**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to 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 disease and infection for 1 of 2 residents (Resident #1) reviewed for infection control, in that: - CNA Z and CNA R failed to wear PPE for EBP, when they provided incontinence care to Resident #1.- The facility failed to have Enhanced Barrier Precaution signage on the door or anywhere visible in Resident #1's room.- The facility failed to have PPE readily available for staff to don before entering Resident #1's room. This deficient practice could place residents at risk for infection, sepsis (infection throughout body), and hospitalization due to cross contamination.Findings included: Record review of Resident #1's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with diagnoses of dementia (decline in mental ability severe enough to interfere with daily life), hemiplegia and hemiparesis (paralysis and weakness) after a stroke, affects from a stroke, history of falling, unspecified psychosis (psychotic disorder where the symptoms are present but don't fully meet the criteria for a more specific diagnosis), acute embolism and thrombosis (blockage/blood clot in a blood vessel) of deep veins in lower extremity, major depression, aphasia (trouble speaking), muscle wasting and atrophy (muscle decreases in size), and muscle weakness. Record review of Resident #1's Quarterly MDS Assessment, dated 7/1/2025, revealed a BIMS could not be performed due to the resident's condition. The resident had moderately impaired cognitive skills for daily decision making. The MDS indicated the resident had impairment on one side of his upper and lower extremities and had a limb prosthesis. The resident was dependent (the helper does all of the effort, or the assistance of 2 or more helpers is required) with all ADL's. The resident was always incontinent of bowel and bladder. The MDS indicated Resident #1 had 1 unstageable (wound has dead tissue and wound bed cannot be seen) pressure ulcer and was receiving wound care. Record review of Resident #1's care plan dated 12/13/23, revealed the care plan did not have the resident's pressure ulcer or the EBP on it. Record review of Resident #1's Progress Notes from 6/26/25 by LVN F, revealed the Wound Care MD recommended an MRI of the L ankle/foot due to an unstageable wound on the L heel. Record review of Resident #1's Progress Note from 6/27/25 by NP M, revealed he was being seen for an unstageable wound on the L heel. The resident had just finished abx for a wound infection and there was concern about the wound not healing over the past couple weeks. Record review of Resident #1's Physician Orders revealed the following orders from MD C:- Wound Treatment to left heel: Cleanse with Dakin's solution (wound cleanser), pat dry, apply Santyl (wound debridement), Bactroban (antibiotic), cover with alginate (promotes wound healing), and secure with dry dressing. Ordered on 6/25/25 at 2:06pm.- MRI of the ankle and foot. DX: LT heel wound. Ordered on 7/1/25 at 9:25am.- Enhanced Barrier Precautions due to wounds. Ordered on 7/2/25 at 12:55pm. In an observation on 7/9/25 at 1:22pm, Resident #1 was lying in bed on his back, sleeping. His L heel had a pressure relieving boot on it and his heels were floated off the bed. There were no isolation signs on the door. An observation on 7/9/25 at 2:31pm, revealed CNA Z and CNA R provided incontinence care to Resident #1. Neither CNA had a gown on during incontinence care. An observation and interview on 7/9/25 at 2:40pm, revealed RN U was about to start wound care on Resident #1 without a gown on, when the ADON had CNA Z come into the room and handed RN U a gown to put on. CNA Z said, The ADON told me to bring these gowns in for y'all. I did not know he had a wound and we messed up when we changed him because we did not have gowns on. In an interview on 7/9/25 at 2:56pm, RN U said she had to wear a gown during wound care, but she was unsure of what residents were supposed to be on EBP. She said she was a brand-new nurse out of school and was brand new with the facility. She said cross contamination could happen if a gown was not worn. In an interview on 7/9/25 at 2:58pm, CNA Z said EBP was for wounds, but she was not sure what else. She said she was supposed to wear a gown and gloves, and it was to prevent cross contamination. She said she was supposed to wear a gown during Resident #1's incontinence care but she did not know he had a wound because that was not her resident, and she was just assisting. In an interview on 7/9/25 at 3:29pm, the ADON said EBP was for resident's who had wounds, Foleys (tube into bladder for draining urine), or dialysis (machine that filters blood instead of kidneys) and gloves, a gown, and a mask should be worn during close contact, like incontinence care or wound care. She said the PPE was to prevent contamination to the resident and to the staff. The ADON said she had she had given in-services on Enhanced Barrier Precautions the week before. Record review of the facility's policy and procedure on Candida auris (C. auris) Screening and Infection Control Recommendations (Revised 9/27/23) read in part: .Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. aureus and MDROs. EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Infection or colonization with an MDRO. A policy on Infection Control was requested from the facility on 7/9/25 but was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 5 residents (Resident #4) reviewed for pain management. The facility failed to ensure Resident #4's pain control was maintained at a level acceptable to the resident. This failure could place the resident at risk of a decrease in quality of life due to pain. Findings included: Record review of a face sheet dated 08/29/24 indicated Resident #53 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with behaviors), End Stage Renal Disease (Condition in which the kidneys lose the ability to remove waste and balance fluids), Benign Prostatic Hyperplasia (noncancerous enlargement of the prostate gland), and Type 2 Diabetes Mellitus (Chronic condition when your body cannot use insulin properly). Record review of Resident #4's Quarterly MDS Assessment on 07/24/24 revealed resident had a BIMS Summary Score of a 05 (severe impairment). Record review of Resident #4's care plan date initiated 02/21/24 indicated he had a risk for pain related to ESRD , Vascular wound, PVD, and right Below Knee amputation. The Physicians was to be notified if current complaint was a significant change from residents past experience of pain. Record review of Resident #4's physician orders started on 07/17/24 indicated Tylenol with Codeine #3 300- 30 MG 1 tab every 8 hours for pain and Tylenol 325 mg 2 tabs every 4 hours as needed for pain. Record review of Resident #4's MAR dated 8/28/2024 revealed resident was administered his 8:00 AM Tylenol with Codeine #3 300- 30 MG 1 tab. Observation and interview with Resident #4 and RN A on 08/28/24 at 8:21 AM. revealed the resident awake and alert and complained of pain to penis. RN A was aware and stated the resident had received his scheduled medication. Record review of progress notes indicated that RN A reassessed resident complaint of pain and noted it was a 4 on the pain scale. He was administered Tylenol 325 mg 2 tabs every 4 hours as needed for pain. At 11:08 AM, the pain was listed as a 0 on the pain scale. Interview with the ADON on 08/29/24 at 10:53 AM, who said she was not aware Resident #4 had complaint of pain. She said if the pain medication was not sufficient and the resident was not getting relief from the pain medication, or have a new pain concern the staff should notify the physician. She said if the resident was having penial pain, he should be referred to the Urologist and the pain management doctor. Interview on 08/29/24 at 4:15 p.m. the Administrator, said it was her expectation to see pain levels decrease once pain medication was administered. She said staff should follow the nursing protocol and notify the physician if the resident was not provided relief after administration. She said the risk of constant pain could cause adverse effects and decrease quality of life. Observation and interview Resident #4 and RN B on 08/29/24 at 4:25 PM who said his dick hurt. Nurse pulled brief back and there was a skin tear noted near the urethral opening of the penis. RN B moved penis to assess tear. Facial grimaces were noted from resident during the assessment. Resident verbalized he was in pain. Nurse B stated she was aware of the skin tear that had been there for weeks. RN B said she did not inform the doctor of the resident's penis pain because he was confused and his pain comes and goes. Review of the facility's policy Pain Management, not dated, read in part .The facility must ensure that pain management is provided to residents who require such services . Pain Management and Treatment: 7. i. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure there was a communication process, which included how the communication would be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day for 1 of 2 residents (Resident #36) reviewed for hospice services. -The facility failed to maintain required hospice forms and documentation to ensure Resident #36 received adequate end-of-life care. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care. Findings included: Record review of the admission sheet (undated) for Resident #36 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. She had diagnoses which included dysphagia (swallowing difficulties) , cognitive communication deficit (reduced awareness and ability to initiate and effectively communicate needs) and encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). Record review of Resident #36's Quarterly MDS, dated [DATE], revealed the BIMS score was 12 out of 15 indicated intact cognitively. She required supervision from staff for personal hygiene, toilet and transfer. Record review of Resident #36's physician order, dated 07/17/2024 read in part, .Patient is admitted to [hospice company name] under services of hospice Dr. [name] and facility services of Dr [name] . Record review of Resident #36's Care plan, initiated 08/06/2021 and revised on 07/25/2024, revealed the following: Focus: [Resident #36] is under hospice care and requires special attention for comfort and hospice care. Goal: The resident's comfort will be maintained through the review date. Interventions: Consult with physician and Social Services to have Hospice care for resident in the facility. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record Review of Resident #36's medical file revealed there was no documentation of coordination of care or any communication with hospice company after 7/16/24. In an interview and record review with on 8/29/23 at 12: 37 p.m., with RN C she said she was the nurse for Resident #36. She said Resident #36 was receiving hospice services. RN C said hospice staff communicated with the facility by always logging in their binder when they were there. She said they told them verbally what they did, and they also documented in their binders. When asked when did the last time hospice came and what they did when they were there, she said, RN C stated I need to check the binder to see when hospice last came to see the resident. RN C reviewed the hospice binder for Resident #36 with the Surveyor. RN C said she could not find the documentation which stated what Hospice did while they were there. She checked the binder and said, there is RN initial assessment dated [DATE] but no weekly assessment. RN C said she did not know who was responsible for ensuring hospice was documenting in the binder. RN C said it was important for nursing to know the hospice's plan of care for the patient. In an interview and record review on 8/29/23 at 1:23 p.m., the DON reviewed Resident #36's hospice binder and said the hospice nurse came once a week and the hospice aides were supposed to come 3 times a week. The DON said, she would get with hospice company to see what the plan was and to request current notes for the binder. She said it was important to have the current hospice plan of care for the resident if there were any changes to keep the facility informed and for communication purpose. In an interview on 8/29/24 at 2:34p.m., the DON presented Surveyor Resident#36's skilled nursing visit documentations. DON stated medical records had access to hospice documentation. Medical records was responsible for printing hospice documentation and file in resident's hospice binder for nursing staff. In an interview on 8/29/24 at 3:55p.m., the Medical Records/HR, she said hospice company randomly sent documentation either by email or paper and her responsibility was to print the documents and upload them in PCC (electronic medical records) for nursing to review. Medical records/HR said she was not a nurse and did not review the hospice documents when received. Record review of facility's Hospice Services Facility Agreement (February 2023 Revision) read in part: .Policy: It is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. Policy Explanation and Compliance Guidelines: 6d. Obtaining the following information from the hospice: i. The most recent hospice plan of care specific to each resident ii. Hospice election form iii. Physician certification and recertification of the terminal illness specific to each resident iv. Names and contact information for hospice personnel involved in hospice care of each resident v. Instructions on how to access the hospice's 24-hour on-call system vi. Hospice medication information specific to each resident vii. Hospice physician and attending physician (if any) orders specific to each resident 7. The facility will, under a written agreement, ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility 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 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 1 of 6 residents (Resident #53) reviewed for infection control. The facility failed to ensure CNA A followed proper infection control and hand washing procedure during incontinent care for Resident #53. This failure could lead to cross-contamination and the development of infection. Findings included: Record review of a face sheet dated 08/29/24 indicated Resident #53 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with behaviors), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and Benign Prostatic Hyperplasia (noncancerous enlargement of the prostate gland). Record review of Resident #53's Quarterly MDS Assessment on 06/13/24 revealed resident had a BIMS Summary Score of a 09 (moderate impairment). Record review of Resident #53's care plan date initiated 03/22/24 indicated he had an ADL self-care performance deficit and required 1 to 2 persons extensive to total assistance with toileting, bed mobility and transfers. Observation on 08/28/24 at 3:36 PM, revealed CNA A provided Resident #53 with incontinence care. CNA A did not perform hand hygiene prior to entering the resident's room, nor prior to donning clean gloves. CNA A provided peri care 3 times with wet wipes from [NAME]-wipe packet. She turned the resident over to his right side and cleaned moist, brown stool of resident's buttocks, retrieving wipes from the same multi-use packet without changing gloves. CNA A wiped buttocks 6 times until resident wet wipe was clean and free from discoloration. Soiled linen was removed and placed in bag. CNA did not doff gloves and attempted to apply clean lined with same soiled gloves. Surveyor intervened when staff attempted to retrieve new linen, gown, and brief. CNA A doffed soiled gloves without washing or sanitizing her hands and donned clean gloves. CNA A completed incontinent care and with the new gloves she touched the resident's clean gown, brief, and sheets. She completed her incontinent care and did not wash her hands after doffing gloves before leaving the room. Interview on 08/28/24 at 3:35 PM with CNA A who said she started working full time at the facility 4 years ago. She said she did not recall doing CNA competency checks for incontinent care but had an in-service last month regarding hand hygiene. CNA A said not performing hand hygiene while changing gloves could cause infection and cross-contamination. Interview on 08/29/24 at 12:40 PM, with the DON, she said she expected staff to make sure they provided complete and proper incontinent care each time they perform incontinent care. She said staff should wash/sanitize their hands upon entering a resident's room, in between glove changes, and before leaving the resident's room. She said these failures could result in cross-contamination. Interview on 08/28/24 at 3:32 PM the Administrator said she expected staff to wash/sanitize their hands before, during and after providing incontinent care to residents. She said the risk of not washing/sanitizing their hands was spreading infection and contaminating surface areas. Record review of facility's In-Service Program Attendance Record dated 8/22/2024 revealed Topic: Hand Hygiene was signed by CNA A. Record review of facility's Hand Hygiene Policy undated, read in part: .Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 6.Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Record review of facility's Standard Precautions Infection Control Policy not dated, read in part: .Policy: All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff, and visitors. Explanation and Compliance Guidance: 1. Hand Hygiene: a. During delivery of resident care services, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. b. Perform hand hygiene in accordance with the facility's Hand Hygiene Policy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a copy of the 30-day discharge notice was sent to a representative of the State Long-Term Care Ombudsman for one (Resident #35) of four residents reviewed for discharge planning. -The Long-Term Care Ombudsman did not receive a copy for Resident #35's discharge notice. -The Ombudsman contact information on the letter was incorrect. The failure could place residents at risk for not being able to have representation to contest the discharge. Findings include: Record review of the admission Record (copied 08/29/24) revealed Resident #35 was a [AGE] year old female, and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Alzheimer's disease, bipolar disorder, and dementia. Record review of the MDS dated [DATE] for Resident #35 revealed she scored 0 of 15 on the BIMS, indicative of severely impaired cognition. Record review of the Care Plan (revised 02/28/23) for Resident #35 revealed she required living on a secured unit due to wandering risk. Record review of the 30-Day Discharge Notice for Resident #35, dated 08/01/24 revealed the letter was sent to the resident's family member on that date. The Notice reflected a move-out date of 08/31/24. The Ombudsman contact information (address and telephone number) was not for the county (County A) of where Resident #35 resided. The contact information reflected on the Notice was for County B. In a telephone interview on 08/27/24 at 8:48 a.m. the Ombudsman for County A said Resident #35's family member was given a 30-Day Discharge Notice by the facility. He said the Notice did not have the correct contact information, and a copy had not been received by County A Ombudsman. He said the family did contact him and provided him with a copy of the Notice. At that time, he was able to schedule an appeal meeting. He said he contacted the County B Ombudsman, and was told they had not received a copy of the Notice either. Observations of the secure unit on 08/27/24 revealed the following: *At 09:12 a.m. and 01:05 p.m. revealed Resident #35 was asleep in her room. *At 1:05 p.m. Resident #35 was asleep in her room. In an interview on 08/29/24 at 01:05 p.m. the Administrator said Resident #35 was the only resident issued a 30-day Discharge Notice since she has been the Administrator of this facility. She said a copy was sent to the Responsible Party via Certified Mail. She said the Ombudsman's copy was not sent Certified Mail. In an interview on 08/29/24 at 2:05 p.m. the Administrator said the Ombudsman in County A was sent a copy of the Notice for Resident #35 after the facility realized the contact information on the Notice was incorrect. She did not provide a date. She provided a copy of an email dated 08/09/24 in which the Ombudsman in County A discussed the Notice. In an interview via telephone on 08/29/24 at 2:14 p.m., the Ombudsman in County A said he had an email from the Ombudsman in County B confirming they did not receive a copy of the Notice for Resident #35. Review of the email from the Ombudsman in County B, dated 08/15/24 revealed they had not received a copy of the Notice for Resident #35 as of that date. In an interview via telephone on 08/29/24 at 5:15 p.m., the Ombudsman in County B said they had not received a copy of the Notice for Resident #35. When the Surveyor read him the address on the Notice, the Ombudsman said that was the address to the school of nursing. Record review of the facility policy Transfer and Discharge (2003) read, in part, .4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will contain all of the following at the time it is provided .h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman. In addition, the document read, in part, .7. The facility will maintain evidence that the notice was sent to the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the 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 18 residents (Resident #53) reviewed for ADLs. The facility failed to ensure CNA B provided incontinent care every two hours as required for Resident #53 on 08/28/24, which resulted in a saturated brief, linens, and mattress. This failure could result in pressure injuries, infections, psychosocial harm, and a decreased quality of life. Findings included: Record review of a face sheet dated 08/29/24 indicated Resident #53 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with behaviors), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and Benign Prostatic Hyperplasia (noncancerous enlargement of the prostate gland). Record review of Resident #53's MDS quarterly assessment dated [DATE] revealed resident had a BIMS Summary Score of a 09 (moderate impairment). Record review of Resident #53's care plan date initiated 03/22/24 indicated he had bowel and bladder incontinence. Resident #53's care plan indicated he should be checked every 2 hours and as required for incontinence. His perineum should be washed, rinsed, and dried, with change of clothes as needed. The goal was for the resident to remain free from skin breakdown due to incontinence and use of briefs. Observation and interview on 08/28/24 at 3:25 PM, Resident #53 said he had not been changed and felt dirty. He was unable to provide a timeframe but pushed the call light for assistance . CNA A entered the room and said she would assist the resident; however, this was not her assigned room. CNA A removed the covers and observed resident brief, gown, and linen saturated with urine. CNA A provided peri care times 2 wipes with wet towelette. She turned Resident #53 to right side, and soft brown stool was noted on his buttocks. CNA A agreed the linen, gown and brief was saturated. The resident's blue mattress was darker where his buttocks was laying and lighter above and below the buttocks area. Interview on 08/28/24 at 3:45 PM with CNA A, said she was not aware of the CNA who was assigned the room but it was usually located in the assignment book. CNA A said the CNAs was supposed to round on the residents and check them every 2 hours. CNA A said it was important to provide incontinent care to the residents frequently so they did not have skin breakdown, and because they could get an infection. Interview on 08/28/24 at 5:30 PM Resident #53 stated he does not remember being changed after 6:00 AM. He said he enjoyed being change every two hours and having clean and fresh gowns on. He said he deflated when his brief was soiled and he does not get changed regularly. Interview on 08/28/24 at 5:47 PM CNA B, said she did not check her assignment today and was not aware she was assigned to Resident #53's room. CNA B said she had not checked on Resident #53 today. CNA B said she was supposed to check on incontinent residents every two hours. CNA B said it was important to provide incontinent care to prevent skin breakdown. Interview on 08/28/24 at 6:04 PM LVN F, said she was informed by CNA C that CNA B had not been in Resident #53's room today and it appeared Resident #53 had not been changed all day. LVN F said the CNAs should be checking on the residents at least every 2 hours. LVN F said not providing incontinent care could cause pressure ulcers and infections. Interview on 08/28/24 at 6:08 PM with the DON, stated Resident #53 had not received care since change of shift at 6:00 AM. The DON said the CNAs should be checking on the residents at least every 2 hours. The DON said she was unaware of why the assigned CNA (CNA B) did not check her assignment this morning. She said not assessing a resident in 8 hours can contribute to a multitude of issues including pressure injuries and infection. During an interview on 08/28/24 at 7:37 PM, the Administrator said Resident #53 was wet and had not been changed until after 3:30 PM. The Administrator said the CNAs should be checking on the residents every 2 hours and as needed. The Administrator said not changing the residents in adverse effects such as skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safeguard, manage, and account for the personal funds of the residents, deposited with the facility, for one (Resident#2) of three residents reviewed for trust funds - The facility failed to provide Resident#2 with the $75 that she was supposed to get. This failure could place residents whose personal funds were managed by the facility at risk of loss of those funds. Finding included: Record review of Resident#2's Face Sheet (undated) revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: chronic systolic congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should ), hypertension (a condition in which the force of the blood against the artery walls is too high) and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. She was independent with bed mobility, dressing, personal hygiene, and toilet use. Resident#2 was continent of bladder and bowel. Record review of Resident#2's Care Plan initiated 08/28/2023 and updated on 01/19/2024 revealed the following: Focus: Resident has COVID-19 infection related to Multiple Co-morbidities. Goal: Resident will have minimal complications associated with the COVID-19 infection through next review date. Interventions: Assist resident with ADL's in room as indicated. Assist resident with application of a face mask when exiting their room. Remind resident to wash hands/perform hand hygiene before and after meals and as needed. Resident will adhere to room restrictions. Resident will donn a face mask when staff are in their room. In a telephone interview on 02/09/2024 at 8:54 a.m., with the Ombudsman, he said his volunteer Ombudsman notified him that some of the residents did not receive the $75 increase of their allowance from Social Security. The increase was on January 1, 2024. In an interview on 02/09/24 at 10:10a.m., with Resident#2, she said there was an increase as of January 1st on the Social security allowance from $60 to $75. She said she received an allowance on the 3rd Wednesday of each month. Resident#2 provided a bank statement to Surveyor A to show the payment of $60 received on Wednesday, January 17, 2024. She said she had a neurologist appointment on Wednesday (02/07/24) which she had to cancel. She said when she got to the appointment, she was asked to pay co-pay of $34. She said, If I had paid $34 co-pay out of $60, I would not have enough money to last me until I get the next allowance. In an interview on 02/09/2024 at 11:01 a.m., the Social Worker said Resident#2 had a neurologist follow up appointment on Wednesday (02/07/24) that she had scheduled. She said when Resident #2 went to the neurologist the front office asked for a $34 copay. She said the facility's scheduling coordinator that accompanied Resident#2 called and informed her that the resident had to pay a copay and the resident refused to pay. She said she went and asked the business office if we cover the co-pay the business office said she was not sure. SW said she asked interim Administrator yesterday (02/08/24) if we ever pay copay and he said yes, we can.'' In an interview on 02/09/2024 at 11:24 a.m., the interim Administrator said after Surveyor A brought it to his attention, the BOM reconciled, and a few residents were short paid $15 last month (January). He said it was an honest error on the Business Office Manager's part. Resident #2 got cash in advance, so it was an error in calculation. He said corporate spot checked BOM and the corporate said it was overlooked on her part. In an interview on 02/09/2024 at 12:04 p.m., with the BOM, she said she started working at this facility towards the end of November of last year. She said she was still in training. She said residents funds went directly into the resident trust fund account. When the resident asked for money, she gave $60, and the rest went towards the care cost of the month. She said it was discussed in training, at that beginning of 2024, there was an increase from $60 to $75. She said, I'm finding out now that I have to deduct $75, and the rest will go to care cost depending on patients' liability. She said sometime this week the social worker came to her and asked her how the copay was taken care of. BOM said Resident#2 had Medicare/Medicaid, but the resident went to an appointment which was out of network. She said interim Administrator told her today that the facility could pay with the company card so the resident would not miss appointments. In an interview on 02/09/2024 at 12:34 p.m., the ADON said, the Social Worker was responsible to set up the appointments and facility transportation for the resident to their appointment. She said Resident#2 had a follow up appointment with the neurologist this week but she was not aware that the resident canceled the appointment because of co-pay. She said when setting up the appointment the Social Worker needed to find out if there was a co-pay. In an interview on 02/09/2024 at 1:33 p.m., the interim Administrator said, I was not aware of any resident missing a doctor's appointment because they were short paid $15 last month. When asked who was responsible to ensure the staff were trained regarding this. He said at corporate level, notices were sent to the facilities Administrators about the increase. He said, I don't know if the previous Administrator notified the BOM. That's the previous administrator's question. Record review of the facility's Surety Bond policy (Revised March 2021) read in part: .Policy Statement: Our facility has a current surety bond to assure the security of all residents' personal fund deposited with the facility. Policy Interpretation and Implementation: 2. This facility holds a surety bond to guarantee the protection of residents funds managed by the facility on behalf of its residents. 4. The purpose of the surety bond is to guarantee that the facility will pay the resident for losses occurring from any failure by the facility to hold, account for, safeguard, and manage the residents funds (i.e., losses occurring as a result of acts or errors of negligence, incompetence or dishonesty) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for 1 of 2 residents (CR #1) reviewed for discharge requirement, in that: -The facility failed and refused to readmit CR #1 from the hospital where he was transferred for evaluation and treatment. This failure placed residents at risk of not receiving care and services to meet their needs upon discharge. Findings included: Record review of CR#1's Face Sheet (undated) revealed, a [AGE] year-old male who admitted to the facility on [DATE] and discharged to acute care hospital on [DATE] with diagnoses which included: fracture of unspecified part of neck or right femur (type of hip fracture of the thigh bone (femur) just below the ball of the ball-and-socket hip joint), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and cognitive communication deficit (those thought processes that allow humans to function successfully and interact meaningfully with each other). (Date of Discharge 01/17/2024 at 10:30pm to acute care hospital) Record review of CR#1's Discharge MDS assessment dated [DATE] revealed a BIMS score of blank indicating severely impaired cognitively. He required substantial/maximal assistance with bed mobility, dressing, personal hygiene, and toilet use. CR#1 was occasionally incontinent of bladder and always incontinent of bowel. Section A. Entry/discharge reporting coded: 11. Discharge assessment-return anticipated. Record review of CR #1's electronic medical records on 02/09/2024 revealed CR #1 did not have a Baseline Care Plan. Record review of CR #1's nurses notes dated 01/18/2024 at 1:25am written by LVN B revealed read in part: .around 2230 [EMS company] here to transport resident to [hospital name] ER. Alert and oriented, no distress noted . In a telephone interview on 02/09/24 at 9:03 a.m., with CR#1's family member, she said as per family's request CR#1 was sent to the ER around 10:00-10:30pm on 1/18/24. The doctor at the hospital did a CT of the stomach and it showed the CR#1's bowels were full and ordered an enema. By 3:30-4am CR#1 was cleared to go back to the facility to continue rehabilitation services. She said the ER nurse in charge said policy dictated that he was an outpatient and was required to go back to the facility. EMS workers loaded CR#1 along with her and went back to the facility. Upon arrival at the facility, LVN B said that policy was that if he was out past midnight that Medicare would not pay. LVN B said that the hospital had to call to readmit him and that he forfeited his bed at that facility. The family member said she asked what she needed to do with CR#1 and LVN B did not care. The EMS workers said if the facility denied entry than they had to transport CR#1 back to the hospital. The nurse denied him at the facility and so without any choice EMS loaded CR#1 and her back up and went back to the hospital. The hospital staff were adamant that the facility could not deny him because he was considered outpatient. They proceeded to call several administrators at the facility and by 6am the EMS had to go, so CR#1 was put in an ER bed and they waited. CR#1 was completely exhausted and was in a state of confusion and had anxiety about being transported back and forth. Family member said, CR#1 is 89 and has dementia. This was such a roller coaster for him. She said she ended up taking him home for a few hours while the new facility worked with insurance to expedite his transfer. In an interview on 02/09/24 at 10:46a.m., with the interim Administrator, he said CR#1 was sent to the hospital and the hospital sent the resident back around 2am without calling a report to the facility and without an authorization. He said CR#1 had insurance that required an authorization after midnight. He said the facility needed authorization from his insurance company, without an authorization the resident would be private pay. In an interview on 02/09/24 at 12:34p.m., with the ADON, she said she received a call from LVN B that CR#1 was sent to the hospital as per family's request. The previous administrator said the resident was not allowed to come back to the facility after midnight, it had something to do with the insurance. CR#1 was sent to the facility from the hospital without calling a report. The ADON said it was late at night, but she tried calling the previous Administrator regarding denied entry. The previous Administrator did not answer. She said she called the Marketing Representative and she said that the resident was allowed entry to the facility regardless the type of insurance the resident had. The ADON said she called LVN B to allow CR#1 entry to the facility. LVN B said that EMS ended up taking the resident back to the hospital. The ADON said she called the hospital and notified them that the resident could return to the facility and that the facility was not denying entry. She said the hospital staff said that the resident was back at the ER, and they had to restart the whole process. The ADON said, either way we got to take the resident back. I don't know why the previous Administrator did not allow entry. In a telephone interview on 02/09/24 at 1:09a.m., with LVN B, she said as per the family's request CR#1 was transferred to the hospital. LVN B said the facility's policy was anytime a resident was sent to the hospital the nurse needed to notify the Administrator. She said she called the previous Administrator, and the previous Administrator asked her for the type of insurance that CR#1had. She said she looked at the resident's insurance from the EMR and gave the information to the Administrator. The previous Administrator said that CR#1 would not be able to readmit after midnight due to the type of insurance he had. LVN B said CR #1 showed up at the facility's door with the EMS the same night. She said she told the family member that the resident was not allowed re-entry to the facility as per the administrator. She said that EMS ended up taking CR#1 back to the hospital. In an interview on 2/9/24 at 3:16p.m., with the interim Administrator and the Regional Nurse, the interim Administrator said per (managed care insurance) policy, they can't accept the resident without authorization unless they are private pay. He said managed care insurance that CR #1 had, ran from midnight to midnight. If the resident was to return after midnight an authorization was required for reentry, or the facility would not get paid. He said the resident was not allowed entry because the facility had to call the insurance. It was 1:00am in the morning and the facility had to wait for the insurance company to open in the morning to obtain authorization. Record review of facility's Transfer or Discharge Notice dated (Revised March 2021) read in part: .Policy Statement: Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. Policy Interpretation and Implementation 1. Transfer and discharge includes movement of, a resident from a certified bed in the facility to a noncertified bed in another part of the facility, or to a non-certified bed outside the facility. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. Specifically: a. transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility; and b. discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. 2.Residents are permitted to stay in the facility and not be transferred or discharged unless: a. the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. c. the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. (1) Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. 2) For a resident who becomes eligible for Medicaid after admission to a facility, the facility will only charge a resident allowable charges under Medicaid. d. the facility ceases to operate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviews, 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 meet professional standards of quality of care for 1 (CR#1) out of 3 residents reviewed for base-line care plans. -The facility failed to ensure CR#1 had a baseline care plan developed within 48-hours after admission with goals and interventions. The failure could place newly admitted residents at risks of not receiving the care and continuity of services. Findings included: Record review of CR#1's Face Sheet (undated) revealed, an [AGE] year-old male who admitted to the facility on [DATE] and discharged to acute care hospital on [DATE] with diagnoses which included: fracture of unspecified part of neck or right femur (type of hip fracture of the thigh bone (femur) just below the ball of the ball-and-socket hip joint), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and cognitive communication deficit (those thought processes that allow humans to function successfully and interact meaningfully with each other). Record review of CR#1's Discharge MDS assessment dated [DATE] revealed a BIMS score of blank indicating severely impaired cognitively. He required substantial/maximal assistance with bed mobility, dressing, personal hygiene, and toilet use. CR#1 was occasionally incontinent of bladder and always incontinent of bowel. Record review of CR #1's electronic medical records on 02/09/2024 revealed CR #1 did not have a baseline care plan. In an interview on 02/09/2024 at 12:30 p.m., with the Regional Nurse and the interim Administrator, Regional Nurse said she looked in CR#1's EMR and could not locate a base-line care plan for CR#1. Regional Nurse said the base line care plan was a collaboration of IDT/ and nurse leadership. Regional Nurse said nurses needed to follow the plan of care. In an interview on 02/09/2024 at 12:34 p.m., the ADON said baseline care plans were supposed to be developed within 48-hours after admission by the nurses on the floor/management (DON, ADON) and different departments (dietary, activities). She said she and the DON were responsible for checking for completion. She said she checked UDA every day if not every other day. She said UDA were (assessments that patient was scheduled). She said the importance of the baseline care plan was to provide nursing staff with information and interventions about residents so the staff could provide appropriate care and services. The ADON said CR#1's baseline care plan was missed. Record review of the facility's Care Plans- Baseline policy (Revised December 2016) read in part: .Policy Statement: 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 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 1 (Resident #2) of 2 residents reviewed for respiratory care. -Resident #2's Nebulizer mask was not labeled/bagged while not in use on 02/09/2024. This failure could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Included: Record review of Resident#2's Face Sheet (undated) revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: chronic systolic congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypertension (a condition in which the force of the blood against the artery walls is too high), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident#2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. She was independent with bed mobility, dressing, personal hygiene, and toilet use. Resident#2 was continent of bladder and bowel. Record review of Resident#2's Care Plan initiated 08/28/2023 and updated on 01/19/2024 revealed the following: Focus: Resident has COVID-19 infection related to Multiple Co-morbidities. Goal: Resident will have minimal complications associated with the COVID-19 infection through next review date. Interventions: Assist resident with ADL's in room as indicated. Assist resident with application of a face mask when exiting their room. Remind resident to wash hands/perform hand hygiene before and after meals and as needed. Resident will adhere to room restrictions. Resident will don a face mask when staff are in the their room. Record review of Resident #2's physician order dated 08/24/24 revealed an order to administer Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 milliliter inhale orally three times a day for Wheezing at 9:00am, 2:00pm, and 9:00pm. Record review of Resident #2's physician order dated 02/09/24 at 1:14pm by the Regional Nurse for Nebulizer tubing: change nebulizer tubing when visibly soiled or malfunction present every 12 hours as needed AND every night shift every Sun. Observation and interview on 02/09/24 at 10:10 a.m., with Resident#2 revealed her sitting on the side of the bed. Resident's nebulizer mask was sitting on top of the bedside table not labeled orbagged while not in use. Resident#2 said she received routine breathing treatment several times a day. She said she was not sure how often the nebulizer mask set was changed. She said, I had COVID two weeks ago and had to request the nurse to change the neb mask, so I don't get re-infected. Observation and interview on 02/09/24 at 10:39 a.m., with LVN A revealed Resident #2 was resting on her bed. Resident's nebulizer mask was sitting on top of the bedside table. LVN A said Resident #2's nebulizer mask was not dated and not bagged while not in use. LVN A said nebulizer mask and tubing was supposed to be changed weekly by the nurses. She said it was standard practice to change/label tubing. She said MAR/TAR prompted nurses to change the set. She said the risk of not changing the neb mask was infections. She said she administered the routine breathing treatment this morning but did not check for the label/date and forgot to place the mask back in the bag after use. In an interview on 02/09/24 at 12:34 p.m., with the ADON, she said the nurse that entered the treatment order needed to enter the order to change tubing/neb mask every Sunday. She said there was a place on the MAR or TAR for nurses to sign off after the nurse changed the tubing. The ADON said the nurses should be checking prior to administering the treatment. She said the risk of not changing the nebulizer mask was infections. Record review of facility's Department (Respiratory Therapy)-Prevention of Infection policy (Revised November 2011) read in part: .Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents, and staff. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. 9. Discard the administration set-up every seven (7) days .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure all alleged violations involving abuse were reported immediately within 2 hours to state agency for 1(Resident #1) of 6 reviewed for reporting in that: Administration failed to report to the state agency when Resident #1, who had dementia was not able to tell them how she got skin tears to both sides of her neck on 1/10/2024. This failure placed current residents at risk for abuse. Findings Included: Observation on 1/12/2024 at 10:00 a.m. of Resident #1's neck revealed a skin tear and bruise on the right side of her neck and a bandage slightly left of her throat. Record review of Resident #1 undated face sheet revealed a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses: Dementia (unspecified), Emphysema (is a chronic lung condition that cause blockage of airflow in the lungs), Traumatic subdural hemorrhage without loss of consciousness(caused by a head injury, such as a blow to the head), heart failure(a chronic condition in which the heart does not pump blood as well as it should), chronic kidney disease and age-related osteoporosis. Record review of Resident #1's MDS dated [DATE] revealed BIMS score was coded at 06 which suggests severe cognitive impairment. Functional Abilities & Goals revealed Roll left and right, sit to lying, lying to sitting, sit to stand, chair to bed transfers, and toileting transfers were all coded as (03)- which meant Partial/moderate assistance with helper did more than half the effort. Record review of the incident reports from 10/12/2023-1/12/2024 did not notate skin tears to Resident #1's neck. Record review of Resident #1 progress nursing note dated 1/11/2024 revealed Nurse A wrote: The outgoing nurse reported Resident #1 had skin tears to both left and right neck. The writer did skin assessment and noted the tears had been covered with bandages. No acute distress, shortness of breath noted. At 12:35 a.m. Resident #1 FM came into the facility to check on her wellbeing. The resident denied pain and no further concerns as of present. Plan of care ongoing and call light within reach . An interview with Resident #1 on 1/12/2024 at 10:03 a.m. revealed she did not know what happened to her neck. She did not recall having a fall. She said she never had visitors to come see her. She could not recall CR#2(roommates' name). She said no one told her about what happened to her. She fell asleep so the interviewed ended. An interview and observation with FM of CR#2 on 1/12/2024 at 10:15 a.m. revealed CR#2 was at a local hospital because of a medical condition. He said she was confused and sometimes combative since she had a stroke in June 2023. He said Resident was a young robust person and really needed to be in another type of facility mostly for her behaviors. He said she does use profanity at times but denied any knowledge of an altercation with Resident #1, CR#2, or her family member. He stated that he visited with her every other week. He said he was not her RP. He began to pack her personal belongings and said she would not be returning to the facility. He said he was not her RP. An interview with Nurse B on 1/12/2023 at 10:30 a.m., revealed she was not at work on 1/10/2024 or 1/11/2024, she returned to work on today (1/12/2024). She said the notes in PCC stated that it was unknown how the skin tears happened . She said that she was not aware of any altercations verbal or physical between Resident #'s 1 and 2. She stated she has been employed at the facility for 3 months and worked on this unit daily. Interviews separately with two CNA's on 1/12/2024 at 10:42 a.m. revealed they were not aware of what happened to Resident #1's neck. They said the Abuse Coordinator was the Administrator. They were able to identify types of abuse. An interview attempted with Resident #1's RP was unsuccessful on 1/12/2024 at 11:17 a.m. An interview with the DON on 1/12/2024 at 1:30 p.m., revealed Resident #1 most likely scratched herself. She said she asked Resident #1 what happened to her, and she said some man tried to kill her . She said in speaking with staff no one saw how Resident #1 got the skin tears. She said she spoke with Resident #1's RP on or about 1/11/2024 and she said she had recently (over previous weekend on or about 1/6/24), had Resident #1's nails cut. So, she did not believe that she could have scratched herself unless a hang nail was left. She stated Resident #1's RP complained that CR#2 was talking crazy recently. She said CR#2 was using profanity towards Resident #1's FM, not Resident #1. She said RP said she turned the television up to tune her out. She said RP had not reported any behavior towards her or Resident #1 prior to that incident. She said RP never implied that she suspected CR#2 of abusing Resident #1. The DON stated Nurse C had discovered the skin tears on 1/10/2024. She said a skin tear could be considered an injury of unknown origin if the resident had dementia or could not verbally tell them what happened. She said this would be considered something reportable to State agency. She said either the Administrator or herself would report an incident to State agency. She said they had no evidence of abuse by CR#2 or staff. So, it was not reported. She said she was not aware of any other incidents with CR#2 other than her wandering at night. An interview with Resident #1's FM on 1/12/2024 at 1:50 p.m., revealed yesthe DON was made aware of the incident concerning CR#2 using profanity towards her, not Resident #1. She said she could not recall the exact date, but this incident occurred between 1/9/2024-1/10/2024. She said, she was visiting Resident #1 when CR#2 attempted to sit down on her bed. The FM stated she told her she could not sit on Resident #1's bed. She said CR#2 was about to sit on Resident #1's leg so she walked towards the bed to stop her from sitting. She said CR#2 began using profanity towards her, so she yelled for a nurse. She said she did not know the CNA's name, but she came in after hearing CR#2 cursing and asked her to reframe from using profanity. She said the CNA pulled the curtain to give FM and Resident #1 privacy, but CR#2 tried to open the curtain and continued to use profanity. She said she had not received a call about a fall, so she told the DON that she felt badly to think that CR#2 might have done this to Resident #1. But it was possible given her behavior the previous day. She denied any other incidents involving Resident #1 and CR#2. An interview with an anonymous FM on 1/12/2024 at 2:18pm, revealed Nurse C reported CR#2 was no longer at the facility because she had attacked Resident #1. An interview attempted with Nurse C on 1/12/2024 at 2:26 p.m., was unsuccessful. Record review of an undated facility responsibilities reporting allegations policy read in part: Injuries of unknown source when it is unobserved/unexplained scratches and bruises found in suspicious locations such as head, neck, upper chest or back is reportable. There was no timeframe indicated to report injuries of unknown source.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 2 (Resident #1 and Resident #12) of 3 residents reviewed for dignity in that: The facility failed to provide dignity and respect for Resident #1 and Resident #12 by leaving the resident's privacy bag off their foley bag exposing the full urinary bag to open doorway. This failure placed resident with an indwelling catheter at risk for embarrassment and low self- esteem. Findings included: Resident #1 Record review of Resident #1's face sheet dated 11/3/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included: hypoglycemia (low blood sugar), acute respiratory failure with hypoxia (difficulty breathing), metabolic encephalopathy (problem in brain caused by chemical imbalance in the blood), sepsis (life threatening infection), bacteremia pulmonary candidiasis (fungal infection in the lungs), type 2 diabetes (insulin resistant) muscle weakness (generalized), dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, muscle wasting and atrophy, left and right shoulder, other lack of coordination, retention of urine, anemia, hypothyroidism, hyperlipidemia, anxiety disorder, essential (primary) hypertension, cellulitis (skin infection) of unspecified part of limb, dorsalgia (back pain), altered mental status, elevation of levels of liver transaminase levels. Record review of Resident #1's Comprehensive MDS dated [DATE] revealed all cognitive test revealed a 0. Resident #1 had a BIMS of 00 which indicated severe cognitive deficit. Section H noted the resident had an indwelling catheter. Record Review of Resident #1's undated care plan revealed Resident #1 had an Indwelling Catheter: Interventions included were to perform catheter care every shift and as needed. The resident has a 16F Foley catheter, position catheter bag and maintain tubing below the level of the bladder, make sure tubing is secured. Change catheter PRN based on clinical indications such as infection, obstruction, or when the closed system is compromised OR per physician's order. Document and notify physician for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. Obtain and record output as per facility policy and/or physician order. Observation on 11/4/23 at 6:45 p.m. revealed Resident #1 was lying in bed. She was in her room alone, her spouse was not present. Resident #1's Foley bag was on the floor, and without a privacy bag, and half full of dark urine. The foley bag was visible at the doorway. In an interview on 11/4/23 at 6:51 p.m. with LVN G, she stated that the catheter bag should be covered. She said Resident #1 was her resident to provide care for. She stated she was unaware the bag was uncovered. She said she had not looked at the catheter bag all day. In an interview on 11/10/23 at 9:54 a.m. with CNA G, he stated that he was aware the Foley bags should be covered. He stated Resident #1's family member liked to take the privacy cover off. CNA G stated that he did try to keep them covered. Resident #12 Record review of Resident #12's face sheet dated 11/1323 revealed Resident #12 was a [AGE] year old[AGE] year-old female admitted to the facility on [DATE]. Resident #12's diagnoses included: chronic obstructive pulmonary disease, unspecified, type 2 diabetes mellitus with diabetic chronic kidney disease, type 2 diabetes mellitus with hyperglycemia, major depressive disorder, hyperlipidemia, chronic kidney disease, stage 3 unspecified, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or chronic kidney disease, need for assistance with personal care, malignant neoplasm of unspecified ovary (malignant tumor in the ovary), malignant neoplasm of endometrium (cancer in the uterus), nausea with vomiting, dehydration, pressure ulcer of sacral (bottom of the spine) (region, stage 3, flaccid neuropathic bladder (overactive bladder), and essential (primary) hypertension. Record review of Resident #12's Quarterly MDS dated [DATE] revealed Resident #12 had a BIMS of 15, which indicated the resident's cognition was intact. Section H noted the resident had an indwelling catheter. Record review of Resident #12's Care plan revealed resident had a catheter to promote wound healing of sacrum per MD orders. Interventions included: Catheter care every shift and as needed. Document and notify physician for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Skilled Nurse to Change catheter every 30 days and PRN based on clinical indications such as infection, obstruction, or when the closed system is compromised OR per physician's order. Observation and interview with Resident #12 on 11/13/2023 at 1:53 p.m. revealed she was laying in her bed. Resident #12 was alert and oriented. She said staff to emptied her catheter bag and changed it when needed. Observation of Resident #12's catheter bag revealed it was hanging at the bottom of her bed. There was no privacy bag covering the catheter bag. Resident #12's urine was very dark. Resident #12's bed and catheter bag could be seen from the hall. In an interview on 11/8/23 at 10:15 a.m. with the DON, she stated Resident #1 had a catheter. She said the catheter should be covered with a privacy bag. She stated the bag should be covered for privacy and dignity. Resident #1's family member likes to take it off. The Investigator informed the DON that during observation of the uncovered foley bag, Resident #1's family member was not in the building. The DON stated every shift should be monitoring the foley bags to ensure they are covered and not on the floor. In an interview on 11/13/23 at 12:36 p.m. with the Administrator, she stated that the family member to Resident #1 will remove the privacy bag. She stated the expectation is that staff should ensure the urine is always covered when the family member is not in the building. She stated the nurses and CNA's were responsible to ensure the bag is covered to protect the resident's dignity. In an interview on 11/13/23 at 2:20 p.m. with the Administrator, she stated that she saw Resident #12's catheter bag was missing the privacy bag. She stated that all catheter bags should be covered for privacy. Record review of facilities policy titled Quality of Life-Dignity revised February 2020 revealed in part, Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example: helping the resident to keep urinary catheter bags covered

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations , interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 1 (Resident #1) of 3 residents reviewed for care plans in that: The facility failed to implement a fall mat for Resident #1 who was care planned for a fall mat due to being a high risk for falls. The facility failed to implement the intervention that the bed should be in low position at night for Resident #1 who was care planned for high risk for falls. These failures place residents at risk of not receiving appropriate needs based on interventions listed in resident's care plans. Findings included: Record review of Resident #1's face sheet dated 11/3/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnosis included: hypoglycemia (low blood sugar), acute respiratory failure with hypoxia (difficulty breathing), metabolic encephalopathy (problem in brain caused by chemical imbalance in the blood), sepsis (life threatening infection), bacteremia pulmonary candidiasis (fungal infection in the lungs), type 2 diabetes (insulin resistant) muscle weakness (generalized), dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, muscle wasting and atrophy, not elsewhere classified, left and right shoulder, other lack of coordination, retention of urine, unspecified, anemia, unspecified, hypothyroidism, unspecified, hyperlipidemia, unspecified, anxiety disorder, unspecified, essential (primary) hypertension, cellulitis (skin infection) of unspecified part of limb, dorsalgia (back pain) altered mental status, unspecified, and elevation of levels of liver transaminase levels. Record review of Resident #1's Comprehensive MDS dated [DATE] revealed all cognitive test revealed a 0. Resident #1 had a BIMS of 00 which indicated severe cognitive deficit. Record Review of Resident #1's undated care plan revealed Resident #1 is high risk for falls related to new admission, lack of safety awareness, decreased mobility, increased weakness, and new environment. Resident #1 is at risk of injury. Interventions included: needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light; bed in low position at night; enabling devices to sides of bed; handrails on walls; personal items within reach. Resident #1 had an actual fall with minor injury d/t poor balance, poor safety awareness, and unsteady gait. Interventions included: Floor fall mat in place. Observation on 11/4/23 at 6:45 p.m. revealed Resident #1 was laying in her bed. She was in her alone and, her family member was not present. Resident #1 had a scab below her left eye. There was not a fall mat on the floor, and her bed was in high position, about waist high of the surveyor. In an interview on 11/4/23 at 6:45 p.m., with Resident #1, she stated that she had a fall and when she fell, she fell very carefully. Resident #1 stated that she fell a lot. Resident #1 stated that she was tired and to catch her at another time . In an interview on 11/8/23 at 10:15 a.m. with the DON, she said Resident #1 was care planned to have a fall mat, and low- lying bed. She said the risk is her falling and injuring herself . In an interview on 11/10/23 at 9:54 a.m. with CNA G, she stated that Resident #1 is supposed to have a fall mat and her bed is supposed to be low- lying, all the way to the floor, and locked. CNA G stated that Resident #1's family member came in a lot and he moved the mat and changed the bed. CNA G stated that every now and again Resident #1 will changed it, but the family member did it mostly . In an interview on 11/20/23 at 9:40 a.m. with LVN G, she stated that the family member would pick up the fall mat and raise the bed. LVN G stated that she doesn't know exactly what the care plan specifies , but she is aware Resident #1's bed should be low and a fall mat in place. LVN G stated that she should have put the fall mat in place and adjusted the bed after Resident #1's family member leaves . In an interview on 11/13/23 at 12:36 p.m. with the Administrator, she stated the expectation of the staff is to follow the care plans. She said the spouse will remove the fall mat. The family member thought that if he was sitting with her she didn't need the fall mat. She stated that, the facility had educated him plenty of times . The expectation is the care plan should be followed when the family member is not in the building . Record review of the facilities policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, revealed in relevant part 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 1 (Resident #1) of 3 residents reviewed for infection control in that: The facility failed to ensure Resident #1's Foley bag was secured to the bed and not touching the ground. This failure placed residents with an indwelling catheter at risk of unnecessary infections. Findings included: Record review of Resident #1's face sheet dated 11/3/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnosis included: hypoglycemia (low blood sugar), acute respiratory failure with hypoxia (difficulty breathing), metabolic encephalopathy (problem in brain caused by chemical imbalance in the blood), sepsis (life threatening infection), bacteremia pulmonary candidiasis (fungal infection in the lungs), type 2 diabetes (insulin resistant) muscle weakness (generalized), dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, muscle wasting and atrophy, not elsewhere classified, left and right shoulder, other lack of coordination, retention of urine, unspecified, anemia, unspecified, hypothyroidism, unspecified, hyperlipidemia, unspecified, anxiety disorder, unspecified, essential (primary) hypertension, cellulitis (skin infection) of unspecified part of limb, dorsalgia (back pain) unspecified, altered mental status, unspecified, and elevation of levels of liver transaminase levels. Record review of Resident #1's Comprehensive MDS dated [DATE] revealed all cognitive tests revealed a 0. Resident #1 had a BIMS of 00 indicating a BIMS was not obtained or a severe cognitive deficit. Section H noted an indwelling catheter. Record Review of Resident #1's undated care plan revealed Resident #1 had an Indwelling Catheter: Interventions included were to perform catheter care every shift and as needed. The resident has a 16F foley catheter, position catheter bag, and maintain tubing below the level of the bladder, make sure tubing is secured. Change catheter PRN based on clinical indications such as infection, obstruction, or when the closed system is compromised OR per physician's order. Document and notify physician for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. Obtain and record output as per facility policy and/or physician order. Observation on 11/4/23 at 6:45 p.m. revealed Resident #1 was lying in her bed. She was in her alone, her family member was not present. Resident #1's foley bag was on the floor. In an interview on 11/4/23 at 6:51 p.m. with LVN G, she stated that the catheter bag should not be on the floor. She said Resident #1 was her resident to provide care for. She stated she was unaware the bag was on the floor. She said she had not looked at the catheter bag all day. She said it should not be on the floor for sanitary precautions and it was unsafe. In an interview on 11/10/23 at 9:54 a.m. CNA G, stated that he does try to keep the bag off the ground. In an interview on 11/8/23 at 10:15 a.m. with the DON, she stated Resident #1 had a catheter. She said the catheter should not be on the ground due to the risk of infection or the bag being stepped on and leaking and making a mess. She said every shift should be monitoring the foley bags to ensure they were not on the floor. All staff are responsible for ensuring Catheter bags are not on the floor. Record review of facility's policy titled, Catheter Care, Urinary dated August 2022 revealed in part, Infection Control; Be sure the catheter tubing and drainage bag are kept off the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing care to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 12 of 30 days reviewed for sufficient staffing. The facility failed to ensure there were enough staff to administer medications timely from 11/3/23 through 11/10/23. The facility failed to ensure the night and weekend staff had an appropriate amount of nurses and CNAs to meet the needs of the residents. This failure could place residents at risk of their needs not being met, injury, skin breakdown, low self-esteem, depression, embarrassment, and psychological harm. Findings included: Record review of the Facility Assessment Tool updated 9/20/23 revealed the average daily census was 54-59 residents. The facility averaged 24-28 residents with behavioral needs, and 18 -22 residents required injections. The facility residents break down of ADL care was dependent dressing, 6 dependent on bathing, 5 dependent on transfer, 4 dependent on eating, 1 dependent on toileting, and 40 residents in the chair most of the time and required an assistive device used to ambulate. The facility had 52 residents that required 1 to 2 person assist in dressing, 45 for bathing, 50 for transfers, 25 for eating and 53 for toileting. The average number suggested for licensed nurses providing direct care was 2 to 5, and nurse aides was 4 to 7. The Facility Assessment tool revealed the staffing may be increased to meet the needs of the residents. Record review of the facility CMS 672 dated 11/3/23 revealed a census of 61 residents with the following: *24 residents required assist of one or two staff for bathing. *29 residents were dependent for bathing. *59 residents required assist of one or two staff for dressing. *2 residents were dependent for dressing. *48 residents required assist of one or two staff for transfers. *13 residents were dependent for transfers. *53 residents required assist of one or two staff for toilet use. *8 residents dependent on toilet use *58 residents required one or two staff for eating *3 residents dependent on staff for eating Record review of a list provided by Administrator revealed in rooms 109-116 there were 7 residents that were two person assist, in rooms 117-208 there were 8 residents that were 2 person assist, and in rooms 101-108 there were 7 residents that were 2 person assist. Record review of facility map revealed Station 1 was room [ROOM NUMBER] through 116; Station 2 was 117 through 124 and rooms 201 through 208; Station 2 had the skilled hall which was rooms 117 through 124. The memory care unit included rooms 215 through 226. Record review of the facility resident roster dated 11/3/23 revealed Station 1, rooms 101-116, included 14 residents; Station 2, rooms 117-208 (including the skilled hall) revealed 16 residents; and the memory care, rooms 215 through 226, included 15 residents. Record review of the Master Schedule for 4 weeks printed on 11/3/23 revealed staff scheduled to work for the following days: *10/23/23: Night shift, 1 LVN, and 1 RN, with 4 CNAs *10/28/23: Night Shift, 2 LVNs, 1 RN, and 2 CNAs *11/2/23: Night shift, 2 LVNs, 1 RN, and 3 CNAs *11/3/23: Night Shift, 2 LVNs, 1 RN, and 3 CNAs *11/4/23 weekend day shift included 5 CNAs, 1 LVN and 1 RN; night shift was 1 LVN and 4 CNAs *11/6/23 Night shift, 1 LVN and 4 CNAs *11/7/23 : Night shift, 2 LVNs, 2 RNs, and 3 CNAs *11/8/23: Night shift, 3 CNAs, 2 LVNs, and 2 RNs Record review of Daily Staffing Report revealed the following: *10/23/23: Census of 60 residents. Night shift: 1 RN and 1 LVN and 4 CNAs *10/28/23: Census of 60 residents. Night Shift: 1 RN, 2 LVNs and 4 CNA *10/29/23: Census of 60 residents. Night shift: 1RN, 2 LVN, 3 CNA *11/1/23: Census of 61: Night shift: 2 LVNs, 4 CNA *11/2/23: Census of 61: Night shift : 1RN, 2 LVNs, and 4 CNAs *11/3/23: census 62: Night shift : 1RN, 2 LVN, 4 CNAs *11/4/23: Census 61: Day Shift: 1 RN, 2 LVNs, 5 CNAs and 1 MA; Night shift: 1 RN, 2LVNs, 4 CNA *11/6/23 Census of 61: Night shift: 2 LVNs, 4 CNA *11/7/23 census of 61 Night Shift: 1 RN, 2 LVN, 4 CNA *11/8/23 census of 61 Night shift: 1 RN, 1 LVN, and 4 CNA *11/9/23 census of 61: Night shift: 2 LVN and 4 CNA *11/10/23 census of 62: Night shift: 2 LVN and 4 CNAs Record review of the Medication Administration Audit Report for 11/03/2023 through 11/10/2023 revealed 46 of 61 residents received morning, afternoon, and evening medications up to eight hours late. The medications included insulin, Benzodiazepines (anxiety and panic disorders), antibiotics, decarboxylase inhibitors (for Parkinson's Disease), SSRI's (for depression and psychiatric disorders), anticonvulsants, antidepressants, antihypertensives, anticoagulants, beta blockers, narcotics, and antipsychotics. In an interview on 11/3/23 at 10:45 a.m. with CNA V she stated her shift is 6am to 6pm. She said she works room numbers 109-116, and 101- 108. She said she sometimes had to work by herself. She said many residents are total care that she is assigned to. She said some residents requires more assistance. She said they do not have a lot of staff. She said suddenly they do not have enough staff to care for the residents. She said she believes some families have complained as well. She said 101-108 is being worked by someone else today, and today she only has 109-116. She said she is providing care for 16 residents today. She said only one resident is continent. She said the number of residents that require two people assist for ADLs is 7. She said when she needs to assist them, the other CNA on the other hall will help her. She said there was only one nurse, but she didn't know how many halls the nurse had. She said there are two nurses for the entire building. She said the two nurses includes the memory care nurse. When she started they used to have more staff, but now it's smaller. She said that the Administrator has only been here about a month and half. She said she heard that the night staff have a hard time and they do not even know their assignments. In an interview on 11/3/23 at 11:00 a.m. with Med Tech A, she said she worked a 12-hour shift from 7am to 7pm shift. She only passed meds. She said she was the only med tech on duty. She said she did not pass medications to memory care residents. She said that she passed meds to 38 residents. She said she had to be patient with quite a few of them, because they are slow takers or fight and refuse. She said she was sometimes overwhelmed. She said it's always been that way. She said sometimes she passed meds late, but it was only considered late for certain people because they are slow takers so she did those residents last. She said the 9 AM meds are sometimes passed at 11 AM for the slow taker residents. In an interview on 11/3/23 at 11:08 a.m. with LVN E, he stated that he worked 6a to 6pm today. He said he worked unit 1, which had about 22 residents. He worked 101- 116. There was another station, station 2 which has another nurse. He said he was working with 2 aides for about the 22 residents. If an aide called out they would have to share, sometimes they will pull from memory care, because there are 2 aides on memory care. He said there are a few behaviors of screaming and crying for no reason. He said there are people with falls as well and sometimes they roll out of bed. He said there was enough staff, but sometimes they aren't scheduled enough or when someone doesn't show up it's a big issue. He said if a staff called in the staff would just call whoever is on call and let that person know. If there is not a replacement provided, then the staff are shared. He said that the problem that is going on with management is the way they talk to staff, and that makes staff get angry and mad, especially when they are short of the floor, they will call management and they are slow and not proactive. He said communication was not good. He said 2 to 3 days ago they were short on nurses, and because of that they were using 2 nurses for 3 units. When they pull nurses to the floor it puts too much pressure on the staff. He said it affected the residents because they do not get proper care. For example, call lights were left unanswered and took some time to answer. He said there haven't been any incidents, and no one has been harmed from insulin or other meds being administered late that he was aware of. Interview on 11/3/23 at 11:40 a.m. with CNA C, she stated there were 15 residents in memory care. The schedule changed from 3 nurses to 2 nurses at night. One nurse quit so she could protect her license in case something happened. On Saturday, 10/28/23, the Administrator sent a text message to her, because she was very upset because there were only 2 aides on 10/28/23 and there were supposed to be 4 aides for the entire building. She told the Administrator there were only 2 aides in the building and that was unsafe due to the number of fall risk residents in the building. The Administrator just told her that one other aide may come. CNA C told the Administrator there should be 4 aides, but the Administrator said that wasn't what was agreed on and there should only be 3 aides. She said she told the Administrator she had been at the facility since April 2023 and there is always supposed to be 4 aides. The Administrator then stopped speaking to her. She said she was working the memory care and skilled care which is 22 to 23 residents, CNA M had station 1 and CNA R had all of station 2 and a part of station 1 and she had a nurse on memory. In an interview on 11/3/23 at 1:00 p.m. with LVN B, she said she worked 6am to 6pm today. She said she was on station 2. She said she worked with 23 residents; Rooms 110-118, and also rooms all 200 numbers except memory care numbers which was also 200. She said she had only 2 aides. She said there were currently 3 nurses at the facility today. She said that is the normal staffing pattern; two nurses for the floor and 1 nurse for memory care unit. In an interview on 11/3/23 at 1:07 p.m. with Resident #18, she stated that the staffing can depend on the day. She said she didn't' want to be a pain. She said the last few days had been rough to get up out of bed and changed due to staffing. She said she understood there was an issue with staffing, she tried to be patient, and she didn't have a lot of needs. She said she realized staffing was an issue and voiced her concerns to aides, DON, and nurses. They tell her we are doing the best we can. In an interview on 11/3/23 at 1:18 p.m. with Resident #17, she said the facility had some staffing issues. She said residents needs weren't being met. She said that no one knows what they are doing at the facility. She said they took the list down that tells staff the schedule, and it should have dates. On Friday they had no idea who was working or what halls. She said she had observed 2 to 3 nurses at night. At night it's a joke; they don't know who was where or even who was working. The management is not managing. There was no communication. She said the issues have come up in resident council and it has been reported to management and they just say they will change and make things better, but it does not get better. In an interview on 11/3/23 at 1:40 p.m. with the Administrator, she stated she had one specific nurse reaching out about wanting more staff. The nurse reached out to her and she talked to her last night. The situation was resolved last night. She was looking for the staffing assignment sheet, but a nurse moved it to another location. She said for the day time she staffed 6a to 6p with 4 to 5 nurses and 5 to 7 CNAs; depending on acuity and the census. At night, staffing should be 3 nurses and 4 to 5 CNAs. She said memory care is 1 to 2 aides depending on how many residents and outside the unit should be 3 CNAs. The CNAs assignments are 2 CNAs for memory care and 1 aide for each side of the 100 hall and 1 aide on the skilled hall. She said the DON and staffing coordinator/Receptionist completed the schedule daily. In an interview on 11/4/23 at 6:32 p.m. with RN D she stated that she worked the morning shift on this day, 6 am to 6pm. She completed her progress notes and then would leave at 7 p.m., late and after her shift was over. She said she worked station 1 rooms 101 to 108 and then rooms 109, 111, 113, and 115. She said she had one aide on each side of the 100 hall, so she had two aides for her halls. She said the total number of aides in the building today was 4 aides. There were 3 nurses, her, LVN G and LVN D who was in memory care. She said the census today was 62. She said there were not enough aides. She said 1 nurse was for memory care and then 2 other nurses for the rest of the building. She said LVN F is relieving her. She said there will be LVN C (memory care) and then an RN on station 2 and LVN F for station 1. In an interview on 11/4/23 at 6:33 p.m. with Med Tech B, she said she wasn't late on meds yet for the evening. In the morning she had to pass meds late due to her being the only med aide for 30 residents, but she has not seen any negative effects on residents. In an interview on 11/4/23 at 6:37 p.m. with LVN C she stated that she was working the memory care unit which has 13 residents. She was working the 6pm to 6am shift. She is working with one aide. She stated that if someone didn't come to work then there isn't anyone to work. In an interview on 11/4/23 at 6:40 p.m. with CNA D, she stated that she was worked the 6pm to 6am shift and she was the only aide on the memory care unit. She said when she takes her lunch only the nurse on the memory care unit will be there and she will be by herself. Residents should be asleep. In an interview on 11/4/23 at 6:51 p.m. with LVN G, she stated that she worked 6a to 6p. She couldn't tell surveyor what room numbers she worked, she didn't know the numbers of the rooms, she had station 2 and part of station 1. She had the whole hall. She had about 27 residents total. She believes she had 3 aides but can only remember two aides. She stated this was her first day on the floor. In an interview on 11/4/23 at 7:03 p.m. LVN F, she stated that she worked the 6pm to 6am shift. She said there had been issues with staffing overnight and not had enough staff. She said two nurses worked the floor. She said scheduling is confusing. Facility online schedule is different than the hand the written schedule. In an interview on 11/07/2023 at 6:15 P.M with RN F, she stated that she quit over week ago. She usually worked the MC. There would be an aide and RN on the unit. Usually, 3 nurses on duty and one aide on each hall. The reason she quit was because administration wanted to change to only staffing two nurses at night time. RN F did not agree with that, for residents safety. There was no med aide at night, anything can happen at night. Nurses and aides needed more staffing support. The DON wanted three nurses at night, it was the Administrator who wanted two nurses at night. She would have stayed if there were three nurses, and not being rushed. One night, someone called in, so there were only two nurses. After that, the administrator stated the facility was changing to two nurses, staring Nov. 1, 2023. Observation of medication pass and interview with Med Tech A on 11/08/2023 at 9:40 a.m. revealed she was passing morning mediations. Med Tech A stated she passed morning, afternoon, and evening medications to the entire building, other than the memory care unit and a few other residents on the other halls. She said her shift was from 7:00 a.m. to 7:00 p.m. and there was only one medication aide on each morning shift. She said the nurses passed their own medications on the night shift (7:00 p.m. - 7:00 a.m.). She said some residents took longer to take their medication, so she passed their medications last on their particular hall. She said she normally passed medications to all the other residents on the hall, then she went back and passed medications to the slow takers. She stated she had already passed medications to half of the 100 hall, but she still had to complete the other half of the 100 hall (ten residents), who were mostly bed bound. She said she completed medication pass on the 200 hall, other than Resident #6 (she was passing Resident #6's medications at that time- 10:11 a.m.) Med Tech A said the facility's management all knew it took her a long time to get all residents' medications passed and that she was late daily. She said she did not have a conversation with the DON or Administrator about not completing medication passes timely, but she did voice her concerns to her nurse, LVN E. She was told by LVN E that there were not enough residents to get another med aide on the shift. At 10:13 a.m., Med Tech A stated she still had to pass medications to the residents on the 100 hall and all of the resident's medications turned red on the eMAR at 10:00 a.m., indicating they were all late at that time. Observation of Med Tech A's computer screen at that time revealed the medications on each resident's eMAR were highlighted in red. She said she had only spoken to LVN E about her concerns because she did not want to jump the chain of command. In an interview on 11/8/23 at 10:15 a.m. with the DON, she stated that the staffing seems to be an issue everywhere ever since COVID-19. She said that the person that had been doing the schedule was the Receptionist and she did the schedule independently. She stated that if a nurse didn't show up, they would try to call staff and provide incentives to pick up the shift. If no one picked up shift, then the facility will post on the agency staff website. She said it could take a few minutes to an hour to get staff from the agency, depending on the shift. She stated that there was one med tech to pass medications on station 1 and station 2 and that is 45 residents. The nurse passed medications to peg tube residents which is 3, and then to 3 additional residents. Med techs passed meds to 39 residents. She said meds are given on time, and the med techs haven't complained at all. She said she reviewed medication administration when she needs to which is only if someone says medications are late or missing medications. She said meds can be given one hour before and one hour after its due. The medication aide arrives at facility at 7am and then the medications start at 8 a.m. on the 200 hall. Medications for rooms 117 to 123 are at 9 a.m. and then the long-term hallway which is rooms 101 to 116 are at 10 a.m She stated that she didn't observe medications being passed late because she was doing wound care. She said medication administration time is documented on the MAR. She said she had not looked at the MAR recently. She should review the MAR every day, but she did not because her hands are full; she is the ADON, the DON, the wound care nurse, and has been an aide before on the floor because there were only 2 aides. She said they did reach out to staffing agency to get an aide. She was an aide for a few hours which last Thursday (11/2/23) during the day shift. She said she did not remember a staffing issue Thursday evening. She stated that 2 aides ended up showing up for that day, one of their own and one from staffing agency. She had raised these concerns with the staffing coordinator, the Receptionist, and she just says people call out and that the facility tried to offer bonus or gift. The Receptionist is scheduling coordinator, maintains the front desk as a receptionist, and is accounts payable which means she is over billing, bills, and invoices. She was also a CNA but she did not get pulled to the floor to assist with care because she was told she cannot because she is Accounts Payable. She asked the Administrator if she could use the Receptionist as an aid and she was told no because she was Accounts Payable. A nurse quit last week, and a few staff members are leaving because of the issues. In an interview with LVN E on 11/08/2023 at 10:20 a.m., he stated morning medication pass times were between 9:00 a.m. and 10:00 a.m. He said they could pass medications for an hour before and an hour after the scheduled medication pass times and still be considered on-time. He said the medication aides could not administer every resident's medication exactly at their scheduled times because the time it took each resident to take their medication was different. He said some residents took their medications right away and some took longer, which would slow the medication aide down. LVN E said Med Tech A kept telling him she could not pass all medications on time, but there was nothing he could do about it. He said sometimes, the workload was different based on the fluctuating census. LVN E said he did not have any conversations with the DON, or the Administrator regarding Med Tech A's late medication passes or her concerns because he did not think they would do anything about it. He said talking to management would have been a waste of time because they would have said it was not too much work. He said administering residents' medications late meant a medication could be given too close to the time they were scheduled for the next dose and would not be able to take that next dose. He said Med Tech A always complained about not completing medication pass on time. He stated there were no negative outcomes due to late medication administration. In an interview on 11/10/23 at 9:54 a.m. with CNA G, he stated he typically works with 3 CNAs for the outside of the memory care unit. It depends on the census. But on average there were 3 to 4 CNAs, and 1 med tech and the nurses pass meds too. There is a charge nurse on each station, one in memory care, and one on each station, 1 and 2. In an interview on 11/10/23 at 10:30 a.m. with CNA H, she stated that she has worked both shifts but is now on day shift. Recently, they had staffed three aides on the floor, one per hall and had one nurse and one aide in MC. Currently, there was2 aides and one nurse in MC. CNA was a shower tech and restorative aide for a month. She then received a text and stating she was going back to floor because of budget. CNA was told the facility had too many aides staffed and they needed to save money and had to cut back on aides. She stated that with only one aide on a hall, it was very hard and stressful. She didn't get a break sometimes. There was one hall that was difficult to work and get everyone bathed because there were 7 to 8 hoyer transfers required to get the residents out of bed. The rooms numbers were 108-116. The room [ROOM NUMBER]-116 required two people at all times on the hall to provide proper care to the residents. When the facility staffed one aide per hall, the aides had to go look for another aide for help. The nurses were busy and didn't come help. Med aides cannot assist with resident care because they pass medications. She believed there was an increase of skin break down of skilled hall due to not being changed and turned properly and timely. She believed that because there are certain aides, mostly at night who are don't change the residents as often as needed. The Receptionist was a CNA, but the Administrator told her not to work the floor. Its hard to get additional aides because nobody wanted to come in and work another 12 hours while they were off. The facility did not have PRN staff (aides) and did not use agency staff (aides) for aides. Staffing trended down to one nurse at night, one aide in MC and MC nurse had to split with station one. She stated that the nurses who also had to pass meds at night sometimes felt overwhelmed. She talked to the Administrator and she said the nurses needed to get up and help the med aide. CNA talked to nurses and med aide, but they have their own job to do; nobody wanted to work two jobs. The facility cut out OT. She had to leave things for the next shift to do; she ran out of time on a regular shift. The facility had a meeting about not having time to complete everything and the administration said just to leave it to the next shift. She stated all the staff are all tired. Receptionist made it seem like residents were just a number, not like they cared about residents. In an interview on 11/10/23 at 11:05 am. with the Receptionist, she said she just does a little bit of everything wherever she can help. She said her job duties consist of the staffing coordinator; she has put the schedule in through January. She is the receptionist, and has been a CNA. She stated to determine how many staff she needed she went by PPD, she did not know what it meant but to her knowledge, it was based on money and people. She stated that 60 residents would be 5 to 6 aids during the day and 3 nurses during the day. For 60 residents there should be 3 nurses at night and 4 aids at night. Currently the census was 60 and there were only 2 full time nurses on shift at night. She stated that they can run 3 at night but have 2 on each rotation. They use 2 full time nurses at night and will ask a nurse from the other rotation to work and pick up a shift. The facility will staff 2 nurses and if an agency nurse is available to pick up then they have a third nurse. She said it's been a few weeks that she can think of that an agency has picked up. The nurses help each other and are really good with working as a team. She said currently nothing is going on other than one nurse RN F who complained. She said it was unsafe and too much. She stated that if people call out there was still enough people to work. On the floor they always work 4 to 6 aides. She said there are two CNAs in memory and 4 on the outside. They staff one med aide. She stated that there had not been any increase of staffing issues lately that she is aware of. One of the aides had to leave and go home early and they used an agency staff then for an aide. She stated that they used an agency CNA when one of the aides had to go home, she couldn't remember the date, but it was recently. She said she had not worked the floor but if needed she will and would not mind. She said no one has had to work the floor that shouldn't and they haven't been short enough for her to have had to come in. She said she doesn't know why anyone would say that they have been short and asked her to work the floor. She said there's normal work issues like aides bickering because someone wont help. It took nurses extra time to pass meds, so they needed help and got a med aide, but only one. The one med aide passed meds to everyone except the memory care. She said she isn't a med aide so she doesn't know how they do their pass; she only makes sure there is a med aide in the building. She said she doesn't believe nurses have had to take on the med aid job. It's too much for nurses to do both. She hasn't been told they are not able to pass meds on time. When asked how does she know if she is scheduling enough, she said no one has come to report anything about staffing to her or bring it up in the meeting. She said if its reported there are staffing issues, she has to go through chain of command, and it would be up to Administrator and corporate to adjust staffing. She said staffing is based on the census and corporate. She said she had made adjustments they had a shower aide, and not the shower aid is a CNA and CNAs do showers. In an interview on 11/10/23 at 11:40 a.m. LVN D said the receptionist does schedule. Days are ok with number of staff they have now that state is here. LVN D stated that on her rotation, they staff one aide in MC. She was on MC. Now, she has two aides since state is here for residents to get proper ADLs. They said the budget was cut so cut back on staffing. Shen never worked at night, but has talked to night staff. Two weeks ago, there was a nurse and 2 aides for whole building. If no one is available, the scheduler (Receptionist) should work; she is a CNA. The Receptionist said they did not want her to work extra. They called staff to come in and work. Two staff came in. If someone called in, it's the Receptionist's responsibility to provide. Residents are up, especially in the MC. When facility had two nurses at night, MC nurse has to come out. In an interview on 11/10/23 at 12:39 p.m. LVN A stated that she worked nights. There are 3 nurses, and the facility is going down to 2 nurses. On Tuesday there was only 2 nurses, and that was to cover the memory care and the other halls . The date was 11/7/23. Prior to that, there were 3 nurses, and if one didn't show up there were just 2 nurses. They were told the facility was cutting down to 2 CNAs as well. She said she is supposed to work with 4 aides. Sometimes there was a call in, and management would tell her that they were calling and no one wanted to work. She found staff herself to work and called management and staffing and asked for approval for the CNA to work, and no one called back. She said she did medication administration as soon as she started her shift at 7 p.m She did assist CNAs with lifting, and does dressing changes when dressings fell off, she had to do incontinent care and emptied urinals. She said she had expressed her concerns and was met with rudeness from the staffing coordinator. The Receptionist would give excuses of working two to three jobs. She said the med aid left around 6 p.m. to 7 p.m. and she started the 8 p.m. med pass on station 1 which is 22 residents, and sometimes she will divide the hall between her and another nurse when only 2 nurses and then it's 30 residents. She said many medications are administered late because sometimes her administration is interrupted. She said many times she is pulled to other tasks and meds get passed late. She stated that she has asked if a med tech could stay until 8 to get it done and she has asked to have that concern addressed with the staffing coordinator. But it had not been addressed. In an interview on 11/12/23 at 9:45 p.m. RN E stated that she always worked nights. He stated he has given late meds because too many residents. Recently down to two nurses at night. One on station one and he gets middle section, skilled and MC. About 30 residents at one time. To give all at one night is difficult. MC get agitated and don't stay still. Hard to get them to take meds and they are late by the time he gets out of there. Just started last week with 2 nurses. Prior to that was 3. Only concern is working with two nurses at night. Workload has increased heavily. It's late because workload been heavier with two nurses. Residents don't sleep in MC. Sometimes, go to bed at 1 a.m., mixed half go by 9:30 then other half up sitting watching TV. By 2 a.m. all asleep. Last night, they were told there were going to be two on staff. Corporate said they were over budget, so switched to two nurses. In an interview on 11/13/23 at 9:21 a.m. with CNA O, she said the staffing is so short. She said CNAs can't reposition and turn residents nor change them timely. In an interview on 11/13/23 at 9:24 a.m. with CNA V- she said she is still by herself on the hall with residents that are two-person assist for everything. The facility had not made any adjustments to staffing. In an interview on 11/13/23 at 10:29 a.m. CNA L, she stated she worked day shift 6a to 6p all the time. She said she had 18 residents today. She had 117 through 208. She was working by herself. She said she 5 aides today. 2 aides are in memory care and outside is just 3. They have told staffing coordinator and the DON that the work is too much. She said her residents were total care and many are two person assist and incontinent. She said she was overwhelmed and tired. Rooms 109 to 116 were also total care many two person assist and that is the hall that another CNA V was working. Rooms 101 to 108 is the third aides hall. Interview on 11/13/23 at 12:18 p.m. with the Administrator and Regional Director revealed they confirmed that they had not used agency staff from 10/1/2023 through current for any CNA position. The only agency staff used was for an LVN on 10/1/23. In an interview on 11/13/23 at 12:36 p.m. with the Administrator, she stated that she didn't think the staff were having a hard time getting their job done. She[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permitted only authorized personnel to have access in accordance with State and Federal laws for 3 of 3 storage rooms, (Medication room [ROOM NUMBER], Medication room [ROOM NUMBER], and Oxygen Storage room [ROOM NUMBER]) reviewed for storage of drugs and biologicals. The facility failed to ensure all drugs, including antipsychotics, anticonvulsants, antidepressants, anti-hypertensives, blood thinners, antibiotics, and antihistamines, were properly secured when staff conspicuously wrote the code to the keypad lock on the door/door frame for two of two medication rooms and an oxygen tank storage room. This failure placed residents at risk of drug overdose, drug interactions, and other health complications from possible misuse of medications and supplies. Findings include: Observation of Medication room [ROOM NUMBER], on 11/10/2023 at 1:15 p.m. which was located across from Nurse's Station 1, near the corner of the 100 Hall and 200 Hall, and interview with Resident #17 revealed there was a sequence of numbers written on left side of the doorframe attached to the medication room's door. The numbers were written in dark black marker at eye level. There was a sign on the door which indicated it was a medication room. Interview at that time with Resident #17 who was sitting in her wheelchair, facing Medication room [ROOM NUMBER] stated, I know what you are looking at, and it is not good. Resident #17 stated the code to the medication room had been written on the doorframe for several months. Resident #17 said the code to the medication room was previously written on the light switch panel, which was next to the medication room door. Resident #17 said after the code was removed from the light switch, someone wrote it on the doorframe. Resident #17 stated other residents were aware the code to the medication room was written on the doorframe. Observation reflected when the sequence of numbers was entered on the keypad to the mediation room, the door opened. Observation of Medication room [ROOM NUMBER] and interview with RN D inside Medication room [ROOM NUMBER] on 11/10/2023 at 1:25 p.m., revealed RN D stated most of the residents' medications were stored in the medication carts. The refrigerator inside the medication room was stocked with various bags of insulin pens and an emergency drug kit with three different types of insulin pens and the pen needles used to administer the insulin. There were two E-kits (emergency drug kits) with various drugs for emergency use. The E-kits were large plastic containers with handles and were secured with zip-ties. One E-kit contained Methylprednisone (steroid), Glucagon (for low blood sugar), Insta-Glucose (for low blood sugar), Lokelma (for high potassium), Catapress (Clonidine - sedative and antihypertensive), Coumadin (blood thinner), Decadron (steroid), Dilantin (anticonvulsant), Lasix (a diuretic for fluid retention), Mephyton (for vitamin K deficiency), Nitrostat (a vasodilator for chest pain), Lopressor (for high blood pressure), Amoxil (antibiotic), Ampicillin (antibiotic), Augmentin (antibiotic), Ceftin (antibiotic), Cipro (antibiotic), Clindamycin (antibiotic), Diflucan (antifungal), Doxycycline (antibiotic), Zithromax (antibiotic), Atropine (involuntary nervous system blocker), Adrenalin (blood pressure support), Aquamephyton (used to help blood clot), filter needle, Benadryl (antihistamine), Decadron (steroid), Garamycin (antibiotic), Haldol (antipsychotic), Heparin )anticoagulant), Kenalog (used to treat inflammation), Lasix (diuretic), Lovenox (anticoagulant), Narcan (opioid overdose treatment), Rocephin (antibiotic), Solumedrol (steroid), Tobramycin (antibiotic), Zofran (for nausea), Lidocaine (pain reliever), Albuterol (used to treat bronchospasms), and Toradol (pain relief). The second E-kit contained solutions, including Dextrose (sugar substitute), Sodium Chloride (salt water), Heparin (anticoagulant), various antibiotics, catheter supplies, and other supplies. The room contained a large box with a red bag inside that contained the facility's discontinued medications. The box was full and contained various prescription drugs, including Farxiga (used to treat diabetes), Buspirone HCL (for anxiety), Digoxin (antiarrhythmic), Losartan (antihypertensive), Glimepiride (for diabetes), Benzonate (cough suppressant), Levetiracetam (anticonvulsant), Trazodone (antidepressant and sedative), Quetiapine (antipsychotic), Gabapentin (anticonvulsant and nerve pain), and Midodrine (blood pressure support). There were additional drugs inside the room, including over-the-counter heartburn medication, aspirin, vitamin D, magnesium, sodium chloride, and cough syrup. RN D stated she worked at the facility for five months and the code to the medication room was written on the doorframe since she was hired. RN D said she knew the code, so she did not have to look at it. RN D said residents did not know the code was written there, so they would not know to check it. RN D said CNAs did not go into the room, so they did not know the code was written on the doorframe. Observation of the Oxygen Storage room [ROOM NUMBER] on 11/10/2023 at 1:45 p.m. revealed it was located on the same hall as Medication room [ROOM NUMBER]. There was a sequence of numbers written at eye level on the right side of the doorframe. The sequence of numbers unlocked the door. There were multiple oxygen tanks around the room. There were also other supplies related to oxygen use, including masks and tubing. Observation of Medication room [ROOM NUMBER], which was located behind Nurse's Station 2 on 11/10/2023 at 2:00 p.m. revealed a sequence of numbers written on the door in pen directly above the keypad. The sequence of numbers opened the door to the medication room. There was a refrigerator inside which contained insulin pens, IV antibiotics, and dextrose sodium chloride. There were also other supplies in the room including a box of pen needles (for use on insulin pens), syringes, colostomy bags (a bag attached to the intestines for the collection of feces), IV needles, lancet needles, and feeding kits. In an interview with the Regional Director, Regional Nurse, Administrator, and DON on 11/10/2023 at 2:30 p.m., the Regional Nurse stated they were alerted by staff regarding the medication room codes on the doors. The Administrator said the codes were no longer written on the doors and the codes were changed. The Administrator said they previously changed the codes to the medication rooms back in September 2023. The Regional Director stated he never previously noticed the codes written on the doors. The Regional Nurse said she never saw the codes. The DON said she previously knew the code to the linen room was written on the door, but they changed the code there as well. The Administrator stated having an unsecured medication room made the drugs/medications easily accessible to anybody, including residents, family members, aides, and nurses. The Administrator stated nobody had ever brought the codes to their attention. The DON stated she entered the medication rooms weekly and she never noticed the codes. In an interview with Med Tech A on 11/11/2023 at 5:50 p.m., she stated she was hired in February 2023 and the codes to the medication rooms were written on the doors since she arrived. She said she asked someone for the codes She asked for the code when she started working and the Receptionist, who was a CNA at that time, showed her where it was written on the door frame. She said she did not know if management knew the codes were written on the doors. In an interview with CNA F on 11/11/2023 at 5:55 p.m., she stated the codes to the medication room were written on the door frames since she was hired in April 2023. She stated another CNA told her about the codes. She said everyone knew the codes were written there because they were so visible. She said based on conversations, even the residents knew about the codes. She said she never knew of any resident or visitor who attempted to get into the rooms. In an interview with LVN E on 11/11/2023 at 6:00 p.m., he stated the codes to the medication rooms were written there by other staff, although he did not know who wrote them. He said he could not say management knew about the codes. In a telephone interview with LVN A on 11/12/2023 at 9:22 p.m., she stated management recently changed the codes to the medication rooms. She said she did not know who wrote the codes on the doors. She said she and LVN E previously erased the codes from the doors with alcohol. She said they were off two to three days, and the codes were written on the doors again when they came back. She said she had no knowledge that any resident or visitor attempted to enter the rooms. In an interview with LVN E on 11/13/2023 at 10:39 a.m., he stated he and other staff were in-serviced on 11/12/2023 regarding the medication room codes. He said management told them where they could find the codes and informed them not to give anybody the codes. He said he and LVN A previously removed the codes from the doors once. He said LVN A showed him where the codes were written and that was not appropriate. He said that day (he could not recall when this happened), they wiped the codes off. He said the following day, the codes were written again. In an interview with the Administrator on 11/13/2023 at 12:32 p.m., she stated she was not aware staff wrote the codes to the medication rooms on the doors. She said she never would have allowed the codes to remain on the doors. She said after administration was made aware of the situation, they tried to ask around to see who wrote the codes, but they were unsuccessful. She said they in-serviced and educated staff on the importance of securing the medication rooms. She said management would continue to check the doors to ensure the situation does not occur again. She said they planned to remove the keypad and replace them with locks and keys. She said there was no negative outcome. Observation of Medication room [ROOM NUMBER], Medication room [ROOM NUMBER], and Oxygen Storage room [ROOM NUMBER] on 11/13/2023 at 1:00 p.m. - 1:15 p.m. revealed the codes were removed from the doors/doorframe and the previous codes were changed. Record review of facility policy, Storage of Medications revised 11/2020 revealed, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe. And sanitary manner

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement policies addressing resident admission to the facility for 1 of 6 residents (Resident #1) reviewed for admissions. -The facility failed to provide a signed admission packet for Resident #1 upon his admission. Resident #1 continued to reside in the facility without a signed admission agreement since 03/21/22. This deficient practice could place residents at risk of not being made aware of their rights, the facility characteristics, and services provided by the facility or policies of the facility. Findings Included: Record review of Resident #1's face sheet, dated 06/08/2023, revealed a [AGE] year-old male with an admit date of 03/21/2022. Diagnoses included epilepsy with status epilepticus (sudden, uncontrolled recurring seizures), diffuse (widespread) traumatic brain injury with loss of consciousness, hydrocephalus (buildup of fluid in the brain), cerebral infarction (stroke), contracture (tightening of the muscles, tendons, skin, and surrounding tissues) of the right elbow and hand, functional quadriplegia (complete inability to move), and cognitive communication deficit (difficulty with thinking and use of language). Record review of Resident #1's MDS, dated [DATE], revealed a BIMS score of 0 out of 15 indicating severe cognitive impairment. Functional status revealed resident required two-persons physical assist with bed mobility, transfer, and toilet use, and one-person physical assist with dressing and personal hygiene. Record review of Resident #1's business office file folder revealed there was not a signed admission agreement packet on file or any other documents During an interview on 06/08/2023 at 10:36 a.m., the BOM said she had been working at the facility for about 4 weeks. She said Resident #1 did not have a signed admission agreement on file. On 06/08/2023 at 3:59 p.m., Surveyor attempted an interview with Resident #1's RP via telephone but was unsuccessful. During an interview on 06/08/2023 at 4:49 p.m., the Administrator said they did not have a signed admission agreement for Resident #1. He said an admission agreement had been signed at the time of the Resident's admission, but it had since been misplaced. He said the facility realized it had been misplaced about a month ago. He said the facility made several attempts to contact the resident's RP requesting she sign an admission agreement. He said the RP did not answer her phone a lot of the times. He said the RP was refusing to sign the agreement because the RP was wanting to move the resident to another facility. He said an admission agreement had to be signed within 24 hours of admission. He said this timeframe and requirement was not in any policy. He said the business office oversees the admission agreements to ensure they are signed.

**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 that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #48) of 6 residents reviewed for baseline care plans. -The facility failed to complete a baseline care plan within the required 48-hour timeframe for Resident #48. This failure could place residents at risk for not receiving necessary care and services or not having important care needs identified. Findings Included: Record review of Resident #48's face sheet, dated 06/08/2023, revealed an [AGE] year-old female with an initial admit date of 02/09/2023. Diagnoses included traumatic subdural hemorrhage (bleeding under the membrane covering the brain) with loss of consciousness, unspecified fracture of T11-T12 vertebra (spinal fracture), unspecified fracture of first lumbar vertebra (spinal fracture), and dementia (group of symptoms affecting memory). Record review of Resident #48's MDS, dated [DATE], revealed a BIMS score of 7 out of 15 indicating a severe cognitive impairment . Functional status revealed the resident required one-person physical assist with bed mobility, transfer, dressing, toilet use, and personal hygiene. Record review of Resident #48's baseline care plan, dated 02/09/23, revealed Sections I (general information and initial goals), II (safety and risk), VI (baseline care plan summary), and VII (RN review) were not completed until 02/13/2023 and Section III (health conditions) was not completed until 02/14/23. During an interview on 06/08/2023 at 2:52 p.m., the DON said the timeframe to have the baseline care plan completed was within 72 hours after the resident was admitted to the facility. She said the resident's baseline care plan was not completed timely. She said there was no reason for it being completed late. She said the risk posed to a resident if it were not completed within the required timeframe was the aides and nurses would not know the resident's level of care. She said if staff did not know their level of care, they could cause harm to the resident. Record review of the facility's Care Plans - Baseline policy revised December 2016, read in part . Policy Statement: 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 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 1 (Resident #6) of 7 residents reviewed for medication administration. -1) MA L dispensed medications for Resident #6 but was following the MAR of Resident #44. -2) Surveyor intervention was necessary to prevent the possibility of Resident #6 receiving incorrect medications. These failures could place residents at risk for receiving the wrong medications and the possible complications from those medications. Findings Include: Record review of the admission Record for Resident #6 (printed on 06/08/2023) revealed Resident #6 was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included, but were not limited to, seizures, dementia (decreased ability to think), chronic obstructive pulmonary disease (difficulty breathing), and congestive heart failure (weak heart). Record review of the Quarterly MDS dated [DATE] revealed a score of 5 out of 15, indicating severe cognitive impairment. Record review of Resident #6's Care Plan not dated read in part . re-admission date 06/07/2023. Focus: resident had a seizure disorder. Intervention: administer medications as ordered Observation and interview on 06/08/2023 at 7:57 a.m. revealed MA L standing in the doorway of Resident #6's room. He said he was going to administer medications for Resident #6. The identifier sign on the wall next to the doorway reflected the name of Resident #6. Resident #6 was observed to be lying on his bed. Observation revealed the laptop computer on the medication cart facing MA L. The resident name on the displayed MAR was that of Resident #44. MA L opened the third drawer of the medication cart and retrieved a stack of medications cards. He began dispensing medications from the cards. Observation revealed the cards had Resident #6' name, but the MAR was still that of Resident #44. MA L dispensed one tablet of Amlodipine 10 mg (for high blood pressure), one tablet of aspirin 81 mg, one tablet of Keppra 500 mg (for seizures), one tablet of Sevelamer Carbonate 800 mg (to treat kidney disease). MA L said Resident #6 was to receive 100 mg of Metoprolol Tartrate (for high blood pressure), but he only had 25 mg tablets. He dispensed four 25 mg tablets. Further observation revealed MA L place the medication cards back into the cart. The surveyor noted the location of where MA L placed the cards: third drawer, second from the front. MA L then closed out the screen on the laptop. MA L placed the dispensed medications into a plastic sleeve to be crushed. At that time, the surveyor asked MA L to pause. The surveyor asked MA L to pull up the MAR he was using on the screen. MA L pulled up the MAR for Resident #44. MA L confirmed that was the screen he used. The surveyor informed MA L that the name on the MAR was that of Resident #44. MA L acknowledged. MA L said he had not worked the previous two days, and that the residents 'changed names.' He said he pulled medications for the wrong resident, and he would destroy them. Observation and interview on 06/08/2023 at 10:28 a.m. revealed the Administrator asked the surveyor to meet with him, the Regional Nurse, the DON, and MA L. in the Administrator's office. MA L said he was dispensing the medications for Resident #44 because he was going to dialysis. He acknowledged Resident #44's MAR was on the screen. MA L acknowledged he was showing the surveyor each medication card as he dispensed the medications, and that the surveyor was writing notes. MA L said he did not recall whose name was on the medication cards he was dispensing from. He said the medications he was dispensing were for Resident #44, not Resident #6. At that time, the surveyor asked MA L to bring his medication cart. MA L brought the cart to the doorway of the Administrator's office. Prior to MA L opening the cart, this Surveyor presented his notes from the medication pass observation. The note reflected the medication cards used to dispense the medications were in the third drawer, second from the front. The surveyor added that the location was on the left side of the drawer. The DON accompanied MA L and this Surveyor to the cart. MA L opened the third drawer of the cart. This Surveyor asked MA L to retrieve the medication cards that were in the third drawer, left side, second from the front. MA L retrieved the cards and placed them on the left side of the top of the cart. MA L and the DON acknowledged they were those of Resident #6. MA L then retrieved a stack of medication cards from the right side of the drawer. They were the medication cards for Resident #44. He placed them on top of the cart. This Surveyor asked MA L to demonstrate which resident's medication cards contained Amlodipine. MA L sorted through the cards for Resident #44 but did not locate any Amlodipine. MA L then located Amlodipine 10 mg in Resident #6' cards. Both residents had Keppra and Sevelamer Carbonate in their medication cards. MA L presented a medication card for Resident #44 that contained Metoprolol Tartrate 100 mg tablets. This Surveyor presented the note from the medication pass observation that reflected MA L had dispensed four 25 mg tablets of Metoprolol Tartrate from Resident #6' card. MA L sorted through Resident #6' medication cards and presented one that contained Metoprolol Tartrate 25 mg. Interview on 06/09/2023 at 11:44 a.m. with the DON, she said the proper procedure was for the nurse or MA to check vital signs, then apply the '6 Rights.' She said, Having the right MAR in front of you is key. She acknowledged the medications were likely those of Resident #6. She said the '6 Rights' were not done. Record review of a facility policy Titled: Six Rights of Medication Administration dated September 2013 read in part . Right Resident - Identify resident to assure you are giving the medication to the resident who is supposed to receive the medication and using procedure required by the facility, such as a photo on the MAR, asking the resident his/her name, etc.

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 for 1 of 1 facility kitchen, reviewed for sanitation in that: 1) The facility failed to ensure the stove's vent hood was free from dust build-up. 2) The facility failed to ensure the ice machine's vent cover was free from grease and dust build-up. These failures could affect all residents who receive meals from the kitchen and place them at risk for foodborne illness. Findings Include: Observation on 06/06/2023 at 8:40 a.m. accompanied by the DM during a walk-through inspection of the kitchen revealed the following: -Dust build-up on the stove vent hood. -Dust and grease build-up on the ice machine's vent cover located above the ice bin. Observation on 06/06/2023 at 8:45 a.m. of the stove's cleaning sticker located on the hood revealed it was last serviced by an outside company on April 12, 2023, and the next service due date was 07/2023. During an interview on 06/06/2023 at 8:45 a.m., the DM acknowledged the dust build-up on the stove's vent hood. She also acknowledged the dust and grease build-up on the vent cover located on the ice machine. She said the stove's vent hood was cleaned in between serviced dates. She said additional cleanings of the vent hood were based on usage. She said the last time she cleaned the vent cover on the ice machine was about a week ago. She said she checked the stove's vent hood every couple of weeks. She said the stove's vent hood did not require additional cleanings in between the serviced date very often. She said when a cleaning was required, she worked together with the Maintenance Director to ensure it got cleaned. During an interview on 06/08/2023 at 7:10 a.m. the Maintenance Director said he had been working at the facility for a year. He said he worked together with the DM to clean the stove's vent hood if additional cleanings were needed, but the DM handled the in between cleanings on her own. He said he could not recall if the DM requested that he clean the stove's vent hood prior to the survey. He said the computer program that was used to track maintenance tasks included the vent hood. He said the potential risk of not keeping the vent hood free from dust build-up was food contamination and the potential for becoming a fire hazard. During an interview on 06/08/2023 at 7:47 a.m., the DM said she had been working at the facility for about a year. She said the potential risk of not keeping the stove vent hood free from dust build-up was that it could be a potential fire hazard. She said dust and grease accumulates quickly on the vent cover located on the ice machine. She said she monitored it and cleaned it once a week. She said the potential risk of not keeping the vent cover free from dust and grease build-up was dirty ice which could exposed residents to bacterial infection. Record review of the dietary Food & Nutrition: Ice Machine - Cleaning & Sanitation Log revealed the ice machine was cleaned on 05/29/2023. Record review of the dietary's Weekly Cleaning Schedule revealed the ice machine was cleaned on 05/29/2023 and the vent hood and filters on 06/01/2023. Record review of the facility's policy titled: Hoods and Filters policy revised June 1, 2019, read in part . The facility will maintain hoods and filters in a clean and sanitary manner to minimize the risk of food hazards. Hoods and filters will be cleaned every 6 months or as needed . Record review of the facility's policy titled: Ice Machines dated October 1, 2018, read in part . The facility will maintain the ice machine . in a sanitary manner to minimize the risk of food hazards. The ice machine will be cleaned once per month or more often as needed. Procedure: 5. Clean the exterior with detergent solution and rinse .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 of 1 facility reviewed for pest control. -The facility failed to ensure it was free from ants. This failure placed residents at risk of a decreased quality of life. Findings included: Observation on 06/07/2023 at 10:13 a.m. of the entrance door to the kitchen and coffee station located in the dining room revealed the following: -Small black bugs ranging from 1 to 3 mm were crawling around the doorframe of the entrance door to the kitchen. -Small black bugs ranging from 1 to 3 mm were crawling on the plastic food tray where two large stainless steel coffee dispensers were sitting on top. During an interview on 06/07/2023 at 10:20 a.m., the Maintenance Director acknowledged that there were small black bugs crawling around the doorframe and coffee station. During an interview on 06/08/2023 at 7:10 a.m., the Maintenance Director said the facility had a pest control company that came once a month or as needed. He said the small black bugs were sugar ants. He said he was not aware that there were sugar ants prior to the survey. He said he believed dietary was responsible for maintaining the coffee station. He said the potential risk posed to residents when there were pests in the building was infections. During an interview on 06/08/2023 at 7:47 a.m., the DM said dietary was responsible for maintaining the coffee station. She said she never noticed sugar ants around the station. She said dietary staff cleaned the station in the morning and throughout the day. She said she did not know where the ants came from. Record review of the facility's pest control receipts revealed their pest control company last treated the facility on 05/06/2023. Record review of the facility policy titled: Pest Control revised May 2008, read in part . Our facility will maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer resident with newly evident or possible serious mental disorder condition for level II resident review upon a significant change in status assessment for 1 of 1 resident (Resident #8) reviewed for PASARR screening, in that: This facility failed to refer Resident #8 for PASARR level 2 assessment after being diagnosed with multiple mental disorder. This failure could place PASARR positive residents at risk of not having their medical and psychosocial needs met due to not receiving the appropriate services and medical equipment. Findings include: Record review of facesheet showed resident #8 was a [AGE] year old female who was initially admitted to the facility on [DATE]. Current admission was on 6/15/2021 with the diagnosis of Systolic congestive heart failure, delusional disorder, dementia, osteoarthritis, hypertension, Record review of patient's PASARR Level I screening performed on 5/27/2020 showed patient was negative for Mental Illness, Intellectual Disability and Developmental Disability. Record Review of resident diagnosis showed Resident #8 was diagnosed with delusional disorders in 6/23/2020; unspecified psychosis in 6/9/2020. However, the facility failed to follow up with PASARR Level II assessment. On 4/14/2022 at 12:25 PM during interview with Social Worker and DON, the Social worker stated usually they would go back and do the PASARR Level I again which would have triggered the PASARR Level II assessment and they would have followed up from there, she said but in this case it was not done. She stated further that at the time of the occurrence, there was a different MDS nurse who was doing the PASSAR at that time. DON stated this deficient practice could have denied the patient the special service Patient could have received. On 4/14/2022 at 1:02 PM Record review of the PASARR policy titled 'admission Criteria' (Revised March 2019) revealed all new admissions and re-admissions are screened for mental disorders (MD), intellectual disabilities (ID) ore related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. However, Record review also showed when resident was readmitted on [DATE] - current admission, there was no assessment for PASARR according to the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one (Resident #490) of four residents reviewed for medication administration. The facility failed to administer sliding scale insulin timely before meals as ordered by the physician for Resident #490 on 4/13/22 This failure could place residents receiving insulin at risk for hypoglycemic episodes, increased HbA1c hospitalization, and/or death. Findings included: Record review of the admission sheet for Resident #490 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cellulitis of right lower limb, gastro-esophageal reflux disease without esophagitis, hyperlipidemia Record review of Resident #490's comprehensive MDS, dated [DATE] revealed the BIMS score 15 out of 15 indicating intact cognitively. Record review of Resident #490's Care plan initiated 3/28/22 and revised on 4/4/22 revealed the following: Focus: The resident has Diabetes Mellitus Goal: The resident will be free from any s/sx of hyperglycemia through the review date. Interventions: Accu checks as ordered and/or prn for s/s of hypo/hyperglycemia, intervene as appropriate, document and notify MD. Record review of Resident #490's physician order dated 3/26/22 revealed an order for Insulin Regular Human Solution Inject as per sliding scale: if 60 - 150 = 0 Units < 60 Follow Hypoglycemia Protocol; 151 - 200 = 5 Units; 201 - 250 = 8 Units; 251 - 300 = 10 Units; 301 - 350 = 12 Units; 351 - 400 = 16 Units > 400 Give 16 Units & Call MD, subcutaneously before meals and at bedtime for DM2. Record review of blood sugar levels for Resident #490's revealed blood sugar was 235.0 mg/dl documented on 4/13/2022 at 8:39am by LVN AA. Observation of the med pass on 4/13/22 at 8:56 a.m. revealed LVN AA, said to Resident#490 his blood sugar was 235 so she would have to give him 8 units. Resident #490 said, I waited for you before I ate my breakfast. My blood sugar was high. You needed to give me the insulin before I ate breakfast. It's going to be even higher now. LVN AA did not respond. In an interview on 4/13/22 at 1:14p.m., with Resident #490, he said, LVN AA checked my blood sugar this morning before breakfast it was 200 something. LVN AA didn't come back with insulin. I waited for some time for her to come and give me insulin. I ate my breakfast around 7:30am. The insulin should be given before I ate not after. In an interview on 4/13/22 at 1:25 p.m., with LVN AA, she said she checked Resident #490's blood sugar around 7:15am. But the resident did not have his breakfast at that time so that is why she did not give him insulin. She said she was the agency nurse and today was her first day on the floor. She said she was aware the order was ac meaning before meals. She said, I don't know these residents or their meds. She said it was important to give insulin before the resident ate or his blood sugar would get higher. In an interview on 4/13/22 at 1:32 p.m., with the DON, she said insulin should be given before meal right then when the nurse checked resident's insulin. In a follow up interview on 4/14/22 at 12:27 p.m., with the DON, she said the expectation from the staff was that they follow orders as prescribed ac and bedtime. She said it was important to administer insulin as ordered so the blood sugar could be managed and stay in appropriate range. Record review of facility's Insulin Administration policy (Revised September 2014) read in part: .Purpose: to provide guidelines for the safe administration of insulin to residents with diabetes. Preparation: 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #490) reviewed for pharmacy services. -The facility failed to ensure Resident #490's Fexofenadine HCl Tablet 180 MG (antihistamine used to relieve allergy symptoms) medication was available as order by the physician. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of the admission sheet for Resident #490 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cellulitis of right lower limb, gastro-esophageal reflux disease without esophagitis, hyperlipidemia Record review of Resident #490's comprehensive MDS, dated [DATE] revealed the BIMS score 15 out of 15 indicating intact cognitively. Record review of Resident #490's Care plan initiated 3/28/22 and revised on 4/4/22 revealed the following: Focus: The resident has Diabetes Mellitus Goal: The resident will be free from any s/sx of hyperglycemia through the review date. Interventions: Accu checks as ordered and/or prn for s/s of hypo/hyperglycemia, intervene as appropriate, document and notify MD. Record review of Resident #490's physician order dated 3/26/22 revealed an order for Fexofenadine HCl Tablet 180 MG Give 1 tablet by mouth one time a day for Allergy Symptoms. Record review of Resident #490's MAR for the month of April 2022 revealed nurses documented '9' on 4/4/22, 4/11/22, 4/13/22 for the order Fexofenadine HCl Tablet 180 MG Give 1 tablet by mouth one time a day for Allergy Symptoms. '9' stood for 9=other/ see progress notes. Record review of Resident #490's nurses notes for the month of April 2022 revealed the Doctor/NP were not notified of the missed doses for the medications prescribed. Observation of the med pass on 4/13/22 at 8:56 a.m. revealed LVN AA, administered Resident #490 prescribed morning meds. Resident #490 said, I am missing my Fexofenadine for a week and a half now. Can you call pharmacy to find out please? I need it. LVN AA did not respond. In an interview on 4/13/22 at 1:14 p.m. with Resident #490, he said he was getting his Fexofenadine meds from the blister pack when he arrived at the facility. He said the facility had been out of this allergy med for a week and a half now. He said he was an RN and knew all his meds. He said he had asked several different agency nurses to place an order from pharmacy but there was no follow up. He said, there was always a new agency nurse. There is not continuity of care. In an interview and record review on 4/13/22 at 1:25 p.m., with LVN AA, of Resident #490's MAR with LVN AA. Surveyor A explained to LVN AA that she documented she administered resident's Fexofenadine medication this morning but during med pass LVN AA told surveyor that resident was out of this medication. The LVN AA said, I accidently documented I gave it. I will change it now to 'hold'. This Surveyor asked LVN AA if she was able to inquire from pharmacy when resident's allergy medication would be delivered. Did she notify the DON that the medication was not available and what was the facility's process to re-order the medication and if she notified the doctor that resident had missed his dose this morning? LVN AA said she was new to this facility and did not know the process to re-order meds. She said she would call the doctor and go talk to the DON now. In an interview 4/13/22 at 1:32p.m., with the DON, Surveyor A shared med pass observation that Resident #490 expressed concern that he was out of his Fexofenadine allergy meds for week and a half now. The DON said Fexofenadine was Allegra. She said, we can go and get it. It's over the counter. Nobody told me we needed ASAP. She said if the med was not available nurse needed to document '9' and make a note why the med was not given. In an interview 4/14/22 at 12:27p.m., with the DON, this Surveyor reviewed Resident #490's MAR with the DON. The DON said when the Surveyor brought it to her attention, yesterday 4/13/22 the facility got the meds within 20 minutes. She said Allegra was over the counter. The pharmacy would not send it. She said nobody told her that they needed this med. She said normally the facility did not keep Allegra. The most common allergy med kept in the facility was Claritin. She said the nurses needed to let her know what meds they needed. If the resident missed a dose, process was to notify the doctor that there was an elapse in treatment and order received. At this time policy on pharmacy services/ordering medications was requested. In an interview 4/14/22 at 1:12p.m., with the Administrator, he said the facility did not have a policy on Pharmacy services/ ordering medications. Record review of facility's Medication and Treatment Orders policy (Revised July 2016) read in part: .11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #20) reviewed for clinical records. The facility failed to ensure staff documented wound care treatments on Resident #20's MAR/TAR. This failure could affect residents that received wound care and place them at risk of inaccurate or incomplete clinical records. Findings include: Record review of the admission sheet for Resident #20 revealed an [AGE] year-old female admitted to the facility on [DATE] on admitted and re-admitted on [DATE]. Her diagnoses included unspecified dementia without behavioral disturbance, mild protein-calorie malnutrition vitamin b deficiency and encounter for palliative care. Record review of Resident #20's admission MDS, dated [DATE], revealed the BIMS score was blank. Staff assessment for mental status was conducted resident was unable to complete interview. Resident#20 has short term memory problem, long term memory problem, and cognitive skills for daily decision making is severely impaired never/rarely made decision. Further review of the MDS revealed she required total dependence from one-person physical assist for personal hygiene, toilet and transfer. Resident was always incontinent of bowel and bladder. Record review of Resident #20's Care plan initiated 8/7/2017 and revised on 4/8/2020 revealed the following: Focus: Resident #20 at risk for skin breakdown Goal: Resident #20 will have no skin issue throughout the next review date Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Identify potential causative factors and eliminate/resolve when possible. If skin tear occurs, treat per facility protocol and notify MD, family. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Record review of Resident #20's physician order dated 7/1/21 revealed an order for left lateral ankle over bony prominence: apply liquid skin protectant every shift for skin callous/ blanchable red area. Record review of Resident #20's MAR/TAR for the month of April 2022 for left lateral ankle had blanks on the TAR indicating the treatment did not occur on 4/1/22, 4/2/22, 4/6/22, 4/9/22, 4/11/22 and 4/13/22. Record review of Resident #20's physician order dated 10/22/2020 revealed an order for Apply barrier cream to buttocks q shift every shift. Record review of Resident #20's MAR/TAR for the month of April 2022 for barrier cream to buttocks had blanks on the TAR indicating the treatment did not occur on 4/1/22. 4/2/22 and 4/9/22. Record review of Resident #20's nurses note for the month of April 2022 revealed there was no documentation of Resident #20's treatments not being done, notification to the MD or a Nurse Practitioner of treatment not being done, or of Resident #20's refusing treatment. There was no documentation indicating why the scheduled treatment was withheld or not administered as ordered. In an interview and record review on 4/14/22 at 12:27p.m., with the DON, Surveyor A reviewed Resident #20's TAR/MAR. The DON confirmed the floor nurse did not document on the TAR/MAR after performing the treatments in April 2022. She said there should not be any open/blank spaces in the MAR/TAR and that if it is not documented it means it was not completed. The DON said, there was no explanation for the holes in the MAR. We use agency nurse. The DON said she went over MAR once a week. She said it was important to document. if it's not documented, it's not done. Treatments were not done. Record review of facility's Charting and Documentation policy (Revised July 2017) read in part: .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of individual(s) who provided the care; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure there was a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day for 1 of 2 residents (Resident #20) reviewed for hospice services in that: There was no hospice communication documentation for Resident #20 after 3/16/2021 in her medical record or hospice communication binder. This deficient practice could affect residents on hospice and could result in treatments and services not being coordinated. Findings include: Record review of the admission sheet for Resident #20 revealed an [AGE] year-old female admitted to the facility on [DATE] on admitted and re-admitted on [DATE]. Her diagnoses included unspecified dementia without behavioral disturbance, mild protein-calorie malnutrition vitamin b deficiency and encounter for palliative care Record review of Resident #20's admission MDS, dated [DATE], revealed the BIMS score was blank. Staff assessment for mental status was conducted resident was unable to complete interview. Resident#20 has short term memory problem, long term memory problem, and cognitive skills for daily decision making is severely impaired never/rarely made decision. Further review of the MDS revealed she required total dependence from one-person physical assist for personal hygiene, toilet and transfer. Resident was always incontinent of bowel and bladder. Record review of Resident #20's physician order dated 2/11/22 revealed an order to admit to [Company name] Hospice DX: [Hospice company address] Under care of Hospice Dr. & facility Dr. Dx: Senile Degeneration of the Brain. Dementia, CKD Stage 3, HTN, Dysphagia, Malnutrition, FTT S/P Covid-19 Contact [company name] Hospice 1st for COC, Orders, Time of Death @ Phone. D/C all Labs. Record review of Resident #20's Care plan initiated 8/7/2017 and revised on 5/06/21 revealed the following: Focus: Resident #20 is a DNR code status and is receiving hospice services through Hospice Goal: Treatment will respond to Resident #20's advanced directives as condition warrants Interventions: Appropriate care within guidelines of advanced directives. Arrange for clergy support as desired. Educate patient/family on condition and disease process. Hospice Referral as desired. Keep patient comfortable Send copy of DNR to hospital at time of transfer. Talk to resident/family about treatment needs/decisions. Observation and attempted interview with Resident #20 on 4/13/22 at 7:40 a.m., revealed resident was resting on an air mattress. Resident did not respond to the questions asked about her stay at the facility. Record review of Resident #20's Visitor Sign-in sheet from hospice revealed hospice staff visited him on the following days: 3/31/22, 4/7/22, 4/8/22, 4/11/22, 4/12/22, 4/13/22, 4/14/22. Record Review of Resident #20's medical file revealed no documentation of any coordination of care or any communication with hospice since 3/16/2021. Interview, observation, and record review with LVN CC on 4/14/22 at 10: 30a.m., he said he was the nurse for Resident #20. He said Resident #20 was receiving hospice services. He said he was not sure exactly what days the hospice came but he knew they came weekly. He said when the hospice staff came, they gave the resident a shower and the nurse would do assessments. He said the hospice staff always announced when they were there and asked the nurse if there were any concerns or anything, they should be aware of. When asked how the hospice staff communicated with the facility, he said they always logged in their binder when they were there. He said they told them verbally what they did, and they also documented in their binders. When asked when was the last time the hospice came and what they did when they were there, he said, Let's check the binder. He reviewed the binder for Resident #20 with Surveyor A and said, Looks like they were last here on today 4/14/22. When asked what they did on 4/14/22 when they were there, he checked the binder and said he could not find the documentation. He checked the binder and said the last documentation he saw was from 3/16/21. When asked who was responsible for ensuring they were documenting in the binder, he said I don't know but I could find out In an interview and record review on 4/14/22 at 12:27p.m., with the DON, of Resident #20's hospice binder. The DON said the hospice nurse came once a week. She said the hospice admit nurse went over the hospice binder with the floor nurses. I am not on the floor. I don't know if nurses go over with hospice nurse. It's on my attention now. Will get with hospice nurse to see what the plan was. Have to have current notes in there. She said it was important to have current hospice plan of care for the resident if there were any changes to keep us informed and for communication purpose. Record review of facility's Hospice Program policy (Revised July 2017) read in part: .10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These responsibilities include the following: d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day; 12b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family; 12. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to 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 maintain infection prevention and control process designed to provide safe and sanitary environment and to help prevent the development and transmission of diseases and infections for one (Resident #25) of two Residents observed for infection control during incontinent/perineal care, in that: 1. CNA MA and CNA BA kept gloves being used for resident's incontinent/ perineal care in their scrub pocket. 2. CNA BA failed to perform hand hygiene when changing gloves during incontinent /perineal care. These failures could place residents at risk for infection and hospitalization. Findings include: Record review of facesheet revealed resident #25 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis, Bipolar disorder, major depressive disorder, anxiety disorder, vascular dementia, type 2 diabetes mellitus. On 4/13/2022 at 4:30 PM observation of Resident #25's perineal/ incontinent care with CNA MA and CNA BA revealed the following: - CNAs (CNA BA and CNA MA) entered restroom, washed hands and donned clean gloves - Assisted patient from wheelchair to bed and removed gloves - Both CNAs stepped out to hallway to use sanitizer mounted on the wall close to the entrance of Resident's room. - CNAs came back inside and wore clean gloves. (gloves were pulled from CNAs' pocket.) - CNA BA wiped resident front-to-back, she removed her gloves and wore clean gloves - she failed to perform hand hygiene before wearing clean gloves. - CNA BA cleaned resident's catheter at the urinary meatus. - CNA BA removed gloves and donned clean gloves - she failed again to perform hand hygiene before wearing clean gloves. - Both CNAs assisted resident to lay on her side. CNA BA cleaned resident's peri-anal area from front-to-back. - CNA BA changed her gloves and donned clean gloves, she failed again to sanitize or wash her hands before wearing clean gloves. - CNAs gave resident diaper and assisted resident to wheelchair. - Both CNAs removed their gloves and stepped out to the hallway to sanitize hands using the wall-mount sanitizer. On 4/13/2022 at 5:02 PM during interview with the two CNAs, Surveyor discussed with CNA BA and CNA MA about the deficient practices (keeping gloves in their pockets and failure to perform hand hygiene between glove changes) observed during incontinent care for Resident #25. CNA BA stated there was no sanitizer in the resident's room and that was why she was unable to perform hand hygiene between glove changes. Both CNAs stated they understood they were not supposed to put gloves inside their pockets and that these practices placed resident at risk for infection. On 4/14/2022 at 12:39 PM in an interview with DON, she stated the gloves kept in the CNAs pocket could have contacted germs in their pocket and the CNAs would have transferred those germs to the patient. DON stated further that every employee was expected to always perform hand hygiene between gloves changes as one of the measures to prevent infection. On 4/14/2022 at 1:45 PM Record review of Infection Control policy titled 'Handwashing/Hand Hygiene' (revised August 2019) line number 2 stated .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors. Line number 7m also revealed alcohol-based hand rub or soap and water should be used for hand hygiene after removing gloves.