**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of three residents reviewed. The facility failed to notify the NP immediately when Resident #1 was admitted and they did not have his prescribed insulin. This failure could affect residents by putting them at risk of exacerbation of their health conditions and deterioration of their health. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type II diabetes, history of stroke, coronary artery disease, and cholecystitis (inflammation of the gall bladder). Review of Resident #1's EMR, on 11/04/24, reflected his 5-day MDS assessment had not been completed. Review of Resident #1's baseline care plan, dated 11/03/24, reflected he had an ADL self-care performance deficit with an intervention of receiving a therapy evaluations and treatment per physician's orders. Review of Resident #1's hospital discharge records, dated 11/02/24, reflected an order for Insulin, 42 units - HumuLIN 70/100 units/ML - twice a day. Review of Resident #1's physician's order, dated 11/02/24, reflected HumuLIN 70/30 Subcutaneous Suspension (70-30) 100 UNIT/ML - Inject 42 units subcutaneously two times a day for blood sugar. Review of Resident #1's November 2024 MAR, on 11/04/24, reflected he had not been administered either dose of insulin on 11/03/24 or his morning dose on 11/04/24. Review of Resident #1's progress note, dated 11/03/24 at 4:27 PM and documented by RN A, reflected insulin was not administered due to it not being available. Review of Resident #1's progress note, dated 11/03/24 at 7:27 PM and documented by RN A, reflected insulin was not administered due to it not being available. Review of Resident #1's progress note, dated 11/04/24 at 9:03 AM and documented by LVN B, reflected insulin was not administered due him being a new admission and waiting delivery. Review of Resident #1's blood sugar readings in his EMR, on 11/04/24, reflected the following: 11/02/24 9:32 PM - 176.0 mg/dL 11/03/24 7:33 AM - 184.0 mg/dL 11/03/24 1:00 PM - 283.0 mg/dL 11/03/24 4:40 PM - 245.0 mg/dL 11/03/24 8:15 PM - 237.0 mg/dL 11/04/24 8:05 AM - 200.0 mg/dL 11/04/24 12:51 PM - 312.0 mg/dL During an interview on 11/04/24 at 12:05 PM, Resident #1 stated he was not sure if he had been getting his insulin as he was still groggy from his procedure in the hospital. He stated it was hard to know if he felt off (regarding his sugar levels) due to him having an infection and being in pain. He was asked if it was normal for his sugar levels to be in the upper 200's. His eyes opened wide and he said, Absolutely not! and that was very concerning to him. During an interview on 11/04/24 at 12:11 PM, LVN B stated she noticed Resident #1 did not have insulin to be administered that morning and had reached out to the pharmacy. She stated she was not sure why no one had reached out to the pharmacy sooner. She stated that particular dosage of insulin was not in their e-kit but the pharmacy assured her it would be delivered that day. During an interview on 11/04/24 at 12:55 PM, Resident #1's NP stated she was not notified about the insulin until that day (11/04/24). She stated she ideally would have liked to have been notified sooner. She stated if she had been notified sooner, she would have reinforced to reach to the pharmacy or could have placed an order for a different type of insulin. She stated a negative outcome of going too long without insulin could be hyperglycemia or other acute issues. During a telephone interview on 11/04/24 at 1:05 PM, RN A stated she was the nurse who admitted Resident #1 on 11/02/24. She stated she was pretty new to the facility and had put his orders in and was just waiting for the medications to be delivered. She stated she thought it would be a given that they needed the insulin STAT so she did not think to tell the pharmacy. She stated she kept a close eye on his sugar levels and they never reached 400 or above . During an interview on 11/04/24 at 2:09 PM, the DON stated when a resident was being admitted they would come in with orders, the nurses would put the orders in, and the orders went straight to the pharmacy. She stated they did have insulin in their e-kit, but not specific insulin Resident #1 had an order for. She stated she would have expected RN A to contact the on-call NP to notify her. She stated it was not okay to go without scheduled insulin and they could have given him an alternate. Review of the facility's Medication Administration Policy, revised May of 2007, reflected the following: It is the policy of this facility to prepare, administer, and document medications. . 12. Any irregularity in pouring or administering must be reported to the doctor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of three residents reviewed for medications. The facility failed to administer three doses of insulin after Resident #1 was admitted on [DATE] due to pending delivery from the pharmacy. This failure could affect residents by putting them at risk of exacerbation of their health conditions and deterioration of their health. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type II diabetes, history of stroke, coronary artery disease, and cholecystitis (inflammation of the gall bladder). Review of Resident #1's EMR, on 11/04/24, reflected his 5-day MDS assessment had not been completed. Review of Resident #1's baseline care plan, dated 11/03/24, reflected he had an ADL self-care performance deficit with an intervention of receiving a therapy evaluations and treatment per physician's orders. Review of Resident #1's hospital discharge records, dated 11/02/24, reflected an order for Insulin, 42 units - HumuLIN 70/100 units/ML - twice a day. Review of Resident #1's physician's order, dated 11/02/24, reflected HumuLIN 70/30 Subcutaneous Suspension (70-30) 100 UNIT/ML - Inject 42 units subcutaneously two times a day for blood sugar. Review of Resident #1's November 2024 MAR, on 11/04/24, reflected he had not been administered either dose of insulin on 11/03/24 or his morning dose on 11/04/24. Review of Resident #1's progress note, dated 11/03/24 at 4:27 PM and documented by RN A, reflected insulin was not administered due to it not being available. Review of Resident #1's progress note, dated 11/03/24 at 7:27 PM and documented by RN A, reflected insulin was not administered due to it not being available. Review of Resident #1's progress note, dated 11/04/24 at 9:03 AM and documented by LVN B, reflected insulin was not administered due him being a new admission and waiting delivery. Review of Resident #1's blood sugar readings in his EMR, on 11/04/24, reflected the following: 11/02/24 9:32 PM - 176.0 mg/dL 11/03/24 7:33 AM - 184.0 mg/dL 11/03/24 1:00 PM - 283.0 mg/dL 11/03/24 4:40 PM - 245.0 mg/dL 11/03/24 8:15 PM - 237.0 mg/dL 11/04/24 8:05 AM - 200.0 mg/dL 11/04/24 12:51 PM - 312.0 mg/dL During an interview on 11/04/24 at 12:05 PM, Resident #1 stated he was not sure if he had been getting his insulin as he was still groggy from his procedure in the hospital. He stated it was hard to know if he felt off (regarding his sugar levels) due to him having an infection and being in pain. He was asked if it was normal for his sugar levels to be in the upper 200's. His eyes opened wide and he said, Absolutely not! and that was very concerning to him. During an interview on 11/04/24 at 12:11 PM, LVN B stated she noticed Resident #1 did not have insulin to be administered that morning and had reached out to the pharmacy. She stated she was not sure why no one had reached out to the pharmacy sooner. She stated that particular dosage of insulin was not in their e-kit but the pharmacy assured her it would be delivered that day. During an interview on 11/04/24 at 12:55 PM, Resident #1's NP stated she was not notified about the insulin until that day (11/04/24). She stated she ideally would have liked to have been notified sooner. She stated if she had been notified sooner, she would have reinforced to reach to the pharmacy or could have placed an order for a different type of insulin. She stated a negative outcome of going too long without insulin could be hyperglycemia or other acute issues. During a telephone interview on 11/04/24 at 1:05 PM, RN A stated she was the nurse who admitted Resident #1 on 11/02/24. She stated she was pretty new to the facility and had put his orders in and was just waiting for the medications to be delivered. She stated she thought it would be a given that they needed the insulin STAT so she did not think to tell the pharmacy. She stated she kept a close eye on his sugar levels and they never reached 400 or above . During an interview on 11/04/24 at 2:09 PM, the DON stated when a resident was being admitted they would come in with orders, the nurses would put the orders in, and the orders went straight to the pharmacy. She stated they did have insulin in their e-kit, but not specific insulin Resident #1 had an order for. She stated she would have expected RN A to contact the on-call NP to notify her. She stated it was not okay to go without scheduled insulin and they could have given him an alternate. Review of the facility's Medication Administration Policy, revised May of 2007, reflected the following: It is the policy of this facility to prepare, administer, and document medications. . 12. Any irregularity in pouring or administering must be reported to the doctor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medications errors for one of one (Resident #1) of three residents reviewed for significant medication errors. The facility failed to administer three doses of insulin after Resident #1 was admitted on [DATE] due to pending delivery from the pharmacy. This failure could affect residents by putting them at risk of exacerbation of their health conditions and deterioration of their health. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type II diabetes, history of stroke, coronary artery disease, and cholecystitis (inflammation of the gall bladder). Review of Resident #1's EMR, on 11/04/24, reflected his 5-day MDS assessment had not been completed. Review of Resident #1's baseline care plan, dated 11/03/24, reflected he had an ADL self-care performance deficit with an intervention of receiving a therapy evaluations and treatment per physician's orders. Review of Resident #1's hospital discharge records, dated 11/02/24, reflected an order for Insulin, 42 units - HumuLIN 70/100 units/ML - twice a day. Review of Resident #1's physician's order, dated 11/02/24, reflected HumuLIN 70/30 Subcutaneous Suspension (70-30) 100 UNIT/ML - Inject 42 units subcutaneously two times a day for blood sugar. Review of Resident #1's November 2024 MAR, on 11/04/24, reflected he had not been administered either dose of insulin on 11/03/24 or his morning dose on 11/04/24. Review of Resident #1's progress note, dated 11/03/24 at 4:27 PM and documented by RN A, reflected insulin was not administered due to it not being available. Review of Resident #1's progress note, dated 11/03/24 at 7:27 PM and documented by RN A, reflected insulin was not administered due to it not being available. Review of Resident #1's progress note, dated 11/04/24 at 9:03 AM and documented by LVN B, reflected insulin was not administered due him being a new admission and waiting delivery. Review of Resident #1's blood sugar readings in his EMR, on 11/04/24, reflected the following: 11/02/24 9:32 PM - 176.0 mg/dL 11/03/24 7:33 AM - 184.0 mg/dL 11/03/24 1:00 PM - 283.0 mg/dL 11/03/24 4:40 PM - 245.0 mg/dL 11/03/24 8:15 PM - 237.0 mg/dL 11/04/24 8:05 AM - 200.0 mg/dL 11/04/24 12:51 PM - 312.0 mg/dL During an interview on 11/04/24 at 12:05 PM, Resident #1 stated he was not sure if he had been getting his insulin as he was still groggy from his procedure in the hospital. He stated it was hard to know if he felt off (regarding his sugar levels) due to him having an infection and being in pain. He was asked if it was normal for his sugar levels to be in the upper 200's. His eyes opened wide and he said, Absolutely not! and that was very concerning to him. During an interview on 11/04/24 at 12:11 PM, LVN B stated she noticed Resident #1 did not have insulin to be administered that morning and had reached out to the pharmacy. She stated she was not sure why no one had reached out to the pharmacy sooner. She stated that particular dosage of insulin was not in their e-kit but the pharmacy assured her it would be delivered that day. During an interview on 11/04/24 at 12:55 PM, Resident #1's NP stated she was not notified about the insulin until that day (11/04/24). She stated she ideally would have liked to have been notified sooner. She stated if she had been notified sooner, she would have reinforced to reach to the pharmacy or could have placed an order for a different type of insulin. She stated a negative outcome of going too long without insulin could be hyperglycemia or other acute issues. During a telephone interview on 11/04/24 at 1:05 PM, RN A stated she was the nurse who admitted Resident #1 on 11/02/24. She stated she was pretty new to the facility and had put his orders in and was just waiting for the medications to be delivered. She stated she thought it would be a given that they needed the insulin STAT so she did not think to tell the pharmacy. She stated she kept a close eye on his sugar levels and they never reached 400 or above . During an interview on 11/04/24 at 2:09 PM, the DON stated when a resident was being admitted they would come in with orders, the nurses would put the orders in, and the orders went straight to the pharmacy. She stated they did have insulin in their e-kit, but not specific insulin Resident #1 had an order for. She stated she would have expected RN A to contact the on-call NP to notify her. She stated it was not okay to go without scheduled insulin and they could have given him an alternate. Review of the facility's Medication Administration Policy, revised May of 2007, reflected the following: It is the policy of this facility to prepare, administer, and document medications. . 12. Any irregularity in pouring or administering must be reported to the doctor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to assist residents in obtaining routine dental services to meet the needs of 2 of 12 (Resident # 13 and Resident # 79) reviewed for dental services. The facility did not assist Resident # 13 with obtaining dental services when her bottom denture broke. The facility did not assist Resident # 79 with obtaining dental services when he reported his dentures had been left in Mexico. This deficient practice could affect residents by placing them at risk of not receiving necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being which could result in a decreased quality of life. Findings included: Record review of Resident # 13's face sheet dated 8/15/2024 with an admission date of 10/02/2023 reflected a [AGE] year-old female with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a severe or complete loss of strength or paralysis that prevents you from moving the affected body parts), diabetes mellitus (a group of diseases that result in too much sugar in the blood), acute respiratory failure (respiratory failure from inadequate gas exchange by the respiratory system), protein-calorie malnutrition, muscle weakness, muscle wasting and atrophy, diabetic retinopathy with macular edema (damage to the blood vessels in the eyes due to complications from diabetes), contracture of left hand muscle, dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus), atherosclerotic heart disease (damage or disease in the hearts major blood vessels), anemia (Lack of red blood cells), abnormalities of gait and mobility, cognitive communication deficit, depression, hypertension (high blood pressure), myocardial infarction (a blockage of blood flow to the heart muscle), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), chronic kidney disease (longstanding disease of the kidneys leading too renal failure), and transient visual loss. Record review of Resident # 13's quarterly MDS dated [DATE] reflected a BIMS score of 11 which indicated moderate cognitive impairment at the time of the assessment. Further review of functional abilities reflected Resident # 13 had no impairment for upper and lower extremity for functional limitations for range of motion and needed setup or clean-up assistance for eating and oral hygiene. Review also reflected Resident # 13 received a regular textured diet. MDS also reflected no weight loss of 5% in the last month or 10% or more in last 6 months under the swallowing/nutritional status section. MDS reflected under oral/dental status, no broken or loosely fitting full or partial denture and no mouth or facial pain, discomfort, or difficulty with chewing. Record review of Resident # 13's care plan dated initiated 4/21/2022 revised on 1/6/2024 reflected Resident # 13 had ADL self-care performance deficit related to debility with interventions of personal hygiene, needs extensive assistance with ADL's, and able to eat independently. Record review of Resident # 13's SLUMS (St. Louis University Mental Status) examination dated 4/4/2024 reflected a score of 20 out of 30 which reflected a diagnosis of dementia. Record review of Resident # 13's oral health screening form dated 1/19/2023 reflected under notes need dentures repaired to eat, lower denture broken, minimal lower ridge. Record review of Resident # 79's face sheet dated 8/15/2024 with an admission date of 11/30/2022 reflected an [AGE] year old male with diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), hypertension (high blood pressure), muscle wasting and atrophy, muscle weakness, dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus), cognitive communication deficit, hypothyroidism (underactive thyroid), chronic pain, severe protein calorie malnutrition, atrial fibrillation (irregular heart rate), peptic ulcer, osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), benign prostatic hyperplasia (age-related prostate gland enlargement that can cause urination difficulty), GERD (a digestive disease in which stomach acid or bile irritates the food pipe lining), lack of coordination, and abnormal weight loss. Record review of Resident # 79's quarterly MDS dated [DATE] reflected a BIMS score of 7 which indicated severe cognitive impairment at the time of the assessment. Further review of functional abilities reflected Resident # 79 had no impairment for upper and lower extremity for functional limitations for range of motion and needed setup or clean-up assistance for eating and oral hygiene. Review also reflected Resident # 79 received a mechanically altered diet. MDS also reflected no weight loss of 5% in last month or 10% or more in last 6 months under the swallowing/nutritional status section. MDS reflected under oral /dental status, no broken or loosely fitting full or partial denture, and no mouth or facial pain, discomfort, or difficulty with chewing. Record review of Resident # 79's care plan dated initiated 11/30/2022 revised on 8/5/24 reflected Resident # 79 had a nutritional problem or potential nutritional problem related to new admission. Diet ordered mechanical soft no added salt lactose free thin liquids. Interventions of if resident eats less than 50% of meal offer meal replacement. RD to evaluate and make diet change recommendations PRN. Weekly weights times 4 weeks then monthly if stable. Order appetite stimulant. Resident # 79 has unplanned/unexpected weight loss initiated 5/14/2024 and revision on 8/5/2024. On date 6/13/2024 weight loss recording of 6% in 1 month and 10.2% in 6 months. Intervention of alert RD if consumption was poor for more than 48 hours, monitor and evaluate any weight loss, monitor, and record food intake at each meal, provide supplement as ordered of 2 Cal 120 cc TID. Resident # 79 has oral/dental health problems related to no natural teeth date initiated 12/9/2022 and revision on 12/9/2022. Interventions include coordinate arrangements for dental care, transportation as needed/as ordered, monitor/document/report to MD PRN signs and symptoms of dental problems needing attention pain, abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, tongue inflammation, ulcers in mouth, lesions, and provide mouth care as per ADL personal hygiene. Record review of Resident # 79's SLUMS (St. Louis University Mental Status) examination dated 6/21/2024 reflected a score of 11 out of 30 which reflects a diagnosis of dementia. Record review of Resident # 79's oral health screening form dated 4/5/2023 reflected under notes wanted dentures, possibility to make a new set. Record review of Resident # 79's dental hygienist report dated 5/2/2024 reflected the patient tolerated dental hygiene treatment well with no complaints. Oral tissues within normal limits. The patient explained once again his dentures were left in Mexico and will need a new set. An email was sent to inform the dentist. Oral hygiene was reviewed and stressed. Dental hygiene supplies were provided to the patient. Record review of Resident # 79's dental appointment progress report dated 5/16/2024 reflected six-month recall. Patient wants to finally replace teeth. Diagnosis soft tissue within normal limits. Next visit impressions. Record review of Resident # 79's dental hygienist report dated 6/3/2024 reflected the patient tolerated dental hygiene treatment well with no complaints. Oral tissues within normal limits. The patient explained once again his dentures were left in Mexico and will need a new set. An email was sent to inform the dentist. Oral hygiene was reviewed and stressed. Dental hygiene supplies were provided to the patient. Record review of Resident # 79's dental hygienist report dated 7/2/2024 reflected the patient stated he wants dentures and has not seen the dentist for new dentures. The patient tolerated dental hygiene treatment well with no complaints. Oral tissues within normal limits. The patient explained once again his dentures were left in Mexico and will need a new set. An email was sent to inform the dentist. Oral hygiene was reviewed and stressed. Dental hygiene supplies were provided to the patient. During observation and interview on 8/13/2024 at 8:47 AM Resident # 79 observed to be in his room in bed asking for his teeth and saying he needs his teeth to eat. Resident observed to have no teeth in his mouth. During an observation and interview on 8/14/2024 at 8:34 AM Resident # 13 observed to be in her room in bed eating breakfast. Resident # 13 apologized for being a mess and having dropped food particles on the front of her bed sheet covering her chest. Resident # 13 said it was hard for her to eat since she was partially paralyzed on one side, had tremors on the other side, and had no teeth. Resident # 13 said she had not been seen by a dentist that she could remember. Resident # 13 said the staff would cut up her meat to help make it easier for her to eat. During an interview on 8/15/2024 at 10:02 AM the Social Worker said Resident # 13 had her initial dental evaluation completed 1/19/2023. The SW could not answer as to why no other steps had been taken in a timely manner in securing Resident # 13 with new dentures. The SW said and was able to show the state surveyor their dry erase board which listed all active services residents were receiving which had Resident # 13 listed under dental services. The SW said Resident # 79 had his initial dental evaluation completed on 4/5/2023. The SW said the dentist had contacted her on 7/22/2024 and told her that Resident # 79 would need to be seen in the office to have dental impressions completed for dentures to be made. The SW said it was their fault that no note had been entered into Resident # 79's medical chart about this conversation with the dentist. The SW said they had been attempting to coordinate transportation to the dental office for Resident # 79 and one other resident because the SW wanted both residents to be seen on the same day. The SW said there had been some delays in getting family consent and travel arrangements made. The SW could not answer as to why no other steps had been taken in a timely manner in securing Resident # 79 with new dentures. The SW said and was able to show the state surveyor their dry erase board which listed all active services residents were receiving which did not have Resident # 79 listed under dental services. During an interview on 8/15/2024 at 11:40 am the SW said the dentist was scheduled to be in the facility on 8/30/2024 to complete the initial screen and full assessment of Resident # 13. The SW said the dentist said they would be in the facility prior to the end of the month to obtain the impressions for Resident # 79 's dentures. The SW also stated they were familiar with the facility dental policy and could not provide an answer as to why the dental services had not been obtained for Resident # 13 and Resident # 79 per the facility policy procedures. The SW said a negative impact of residents not having their dental needs met could be improper meal intake and communication problems. During an interview on 8/15/2024 at 3:17 pm the SW said the dentist had called and set an appointment on 8/21/2024 to complete step 1 of a 5-step process in obtaining a new set of dentures for Resident # 13 and Resident # 79. The SW said the initial screen had been completed on Resident # 13, but they had never been enrolled in dental services. During an interview on 8/15/2024 at 3:53 pm the ADM said his expectation was for the facility to provide needed dental services in a timely manner. The ADM said a risk of not receiving timely dental services was it could affect the residents intake of their meals. ADM said it was the SW responsibility to ensure dental services were completed. Record review of the facility Dental Services policy dated 1/2018 and revised on 12/2023 reflected under heading Policy: It is the policy of this facility to ensure that its residents who require dental services on a routine or emergency basis have access to such services without barrier. It is likewise the policy of the facility to repair or replace dentures of a resident except in those situations where the loss or damage directly results from the action of an alert and oriented resident who is responsible for his/her own medical decisions. Under heading Definitions: Promptly means within 3 business days or less from the time the loss or damage to dentures is identified unless the facility can provide documentation of extenuating circumstances that resulted in the delay. Under heading Procedure: 1.In the event that a Facility resident experiences loss or damage to his/her dentures, the Facility will: o Gather the necessary facts and information in order to make a determination as to whether the loss/damage directly results from the action of an alert and oriented resident who is responsible for his/her own medical decisions. o If so, and absent some extenuating or unusual circumstance, the Facility will not be financially responsible for the repair or replacement. o If not, and absent some extenuating or unusual circumstance, the Facility will be financially responsible for the repair or replacement. o If it is determined that the Facility is responsible for the loss of or damage to the dentures, there will be no charge to the resident for the repair or replacement. Repair or replacement will be accomplished in a reasonable manner, with the goal of returning the resident to his/her dentition baseline pre-loss or damage. 2. In the event that a Facility resident requires emergency dental services, for the repair or replacement of dentures or otherwise, the Facility will: o Promptly and, in any event, no later than three (3) business days from the date of loss/damage, refer the resident for dental services. o Assist the resident in making the necessary dental appointments, when necessary or requested. o Arrange for transportation to and from the dental services appointment/location, using the lowest cost or no cost option to minimize the financial burden on the resident. 3. If a referral for dental services does not occur within three (3) business days from the date of the loss/damage, the Facility will: o Document what actions were taken to ensure the resident could eat, drink and communicate (if applicable) adequately while awaiting dental services. o Document the nature of the extenuating circumstances which led to the delay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to respect the residents' right to personal privacy of medical records for 3 of 8 Residents (Residents #95, #34, and #50) reviewed for privacy. The facility failed to ensure MA H protected confidential resident health care information of Residents #95, #34, and #50. This failure could place residents at risk of personal information being exposed to unauthorized persons. Findings included: Record review of the undated Face Sheet for Resident #95 reflected he was an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Essential (primary) Hypertension (high blood pressure). Record review of Physicians Orders for Resident #95 dated 07/01/2024 reflected Order Summary: Coreg Oral Tablet 12.5 mg Give one tablet by mouth two times a day for heart failure. Hold for SBP less than 110, HR less than 60. Record review of the undated Face Sheet for Resident #34 reflected he was an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Essential (primary) Hypertension (high blood pressure). Record review of Physicians Orders for Resident #34 dated 04/30/2024 reflected Order Summary: Carvedilol Oral tablet 25 mg, give one tablet by mouth two times a day for HTN, hold if SBP is below 110. Record review of the undated Face Sheet for Resident #50 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Essential (primary) Hypertension (high blood pressure). Record review of Physicians Orders for Resident #50 dated 04/12/2024 reflected Order Summary: Cozaar tablet 50 mg. Give one tablet by mouth two times a day for HTN, Hold if SBP less than 110. Observation on 08/14/2024 from 7:52 AM until 8:20 AM revealed MA H left a notepad with Resident's #95, #34, and #50 names and vital signs (blood pressure and pulse) open on top of her medication cart which was facing the hallway . In an interview on 08/14/2024 at 8:37 AM MA H stated she had been a medication aide for a total of seven years and had been at the facility for one year and six months. She stated she should have protected confidential resident information by turning over or covering the vital sign sheet . In an interview on 08/15/2024 at 11:15 AM ADON A stated confidential medical information should be kept in a drawer or covered up. She stated it was a breach of resident confidentiality and could expose their personal medical information. In an interview on 08/15/2024 at 12:44 PM ADON B stated they always told staff to cover their notepads with patient information on them because it was a breach of confidentiality to leave it where people can see it . In an interview on 08/15/2024 at 1:56 PM the RNC stated the facility expected staff to have confidential resident information covered. She further stated it was a violation of HIPAA privacy for medical information . In an interview on 08/15/2024 at 4:24 PM the ADM stated staff were specifically trained to protect the PHI of residents . Record review of a facility Access and Confidentiality Agreement dated June 2023 reflected Confidential patient care information includes individually identifiable information in the possession of a health care provider regarding a patient's medical history, mental or physical condition or treatment, Examples include, but are not limited to: Medical and psychiatric records including paper . This information is sensitive, valuable and is protected by law and our privacy and security policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 2 of 14 residents (Residents #75 and 450) reviewed for environment. The facility failed to ensure the room for Residents #75 and #450 did not possess a strong, foul odor due to Resident #75's behavior of urinating in places other than his toilet. This failure placed residents at risk of infection and diminished quality of life. Findings included: Review of the undated face sheet for Resident #75 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), difficulty in walking, cognitive communication deficit, lack of coordination, muscle weakness, history of falling, speech and language deficits following unspecified cerebrovascular disease (any condition that affects the blood vessels of the brain), depression, edema, dementia, insomnia, and hemiplegia and hemiparesis (paralysis on one side of the body) following cerebral infarction. Review of the admission MDS assessment for Resident #75 dated 01/25/24 reflected a BIMS score of 15, reflecting intact cognition. It reflected he answered the assessment for activity preferences himself, finding it very important to have books, newspapers, and magazines to read, keep up with the news, and go outside to get fresh air when the weather was good. It reflected that he required set-up or clean-up assistance with toileting hygiene. Review of the care plan for Resident #75 dated 04/04/24 reflected the following: Potential for a behavior problem: the resident resists using a urinal. Attempts to ambulate to use the toilet. When he is unable to ambulate quickly enough, he will proceed to use the restroom in inappropriate places, such as outdoors or on the floor of his room. Will have fewer episodes of behaviors by review date. Administer medications as ordered. Monitor/document for side effects and effectiveness. o Anticipate and meet needs. o Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. o Praise any indication of progress/improvement in behavior. o Referral to an appropriate psychiatric provider as needed. Review of the undated face sheet for Resident #450 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included rheumatoid arthritis, weakness, muscle, wasting and atrophy, chronic, obstructive, pulmonary disease, limitation of activities due to disability, blindness of right eye, protein, calorie, malnutrition, gout, adult failure to thrive, diarrhea, cognitive, communication deficit, chronic pain, depression, and abdominal pain. Review of the annual MDS assessment for Resident #450 dated 07/28/24 reflected a BIMS score of 14, reflecting intact cognition. It reflected none of the offered activities in the assessment for activity preferences were important to him. Review of the care plan for Resident #450 dated 07/25/24 reflected the following: Potential for a psychosocial well-being problem r/t ineffective coping. Will demonstrate adjustment to nursing home placement by/through review date. Needs assistance/supervision/support to identify precipitating factors/stressors. Observation on 08/13/24 at 08:06 AM revealed Resident #75 sitting in his room and in his wheelchair and Resident #450 lying in his bed. A bedside men's urinal half-full of yellow liquid sat on Resident #75's bedside table. The room possessed a strong, foul urine odor. Observations on 08/13/24 at 01:06 PM, 08/14/24 at 09:41 AM, and 08/14/24 at 02:12 PM revealed Resident #75 and #450's room had a strong, foul urine odor. During an interview and observation on 08/15/24 at 09:03 AM, Resident #450 stated he preferred to stay in bed because he did not feel very well, but he had noticed the foul odor, and it was awful. When asked if he knew the source of the odor, he pointed across the room. He stated, just look over there; it's filthy. He stated it smelled like urine, and he hated it. The room had a very strong, foul odor. There was a urinal on Resident #75's bedside table that was two-third full of yellow liquid. There was no sign of wetness on the floor or on Resident #75's bed. During an interview on 08/15/24 at 09:12 AM, MA H stated she had often noticed the foul smell in Resident #75's and #450's room, and the odor was that of urine. She stated Resident #75 sometimes urinated on the floor of the room. She stated she was not aware of any interventions to prevent Resident #75 from urinating on the floor or to handle the foul odor. MA H stated the housekeeping staff came along and cleaned, but the odor did not leave the room entirely and came back full strength soon after the room was cleaned. She stated she was not aware of anything the medication aides, CNAs, or nurses were supposed to do to make the situation better. MA H stated resident #75 was independent so there was not very much they could do to control his behavior . During an interview on 08/15/24 at 09:18 AM, CNA J stated Resident #75 urinated on the floor and other places and refused to wear briefs. She stated the housekeeper would enter the room to clean and the next thing you knew, there was urine on the floor again. CNA J stated she was not aware of any particular intervention except to try to catch him before he urinated, but every time they tried, it was too late. CNA J stated Resident #450 had not complained to her, but she thought he probably hated the smell . During an interview on 08/15/24 at 01:04 PM, RN E stated she was aware that Resident #75's and #450's room smelled terribly of urine. She stated Resident #75 was very challenging, and they could not get him to stop urinating or spilling his urine or something. She stated he must be spilling his urinal or urinating in the bed for it to smell so badly, and he often had his bedside urinal under the covers or placed between his legs. RN E stated there had not been any specific guidance from management about how to handle the odor or Resident #75's behavior of urinating in places other than the toilet. RN E stated they opened the window sometimes to let the smell out but then people forgot to shut it, and it became hot. RN E stated she had read the care plans and learned about the residents from them, but she had not participated in care planning strategies for Resident #75. RN E stated the negative impact of the room smelling so badly was the residents would not want to be in the facility and family members were turned off from visiting. During an interview on 08/15/24 at 03:53 PM, the ADM stated Resident #75 urinated where he wanted to urinate. He stated they had tried to encourage him to use the commode or to use the urinal and he did not always cooperate. The ADM stated he urinated in lots of places in the room, and they found where he went by having housekeeping clean morning and afternoon. The ADM stated ADON A might know more about interventions to prevent Resident #75 from urinating in inappropriate places. The ADM stated the foul-smelling room could have a negative impact on residents but did not elaborate how. He stated they had offered to move Resident #450 out of that room, but he had chosen not to due to not wanting to move into one of the only open beds in the facility, all of which were in 3- or 4-person bedrooms. During an interview on 08/15/24 at 04:25 PM, ADON A stated Resident #75 had a habit of keeping his urinal full and urinating anywhere. She stated he refused to wear briefs and refused to allow them to empty his urinal sometimes. ADON A stated he was trying very hard to maintain his independence and would not admit that he needed help toileting. ADON A stated their interventions were not to monitor in documentation but to physically direct and visually monitor him. She stated she did not think there were any interventions that had been devised that were not in the care plan . Review of facility policy dated 05/22 and titled Homelike Environment reflected the following: It is the policy of this facility to provide a homelike environment, and to encourage and provide opportunities for each resident to occupy an area, reflecting his/her interests .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 5 of 8 residents (Residents #10, 71, 75, 449, and 450) reviewed for care plans. The facility failed to ensure the care plans for Residents #10, 71, 75, 449, and 450 included person-centered goals and interventions for activities. This failure placed residents at risk of not having their recreational and social needs met. Findings included: Review of the undated face sheet for Resident #10 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia, difficulty in walking, muscle weakness, abnormal weight loss, abnormalities of gait and mobility, reduced mobility, abnormal posture, repeated falls, cognitive communication deficit, need for assistance with personal care, and major depressive disorder. Review of the annual MDS assessment for Resident #10 dated 11/04/24 reflected a BIMS score of 00, reflecting severe cognitive impairment. It reflected the staff assessed her for activity preferences and she enjoyed: listening to music, being around animals such as pets, doing things with groups of people, and spending time outdoors. Review of the care plan for Resident #10 dated 12/14/23 reflected the following: Has little or no activity involvement r/t Anxiety, Depression, behaviors (screaming/disruptive) resident will self-isolate and refuse activities offered. Will express satisfaction with type of activities and level of activity involvement when asked through the review date. Establish and record prior level of activity involvement and interests by talking with resident, caregivers, and family on admission and as necessary. o Explain the importance of social interaction and leisure activity time. Encourage participation by next review. o Explain that may leave activities at any time and is not required to stay for entire activity. o Invite to scheduled activities. o Invite/encourage family members to attend activities with resident in order to support participation. o Modify daily schedule and/or treatment plan to accommodate activity participation. o Monitor/document for impact of medical problems on activity level. There was no care planning for the particular activities that Resident #10 enjoyed. Observation on 08/13/24 at 09:20 AM revealed Resident #10 sitting in a wheelchair in the common area in front of a large television. She was not watching television and did not respond to efforts to communicate with her. Review of the undated face sheet for Resident #71 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included pneumonia, chronic pain, muscle weakness, unsteadiness on feet, diverticulitis (inflammation of abnormal pouches in the bowel), difficulty in walking , muscle wasting and atrophy, protein -calorie malnutrition, depression, insomnia, repeated falls, suicidal ideation, dementia, weakness, and cognitive communication deficit. Review of the annual MDS assessment for Resident #71 dated 08/06/24 reflected a BIMS score of 12, reflecting moderately impaired cognition. It reflected he answered the assessment for activity preferences himself, finding it very important to be around animals such as pets, somewhat important to keep up with the news, and go outside for fresh air when the weather was good. Review of the care plan for Resident #71 dated 10/31/23 reflected the following: Has little or no activity involvement r/t Depression, Disinterest will observe activities but will be reluctant to join, will join if friends do. Will express satisfaction with type of activities and level of activity involvement when asked through the review date. Establish and record prior level of activity involvement and interests by talking with resident, caregivers, and family on admission and as necessary. o Explain the importance of social interaction and leisure activity time. Encourage participation by next review. o Explain that may leave activities at any time and is not required to stay for entire activity. o Invite to scheduled activities. o Preferred activities are watching tv and socializing with other residents independently. o Provide activities calendar monthly. There was no care planning for the particular activities that Resident #71 enjoyed. Observation and interview of Resident #71 on 08/13/24 at 09:45 AM revealed he was lying in bed in the dark, with no music playing and no television on. He stated he wanted to rest. He stated he never did anything and did not think there was anything he would like to do. He stated he was cold all the time. He stated he might warm up if he went outside, but he did not know if he wanted to go outside. He stated he did not know what he wanted to do. Review of the undated face sheet for Resident #75 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), difficulty in walking, cognitive communication deficit, lack of coordination, muscle weakness, history of falling, speech and language deficits following unspecified cerebrovascular disease (any condition that affects you're the blood vessels of the brain), depression, edema, dementia, insomnia, and hemiplegia and hemiparesis (paralysis on one side of the body) following cerebral infarction. Review of the admission MDS assessment for Resident #75 dated 01/25/24 reflected a BIMS score of 15, reflecting intact cognition. It reflected he answered the assessment for activity preferences himself, finding it very important to have books, newspapers, and magazines to read, keep up with the news, and go outside to get fresh air when the weather was good. Review of the care plan for Resident #75 dated 04/04/24 reflected the following: Dependent on staff for activities, cognitive stimulation, social interaction r/t [sic]. Resident will participate in some activities he is interested in. Will attend/participate in activities of choice by next review date. o Invite to scheduled activities. o Provide with activities calendar. Notify resident of any changes to the calendar of activities. There was no care planning for the particular activities that Resident #75 enjoyed. Observation and interview on 08/13/24 at 08:06 AM revealed Resident #75 was dressed and sitting up in his wheelchair. He stated he wanted the bed made. He stated he spent most of his day sitting outside in the shade but had just finished his breakfast. Review of the undated face sheet for Resident #449 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included senile degeneration of brain (Mental deterioration associated with old age), depression, anxiety disorder, dementia, fracture of femur neck, and conversion disorder with seizures or convulsions (a mental health condition that causes physical symptoms). Review of the admission MDS assessment for Resident #449 dated 07/28/24 reflected a BIMS score of 04, reflecting severe cognitive impairment. It reflected she answered the assessment for activity preferences himself, finding it very important to have books, newspapers, and magazines to read, listen to music she liked, be around animals such as pets, go outside to get fresh air when the weather was good, and participate in religious services or practices. Review of the care plan for Resident #449 dated 08/12/24 reflected the following: Dependent on staff for activities, cognitive stimulation, social interaction r/t [sic]. Resident will participate in some activities he is interested in. Will attend/participate in activities of choice by next review date. o Invite to scheduled activities. o Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility. o Provide with activities calendar. Notify resident of any changes to the calendar of activities. There was no care planning for the particular activities that Resident #449 enjoyed. Observation and interview on 08/13/24 at 07:41 AM revealed Resident #449 lying in her bed with head of bed elevated. She stated she did not know what she was supposed to do or how to get anyone's attention in the facility. She stated she was brand new and had just arrived at the facility. She stated she did not know what she wanted to do and did not know what her options were. Review of the undated face sheet for Resident #450 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included rheumatoid arthritis, weakness muscle wasting and atrophy, chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), limitation of activities due to disability, blindness of right eye, protein-calorie malnutrition, gout, adult failure to thrive, diarrhea, cognitive communication deficit, chronic pain, depression, and abdominal pain. Review of the annual MDS assessment for Resident #450 dated 07/28/24 reflected a BIMS score of 14, reflecting intact cognition. It reflected none of the activities listed as options in the assessment for activity preferences were important to him. Review of the care plan for Resident #450 dated 08/12/24 reflected the following: Has little or no activity involvement r/t Resident wishes not to participate. Will express satisfaction with type of activities and level of activity involvement when asked through the review date. o Explain the importance of social interaction and leisure activity time. Encourage participation by next review. o Explain that may leave activities at any time and is not required to stay for entire activity. o Invite to scheduled activities. o Provide activities calendar monthly. There was no care planning for the particular activities that Resident #450 enjoyed. Observation and interview on 08/13/24 at 08:26 PM revealed Resident #450 lying in bed but not asleep. He smiled and stated he liked to spend most of his time in bed. During an interview on 08/15/24 at 10:18 AM, MDSN C stated MDSN D was responsible for the care plans but had only been doing the job for a couple months. She had a lot to learn to ensure care plans were completed. She stated the department heads were responsible for their own disciplines. She stated MDSN C entered the item into the care plan and then the department heads had to go in to personalize the plans. She stated they discuss care planning in the morning meetings, and they have care plan meetings with families and residents, and the AD is in both of those meetings. She stated the AD came to her sometimes for guidance on care pans, but she had only recently looked at the specific care plans to see that they did not have personalized activities included in them. She stated they needed to better educate the AD on her role in the care planning process. During an interview on 08/15/24 at 10:25 AM, MDSN D stated she was still learning the MDS/care plan process, but she could say that care plans were important because they let people know what specifically each resident needed. MDSN D stated several people in the facility used care plans including nurses and CNAs. She stated if the AD had to quit or be on leave unexpectedly, they would need the care plans to know what activities residents enjoyed . She stated specific activities resident liked should have been added to the care plans. During an interview on 08/15/24 at 02:59 PM, the AD stated she was responsible for completing her activity assessments and the activities portion of the MDS. She stated she met with residents, found out what they liked and did not like, and then she created her activity care plan. She stated she had not been creating the care plan items but had been using the drop-down menus to make choices for residents. She stated she only found out that morning that she could type specific things into the care plans and did not know that was an option . During an interview on 08/15/24 at 03:59 PM, the ADM stated he knew Resident #71 refused a lot of things, the staff tried to intervene and offer things, but he was not interested. The ADM stated they tried to reapproach Resident #71 and encourage him to make the right decision. He stated Resident #71 did not want to participate in any activities. The ADM stated he did not think they should give up on finding something Resident #71 wanted to do, but they needed to encourage, and it was hard to do so when they ran out of options and good ideas. The ADM stated it was possible that bringing in his direct caregivers might help generate new ideas, and he did not know if that had been done. He stated the purpose of the care plan meeting was to discuss possible interventions and give feedback on what has worked in the past. The ADM stated he was not familiar with Resident #449, as she was a newer admission, but it was very important for her and all residents to be invited to and reminded of activities. He stated it was good for their mental health and socialization. The ADM stated he would think the care plan team would care plan for specific activity preferences. He stated care plans should be person-centered, personalized, and specific. Review of facility policy dated 12/23 and titled Comprehensive Person-Centered Care Planning reflected the following: It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives in time frames to meet a residence. Medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 15 residents (Residents #49, #41, and #34) reviewed for ADLs. The facility failed to ensure Residents #49, #41, and #34 were provided nail care as documented in their plan of care and MDS. This failure could place residents at risk of scratches, infection, and poor self-esteem. Findings included: Record review of an undated Face Sheet for Resident #49 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy. The pancreas (gland) does not make enough insulin to carry sugar into cells to fuel the body), need for assistance with personal care, and unspecified visual loss. Record review of an annual MDS dated [DATE], for Resident #49 reflected a BIMS score of 15 indicating intact cognitive status. Section GG -Functional Abilities and Goals reflected she was dependent for all personal hygiene. Record review of a Care Plan dated 07/26/2021 for Resident #49 reflected ADL self-care performance deficit r/t debility. Personal Hygiene needs total assistance X 1, nursing. Observation and interview on 08/13/2024 at 07:24 AM Resident #49's fingernails were jagged with brown debris under them. Resident #49 stated she would like to have her nails cut. In an interview on 08/15/2024 at 8:48 AM Resident #49 stated she still needed her nails trimmed as they were breaking, and she had almost scratched her eye on 8/14/2024 as they were so jagged. In an interview on 08/15/2024 at 9:20 AM LVN F stated Resident #49 needed her nails cleaned, trimmed, and filed down. She stated if she scratched herself there was a risk for infection . Record review of an undated Face Sheet for Resident #41 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus without complications (a long-term condition in which the body has trouble controlling blood sugar and using it for energy. The pancreas (gland) does not make enough insulin to carry sugar into cells to fuel the body). Record review of an annual MDS dated [DATE], for Resident #41 reflected she had a BIMS score of 9 indicating moderate cognitive impairment. Section GG -Functional Abilities and Goals reflected she was dependent for all personal hygiene. Observation and interview on 08/13/2024 at 07:34 AM revealed Resident #41 had long, thick toenails on both feet. Resident #41 stated she would like to have her toenails trimmed. In an interview on 08/15/2024 at 9:24 AM LVN F stated referrals for diabetics to be seen by podiatry were given to the Social Worker. She stated Resident #41 would need to be seen by a Podiatrist for her toenails as she had a diagnosis of Diabetes. Record review of a facility podiatry list with next date of service 08/30/2024 at 9:00 AM reflected Resident #41's name was not on the list. Record review of an undated Face Sheet for Resident #34 reflected he was an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy. The pancreas (gland) does not make enough insulin to carry sugar into cells to fuel the body). Record review of the Quarterly MDS for Resident #34 dated June 19, 2024, reflected he had a BIMS score of 9 indicating moderate cognitive impairment. Section GG -Functional Abilities and Goals reflected he was dependent on staff for all personal hygiene. Record review of a Care Plan dated 03/27/2023 for Resident #34 reflected he had an ADL self-care performance deficit, will maintain and or improve current level of function in personal hygiene through the review date. Personal hygiene, assist as needed X 1 staff, nursing. Observation on 08/13/2024 at 07:54 AM revealed Resident #34 had ½-inch long fingernails on both hands with brown debris under them. In an interview on 08/15/2024 at 9:24 AM LVN F stated residents with a diagnosis of Diabetes should have their fingernails trimmed and cleaned by nursing staff. She further stated there was a risk for contamination and infection if they ate with dirty fingernails. She stated nurses were responsible for ensuring the residents were on the podiatrist list. She stated she performed necessary nursing care but could not say she always looked at nails while doing rounds. In an interview on 8/15/2024 at 9:34 AM the SW stated she had some residents scheduled to see the podiatrist at the end of August on the 30th. She further stated the nurses would tell her which residents needed to be on the list. She printed a list of residents who had been seen by the podiatrist and those who were scheduled . In an interview on 08/15/2024 at 11:15 AM ADON A stated she had worked at the facility for 8 years and had been an ADON since 2022. She stated the nurses and CNAs knew to give the social worker a list of who needs to see podiatry, but the nurses can trim a diabetics fingernails. She stated if the resident was not a diabetic, the CNAs can file their fingernails with emery boards and use an orange stick to clean under them. She stated ADON B was the ADON in charge of making resident rounds on 200 and 300 halls. She stated the potential risk to the residents with long, jagged fingernails were they could get skin tears, scratch their skin, and cause infections. In an interview on 08/15/2024 at 12:44 PM ADON B stated residents with long nails could sustain an injury if their nails were too long. She stated unclean nails could be an infection control issue if they put their fingers in their mouth. She further stated she did not always look at nails during her daily rounds . In an interview on 08/15/2024 at 4:24 PM the ADM stated his expectation was for residents to be cared for appropriately including nail care. He stated the possible risk of having dirty nails could be an infection . Record review of a facility Policy and Procedure revised 05/2007 and titled Nursing Administration Subject: Nursing Services - ADLS reflected Nursing service staff cares for its residents in manner and in an environment that promotes maintenance or enhancement of each resident's quality of life and promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Residents receive assistance as needed to manage their physical needs which includes personal hygiene, grooming, dressing, toileting, transferring, ambulating, and eating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 of 12 residents (Residents #71 and #449) reviewed for activities. The facility failed to provide Resident #71 and #449 with activities from 08/13/24, 08/14/24, and 08/15/24. This failure placed residents at risk of not having their recreational and social needs met. Findings included: Review of the undated face sheet for Resident #71 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included pneumonia, chronic pain, muscle weakness, unsteadiness on feet, diverticulitis (inflammation of abnormal pouches in the bowel), difficulty in walking , muscle wasting and atrophy, protein -calorie malnutrition, depression, insomnia, repeated falls, suicidal ideation, dementia, weakness, and cognitive communication deficit. Review of the annual MDS assessment for Resident #71 dated 08/06/24 reflected a BIMS score of 12, reflecting moderately impaired cognition. It reflected he answered the assessment for activity preferences himself, finding it very important to be around animals such as pets, somewhat important to keep up with the news, and go outside for fresh air when the weather was good. Review of the care plan for Resident #71 dated 10/31/23 reflected the following: Has little or no activity involvement r/t depression, disinterest will observe activities but will be reluctant to join, will join if friends do. Will express satisfaction with type of activities and level of activity involvement when asked through the review date. Establish and record prior level of activity involvement and interests by talking with resident, caregivers, and family on admission and as necessary. o Explain the importance of social interaction and leisure activity time. Encourage participation by next review. o Explain that may leave activities at any time and is not required to stay for entire activity. o Invite to scheduled activities. o Preferred activities are watching tv and socializing with other residents independently o Provide activities calendar monthly. There was no care planning for the particular activities that Resident #71 enjoyed. Review of activity logs for Resident #71 from 08/02/24 to 08/15/24 reflected seven instances of Observing Surroundings and 12 instances of TV/Radio/Movies. Observation and interview of Resident #71 on 08/13/24 at 09:45 AM revealed he was lying in bed in the dark, with no music playing and no television on. He stated he wanted to rest. He stated he never did anything and did not think there was anything he would like to do. He stated he was cold all the time. He stated he might warm up if he went outside, but he did not know if he wanted to go outside. He stated he did not know what he wanted to do. Observation on 08/13/24 at 10:12 AM, 11:55 AM, 12:42 AM, 01:12 PM, and 02:04 PM, 08/14/24 at 08:07 AM, 09:14 AM, 10:20 AM, 11:58 AM, 12:43 AM, 02:13 PM, 03:10 PM, and 04:00 PM, and 08/15/24 at 08:02 AM, 09:00 AM, 10:06 AM, 12:15 PM, and 01:27 PM revealed Resident #71 was lying in bed in the dark, with no music playing and no television on. Review of the undated face sheet for Resident #449 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included senile degeneration of brain (mental deterioration associated with old age), depression, anxiety disorder, dementia, fracture of femur neck, and conversion disorder with seizures or convulsions (a mental health condition that causes physical symptoms). Review of the admission MDS assessment for Resident #449 dated 07/28/24 reflected a BIMS score of 04, reflecting severe cognitive impairment. It reflected she answered the assessment for activity preferences himself, finding it very important to have books, newspapers, and magazines to read, listen to music she liked, be around animals such as pets, go outside to get fresh air when the weather was good, and participate in religious services or practices. Review of the care plan for Resident #449 dated 08/12/24 reflected the following: Dependent on staff for activities, cognitive stimulation, social interaction r/t [sic]. Resident will participate in some activities he is interested in. Will attend/participate in activities of choice by next review date. o Invite to scheduled activities. o Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility. o Provide with activities calendar. Notify resident of any changes to the calendar of activities. There was no care planning for the particular activities that Resident #449 enjoyed. Review of activity logs for Resident #449 from 08/02/24 to 08/15/24 reflected four instances of Observing Surroundings, one instance of Walking/Wheeling and 13 instances of TV/Radio/Movies. Observation and interview on 08/13/24 at 07:41 AM revealed Resident #449 lying in her bed with head of bed elevated. She stated she did not know what she was supposed to do or how to get anyone's attention in the facility. She stated she was brand new and had just arrived at the facility. She stated she did not know what she wanted to do and did not know what her options were. Observation on 08/13/24 at 10:10 AM, 11:53 AM, 12:40 AM, 01:10 PM, and 02:02 PM, 08/14/24 at 08:05 AM, 09:12 AM, 10:18 AM, 11:56 AM, 12:41 AM, 02:11 PM, 03:08 PM, and 03:58 PM, and 08/15/24 at 08:00 AM, 08:58 AM, 10:04 AM, 12:13 PM, and 01:25 PM revealed Resident #449 was lying in her bed and looking straight ahead of her with the television on. During an interview on 08/15/24 at 01:18 PM, RN E stated she was the charge nurse who worked with Residents #71 and #449 during the day. She stated Resident #71 had experienced a decline and began refusing a lot of things like dressing, medications, and possibly activities. She stated she was not aware of his activity involvement, but if he was lying in bed all day in the dark, that was not good for him. She stated she sometimes rubbed his arms with cream, and she visited with him at least once, but she could not say she had seen him receiving any activities. She stated Resident #71's roommate insisted on lying in bed all day in the dark even though he could get up and maybe Resident #71's room was too depressing for him. She stated she was not aware of any care planning or efforts of the IDT to find activities that Resident #71 would be willing to do. She stated she knew Resident #449 less well, as Resident #449 was new to the facility. She stated she thought maybe Resident #449 was not feeling well and that might be why she was not out of bed during the survey. She came back a few minutes after the initial interview to say she was correct, and that Resident #449 was not feeling well . During an interview on 08/15/24 at 03:05 PM, the AD stated she was responsible for ensuring activities were completed for each resident. did not have Resident #71 on her one-on-one list. She stated she was not aware of any care planning about activities or IDT meeting about how to get him engaged in any activity he might enjoy. She stated she was new as activity director and did not know when she took the position how important her role was. She stated she loved that it was important, but she was still learning just how important it was. The AD stated she had been trying to develop ways to get residents like Resident #71 to come out of their rooms such as coffee in the rotunda (common area). She stated she had been in the position since March 2024 and was still learning her residents. The AD stated the activity Observing Surroundings referred to residents who sat in the common area watching people go by or watching television. She stated it was not a suitable activity for residents who were not mobile and just sat in their beds. She stated she had documented it for Resident #71 not because she thought he was actually observing his surroundings as an activity, but because she was instructed to do so. She did not say who instructed her to do so. The AD stated she was not super familiar with Resident #449. The AD stated she looked at Resident #49's activity assessment and saw that she needed to be reminded of activities. The AD stated she had stopped at Resident #449's room to invite her, but she had not been feeling well. The AD stated she had been given no guidance about talking with the aides and the nurse about what specific residents might like to do. The AD stated a possible negative consequence of not receiving activities was residents would be upset because they did not get to do something they would want to do. During an interview on 08/15/24 at 03:59 PM, the ADM stated he knew Resident #71 refused a lot of things, and the staff tried to intervene and offer things, but he was not interested. The ADM stated they tried to reapproach Resident #71 and encourage him to make the right decision. He stated Resident #71 did not want to participate in any activities. The ADM stated he did not think they should give up on finding something Resident #71 wanted to do, but they needed to encourage him, and it was hard to do so when they ran out of options and good ideas. The ADM stated it was possible that bringing in his direct caregivers might help generate new ideas, and he did not know if that had been done. He stated the purpose of the care plan meeting was to discuss possible interventions and give feedback on what has worked in the past. The ADM stated he was not familiar with Resident #449, as she was a newer admission, but it was very important for her and all residents to be invited to and reminded of activities. He stated it was good for their mental health and socialization . Review of facility policy dated 12/23 and titled, Activities Programming reflected the following: It is the policy of this facility to ensure that activities are available to meet. Resident needs and interests that support the physical, mental, and psychosocial well-being of the resident. May be facilities, sponsored group or independent. End of life: spiritual support, touch, massage, music, reading to the resident, etc.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for dietary services. The cook failed to wear gloves while touching ready to eat food such as tortillas while making breakfast tacos on the breakfast tray service line. A container of sugar in the dry storage room was not sealed with an approximate 2-centimeter gap opening of the sugar container lid allowing for possible pest contamination. A 50 lb. bag of rice in the dry storage room was not sealed. The opening of the top of the bag was completely open to possible pest contamination. The temperature/sanitizer log for the dish machine was not completed, filled out, and up to date. The temperature/sanitizer log for the 3-compartment sanitizing sink was not completed, filled out, and up to date. The food temperature log was not completed, filled out, and up to date. The juice dispenser nozzle had pinkish orange slimy buildup inside the juice dispenser nozzle. The lower-level stainless steel shelving, where the plate dome covers, were stored, had food debris and buildup on the shelving surface. The cook failed to wear gloves when preparing pureed and ground food items for meal service. The cook failed to wear gloves while taking lunch meal temperatures and picking up ready to eat chicken leg quarters. These failures could place residents at risk for food borne contamination and food borne illness. The findings included: During an observation on 8/13/2024 revealed the following: At 7:15 AM the cook to be serving breakfast tray line without wearing gloves while picking up tortillas to construct breakfast tacos. At 7:18 AM the juice dispenser nozzle to have pinkish orange slimy buildup inside the juice dispenser nozzle. At 7:20 AM a container of sugar in the dry storage room was not sealed with an approximate 2-centimeter gap opening of the sugar container lid allowing for possible pest contamination. At 7:21 AM a 50 lb. bag of rice in the dry storage room was not sealed. The opening of the top of the bag was completely open to possible pest contamination. At 7:37 AM the food temperature log was not completed, filled out, and up to date. At 7:39 AM observation of signage posted in kitchen stating wear gloves when handling food. Sign was signed by Dietary Manager. At 7:41 AM the lower-level stainless steel shelving, where the plate dome covers were stored, had food debris and buildup on the shelving surface. Record review on 08/13/24 reflected the temperature/sanitizer log for the 3-compartment sanitizing sink was not completed, filled out, and up to date and the temperature/sanitizer log for the dish machine was not completed, filled out, and up to date. During an observation on 8/14/2024 revealed the following: At 10:30 AM the cook failed to wear gloves when preparing pureed and ground food items for meal service. At 11:30 AM the cook failed to wear gloves while taking lunch meal temperatures and picking up ready to eat chicken leg quarters. During an interview on 8/14/2024 at 11:42 AM CK J said they had been instructed by DM to wear gloves when handling cold food such as salads and sandwiches. line CK J stated the staff do not wear gloves on the tray line they have just been instructed by DM to wash hands frequently. During an interview on 8/14/2024 at 3:26 PM the DM said gloves were worn when handling any ready to eat food during any process in the kitchen. The DM also said all food was to be labeled and dated upon receipt, with the preparation date, and with the discard date. The DM said all food was to be stored and sealed to prevent food contamination. The DM said all staff were responsible for cleaning the kitchen areas they work in. The DM said a negative impact of dietary staff not following professional standards for food service safety in the storage, preparation, distribution, and serving of food could be food contamination and possible food borne illness for the residents. During an interview on 8/15/2024 at 9:35 AM the DM said the facility followed the TFER (Texas Food Establishment Rules) guidelines as their policy for hand hygiene and labeling and dating. During an interview on 8/15/2024 at 3:53 PM the ADM said his expectation for hand hygiene and glove usage by dietary staff was for the dietary staff to wear gloves when touching food and to wash hands frequently. The ADM said a possible risk of not completing hand hygiene and glove usage would be possible bacteria and infection risk to the residents. The ADM said his expectation for labeling and dating of food products would be that items would be labeled and dated upon receipt and again when prepared with discard date. The ADM said the risk of dietary staff not storing, preparing, and serving food according to professional standards for food service safety could be serving food that was out of date, not safe, and has potential for food borne illness. Record review of hand hygiene / glove usage policy provided was excerpt of the TFER (Texas Food Establishment Rules) undated revealed: under 228.65 Preventing contamination by employees: a. Preventing contamination from hands 1. Food employees shall wash their hands as specified under 228.38 of this title relating to management and personnel. 2. Except when washing fruits and vegetables as specified under section 228.66f of this title or as specified in paragraphs 4 and 5 of this subsection, food employees may not contact exposed, ready to eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single use gloves, or dispensing equipment. 3. Food employees shall minimize bare hand and arm contact with exposed food that is not in a ready to eat form. (E) documentation that hands are washed before food preparation and as necessary to prevent cross contamination by food employees as specified under §228.38(a) -(b) and subsections (d) -(e) during all hours of operation when the specific ready-to-eat foods are prepared. (F) documentation is maintained at the food establishment that food employees contacting ready-to-eat foods with bare hands utilize two or more of the following control measures to provide additional safeguards to hazards associated with bare hand contact: (iv) where to wash their hands as specified under §228.38(e) of this (v) proper fingernail maintenance as specified under §228.39 of (vi) prohibition of jewelry as specified under §228 .40 of this title, (vii) good hygienic practices as related to §228.42(a) and (b) of (viii) employee health policies that detail how the food establishment complies with §228.35, 228.36, and 228.3 7 of this title. (E)documentation that hands are washed before food preparation and as necessary to prevent cross contamination by food employees as specified under §228.38(a) -(b) and subsections (d) -(e) during all hours of operation when the specific ready-to-eat foods are prepared, (F)documentation is maintained at the food establishment that food employees contacting ready-to-eat foods with bare hands utilize two or more of the following control measures to provide additional safeguards to hazards associated with bare hand contact: (i) double handwashing. (ii) nail brushes. (iii) a hand sanitizer after handwashing as specified under (iv) incentive programs that assist or encourage food employees not to work when they are ill such as paid sick leave; other control measures approved by the regulatory authority; and (G)documentation is maintained at the. food establishment-that corrective actions are taken when paragraph (5)(A)-(E) of this subsection are not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 3 of 3 residents reviewed (Resident #49, #90, and #66) for medication administration, urinary catheter care, and wound care. as indicated by: 1. The facility failed to ensure MA H did not cross contaminate a medication cup and place medications in it for administration to Resident #49. 2. The facility failed to ensure nursing staff kept Resident #90's urinary catheter bag off of the floor. 3. The facility failed to ensure LVN G used proper infection control practices while providing wound care to Resident #66. These failures could place residents at risk for cross contamination and infection. Findings included: 1. Record review of an undated Face Sheet for Resident #49 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy. The pancreas (gland) does not make enough insulin to carry sugar into cells to fuel the body), need for assistance with personal care, and unspecified visual loss. Record review of an annual MDS dated [DATE], for Resident #49 reflected she had a BIMS score of 15 indicating intact cognitive status. Observation on 08/14/2024 at 7:52 AM MA H placed her unsanitized finger inside of a medication cup which she then used to administer medications to Resident #49. In an interview on 08/14/2024 at 8:40 AM MA H stated placing her finger inside of a medication cup was cross contamination and could cause infection. 2. Record review of an undated Face Sheet for Resident #90 reflected he was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of sepsis, (body's extreme reaction to infection which can lead to organ failure, tissue damage, and death) unspecified organism and benign (non-cancerous) prostatic hyperplasia (enlarged prostate gland) with lower urinary tract symptoms. Observation on 08/13/2024 at 8:58 AM revealed Resident #90 was ambulating in his wheelchair into the rotunda and his foley catheter bag was dragging on the floor. Observation on 08/14/2024 at 9:32 AM in Resident #90's room revealed he was resting in bed and his urinary catheter bag was laying on the floor under his bed. In an observation and interview on 08/14/2024 at 9:48 AM the RNC observed Resident #90's urinary catheter bag on the floor under his bed and stated it should be hooked to the side of the bed. She further stated by being on the floor it increased his risk of infection . In an interview on 08/14/2024 at 9:54 AM LVN G stated urinary catheter bags should be hooked to the side of a wheelchair or the bed. She further stated if it was on the floor, it could be an infection control issue . 3. Record review of an undated Face Sheet for Resident #66 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of severe intellectual disabilities, dysphagia (difficulty swallowing), and pressure induced deep tissue injuries to bilateral (both) heels. Record review of a Quarterly MDS for Resident #66 dated July 1, 2024, reflected she was unable to complete a BIMS evaluation as she was rarely or never understood. Section M - Skin Conditions reflected she had one Stage 2 Pressure Ulcer (partial thickness loss of the skin's epidermis (top layer of skin) that appears as an open wound or blister). Record review of the Care Plan for Resident #66 dated 07/01/2024 and revised on 08/14/2024 reflected she had a Stage 2 pressure ulcer to the coccyx (base of the spine). In an observation of wound care on 08/14/2024 at 10:50 AM for Resident #66, LVN G touched the wound care cart drawer with unsanitized hands and grabbed 4 stacks of 4 X 4 gauze and placed them on wax paper on a tray table. LVN G then sanitized her hands, grabbed a stack of gloves, and pushed the cart into the room. She washed her hands, paused the resident's tube feeding, and after donning gloves, she touched the resident's brief. The resident was having a bowel movement, so LVN G removed her soiled gloves, did not clean her hands, and then grabbed another stack of gloves from a box in the room and placed them on top of the other clean gloves on the tray table. She cleaned her hands, placed gloves on and cleaned and dried the coccyx pressure ulcer with contaminated 4 X 4 gauze. She then placed collagen into the wound using a sterile cotton swab and then placed an island dressing on the wound. In an interview on 08/14/2024 at 11:39 AM LVN G stated she had worked at the facility for 17 years in various positions. She stated by touching the 4 X 4 gauze with unclean hands, she could have transferred bacteria to the wound which could possibly cause an issue with infection control. She stated she could have transferred bacteria from the gloves to the wound. She further stated she had received in-services on wound care and attended a skills fair. In an interview on 08/15/2024 at 11:15 AM ADON A stated her expectation was that nurses and medication aides know how to do hand hygiene. She stated they should not put their finger inside of a medication cup as it is an infection control risk. She stated regarding wound care, staff can contaminate the supplies by not cleaning their hands. She stated if the supplies [NAME] contaminated, they should be discarded. She stated LVN G should have sanitized her hands after removing her gloves and before gathering more clean supplies. She further stated using the contaminated supplies could infect the wound. Regarding Resident #90's urinary catheter, she stated the CNAs and nurses know to hang the urinary catheter bag where it [NAME] not touching the floor. She stated when a resident [NAME] in the bed, the catheter bag needs to be hooked on the side of the bed and not left on the floor. She further stated the potential risk to the resident was a urinary tract infection. In an interview on 08/15/2024 at 4:24 PM the ADM stated the Medication Aide placing her unclean finger in the medication cup, could possibly spread infection to a resident. He further stated the issue regarding Resident #90's urinary catheter bag being on the floor was a clinical question for nursing. Record review of an on-line federal government CDC article titled Guidelines for Prevention of Catheter Associated Urinary Tract Infection dated 2009 and attached to an article dated April 12, 2024, reflected page 13 of 61, III. Proper Techniques for Urinary Catheter Maintenance 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. (Category IB) This recommendation is based on maintaining proper hygiene and preventing contamination. Placing the catheter bag on the floor can lead to the introduction of pathogens [bacteria] and increase the risk of infection for the patient using the catheter. By keeping the bag off the floor, the chances of contamination are reduced, promoting better patient care, and reducing the risk of catheter-associated urinary tract infections (CAUTI). Record review of a facility Policy and Procedure titled Infection Prevention and Control Program dated 06/2021 and revised 10/2022 reflected Goals: recognize infection control practices while providing care. Ensure compliance with state and federal regulations related to infection control. Communicable disease is an infection transmissible by direct contact with an affected individual or the individuals body fluids or by indirect means (e.g., contaminated object). Record review of a facility Policy and Procedure titled Skin and Wound Monitoring and Management dated 03/2015 and last revised on 12/2023 reflected It is the policy of this facility that 2. A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection and prevent new, avoidable pressure injuries form developing. Purpose: Promote the healing of pressure injuries that are present (including prevention of infection to the extent possible).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 8 residents (Resident #57) reviewed for call lights in that: Resident #57 was observed in his room with the call lights not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #57's admission record dated 06/16/23 documented a [AGE] year-old male admitted on [DATE]. Resident #57 documented diagnoses included: hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side (weakness or a slight paralysis on one side of their body), cognitive communication deficit (difficult with thinking and how someone uses language), and schizoaffective disorder, bipolar type (depressive episodes with manic or hypomanic episodes). Record review of Resident #57's quarterly MDS dated [DATE] revealed resident had a BIMS score of 12 indicating the resident was cognitively moderately impaired. The MDS also revealed the resident required extensive assistance in various areas of activities of daily living such as bed mobility, transfer, dressing, toilet use and personal hygiene. Record review of Resident #57's care plan dated 06/16/22 revealed Resident #57 is care planned for alteration in musculoskeletal status related to contracture left hand, at risk for impaired visual function related to diabetes, ADL self-care performance deficit related to left hemiplegia, impaired cognition, and actual fall related to poor balance, unsteady gait. Interventions included: Staff to ensure call light was in reach, remind to use call light for assistance, and be sure the call light was within reach and encourage to use it to call for assistance as needed. Observation of Resident #57 on 06/14/23 at 7:45am revealed his call light was pinned to the privacy curtain and out of his reach. Observation of Resident #57 on 06/14/23 at 9:45am revealed his call light was pinned to the privacy curtain and out of his reach. Interview of Resident #57 on 06/14/23 at 10:53am, Resident #57 stated that his call light was often out of reach. Resident #57 stated when his call light was out of reach, he will yell for assistance or bang on the wall to get someone's attention. An interview with CNA #A on 06/16/23 at 12:45 pm, revealed CNAs are required to make rounds at least every two hours. When CNAs make, rounds they should ensure call lights are in reach of all residents. CNA #A stated if call light was out of reach, then the resident wouldn't be able to notify staff for assistance. An interview with DON on 06/16/23 at 12:55 pm, DON stated that call lights should be within reach of the resident. Call lights are often place on the bed, pillow, or clothing to ensure the resident can reach it for assistance. DON stated CNAs make round at least every two hours but most times more frequently. During the rounds the CNAs should be looking to see if the call light were in reach of the resident. If a call light was not in reach of a resident, then the resident may not be able to call for assistances when needed. An interview with ADM at 1:25pm, ADM stated that the call lights are typically pinned on the bed or sometimes the resident's wheelchair depending on the residents' preference. The ADM stated that CNAs are remind often to ensure call lights are in the reach of the residents. ADM stated that if a call light was out of reach of the resident than it would delay the resident getting care. Record review of the facility's policies revealed the facility had no policy regarding reasonable accommodations of needs and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for one of 32 residents (Resident #32) reviewed for activities. Resident #32 was receiving no activities in the facility. This failure placed Resident #32 at risk of boredom, depression, and diminished quality of life. Findings included: Review of the undated face sheet for Resident #32 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of rhabdomyolysis ( condition in which damaged skeletal muscle breaks down rapidly), symbolic dysfunctions (speech and language disorder), muscle wasting and atrophy, difficulty in walking, dementia, major depressive disorder, anxiety disorder, muscle weakness, Parkinson's disease (chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), unsteadiness on feet, cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition), need for assistance with personal care, lack of relaxation and leisure, and chronic pain. Review of the annual MDS for Resident #32 dated 11/04/22 reflected a BIMS score of 10, indicating a moderate cognitive impairment. Review of the MDS section Preferences for Customary Routine and Activities. of the MDS reflected it was somewhat important to Resident #32 to have books, newspapers, and magazines to read, listen to music he liked, keep up with the news, do his favorite activities. Review of the care plan for Resident #32 dated 06/14/23 reflected the following (Resident #32) is at risk for depression r/t major depressive disorder diagnosis. He will engage in 1:1 at least 2 times a week through the review date. Attempt non-pharmacological interventions, such as redirecting, activities, relaxation, food, etc. Has little or no activity involvement r/t Disinterest. He will enjoy one-on-one visits with staff at least 2 times weekly. He will successfully entertain himself independently and was aware he was invited to attend all activities outside of his room. Will participate in activities of choice as he desires daily by review date. Explain the importance of social interaction and leisure activity time. Encourage participation by next review. Preferred activities are: talking to staff, watching TV, reading the (newsletter)/daily news. Review of the one-on-one activity logs for Resident #32 reflected no one-on-one activities from 05/16/23 to 06/16/23. Review of the independent activity log for Resident #32 from 06/03/23 to 06/16/23 reflected the following: TV/Radio/Movies on 06/05/23, 06/06/23, 06/08/23, 06/08/23, and 06/12/23; Reading/Audio Books on 06/11/23; and Observing Surroundings on 06/03/23, 06/04/23, 06/07/23, 06/10/23, 06/13/23, 06/14/23, and 06/15/23. During observation and interview on 06/14/23 at 08:30 AM, Resident #32 stated he was bored at that moment and was bored all the time. He stated he did not like television anymore, and there was nothing to do. His television was off, and his blinds were closed. He lay in bed in a hospital gown with no book, magazine, radio, or other obvious stimulus nearby. Observation on 06/14/23 at 10:00 AM revealed the AA entered Resident #32's room with a cup of coffee and a piece of paper and exited the room less than one minute later. Observation on 06/14/23 at 10:30 AM, 11:09 AM, 12:30 PM, and 01:12 PM revealed no activity being provided to Resident #32. The only times staff entered his room during these periods was to provide nursing care or drop off/pick up meal trays. Observation on 06/15/23 at 09:18 AM, 10:40 AM, 11:32 AM, and from 12:50 PM to 2:10 PM revealed no activity being provided to Resident #32. The only times staff entered his room during these periods was to provide nursing care or drop off/pick up meal trays. He had a copy of the daily newsletter, which was one sheet of paper, on his overbed table. Observation on 06/16/23 from 08:47 AM to 11:08 AM, Resident #32 was in his bed with the television off and the blinds closed. No staff went into his room specifically to visit with him. During an interview on 06/16/23 at 11:08 AM, Resident #32 stated he was still bored. When asked what activities he enjoyed, he stated he liked volleyball but had four hip replacements so could not play real volleyball. He stated he liked golf, but he could not stand up to play golf. He stated he was aware there was a putting green on the back porch of the facility, but he had not been out there in a long time. He stated he would like to do more and have something to do, but the staff did not come around and check in with him about activities very often. He stated he had not received enough one-on-one visits with the activities staff. When asked how many would be enough, he stated any visits at all would be better than none. During an interview on 06/15/23 at 12:15 PM, CNA B stated she did get residents up for activities, and that was a part of her responsibilities. She stated Resident #32 liked to watch television and nap, but mostly he liked to talk with the staff when they had time. CNA B stated she had good conversations with Resident #32 sometimes, and she thought therapy worked with him. She stated she had not seen the activity director or aide spend much time in his room. During an interview on 06/16/23 at 12:14 PM, the SW stated she had not seen Resident #32 in activities. She stated she had not seen the activity director visit Resident #32. The SW stated she had seen the AA drop off coffee and newsletter but not going in for a longer visit. She stated she did not have any hand in the activities program at the facility. During an interview on 06/16/23 at 12:32 PM, the AA stated the primary activity director was on vacation. The AA stated the activity director did one-on-one visits when she was working. The AA stated most of what she did was dropping off coffee and newsletter to all the residents each morning, and in the activity director's absence, she and the entire team were pulling together for group activities. The AA stated when she dropped off coffee and newsletter, she usually only stayed for a moment to say hello. The AA stated for Resident #32, she knew they used to put his television on for him, but he had not been able to use it as much lately. She stated they would turn it on for him, but he was unable to change the channel and would just push buttons until it did not work anymore. The AA stated he would usually just turn it off, because he could not handle those circumstances. The AA stated Resident #32 mostly likes to chat with staff. She stated he was very educated, and they had to be more patient with him due to speech issues, but he would talk if he was given the time. The AA stated she did not have a role in planning activities. She stated the activity director sometimes asked her for input on what the AA thought certain residents might like, but she did not do the activity assessments or plan any resident-centered activities. When asked how the concept of Observes Surroundings as an independent activity applied to Resident #32, she stated she did not think his surroundings were interesting, and that was the best she could do to describe what he had been doing. During an interview on 06/16/23 at 02:31 PM, the DON stated Resident #32 used to be up and about, and now he preferred to be in his bed. The DON stated he was a social worker before and knew he had the right to refuse to get up and participate in group activities. The DON stated he liked television, and that was his primary activity. She stated he also enjoyed the morning coffee rounds. The DON stated she saw him watching television that morning. She stated she had been helping serve breakfast, was sure he had his television on when she went in his room and was not aware that he was no longer interested in television. When asked what the plan was to meet his recreational needs if he did not watch television, she stated they could always ask him about what interests him. When asked if Observes Surroundings was an adequate independent activity for someone who stayed in his bed with the blinds closed, she stated that would not be adequate as his surroundings were not stimulating at all. The DON stated the concept of Observes Surroundings as an activity was for residents who enjoyed watching people or nature. During an interview on 06/16/23 at 02:52 PM, the ADM stated the procedure for new and changing activity needs to be identified began when they (usually clarified the nursing staff) noticed a change in what a resident was able to do or if the resident provided any feedback. The ADM stated if a resident was having a decline, there might have been a change in their attendance to activities or the type of activities they preferred, and this might trigger a new assessment. The ADM stated he monitored for compliance with the process of identifying changes in activity needs and preferences by visiting with staff and sometimes the residents themselves. The ADM stated Resident #32 used to go get coffee and that was his primary activity along with maybe arguing with other residents on the way back to his room. The ADM stated when they had a resident someone who was not interested in group activities, they should have figure out what he liked to do. The ADM has gotten some feedback that Resident #32 liked it when the AA went by Resident #32's room and poked her head in to say hello. The ADM stated when a resident like Resident #32 was not satisfied with the activities he was offered, they should not have stopped trying to find something he enjoyed. The ADM stated a potential impact on Resident #32 could be that he would not be able to live out the rest of his life in as fruitful a way as possible. The ADM stated they did not want Resident #32 to be bored for the rest of his life but rather wanted to make what time he had left as comfortable and appropriate as possible. Review of undated facility policy titled Activities Program reflected the following: It is the policy of this facility to ensure each resident has access to daily, social, recreational, or rehabilitative activities, provided and available to them. Activities are planned according to the residents, preferences, needs, and abilities. Every resident will be interviewed for preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents' right to formulate an advance directive for 1 of 99 residents (Resident #1) reviewed for advance directives. There was no evidence showing there was an advance directive completed for Resident #1, who was coded as, DNR/Do not Attempt Resuscitation, in her electronic health records. This deficient practice could place residents at risk of having their wishes to accept or refuse emergency medical treatment dishonored and emergency medical treatment performed or delayed against their choices and wishes. Findings included: Record review of Resident #1's admission record dated 11/04/22 revealed she was an [AGE] year-old female admitted on [DATE] with diagnoses including osteoporosis (bone disease in which bones become weak and brittle), major depressive disorder, hypertension (blood pressure that is higher than normal) and hyperlipidemia (high levels of lipids in the blood), and gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints). Resident #1's admission record also revealed she had a DNR code status listed under the advance directive section. Record review of Resident #1's admission packet face sheet dated 11/04/22 revealed she informed the facility that she had an advanced directive and had been informed of her rights and regulations to make decisions concerning her medical care, including the right to accept or refuse medical or surgical treatments and the right to formulate and issue advance directives to be followed should she become incapacitated. Record review of Resident #1's electronic health record dashboard revealed an order for DNR with an order and revision date of 11/04/22 and order status of active. Record review of Resident #1's order summary report dated 12/27/22 revealed there was no order for DNR. Record review of Resident #1's electronic health record face sheet revealed her code status was, DNR/Do not Attempt Resuscitation. Record review of the facility's crash cart binder, updated on 01/08/22, revealed Resident #1 was coded as, DNR/Do not Attempt Resuscitation. There was also no advanced directive for Resident #1 in the binder. Record review of Resident #1's care plan completed on 11/21/22 revealed she elected DNR status with interventions including, Do Not Resuscitate in the event of cardiac arrest .Review code status quarterly and PRN (as needed) with resident/RP .Update resident's chart to reflect elected code status, staff must be aware of code status election. Record review of Resident #1's progress notes from 11/07/22 and 11/08/22 revealed her advanced care planning/counseling discussion indicated, Pt (patient) desires to be DNR .Discussed with facility staff who will help obtain OOHDNR (Out of Hospital DNR). Resident #1's progress notes from 12/01/22, 12/05/22, 12/06/22, and 12/09/22 revealed, Code Status: DNR. In an interview on 01/07/23 at 5:00pm the DON stated Resident #1 told her that she had an advanced directive and the FM had it. The DON stated the FM did not provide facility staff with Resident #1's advanced directive. The DON stated staff did not contact the FM to request Resident #1's advanced directive because Resident #1 told staff not to contact the FM. The DON stated staff did not attempt to contact Resident #1's medical doctor to obtain a copy of her advance directive because they did not know if Resident #1's medical doctor would have it. In an Interview on 01/09/23 at 1:02pm the DSS stated as soon as a resident/resident representative requests an advanced directive, she immediately began the process of obtaining or formulating an advanced directive. The DSS stated when an advanced directive was ordered by a resident/resident representative, the facility must obtain or formulate an advanced directive and upload it to the resident's electronic health records. The DSS stated the NP communicated with her when a resident/resident representative requested an advanced directive. The DSS stated she uploaded the residents' advanced directives to their electronic health records. The DSS stated she notified the charge nurses when residents' advanced directives were uploaded to their electronic health records. The DSS stated the charge nurses would then change the resident's code status. The DSS stated she reviewed and followed up with residents and resident representatives to ensure their choices and wishes regarding advance directives were respected and followed by staff. The DSS stated when Resident #1 arrived at the facility on 11/04/22, she told the NP that she had an advanced directive and the FM had it. The DSS stated she attempted to contact the FM and left a voicemail. The DSS stated the FM did not return her call. The DSS stated she did not make other attempts to contact the FM. The DSS stated she had spoken with Resident #1, and Resident #1 told the DSS that she would contact the FM and get her advance directive. The DSS stated she followed up with Resident #1 a few days later about the advance directive and Resident #1 stated the FM had not brought her advanced directive to the facility. The DSS stated for the next two weeks, she asked Resident #1 if she wanted to formulate a new advanced directive. The DSS stated Resident #1 refused and told her that the FM would bring the advanced directive to the facility. The DSS stated she made two attempts to formulate a new advanced directive for Resident #1. The DSS stated her intern had made an attempt to formulate a new advanced directive for Resident #1. The DSS stated Resident #1 refused all three attempts to formulate a new advanced directive. The DSS stated she stopped making attempts with Resident #1 to formulate a new advanced directive because she did not want Resident #1 to feel pressured. The DSS stated there was no documentation and progress notes illustrating the attempts made to contact the FM and formulate a new advanced directive for Resident #1. The DSS stated she informed the NP that Resident #1 refused to formulate a new advanced directive. The DSS stated she did not know Resident #1's code status in her electronic health records remained as, DNR/Do not Attempt Resuscitation. The DSS stated she did not think Resident #1's code status should have been listed as DNR until her advanced directive was uploaded in her electronic health record. The DSS stated one adverse consequence of a resident not having an advance directive in his/her record and remaining coded as DNR would be that emergency medical services would perform emergency medical treatment, which would be against the resident's wishes. The DSS stated the binder in the facility's crash cart was updated every day. The DSS stated charge nurses were responsible for updating the crash cart binder. In an interview on 01/09/23 at 1:39pm the NP stated when Resident #1 was admitted to the facility on [DATE], Resident #1 told her that she wanted to be coded as DNR. The NP stated she communicated Resident #1's request with DSS. The NP stated there were no emails and progress notes illustrating Resident #1's request to be coded as DNR. Th NP stated the DSS told her obtaining Resident #1's advanced directive was a work in progress. The NP stated the DSS communicated with her about the DSS's attempts to formulate a new advanced directive for Resident #1. The NP stated she did not know when was the DSS's last attempt to formulate a new advanced directive for Resident #1. The NP stated she did not know who coded Resident #1 as, DNR/Do not Attempt Resuscitation, in Resident #1's electronic health record without Resident #1's advanced directive. The NP stated, per the Advanced Directive procedure, a resident's advanced directive must be uploaded to their electronic health record before changing his/her code status as, DNR/Do not Attempt Resuscitation. The NP stated there were adverse consequences from changing a resident's code status as, DNR/Do not Attempt Resuscitation, without having an advanced directive for the resident in his/her electronic health record. The NP could not provide an example of an adverse consequence. The NP stated there was no designated charge nurse who changed residents' code statuses in their electronic health records. The NP stated either the DSS or nursing staff (the DON or the ADON) changed residents' code statuses in their electronic health records. In an interview on 01/09/23 at 1:55pm the DON stated a PRN nurse changed Resident #1's code status as, DNR/Do not Attempt Resuscitation, and did not verify Resident #1 had an advanced directive. The DON stated there was no policy and procedure for how charge nurses change residents' code statuses and how to obtain advanced directives. The DON stated her expectations were that before a resident/resident representative orders a change in their code status, staff must have obtained or formulated an advanced directive and uploaded it to the resident's electronic health records. The DON stated the resident should have remained coded as, Full code, in his/her electronic health record until an advanced directive was uploaded to his/her record. The DON stated there were adverse consequences from changing a resident's code status as, DNR/Do not Attempt Resuscitation, without having an advanced directive for the resident in his/her electronic health record. The DON stated one adverse consequence would be that a resident would receive emergency medical treatment by emergency medical services against his/her wishes. The DON stated when a resident does not have an advanced directive, staff cannot change his/her code status to state, DNR/Do not Attempt Resuscitation. The DON stated the facility's crash cart binder was updated by the night shift charge nurses every day. The DON stated there was no designated charge nurse responsible for changing residents' code statuses. The DON stated the night shift charge nurses do not look for the advanced directive in the resident's electronic health record before updating the facility's crash cart binder. The DON stated she did not know Resident #1 did not have an advanced directive in her electronic medical record. The DON stated staff did not communicate with her that they stopped attempts to obtain and formulate an advanced directive for Resident #1. The DON stated there were no progress notes illustrating the attempts made by staff to obtain and formulate an advanced directive for Resident #1. The DON stated the nursing staff should have seen that Resident #1 did not have an advanced directive in her electronic medical record. The DON stated Resident #1's medical doctor did not communicate with her that Resident #1's order for an advanced directive was stopped. The DON stated she would change Resident #1's code status as Full Code. Record review of the facility's policies and procedures on Advance Directives dated 05/01/07 revealed, It is the policy of this facility that a resident's choice about advanced directives will be respected. Procedures revealed, Prior to, or upon admission, the care plan team will ask residents, and/or their family members, about the existence of any advance directives. Should the resident indicate that he or she has issued advance directives about his/her care and treatment, the facility will require that a copy of such directives be included in the medical record .The care plan team will review periodically, at least quarterly, annually, and change of condition, with the resident his/her advance directives to ensure that they are still the wishes of the resident. Such reviews will be made during the assessment process and recorded on the resident assessment instrument (MDS). Changes or revocations of a directive must be submitted to the facility, in writing. The facility may require new documents if changes are extensive. The care plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. The facility will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical records and plan of care. Inquiries concerning advance directives should be referred to social services, and/or to the director of nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 4 Residents (Resident #37) reviewed for dignity. S.L.P F was observed standing next to seated R#37 while assisting with eating. The failure could negatively affect the mental and psychological well-being of all residents who required the assistance of staff with eating. The findings were: Record review of R#37's Order Summary Report, dated 04/22/22, revealed R#37 was admitted on [DATE], diagnosis included: dementia (a chronic or persistent disorder of the mental processess caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning)with behavioral disturbance, cognitive communication deficit, and need for assistance with personal care. Record review of R#37's Care plan revealed: Date initiated 10/23/18, revision on 03/28/19, R#37 has ADL Self Care Performance Deficit r/t dementia. Interventions included: Eating requires extensive assistance and X1 staff participation to eat. On 04/19/22 at 12:13 p.m., surveyor observed SLP F standing next to seated R#37 while assisting R#37 to eat. SLP was noted to help feed Resident #37. In an interview on 04/19/22 at 12:18 p.m., SLP F said it is okay to stand and help assist feed the residents unless you are consistently helping feed a resident. On 04/19/22 at 12:23 p.m. Attempted to interview Resident #37, Resident #37 did not say anything and just smiled. In an interview on 04/19/22 at 3:12 p.m., DON said when staff are helping to assist feeding residents, the staff have to sit down. DON said cuing is different, but when staff are scooping the food for the resident, the staff member should be sitting. DON said staff should be at eye level with the resident, because it is a dignity issue. Record review of facility policy, titled Section: Routine Procedures, Subject: Eat, Assisting the Resident to, undated, revealed: Assist the resident, as necessary. If the resident needs to be fed: A. Ask his preference about the order in which he would like to eat the food. B. Position self at eye level, if possible, when feeding resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 of 32 (Resident #20 and Resident #58) residents reviewed for ADL's. The facility failed to ensure the Resident #20 had his fingernails trimmed and cleaned. The facility failed to ensure Resident #58 had trimmed and clean fingernails. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. The findings included: 1. Record review of Resident # 20's Physician Orders, dated 04/21/22, reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Dementia (A group of symptoms that affects memory, thinking and interferes with daily life), Diabetes (A metabolic disorder in which the body has high sugar levels for prolonged periods of time, Hemiplegia (unilateral paralysis) and Hemiparesis (muscle weakness) following unspecified cerebrovascular disease (stroke). Record review of Resident # 20's MDS, dated [DATE], reflected his cognitive status was severely impaired. He did not have a behavior of rejecting care. The MDS reflected Resident #20 was extensive assistance on 1 staff for personal hygiene and had Functional Limitation in Range of Motion on one side of his upper extremities, and in both sides of his lower extremities. Record review of Resident # 20's Care Plan, revised on 12/17/19, reflected Resident #20 required extensive assistance to complete his activities of daily living including personal hygiene. Record review on 04/21/22 of the, undated, electronic facility form titled Nail Care (located electronically in Point Click Care) revealed there was no documentation in the last 14 days of when the last time Resident #20 had nail care. During an observation on 04/20/22 at 09:20 a.m. revealed Resident # 20 was seating in his wheelchair in the activity room. Resident #20's left hand fingernails were approximately 0.3 centimeters long past the tip of his finger and had under his middle and index dark brown/black debris. In an interview on 04/20/22 at 03:08 p.m., Resident #20 said he preferred his nails trimmed and short. Resident #20 said he felt his fingernails were long, and he was not able to cut or trimmed his fingernails. He said he did not remember when the last time a staff member cut his fingernails, however it could had been the previous week. Resident #20 said preferred too have his fingernails short and clean. In an interview on 04/20/22 at 03:11 p.m., CNA A said if a resident had a diagnosis of diabetes CNAs were not to provide nail care to residents. CNA A said Resident #20 had a diagnosis of diabetes and nurses were in charge of nail care, however, CNAs were to tell nurses when a resident required nail care. CNA A said Resident #20's nails appeared to be long and in need of cleaning. She said she had not mentioned to nursing staff that Resident #20 needed nail care. In an interview on 04/20/22 at 03:17 p.m., RN B said CNAs would let nursing staff know which residents with a diagnosis of diabetes required nail care. She said there was no set date to provide residents with nail care. RN B said nail care was provided as needed. Interview and observation on 04/20/22 at 3:18 p. m. revealed RN B entered Resident #20's room. It RN B said Resident #20's fingernails nails on both hands were approximately between 0.2 and 0.3 centimeters long from the top of the finger. RN B said Resident #20's left hand middle and index fingernails had a black unidentified substance that should not be there. At 3:30 p.m. RNB asked Resident #20 if he wanted his fingernails cut and trimmed. Resident #20 was observed saying yes to RN B. In an interview on 04/20/22 at 3:38 p.m., the DON said all nursing staff should observe residents in their totality; including overall aspect of the resident and nail care. The DON said nursing staff should had noticed Resident #20's fingernails and the black substance under the nails. The DON said CNAs could do nail care for residents that have a diagnosis of diabetes, however no toenails. She said Resident #20 should not have long and dirty fingernails. DON said resident should have clean fingernails and the length of the nails would depend on the resident's preference. In an interview on 04/21/22 at 09:50 a.m., RN C said Resident #20 required extensive care for all his ADLs and he would not be able to trim or cut his own fingernails because of his upper range of motion impairment. RN C said having long nails could be a resident's preference, however fingernails should be cleaned and not with a dark substance between the nails. RN C said for residents with a diagnosis of diabetes the CNAs were the ones who would let the nurses know which resident needed nail care, because residents with diabetes nail care needed to be provided by nursing staff to prevent infections and skin tears. In an interview on 04/21/22 at 10:17 a.m., CNA D said Resident #20 required total assistance for nail care, because he was able to only move one arm. CNA D said Resident #20 had a diagnosis of diabetes and nurses were the ones who provided nail care for him. She said CNAs needed to inform the nurses which residents required nail care. CNA D said she had not informed the nurses that Resident #20 had long nails that also required cleaning. 2. Record review of Resident #58's April 2022 consolidated physician orders revealed a [AGE] year-old man who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #58's diagnoses included muscle weakness (generalized) (reduction in the power exerted by muscles resulting in an inability to perform a given task on first attempt), need for assistance with personal care, contracture (unspecified joint) (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), abnormal posture (an involuntary flexion or extension of the arms and legs, indicating severe brain injury), stiffness of unspecified knee and cerebral palsy (a group of disorders that affect movement and muscle tone or posture). Record review of Resident #58's quarterly minimum data set assessment, dated 02/15/22, revealed Resident #58 had adequate hearing, had no speech, was rarely/never understood by others and sometimes understood others. Resident #58 had severely impaired cognitive skills for daily decision making. Resident #58 required extensive assistance with personal hygiene. Resident #58 had a functional limitation in range of motion to his upper and lower extremities. The impairment was on both sides of his body. Record review of Resident #58's, undated, care plan revealed a focus area titled, ADL Self Care Performance Deficit related to cerebral palsy, with a created date of 07/01/21 and a date initiated of 01/11/22. This focus area revealed an intervention of Personal Hygiene Routine, which revealed Resident #1 needed total assistance from one staff. During an observation of Resident #58 on 04/19/22 at 9:55 a.m., Resident #58's left hand fingernails appeared long. A dark substance was observed under Resident #58's fingernails. At the time of the observation, Resident #58 was interviewed. Resident #58 is not interviewable. During an observation of Resident #58 on 04/20/22 at 10:00 a.m., Resident #58's left hand fingernails appeared long, with a dark substance underneath. During an observation of Resident #58 on 04/20/22 at 3:56 p.m., RN G said Resident #58's left hand fingernails were long. RN G said she did not know what the dark substance was underneath the residents' fingernails. During an observation of Resident #58 on 04/21/22 at 9:16 a.m., the resident's fingernails on his left hand were cut and short. A dark substance was observed under Resident #58's cut fingernails on his left hand. During an observation and interview on 04/21/22 at 9:52 a.m., CNA H said she did not know who cut Resident #58's fingernails. CNA H said anyone could perform nail care on residents. CNA H said she did not know what the dark substance was under Resident #58's fingernails. During an interview with the Administrator and Director of Nursing on 04/22/22 at 10:39 a.m., the Director of Nursing stated staff were expected to look at resident's fingernails during care to determine if they needed attention. The Director of Nursing stated it was best to clip the nails after a resident was bathed. Staff typically cut residents nails on Sundays. The Director of Nursing explained the potential risk to the resident, if this care was not performed, was they could get sick, and it was also a dignity issue. The Director of Nursing and Administrator round in the facility to ensure this was done and they made themselves available to any resident or family member. The Director of Nursing stated she would get with staff to see how they could remove the dark substance from underneath Resident #58's fingernails. Staff may need to soak Resident #58's fingernails and that was perhaps why there was a dark substance observed under his nails. Record review of the facility's, undated, policy titled, Nail Care, revealed: POLICY: It is the policy of this facility to promote cleanliness, safety, and neat appearance of our residents .Note: refer to the nurse residents with infected wounds, on treatments and diabetics.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 1 medication refrigerators reviewed for medication storage. The facility failed to ensure the medication room had a permanently affixed lock box inside the medication refrigerator. This failure could place residents at risk of drug diversion. Findings include: During an observation and interview on 04/22/22 at 8:45 a.m., accompanied by RN C, revealed a locked refrigerator in the locked medication room, with an emergency supply of insulin in the top part of the refrigerator and 4 separate bags, each containing different amounts of vials of Lorezepam 2 mg/ml (a controlled substance used to relieve anxiety, treat seizure disorders, or before medical procedures), in the bottom part of the refrigerator. On the inside of the refrigerator door, there was a permanently affixed locked box, that was unlocked and opened. RN C said the narcotics are accounted for during shift change. In an interview on 04/22/22 at 11:22 a.m., the DON said the refrigerator inside the medication room, had always been without an attached lock box inside the refrigerator, since the refrigerator and medication room was kept locked. The DON said it was double locked, by the door to the medication room, and the refrigerator being locked. The DON said she knew if there were other medications in the refrigerator, then there had to be a locked box inside the refrigerator. The DON said there was only one nurse that had the key to the medication room, and one key to the locked refrigerator. Record review of the facility's policy, titled, Section: Care and Treatment, Subject: Medication Access and Storage, revised on 05/2007, revealed: Schedule III and IV controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose. Alternatively, Schedule III-IV medications may be stored in the trays with the other medications. Schedule II medications are stored in a separate area under double lock.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, in one of one kitchen, reviewed for kitchen sanitation. The facility failed to ensure [NAME] E did not touch her face mask several times during the puree process. The facility failed to ensure [NAME] E transferred the chicken stock correctly to the puree bowl. [NAME] E did not use a spoon or ladle when transferring the chicken stock from the container it was held in. The chicken stock dripped down the edge of the container, touching the bottom of the container and then that liquid entered the puree bowl. These failures could place residents at risk for food borne illness. The findings include: During an observation on 04/20/22 at 10:15 a.m., revealed [NAME] E pureeing enchiladas. After [NAME] E pureed the enchiladas, [NAME] E placed the enchiladas in a stainless-steel container. [NAME] E then took the stainless-steel container to another area in the kitchen. Before [NAME] E touched the saran wrap, [NAME] E touched the side of her surgical mask. [NAME] E did not wash or sanitize her hands. [NAME] E placed saran wrap over the stainless-steel container the enchiladas were in. Afterwards [NAME] E washed her hands and then touched the side of her face mask. [NAME] E obtained another stainless-steel container to puree the rice. Throughout the puree process, [NAME] E used chicken stock. [NAME] E did not use a spoon or ladle to transfer the chicken stock from the container to the puree bowl. [NAME] E poured the chicken stock from the container it was in and tipped it over into the puree bowl. There were two instances when [NAME] E tipped over the container the chicken stock was in, the chicken stock dripped on the side of the container it was in and touched the bottom of the container before going into the puree bowl. During an interview on 04/20/22 at 1:50 p.m., [NAME] E said she was focused on the puree process and was not aware she touched her surgical mask several times. [NAME] E was asked why she should not touch her face mask. [NAME] E did not answer that question. [NAME] E said they were trained to wash their hands after touching their face mask. [NAME] E said they were trained to wash their hands frequently in the kitchen. [NAME] E said she forgot to use a spoon or ladle and instead poured the chicken stock into the puree bowl. [NAME] E said she should have used a spoon or ladle to make sure she was putting the correct amount of stock. During an interview on 04/20/22 at 2:00 p.m. with the Dietary Manager and Dietary Consultant, the Dietary Manager stated staff were trained to wash their hands after touching their face mask. The Dietary Manager stated this was to prevent the spread of infection and cross contamination. The Dietary Manager stated once you touched your face mask, whatever was on your face mask was transferred to your hands. The Dietary Manager stated she understood the concern with the cook not using a ladle or spoon could lead to staff adding too much liquid to the puree. The Dietary Consultant said she understood the concern with [NAME] E not using a ladle or spoon to pour the broth into the puree bowl was that there was a potential for cross contamination since the broth dripped down the side of the container. The Dietary Manager said she monitored staff in the kitchen to make sure they performed hand hygiene appropriately and handling food correctly. Record review of the facility's, undated, policy titled, Puree Procedure, revealed .1. Measure number of portions needed. 2. Drain item well. 3. Add to blender, robot coupe or other equipment. 4. A small amount of liquid may need to be added to obtain a pudding like consistency. Record review of the facility's policy titled, Hand Washing, with a revision date of 05/2007, revealed, POLICY: It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff. PURPOSE: Hand washing is generally considered the most important single procedure for preventing nosocomial infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for 4 of 32 residents (Resident #12, Resident #58, Resident #76 and Resident #206) reviewed for comprehensive person-centered care plans. 1. The facility failed to ensure Resident #12's comprehensive person-centered care plan included the use of a pillow between the legs to prevent pressure injuries. 2. The facility failed to ensure Resident #58's comprehensive person-centered care plan reflected the resident's advanced directives. 3. The facility failed to ensure Resident #76's comprehensive person-centered care plan reflected the resident's advanced directives. 4. The facility failed to ensure Resident #206's comprehensive person-centered care plan reflected the resident's advanced directives. These deficient practices could place residents at risk of missed or inappropriate care. The findings include: 1. Record review of Resident #12's April 2022 consolidated physician orders revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #12's diagnoses included abnormal posture, need for assistance with personal care, cognitive communication deficit (difficulty with thinking and how someone uses language) and muscle weakness (generalized). Record review of Resident #12's quarterly minimum data set assessment dated [DATE] revealed Resident #58 had adequate hearing, had no speech, was rarely/never understood and sometimes understood others. Resident #12 had severely impaired cognitive skills for daily decision making. Resident #58 had a functional limitation in range of motion upper and lower extremity impairment to both sides. Resident #58 had no skin conditions. Review of Resident #12's care plan revealed a focus area titled, Resident #12 has alteration in musculoskeletal status related to contracture bilateral lower extremity and bilateral upper extremity, with a date initiated of 10/04/20. There was no mention in this area of the use of a pillow between Resident #12's legs to prevent pressure injuries. During an observation on 04/21/22 at 10:18 a.m., Central Supply K said Resident #12 had severe contractures to his lower extremities. Central Supply K said staff placed a pillow between Resident #58's legs to prevent injuries. Central Supply K said she did not know why Resident #58 did not have a pillow between his legs. At the time of the observation Resident # 58 was interviewed. Resident #58 did not respond to any questions asked. 2. Record review of Resident #58's April 2022 consolidated physician orders revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #58's diagnoses included muscle weakness (generalized) (reduction in the power exerted by muscles resulting in an inability to perform a given task on first attempt), need for assistance with personal care, contracture (unspecified joint) (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), abnormal posture (an involuntary flexion or extension of the arms and legs, indicating severe brain injury), stiffness of unspecified knee and cerebral palsy (a group of disorders that affect movement and muscle tone or posture). Resident #58 had a full code advanced directive. Record review of Resident #58's quarterly minimum data set assessment dated [DATE] revealed Resident #58 had adequate hearing, had no speech, was rarely/never understood by others and sometimes understands others. Resident #58 had severely impaired cognitive skills for daily decision making. Record review of Resident #58's, undated care plan, revealed no focus area addressing Resident #58's advanced directives. During an observation of Resident #58 on 04/19/22 at 9:55 a.m., Resident #58's was interviewed. Resident #58 is not interviewable. 3. Record review of Resident #76's April 2022 consolidated physician orders revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident #76's diagnoses included lower abdominal pain, hyperlipidemia (elevated lipid levels within the human body), insomnia (trouble falling and/or staying asleep), other lack of coordination, paint to right knee, dysarthria (difficulty in speech due to weakness of speech muscles) and anarthria (when someone cannot coordinate or control the muscles used for speaking) and generalized abdominal pain. Resident #76 was a DNR. Record review of Resident #76's quarterly minimum data set assessment dated [DATE] revealed Resident #76 had adequate hearing, clear speech, was usually understood by others and usually understands others. Resident #76 had a brief interview for mental status score of fourteen which indicated Resident #76 was cognitively intact. Record review of Resident #76's, undated, care plan revealed no focus area addressing Resident #76's advanced directives. During an interview of Resident #76 on 04/21/22 at 9:38 a.m., Resident #76 said she does not want to be resuscitated. 4. Record review of Resident #206's April 2022 consolidated physician orders revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #206's diagnoses included dependence on renal dialysis (a blood purifying treatment given when kidney function is not optimum), essential (primary) hypertension (high blood pressure), anemia (deficiency of healthy red blood cells in blood), presence of angioplasty implant and graft (a procedure used to widen the coronary artery/ies that are blocked or narrowed) and other abnormalities of gait and mobility. Resident #206 was a full code. Record review of Resident #206's admission minimum data set assessment dated [DATE] revealed Resident #206 had minimal difficulty hearing, had clear speech, makes self understood and understands others. Resident #206's had a brief interview for the mental status score of fifteen which indicated Resident #206 was cognitively intact. Record review of Resident #206's, undated, care plan revealed no focus area addressing Resident #206's advanced directives. During an interview on 04/20/22 at 2:59 p.m. with Resident #206, Resident #206 said he wants to be resuscitated if he becomes unresponsive. During an interview on 04/22/22 at 9:48 a.m. with MDS Coordinator J, MDS Coordinator J said the Social Worker did the care planning on the code status. MDS Coordinator J said 04/22/22 was the Social Worker's last day. MDS Coordinator J said maybe missed communication with the current Social Worker caused Resident #58, #76 and #206's care plan to be missing the advanced directives information. MDS Coordinator J said she updated Resident #58, #76 and #206's care plans with that information on 04/22/22 after she was informed the surveyor could not locate this information in the resident's care plans. MDS Coordinator J said she will review the care plans to ensure the information was entered. MDS Coordinator J stated the charge nurses had access to the resident's clinical record. MDS Coordinator J said the charge nurse reviewed the resident's care plan to understand the resident's care needs and to understand the resident's code status. MDS Coordinator J said she did not know how residents could be affected by this failure since staff can access the code status in other areas of the resident's clinical record. The care plan generated the [NAME] (which was an abbreviated care plan the certified nurse aides had access to). The [NAME] guided and explained to the certified nurse aide what a resident's level of assistance was and what the resident's care needs were. During an interview on 04/22/22 at 10:57 a.m. with the Administrator and Director of Nursing, the Director of Nursing stated during their morning meetings they went over any residents' changes and updated the care plans as needed. The Administrator stated Resident #58, #76 and #206's care plans did not have the advanced directives care planned and they thought this was overlooked. The Director of Nursing stated the charge nurse had access to resident's care plans and used the resident's care plan. The Director of Nursing stated a new social worker was hired since their current social worker's last day was 04/22/22. The Director of Nursing stated they would monitor the new social worker and ensure the new social worker entered the resident's advanced directive information. The Director of Nursing stated the potential risk to the resident was minimal since staff could access the advanced directive information in other areas in the clinical record. The Director of Nursing said residents would not be affected by this since staff can access their code status in other locations. Record review of the facility policy titled, Advance Directives,, with a revision date of 05/2007, revealed, POLICY: It is the policy of this facility that a resident's choice about advance directives will be respected. PROCEDURES . 5. The care plan team will review periodically, at least quarterly, annually, and change of condition, with the resident his/her advance directives to ensure that they are still the wishes of the resident. Such reviews will be made during the assessment process and recorded on the resident assessment instrument .7. The facility will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical records and plan of care. Record review of the facility policy titled, Comprehensive Person-Centered Care Planning,, with a revision date of 08/2017, revealed POLICY: It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 3 of 32 residents (Resident #5, Resident #12 and Resident #52) reviewed for pressure ulcers. 1. The facility failed to ensure Resident #5's air mattress, which was used to prevent skin breakdown, was set to Resident #5's weight. 2. The facility failed to ensure Resident #12 wore prevalon boots as was care planned to prevent skin breakdown. 3. The facility failed to ensure Resident #52's air mattress, which was used to prevent skin breakdown, was set to Resident #52's weight. These failures could place residents at risk for the development of pressure injuries. The findings include: 1. Record review of Resident #5's April 2022 consolidated physician orders revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5's diagnoses included need for assistance with personal care, unspecified lack of coordination, muscle wasting and atrophy and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). Record review of Resident #5's annual minimum data set assessment, dated 02/13/22, revealed Resident #5 had adequate hearing, clear speech, makes self-understood and understood others. Resident #5 had severely impaired cognitive skills for daily decision making. Resident #5 had moisture associated skin damage. Record review of Resident #5's braden scale for predicting pressure sore risk, dated 02/09/22, revealed Resident #5 was a low risk for a pressure injury. Record review of Resident #5's weights revealed on 04/14/22 Resident #5 weighed 124 lbs. Observation on 04/19/22 at 9:05 a.m. revealed Resident #5's bed had an air mattress that was set to 300 lbs, firm, normal pressure. During the time of the observation, Resident #5 was interviewed. Resident #5 did not respond to any questions asked. During an observation and interview on 04/20/22 at 9:28 a.m. of Resident #5 with ADON L, ADON L said Resident #5's air mattress was set according to her weight. ADON L verified Resident #5's weight from her clinical record. ADON L said Resident #5's air mattress was not set correctly and ADON L adjusted Resident #5's air mattress to her weight. ADON L did not state what the air mattress was set to. ADON L said Resident #5's weight was 124 lbs. ADON L explained the nurses set the air mattress setting. 2. Record review of Resident #12's April 2022 consolidated physician orders revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #12's diagnoses included abnormal posture, need for assistance with personal care, cognitive communication deficit (difficulty with thinking and how someone uses language) and muscle weakness (generalized). Record review of Resident #12's quarterly minimum data set assessment, dated 02/10/22, revealed Resident #58 had adequate hearing, had no speech, was rarely/never understood and sometimes understood others. Resident #12 had severely impaired cognitive skills for daily decision making. Resident #58 had a functional limitation in range of motion upper and lower extremity impairment to both sides. Resident #58 had no skin conditions. Record review of Resident #12's braden scale for predicting pressure sore risk, dated 04/14/22, revealed Resident #12 was a high risk for pressure injuries. Record review of Resident #12's, undated, care plan revealed a focus area titled, Has non-pressure wound to medial lateral left great toe related to PVD, contracture and debility, with a date initiated of 04/19/22. An intervention for this focus area was prevalon boots to float heels. During an observation and interview on 04/21/22 at 10:18 a.m., Central Supply K said Resident #12 had severe contractures to his lower extremities. Central Supply K said staff placed prevalon boots on Resident #58's feet to prevent injuries. Central Supply K said she did not know why Resident #58 did not have prevalon boots on. At the time of the observation Resident #58 was interviewed. Resident #58 did not respond to any questions asked. 3. Record review of Resident #52's April 2022 consolidated physician orders revealed a [AGE] year-old man who was admitted to the facility on [DATE]. Resident #52's diagnoses included encephalopathy (a disease that affects brain structure or function), central demyelination of corpus callosum (progressive degeneration of the corpus callosum [bundle of nerve fibers in the longitudinal fissure of the brain that enables corresponding regions of the left and right cerebral hemispheres to communicate] characterized by progressive intellectual deterioration, emotional disturbances, confusion, hallucinations, tremor, rigidity, and convulsions), cognitive communication deficit and dysphagia (difficulty in swallowing). Record review of Resident #52's quarterly minimum data set assessment, dated 03/03/22, revealed Resident #52 had adequate hearing, had clear speech, makes self-understood and usually understood others. Resident #52 had a brief interview status score of ten which indicated moderate cognitive impairment. Resident #52 was at risk for pressure injury development and had no skin conditions. Record review of Resident #52's braden scale for predicting pressure sore risk dated 02/06/22 revealed Resident #52 was a low risk. Observation on 04/20/22 at 10:03 a.m. Revealed Resident #52's bed had an air mattress that was set to 350 lbs. Observation and interview on 04/21/22 at 9:23 a.m. revealed Resident #52's air mattress was set to 150 lbs. During an interview at the time of the observation, Resident #52 said 04/20/22 after lunch two staff entered his room and adjusted his air mattress. Resident #52 said his air mattress felt less firm. Resident #52 said he did not have any pressure injuries. During an interview with Central Supply K on 04/21/22 at 10:18 a.m., Central Supply K stated residents used an air mattress due to medical necessity and to prevent skin break down. Central Supply K said Resident #5 and Resident #52's air mattress were set to their weight. Central Supply K said if the air mattress was too soft the resident could move around the bed and slide off. Central Supply K stated the air mattress should be set to a setting where residents would not fall. Central Supply K stated she rounds and checks on the resident's air mattresses. Central Supply K stated nursing staff were trained to perform visual checks and to see if the air mattress was deflated or had a malfunction. During an interview with the Director of Nursing and Administrator on 04/22/22 at 11:08 a.m., the Director of Nursing said resident's air mattresses were set to comfort and weight. An air mattress was used to prevent pressure injuries. Nursing staff were expected to visually check the resident's air mattresses. The Director of Nursing stated if the air mattress was too hard residents could experience redness on areas of their body. The Director of Nursing said Resident #5 and Resident #52 did not have any skin issues at this time. The Director of Nursing said these residents used an air mattress as a preventative measure. The Director of Nursing said prevalon boots were also used to prevent skin breakdown. Record review of the facility policy titled, Skin Management System, with a revised date of 03/2015, revealed Policy: It is the policy of this facility that any resident who enters the facility without pressure ulcers will have appropriate preventative measures taken to ensure that the resident does not develop pressure ulcers, or that residents admitted with wounds will not develop signs and symptoms of infection, unless the resident's clinical condition makes the development unavoidable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews 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 3 of 4 staff (COTA O, CNA P and CNA D)reviewed for infection control. 1. The facility failed to ensure COTA O performed hand hygiene, after taking off Resident #45's face mask. 2. The facility failed to ensure C.N.A P properly sanitized her hands, when providing incontinent care to Resident #258. 3. The facility failed to ensure C.N.A D performed hand hygiene or changed gloves when going from dirty to clean when incontinent care to Resident #10 was provided. 4. The facility failed to ensure staff donned PPE prior to exiting Resident #24's room who was on droplet precautions. These failures could place residents at risk for cross contamination, infections and COVID-19. The findings were: 1. Record review of Resident #45's Order Summary Report, dated 04/22/22, revealed an [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #45 had diagnoses which included: age related physical debility, muscle weakness, and need for assistance with personal care. Observation on 04/19/22 at 12:35 p.m. revealed COTA O removed the face mask from Resident #45, did not perform hand hygiene, and proceeded to handle Resident #45's butter knife, and spoon. COTA O then grabbed Resident #45's bread with her hands, and assisted Resident #45 with feeding. In an interview on 04/29/22 at 12:59 p.m., COTA O said when removing any face mask, you should perform hand hygiene, because the mask maybe soiled. In an interview on 04/19/22 at 3:12 p.m., the DON said staff were encouraged to sanitize hands when removing face masks, because it was an infection control issue. 2. Record review of Resident #258's Order Summary Report, dated 04/22/22, revealed a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #258 had diagnoses which included: acute kidney failure (kidneys cannot filter waste from the blood) , muscle weakness, and systemic lupus erythematosus (inflammatory disease caused when the immune system attacks its own tissues). Observation on 04/22/22 at 10:03 a.m. revealed C.N.A P and C.N.A Q provided incontinent care to Resident #258, C.N.A P wiped the front perineal area of Resident #258, removed her gloves, put hand sanitizer on both hands, quickly rubbed it over both hands, leaving her hands visibly wet with hand sanitizer, then continued to don clean gloves. C.N.A P continued to wipe the buttocks of Resident #258, removed her gloves, put hand sanitizer on her hands, quickly rubbing it over both hands, leaving her hands visibly wet with hand sanitizer. During the observation, C.N.A P said to C.N.A Q, I think it's easier to put them (referring to gloves) on when your hands are wet. After applying the clean brief, C.N.A P removed her gloves, put hand sanitizer on both hands, quickly rubbed it over both hands, leaving her hands visibly wet with hand sanitizer. In an interview, on 04/22/22 at 10:19 a.m., C.N.A P said she was supposed to rub her hands together when using hand sanitizer for 20 seconds to kill the germs. C.N.A P said she used too much hand sanitizer when she proved care. 3. Record review of Resident #10's Order Summary Reported, dated 04/22/22, revealed an 81- year-old male, who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included: type 2 diabetes mellitus (the body either doesn't produce enough insulin, or it resists insulin) with diabetic chronic kidney disease, chronic kidney disease (kidneys filter waste and excess fluid from the blood, as kidneys fail, waste builds up), and functional urinary incontinence (person's bladder and/or bowel is working normally but they are unable to access the toilet). Observation and interview on 04/22/22 at 11:23 a.m., revealed C.N.A D and C.N.A H provided incontinent care to Resident #10, after C.N.A D cleaned Resident #10's buttocks, she proceeded to apply the clean brief and put it on Resident #10. C.N.A D then removed her gloves, hand sanitized, then donned clean gloves. Following the observation, C.N.A D said staff are to remove their gloves, and hand sanitize when going from dirty to clean, but she got nervous, and did not do it. In an interview on 04/22/22 at 2:05 p.m., the DON said staff were to rub their hands together for at least 15 seconds and wait until the hand sanitizer was dry. The DON said if staff used too much hand sanitizer, then they should rub their hands longer. The DON said anytime staff went from dirty to clean, staff were to change their gloves and sanitize. The DON said this was done in case there was contamination. The DON said anytime, there was a trend of residents getting UTI's, the first that was checked was the incontinent care. The DON said C.N.As had a checklist that was done when they were hired, then it was done annually, and refresher trainings were completed as needed. Record review of C.N.A P revealed CNA P passed a skills check off on hand hygiene on 05/26/21. Record review of C.N.A D revealed CNA D passed a skills check off on pericare and hand hygiene on 05/26/21. Record review of the CDC website on Hand Sanitizer Use out and About, last updated on 08/10/21 revealed: .Use an alcohol-based hand sanitizer that contains at least 60% alcohol . Put enough sanitizer on your hands to cover all surfaces. Rub your hands together until they feel dry (this should take around 20 seconds). Do not rinse or wipe off the hand sanitizer before it's dry; it may not work well against germs. https://www.cdc.gov/handwashing/hand-sanitizer-use.html Record review of the facility policy, titled Section: Routine Procedures, Subject: Perineal Care, revised on 10/2017, revealed: Wash perennial area thoroughly, with each stroke beginning at the base of the labia and extending up over the buttocks. A. Washing should alternate side to side. Discard wipes per stroke. Dry area thoroughly and then remove dirty gloves. Wash hands with soap and water or hand sanitizer. Don gloves. Apply barrier cream/skin barrier. Place new brief as needed. 4. Record Review of Resident #24 admission Record, dated 4/22/22, revealed a [AGE] year-old male admitted on [DATE]. Resident #24 had diagnoses which included Peripheral Vascular Disease Unspecified; a slow circulation disorder, Personal History of Other Infectious and Parasitic Diseases; infectious disease caused by parasites. During an observation on 4/20/22 at 3:40 p.m. revealed two hampers with no lid were located outside of Resident #24's room in the hallway. There was Signage on door that said, Warm zone; everyone must wear PPE when entering room; sanitize hands, wear gown, put on N95 mask, wear face shield, wear gloves. Plastic compartments/drawers containing clean, unused PPE were also observed. During an observation on 4/20/22 at 3:58 p.m. revealed CNA M and CNA W exited Resident #24's room and both began to doff PPE; gloves, gown, face shield and face mask in the hallway outside Resident#24's room and placed their PPE in an open hamper with no lid, that was located in the hallway next to Resident #24's door. In an interview on 4/20/22 at 4:00 p.m., CNA M said there were no bins inside the room to dispose of the PPE. She said they were told to doff PPE outside Resident #24's room and place them on the bin outside his room. As per DON, Resident #24 is in isolation. The facility's donning and doffing Personal Protective Equipment states PPE should be removed at doorway or in designated area and only respirator should be removed after leaving room and closing the door. In an interview on 4/20/22 at 4:04 p.m., CNA W said if a resident had an infection, then the bins for doffing were put inside that resident's room and they donned and doffed their PPE inside the room. She also said the reason Resident #24 was in isolation was because he was not vaccinated for COVID-19 and he just came in from the hospital so it was for precaution only. In an interview on 4/21/22 at 9:28 a.m., the DON said the reason the staff both donned and doffed their PPE outside Resident #24's room, in the hallway was because of the configuration of Resident #24's room. She said there was not enough room to place bins inside his room, near the exit door. She said Resident #24 was in isolation because he had not had a COVID-19 vaccination and was recently admitted to the facility from the hospital. The DON also said they did not have a policy on where to specifically place disposal bins for residents who were in isolation. Record review of the facility's Donning and Doffing Personal Protective Equipment (PPE) - Skills Checklist Description, Revised 05/2007, stated, Doffing PPE (Removing) - Except for respirator, remove PPE at doorway or in the designated area. Remove respirator after leaving room and closing the door.