**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 3 (Resident #135, #79 and 72) 8 residents reviewed for comprehensive care plans. The facility failed to ensure Residents #135, #79, and #72's comprehensive care plans reflected the residents were at a high risk for wandering and them residing in the memory care unit. This deficient practice could place residents at risk for receiving improper care and services due to inaccurate care plans. Findings included: 1. Review of Resident # 135's face sheet dated 11/19/2024 revealed an [AGE] year-old female admitted on [DATE] with a readmission on [DATE]. Her diagnosis included Dementia in other Diseases classified elsewhere, moderate, with other behavioral disturbance (long-term brain disorder causing personality changes and impaired memory, reasoning, and social function), Arteriosclerotic heart disease (abnormal called lesions in the walls of arteries), and anxiety disorder (a group for mental disorders characterized by significant and uncontrollable feelings of anxiety). Review of Resident # 135's admission MDS assessment dated [DATE] revealed a BIMS score of 10 which can indicate she had moderate cognitive impairment. Section E - Behavior revealed the resident had verbal behavior occurred 1 to 3 days, and other behavioral symptoms not directed at others occurred 1 to 3 days, these behavioral symptoms did not put the resident or others are risk. The resident had wandering behavior that occurred 1 to 3 days with no impact of risk to resident or the privacy of others during the seven day look back period. Review of Resident # 135's Care plan dated 10/4/2024 revealed no indication of wandering behavior or interventions present. No indication in care plan for need for memory care unit or any interventions. Review of Resident #135's physician orders dated 10/08/2024 revealed admit to memory care unit. Review of Resident # 135's Memory Care Unit admission screening for placement dated 10/08/2024 revealed the resident has Alzheimer's of related dementia diagnosis; a habit of wandering, and was able to ambulate independently, and less restrictive alternative have been unsuccessful and will benefit from a structured environment with specialized activities therefore met criteria. Review of Resident # 135's Wandering assessment dated [DATE] revealed a wandering score of 11 (Above high risk to wander) Review of Resident # 135's Consent for Memory care unit dated 10/7/2024 revealed it was signed by resident's responsible party. 2. Review of Resident # 79's Face sheet dated 11/19/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Congestive Heart Failure (a long-term condition that happens when your heart can't pump blood well enough to meet your body's needs), and bipolar disorder (a mental disorder characterized by period of depression and periods of abnormally elevated mood that each last from days to weeks.) Review of Resident # 79's review of admission MDS dated [DATE] revealed a BIMS score of 15 (cognitively intact). Behavior section revealed Physical behavioral symptoms towards others occurred 1-3 days during the look back period, verbal behavioral symptoms towards others occurred 1-3 days 1 to 3 days during the 7-day look back period and other behavioral symptoms not directed toward others occurred 1 to 3 days during the same look back period. Behaviors did not have an impact on the resident or others. Wandering occurred 1 to 3 days during the 7-day look back period with no impact on the resident or invasion of others privacy. Behavior symptoms remained the same. Review of Resident # 79's care plan dated 10/8/2024 revealed no problem or interventions for wandering behavior and no problem of interventions for need to be in the memory care unit. Review of Resident # 79's physician order dated 9/19/2024 revealed admit to Memory care unit. Review of Resident # 79's memory care unit admission screening dated 9/18/2024 revealed the resident had a habit of wandering and less restrictive alternatives had been unsuccessful. The resident was able to ambulate independently and would benefit from a structured environment with specialized activities. Review of Resident # 79's wandering risk scale dated 9/18/2024 revealed a score of 11 which placed the resident at high risk to wander. Review of Resident # 79's memory care unit consent for placement dated 9/18/2024 revealed it was signed by Resident # 79. 3. Review of Resident #72's face sheet dated 11/19/2024 revealed an [AGE] year-old female admitted on [DATE] with diagnoses that include Alzheimer's disease (a biological process that begins with the appearance of buildup of proteins in the brain), and schizoaffective disorder (a mental disorder characterized by symptoms of schizophrenia (a mental disorder characterized by hallucinations, delusions, disorganized thought process, a flat or inappropriate affect, and a mood disorder.) Review of Resident # 72's Quarterly MDS dated [DATE] revealed the resident has a BIMS score of 4 (severe cognitive impairment). Behavioral symptoms include verbal behavioral symptoms directed toward others and other behavioral symptoms not directed at others occurred 1 to 3 days during the 7-day look back period. Wandering behavior occurred 4-6 days but less than daily during the 7-day look back period. Review of Resident # 72's care plan dated 10/8/2024 revealed no problem or interventions for wandering or placement on the memory care unit. Review of Resident # 72's order listing report dated 11/19/2024 revealed an order to admit to memory care unit dated 3/14/2024. Review of Resident # 72's Memory care unit admission for screening for placement dated 9/17/2024 revealed the resident had a diagnosis of Alzheimer's, habitually wandered, less restrictive measures had been unsuccessful, resident was able to ambulate independently, and would benefit from a structured environment with specialized activities. Review of Resident # 72's Wandering risk scale dated 10/17/2024 revealed a score of 11 which indicated the resident was high risk for wandering. Review of Resident # 72's Memory care unit consent for placement dated 10/17/2024 revealed the consent was signed by resident's responsible party. Observation 11-19-24 at 11:30 am . Resident # 135 was sitting at a table drinking some water ready for lunch clean dry and odor free. Resident # 79 was sitting in the common room in her wheelchair Resident # 72 was roaming around the unit interacting with other resident and staff clean dry and odor free. Interview with SW on 11/20/2024 at 10:00 am stated that the IDT were responsible for updating the care plan. She stated she does the assessment to determine if a resident needs memory care and get with the nurse to get the order. She stated she was not aware of care planning behaviors and the need to be on the locked unit. Interview with the Corporate MDS nurse,11/20/2024 at 11:00 am revealed she came to the facility about once a week, and the remote MDS coder is responsible for updating the care plan for the care items that triggered on the MDS, nursing and the social worker could have updated the care plan for behaviors and the need for memory care. Interview with the DON on 11/20/2024 at 12:30 PM revealed that her expectation was the care plans are up to date and show an accurate picture of the resident's actual needs. She stated, I currently do not have a MDS nurse and that the IDT team were trying to fill in and make sure care plans are accurate. She stated they have a stand-up meeting daily to discuss current issues and a pre-admission meeting for new residents. She stated she is not sure how the behaviors and the need for the memory care unit did not get placed on the care plans. She stated if a care plan is not current it can place the resident at risk to get inappropriate care. She stated, at the least, her expectation is that the care plan is accurate when the quarterly assessment is completed. Interview on 11/202/2024 at 2:30 PM with the ADM revealed his expectation are that care plans are updated at least 24 hours after a need is identified. He stated the team has a daily meeting Monday through Friday, and any issues raised in this meeting, should be addressed on the care plan if needed. An undated care plan is essential for the resident to receive the care they need and deserve. Review of the facility's policy titled Care Plan; Comprehensive Person-Centered revised December 2016 reflected the following: .13. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change. 14. The Interdisciplinary team must review and update the care plan: a. when there has been a significant change in the resident condition, B. when the desired outcome is not met, d. At least quarterly, in conjunction with the required quarterly MDS Assessment .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure food items in both refrigerators, in the kitchen, were dated and labeled. The facility failed to ensure personnel items were not stored in facility refrigerator with resident food. This failure could place the residents at risk for food borne illness and cross contamination. Findings included: Observation of the kitchen on 11/18/2024 at 7:25 am of refrigerator #1 revealed two opaque plastic pitchers with covers of unknown substance with no label as to contents or use by date. Observation of the kitchen on 11/18/2024 at 7:28 am of refrigerator # 2 revealed a personnel water bottle, A Ziploc bag containing a bag of yellow slivers not identified or labeled with a use by date. A Ziploc bag containing large brown and white objects, not labeled with an identifier or a use by date. A Ziploc bag containing oval shaped pink with brown on the outside objects with no identifier or use by date noted. Interview with the DC on 11/18/2024 at 11:30 am revealed that all foods placed in the refrigerators ere to be labeled with the identification of the product, the date it was opened, and the use by date. She stated that she would not use any food not labeled as it may pose a risk to the residents for food borne illnesses. She stated it was the responsibility of the staff member to have labeled correctly and food items placed in the refrigerators. Interview on 11/18/202 at 12:30 PM with the RD revealed that all opened items should be labeled with what they are, when they were opened, and when the use by date is; no matter where they are stored. The risk of using undated and unlabeled food products, is a food borne illness for the residents. Interview on 11/20/2024 at 8:30 am with the DM revealed his expectation was any product opened and placed in another container should be labeled with its name, date of when open and when used by placed on the outside of the new container. He had instructed his staff not to use items not labeled correctly. He said the use of food items not labeled correctly could put the residents at risk for foodborne illnesses. Interview on 11/20/2024 at 2:30 PM with the ADM who stated all food in the kitchen should be safely stored which includes labeling and dating. The ADM stated his expectation is that any food not labeled correctly, not be served to the residents due to the risk of foodborne illnesses. Record review on 11/20/2024 of the facility's policy entitled Food Storage updated 2018 reflected: .2. Refrigerators d. Date, label and tightly seal all refrigerated food using clean, nonabsorbent covered containers that are approved for food storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for one of three residents (Resident #1) reviewed for misappropriation. The facility failed to prevent a diversion (misappropriation) of Resident #1's Hydrocodone-Acetaminophen (Norco) 10-325mg, 30 tablets (a narcotic pain reliever) received from the pharmacy on 12/19/23 and reported missing on 12/20/23. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity. Findings included: Review of Resident #1's face sheet printed 02/22/24 reflected a [AGE] year-old female originally admitted to the facility 10/02/22 and readmitted [DATE]. Her diagnoses included type 1 diabetes mellitus (a condition that affects the way the body processes blood sugar), end stage renal disease (loss of function of the kidneys), dependence on renal dialysis (a treatment that assists the body in removing extra fluid and waste from the blood), anemia (lack of red blood cells in the blood), hypertension (high blood pressure), legal blindness, and chronic pain syndrome. Review of Resident #1's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected she required moderate assistance with hygiene and bathing and only supervision with most other ADLs. Section J (Health Conditions) the resident had pain occasionally during the assessment period. Review of Resident #1's comprehensive care plan, revised 03/06/23, reflected risk for acute and chronic pain related to a history of rib fractures and chronic pain syndrome. Interventions included administer analgesic (pain medicine), anticipate the need for pain relief, evaluate the effectiveness of pain interventions, monitor for side effects, and the resident prefers to have pain controlled by Hydrocodone-Acetaminophen. Review of Resident #1's physician order dated 11/17/23 reflected Norco oral tablet 10-325mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 4 hours as needed for pain. Review of Resident #1's medication administration record for December 2023, reflected eleven doses of Norco (Hydrocodone-Acetaminophen) were administered during the month. Review of the Provider Investigation Report dated 12/28/23 reflected, on 12/20/23 at 9:00 PM, drug diversion was reported. The alleged perpetrator was unknown. Four staff members were named as witnesses. The allegation reflected, Blister pack of 30 Norco (a narcotic pain reliever) along with all documentation missing from medication cart for a single resident (Resident #1). The charge nurse that had been on duty when Norco was received noticed that the blister pack of Norco and documentation was missing when she came back for her shift next day. The report reflected on injury or harm to the resident. The facility notified the police, the medical director, their family, and regional corporate nurse. The resident had no knowledge of the drug diversion. The statements were obtained, and staff were drug tested. The investigation findings confirmed the drug diversion. Review of the pharmacy packing slip dated 12/19/23 reflected 30 hydrocodone/APAP tablets 10-235mg, were delivered to the facility. Review of the business card left by the responding police officer reflected, CASE NO: P23100075 DATE: 12/21/23. During an interview on 2/22/24 at 1:00 PM, the DON stated they did not identify a perpetrator or find the missing medications. She stated, Maybe the medication had been accidently discarded, but that would not have accounted for the missing paperwork. During a phone interview on 2/22/24 at 3:35 with the local police department, the officer stated the case number he provided was not a case number. The call was transferred to the narcotics division, but the call went unanswered. During an interview on 2/22/24 at 3:58 PM, the DON stated after the medication was noticed to be missing, the narcotic drawer was recounted by two staff. The other medication cart was counted, then the nurse's switched carts, and recounted again. She stated they looked at each bubble-pack in both medication carts incase the medication was accidently put in the cart and not the locked drawer. She stated they notified the regional nurse, called the police, and notified family. She stated the pharmacist came to check the facility. She stated the resident had not missed any doses of the medication, there was no adverse effect for the resident. She stated that neither the medications nor the count sheet was ever located. She stated the nurses and medication aides were drug tested and all the results were negative . During an interview on 2/22/24 at 4:12 PM with ADON A, she stated she received 30 Norco tablets from the pharmacy on the night of 12/19/23. She matched the paper to the bubble pack confirming the number of pills delivered. She placed the medication in the narcotics drawer on the medication cart and locked the medication cart. She stated she counted the narcotics drawer at the end of her shift. The next day when she returned to work, she stated she was counting the narcotics with the off going nurse when she noticed the Norco, she received the night before was not in the narcotic drawer. She stated they looked in the other medication cart but could not locate the medication. She stated they notified the DON at that time. She stated she was drug-tested . During an interview on 2/22/24 at 4:23 PM, the ADM stated he was notified when the medication went missing. He stated they investigated and looked for the medication. He stated the police were notified and came to the facility, but they were there for less than five minutes. He stated the staff who had access to the medication all wrote statements and were drug tested. He stated they were not able to identify a perpetrator . Review of the facility policy Identifying Exploitation, Theft, and Misappropriation of Resident Property dated April 2021 reflected in part, 1. Exploitation, theft, and misappropriation of resident property are strictly prohibited. 4. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 5. Examples of misappropriation of resident property include: f. drug diversion (taking the resident's medication).

Based on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility for one of one facility. The facility failed to ensure the survey result from the previous recertification surveys were readily available to the residents and family. This failure could place residents and visitors at risk of not being aware of the facility's past deficiencies. Findings included: Record review of ASPEN Central Office reflected the most recent annual recertification and re-licensure survey took place on 06/09/2022. Observation on 09/26/23 at 12:30 PM revealed that there was no state survey result available at the facility in a place readily accessible to residents and family members. During an interview on 09/26/23 at 1:00PM, the ADMIN stated he was not aware that the survey result should be posted at the facility for residents and family. He stated he never heard of this regulation and asked the investigator, since when this rule came into effect. When the investigator showed and explained the relevant portion of the regulation to ADMIN, he stated, he would make it available at the earliest. Observation on 09/26/23 at 3:00PM revealed the availability of the previous state survey results in a folder placed on a table towards the wall opposite to the reception counter however it was difficult to locate as there was no notice posted, indicating the availability of the state survey result. On 09/26/23, there was no policy available at the facility reflecting residents' right to readily access the results of the most recent survey conducted at the facility. Review of https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/regulatory-services-facility-surveyors-liaisons/required-postings accessed on 09/28/2023 reflected: F577 - Most Recent Survey/Inspection Results and Notice of Availability of Survey/Inspection Results 42 CFR Section 483.10(g)(11) - An NF must: Post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility. Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the three preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request. Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.

Based on observation, interview, and record review the facility failed to post nurse staffing information to include the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides per shift and the resident census on a daily basis for one of two days (09/26/23) reviewed for nurse staffing information. The facility did not post the required current nurse staffing information on 09/26/2023. This failure could place residents at risk of not having access to information regarding staffing data and the facility census. Findings include: Observation on 09/26/23 at 9:00AM., revealed the nurse staffing information form on the wall next to the facility's nursing station was not filled out. During an interview on 09/26/23 at 9:30 AM, the DON stated she would fill out the form immediately. Observation on 09/26/23 at 10:00AM revealed the nurse staffing information was posted however it did not have the component of the total number and actual hours worked by Registered Nurses. During an interview on 09/27/23 at 11:00AM, the corporate nurse stated the everyday nurse staffing information form used by the facility was incomplete and she would direct the facility to use the correct form that reflects the total number and actual hours worked by Registered Nurses (RNs), Licensed Vocational Nurses (LVNs) and Certified Nurse Aides (CNAs) Observation on 09/28/23 at 2:00PM revealed the nurse staffing information was posted however the Registered Nurse component was absent. During an interview on 09/28/23 at 3:00PM the DON stated she was responsible for making sure the posting of the nurse staffing and census data daily. She stated posting needed to be done by 6:00AM immediately after the shift change over meeting finished. When investigator asked about the relevance of the staffing posting, the DON said posting the daily census and nurse staffing information was important for the residents and facility visitors, to determine if the facility had adequate staffing. On 09/26/23 there was no policy available at the facility reflecting the requirement of posting daily, the nurse staffing information at a prominent place readily accessible and available to residents, employees, and visitors. Review of https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/regulatory-services-facility-surveyors-liaisons/required-postings accessed on 09/28/2023 reflected: 42 CFR Section 483.35(g) and 26 TAC Section 554.1001(b)(1)-(2) and Section 554.1921(e)(13) - An NF must conspicuously and prominently post the following information, in a clear and readable format and a prominent place readily accessible and available to residents, employees, and visitors, in accordance with Section 554.1921(e): On a daily basis: o Facility name o Current date o Resident census o Specific shifts for the day At the beginning of each shift, the total number of hours and actual time of day to be worked by the following licensed and unlicensed nursing staff, including relief personnel directly responsible for resident care: o Registered nurses (RNs) o Licensed vocational nurses (LVNs) o Certified nurse aides (CNAs) In addition, the licensed NF must make the information required to be posted available to the public upon request.

Based on observation, interview and record review, the facility failed to store and prepare food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items in the refrigerator were dated, labeled, and sealed appropriately. 2. The facility failed to discard food stored in the refrigerator that should no longer be consumed. These failures could affect the residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness and food contamination. Findings included: An observation of the facility's kitchen walk-in refrigerator, on 09/26/23 at 7:18 a.m., revealed the following: 1 10-pound roll of thawed hamburger meat, un-dated. 1 30-pound box of thawed slab bacon unsealed with date on outside of box 09/15/23. Record review of the Facility Storage and Retention Guide, undated, posted on the outside of walk-in refrigerator reflected that bacon, that is thawed, was to be retained up to 7 days . 1 5-pound clear bag of lettuce, turning brown, expiration dated 09/20/23. 1 of 2 boxes containing 7 cucumbers with 5 cucumbers spotted white mold. 2 of 2 boxes containing 4 cucumbers all spotted with white mold and black spots. Plastic bin with lid containing approximately 30 green bell peppers with 1 bell pepper turning a deep green color with white mold covering the fruit located in the center of remaining peppers. 1 box containing 16 tomatoes. One tomato with 4 black spots and a soft to the touch. 9 additional tomatoes soft to touch, dark red, and wrinkled and one with 3 spots of white mold on the top. 1 box of thawed breakfast sausage, unsealed. Interview on 09/28/23 with the ADA at 9:43 am, revealed that if residents consume food that is spoiled or gone bad, residents could become sick or might have to go to the hospital. Interview on 09/28/23 with the ADMIN at 3:38 p.m., revealed, after he was shown the photographs of the rotten tomatoes and cucumbers, revealed that if residents consumed food that is spoiled or gone bad, they could become sick or might go to the hospital. Review of facility policy title Food Storage dated 2018 revealed: Policy: to ensure that all food served by the facility is of good quality and safe consumption. Refrigerators: Date, label and tightly seal all refrigerated foods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 6 residents (Resident #44) reviewed for infection control, in that: CNA A failed to wash or sanitize her hands or change gloves before touching the package of wipes and after cleaning Resident #44's buttock area. This deficient practice could place residents at-risk for infection due to improper care practices. Findings include: Record review Resident #44's face sheet, dated 09/28/2023, revealed an admission date 03/06/2020 and, a readmission date of 08/23/2022 with diagnoses including: Fracture right pubis, Dementia (decline in cognitive abilities), Hypertension (High blood pressure), Osteoarthritis, Muscle weakness, and a need for assistance with personal care. Record review of Resident #44's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 2 indicating severe cognitive impairment. Resident #44 required extensive assistance, was always incontinent of bladder and bowel. Observation conducted on 9/27/2023 at 9:47 AM, revealed CNA A and CNA B conducted peri-care for Resident #44. CNA A cleansed Resident #44's bottom with multiple wipes and was pulling them directly out of the package. CNA A then removed more wipes from the package to cleanse Resident #44's peri area without changing gloves or conducting hand hygiene. In an interview on 09/28/23 at 09:10 AM, CNA A revealed she did not set up her station all the way during peri-care for Resident #44 by not removing the wipes from their package prior to providing peri-care. CNA A also stated the package of wipes became contaminated when she pulled more wipes while still wearing contaminated gloves. CNA A revealed she had received training on peri-care during CNA training at a nursing school, and in-servicing conducted in the facility. CNA A also revealed she felt remorseful about making the mistake and had become anxious with so many eyes watching the care. In an interview on 9/28/2023 at 2:30 PM, the DON stated a breach in infection control while providing resident care could cause an infection to develop. The DON's expectation for staff following Infection Control protocols during resident care included monthly training, and an expectation to conduct peri-care correctly. The DON further stated she would re-educate her staff on peri-care and hand hygiene during resident care. In an interview on 9/28/2023 at 2:45 PM, the ADMIN stated a breach in infection control could cause excoriation in the peri area, which could then lead to skin breakdown. The ADMIN's expectation was for staff to follow infection control protocol and proper handwashing techniques while providing resident care. Review of Policy and Procedures for Perineal Care dated October 2018 reflected, Always perform hand hygiene before and after glove use. Review of Policy and Procedures for Infection Control dated October 2018 reflected, To maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public and To prevent, detect, investigate, and control infections in the facility.

Based on observation, interview, and record review the facility failed to ensure storage and/ or label of medications used in the facility in accordance with currently accepted professional principles and include the appropriate expiration dates for 2 of 4( unit 300, and unit 500) medication carts reviewed for medication storage. -The facility failed to date Insulin Injections ( unit 100/200, ) when the product was first opened according to manufacture and professional standards. -The facility failed to ensure expired medications were removed from the medication carts ( unit 300, and unit 500). These failures could place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication. Findings Included: Observation on 09/26/2023 at 08:45 AM revealed the Unit 100 Medication cart with an Insulin Aspart 100 U/ ml injection with no open date. Observation on 09/26/2023 at 08:41 AM revealed the Unit 200 Medication cart with an Insulin Glargine 100 U/ ml injection with no open date. Observation on 09/26/2023 at 08:30 AM revealed the Unit 300 Medication cart with an Insulin Glargine 100 U/ ml injection with an open date of 08/17/2023. Observation on 09/26/2023 at 09:02 AM revealed the Unit 500 Medication cart with an Insulin Humalog 100 U/ ml injection with an open date of 08/05/2023. Observation on 09/26/2023 at 09:10 AM revealed the Unit 500 Medication cart with an Insulin Aspart 100 U/ ml injection with an open date of 08/17/23. In an interview on 09/26/2023 at 8:50 PM, LVN A stated insulin is supposed to be dated after opening to ensure medication does not expire. LVN A stated that insulin medication given after 28 days can impact the efficacy of the medication affecting treatment. In an interview on 09/26/2023 at 9:15 PM, LVN B stated the Nurse does not know how the insulin was overlooked. They should have been dated and the insulin that is passed 28 days should not be on the med cart. LVN B stated that insulin used passed the 28 days can lead to ineffective therapy. In an interview on 09/28/2023 at 2:00 PM, the DON stated Insulins should be dated as soon as they are removed from the refrigerator, staff are required to put the open date on them and keep them in the med cart for up to 28 days after opening them. The DON further stated Insulins have an expiration date and when given outside of the time allotted the potency can diminish and cause issues effecting residents' diabetes. In an interview on 09/28/2023 at 2:15 PM, the ADMIN stated his expectations are that Insulins should be dated as soon as they are removed from the refrigerator, staff are required to put the open date on them and keep them in the med cart for up to 28 days after opening them to sustain the efficacy. Review of the facility's Policy Storage of Medications dated April 2022 reflected The facility should ensure the medications requiring refrigeration are stored appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's right to be informed of, and participate in, his treatment, including the right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 2 of 3 (Resident #11 Resident #13) residents reviewed for right to be informed/make treatment decision, in that: Resident's #11, and #13 were Spanish speaking only residents and facility did not implement the use of an interpreter to allow resident to participate in their care and treatment and to be informed in their preferred language. This could place residents at risk of not being informed of their care and treatment. The findings were: Record review of the MDS dated [DATE] revealed Resident #11 was usually understood and usually understood others. The MDS revealed Resident #11 preferred language was Spanish. The MDS revealed Resident #11 BIMS was not completed. The MDS revealed Resident #11 had short-and-long term memory loss. The MDS revealed Resident #11 required extensive assistance for bed mobility, transfer, dressing, and toilet use, supervision for eating, and total dependence for personal hygiene and bathing. Record review of the undated care plan received on 6/9/22 revealed Resident #11 was Spanish speaking and required interpretation related to communication. The goal of Resident #11 was to be able to effectively communicate needs. Interventions included encourage family participant to ensure resident needs were being met and utilize translation tools to assist in communicating with resident. During an interview with Resident #11 in which a family member acted as an interpreter on 6/9/22 at 5:15 p.m., Resident #11 said staff treat her well and cleaned her sunglasses. Resident #11 said she liked to go to therapy so she could interact with the Spanish speaking therapist. The family member of Resident #11 said she was blind, hard of hearing, and primarily Spanish speaking. The family member said most of the staff at the facility were English speaking. Resident #11 said she asked staff to take her to therapy, but they take her to the dining room instead. Resident #11 said no one talks to her during meals and she would love someone to speak Spanish to her. The family member said Resident #11 experienced phantom pain in her amputated leg and instructed her family member to notify staff but Resident #11 said it would take a while and staff did not understand her. The family member said the facility occasionally contacted her to interpret Resident #11's pain. Resident #11 said she only knew where her hairbrush was and had to feel around to find her stuff. Resident #11 said she does not like the food and would like more Mexican food options. She said no one tells her what is on her plate and take small bits of the food to figure out want it was. The family member said Resident #11 does not get much social interaction and all the activities are in English and require good vision. The family member said Resident #11 spends a lot of time in her room. Resident #11 said she felt isolated because no one talked to her. She said she would like more things in Spanish or someone to help her play games. Record review of Resident #13's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included dementia, Alzheimer's, diabetes, weakness, schizophrenia, depression, anxiety, high blood pressure, heart disease, and kidney disease. Record review of resident #13's admission MDS dated [DATE] revealed the resident was Hispanic; resident needed or wanted an interpreter to communicate with a doctor or health care staff and her preferred language was Spanish; had a BIMS of 3 indicating she was cognitively severely impaired. The MDS indicated the resident required limited to extensive assistance of one person to physically assist with ADLs. Record review of resident #13's Resident Assessment and Care Screening MDS dated [DATE] revealed the resident was Hispanic and did not want or need an interpreter to communicate with a doctor or health care staff; had a BIMS of 3 indicating she was cognitively severely impaired. The MDS indicated the resident required limited to extensive assistance of one person to physically assist with ADLs. Record review of resident #13's care plan not dated, but facility provided to surveyor on 6/9/22, read in part: Problem: Resident #13 had a communication problem related to the dementia disease process and cognitive communication deficit. Goal: Resident #56 will be able to make basic needs known on a daily basis through the review date. Approach: Anticipate and meet needs; discuss with resident/family concerns or feelings regarding communication difficulty; encourage resident to continue stating thoughts even if resident is having difficulty; focus on a word or phrase that makes sense or responds to the feeling resident is trying to express; monitor/document for physical/nonverbal indicators of discomfort or distress and follow up as needed. During a phone interview on 6/07/22 at 10:02 AM with the family of Resident #13, she said the facility took excellent care of Resident #13. She said there were some staff that spoke Spanish in the facility, and they could go get them if needed to translate or there were some other residents in the memory unit that could translate also. She said they could also call her or the family if needed. She said Resident #13 had not reported any concerns to her during her conversations with her, but she said Resident #13 had dementia and probably would not remember. During an interview on 6/9/22 at 2:02 PM LVN M said if a resident's care plan says they needed an interpreter they would have to get a coworker to help with that speaks Spanish. She said there is no line or app they have available to translate for residents. She said some residents that are Spanish speaking only she can understand some little words and they can too. She said for immediate assistance with a Spanish speaking only resident they would have to get someone who speaks Spanish or base solely on their assessment. During an interview on 6/9/22 at 2:54 PM the DON said the Residents #11 and 13 were Spanish speaking only. She said that she could not speak about their care plans and Spanish speaking as she had not seen them. She said if their care plan says they need an interpreter they have staff that speak Spanish. She said sometimes google had a translation application and it tells them what they need. She said staff don't use it because they can't have their phones. She doesn't know if staff that speak Spanish are skilled in Spanish or just speak it. She said some staff know small words like [NAME] (bathroom), and the social worker gave staff a handout that they can call and give the phone to resident, and they would interpret as well, that was in place and staff were supposed to use it. The DON stated she did not think staff have used the line in the last 2 months, but prior to that they had. She said speaking to Residents in their preferred language was important to meet their needs. During an interview on 6/9/22 at 3:30 PM the Administrator said for Spanish speaking only residents they have a few staff that speak Spanish. He said for Residents that speak Spanish they have language boards and a translation line. He agreed staff don't use these options often they are used as a backup but they aren't used as a backup often. If the staff can't communicate with the Resident then they would use the phone system, as it is important to have in their native language because it is their native language and their source of communication. Policy was requested on Care Plans from the Administrator; no care plan policy was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of needs and preferences for 1 (Resident #11) of 19 residents reviewed for reasonable accommodation of needs/preferences. The facility failed to make staff aware of Resident #11's visual impairment and provide tools to promote independence. This failure could place residents at risk for unmet needs and decreased quality of life. Findings included: Record review of the consolidated physician orders dated 6/9/22 revealed Resident #11 was a [AGE] years old, female and admitted on [DATE] with diagnoses including Alzheimer's, dementia, dysphagia (difficult swallowing), legal blindness, severe stage glaucoma bilateral (is little to no healthy eye tissue left, and vision is increasingly limited), presbyopia (A gradual, age-related loss of the eyes' ability to focus actively on nearby objects), muscle wasting and atrophy (is the wasting (thinning) or loss of muscle tissue), and absence of left leg above knee. Record review of the MDS dated [DATE] revealed Resident #11 was usually understood and usually understood others. The MDS revealed Resident #11 had moderate difficulty hearing with no hearing aid, unclear speech, moderately impaired vision with no corrective lenses. The MDS revealed Resident #11 preferred language was Spanish. The MDS revealed Resident #11 BIMS (Brief interview for Mental Status-screening tool to assist with identifying a resident's current cognition status) was not completed. The MDS revealed Resident #11 had short-and-long term memory loss. The MDS revealed Resident #11 had severely impaired cognition skills for daily decision making. The MDS revealed Resident #11 required extensive assistance for bed mobility, transfer, dressing, and toilet use, supervision for eating, and total dependence for personal hygiene and bathing. The MDS revealed Resident #11 had upper and lower impairment to both sides. Record review of the undated care plan received on 6/9/22 revealed Resident #11 had ADL self-care deficit performance deficit related to left above knee amputation, poor cognition, and debility. Goal of resident will maintain current level of function. Interventions of supervision/set up for eating, limited to extensive assist for bed mobility, toilet use, and transfer. Encourage resident to use bell to call for assistance and fully participate possible. The care plan revealed Resident #11 had impaired cognitive function related to Alzheimer's/Dementia. Intervention included ask yes/no questions to determine the resident's needs and present just one thought, idea, question, or command at a time, and engage the resident in simple, structured activities. The care plan revealed Resident #11 had impaired visual function related to legal blindness and glaucoma. Goal of resident will maintain optimal quality of life within limitation imposed by visual function through the use of eyeglasses, magnifying glass through the review date. Interventions included ensure appropriate visual aids are available to support resident's participation in activities, identify/record factors affecting visual function including physiological, environment, and choices, and monitor/document/report prn any signs and symptoms of acute eye problems. The care plan revealed Resident #11 was Spanish speaking and required interpretation related to communication. Goal of Resident #11 would be able to effectively communicate needs. Interventions included encourage family participant to ensure resident needs were being met and utilize translation tools to assist in communicating with resident. During an observation on 6/6/22 at 12:00 p.m., Resident #11 was in the dining room sitting at a table alone with sunglasses on. Resident #11 had random items stored in her jacket which was folded in half, The DON placed a food tray in front of Resident #11 and left, no one else approached. Resident #11 ate less than 25% of the food. The DON tried to offer a shake and resident asked what it was. This surveyor observed Resident #11's cup placed on top of her uneaten cabbage. The DON said, she (Resident #11) put her cup on top of the cabbage. During an interview on 6/8/22 at 7:55 a.m., CNA F said Resident #11 could do stuff on her own and no deficits. She said Resident #11 was blind and staff told her where things were, and she could do it. She said staff told her what and where things were on her plate and she goes to town on it. During an interview on 6/8/22 at 8:30 a.m., CNA G said Resident #11 had been at the facility for a year but had been admitted a couple times before. She said Resident #11 had good vision, but she did notice she struggled to see where things were. She said Resident #11 did not have a magnifying glass in her room. She said if a resident used glasses or was legally blind, nurses would let the CNAs know. During an interview on 6/8/22 at 9:03 a.m., CNA H said she worked with Resident#11 and she did not have any special needs and just wore sunglasses. She said some staff say Resident #11 cannot see, but she can. She said staff set up Resident #11 tray and she does the rest. She said Resident #11 could feed and use the restroom by herself. During an interview on 6/9/22 at 1:10 p.m., LVN L said she had been at the facility for 19 years and was a charge nurse on the secured unit. She said she was the ADON for a couple years before she became a charge nurse. She said Resident #11 probably had visual impairments. She said the information should be on her MDS and care plan so all staff would know. She said she felt likes staff helped residents who could not see but had never seen a magnifying glass or anything else to aide resident with visual impairments. During an interview on 6/9/22 at 2:02 p.m., LVN M said she had been at the facility for 13 years and was a charge nurse. She said resident with disabilities was verbally communicated amongst staff members, review medical diagnoses, or on the care plan. She said she had seen magnifying glasses for some residents. She said she did not know if Resident #11 had visual impairments. She said it was important for staff to know if Resident #11 was to have assistance her with feeding, take her around her room and tell her where things are, and let her touch the items. She said she had not noticed Resident #11 making a mess with her, but she knew she was picky. She said Resident #11's family had not requested assisting her with eating due to her visual impairment. During an interview on 6/9/222 at 2:54 p.m., the DON said Resident #11 was legally blind. She said all staff that worked with Resident #11 knew she was. When informed that several of the staff did not know Resident #11 was legally blind, she said she would do an in-service, but the information was in their charting system. She said she could not say if Resident #11 had a bigger clock or magnifying glass in her room. She said staff helped Resident #11 during meals by telling her where things were, but she still felt around, and she did not have a weight loss. She said for receptive residents, speech therapy could do an evaluation and recommend accommodations such as longer straws. During an interview on 6/9/22 at 3:30 p.m., the Administrator said the facility did not have any resident that were blind or had visual impairments. He said he did not know Resident #11 was legally blind. He said he had never had a visual impaired resident and would need to investigate accommodations to assist residents with corporate. During an interview with Resident #11's family member as the interpreter on 6/9/22 at 5:15 p.m., the family member of Resident #11 said she was blind, hard of hearing, and primarily Spanish speaking. The family member said most of the staff at the facility were English speaking. Resident #11 said she asked staff to take her to therapy, but they take her to the dining room instead. Resident #11 said no one talks to her during meals and would love someone to speak Spanish to her. Resident #11 said she only knew where her hairbrush was and had to feel around to find her stuff. Resident #11 said she does not like the food and would like more Mexican food options. She said no one tells her what is on her plate and take small bits of the food to figure out want it was. The family member said she had asked the DON to have staff assist Resident #11 with her meals but when she visited this Wednesday, no one helped her. The family member said Resident #11 does not get much social interaction and all the activities are in English and require good vision. The family member said Resident #11 spends a lot of time in her room. Resident #11 said she felt isolated because no one talked to her. She said she would like more things in Spanish or someone to help her play games. Resident #11 said if no one comes by to check on her, she will go to the restroom without assistance then pull the light in there. Resident #11 said her call light shocked her or something was wrong with it, so she wound not use it. She said she told a CNA it was shocking her. Resident #11 and the family member said the facility had not offered her a special call light to accommodate her visual impairment. Resident #11 said she does not use her call light but when she sees a shadow, she calls out senorita (unmarried lady or Miss in Spanish) to get their attention. This surveyor notified the DON of Resident #11's possible malfunctioning call light. Record review of a facility assistive devices and equipment policy revealed .our facility maintains and supervises the use assistive devices and equipment for residents .certain devices and equipment that assist with resident mobility, safety and independence are provided .the facility provides the resident with assistance in locating available resources to obtain assistive devices that are not provided by the facility including but not limited to .glasses, or magnifying devices .recommendation for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the notice to residents when changes in coverage were made to items and services covered by Medicare as soon as is reasonably possible provided to 2 of 3 residents (Resident #75 and Resident #69) who were provided skilled Medicare services, were discharge from services, and remained in the facility in that: Resident #75 and Resident #69 were not given a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could affect residents who use skilled services and could place them at risk of not being aware of changes to provided services. The findings were: Record Review of Resident #75's face sheet, dated 06/09/2022, revealed the resident was admitted on [DATE] with diagnoses that included: unspecified dementia, repeated falls, and hypertension. Record Review of Resident #75's MDS dated [DATE], indicated that Resident #75 was usually understood and usually understands. Resident #75 had a BIMS of 03 which indicated severe memory deficits. Resident #75 required supervision to limited assistance with ADL, as indicated on the MDS for 05/24/2022. Record Review for Resident #75 revealed that the Notice of Medicare Non-Coverage (NOMNC) had been initiated on 02/14/2022 by LVN AA with the effective end date of coverage being on 02/16/2022, this document was signed as verbally notified family on 02/14/2022, however it was revealed that a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was not completed which would have informed Resident #75 of the option to continue services at the risk of out-of-pocket cost. Record Review of Resident #69's face sheet, dated 06/09/2022, revealed the resident was originally admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses that included: hypertensive heart disease, dementia, and osteoarthritis (A type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record Review of Resident #69's MDS dated [DATE] indicated Resident #69 was understood and usually understands. Resident #69 had a BIMS of 03, which suggested severe memory impairment. Resident #69 required limited assistance with ADLs. Record Review for Resident #69 revealed that the Notice of Medicare Non-Coverage (NOMNC) had been initiated on 03/30/2022 by LVN AA with the effective end date of coverage being on 04/01/2022, this document was verbally consented understanding by resident #69's representative, however it was revealed that a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was not completed which would have informed Resident #69 of the option to continue services at the risk of out-of-pocket cost. During an interview on 06/08/2022 at 1:37 p.m. the corporate MDS nurse stated the facility MDS nurse was responsible for the completion of both NOMNC forms and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) forms. The corporate MDS nurse further explained that there was currently no one in that position and had not been for the last 3 months and that the BOM was ensuring the NOMNC and ABN were signed according to Medicare guidelines. The corporate MDS nurse stated normally when there were no Medicare days left that she would not do a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) form for residents, however Resident #75 and Resident #69 had not exhausted benefit days. The corporate MDS confirmed the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) form was required, were important to keep the residents informed of their rights, and the company had no specific policy for the issuance of denial letters. The company followed CMS guidelines as guidance. During an interview on 06/08/2022 at 2:00 p.m., the BOM stated she was just given the responsibility of ensuring the NOMNC and ABN were completed timely about 2 weeks ago. There was no formal training given. The BOM could not recall when a ABN was due for each resident that came off of Medicare A services and remained in the facility with days remaining in their benefit. BOM stated she had completed only a few NOMNC since taking over that role. During an interview on 06/09/2022 at 9:33 a.m. the Administrator stated that the facility does not have a policy regarding providing Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) at end of daily skilled care that the facility followed CMS guidelines. Record review of CMS guidelines Beneficiary Notice Guidelines, approved by CMS-10124-DENC December 31, 2011, revealed Scenario Part A stay will end because: SNF (Skilled Nursing Facility) determines the beneficiary no longer requires daily skilled services. Resident has days remaining in the benefit period. Resident will remain in the facility (custodial care) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) CMS-10055 (2018) and Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (12/31/11)) to be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure that residents had a safe homelike environment for one (room [ROOM NUMBER]) of nineteen rooms reviewed for environment: The facility failed to ensure room [ROOM NUMBER]'s bathroom had a functioning leak free toilet, was free of odors from used linens (used to absorb leaking toilet) and was free of pests living in exposed drywall. This failure placed residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings included: Record Review of Resident #19's face sheet dated 6/9/2022 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Hepatitis A( A highly contagious liver infection caused by the hepatitis A virus), major depressive disorder, and peptic ulcer (A sore that develops on the lining of the esophagus, stomach, or small intestine). Record Review of Resident #19's MDS, dated [DATE], reflected a BIMS of 14, indicating no cognitive impairment. The MDS reflected that Resident #19 was usually understood and understood others. The MDS reflected that Resident #19 was continent of bowel and bladder. During an interview on 6/6/2022 at 10:15 AM with Resident #19 revealed that his shared bathroom was in disrepair. Resident #19 stated that the toilet had been leaking for several months. Resident #19 revealed he reported it to the CNA Z each day she worked because he was unaware if the leaking water was clean water from the tank or dirty water from the bowl. Resident #19 revealed there were big roaches that climbed out of the wall in the bathroom, as well. Resident #19 stated this made him feel forgotten and uncared for. Resident #19 stated that he spoke to a mental health counselor and the condition of his bathroom was something they discussed during his sessions. During an observation on 6/6/2022 at 10:17 AM, the bathroom in room [ROOM NUMBER] was noted to have a leaking toilet with a blanket to the left side of the bowl that was browning in color and smelled of sour laundry. The drywall under the sink had a hole in it that exposed pipes. Large water bugs crawled from the open dry wall. Record Review of Resident # 192 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnoses that included: cachexia (weakness and wasting of the body due to severe chronic illness), heart failure and insomnia. Record Review of the MDS dated [DATE] revealed Resident #192 was usually understood and usually understood others. The MDS revealed Resident #192 had a BIMS (Brief Interview of Mental Status) of 14 which indicated the resident was cognitively intact. The MDS reflected that Resident #192 was incontinent of bladder and frequently incontinent of bowel. During an interview on 6/6/2022 at 10:22am, Resident #192 stated he had no concerns about his care at the facility but wet socks. Resident #192 declined to elaborate. During an interview on 6/7/2022 at 1:10 pm, CNA Z stated that Resident #19 did not require assistance to the bathroom. CNA Z revealed that Resident #19 asked for an extra roll of toilet paper frequently and that at least twice weekly housekeeping had to unclog the toilet. CNA Z stated she was aware that a blanket was placed beside the toilet to dry up water that leaked from the toilet. CNA Z was unaware of how long the blanket had been there. CNA Z stated she assisted Resident # 192 to the toilet on occasion for a bowel movement. CNA Z stated the bathroom toilet had leaked and the drywall had been exposed for around 1-2 months. CNA Z stated she had not seen any insects or pests. CNA Z states she had not reported the condition of the bathroom to maintenance because housekeeping handled clogged toilets. Review of the maintenance log dated 05/01/2022 to 06/01/2022 reflected no maintenance work order request for room or bathroom of 112. During an interview on 6/8/2022 at 2:45pm the maintenance man revealed he was not aware of any issues in room [ROOM NUMBER] or the bathroom of 112 in the facility since he had arrived 30 days prior. During an interview on 6/8/2022 at 3:15pm the administrator revealed he was unaware of any issues in room [ROOM NUMBER] or the bathroom of 112. The administrator was taken to room [ROOM NUMBER] by the surveyor to view the issues found in the bathroom. The administrator revealed the process to have something fixed was for the nurse put a work order in the computer and that triggered the maintenance man to look at the issue. The administrator stated he reviewed the maintenance request report frequently. The administrator revealed that no work order was put in for the bathroom in room [ROOM NUMBER] or the facility would have fixed it promptly. The administrator stated that leaking toilets could lead to falls and unsafe conditions for the residents. The administrator stated he would move the residents to another room immediately if he were aware of the condition of the bathroom. During observation on 6/8/2922 at 3:15pm it was noted that there was a large wet blanket with brown rings on the floor beside the toilet. The dry wall under the sink was exposed and crumbling. A policy pertaining to environment was requested by the team leader and none was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 1 of 19 residents (Resident #17) reviewed for significant change assessments. The facility failed to accurately code Resident #17 as being hospice and having a terminally illness or condition. This failure could place residents at risk of having inaccurate assessment, not having individual needs met and decreased quality of life. Findings included: Record review of the consolidated physician orders dated 6/9/22 revealed Resident #17 was [AGE] years old, female and admitted on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (result from either nonpenetrating or penetrating trauma to the head), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epilepsy (a disorder of the brain characterized by repeated seizures), hemiplegia (paralysis of one side of the body), and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). The consolidated physician order dated 4/7/22 revealed admit to hospice with diagnosis of cerebral infarct (stroke). Record review of the MDS dated [DATE] revealed Resident #17 was rarely/never understood and rarely/never understood others. The MDS revealed since Resident #17 was rarely/never understood, the BIMS (Brief Interview for Mental Status) could not be completed. The MDS revealed Resident #17 required extensive assistance for dressing and personal hygiene. The MDS revealed Resident #17 required total dependence for transfer with two persons assist, eating, toilet use and bathing. The MDS revealed Resident #17 had no impairment to upper or lower extremities. The MDS revealed Resident #17 did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. The MDS revealed Resident #17 was not on hospice while a resident. The facility did not provide an updated MDS for significant change assessment. Record review of the undated care plan revealed Resident #17 had ADL self-care performance deficit related to impaired cognition/declined manifested with diagnosis of dementia. Interventions included bathing/showers required extensive assistance with 1 person assist, ambulate with supervision, and bed mobility required total assistance of 1-2 persons. The care plan revealed Resident #17 had palliative care due to disease process. Record review of a physician certification of terminal illness dated 4/7/22 revealed Resident #17 was terminally ill with a medical prognosis of six months or less to live signed my hospice physician and nurse. Record review of a hospice physician orders dated 4/7/22 revealed Resident #17 was admitted to hospice due to diagnosis of cerebral infarct. During an interview on 6/6/22 at 2:46 p.m., the family member of Resident #17 said she had been on hospice since March of this year. During an interview on 6/8/22 at 11:16 a.m., the hospice director of clinic service said Resident #17 had been on their service since 4/7/22. During an interview by phone on 6/8/22 at 1:37 p.m., the corporate MDS nurse stated she did not complete MDS assessments at the facility. She only comes on Monday and completes the assessments required to complete the MDS. The facility employees 3 prn nurses that come in when they can and work on MDSs to keep them up to date. The MDS nurses were responsible for completing and updating the care plans as they completed the MDS. Baseline care plans were the responsibility of the charge nurse. She stated MDS accuracy was important because the plan of care is created by the information coded on the MDS. The plan of care was how the employees knew what kind of care each resident needs. The corporate MDS nurse stated inaccurate assessments and care plans that are not complete or revised could negatively affect the care of the residents because the resident might not receive appropriate care, decreasing their quality of life. During an interview on 6/9/22 at 1:10 p.m., LVN L said she had been at the facility for 19 years and was a charge nurse. She said she did not know if Resident #17 was on Hospice or if she was on palliative care. She said it was important to know if Resident #17 was hospice to ensure she received the care according to family wishes. She said it should be on her MDS and care plan. During an interview on 6/9/22 at 2:02 p.m., LVN M said she had been at the facility for 13 years and was a charge nurse. She said when a resident has a change of condition, staff should verbally notify the MDS coordinator and write a progress note. She said it was important for accurate information to be documented no significant change was not missed. She said Resident #17 was on hospice and it should be documented in her chart and on her MDS and care plan. She said Resident #17 hospice status should be known to provide what the hospice company request. During an interview on 6/9/22 at 2:54 p.m., the DON said she had been at the facility for 20 years. The DON said MDSs, and care plans should be accurate to show who the residents are. She said the facility did not have a MDS nurse or social worker. She the corporate MDS was handling assessments. She said inaccurate assessments can affect the resident's care and cause wrong coding on the MDS. She said Resident #17 was on hospice and it should be on her MDS and care plan. She said it was important to follow the hospice plan of care. During an interview on 6/9/22 at 3:30 p.m., the Administrator said the facility did not have a MDS coordinator or social works for the last 30 days, so care plan and MDS may be inaccurate. On 6/8/22 at 3:35 p.m., a policy regarding accuracy of assessment on the MDS was requested from the DON. The DON said the facility did not have one but followed CMS guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 9 of 24 residents reviewed for resident rights. (Resident #8, Resident #16, Resident #24, Resident #45, Resident #56, Resident #80, Resident # 83, Resident # 84, and Resident #193) The facility failed to treat Residents #8, #16, #24, #56, #83, #84, and #193 with respect and dignity when they had to wait extended lengths of time at their tables where other residents had already been served their meals. The facility failed to treat Resident #45 with respect and dignity when her meal tray card was marked with large black marker with the word FEEDER. The facility failed to treat each resident with respect and dignity when multiple staff members referred to residents who required assistance with feeding, as feeders. The facility failed to treat Resident #56 with respect and dignity when she was wheeled in a reclined wheelchair to the assisted dining room and parked facing the back wall away from the other residents who were watching a movie on the TV. The facility failed to treat Resident #80 with respect and dignity when his door was left open, and the curtain was not pulled to provide privacy when the nurse exposed his abdomen while she performed feeding tube flushes and medication administration. These failures could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: 1. Record review of resident #8's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included dementia with behavioral disturbance, dysphagia (difficulty swallowing), adult failure to thrive (a decline seen in older adults usually from multiple long-term illnesses), malnutrition, weakness, cognitive communication deficit, depression, anxiety, and high blood pressure. Record review of resident #8's quarterly MDS dated [DATE] revealed the resident's BIMS was 3 indicating she was cognitively severely impaired. The MDS indicated the resident required supervision and set up while eating. 2. Record review of resident #16's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included dementia with behavior disturbance, dysphagia (difficulty swallowing), weakness, cognitive communication deficit, aphasia (difficulty speaking), heart failure, depression, high blood pressure, and anxiety. Record review of resident #16's quarterly MDS dated [DATE] revealed the resident was unable to complete the BIMS. The MDS indicated the resident required extensive assistance with 1 person assist while eating. 3. Record review of Resident #24's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included cognitive communication deficit, weakness, anxiety, pain, depression, and Alzheimer's (a progressive disease that affects memory and important mental functions). Record review of Resident #24's quarterly MDS dated [DATE] revealed the resident's BIMS was 8 indicating she was cognitively moderately impaired. The MDS indicated the resident required supervision and set up while eating. 4. Record review of Resident #45's face sheet dated 6/9/2022 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included hypertension, dementia, and congestive heart failure. Record review of Resident #45's MDS dated [DATE] revealed the resident's BIMS was 00 indicating she was severely cognitively impaired, she had disorganized thinking and she was sometimes understood and sometimes she understands. The MDS revealed resident required extensive assistance of one staff member for eating. The MDS also revealed resident was on a mechanically altered therapeutic diet. Record review of Resident #45's physician orders dated 6/9/2022 revealed resident had a diet order for regular, mechanical soft texture, fortified foods with meals, serve meals in bowls dated 07/30/2021. 5. Record review of resident #56's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included dementia with behavioral disturbances, cognitive communication deficit, weakness, stiffness, anxiety, depression, high blood pressure, schizophrenia (mental disorder), malnutrition, dysphagia (difficulty swallowing), and Alzheimer's (a progressive disease that affects memory and important mental functions). Record review of resident #56's annual MDS dated [DATE] revealed the resident was unable to complete the BIMS. The MDS indicated the resident required extensive assistance of 1-person physical assist while eating. 6. Record review of resident #80's face sheet dated 6/9/22 revealed a [AGE] year-old male who was admitted on [DATE]. His diagnoses history of a stroke with paralysis of both sides of his body, anxiety, dysphagia (difficulty swallowing), history of a traumatic brain injury (brain function problem caused from a hard hit the head), and history of respiratory failure (unable to breathe). Record review of resident #80's annual MDS dated [DATE] revealed the resident was unable to complete the BIMS. The MDS indicated the resident required total assistance of 1 to 2 persons for all ADLs. 7. Record review of resident #83's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included dementia with behavioral disturbances, cognitive communication deficit, weakness, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and high blood pressure. Record review of resident #83's annual MDS dated [DATE] revealed the resident's BIMS was 0 indicating she was cognitively severely impaired. The MDS indicated the resident required limited assistance with 1 person assist while eating. 8. Record review of resident #84's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included dementia with behavioral disturbance, Alzheimer's disease (a progressive disease that affects memory and important mental functions), cognitive communication deficit, weakness, malnutrition, lack of coordination, depression, and high blood pressure. Record review of resident #84's annual MDS dated [DATE] revealed the resident's BIMS was 0 indicating she was cognitively severely impaired. The MDS indicated the resident required limited assistance with 1 person assist while eating. 9. Record review of resident #193's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included a left femur (upper leg) fracture and diabetes (blood sugar disease) Record review of resident #193's admission MDS dated [DATE] revealed the resident's BIMS was 13 indicating she was cognitively intact. The MDS indicated the resident required extensive assistance of 1-person physical assist for ADLs. During an observation and interview on 6/6/22 at 11:50 AM, lunch service began in the main dining room B. Resident #193 shared a table with 2 other residents. At 11:54 AM the two residents' sharing the table with Resident #193 were served. Resident #193 was served lunch at 12:18 PM. Resident #193 said she was always the last served and she was tired of sitting and staring at the other residents eat. During an observation and interview on 6/6/22 at 11:50 AM, one other resident at the table with Resident #24 was served lunch. Resident #24 was served lunch at 12:15 PM. Resident #24 asked the other resident at her table multiple times if the food was good, and she said she hoped hers came out soon. During an interview on 6/06/22 at 11:55 PM with CNA K, when surveyor asked her where a certain resident was, she said the resident was on the feeder side then corrected herself and said the assisted dining side. During an observation on 6/06/22 at 12:04 PM, observed dining staff place the 1st plate of food served from the kitchenet in the assisted dining area of the memory care unit on the table in front of Resident #56, who was in a reclined wheelchair and unable to feed self. Observed the resident look over at food multiple times and starring at the food. At 12:19 PM after all the other residents had been served, a CNA sat down and served Resident #56 her first bite of food. During an observation on 6/06/22 at 12:04 PM, observed four residents sitting at a table in the assisted dining area of the memory care unit. Lunch service began and Resident #83 was served her lunch at 12:04 PM, then at 12:07 PM Resident #84 was served her lunch. At 12:09 PM, observed CNA K sit down to assist Resident #83 with feeding. At 12:11 PM observed Resident #16 receive her lunch meal and then at 12:13 PM Resident #8 received her lunch meal. Observed CNA K originally sit down to assist feeding Resident #83, then she stood and went from resident-to-resident walking around the table feeding each resident a bite and/or drink, then to the next resident and only sanitized her hands prior to sitting down to assist Resident #83. Observed CNA K standing over Resident #84 while feeding the resident during mealtime, then CNA K walked around the table and was standing over Resident #16 while assisting the resident at mealtime, then CNA K continued to walk around the table and stood over Resident #8 while assisting the resident during mealtime, then she walked around the table and stood over Resident #83 while assisting the resident during mealtime feeding each resident a bite. During an observation on 6/07/22 at 8:35 AM observed LVN N leave Resident #80's door open and did not close the curtain when the nurse exposed his abdomen while she performed feeding tube flushes and medication administration. During an interview on 6/07/22 at 8:45 AM with LVN N, after she performed the feeding tube flushes and medication administration, she said she could not think of anything that she should have done differently and asked surveyor for help with the question. Surveyor asked LVN N, if there was anything, she could have done to promote dignity while performing the feeding tube procedure and she stated, I should have closed the door. She said the resident could feel uncomfortable with the door left open during procedures. During an observation on 6/7/22 at 11:45 AM, Resident #45's tray card was marked in large black marker as a feeder. Resident #45 was seated in the assisted dining room. Resident #45 fed herself 50% of her lunch. Verbal cuing by staff was offered but no physical assistance with feeding was noted. During an observation and interview on 6/7/22 at 12:00 PM, lunch service began in the main dining room B. Resident #193 shared a table with 2 other residents. At 12:03 PM the two residents' sharing the table with Resident #193 were served. Resident #193 said she was going to wheel herself to a restaurant nearby for a burger if she had to continue to wait. Resident # 193 continued to make comments about how hungry she was until Resident #193 was served at 12:23pm. During an interview on 6/7/22 at 12:15 PM with CNA P, she said the kitchen staff wrote feeder on the bottom of Resident #45's tray card to help them know where the tray needed to be sent. She said no resident should be labeled as a feeder for dignity. She said labeling the resident as a feeder could make the resident feel less worthy and childlike. During an observation on 6/08/22 at 9:15 AM, observed CNA J push Resident #56 into the assisted dining room in the memory care unit with the wheelchair reclined back and she parked the wheelchair with the resident facing the back wall away from the other residents, who were watching a movie. CNA J then left the dining room area. At 9:20 AM observed Resident #56 sitting up in her wheelchair at the table with other residents facing the TV. During an observation on 6/8/22 at 12:00 PM. Resident #45's tray card was marked with large black maker the word FEEDER. Resident #45 was served lunch in the assisted dining room and consumed 25% of lunch. Resident #45 was not fed by staff at this meal. During an interview on 6/8/22 at 8:30 AM with CNA G, she said when you set up meal trays, and if the resident had a disability, you would tell them where the food was on the tray, cut up meat, open any containers that would need to be opened, and the feeders you would tell them what you are giving them and make sure they are sitting up with proper posture. She said staff should sit to keep eye contact when feeding residents. She said it is important to sit, because when standing up, they take that as standing over them or they are lower. She said we usually feed 2 residents and you just sit in between the residents, and she did not know how she would manage 4 residents. She said, I guess give each one of them a bite. She said if staff stood to feed a resident, that is not appropriate. She said if she was feeding multiple residents, she would just use my left hand for the resident on her left and my right hand for the resident on the right. She said we do not have many feeders right now. During an interview on 6/8/22 at 9:03 AM with CNA H, she said she had worked at the facility for 18 to 19 years. She said her CNA job duties included everything any everything all over the facility. She said when she assists a resident with feeding, you should encourage them to eat, tell them what she was putting in their mouth, and tell them to blow on the food if it is hot. She said we sit when feeding residents, we are trained to do that because it is a dignity/respect issue. She said standing over a resident while feeding them would make the resident feel awful and make them feel rushed. She said she would not be the only person to assist residents at a table with multiple residents. She said we try to not to put residents that need assistance with feeding all together. She said it would be an infection control issue with cross contamination to feed multiple persons. During an interview on 6/8/22 at 10:06 AM with CNA J, she said she has worked at the facility for 7 years. She said she usually worked the memory unit. She said her job duties included assisting residents with daily activities of life, meals, getting ready for bed, and doing activities. She said she assisted residents with eating. She said she would go to the feeder side to help. She said she would set up the resident's food, tell them hello, tell them what she was feeding the resident for their meal one item at a time. She said if the resident does not like the food, she would give them a nutritional shake. She said she would sit to feed residents. She said you should sit so you can make sure you are hitting their mouth. She said she has had multiple residents at a table. She said there would be two staff at a table and the staff would sit between two residents. She said she has not had to feed more than two residents at one time. She said she would put on gloves or wash hands and change gloves out between residents. She said she learned to do that in CNA school. She said, sometimes, she has had to help both residents without washing/sanitizing hands due to behavior issues. She said all residents at a table should get their meals timely. She said it would not happen often, because they tried to get the tickets lined up, so the food would come out together for the residents at the same table. She said it would be upsetting to the residents if they did not receive their meals at the same time, because they could be very hungry. During an interview on 6/9/22 at 1:10 PM with LVN L, she said she has worked at the facility for 19 years. She said her job duties included taking care of residents, supervising CNA's, blood sugars, passing medications, and toileting residents. She said staff should sit in a chair when feeding a resident. She said staff needed to be at eye level with the resident while feeding them, because the resident could feel fearful or inferior. She said staff have been in-serviced and trained on how to properly feed a resident. She said the appropriate term to use is they or they need assistance and the term feeder is not appropriate. She said calling a resident a feeder could be a dignity issue. She said she had never seen feeder on a meal ticket. She said they had an assisted dining room and an independent dining room. She said it was not okay for one resident to get their food and the other residents at the same table get their food fifteen minutes later. She said she would not want that to happen with my family if she was eating. She said it could make the ones eating feel bad and the ones not eating think they were not getting anything. She said they try to get the whole table their food at the same time, especially in the memory unit. She said they sometimes had to make abrupt changes to tables, based on how residents were getting along, and she would do the meal tickets to make sure we have it running smooth. She said it was not appropriate for one staff to feed four residents at a table at the same time. She said cross contamination would be a problem and by the time you get to the 4th person their food may be cold. She said she thought CNAs got ahead of themselves sometimes. During an interview on 6/9/22 at 2:02 PM with LVN M, she said she had worked at the facility for 13 years. She said her job duties included passing medications, treatments, head to toe assessments, and discharges. She said resident assistance eating staff should be seated and give small bite size pieces. She said staff should not stand over the resident so not to intimidate or rush resident. She said terminology feeder is not a term to use, it was degrading to the resident. She said residents at the same table should receive their food at the same time, so that one does not feel left out. She said the one without a meal tray may feel left out and the other may feel special for getting their meal tray before others at the table. She said when there was a table of four residents that needed assistance with feeding, you would just have to go to each resident and feed each. She said that was not the ideal way, because one resident could feel like they were not getting enough food or attention at that time. She said hand sanitizer should be used between residents for infection control. She said a nurse should introduce themself to the resident, wash hands, and it is important to close the door to while providing care with the resident's feeding tube. During an interview on 6/9/22 at 2:54 PM with the DON, she said she had worked at the facility for 20 years. She said we try to feed just one resident at a time. She said staff should be seated when feeding a resident. She said the resident could feel intimidated if staff were standing over them. She said when multiple residents were at the same table, they should all receive their meal trays at the same time, because residents would try to take food from another resident's plate sometimes. She said staff should not be feeding four residents at a table, that would not be best practice. She said staff not using hand sanitizer between residents when assisting with feeding multiple residents, would not be best practice. She said when staff are providing care to a resident, they should close the door or pull the curtain to preserve the resident's dignity. She said she was responsible to ensure staff were treating residents with respect and dignity and was responsible for providing training to the staff. During an interview on 6/9/22 at 3:30 PM with the Administrator, he said he has worked at the facility for 6 years. He said his job duty was to oversee the complete operation of the facility. He said he expected residents at the same table would have their meals delivered to the table at the same time. He said not receiving their meals at the same table at the same time was a dignity issue and the residents that had not received their meals might be afraid of not receiving their meal. He said when staff were assisting multiple residents at a table with feeding, staff should not be feeding all four residents at the same time. He said not using gloves or hand sanitizer between assisting each resident with feeding would be an infection control issue. He said he was not aware these things were happening and would address it with his staff. Record Review of In-service logbook revealed there were no in-services on Resident Rights performed. Record review of a facility Resident Rights policy titled Resident Rights dated 12/16 revealed . federal and state laws guarantee certain basic rights to all residents of this facility . resident's right to a dignified existence . be treated with respect, kindness, and dignity . orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights . Record review of a facility Meal Service policy titled Meal Service dated 2018 revealed . Residents will be properly positioned in chairs, wheelchairs or geri-chairs at an appropriate distance from the table . residents will be treated with respect and courtesy . all residents at one table will be served at the same time prior to serving residents at other tables . table service will be rotated so that the same table is not always served first or last . residents who require dining assistance will not have their trays delivered until a staff member is available to assist with dining .

Based on observation, interview, and record review, the facility failed to ensure that residents had a right to organize and participate in resident groups, in that: Eleven residents in a confidential resident group interview were aware that they had the right to organize and participate in a group meeting monthly, but said they weren't done. This failure placed residents at risk of not having the right to voice their concerns in a Resident meeting. Findings include: During observations on 6/6/22 at 9:30am, 11:30 am, 1:30 pm and 3:30pm, 6/7/22 at 9:30am, 11:30 am, 1:30 pm and 3:30pm and 6/8/22 at 9:30am, 11:30 am, 1:30 pm and 3:30 pm the following was noted: No facility organized activities occurred. During a confidential resident group interview on 6/7/22 at 10:00 AM, the 11 residents in attendance stated the facility does not have regular Resident Council meetings, but if they did, they would attend. Residents indicated there had been one or two meetings in the last year. Residents in the confidential group interview were aware that they had the right to have a monthly Resident Council meeting. All residents expressed they would attend if they were held. Residents in attendance said there was no Resident Council President or other officers. Residents said there had not been an Activity Director in over a year. During an interview on 6/9/22 at 1:10 p.m. LVN L said she had not seen any Resident Council meetings on the memory care unit. She knew they should provide a space and have them if residents wanted to attend. During an interview on 6/9/22 at 2:54 p.m. the DON said Resident council meetings happen monthly or were supposed to happen. She could not say how long it had been since the last resident council meeting. She said Resident council meeting notes were supposed to be taken but when they asked for the minutes, she did not have them. She said the Activity Director was not doing notes and the facility thought it was happening, but it was not. The DON said they had just been so busy and had mentioned about this in morning meeting, but she did not follow through on it. She said it was important for residents to have for their wellbeing. It was the responsibility of the Administrator to ensure the resident council meetings were happening. During an interview on 6/9/22 at 3:30 p.m. the Administrator said they had not had an Activity Director since July of last year. He acknowledged that Resident Council meetings had not been held as they should have been. The Administrator said these meetings not being held could make residents feel ignored or neglected if they can't get their issues addressed. He said he was the one responsible to ensure the resident council meetings were happening and grievances were being followed up on in absence of the social worker. The minutes of the Resident Council meetings for the past 12 months were reviewed and did not provide detailed information according to paperwork provided the last resident council was on 2/21/22. The papers provided were scraps of notebook paper with doodles of hearts and residents' names listed on it. Policy regarding Resident Council was requested, and the Administrator said there was no policy; they used the job description for the Activity Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were made aware of the grievance process for 12 of 12 Residents (Resident #19 and 11 confidential resident) who were reviewed for grievances This deficient practice could place the residents at risk for decrease quality of life and feelings of hopelessness. Findings include: Record review of the face sheet dated 6/9/2022 revealed Resident #19 was a [AGE] year-old-male that admitted to the facility on [DATE]. Resident #19 had diagnoses of polyneuropathy, hemiplegia, unspecified affecting left nondominant side, and major depressive disorder. Record review of an MDS dated [DATE] revealed Resident #19 usually understood and was usually understood by others. The BIMS assessment (Brief interview for Mental Status)-screening tool to assist with identifying a resident's current cognition status) was a 14 which indicated intact cognition. Resident #19 required supervision to limited assistance with ADLs. Record review of undated care plan revealed Resident #19, Activities revealed he would be invited to scheduled activities and be provided with an activities calendar. During a confidential resident group interview on 6/7/22 at 10:00 AM, 11 residents in attendance stated the facility does not have regular Resident Council meetings, but if they did, they would attend. Residents indicated there had been one or two meetings in the last year. Residents in the confidential group interview were aware that they had the right to have a monthly Resident Council meeting. All residents expressed they would attend if they were held. Residents in attendance said there was no Resident Council President or other officers. Residents said there had not been an Activity Director in over a year. Residents said they had not had a social worker for approximately a year. Residents said they did not know how to file a grievance. Residents said when they made complaints or had issues that no one resolved those issues for them. Residents said they felt like no one wanted to address their concerns. During an interview on 6/6/2022 at 10:15 AM Resident #19 said he had filed grievances. He said the grievance process was a joke here. He said nobody writes anything down, so there will be no trail of complaints. Resident #19 said he asked for the issues with his bathroom to be a grievance and the air conditioner vents needing to be cleaned. He said, As you can see both are still untouched. He said it was very frustrating and it made him feel discouraged. He said he was stuck there because of finances and he was miserable. During an interview on 6/9/22 at 2:02 PM, LVN M said grievances were handled by the Social Worker and are filled out on a paper form and the Social Worker then follows up with whatever department it falls under to address. During an interview on 6/7/2022 at 1:22 PM, the DON brought in grievance log for the past 12 months. Three grievances were noted in total in the book. The DON was tearful and stated we don't write grievances down. If a resident has a problem, we just fix it. When asked where they document what the problem was and how they fixed it, the DON stated we don't document it. If a resident is missing clothing, we just go buy them some more clothes, if they lost money, we replace the money. Grievances are a Social Worker job, and we don't have a social worker. I can only be responsible for so much. We are doing our best. During an interview on 6/9/22 at 2:54 PM the DON said grievances were known to them by the Social Worker and since they haven't had a social worker, she was not sure who was in charge that would be a question for the administrator. The DON said when residents had complaints, they handled them and did not document the complaint or the outcome. During an interview on 6/9/22 at 3:30 PM the Administrator said the Social Worker's job had not been done and the grievance process fell through. He said this could leave residents feeling neglected or ignored regarding their concern or complaint. The facility had been without a Social Worker for 2 months. Record review of Grievance log from 6/2021 to 6/2022 indicated 3 grievances were addressed during 2/2022. These were the only grievances noted for the last year. There were no grievances for Resident #19. Policy for Grievances/Complaints was requested, and Administrator said there were no policies the facility followed CMS guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the right to be free from abuse for 3 of 19 residents reviewed for abuse. (Resident #21, Resident #25 and Resident #61) CNA G stated she reported sexually inappropriate behavior to the SW and DON in early March 2022 when Resident #29 was continually being inappropriate with Resident # 21, Resident #25 and Resident #61. CNA G stated she felt the need to report the behaviors because none of the female residents were cognitive enough to understand what was going on and give consent for Resident #29's actions. CNA G stated nothing happened after she reported it for about 3 weeks and then Resident #29 was moved to the memory care unit. The memory care unit was comprised of male and female (28) residents. This failure could place residents at risk for abuse, physical or psychological harm or injury. Findings included: 1. A review of the face sheet dated 6/9/2022 revealed Resident #21 was an [AGE] year-old female with diagnosis that included: dementia, major depressive disorder, anxiety, and contractures of the joints. A review of the MDS provided by the facility revealed an incomplete blank MDS. A review of care plans for Resident #21 with a target date of 4/07/2022 indicated Resident #21 had dementia and was a risk for increased confusion and had a BIMS of 5 which indicated some cognitive impairment. The care plan indicated Resident #21 was usually understood and usually understood others but may miss some part or intent of the message. The care plan indicated Resident #21 was dependent on staff for emotional, leisure, cognitive, religious, physical, and social needs related to cognitive deficits. 2. A review of the face sheet dated 6/9/2022 revealed Resident #61 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included Alzheimer's disorientation, and cognitive communication deficit. A review of the MDS dated [DATE] indicated Resident # 61 was sometimes understood and sometimes understood others. Resident #61 had a BIMS of 00 which indicated severe cognitive deficits. Resident #61 required extensive assistance with ADLs and exhibited no behaviors according to the MDS. A review of the care plan dated 7/20/2021 indicated that Resident #61 had elected to distance herself from others, had trust issues, was confused and dependent on staff for emotional, leisure, cognitive, religious, physical, and social needs related to cognitive deficits. 3. A review of the face sheet dated 6/9/2022 revealed Resident #25 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of cognitive communication deficit, anxiety, Alzheimer's disease, and dementia. A review of the MDS dated [DATE] indicated Resident #25 was usually understood and usually understood others. Resident #25 had a BIMS of 06 which indicated a moderate cognitive impairment. The MDS also revealed inattention and disorganized thinking daily. No behaviors were noted on the MDS. Resident #25 required extensive assistance for ADLs. Review of the care plan for Resident # 25 dated 6/5/2020 revealed impaired cognition related to dementia with impaired decision-making, long-term memory loss and short-term memory loss. 4. A review of the face sheet dated 6/9/2022 revealed Resident #29 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of diabetes type II, anemia and problems related to living alone. Review of the MDS dated [DATE] revealed Resident #29 was usually understood and usually understood others. The BIMS score for Resident #29 was 07 which indicated a moderate cognitive impairment. No behaviors were noted on the MDS. Review of the care plan dated 6/11/2021 revealed Resident #29 had impaired cognition with no behaviors. The care plan revealed Resident #29 was independent and in need of staff for meeting emotional, intellectual, physical, leisure and social needs related to personal choice. During an interview on 6/8/2022 at 10:30am CNA G revealed she reported sexually inappropriate behavior to the SW and DON in early March 2022. There was no documentation of her observations by CNA G. She stated Resident #29 was continually being inappropriate with Resident # 21, Resident #25 and Resident #61. CNA G stated Resident # 29 would rub the inner thigh of these residents, as well as hold their hands and rub their arms while making kissing noises with his mouth. CNA G stated Resident #29 would ask the ladies if they liked sex. CNA G stated she felt the need to report the behaviors because none of the ladies were cognitive enough to understand what was going on and give consent for his actions. CNA G stated no interventions that included the staff were made after she reported it for about 3 weeks and then Resident #29 was moved to the memory care unit. The memory care unit was compromised of male and female (28) residents. CNA G stated there was annual training on abuse and neglect for all staff. During an interview on 6/8/2022 at 10:45 am CNA H revealed Resident #29 liked to smoke, who needed to be encouraged to use the bathroom. Resident #29 responded to verbal cueing easily and was on the unit for wandering in and out of other resident's rooms. Resident #29 was friendly with the female residents. CNA H revealed that those females were gone now, except Resident #25. CNA H revealed Resident #29 had quite a few women he liked to blow kisses and pet on. CNA H participated in annual abuse and neglect training. During an interview and observation on 6/8/22 at 1:05 p.m. Resident #29 stated he had been a resident of the facility for about 1 year. Resident #29 believed he was put on the memory care unit about 2 months ago. Resident #29 stated he liked to hold hands with the female residents in dining room. Resident #29 stated he had blown kisses at and touched the legs of several females when he was outside of the memory care unit. Resident #29 stated he was looking for a woman friend. Resident #29 said that he understood what appropriate and inappropriate behavior was. Resident #29 stated he just stopped if the female staff told him to stop because he did not want any problems or to get into trouble. Resident #29 stated he got in a little trouble when he was outside of the memory care unit for being too friendly and touching female residents. Resident #29 stated staff did not always see when he was being inappropriate but when they did see it, they did correct him and he would stop. Resident #29 stated there were a few women on the memory care unit he would like to have as his woman friend. He stated he blew them kisses and held hands but did not touch legs or ask them for sex. During observations on 6/8/2022 at 1:05PM it was noted that staff were not monitoring Resident #29. Resident #29 was on both halls and in the dining room during observation. Resident #29 was mobile per self-propelled wheelchair. During a record review on 6/8/2022 at 1:15pm the progress notes made by the SW revealed a note from 3/4/2022 at 3:40pm: SW visited with res(ident) to discuss recent behaviors he has been observed displaying related to sexually inappropriate language towards female residents. SW explained that res. is not to physically touch any of the ladies stating you are not allowed to place your hands on any body part of any of the ladies. I understand that you may feel a little lonely and may be looking for companionship, but this is not the place. It is inappropriate to ask female residents about the relationship status or anything related to their sexually. I need you to stop this behavior now, because it can be considered sexual harassment, and could impact your continued stay here. Res verb understanding stating ok, I understand, this is just between you and I right? SW responded. for now, but if I am told that you are still being inappropriate, I will have to discuss with the administrator. Res verb understanding. During an interview on 6/8/2022 at 1:30 pm the DON stated she was unaware of any inappropriate behavior by Resident #29. The DON stated nothing had been reported to her about Resident #29 physically touching or making sexually inappropriate comments to any female residents. The DON read the note by the SW from 3/4/2022 regarding Resident #29 and stated she had no idea the note was in the chart and the SW no longer worked there. The DON stated had she been made aware she would have started an investigation for the incidents. The DON stated inappropriate behavior can be harmful psychologically to the residents. The DON stated the only behaviors she was aware of from Resident #29 was him holding hands with some of the female residents but nothing that was sexually inappropriate. The DON stated abuse of any kind cause depression, anxiety, and fearfulness to any resident effected by it. During an interview on 6/8/2022 at 1:45 pm the Administrator stated he was unaware of any inappropriate behavior by Resident #29. He stated he was the abuse prohibition coordinator, and nothing had been reported to him. He stated that he or the DON are the only abuse coordinators in the building and the staff knew to report to them immediately. The administrator stated if he was made aware of an allegation of abuse of any kind, he immediately investigated it and would report it to state if warranted. The administrator was made aware of the note the SW wrote on 3/4/2022 regarding Resident #29. The administrator stated abuse cause mental as well as physical harm to residents by making them withdrawn. During a phone interview on 6/8/2022 at 3:00pm, Resident #21's responsible party stated he had no concerns with Resident #21's care and nothing concerning or alarming had been reported to him. An interview was attempted on 6/8/2021 at 3:15pm with no answer or return call with the family representative of Resident # 61. During a telephone interview on 6/8/2022 at 3:30 pm Resident #25's family was called with no answer or returned call. During a telephone interview on 6/8/2022 at 3:35pm, Resident #29's family stated no calls had been made to her concerning any behaviors from the facility. The family asked if Resident #29 was misbehaving or was in trouble. She stated the facility only called her for money, they did not call her with care concerns because he was his own responsible party. During a telephone interview on 6/9/2022 at 3:45pm, the SW responsible for the SW note on 3/4/2022 called and stated she remembered the event well. The SW stated that on 3/4/2022 an employee came to her on their way out for the day and stated that Resident #29 was displaying some sexual behaviors that made her uncomfortable. The employee stated that Resident #29 asked a few different residents if they wanted to have sex with him while rubbing on their legs. SW stated she called Resident #29 into her office and spoke with him about his behavior. He stated he understood the behavior could not continue. SW stated this was late on a Friday and everyone was gone. The SW stated she did not think of the incident as abuse at the time. The SW stated she looked over and spoke with the resident he was inappropriate with and there was no evidence of harm. On Monday the SW reported the incident to the DON and asked what interventions would be best for his situation. SW stated the DON said just keep an eye on him. The SW stated she did keep an extra eye on him and did not notice any further behavior. The SW called the psychological service that the facility was using at the time and requested an evaluation related to his behavior. The SW stated that a counselor came out and spoke with Resident #29, however the facility was changing counseling services at this time and it was a few weeks before the other counseling service got him was able to assess Resident #29. The SW stated the DON wanted to get Resident #29 some medication to keep him from getting excited. The SW stated in the meantime the DON requested the MD start Resident #29 on some medication. The SW stated Resident #29 was started on Paxil about 3 weeks after the incident of sexual inappropriateness. None of the observations were noted in Resident #29's file because The SW stated she was directed by the DON to just keep an eye on him. Resident #29 was on the memory care unit. The SW stated Resident #29 never tried to elope and was cognitively intact. The SW stated the facility staff would ask Resident #29 for assistance in translating for some of the Spanish only speaking residents. The SW ended by stating that some of the staff was intimidated by the DON and afraid of retaliation if they reported things to her, that is why she received the report on Resident #29. The SW stated her only role in the process when an abuse allegation was made was to investigate what she was directed by the administrator or DON to investigate. The SW stated she took yearly abuse and neglect courses. An undated facility policy titled Abuse and Neglect Prohibition Policy indicated, 'each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but no limited to, facility staff, other residents, consultants, or volunteers .All direct care staff have been trained to identify the three signs that might indicate abuse of residents. Staff can recognize physical changes, sudden changes in behavior or personality, and fear and anxiety All employees who suspect abuse at any time are to report it to their immediate supervisor. The immediate supervisor will report it to the DON who will report it to the abuse coordinator (the administrator). An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator It is of utmost importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm Inappropriate sexual behavior .must be addressed. The facility must document the behavior, conduct a resident assessment, as necessary, and incorporate in the care plan procedures to address the behavior and protect other residents from the inappropriate behavior.'

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an allegation of sexually abuse was reported immediately for 3 of 19 residents reviewed for abuse. (Resident #21, Resident #25 and Resident #61) CNA G stated she reported sexually inappropriate behavior to the SW and DON in early March 2022 when Resident #29 was continually being inappropriate with Resident # 21, Resident #25 and Resident #61. CNA G stated she felt the need to report the behaviors because none of the female residents were cognitive enough to understand what was going on and give consent for Resident #29's actions. CNA G stated nothing happened after she reported it for about 3 weeks and then Resident #29 was moved to the memory care unit. The memory care unit was comprised of male and female (28) residents. This failure could place residents at risk for abuse, physical or psychological harm or injury. Findings included: 1. A review of the face sheet dated 6/9/2022 revealed Resident #21 was an [AGE] year-old female with diagnosis that included: dementia, major depressive disorder, anxiety, and contractures of the joints. A review of the MDS provided by the facility revealed an incomplete blank MDS. A review of care plans for Resident #21 with a target date of 4/07/2022 indicated Resident #21 had dementia and was a risk for increased confusion and had a BIMS of 5 which indicated some cognitive impairment. The care plan indicated Resident #21 was usually understood and usually understood others but may miss some part or intent of the message. The care plan indicated Resident #21 was dependent on staff for emotional, leisure, cognitive, religious, physical, and social needs related to cognitive deficits. 2. A review of the face sheet dated 6/9/2022 revealed Resident #61 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included Alzheimer's disorientation, and cognitive communication deficit. A review of the MDS dated [DATE] indicated Resident # 61 was sometimes understood and sometimes understood others. Resident #61 had a BIMS of 00 which indicated severe cognitive deficits. Resident #61 required extensive assistance with ADLs and exhibited no behaviors according to the MDS. A review of the care plan dated 7/20/2021 indicated that Resident #61 had elected to distance herself from others, had trust issues, was confused and dependent on staff for emotional, leisure, cognitive, religious, physical, and social needs related to cognitive deficits. 3. A review of the face sheet dated 6/9/2022 revealed Resident #25 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of cognitive communication deficit, anxiety, Alzheimer's disease, and dementia. A review of the MDS dated [DATE] indicated Resident #25 was usually understood and usually understood others. Resident #25 had a BIMS of 06 which indicated a moderate cognitive impairment. The MDS also revealed inattention and disorganized thinking daily. No behaviors were noted on the MDS. Resident #25 required extensive assistance for ADLs. Review of the care plan for Resident # 25 dated 6/5/2020 revealed impaired cognition related to dementia with impaired decision-making, long-term memory loss and short-term memory loss. 4. A review of the face sheet dated 6/9/2022 revealed Resident #29 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of diabetes type II, anemia and problems related to living alone. Review of the MDS dated [DATE] revealed Resident #29 was usually understood and usually understood others. The BIMS score for Resident #29 was 07 which indicated a moderate cognitive impairment. No behaviors were noted on the MDS. Review of the care plan dated 6/11/2021 revealed Resident #29 had impaired cognition with no behaviors. The care plan revealed Resident #29 was independent and in need of staff for meeting emotional, intellectual, physical, leisure and social needs related to personal choice. During an interview on 6/8/2022 at 10:30am CNA G revealed she reported sexually inappropriate behavior to the SW and DON in early March 2022. There was no documentation of her observations by CNA G. She stated Resident #29 was continually being inappropriate with Resident # 21, Resident #25 and Resident #61. CNA G stated Resident # 29 would rub the inner thigh of these residents, as well as hold their hands and rub their arms while making kissing noises with his mouth. CNA G stated Resident #29 would ask the ladies if they liked sex. CNA G stated she felt the need to report the behaviors because none of the ladies were cognitive enough to understand what was going on and give consent for his actions. CNA G stated no interventions that included the staff were made after she reported it for about 3 weeks and then Resident #29 was moved to the memory care unit. The memory care unit was compromised of male and female (28) residents. CNA G stated there was annual training on abuse and neglect for all staff. During an interview on 6/8/2022 at 10:45 am CNA H revealed Resident #29 liked to smoke, who needed to be encouraged to use the bathroom. Resident #29 responded to verbal cueing easily and was on the unit for wandering in and out of other resident's rooms. Resident #29 was friendly with the female residents. CNA H revealed that those females were gone now, except Resident #25. CNA H revealed Resident #29 had quite a few women he liked to blow kisses and pet on. CNA H participated in annual abuse and neglect training. During an interview and observation on 6/8/22 at 1:05 p.m. Resident #29 stated he had been a resident of the facility for about 1 year. Resident #29 believed he was put on the memory care unit about 2 months ago. Resident #29 stated he liked to hold hands with the female residents in dining room. Resident #29 stated he had blown kisses at and touched the legs of several females when he was outside of the memory care unit. Resident #29 stated he was looking for a woman friend. Resident #29 said that he understood what appropriate and inappropriate behavior was. Resident #29 stated he just stopped if the female staff told him to stop because he did not want any problems or to get into trouble. Resident #29 stated he got in a little trouble when he was outside of the memory care unit for being too friendly and touching female residents. Resident #29 stated staff did not always see when he was being inappropriate but when they did see it, they did correct him and he would stop. Resident #29 stated there were a few women on the memory care unit he would like to have as his woman friend. He stated he blew them kisses and held hands but did not touch legs or ask them for sex. During observations on 6/8/2022 at 1:05PM it was noted that staff were not monitoring Resident #29. Resident #29 was on both halls and in the dining room during observation. Resident #29 was mobile per self-propelled wheelchair. During a record review on 6/8/2022 at 1:15pm the progress notes made by the SW revealed a note from 3/4/2022 at 3:40pm: SW visited with res(ident) to discuss recent behaviors he has been observed displaying related to sexually inappropriate language towards female residents. SW explained that res. is not to physically touch any of the ladies stating you are not allowed to place your hands on any body part of any of the ladies. I understand that you may feel a little lonely and may be looking for companionship, but this is not the place. It is inappropriate to ask female residents about the relationship status or anything related to their sexually. I need you to stop this behavior now, because it can be considered sexual harassment, and could impact your continued stay here. Res verb understanding stating ok, I understand, this is just between you and I right? SW responded. for now, but if I am told that you are still being inappropriate, I will have to discuss with the administrator. Res verb understanding. During an interview on 6/8/2022 at 1:30 pm the DON stated she was unaware of any inappropriate behavior by Resident #29. The DON stated nothing had been reported to her about Resident #29 physically touching or making sexually inappropriate comments to any female residents. The DON read the note by the SW from 3/4/2022 regarding Resident #29 and stated she had no idea the note was in the chart and the SW no longer worked there. The DON stated had she been made aware she would have started an investigation for the incidents. The DON stated inappropriate behavior can be harmful psychologically to the residents. The DON stated the only behaviors she was aware of from Resident #29 was him holding hands with some of the female residents but nothing that was sexually inappropriate. The DON stated abuse of any kind cause depression, anxiety, and fearfulness to any resident effected by it. During an interview on 6/8/2022 at 1:45 pm the Administrator stated he was unaware of any inappropriate behavior by Resident #29. He stated he was the abuse prohibition coordinator, and nothing had been reported to him. He stated that he or the DON are the only abuse coordinators in the building and the staff knew to report to them immediately. The administrator stated if he was made aware of an allegation of abuse of any kind, he immediately investigated it and would report it to state if warranted. The administrator was made aware of the note the SW wrote on 3/4/2022 regarding Resident #29. The administrator stated abuse cause mental as well as physical harm to residents by making them withdrawn. During a phone interview on 6/8/2022 at 3:00pm, Resident #21's responsible party stated he had no concerns with Resident #21's care and nothing concerning or alarming had been reported to him. An interview was attempted on 6/8/2021 at 3:15pm with no answer or return call with the family representative of Resident # 61. During a telephone interview on 6/8/2022 at 3:30 pm Resident #25's family was called with no answer or returned call. During a telephone interview on 6/8/2022 at 3:35pm, Resident #29's family stated no calls had been made to her concerning any behaviors from the facility. The family asked if Resident #29 was misbehaving or was in trouble. She stated the facility only called her for money, they did not call her with care concerns because he was his own responsible party. During a telephone interview on 6/9/2022 at 3:45pm, the SW responsible for the SW note on 3/4/2022 called and stated she remembered the event well. The SW stated that on 3/4/2022 an employee came to her on their way out for the day and stated that Resident #29 was displaying some sexual behaviors that made her uncomfortable. The employee stated that Resident #29 asked a few different residents if they wanted to have sex with him while rubbing on their legs. SW stated she called Resident #29 into her office and spoke with him about his behavior. He stated he understood the behavior could not continue. SW stated this was late on a Friday and everyone was gone. The SW stated she did not think of the incident as abuse at the time. The SW stated she looked over and spoke with the resident he was inappropriate with and there was no evidence of harm. On Monday the SW reported the incident to the DON and asked what interventions would be best for his situation. SW stated the DON said just keep an eye on him. The SW stated she did keep an extra eye on him and did not notice any further behavior. The SW called the psychological service that the facility was using at the time and requested an evaluation related to his behavior. The SW stated that a counselor came out and spoke with Resident #29, however the facility was changing counseling services at this time and it was a few weeks before the other counseling service got him was able to assess Resident #29. The SW stated the DON wanted to get Resident #29 some medication to keep him from getting excited. The SW stated in the meantime the DON requested the MD start Resident #29 on some medication. The SW stated Resident #29 was started on Paxil about 3 weeks after the incident of sexual inappropriateness. None of the observations were noted in Resident #29's file because The SW stated she was directed by the DON to just keep an eye on him. Resident #29 was on the memory care unit. The SW stated Resident #29 never tried to elope and was cognitively intact. The SW stated the facility staff would ask Resident #29 for assistance in translating for some of the Spanish only speaking residents. The SW ended by stating that some of the staff was intimidated by the DON and afraid of retaliation if they reported things to her, that is why she received the report on Resident #29. The SW stated her only role in the process when an abuse allegation was made was to investigate what she was directed by the administrator or DON to investigate. The SW stated she took yearly abuse and neglect courses. An undated facility policy titled Abuse and Neglect Prohibition Policy indicated, 'each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but no limited to, facility staff, other residents, consultants, or volunteers .All direct care staff have been trained to identify the three signs that might indicate abuse of residents. Staff can recognize physical changes, sudden changes in behavior or personality, and fear and anxiety All employees who suspect abuse at any time are to report it to their immediate supervisor. The immediate supervisor will report it to the DON who will report it to the abuse coordinator (the administrator). An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator It is of utmost importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm Inappropriate sexual behavior .must be addressed. The facility must document the behavior, conduct a resident assessment, as necessary, and incorporate in the care plan procedures to address the behavior and protect other residents from the inappropriate behavior.'

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an allegation of sexually abuse was thoroughly investigated for 3 of 19 residents reviewed for abuse. (Resident #21, Resident #25 and Resident #61) CNA G stated she reported sexually inappropriate behavior to the SW and DON in early March 2022 when Resident #29 was continually being inappropriate with Resident # 21, Resident #25 and Resident #61. CNA G stated she felt the need to report the behaviors because none of the female residents were cognitive enough to understand what was going on and give consent for Resident #29's actions. CNA G stated nothing happened after she reported it for about 3 weeks and then Resident #29 was moved to the memory care unit. The memory care unit was comprised of male and female (28) residents. This failure could place residents at risk for abuse, physical or psychological harm or injury. Findings included: 1. A review of the face sheet dated 6/9/2022 revealed Resident #21 was an [AGE] year-old female with diagnosis that included: dementia, major depressive disorder, anxiety, and contractures of the joints. A review of the MDS provided by the facility revealed an incomplete blank MDS. A review of care plans for Resident #21 with a target date of 4/07/2022 indicated Resident #21 had dementia and was a risk for increased confusion and had a BIMS of 5 which indicated some cognitive impairment. The care plan indicated Resident #21 was usually understood and usually understood others but may miss some part or intent of the message. The care plan indicated Resident #21 was dependent on staff for emotional, leisure, cognitive, religious, physical, and social needs related to cognitive deficits. 2. A review of the face sheet dated 6/9/2022 revealed Resident #61 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included Alzheimer's disorientation, and cognitive communication deficit. A review of the MDS dated [DATE] indicated Resident # 61 was sometimes understood and sometimes understood others. Resident #61 had a BIMS of 00 which indicated severe cognitive deficits. Resident #61 required extensive assistance with ADLs and exhibited no behaviors according to the MDS. A review of the care plan dated 7/20/2021 indicated that Resident #61 had elected to distance herself from others, had trust issues, was confused and dependent on staff for emotional, leisure, cognitive, religious, physical, and social needs related to cognitive deficits. 3. A review of the face sheet dated 6/9/2022 revealed Resident #25 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of cognitive communication deficit, anxiety, Alzheimer's disease, and dementia. A review of the MDS dated [DATE] indicated Resident #25 was usually understood and usually understood others. Resident #25 had a BIMS of 06 which indicated a moderate cognitive impairment. The MDS also revealed inattention and disorganized thinking daily. No behaviors were noted on the MDS. Resident #25 required extensive assistance for ADLs. Review of the care plan for Resident # 25 dated 6/5/2020 revealed impaired cognition related to dementia with impaired decision-making, long-term memory loss and short-term memory loss. 4. A review of the face sheet dated 6/9/2022 revealed Resident #29 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of diabetes type II, anemia and problems related to living alone. Review of the MDS dated [DATE] revealed Resident #29 was usually understood and usually understood others. The BIMS score for Resident #29 was 07 which indicated a moderate cognitive impairment. No behaviors were noted on the MDS. Review of the care plan dated 6/11/2021 revealed Resident #29 had impaired cognition with no behaviors. The care plan revealed Resident #29 was independent and in need of staff for meeting emotional, intellectual, physical, leisure and social needs related to personal choice. During an interview on 6/8/2022 at 10:30am CNA G revealed she reported sexually inappropriate behavior to the SW and DON in early March 2022. There was no documentation of her observations by CNA G. She stated Resident #29 was continually being inappropriate with Resident # 21, Resident #25 and Resident #61. CNA G stated Resident # 29 would rub the inner thigh of these residents, as well as hold their hands and rub their arms while making kissing noises with his mouth. CNA G stated Resident #29 would ask the ladies if they liked sex. CNA G stated she felt the need to report the behaviors because none of the ladies were cognitive enough to understand what was going on and give consent for his actions. CNA G stated no interventions that included the staff were made after she reported it for about 3 weeks and then Resident #29 was moved to the memory care unit. The memory care unit was compromised of male and female (28) residents. CNA G stated there was annual training on abuse and neglect for all staff. During an interview on 6/8/2022 at 10:45 am CNA H revealed Resident #29 liked to smoke, who needed to be encouraged to use the bathroom. Resident #29 responded to verbal cueing easily and was on the unit for wandering in and out of other resident's rooms. Resident #29 was friendly with the female residents. CNA H revealed that those females were gone now, except Resident #25. CNA H revealed Resident #29 had quite a few women he liked to blow kisses and pet on. CNA H participated in annual abuse and neglect training. During an interview and observation on 6/8/22 at 1:05 p.m. Resident #29 stated he had been a resident of the facility for about 1 year. Resident #29 believed he was put on the memory care unit about 2 months ago. Resident #29 stated he liked to hold hands with the female residents in dining room. Resident #29 stated he had blown kisses at and touched the legs of several females when he was outside of the memory care unit. Resident #29 stated he was looking for a woman friend. Resident #29 said that he understood what appropriate and inappropriate behavior was. Resident #29 stated he just stopped if the female staff told him to stop because he did not want any problems or to get into trouble. Resident #29 stated he got in a little trouble when he was outside of the memory care unit for being too friendly and touching female residents. Resident #29 stated staff did not always see when he was being inappropriate but when they did see it, they did correct him and he would stop. Resident #29 stated there were a few women on the memory care unit he would like to have as his woman friend. He stated he blew them kisses and held hands but did not touch legs or ask them for sex. During observations on 6/8/2022 at 1:05PM it was noted that staff were not monitoring Resident #29. Resident #29 was on both halls and in the dining room during observation. Resident #29 was mobile per self-propelled wheelchair. During a record review on 6/8/2022 at 1:15pm the progress notes made by the SW revealed a note from 3/4/2022 at 3:40pm: SW visited with res(ident) to discuss recent behaviors he has been observed displaying related to sexually inappropriate language towards female residents. SW explained that res. is not to physically touch any of the ladies stating you are not allowed to place your hands on any body part of any of the ladies. I understand that you may feel a little lonely and may be looking for companionship, but this is not the place. It is inappropriate to ask female residents about the relationship status or anything related to their sexually. I need you to stop this behavior now, because it can be considered sexual harassment, and could impact your continued stay here. Res verb understanding stating ok, I understand, this is just between you and I right? SW responded. for now, but if I am told that you are still being inappropriate, I will have to discuss with the administrator. Res verb understanding. During an interview on 6/8/2022 at 1:30 pm the DON stated she was unaware of any inappropriate behavior by Resident #29. The DON stated nothing had been reported to her about Resident #29 physically touching or making sexually inappropriate comments to any female residents. The DON read the note by the SW from 3/4/2022 regarding Resident #29 and stated she had no idea the note was in the chart and the SW no longer worked there. The DON stated had she been made aware she would have started an investigation for the incidents. The DON stated inappropriate behavior can be harmful psychologically to the residents. The DON stated the only behaviors she was aware of from Resident #29 was him holding hands with some of the female residents but nothing that was sexually inappropriate. The DON stated abuse of any kind cause depression, anxiety, and fearfulness to any resident effected by it. During an interview on 6/8/2022 at 1:45 pm the Administrator stated he was unaware of any inappropriate behavior by Resident #29. He stated he was the abuse prohibition coordinator, and nothing had been reported to him. He stated that he or the DON are the only abuse coordinators in the building and the staff knew to report to them immediately. The administrator stated if he was made aware of an allegation of abuse of any kind, he immediately investigated it and would report it to state if warranted. The administrator was made aware of the note the SW wrote on 3/4/2022 regarding Resident #29. The administrator stated abuse cause mental as well as physical harm to residents by making them withdrawn. During a phone interview on 6/8/2022 at 3:00pm, Resident #21's responsible party stated he had no concerns with Resident #21's care and nothing concerning or alarming had been reported to him. An interview was attempted on 6/8/2021 at 3:15pm with no answer or return call with the family representative of Resident # 61. During a telephone interview on 6/8/2022 at 3:30 pm Resident #25's family was called with no answer or returned call. During a telephone interview on 6/8/2022 at 3:35pm, Resident #29's family stated no calls had been made to her concerning any behaviors from the facility. The family asked if Resident #29 was misbehaving or was in trouble. She stated the facility only called her for money, they did not call her with care concerns because he was his own responsible party. During a telephone interview on 6/9/2022 at 3:45pm, the SW responsible for the SW note on 3/4/2022 called and stated she remembered the event well. The SW stated that on 3/4/2022 an employee came to her on their way out for the day and stated that Resident #29 was displaying some sexual behaviors that made her uncomfortable. The employee stated that Resident #29 asked a few different residents if they wanted to have sex with him while rubbing on their legs. SW stated she called Resident #29 into her office and spoke with him about his behavior. He stated he understood the behavior could not continue. SW stated this was late on a Friday and everyone was gone. The SW stated she did not think of the incident as abuse at the time. The SW stated she looked over and spoke with the resident he was inappropriate with and there was no evidence of harm. On Monday the SW reported the incident to the DON and asked what interventions would be best for his situation. SW stated the DON said just keep an eye on him. The SW stated she did keep an extra eye on him and did not notice any further behavior. The SW called the psychological service that the facility was using at the time and requested an evaluation related to his behavior. The SW stated that a counselor came out and spoke with Resident #29, however the facility was changing counseling services at this time and it was a few weeks before the other counseling service got him was able to assess Resident #29. The SW stated the DON wanted to get Resident #29 some medication to keep him from getting excited. The SW stated in the meantime the DON requested the MD start Resident #29 on some medication. The SW stated Resident #29 was started on Paxil about 3 weeks after the incident of sexual inappropriateness. None of the observations were noted in Resident #29's file because The SW stated she was directed by the DON to just keep an eye on him. Resident #29 was on the memory care unit. The SW stated Resident #29 never tried to elope and was cognitively intact. The SW stated the facility staff would ask Resident #29 for assistance in translating for some of the Spanish only speaking residents. The SW ended by stating that some of the staff was intimidated by the DON and afraid of retaliation if they reported things to her, that is why she received the report on Resident #29. The SW stated her only role in the process when an abuse allegation was made was to investigate what she was directed by the administrator or DON to investigate. The SW stated she took yearly abuse and neglect courses. An undated facility policy titled Abuse and Neglect Prohibition Policy indicated, 'each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but no limited to, facility staff, other residents, consultants, or volunteers .All direct care staff have been trained to identify the three signs that might indicate abuse of residents. Staff can recognize physical changes, sudden changes in behavior or personality, and fear and anxiety All employees who suspect abuse at any time are to report it to their immediate supervisor. The immediate supervisor will report it to the DON who will report it to the abuse coordinator (the administrator). An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator It is of utmost importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm Inappropriate sexual behavior .must be addressed. The facility must document the behavior, conduct a resident assessment, as necessary, and incorporate in the care plan procedures to address the behavior and protect other residents from the inappropriate behavior.'

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure assessments accurately reflected the status for 5 of 19 residents reviewed for assessments. (Resident #13, Resident #17, Resident #19, Resident #48, Resident #60). The facility failed to accurately code Resident #13's preferred language as Spanish and needed or wanted interpreter for communication on following MDS after the admission MDS. The facility failed to accurately code Resident #17 as having contractures to upper and lower extremities on the MDS. The facility inaccurately coded Resident #19's Plavix (antiplatelet) as an anticoagulant on the MDS. The facility failed to accurately code Resident #48 as PASRR (Pre-admission Screening and Resident Review) positive and qualified due to intellectual and developmental disability on the MDS. The facility failed to accurately coded Resident #60's preferred language of Spanish and wish or need for interpreter to communicate with doctor or healthcare staff on the MDS. The facility failed to complete Resident 60's annually MDS assessment for Sections B, C, D, E, F, part of J, and Q dated 5/18/22. These failures could place residents at risk of having inaccurate assessments, not having individual needs met and a decreased quality of life. Findings included: 1. Record review of Resident #13's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included dementia, Alzheimer's, diabetes, weakness, schizophrenia (mental disorder), depression, anxiety, high blood pressure, heart disease, and kidney disease. Record review of Resident #13's admission MDS dated [DATE] performed by LVN EE and LCSW FF, revealed the resident was Hispanic; resident needed or wanted an interpreter to communicate with a doctor or health care staff and her preferred language was Spanish; had a BIMS of 3 indicating she was cognitively severely impaired. The MDS indicated the resident required limited to extensive assistance of one person to physically assist with ADLs. Record review of Resident #13's Resident Assessment and Care Screening MDS dated [DATE], completed by LVN AA, revealed the resident was Hispanic and did not want or need an interpreter to communicate with a doctor or health care staff; had a BIMS of 3 indicating she was cognitively severely impaired. The MDS indicated the resident required limited to extensive assistance of one person to physically assist with ADLs. 2. Record review of the consolidated physician orders dated 6/9/22 revealed Resident #17 was [AGE] years old, female and admitted on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (result from either nonpenetrating or penetrating trauma to the head), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epilepsy (a disorder of the brain characterized by repeated seizures), hemiplegia (paralysis of one side of the body), and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). The consolidated physician order dated 4/7/22 revealed admit to hospice with diagnosis of cerebral infarct (stroke). Record review of the MDS dated [DATE], completed by RN DD and LCSW BB revealed Resident #17 was rarely/never understood and rarely/never understood others. The MDS revealed since Resident #17 was rarely/never understood, the BIMS (Brief Interview for Mental Status) could not be completed. The MDS revealed Resident #17 required extensive assistance for dressing and personal hygiene. The MDS revealed Resident #17 required total dependence for transfer with two persons assist, eating, toilet use and bathing. The MDS revealed Resident #17 had no impairment to upper or lower extremities. Record review of the undated care plan revealed Resident #17 had ADL self-care performance deficit related to impaired cognition/declined manifested with diagnosis of dementia. Interventions included bathing/showers required extensive assistance with 1 person assist, ambulate with supervision, and bed mobility required total assistance of 1-2 persons. The care plan revealed Resident #17 had palliative care due to disease process. The care plan revealed Resident #17 had alternation in muscle skeletal status related to contracture of neck and bilateral foot drop. Intervention included anticipate and meet needs, monitor for fatigue, and PT/OT services/interventions in place. The care plan revealed Resident #17 was at risk for falls due to poor safety awareness, impaired cognition, and unsteady gait/balance. Interventions included required supervision-limited assistance for ambulation and assist to activities. During an observation on 6/6/22 at 10:30 a.m. Resident #17 was in a wheelchair. Resident #17 had contractures to her neck and upper extremities. During an observation on 6/7/22 at 9:20 a.m., Resident #17 was in bed and was getting prepped for mechanical lift transfer by CNA D and CNA P. Resident #17's blanket was removed, and contractures noted to left arm and leg. During an interview on 6/6/22 at 2:46 p.m., the family member of Resident #17 said she had been on hospice since March of this year. The family member said Resident #17 was wheelchair bound and occasionally would squeeze his hand when prompted. The family member said Resident #17 disease process had rapidly changed her and she no longer hung out at the nurse's station or listened to music. 3. Record review of the consolidated physician orders dated 6/9/2022 revealed Resident #19 was a [AGE] year-old-male that admitted to the facility on [DATE]. Resident #19 had diagnoses of cerebral infarction (stroke) due to unspecified occlusion or stenosis (narrowing), peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and hypertension (high blood pressure). The consolidated physician orders dated 3/30/19 revealed Plavix (works by blocking platelets from sticking together and prevents them from forming harmful clots. It is an antiplatelet drug) for peripheral vascular disease. Record review an MDS dated [DATE], completed by LVN AA and LCSW BB, revealed Resident #19 usually understood and was usually understood by others. The BIMS assessment (Brief interview for Mental Status)-screening tool to assist with identifying a resident's current cognition status) was a 14 which indicated intact cognition. Resident #19 required supervision to limited assistance with ADLs. The MDS revealed Resident #19 received an anticoagulant (medications that decrease your blood's ability to clot; help stop your blood from thickening or clotting.) in last 7 days. Record review of undated care plan received from the facility on 6/9/22 revealed Resident #19 received an anticoagulant medication and was at risk for increase bleeding, bruising, etc. Interventions included attempt to avoid any injury causing bruising, cuts, or abrasions, give meds per MD order, and monitor for increased bruising, bleeding, dark brown or blood-tinged body secretions, abnormal pain or swelling, back pain, severe headache or increased joint pain. 4. Record review of the consolidated physician order dated 6/9/22 revealed Resident #48 was [AGE] years old, female and admitted on [DATE] with diagnoses including chronic respiratory failure (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide), dyspnea (difficulty or labored breathing), lymphedema (a blockage in the lymphatic system, part of the immune and circulatory systems.), intellectual disability (Below average intelligence and set of life skills present before age [AGE]), stage 2 chronic kidney disease (damage to your kidneys is still mild), bipolar disorder (is a mental health condition that causes extreme mood swings), and difficulty walking. The consolidated physician order did not reveal an order for oxygen therapy. Record review of the MDS dated [DATE], completed by LVN AA, revealed Resident #48 was not considered by the state level to have serious mental illness and/or intellectual disability or a related condition on the PASRR II. The MDS revealed Resident #48 did not have dyspnea (shortness of breath). The MDS revealed Resident #48 was understood and understood others. The MDS revealed Resident #48 had a BIMS score of 15 which indicated intact cognition. The MDS revealed Resident #48 required supervision for ADLs except extensive assistance for bathing. The MDS did not address Resident #48's PASRR positive status or short of breath (dyspnea) which she has a diagnosis of. Record review of the undated care plan revealed Resident #48 had ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, limited range of motion, and chronic pain. Intervention included supervision for ADLs and assist with sponge bath when shower cannot be tolerated. The care plan revealed Resident #48 had diagnosis of obstructive sleep apnea (serious sleep disorder in which breathing repeatedly stops and starts), chronic respiratory failure, asthma (a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe.), morbid obesity (weight is more than 80 to 100 pounds above their ideal body weight), and chronic allergies. Intervention included pain management and position resident with proper alignment as needed for optimal breathing pattern. The care plan revealed Resident #48 was PASRR positive related to intellectual disability. Record review of PASRR Comprehensive Service Plan Form dated 4/22/21 revealed Resident #48 was PASRR positive for intellectual disability. During an observation and interview on 6/6/22 at 11:20 a.m., Resident #48 was lying in bed with a nasal cannula on her face. Resident #48 struggled to sit up in bed and became slightly short of breath. 4. Record review of the consolidated physician orders dated 6/9/22 revealed Resident #60 was [AGE] years old, female, and admitted on [DATE] with diagnoses including COVID-19, Alzheimer's disease, cognitive communication deficit, heart failure, and need for assistance with personal care. Record review of the MDS dated [DATE], completed by LVN CC revealed Resident #60 was Hispanic or Latino. The MDS revealed Resident #60 did not have preferred language and did not need or want an interpreter to communicate with a doctor or health care staff. The MDS revealed Resident #60 required extensive assistance for dressing, toilet use, and personal hygiene but total assistance for bathing. The MDS revealed Sections B, C, D, E, F, part of J, and Q were not answered for Resident #60's assessment. Record review of the undated care plan received from the facility on 6/9/22 revealed Resident #60 had a diagnosis of Dementia and at risk for increase in confusion and decline in ADLs as the disease progresses. Resident #60 had a BIMS score of 10 which indicated moderately impaired cognition. Goal of Resident #60 will be able to communicate basic needs on a daily basis. The care plan revealed Resident #60 had potential for communication problems related to Spanish being primary language but speak and understood some English. Interventions included allow time to respond, request clarification, and provide translator as needed. During an interview by phone on 6/8/22 at 1:37 p.m., the corporate MDS nurse stated she did not complete MDS assessments at the facility. She only comes on Monday and completes the assessments required to complete the MDS. The facility employees 3 prn nurses that come in when they can and work on MDSs to keep them up to date. The MDS nurses were responsible for completing and updating the care plans as they completed the MDS. Baseline care plans were the responsibility of the charge nurse. She stated MDS accuracy was important because the plan of care is created by the information coded on the MDS. The plan of care was how the employees knew what kind of care each resident needs. The corporate MDS nurse stated inaccurate assessments and care plans that are not complete or revised could negatively affect the care of the residents because the resident might not receive appropriate care, decreasing their quality of life. During an interview on 6/9/22 at 1:10 p.m., LVN H said she had been at the facility for 19 years and was a charge nurse. She said Resident #17 used to walk and is currently wheelchair bound. She said she did not know if Resident #17 was on Hospice or if she was on palliative care. She said it was important to know if Resident #17 was hospice to ensure she received the care according to family wishes. She said it should be on her MDS and care plan. LVN H said she believed Resident #48 was PASSR positive. LVN H said nursing staff should document accurately to ensure correct information is transferred to the care plan and MDS. She said Resident #60's primarily language was probably Spanish, but she can speak some broken English. She said the facility should have a process in place to communicate with non-English speaking residents. She said it was important be able to communicate with non-English speaking residents in case anything changes with them. She said if the MDS or care plan said Spanish speaking only or wanted and needed interpreter, then it is important to do that. LVN H said Plavix was an anticoagulant or antiplatelet. She said coding the wrong medication class could cause staff to be looking for the wrong side effects. She said currently the facility was using a corporate MDS coordinator and they were responsible for the care plan and MDSs. During an interview on 6/9/22 at 2:02 p.m., LVN L said she had been at the facility for 13 years and was a charge nurse. She said when a resident has a change of condition, staff should verbally notify the MDS coordinator and write a progress note. She said it was important for accurate information to be documented no significant change was not missed. She said Resident #17 was on hospice and it should be documented in her chart and on her MDS and care plan. She said Resident #17 hospice status should be known to provide what the hospice company request. LVN L said Resident #48 was PASRR positive and was documented under the medical diagnosis. She said it should be on the MDS then placed on the care plan. She said it was important to monitor for behaviors, address them correctly, and receive appropriate services. She said there should be procedures in place to communicate with non-English speaking residents. She said accurate communication would be nice for resident. LVN L said she thought Plavix was an anticoagulant or maybe it was an antiplatelet which can be confusing. She said on the physician orders, the medication class is noted. She said if Plavix was coded wrong, it may be mixed with another drug or wrong labs could me ordered. LVN L said resident's needs and wants could not be addressed and overall care could be poor. During an interview on 6/9/22 at 2:54 p.m., the DON said she had been at the facility for 20 years. The DON said MDSs, and care plans should be accurate to show who the residents are. She said the facility did not have a MDS nurse or social worker. She the corporate MDS was handling assessments. She said inaccurate assessments can affect the resident's care and cause wrong coding on the MDS. She said Resident #48 was PASRR positive and should code on her MDS. She said all the information should be documented so everyone knowns and the social worker should have documented it. She said Resident #17 was on hospice and it should be on her MDS and care plan. She said it was important to follow the hospice plan of care. She said Resident #13 and Resident #60's primary language was Spanish. She said it was important to communicate in the Resident's preferred language to meet there needs. During an interview on 6/9/22 at 3:30 p.m., the administrator said the facility did not have a MDS coordinator or social works for the last 30 days, so care plan and MDS may be inaccurate. He said if staff could not communicate with residents through staff then they should use the phone system. He said it was important to provide information in the resident native language to accurately communicate. On 6/8/22 at 3:35 p.m., a policy regarding accuracy of assessment on the MDS was requested from the DON. The DON said the facility did not have one but followed CMS guidelines.

**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 baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 4 (Resident #188, Resident #46, Resident #73, and Resident #58) of 5 residents reviewed for baseline care plans. The facility failed to ensure resident's baseline care plan accurately reflected the resident's goals and discharge planning and were shared with the resident and/or family. This failure could place newly admitted residents at risk of receiving inadequate care and services. Findings included: 1.Record review of the face sheet dated 6/9/2022 indicated that Resident #188 admitted on [DATE] with the following diagnoses: acquired absence of the left foot, hypertension, and depression. Record review of the MDS for Resident #188 dated 6/13/2022 was incomplete with no BIMS information noted. Record review of MD orders for Resident #188 dated 06/09/2022 revealed orders for IV Vancomycin 750mg in 250ml of normal saline for wound infection daily ordered 5/31/2022 and clean surgical wound to left foot apply with NS (normal saline) to wound bed, pat dry, apply green foam, apply wound vac at 125 mm HG continuous suction every Monday-Wednesday- Friday until healed dated 5/31/2022. Record review of care plan for Resident #188 initiated on 6/7/2022 revealed a problem listed as: The resident wishes to go home. The goal area of the care plan was left blank. No care plan was noted for IV medication or wound vac for wound care. During a record review of the admission assessment for Resident #188 with the start date of 5/31/2022 and the completion date of 6/1/2022 it was noted under the baseline care plan section that no discharge goals were selected. The discharge section under baseline care plan is blank. There was no indication of IV antibiotics or wound vac for wound care. During an interview on 6/6/2022 at 10:00am, Resident #188 stated she had been in the facility about 1 week and no one had talked with her about her discharge goals. Resident #188 was able to understand questions and was understood. Resident #188 stated she was waiting for someone to tell her how long she would have to be here and how long she would have to take IV medications. Resident #188 stated she asked LVN N on multiple occasions if she knew anything about her going home and LVN N always responded she did not know but would find out. Resident #188 stated she had not been involved with a care plan meeting and never received a copy of her baseline care plan. 2. Record review of the face sheet dated 6/9/2022 indicated that Resident #46 was an [AGE] year-old female that admitted on [DATE]. Resident #46 had the following diagnosis: need for assistance with personal care, anxiety, and presence of a left artificial hip joint. Record review of the MDS dated [DATE] indicated Resident #46 was understood and understood others. Resident #46 had a BIMS scored of 14 which indicated no memory problems or cognitive deficit noted. Record review of a care plan dated 06/01/2022 indicated Resident #46 wished to discharge to the community. The goal section of the care plan had no dates, milestones or abilities listed. There was no baseline care plan located in the file. During a record review of the admission assessment with the open date of 4/19/2022 and the closed date of 4/21/2022 the section on discharge planning was filled out incorrectly with all boxes being checked. This indicated that the resident wanted to discharge home, stay in the facility long term, and be transferred to another facility. No clear plan or goals were selected. During an interview on 6/6/2022 at 10:15am, Resident #46 revealed the desire to discharge to the community and stated she was told by the nursing staff the social worker would help her with discharge planning. Resident #46 stated no one asked her about discharge planning since her admit. Resident #46 stated she did not participate in a care plan meeting and was not given a copy or able to review her plan of care. 3. Record review of the face sheet dated 6/9/2022 indicated that Resident # 73 was admitted to the facility on [DATE] with the diagnosis of diabetes type II, morbid obesity(Individuals are usually considered morbidly obese if their weight is more than 80 to 100 pounds above their ideal body weight), and depressive disorder. Record review of the MDS dated [DATE] indicated Resident #73 was understood and understands. The BIMS for Resident #73 was 14, which indicated Resident #73 had no cognitive deficit. Resident #73 required supervision for ADLs and expected to be discharged back to the community per the MDS. During a record review of the admission assessment for Resident #73 with the open date of 5/21/2022 and the closed date of 5/21/2022 the section on discharge planning was filled out incorrectly with all boxes being checked. This indicated that the resident wanted to discharge home, stay in the facility long term, and be transferred to another facility. No clear discharge plan or goals are indicated. During an interview on 6/6/2022 at 11:16 am, Resident #73 stated he had not been informed of when he would discharge or what goals he needed to meet to discharge. Resident #73 stated no baseline care plan was completed with him present and no copy of the baseline care plan was given to him. 4. Record review of the face sheet dated 6/9/2022 indicated that Resident #58 was an [AGE] year-old female that admitted on [DATE] with the diagnoses of diabetes type II, epilepsy (seizure with no known origin), and morbid obesity (Individuals are usually considered morbidly obese if their weight is more than 80 to 100 pounds above their ideal body weight). A record review of the MDS dated [DATE] indicated Resident #58 was understood and understood others. The MDS indicated Resident #58 had a BIMS of 02, which indicated cognitive impairment. The MDS from 6/8/2022 also indicated Resident # 58 was extensive to dependent for ADLs and had a discharge plan decided by the legal representative to stay in the facility long term. A record review of the care plans for Resident #58 indicated no care plan for discharge planning and no baseline care plan was created. During a record review of the admission assessment for Resident #58, dated 5/6/2022 opened and 5/10/2022 locked it was noted that the discharge section of the assessment was blank. During an interview on 6/7/2022 @ 2:13 pm the DON stated that it was the responsibility of the ADON or the charge nurse to complete the baseline care plan. The DON explained that the admission assessment had a section titled baseline care plan and the admitting nurse or the ADON completed this section. During an interview on 6/7/2022 @ 2:15pm RN O indicated the charge nurses completed a portion of the admission assessment that was labeled base line care plan. RN O stated she left the discharge section blank because that was a social worker function. RN O replied when asked who the social worker was .we don't have one at this time. RN O stated we haven't had a social worker for a few months now. RN O indicated she did not go over the information in the baseline care plan section with the resident or the family of the resident, stating she was unaware that she was required to do that. During an interview on 6/7/2022 @ 2:21 pm the DON stated she was unaware that the baseline care plans had to be reviewed with the resident or the family within the first two days of admission. The DON stated she would be responsible for ensuring that was completed and reviewed in the future and there was no one assigned to review baseline care plans with the residents presently. The DON stated it was the residents right to be a part of their care planning and discharge planning and it could lead to increased anxiety or depression and decreased outcomes if they are not given the information from the baseline care plan meeting. The DON stated there was no current policy for baseline care plans. The facility followed CMS guidelines.

**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 each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 3 of 19 residents (Resident #48, Resident #52, and Resident #56) reviewed for care plans. The facility failed to include Resident #48's discharge wishes and planning on the comprehensive care. The facility failed to include Apixaban (anticoagulant) and Clonazepam (antianxiety) and sign/symptoms or side effect monitoring for anticoagulant (help prevent a blood clot from forming) and antianxiety (reduces anxiety) on Resident #52's comprehensive care plan. The facility failed to update Resident #56's functional status on her comprehensive care plan. These failures could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of the consolidated physician order dated 6/9/22 revealed Resident #48 was [AGE] years old, female and admitted on [DATE] with diagnoses including chronic respiratory failure (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide), dyspnea (difficulty or labored breathing), lymphedema (a blockage in the lymphatic system, part of the immune and circulatory systems.), intellectual disability (Below average intelligence and set of life skills present before age [AGE]), stage 2 chronic kidney disease (damage to your kidneys is still mild), bipolar disorder (is a mental health condition that causes extreme mood swings), and difficulty walking. Record review of the MDS dated [DATE], completed by LVN AA, revealed Resident #48 was understood and understood others. The MDS revealed Resident #48 had a BIMS score of 15 which indicated intact cognition. The MDS revealed Resident #48 required supervision for ADLs except extensive assistance for bathing. The MDS revealed Resident #48 had active discharge planning to return to the community. Record review of the undated care plan revealed Resident #48 had ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, limited range of motion, and chronic pain. Intervention included supervision for ADLs and assist with sponge bath when shower cannot be tolerated. The care plan revealed Resident #48 had impaired communication as evidence by reduced ability to understood others and usually understood related to intellectual disability. Intervention included anticipate and meet needs, allow adequate time to respond, and speak on an adult level. The care plan revealed Resident #48 elected to remain at the facility for long term care. Intervention included assess mood quarterly and review discharge potential quarterly. The care plan did not address Resident #48 discharge planning to return to the community. During an observation and interview on 6/6/22 at 11:20 a.m., Resident #48 was lying in bed with a nasal cannula on her face. Resident #48 said she wanted to discharge to a group home because at one time she lived on her own. She said the facility currently did not have a social worker helping her with this discharge plan. She said a community social worker was helping her. 2. Record review of the consolidated physician orders dated 6/9/22 revealed Resident #52 was [AGE] years old, male, and admitted on [DATE] with diagnoses including sepsis (A life-threatening complication of an infection), hypertension (high blood pressure), atrial fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow), atherosclerotic heart disease of native coronary artery without angina pectoris (The build-up of fats, cholesterol, and other substances in and on the artery walls), generalized anxiety disorder and cognitive communication deficit. The consolidated physician order dated 5/2/22 revealed Apixaban for prevention of thromboembolism (obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation) in atrial fibrillation. The consolidated physician order dated 5/2/22 revealed Clonazepam for anxiety. Record review of the MDS dated [DATE], completed by LVN AA, revealed Resident #52 was usually understood and usually understood others. The MDS revealed Resident #52 had a BIMS score of 15 which indicated intact cognition. The MDS revealed Resident #52 required limited assistance for ADLs. The MDS revealed Resident #52 received anticoagulant and antianxiety. Record review of the undated care plan revealed Resident #52 had ADL self-care deficit related to impaired cognition, debility (physical weakness, especially as a result of illness), and weakness. Intervention included extensive assist for bathing, limited assist for bed mobility and transfer, supervision for eating, and PT/OT evaluation and treatment. The care plan did not address Resident #52's prescribed anticoagulant and antianxiety. 3. Record review of resident #56's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included dementia with behavioral disturbances, cognitive communication deficit, weakness, stiffness, lack of coordination, history of traumatic subdural hemorrhage (brain bleed), anxiety, depression, high blood pressure, schizophrenia (mental disorder), malnutrition, dysphagia (difficulty swallowing), and Alzheimer's. Record review of resident #56's annual MDS dated [DATE], completed by LVN AA and LCSW BB, revealed the resident was unable to complete the BIMS. The MDS indicated the resident required extensive assistance of one person to physical assist for bed mobility, locomotion on and off the unit, dressing, eating, toilet use, personal hygiene, and totally dependent on staff for bathing. The MDS indicated the resident required extensive assistance of two persons for transfers and walking in room or corridor were activities that did not occur. The MDS indicated that the resident used a wheelchair for mobility. Record review of Resident #56's care plan not dated, but facility provided to surveyor on 6/9/22, read in part: Problem: Resident #56 was able to independently walk around the unit, I am a very high fall risk, unable to recall to not get up without staff assistance. I have a bad habit of habitually stooping and bending to pick up items of the floor while I have and unsteady gait. Goal: Resident #56 will enjoy being with others and need the structure activities provide, attend/participate in activities of choice at least daily by next review date. Resident #56 is constantly on the move. Approach: All staff to converse with resident while providing care; Resident #56 requires supervision as well as some total anticipatory care per staff to assure my needs are met; Resident #56 is a high fall risk due to constantly stooping, bending, and picking up items off the floor; Resident is constantly attempting to walk, talk and at times invade others personal space. During an observation on 6/06/22 at 12:04 PM, observed Resident #56 in a reclined wheelchair and unable to feed self in the assisted dining area of the memory care unit. During an observation on 6/07/22 at 4:16 PM, observed Resident #56 in assisted dining area room in a reclined wheelchair. During an interview on 6/07/22 at 4:50 PM with LVN T, she said Resident #56 was wheelchair dependent. During an observation on 6/08/22 at 09:15 AM, observed CNA J push Resident #56 into the assisted dining room in the memory care unit with the wheelchair reclined back and she parked the wheelchair with the resident facing the back wall away from the other residents, who were watching a movie. During an interview on 6/08/22 at 10:06 AM with CNA J, she said Resident #56 sometimes has episodes of body spasms and the wheelchair she had was a special chair that therapy ordered to keep her from having the spasms or jumping out of the chair. She said the keep her wheelchair reclined to prevent spasms or the resident falling out of the chair. She said the resident could not walk, but she was able to walk a long time ago. During an interview on 6/8/22 at 9:03 a.m., CNA H said she had worked at the facility for 18-19 years. She said there was several residents that required total assistance for transfers. She said she felt comfortable using the mechanical lift alone because I know what I am doing. She said she got assistance with the mechanical lift if needed. During an interview by phone on 6/8/22 at 1:37 p.m., the corporate MDS nurse stated she did not complete MDS assessments at the facility. She only comes on Monday and completes the assessments required to complete the MDS. The facility employees 3 prn nurses that come in when they can and work on MDSs to keep them up to date. The MDS nurses were responsible for completing and updating the care plans as they completed the MDS. Baseline care plans were the responsibility of the charge nurse. She stated MDS accuracy was important because the plan of care was created by the information coded on the MDS the plan of care was how the employees know what kind of care each resident needs. The corporate MDS nurse stated inaccurate assessments and care plans that are not complete or revised could negatively affect the care of the residents because the resident might not receive appropriate care, decreasing their quality of life. During an interview on 6/9/22 at 1:10 p.m., LVN H said she had been at the facility for 19 years and was a charge nurse. LVN H said she believed Resident #48 was PASSR positive. LVN H said she did not know Resident #48 very well but if she wanted to return to the community, she would notify the social worker or DON and write a progress note or 24-hour report to ensure all team members were informed. LVN H said the discharge planning information should be on the MDS then flows to the care plan. She said it was important for Resident #48's discharge wishes to be known because she may be depressed and want to go home. LVN H said Resident #56 talks some but not freely and did not walk. She said she did not know Resident #52 well but believed he was on an anticoagulant which should be monitored for falls and bleeding. LVN H said nursing staff should document accurately to ensure correct information is transferred to the care plan and MDS. She said currently the facility was using a corporate MDS coordinator and they were responsible for the care plan and MDSs. During an interview on 6/9/22 at 2:02 p.m., LVN L said she had been at the facility for 13 years and was a charge nurse. LVN L said Resident #48 was PASRR positive and was documented under the medical diagnosis. She said it should be on the MDS then placed on the care plan. She said it was important to monitor for behaviors, address them correctly, and receive appropriate services. LVN L said she did not know Resident #56 because she was on the secure unit. She said it was important to know the medication classes such as anticoagulants and antiplatelet to monitor lab values. She said Resident #52 was on an anticoagulant which required labs, monitor for bruising and blood in his urine. She said it should be documented in Resident #56 chart. LVN L said Resident #48 had not told her she wanted to return to the community. She said if she does then it should be on her care plan under discharge. She said we should all know this information to be on the same page. She said the MDS coordinator and social worker are responsible for discharge planning. During an interview on 6/9/22 at 2:54 p.m., the DON said she had been at the facility for 20 years. The DON said MDSs, and care plans should accurate show who the residents are. She said care plans are developed 48 hours from admission then done quarterly and if something happens in care plan meetings. She said the facility did not have a MDS nurse or social worker. She the corporate MDS was handling assessments. She said inaccurate assessments can affect the resident's care and cause wrong coding on the MDS. She said Resident #52 was on anticoagulants and signs and symptoms of bleeding should be monitored. She said Resident #56 no longer walked and only said a few words. She said if her care plan said she did, then it was not updated. The DON said Resident #48 wanted to return to the community and should be documented on her care plan and on her PASRR positive paperwork. She said Resident #48 was PASRR positive and should code on her MDS. She said all the information should be documented so everyone knowns and the social worker should have documented it. During an interview on 6/9/22 at 3:30 p.m., the administrator said the facility did not have a MDS coordinator or Social Worker for the last 30 days, so care plan and MDS may inaccurate. He said inaccurate care plans can affect quality of care. He said care plan lets the facility know resident and family wishes, special needs, and dietary requirements. On 6/8/22 at 3:35 p.m., a policy regarding comprehensive care plans was requested from the DON. The DON said the facility did not have one but followed CMS guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being of 14 of 24 residents reviewed for activities. The facility did not provide Resident #19, #188, #46 and 11 anonymous residents with individual or group activities. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: 1.Record review of the face sheet dated 6/9/2022 revealed Resident #19 was a [AGE] year-old-male that admitted to the facility on [DATE]. Resident #19 had diagnoses of cerebral infarction due to unspecified occlusion or stenosis, unspecified psychosis not due to a substance or known physiological condition, and generalized anxiety disorder. Record review an MDS dated [DATE] revealed Resident #19 usually understood and was usually understood by others. The BIMS assessment (Brief interview for Mental Status-screening tool to assist with identifying a resident's current cognition status) was a 14 which indicated intact cognition. Resident #19 required supervision to limited assistance with ADLs. Record review of undated care plan revealed Resident #19, Activities revealed he would be invited to scheduled activities and be provided with an activities calendar. During an interview and observation on 6/6/22 at 10:15 a.m. Resident #19 was laying in his bed with no music or television playing. Resident #19 said they don't have activities. They used to have them about a year ago when they had an activity director. He said they are not allowed to shop for ourselves themselves for snacks or hygiene items. The facility does not send anyone to the store for them. He said they are just stuck in their rooms bored to death. He said they do play bingo but the facility does not put it on, a residents family member was kind enough to get them stuff and call the numbers for them because she saw they were so bored. He said they don't have resident birthday parties. He said they have a church that comes in once a week and that is the highlight of his week. He said they go back and forth to the lunchroom with nothing in between. Resident #19 said this adds to his depression and he talks with his psychologist about it each time he sees him. 2. Record review of the face sheet dated 6/9/2022 revealed Resident #46 was a [AGE] year-old-female that admitted to the facility on [DATE]. Resident #46 had diagnoses of lymphedema, morbid (severe) obesity due to excess calories, and cognitive communication deficit. Record review an MDS dated [DATE] revealed Resident #46 understood and was understood by others. The BIMS assessment (Brief interview for Mental Status-screening tool to assist with identifying a resident's current cognition status) was a 14 which indicated intact cognition. Resident #46 required supervision to limited assistance with ADLs. Record review of undated care plan revealed Resident #46, Activities were not addressed on her care plan. During an observation on 6/6/22 at 10:30 a.m., Resident #45 was in her wheelchair in her room with no activities being done. 3.Record review of the face sheet dated 6/9/2022 revealed Resident #188 was a [AGE] year-old-female that admitted to the facility on [DATE]. Resident #188 had diagnoses of cerebral infarction, type 2 diabetes mellitus with hyperglycemia, and type 2 diabetes with diabetic chronic kidney disease. Record review an MDS dated [DATE] revealed Resident #188's BIMS, ADL abilities, and understanding were not completed Record review of undated care plan revealed Resident #188, Activities, were not addressed on her care plan. During an interview and observation on 6/6/2022 at 10:45 AM, Resident #188 was laying in her be with no activities being done. Resident #188 said they had bingo once and doesn't think she had seen a calendar. She said there was not one in her room because she had stared at the walls for a solid week and knew what was on each one. She said she had only been here a week this time but did hear at the lunch table the activity director was sick. She said it got boring trying to watch a little bitty TV and she just slept all the time as there was nothing else to do. During an interview 11 of 11 residents, on 6/7/22 at 10:00 a.m. Residents interviewed stated the facility was not doing scheduled group activities. The only activities done were those put on by residents, or a resident family member sometimes, and church once a week. During an interview on 6/7/22 at 9:00 a.m. Resident #46 said there are no calendars passed out here that tell her what activities they have planned. She said, other than bingo she didn't know that they have any activities. She said that she had not been there that long but no one had come and invited her to activities. Resident #46 said sometimes she just sat in her doorway and waited for someone to come by and tell her what to do. She said she went to go to meals and therapy and the nurse wrapped her legs and guessed that counted as an activity. Resident #46 said it got really boring around there. During an interview on 6/9/2022 at 2:54 PM the DON said activities are needed to meet the needs of residents. She said they have church on Tuesday and BINGO on Friday. She said during COVID at one time they had 52 positive residents and she thinks residents are scared to come out of their rooms. She said it was important to have scheduled activities for their well-being. She said that she had not seen an Activity calendar for June posted. She said they had been without an Activity Director and social worker. During an interview on 6/9/22 at 3:30 PM the Administrator said the expectation for activities would be they happen every day at least 8 hours a day, if not longer. He said due to COVID and not having an activity director since last July activities have not been done regularly. The Administrator said prior to COVID they had a robust activity program. He said they also did not have a social worker. He said lack of activities could cause depression and lower moral for residents. The Activity Calendar provided by the Administrator had no month, no days, and no dates on it. It showed the following: 11:00 a.m. relaxing music 11:30 lunch 1:00 me time, ADL's and Grooming 1:45 table time, checkers, card games, dominoes, board games, puzzles, jenga, sandbox game 2:30 [NAME] time, a light snack, some beverages, and small talk. If the Activity Calendar was labeled with weekdays: each day had the same information. The administrator was asked for Policy regarding activities and no policy was provided. The DON provided a job description for the activities coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 24 residents (Resident #8, Resident #16, Resident #83, and Resident #84) reviewed for transmission-based precautions. The facility failed to ensure residents that required assistance with feeding during mealtimes at a table with four residents were served in a manner to provide infection control and prevent cross contamination between each resident. These failures could place residents at risk for being exposed to health complications and infectious diseases. Findings included: 1. Record review of Resident #8's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included dementia with behavioral disturbance, dysphagia (difficulty swallowing), adult failure to thrive (a decline seen in older adults, usually related to multiple long-term medical conditions), malnutrition (lack of proper nutrition), weakness, cognitive communication deficit, depression, anxiety, and high blood pressure. Record review of Resident #8's quarterly MDS dated [DATE] revealed the resident's BIMS was 3 indicating she was cognitively severely impaired. The MDS indicated the resident required supervision and set up while eating. Record review of Resident #8's care plan read in part: Problem: Resident #8 has an ADL self-care performance deficit related to poor cognition, and increased weakness/debility. Goal: Resident #8 will maintain current level of function through the review date. Approach: The resident requires supervision to limited assist by one staff to eat. 2. Record review of Resident #16's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included dementia with behavior disturbance, dysphagia (difficulty swallowing), weakness, cognitive communication deficit, aphasia (difficulty speaking), heart failure, depression, high blood pressure, and anxiety. Record review of Resident #16's quarterly MDS dated [DATE] revealed the resident was unable to complete the BIMS. The MDS indicated the resident required extensive assistance with 1 person assist while eating. Record review of Resident #16's care plan read in part: Problem: Resident #16 has potential for nutrition problems, weight loss related to history of significant weight loss and she is a picky eater and sometimes refuses meals. Goal: Resident #16's nutritional needs will be met as evidenced by/through the next review date. Approach: Assist with meal as needed, offer food preferences/snacks, monitor/record/report to physician as needed for signs and symptoms of malnutrition. 3. Record review of Resident #83's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included dementia with behavioral disturbances, cognitive communication deficit, weakness, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and high blood pressure. Record review of Resident #83's annual MDS dated [DATE] revealed the resident's BIMS was 0 indicating she was cognitively severely impaired. The MDS indicated the resident required limited assistance with 1 person assist while eating. Record review of Resident #83's care plan read in part: Problem #1: Resident #83 has an ADL self-care performance deficit related to impaired cognition, debility. Goal: Resident #83 will maintain current level of function through the review date. Approach: The resident requires limited to extensive assist by one staff to eat. Problem #2: Resident #83 has nutritional problem or potential nutritional problem related to decreased oral intake when resident is able to see the plate in front of her. Goal: Resident #83 will maintain adequate nutritional status as evidenced by maintaining weight through the review date. Approach: Provide and serve supplements as ordered; provide, serve diet as ordered; turn resident away from plate during meals when assisted with meals. 4. Record review of Resident #84's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included dementia with behavioral disturbance, Alzheimer's disease, cognitive communication deficit, weakness, malnutrition, lack of coordination, depression, and high blood pressure. Record review of Resident #84's annual MDS dated [DATE] revealed the resident's BIMS was 0 indicating she was cognitively severely impaired. The MDS indicated the resident required limited assistance with 1 person assist while eating. Record review of Resident #84's care plan read in part: Problem #1: Resident #84 has an ADL self-care performance deficit related to impaired cognition, and Alzheimer's/dementia. Goal: Resident #84 will maintain current level of function through the review date. Approach: The resident requires supervision/setup assist by one staff to eat. Problem #2: Resident #84 has nutritional problem or potential nutritional problem related to history of poor nutritional intake, and a diagnosis of protein-calorie malnutrition. Goal: Resident #84 will maintain adequate nutritional status as evidenced by maintaining current weight, no signs or symptoms of malnutrition through the review date. Approach: Explain and reinforce to the resident the importance of maintaining the diet ordered; provide and serve supplements as ordered; regular diet; monitor/record/report to physician as needed for signs or symptoms of malnutrition. During an observation on 6/06/22 at 12:04 PM, observed CNA K, sat down at a four-resident table in the dining room with residents that required assistance while eating. She sat down to assist with feeding Resident #83, then she stood and walked from resident to resident around the table feeding each resident a bite and/or a drink. CNA K sanitized her hands before feeding 1st Resident #83, but she did not sanitize her hands between Resident #83 and Resident #16, Resident #16 and Resident #8, Resident #8 to Resident #84, or Resident #84 to Resident #83. Observed CNA K touch each residents' eating utensils after residents had already tried to feed themselves using the same utensils, she also picked up Resident #16's drink cup and Resident #8's drink cup while assisting the residents to take a drink and she failed to sanitize her hands between touching the residents' drink cups after the residents had handled them while trying to take a drink on their own. During an interview on 6/07/22 at 09:36 AM with CNA K, she said she had worked at the facility for 17-18 years. She said she provided care to meet of all the residents' needs, such as assists with feeding, hygiene, mental, and physical needs. She said she has not received any recent in-services related to feeding residents. She said on the Feeder side, if there were four residents at a table that needed assistance or be fed, there would ideally be two staff to feed the residents at the table and sit between the two residents that needed to be fed. She said staff should sanitize their hands between assisting each resident. She said she was the one that was standing and feeding the four residents yesterday. She said she originally sat down to assist Resident #83, then saw that Resident #16 wasn't eating and Resident #8 had stopped eating and as she walked around, she felt Resident #84 needed assistance with feeding. She said she just had to do what she had to do to make sure the residents were eating when there was not enough staff for two staff at the table, so residents' food would not get cold, and residents got the nutrition they needed. She said she did not remember that she did not use her sanitizer between residents yesterday, because she always had it in her pocket to use. During an interview on 6/8/22 at 9:03 AM with CNA H, she said she had worked at the facility for 18 to 19 years. She said her CNA job duties included everything any everything all over the facility. She said when she assists a resident with feeding, you should encourage them to eat, tell them what she was putting in their mouth, and tell them to blow on the food if it is hot. She said we try to not to put residents that need assistance with feeding all together. She said it would be an infection control issue with cross contamination to feed multiple persons. During an interview on 6/8/22 at 10:06 AM with CNA J, she said she has worked at the facility for 7 years. She said she usually worked on the memory unit. She said her job duties included assisting residents with daily activities of life, meals, getting ready for bed, and doing activities. She said she assisted residents with eating. She said she would go to the feeder side to help. She said she would set up the resident's food, tell them hello, tell them what she was feeding the resident for their meal one item at a time. She said she would sit to feed residents. She said she has had multiple residents at a table and there would be two staff at a table. She said the two staff would sit between two residents. She said she has not had to feed more than two residents at one time. She said she would put on gloves or wash hands and change gloves out between residents. She said she learned to do that in CNA school. She said, sometimes, she has had to help both residents without washing/sanitizing hands due to behavior issues of residents and she had to intervene quickly. During an interview on 6/9/22 at 1:10 PM with LVN L, she said she has worked at the facility for 19 years. She said her job duties included taking care of residents, supervising CNA's, blood sugars, passing medications, and toileting residents. She said staff have been in-serviced and trained on how to properly feed a resident. She said they had an assisted dining room and an independent dining room. She said it was not appropriate for one staff member to feed four residents at a table at the same time. She said cross contamination would be a problem and by the time you get to the 4th person their food may be cold. She said she thought CNAs got ahead of themselves sometimes. During an interview on 6/9/22 at 2:02 PM with LVN M, she said she had worked at the facility for 13 years. She said her job duties included passing medications, treatments, head to toe assessments, and discharges. She said when there was a table of four residents that needed assistance with feeding, you would just have to go to each resident and feed each. She said that was not the ideal way, because one resident could feel like they were not getting enough food or attention at that time. She said hand sanitizer should be used between residents for infection control. During an interview on 6/9/22 at 2:54 PM with the DON, she said she had worked at the facility for 20 years. We try to feed just one at a time. She said staff should not be feeding four residents at a table, that would not be best practice. She said staff not using hand sanitizer between residents when assisting with feeding multiple residents, would not be best practice. She said she expected all kitchen staff to always wear a mask and beard guard. She said not wearing these items was an infection control issue causing illness. During an interview on 6/9/22 at 3:30 PM with the Administrator, he said he has worked at the facility for 6 years. He said his job duty was to oversee the complete operation of the facility. He said when staff were assisting multiple residents at a table with feeding, staff should not be feeding all four residents at the same time. He said not using gloves or hand sanitizer between assisting each resident with feeding would be an infection control issue. He said masks and beard covers were an infection control issue and was important due to COVID-19 and infection control. He said they had an in-service with staff. He said the first time that we see mask down or not wearing beard covers the staff member would be written up and sent home and the second time would result in termination. The administrator provided a COVID-19 tracking spreadsheet by county and noted Bell County was a red county, which indicated high numbers of COVID positive residents. Record review of the facility's infection control policy titled Infection Control dated 10/2018 revealed, . This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections . all personnel will be trained on infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control . depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities .

FACILITY Dining Observation Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility did not label and date all food items stored in the refrigerators and freezer. The facility failed to ensure a cleaning schedule was followed. The facility did not keep the kitchen neat and orderly. The facility failed to ensure kitchen staff used infection control prevention in the kitchen. The facility failed to discard pots and pans with carbon build up. The facility failed to ensure the drink dispenser and holder did not have slimy, brown build up. These failures placed residents at risk of food-borne illness. Findings included: During an observation on 6/6/22 at 9:20 a.m., [NAME] A was at the sink in the main kitchen area with her mask on her chin. During an observation on 6/6/22 at 9:25 a.m., the Assistant Dietary Manager was in the dishwasher area with no mask or beard guard on his face. During an observation in the dry storeroom on 6/6/22 starting at 9:26 a.m., revealed 1 opened puree rice mix with no date; 1 unopened puree rice mix with no date; 1 large tub of what appeared to be grits, with no label; 1 opened box of mashed potato granules with no date; 13 unopened boxes of drink concentrate with no date. During an observation in the kitchen hallway on 6/6/29 at 9:29 a.m., revealed a laminated daily cleaning schedule. The laminated cleaning schedule with no months or dates noted, had the items listed to be cleaned, when to clean, position responsible, days of the week, initials, and date. The schedule had no initials or dates marked for any of the 17 items list. During an observation in the dry storeroom on 6/6/22 at 9:35 a.m., revealed a white blanket with brown edges was noted next to a large metal equipment which was the air conditioner. Underneath the air conditioner, a medium size opening was visualized with debris and dust. During an observation in the main kitchen area on 6/6/22 at 9:40 a.m., revealed 3 skillets with carbon build up on the bottom was hanging from a rack; drink dispenser nozzle and holder with slimy, brown film was noted; 5 opened and in use boxes of drink concentrate, with no date; greasy film noted under and around the deep fryer. During an observation in the back area of the kitchen on 6/6/22 at 9:45 a.m., revealed 12 large metal pans with carbon buildup around the edges and sides. During an observation and interview in refrigerator 1 in the main kitchen area on 6/6/22 at 9:48 a.m., revealed 20 chocolate house shakes in a large clear container with no dates and 42 minis nondairy creamers in a large box with no date. The dietary manager said those were probably received on 6/3/22 and no one placed the date on the boxes. During an observation in the freezer on 6/6/22 at 3:05 p.m., revealed two partially frozen brown bags with no label or date and 1 opened box of 15 biscuits with freezer burn. During an observation on 6/7/22 at 10:28 a.m., cook B was frying chicken with no mask on her face. During an observation on 6/7/22 at 12:00 p.m., dietary aide D was checking meals cards and placing plated food on the transport cart with his mask on his chin and three flies noted flying around the kitchen. During an interview on 6/8/22 at 2:41 p.m., dietary aide E said it was everyone's responsibility for food items to be labeled and dated. He said it was the assistant dietary manager and the dietary manager responsibility to ensure items were labeled and dated by staff. He said it was important for food items to be labeled and dated to know when things are opened and to make sure residents do not receive expired food items. He said he had only worked at the facility for three weeks and did not believe they had a cleaning schedule. He said keeping the kitchen clean was a team effort. He said the dry storeroom was cleaning and organized, and he did not notice the area underneath the air conditioner. He said he did not notice the drink dispenser spout and holder being dirty. He said it was not his responsibility and did not know whose responsibility it was but knew it should be cleaned every day. He said he was responsible for making the resident's drinks. He said the drink dispense spout and holder should be cleaned to prevent germs from affecting the resident's respiratory and immune system. He said all staff should always wear their mask in the kitchen. He said it was important to wear masks to prevent spreading of germs or COVID-19. He said he only noticed staff pull down their masks when people could not hear them. During an interview on 6/8/22 at 3:00 p.m., cook C said she had worked at the facility for 7 years and worked the 11 a.m.-8 p.m. shift. She said her duties included preparing food, cleaning, and sanitation, washing dishes, and taking out the trash. She said dietary staff should label and date all food items. She said the cook was responsible for everything except desserts, which dietary aides handled. She said it was important to label and date food to not feed residents expired foods. She said about 20% of the pots and pans had carbon build up. She said pots and pans should not have carbon buildup because it could get in the resident's food and make them sick. She said the dietary manager did pot and pan inventory every 2-3 months, but the cooks should be notified also of carbon build up on pans. She said occasionally the air conditioner in the dry storeroom leaked water on the floor. She said staff place a blanket down to absorb the water leaking. She said the leaking should be fixed to prevent mold and falls. She said there was an established cleaning schedule, and it was posted on the wall near the dietary manager's office. She said basic cleaning was done after each shift, but weekly detailed cleaning was assigned to staff. She said the dietary aides were responsible for the drink dispenser. She said the drink dispenser and holder should be cleaned every night. She said the drink dispenser being cleaned was important to prevent mold and bacteria which could cause residents gastrointestinal issues. She said mask should be always worn. She said some staff do forget to keep them on. She said masks and beard guards were important for covid-19 precaution and help keep hair out of food which was contamination. During an interview on 6/8/22 at 3:20 p.m., the dietary manager said he had worked at the facility for a year. He said the kitchen had an assigned cleaning schedule by shift and position. He said the staff followed the cleaning schedule. He said he expected all dietary staff to label and date food items. He said it was the assistant dietary manager and dietary manager responsibility to ensure it was happening. He said he and the assistant DM did sanitation audits to make sure the kitchen was clean and organized. He said the staff normally get a 90% or better for the audits. He said the day I arrived, the kitchen was not clean and organized. He said the area underneath the air conditioner in the dry storeroom did have debris and needed to be cleaned and covered. He said he verbally told the maintenance worker about the issue and it would take approximately 2 weeks to cover it. He said it was the dietary aide's responsibility to clean the drink dispenser and holder. He said it was to be cleaned on the pm shift. He said it was important for it to be cleaned to prevent bacteria, mold, and gnats. He said those things could cause foodborne illnesses. He said the air conditioner leaked in the hot months and maintenance knew about the issue but did not have an estimated time it would get fixed. He said water leakage could cause slips, dry goods to get wet causing cross contamination and mold issues. He said it could cause residents to get sick. He said carbon build up on pots and pan could cause a fire. He said he or the cooks should be checking every day to ensure pots and pans did not have carbon build up. He said mask and beard guards should be always worn in the kitchen to prevent hair in the food and contamination. He said occasionally he did have to remind staff to keep masks on. He said cook B did not have a mask on when she was frying chicken yesterday. He said contamination of food could cause residents to get sick. At the end of the interview, the dietary manager brought the posted cleaning schedule. He said it was blank and should not be. During an interview on 6/9/22 at 2:54 p.m., the DON said she expected all kitchen staff to always wear a mask and beard guard. She said not wearing these items was an infection control issue causing illness. She said she expected all food items to be labeled and dated to prevent resident getting served expired or spoiled food making them sick. She said the kitchen should follow the cleaning schedule to prevent infection control issues. During an interview on 6/9/22 at 3:30 p.m., the administrator said staff wearing masks and beard guard was important due to COVID-19 and infection control. He said the kitchen should have a set cleaning schedule and clean after each meal and shift. He said kitchen staff should label and date food items was critical. He said the dietary manager should ensure it was happening. Record review of a facility food storage policy dated 6/1/19 revealed .to ensure that all food served by the facility is of good quality and safe for consumption .all food will be stored according to the state, federal and US food codes and HACCP guidelines .all containers must be labeled and dated .leave items in the original cartons placed with date visible .date, label, and tightly seal all refrigerated foods . Record review of a facility employee sanitation policy dated 10/1/18 revealed .employees of the facility will practice good sanitation practice .minimize the risk of infection and food borne illness .beard covering, or effect hair restraints must be worn to keep hair from food and food contact surfaces . Record review of a facility general kitchen sanitation policy dated 10/1/18 revealed .employees will maintain clean, sanitary kitchen facilities .in order to minimize the risk of infection and food borne illness .all cooking equipment free of encrusted grease deposits . Record review of a cleaning schedule facility policy dated 10/1/18 revealed .the facility will maintain a cleaning schedule .followed by employees as assigned in order to ensure that the kitchen is clean and free of hazards .the cleaning list will be posted weekly and initialed off and dated by each employee upon completion if the task .the Nutrition and Food service manager or designee will verify that the tasks were completed as assigned .