was the first time she noticed the room to be hot. An observation on 9/25/2023 at 12:48 p.m. revealed the ambient air of room [ROOM NUMBER], using a surveyor device, measured to then be 81.6 degrees Fahrenheit. During an interview on 9/25/2023 at 12:50 p.m., the Maintenance Manager stated there had been no central AC in room [ROOM NUMBER] since the week before. The Maintenance Manager stated Resident #1 and Resident #2 refused to move rooms. The Maintenance Manager stated the facility's policy required them to keep resident rooms between 70-80 degrees Fahrenheit and no one had notified him of any temperature concerns over the weekend. The Maintenance Manager said no one had told him about the exhaust from the portable AC unit in room [ROOM NUMBER] had been blowing into the room instead of out the window and no one had notified him the temperature was that high. During an interview on 9/25/2023 at 12:57 p.m., CNA D stated she had been working the 6:00 a.m.-2:00 p.m. shift on 300 hall that day (9/25/2023). CNA D stated she first rounded on residents in room [ROOM NUMBER] at about 6:45 a.m. that morning and then after breakfast around 9:45 a.m. or a little after 10:00 a.m. CNA D said rooms #306 and #307 were always warmer to her compared to the 400 hall. CNA D stated for her, it was not comfortable but Resident #1 and Resident #2 had not complained about heat. CNA D stated she started working in the facility about two weeks prior and it had always been warm over there. CNA D stated when she rounded on Resident #1 and Resident #2 that morning, she did not notice the AC unit was unplugged. CNA D stated she had never reported the warmness to management, but she thought they were aware because AC units were there. CNA D said she did not think it was okay for room [ROOM NUMBER] to reach 89 degrees Fahrenheit and she wouldn't want her mom in this. During an interview on 9/25/2023 at 2:35 p.m., the Administrator stated the contractor was out Friday 9/22/2023 to fix the AC but it was the wrong compressor because the manufacturer had sent the wrong part. The Administrator stated a technician was coming out to fix it that day. The Administrator stated cool air would filter into resident rooms if they kept their doors open. The Administrator stated residents on 300 hall were offered a room change. When asked how many compressors were on each hall, the Administrator stated one AC unit may work for multiple halls. When asked if residents were offered a portable AC unit to be placed in their rooms, the Administrator said, I don't think so because no one wanted to move rooms and no one complained about heat except room [ROOM NUMBER] and that was why a unit was placed in the room. The Administrator stated the Maintenance Manager checked ambient air temperatures once a week. The Administrator stated the facility's policy was to maintain temperatures of 71-81 degrees Fahrenheit, but she was not sure if all rooms were at that temperature because she would have to check. The Administrator stated she walked the 300 hall that morning and the back rooms felt hotter than the front. The Administrator said there was central AC on the 300 hall, just the front half of the hall. During an interview on 9/25/2023 at 3:15 p.m., MA G stated she worked the 300 hall and entered residents' rooms to pass medications. MA G said yes the compressor on the back of 300 hall was out and the only way she knew the compressor was out, was because a resident told her. MA G stated she had worked in room [ROOM NUMBER] the day prior on Sunday 9/24/2023 and it was warm. MA G said she had made a comment twice to Resident #1 and Resident #2 that it felt stuffy in there and then told them 'if y'all are okay with it I'm okay with it'. MA G stated she had told a nurse what she felt in room [ROOM NUMBER] but she could not remember which nurse, just that it was not the charge nurse. MA G said [Resident #1] and [Resident #2] seemed to be okay with it so I left it as is. MA G stated no she did not report it to the DON, ADON or Administrator because they were okay with it. MA G said if Resident #1 and Resident #2 had told her they could not breath or it was too stuffy, she would have gone farther and escalated the situation but because the residents did not complain, she did not take it further. MA G stated she first noticed it was warm in room [ROOM NUMBER] at the beginning of September 2023 and it had always been kinda stuffy in there but she did not report it because neither resident complained about it. During an interview on 9/25/2023 at 4:12 p.m., CNA E stated she had worked 6:00 p.m.-6:00 a.m. shift on Saturday 9/23/2023 and Sunday 9/24/2023. CNA E said, last night me and CNA F worked 300. CNA E stated it was always hot down there-that's why another resident moved. CNA E said she had told nurses it was hot, most of those rooms were hot, and there was no kinda air circulation. CNA E stated her and LVN B, we talk about it a lot-about hot the building was. CNA E stated she had reported it to LVN B last week but did not report it to the DON, Administrator or the Maintenance Manager because she was not there during the daytime. CNA E said she had commented to residents in room [ROOM NUMBER] that it was hot, but they did not want their door open. CNA E stated residents in room [ROOM NUMBER] had not complained of heat and that she had not reported it to the Maintenance Manager because she had not seen him on her shift. CNA E said, when I report to nurses, I expect they're passing along the message. CNA E stated CNA F was assigned to work room [ROOM NUMBER] on the overnight shift on 9/24/2023. CNA E said no she did not think the facility was taking care of the issue and I do ask why is it so hot. CNA E stated, I bet it would affect their breathing because when I'm too hot I feel like I'm hyperventilating. During an interview on 9/25/2023 at 4:35 p.m. CNA F stated yes she had worked in room [ROOM NUMBER] the night before (9/24/2023) and it feels warmer on that side. CNA F stated she did not notice a portable AC unit in the room, but she did not go that far into the room. During an interview on 9/25/2023 at 5:12 p.m., the Administrator stated she thought the Maintenance Manager had checked room temperatures in room [ROOM NUMBER] after the compressor went out on 9/19/2023 but she did not have it documented. During an observation and interview on 9/26/2023 at 9:07 a.m., the Maintenance Manager stated he was responsible for monitoring temperatures of resident rooms, and he checked room temperature once a week by picking random rooms at the beginning and end of each hallway. The Maintenance Manager said only rooms #306 and #307 were affected by the broken compressor. When asked how residents who chose not to leave the affected area were monitored for room temperature from 9/19/2023-9/25/2023, the Maintenance Manager said himself and the Maintenance Assistant came to the facility over the weekend (9/23/2023-9/24/2023) to complete daily checks of those rooms and had a separate log. The Maintenance Manager stated their ambient temperature measuring device broke on Friday 9/22/2023 so they used their laser temperature gun over the weekend and he said it was within a ballpark range. When asked what prompted him to purchase a new thermometer around noon the previous day (9/25/2023) if he had worked over the weekend and the old device broke on Friday 9/22/2023, the Maintenance Manager stated, we had this, pointed to the laser thermometer, and said it was within ballpark range, so I thought I'd wat until Monday to get it. The Maintenance Manager stated the air was on and there's no way it would have gotten to 88 degrees in room [ROOM NUMBER]. The Maintenance Manager stated, LVN C, was the overnight nurse on Sunday 9/24/2023 and she checked residents to make sure they were comfortable. The Maintenance Manger stated himself and the Administrator oversaw the facility's emergency preparedness process. During an interview on 9/26/2023 at 9:28 a.m., the Maintenance Manager stated the facility's emergency preparedness plan reflected that if it was over 85 degrees for four hours, the facility needed to evacuate residents from the affected area to another area of the facility. During an observation and interview on 9/26/2023 at 9:40 a.m., the Maintenance Manager stated he did ambient checks once a week on Fridays and documented it in their electronic system but said there was no way to print a report. Observed the Maintenance Manager's computer screen which revealed instructions on how he was to complete temperature checks. The Maintenance Manager stated he would print the page. When asked why the paper log he provided reflected September 2023 but dates of 5/19, 5/20, 5/21, 5/22, 5/23, 5/24, and 5/25, the Maintenance Manager said, I must've wrote the wrong date. During an interview on 9/26/2023 at 10:59 a.m., LVN A stated on 9/25/2023 when she entered room [ROOM NUMBER] around 10:00 a.m., the plastic piece was missing, the portable AC unit was not running, and she did not know how long it had been turned off. LVN A stated around 10:00 a.m. was the first time she entered room [ROOM NUMBER] on 9/25/2023. During an interview on 9/26/2023 at 11:17 a.m., LVN C stated she was on call the previous weekend (9/23/2023-9/24/2023) and worked the overnight shift on Sunday 9/24/2023. LVN C said she had been in room [ROOM NUMBER] twice that night and it was not hot. LVN C said she last rounded in room [ROOM NUMBER] around 5:00 a.m. on Monday 9/25/2023 and it was not hot in there. During an interview on 9/26/2023 at 11:12 a.m., the Maintenance Assistant said the compressor on 300 hall went out on September 14th or 15th and it took a while for the part to get there. During an interview on 9/26/2023 at 11:51 a.m., Resident #2 stated the Maintenance Manager did not work weekends and no she did not remember him being there the most recent weekend (9/23/2023-9/24/2023) because he was usually off. Resident #2 stated she did not remember there being an emergency last weekend where management would need to come in. Resident #2 stated the Maintenance Manager had not been feeling well the day prior (on 9/25/2023) but he stayed anyway. During an interview on 9/26/2023 at 1:32 p.m., LVN C stated the Maintenance Manager worked Monday-Friday unless the facility needed him there for something during the weekend. LVN C stated she could not remember the last time the Maintenance Manager worked on the weekend, but she was not exactly sure what his schedule was. During an interview on 9/26/2023 at 3:21 p.m., the DON stated the Maintenance Manager installed a portable AC unit in room [ROOM NUMBER] after the compressor went out. In regard to the function of the unit, the DON stated, that is something [the Maintenance Manager] would check and staff would make sure residents were okay. The DON stated nursing staff would see if residents had complaints and make sure they were okay by checking on them and giving them their medications. The DON stated, what we might consider warm, for them it's perfect. The DON stated she was not sure whether the Maintenance Manager tested room temperatures because she focused on clinical. The DON stated clinical signs of heat exhaustion included heavy breathing, elevated pulse and elevated blood pressure. The DON stated residents were monitored via visual checks and since there were no complaints of them being uncomfortable, there would not be a need to document. The DON stated no staff had reported to her that it felt hot on 300 hall or in room [ROOM NUMBER]. The DON stated, residents want it above 80. The DON stated residents were offered a room change and a portable AC unit after the compressor on the 300 hall went out on 9/29/2023. The DON stated she was not sure whether there was increased monitoring and she was not sure whether the Maintenance Manager had been doing daily temperature checks, but he did weekly checks. The DON stated yesterday (9/25/2023) was the first time she heard it was that high. The DON stated if a resident said they were okay, it did not indicate that staff needed to check whether something was not functioning. When asked how she knew the room did not exceed 85 degrees Fahrenheit for five hours if there was no increased monitoring for the function of the cooling device, the DON stated, it depends when the resident complained. When asked how she ensured a homelike environment when residents liked to be warm, the DON stated, they do have rights and what's hot for me is not hot for them. The DON stated if a resident complained of being hot, she walked down the hall and figured out it was hotter, that would prompt her to test the temperature. The DON stated yes she expected staff to report heat to her and she asked how she could have known if it did not get reported to her. The DON stated, what's hot for a staff member is not hot for a resident and we have to provide temperatures according to the residents' comfort level. The DON stated a temperature of above 81 degrees Fahrenheit had a potential to affect residents but they weren't affected and they didn't have any adverse reactions to the temperature. The DON stated when it was reported that temperatures were hotter than normal, it was addressed and it's not like we sat on it. The DON stated if it were an issue and residents did not want to move rooms, she would call her corporate nurse. When asked why she had not done that, the ODN stated because the problem was fixed Monday. During an interview on 9/27/2023 at 9:53 a.m., Resident #2 stated no the facility had never offered to move her to another room. During an interview on 9/27/2023 at 9:55 a.m., Resident #1 stated no she did not remember staff offering her a room change when the compressor went out, but she was not sure because her memory was bad. Resident #1 stated, I would just go out of the room to a different place to try to stay cool. During an interview on 9/28/2023 at 12:07 p.m., the Maintenance Assistant stated either him or the Maintenance Manager did temperature checks every week on Wednesdays and no they had not been completing daily temperature checks since the week prior (9/19/2023-9/25/2023) because the temperatures are always the same. The Maintenance Assistant stated he had not worked the most recent weekend (9/23/2023-9/24/2023) because he only worked weekdays. A record review of the facility's document dated September 2023 titled Daily Temp Check reflected a table with three columns and seven rows. The three columns reflected room [ROOM NUMBER], Date 5/19, 5/20, 5/21, 5/22, 5/23, 5/24, 5/25, and Temp 77, 76, 77, 75, 76, 75, 77. A record review of the facility's undated invoice reflected the compressor went out on 9/19/2023 and was replaced on 9/25/2023. A record review of the facility's document dated 9/26/2023 titled Test and log air temperatures reflected the following: Instructions All buildings are required to maintain an ambient temperature throughout resident and patient areas in a temperature range of 71 to 81 degrees Fahrenheit or at a more restrictive range required by state or local requirements. Exceptions to this range may be available for brief periods of unseasonably warm or cold temperatures; however, the variance in temperatures must not adversely affect resident or patient health and safety. 1. Take environmental temperatures approximately 36 from the floor. 2. Using a digital thermometer take random location temperatures throughout the building. 3. The time of day that the temperatures are taken should vary to ensure that the desired temperature range is achieved under a variety of conditions. 4. While meeting the requirement for the indoor air temperature, it is also important to consider the effective air temperature and the impact that humidity and air movement in the building may be having on comfort. 5. If air temperature monitoring tests are not within acceptable ranges, immediately create a high priority TELS work order. A record review of weather in [NAME], Texas on 9/25/2023 reflected at 6:00 a.m., the low was 79 degrees Fahrenheit and the high was 84 degrees Fahrenheit. At 12:00 p.m., the low was 88 degrees Fahrenheit and the high was 95 degrees Fahrenheit. A record review of TULIP on 9/28/2023 reflected no self-reported incidents regarding the compressor outage. A record review of the facility's policy dated August 2018 titled Emergency Procedures - Utility Outage reflected the following: Policy Statement Residents will remain safe and comfortable during a temporary loss of power. Policy Interpretation and Implementation 1. Staff will implement safety precautions and comfort measures for residents during a temporary loss of power. 2. If extended utility outage occurs during severe weather (cold or heat), evacuation of residents may be necessary. Emergency Procedure - Utility Outage 10. Monitor residents to ensure they are safe and check resident-used medical equipment. See attached SEVERE COLD and HOT WEATHER PROCEDURES to prevent hypothermia during loss of heating functions and procedures to prevent hyperthermia during loss of cooling functions. 11. Continuously monitor equipment that may be adversely impacted due to the failure itself (electrical grounding, failure of other systems, etc.) as well as negative circumstances that may occur upon sudden resumption of utility (over-pressurization, power surge, etc.). 13. If the outage is long term and threatens resident safety and welfare, contact Emergency Management Office and State Licensing and Certification Agency. Severe Hot Weather Procedures Utilize the following procedures if there is a loss of cooling functions (the facility temperature reaches 85 degrees Fahrenheit and remains so for four hours) to prevent hyperpyrexia. 1. Move residents to an air-conditioned part of the facility, if available. 2. Encourage the residents to drink fluids. 3. Provide cold washcloths as needed. 7. Evacuate residents if necessary. 8. Monitor environmental thermometers. 9. Notify Medical Director. A record review of the facility's undated policy titled Homelike Environment reflected the following: Policy Statement Residents are provided with a homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: h. comfortable and safe temperatures (71°F-81°F)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #234) reviewed for Activities of Daily Living care provided to dependent residents. The facility failed to ensure Resident #234 received baths or showers since being admitted to the facility on [DATE]. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene. Findings include: Record review of Resident #234's face sheet, dated 06/15/23, revealed a 66 -year-old male who was admitted to the facility on [DATE]. Resident #234's relevant diagnoses included Quadriplegia (Paralysis) and Neuromuscular Dysfunction of Bladder (Bladder control). Record review of Resident #234's Baseline Care Plan, dated 06/07/23, revealed for personal hygiene, the resident required a One-person, and for transfer support, Resident #234 required Two + persons physical assist. The Baseline Care Plan indicated Resident #234 was Cognitively intact. Record review of Resident #234's Bathing/Shower report revealed, the resident had not received his scheduled shower/bath on 06/08/23 nor on 06/10/23. The report indicated the resident received a bed bath on 06/13/23 at 4:09 PM. Interview and observation of Resident #234 on 06/13/23 at 11:29 AM revealed he was admitted to the facility on [DATE] at or around 8:00 AM. He stated he had been at the facility a week and was still waiting for a shower. He stated he spoke with the nursing staff a few days ago and was advised he would get a shower. He stated he was scheduled to receive three shower/baths a week and his days were Tuesday, Thursday, and Saturdays. He stated he really wanted a shower or bath because he felt dirty. Interview on 06/15/23 at 9:10 AM with CNA W revealed, they were required to provide residents a shower/bath three days a week and Resident #234 was a B Bed and he was scheduled on Tuesday, Thursday, and Saturday. She stated there was no reason why the resident had not received a shower/bath since being admitted to the facility on [DATE]. She stated the risk to the resident not having a shower/bath could result in a dignity issue and skin breakdown. She stated CNAs were responsible for ensuring residents receive their bath/showers when scheduled the Unit nurse is overall responsible. Interview with LVN P on 06/15/23 at 9:54 AM revealed she had been at the facility for over a year and she was the Day Charge nurse for the 300 and 400 Halls. She stated she ensured her residents received their bath and shower when scheduled. She stated the protocol whenever a resident refused a shower, and her role was attempting to persuade the resident into taking a bath/shower and contacting responsible parties if needed. She was advised of Resident #234 not receiving a shower/bath since arriving to the facility on [DATE], and she stated she was not familiar with this resident. She was advised that the resident advised that he had not refused a bath/shower nor were there any progress notes indicating a refusal. She stated the risk of not ensuring residents received their bath/shower when scheduled, could result in skin breakdown. Interview with ADON on 06/15/23 at 10:35 AM revealed his expectation for residents getting their baths/showers were for residents to receive their scheduled bath/shower three days a week. He stated the protocol for CNAs and Nurses whenever a resident refused a shower, and he stated that 3 attempts were made and the Responsible party was contacted. He stated he was unsure why Resident #234 had not had a shower since being admitted to the facility, but he would look into it and in-service staff on shower/bath protocols. He stated the risk for residents not getting their scheduled bath/shower could result in skin break down and dignity. Interview with the DON on 06/15/23 at 11:00 AM revealed she was made aware by staff that Resident #234 had not received a shower/bath since being admitted to the facility on [DATE]. The DON stated she was unsure why this was overlooked by staff and would in-service her team on the shower/bath protocol to ensure this did not occur again. She stated her hall-nurses should be auditing for shower/baths weekly and she would implement a quality assurance and performance improvement plan this with the Administrator. She stated the risk of the resident not receiving a shower/bath could result in skin breakdown and cause pressure ulcers and other problems. Record review of the facility's policy on Resident Rights, revised October 2009, revealed Employees shall treat all residents with kindness, dignity, and respect .Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on observation and interview the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and the facility failed to ensure, in accordance with State and Federal laws, all drugs were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 4 medication carts (#1 and #2) reviewed for medication storage. 1. The facility failed to ensure the medication carts #1 and #2 were secured and unable to be accessed by unauthorized personnel and residents. These failures could place residents at risk for not receiving drugs and biologicals as needed and a drug diversion. Findings include: An observation on 06/14/23 at 12:15 PM revealed a medication cart #1 was parked at the nurse's station and was unlocked. There were no staff observed at or near the medication cart or nurse's station. There were no residents observed near the medication cart. During an observation on 06/14/23 at 12:15 PM revealed the MDS Coordinator walked by, saw the State Surveyor examining the unlocked and unattended medication cart. The MDS Coordinator locked medication cart. In an interview with on 06/14/23 at 12:20 PM with the MDS coordinator who stated that she did not know who was assigned to medication cart #1, but it should not have been left unlocked, nor should medication bottle be left on top. She said she would ask the DON who was assigned the cart and lock it now to prevent access by visitors, other staff, or residents that could cause harm if accessed or other residents to miss medication. An observation on 06/14/23 at 12:20 PM revealed the RN-R (assigned medication cart #1) was located near the administrator's office in the lobby. An observation on 06/15/23 at 1:45 PM revealed medication cart #2 was parked in front of a resident room. The resident room door was open, and no residents or visitors were observed near the medication cart. The MDS Coordinator locked the cart and stated that she did not know how was assigned to medication cart #2, but she would contact the ADON. In an interview with RN-R-R on 06/14/23 at 12:22 PM revealed he left the cart to speak with a staff up front (in the lobby). Upon closer examination the medication bottle was empty and discarded. He said he was gone for few minutes. The RN-R said he did not recall leaving the medication cart unlocked. He said the protocol was for the medication cart to be locked when unattended to prevent unauthorized staff, visitors, and residents from accessing the medication. He said leaving a medication cart unlocked could lead to a resident accessing and overdosing or being harmed. RN-R said he was responsible for locking the medication cart when walking away and discarding empty medication bottles. During an interview on 06/15/23 at 2:00 PM, LVN N said she was not thinking when she left medication cart #2 unlocked. LVN N said the medication cart should have never been left unlocked as it could allow residents to access medication and take the incorrect meds or for medications to be stolen. She said the medication carts should be locked when not attended by authorized personnel. During an interview on 06/15/23 at 2:10 PM, the ADON who said medication carts should never be left unattended. The ADON said the importance of locking medication carts was due to prevent others from accessing the resident medications and narcotics and taking medications that could cause harm or steal and residents miss their medications. She said authorized personnel was responsible for managing the medication carts on the units and locking when away. During an interview on 06/15/23 at 2:25 PM, the DON said she expected medication carts to always be locked when unattended by authorized personnel. The DON said the importance of keeping the medication carts locked was to keep residents, visitors, and staff out of the medications. During an interview on 06/15/23 at 2:29 PM with the ADM revealed she expected medication carts to be locked when unattended by authorized personnel. The ADM said the importance of locking the medication carts was to protect the residents, visitors, and staff out of the medications. Record review of the facility's in-service with RN-R, dated 06/14/23, revealed no time. Subject: medication/TX carts must be locked when not in use. The RN-R was able to demonstrate how to lock the cart and ensure the medications were secured. The in services one on one Inservice was signed by RN-R and the DON. Record review of the facility's, undated, policy titled Storge of Medication indicated, .compartments containing drugs and biologicals are locked when not in use. Unlocked medications carts are not left

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of three residents (Resident #10 and Resident #24) reviewed for infection control. The facility failed to ensure MA S sanitized the blood pressure device and cuff between use with Resident #10 and Resident #24. This failure could place residents at risk of cross-contamination and infections. Findings include: Record review of Resident #10's face sheet, dated 06/15/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10's relevant diagnoses included breast cancer, difficulty swallowing, difficulty walking, anxiety and dementia. Record review of Resident #24's face sheet, dated 06/15/23, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #24's relevant diagnoses included heart failure, kidney failure, difficulty swallowing, difficulty walking, anxiety, depression, post traumatic stress disorder, and bi-polar disorder with mania episodes. In observation of MA S on 06/13/23 at 9:10 AM, she obtained Resident #24's blood pressure by placing the device cuff on her right wrist. MA S failed to sanitize the blood pressure device and cuff before or after use with Resident #24. In observation of MA S on 06/13/23 at 9:18 AM, she obtained Resident #10's blood pressure by placing the device cuff on her left wrist. MA S failed to sanitize the blood pressure device and cuff before or after use with Resident #10. In interview with MA S on 06/13/23 at 9:48 AM, she stated she forgot to sanitize the blood pressure device and cuff between use on Resident #24 and Resident #10. She stated the facility had educated her on sanitizing shared use equipment but during the time of observation, she forgot. She stated it was important to sanitize shared use equipment for infection control purposes. In interview with ADON W on 06/15/23 at 10:19 AM, he stated all staff were expected to sanitize shared use equipment between resident use. He stated MA S should have sanitized the blood pressure cuff and device between use with residents in her care. He stated it was important to sanitize shared use equipment between resident use to prevent infection and cross-contamination. He stated it was the floor nurse who oriented and trained MA S to ensure she adhered to infection control policies and procedures. In interview with the DON on 06/15/23 at 10:59 AM, she stated all staff were expected to sanitize shared use equipment between resident use. She stated MA S should have sanitized the blood pressure cuff and device between use with residents in her care. She stated it was important to sanitize shared use equipment between resident use to prevent infection at the facility. She stated MA S was agency sourced staff, and it was expected she was trained in infection control policies and procedures by the agency. She stated MA S was oriented by a staff nurse before being able to work on her own; but stated there was not any documentation of a facility generated skills check-off or competencies for review. In interview with the Administrator on 06/15/23 at 1:22 PM, she stated she expected all staff to sanitize shared use equipment between resident use. She stated it was important to sanitize shared use equipment between resident use for infection control purposes. She stated it was the DONs responsibility to ensure staff adhere to infection control policies and procedures. Record review of the facility's, undated, policy, Cleaning and Disinfection of Resident Care Items and Equipment, revealed: d. Reusable items are cleaned and disinfected or sterilized between residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment which included but was not limited to receiving treatment and supports for daily living safely for three of eight rooms (Room # 305, #310, and #508) reviewed for environment. The facility failed to ensure resident rooms were cleaned and sanitized daily, and in accordance with the facility's Housekeeping Workers' Checklist. This failure could place residents at risk of the spread of disease-causing organisms in the residents' living areas and on resident care equipment. Findings include: Observations on 06/13/23 at 10:35 AM and 06/14/23 at 2:00 PM of room [ROOM NUMBER], which was occupied by two residents that could not be interviewed, revealed the center area of the room floor had black dirt spots and the corner of the floors had thick black dirt patches. The residents' bathroom bottom wall had some drywall work done but it was dirty and the wood looked as if it was rotting and was not painted. Observations on 06/13/23 at 10:57 AM and 06/14/23 at 11:10 AM of room [ROOM NUMBER], which was occupied by one resident that could not be interviewed, revealed the room floor had visible black dirt spots and the corner of the floor had thick built-up black dirt along the walls and corner. There was a white paper stuck to the floor in the corner of the room. Observations on 06/13/23 at 11:41 AM and 06/14/23 at 11:20 AM of room [ROOM NUMBER], which was occupied by a resident that was unavailable for interview, revealed the room floor had visible black dirt spots on the floor and in the corner of the floors was a black thick built-up of dirt. There was a white paper stuck to the floor in the corner of the room. The resident's bathroom floor was visibly dirty and had black [NAME] spots all over it. Interview with Resident #3 on 06/13/23 at 10:57 AM revealed she had concerns about the cleanliness of the facility a few weeks ago. She stated the Housekeeping Manager was fired some weeks ago but the cleaning was still bad when he was at the facility. She stated that housekeeping basically swept the middle of the room, emptied the trash, and did a light mop. She stated she had complained to the Administrator and DON recently. Interview with the DON on 06/14/23 at 2:25 PM revealed she was shown the pictures of the concerns regarding the cleanliness of the resident rooms. She stated the facility currently did not have a Housekeeping Supervisor but she thought they were doing a good job cleaning resident rooms daily. She stated she expected the rooms to be cleaned from top to bottom daily. She sated the risk of residents' rooms not being thoroughly cleaned could impact the residents' ability to have a homelike environment. She stated they had at least two housekeeping aides daily to clean rooms. Interview with the ADON on 06/15/23 at 10:35 AM revealed housekeeping had staffing concerns but they cleaned pretty good. He stated he walked into a lot of other facilities and this one did not smell like others. He stated the previous Housekeeping Supervisor was terminated about 2 or 3 weeks ago. He advised that they did not really have a Lead Housekeeper and staff had been advised that if they observe a room that needed cleaning, to get someone I housekeeping to resolve the issue. He stated the risk of not cleaning resident rooms thoroughly impacted the residents' ability to have a comfortable homelike environment. Interview with Housekeeping Aide H on 06/15/23 at 10:20 AM revealed she had been at the facility since February 2023, and she usually cleaned the 200 hall. She stated she was the only housekeeper currently available in the facility because the other Housekeeping Aide had left the facility for lunch. She stated when she cleaned resident rooms, she emptied the trash, cleaned the bathroom, mopped the floor, and used air freshener. She stated they swept and mop the entire floor. She stated she was never given a checklist when she started. She stated she was just taken to a room and shown what to clean in the resident rooms. She was shown pictures of areas that were of concern, and she stated she tried to do the best she could to clean the rooms. She stated the impact to the residents' rooms not being thoroughly cleaned was not good for the resident because they were ill and needed to be cared for. Interview on 06/15/23 at 12:05 PM with the Administrator revealed she terminated the Housekeeping Supervisor about three weeks ago and they were currently seeking a new Housekeeping Supervisor. She stated she was currently responsible for the Housekeeping at the facility and she was aware they could be better at cleaning the facility more thoroughly. She stated she directed staff to check for the cleanliness of the rooms whenever they completed their rounds and report any concerns to housekeeping immediately. She stated the risk of not ensuring rooms were thoroughly cleaned was an infection control and dignity concern for the residents. Record review of the facility's Housekeeping Workers' Checklist dated 7/2017, revealed the resident rooms were expected to be cleaned daily, including the cleaning of all fixtures and furniture, walls, and dusting and mopping floors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide food was prepared by methods that conserve nutritive value, flavor and appearance and food and drink was palatable, attractive, and at a safe and appetizing temperature for 1 of 8 residents (Residents #72 ) that were reviewed for meal presentation and taste. 1. The facility failed to ensure [NAME] A prepared regular, mechanical, and puree stir fry chicken and vegetables with taste and not overcooked during meal service on 06/14/23. Resident meals were observed mushy and watery for the puree, and the vegetables overcooked. 2. The DM failed to serve juice that was not watered down. The apple and cranberry juice contained more water than juice. 3. The DM failed to have orange juice available to resident's during the machine outage from 6/10/23 to 06/14/23. The failures could place resident's at risk of a loss of appetite, altered nutritional status and weight loss. Findings include: Observation on 06/14/23 at 12:45 PM revealed [NAME] A placed prepared stir vegetables which consisted of French green beans, carrots which were mushy and overcooked with chicken. The puree vegetables and meat were separated and with a liquid soup consistency. During survey test tray sample on 06/15/23 the puree vegetables had no flavor. An observation on 06/15/23 at 1:15 PM of the apple and cranberry juice dispenser machine revealed only water dispensed for 3oz. of the cup then 1oz. of juice, which tasted like water and the orange juice was out. A record review of Resident #72's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #72 had diagnoses which included: benign neoplasm of pituitary gland (non-cancerous), type 2 diabetes mellitus without complications (fluctuating blood sugar levels), primary adrenocortical insufficiency (bodies fails to produce hormones of the adrenal, and depression (mood). A record review of Resident #72's quarterly MDS, dated [DATE], revealed a BIMS of 11, which indicated moderate cognitive impairment. Resident #72 required supervision for assistance and 1 person assist with showers. In an interview on 06/14/2023 at 10:15 AM, Resident #72 revealed the food did not taste good and residents were not offered alternate selections. There was no orange juice and the food had no taste. Interview with [NAME] A on 06/14/23 at 12:55 PM revealed he used thickener to manage the consistency for puree vegetables and meat. He said broth was another form of flavoring used in the puree to maintain the taste of the vegetable and meat. He said he had not tasted the lunch food prepared as he did not like Chinese food. He would not taste the juice. He further stated he did not taste puree meals, because he did not like the texture. He said the juice was watery because the juice machine was not working properly, and the repairman had not arrived to repair the machine. He said this also, prevented the orange juice and thickener for tea and water to work properly. He said he would have the dietary manage to taste the food that he did not eat. The cook denied complaints about the taste of the food. Interview with the DM on 06/14/23 at 1:18 PM revealed the juice machines had not been dispensing orange juice and dispensed watery apple, thickener, and cranberry juice since 6/10/23. The DM said she tasted the food prepared by [NAME] A. The DM said she had not purchased orange, apple, or cranberry juice since the juice machine stop working properly. She said she had contacted the repairman to come out, however he could not give her an exact day and time. She had not attempted to contact another provider for equipment repair to resume adequate juice to the residents for meals as she was waiting for the initial repairman to come. The DM said all residents were offered shakes with every meal or a choice of an alternate meal. She stated the that the food taste good. Interview with the DM on 06/15/23 at 1:18 PM revealed she expected the food in the kitchen to be freshly prepared, appealing, and taste good for residents to consume. She expected the resident beverages to have the proper portions of mixture to maintain nutrition levels. She did routinely eat the meals and she did not have any concerns with the food taste and texture. A record review of the kitchen diet roster revealed 68 regular diets, 7 mechanicals soft, and 6 pureed. A record review of the facility's, undated, policy titled Food prep and services revealed .maintaining food temperatures of a safe zone and temperature for mechanically modified foods to maintain taste and nutrients. The facility did not provide policy to address the pallability of the food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen sanitation for 84 residents that received meals from the kitchen. The facility kitchen staff failed to label and date food stored in the dry storage, preparing areas and the kitchen. These failures could place residents at risk for food-born illness and food contamination. The findings include: During an initial tour of the facility kitchen on 06/13/23 at 9:00 AM revealed the following: 1- thickener observed in a clear plastic 4 oz. cup, therefore being exposed to environment and contaminants that affect the food quality. 1-28 oz. container of black pepper dated 4/18/21 indicating it had expired. 1-28 oz. container of cayenne pepper dated 1/5/21 indicating it had expired. 1 box of [NAME] noodles was undated 1 package of crackers revealed the date had rubbed off on the plastic unable to determine date opened or delivered. 2 boxes of coffee filters were unsealed and exposed to the environment. 3 white buckets with dirty rags were unlabeled 3 boxes of cranberry juice were undated. 1 pair of latex gloves, used foil and ground meat soiled plastic. 1- 28 oz container of Basil lease was undated, 3 dish container chemical boxes were undated in dish room. 1 undated and exposed disposable drink tops were under the steam table. 1 clear container of individual honey packets were undated with spilled honey on the inside. 1 container of cooking and serving utensils were uncovered under and exposed to environment. 1-salt container of salt packets were undated. 1 container of yellow sweetener was undated. 1 container of Heinz bar-b-cue sauce was undated 1 container of salsa packets was undated 1 box of smuckers jelly was undated 1 trash can observed in the dining room was uncovered. 1 dining room hand sanitizer container was observed with dirt and grime on the handle and under the bottom. In an interview on 06/13/23 at 09:00 AM with the DM, revealed she had been the dietary manager for two months. She said the coffee filters were exposed at the top of the box, because staff used the coffee filters for breakfast preparation of coffee. She said the iced tea container was uncovered because she just made tea. She said the packets in the clear containers located under the steam table were labeled initially and an observation revealed they were not, and she said she would label them immediately. The DM said deep cleaning was conducted monthly, and she did not have documentation as this was something assured was done by staff. She said the facility policy was to label and date items delivered to the facility prior to storing on shelves to monitor dates for first come and first out as well as food integrity for resident meals. She expected the coffee filters to be properly covered when staff accessed them from the storage box, she expected the cook to cover and label food retrieved for preparation of meals, and she expected staff to practice sanitation in the kitchen during meal preparation by discarding all boxes, old food, and other trash properly in a covered garbage can. Failing to do so cold expose foods to the environment and food borne illnesses that could lead to resident complications. In an interview on 6/13/23 at 9:30 AM with [NAME] A revealed he poured the thickener in a glass, to use while cooking the vegetables. He said it had only been uncovered int eh kitchen for 2 minutes. He said that he does not cover ingredients that are dispensed while cooking. He said he had not started cooking the vegetables; however he wanted the thickener in the prep area. He said failing to cover the thickener could lead to food borne illnesses and food contamination. In an interview on 06/14/23 at 1:45 PM with the DM, revealed she had been working at the facility in this role for 2 months. She said the dish towels in the white bucket were dirty, and she was in the process of cleaning them. She said the coffee filters were open because they just finished breakfast. She said the iced tea container was uncovered because she just made tea. She said the packets in the clear containers were labeled initially. She said she will redate the containers. The DM said deep cleaning was conducted monthly, and she did not have documentation. The DM said it was all dietary staff responsibility to assure food items were dated in the kitchen upon being delivered. She was said it was her responsibility to assure the foods were not outdated and discarded, food labeled and dated, and sanitary conditions for food preparations were compliant in the kitchen as the food could cause illnesses to residents if not discarded timely or labeled. In an interview with the ADM on 6/15/23 at 1:55 PM revealed she expected the dietary staff to follow the diet per nutrients and MD orders, label and date the food upon being delivered to the facility and seal opened dietary food and materials to protect against food born bacteria's and discarding when outdated. She said failing to date, label, cover food and seal containers and packages were important for all dietary staff to prevent environment exposure and food contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 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 for three (Resident #1, Resident #4, and Resident #5) of four residents, in that: The facility failed to use dishes and silverware for Resident #1, Resident #4, and Resident #5, instead using disposable plasticware and Styrofoam. This failure placed residents at risk of living in an undignified and unhomelike environment leading to a risk loss of self-worth and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified protein-calorie malnutrition, age-related physical debility, and adult failure to thrive. Review of Resident #1's quarterly MDS assessment, dated 03/27/23, reflected a BIMS of 11, indicating a moderate cognitive impairment. Review of Resident #1's quarterly care plan, revised 03/27/23, reflected she was at risk for impaired skin integrity with an intervention of encouraging adequate food/fluid intake. During an observation and interview on 04/18/23 at 8:50 AM, Resident #1 was attempting to cut a piece of breakfast sausage on a Styrofoam plate with a plastic fork and knife. She stated it was not right that they were served meals on Styrofoam all of the time. She said she did not like it at all and never used Styrofoam when she was at home. Review of Resident #4's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including paraplegia (paralysis that affects the ability to move the lower half of the body), traumatic brain injury, and type II diabetes. Review of Resident #4's quarterly MDS assessment, dated 02/24/23, reflected a BIMS of 15, indicating no cognitive impairment. Review of Resident #4's quarterly care plan, revised 02/24/23, reflected he had an ADL self-care performance deficit with an intervention of being able to eat meals on his own and at times, required tray set up. During an observation and interview on 04/18/23 at 8:43 AM, Resident #4 was just finishing up his breakfast that was served on a Styrofoam plate. He stated they were not served meals on Styrofoam all of the time and was not sure why they occasionally were. He stated it annoyed him, but as the Resident Council President, he heard a lot of grumblings about it from the other residents, and believed they were even more upset by it than he was. Review of Resident #5's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, major depressive disorder, and osteoarthritis (inflammation of joints). Review of Resident #5's quarterly MDS assessment, dated 03/30/23, reflected a BIMS of 15, indicating no cognitive impairment. Review of Resident #5's quarterly care plan, revised 03/30/23, reflected she had an ADL self-care performance deficit with an intervention of requiring supervision assistance by (1) staff to eat. During an interview on 04/18/23 at 9:28 AM, Resident #5 was in her room. She stated she had already finished her breakfast. She stated her breakfast was not served on Styrofoam that morning, but meals were served with it (and plastic cutlery) a lot of the time, especially at night and on weekends. She stated it was ridiculous and made her feel like an idiot. During an interview on 04/18/23 at 1:11 PM, the DM stated she had only been working at the facility for a couple of weeks. She stated they rarely utilized Styrofoam/plasticware, but they sometimes had to because they only had the exact number of dishes per resident. She stated that morning (04/18/23), they had to utilize Styrofoam/plasticware for about 15 meal trays because not all of the dirty dinner trays had been returned to the kitchen from the night before. She stated they did not have time to get them sanitized before the breakfast meal. She stated dishes/silverware had been ordered and she had been thinking about going (local store) to purchase some in the meantime. During an interview on 04/18/23 at 1:25 PM, the DON stated she had seen Styrofoam/plasticware being utilized a few times, but not a lot. She stated she was not sure why it had been used. She stated she could understand why the residents would not like it as she did not like them herself. She stated the residents should be served their meals on glass plates and bowls with silverware. During an interview on 04/18/23 at 1:55 PM, the AD stated she had only been working at the facility for about two. She stated she was unable to locate the resident council minutes from January or February of 2023. She stated she had not paid attention during mealtimes and was not sure if Styrofoam was being utilized to serve residents their food. Review of the Resident Council Minutes, March of 2023, reflected no grievances concerning the use of Styrofoam. A request was made for the minutes from January and February of 2023, but they were not provided prior to exit. Review of the facility's undated Resident Rights policy reflected the following: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. A dignified existence

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for three (Resident #1, Resident #2, and Resident #3) of five residents' meal trays reviewed for accuracy, in that: The facility failed to ensure milk was provided for dry cereal that was served for Resident #1 and Resident #2 and serve house shakes as ordered for Resident #2 and Resident #3 during breakfast on 04/18/23. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified protein-calorie malnutrition, age-related physical debility, and adult failure to thrive. Review of Resident #1's quarterly MDS assessment, dated 03/27/23, reflected a BIMS of 11, indicating a moderate cognitive impairment. Review of Resident #1's quarterly care plan, revised 03/27/23, reflected she was at risk for impaired skin integrity with an intervention of encouraging adequate food/fluid intake. Review of Resident #1's breakfast meal ticket, on 04/18/23, reflected milk as one of her beverage preferences. During an observation and interview on 04/18/23 at 8:50 AM, Resident #1's call light was on. She stated she had pressed it at least an hour ago because she could not eat her breakfast as she was served dry cereal with no milk. Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, muscle wasting and atrophy, and hypertensive (high blood pressure) heart disease. Review of Resident #2's quarterly MDS assessment, dated 01/18/23, reflected a BIMS of 1, indicating a severe cognitive impairment. Review of Resident #2's quarterly care plan, revised 03/23/23, reflected she was at risk for the potential for nutritional problems with an intervention of providing/serving diet as ordered. Review of Resident #2's breakfast meal ticket, on 04/18/23, reflected milk as one of her beverage preferences and house shakes should be provided for all meals. During an observation and interview on 04/18/23 at 8:58 AM, Resident #2 motioned this Surveyor into her room. She was upset pointing to her meal tray. She was eating dry cereal with her hands and stated, Why would I get cereal with no milk? There was no house shake on her tray. She stated she rarely received a house shake with her meals. Review of Resident #3's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness, hypertensive heart failure, multiple fractures, and adult failure to thrive. Review of Resident #3's quarterly MDS assessment, dated 01/23/23, reflected a BIMS of 5, indicating a severe cognitive impairment. Review of Resident #3's quarterly care plan, revised 02/24/23, reflected she was at risk of unplanned/unexpected weight loss related to poor food intake with an intervention of providing a house shake as ordered. Review of Resident #3's breakfast meal ticket, on 04/18/23, reflected house shakes should be provided for all meals. Observation on 04/18/23 at 9:05 AM revealed Resident #3 sleeping. Her breakfast tray was on her bed side table. There was no house shake present. During an interview on 04/18/23 at 1:06 PM, the ADON stated that a nurse always checked the meal trays when they exited the kitchen to ensure accuracy, consistency of the food, and for supplements (house shakes). He stated if dry cereal was being served, the nurse should ensure there was milk on the tray. He stated the kitchen staff were to follow the meal tickets, but the nurse was ultimately responsible for ensuring all accurate items were accounted for. During an interview on 04/18/23 at 1:11 PM, the DM stated she conducted training daily with her cooks and dietary aides on ensuring accuracy of the trays - house shakes accounted for, accurate diet. She stated she had been standing at the end of the serving line during each meal so she could double-check the trays. She stated that morning (04/18/23), she was not able to double-check the trays as she had run late due to traffic. She stated when the NP or RD ordered supplements, such as house shakes, the resident's meal ticket would reflect the order. During an interview on 04/18/23 at 1:15 PM, the DON stated a nurse was always assigned and responsible for checking meal trays before they were passed out to the residents. She stated they were to check for diet consistency, specialized equipment, and that the items were correct. She stated some residents may prefer to eat cereal dry, but for the most part, milk should be served when dry cereal was being served. She stated if residents were not receiving accurate items or their ordered house shakes, it could lead to malnutrition or weight loss. Review of the facility's undated Food Preparation and Service Policy reflected nothing regarding accuracy of meal trays/dining services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for three (Resident #1, Resident #2, and Resident #3) out of five residents reviewed for ADLs, in that: The facility failed to provide showers to Resident #1, Resident #2, and Resident #3 in compliance with their shower schedules. This deficient practice placed residents at risk of a decline in hygiene, at risk of skin breakdown, and reduced feelings of self-worth. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including morbid obesity, chronic pain syndrome, and muscle weakness. Review of Resident #1's MDS assessment, dated 02/01/23, reflected a BIMS of 15, indicating no cognitive impairment. Section G (Functional Status) reflected she was totally dependent for bathing. Review of Resident #1's initial care plan, dated 01/18/23, reflected she had an ADL self-care performance deficit related to decreased strength and mobility with no intervention for bathing. Review of Resident #1's bathing tasks in her EMR, on 02/11/23, reflected she went eight days without a shower, from 01/31/23 - 02/07/23. There was no documentation that she refused a shower. During and observation and interview on 02/07/23 at 10:26 AM, Resident #1 was laying in her bed softly crying. Her hair was matted to the back of her head and her face was greasy. She stated she just wanted to be clean. She stated she had gone at least eight days without a shower, and she felt gross. She stated if she asked for a shower, the aides would respond, it is not your shower day. She stated not receiving regular showers had made her depressed . Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), osteoarthritis (inflammation of joints), and muscle weakness. Review of Resident #2's quarterly care plan, dated 11/09/22, reflected she had an ADL self-care performance deficit related to Parkinson's and fracture of pelvis and weakness, with an intervention of requiring assistance by one staff with bathing. Review of Resident #2's quarterly MDS assessment, dated 01/31/23, reflected a BIMS of 11, indicating a moderate cognitive impairment. Section G (Functional Status) reflected she was totally dependent for bathing. Review of Resident #2's bathing tasks in her EMR, on 02/11/23, reflected she received two showers - 01/27/23 and 01/30/23 (total dependance) within the last 30 days. There was no documentation that she refused a shower. During an observation and interview on 02/11/23 at 10:43 AM, Resident #2 was sitting in her wheelchair in her room. Her hair and face were greasy. She stated she could not remember the last time she was given a shower. She stated the aides always seemed too busy. She stated it made her feel like she was not important . Review of Resident #3's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including tremors, unspecified dementia, and muscle weakness. Review of Resident #3's initial care, dated 01/12/23, reflected he had an ADL self-care performance deficit related to recent hospital stay with an intervention of requiring one staff physical assistance with bathing. Review of Resident #3's admission MDS assessment, dated 01/16/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section G (Functional Status) reflected she was totally dependent for bathing. Review of Resident #3's bathing tasks in her EMR, on 02/11/23, reflected she received two showers - 01/13/23 and 02/06/23 (total dependance) within the last 30 days. She refused shower once - on 01/16/23. During an observation and interview on 02/11/23 at 12:42 PM, Resident #3 was in her room which had a foul urine odor. Her hair was matted to the back of her head. She stated, while in tears, that she had not received a shower in a long time, and she hated feeling dirty . During an interview on 02/11/23 at 12:54 PM, the DON stated it was her expectations that residents were to be showered at least three times a week and as needed. She stated it was a little bit of everybody's responsibility to review the care tracker to ensure showers were getting done. She stated if a resident was not receiving a shower regularly, it could lead to skin breakdown or a fungal rash. During an interview on 02/11/23 at 1:13 PM, RN A stated residents should be showered at least three times a week. She stated the expectation was that the nurses wrote down who should be showered that day according to the residents' shower schedule, and the aides would notify them when it had been completed or if a resident had refused. During an interview on 02/11/23 at 1:22 PM, CNA B stated the aides knew when it was a resident's shower day because it would pop up on the kiosk (where they document completed resident care tasks). She stated that sometimes it was hard to get all residents showered on their scheduled day because of being short-staffed. She stated she was unaware she was supposed to notify the nurse each shift of who was showered or who refused. She stated if a resident refused a shower, there was an option for refusal in the care tracker. During an interview on 02/11/23 at 1:27 PM, the ADM stated it was the nurses' responsibility to ensure showers were getting down by looking in the residents' chart in the care tracker. She stated if a resident refused a shower, her expectation would be for the aide to notify the nurse and for the resident to be asked again later in the day. She stated not receiving showers regularly could lead to a lot of different skin issues. She stated they did not have a policy on ADL care or showers.