**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, but not limited to, aftercare following joint replacement surgery, difficulty in walking, muscle weakness, type 2 diabetes mellitus with hyperglycemia, major depressive disorder, anxiety disorder, essential hypertension, unsteadiness on feet, and history of falling. On 11/4/24 at 8:16 AM, an observation was made of resident 27 eating cereal out of a small disposable cup. On 11/4/24 at 8:16 AM, an interview was conducted with resident 27. Resident 27 stated that she had received her cereal in a disposable container. Resident 27 stated the she would like to eat cereal out of a larger bowl and not a small disposable container. Based on observation and interview it was determined, for 2 of 65 sampled residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality. Specifically, observations were made during multiple meal services of food being served on disposable dishes. Resident identifier: 22 and 27. Findings included: 1. On 11/03/24 at 1:35 PM, an observation was made of the lunch meal service on the 300 hallway. The meal tray for room [ROOM NUMBER] A was observed with the pudding dessert served in a disposable bowl. On 11/05/24 at 11:03 AM, a telephone interview was conducted with the Registered Dietitian (RD). The RD asked why the facility was serving meals with plastic wear and to go containers. The RD stated that they should be served on plates and dishware. The RD stated she did not know if the facility was low on supplies of plates and dishes or if they were doing this to cut down on the time for washing dishes. The RD stated that she was not sure if the facility had enough supply of hot plates. On 11/05/24 at 3:47 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated that they procured more supplies for dishes and that they were now in stock. The ADMIN stated that he did not think he had a shortage of dishes but that the challenge was making sure that all the dirty dishes were returned timely to be washed. The ADMIN stated that they had never had an issue with hot plate supplies. The ADMIN was asked why they were using disposable dishes and he responded, That's a good question? The ADMIN stated that as far as he was aware they had enough supplies and were not using disposable dishes. 2. On 11/4/24, an observation was made of the breakfast meal. Resident 22 was observed to have 2 Styrofoam bowels with frosted flakes in them. On 11/5/24 at 8:39 AM, an interview was conducted with the Assistant Dietary Manager (ADM). The ADM stated disposable dishware was used because the kitchen ran out of non-disposable. The ADM stated cereal came out in Styrofoam because there were not enough bowls. The ADM stated when the kitchen sent out dishware only about 2/3 of it came back to be washed for the next meal. The ADM stated she had to juggle to dishware. The ADM stated the staff tried not to use Styrofoam because Personally if you live here you don't want to eat off of Styrofoam. The ADM stated the residents were not getting fancy food and it would be nice for them to get real dishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for 1 of 65 sampled residents, the facility failed to provide the residents the right to participate in the development and implementation of a person-centered care plan, the right to attend meetings regarding the person-centered care plan, and the right to request revisions to the person-centered plan of care. Specifically, a resident who wished to participate in her plan of care was not included, and there was no documentation that care plan meetings were being held. Resident identifier: 3. Findings include: Resident 3 was admitted to the facility on [DATE] with diagnoses that included Arnold Chiari Syndrome with spina bifida and hydrocephalus, severe protein-calorie malnutrition, osteomyelitis right ankle and foot, paraplegia, borderline personality disorder, major depressive disorder, morbid obesity, bipolar disorder, and anxiety disorder. On 11/3/24 at 5:16 PM, an interview was conducted with resident 3 who stated the facility was not having care conferences and that she wanted to be included in decisions that were made about her care. Resident 3's medical records were reviewed between 11/3/24 and 11/13/24. According to resident 3's medical records, the last care conference attended was on 12/8/23. Resident 3's MDS (Minimum Data Set) documentation revealed that a quarterly MDS assessment was completed on 2/26/24, an annual MDS assessment was completed on 5/28/2024, and a quarterly MDS assessment was completed on 8/28/2024. On 8/28/24, resident 3's Brief Interview for Mental Status (BIMS) was 15 indicating normal cognition. A review of resident 3's care plan revealed, The resident has expressed a desire to remain in the facility for long term care. Date initiated: 11/30/23. The goal was, The resident will feel safe and comfortable in their home. Date initiated: 11/30/23, Revision on: 12/12/23, Target date: 1/31/25. Interventions included, .Resident will have the opportunity to attend care conferences upon admission and at least quarterly to discuss plan of care, discharge plan/goals, questions/concerns, etc. Discharge plan will be revised as indicated. Date initiated: 11/30/23 . A review of resident 3's medical record revealed care conference documentation for 3/21/23, 6/7/23, and 12/8/23. No care conference documentation was found for 2024. On 11/12/24 at 1:22 PM, an interview was conducted with the Director of Nursing (DON) who stated she attended the resident care conferences if she was invited. The DON stated the Activities Director (AD) had picked up some of the Resident Advocate (RA) duties. The DON also stated that the previous AD was still working part time and could provide training for the services that the RA would provide. On 11/13/24 at 9:27 AM, an interview was conducted with the DON who stated care conferences were held quarterly or with a significant change in condition. The DON stated if something needed to be changed, it would trigger for a review after the quarterly assessment. The DON stated care conference forms were found in the medical record under the forms care tab and were described as care conference summaries. The DON stated the form should include who attended the conference and what was discussed. The DON stated the AD was planning care conferences and sending out invitations for those conferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined, for 2 of 65 sampled residents, that the facility did not ensure the resident right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Specifically, the resident call lights were out of reach. Resident identifiers: 1 and 30. Findings included: 1. Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cerebral infarction, cognitive communication deficit, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus, chronic viral hepatitis C, non-pressure chronic ulcer of left lower leg, mood disorder, encephalopathy, atrial fibrillation, pulmonary embolism, hypospadias, retention of urine, chronic kidney disease, major depressive disorder, pyelonephritis, multiple fractures of ribs, bipolar disorder, dysphonia, insomnia, peripheral vascular disease, chronic pain syndrome, opioid dependence, extended spectrum beta lactamase resistance, obstructive and reflux uropathy, anxiety disorder, polyosteoarthritis, hypertension, gout, and methicillin resistant staphylococcus aureus infection classified elsewhere. On 8/2/24, resident 1's Minimum Data Set (MDS) Assessment documented a Brief Interview of Mental Status (BIMS) score of 5 out of 15, which would indicate a severe cognitive impairment. The assessment documented that the resident was a two-person total dependence physical assist for bed mobility, transfer, and toilet use. On 11/03/24 at 4:47 PM, an observation was made of resident 1. Resident 1 was sleeping in bed and his call light was observed on the floor at the foot of the bed, under a trash can, and out of reach. On 11/07/24 at 8:53 AM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that resident 1 was fully dependent on staff for assistance with incontinence care and bed baths, and that the resident preferred to stay in bed. 2. Resident 30 was admitted to the facility on [DATE] with diagnoses which consisted of Alzheimer's disease, osteoporosis, bradycardia, hypertension, hyperlipidemia, major depressive disorder, and post-traumatic stress disorder. On 8/28/24, resident 30's MDS Assessment documented a BIMS score of 3 out of 15, which would indicate a severe cognitive impairment. The assessment documented that the resident was a limited one-person physical assist for bed mobility, transfer, and toilet use. On 11/03/24 at 4:43 PM, an observation was made of resident 30. Resident 30 was seated in her recliner towards the foot of the bed. Resident 30's call light was observed on the floor under the bed, at the head of the bed, and out of reach. On 11/12/24 at 1:46 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 1 and resident 30 could utilize their call light if it was within reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that for 1 of 65 sampled residents, the facility failed to ensure the resident had reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. Specifically, a resident was not provided access to a phone in her room as requested. Resident identifier: 28. Findings included: On 11/03/24 at 1:42 PM, an interview was conducted with resident 28. Resident 28 stated multiple staff members told her that she cannot get a phone in her room. Resident 28 stated her cell phone did not work. Resident 28 stated she had to use the phone at the nurse's station. On 11/06/24 at 10:16 AM, an observation of Registered Nurse (RN) 2. RN 2 was observed to tell the resident in room [ROOM NUMBER] that the phone had to stay at the nurse's station because it kept getting lost. Resident 28's medical record was reviewed 11/3/24 through 11/13/24. Resident 28 was admitted to the facility on [DATE] with diagnoses which included hypertension, severe persistent asthma with acute exacerbation, and muscle weakness. A Minimum Data Set (MDS) Assessment, dated 9/23/24, indicated resident 28 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated a moderately impaired cognition. On 11/6/24 at 3:11 PM, an interview was conducted with Certified Nurse Assistant (CNA) 4. CNA 4 stated she was not sure if a resident could have a landline phone in their room, but they could have their own cell phones or use the facility phone. On 11/7/24 at 10:26 AM, an interview was conducted with CNA 3. CNA 3 stated that nobody in the facility had a landline phone in their room. CNA 3 stated that if a resident asked to have a landline phone in their room, she would report that to the CNA Coordinator. On 11/13/24 at 8:48 AM, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated there was a Daily Maintenance Log kept at the nurse's station where staff could notify him of items that needed repair. The Maintenance Supervisor stated he was not sure if the resident's rooms had phone [NAME] in them. A concurrent observation was made of resident 28's room, room [ROOM NUMBER], and 2 phone [NAME] were observed on the wall. The Maintenance Supervisor stated they probably did not work, but he would figure out an option for resident 28 to have a phone in her room. The facility Daily Maintenance binder from the front nursing station was reviewed on 11/13/24 at 8:54 AM. One request was documented from 11/8 for a broken television. No other documentation was provided. On 11/13/24 at 11:25 AM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated the facility did not have phones in the resident's rooms but had cordless phones at the nurse's stations and some on the nurse's carts that the residents could use. The ADMIN stated the residents needed to be provided a private place to talk on the phone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 1 of 65 sampled residents had the right to refuse medical treatment and formulate an advance directive. Specifically, a resident had a signed Provider Order for Life-Sustaining treatment (POLST) form for a Do Not Resuscitate (DNR) but the electronic medical records banner documented that the resident wanted full treatment. Resident identifier: 22. Findings included: Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia, cognitive communication deficit and generalized anxiety. Resident 22's medical record was reviewed on [DATE]. A physician's order dated [DATE] revealed FULL CODE; FULL TREATMENT. No directions specified for order. A POLST form dated [DATE] revealed resident 22 desired for no attempt or any continued resuscitation (DNR) and resident wanted comfort measures for medical interventions with no artificial nutrition. According to the banner in resident 22's electronic medical record, resident 22 was a full code with full treatment. On [DATE] at 10:53 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated residents decisions on CPR and medical interventions was documented in the electronic medical record. LPN 3 stated when a resident was admitted the nurse completed a POLST form or Advanced Directives with the resident or family. LPN 3 stated LPN 4 had completed resident 22's POLST form when she was readmitted . LPN 3 stated resident 22 went back and forth between full treatment and being a DNR. LPN 3 stated resident 22 was her own responsible party. LPN 3 stated she did not know why the POLST form and the banner in the electronic medical record were different. LPN 3 stated if resident 22 had coded, she would have looked at the electronic medical record and would have treated resident 22 as a full code and provided CPR. On [DATE] at 11:01 AM, an interview was conducted with LPN 4. LPN 4 stated she completed a POLST form with resident 22 on [DATE]. LPN 4 stated resident 22 changed her mind a lot so maybe she had changed her mind. LPN 4 stated there should be a new physician's order and POLST form if resident 22 changed her mind with her code status. On [DATE] at 10:44 AM, an interview was conducted with the Director of Nursing (DON). The DON stated nurses completed the POLST forms with the resident upon admission. The DON stated the POLST form was then put into the physician's folder for the physician to sign. The DON stated she was not sure how long it took for the POLST form to be put into the residents medical record. The DON stated the nurse, Minimum Data Set (MDS) coordinator or herself updated physician orders which automatically populated the banner in the electronic medical record. On [DATE] at 11:03 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if there was a question about the resident's code status, then the resident was a full code. The DON stated she was not sure why there was a physician's order by her on [DATE] that was different from what the POLST form had on it. The DON stated she was not sure if there was a new POLST. The DON stated she would have to investigate why resident 22's POLST and physician's order did not match. The DON stated a nurse can update the physician's order. The DON stated there was a binder at each nurses station with the POLST forms. The DON was observed to check the binder and located the same POLST form dated [DATE]. On [DATE] at 11:10 AM, a follow up interview was conducted with the DON. The DON stated the MDS coordinator just went through and updated all the POLST forms. The DON stated the MDS coordinator and Resident Advocate asked residents in care conferences about updating a POLST form. The DON stated if the POLST and the physician's order were different then she would go with what the banner in the medical record had on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for 1 of 65 sampled residents, the facility did not take all the necessary steps to prevent the exploitation of a resident for personal gain. Specifically, when the facility became aware of possible exploitation of a resident, the police were not notified, and no follow-up occurred to protect the resident. Resident identifier: 13. Findings include: Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, muscle weakness, major depressive disorder, and chronic pain. Resident 13's medical record was reviewed between 11/3/24 and 11/13/24. On 6/11/24, an admission Minimum Data Set (MDS) assessment revealed resident 13 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated a normal cognition. On 8/6/24 at 7:53 AM, a progress note revealed, RA [resident advocate] met with RT [resident] to discuss help with setting up crypto account. RA quickly determined RT is a victim of scam. Perpetrator is stating they are [celebrity] the singer and they are going to marry RT. RT is excited about this relationship and [celebrity] coming to [city] while touring in Las Vegas to meet RT. RA made it very clear that any requests for money, or crypto, loans is a scam and RT could fall victim to identity and financial theft. RA contacted [bank] after learning RT has provided log in information for her online banking. [Bank] closed down the accounts and froze a fraudulent deposit. RA facilitated RT visiting the DLD [drivers license division] to renew her license, this was first step for RT to visit the branch in person and have new accounts created. RA offered support to RT and explained feelings of grief are normal and expected when any relationship ends. RA made it clear that RT should no longer speak with this person and block any further communication. On 8/13/24 at 7:45 AM, a psychological progress note revealed, .Her bank account was shut down when [celebrity] tried to deposit some money into her account so that she could buy a house. SW [social work] and bank worked with her to close accounts and protect her assets. She continues to speak to [celebrity and his son] on the internet. She does not believe it to be a scam .The patient has had increased sadness and loneliness since changes in her relationship with [celebrity]. On 8/13/24 at 7:58 AM, a social service progress note revealed, RA has communicated with RT therapist [name], [Behavioral Health Provider]. Therapist confirmed RT has continued online relationship, and is having difficulty accepting that relationship was a scam. RA has learned that RT was upset about account being closed, and was not happy RA intervened to help RT not fall victim to scam. RT has communicated with nursing staff that she is attempting to repair online relationship and that [celebrity-son] is not speaking with her about repairing damage to the relationship by asking RT to qualify for a loan to make it up to him. RA has communicated this with RT therapist, and [name] RT, APRN [advanced practice registered nurse]. All treatment providers agree it is best to allow RT to make her own decisions and respect her autonomy. RT has been warned about scam, and is being offered support regardless of her choices. RT has been determined to be capable of making her own decisions. RA met with RT and offered support. RA also apologized for quickly acting on scam and having RT account closed, even with RT consent and being present for the calls to [bank]. RA explained this was done in an effort to help RT avoid suffering and that RT wishes are important and RA wants to honor them. RT stated she understood and appreciated the talk. On 8/22/24 at 3:59 PM, a social service progress note revealed, RA contacted APS [adult protective services] to file report about online relationship-RA explained the situation and APS provided case #180980. Resident 13's care plan revealed the following: a. Mood & Behavior: [resident 13] has potential for coping and adjustment issues, related to a desire for an online relationship and potential for online exploitation. Depression. Due to this desire, [resident 13] has had a capacity to consent evaluation done and has been found to have the ability to consent to relationship. Date initiated 8/14/2024, Revision on: 11/8/24. The goal was, Dignity will be preserved and quality of life improved by allowing [resident 13] to make her own informed decisions. Date initiated: 8/14/2024, Revision on: 8/14/2024, Target Date: 2/7/2025. Interventions included, Allow resident [resident 13] to calm down and reapproach at a later time if agitated. Date initiated: 8/14/2024, Revision on: 8/14/2024. Evaluate for need and refer to psychological counseling as recommended by physician. Date initiated: 8/14/2024. Monitor and document each behavioral event PRN [as needed]. Date initiated: 8/14/2024, Revision 8/14/2024. Offer 1:1 interaction as needed, Date initiated: 8/14/2024. Provide information to [resident 13] regarding potential financial and emotional exploitation. Assist PRN with banking issues if [resident 13] requests. Follow mandatory reporting policies if needed. Date initiated: 8/14/2024. b. The resident has a psychosocial well-being problem r/t sexual activity capacity. 11/8/24-Resident does not have capacity for sexual activity consent. Date initiated: 11/8/24, Revision: 11/8/24. The goal was, The resident will have no indications of psychosocial well-being problem by/through review date. Date initiated: 11/8/24, Revision on: 11/8/24. Interventions included, .conduct sexual activity capacity for consent every quarter, as needed, and with every change in condition. Consult with MD for input on sexual activity capacity for consent. Date initiated: 11/8/24 .Provide opportunities for the resident and family to participate in care. Date initiated: 11/8/24. The resident needs assistance/encouragement/support to identify causative and contributing factors. Date initiated: 11/8/24. Resident advocate was unable to be reached for interview. On 11/13/24 at 8:59 AM, an interview was conducted with the Director of Nursing (DON) who stated that resident 13 believed she was in a relationship with a celebrity. The DON stated that APS and the ombudsman were involved. The DON stated she would check with the previous RA. The DON stated the police should be contacted if financial exploitation was suspected. The DON stated the previous RA had helped resident 13 with her bank accounts. The DON stated they had to get resident 13 new accounts to protect her information. The DON stated resident 13 was trying to cash a check that was fraudulent. The DON stated she would obtain and provide more information. The DON stated the MDS [minimum data set] coordinator was responsible to update resident care plans related to the ability to consent. The DON stated not properly updating the care plan could confuse staff who were providing care to the resident. It should be noted that the DON did not provide additional information about whether the police were contacted and if any additional follow-up was conducted. The facility abuse policy and procedures were reviewed. The policy revealed, The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property is reported immediately but no later than 2 hours, after the allegation is made . Resident abuse: .Abuse includes any type of abuse that is facilitated or enabled through use of technology or social media .Exploitation: Taking advantage of a resident for personal gain through use of manipulation, intimidation, threats or coercion .If there is suspicion that a crime occurred that did not result in major bodily injury, the incident must be reported to law enforcement within 24 hours in compliance with the Elder Justice Act. On 11/13/24 at 1: 01 PM, the facility Administrator (ADMIN) submitted an entity report 358 related to Misappropriation of Resident Property/ Exploitation. The entity 358 indicated [name redacted] was the perpetrator and the relationship was online. The entity 358 stated the facility became aware of the concern on 8/6/24 at 7:53 AM and the RA was the staff member who became aware. The entity 358 stated the ADMIN was notified around 10 am. The entity 358 stated there was a witness, however, the remainder of the section was left blank. The entity 358 report indicated police were notified on 11/13/24 at 1:00 PM. No report number was listed. APS and the ombudsman were notified on 8/6/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for 1 of 65 sampled residents, that the facility, in response to allegations of abuse, neglect, exploitation, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the State Survey Agency, within 5 working days of the incident. Specifically, after a resident sustained a fall resulting in a major injury, the facility did not investigate the incident and did not update the resident's care plan to initiate interventions to prevent additional falls. Additionally, the incident was not reported and investigative results were not submitted to the State Agency within 5 working days. Resident identifier: 13. Findings included: Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, muscle weakness, major depressive disorder, and chronic pain. On 11/4/24 at 11:10 AM, an interview was conducted with resident 13 who stated she had several falls while at that the facility, one of which included a fracture of her shoulder. Resident 13's medical records were reviewed between 11/3/24 and 11/13/24. An admission MDS (minimum data set) dated 6/11/24 revealed resident 13 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated a normal cognition. On 5/27/24 at 4:45 AM, an alert charting progress note revealed, Found pt [patient] laying on her bed with a hematoma to her forehead. Pt with laceration to her nose. Severe pain to her right shoulder and pain and bruising to her left knee. Pt states that her pant leg got caught on her electric w/c [wheelchair] and she fell forward. Pt got herself up into there bed and then called for assistance. Pt requested to go to ER [emergency room] for evaluation of her right shoulder. Non-emergent ambulance called. Notified physician on call and pt's [family member]. Pt sent out at this time. Resident 13's care plan revealed: a. Risk for falls r/t [related to] neuropathy, gout, dependence on supplemental oxygen, impaired mobility with use of assistive device, hx [history] of falls. Date initiated: 7/18/22; Revision on: 6/26/23. The goal was, The resident will be free of falls with injury through the review date. Date initiated 7/18/22; Revision on: 4/12/24; Target Date: 2/7/25. The interventions included, 1/22/23 Patient hat [sic] a fall in the community. Educated patient to be more aware of her surroundings when accessing the community. Date initiated 7/28/23; 5/27/24-unwitnessed fall, risk management done, resident educated. Date initiated: 5/28/24; 6/23/24-Resident educated and encouraged to ask for staff assistance with toileting so safety reminders/prompts can be provided as needed. Date initiated: 6/26/23; Anticipate and meet the resident's needs. Keep frequently used items within reach. Date initiated: 7/18/22; Educate and encouraged the resident to wear appropriate footwear, such as non-skid socks or shoes, when ambulating/mobilizing. Date initiated: 7/18/22; Follow facility fall protocol if a fall occurs. Date initiated: 7/18/22; Order placed for no transfers without assistance to prevent falls/injury d/t [due to] weakness. Date initiated: 10/1/24; Orient resident to call light. Keep the resident's call light within reach and encourage the resident to use it for assistance as needed. Date Initiated: 7/18/22. b. The resident has had an actual fall. Poor balance, Poor safety awareness. 10/12/24. Date initiated: 8/30/24, Revision on 10/21/24. The goal was, Resident will not have a fall with major injury. Date initiated 8/30/24, Target date 2/7/24. Interventions included, Carry out additional orders from PCP [Primary Care Provider]. Date initiated: 8/30/24; Encourage resident to participate in her fall intervention. Date initiated: 8/30/24; Monitor/document/report PRN [as needed] x 72 h [hours] to MD [medical doctor] for s/sx [signs and symptoms]: Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Date initiated 8/30/24, Revision: 8/30/24; Neuro checks x 72 hours. Date initiated: 8/30/24, Revision on: 8/30/24. Promote participation in activities to help encourage and teach safety awareness. Date initiated: 8/30/24; Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. Date initiated: 8/30/24; Resident currently in therapy with additional therapy evaluation, for safety and education. Date initiated: 8/30/24; Resident reminded of the importance of using call button and therapy to evaluate. Date initiated: 10/21/24; Vital signs Q [every] shift/PRN. Take BP [blood pressure] lying/sitting/standing x 1 in first 24 hr [hours]. Date initiated: 8/30/24, Revision on 8/30/24. It should be noted that the only change to resident 13's care plan after her fall on 5/27/24 was, unwitnessed fall, risk management done, resident educated. On 11/7/24 at 9:31 AM, an interview was conducted with Licensed Practical Nurse [LPN] 4 who stated that resident 13 fell a lot and had poor safety awareness. LPN 4 stated resident 13 had been encouraged to call for help but she did not always call. LPN 4 stated resident 13 needed assistance getting out of bed and had fallen trying to transfer to her wheelchair. On 11/7/24 at 11:59 PM, an interview was conducted with the MDS [minimum data set] coordinator who stated if a resident had a fall it would be discussed in the next day's morning meeting. The MDS coordinator stated the discussion included what happened, why the fall happened and how it could be prevented. The MDS coordinator stated resident 13 caught her pant leg on her wheelchair on 5/27/24 and that was the reason for the fall. MDS coordinator stated resident was provided verbal education for wheelchair safety when she returned from the hospital on 6/4/24. On 11/7/24 at 12:46 PM, an observation was made of resident 13 talking with another resident. Resident 13 was sitting in her wheelchair and was wearing long pants that draped over the foot rests of her wheelchair. On 11/12/24 at 2:45 PM, an interview was conducted with the Director of Nursing (DON) who stated for a resident who had frequent falls, there should be an evaluation of the resident's current care plan interventions and new interventions should be put into place. No documentation was provided regarding an investigation of the causative factors for resident 13's fall, and no new interventions were documented for prevention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined for 3 out of 65 sampled residents, that the facility did not ensure that the receiving health care institution had the resident's medical record information including: the contact information of the practitioner responsible for the care of the resident, resident representative information, advance directive information, special instructions for ongoing care, comprehensive care plan, and any other documentation to ensure a safe and effective transition of care. Specifically, the residents were transferred to the local area hospital emergency department (ED) without any accompanying medical records. Resident identifiers: 8, 123, and 371. Findings included: 1. Resident 8 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, but not limited to, unspecified intracranial injury with loss of consciousness, human immunodeficiency virus, acute respiratory failure with hypoxia, major depressive disorder, candidal stomatitis, acute kidney failure, unspecified speech disturbance, and history of falling. A review of resident 8's medical record revealed the following: On 8/1/23 at 2:43 PM, an alert charting note documented, Late Entry: Note Text: resident sent to ed [emergency department] via 911 for chest pain. np [nurse practitioner] in building did assessment and said to sent resident. called 911 sent resident via [ambulance company]. A review of resident 8's electronic medical record revealed no documentation of a transfer/discharge assessment or paperwork that might have accompanied the resident to the hospital. 2. Resident 123 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, myotonic muscular dystrophy, cognitive communication deficit, type 1 diabetes mellitus with hyperglycemia, hyperlipidemia, gastro-esophageal reflux disease without esophagitis, cachexia, and hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side. A review of resident 123's medical record revealed the following: On 8/1/24 at 3:29 PM, an alert charting note documented, Note Text: Pt's [patient's] vomit appears dark brown/coffee ground. Per NP send to ED. Patient refuses stating he is fine. VS [vital signs] as follows: 101/57, 63, 97.8, 16 and 91% @ [at] ra [room air]. Cognition and ROM [range of motion] remains at baseline at this time. Fluids offered, taken fair. Will continue to assess. Resting in bed. On 8/1/24 at 4:42 PM, an alert charting note documented, Note Text: Sent to ED for eval [evaluation] and treat via facility transport. DON [Director of Nursing] and MD [medical doctor] notified. A review of resident 123's electronic medical record revealed no documentation of a transfer/discharge assessment or paperwork that might have accompanied the resident to the hospital. On 11/7/24 at 8:55 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that when a resident needed to be sent to the hospital the nurse should obtain vitals and inform the family. RN 2 stated she would obtain a SBAR (situation, background, assessment, recommendations), the resident's face sheet, the resident's medication list, and a POLST (Physician Orders for Life Sustaining Treatment) form to send with the resident. RN 2 stated that all of this information should be documented in the resident's medical chart. RN 2 stated this information was important for the hospital and the ambulance staff to understand what treatment the resident might need. On 11/12/24 at 10:22 AM, an interview was conducted with the Director of Nursing (DON). The DON stated there was a process for sending a resident to the hospital. The DON stated that for a period of time the facility was not able to use the e-interact form. The DON stated that her expectation from the nursing staff was to print out the discharge/transfer form and this got sent with transport. The DON stated the resident's medications and POLST form would be included on the e-interact form. The DON stated that some of the nursing staff might not document what documentation got sent to the hospital. 3. Resident 371 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included paraplegia, cognitive communication deficit, and pressure ulcer of sacral region. Resident 371's medical record was reviewed 11/12/24 through 11/13/24. On 7/11/24 at 12:52 PM, an alert charting progress note revealed resident 371 was sent to the emergency department for an evaluation. There was no documentation provided in the medical record that indicated the basis for the hospital transfer. On 11/13/24 at 2:29 PM, an interview was conducted with the DON. The DON stated that when a resident was transferred or discharged there was a transfer form that was filled out and placed in the residents chart. The DON stated that it was the nurse's responsibility to write a progress note detailing the reason for a residents transfer or discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide and document sufficient preparation to 1 of 65 sampled residents to ensure a safe and orderly transfer or discharge from the facility. Specifically, one resident with cognitive impairment signed out of the facility against medical advice and was subsequently imprisoned and charged with criminal trespassing. Resident identifier: 419. Findings Included: Resident 419 was admitted to the facility on [DATE] and discharged on 3/25/24 with diagnoses of metabolic encephalopathy, schizophrenia, psychological and behavioral factors, and polydipsia. Resident 419's medical record was reviewed on 11/13/24. A hospital history and physical dated from 2/6/24 to 3/20/24 documented resident 419 was unable to care for themselves nor make medical decisions and lacked self-awareness. The physician documented resident 419 needed to be placed into a care facility with 24-hour supervision. On 3/7/24, an inpatient psychiatric (psych) evaluation was conducted on resident 419 and the psychiatrist deemed resident 419 decisionally incompetent and unable to reliably care for themselves. The psych note indicated, Patient would be best suited for admission to long-term skilled nursing facility. Due to patient's current cognitive impairment and condition, she is unsafe to be discharged home as she is unable to safely take care of herself. On capacity testing again she remains unable to exhibit the four generally accepted decision-making abilities that constitute capacity, understanding, expressing a choice, appreciation, and reasoning. On 3/15/24 at 10:51 AM, an emergency court ordered appointed guardian was granted to resident 419, who was declared to be an incapacitated adult. The document indicated the emergency guardian had the authority to make medical, financial, placement, and end-of-life decisions. The temporary guardianship was to be effective for 30 days. An admission wander/elopement risk evaluation completed on 3/20/24 stated resident 419 was a high wander/elopement risk. Resident 419 was documented to have the following risk factors: History of wandering, cognitive impairment, impaired decision-making skills, memory impairments, and previous elopement attempts. A care plan focus area initiated on 3/20/24 indicated resident 419 wanted to discharge back into the community. Listed interventions included encouraging resident 419 to discuss feelings and concerns related to discharge and staff were to monitor and address sources of anxiety, fear, or distress in order to promote a calm and orderly discharge. Another intervention indicated the resident advocate was to make a referral to the local contact agency when indicated to help facilitate resident 419's discharge plan. A care plan focus area initiated and revised on 4/12/24 indicated resident 419 had impaired cognitive function/impaired thought processes related to a BIMS (Brief Interview for Mental Status) score of 6, and impaired safety awareness. [Note: It should be noted this was initiated 18 days after the resident left the facility against medical advice and was charged with criminal trespassing and sent to jail.] An admission Minimum Data Set (MDS) completed on 3/25/24 documented resident 419 had a BIMS score of 6 which indicated severe cognitive impairment. A care conference, dated 3/25/24, documented resident 419 wanted to look into housing and an evaluation was being set up with local housing for a possible housing transition. Resident 419's discharge progress notes were reviewed and documented as followed: a. On 3/25/24, a social service note created at 12:52 PM, indicated resident 419 had walked out of the facility Against Medical Advice (AMA). Resident 419 stated they were fine on their own and had packed their belongings in a plastic bag and was heading to a local homeless center where they could live by themselves. The Resident Advocate (RA) stated resident 419 had not given a reason to their change of mind and left the faciity on foot. The RA contacted resident 419's guardian and the local police. The RA contacted Adult Protective Services at 12:59 PM and filed a report due to resident 419 leaving the facility AMA. A discharge progress note created at 1:03 PM, indicated resident 419 had left the facility AMA at 12:30 PM and was going to a local homeless center on foot. It was documented the case manager had called the local homeless center and was informed residents 419 was above their level of care. The homeless center was provided resident 419's guardian name and phone number by the RA. b. On 3/26/24 at 12:12 PM, a social service note indicated resident 419's whereabouts were unknown. c. On 4/1/24 at 3:41 PM, a social service note stated resident 419 was being held at the local jail for criminal trespassing. The RA and resident 419's guardian were documented to be working on resident 419's release from jail. d. On 4/2/24 at 11:26 AM, a social service note stated resident 419's guardian informed the RA that resident 419 was being held in the local jail until 4/9. The RA documented they were working on finding resident 419 another facility to go to. On 11/13/24 at 9:36 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that depending on a resident's individual situation, they were assigned a guardian. The DON stated a guardian was appointed to look out for the resident and their best interest and they helped the resident with informed consent. The DON stated if a resident wanted to sign out AMA, they notified the provider and ombudsman. They also notify the police to ensure resident safety and to follow up with them. The DON stated the resident also signed AMA paper work if they wanted to leave. The DON stated resident 419 was very insistent on leaving and walking out of the building. The DON stated resident 419 walked out of the building. The DON stated they were unsure if resident 419 signed the AMA paperwork but they did try to deescalated resident 419. The DON stated the Police and the guardian were called and notified that the resident had left AMA. On 11/13/24 at 11:07 AM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated an elopement was considered when staff lost sight of a resident who left the facility property. The ADMIN stated if a resident did not have the capacity to sign out AMA and they left the facility, they would consider it an elopement. The ADMIN stated resident 419's AMA occurred before they were the Administrator. A follow up interview was conducted with the ADMIN at 11:53 AM. The ADMIN stated they were working on submitting a report for resident 419's elopement. On 11/13/24 at 12:06 PM, an interview was conducted with the [NAME] President of Clinicals (VPC). The VPC stated a resident was appointed a guardian depending on their situation. The VPC stated a guardian was appointed to look out for the resident and their best interest. The VPC stated resident 419's discharge was not reported to the state because they believed the resident left AMA and had not eloped.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for 1 of 65 sampled residents, the facility failed to obtain the written and/or verbal physician orders to provide essential care to the resident upon admission to the facility. Specifically, a resident who was admitted with an indwelling catheter did not have physician orders for catheter care. Resident identifier: 221. Findings included: Resident 221 was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, paraplegia, infection and inflammation due to indwelling urethral catheter, and extended spectrum beta lactamase resistance. On 11/4/24 at 10:04 AM, an interview was conducted with resident 221. Resident 21 stated he had a catheter and staff would come to empty the bag or change it when he called them. Resident 221's medical record was reviewed between 11/3/24 and 11/13/24. On 10/18/24 an admission Minimum Data Set (MDS) revealed that resident 221 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated a normal cognition. On 10/11/24, resident 221's diagnoses revealed, Infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter. On 10/13/24 at 3:09 AM, a progress note alert charting revealed, Resident recently admitted to facility. Alert and oriented x 4 and able to make needs known and use call light appropriately. Resident takes pills whole without difficulty. 20 Fr [french] indwelling catheter with 30 mL [milliliters] balloon leaking and unable to flush. Replaced using sterile technique. Resident tolerated procedure well, insertion somewhat difficult r/t [related to] enlarged prostate. Head of penis completely split and healed with insertion of catheter starting at the shaft. Ostomy to L [left] abd [abdomen] dressings to bilateral lower abd and coccyx. Refused to take off compression socks. Refused HS [hour of sleep] dose. On 10/14/24 at 1:00 AM, a provider progress note revealed, .Visit type: New Patient .Patient was transferred to [facility] rehab on 11 October 2024 .Past medical history .indwelling Foley catheter .Physical exam .Genitourinary: Foley catheter in place .Diagnosis, Assessment and Plan .Infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter. Currently stable, continue to monitor . On 11/3/24, physician orders were placed for catheter care and revealed: a. 20 F [french]/ 30 cc [cubic centimeters] (Foley/Suprapubic) catheter to down drain for dx [diagnosis] of (Neurogenic bladder/obstructive uropathy) r/t (Neuromuscular Dysfunction of Bladder, Unspecified). May change PRN [as needed] if dislodged or clogged. as needed related to Neuromuscular dysfunction of bladder, unspecified. Active 11/3/24 7:11 PM. b. Change catheter down drain bag weekly. every night shift every Sun [Sunday]. Active 11/10/24 6:00 PM. c. Perform catheter care q [every] shift: cleanse tubing, ensure tubing is not kinked, ensuring tubing is not resting on the ground, ensure catheter bag is in a privacy bag. every shift for CATHETER USE. Active 11/4/24. Resident 221's care plan revealed: a. The resident has (indwelling suprapubic) Catheter: Neurogenic bladder. Date Initiated: 11/2/2024, Revision on 11/3/2024. The goal was, The resident will be/remain free from catheter-related trauma through review date. Date initiated: 11/3/2024. Target date: 1/10/2025. Interventions included, CATHETER: The resident has (20f 30 cc balloon) (suprapubic catheter). Position catheter bag and tubing below the level of the bladder and away from entrance room door. Date initiated: 11/3/2024. Revision: 11/3/2024. b. Check tubing for kinks each shift. Date initiated: 11/3/2024. Revision on 11/3/2024. c. Monitor and document intake and output as per facility policy. Date initiated: 11/2/2024. d. Monitor for s/sx [signs and symptoms] of discomfort on urination and frequency. Date initiated: 11/2/2024. e. Monitor/document for pain/discomfort due to catheter. Date initiated: 11/2/2024. f. Monitor/record/report to MD [medical doctor] for s/sx UTI [urinary tract infection]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp [temperature], urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Date initiated: 11/2/2024. On 11/12/24 at 1:22 PM, an interview was conducted with the Director of Nursing (DON) who stated the DON or the MDS (minimum data set) coordinator put physician orders into the resident's medical record on admission. The DON stated sometimes the nurse manager would enter orders. The DON stated the provider never entered physician orders into the resident's medical record. The DON stated that resident 221 was admitted with a catheter. The DON stated there should be an order for catheter care when a resident is admitted with a catheter. The DON stated if a nurse was aware that an order was missing, they should notify the DON so it could be corrected. The DON stated the order may have been missed and nursing staff should have checked orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 65 residents sampled, that the facility did not ensure the timely transmission and completion of the Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid (CMS) System. Specifically, two resident's MDS assessments were not encoded and transmitted within 14 days after the facility completed the resident assessment. Resident identifier: 13 and 32. Findings included: 1. Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of neuropathy, chronic respiratory failure, epilepsy, chronic kidney disease, congestive heart failure, anterior dislocation of the right humerus, anxiety disorder, hypothyroidism, hypertension, thrombophilia, major depressive disorder, cataract, gout, suicidal ideation, mild cognitive impairment, chronic pain, osteoarthritis, scoliosis, insomnia, hyperlipidemia, obstructive sleep apnea, and fracture of right humerus. Resident 13's medical records were reviewed. On 9/5/24, resident 13's MDS Assessment documented a completion and accepted date of 9/25/24. It should be noted that the accepted date was 20 days after the Assessment Reference Date (ARD). 2. Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included cerebral infarction, cognitive communication deficit, type 2 diabetes mellitus, major depressive disorder, mixed hyperlipidemia, flaccid hemiplegia of left side, morbid obesity, generalized anxiety disorder, metabolic encephalopathy, hypertension, acute duodenal ulcer with hemorrhage, atrial fibrillation, and insomnia. Resident 32's medical records were reviewed. On 9/20/24, resident 32's MDS Assessment documented a completion and accepted date of 11/4/24. It should be noted that the accepted date was 45 days after the ARD. On 11/13/24 at 11:30 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the time frames for submitting a annual comprehensive and quarterly assessment was 14 days from the ARD date. The MDS Coordinator stated that he was a Licensed Practical Nurse and a Registered Nurse had to transmit them. The MDS Coordinator stated that the Director of Nursing (DON) or Corporate Resource Nurse (CRN) transmitted the assessment for him. On 11/13/24 at 12:03 PM, an interview was conducted with the DON. The DON stated that she oversees the transmitting of the MDS Assessments along with the Corporate MDS staff. The DON stated that resident 13 and resident 32's MDS Assessments were not transmitted on time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 26 was admitted to the facility on [DATE] with diagnoses which include, but not limited to, facioscapulohumeral muscular dystrophy, unspecified protein-calorie malnutrition, hyperlipidemia, hypomagnesemia, hypo-osmolality and hyponatremia, and weakness. On 11/3/24 at 3:36 PM, an interview was conducted with resident 26. Resident 26 stated she liked to attend activities at the facility but lately they had been getting canceled or were occurring during meal times. Resident 26 stated that this was very disappointing to her as she relies on activities to get her out of her room and gives her something to do. Resident 26's medical record was reviewed 11/3/24-11/13-24. A care plan dated 7/12/23 and revised on 6/19/24 revealed Recreational Therapy: [resident 26] exhibits impaired activity patterns manifested by: muscular dystrophy; impaired mobility, need for adaptive equipment, poor health/pain limits activity involvement, need for reminders and assistance to/from activities, fatigue for treatments/therapies. sensory problems, difficulties communicating other relevant conditions: hx [history] of falling; eye pain/difficulty seeing; heart palpitations; difficulty walking. The goal was [Resident 26 will attend 1 social activity or 1:1 per week for building a support system as evidenced by connecting with other residents and/or family; Will continue life roles/independent activities in accordance with preferences, strengths, and functional capacity weekly x 90 days, Will engage in 1 spiritual activity per week to decrease in signs of symptoms of depression as evidenced by increase in positive attitude during activities x 90 days. Interventions included the following: a. Invite and involve me in my activities of importance/interest including: dog visits, plants/horticulture, arts and crafts, musical performances, Christmas light drives, visiting with family/posterity, and watching the news and Calvary Chapel services on the TV, [resident 26] used to enjoy some of the following, that she is interested in trying again/learning: knitting/crocheting, drawing/sketching, checkers, fishing, nature walks, and using her devices for gaming/guided imagery. b. Monitor for satisfaction with my leisure choices. c. Please post the calendar in my room. d. Supply me with independent leisure materials PRN [as needed]. e. Please invite and/or assist to/from group activities. f. Please encourage me to participate in activities of interest. g. Please help ensure I have proper lighting & sufficient space for activities both in and out of my room. h. Please encourage and support the continuation of my life roles. i. Please support my family/friend involvement & my need for privacy during visits. j. Monitor for fall risk. k. Coordinate with CNA [certified nurse aide] to help assist with my setup/positioning/toileting needs during activities PRN. l. Monitor for my diet precautions for food related activities. m. Provide adaptations to activities PRN: n. Vision: provide me with large print material, be mindful of my eye sensitivity and difficulty seeing; o. physical: adapt/size/height/weight of items to match my physical abilities; monitor for fatigue p. communication: allow me time to speak and encourage to communicate during activities or attend to non-verbal cues q. Use validation to help me express my feelings appropriately, r. Encourage me to make positive statements and help uplift my mood during activities. s. Provide 1:1 visits 1x per week, PRN. On 9/20/24, there was a care conference conducted. The following was noted in the care conference: [Resident 26] expressed that she feels RT [recreation therapy] needs more staff because the Act. [Activities] Director is doing more assessments and meetings than previous activities people did. On 11/6/24 at 9:26 AM, an interview was conducted with the Activities Director (AD). The AD stated that the Resident Advocate at the facility recently took another position and she had to schedule all the care conferences and this took up a significant amount of her time. The AD stated that every once in a while there had been times that other duties overlapped and she was not able to do the scheduled activity. The AD stated that meal times have interfered with activities and meals weren't getting out on time and residents would not go to group because of meal time. The AD stated that every once in awhile a volunteer had canceled and she had to let management know that the activity was canceled. The AD stated that she did not work on the weekends and she relied on volunteers to carry out the activities on the weekend or the residents would lead the activities themselves. On 11/7/24 at 8:28 AM, an observation was made of the facility's activity calendar posted in the 100 hallway. The 4:00 PM activity of a piano performance scheduled for 11/7/24 was crossed out and Canceled-Sorry! was written. It was also observed that on 11/28 and 11/29 the calendar showed that (AD) on vacation; reduced programming in her absence. On 11/13/24 at 9:09 AM, a follow up interview was conducted with the AD. The AD stated that she did not have an assistant and she was responsible for all of the resident activities. The AD stated that she always posted the activities calendar on the first of the month. The AD stated that for the month of November there were some difficulties because there was no money in the budget to get the calendar printed. The AD stated she was going to be off for a few days and there was no one to fill in her for, so that was why the calendar stated reduced programing. (Cross Refer to F725) Based on observation, interview and record review it was determined, 3 out of 65 sampled residents, that the facility did not provide an ongoing program to support resident in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community based on the residents comprehensive assessment and care plan. Specifically, there was no activity calendar, there were no activities on the weekends, resident complained of not enough activities, activities were observed during meal times, and there were complaints in resident council minutes. Resident identifiers: 26, 38 and 49. Findings included: 1. On 11/3/24 at 1:04 PM, an observation was made of the activity calendar. The calendar was for October 2024. On 11/4/24 an observation was made of the activity calendar for November 2024 hanging on the wall by the nurses station. 2. On 11/5/24 at 6:31 PM, an observation was made in the activity room. There were residents in there attending a bible study. An observation was made of the Housekeeping Supervisor (HS) taking resident 38's meal tray into the activity room. The HS was observed to move resident 38's things and put his meal tray in front of him while the activity was going. 3. Resident 49 was admitted to the facility on [DATE] with diagnoses which included dementia, paroxysmal atrial fibrillation, heart failure, cognitive communication deficit, and chronic pain. On 11/3/24 at 6:43 PM, an interview was conducted with resident 49. Resident 49 stated he would like to have more activities to stimulate his brain. Resident 49 stated he would like to play chess, horse shoe or other games like that. Resident 49's medical record was reviewed 11/3/24 through 11/13/24. Resident 49's admission Minimum Data Set (MDS) dated [DATE] revealed it was very important for resident 49 listen to music and participate in religious services or practices. It was somewhat important to go outside to get fresh air when the weather was good, do his favorite activities, do things with groups of people, be around animals such as pets, and read books, newspapers, and magazines. A quarterly MDS revealed resident 49 had a Brief Interview of Mental Status (BIMS) score of 15. A care plan dated 3/25/24 and revised on 8/19/24 revealed Recreational Therapy: [resident 49] exhibits impaired activity patterns manifested by: impaired mobility, need for adaptive equipment, sensory problems, poor health/pain limits activity involvement, need for reminders and assistance to/from activities, fatigue from treatments; problems with coping skills; exhibits behaviors, at times. The goal was [Resident 49] will continue life roles and maintain independence in accordance with preferences, strengths, and functional capacity by being oriented to make decisions regarding leisure participation, communicating wants/needs during interventions, and participating in leisure activities regularly, through the review period. [Resident 49] will accept at least 1 1:1 visit OR attend 1 group per week, through the review period, for coping and social skill development, enhancing self esteem, positive self-expression, goal-setting, improving problem solving and decision-making skills, anger and stress management, improving self perceived wellness, and/or building and strengthening interpersonal relationships. Interventions included the following: a. Invite and involve in present/past activities of importance/interest including: Book Club, Mystery Person Trivia, C/C [coffee and choc] social, walking groups, Ping-Pong and Chess tournaments, religious groups. b. Voting: move here, if he decides to stay living here. c. Religious: Church of Jesus Christ of Latter-day Saints, Consents to receiving services d. Trauma r/t [related to]: perceived religious persecution. e. Monitor for satisfaction with my leisure choices. f. Please post the calendar in my room. g. Supply me with independent leisure materials PRN [as needed]. h. Please invite and/or assist to/from group activities. i. Please encourage me to participate in activities of interest. j. Please help ensure I have proper lighting & sufficient space for activities both in and out of my room. k. Please encourage and support the continuation of my life roles. Please support my family/friend involvement & my need for privacy during visits. l. Monitor for fall risk. m. Coordinate with CNA to help assist with my setup/positioning/toileting needs during activities PRN. n. Monitor for my diet precautions for food related activities. Provide adaptations to activities PRN: o. Cognition: provide opportunities to recall memories and/or make decisions. Provide assistance with orientation and decision-making, PRN. p. Vision: provide me with large print material q. Hearing: increase volume and speak clearly to me r. physical: adapt size/height/weight of items to match my physical abilities, low energy programming s. communication: allow me time to speak and encourage to communicate during activities, attend to non-verbal cues. Use validation to help re-direct my behaviors and be calm with me. t. Use validation to help me express my feelings appropriately. u. Encourage me to make positive statements and help uplift my mood during activities. v. Encourage me to interact appropriately with others and provide me with positive feedback when I do. w. Encourage/support the development of old/new interests, hobbies, or skills. On 8/15/24, there was a care conference conducted. The following was noted in the care conference [Resident 49] expressed that he has no concerns/issues, but would like to see a couple of particular activities on the resident Calendar (Ping-Pong/Chess Tournament), and have the facility create an outdoor Horseshoes arena. [Resident 49] enjoys sitting & socializing with his significant other watching TV in the act. [activity] room. He enjoys participating in Book Club, Coffee/Cocoa Social, walking groups, and Church groups for the Church of Jesus Christ of Latter-day Saints. He has enjoyed Chess and Ping Pong Tournaments, in the past. A form titled Activities - Quarterly/Annual Participation Review completed on 8/19/24 revealed [Resident 49] enjoys independent leisure activities including sitting and socializing with his significant other watching TV in the activity room. He enjoys participating in Book Club, Coffee/Cocoa Social, walking groups, and Church groups for the Church of Jesus Christ of Latter-day Saints. He has enjoyed Chess and Ping Pong Tournaments, in the past. Changes to interventions and approaches revealed Adjusted to personalize/update, per MDS and observation/interview information. Added interests and personalized adaptations. On 11/12/24 at 3:09 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the Activities Director (AD) was in charge of activities. The DON stated the AD had a staff member trained to do activities on the memory care unit. The DON stated there had been miscommunication regarding the time of activities lately. The DON stated the activity was usually paged over the intercom system if there was a change in the time. The DON stated resident's have not been able to hear the changes in times. The DON stated meals did not usually overlap with meals, but there was a Bible study that overlapped with dinner last week. The DON stated the AD provided activities Monday through Friday and a resident volunteer to did activities on the weekends. On 11/13/24 at 9:13 AM, an interview was conducted with the AD. The AD stated resident 49 loved trivia, prides himself on history, book club, loves walks, coffee and hot chocolate social, napping, news and walks. The AD stared resident 49 watched a lot of TV on the weekends. The AD stated activities on the weekends included resident led activities and church. The AD stated sometimes every other Sunday there were card games. The AD stated she referenced community events because residents can use the bus system to go to activities. On 11/12/24 at 11:04 AM, an interview was conducted with Certified Nursing Assistant (CNA) 8. CNA 8 stated there were activities every day but the activities were things like book club that people did not like. CNA 8 stated usually resident 49 watched TV in the activities room or in his room. CNA 8 stated there was nothing going on during the weekends.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for 1 of 65 sample residents, the facility did not ensure a resident who required colostomy services received care consistent with professional standards of practice, the person-centered care plan, and the resident's goals and preferences. Specifically, the facility ran out of colostomy supplies and when the supplies were ordered, the wrong item was ordered leaving the resident without colostomy supplies. Resident identifier: 3. Resident 3 was admitted to the facility on [DATE] with diagnoses that included Arnold Chiari Syndrome with spina bifida and hydrocephalus, severe protein-calorie malnutrition, osteomyelitis right ankle and foot, paraplegia, borderline personality disorder, major depressive disorder, morbid obesity, bipolar disorder, and anxiety disorder. On 11/4/24 at 10:59 AM, an interview was conducted with resident 3 who stated the facility had run out of wafers needed for her colostomy care and then the wrong ones were ordered. Resident 3's medical record was reviewed between 11/3/24 and 11/13/24. An annual Minimum Data Set (MDS) dated [DATE] revealed resident 3 had a Brief Interview for Mental Status (BIMS) score of 15 indicating normal cognition. Physician orders included: a. Ostomy care for colostomy type of wafer/bag to be used: Collar 12561 (2.75) Pouch 416242 (2.75)- change wafer/bag two times a day for wound care. Order date: 8/8/24. b. Ostomy care for colostomy type of wafer/bag to be used: Collar 125261 (2.75) Pouch 416242 (2.75)-change wafer/bag every 4 hours as needed for wound care. Order date 8/8/24. Resident 3's care plan revealed, Potential for complications related to colostomy and urostomy. Date initiated: 4/19/22, Revision on: 9/23/22. The goal was, Resident will be able to demonstrate assisted ability to care for ostomy daily through next 90 day review. Date initiated: 4/29/22, Revision on: 12/12/23, Target date: 1/31/25; Resident will have no complications r/t [related to] colostomy and/or urostomy through the next review date. Date initiated: 10/7/22, Revision on 12/12/23, Target date: 1/31/25. Interventions included, Medications as ordered. Date initiated: 4/19/22, Revision on 4/29/22; Monitor ostomy site for swelling, pain, and redness and report to MD [medical doctor]. Date initiated: 4/19/22, Revision on 4/19/22; Ostomy care as needed to prevent odor. Date initiated: 4/19/22, Revision on: 4/19/22; Resident enjoys assisting with colostomy bag change. Allow resident to change colostomy bag under supervision of licensed nurse. Date initiated; 9/23/22. Resident teaching on ostomy care if appropriate. Date initiated: 4/19/22, Revision on 4/19/22. On 11/7/24 at 9:48 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4 who stated the facility waited until she was completely out before ordering additional wafers. LPN 4 stated when they finally came, the wrong wafer's had been ordered. LPN 4 stated resident 3 went a week without the wafers needed in the colostomy changes. LPN 4 stated after that incident, the product codes were put into the resident's Medication Administration Record (MAR) so they would not have that happen again. On 11/13/24 at 9:19 AM, an interview was conducted with the Director of Nursing (DON) who stated that she and Certified Nursing Assistant (CNA) 1 were responsible for ordering supplies for colostomy care. The DON stated she was unsure about how often they were being ordered or how things were being tracked for ordering purposes. The DON stated the facility had a good relationship with their neighbors who would help with supplies if the facility ran out. The DON stated they could also reach out to the resident's provider for an alternative. The DON stated the wafer was to protect the skin and if a wafer was not in place the resident could experience skin breakdown and irritation. The DON stated they have borrowed from their neighbors before. The DON stated that over the summer, the wafer's were back ordered and the problem was an issue with the supply chain. The DON stated if there was a negative outcome such as skin irritation, the nurse would document it in the skin assessment and notify the wound nurse. The DON stated resident 3's order was for assessing the need for a colostomy bag change every other day.

Based on observation and interview, it was determined that the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed practical nurse, Certified Nurse aides, and resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors. Specifically, there were days when the nurse staffing information was not posted by 6:00 AM with the current date and the nurse staffing information was not posted on 11/8/24. Findings include: a. On 11/3/24 at 1:04 PM, during the initial tour of the facility, the nurse staff posting was dated 11/1/24. b. On 11/5/24 at 7:54 AM, the nurse staff posting was dated 11/4/24. c. On 11/6/24 at 7:41 AM, the nurse staff posting was dated 11/5/24. d. On 11/8/24 at 8:36 AM, the nurse staff posting was not readily accessible. e. On 11/8/24 at 11:29 AM, the nurse staff posting was not readily accessible. On 11/7/24 at 11:11 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that Certified Nurse Assistant (CNA) 1 and CNA 4 were responsible for staffing and posting the nurse staffing sheet. On 11/7/24 at 12:04 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated that the staffing coordinators were responsible for posting the staffing sheets. The ADMIN stated that CNA 1 and CNA 4 were the staffing coordinators. On 11/12/24 at 9:24 AM, an interview was conducted with CNA 1. CNA 1 stated she was responsible for filling out the daily nurse staff posting. CNA 1 stated that the shifts for nursing staff were 6:00 AM-6:00 PM and 6:00 PM-6:00 AM. CNA 1 stated that the nurse staff posting was located right outside the business office on the wall. CNA 1 stated that she would have CNA 4 post the daily nurse staff posting before she left her shift at 6:00 AM. CNA 1 stated there had never been a day that the daily nurse staffing post had not been posted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 64 sampled residents, that the facility did not ensure that a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Specifically, staff reported ignoring resident behaviors and were not able to identify person-centered interventions or non-pharmacological approaches to resident's dementia care. Resident identifier: 65. Finding included: Resident 65 was admitted to the facility on [DATE] with diagnoses which included dementia, seizures, hypothyroidism, obstructive sleep apnea, depression, presence of a cardiac pacemaker, and violent behaviors. On 11/03/24 at 3:56 PM, an observation was made of resident 65 sleeping in a recliner in his room. The resident's call light was observed on the arm rest within reach and a walker was located near the door. On 11/05/24 at 1:08 PM, an observation was made of resident 65 exiting his room and pushing a walker. The resident said hello and had a smile on his face. Resident 65's electronic medical records were reviewed. On 9/17/24, resident 65's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 4/15, which would indicate a severe cognitive impairment. The assessment documented a PHQ-9 mood score of 7 which would indicate a mild depression severity. The assessment documented that physical or verbal behavioral symptoms were not exhibited. Resident 65's physician orders revealed: a. On 10/18/24, an order was initiated for Haloperidol Tablet 5 milligram (mg), give 1 tablet by mouth every 1 hours as needed for agitation at bedtime, if still showing agitation after one hour give another 5 mg tablet. b. On 10/18/24, an order was initiated for Haloperidol Tablet 5 mg, give 1 tablet by mouth every 22 hours as needed for agitation at bedtime, if still showing agitation after one hour give another 5 mg tablet. c. On 10/17/24, an order was initiated for Hydroxyzine Tablet 25 mg, give 1 tablet by mouth every 6 hours as needed for anxiety. d. On 9/10/24, an order was initiated for Sertraline Tablet 100 mg, give 1 tablet by mouth two times a day for depression. d. On 9/10/24, an order was initiated for Risperidone Tablet 0.5 mg, give 1 tablet by mouth two times a day for dementia/depression. Resident 65's October Medication Administration Record (MAR) documented the following: a. The Haloperidol PRN order was administered on 10/20/24 at 7:45 PM for agitation and was documented as effective. b. The Hydroxyzine PRN order was administered on 10/18/24 at 8:17 AM, on 10/19/24 at 8:49 AM, on 10/20/24 at 3:24 PM, on 10/22/24 at 4:31 PM, on 10/26/24 at 1:45 PM, and on 10//27/24 at 3:39 PM for anxiety and all were documented as effective. c. The behavior monitoring for number of episodes of agitation every shift documented a total of 29 episodes for the month. d. The behavior monitoring for number of verbal outbursts every shift documented a total of 23 episodes for the month. It should be noted that no documentation was found of non-pharmacological interventions that were provided to resident 65 in response to his episodes of behavior for October 2024. Resident 65's November MAR documented the following: a. The Haloperidol PRN order was administered on 11/2/24 for agitation and was documented as effective. It should be noted that behavior monitoring for episodes of agitation or verbal outburst did not document any episodes on 11/2/24 at the time the medication was administered. b. The Hydroxyzine PRN order was administered on 11/2/24 for anxiety and was documented as effective. It should be noted that behavior monitoring for episodes of agitation or verbal outburst did not document any episodes on 11/2/24 at the time the medication was administered. It should be noted that no documentation was found of non-pharmacological interventions that were provided to resident 65 in response to his episodes of behavior for November 2024. Resident 65's progress notes revealed the following: a. On 9/11/2024 at 1:00 AM, the provider note documented, Patient is a [AGE] year-old male with past medical history significant for dementia, seizure disorder, hypothyroidism, history of sick sinus syndrome status post cardiac pacemaker, and BPH [benign prostatic hyperplasia]. He presented to the emergency department via EMS [emergency medical services ]with agitation and violent behavior. The patient is currently a resident at the [name omitted] memory care assisted living facility. Staff report that he was assaulting them and the police were called. EMS services were then contacted and the patient was picked up with police assistance and brought here to the emergency department under a pink sheet. The patient continued to be violent and agitated upon arrival. b. On 9/13/2024 at 3:23 AM, the note documented, Resident aggressive during brief change. He was kneeing CNA [Certified Nurse Assistant] and attempting to hit CNA and stating 'don't touch me, get out.' c. On 9/25/2024 at 9:46 AM, the note documented, CNA reports resident standing by Memory Care Unit door attempting to exit. When CNA intervened, pt [patient] states 'I'm going to slap.' Per CNA, patient poured water on her. CNA notified this nurse. Pt redirected. Call place to SO [significant other]. Pt able to calm down. Sitting next to nurse cart at this time. d. On 9/29/2024 at 1:26 PM, the note documented, Pt wandered out of unit, was stopped by Nurse and Aid and redirected back to memory care. Pt stated that he would like to go outside and is not happy about being here. e. On 10/15/2024 12:30 AM, the note documented, Resident came out of room and went to the memory care doors in attempt to leave, when he realized he could not leave he asked why he could not. Nurse attempted to redirect resident but resident became very agitated and threatened to call the police and went back to his room and slammed his door shut. Resident then preceded to barricade his door from the inside made out of his wheelchair, walker,and a small cardboard box. f. On 10/15/2024 at 6:36 PM, the note documented, RA [resident] agitated and exit seeking this afternoon. Blocked Memory Unit main door. Difficult to redirect. POA [Power of Attorney] on phone unable to redirect. RA appear to calm down when female friend in to visit at About 1720 [5:20 PM]. RA in room resting on recliner chair at this time. g. On 10/16/2024 1:00 AM, the provider note documented, Today patient is being seen for concern for agitation and exit seeking. Nursing staff reported that he has had 2 episodes of agitation over the last two days. Yesterday he became agitated after he was let put of [sic] the memory care unit on accident and was difficult to get him back into his room. A family friend was able to calm him down yesterday. The provider ordered Hydroxyzine for agitation. h. On 10/16/2024 at 4:00 PM, the note documented, Resident pushed his way past the housekeeper when she was trying to exit the unit. Resident became agitated and stated that he was going to leave. Attempted to reassure resident. Resident was sitting in his walker outside the unit and threw himself on the floor and began to try to kick and punch staff. Resident assisted from floor x [times] 6 [staff] and walked back into unit and into room. Resident assessed once he had a chance to calm down. No injuries noted. Will continue to monitor. MD [Medical Doctor] notified. i. On 10/16/2024 at 6:31 PM, the note documented, RA continue to require assistance w/ [with] med administration and ADLs [activities of daily living]. Denies pain. Skin intact. Agitated, combative to staff this pm. Is exit seeking. Difficult to redirect. Family and MD aware. j. On 10/17/2024 at 1:00 AM, the provider note documented, Today patient is being seen for a clarification regarding orders. Patient was seen recently by [provider name omitted]. Nursing staff is unable to locate the hydroxyzine order that was left for them. We will go ahead and do this today. Will begin patient on hydroxyzine 25 mg, will give 1 tablet by mouth every 6 hours as needed for agitation. k. On 10/18/2024 at 1:00 AM, the provider note documented, Today patient is being seen for concern for aggression and nursing staff reports that he has had multiple episodes over the last several days. Previously he had episodes of exit seeking. Family friends were able to calm him down previously. He had previously gotten out of the memory care unit and it was difficult to get him back into his room. Previously had a diagnoses of depression but also was placed on Haldol in the past We will place referral for behavioral health. In the meantime we will place the patient on Haldol 5 mg for aggression, may give 5 more milligrams after 1 hour if needed. No documentation could be found of any behavioral health services that were provided to the resident. l. On 10/18/2024 at 3:03 AM, the note documented, Aide alerted nurse that resident was being extremely erratic in the hallway. When nurse walked into memory care unit, resident was slamming on the unit doors very aggressively. Nurse attempted to have resident stop slamming on the door. Resident began yelling at the staff saying 'get me the f*** out of here' and 'open the G** d*** door'. Nurse attempted to explain to the resident that he could not leave he then told nurse 'you're a f****** lying b****'. Nurse and aide attempted to stop resident from hitting door because he stated his hand hurt. Resident then struck nurse in the arm. Nurse and aides then tried to walk him to his room but he started to lower himself to the floor, so with assistance we lowered resident to the floor. While resident was sitting on the floor he reached out and struck the nurse on the hand. Resident lowered himself to where he was lying on the floor. We left resident on the floor to calm down for a few minutes, he continued to yell at staff threatening to 'bloody your noses'. When aide touched residents knee and asked him if he was ready to go back to his room, resident stated 'I'm gonna slap the s*** out of you'. Resident continued to be verbally aggressive towards all 3 staff members that were attempting to help him. When it became evident that he wasn't going to calm down and that he was not safe to stay laying on the floor in front of the memory unit door, we decided to escort him back to his room. During this process the resident slammed his head into the aides head. Resident was put back in his recliner in his room and left to calm down. CNA's sat in chairs in the hallway to continue to monitor him from a distance. When nurse returned to the room to assess resident, he was asleep in his recliner, no injuries were noted to his hands or head. m. On 10/18/2024 at 11:14 AM, the note documented, [Doctor name omitted] seen the resident and ordered Haloperidol 5 mg every bedtime and may add another dose if not effective after an hour of administration. Called his son, [name omitted] and left a message saying about the new order and asked to return call. n. On 10/19/2024 at 6:39 AM, the note documented, Resident is on Hydroxyzine, Risperidone and Haldol and seems helping well with the resident's behavior. He is able to use call light when needed. Will continue monitor resident. o. On 10/20/2024 at 5:43 PM, the note documented, Observed resident w/ [with] increasing anxiety/agitation, PRN [as needed] hydroxyzine administered w/ effective result. No exits seeking this shift. p. On 10/21/2024 at 2:09 AM, the note documented, Observed resident w/ increasing anxiety/agitation, PRN haloperidol administered w/ effective result. No exit seeking this shift. q. On 10/22/2024 at 5:42 PM, the note documented, RA appears anxious and exit seeking. Redirection appears unsuccessful. PRN hydroxyzine administered. Will monitor for effectiveness. r. On 10/23/2024 12:01 AM, the note documented, Pt had episode of agitation during med pass. Stating he felt like he is in prison and cant trust any of the staff members. PRN hydroxyzine was not given do to previous dose given two hours before. No further episodes of aggression or agitation. s. On 10/26/2024 at 10:34 PM, the note documented, Pt with exit seeking behavior. Pt sat by the doors until his supper came. After supper, pt would walk around in his room. No other behaviors noted this evening. Received 1 person assist with adl's. t. On 10/27/2024 at 5:25 PM, the note documented, Resident w/ increasing anxiety and exit seeking. Multiple interventions offered, appears unsuccessful. PRN hydroxyzine administered per order and is effective. Pt appears calm. Safety precautions in place. u. On 10/31/2024 9:52 PM, the note documented, Pt is seeking to leave the building on this shift asking staff to take him outside. When offered to go on the back patio he stated he knows that does not go anywhere. Pt then proceed to sit on his wheelchair by the locked door in order to leave. Pt later sat in room for the rest of the night. Pt adhered to medication administration and cares. v. On 10/31/2024 at 10:50 PM, the note documented, Pt stated that he needed to leave. Pt proceed to stand by exit for a period of time waiting for someone to open the door. w. On 11/2/2024 at 10:15 PM, the note documented, Pt verbalized that he wanted to leave the facility and was sitting by the memory care doors this shift. Attempted to redirect with dinner and tv. PRN anxiety medications administered. x. On 11/5/2024 at 11:57 PM, the note documented, Resident was very agitated tonight, banging on the door and yelling stating he needed to get out. He wouldn't let staff leave the unit and got very agitated and aggressive with staff. Resident hit nurse when she tried to exit the unit and walk around him. After about an hour resident went into his room and went to bed. On 10/18/24, resident 65 had a care plan initiated for The resident is/has potential to be physically aggressive r/t [related to] Dementia. Interventions identified on the care plan were to administer medications as ordered and monitor for effectiveness; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate resident's needs; give the resident as many choices as possible; psychiatric/psychogeriatric consult as indicated; On 10/21/24, resident 65 had a care plan initiated for MOOD & BEHAVIOR: [resident 65] has a history for an alteration in mood or exhibition of behavioral symptoms r/t: Alzheimer's/Dementia, Physically Aggressive and Violent Behaviors. Interventions identified on the care plan were to administer medication as ordered, allow time to calm down and approach later, interact in an empathetic and supportive manner, monitor and document each behavioral event, and offer one-to-one interaction as needed. On 11/2/24, resident 65 had a care plan initiated for The resident has diagnosis/diagnoses of (depression, dementia, history of violent behaviors). Resident requires the use of (psychotropic medications) to help manage this condition. Interventions identified on the care plan were administer psychotropic medications per physician order and monitor for ASE; monitor and document occurrence of target symptoms; psychotropic committee will review medication regimen, ASE, and target symptoms quarterly; and staff should use the following non-pharmacological interventions to manage symptoms (active listening/support/encouragement, validation, reality orientation, re-direction/distraction, and identification and elimination of triggers). It should be noted that the resident had been receiving psychotropic medications since admission on [DATE] and the care plan for the psychotropic medications was not initiated until 11/2/24. On 11/04/24 at 3:27 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 65 would forget where he was and attempted to escape a lot. CNA 3 stated that resident 65 thought he did not belong at the facility and he was trying to get home. CNA 3 stated that resident 65 would push on the door and knock on the windows. On 11/04/24 at 3:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 65 had behaviors of exit seeking and was aggressive. LPN 3 stated that resident 65 would block the door so no one could enter or exit, he would push staff, and yells at staff. LPN 3 stated that when she noticed his anxiety was increasing she gave Hydroxyzine. LPN 3 stated that resident 65 had a PRN order for Haldol for anxiety and aggression. LPN 3 stated that resident 65 had only needed that medication a couple of times. LPN 3 stated that when resident 65 focused on leaving they attempted to re-direct him. LPN 3 stated that some days he was not able to be re-directed. LPN 3 stated that on those days they tried to contact his son or girlfriend. LPN 3 stated that resident 65 received Risperidone for depression and dementia and that he had a diagnoses of behavioral disturbance. LPN 3 stated that resident 65 did not have a diagnosis of schizophrenia, or bipolar disorder, just dementia with violent behaviors. LPN 3 stated one time resident 65 became really aggressive. They had a new housekeeper that let him out of the locked unit and it was hard to bring him back into the unit. On 11/05/24 at 1:27 PM, an interview was conducted with CNA 5. CNA 5 stated that she completed dementia training in October 2024. CNA 5 stated that all she recalled from her dementia training was to re-direct the resident when behaviors occurred. CNA 5 stated that she sometimes ignored residents with behaviors and if they became more agitated would tell them to go lie down. CNA 5 was not able to identify any other resident specific interventions for behaviors of agitation, aggression or verbal outbursts. On 11/06/24 at 8:55 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 65's psychotropic medication should have monitoring for behaviors and adverse side effects. The DON stated that any non-pharmacological interventions were listed in the resident care plan and should address de-escalation techniques. The DON stated that they conducted staff training for de-escalation techniques for each resident upon admission. The DON stated that they conducted a psychotropic meeting monthly to see how the resident trends and any PRN medication usage. The DON stated that typically they did not administer antipsychotics for dementia, but it would depend on each resident's case. The DON stated that she would like to have a list of interventions that were attempted to manage behaviors prior to medication management. The DON stated that those non-pharmacological interventions should also be documented in the resident progress notes. The DON stated that for resident 65 if the staff called his son or girlfriend they were good at calming him down. The DON stated that typically PRN antipsychotics were only ordered for 14 days. The DON stated that to justify the extended use of the PRN antipsychotics they had a form that was filled out by the MD. The DON stated that they conducted a monthly psychotropic review and they just reviewed resident 65 in October. The DON stated that she had not filled out any of the paperwork for resident 65's October review yet. On 11/06/24 at 11:59 AM, an interview was conducted with CNA 6. CNA 6 stated that he had been employed at the facility for a year and had not received dementia training from the facility. CNA 6 stated that the training that was provided to him upon hire was on each resident care needs and how to use a mechanical lift. CNA 6 stated that he also completed some computer based training. On 11/06/24 at 1:59 PM, an interview was conducted with CNA 3. CNA 3 stated that she had not received dementia training from the facility. CNA 3 stated that the training she did receive was to shadow another employee when she was first hired and that orientation period was two weeks. CNA 3 stated that resident 65 had behaviors of exit seeking. CNA 3 stated that resident 65 would sit by the door, yell at staff, and would grab staff if they came too close. CNA 3 stated that resident 65 had struck out at her, hit her, and yelled at her in the past. CNA 3 stated that she gave resident 65 space to calm down, and when he was really paranoid they let him talk to his girlfriend. CNA 3 was not able to identify any other resident specific interventions for behaviors of agitation, aggression or verbal outbursts for resident 65. On 11/07/24 at 12:13 PM, an interview was conducted with the Resident Advocate. The Resident Advocate stated that resident 65 had end stage dementia induced aggression and was exit seeking. The Resident Advocate stated that staff should approach resident 65 from the front, use calm tones when speaking, explain what they were doing, validate what he was feeling in the moment, and let him know that he was safe. The Resident Advocate also stated that he would get down on resident 65's eye level and not tower over him. The Resident Advocate stated that whenever he had other staff with him he would communicate what he was doing to them and why. The Resident Advocate stated that he never conducted any formal training with staff on dementia care, de-escalation techniques or how to handle resident 65's behaviors. On 11/12/24 at 1:46 PM, a follow-up interview was conducted with the DON. The DON stated that the CNA Supervisors were in charge of training but that they were newly hired as coordinators in September. The DON stated that they had computer based training modules that were required and included dementia training. The DON stated that they also conducted in-service training for staff. The DON stated that the Activities Director was certified in dementia care and had conducted some dementia training for all staff. On 6/4/24, the facility conducted dementia training for all staff. An Agenda and attendance roster was provided. It should be noted that CNA 3 and CNA 5 were not in attendance of the training. On 11/13/24 at 9:02 AM, a follow-up interview was conducted with the DON and included the Regional Nurse Consultant (RNC)1. The RNC 1 stated that they were not currently using the [NAME] system that would link the care plan interventions for the CNAs to view. The DON stated that they had a CNA report sheet that they utilized and it contained resident specific information. The DON stated that the information was updated on a google sheet and all staff had access to update it. The DON stated that it was a collective effort to make sure the information was accurate but was supervised by the CNA Coordinator. A copy of the CNA report sheet was viewed with the DON. The report sheet was not filled in with resident names or any resident specific information. The DON stated that she would look into how the care plan interventions and resident specific care was communicated to the aides.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 65 sampled residents, that the facility did not provide pharmaceutical services which included procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's to meet the needs of each resident. Specifically, Darbepoetin Alfa injection for anemia was not available from the pharmacy for administration and laboratory values were abnormal. Additional medications were not available for administration. Resident identifier: 55. Findings included: Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and anemia. On 11/12/24 at 10:26 AM, an interview was conducted with resident 55. Resident 55 stated he had not been administered an injection and had not been told why he had not received it. Resident 55's medical record was reviewed from 11/3/24 through 11/13/24. a. A physician's order dated 9/14/24 and discontinued on 10/13/24 revealed Darbepoetin Alfa Injection Solution 40 MCG [microgram] / [per] ML [milliliter]. Inject 1 ml subcutaneously one time a day every Sun [Sunday] for anemia. According to the October 2024 Medication Administration Record (MAR) Darbepoetin Alfa was not administered on 10/6/24 with the code held- see progress note. On 10/13/24, there was no documentation the medication was administered. An Orders - Administration progress note dated 10/6/24 at 12:05 PM revealed, waiting for pharmacist delivery. There were no progress notes for 10/13/24. A physician's order dated 10/13/24 Darbepoetin Alfa Injection Solution 40 MCG/ML. Inject 1 ml subcutaneously one time a day every Tues [Tuesday], Sun for anemia. According the the October 2024 MAR resident 55 was not administered the injection on 10/15/24, 10/20/24, 10/22/24 and 10/29/24. The November 2024 MAR Darbepoetin was not administered on 11/3/24, 11/5/24, 11/10/24 and 11/12/24. An order - Administration progress note dated 10/20/24 at 3:03 PM revealed Weighting [sic] on pharmacy. An order - Administration progress note dated 10/22/24 at 7:39 PM revealed Will verify delivery from pharmacy. An order - Administration progress note dated 10/29/24 at 2:13 PM revealed Awaiting PA [prior authorization] from insurance. An order - Administration progress note dated 11/3/24 at 12:50 PM revealed waiting for pharmacist delivery. An order - Administration progress note dated 11/5/24 at 2:06 PM revealed waiting for pharmacist delivery. An order - Administration progress note dated 11/10/24 at 11:31 AM revealed weighting [sic] on pharmacy. There were no progress note regarding the medication not administered on 11/12/24. b. A physician's order dated 9/25/24 revealed Valbenazine Tosylate Oral Capsule 80 MG [milligrams]. Give 1 capsule by mouth at bedtime for Tardive dyskinesia. Needs to go through [name removed] pharmacy. According to the October 2024 MAR Valbenazine Tosylate was not administered on 10/4/24 through 10/9/24, 10/14/24 and 10/22/24. An order - Administration progress note dated 10/4/24 at 7:03 PM revealed Waiting for order too [sic] come. An order - Administration progress note dated 10/5/24 at 8:15 PM revealed, need insurance approval. An order - Administration progress note dated 10/6/24 at 6:58 PM revealed waiting for insurance approval. An order - Administration progress note dated 10/7/24 at 7:27 PM revealed Waiting for approval from insurance. An order - Administration progress note dated 10/8/24 at 6:54 PM revealed unavailable. An order - Administration progress note dated 10/9/24 at 7:09 PM had no information why the medication was not administered. An order - Administration progress note dated 10/14/24 at 11:45 PM revealed out of stock. An order - Administration progress note dated 10/22/24 at 7:39 PM revealed waiting for delivery. According to the November 2024 MAR Valbenazine was not administered 11/5/24, 11/6/24 and 11/7/24. An order -Administration progress note dated 11/5/24 at 8:16 PM revealed Waiting for pharmacy delivery. An order - Administration progress note dated 11/6/24 at 7:08 PM revealed out of stock. Pharmacy will be called 11/7 for restock. An alert charting progress note dated 11/7/24 at 9:17 AM revealed Called [name removed] pharmacy but just able to leave a message regarding Valbenazine Tosylate 80 mg.for [sic] this resident requested delivery and asked to call if there is a problem delivering it. Laboratory results of a Complete Blood Count (CBC) for resident 55 dated 9/23/24 revealed a Red blood cells (RBC) 3.62 was low with a reference range on 4.5 - 5.9 M/uL (million red blood cells per microliter), Hemoglobin (hgb) level of 11.9 which was low with a reference range of 13.5 - 17.5 g/dL (grams per decilitre), Hematocrit (HCT) level was 36.8 which was low with a reference range of 41.0 - 53.0 percent (%). Resident 55's mean corpuscular volume (MCV) was 101.7 which was high with a reference range of 80.0 - 100.0 fL (femtoliters). A physician's encounter note dated 9/25/24 at 1:00 AM revealed, .CBC RBC 3.62 Hemoglobin 11.9 Hematocrit 36.8 MCV [Mean Corpuscular Volume] 36.8 RDW [red cell distribution width] . Diagnosis, Assessment and Plan. Anemia, unspecified Folic acid 1 mg, give 1 tablet by mouth once daily. Darbepoetin alpha injection solution 40 mcg/mL, inject 0.4 mg subcutaneously every Friday. Cyanocobalamin oral tablet 1000 mcg, give 1 tablet by mouth once daily. We will obtain routine lab work every 6 months to monitor this. A physician's encounter note dated 10/15/24 at 1:00 AM, .Chief Complaint / Nature of Presenting Problem: Lab review.CBC RBC 3.61 Hemoglobin 11.9 Hematocrit 37.3 MCV 103.3 MCHC [Mean corpuscular hemoglobin concentration] 31.9 RDW SD [actual measurement of the width of the red cell distibution curve in femtoliters] 48.6.Anemia, unspecified Folic acid 1 mg, give 1 tablet by mouth twice daily. Darbepoetin alpha injection solution 40 mcg/mL, inject 0.4 mg subcutaneously every Friday. Cyanocobalamin oral tablet 1000 mcg, give 1 tablet by mouth twice daily. We will obtain routine lab work every 6 months to monitor this.Continue plan of care as outlined. Today we discussed the plan with the patient and nurse. All questions answered. Patient states understanding and agrees to plan. Reviewed vital signs and medication list today. Continue medications as ordered. It should be noted there was a new physician's order dated 10/13/24 for Darbepoetin Alfa Injection Solution 40 MCG/ML to be administered twice weekly on Tuesday and Sunday not once weekly as noted in the physician's encounter note. Laboratory results for resident 55 dated 11/4/24 revealed RBC was 2.95 which was low, hgb was 10.0 which was low, HCT was 30.2 which was low and MCV was 102.4 which was high. The reference values were the same as above. There was no physician's encounter note after the laboratory results were obtained on 11/4/24. On 11/12/24 at 10:43 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated she had not administered Darbepoetin Alfa because it might be in the fridge and nurses did not know it was in there. LPN 3 stated the medication might also need a preauthorization or a physician's approval. On 11/12/24 at 1:38 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the process for obtaining medications from the pharmacy depended on the medication. The DON stated if the medication was a narcotic, then the nurse faxed the order to the pharmacy and then the pharmacy delivered daily except for Sunday night to the facility. The DON stated she was not sure why resident 55's Valbenazine and Darbepoetin Alfa were not available for administration. The DON stated she would have to look into why resident 55 was not receiving his medications as ordered. It should be noted the DON did not provide additional information. (Cross Refer to F775)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 65 sampled residents, that the facility did not provide or obtain laboratory services timely to meet the needs of its residents. Specifically, a resident's urinalysis (UA) with culture and sensitivity (C & S) was not followed up on timely resulting in a delay of treatment and another resident did not have weekly labs completed for an ordered Complete Blood Count (CBC) and a Comprehensive Metabolic Panel (CMP). Resident identifiers: 1 and 55. Findings included: 1. Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included but were not limited to hypospadias, retention of urine, chronic kidney disease, pyelonephritis, extended spectrum beta lactamase resistance, obstructive and reflux uropathy, and methicillin resistant staphylococcus aureus infection classified elsewhere. On 11/4/24 at 9:07 AM, an observation was made of resident 1's room. A sign was posted outside of resident 1's room for enhanced barrier precautions (EBP) and a personal protective equipment (PPE) cart was located outside the door. The cart contained gowns and gloves. On 11/4/24 at 9:22 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 1 was on EBP for a suprapubic (SP) catheter and had an ongoing extended-spectrum beta-lactamase (ESBL) infection. LPN 3 stated that they obtained a urinalysis (UA) this past weekend for resident 1 and that the resident always had a urinary tract infection (UTI). LPN 3 stated that they pushed fluids but sometimes resident 1 was non-compliant with care. Resident 1's electronic medical records were reviewed. Resident 1's physician orders revealed the following: a. On 10/31/24, an order was initiated for a UA with C & S for uremia. b. On 10/31/24, an order was initiated for a swab of the purulent drainage on the suprapubic area for possible urine infection. Resident 1's November Medication Administration Record (MAR) revealed the following: a. On 11/7/24 at 3:06 PM, an order was initiated for Ertapenem Sodium Injection Solution Reconstituted 1 gram (gr), inject 1 gram intramuscularly one time a day for 10 days related to a local infection of the skin. b. On 11/7/24 at 2:24 PM, an order was initiated for Penicillin V Potassium Oral Tablet 500 milligrams (mg), give 1 tablet by mouth three times a day for 10 days for infection of suprapubic site. Resident 1's progress notes revealed the following: a. On 10/31/2024 at 6:25 PM, the note documented, Resident has a foul smelling drainage from his suprapubic catheter site and his [sic] blood in urine and reported to PCP [primary care provider] via telephone and [doctor's name omitted] ordered a UA and purulent drainage swab test. PCC updated b. On 11/6/2024 at 5:10 PM, the note documented that the culture and sensitivity report was sent to the PA and they were awaiting orders. On 11/1/24, resident 1's suprapubic site culture documented the organisms identified as Staphylococcus aureus Methicillin Sensitive, Escherichia coli ESBL (extended beta-lactamase) producer, Proteus Mirabilis, and Klebsiella pneumoniae ESBL producer. The susceptibility report for the suprapubic site documented that the Staphylococcus was resistant to Penicillin; the Escherichia coli was susceptible to Ertapenem; and the Klebsiella was susceptible to the Ertapenem. The laboratory results had a handwritten note that it was reviewed by the provider on 11/7/24 and Ertapenem 1 gram (gr) daily for 10 days was ordered. It should be noted that the laboratory results were faxed to the facility on [DATE]. Additionally, the laboratory results were obtained from the provider binder and were not located in resident 1's electronic medical records. On 11/1/24, resident 1's urine culture documented the organisms identified as Proteus Mirabilis and Escherichia coli. The susceptibility report for the urine culture documented that the Proteus Mirabilis and Escherichia coli were susceptible to Ertapenem. The result was documented as reviewed by the provider on 11/7/24 and ordered Ertapenem 1 gr daily for 10 days. It should be noted that the laboratory results were faxed to the facility on [DATE]. Additionally, the laboratory results were obtained from the provider binder and were not located in resident 1's electronic medical records. On 11/7/24 at 8:45 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that she needed to call the lab to see if they had the urine C & S results back for resident 1. On 11/07/24 at 9:11 AM, an interview was conducted with RN 2. RN 2 stated that she received the culture results and placed them in the doctor notification book. RN 2 stated that the doctors were always in the building. RN 2 stated that the Physician Assistant (PA) or Nurse Practitioner (NP) were at the facility Monday through Friday and they could review the laboratory results when they arrived. RN 2 stated that resident 1's urine culture grew out Escherichia coli. RN 2 stated that the laboratory usually faxed the results to the facility but lately they were not doing that. RN 2 stated that the urine cultures usually took 3 days to grow out any organisms. RN 2 stated that resident 1's SP site was draining and had a foul odor, and the urine had blood in it so the provider ordered a UA. It should be noted that the labs were ordered on 10/31/24 and the results were obtained on 11/7/24. [Cross-refer F690] 2. Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and anemia. Resident 55's medical record was reviewed 11/3/24 through 11/13/24. A physician's order dated 6/27/24 revealed weekly CMP/CBC for monitoring of kidney function. One time a day every Monday for monitoring. Another physician's progress note dated 5/1/24 revealed routine labs to draw a CBC, CMP, HBA1c (hemoglobin A1c) every 6 months starting on the 25th for 3 days for routine labs. Laboratory values in resident 55's medical record were the following: a. A CBC and CMP completed on 11/4/24. b. A CBC and CMP completed on 9/24/24. c. A CBC and CMP completed on 9/17/24. On 11/12/24 at 1:24 PM, an interview was conducted with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) 1. The DON stated nurses obtained the specimen and the laboratory picked up the sample. The DON stated the results were faxed to the facility. The DON stated nurses passed on verbally in report that there was a laboratory draw completed. The DON stated staff should be watching for the results within a few days. The DON stated nurses could call the lab if results were not sent to the facility within a few days. The DON stated results were faxed to the facility but the DON also had access to pull the labs from the lab computer system. The DON stated nurses did not have access to the lab portal. The DON stated if nurses did not receive results within 2 to 3 days, they should be contacting the lab via phone. The DON stated nurses could notify the DON to see if the results were in the system and nurses were aware she had access to the portal. The DON stated the physician was notified of the lab results form that was faxed from the lab and then the lab results form was uploaded into the residents document section of the medical record. The DON stated there was no timeframe to have documents uploaded, it was just when medical records staff had time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined for 1 of 65 sampled resident, that the facility did not provide therapeutic diets as prescribed by the attending physician. Specifically, a resident with a physician's order for thickened liquids was observed to have thin water at the bedside. Resident identifier: 60. Findings include: Resident 60 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, dysphagia, history of falling, Gastroesophageal reflux disease (GERD), constipation and dementia. On 11/7/24 at 11:51 AM, an observation was made of resident 60. Resident 60 was laying in bed with 2 bottles half full with water on his bedside table. An interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated the water on resident 60's bedside table was not thickened. CNA 4 stated resident 60 requested regular water. CNA 4 stated she needed to ask the nurse if resident 60 was able to drink regular water. CNA 4 was observed asking Registered Nures (RN) 3 if resident 60 had a risk vs. benefit to drink thin liquid. RN 3 was observed to tell CNA 4 she would have to ask the Director of Nursing (DON) about the water. Resident 60's medical record was reviewed. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 60 had no signs and symptoms of a possible swallowing disorder. Resident 60 was on a therapeutic diet and mechanically altered diet. A care plan dated 8/27/24 revealed The resident has potential nutritional problem r/t [related to]dysphagia. The goal was The resident will maintain adequate nutritional status as evidenced by no unplanned/undesired significant weight changes, no s/sx [signs or symptoms] of malnutrition, and adequate nutritional intake at meals through review date. Interventions included Provide, serve diet as ordered. Monitor intake and record q [every] meal; RD [Registered Dietitian] to evaluate and make diet change recommendations PRN [as needed]; Weigh per facility protocol or NAR [nutrition at risk] committee recommendation. A physician's order dated 8/27/24 revealed CCHO (carbohydrate controlled) diet Mechanical soft texture with nectar consistency. An admission Nutritional Assessment that was started on 8/28/24 was in progress and had not been completed. The diet was CCHO, mech (mechanical) soft, nectar thick liquids. Resident 60 had chewing and swallowing difficulty. There was no other information in the assessment. A Speech Language Pathology (SLP) Evaluation and Plan of Treatment dated 8/27/24 revealed Treatment of swallowing dysfunction and/or oral function for feeding. It further revealed resident was newly downgraded to mechanical soft/nectar thick liquids. The reason for referral or current illness was resident was an [AGE] year old male with a history of dementia, dysphagia and GERD referred to skilled Speech Therapy (ST) services to assess and treat dysphagia and cognition/communication. Patient was provided with regular trials with thin liquids. Resident 60 exhibited immediate cough on thin liquids in small amounts by cup, despite self feeding with small sips without cues. He exhibited mild oral phase delays and moderate impulsivity of self feeding on regular solids, with mild to moderate pocketing and lingual residue noted. Diet was downgraded to mech soft/nectar thick liquids for safety, with further observation of tolerance to follow newly downgraded diet. A SLP Evaluation and Plan of Treatment dated 10/23/24 revealed Patient remains on mech soft/nectar thick liquids, with suboptimal positioning while eating in bed his current barrier to dietary trials and advance. Patient was focused on cognitive tasks provided, and was very fatigued - trials of higher level solids and liquids to follow. The Medical Factors were Precautions: Falls risk, mech soft/nectar thick liquids, aspiration precautions. There was no information regarding resident's swallowing or treatments provided for swallowing. A SLP Therapy Discharge summary dated [DATE] revealed resident 60 was treated from 10/23/24 through 10/27/24. There treatments provided were for cognition. There was no information that resident 60's swallowing had been evaluated or treated. There was no risk verse benefits for thin liquids located in resident 60's medical record. On 11/12/24 at 11:17 AM, an interview was conducted with CNA 8. CNA 8 stated she thought resident 60 needed thickened liquids because the kitchen sent thickened with his meals. CNA 8 stated she was not sure what staff were to do for thickened drinks between meals. CNA 8 stated she had heard there were packs for the beverages but she had never seen them. On 11/7/24 at 9:20 AM, an interview was conducted with the Registered Dietitian (RD). The RD stated resident 60 was on nectar thickened liquids. The RD stated she asked Director of Nursing (DON) to reach out to SLP to do an evaluation on him to see if he still needs thickened liquids. The RD stated if a resident was on thickened liquids then there was usually a decreased liquid intake. The RD stated maybe the SLP had approved resident 60 to drink thin water between meals. The RD stated she was not able to access the therapy notes in the medical record. The RD stated she had not contacted the SLP regarding coordination of care for resident 60. On 11/12/24 at 2:58 PM, an interview was conducted with the DON. The DON stated there were packets of thickener in the nurses carts to thicken the beverages. The DON stated maybe on the CNA report sheet, it showed who required thickened liquids. The DON stated there was not a system to ensure residents were provided thickened liquids. The DON stated there was a risk vs. benefit after last week for resident 60 to drink regular water between meals. The DON stated resident 60 wanted to be able to drink his water bottles when eating his peanuts. The DON stated a Speech Therapy evaluation was done after the CNA found the water at resident 60's bedside. It should be noted the surveyor identified the thin liquid. (Cross refer to F807)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined for 1 of 65 sampled residents, that the facility failed to provide special eating equipment and utensils for residents who needed them to ensure that the resident could use the assistive devices when consuming meals and snacks. Specifically, one resident was not provided with a lipped plate when identified as needing one. Resident identifier: 5. On 11/4/24 at 10:06 AM, an observation was made of resident 5 feeding himself in his room. The resident was eating off of a flat plate, no lip or divided plate was observed. A meal ticket was observed on his tray and indicated, Adaptive Equip: Lip Plate. Findings included: Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included quadriplegia, dysphagia, chronic kidney disease, chronic obstructive pulmonary disease, paralysis of vocal cords and larynx, congestive heart failure, and major depressive disorder. Resident 5's medical record was reviewed 11/3/24 through 11/13/24. A Minimum Data Set (MDS) admission assessment Section GG- Functional Abilities and Goal, dated 10/21/24, indicated resident 5 had impairment on one side of his upper extremity. A physician's order, dated 6/21/24, indicated, Regular diet Regular texture, Thin liquids consistency, Divided plate. The Care Plan included a focus of, [Resident 5] requires a Regular diet, Regular texture and thin liquids & is at risk for nutritional decline d/t [due to] dx [diagnosis] quadriplegia, Tracheotomy, dysphagia, COPD [chronic obstructive pulmonary disease], protein calorie malnutrition, GERD [gastroesophageal reflux disease], Constipation & ileus, & recent bowel obstruction & pneumonia. It indicated a goal of, The resident will maintain adequate nutritional status as evidenced by no undesired significant weight changes, no s/sx [signs or symptoms] of malnutrition, and adequate nutritional intake at meals through review date. Date Initiated: 07/29/2023 Revision on: 12/20/2023 Target Date: 02/04/2025. It further indicated inventions that included, Patient to use divided plate to promote adequate nutrition. Date Initiated: 02/22/2023. On 11/12/24 at 2:34 PM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated resident 5 needed assistance with setting up but that he could feed himself. CNA 6 stated he needed a lipped plate because he did not have a full range of motion with his arms, and it helped him from dropping food. On 11/12/24 at 2:40 PM, an interview was conducted with the Assistant Dietary Manager (ADM). The ADM was reading resident 5's meal ticket and stated that staff would provide a lipped plate unless they were out of them. The ADM stated that a lipped plate should be provided and that they were ordering more lipped plates. On 11/12/24 at 2:52 PM, an interview was conducted with the Occupational Therapist (OT). The OT stated that she talked to resident 5 about using a scooped plate and that he did not find it useful for him. The OT stated that they were struggling to find him an extended fork that would help him eat. The OT stated it was important for resident 5 to get his nutrition but when he feeds himself, the food will drop off the utensil and he would miss his mouth. The OT stated he practiced using an extended fork when she could help him but that he was currently using a regular fork when she could not assist him.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 65 sampled residents, that the facility did not ensure that the hospice services met professional standards and principles that applied to individuals providing services in the facility, and to the timeliness of those services. Specifically, facility staff documented they were unable to contact hospice, the facility did not obtain from the hospice provider the nursing notes and there were no coordination of care notes. Resident identifier: 4. Findings include: On 11/4/24 at 8:06 AM, an interview was conducted with resident 4. Resident 4 stated she needed her brief changed. Resident 4 was laying in bed with greasy hair and a substance coming out the side of her mouth. On 11/6/24 at 1:23 PM, an observation was made of resident 4. Resident 4 was laying in bed with her eyes closed. At 1:36 PM, an observation was made of Certified Nursing Assistant (CNA) 6 standing and feeding resident 4. Resident 4's bed was in a high position with the head of her bed elevated and she was holding a sandwich and was observed to take a bite. Resident 4's medical record was reviewed. A significant Minimum Data Set (MDS) dated [DATE] revealed resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. A care plan dated 11/3/24 revealed The resident has a terminal prognosis and RESIDENT RECEIVES HOSPICE SERVICES THROUGH [name and phone number removed]. The goal was The resident's comfort will be maintained through the review date. Some of the interventions included: a. Consult with physician and Social Services to have Hospice care for resident in the facility. b. Encourage resident to express feelings, listen with non-judgmental acceptance, compassion. A Physician's order dated 9/21/23 revealed resident was to receive hospice services through a local company. A Physician's order dated 10/4/24 revealed Ordered by [Name removed] RN [Registered Nurse] of [hospice company name removed] hospice to assist the resident with meals. every shift resident's care. A binder at the nurses station with resident 4's name on it revealed skin sheets for bathing for resident 4. Resident 4 had skin sheets which revealed resident 4 was bathed 2 times per week. The last nursing visit form was dated 5/23/24 in the binder at the nurses station by an aide. There was no other documentation from the nurses or plan of care information in the binder. Resident 4's documentation tab in the medical record was reviewed and the last hospice note was from 8/17/24. An alert charting nursing progress note dated 10/18/24 at 5:48 AM revealed, Resident vomited on herself. Face is flushed and hot to the touch. Resident lethargic, but not verbally responsive. Vitals as follows BP [blood pressure] 181/99, Pulse 105, O2 [oxygen] 92% on RA [room air], Temp [temperature] 99.8 F orally, Resp [respirations] 18 breaths/min [minute]. Attempted to notify hospice at 0552 [5:52 AM], no answer. On 11/6/24 at 3:29 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated if she needed to communicate with hospice she called the hospice nurse. LPN 4 stated that when the nurse visited a resident, the hospice nurse talked to the facility nurse and let her know what was going on. LPN 4 stated the hospice nurses phone number was available. LPN 4 stated hospice staff usually did not leave paper work unless it was a physician's order. On 11/12/24 at 10:45 AM, an interview was conducted with LPN 3. LPN 3 stated she was friends with resident 4's hospice case manager. LPN 3 stated she was able to contact her friend and leave a message if the resident needed something. LPN 3 stated she did not know if hospice staff provide documentation. On 11/12/24 at 3:04 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the hospice team checked in with the nurse and signed a sheet when they visited the resident. The DON stated hospice staff should meet with nurse or Certified Nursing Assistant (CNA) to coordinate care. The DON stated physician's orders and notes were faxed to the facility or given to the nurse from hospice. The DON stated she was not sure how often hospice notes were provided to the facility. The DON stated she was not sure why there were no hospice notes in resident medical record since 8/17/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 65 sampled residents, that the facility did not establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. Specifically, a resident was treated for a urinary tract infection (UTI) with an antibiotic that the organism was resistant to. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included but was not limited to hypospadias, retention of urine, chronic kidney disease, pyelonephritis, extended spectrum beta lactamase resistance, obstructive and reflux uropathy, and methicillin resistant staphylococcus aureus infection classified elsewhere. On 11/4/24 at 9:07 AM, an observation was made of resident 1's room. A sign was posted outside of resident 1's room for enhanced barrier precautions (EBP) and a personal protective equipment (PPE) cart was located outside the door. The cart contained gowns and gloves. On 11/4/24 at 9:22 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 1 was on EBP for a suprapubic (SP) catheter and had an ongoing extended-spectrum beta-lactamase (ESBL) infection. LPN 3 stated that resident 1 always had a UTI. Resident 1's electronic medical records (eMR) were reviewed. On 9/12/24, resident 1 had a physician order for a urinalysis (UA) with a culture and sensitivity (C & S). No documentation could be found for the results of the UA with C & S in resident 1's eMR. On 11/12/24, the facility infection control tracking and trending log was reviewed for September 2024. The log documented that resident 1 had a urinary tract infection on 9/16/24 that was treated with Bactrim DS Tablet 800 milligram (mg) - 160 mg, give one tablet by mouth two times a day for 10 days. On 11/13/24 at 11:55 AM, the facility emailed a copy of resident 1's UA results for 9/13/24. The UA documented abnormal results for the following: Nitrite 1+, urine hemoglobin (Hgb) 2+ moderate, urine protein 1+, large leukocyte esterase, high [NAME] Blood Cell (WBC) at greater (>) than 30, high Red Blood Cell (RBC) at 27, bacteria 3+, and mucus 1+. The results report documented that the report was printed on 11/13/24. On 11/13/24 at 3:02 PM, the facility emailed a copy of resident 1's C & S report for 9/17/24. The results report documented that the report was printed on 11/4/24. The urine culture documented the organism as Escherichia coli with ESBL (extended beta-lactamase) producer. The susceptibility report documented that the organism was resistant to Bactrim DS. The September Medication Administration Record (MAR) documented that resident 1 was administered Bactrim DS 800 milligram (mg) - 160 mg, give one tablet by mouth two times a day for UTI for 10 days. The medication was documented as administered from 9/16/24 through 9/26/24 with a total of 20 doses administered. The facility Antibiotic Stewardship Policy stated that the purpose of the program was to monitor the use of antibiotics for facility residents. The guidance further documented, When a culture and sensitivity (C&S) or other diagnostic tests are ordered, test results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. The policy was last revised on 7/21/23. The facility Infection Prevention and Control Program Policy documented, The infection preventionist is chiefly responsible to ensure that antibiotics are used consistently with best practice standards. The policy further stated that Antibiotic usage is evaluated and tracked and practitioners are provided feedback on reviews. The policy was last revised on 12/19/16. On 11/12/24 at 1:22 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was the facility infection preventionist (IP) and had her certification. The DON stated that they had an antibiotic stewardship form to track if the antibiotics ordered were appropriate for the organism identified. The forms were located in the electronic medical records and included the antibiotic prescribed, the time, dose, any changes, and if the infection was resolved. The DON stated that they utilized the McGreer criteria for surveillance tracking. The DON stated that she was responsible for tracking and ensuring that the antibiotic ordered was susceptible to the organism identified on the urine culture. The DON stated that the timeframe for when she would expect to see a UA result was within 1-2 days and within 3 days for a C & S result. The DON stated that she also had access to the laboratory computer portal and could see the lab results that way.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 3 of 5 sampled residents, that the facility did not ensure that residents were offered the influenza and pneumococcal immunizations and that the medical records included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, three residents did not have immunizations documentation in their medical records. Resident identifiers: 49, 61, and 269. Findings included: 1. Resident 49 was admitted to the facility on [DATE] with diagnoses which included dementia, paroxysmal atrial fibrillation, heart failure, cognitive communication deficit, and pain. On 11/12/24 resident 49's medical records were reviewed. No documentation could be found for the administration or declination for the Influenza or Pneumococcal vaccine for the current season. 2. Resident 269 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, severe sepsis, cognitive communication deficit, dementia, anxiety disorder, cardiac arrhythmia, acute respiratory failure, rhabdomyolysis, and acute kidney failure. On 11/12/24 resident 269's medical records were reviewed. No documentation could be found for the administration or declination for the Influenza and Pneumococcal vaccine for the current season. 3. Resident 61 was admitted to the facility on [DATE] with diagnoses which consisted of fibromyalgia, dementia, hypertension, edema hypothyroidism, and insomnia. On 11/12/24 resident 61's medical records were reviewed. No documentation could be found for the administration or declination for the Influenza and Pneumococcal vaccine for the current season. On 11/12/24 at 9:21 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that they already offered the Respiratory syncytial virus (RSV) vaccine, Hepatitis B vaccine, Hepatitis A vaccine, influenza vaccine, COVID vaccine, pneumonia vaccine, and Human papillomavirus (HPV) for the current season. The DON stated that she had not filed the paper copies of the vaccines administered into the resident medical records yet. On 11/12/24 at 1:22 PM, the DON stated that resident 269 and resident 61 had declined the vaccine and wanted to discuss it with their POA first. The DON stated that she was going to approach them again later. The DON stated that resident 49 had initially consented but on the day of the vaccine clinic he declined. The DON stated that she had no documentation of resident 49's refusal. On 11/13/24 at 9:02 AM, a follow-up interview was conducted with the DON and the Regional Nurse Consultant (RNC) 1. The DON stated she should have had documentation of the resident 269, resident 61 and resident 49's vaccine declinations. The DON stated that the immunization clinic was held the first Tuesday in October.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 13 out of 65 sampled residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. Specifically, residents complained of cold temperatures in their rooms, resident rooms were not cleaned, resident toilets leaked and a toilet seat was loose, a resident sink leaked water, resident showers flooded rooms, holes were found in a residents door, a brown substance was observed on a resident's wall, and resident personal belongings were lost. Resident identifiers: 3, 13, 20, 22, 26, 27, 29, 30, 32, 51, 53, 55, and 120. Findings Included: 1. Resident 53 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, osteomyelitis of vertebra, anxiety disorder, type 1 diabetes mellitus with hyperglycemia, unspecified protein-calorie malnutrition, sepsis, psoas muscle abscess, alcohol abuse, and major depressive disorder. On [DATE] at 2:08 PM, the following observations were made of resident 53's room: a. Towels were wrapped around the base of the toilet and water was leaking out of the bottom of the toilet. b. Toilet seat was loose and covered in brown stains. On [DATE] at 2:08 PM, an interview was conducted with resident 53. Resident 53 stated that her toilet was not getting clean by the facility, the toilet was leaking water on to the floor, and the toilet seat was loose. On [DATE] at 1:26 PM, a follow up interview was conducted with resident 53. Resident 53 stated that the leak for the toilet was fixed, but the toilet lid was still loose and covered in brown stains. 2. Resident 20 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, but not limited to, displaced intertrochanteric fracture of right femur, mild protein-calorie malnutrition, muscle weakness, rheumatoid arthritis, hypothyroidism, essential hypertension, and unsteadiness on feet. On [DATE] at 4:21 PM, an observation was made of resident 20 in bed covered with multiple blankets around her body and two blankets wrapped around her head. On [DATE] at 4:23 PM, an interview was conducted with resident 20. Resident 20 stated that her room was cold and the air conditioner always felt like it was on. Resident 20 stated that she had asked staff to make her a shawl out of blankets to keep warm. Resident 20 stated that a few months ago the maintenance man placed a plastic device near the vent to divert the cold air, but that did not help her room from being cold. 3. Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, aftercare following joint replacement surgery, difficulty in walking, muscle weakness, type 2 diabetes mellitus with hyperglycemia, major depressive disorder, anxiety disorder, essential hypertension, unsteadiness on feet, and history of falling. On [DATE] at 8:14 AM, the following observations were made of resident 27's room: a. There was no screen on the window. b. There were scrapes on the door. c. There were holes in the bathroom door. d. There was a large basin under the sink collecting leaking water. On [DATE] at 8:14 AM, an interview was conducted with resident 27. Resident 27 stated that she could not leave her window open because she did not have a screen on and was worried someone would get in. Resident 27 stated that when she turned on her sink it would leak and there was a container that collected the water. Resident 27 stated that her bathroom door had holes in it. 4. Resident 26 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, facioscapulohumeral muscular dystrophy, unspecified protein-calorie malnutrition, hyperlipidemia, hypomagnesemia, hypo-osmolality and hyponatremia, and weakness. On [DATE] at 3:20 PM, the following observations were made of resident 26' room: a. The shower floor had a black colored stain. b. The ceiling air vent was blowing cold air. c. The bathroom sink would only dispense a small trickle of water. On [DATE] at 3:20 PM, an interview was conducted with resident 26. Resident 26 stated that her bathroom sink would only dispense a trickle of water. On [DATE] at 8:43 AM, a follow up interview was conducted with resident 26. Resident 26 stated that heat was not coming on in her room at all. Resident 26 stated that she told maintenance and Certified Nursing Aides (CNA's) multiple times that her room was cold, there was no heat coming from the vent, and the vent would blow cold air every once in a while. Resident 26 stated that her shower would flood when taking a shower and the CNA's had to put towels around the floor to create a barrier to prevent the water from going into her room. 5. Resident 120 was admitted to the facility on [DATE] with diagnoses which included, but not limited to lymphedema, superficial mycosis, cellulitis of right lower limb, activated protein c resistance, cellulitis of left lower limb, and morbid (severe) obesity due to excess calories. On [DATE] at 2:18 PM, an interview was conducted with resident 120. Resident 120 stated that her room had not gotten cleaned and the garbage had not been taken out. Resident 120 stated that this happened on a daily basis. On [DATE] at 8:45 AM, an interview was conducted with the housekeeping supervisor (HS). The HS stated resident rooms got cleaned daily. The HS stated that cleaning a resident room entailed sweeping and mopping the floor, wiping down side tables, nightstands and dressers, and dusting pictures. The HS stated that cleaning the bathroom entailed cleaning the toilet, mirrors and checking the tissue and toilet paper. The HS stated that all garbage should be removed from the resident's rooms. The HS stated that expectations for the housekeeping staff were for the resident rooms to be cleaned daily. On [DATE] at 10:24 AM, an interview was conducted with the Maintenance Supervisor (MS). The MS stated that for all maintenance issues, it should be written down in the maintenance log book unless it was an emergency and then he would expect a text or verbal request. The MS stated that the maintenance logs were checked daily, Monday through Friday. The MS stated that he would write in the log and initial when a request was completed. The MS stated that there were thermostats all over the facility and he was still learning where they were located. The MS stated that in the hallway where residents 20, 26, 27, and 53 were located, he had heard some complaints about the temperature and rooms being cold, but had since remedied the situation. The MS stated that all the windows in the facility should have screens. The MS stated he had not heard about any residents with leaking sinks or toilets. The MS stated that he had not heard about showers in the facility flooding and would assume that it would be reported to him because it might have been ignored in the past. 10. Resident 3 was admitted to the facility on [DATE] with diagnoses that included Arnold Chiari Syndrome with spina bifida and hydrocephalus, severe protein-calorie malnutrition, osteomyelitis right ankle and foot, paraplegia, borderline personality disorder, major depressive disorder, morbid obesity, bipolar disorder, and anxiety disorder. On [DATE] at 4:40 PM, an interview was conducted with resident 3 who stated one of her blankets had gone missing and was never found. Resident 3 stated that she notified one of the laundry staff members, but they were unable to find the blanket. Resident 3's medical records were reviewed between [DATE] and [DATE]. Resident 3's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated a normal cognition. On [DATE] at 3:30 PM, medical records revealed there was no documentation of resident 3's belongings when she was admitted to the facility. 11. Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, muscle weakness, major depressive disorder, and chronic pain. On [DATE] at 4:04 PM, an interview was conducted with resident 13 who stated she had several items of clothing that were missing. Resident 13 stated tops, bottoms, and some of her temple garments were missing. Resident 13 stated a new bag of garments had been thrown away. Resident 13 stated when clothing items went missing the staff would search for them. Resident 13 stated staff have been able to find most, but not all of her clothing. Resident 13's medical records were reviewed between [DATE] and [DATE]. On [DATE], an admission MDS assessment dated [DATE] revealed resident 13 had a BIMS score of 13, which indicated a normal cognition. On [DATE] at 3:34 PM, a review of resident 13's medical records revealed an inventory sheet from [DATE]. The inventory form included 4 t-shirts, 1 sweater, 4 pairs of pants, 2 pajama tops, 2 pajama bottoms, 6 garment tops, 6 garment bottoms, 1 pair shoes, 1 pair sandals, 4 pairs socks, 6 rings, 20 pairs earrings, 2 pair glasses, 1 black cell phone, 1 cell phone charger, 2 headphone sets, 1 black radio with CD player and cassette player, 1 gray HP laptop, 1 black water filter pitcher, DVD rack with DVDs, CDs and videos, 1 power chair, 1 power amp, craft supplies, 3 book cases with books, 1 nebulizer, 1 CPAP. No updated inventory sheets were found. Grievances were reviewed between [DATE] and [DATE]. No documentation was found regarding resident 3's missing blanket or resident 13's missing clothing items. On [DATE] at 4:06 PM, an interview was conducted with CNA 4 and CNA 5 who stated if a resident's clothing went missing, they would first go to the laundry to see if the item was there. CNA 4 stated she would report the missing item to the nurse and to the Human Resource (HR) manager. CNA 4 stated the nurse would document missing items. CNA 5 stated mostly the CNA's looked in the resident's room, but would also look in the activities room or the kitchen. On [DATE] at 10:58 AM, an interview was conducted with LS 1 who stated the process for missing clothing was that the CNA's were supposed to put new resident's clothing in a bag and put a tag on the bag so the clothing and other items could be labeled. LS 1 stated that process had not been happening for 3 to 4 years. LS 1 stated she had been taking unlabeled laundry out every Friday and asking residents to identify items that belonged to them. LS 1 stated if clothing items were not claimed, they used to be taken to a room where they were stored, but she did not know if that was being done now. LS 1 stated there was a label machine in the laundry room, but had not labeled the laundry for quite some time since resident clothing was being brought to the laundry room in large laundry barrels with clothing of several residents inside. LS 1 stated laundry was done every day so there should not be a long wait for laundry to return to the resident. LS 1 stated CNA's had not come to look for laundry in quite some time. LS 1 stated she was aware of resident 3's missing blanket, but was unable to find it. On [DATE] at 3:15 PM, an interview was conducted with the DON who stated the RA was taking care of grievances, and was responsible for missing personal property. The DON stated she and the ADMIN would follow up on those grievances. The DON stated residents could use a grievance form to let staff know about missing personal items, or could tell them directly. The DON stated all residents should know how to fill out a grievance form. The DON stated she was not sure if there was a posting to let residents know who they could contact for a grievance form. The DON stated depending on the type of clothing that was missing, the HS would be contacted. The DON stated staff could help the resident look through their room to locate the missing item. The DON stated there were mesh bags that were sent to the laundry with resident clothing when the resident was admitted so clothing could be labeled. The DON stated that CNA's should fill out a new inventory sheet upon admission and when new clothing items came to the facility. 6. ODORS On [DATE] at 3:44 PM, a strong odor of urine was noted in the memory unit immediately upon entrance past the locked double doors. On [DATE] at 1:44 PM, a strong odor of urine was noted on the memory unit outside of room [ROOM NUMBER]. Resident 30 was pacing the hallway and smelled of urine. On [DATE] at 9:13 AM, a strong odor of urine was noted in the 300 hallway outside of room [ROOM NUMBER]. On [DATE] at 10:25 AM, an observation was made of CNA 5 spraying air freshener multiple times in room [ROOM NUMBER] and 321. 7. On [DATE] at 5:27 PM, an observation was made in the main dining area. A coffee cart was located against the wall towards the main door/corridor. The cart contained a large carafe that was not warm to the touch, a tray of coffee cups, creamer and sweetener. The coffee cart was observed dirty with spilled coffee noted on the shelf. Two empty and used coffee cups were observed in the window sill. On [DATE] at 9:40 AM, an observation was made of the dining room located in the locked memory unit. The floor was observed to be scuffed and dirty. The walls were also scuffed and spackled. The table nearest to the courtyard door had a soiled table cloth on it, and the table near the sink had a soiled table cloth on it. On [DATE] at 9:56 AM, an interview was conducted with Housekeeper (HK) 1. HK 1 stated that she was assigned to the memory unit and the 400 hallway and worked on Wednesday, Thursday, and Saturday. HK 1 stated that she cleaned all the resident rooms and the dining room. HK 1 stated that the resident room cleaning process included cleaning the bathroom sink, toilet, sweeping and mopping the floors, cleaning the bedside tables, wiping off the door handles and light switches, and restocking the toilet paper and paper towels. HK 1 stated that there were usually 4 to 5 housekeeping staff in the building at a time, but lately it had been 4 staff because they were short staffed. HK 1 stated that due to the short staff situation she was helping out in other areas once her area was completed. HK 1 stated that there had been occasions that she was not able to complete her area assigned tasks because resident rooms were extra dirty. HK 1 stated that sometimes she was not able to clean all her assigned rooms and when that happened it would be passed off to the next shift. Review of a housekeeping checklist revealed a line for each resident room. Next to the resident room were columns with sections for check marks in which the housekeeper could document that the following was cleaned: surfaces, sink, toilet, mirror, toilet paper/paper towel, sweep, mop, and trash. There was a column for the housekeeper to document the date and time that the cleaning started and the time finished for that room, and if the resident refused the cleaning. On [DATE] at 2:08 PM, an interview was conducted with the HS. The HS stated that she had just started this week and had begun the scheduling for the housekeeping department. The HS stated that scheduling for housekeepers was to have four staff on the floor, one per hallway, seven days a week during the daytime. The HS stated that she had two laundry staff that were separate from housekeeping staff and one staff was scheduled seven days a week during the daytime. The HS stated that there were new sheets and towels in the laundry room that were ordered last week, and she just ordered 4 dozen towels, 4 dozen flat sheets, and 4 dozen fitted sheets. 8. Resident 29 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included drug induced secondary Parkinsonism, adult failure to thrive, dementia, bipolar disorder, anxiety disorder, drug induced akathisia, suicidal ideation, post-traumatic stress disorder, nephrogenic diabetes insipidus, hyperparathyroidism, chronic kidney disease, schizoaffective disorder, hyperlipidemia, Meniere's disease, non-ST elevation (NSTEMI) myocardial infarction, obstructive sleep apnea, cognitive communication deficit, insomnia, hypertension, and chronic pain. On [DATE] at 2:26 PM, an interview was conducted with resident 29. Resident 29 stated that she had clothes go to laundry that had not been returned. Resident 29 stated that she had two t-shirts and two pairs of shorts go missing in the last 6 months. Resident 29 stated that she informed staff but had never had a resolution to the missing items. Resident 29 stated that she had never had her missing items returned or replaced and had to buy more clothing items herself. Resident 29 stated that her room was cold for about a month now and that she had complained about it to the staff. Resident 29's medical records were reviewed. On [DATE], resident 29's Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 10, which would indicate that the resident had a moderate cognitive impairment. On [DATE], resident 29's New Admit Belonging Inventory documented the following: one sweater, one pant, one black iPhone, one charging cord. No documentation could be found of an updated and current resident inventory list. The grievances were reviewed from [DATE] through [DATE] and no documentation could be found for resident 29's missing personal property. On [DATE] at 1:56 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 29 was alert and oriented times 4 to person, place, time, and situation. LPN 3 stated that resident 29 use to have intermittent confusion but had been more stable in the last 5 months since some medication adjustments. On [DATE] at 1:59 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 29 had not reported any missing property. CNA 3 stated that the process for locating any missing property was to look in the laundry room for any missing clothing and if she could not find it she would report it to the laundry staff to keep an eye out for it. CNA 3 stated that she would then report the missing item to the CNA Coordinator who would then put it on the group chat. On [DATE] at 10:58 AM, an interview was conducted with Laundry Staff (LS) 1. LS 1 stated that the previous process for labeling resident clothing was that the aides were to bag the clothing and tag it so that it could be labeled in the laundry room. LS 1 stated that the aides had not been following that process. LS 1 stated that on Fridays she would take any unlabeled clothing out and ask the residents and staff if they knew who it belonged to. LS 1 stated that if no one claimed the clothing they were previously stored in a big room but does not know where the clothing was located now. LS 1 stated that if a resident was missing clothing the aides would come and look for it in the laundry room. LS 1 stated that she had not had any aides ask about missing clothing for quite some time. 9. Resident 51 was admitted to the facility on [DATE] with diagnoses which included intracerebral hemorrhage, hemiplegia and hemiparesis of left side, neurologic neglect syndrome, chronic kidney disease, hypertension, congestive heart failure, cognitive communication deficit, aphasia, visual loss both eyes, and insomnia. On [DATE] at 2:34 PM, an interview was conducted with resident 51. Resident 51 stated that she had multiple items of missing clothing. Resident 51 stated that she had informed the Resident Advocate (RA) of the missing items but that he was no longer at the facility. Resident 51 stated she was missing jackets, a pink hamper, pajamas, sweat pants, and t-shirts. Resident 51 was unable to state the quantity of the missing clothing items. Resident 51 stated that she had never had her missing items returned or replaced. Resident 51 also stated that she was missing her bottom dentures and that they had been gone since she changed rooms. Resident 51 stated that her room was cold and that she had informed management but they had not done anything about it. Resident 51 stated that the vents were still blowing cold air into the room and it was worst at night. Resident 51's bathroom was observed with the toilet seat soiled with stool. Resident 51 stated that the remote control for her television did not allow her to select anything and the volume did not work. Resident 51 stated that she could only turn the television on and off. Resident 51 stated that the previous Maintenance Director left last week and no one had fixed her thermostat or television. Resident 51 stated that during incontinence care, CNA 5 threw a soiled chuck pad towards the wall and it smeared stool on the wall. The area pointed out by resident 51 was observed with a dried brown mark consistent with stool. Resident 51's medical records were reviewed. On [DATE], resident 51's MDS Assessment documented a BIMS score of 14, which would indicate that the resident was cognitively intact. The assessment documented that resident 51 did not have any hallucinations or delusions and did not have any physical or verbal behavioral symptoms. On [DATE], resident 51's New Admit Belonging Inventory documented the following: 7 t-shirts, 1 coat, 9 sweats, 1 short, 3 bras, 6 underwear, 6 pairs of socks, a cell phone and a charger. The grievances were reviewed from [DATE] through [DATE] and no documentation could be found for resident 51's missing personal property. On [DATE] at 12:53 PM, an interview was conducted with CNA 6. CNA 6 stated that if a resident reported missing property they would inform the nurse and the nurse would inform the Administrator (ADMIN). CNA 6 stated that they would then attempt to find the missing item. CNA 6 stated that upon admission they obtained an inventory of all the resident's belongings. CNA 6 stated that it was difficult to keep track of any additional personal items that were brought to the facility and he did not know if they updated the resident inventory sheet. CNA 6 stated that resident 51 had reported missing clothing but they had found them. On [DATE] at 9:39 AM, an interview was conducted with LPN 3. LPN 3 stated that resident 51 was alert and oriented times 4 to person, place, time and situation and had no memory deficits. LPN 3 stated that resident 51 did not have any missing personal items. LPN 3 stated that missing money was reported to the ADMIN. LPN 3 stated that if the missing items were clothing she would wait for laundry to check and search in the resident room then if the items could not be located she would notify the ADMIN. LPN 3 stated that sometimes the laundry staff misplaced a clothing item and she would inform them first in an attempt to locate the missing item. LPN 3 stated that resident 5 wore dentures and to her knowledge she did not have any missing dentures. LPN 3 stated that approximately 4 months ago resident 51 resided in a different room. LPN 3 stated that if a resident was missing dentures she would notify the kitchen in case they were left on a meal tray. LPN 3 stated that no one brought missing teeth to her attention and those were expensive so they needed to follow up on that. On [DATE] at 1:59 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 51 had not reported any missing property. CNA 3 stated that resident 51 had reported she could not find an article of clothing but it was located inside the room. On [DATE] at 2:58 PM, an interview was conducted with the HS. The HS stated that for missing property they would leave a rack with unlabeled clothing in the activity room for residents to claim. The HS stated that they asked the residents to come down hall by hall to see if any of the items were theirs. The HS stated that when they were notified of missing items they kept track of them on a sheet of paper. A resident roster with room numbers was observed on the wall. The HS stated that she would write any missing items next to the resident's name. The HS stated that she was not aware of any missing items for resident 29 or resident 51. The HS stated that as the supervisor the missing item log was supposed to go to her, but she had not received any of those logs yet. The HS stated that there were no clothes in laundry that were not labeled and unaccounted for. On [DATE] at 3:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the grievance form was located on the Resident Advocate (RA) door. The DON stated that staff were to fill out the form, place it under the RA's door and he would determine which department would investigate the grievance. The DON stated that the resident, ADMIN and RA signs the form. The DON stated that missing personal property would go to the ADMIN and RA and the RA would determine if a grievance needed to be filled out for the missing property. The DON stated that if a grievance was escalated to her it would be investigated. The DON stated that when she investigated a grievance she would ask the resident when was the last time they saw the item, the timeframe of it being missed, ask staff if they noticed the item was missing, review camera footage, and then replace the property as needed. The DON stated that staff should report missing property to the RA or ADMIN. The DON stated that if a missing item was located in the resident room then they would not fill out a grievance form. The DON stated that staff should just know to inform the DON, ADMIN or RA of any missing property. On [DATE] at 9:08 PM, an interview was conducted with the RA. The RA stated he was in charge of the grievances. The RA stated the process was that when a complaint came in, the facility had 5 days to investigate the complaint. The RA stated there was a form that was filled out by the resident, staff or family members. The RA stated that staff looked for missing items and if they were unable to find the item then they would talk to the resident about what they wanted to happen. The RA stated they replaced clothing items. The RA stated that when the investigation was completed he went over it with the resident and the ADMIN signed the form. On [DATE] at 9:40 AM, a follow-up interview was conducted with the RA. The RA stated that resident 29 had not informed him of any missing personal property. The RA stated that typically, if something was missing, they would take the resident to the lost and found to locate the item. The RA stated if the resident was still unable to locate the missing item they would let the ADMIN know so that the item could be replaced. The RA stated that if a resident was missing dentures, they would first look to see if they were thrown away by mistake. The RA stated that if the dentures could not be located, he would make an appointment with the dental provider to obtain a replacement. The RA stated that resident 51 would state that clothing items were missing but it was determined that those items were never brought into the facility. The RA stated that the resident's inventory sheet did not contain the extensive list of items that resident 51 had said was missing. The RA stated that the resident inventory list should be updated anytime they brought new items into the facility. The residents should notify the CNA's so they could update the inventory. The RA stated that if a CNA noticed that the resident had new items they should inventory those new items right away. The RA stated that items came and went from the facility and if something was delivered to the facility for a resident and staff was aware then it should be added to the inventory list. The RA stated that resident 51 never mentioned to him that she was missing her dentures. The RA stated that resident 51 had a habit of leaving her dentures out. The RA stated that if resident 51 was stating that her dentures were missing then they needed to locate them or obtain new ones. On [DATE] at 9:55 AM, an observation was made of the facility thermostats. The 400/500 hallway had two thermostats, one with a #4 written in sharpie on it and a second unlabeled one next to it. The #4 thermostat read 64 degrees and was set at 74 degrees Fahrenheit. The second unlabeled thermostat read 66 degrees and was set to 74 degrees. The 300 hallway across from the nurse's station read 70 degrees and was set at 72 degrees. The memory unit thermostat located at the nurse's station read 69 degrees and was set to 82 degrees. The door to the outside patio was observed propped open in the dining room. On [DATE] at 1:46 PM, a follow-up interview was conducted with the DON. The DON stated that dental appointments were now being scheduled by her, but previously it was the RA's responsibility. The DON stated that missing personal property was investigated through the grievance process by the ADMIN and DON now. The DON stated that the staff should help the resident fill out the form. The DON stated that for missing items, such as clothing, staff should contact the HS and see if the item could be located in laundry, then they should look in the resident room. The DON stated that if the item was not found they would replace the item as needed. The DON stated that the CNA's should update the resident inventory list and fill out a new sheet every time there are new items brought into the facility. The DON stated that the grievance notice needed to be updated. The DON stated that new dentures would be obtained for resident 51 and she would make the appointment now. On [DATE] at 10:24 AM, an interview was conducted with the MS. The MS stated that he started at the facility approximately 2 weeks ago. The MS stated that the process for maintenance requests or repairs was that staff would text him in an emergency situation and if it was not an emergency, staff would write it in the daily maintenance log. The MS stated that he checked the log daily, Monday through Friday. The MS stated that he documented in the log any issues that were resolved or passed off to another department. The MS stated that the facility temperature was regulated by ambient air by the thermostats. The MS stated that a few rooms on the 100 and 200 hallway had the thermostat located inside the room and another thermostat in the hallway. The MS stated the when he was hired he had no training and nothing was passed off to him. The MS stated that the previous supervisor was gone when he started. The MS stated that he had complaints of residents being cold and resident 51 was one of those residents to complain. The MS stated that he had taken care of the cold temperature complaints. The MS stated that one of the rooms was on a different thermostat and he changed it from cold to heat. The MS stated that the thermostat in the 400/500 hallway was turned off. The MS stated that if the thermostat was reading a lower temperature than it was set to, it was set to cool. The MS stated that when he arrived the thermostats had not been set to heat yet. The MS stated that he was not sure of any records prior to his start date. The MS stated that the televisions not in working condition would be replaced. The MS stated that he had provided resident 51 with a new television remote when he first started. 12. On [DATE] at 10:16 AM, an observation was made of room [ROOM NUMBER]B. The privacy curtain had a red substance on it and there was a brown splatter on the wall. Resident 32 resided in room [ROOM NUMBER]B and was interviewed. Resident 32 stated it had been a while since his room and privacy curtain was cleaned. Resident 32 stated, This isn't the greatest place to be at this time in life. 13. On [DATE] at 4:09 PM, an observation was made of room [ROOM NUMBER]A. There was a brown stain on Resident 55's sheet by his elbow. The bathroom had a strong urine odor. Resident 55 stated staff cleaned his room daily and changed his bedding wee[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 out of 65 sampled residents, that the facility did not make prompt efforts to resolve grievances. Specifically, residents expressed grievances about missing personal property to staff and there was no resolution to the grievances. Resident identifiers: 29, 51. Findings included: 1. Resident 29 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included drug induced secondary Parkinsonism, adult failure to thrive, dementia, bipolar disorder, anxiety disorder, drug induced akathisia, suicidal ideation, post-traumatic stress disorder, nephrogenic diabetes insipidus, hyperparathyroidism, chronic kidney disease, schizoaffective disorder, hyperlipidemia, Meniere's disease, non-ST elevation (NSTEMI) myocardial infarction, obstructive sleep apnea, cognitive communication deficit, insomnia, hypertension, and chronic pain. On 11/03/24 at 2:26 PM, an interview was conducted with resident 29. Resident 29 stated that she had clothes go to laundry that had not been returned. Resident 29 stated that she had two t-shirts and two pairs of shorts go missing in the last 6 months. Resident 29 stated that she informed staff but had never had a resolution to the missing items. Resident 29 stated that she had never had her missing items returned or replaced and had to buy more clothing items herself. Resident 29's medical records were reviewed. On 9/29/24, resident 29's Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 10, which would indicate that the resident had a moderate cognitive impairment. On 12/13/21, resident 29's New Admit Belonging Inventory documented the following: one sweater, one pant, one black iPhone, one charging cord. No documentation could be found of an updated and current resident inventory list. The grievances were reviewed from January 2024 through October 2024 and no documentation could be found for resident 29's missing personal property. On 11/06/24 at 1:56 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 29 was alert and oriented times 4 to person, place, time, and situation. LPN 3 stated that resident 29 use to have intermittent confusion but had been more stable in the last 5 months since some medication adjustments. On 11/06/24 at 1:59 PM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that resident 29 had not reported any missing property. CNA 3 stated that the process for locating any missing property was to look in the laundry room for any missing clothing and if she could not find it she would report it to the laundry staff to keep an eye out for it. CNA 3 stated that she would then report the missing item to the CNA Coordinator who would then put it on the group chat. 2. Resident 51 was admitted to the facility on [DATE] with diagnoses which included intracerebral hemorrhage, hemiplegia and hemiparesis of left side, neurologic neglect syndrome, chronic kidney disease, hypertension, congestive heart failure, cognitive communication deficit, aphasia, visual loss both eyes, and insomnia. On 11/03/24 at 2:34 PM, an interview was conducted with resident 51. Resident 51 stated that she had multiple items of missing clothing. Resident 51 stated that she had informed the Resident Advocate (RA) of the missing items but that he was no longer at the facility. Resident 51 stated she was missing jackets, a pink hamper, pajamas, sweat pants, and t-shirts. Resident 51 was unable to state the quantity of the missing clothing items. Resident 51 stated that she had never had her missing items returned or replaced. Resident 51 also stated that she was missing her bottom dentures and that they had been gone since she changed rooms. Resident 51's medical records were reviewed. On 10/9/24, resident 51's MDS Assessment documented a BIMS score of 14, which would indicate that the resident was cognitively intact. The assessment documented that resident 51 did not have any hallucinations or delusions and did not have any physical or verbal behavioral symptoms. On 1/11/24, resident 51's New Admit Belonging Inventory documented the following: 7 t-shirts, 1 coat, 9 sweats, 1 short, 3 bras, 6 underwear, 6 pairs of socks, a cell phone and a charger. The grievances were reviewed from January 2024 through October 2024 and no documentation could be found for resident 51's missing personal property. On 11/05/24 at 12:53 PM, an interview was conducted with CNA 6. CNA 6 stated that if a resident reported missing property they would inform the nurse and the nurse would inform the Administrator (ADMIN). CNA 6 stated that they would then attempt to find the missing item. CNA 6 stated that upon admission they obtained an inventory of all the resident's belongings. CNA 6 stated that it was difficult to keep track of any additional personal items that were brought to the facility and he did not know if they updated the resident inventory sheet. CNA 6 stated that resident 51 had reported missing clothing but they had found them. On 11/06/24 at 9:39 AM, an interview was conducted with LPN 3. LPN 3 stated that resident 51 was alert and oriented times 4 to person, place, time and situation and had no memory deficits. LPN 3 stated that resident 51 did not have any missing personal items. LPN 3 stated that missing money was reported to the ADMIN. LPN 3 stated that if the missing items were clothing she would wait for laundry to check and search in the resident room, then if the items could not be located she would notify the ADMIN. LPN 3 stated that sometimes the laundry staff misplaced a clothing item and she would inform them first in an attempt to locate the missing item. LPN 3 stated that resident 5 wore dentures and to her knowledge she did not have any missing dentures. LPN 3 stated that approximately 4 months ago, resident 51 resided in a different room. LPN 3 stated that if a resident was missing dentures, she would notify the kitchen in case they were left on a meal tray. LPN 3 stated that no one brought missing teeth to her attention and those were expensive so they needed to follow up on that. On 11/06/24 at 3:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the grievance form was located on the RA door. The DON stated that staff were to fill out the form, place it under the RA's door and he would determine which department would investigate the grievance. The DON stated that the resident, ADMIN and RA signs the form. The DON stated that missing personal property would go to the ADMIN and RA and the RA would determine if a grievance needed to be filled out for the missing property. The DON stated that if a grievance was escalated to her it would be investigated. The DON stated that when she investigated a grievance she would ask the resident when was the last time they saw the item, the timeframe of it being missed, ask staff if they noticed the item was missing, review camera footage, and then replace the property as needed. The DON stated that staff should report missing property to the RA or ADMIN. The DON stated that if a missing item was located in the resident room then they would not fill out a grievance form. The DON stated that staff should just know to inform the DON, ADMIN or RA of any missing property. On 11/6/24 at 9:08 PM, an interview was conducted with the RA. The RA stated he was in charge of the grievances. The RA stated the process was that when a complaint came in, the facility had 5 days to investigate the complaint. The RA stated there was a form that was filled out by the resident, staff or family members. The RA stated that staff looked for missing items and if they were unable to find the item then they would talk to the resident about what they wanted to happen. The RA stated they replaced clothing items. The RA stated that when the investigation was completed he went over it with the resident and the ADMIN signed the form. On 11/07/24 at 9:40 AM, a follow-up interview was conducted with the RA. The RA stated that resident 29 had not informed him of any missing personal property. The RA stated that typically if something was missing they would take the resident to the lost and found to locate the item. The RA stated if the resident was still unable to locate the missing item they would let the ADMIN know so that the item could be replaced. The RA stated that if a resident was missing dentures, they would first look to see if they were thrown away by mistake. The RA stated that if the dentures could not be located he would make an appointment with the dental provider to obtain a replacement. The RA stated that resident 51 would state that clothing items were missing but it was determined that those items were never brought into the facility. The RA stated that the resident's inventory sheet did not contain the extensive list of items that resident 51 had said was missing. The RA stated that the resident inventory list should be updated anytime they brought new items into the facility. The residents should notify the CNA's so they could update the inventory. The RA stated that if a CNA were to notice that the resident had new items they should inventory those new items right away. The RA stated that items came and went from the facility and if something was delivered to the facility for a resident and staff was aware then it should be added to the inventory list. The RA stated that resident 51 never mentioned to him that she was missing her dentures. The RA stated that resident 51 had a habit of leaving her dentures out. The RA stated that if resident 51 was stating that her dentures were missing, they needed to locate them or obtain new ones. On 11/12/24 at 1:46 PM, a follow-up interview was conducted with the DON. The DON stated that dental appointments were now being scheduled by her, but previously it was the RA's responsibility. The DON stated that missing personal property was investigated through the grievance process by the ADMIN and DON now. The DON stated that the staff should help the resident fill out the form. The DON stated that for missing items such as clothing staff should contact the HS and see if the item could be located in laundry, then they should look in the resident room. The DON stated that if the item was not found they would replace the item as needed. The DON stated that the CNA's should update the resident inventory list and fill out a new sheet every time there are new items brought into the facility. The DON stated that the grievance notice needed to be updated. The DON stated that new dentures would be obtained for resident 51 and she would make the appointment now. 3. A review of the facility's resident council meeting minutes revealed: a. April 2024: .resident concerned that his non-labeled clothes are disappearing. Another resident commented that she had the same issue with a pair of pants that were not labeled not coming back through laundry .lost & found 'laundry day' for residents to search through unmarked clothing to find their missing property .proposed system changes for noting missing clothes, labeling clothes properly, or repairing/replacing damaged clothing .asked for grievances for all damaged/missing clothing, to be followed-up on, after the lost-&-found event, if still missing . b. July 2024: .Various interventions being taken, including process being implemented for labeling and bagging new clothing, a large clothing reclamation event being held, a weekly unlabeled laundry lost and found rack, a staff meeting in-service on process, and regular training for implementing consistent labeling procedure . c. August 2024: .Laundry Missing PIP [performance improvement plan] in process, to address . d. September 2024: .Laundry Missing Incidents were individually investigated and resolved . On 11/6/24 at 3:00 PM, the facility's resident council meeting was attended. Multiple residents stated that they did not know how to file a grievance and to whom the grievance should be filed with. On 11/7/24 at 10:07 AM, an observation was made of the facility's posted grievance procedure with an outdated resident advocate's name listed as the grievance official. On 11/7/24 at 12:04 PM, an interview was conducted with the ADMIN. The ADMIN stated that he had attended the resident council meeting on 11/6/24. The ADMIN stated that he did not know that some residents did not how to fill out a grievance form and that he learned that in the resident council meeting. The ADMIN stated that he would discuss grievances with the management staff and how to notify residents about the grievance process. [Cross-refer F584]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined for 5 out of 65 sampled residents, that the facility did not develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, facility staff did not conduct capacity to consent to sexual relationships for residents prior to residents engaging in sexual relationships. Resident identifiers: 6, 49, 54, 121 and 319. Findings include: The facility's Abuse Policy revised on 6/11/24, was reviewed and revealed the following: Definitions .3. Sexual abuse: Non-consensual sexual contact of any type with a resident . Abuse Prevention .4. This facility honors a resident's right to engage in consensual sexual relationships. a. A licensed nurse or social worker shall complete the facility's designated assessment in the resident's medical record to determine whether the resident has the capacity to consent upon becoming aware that a resident wishes to engage in a consensual sexual relationship with another individual. b. The facility will re-evaluate a resident's capacity to consent as needed based on changes in the individual resident's physical, mental and psychosocial needs. c. If a resident has a legal or other designated representative to make decisions on his or her behalf, it is important for the resident, resident representative and facility staff to understand the types and scope of decision-making authority of the representative . 1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, diffuse traumatic brain injury (TBI) with loss of consciousness, unspecified ataxia, adjustment disorder with mixed disturbance of emotions and conduct, unspecified depression, and cognitive communication deficit. On 4/23/24 a Brief Interview for Mental Status (BIMS) assessment was conducted on resident 54. Resident 54 scored a 12. A score of 8-12 indicated moderately impaired cognition. A review of resident 54's care plan revealed, Focus: Resident has mental health diagnoses of TBI [traumatic brain injury] and adjustment disorder with aggression and depression as well as impulsive sexual behaviors. He uses of [sic] anti-depressant, anti-anxiety, anti-psychotic medications. Date initiated: 3/28/24 Revision on 5/16/24 Interventions included the following: a. Administer medication per physician order. Monitor for side effects and notify MD [medical doctor] of any adverse or consistent side effects that occur r/t [related to] psychotropic drug use. Date initiated: 3/28/24 b. Document target symptoms Q [every] shift. Notify MD of any new/worsened symptoms of mental illness that are not effectively managed with current pharmacological and non-pharmacological interventions. Date initiated: 3/28/24 c. If resident's mental health symptoms become unmanageable in-house or a mental health crisis occurs, call the crisis line or notify the MD to obtain transfer orders for a psychiatric evaluation in the hospital setting. Date initiated: 3/28/24 d. MD will perform a medication review and make adjustments to medication regimen as indicated to target impulsive sexual behaviors that have not responded to non-pharmacological approaches. Date initiated: 5/15/24 e. Obtain informed consent for use of psychotropic medication. Medication regimen including black box warnings will be reviewed in each care conference meeting. Date initiated: 3/28/24 f. Psychotropic committee will review the medication regimen, target symptoms and side effects at least quarterly and make recommendations as indicated. Date initiated: 3/28/24 g. Staff should use the following non-pharmacological interventions to help manage resident's behavioral symptoms: 1) Provide opportunities for socialization 2) Provide encouragement, support and active listening 3) Provide reminders about appropriate interactions with others. Set boundaries and reminder [sic] resident about boundaries for interactions with others as needed. 4) Due to religious beliefs, resident's RP [responsible party] prefers that resident not have materials provided to him to be able to self-express sexual needs. 5) Involve resident's family in care. Family to take resident out of facility on outings as able. Resident's dad identified that working out is a helpful outlet for sexual frustration. Date initiated: 5/16/24 Revision on 5/16/24 A review of resident 54's progress notes revealed the following: a. On 4/24/24 at 4.46 PM, a social service note documented, Note Text: RA [resident advocate] met with RT [resident] and RT father to discuss RT being physical with one of facilities NA [nursing aides]. RT apologized for this and promised to not do it again. RT would like to apologize to NA and RA will facilitate this meeting. RT father explained to RT in office that this is not allowed and also apologized to facility for this happening. RA spoke with RT about sexual health and keeping it private. Father said that he is going to start taking RT to the gym more to help provide an outlet for RT. Pend [sic] b. On 5/6/24 at 9:49 AM, a social service note documented, Late Entry: Note Text: RA interviewed [resident 54] separately and asked what happened? [resident 54] stated he hugged [resident 319] and then grabbed her breast. RA asked resident why he would grab a woman's breast without consent? [resident 54] replied 'because I am a guy.' RA explained that just because he is a guy he cannot grab another woman's body without consent. [resident 54] stated 'I see a tit I grab one.' RA explained that the victim of this could press charges and call the police for assault, [resident 54] then reminded RA that his father is a retired police man. Resident then told RA that he was sorry. c. On 5/22/24 at 11:23 AM, an alert charting note documented, Note Text: Helped get resident some water and medications for the morning. Ensured that call light was in reach and asked if there was anything else I could get him. He asked 'can I see your tits?' I told him no and that it was not an appropriate thing to ask. d. On 5/23/24 at 5:27 PM, an alert charting note documented, Note Text: Resident asked CNA [Certified Nurses Aide] who was helping him to shower 'it is not fair that I have to be naked' and you are not. 'You should also get naked'. Also tried to spray CNA with the shower hose. When to talked to Resident and explained that it is not appropriate this type of comments and that it is also not appropriate to try to get CNA wet with the shower hose . It is becoming hard for female CNA to provide care for this resident who continue to be have inappropriate behavior. e. On 5/23/24 at 11:45 PM, a general progress note documented, Note Text: Resident continuously tried to convince aide to go out on a date with him. Aide continued to tell him no. Educated resident that this behavior is inappropriate. Resident apologized and went to his room. f. On 5/24/24 at 1:00 AM, a provider encounter note documented, .Patient seen today for behaviors. Nurses report patient has been having low moods and inappropriate sexual behaviors . g. On 5/31/24 at 6:02 PM, an alert charting note documented, Note Text: Resident is fixated on a female CNA. She reported that he is following her in the Facility. When confronted by CNA to stop this behavior, resident just continue [sic] following her. Resident has to be re- directed several times according to CNA by managementsand [sic] nurses but resident continue to pursed [sic] her unwanted attention. h. On 6/1/24 at 1:15 AM, a general progress note documented, Note Text: Aide reported to nurse that she and other aides have previously experienced inappropriate behaviors from resident while assisting with showers. Aide stated that when giving the resident a shower, resident began to inappropriately touch himself, aide told resident that it was inappropriate and resident stated 'he was almost finished', aide said she would return when he was ready to get out of shower. Aide did not report this until hearing of his continued behavior because she was scared she would get in trouble for leaving resident alone. i. On 6/1/24 at 6:13 PM, an alert charting note documented, Note Text: During lunch in Dinning [sic] room A CNA dropped something on the floor. When she bend down to pick it up resident make [sic] a comment 'Nice ass'. This unsolicited comment made the female CNA very uncomfortable. CNA told resident that those type of comments are very inappropriate. I also when to talk to resident privately about this comment and explain again that his actions and comments are very inappropriate towards females. j. On 6/1/24 at 11:07 PM, an alert charting note documented, .Pt [patient] kept staring at a female cna this evening. Pt kept asking female cna about her boyfriend. Made female cna feel uncomfortable . k. On 6/3/24 at 1:00 AM, a provider encounter documented, .Today I was also informed by the staff that patient has been displaying inappropriate sexual behaviors toward female staff at the facility, such as groping an underage CNA. When speaking to patient about this she [sic] denies doing anything wrong. At this point after discussion with the facility management we will arrange a care coordination meeting with the patient's power of attorney to help decide on the best course of action. This could possibly include additional medications to help suppress his behavior, or a possible referral to the behavioral health unit . l. On 6/4/24 at 5:32 PM, an alert charting note documented, Note Text: Resident is to be male only when preforming [sic] cares due to hypersexual behaviors. Must have 2 females present if female staff is preforming [sic] cares. m. On 6/28/24 at 9:00 PM, an alert charting note documented, Note Text: Resident had call light on. When CNA entered room and asked what he wanted he said 'your number.'CNA asked if he actually needed anything and resident started to use his urinal in front of her. CNA told resident to call when he was done and left the room. n. On 11/7/24 at 10:40 AM, a communication with resident note documented, Resident [resident 54] was observed kissing resident [resident 121] in his room. Administration met separately with [resident 54] to discuss his relationship with [resident 121]. [Resident 54] stated that they are just friends and confirmed that that both she and [resident 54] consented to the kiss. A review of resident 54's Monitoring Record revealed the following number of episodes of inappropriate sexual comments every shift: a. On 5/23/24 PM shift- 2 b. On 5/25/24 PM shift- 2 c. On 5/26/24 AM shift- 2 d. On 6/14/24 AM shift- 1 e. On 6/21/24 AM shift- 4 f. On 6/28/24 PM shift- 1 g. On 9/1/24 AM shift- 2 h. On 9/1/24 PM shift- 2 i. On 9/7/24 PM shift- 1 j. On 9/9/24 AM shift- 1 k. On 9/10/24 AM shift- 2 l. On 9/16/24 AM shift- 2 m. On 9/16/24 PM shift- 2 n. On 9/17/24 AM shift- 1 o. On 9/22/24 AM shift- 2 p. On 9/23/24 AM shift- 2 q. On 9/24/24 AM shift- 1 r. On 9/29/24 AM shift- 2 s. On 9/30/24 AM shift- 1 t. On 10/1/24 AM shift- 1 u. On 10/1/24 PM shift- 1 v. On 10/5/24 AM shift- 2 w. On 10/6/24 AM shift- 2 x. On 10/7/24 AM shift- 2 y. On 10/13/24 AM shift- 1 z. On 10/14/24 AM shift- 1 aa. On 10/15/24 AM shift- 1 bb. On 10/20/24 AM shift- 2 cc. On 10/21/24 AM shift- 2 dd. On 10/22/24 AM shift- 2 ee. On 10/26/24 AM shift- 2 ff. On 10/27/24 AM shift- 2 gg. On10/28/24 AM shift- 1 hh. On 11/3/24 AM shift- 2 ii. On 11/4/24 AM shift- 2 jj. On 11/4/24 PM shift- 2 kk. On 11/5/24 AM shift- 2 2. Resident 121 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, metabolic encephalopathy, type 2 diabetes mellitus with hypoglycemia, acute respiratory failure with hypoxia, iron deficiency anemia, other seizures, unspecified dementia, restlessness and agitation, and mild neurocognitive disorder due to known physiological condition with behavioral symptoms. Resident 121's medical record was reviewed. On 9/30/24 a BIMS assessment was conducted on resident 121. Resident 121 scored a 10. A score of 8-12 would indicate moderately impaired cognition. A review of resident 121's care plan revealed, Focus: The resident has a behavior problem of angry outburst, wandering, hallucinations and delusions at times Date initiated: 10/25/24 Revision on: 11/5/24 Interventions included teh following: a. Anticipate and meet The resident's needs. Date initiated: 10/25/24 b. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Date initiated: 10/25/24 c. If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Date initiated: 10/25/24 d. Praise any indication of The resident's progress/improvement in behavior. Date initiated: 10/25/24 e. Provide a program of activities that is of interest and accommodates residents status. Date initiated: 10/25/24 Another care plan revealed, Focus: The resident has an alteration in neurological status r/t disease process MILD NEUROCOGNITIVE DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH BEHAVIORAL DISTURBANCE Date initiated: 11/4/24 Revision on 11/4/24 Interventions included the following: a. Allow the resident a rest period when she is upset. Date initiated: 11/4/24 b. Cueing, reorientation as needed. Date initiated: 11/4/24 c. Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments. Date initiated: 11/4/24 d. Give medications as ordered. Monitor/document for side effects and effectiveness. Date initiated: 11/4/24 e. Provide emotional support when the resident appears agitated. Date initiated: 11/4/24 f. Special attention provided when the resident has contact with her mother. Date initiated: 11/4/24 A review of resident 121's progress notes revealed the following: a. On 9/25/24 at 3:35 AM, an admission progress note documented, 9/25/2024 03:35 (3:35 AM) admission Progress Note admission Date/Time:: 9/24/2024 1930 (7:30 PM) admitted from/Transported by:: [Hospital Name] transported by mother Primary diagnosis for admission: : Pneumonitis Secondary diagnoses:: DM2 [diabetes mellitus type 2], Acute Respiratory Failure with hypoxia Hx [history] of methamphetamine abuse Vital signs upon admission: : 150/93 bp [blood pressure] 96 pulse 24 rr [respiratory rate] 97.5 t [temperature] 96 o2 [oxygen] 61 inches tall 148.5 lbs Pain level/interventions administered as applicable:: na [not applicable] Mental status upon admission: : Resident was very anxious and hysterically crying. Resident stated she was angry her mom left her here. Mother brought a few belongings in, and told the staff good luck and left facility. Pt very stressed and pacing in the halls. CNA showered resident andpt [sic] calmed down. During assessment patient was oriented and answered questions appropriately, but gets distracted and confused easily. Mobility status/mobility devices:: patient ambulates independently. States she used a walker in the hospital and is requesting a walker to use.Special devices used:: na Oriented to facility. b. On 9/25/24 at 11:45 AM, a skilled charting note documented, Late Entry: Note Text: Resident is A/A/O [sic] [alert and oriented] x 2 with intermittent confusion with auditory and visual hallucinations noted. c. On 9/26/24 at 12:28 AM, an alert charting note documented, Note Text: Pt very anxious at beginning of shift. Returned from an outing with her mother and was very upset and crying. pt stated her mom doesn't care about her and only wants to visit her so she can lecture her about using drugs. Nurse took pt to her room and talked to her for a few minutes while giving her, her medications. Pt took medications and stated she needed to go walk the halls because she continued to be so upset with her mom. After pacing the halls for 20 minutes patient returned to room to watch tv [television]. d. On 9/30/24 at 11:15 PM, a skilled charting note documented, Note Text: Resident alert and oriented to self. no resp [respiratory] distress noted, lungs clear. Denies pain at this time. Requires frequent redirection. talks to self and wanders up and down the hallways, yelling at self and staff and other residents. Neighbor reports she was kicking at the walls in the middle of the night last night. pt skin turgor supple, intact. continent of bowel and bladder. good appetite, eats rapidly. takes fluids well. e. On 10/1/24 at 8:00 AM, a psychological provider note documented, [resident 121] exhibits poor cognition throughout interview including poor attention, distractibility, poor memory, poor social understanding or decreased complex attention. She is unable to explain how she became homeless or how she took care of herself prior to or during homelessness. She is unable to verbalize a plan after discharge. [Resident 121] has persistent abnormal movements including rubbing at her face, neck and arms. She is unable to remain still. Subjective interview and objective assessment of MOCA [Montreal Cognitive Assessment] scoring 14 indicate Major Neurocognitive Disorder, most likely drug induced from many years of alcohol and methamphetamine abuse . f. On 10/1/24 at 9:19 AM, a skilled charting note documented, Note Text: pt had overdose on meth [methamphetamine] use. pt currently on augmentin for s/s [signs and symptoms] of resp [respiratory] infection. no resp distress noted. lungs clear. room air sats [saturations] at 97. Denies pain this am. needs redirected often. talks to self and wanders up and down the hallways, yelling at self and other staff and residents. pt educated to stop slamming doors and raising her voice at others. pt skin turgor supple, intact. continent of bowel and bladder. good appetite, eats rapidly. takes fluids well. Today pt reported by management that pt is going to be staying long term. g. On 10/6/24 at 9:27 AM, a skilled charting note documented, Note Text: pt wandering up and down hallways, talking loudly to self and arguing with staff and other residents. unable to redirect pt. h. On 10/7/24 at 1:34 AM, a skilled charting note documented, Late Entry: Note Text: Pt returned to facility from outing with mom and granddaughter. Pt very agitated and crying stating her mother makes her super upset. Pt states she does not want mother or granddaughter into the facility. Pt very upset and pacing the halls yelling at her self for 30 min [minutes]. i. On 10/18/24 at 11:21 PM, a skilled charting note documented, Note Text: Resident is alert and oriented x 2-3. Often confused, not oriented to situation. Pleasant with staff. Wanders hallways often. Good appetite. Compliant with BS [blood sugar] checks and insulin administration. Takes pills whole. Denies pain. Has not slept well the past two nights. j. On 10/27/24 at 3:36 PM, an alert charting note documented, Note Text: Corporate nurse found pt walking by street in front of facility this afternoon, nurse was able to direct pt back into the facility. notified DON [Director of Nursing] k. On 10/29/24 at 1:57 PM, a skilled charting note documented, Note Text: Resident is alert and oriented x 2 self, situation. Resident has episodes of confusion. Resident shows signs of anxiety and sadness. Resident is found often pacing the hallways and talking to self. Resident was redirected and invited to multiple activities during the day. Resident has redness under pannus. Resident is a limited assistance with dressing ADL [activities of daily living] and toileting. WCTM [will continue to monitor]. l. On 10/31/24 at 4:00 PM, a skilled nursing note documented, Late Entry: Note Text:. No changes in LOC [level of consciousness]. Resident did have multiple verbal outburst. Resident was upset because mother would not take her trick or treating. Resident was given time to calm down and verbalize why she was upset. Resident calmed and went to socialize with other residents in theactivity [sic] room. WCTM. m. On 11/8/24 at 8:49 AM a COMMUNICATION - with Resident note documented, Note Text: Resident [121] was observed kissing resident [54] in his room. Administration met separately with [resident 121] to discuss her relationship with [resident 54]. [Resident 121] stated that they are just friends and confirmed that both she and [resident 54] consented to the kiss. 3. Resident 319 was admitted to the facility on [DATE] and readmitted on [DATE] and discharged on 8/1/24 with diagnoses which included metabolic encephalopathy, hypothyroidism, bipolar II disorder, anxiety, disease of blood and blood-forming organs, hypertension, and traumatic brain injury. Resident 319's medical record was reviewed 11/3/24 through 11/13/24. A quaterly MDS dated [DATE] revealed resident 319's BIMS score was 13 which indicated congitively intact. A social services note dated 5/6/24 at 9:45 AM revealed a late entry RA met with [resident 121] to inquire about report that [resident 54] grabbed her breast. [Resident 121] stated that she was coming down 200 hall towards the gym area and stopped to give [resident 54] a hug and as he hugged her he moved his hand down her body and grabbed her breast, [resident 121 stated that she immediately told [resident 54] no and he said he was sorry and continued moving away from her towards 300 hall and she went outside. That was the end of it. A social services note dated 5/6/24 at 9:47 AM was a late entry created on 5/14/24. The note revealed, RA met with RT again and asked if RT would like to press charges against RT for what she reported? RT stated 'No, I don't want to cause trouble for anyone.' RA asked RT if she was sure, and maybe wanted to think about it longer? RT replied 'I am sure, I don't want to press charges, period.' Potiential for Harm 4. Resident 6 was admitted to the facility on [DATE] with diagnoses which include hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, other abnormalities of gait and mobility, aphasia, dysphagia following cerebral infarction, epilepsy, cognitive communication deficit, and major depressive disorder. On 11/3/24 at 6:14 PM, an observation was made of resident 49 pushing resident 6 in her wheelchair in the 100 hallway. On 11/3/24 at 6:45 PM, an interview was conducted with resident 49. Resident 49 was sitting in the dining room when resident 6 entered the dining room in a wheelchair. Resident 6 was observed to sit at resident 49's table. Resident 49 pointed to resident 6 and stated that was his girlfriend. Resident 6 was observed to move her head in a yes motion and smiled. On 11/6/24 at 3:37 PM, an observation was made of resident 49 and resident 6 in the activity room. Resident 6 and resident 49 were sitting on a sofa. Resident 6 was observed to have her head on resident 49's chest and resident 49 had his arm around resident 6. Both residents were observed with their eyes closed. Resident 6's medical record was reviewed. On 2/6/24 a BIMS assessment was completed on resident 6. Resident 6 scored a 9. A score of 8-12 would indicate moderately impaired cognition. A review of resident 6's sexual activity capacity for consent dated 2/21/24 revealed: a. Describe resident's stated choice: She stated, 'I love him' she said and likes to cuddle with him, but does not want a sexual relationship. She does not want any sexual touching. A review of resident 6's care plan revealed Focus: MOOD & BEHAVIOR: [Resident 6] has potential for mood and coping issues due to desire to have a romantic relationship with another resident. [Resident 6's] outside medical provider [name redacted] has been consulted and confirmed [resident 6] has capacity to make her own decisions and provide consent. Date initiated: 5/29/24 Revision on 6/26/24 Interventions included the following: a. Assess [resident 6's] capacity to give consent for romantic relations with another resident. Date initiated: 5/29/24 Revision on: 5/29/24 b. If any other resident requests romantic encounter with [resident 6], staff will verify if [resident 6] also wants encounter and if she doesn't, staff will make sure her rights are protected. Staff will make sure other resident respects [resident 6's] wishes. Date initiated: 5/29/24 c. Offer psychosocial support as needed Date initiated: 5/29/24 Revision on: 5/29/24 d. Whenever [resident 6] elects to spend time with other resident, staff will ask and verify that spending time is what she wants and that there is no coercion involved. Reinforce that any kind of romantic and/or sexual expression is her choice. Date initiated: 5/29/24 Revision on: 5/29/24 Another care plan revealed Focus: [Resident 6] has an on again off again relationship with another consenting resident. Date initiated: 6/26/24 An intervention included [Resident 6] will only have romantic companionship with other consenting residents. Staff will verify that 321B is interested in a romantic encounter with [resident 6] PRN [as needed]. [Resident 6] and 321B will confine their romantic relations to a location that is appropriate and separate from other residents. [Resident 6] and 321B will be respectful of other resident's and their rights. Date initiated: 6/26/24 A review of resident 6's progress notes revealed the following: a. On 3/4/24 at 11:22 AM, a social service note documented, RA met with resident and confirmed resident no longer wants to associate with [resident 49] after the incident at church yesterday. RA asked if resident has attempted to talk with resident since, and resident stated no. RA asked resident to notify staff if she feels unsafe. RA will meet with [resident 49] and talk with him about no contact with [resident 6]. b. On 3/4/24 at 1:27 PM, a social service note documented, RA received call from responsible party who is upset about learning of incident yesterday from her brother rather than us calling her directly. RA was able to ascertain that resident called her son and informed him of incident with [resident name redacted] through facetime [sic] with the help of her aid [sic] at her request. RA contacted responsible party back and explained situation. Responsible party stated she spoke with residents nurse and was able to learn the fact of the situation and it has put her mind to rest. RA assuredresponsible [sic] party that staff is

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 6 out of 65 sampled residents, that in response to an allegation of abuse, neglect, exploitation, or mistreatment, the facility failed to report immediately, but not later than 2 hours to the other officials including the State Survey Agency (SSA). Specifically, sexual abuse, a fall with a major injury, a fall from a hoyer lift, exploitation of a resident, involuntary seclusion, and an elopment were not reported to the SSA. Resident Identifiers: 5,13, 46, 54, 121, 419 Findings Include: The facility's Abuse Policy and Procedures were reviewed. The following was documented in the policy: .The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property is reported immediately but no later than 2 hours, after the allegation is made . 1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, diffuse traumatic brain injury (TBI) with loss of consciousness, unspecified ataxia, adjustment disorder with mixed disturbance of emotions and conduct, unspecified depression, and cognitive communication deficit. 2. Resident 121 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, metabolic encephalopathy, type 2 diabetes mellitus with hypoglycemia, acute respiratory failure with hypoxia, iron deficiency anemia, other seizures, unspecified dementia, restlessness and agitation, and mild neurocognitive disorder due to known physiological condition with behavioral symptoms. On 11/7/24 at 10:40 AM, a communication note documented, Note Text: Resident [54] was observed kissing resident [121] in his room. Administration met separately with [resident 54] to discuss his relationship with [resident 121]. [Resident 54] stated that they are just friends and confirmed that both she and [resident 54] consented to the kiss. On 11/7/24 at 1:41 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN was asked for a copy of the 358 that was submitted to the state in reference of the incident that occurred with resident 54 and 121. The ADMIN asked the state surveyor if the incident was a reportable one and that he did not report the incident to the state. On 11/7/24 at 1:45 PM, a follow up interview was conducted with the ADMIN. The ADMIN stated that his definition of sexual abuse was exploiting or taking advantage of someone especially if they can't consent. The ADMIN stated he had contacted the Ombudsman and was told that as long as the residents were consenting then it was fine. The ADMIN stated that the residents 121 and 54 had their own right to kiss, he made a note in their medical records about it and thought everything was fine. On 11/7/24 at 3:38 PM, an interview was conducted with the ADMIN. The ADMIN stated that he had submitted the reportable 358 to the state. 5. Resident 46 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, aphasia, cognitive communication deficit, chronic obstructive pulmonary disease with acute exacerbation, lack of coordination, acute kidney failure, major depressive disorder, and anxiety. On 11/7/24 at 11:38 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that resident 46 was moved into the memory care unit on 10/2/24 and moved back out on 10/17/24. On 11/7/24 at 1:17 PM, an interview was conducted with the ADMIN. The ADMIN stated resident 46 was put into the memory care unit because she was noncompliant with smoking. The ADMIN stated she should be able to understand the smoking policy. The ADMIN stated she was moved out of the memory care unit because her daughter was upset that the doors were locked and wanted her moved out. Said surveyor reported the act of involuntary seclusion for resident 46 to the ADMIN during interview. On 11/13/24 at 11:07 AM, a follow-up interview was conducted with the ADMIN. The ADMIN stated that he had not reported the involuntary seclusion allegation for resident 46 to the SSA and that he should have reported it already. 6. Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included quadriplegia, dysphagia, chronic kidney disease, chronic obstructive pulmonary disease, paralysis of vocal cords and larynx, congestive heart failure, and major depressive disorder. Resident 5's medical record was reviewed 11/3/24 through 11/13/24. An Alert Charting note, dated 11/8/2024 at 2:55 AM, indicated, Resident was being lifted up in the hoyer sling x2 [times two] CNAs [certified nursing assistant] from wheelchair to bed placed in bed to go to sleep. CNA's Stated that sling snapped and Pt [patient] slid onto floor. Pt was assessed by nurse and took Pt vitals were WNL [within normal limits] BP [blood pressure]= 133/80, P [pulse]=73, O2 [oxygen saturation]= 93, R [respirations]=20. Pt got skin tear to Left arm. no other injury appeared at this time. dressing applied by nurse. no other issues were noted at this time. On 11/13/24 at 11:53, an interview was conducted with the ADMIN. The ADMIN stated he should have reported the hoyer lift fall because the staff used the sling and it could have been neglect. The ADMIN stated he did look at the sling when it happened and saw that the sling was frayed. The ADMIN stated that he was still working on the report for resident 5's hoyer lift fall and that he should have reported it to the SSA last week when it happened. 4. Resident 419 was admitted to the facility on [DATE] and discharged on 3/25/24 with diagnoses of metabolic encephalopathy, schizophrenia, psychological and behavioral factors, and polydipsia. Resident 419's medical record was reviewed on 11/13/24. A hospital history and physical dated from 2/6/24 to 3/20/24 documented resident 419 was unable to care for themselves nor make medical decisions and lacked self-awareness. The physician documented resident 419 needed to be placed into a care facility with 24-hour supervision. On 3/7/24, an inpatient psychiatric (psych) evaluation was conducted on resident 419 and the psychiatrist deemed resident 419 decisionally incompetent and unable to reliably care for themselves. The psych note stated, Patient would be best suited for admission to long-term skilled nursing facility. Due to patient's current cognitive impairment and condition, she is unsafe to be discharged home as she is unable to safely take care of herself. On capacity testing again she remains unable to exhibit the four generally accepted decision-making abilities that constitute capacity, understanding, expressing a choice, appreciation, and reasoning. On 3/15/24 at 10:51 AM, an emergency court ordered appointed guardian was granted to resident 419, who was declared to be an incapacitated adult. The document stated the emergency guardian had the authority to make medical, financial, placement, and end-of-life decisions. The temporary guardianship was to be effective for 30 days. An admission wander/elopement risk evaluation completed on 3/20/24 stated resident 419 was a high wander/elopement risk. Resident 419 was documented to have the following risk factors: History of wandering, cognitive impairment, impaired decision-making skills, memory impairments, and previous elopement attempts. A care plan focus area initiated on 3/20/24 stated resident 419 wanted to discharge back into the community. Listed interventions included encouraging resident 419 to discuss feelings and concerns related to discharge and staff were to monitor and address sources of anxiety, fear, or distress in order to promote a calm and orderly discharge. Another intervention stated the resident advocate was to make a referral to the local contact agency when indicated to help facilitate resident 419's discharge plan. A care plan focus area initiated and revised on 4/12/24 stated resident 419 had impaired cognitive function/impaired through processes related to a BIMS of 6, and impaired safety awareness. [Note: It should be noted this was initiated 18 days after the resident left the facility against medical advice (AMA) and was charged with criminal trespassing and sent to jail.] An admission MDS completed on 3/25/24 documented resident 419 had a BIMS score of 6 which indicated severe cognitive impairment. A care conference documented resident 419 wanted to look into housing and an evaluation was being set up with local housing for a possible housing transition. On 3/25/24, a social service note created at 12:52 PM, stated resident 419 had walked out of the facility AMA. Resident 419 stated they were fine on their own and had packed their belongings in a plastic bag and were heading to a local homeless center where they could live by themselves. The RA stated resident 419 had not given a reason to their change of mind and left the faciity on foot. The RA contacted resident 419's guardian and the local police. The RA contacted Adult Protective Services at 12:59 PM and filed a report due to resident 419 leaving the facility AMA. A discharge progress note created at 1:03 PM, stated resident 419 had left the facility AMA at 12:30 PM and was going to a local homeless center on foot. It was documented the case manager had called the local homeless center and was informed residents 419 was above their level of care. The homeless center was provided resident 419's guardian name and phone number by the RA. [Note: It should be noted this incident was not reported to the state survey agency. Resident 419 was appointed a guardian due to being unable to make medical decisions for themselves. Resident 419 did not have the cognitive capacity to sign out AMA and the facility did not notify the guardian about resident 419's desire to leave AMA before they left the facility.] On 11/13/24 at 11:07 AM, an interview was conducted with the ADMIN. The ADMIN stated an elopement was considered when staff lost sight of a resident who left the facility property. The ADMIN stated if a resident did not have the capacity to sign out AMA and they left the facility, they would consider it an elopement. The ADMIN stated resident 419's AMA occurred before they were the Administrator. A follow up interview was conducted with the ADMIN at 11:53 AM. The ADMIN stated they were working on submitting a report for resident 419's elopement. On 11/13/24 at 12:06 PM, an interview was conducted with the [NAME] President of Clinicals (VPC). The VPC stated a resident was appointed a guardian depending on their situation. The VPC stated a guardian was appointed to look out for the resident and their best interest. The VPC stated resident 419's discharge was not reported to the state agency because they believed the resident had left AMA and had not eloped. 3. Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, muscle weakness, major depressive disorder, and chronic pain. On 11/3/24 at 4:04 PM, an interview was conducted with resident 13 who stated she had sustained several falls in the facility over the past year. Resident 13 stated earlier in the year, one of her falls resulted in a shoulder fracture. Resident 13's medical record was reviewed between 11/3/24 through 11/13/24. On 6/11/24, an Minimum Data Set (MDS) admission assessment revealed resident 13 had a Brief Interview for Mental Status (BIMS) score of 13 indicating normal cognition. Progress notes: On 5/27/24 at 4:45 PM, an alert charting progress note revealed, Found pt [patient] laying on her bed with a hematoma on her forehead. Pt with a laceration on her nose. Severe pain to her right shoulder and pain and bruising to her left knee. Pt states that her pant leg got caught on her electric w/c [wheelchair] and she fell forward. Pt got herself up into her bed and then called for assistance. Pt requested to go to ER [emergency room] for evaluation of her right shoulder. Non-emergent ambulance called. Notified physician on call and pt's [family member]. Pt sent out at this time. On 5/27/24 at 4:48 AM, a discharge progress note revealed, Date/time of discharge/transfer: 5-27-24 at 4:35 AM. Discharge/transfer location: [Hospital name]. Mode at transportation at time of discharge/transfer: non-emergency ambulance. Reason for transfer/discharge: severe pain to right shoulder- possible fracture. Discharge teaching/instructions completed during discharge/transfer: [blank]. Discharge paperwork released with resident at time of discharge/transfer: Transfer/discharge record, order summary, face sheet. Resident's response to discharge/transfer process: Pt wanting to go to the ER. How were the resident's personal effects stored/handled at time of discharge/transfer?: Personal items left in her room. Pt took her phone and phone charger with her. Name of individual to whom report was provided at new location: [blank]. Name of resident representative notified (if resident is not self-responsible): [family member]. Name of physician notified [name redacted] on call for [physician name]. On 6/4/24 at 6:46 PM, a progress note alert charting revealed, Pt re-admitted to facility via facility transport. A/O [alert and oriented] x 4. Able to verbalize needs. Continent of bowel and bladder. Resident using sling to R [right] shoulder. Has bruises to: forehead, L [left] knee, Rt [right] shoulder, LFA [left femoral artery], L elbow, 2 small bruises on bilat [bilateral] ankle, RFA [right femoral artery]. She has small scan on bridge of nose. Incision to R chest area intact, no s/s [signs and symptoms] of infection. Uses motorized w/c for mobility. Last BM [bowel movement] 6/3/24. C/O [complains of] pain to R shoulder Oriented to facility. Call light is within reach. On 8/6/24 at 7:53 AM, a social service progress note revealed, RA [Resident Advocate] met with RT [resident] to discuss help with setting up crypto account. RA quickly determined RT is victim of scam. Perpetrator is stating they are '[celebrity]' the singer and they are going to marry RT. RT is excited about this relationship and '[celebrity]' coming to St. [NAME] while touring in Las Vegas to meet RT. RA made it very clear that any requests for money, or crypto, loans is a scam and RT could fall victim to identity and financial theft. RA contacted [bank] after learning RT has provided log in information for her online banking. [Bank] closed down the accounts and froze the fraudulent deposit. RA facilitated RT visiting the DLD [Drivers License Division] to renew her license, this was first step for RT to visit the branch in person to have new accounts created. RA offered support to RT and explained feelings of grief are normal and expected when any relationship ends. RA made it clear that RT should no longer speak with this person and block any further communications. On 8/13/24 at 7:58 AM, a social service progress note revealed, RA has communicated with RT therapist [name], [Local Behavioral Health Center]. Therapist confirmed RT has continued online relationship, and is having difficulty accepting that relationship was a scam. RA has learned that RT was upset about account being closed, and was not happy RA intervened to help RT not fall victim to scam. RT has communicated with nursing staff that she is attempting to repair online relationship and that '[celebrity]'son is now speaking with her about repairing damage to the relationship by asking RT to qualify for a loan to make it up to him. RA has communicated with RT therapist, and [name] RT APRN [Advanced Practice Registered Nurse]. All treatment providers agree it is best to allow RT to make her own decisions and respect her autonomy. RT has been warned about scam, and is being offered support regardless of her choices. RT has been determined to be capable of making her own decisions. RA met with RT and offered support, RA also apologized for quickly acting on scam and having RT account closed, even with RT consent and being present for the calls to [bank]. RA explained this was done in an effort to help RT avoid suffering and that RT wishes are important and RA wants to honor them. RT stated she understood and appreciated the talk. On 8/22/24 at 3:39 PM, a social service progress note revealed, RA contacted APS [adult protective services] to file report about online relationship-RA explained the situation and APS provided case [number redacted]. Resident 13's care plan revealed: a. Risk for falls r/t [related to] neuropathy, gout, dependence on supplemental oxygen, impaired mobility with use of assistive device, hx [history] of falls. Date initiated: 7/18/22, Revision on 6/26/23. The goal was, The resident will be free of falls with injury through the review date. Date initiated: 7/18/22, Revision on: 4/12/24, Target Date: 2/7/25. Interventions included, .5/27/24- unwitnessed fall, risk management done, resident educated. Date initiated: 5/28/24 .Follow facility fall protocol if a fall occurs. Date initiated: 7/18/22 . b. The resident has had an actual fall. Poor balance, poor safety awareness. 10/12/24. Date initiated: 8/30/24, Revision on 10/21/24. The goal was, Resident will not have a fall with major injury. Date initiated: 8/30/24, Target date: 2/7/25. Interventions included, .Encourage resident to participate in fall prevention. Date initiated: 8/30/24 .Monitor/document/report PRN [as needed] x 72 h [hours] to MD [medical doctor] for s/sx [signs and symptoms]: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Date initiated: 8/30/24, Revision on 8/30/24 . c. Mood & Behavior: [resident 13] has potential for coping and adjustment issues, related to a desire for an online relationship and potential for online exploitation. Depression. Due to this desire, [resident 13] has had a capacity to consent evaluation done and has been found to have the ability to consent to a relationship. Date initiated: 8/14/24, Revision on 11/8/24. The goal was, Dignity will be preserved and quality of life improved by allowing [resident 13] to make her own informed decisions. Date initiated 8/14/24, Revision on 8/14/24, Target date: 2/7/25. Interventions included, .Provide information to [resident 13] regarding potential financial and emotional exploitation. Assist PRN with banking issues if [resident 13] requests. Follow mandatory reporting policies if needed. Date initiated: 8/14/24. d. The resident has a psychosocial well-being problem r/t sexual activity capacity. 11/8/24: Resident does not have capacity for sexual activity consent: Date initiated: 11/8/24, Revision on: 11/8/24. The goal was, The resident will have on indications of psychosocial well being problem by/through review date. Date initiated: 11/8/24, Target date: 2/7/25. Interventions included, Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears when conducting sexual activity capacity for consent assessment. Date initiated: 11/8/24; .Provide opportunities for the resident and family to participate in care. Date initiated: 11/8/24; The resident needs assistance/encouragement/support to identify causative and contributing factors. Date initiated: 11/8/24; The resident needs assistance/encouragement/support with identification of potential solutions to present problems. Date initiated: 11/8/24 On 11/7/24 at 11:59 AM, an interview was conducted with the MDS coordinator who stated the incident on 5/27/24 was a result of resident 13's pant leg getting caught on her wheelchair. The MDS stated resident 13 was given verbal education about wheelchair safety on the day of the fall. The MDS stated resident falls were reviewed in morning stand up meeting and then the IDT (interdisciplinary team) meeting. It should be noted that no IDT meeting progress note could be found for resident 13's fall on 5/27/24. The Resident Advocate could not be reached for an interview. On 11/13/24 at 8:59 AM, an interview was conducted with the Director of Nursing (DON) who stated resident 13 believed she was in a relationship with a celebrity. APS and the ombudsman were involved. The DON stated she would have to check with the RA about the situation. The DON stated the police should have been notified about the exploitation. The DON stated the RA helped resident 13 with her bank account. The DON stated resident 13 had to get a new bank account to protect her information. The DON stated resident 13 was trying to cash a check that was fraudulent. The DON stated she would provide more information after speaking with the RA. It should be noted that no additional information was provided regarding exploitation of resident 13. It should also be noted that this injury of unknown origin event was not reported to the SSA within the required 2 hours of becoming aware, and the resident's exploitation was not reported to the SSA until 11/13/24. [cross-refer 689] [cross-refer 602]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 3 out of 65 sampled residents, that the facility did not provide written information to the resident or resident representative the duration of the state bed hold policy, during which the resident was permitted to return and resume residence in the nursing facility. Specifically, residents were transported to the hospital and were not informed of the facility bed hold policy. Resident identifiers: 5, 8, 123. Findings included: 1. Resident 8 was admitted to the facility on [DATE] and readmitted to the facilty on 8/9/24 with diagnoses which included, but not limited to, unspecified intracranial injury with loss of consciousness, human immunodeficiency virus, acute respiratory failure with hypoxia, major depressive disorder, candidal stomatitis, acute kidney failure, unspecified speech disturbance, and history of falling. A review of resident 8's medical record revealed the following: a. On 8/1/23 at 2:43 PM, an alert charting note documented, Late Entry: Note Text: resident sent to ed [emergency department] via 911 for chest pain. np [nurse practitioner] in building did assessment and said to sent resident. called 911 sent resident via [ambulance company]. No documentation could be found that resident 8 or resident 8's representative were notified of the facility bed hold policy prior to transfer to the hospital. 2. Resident 123 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, myotonic muscular dystrophy, cognitive communication deficit, type 1 diabetes mellitus with hyperglycemia, hyperlipidemia, gastro-esophageal reflux disease without esophagitis, cachexia, and hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side. A review of resident 123's medical record revealed the following: a. On 8/1/24 at 4:42 PM, an alert charting note documented, Note Text: Sent to ED for eval [evaluation] and treat via facility transport. DON [Director of Nursing] and MD [Medical Doctor] notified. No documentation could be found that resident 123 or resident 123's representative were notified of the facility bed hold policy prior to transfer to the hospital. On 11/12/24 at 10:22 AM, an interview was conducted with the DON. The DON stated that she was not aware if the bed hold policy had been given to resident's 8 and 123 as there was not documentation in their medical records. The DON stated that residents might have been given a copy of the bed hold policy in the admission packet. On 11/12/24 at 11:09 AM, the facility's bed hold policy revealed: .Policy Statement Our facility shall inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of our bed-hold policy. Policy Interpretation and Implementation 1. Upon admission and when a resident is transferred for hospitalization or for therapeutic leave, a representative of the business office or designee will provide written information concerning the facility's bed hold policy. 2. When emergency transfers are necessary, the facility designee will provide the resident or resident representative with information concerning the facility's bed hold policy within 1 business day of such transfer . On 11/13/24 at 9:52 AM, an interview was conducted with the DON and Regional Nurse Consultant (RNC 1). The RNC 1 stated that she did not think the bed hold policy was getting done by the facility. 3. Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included quadriplegia, dysphagia, chronic kidney disease, chronic obstructive pulmonary disease, paralysis of vocal cords and larynx, congestive heart failure, and major depressive disorder. Resident 5's medical record was reviewed 11/3/24 through 11/13/24. An Alert Charting note, dated 10/5/24 at 8:15 AM, indicated, Upon entering pt [patient] room this am, noted pt had large amounts of dark brown,yellow phlegm to his trach [tracheostomy] site. pt with c/o [complaints of] of resp [respiratory] distress and c/o of not feeling well the past 4 days with vomiting, diarrhea, large amounts of sputum, phlegm. pt also reports not eating well and requesting nurse send him to the ER [emergency room] for eval [evaluation] and treatment as pt reports he is getting scared now due to increased suctioning and difficulty breathing. v/s [vital signs] 118/64, pulse 62, resp [respirations] 24, temp [temperature] 98.8, oxygen sats [saturation] at 91. Notified physician and [company name redacted] for transport to [hospital name redacted] for eval and treatment. Notified management and called pt spouse [name redacted] to let her know nurse transporting pt to ER, [name redacted] reports she is not at her home but will call her daughter to come and sit with him in the ER. An Alert Charting note, dated 10/5/24 at 8:20 AM, indicated, [Company name redacted] here for transport. An Alert Charting note, dated 10/5/24 at 4:17 PM, indicated, Pt admitted to [hospital name redacted] with bowel obstruction and ng [naso-gastric] tube placed at hospital. No documentation could be found that resident 5 or resident 5's representative were notified of the facility bed hold policy prior to transfer to the hospital. On 11/12/24 at 4:10 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated residents were notified of the bed-hold policy when they were admitted . On 11/13/24 at 9:59 AM, an interview was conducted with the DON. The DON stated resident notification of the bed-hold policy was not being done. On 11/13/24 at 11:53 AM, a follow-up interview was conducted with the ADMIN. The ADMIN stated he was not able to find a bed-hold notification for resident 5's transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 65 sampled residents, that the facility did not accurately assess residents. Specifically, one resident's Minimum Data Set (MDS) assessment did not reflect a discharge to home. Resident identifier: 68. Findings included: Resident 68 was admitted to the facility on [DATE] with diagnoses which included fracture of unspecified part of neck of left femur and subsequent encounter for closed fracture with routine healing. Resident 68's medical record was reviewed 11/3/24 through 11/13/24. A Minimum Data Set (MDS) assessment, dated 8/7/24, indicated a discharge status of, Short-Term General Hospital (acute hospital, IPPS). A Discharge Progress Note, dated 8/7/24 at 12:53 PM, indicated resident was discharged to a private residence. On 11/7/24 at 11:38 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated he did not know why the MDS assessment reflected resident 68 went to the hospital because she was discharged home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 66 was admitted to the facility on [DATE] with diagnoses which included acute and subacute hepatic failure, perforation of intestine, suicide attempt, anxiety disorder, and major depressive disorder (MDD). Resident 66's medical record was reviewed 11/3/24 through 11/13/24. A Minimum Data Set (MDS) Section V Care Area Assessment (CAA) Summary, dated 9/18/24, indicated resident 66 had the following care area's triggered: Cognitive Loss/ Dementia, Functional Abilities (Self-Care and Mobility), Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Mood State, Behavioral Symptoms, Activities, Falls, Nutritional Status, Feeding Tube, Dehydration/Fluid Maintenance, Pressure Ulcer/Injury, Psychotropic Drug Use, and Pain. An Alert Charting note, dated 9/12/24 at 5:56 PM, indicated, Resident is admitted to the facility from [Hospital name redacted] via facility transport on wheelchair around 15:15 [3:15 PM] She is admitted with hospital discharged diagnosis of Gatric [sic] perforation, Acute liver perforation, Spleen absent Abnormal digestive function, Major depression Abdominal pain, etc. Resident has JP [Jackson Pratt] drain on L [left] side of abdomen. Has NGT [nasogastric tube]. NPO [nothing by mouth] and on feeding set and ongoing. Resident is alert and oriented to person, place, time and situation. NO skin issue noted. She is on every 2 hours monitoring for possible suicidal . V/S [vital signs] BP [blood pressure] 158/101, PR [pulse rate] 127, T [temperature] 99.3, O2 sat [oxygen saturation] 89 in RA [room air]. A Care Plan indicated one Plan of: [Resident 66] has need for Clear Liquid diet & TF [tube feed] of Glucerna 1.2 @ 65 mls [milliliters]/hr [hour] x [times] 22 hrs & additional 80 mls free water q [every] 6 hrs & is at risk for nutritional decline d/t [due to] dx [diagnosis] hepatic failure, perforated intestines, absence of spleen, MDD, & hx [history] of suicide attempt & suicide behavior. Date Initiated: 09/13/2024 Revision on: 09/13/2024- The resident has nutritional problem or potential nutritional problem (SPECIFY) r/t [related to] Date Initiated: 09/13/2024. A Discharge Progress Note, dated 9/23/24 at 2:55 PM, indicated resident 66 was discharged home on 9/23/24 at 3:30 PM. On 11/12/24 at 4:12 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated resident 66 should have a baseline care plan completed. No baseline care plan was provided. 3. Resident 38 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, type 2 diabetes with skin ulcer and neuropathy, cirrhosis of liver, morbid obesity, hemiplegia affecting right dominant side, anxiety disorder, aphasia, major depressive disorder, seizures and dysphagia. Resident 38's medical record was reviewed between 11/3/24 and 11/13/24. Resident 38's baseline care plan was reviewed. The date the baseline care plan was signed was on 9/17/24, 4 days after admission. Resident 38's care plan was reviewed. All care areas that were initiated after the resident was admitted were dated 9/17/24. On 11/12/24 at 1:22 PM, an interview was conducted with the DON who stated that the MDS coordinator was responsible to ensure resident care plans were up to date. Based on interview and record review it was determined, for 4 out of 65 sampled residents, that the facility did not ensure that baseline care plans were developed and implemented within 48 hours of the resident's admission and contained the minimum information necessary to care for the resident including, but not limited to, initial goals, physician orders, dietary orders, therapy services, social services and Preadmission Screening and Resident Review (PASRR). Specifically, baseline care plans were not completed for residents timely and they did not contain the minimum healthcare information. Resident identifier: 38, 51, 65, and 66. Findings included: 1. Resident 51 was admitted to the facility on [DATE] with diagnoses which included intracerebral hemorrhage, hemiplegia and hemiparesis of left side, neurologic neglect syndrome, chronic kidney disease, hypertension, congestive heart failure, cognitive communication deficit, aphasia, visual loss both eyes, and insomnia. On 1/11/24, resident 51's care plan had focus areas initiated for The resident has expressed a desire to remain in the facility for long term care and The resident has a potential nutritional problem related to modified diet, blindness and reminder to eat slowly with small bites. It should be noted that resident 51 did not have any additional care plan focus areas initiated within the first 48 hours after admission. 2. Resident 65 was admitted to the facility on [DATE] with diagnoses which included dementia, seizures, hypothyroidism, obstructive sleep apnea, depression, presence of a cardiac pacemaker, and violent behaviors. On 10/19/24, resident 65's baseline care plan was initiated and included the resident's initial goals, functional status, health conditions, dietary services, therapy services, and social services. It should be noted that the baseline care plan was initiated 39 days after admission. On 11/06/24 at 8:55 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the baseline care plans were completed by the Minimum Data Set (MDS) Coordinator. The DON stated that the resident baseline care plans should be completed within 48 hours after a resident's admission. The DON confirmed that resident 65 did not have a baseline completed within 48 hours after admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident 34 was admitted to the facility on [DATE] with diagnoses which included traumatic subarachnoid hemorrhage, type 2 diabetes mellitus, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side, major depressive disorder recurrent severe with psychotic symptoms, and anoxic brain damage. On 11/5/24 at 6:39 PM, an interview was conducted with resident 34. Resident 34 was sitting at a table in the dining room with his dinner tray in front of him. CNA 4 was sitting next to resident 34 and preparing his food on his tray. Resident 34 stated, I am a feeder. Resident 34 nodded yes when asked if staff helped him eat. Resident 34 was asked why he needed help to eat and he lifted up his hand. Resident 34 nodded yes when asked if he needed help to eat because he cannot physically use the silverware. Resident 34's medical record was reviewed 11/3/24 through 11/13/24. A MDS Quarterly assessment, dated 9/17/24, indicated a BIMS score of three, which indicated a severe cognitive impairment. It further indicated, Functional Limitation in Range of Motion .Upper extremity (shoulder, elbow, wrist, hand) .Impairment on one side .Lower extremity (hip, [NAME], ankle, foot) .Impairment on both sides . A Nursing Monthly Summary, dated 11/7/24 at 11:46 PM, indicated, Coughing or choking during meals or when swallowing medications. It further indicated, .requires assistance with feeding . A Nutritional Screening Summary, dated 6/24/24, indicated, The following treatments/interventions are in place for this patient .Altered texture diet mech soft/ thin liquids .Assistance with eating/ drinking max assist feeding, in dining room .Supervised dining .Swallowing treatment. A Speech Therapy SLP (Speech-Language Pathologist), dated 12/18/23, indicated, Additional Intake Recommendations = Other (Max assist feeding, patient to be upright in wheel chair in dining room for all meals.) A Speech Therapy SLP (Speech-Language Pathologist), dated 11/12/24, indicated, Chart Review/ Patient Interview .Feeding Patient needs assistance feeding self? = Yes (Max assist feeding required due to limited UE [upper extremity] mobility and due to difficulties with swallow.) A Care Plan indicated, ADL [activities of daily living] self-care performance deficit r/t [related to] traumatic/anoxic brain damage, hemiplegia and hemiparesis, depression, and chronic respiratory failure. Date Initiated: 10/07/2022 Revision on: 10/07/2022. It indicated a goal of, The resident will maintain current level of function in ADLs through the review date. Date Initiated: 10/07/2022 Revision on: 11/15/2023 Target Date: 01/31/2025. It indicated the following interventions, EATING: Provide finger foods when the resident has difficulty using utensils. Date Initiated: 10/07/2022 CNA [Certified Nurse Assistance]; and EATING: The resident requires independent to limited assistance by 1 staff eat. He requires use of large handled silver wear to maximize independence in eating. Date Initiated: 10/07/2022 Revision on: 10/07/2022. On 11/5/24 at 1:27 PM, an interview was conducted with RN 4. RN 4 stated resident 34 ate in the dining room and had to have staff help him eat. On 11/12/24 at 2:34 PM, an interview was conducted with CNA 6. CNA 6 stated resident 34 was on a chopped diet and needed full assistance to eat. On 11/5/24 at 3:36 PM, an interview was conducted with the DON. The DON stated resident 34 needed one CNA to assist him with eating and that he was a total assist with feeding. The DON stated resident 34's care plan did not reflect his need for full assistance with eating and needed to be updated. Based on observation, interview, and record review, for 7 of 65 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident's rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident's care plan was not updated to reflect current ostomy care and wound care being provided, a resident did not have a care plan regarding bowel and bladder care, care plan interventions were not updated after resident falls, and a resident's care plan did not reflect the need for supervised eating. Resident identifiers: 1, 3, 13, 34, 38, 51, and 55. Findings included: 1. Resident 3 was admitted to the facility on [DATE] with diagnoses that included Arnold Chiari Syndrome with spina bifida and hydrocephalus, severe protein-calorie malnutrition, osteomyelitis right ankle and foot, paraplegia, borderline personality disorder, major depressive disorder, morbid obesity, bipolar disorder, and anxiety disorder. On 11/3/24 at 5:16 PM, an interview was conducted with resident 3 who stated she was not being included in care conferences. Resident 3 stated her colostomy bag had burst yesterday because it was not changed. Resident 3 also stated her urostomy bag leaked frequently. Resident 3's medical record was reviewed between 11/3/24 and 11/13/24. On 8/24/24, a quarterly MDS (Minimum Data Set) assessment revealed that resident 3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated a normal cognition. Physician orders included: a. Ostomy care for colostomy type of wafer/bag to be used: Collar 125261 (2.75) Pouch 416242 (2.75)-change wafer/bag; two times a day for wound care. Start date 8/8/24. b. Ostomy care for colostomy type of wafer/bag to be used: Collar 125261 (2.75) Pouch 416242 (2.75)- change wafer/bag; every 4 hours as needed. PRN [as needed]. Start date 8/8/24. c. Urostomy care: remove old urostomy. cleanse with wound cleanser of choice. cut Natura [NAME]-FIT to fit. Current size 1 3/4 in[inches] or 45 mm [millimeters]. apply skin prep. place flexible collar. snap bag to fit. connect tubing. check for privacy bag. every 24 hours for wound care. start date 4/18/24. d. Perform catheter/urostomy care q [every] shift. cleanse tubing, ensure tubing is not kinked, ensuring tubing is not resting on the ground ensure catheter bag is in privacy bag; every day shift for catheter care. Start date 3/28/24. e. Urostomy care: empty bag q shift and document output in POC [point of care]. Burp bag PRN to prevent hyperinflation. Check stability and seal of water daily. CNA [Certified Nursing Assistant] may be assigned task to report to licensed nurse; every shift after ostomy care. Start date 3/28/24. f. Wound tx [treatment]: L [left] and R [right] buttock: remove old dressing, cleanse with NS [normal saline] and gausses [sic]. Place Dakins soak 2 Kerlex to open wound beds. Apply triad cream to peri wound. Cover with ABD [abdominal] or Kerramax and secure with tape. Cover with incontinence brief. Perform daily and PRN every day shift for wound care PRN if needed. Start date: 10/4/24, Discontinue date: 10/23/24. g. Wound tx: L and R buttock: remove old dressing, cleanse with NS and gauze. Place Dakins soak 2 Kerlex to open wound beds. Apply triad cream to peri wound. Cover with ABD or Kerramax and secure with tape. Cover with incontinence brief. Perform daily and PRN. Call wound clinic for any wound care refusals [phone number]. every day shift for wound care PRN if needed. Start date: 10/23/24, Discontinue date 10/28/24. h. Wound tx: L and R buttock: Apply Vashe soaked gause for 10 min. [minutes] Wound Bed: SSD [Silver Sulfadiazine ]. Secure with: layer of gauze against wound bed. Cover: highly absorbent dressing; every day shift for wound care PRN if needed.Start date: 10/28/24. A review of resident 3's care plan revealed: a. Potential for complications related to colostomy and urostomy. Date initiated: 4/19/22, Revision on: 9/23/22. The goal was, Resident will be able to demonstrate assisted ability to care for ostomy daily through next 90 day review. Date initiated: 4/19/22, Revision on 9/23/22. Resident will have no complications r/t [related to] colostomy and/or urostomy through the next review date. Date initiated: 10/7/22, Revision on: 12/12/23, Target date: 1/31/25. Interventions included, Medications as ordered. Date initiated: 4/19/22, Revision on: 4/19/22. Monitor ostomy site for swelling, pain, and redness and report to MD [medical doctor]. Date initiated: 4/19/22, Revision on: 4/19/22. Ostomy care as needed to prevent odor. Date initiated: 4/19/22, Revision on: 4/19/22. Resident enjoys assisting with colostomy bag changes. Allow resident to change colostomy bag under supervision of licensed nurse. Date initiated 9/23/22. Resident teaching on ostomy care if appropriate. Date initiated: 4/19/22, Revision on: 4/19/22. b. [Resident 3] is at risk for impaired skin integrity due to decreased ADL [activities of daily living] function r/t maceration, immobility, cognitive loss, poor nutrition, depression, paraplegia, shortness of breath, pain, malnutrition, presence of wounds. Wounds managed by Outside provider/clinic; R groin/buttock-Followed by outside clinic. Date initiated 4/19/22, Revision on 11/17/23 The goal was, Residents' wounds will improve or not worsen through next 90-day review. Date initiated: 4/19/22, revision on: 12/12/23, Target Date: 1/31/25. Interventions included, Administer treatments for skin impairment per physician order, Notify MD [Medical Doctor] if skin impairment does not respond to current treatment regimen or resident experiences an adverse reaction. Date initiated: 4/19/22, Revision on 4/19/22; Encourage good nutrition and oral fluid intake. Date initiated 4/19/22, Revision on 4/19/22; Encourage/prompt resident to change positions regularly to off-load pressure points. Resident is able to make major and frequent position changes without staff assistance. Date initiated: 4/19/22, Revision on: 4/19/22; Nurses to perform weekly skin assessments. Notify MD of any new skin impairments and obtain treatment orders as indicated. Date initiated: 4/19/22, Revision on 4/19/22; Staff will help promote clean skin by encouraging/assisting resident to bathe regularly. Dry skin thoroughly after bathing. Keep skin moisturized by applying lotion as indicated. Date initiated: 4/19/22, Revision on 4/19/22; Staff will provide peri-care after incontinent episodes and may apply barrier cream as a skin protectant. CNA's may apply unmedicated barrier creams. Date initiated: 4/19/22, Revision on 4/19/22; The resident uses the following devices for pressure reduction: heel protectors, wheelchair cushion, APP [alternating pressure pad]. Date initiated: 4/19/22, Revision on 4/19/22; Use Hoyer for transfers, not slide board to help preserve skin integrity and prevent damage to wounds. Date initiated: 1/23/24, Revision on 1/23/24, Wound care: Right buttock, right posterior thigh: Remove old drsg [dressing], irrigate with NS, apply ACETIC ACID RINSE x [times] 10 minutes then apply Dakins soaked gauze to wound beds. Apply skin prep para wound and allow to dry. Cover with ABD pad and secure with DISPOSABLE BRIEF. Complete daily. Date initiated: 5/24/23. On 11/7/24 at 9:48 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4 who stated resident 3's urostomy bag leaked a lot. LPN 4 stated resident 3 use to change her own bag but was no longer doing so. LPN 4 stated there was an order to change the bag more frequently. On 11/13/24 at 9:24 AM, an interview was conducted with the Director of Nursing (DON) who stated resident 3's care plan should be updated to reflect the needs she has with her ostomy care if it changed. The DON stated she was unsure if the resident's care plan had been updated. The DON stated that resident 3 just changed over from wound care out of the facility to in-house wound care and the care plan should have been updated to reflect those changes. 2. Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, long term use of anticoagulants, personal history of pulmonary embolism, muscle weakness, history of falling, and chronic pain. On 11/4/24 at 11:10 AM, an interview was conducted with resident 13. Resident 13 stated she had several falls while in the facility, including a fracture of her right arm and nose. Resident 13's medical record was reviewed between 11/3/24 and 11/13/24. On 6/11/24, an admission MDS assessment revealed a BIMS score of 13 which indicated a normal cognition. Physician orders included: a. Per hospital no transfers without at least standby assistance to prevent falls. Start date 10/2/24. Resident 13's care plan included: a. Pain medication therapy use r/t multiple comorbidities including radiculopathy and muscle weakness. Date initiated: 10/12/2022, Revision on: 10/12/2022. The goal was, The resident will be free of any discomfort or adverse side effects from pain medication through review date. Date initiated: 10/12/2022, Revision on: 4/12/2024, Target Date: 2/7/2025. Interventions included, Administer ANALGESIC medication as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT [every shift]; .Monitor for increased fall risk for falls. Date initiated: 10/12/2022. b. Risk for falls r/t neuropathy, gout, dependence on supplemental oxygen, impaired mobility with use of assistive device, hx [history] of falls. Date initiated: 7/18/2022, Revision on: 6/26/2023. The goal was, The resident will be free of falls with injury through the review date. Date initiated: 7/18/2022, Revision on: 4/12/2024, Target date: 2/7/2025. Interventions included, 1/22/2023 Patient had a fall in the community. Educated patient to be more aware of her surroundings when accessing the community. Date initiated: 7/28/2023; 5/27/2024-unwitnessed fall, risk management done, resident educated. Date initiated: 5/28/2024; 6/26/2023-Resident educated and encouraged to ask for staff assistance with toileting so safety reminders/prompts can be provided as needed. Date initiated: 6/26/2023. Anticipate and meet the resident's needs. Keep frequently used items within reach. Date initiated: 7/18/2022. Educate and encourage the resident to wear appropriate footwear, such as non-skid socks or shoes, when ambulating/mobilizing. Date initiated: 7/18/2022. Follow facility fall protocol if a fall occurs. Date initiated: 7/18/2022. Order placed for no transfers without assistance to prevent falls/injury d/t [due to] weakness. Date initiated: 10/1/2024. Orient resident to call light. Keep the resident's call light. Keep the resident's call light within reach and encourage the resident to use it for assistance as needed. Date initiated: 7/18/2022. c. The resident has had an actual fall. Poor Balance, Poor safety awareness. 10/12/24. Date initiated: 8/30/2024, Revision on: 10/21/2024. The goal was, Resident will not have a fall with major injury. Date initiated: 8/30/2024, Target Date: 2/7/2025. Interventions included, Carryout additional orders from PCP [Primary Care Physician]. Date initiated: 8/30/2024, Encourage resident to participate in her fall prevention. Date initiated: 8/30/2024. Monitor/document/report PRN x 72 h [hours] for MD for s/sx [signs and symptoms]: Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Date initiated: 8/30/2024, Revision on: 8/30/2024, Neuro-checks x 72 hours. Date initiated: 8/30/2024, Revision on: 8/30/2024, Promote participation in activities to help encourage and teach safety awareness. Date initiated: 8/30/2024. Provide activities to promote exercise and strength building where possible. Provide 1:1 activities if bedbound. Date initiated: 8/30/2024. Resident currently in therapy with additional therapy evaluation, for safety and education. Date initiated: 8/30/2024. Resident reminded of the importance of using call button and therapy to evaluate. Date initiated: 10/21/2024. Vital signs QSHIFT/PRN. Take BP [blood pressure] lying/sitting/standing x1 in first 24 hr. Date initiated: 8/30/2024, Revision on: 8/30/2024. Progress notes revealed: a. On 5/27/2024 at 4:45 AM, Found pt [patient] laying on her bed with a hematoma to her forehead. Pt with laceration to her nose. Severe pain to her right shoulder and pain and bruising to her left knee. Pt states that her pant leg got caught on her electric w/c [wheelchair] and she fell forward. Pt got herself up into her bed and then called for assistance. Pt requested to go to ER [emergency room] for evaluation of her right shoulder. Non-emergent ambulance called. Notified physician on call and pt's daughter. Pt sent out at this time. Cross Reference 656, 609, 610 b. On 6/4/2024 at 6:46 PM, Pt re-admitted to facility via facility transport. A/O [alert and oriented] x 4 [person, place, time and situation]. Able to verbalize needs. Continent of bowel and bladder. Resident using sling to R shoulder. Has bruises to: forehead, L knee, Rt shoulder, LFA [left forearm], L elbow, 2 small bruises on bilat [bilateral] ankle, RFA [right forearm]. She has small scan [sic] on bridge of nose. Incision to R chest area intact, no s/s of infection. Uses motorized w/c for mobility. Last BM [bowel movement] 6/3/24. C/O [complains of] pain to R shoulder Oriented to facility. Call light within reach. c. On 8/18/24 at 4:31 PM, Upon entering the room resident sitting in the floor stating, 'I went down the floor to pick up a something and could not get up.' Called for assistance to help transfer resident during assessment no injuries noted at this time. Resident alert and oriented x 4. Neuro checks started. Educated resident on the importance to ask for assistance. Dr. notified. d. On 8/18/24 at 6:01 PM, Upon continuous assessment resident complaining of dizziness and headache post fall. Dr. called provided this information. Resident requested to go to the hospital. [Ambulance provider] called. e. On 8/18/24 at 11:04 PM, Resident returned from [hospital] ED [emergency department] at 8:51 PM. No findings found on CT [computed tomography scan] or x-ray. VSS [vital signs stable]. f. On 9/23/24 at 1:00 AM, Encounter, Date of service: 9/23/2024, Type of service: Follow up .Chief complaint/Nature of Presenting Problem: Follow-up from hospital visit .On 23 September 2024 patient presents to the emergency department with a chief complaint of fall. Patient states over the last couple days she has been experiencing more frequent falls beyond her baseline. Patient states this morning she had a ground-level fall and experienced a positive loss of consciousness. Patient states that she has had 2 breakthrough DVTs [Deep Vein Thrombosis] and noted some swelling in her legs yesterday associated with pain. Patient states since the fall yesterday she has been experiencing some bruising of her right periorbital region, without any changes in her vision. Patient denies chest pain shortness of breath numbness, back pain, or deformities. On arrival to the ER patient was hemodynamically stable. Exam noted nonpitting edema to bilateral lower extremities, ecchymosis to right side of face. CT images of head/cervical spine/face, chest x-ray, sternum labs ordered that revealed no abnormalities. The only significant injury noted was a nondisplaced nasal bone fracture without any other acute abnormalities. There is a chronic fracture to the right shoulder. Bilateral venous duplex ultrasounds revealed no evidence of DVT to lower extremities All other labs were within normal limits. Patient was readmitted to [facility] on 23 September 2024. Upon speaking with the patient today she states that she is still in a bit of pain. She is currently on a pain management regimen of oxycodone and morphine. Patient does have another follow-up coming up with her orthopedic specialist regarding her shoulder. Patient also states she will be going to see her neurologist about her balance issues. We will place patient on fall precautions at this point. g. On 9/23/24 at 9:01 AM, Late Entry: resident had witnessed fall, resident reported losing balance when walking in room. Resident hit head and neuro checks started. Resident alert and oriented x 4. VS [vital signs] stable. Resident appears to have a repetitive behavior continue to be lack of self-limitations and safety. Reported to Dr. educated resident on safety measures. Daughter no answer the phone, unable to leave message to report this concern. h. On 9/23/24 at 10:46 PM, Pt with fall this morning. Pt was in another pt's room. Pt states that she fell forward and hit her face. Pt with bruising under both eyes. Pt continues to c/o pain in legs. Pt went to ER after infusion appointment today. Pt was afraid that she had a DVT, but no DVT, just inflammation from fluid in her legs. Pt stated that her doctor's are working on a plan of what to do. i. On 9/25/24 at 3:15 AM, Resident had a fall, and has a bruise on her left cheek. No other injuries noted. States she feels like her legs are giving out and she is concerned about this. Has a dr [doctor] appointment on 9/26 and is wanting to address issue with dr. It should be noted that resident 13's care plan was not updated after a fall with major injury on 5/27/24, or the additional falls on 8/18/24, 9/23/24, and 9/25/24, [Cross-refer F689] 3. Resident 38 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, type 2 diabetes with skin ulcer and neuropathy, cirrhosis of liver, morbid obesity, hemiplegia affecting right dominant side, anxiety disorder, aphasia, major depressive disorder, seizures and dysphagia. Resident 38's medical record was reviewed between 11/3/24 and 11/13/24. An admission MDS assessment dated [DATE] revealed resident 38 had a BIMS score of 15 which indicated a normal cognition. The MDS care area summary revealed psychosocial well-being, mood state, and behavioral symptoms were not triggered. Psychotropic drug use was triggered and marked that it was included in the resident's care plan. Physician orders revealed: a. Behavior monitoring: verbalization of sadness Q shift. Order date: 10/30/24. b. Behavior monitoring: # of verbal outbursts Q shift. Order date: 10/30/24. c. Antipsychotic medication side effect monitoring: 0=none; 1=drowsiness; 2=sedation; 3=dry mouth; 4=constipation; 5=blurred vision; 6=extrapyramidal reaction; 7=wt [weight] gain; 8=edema; 9=sweating; 10=loss of appetite; 11=urinary retension. Order date: 9/13/24. d. Resident also had behavior monitoring orders for: hours of sleep, itching, picking at skin, restlessness, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, agression, refusing care. Document any behaviors and enter findings in progress note. Additionally behavior monitoring for paranoid statements, episodes of agitation, expression of hopelessness, anti-depressant medication side effects, anti-anxiety medication side effects, and anxious statements. Order date: 9/13/24. e. Duloxetine HCL [hydrochloride] oral capsule Delayed release particles 60 MG [milligrams]; Give 1 capsule by mouth one time a day for depression. Order date: 9/13/24. It should be noted that resident 38 was not taking any antianxiety medications. Care plan revealed: a. The resident has diagnosis/diagnoses of (depression and anxiety). Resident requires the use of (antidepressant medications) to help manage this condition. Date initiated 11/2/24, Revision on: 11/3/24. The goal was, The resident will have no adverse side effects r/t psychcotropic medications use through the review date. Date initiated: 11/3/24, Target date: 1/1/25. The interventions included, Administer psychotropic medications per physician order. Monitor/document adverse side effects. Notify MD of any consistent, adverse side effects that resident experiences r/t psychotropic medication use. Date initiated: 11/2/24; Follow PASRR [Pre-admission Screening and Resident Review] level II recommendations: monitor for worsening anxiety or SI [suicidal ideation]. Date initiated: 11/9/24, Revision ob [sic]11/9/24; Monitor/document occurrence of target symptoms. Report any new/worsened symptoms that are not effectively managed with current pharmacological and/or non-pharmacological interventions. Date initiated: 11/2/24; Psychotropic committee will review resident's medication regimen, target symptoms, and side effects at least quarterly. Committee will make recommendations for psychotropic regimen as indicated. Date initiated: 11/2/24; Staff should use the following non-pharmacological interventions to help manage resident's symptoms: Active listening/support/encouragement, validation, reality orientation, re-direction/distraction, identify/eliminate triggers for resident's symptoms or behaviors. Date initiated: 11/2/24. b. The resident has a potential psychosocial well-being problem actual r/t anxiety and MDD [major depressive disorder]. Date initiated: 11/9/24, revision on: 11/9/24. The goal was, The resident will have no indications of psychosocial well-being problem by/through the review date. Date initiated: 11/9/24 Target date: 1/1/25. Interventions included, He needs to have something in life that gives him purpose. Ensure he has activities that are meaningful to him. Date initiated: 11/9/24, Increase communication between resident/family/caregivers about care and living environment: Explain all procedures and treatments, medications, results of labs/tests, condition, all changes, rules, options. Date initiated: 11/9/24; Provide opportunities for the resident and family to participate in care. Date initiated: 11/9/24; When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Date initiated: 11/9/24. It should be noted that while resident 38 was admitted with a diagnosis of depression and had orders for an antidepressant and several monitoring orders, the care plan was not updated to reflect care concerns regarding depression until 11/2/24 and 11/3/24. 5. Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cerebral infarction, cognitive communication deficit, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus, chronic viral hepatitis C, non-pressure chronic ulcer of left lower leg, mood disorder, encephalopathy, atrial fibrillation, pulmonary embolism, hypospadias, retention of urine, chronic kidney disease, major depressive disorder, pyelonephritis, multiple fractures of ribs, bipolar disorder, dysphonia, insomnia, peripheral vascular disease, chronic pain syndrome, opioid dependence, extended spectrum beta lactamase resistance, obstructive and reflux uropathy, anxiety disorder, polyosteoarthritis, hypertension, gout, and methicillin resistant staphylococcus aureus infection classified elsewhere. On 11/04/24 at 9:07 AM, an observation was made of resident 1 lying in bed. The bed was positioned with the left side of the bed against the wall. A fall mat was observed on the right side of the bed and was pushed out of the way to accommodate a side table. Resident 1's electronic medical records were reviewed. On 8/2/24, resident 1's MDS Assessment documented a BIMS score of 5 out of 15, which would indicate a severe cognitive impairment. The assessment documented that the resident was a two-person total dependence assist for bed mobility, transfer, and toilet use. Resident 1's progress notes revealed the following: a. On 7/2/2024 at 4:38 PM, the note documented, Heard resident calling for help. CNA and nurse found resident on floor next to his bed. Pt denies hitting his head. No c/o pain. Cognition and ROM [range of motion] appears to be at baseline. No apparent injury. Transferred back into bed using Hoyer lift w/ [with] 5 staff assist. PCP and DON notified. Safety precautions in place. No new care plan interventions were identified. b. On 8/24/2024 at 4:22 AM, the note documented, While walking to 500 hall with another resident, nurse looked into room and saw resident laying on the floor. Nurse called for assistance. Resident was lying on the right side of his bed on the fall mat. Resident was responsive, telling aides and nurse to 'watch it' while getting resident cleaned up. Nurse asked resident what happened and resident could not provide an explanation. Nurse asked if he hit his head on anything during fall, resident could not confirm or deny hitting head on anything. Resident had small scrapes down left side of body from L shoulder to L hip. No deformities or bruises noted. Neuros [neurological assessment] started, VS WNL [within normal limits]. No new care plan interventions were identified. c. On 9/28/2024 at 5:02 AM, the note documented, Aide alerted nurse that resident was on the floor. When nurse entered resident room, resident was found laying on his stomach with head towards the foot of his bed. Resident continued to state that he wants to be on the floor and is asking for help to get to the floor. Neuros started, VS WNL. No injuries noted. Denies pain or discomfort. Call light within reach. Bed in lowest position possible. Fall mats in place. No new care plan interventions were identified. d. On 10/1/2024 at 4:35 AM, the note documented, resident had a fall, with no new injuries or pain reported. pt very agitated tonight, and got very combative with the staff when they changed him. resident threw his water mug at aid [sic], and was screaming and scratching them while they changed him. tried to de-escalate pt but pt very agitated. No new care plan interventions were identified. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 15 was admitted to the facility on [DATE] with diagnoses which included hereditary ataxia, cognitive communication deficit, dysphagia, hypothyroidism, major depressive disorder, anemia, peripheral neuropathy, dysarthria and anarthria, speech disturbance, wedge compression fracture of third lumbar, edema, and insomnia. On 11/03/24 at 2:04 PM, an interview was conducted with resident 15. Resident 15 stated she was incontinent and wore a brief. Resident 15 stated that the brief was changed approximately every 3 hours, but that she needed it changed more frequently than that. Resident 15 stated that she did not currently have any issues with a urinary tract infection. A strong odor of urine was noted from resident 15 during the interview. Resident 15's medical record was reviewed. On 9/11/24, resident 15's MDS Assessment documented a BIMS score of 15, which would indicate that the resident was cognitively intact. The assessment documented that resident 15 required a two-person extensive assist for bed mobility, transfer, and toilet use. The assessment documented that the resident was not on a toileting program for urinary or bowel continence. On 5/2/24, resident 15 had an order initiated for Furosemide Tablet 20 milligrams (mg), give 3 tablet by mouth one time a day related to edema. Resident 15's Bowel and Bladder Elimination task for urinary continence documented that the resident 15 was incontinent of bladder. The task documented that incontinence care was provided 1 to 3 times per day. No documentation could be found of a bowel and bladder program for resident 15. Resident 15's care plan revealed a focus area for ADL [activities of daily living] Self Care Performance Deficit r/t [related to] impaired mobility, physical limitations, pain, and neuropathy. On 2/24/17, the care plan was initiated and the following interventions were implemented: the resident requires extensive to total dependence with 1-2 staff for toilet use; the resident requires limited to extensive assistance with 1-2 staff member for personal hygiene/oral care; and the resident requires mechanical lift with 2 staff for transfers. On 11/5/24 at 12:48 PM, an interview was conducted with CNA 6. CNA 6 stated that resident 15 was a two-person assist for repositioning, hoyer use, transfer, and incontinence care. CNA 6 stated that resident 15 was incontinent of bowel and bladder. CNA 6 stated that resident 15's bowel and bladder program included medication to treat constipation and a medication for increased urinary output. CNA 6 stated that they provided resident 15 with brief changes every 2 hours unless she called for assistance before that. CNA 6 stated that resident 15's briefs were usually saturated with urine at the time of incontinence care. CNA 6 stated that they documented brief changes and incontinence care in the electronic medical records. CNA 6 stated that he was usually able to complete his tasks during a shift. CNA 6 stated that it was always helpful to have more staff. CNA 6 stated that sometimes it was difficult to provide incontinence care every two hours, but they made sure to get it done before shift change. CNA 6 stated that all incontinent residents were changed at least once a shift. On 11/6/24 at 8:10 AM, a continuous observation was started for resident 15. At 8:17 AM, a breakfast meal tray was delivered to resident 15 by CNA 4. Resident 15 was seated in bed in a high fowlers position with the bedside table positioned over their lap. No incontinence care was provided by CNA 4. At 8:46 AM, CNA 5 delivered bed sheets to resident 15's room and placed them at the bedside. No incontinence care was provided by CNA 5. At 9:17 AM, CNA 5 removed resident 15's breakfast tray from the bedside. No incontinence care was provided by CNA 5. At 10:49 AM, the DON and LPN 3 walked by resident 15's room. No incontinence care was provided. At 10:50 AM, CNA 5 was observed to enter resident 15's room. CNA 5 was interviewed upon exit of the room. CNA 5 stated that resident 15 was sleeping and she checked to ensure that the resident was okay. No incontinence care was provided by CNA 5. At 11:51 AM, resident 15's continual observation was completed. It should be noted that a continual observation was conducted of resident 15 from 8:10 AM to 11:51 AM and no observations of incontinence care were provided. On 11/6/24 at 3:17 PM, an interview was conducted with CNA 5. CNA 5 stated that she and another aide got resident 15 up at approximately noon. CNA 5 stated that resident 15's brief was saturated with urine, she doesn't soak that bad. On 11/6/24 at 3:26 PM, an interview was conducted with the DON. The DON stated that incontinence care expectations were that staff rounded on the residents every 2 hours and checked to see if briefs needed to be changed. The DON stated that staff should check with any resident that required assistance with toileting every 2 hours for toileting needs. 4. Resident 51 was admitted to the facility on [DATE] with diagnoses which included intracerebral hemorrhage, hemiplegia and hemiparesis of left side, neurologic neglect syndrome, chronic kidney disease, hypertension, congestive heart failure, cognitive communication deficit, aphasia, visual loss both eyes, and insomnia. On 11/3/24 at 2:48 PM, an interview was conducted with resident 51. Resident 51 stated that she had fallen previously in the morning when attempting to get up and toilet herself. Resident 51 stated that sometimes she had to change her brief because the staff did not come to help her. Resident 51 stated that the call light did not always work either. Resident 51 stated that she could put a pull up brief on by herself but she could not put the tab briefs on by herself. It should be noted that resident 51 had hemiplegia and hemiparesis of the left side that limited her ability to perform toileting tasks independently. Resident 51 stated that she waited 2 hours the other night for assistance. Resident 51 stated that she requested pull up briefs a couple of days ago but never received them. Resident 51's call light was pushed at the bedside and in the bathroom and both were observed not functioning. On 10/9/24, resident 51's MDS Assessment documented a BIMS score of 14, which indicated that the resident was cognitively intact. The assessment documented that the resident was a one-person limited assist for bed mobility and eating, and a one-person extensive assist for transfers and toilet use. The assessment documented that the resident was not on a urinary or bowel toileting program. Resident 51's physician orders revealed the following: a. On 5/22/24, an order was initiated for Spironolactone Oral Tablet 25 mg, give 0.5 tablet by mouth one time. b. On 5/1/24, an order was initiated for a fluid Restriction of 2000 milliliters per 24 hours. Resident 51's Bowel and Bladder Elimination task for urinary continence and bowel continence documented by the CNA's revealed that resident 51 was incontinent of bladder and bowel. The task documented that incontinence care was provided 1 to 4 times per day. Resident 51's Care plan revealed a focus area for The resident has an ADL self-care performance deficit r/t [related to] blindness, Hemiplegia. On 1/24/24, the care plan was initiated and the following interventions were implemented: the resident requires touching to partial assistance by 1 staff for toilet use; the resident requires partial/moderate assistance by 1 staff for personal hygiene and oral care; and the resident requires partial to substantial assistance by 1 staff to move between surfaces with transfers. On 11/5/24 at 12:53 PM, an interview was conducted with CNA 6. CNA 6 stated that resident 51 required a one-person assist for incontinence care due to the resident's visual impairment and paralysis in the left arm. CNA 6 stated that resident 51 was incontinent of bowel and bladder. CNA 6 stated that they used either pull up briefs or tab briefs for resident 51 and that resident 51 did not have a preference. CNA 6 stated that resident 51 would inform them when she needed a brief change. On 11/06/24 at 8:10 AM, a continuous observation was started for resident 51. No incontinence care was provided by CNA 5. At 8:28 AM, a breakfast meal tray was delivered to resident 51 by CNA 5. No incontinence care was provided. At 9:17 AM, an observation was made of CNA 4 assisting resident 51 with dressing. CNA 4 then removed resident 51's breakfast tray from the bedside. No incontinence care was provided by CNA 4. At 10:04 AM, CNA 5 entered resident 51's room and placed clean linen on the bedside table. CNA 5 assisted resident 51 into bed. No incontinence care was provided by CNA 5. At 10:49 AM, the DON and LPN 3 walked by resident 51's room. No incontinence care was provided. At 10:50 AM, CNA 5 was observed to enter resident 51's room. CNA 5 was interviewed upon exit of the room. CNA 5 stated that resident 51 was sleeping and she checked to ensure that the resident was okay. No incontinence care was provided by CNA 5. At 11:51 AM, resident 51's continual observation was completed. It should be noted that a continual observation was conducted of resident 51 from 8:10 AM to 11:51 AM and no observations of incontinence care were provided. [Cross-refer F689, F725, and F919] Based on interview and record review it was determined, for 4 of 65 residents sampled, that the facility did not ensure that the resident was given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. Specifically, resident's were not provided bathing/shower assistance, nail care, and incontience care for over 3 hours. Resident identifier: 15, 49, 51 and 60. Findings included: 1. Resident 49 was admitted to the facility on [DATE] with diagnoses which included dementia, psychotic disturbance, mood disturbance and anxiety. On 11/3/24 at 6:44 PM, an interview and observation was made of resident 49. Resident 49 stated he did not get showers as often as he wanted. Resident 49 stated when his roommate showered there was water everywhere because of how poorly the drain for the shower was designed. Resident 49 stated he would like to shower daily, but was only getting showers once per week because of the poorly designed showers. On 11/3/24 through 11/8/24, an observation was made of resident 49. Resident 49 was observed in the same clothing those days. Resident 49 was observed to have stubby facial hair. On 11/11/24, an observation was made of resident 49. Resident 49 was observed in the same clothing he was wearing the week before. Resident 49 was observed to have different clothing on 11/13/24. Resident 49's medical record was reviewed. A Brief Interview for Mental Status (BIMS) assessment was completed on 5/3/24 and locked on 5/22/24. The BIMS score was 15 which indicated resident 49 was cognitively intact. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 49 required supervision or touching assistance with bathing. A quarterly MDS dated [DATE] revealed resident 49 had a BIMS of 15. A care plan dated 2/12/24 revealed The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] Confusion, Dementia, needing some assistance from staff with ADLs. The goal was The resident will maintain current level of function with ADLs through the review date. Interventions included Encourage the resident to participate to the fullest extent possible with each interaction; Encourage the resident to use bell to call for assistance; Monitor/document/report PRN [as needed] any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function; Praise all efforts at self care; and PT/OT [Physical Therapy/Occupational Therapy] evaluation and treatment as per MD [Medical Doctor] orders. Another care plan dated 10/25/24 revealed, The resident is resistive to care (refuses to wear briefs) r/t Dementia and incontinence. The goal was The resident will cooperate with care through next review date. Interventions included Encourage as much participation/interaction by the resident as possible during care activities; Give clear explanation of all care activities prior to an as they occur during each contact; If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again; Praise the resident when behavior is appropriate; and Provide resident with opportunities for choice during care provision. The Certified Nursing Assistant (CNA) documentation in the plan of care tasks section for shower and bathing revealed the following: a. On 10/14/24, it was documented as not applicable (N/A), b. On 10/16/24, the shower was provided, c. On 10/22/24, the shower was refused, d. On 10/23/24, the shower was provided, e. On 10/31/24, it was documented as N/A, f. On 11/5/24, the shower was refused, g. On 11/6/24, the shower was provided, h. On 11/8/24, the resident was unavailable, i. On 11/11/24, the shower was documented as N/A. On 11/12/24 at 11:06 AM, an interview was conducted with CNA 8. CNA 8 stated she was not sure which days resident 49 was scheduled to have showers. CNA 8 stated if a resident did their own shower then N/A might be marked by CNA's. CNA 8 stated she was not sure if resident 49 needed assistance with showering. On 11/12/24 at 1:51 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 49 should get showers twice per week. The DON stated she was unsure why showers for resident 49 were marked as N/A. On 11/13/24 at 8:54 AM, an interview was conducted with License Practical Nurse (LPN) 3. LPN 3 stated that resident 49 was scheduled for a shower during the night shift, so she was not sure if resident 49 was getting showered. LPN 3 stated if a resident refused a shower, then staff tried to make accommodations for the resident to shower when they wanted. LPN 3 stated on 11/12/24 CNA 6 told her resident 49 needed a shower. LPN 3 stated she asked to see resident 49's Lidocane patch and she told resident 49 his back was dirty and smelled, so she offered to shower him. LPN 3 stated resident 49 told her she could shower himself. LPN 3 stated she was not sure the last time resident 49 had showered prior to 11/12/24. LPN 3 stated she sometimes did not notice when resident smelled, but she did notice resident 49 smelled. LPN 3 stated resident 49 was pleasant, fine and picked out his own clothing. LPN 3 stated she had no problem getting resident 49 to shower. 2. Resident 60 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, dysphagia, history of falling, constipation and dementia. On 11/3/24 at 3:59 PM, an interview was conducted with resident 60. Resident 60 stated he had only had 1 shower since being admitted to the facility. Resident 60 stated he would like to get showers weekly. Resident 60 was observed to have blood on his shirt. Resident 60 had long fingernails that were dirty. Resident 60 stated he would like to have his nails cut and cleaned. Resident 60's medical record was reviewed. A BIMS assessment dated [DATE] revealed a score of 15 which indicated resident 60 was cognitively intact. An MDS assessment dated [DATE] revealed resident 60 required limited to extensive 1 person assistance with ADLs. Resident 60 required partial to moderate assistance with showering or bathing self which included washing, rinsing, and drying self. An admission MDS dated [DATE] revealed resident had BIMS of 9 which indicated moderate cognitive impairment. The MDS revealed that with mobility in and out of the bath tub or shower resident 60 required partial to moderate assistance which meant the helper (staff) does less than half. A care plan dated 8/27/24 revealed Potential for altered skin integrity related to: Diabetes Type 2, falls, incontinence. The goal was Resident will have no s/s [signs and symptoms] of skin breakdown at all times through next 90 day review. One intervention was Staff will help promote clean skin by encouraging/assisting resident to bathe regularly. Dry skin thoroughly after bathing. Keep skin moisturized by applying lotion as indicated. Another care plan dated 8/27/24 revealed Potential for alteration in Health Maintenance related to: Type 2 Diabetes Mellitus, Hypertension, Gastro-esophageal reflux disease, dysphagia, history of falling, constipation. The goal was Resident will have no complications related to disease processes through the review date. One of the interventions was Provide assistance with ADLs as needed. A review of CNA charting in PoC Response history revealed no documented baths or showers from 10/6/24 through 11/6/24. On 11/12/24 at 10:51 AM, an interview was conducted with CNA 8. CNA 8 stated resident 60 was scheduled for shower at night and she was not sure how much assistance he needed or if he preferred a bed bath or a shower. CNA 8 stated when she came into work and was waiting for the vital signs cart, she logged into the CNA charting system to see who needed showers that day. CNA 8 stated as she went through to do vital signs she asked when the resident wanted a shower. CNA 8 stated after a shower was completed she documented in the computer system. CNA 8 stated there were shower sheets that CNA's signed and they were placed in the managers folder. CNA 8 stated the nurses performed nail care, unless CNA's were given different instructions. CNA 8 stated nurses were the only ones to touch residents nails. On 11/12/24 at 10:04 AM, an interview was conducted with CNA 5. CNA 5 stated there was a shower schedule in the CNA charting system. CNA 5 stated that was how CNA's knew who needed a shower. CNA 5 stated there should not be an N/A marked for showers. CNA 5 stated CNA's should be marking how much assistance resident's needed with showers. CNA 5 stated resident 49 received showers during the night shift so she was not sure why N/A was marked. CNA 5 stated if a resident requested nail care, then CNA's could do it unless the resident was diabetic. CNA 5 stated if a resident was diabetic then the nurse needed to clip fingernails. CNA 5 stated resident's needed to ask if they want to be shaved. CNA 5 stated every time resident 60 was showered he wanted to be shaved. CNA 5 stated she was not sure if resident 60 had diabetes. CNA 5 stated CNA's did nail care every 2 weeks or once per week. CNA 5 stated she completed nail care once because it was requested by a resident. On 11/7/24 at 11:59 AM, an interview was conducted with CNA 4. CNA 4 stated the shower schedules were in the CNA charting system, there was a shower icon to alert CNA's the resident needed a shower that day. CNA 4 stated the shower was to be documented in the CNA charting system and then a skin shower sheet was completed. CNA 4 stated if the resident refused, then CNA tired two more times and then the nurse had the resident sign a refusal form. CNA 4 stated the refusals were placed in the nurse manager folder. CNA 4 stated she performed the shower audits starting a few weeks ago. CNA 4 stated nail care was documented on the shower sheet. On 11/13/24 at 8:54 AM, an interview was conducted with LPN 3. LPN 3 stated if a resident had diabetes then the podiatrist cut their toenails. LPN 3 stated for residents that did not have diabetes she preferred to have a nurse cut their nails. LPN 3 stated CNA's should be looking at residents nails and facial hair. LPN 3 stated CNA's should ask residents if they would like to be shaved and nails cut and inform the nurses when those things needed to be done. On 11/7/24 at 11:39 AM, an interview was conducted with the DON. The DON stated the shower process started upon admission when staff asked how the resident wanted to be bathed. The DON stated residents were able to have as many showers as they wanted but at least 2 per week. The DON stated the CNA's charting system alerted CNA's to who needed showers that day. The DON stated the CNA's knew the residents and their preferences. The DON stated if a resident refused, then the CNA offered another time and then the nurse was notified. The DON stated the nurse determined why the resident did not want to shower and the resident signed a refusal form. The DON stated she reviewed why a resident was refusing to determine the root cause. The DON stated there would be information in the CNA charting system and shower sheet were handed to nurse when a shower was completed. The DON stated nail care should be done with showers and documented on the shower sheet. The DON stated if the resident was non-diabetic then CNA's were able to cut their fingernails. The DON stated nurses and the CNA coordinator have come in to preform nail care in the past. The DON provided shower sheets for resident 60. Resident 60 was bathed on 10/31/24 and fingernails and toenails were cleaned. There were no other shower sheets provided. On 11/12/24 at 2:48 PM, a follow-up interview was conducted with the DON. The DON stated that resident 60's showers were not alerting CNA's on his shower days in the CNA computer system. The DON stated she found 1 shower sheet that was completed for resident 60. The DON stated staff say that they have given resident 60 showers but she unable find more shower sheets or any documentation. The DON stated the nail care would be done with showers and was documented on the shower sheets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 3 was admitted to the facility on [DATE] with diagnoses that included Arnold Chiari Syndrome with spina bifida and hydrocephalus, severe protein-calorie malnutrition, osteomyelitis right ankle and foot, paraplegia, borderline personality disorder, major depressive disorder, morbid obesity, bipolar disorder, and anxiety disorder. Resident 3's medical record was reviewed between 11/3/24 and 11/13/24. Physician orders included: a. Med Pass 2.0, two times a day for NUTRITION. Order date: 12/17/23. b. Pro-Stat AWC (Advanced Wound Care), one time a day for SUPPLEMENT. Order date: 12/11/23. c. Boost Breeze. Give 4 oz. [ounces] of Boost Breeze three times a day for SUPPLEMENT/NUTRIENT. Order date 3/25/24. Resident 3's care plan revealed, Potential nutritional problem r/t [related to] impaired skin integrity. Hx [history] malnutrition, wounds, paraplegia, weight loss, antipsychotics, anemia, depression, pain, pressure ulcers. Date initiated: 11/30/23, Revision on 11/30/23. The goal was, The resident will maintain adequate nutritional status as evidenced by no unplanned/undesired significant weight changes, no s/sx [signs and symptoms] of malnutrition, and adequate nutritional intake at meals through next review. Resident's weight goal is 140-155 lbs. [pounds]. Date initiated: 11/30/23, Revision on: 12/12/23, Target Date: 1/31/25. Interventions included, Monitor/document/report PRN [as needed] any s/sx of chewing/swallowing problems r/t [related to] dysphagia or oral health problems such as pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Refer to SLP [Speech Language Pathologist] or dentist as indicated to address dysphagia or oral health. Date initiated: 4/19/22, Revision on: 4/19/22; Monitor/record/report to MD [medical doctor] PRN [as needed] s/sx of malnutrition: Emaciation (cachexia), muscle wasting, significant weight loss: 3 lb. in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Date initiated: 4/19/22, Revision on: 4/19/22; Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 4/19/22, Revision on: 4/19/22; Provide, serve diet as ordered. Monitor intake and record q [every] meal. Date initiated: 4/19/22, Revision on: 4/19/22; RD [Registered Dietitian] to evaluate and make diet change recommendations PRN. Date initiated: 4/19/22, Revision on: 4/19/22; Weigh per facility protocol and/or NAR [nutrition at risk] committee recommendations. Date initiated: 4/19/22, Revision on: 4/19/22. Progress notes revealed: On 8/20/24 at 8:50 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Out of stock. On 8/21/24 at 8:57 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Out of stock. On 8/22/24 at 8:20 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Out of stock. On 8/23/24 at 9:24 AM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Unavailable. On 8/23/24 at 7:24 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Out of stock. On 8/24/24 at 12:05 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Awaiting delivery. On 8/24/24 at 6:32 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Out of stock. On 8/25/24 at 10:21 AM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Waiting for pharmacy delivery. On 8/25/24 at 8:56 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. OOS [out of stock]. On 8/26/24 at 9:09 PM, an Order-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Waiting for pharmacy delivery. On 8/26/24 at 10:11 PM, an Order-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. On order. On 8/27/24 at 9:15 AM, an Order-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Waiting for pharmacy delivery. On 8/27/24 at 10:27 PM, an Order-Administration progress note revealed, Med Pass 2.0 two times a day for Nutrition. Resident offered equivalent. 8/28/24 at 10:08 AM, an Order-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for delivery. On 8/28/24 at 10:49 AM, a nutrition progress note revealed, RD note: Nutrition at risk: Significant weight loss of 20.9#/11.9% x 17 days. Significant weight loss of 18.9#/10.9% x 1 month; Sig. [significant] wt [weight] loss 17.7#/10.2% in 3 months; sig wt loss 19.9#/11.4% x 6 months. Skin: PI [pressure ulcer] noted bilateral heels and R [right] and L [left] buttocks. Current weight 155.1#. PO [by mouth] intake ~ 46% of Reg [regular], reg. thin liquids meals with 7 meals refused this week. Facility snacks accepted 1-3x daily. Resident usually eats outside meals and snacks in addition to facility meals/snacks. However, in light of most recent weight loss, RD is uncertain of current eating habits of resident. Resident has been refusing weights recently, so it is likely resident refused re-weight. Supplements; Boost Breeze 4 oz [ounces] TID [three times daily] 100%, Pro-stat AWC QD [once daily] 100%, MP [Med Pass] 60 ml [milliliters] BID [two times daily] 100% as available. No recent nutrition related labs. CBW [current body weight] 155.1#, HT [height] 59, 163% IWR [ideal weight range] for para: 78-96#. Estimated nutrition needs: 1527 calories, 87 grams protein, 2257 ml fluid (adjusted for obesity). % Estimated needs Met: 100% calories needs should be met, however ,weight loss noted, 86% protein. Some weight loss may be desirable and beneficial per resident preference and d/t [due to] morbid obesity and decreased mobility. Weight loss and skin breakdown considered unavoidable. Staff continues to encourage good po intake of meals, snacks, and supplements. Recommend: Discuss with resident if wt. loss is intentional. F/up [follow-up] re-wt as resident allows. It should be noted that no additional follow-up was documented by the Registered Dietitian. On 8/28/24 at 2:11 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for delivery. On 8/29/24 at 7:06 AM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRITION. Waiting for delivery. On 8/29/24 at 2:00 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRITION. Waiting for delivery. On 9/28/24 at 7:37 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Ordered. On 9/29/24 at 10:11 AM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Waiting for pharmacy delivery. On 9/29/24 at 10:44 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. On order. On 9/30/24 at 9:33 AM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRITIENT [sic]. Waiting for pharmacy delivery. On 9/30/24 at 9:34 AM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Waiting for pharmacist delivery. On 9/30/24 at 11:49 AM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for pharmacist delivery. On 9/30/24 at 5:06 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for pharmacist delivery. On 9/30/24 at 9:05 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Out of stock. On 10/1/24 at 8:23 AM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Waiting for pharmacist delivery. On 10/1/24 at 8:23 AM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for pharmacist delivery. On 10/1/24 at 12:00 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for pharmacy delivery. On 10/1/24 at 4:42 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for pharmacist delivery. On 10/1/24 at 7:57 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTIRITION [sic]. Not available. On 10/3/24 at 10:07 AM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. In progress with delivery. On 10/7/24 at 9:48 AM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Waiting for pharmacist delivery. On 10/7/24 at 7:50 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. On order. On 10/8/24 at 10:07 AM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. In progress with delivery. On 10/10/24 at 10:20 AM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. In progress with delivery. On 10/10/24 at 8:20 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Out of stock. On 10/11/24 at 9:24 AM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Delivery in progress. On 10/12/24 at 10:10 AM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. In progress with pharmacy. On 10/13/24 at 10:05 AM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. In progress with pharmacy. On 10/13/24 at 10:21 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Waiting for shipment to arrive. On 10/14/24 at 10:48 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Out of stock. On 10/15/24 at 8:58 PM, an Orders-Administration progress note revealed, Med Pass 2.0 two times a day for NUTRITION. Not available. On 10/31/24 at 12:51 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. In progress with pharmacy. On 10/31/24 at 3:05 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. In progress with pharmacy. On 11/1/24 at 10:46 AM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. In progress with pharmacy. On 11/1/24 at 1:20 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. In progress with delivery. On 11/1/24 at 3:12 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. In progress with delivery. On 11/2/24 at 10:16 AM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Delivery in progress. On 11/2/24 at 10:25 AM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. In progress with pharmacy. On 11/2/24 at 3:57 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. In progress with delivery. On 11/3/24 at 9:39 AM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for pharmacist delivery. On 11/3/24 at 12:42 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for pharmacist delivery. On 11/3/24 at 2:19 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for pharmacist delivery. On 11/4/24 at 6:49 AM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for pharmacist delivery. On 11/4/24 at 10:50 AM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for pharmacist delivery. On 11/4/24 at 4:38 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for pharmacist delivery. On 11/5/24 at 11:19 AM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for pharmacist delivery. On 11/5/24 at 2:31 PM, an Orders-Administration progress note revealed, Boost Breeze. Give 4 oz of Boost Breeze three times a day, three times a day for SUPPLEMENT/NUTRIENT. Waiting for pharmacist delivery. Resident 3's Medication Administration Record [MAR] was reviewed for the month of August. a. Med Pass 2.0 was not administered from 8/20/24 to 8/27/24. The documented code [5] revealed, Held-see progress note. b. Boost Breeze was not administered from 8/28/24 to 8/29/24. The documented code [5] revealed, Held-see progress notes and that resident 3 refused the noon time offering. Resident 3's MAR was reviewed for the month of September. a. Med Pass 2.0 was not administered from 9/27/24 to 9/30/24. The documented code [5] revealed, Held-see progress notes. b. Boost Breeze was not administered on 9/30/24. Resident 3's MAR was reviewed for the month of October. a. Med Pass 2.0 was not administered on 10/1/24, 10/3/24, 10/7/24, 10/8/24, and 10/11-15/24. b. Boost Breeze was not administered on 10/1/24 and 10/31/24. Resident 3's MAR was reviewed for the month of November. a. Boost Breeze was not administered from 11/1/24 - 11/5/24. On 11/6/24 at 4:32 PM, an interview was conducted with LPN 4 who stated the facility did run out of supplements or they would get back ordered. LPN 4 stated sometimes they had a similar product that was a shake. LPN 4 stated delayed orders happened a lot. LPN 4 stated the supplements were ordered from other places than the pharmacy. On 11/12/24 at 3:22 PM, an interview was conducted with the DON. The DON stated the CNA coordinators were responsible for ordering nutrition supplements. The DON stated they had reached out to other facilities for supplements until the facility orders had arrived. The DON stated if the supplements were not available, the nurses should be letting her know so another solution could be figured out. The DON stated a resident had the right to refuse the supplement, and if that happened, the nurse should reach out to the provider, and the facility should try to get the flavor the resident would take. On 11/13/24 at 9:27 AM, an interview was conducted with the DON who stated if the ordered supplement was not available and a different supplement was offered, it should be documented in the progress note, and the provider should be notified. 3. Resident 65 was admitted to the facility on [DATE] with diagnoses which included dementia, seizures, hypothyroidism, obstructive sleep apnea, depression, presence of a cardiac pacemaker, and violent behaviors. On 11/03/24 at 3:56 PM, an observation was made of resident 65 sleeping in a recliner in his room. The resident's call light was observed on the arm rest within reach and a walker was located near the door. On 11/04/24 at 3:24 PM, an observation was made of resident 65 sleeping in a chair in the dining room. Resident 65's electronic medical records were reviewed. On 9/17/24, resident 65's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 4/15, which would indicate a severe cognitive impairment. The assessment documented that resident 65 required set up assistance for eating. On 09/10/24, resident 65 weighed 187.39 pounds (lbs.). On 10/08/24, resident 65 weighed 167.5 pounds which is a -10.61 % weight loss. On 9/10/24, resident 65's diet orders were for a regular diet, regular RG7 (dysphagia diet level 7) texture, and thin liquids consistency. Resident 65's eating task for the past 30 days documented 68 episodes when the resident had eaten 75-100% of his meal. On 9/16/24, resident 65's admission nutritional assessment documented that the resident was eating 75% of his meal intake, had no chewing or swallowing problems, and was independent with dining. The assessment documented that resident 65 was confused and disoriented and depressed. The assessment documented that resident 65's caloric needs were 2520 kilocalories (kcals) with a factor of 30 kcal/kilogram (kg); and the hydration needs were 2520 milliliters (mls) with a factor of 30 mls/kg. The assessment documented that the resident needed 84-126 grams (gms) of protein with a factor of 1.0 -1.5 gms/kg. The assessment documented that resident 65 was on a regular diet with an average by mouth intake of 75%. The assessment documented resident 65's height was 68 inches, weight (wt.) was 187.4 lbs., the ideal body weight was 122%, and the body mass index (BMI) was 28.4 and was within normal limits. The assessment documented that resident 65 weight and intake would monitored and evaluated weekly for four weeks and then monthly if stable. On 10/14/24 at 11:40 AM, the weight change note documented, WEIGHT WARNING: Value: 167.5 Wt is down 19.8# (lbs.) since admission. RD [Registered Dietician] questions accuracy of admit wt. Resident is active and walks with a walker around facility. BMI 25.5. No nutritional concerns this time. Will have Resident reweighed. Cont [continue] POC [plan of care]. Resident & MD [Medical Doctor] aware of wt loss. It should be noted that no documentation could be found for any repeat weights of resident 65 as requested by the RD. On 10/16/24 at 1:00 AM, the provider note documented Weight: 167.5 pounds (Warnings: -5.0% change, False. -7.5% change, False. -10.0% change, False). On 10/19/24, resident 65 had a care plan initiated for .at risk for nutritional decline d/t [due to] dx [diagnosis] dementia, hx [history] seizures and depression. Interventions identified on the care plan included to invite the resident to activities that promoted additional intake; monitor/record/report to MD any signs and symptoms of malnutrition such as significant wt. loss of 3 lbs in 1 week, greater than 5 % in 1 month, and greater than 7.5 % in 3 months; provide and serve a regular diet as ordered; and weigh per facility protocol or Nutrition At Risk (NAR) committee recommendations. On 11/04/24 at 3:27 PM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that they needed to constantly remind resident 65 to eat or else he would fall asleep. CNA 3 stated that resident 65 typically ate about 80% of his meals. CNA 3 stated that resident 65 did not have any dietary supplements. On 11/04/24 at 3:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 65 did not have any dietary supplements. LPN 3 stated that resident 65 was able to feed himself and if he did not like a food item he would not eat it. LPN 3 stated that resident 65 refused to eat today because he was really sleepy in the morning. On 11/05/24 at 11:03 AM, a telephone interview was conducted with the Registered Dietitian (RD). The RD stated that she had been employed at the facility since September 2024. The RD stated that she was at the facility one time a week for approximately 8 hours. The RD stated that she ran the NAR meetings with the DON and made recommendations to the DON for the residents that were reviewed. The RD stated that she did the nutritional assessments on admission, but had not done any quarterly assessments. The RD stated that she had asked the corporate resource nurse how to do the quarterly assessments because the electronic medical records was not populating them automatically. The RD stated that the previous RD had not been conducting the quarterly assessments. The RD stated that she was just barely keeping her head above water with the NAR reviews and admission assessments. The RD stated that she had not been able to get to the back log of residents that were not newly admitted or were on the NAR list. The RD stated that they struggled with obtaining weights in the building and that they were not consistently being done. The RD stated that she was not sure if resident 65's weight that was entered on 9/10/24 was a hospital weight or an admission weight. The RD stated that she provided the CNA Coordinator or the Director of Nursing (DON) a weekly list of those residents that needed a weight completed. The RD stated that sometimes they were done and sometimes they were not obtained. The RD stated that it was a challenge to conduct an accurate nutritional assessment without a weight. The RD stated that resident 65's weight on 10/8/24 was 167.5 lbs. and she questioned the accuracy of the admission weight on 9/10/24. The RD stated that she requested a repeat weight for resident 65, but she could not demand it that same day. The RD stated that she did not put any new interventions in place for resident 65 when she identified the recorded weight loss. The RD stated that resident 65 had a good BMI, was active and was eating well. The RD stated that every week she informed the DON of the residents that needed weights, but what happened beyond that she was not aware of. On 11/05/24 at 3:32 PM, an interview was conducted with CNA 6 and CNA 8. CNA 6 stated that they tried to get everyone's weight each Monday or the beginning of the month. CNA 6 stated that the weekly weights on Monday were those residents that had issues with their weight and for everyone else it was obtained monthly. CNA 6 stated that the licensed nurse notified them of which residents needed a weight obtained. CNA 8 stated that they documented the weights in the electronic medical records. CNA 8 stated that they obtained the weight anytime of the day. CNA 8 stated that if the resident was wheelchair bound they would obtain the weight of the chair and then the weight of the resident in the chair and subtract the chair weight from the resident weight. On 11/05/24 at 3:36 PM, an interview was obtained with Licensed Practical Nurse (LPN) 3. LPN 3 stated that no one in the unit was on weekly weights and that they did not have a scale in the locked unit. LPN 3 stated that all residents on the locked unit were weighted monthly. LPN 3 stated that depending on the resident's physician orders they might have weights more frequently. LPN 3 stated that if they took resident 65 off the unit to obtain a weight it would be difficult to get him back on the unit and it may agitate him. On 11/05/24 at 3:47 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated that he communicated with the RD and that he tried to attend the NAR meetings. The ADMIN stated that when the RD was done with the NAR meeting she would send him her note. The ADMIN stated that the NAR meeting was attended by the RD, DON, and himself. The ADMIN stated that the RD would notify them of which residents needed weights and he was not aware that it was not getting done. The ADMIN stated that if the RD did not have the update weights it would put the resident's at risk because it was good indicator if the residents were gaining or losing weight. The ADMIN stated that they only had the one scale and the residents on the unit came out off the unit to get their weights obtained. The ADMIN stated that they did not have any residents on the locked unit that was difficult to take off of the locked unit or to get back inside afterwards. On 11/05/24 at 4:46 PM, an interview was conducted with the DON. The DON stated that resident 65 should have weights obtained on the small scale that was located in the unit. The DON stated that resident 65 was on monthly weights and was not addressed in the NAR meeting. The DON stated that she was not aware of any issues with resident 65's weight. The DON stated that the CNA supervisor was responsible for ensuring that all the weights were obtained. The DON stated that she was not aware of resident 65's weight loss or that his weights were not being obtained. The DON stated that she would discuss resident 65 at the NAR meeting and discuss if he needed supplements and what percentage of his meals were eaten. On 11/06/24 at 2:19 PM, a follow-up interview was conducted with LPN 3. LPN 3 stated that resident 65 was pushing staff away and refusing to eat or drink. LPN 3 stated that resident 65's blood pressure was 95/54 and he was not drinking. LPN 3 stated that she was not worried about the blood pressure as resident 65 was currently lying down and in the morning he was eating and drinking. Based on observation, interview and record review, for 4 of 65 sampled residents, the facility did not ensure residents maintained acceptable parameters of nutritional status. Specifically, residents meal portion sizes were not adequate, residents weights were not obtained and residents nutrition assessments were not being completed. Resident identifiers: 3, 4, 55, 60, and 65. Findings included: 1. Resident 60 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, dysphagia, history of falling, constipation and dementia. On 11/3/24 at 4:04 PM, an interview was conducted with resident 60. Resident 60 stated he had not been weighed so he did not know if he had lost weight. Resident 60's medical record was reviewed. Resident 60's weight on 8/26/24 was 170.0 pounds and on 10/6/24 was 178.5 pounds. An admission Nutritional assessment dated [DATE] was in progress and had not been completed by the Registered Dietitian (RD). Progress notes revealed the following skin/wound notes: a. On 10/7/24 at 11:13 AM, oral intake was about 75% on a CCHO (Consistent Carbohydrate Diet) mechanical soft with nectar thick liquids. b. On 10/14/24 at 10:34 AM, oral intake was about 75% on a CCHO mechanical soft with nectar thick liquids. c. On 10/21/24 at 4:03 PM, oral intake was about 75% CCHO mechanical soft with nectar thick liquids. On 11/5/24 at 11:34 AM, a phone interview was conducted with the RD. The RD stated it was a struggle to obtain weights. The RD stated there was a print out of weekly weights provided to the CNA coordinator or DON. The RD stated sometimes the weights were done and sometimes not done. The RD stated that if weights were not done she let the DON know. The RD was asked if weights were not done, how did she complete an accurate nutritional assessment, the RD stated That's a challenge. The RD stated every new admission should be weighed weekly for 4 weeks. The RD stated she can only request weights and hope they were done. The RD stated resident 60's admission nutrition assessment had not been completed. The RD stated in a perfect world nutrition assessments would be done every 90 days. The RD stated from what she understood from the the electronic medical assessment, once an assessment was competed then a new one triggered every 90 days. The RD stated she was trying to keep her head above water with assessments, weights and wound meetings. The RD stated she was unable to get to the back log of assessments that need to be done. On 11/7/24 at 10:14 AM, an interview was conducted with the facility RD. The RD stated the regular diet order provided each resident about 2400 calories and 21 to 28 grams of protein per day. The RD stated if a resident ate 75% of the meal, it would provide 1800 -1950 calories. The RD stated the previous RD calculated resident 60's nutritional needs and did not finish the assessment. The RD stated she had been the RD since September 2024 and the portion sizes were not entirely accurate. The RD stated the other day there was chicken served and it was a larger portion than usual. The RD stated she knew there was a new Dietary Manager, so she did not want to go in and demand things from the kitchen. The RD stated she was grateful they were providing sanitary foods and portion sizes that were close to the correct size. The RD stated if resident 60 was eating less than 75%, then she would add a protein supplement. The RD stated if portion sizes were not correct that would change how she calculated a residents oral intake. The RD stated resident 60's last weight was obtained on 10/6/24. The RD stated she was reviewing resident 60's oral intake and it had decreased this last week to about 50-75%. The RD stated meal intake was how she evaluated if a resident was getting enough to eat. The RD stated if she noticed a decrease in meal intake, or the resident was no feeling well then she added supplements. The RD stated she did not know if there was a snack program. The RD stated she would be surprised if there was a snack program. The RD stated without weekly or monthly weights it was hard to evaluate a resident nutritional needs. On 11/12/24 at 3:22 PM, an interview was conducted with the Director of Nursing (DON). The DON stated Nutrition At Risk (NAR) meetings were on Mondays. The DON stated during

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 5 out of 65 sampled residents, that the facility did not ensure that a resident who used psychotropic drugs was not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Further, as needed (PRN) orders for psychotropic drugs are limited to 14 days, unless the attending physician or prescribing practitioner believes that it was appropriate for the PRN order to be extended beyond 14 days, and should document their rationale in the resident's medical record and indicate the duration for the PRN order. Specifically, a resident was prescribed an antipsychotic without a supporting diagnosis and no gradual dose reduction was initiated. In addition, residents were given PRN psychotropic medications beyond 14 days, a resident was not monitored for adverse side effects to the psychotropic medication, behaviors were not monitored, and non-pharmacological interventions prior to the medication administration were not initiated. Resident identifiers: 13, 46, 54, 65, 270. Findings included: 1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, diffuse traumatic brain injury (TBI) with loss of consciousness, unspecified ataxia, adjustment disorder with mixed disturbance of emotions and conduct, unspecified depression, and cognitive communication deficit. On 11/4/24, resident 54's medical record was reviewed. A review of resident 54's physician's orders dated 5/1/24, revealed that resident 54 was to receive Fanapt 8 milligrams (mg) twice daily (BID) for Adjustment disorder. A review of resident 54's care plan revealed the following: a. Focus: The resident uses psychotropic medications (Fanapt) r/t [related to] adjustment disorder. Date initiated: 5/14/24 Revision on: 5/14/24 b. Interventions: Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q [every]-shift. Date initiated: 5/14/24 Monitor/document/report PRN [as needed] any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS [extra pyramidal symptoms] (shuffling gate, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea [sic], vomiting, behavior symptoms not usual to the person. Date initiated: 5/14/24 Monitor/record occurrence of for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc) and document per facility protocol. Date initiated: 5/14/24 Revision on: 5/14/24 A review of resident 54's behavior monitoring record revealed the following: a. June 2024- no behavior symptoms had been documented b. July 2024- no behavior symptoms had been documented c. August 2024- no behavior symptoms had been documented d. September 2024- behavior symptoms documented on 9/11/24 e. October 2024- behavior symptoms documented on 10/3/24, 10/10/24, 10/14/24, 10/15/24, 10/16/24, 10/22/24, 10/23/24, 10/24/24, 10/25/24, 10/27/24, 10/28/24, 10/29/24, 10/30/24 On 10/30/24 at 1:00 AM, a provider progress note documented the following, .The patient has been on fanapt for adjustment disorder, but this is not an appropriate indication for this medication. We will begin tapering down on this and observe the patient closely. Decrease to 4mg [sic] BID with plans to continue the taper until it is DC'd [discontinued]. May consider alternative medications more appropriate for his dx [diagnosis] in the future if needed. On 11/12/24 at 10:16 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that residents on psychotropic medications were reviewed on the last Wednesday of every month. The DON stated that psychotropic meetings were attended by the DON, Medical Director, behavioral health medical director, MDS (Minimum Data Set) Coordinator, Resident Advocate, and pharmacist. The DON stated that the medical doctor prescribed psychotropic medications. The DON stated that if a medication needed to be changed the orders would be placed in the computer by the MDS Coordinator or the DON depending on what the tapering process was. The DON stated the resident would be monitored for any changes when a medication was being tapered. The DON stated she was unsure if the taper for resident 54 was ordered. On 11/13/24 at 9:52 AM, an interview was conducted with the DON. The DON stated that resident 54's Fanapt was a medication that they were going to taper, but the facility medical director was not the prescriber for Fanapt. The DON stated she was going to reach out to the prescribing medical provider but had not yet. The DON stated that she should have done this the same day as the psychotropic meeting. The DON stated she should have written a progress note regarding this information. 5. Resident 46 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, aphasia, cognitive communication deficit, chronic obstructive pulmonary disease with acute exacerbation, lack of coordination, acute kidney failure, major depressive disorder, and anxiety. Resident 46's medical record was reviewed 11/3/24 through 11/13/24. A Physician's Order, dated 6/27/24 at 4:00 PM, indicated, Clonazepam Oral Tablet 0.5 MG (Clonazepam) *Controlled Drug* Give 0.25 mg by mouth every 12 hours as needed for Anxiety until 8/31/2024 at 23:59 [11:59 PM]. A MAR, dated 7/2024, indicated the ordered clonazepam oral tablet 0.5 mg (Clonazepam) Give 0.25 mg by mouth every 12 hours as needed for anxiety was given as needed at least once every day in July and twice a day on 7/2/24, 7/4/24, 7/8/24, 7/11/24, 7/16/24, 7/18/24, 7/21/24, 7/23/24, 7/25/24, 7/26/24, 7/30/24, and 7/31/24. A MAR, dated 8/2024, indicated the ordered clonazepam oral tablet 0.5 mg (Clonazepam) Give 0.25 mg by mouth every 12 hours as needed for anxiety was given as needed once a day from 8/1/24 through 8/5/24, and twice on 8/3/24. On 11/12/24 at 3:47 PM, an interview was conducted with the DON. The DON stated the PRN Ativan order needed to be ordered for a 14-day period. No rationale for an extension beyond 14 days was provided. 4. Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, muscle weakness, major depressive disorder, and chronic pain. Resident 13's medical records were reviewed between 11/3/24 and 11/13/24. Physician orders included: a. Hydroxyzine HCL [hydrochloride] oral tablet 10 MG (Hydroxyzine HCL); Give 1 tablet by mouth every 8 hours as needed for anxiety. Order date: 7-11-24. b. Behavior Monitoring: # of anxious statements Q shift. On 7/12/24 at 1:00 AM, a provider encounter progress note revealed, .Today patient is in need of a refill on her Hydroxyzine 10 mg. She is taking this for anxiety. Patient does see psychiatry and is being well-managed. She does report good results with this medication and that her anxiety is under control .They are happy with the current dosage and frequency . Care plan included: a. Focus area: Psychotropic medications use r/t depression and anxiety. Date initiated: 10/12/22, Revision: 10/12/22. The goal was, The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/Impaction or cognitive/behavioral impairment through review date. Date initiated: 10/12/22, Revision 4/12/24, Target date: 2/7/25. Interventions included, Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Date initiated: 10/12/22; Consult with pharmacy, MD [medical doctor] to consider dosage reduction when clinically appropriately at least quarterly. Date initiated: 10/12/22; Discuss with MD, family re [regarding] ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Date initiated: 10/12/22; Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date initiated: 10/12/22. Reviewed MAR and TAR: a. July 2024 MAR revealed Hydroxyzine HCL oral tablet 10 mg was started on 7/11/24 with no discontinue date and provided PRN. b. August 2024 MAR revealed Hydroxyzine was provided PRN throughout the month with no discontinue date. c. September 2024 MAR revealed Hydroxyzine was provided PRN throughout the month with no discontinue date. d. October 2024 MAR revealed Hydroxyzine was provided PRN throughout the month with no discontinue date. e. November 2024 MAR revealed Hydroxyzine was provided PRN, as of 11/4/24, with no discontinue date. Reviewed the Pharmacist Consultation documents for 7/24, 8/24, 9/24, 10/24 and 11/24. No concerns or recommendations were noted related to the length of the Hydroxyzine prescription. On 11/7/24 at 9:22 AM, an interview was conducted with LPN 4 who stated resident 13 was taking Hydroxyzine for anxiety. LPN 4 stated resident 13 was taking morphine, oxycodone and Lyrica for pain and that it was prescribed by the pain clinic. LPN 4 stated the pain clinic was trying to adjust her medications due to her being on too many medications. On 11/12/24 at 3:47 PM, an interview was conducted with the DON who stated PRN psychotropic medications needed to be ordered for 14 days. No rationale for extended use was provided. 2. Resident 65 was admitted to the facility on [DATE] with diagnoses which included dementia, seizures, hypothyroidism, obstructive sleep apnea, depression, presence of a cardiac pacemaker, and violent behaviors. On 11/03/24 at 3:56 PM, an observation was made of resident 65 sleeping in a recliner in his room. The resident's call light was observed on the arm rest within reach and a walker was located near the door. Resident 65's electronic medical records were reviewed. On 9/17/24, resident 65's MDS Assessment documented a Brief Interview for Mental Status (BIMS) score of 4/15, which would indicate a severe cognitive impairment. The assessment documented a PHQ-9 (patient health questionnaire) mood score of 7 which would indicate a mild depression severity. The assessment documented that physical or verbal behavioral symptoms were not exhibited. Resident 65's physician orders revealed: a. On 10/18/24, an order was initiated for Haloperidol Tablet 5 milligram, give 1 tablet by mouth every 1 hours as needed for agitation at bedtime, if still showing agitation after one hour give another 5 mg tablet. b. On 10/18/24, an order was initiated for Haloperidol Tablet 5 mg, give 1 tablet by mouth every 22 hours as needed for agitation at bedtime, if still showing agitation after one hour give another 5 mg tablet. c. On 10/17/24, an order was initiated for Hydroxyzine Tablet 25 mg, give 1 tablet by mouth every 6 hours as needed for anxiety. d. On 9/10/24, an order was initiated for Sertraline Tablet 100 mg, give 1 tablet by mouth two times a day for depression. d. On 9/10/24, an order was initiated for Risperidone Tablet 0.5 mg, give 1 tablet by mouth two times a day for dementia/depression. Resident 65's September Medication Administration Record (MAR) was reviewed and revealed no documentation for monitoring of behaviors, adverse side effects (ASE) or non-pharmacological interventions for the Risperidone and Sertraline medications. Resident 65's October MAR documented the following: a. The Haloperidol PRN order was administered on 10/20/24 at 7:45 PM for agitation and was documented as effective. b. The Hydroxyzine PRN order was administered on 10/18/24 at 8:17 AM, on 10/19/24 at 8:49 AM, on 10/20/24 at 3:24 PM, on 10/22/24 at 4:31 PM, on 10/26/24 at 1:45 PM, and on 10//27/24 at 3:39 PM for anxiety and all were documented as effective. c. The behavior monitoring for number of episodes of agitation every shift documented a total of 29 episodes for the month. d. The behavior monitoring for number of verbal outbursts every shift documented a total of 23 episodes for the month. e. The behavior monitoring for number of verbalizations of sadness documented a total of 2 episodes for the month. It should be noted that no documentation was found of non-pharmacological interventions that were provided to resident 65 in response to his episodes of behavior for October 2024. Additionally, no documentation was found of monitoring for adverse side effects of the psychotropic medications. Resident 65's November MAR documented the following: a. The Haloperidol PRN order was administered on 11/2/24 at 6:30 PM for agitation and was documented as effective. It should be noted that behavior monitoring for episodes of agitation or verbal outburst did not document any episodes on 11/2/24 at the time the medication was administered. b. The Hydroxyzine PRN order was administered on 11/2/24 at 6:31 PM for anxiety and was documented as effective. It should be noted that behavior monitoring for episodes of agitation or verbal outburst did not document any episodes on 11/2/24 at the time the medication was administered. c. The behavior monitoring for number of episodes of agitation every shift documented a total of 3 episodes for the month. d. The behavior monitoring for number of verbal outbursts every shift documented a total of 3 episodes for the month. e. The behavior monitoring for number of verbalizations of sadness documented no episodes for the month. It should be noted that no documentation was found of non-pharmacological interventions that were provided to resident 65 in response to his episodes of behavior for November 2024. On 10/18/24, resident 65 had a care plan initiated for The resident is/has potential to be physically aggressive r/t Dementia. Interventions identified on the care plan were to administer medications as ordered and monitor for effectiveness; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate resident's needs; give the resident as many choices as possible; psychiatric/psychogeriatric consult as indicated; On 10/21/24, resident 65 had a care plan initiated for MOOD & BEHAVIOR: [resident 65] has a history for an alteration in mood or exhibition of behavioral symptoms r/t: Alzheimer's/Dementia, Physically Aggressive and Violent Behaviors. Interventions identified on the care plan were to administer medication as ordered, allow time to calm down and approach later, interact in an empathetic and supportive manner, monitor and document each behavioral event, and offer one-to-one interaction as needed. On 11/2/24, resident 65 had a care plan initiated for The resident has diagnosis/diagnoses of (depression, dementia, history of violent behaviors). Resident requires the use of (psychotropic medications) to help manage this condition. Interventions identified on the care plan were administer psychotropic medications per physician order and monitor for ASE; monitor and document occurrence of target symptoms; psychotropic committee will review medication regimen, ASE, and target symptoms quarterly; and staff should use the following non-pharmacological interventions to manage symptoms (active listening/support/encouragement, validation, reality orientation, re-direction/distraction, and identification and elimination of triggers). It should be noted that the resident had been receiving psychotropic medications since admission on [DATE] and the care plan for the psychotropic medications was not initiated until 11/2/24. On 11/04/24 at 3:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 65 had behaviors of exit seeking and was aggressive. LPN 3 stated that resident 65 would block the door so no one could enter or exit, he would push staff, and yells at staff. LPN 3 stated that when she noticed his anxiety was increasing she gave Hydroxyzine. LPN 3 stated that resident 65 had a PRN order for Haldol for anxiety and aggression. LPN 3 stated that resident 65 had only needed that medication a couple of times. LPN 3 stated that when resident 65 focused on leaving they attempted to re-direct him. LPN 3 stated that some days he was not able to be re-directed. LPN 3 stated that on those days they tried to contact his son or girlfriend. LPN 3 stated that resident 65 received Risperidone for depression and dementia and that he had a diagnoses of behavioral disturbance. LPN 3 stated that resident 65 did not have a diagnosis of schizophrenia, or bipolar disorder, just dementia with violent behaviors. LPN 3 stated one time resident 65 became really aggressive. They had a new housekeeper that let him out of the locked unit and it was hard to bring him back into the unit. On 11/06/24 at 8:55 AM, an interview was conducted with the DON. The DON stated that resident 65's psychotropic medication should have monitoring for behaviors and adverse side effects. The DON stated that any non-pharmacological interventions were listed in the resident care plan and should address de-escalation techniques. The DON stated that they conducted staff training for de-escalation techniques for each resident upon admission. The DON stated that they conducted a psychotropic meeting monthly to see how the resident trends and any PRN medication usage. The DON stated that Haldol and Risperidone were indicated for the treatment of Schizophrenia, Tourette's and Parkinson's Disease. The DON stated that typically they did not administer antipsychotics for dementia, but it would depend on each resident's case. The DON stated that she would like to have a list of interventions that were attempted to manage behaviors prior to medication management. The DON stated that those non-pharmacological interventions should also be documented in the resident progress notes. The DON stated that for resident 65 if the staff called his son or girlfriend, they were good at calming him down. The DON stated that typically PRN antipsychotics were only ordered for 14 days. The DON stated that to justify the extended use of the PRN antipsychotics they had a form that was filled out by the MD. The DON stated that they conducted a monthly psychotropic review, and they just reviewed resident 65 in October. The DON stated that she had not filled out any of the paperwork for resident 65's October review yet. On 11/06/24 at 3:42 PM, a follow-up interview was conducted with the DON. The DON stated that she did not have a physician rationale, re-evaluation for the continued use of, or duration of use for the PRN order for the antipsychotic medication that exceeded 14 days. The DON stated that she would reach out to the physician. On 11/06/24 at approximately 5:00 PM, an interview was conducted with the DON. The DON stated that she spoke to resident 65's provider and was informed that the provider prescribed the antipsychotic medication because the resident had requested them. No additional documentation was provided for the PRN Haldol order that exceeded 14 days. [Cross-refer F744] 3. Resident 270 was admitted to the facility on 10//14/24 and re-admitted on [DATE] with diagnoses which consisted of metabolic encephalopathy, paranoid schizophrenia, and generalized anxiety disorder. On 11/03/24 at 3:44 PM, an observation was made of resident 270 pacing the hallway on the phone. The resident was heard asking someone on the phone to bring him more cigarettes. The resident asked the nurse if he had anymore cigarettes and the nurse responded that he had smoked his last one during the last smoke break. Resident 270's electronic medical records were reviewed. On 10/20/24, resident 270's admission MDS Assessment documented a BIMS score of 14/15 which would indicate that the resident was cognitively intact. The assessment documented that physical or verbal behavioral symptoms were not exhibited. Resident 270's physician orders revealed the following: a. On 10/15/24, an order was initiated for Risperidone Tablet 0.5 mg, give 1 tablet by mouth one time a day for Health Maintenance Daily before breakfast. b. On 10/21/24, an order was initiated for Risperidone Tablet 2 mg, give 1 tablet by mouth at bedtime for Schizophrenia. c. On 10/15/24, an order was initiated for Buspirone Tablet 30 mg, give 1 tablet by mouth three times a day for Health Maintenance. No documentation could be found of monitoring for episodes of behavior, ASE, or non-pharmacological interventions for the Risperidone or Buspirone medications. On 11/2/24, resident 270 had a care plan initiated for Has a Level II PASRR [Pre-admission Screening and Resident Review] due to their diagnosis of Paranoid Schizophrenia and Alcohol Dependence. Interventions identified on the care plan were to administer medications as ordered and monitor for adverse effects. On 11/05/24 at 1:27 PM, an interview was conducted with Certified Nurse Aide (CNA) 5. CNA 5 stated that resident 270's behaviors were banging on the door, and he was agitated today. CNA 5 stated that resident 270 wanted to go outside to smoke right now. CNA 5 stated that she took him out 10 minutes early because he was agitated and was going to scream at her. CNA 5 stated that nothing calmed resident 270 down. CNA 5 stated that she sometimes ignored residents with behaviors and if they became more agitated would tell them to go lie down. CNA 5 was not able to identify any other resident specific interventions for behaviors of agitation, aggression or verbal outbursts. On 11/06/24 at 8:35 AM, an interview was conducted with LPN 3. LPN 3 stated that resident 270's behaviors were restlessness related to smoking, and he became agitated. LPN 3 stated she would remind the resident of the smoking times, but he forgets. LPN 3 stated that resident 270 did not fidget about anything else, and when he returned from smoking he was fine. On 11/06/24 at 11:45 AM, a follow-up interview was conducted with LPN 3. LPN 3 stated that she documented resident 270's agitation in a progress note. LPN 3 stated that she did not have documented episodes of behaviors or monitoring for ASE of Risperidone or Buspirone in the Treatment Administration Record (TAR). LPN 3 stated that there should be monitoring on resident 270 in the TAR for this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident 54 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, diffuse traumatic brain injury (TBI) with loss of consciousness, unspecified ataxia, adjustment disorder with mixed disturbance of emotions and conduct, unspecified depression, and cognitive communication deficit. On 11/4/24, resident 54's medical record was reviewed. A physician's orders dated 4/5/24 and 9/26/24 revealed, CBC [complete blood count]. There were no laboratory results in resident 54's electronic medical record that corresponded to the orders from 4/5/24 and 9/26/24. On 11/12/24 at 1:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the labs for resident 54 had been viewed by the medical doctor. The DON stated that it should not take longer than one week for lab results to be uploaded into the resident's electronic health record. The DON stated that she was not sure why the results were not in resident 54's medical record.Based on interview and record review, for 7 of 65 sampled residents, the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, results from laboratory tests completed at outside facilities were not obtained and filed into resident's medical record. Resident identifiers: 1, 2, 13, 50, 52, 54, and 55. Findings included: 1. Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, muscle weakness, major depressive disorder, and chronic pain. Resident 13's medical records were reviewed between 11/3/24 and 11/13/24. On 7/10/24 at 11:01 AM, a general progress note revealed, Phlebotomist was unable to obtain lab draw this morning for CBC [complete blood count], CMP [complete metabolic panel] and RFT [renal function test]. Orders sent to infusion clinic with pt [patient] to see if they can get the labs drawn there. It should be noted that no laboratory results could be found for resident 13 for 7/10/24. On 11/6/24, results from resident 13's laboratory results drawn on 7/10/4 were provided to the state agency and uploaded to the resident's medical record. On 11/13/24 at 8:57 AM, an interview was conducted with the Director of Nursing (DON) who stated that resident 13's labs were drawn at the center where she received her magnesium infusions. The DON stated the center was supposed to be faxing the results to the facility. The DON stated she could pull them from the medical record system if they were not sent. 2. Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included but was not limited to hypospadias, retention of urine, chronic kidney disease, pyelonephritis, extended spectrum beta lactamase resistance, obstructive and reflux uropathy, and methicillin resistant staphylococcus aureus infection classified elsewhere. On 11/4/24 at 9:07 AM, an observation was made of resident 1's room. A sign was posted outside of resident 1's room for enhanced barrier precautions (EBP) and a personal protective equipment (PPE) cart was located outside the door. The cart contained gowns and gloves. On 11/4/24 at 9:22 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 1 was on EBP for a suprapubic (SP) catheter and had an ongoing extended-spectrum beta-lactamase (ESBL) infection. LPN 3 stated that they obtained a urinalysis (UA) this past weekend for resident 1 and that the resident always had a urinary tract infection (UTI). Resident 1's electronic medical records (eMR) were reviewed. On 9/12/24, resident 1's had a physician order for a UA with a culture and sensitivity (C & S). No documentation could be found for the results of the UA with C & S in resident 1's eMR. On 11/13/24 at 11:55 AM, the facility emailed a copy of resident 1's UA results for 9/13/24. The results report documented that the report was printed on 11/13/24. On 11/13/24 at 3:02 PM, the facility emailed a copy of resident 1's C & S report for for 9/17/24. The results report documented that the report was printed on 11/4/24. On 11/12/24 at 1:22 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the laboratory process was that the nurse would obtain the specimen and the lab picked up two times a day or immediately if ordered stat. The DON stated that the lab was located across the street at the hospital. The DON stated that the timeframe for when she would expect to see a UA result was within 1-2 days and within 3 days for a C & S result. The DON stated that staff should be checking for the results within a couple of days and that any pending information should be passed on in report to the next shift. The DON stated that the nurse should call the lab if they did not see the results faxed over within that timeframe. The DON stated that she also had access to the laboratory computer portal and could see the lab results that way. The DON stated that once the results were obtained they should be uploaded into the resident's eMR and should not take longer than a week to be placed in the medical records. The DON stated that when a resident returned from the hospital she would monitor the antibiotics prescribed from the hospital for the appropriateness and she would print those labs and upload them into the resident's chart. [Cross-refer F690] 3. Resident 2 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included but was not limited to metabolic encephalopathy, cognitive communication deficit, hemiplegia and hemiparesis, hydronephrosis, hematuria, history of urinary tract infections, obstructive and reflux uropathy, and autistic disorder. On 11/12/24, the facility infection control tracking and trending log was reviewed for October 2024. The log documented that resident 2 had a urinary tract infection on 10/18/24 that was treated with Bactrim DS 800-160 milligram (mg), give 1 tablet two times a day for 14 days. No documentation could be found for the results of the UA with C & S in resident 2's eMR. On 10/12/24, resident 2's hospital history and physical documented urinalysis shows UTI with WBC [white blood cells] more than 30, RBC [red blood cells] more than 30 and bacteria 4+. Resident 2's hospital discharge orders revealed an order for Bactrim DS 800 mg-160 mg, give one tablet two times a day for 14 days; and Bactrim DS 800 mg- 160 mg, give 1 tablet every day for 30 days after the completion of the 14 day course of twice daily dose. It should be noted that no documentation could be found of resident 2's culture and sensitivity report for the UTI. On 11/12/24, the DON printed the hospital urine culture and sensitivity results. The culture grew out Providencia stuartii (multi drug resistant organism) and Proteus mirabilis. The culture documented that the organism was susceptible to Bactrim. 4. Resident 50 was admitted to the facility on [DATE] with diagnoses which included but was not limited to spina bifida, hydrocephalus, paraplegia, nueromuscular dysfunction of the bladder, and a history of urinary tract infections. On 11/12/24, the facility infection control tracking and trending log was reviewed for October 2024. The log documented that resident 50 had a urinary tract infection on 10/21/24 that was treated with Cipro Tablet, give 500 mg two times a day for 14 days. No documentation could be found for the results of the UA with C & S in resident 50's eMR. On 11/12/24, the DON printed the hospital urine culture results obtained on 10/25/24. The culture grew Pseudomonas aeruginosa, Escherichia coli, and Streptococcus anginosus. The culture documented that the organism was susceptible to Cipro. 5. Resident 52 was admitted to the facility on [DATE] with diagnoses which included but was not limited to rheumatoid arthritis, fibromyalgia, type 2 diabetes mellitus, cognitive communication deficit, major depressive disorder, anxiety disorder, and post-traumatic stress disorder. On 11/12/24, the facility infection control tracking and trending log was reviewed for September 2024. The log documented that resident 52 had a urinary tract infection on 9/16/24 that was treated with Macrobid Capsule, give 100 mg two times a day for 5 days. No documentation could be found for the results of the UA with C & S in resident 52's eMR. On 11/12/24, the DON printed the hospital urine culture results obtained on 9/15/24. The culture grew Escherichia coli. The culture documented that the organism was susceptible to Macrobid. 7. Resident 55 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with dyskinesia without mention of fluctuations, chronic obstructive pulmonary disease, type 2 diabetes mellitus, tremor, and personal history of other infectious and parasitic disease. On 11/4/24 at 8:40 AM, an interview was conducted with resident 55. Resident 55 stated he had pain in his back, that radiated down his right side to his groin and hip. Resident 55 stated he thought it was a pinched nerve but a nurse got a urine sample on 10/28/24. Resident 55 stated he had not heard about the results from his urine and was not sure if he was taking antibiotics. Resident 55 stated the pain from his back to his groin was new. Resident 55 stated that his catheter was removed about a month ago. Resident 55's medical record was reviewed 11/5/24 thought 11/13/24. Another physician's order dated 10/28/24 revealed UA [urine analysis] C&S [culture and sensitivity] one time only for 1 Day. On 10/28/24 at 1:00 AM a nursing progress note revealed .Today patient is being seen regarding flank pain on his right side. Patient states this came on over the past couple days. He states it is around the area of his right kidney. Patient is concerned he might have some type of infection going on. We discussed options of diagnosis including a urinalysis. Today we will go ahead and obtain a urinalysis with culture. I did encourage the patient to hydrate is [sic] much as possible, as this can be an effective way to help clear an infection as well. We did also discuss the possibility of a kidney stone. Patient states that the pain is not very severe at this point. If urinalysis is inconclusive, we can obtain a kidney ultrasound if patient is still having pain. Patient is okay with this plan. Patient had no additional questions or concerns today. Nursing staff had no new concerns on this patient .Continue Foley catheter use . On 10/28/24 at 9:01 PM a nursing progress note revealed, New order received from [name removed] NP [Nurse Practitioner] for UA with C&S. This note was created by Registered Nurse (RN) 3. On 11/10/24 at 2:23 AM a nursing progress note revealed, Alert Charting: Resident c/o R flank pain 8/10. Denies pain in bladder or with urination but does state that he has urgency and frequency with small amounts of urine. States he provided a urine sample already. Called lab to get results faxed. UA abnormals [sic]: slightly cloudy, leukocytes 500(large), WBCH [white blood cells] >30, RBC [red blood cells] H [high] 5, bacteria 1+. bacteria from culture is aerococcus urinae [sic]. On 11/10/24 at 2:34 AM a nursing progress note revealed Alert Charting: Secure message sent to [physician's name removed] and his team regarding symptoms and UA results. There were no UA with C&S located in resident 55's medical record. On 11/12/24 at 10:17 AM, an interview was conducted with resident 55. Resident 55 stated he was now taking antibiotics for his urine test. Resident 55 stated he started antibiotics on Sunday (11/10/24) but did not know what the results were. On 11/12/24 at 10:09 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated if a resident had signs and symptoms of a UTI, she contacted the physician for an order to obtain a urine analysis. RN 3 stated she documented the UA on 10/28/24 for the day shift nurse. RN 3 stated the day shift nurse obtained the physician's order for the UA. RN 3 stated the UA was obtained on 10/28/24. RN 3 stated resident 55 complained of signs and symptoms of a UTI on 11/10/24. RN 3 stated she called the laboratory to obtain the UA results. RN 3 stated she notified the physician and DON about the results. RN 3 stated she passed on in report to the day shift nurse that she found resident 55's UA results. RN 3 stated she was unable to find any follow-up for resident 55 from 10/28/24 until 11/10/24. RN 3 stated a UA results should available by the next day and the culture and sensitivity within 3 days. RN 3 stated there was a glitch in the system with receiving the results from the lab. RN 3 stated the laboratory did not always fax the results to the facility. RN 3 stated nursing staff usually had to call the laboratory and ask for results. RN 3 stated laboratory draws should be passed on verbally during nursing report. RN 3 stated there was a lab book up at nursing station A and with a copy of every lab draw that was done at the facility. RN 3 stated she was not sure if anyone audited the book. RN 3 stated resident 55 complained of flank pain on 11/10/24, some incontinent episodes and frequency of urination with small amounts of urine. RN 3 stated resident 55 told her that a UA probably needed to be done and resident 55 stated he already had his urine collected. RN 3 stated she worked as needed so she worked 10/28/24 and then again on 11/10/24. RN 3 stated resident had a catheter a long time ago but did not have one anymore. On 11/12/24 at 10:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated if a resident had signs and symptoms she would encourage fluids, let the physician know, obtain a physician's order for a urine sample, send the sample to lab and monitor for a change in condition. LPN 3 stated she would not want a resident to become septic for not treating a UTI. LPN 3 stated she would enter the physicians order for a UA into the residents medical record and then would report that to the next nurse. LPN 3 stated it was very important to communicate to the oncoming nurse. LPN 3 stated if there was a progress note, then the DON or nurse managers would see it and watch for the results. LPN 3 stated at times she has had trouble getting laboratory results. LPN 3 stated she had obtained a urine sample for a UA, but then the lab had not communicated the results like sometimes the urine was contaminated and that was not reported to the facility. LPN 3 stated usually the results for a UA were ready by the next day. LPN 3 stated the DON, physician and nurse manager had access to results from the hospital laboratory. LPN 3 stated resident 55 was on antibiotics for a UTI and the results were provided on 11/11/24. LPN 3 stated she was not sure when the UA was obtained but resident 55 should not have waited 12 days for the results and treatment. LPN 3 stated she was not sure what happened with the UA and results. LPN 3 stated there were no residents on bowel and bladder retraining program. On 11/12/24 at 1:24 PM, an interview was conducted with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) 1. The DON stated nurses obtained urine for a UA and then the laboratory picked up the samples twice daily. The DON stated there was a local laboratory and one in Salt Lake City. The DON stated she would expect to get UA results within 1 to 2 days and 3 days for the culture results. The DON stated nurses passed on verbally in report that there was a laboratory draw completed. The DON stated staff should be watching for the results within a few days. The DON stated nurses could call the lab if results were not sent to the facility within a few days. The DON stated results were faxed to the facility but the DON also had access to pull the labs from the lab computer system. The DON stated nurses did not have access to the lab portal. The DON stated if nurses did not receive results within 2 to 3 days, they should be contacting the lab via phone. The DON stated nurses could notify the DON to see if the results were in the system and nurses aware she had access to the portal. The DON stated the antibiotic and physician notification was on the lab results form that was faxed from the lab and then the lab results form was uploaded into the residents document section of the medical record. The DON stated there was no timeframe to have documents uploaded, it was just when medical records staff had time. RNC 1 stated the facility should have the results of a UA and culture no longer than a week after the sample was obtained and for the results to be uploaded into the system. The DON stated resident 55's UA and culture results were longer than the expected time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 3 of 65 sampled residents, that the facility did not have menus that met the nutrition needs of residents in accordance with established nutritional guidelines. Specifically, menus were not followed and correct portion sizes were not provided to residents. Resident identifiers: 15, 16 and 55. Findings included: 1. On 11/3/24 at 1:15 PM, an initial observation was made in the kitchen. Several additional observations were made in the kitchen between 11/3/24 an 11/13/24. a. On 11/3/24 at 1:15 PM an observation was made of the lunch meal being plated. The meal served included 1 piece of chicken, a 4 ounce (oz) slotted spoon of cubed yams, a 6 oz slotted spoon of green beans, 1 dinner roll with a pat of butter, and a slice of chocolate cream pie, serving size unknown. A review of the spreadsheet for the lunch meal revealed the recipe called for a 1-3 oz piece of chicken, 1-5 oz baked sweet potato, a 4 oz serving of green beans, 1 slice of bread or roll, 1 pat of butter and 1/10 slice of cherry pie. b. On 11/3/24 at 5:48 PM, an observation was made of the dinner meal being plated. The meal served included 1 grilled tortilla with a hand-full of cheese, folded in half and cut into 2 pieces, a 4 oz ladle of herbed fettuccine noodles, a green side salad, and a small cup of tapioca pudding. It should be noted that the menu posted listed the main course for the dinner meal on 11/3/24 was to be a savory ham wrap. A review of the spreadsheet for the dinner meal revealed the recipe called for 1 grilled tortilla with ½ cup of cheese, folded in half, 4 oz of rotini-tri-colored pasta, a #8 scoop (4 oz) of creamy coleslaw, and an assorted dessert-1 each. c. On 11/5/24 at 9:13 AM, an interview was conducted with the Dietary Manager (DM) who stated that on 11/4/24 the lunch meal included Pasta [NAME] and vegetables. The DM stated the pasta was made with a white sauce and had peas and broccoli, maybe cauliflower. The DM stated he was not sure if the recipe was in the recipe book. It should be noted that the menu posted listed the main course for the lunch meal on 11/4/24 as Cheese Ravioli with Pesto Sauce. A review of the spreadsheet for the lunch meal on 11/4/24 revealed that the recipe called for 2/3 cup or 8 oz of Pasta [NAME], a 4 oz serving of a cucumber salad, a breadstick with butter, and a 2 x 3 inch piece of chocolate cake with peanut butter frosting. d. On 11/5/24 at 9:35 AM, an observation was made of 2 resident plates during the breakfast meal. The plates contained 3-3 inch waffles, a large serving of scrambled eggs (covering almost ½ of the plate), and 5 pieces of bacon. One tray ticket was for a regular diet, the second tray ticket was for a regular diet but had double portions written on it. A review of the spreadsheet for the breakfast meal on 11/5/24 revealed that the recipe called for 1-3 inch Belgian waffle, 2 slices of bacon ½ cup of seasonal fruit, and a #16 scoop (1/4 cup) of eggs, and 1 ½ cups of hot cereal. e. On 11/5/24 at 6:02 PM, an observation was made of the dinner meal being plated. The meal served was 1 chicken thigh, a small ladle of marinara sauce, a small amount of shredded cheese, apple maple stuffing, and mixed steamed vegetables (cauliflower, broccoli, and carrots). It should be noted that the menu posted listed the menu for the dinner meal on 11/5/24 as Pineapple braised chicken with herbed rice and buttered spinach. A review of the spreadsheet for the dinner meal on 11/5/24 revealed the recipe called for a 4 oz breaded chicken thigh, 2 oz of spaghetti sauce sprinkled with 2 tsp (teaspoons) of parmesan cheese, an #8 scoop (1/2 cup) of apple maple stuffing, a #8 scoop ( ½ cup) of California blend vegetables. f. On 11/7/24 at 12:48 PM, an observation was made of the lunch meal being plated. The meal consisted of 2-4 oz spoons of creamy ranch macaroni and cheese, a ½ cup of cooked zucchini, and a pudding parfait with chocolate and vanilla pudding. For residents who could not have the zucchini or preferred not to have it a side salad was provided. For residents who were lactose intolerant, some noodles with marinara sauce were provided. It should be noted that residents that received the noodles with marinara sauce did not receive a source of protein for that meal. A review of the spreadsheet for the lunch meal revealed the recipe called for 1 cup of creamy ranch macaroni, a #8 or ½ cup of sauteed zucchini, 1 breadstick with butter and 1 Tbsp (tablespoon) of the pudding parfait. On 11/7/24 at 1:32 PM, an interview was conducted with the Assistant Dietary Manager (ADM) about the noodles with marinara sauce. The ADM stated it was not put into the [dietary software] to compare the meal for nutritional adequacy because there was not an alternate so they just had to wing it . The ADM stated they should look at the substitutions because I didn't realize it did not have the protein in it. 4. Resident 15 was admitted to the facility on [DATE] with diagnoses which included hereditary ataxia, cognitive communication deficit, dysphagia, hypothyroidism, major depressive disorder, anemia, peripheral neuropathy, dysarthria and anarthria, speech disturbance, wedge compression fracture of third lumbar, edema, and insomnia. On 11/03/24 at 2:02 PM, an interview was conducted with resident 15. Resident 15 stated that the food was alright, but that sometimes she did not get enough to eat. Resident 15's electronic medical records were reviewed. On 9/11/24 the Annual MDS (Minimum Data Set) Assessment documented that the resident had a BIMS of 15, which would indicate that she was cognitively intact. On 5/1/24, resident 15's diet order was for a Regular (Reg) diet, Chopped Meat texture, Thin liquids consistency. Patient to be upright in wheel chair for all meals. On 9/11/24, the care conference summary documented under Food and Nutrition summary that resident 15 wanted to participate in the snack program and would like snacks at 10:00 AM, 3:00 PM, and 8:00 PM. Resident 15's eating task for the last 30 days documented 59 occasions when the resident consumed 75% to 100% of their meal. The task documented that the resident required set up assist for dining. [Cross-refer F809] On 11/4/24 at 4:37 PM, an interview was conducted with the ADM who stated the spreadsheets for each meal showed the different therapeutic diets and if residents who were on therapeutic diets could have the food items on the menu. The ADM stated for residents with specific therapeutic diets, an alternate would be listed that would be an appropriate substitution. The ADM stated normally if a substitution had to be made, the Administrator would have to be notified or the Registered Dietitian (RD). The ADM stated the software for the menus could be used to put in a substitution and it would verify if the substitution was nutritionally comparable to the item on the menu. The ADM stated if the app did not approve the substitution, it would suggest how to fix it. The ADM stated she had not had a problem reaching the Administrator or the RD when a substitution needed to be made. The ADM stated she would need to know in the morning if a substitution needed to be made so she could be sure there was enough food for the meal. The ADM stated if a resident did not like what was on the menu, they could ask for an alternative. The ADM stated she was told if a resident wanted something they could give it to them. On 11/5/24 at 11:03 AM, an interview was conducted with the RD. The RD stated she started working at the facility in September. The RD stated the ADM, who was previously working as the DM did not have experience in long term care. The RD stated the ADM did not receive much training from the previous DM. The RD stated she was not sure who should be providing education to the dietary staff. The RD stated if she identified a problem she would tell the administrator and would not provide the education. The RD stated the current DM had a lot of experience in long term care. The RD stated she had spoken to the current DM about some of her concerns and the DM told her he was working on it. The RD stated she had not completed any tray audits since she began working at the facility. The RD stated if she did a tray audit it would include asking for a test tray, taking the temperature of the food, looking at the presentation of the food, tasting the food, and compare what was served with the menu. The RD stated she could make substitutions on the menu for the day, which would require going into the software and changing the menu items. The RD stated if substitutions were made, they would be posted for the residents to see and a log of the substitutions would be kept in a binder for a year. The RD stated the DM could go into the software and make substitutions. The RD stated the software would make suggestions for an alternate when a substitution needed to be made. The RD stated she sort of knew if the dietary staff were not following the menu. The RD stated the previous week the DM was making a substitution and she looked it over and it was complete and had a protein on it. The RD stated the substitution would depend on what food items came on the truck in the food delivery. The RD stated the software company offered online training on how to use the software. The RD stated she was not sure if it was part of her role to train the DM on how to use the software. The RD stated she was new to using the software and those particular menus. The RD stated if the software was being used correctly, there was a help line for support. The RD stated when putting in a substitution, the menu would populate and let you know what needed to be added. The RD stated the DM should be self-monitoring when following the menus. The RD stated when reviewing a menu and the substitutions, she looked to ensure there was adequate protein, vegetables and that the menu was meeting the 5-a-day recommendations as well as vitamin A. The RD stated she had not looked at the menu for the current week, but there should be a seasonal rotation of the menu. The RD stated there were menus posted in the hallways, and menus the residents could take to their rooms. The RD stated if a resident did not want what was on the menu they could mark the menu and provide it to the kitchen. The RD stated she thought the Certified Nursing Assistants (CNA)s were taking menus to the resident rooms to ask the residents if they wanted to make any changes to the menu and then bringing the menus to the kitchen at the beginning of the week. The RD stated if the DM had questions or needed to contact her he could always call or text her. The RD stated she had worked with the DM for a long time and he did not have a problem asking questions. The RD stated her contract was for 8 to 12 hours per week. The RD stated with the current census she would need at least 20 hours per week to keep up with resident visits and quarterly assessments. The RD stated the 8 to 12 hours she was currently working did not include kitchen duties. On 11/5/24 at 3:48 PM, an interview was conducted with the Administrator (ADMIN) who stated the RD's responsibilities were in her contract. The ADMIN obtained a copy of the RD contract and stated her duties included, oversees dietary plans for resident's dietary needs based on medical needs .review and approve all menus to ensure they meet resident's nutritional needs in compliance with state and federal regulation .provide staff training on food and nutrition. The ADMIN stated the kitchen always made a little extra to ensure that everyone who wanted a meal would get one. 2. Resident 55 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with dyskinesia without mention of fluctuations, chronic obstructive pulmonary disease, type 2 diabetes mellitus, tremor, and personal history of other infectious and parasitic disease. On 11/4/24 at 8:45 AM, an interview was conducted with resident 55. Resident 55 stated he did not feel like he got enough food to eat and was not offered snacks. 3. Resident 16 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to embolism of left middle cerebral artery, cognitive communication deficit, diabetes mellitus and major depressive disorder. On 11/5/24 at 9:19 AM, an observation was made of resident 16. Resident 16 was observed at the kitchen door yelling I'm [expletive removed] hungry, man! Resident 16 was observed to tell the Maintenance Director he needed to talk to the kitchen staff. The Maintenance Supervisor was observed to tell resident 16 that he needed to talk to the nurse and could not come through any door he wanted. Resident 16 was observed to tell the kitchen staff he was [Expletive removed] hungry and he had not received breakfast. The DM was observed to intervene between resident 16 and the Maintenance Supervisor. The DM asked resident 16 what he would like to eat for breakfast. Resident 16 was observed to tell the DM what he wanted for breakfast. Resident 16 was observed to use his wheelchair to motorize through the hallway to his room. On 11/5/24 at 9:23 AM, an interview was conducted with resident 16. Resident 16 stated the portions were too small. Resident 16 stated he should be getting double portions but never got that much. Resident 16 stated I'm hungry. On 11/5/24 at 6:08 PM, an observation was made resident 16's meal. Resident 16 had 1 breaded chicken breast with marinara sauce and cheese on it over pasta. Resident 16's medical record was reviewed. Resident 16's diet order revealed Consistent Carbohydrate diet regular texture, thin liquids consistency, double protein portions and extra 8 oz fluid with each meal. A care plan dated 7/29/23 and updated on 10/21/24 revealed Potential nutritional problem r/t [related to] diabetes, cognitive communication deficit, depression, aphasia, dysarthria, and anarthria. Non compliance with meals and food safety. Resident refuses to have tray pickup after 1 hour. He is at risk for infection, malnutrition, and potential food poisoning. The goal was The resident will comply with recommended diet for weight reduction daily through review date. Some of the interventions included 6/5/2024: Resident has expressed that he would like to gain weight, wanting to increase weight to 250 pounds. Resident is receiving double protein portions. Resident educated on weight gain.; Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors; and Provide and serve diet as ordered. On 11/5/24 at 1:07 PM, an interview was conducted with Licensed Practical Nurse (LPN) 5. LPN 5 stated if resident 16 received small portions he yelled. LPN 5 stated there were new staff in the kitchen that had not been educated, so they did not send the right food to residents.

5. Resident council Minutes: A review of resident council notes revealed the following regarding the dietary department: a. April 2024: .taste/quality concerns-deteriorated, of late . b. May 2024: .Food Committee: Items to be addressed at next meeting with new dietary manager include allergies/ dietary restrictions being accommodated, snacks available, portions, preferences (fish/eggs served) etc . c. July 2024: Food improvement noted. Coffee/Cocoa Social supplies or able to increase the potency of the coffee left out in the Bistro. A couple of specific residents noted issues with their recent orders, which will be addressed on a case by case basis. d. August 2024: .Some residents indicated that they thought some of their food was expired .The drinks also do not match some resident's expectations . e. September 2024: .Several residents reported that food is cold. [Activities Director] shared that maintenance is in the process of replacing a heating element necessary to keep the trays warmer and those are actively being replaced. Some residents regularly receive clamshells instead of trays and asked why, as they get cold faster. It was reported that sometimes dishes are in short supply .Based on observation, interview and record review it was determined, for 11 out of 65 sampled residents, that the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that was palatable, attractive, and at an appetizing temperature. Specifically, there were multiple complaints from residents about the quality of food, there were multiple resident council complaints about the flavor of food, and when surveyors pulled a test tray during the lunch meal, the food was found to be lacking in flavor and appearance. Resident identifiers: 9, 12, 16, 22, 26, 27, 28, 32, 50, 55, and 120. Findings included: 1. Observations: On 11/3/24 at 5:48 PM, an observation was made of the kitchen staff plating the dinner meal. The meal consisted of a grilled cheese quesadilla, herbed fettuccini noodles and a green salad. The Dietary Manager (DM) was at the steam table plating the food, cook 2 was putting the meal trays together. The Housekeeping Supervisor (HS) was helping in the kitchen, making salad and cooking the quesadillas. The DM put 2 quarters of a quesadilla onto the plate, 4 oz of herbed fettuccini noodles using a slotted serving spoon and handed the plate to cook 2. [NAME] 2 put the plate into a plate holder and covered the plate. For residents who required a mechanical meal, the quesadilla was torn into smaller pieces or cut into smaller pieces. A side salad covered with plastic wrap was placed on the tray. A small plastic cup of tapioca pudding was also placed on the tray. Silverware and drinks were put on the tray and it was placed into the meal cart. On 11/3/24 at 6:12 PM, the DM requested a cup of hot water from [NAME] 2. The DM poured the hot water into the noodles because they were drying out and mixed them up. On 11/3/24 at 6:43 PM, an observation of resident 12's dinner tray was made. The resident's plate had a quesadilla and bowtie pasta cut into bite-sized pieces. On 11/4/24 8:06 AM, an observation was made of resident 27's breakfast meal. The banana was cut up into pieces and appeared brown in color and mushy. 2. Resident Interviews: On 11/3/24 at 2:05 PM, an interview was conducted with resident 50 who stated, There is room for improvement. Some of the meals are edible and some are not. On 11/3/24 at 2:37 PM, an interview was conducted with resident 120. Resident 120 stated the same menu items are repeated. Resident 120 stated the food temperatures were not consistent and food did not always taste good. On 11/3/24 at 5:33 PM, an interview was conducted with resident 9 who stated, The food is cold 90% of the time. On 11/4/24 at 8:06 AM, an interview was conducted with resident 27. Resident 27 stated that the food was undercooked and the bread was dry. Resident 27 stated that the food was not good and looked even worse. On 11/4/24 at 8:09 AM, an interview was conducted with resident 22. Resident 22 stated the portions were small and the food was not good. Resident 22 stated the food that should be hot was always cold and the cold food was warm. Resident 22 stated she wanted hot food hot and cold food cold. Resident 22 stated she ordered meals from a local delivery company because she did not like the meals served. On 11/4/24 at 8:22 AM, an interview was conducted with resident 32. Resident 32 stated the meals were not good and the kitchen had gone through 5 to 6 cooks. Resident 32 stated last night he was not sure what the food was, so he only ate the dessert. On 11/4/24 at 8:43 AM, an interview was conducted with resident 55. Resident 55 stated he had eaten better food than what the facility served. Resident 55 stated he was served a quesadilla and noodles last night. Resident 55 stated he did not get enough food to eat. On 11/4/24 at 8:43 AM, an interview was conducted with resident 26. Resident 26 stated that she was given a banana that was black inside and she was not going to eat it. Resident 26 stated that twice she had been given spoiled cottage cheese and she needed the extra protein in her diet. Resident 26 stated that the pancakes are tough and unable to be eaten. On 11/5/24 at 9:23 AM, an interview was conducted with resident 16. Resident 16 stated he either loved the food or hated it. On 11/5/24 at 12:43 PM, an interview was conducted with resident 28. Resident 28 stated there was not a good cook on the weekends. Resident 28 stated they needed a Dietitian, like one of the real ones that would know about things. 3. Observations in Kitchen On 11/5/24 at 9:03 AM, an observation was made of tray line. There were 6 trays for the hallway that did not have hot pellets. [NAME] 1 stated there were not enough hot pellets so about 6 trays did not have them. On 11/7/24 at 12:48 PM, an observation of the lunch meal tray line was conducted. The lunch meal was ranch macaroni and cheese and zucchini, a bread stick and pudding parfait. For the residents who could not eat zucchini, a salad was served. A container with noodles mixed with marinara sauce was also on the steam table. When asked about the noodles with marinara sauce, the Assistant Dietary Manager (ADM) stated the menu was not entered into the [Vender software] system for an alternate recommendation because there was not an alternate for the ranch macaroni and cheese so she just had to wing it. The ADM stated, they should look at the substitution because she did not realize it did not have any protein in it. On 11/7/24 at 1:35 PM, the trays for the memory unit were started, after the 200, 300, 400 and 500 hallway trays were sent out. A test tray was requested at 1:42 PM, before the cart for the memory care unit left the kitchen. At 1:49 PM, the cart for the memory care unit left the kitchen and was brought to the 300 hallway just outside of the memory care unit doors. At 1:52 PM, a CNA brought the cart into the memory care unit and began to pass meals. All residents were eating in their rooms. 4. Test Tray On 11/7/24 at 1:56 PM, the test tray was taken off of the meal cart after all residents had been served and it was brought to the conference room for testing. The results were as follows: a. Ranch macaroni and cheese- 106.4 degrees Fahrenheit, acceptable flavor, not warm to the taste. b. Marinara macaroni- 107.1 degrees Fahrenheit, tasted like spaghetti sauce on noodles, bland flavor, not warm to the taste. C. Zucchini- 109.2 degrees Fahrenheit, lacking in seasoning, bland, with an over cooked/mushy texture. d. Breadstick- not warm to the taste and dry to the taste e. Passion fruit juice- 52.7 degrees Fahrenheit with a nice flavor It should be noted that the cup the fruit juice was served in was not clean. On 11/5/24 at 11:03 AM, an interview was conducted with the Registered Dietitian (RD) who stated tray audits included asking for a test tray, taking the temperature of the food, tasting the food, observing the presentation of the food and if it was meeting the dietary guidelines and was what was stated on the menu. The RD stated she had not conducted any tray audits since she started working at the facility in September. On 11/5/24 at 3:47 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated there were residents not happy with the food quality. The ADMIN stated a new Dietary Manager (DM) was hired with a lot of experience and the complaints had gone away. The ADMIN stated the DM started 3 weeks ago. The ADMIN stated there was an alternative menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident 26 was admitted to the facility on [DATE] with diagnoses which included facioscapulohumeral muscular dystrophy, unspecified protein-calorie malnutrition, hyperlipidemia, hypomagnesemia, hypo-osmolality and hyponatremia, and weakness. On 11/3/24 at 3:20 PM, an interview was conducted with resident 26. Resident 26 stated that she had an allergy to wheat and that it caused her to get blisters on her body. Resident 26 stated that she was recently given a grilled cheese sandwich that was made on wheat bead and that she could not eat it. Resident 26's meal card revealed that seafood and wheat were listed as allergies. On 11/5/24 at 5:57 PM, an interview was conducted with resident 26. Resident 26 stated that she had eaten all of the stuffing that had come with her dinner. Resident 26 stated that she believed the stuffing was made out of cornbread because the kitchen staff should know that she had an allergy to wheat. Resident 26 stated that the meal ticket also stated that she had a wheat allergy. On 11/5/24 at 3:32 PM, an interview was conducted with the ADM. The ADM stated she did not add onions to the apple maple stuffing and the other ingredients were the same. According to the recipe, the Apple Maple Stuffing was made with bread, white wheat, whole grain. A review of facility resident council meetings revealed: a. May 2024: .Items to be addressed at next meeting with new dietary manager include allergies/dietary restrictions being accommodated, snacks available, portions, preferences (fish/eggs served) etc . b. June 2024: .Want to get issues resolved, once we have a manager: cheese sticks and pudding are usually available, missing often are: sandwiches, yogurt, juice, chips, cookies, crackers, etc. For some, they prefer to take their pills with these as a medium or are used for 'quick fixes' with low blood sugar #s [numbers] . c. August 2024: .Several residents commented that the meals are often missing condiments and that their plates do not match their preferences . 4. Resident 28 was admitted to the facility on [DATE] with diagnoses which included hypertension, severe persistent asthma with acute exacerbation, and muscle weakness. On 11/3/24 at 1:33 PM, an interview and observation were conducted with resident 28. Resident 28 was in her room and had her lunch tray in front of her, a bowl of chocolate pudding with red thick liquid was observed on her tray. Resident 28 stated it was pudding and that it was supposed to be cherry pie. Resident 28 stated that she cannot have any dairy and that it would cause a system wide reaction and would make her nauseated and to have uncontrollable diarrhea. Resident 28's meal ticket was observed on her tray, it indicated, no pudding no cream pies cakes are ok .Alerts: [blank] .Dislikes: Dairy products (ALL DAIRY PRODUCTS) Pineapple rice. Resident 28's medical record was reviewed 11/3/24 through 11/13/24. A Minimum Data Set (MDS) Assessment, dated 9/23/24, indicated resident 28 had a Brief Interview for Mental Status (BIMS) of 10, which indicated a moderately impaired cognition. The resident's banner included, Allergies: Aspirin, Ibuprofen, Penicillin, Dairy, BLEACH. A Nutrition (Dietary) note, dated 6/25/24 at 11:54 AM, indicated, .Res [resident] is not agreeable to accepting supplement d/t [due to] stomach issues. She is also particular regarding food preferences, and has an allergy to dairy. A Nutrition (Dietary) note, dated 8/7/24 at 2:07 PM, indicated, RD Note/Consult: RD met with res regarding c/o [complains of] possible dietary issues. Res stated that her dietary issues/abdominal pain has resolved. She had eaten her whole hamburger at lunch and stated it was good. Res stated she ate some saltine crackers for a few days and this allowed her stomach to settle. Res was agreeable. Stated she didn't need any major changes. Res does have a dairy allergy. Continue to monitor and educate staff regarding dairy allergy. On 11/5/24 at 11:54 AM, an interview was conducted with RD. The RD stated resident 28 was allergic to dairy and should not have dairy, no milk, and no ice cream. The RD stated the pudding served on Sunday was probably made with milk. On 11/5/24 at 1:03 PM, an interview was conducted with CNA 8. CNA 8 stated she did not know of any allergies that resident 28 had, but that it would say it on the meal ticket if she had an allergy. On 11/5/24 at 1:27 PM, an interview was conducted with RN 4. RN 4 stated she did not know if resident 28 had any allergies. RN 4 stated if she did it should have been listed on the meal ticket. RN 4 looked at resident 28's electronic medical record and stated that it was listed on the clinical sheet that she was allergic to dairy. On 11/5/24 at 4:25 PM, an interview was conducted with the ADMIN. The ADMIN stated that if a resident had any allergies that it should have been listed on their meal ticket. The ADMIN stated that the kitchen would verify that the resident's allergies and preferences listed on the meal ticket were correctly followed. On 11/12/24 at 2:40 PM, an interview was conducted with the ADM. The ADM stated the dessert that was served on Sunday for lunch was a pie but it did not hold it's shape so it probably looked like a bowl of chocolate pudding. The ADM stated the chocolate pudding from the pie could have had dairy in it but was not able to provide the ingredients. Based on observation, interview and record review it was determined, for 6 of 65 sampled residents, that the facility did not ensure that each resident received the food and drink that accommodated the resident allergies, intolerances, and preferences. Specifically, residents with food allergies and intolerances were served food containing identified allergens, and one resident who was admitted on [DATE] had not been questioned about food allergies until 11/5/24. Resident identifiers: 1, 10, 16, 26, 28, and 38. Findings included: 1. Resident 38 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, type 2 diabetes with skin ulcer and neuropathy, cirrhosis of liver, morbid obesity, hemiplegia affecting right dominant side, anxiety disorder, aphasia, major depressive disorder, seizures and dysphagia. On 11/5/24 at 12:38 PM, an interview was conducted with resident 38 who stated he was allergic to onions and was provided a lunch entree that contained onions. Resident 38 stated his allergic reaction to onions was that he began to have anaphylaxis. Resident 38 stated that 2 to 3 weeks ago he was served tuna salad with onions and pickles. Resident 38 stated he was unaware that there were onions in the tuna salad. Resident 38 stated he started to feel his throat swell and went to the nurse immediately and was given a pink pill. Resident 38's medical chart was reviewed. Documentation under allergies in the medical chart dated 9/13/24 included onions. On 9/13/24 at 3:30 PM, an alert charting progress note revealed, Received report from [facility name] . Pt [patient] has an allergy to onions. On 9/16/24 at 1:00 AM, a provider progress note included, .Allergy list: Onions 9/13/24. On 10/18/24 at 7:44 PM, an administration progress note revealed, Benedryl allergy Oral Tablet 25 MG [milligrams]; Give 2 tablet by mouth every 4 hours as needed for Allergies. Do not take more than 6 doses in a 24 hour period. On 11/5/24 at 5:36 PM, an interview was conducted with Licensed Practical Nurse [LPN] 1 who stated that during the dinner meal resident 38 stated his meal contained onions. The tray had been removed already. LPN 1 stated that she obtained a different tray and asked the resident if he had been given the same meal. The meal shown to the resident contained green onions. A meal from another cart was observed resident 38 was asked if the meal was the same as what he was given and he replied, yes. Vital signs were WNL [within normal limits], resident 38 had no complaints, vital signs were documented in [medical software], and the Director of Nursing [DON] was texted. The DON was called to see what should be done in the instance. The DON stated to LPN 1 to look in the stat [immediate] safe epi-pen, and if anything happened to call EMS [emergency medical services]. A vial of epinephrine was found to be in the stat safe. LPN 1 stated she assessed for any difficulty breathing, itchiness in throat or body, tingling in throat or mouth, and resident 38 denied any s/sx [signs or symptoms]. LPN 1 stated there was no swelling of the lips observed and resident 38 sat at the nurse's station for 30-40 minutes for monitoring and the resident was fine. LPN 1 stated that she did not notify the MD [medical doctor]. LPN 1 stated that she did not document a note about the incident but just called the DON. LPN 1 stated that after the incident, the nurses were checking resident meals tickets to verify that the meals were correct. LPN 1 stated resident 38 had a behavior of saying his food had onions in an effort to obtain more food. On 11/5/24 at 6:02 PM, an observation was made during the dinner meal service. The meal being served was chicken parmesan with steamed vegetables and apple maple stuffing. The Assistant Dietary Manager (ADM) plated the food by first putting a chicken breast on the plate, covered it in marinara sauce and sprinkled some shredded whole milk cheese on top. The ADM then added stuffing and a serving of steamed mixed vegetables. The ADM stated there were no onions in the stuffing. It should be noted that the marinara sauce contained tomatoes, sea salt, dehydrated onions, dehydrated garlic, spices, natural flavorings, sweet bell pepper, and citric acid. On 11/5/24 at 6:08 PM, an observation was made of Registered Nurse (RN) 1. RN 1 was observed at the meal cart in the 300 hallway. RN 1 was observed to look at each residents meal and meal ticket before handing it to a CNA. RN 1 was observed to look at resident 1's meal and meal ticket and handed it to the Laundry Supervisor (LS). On 11/5/24 at 6:24 PM, the LS brought a tray back to the kitchen and asked if any of the food items had onions. The Assistant Dietary Manager (ADM) stated there was no onion in the stuffing, but made another tray without stuffing as the resident thought there were onions in the stuffing. On 11/5/24 at 6:29 PM, a Certified Nursing Assistant (CNA) came to the kitchen stating that resident 1 received a plate with vegetables on it when vegetables were listed on his dislikes for meals. The ADM prepared another plate for resident 1 without vegetables. On 11/5/24 at 6:31 PM, the LS was observed enter the activity room and provide resident 1 a dinner tray during the activity. On 11/5/24 at 6:32 PM, an interview was conducted with the ADM. The ADM stated she was not aware that that the marinara sauce had dehydrated onions in the ingredients. The ADM stated resident 38 had eaten the sauce a million times and it had not done anything, so he should be fine with it. On 11/5/24 at 6:35 PM, an interview was conducted with the DON. The DON stated she was not aware the marinara sauce had dehydrated onions in it. The DON stated Thank you for letting us know. On 11/5/24 at 6:41 PM, the facility Administrator (ADMIN) came to the kitchen and requested another plate for resident 38. The ADMIN stated resident 38 had received a meal with marinara sauce on it and there was onion in the marinara sauce. The ADMIN took the stuffing off of the plate and put it on a new plate and prepared a chicken breast with just cheese on top and vegetables and brought it to the resident. 2. Resident 10 was admitted to the facility on [DATE] with diagnoses that included personal history of traumatic brain injury, type 2 diabetes, bipolar disorder, post-traumatic stress disorder, morbid obesity, major depressive disorder, anxiety disorder, and cognitive communication deficit. On 11/6/24 at 8:51 AM, an interview was conducted with resident 10 who stated facility staff had come to his room on 11/5/24 and asked if he had any food allergies. Resident 10 stated his meal ticket now indicated he had food allergies to grapefruit, salmon, tuna, and green peas. A review of resident 10's medical record revealed no information about food allergies on admission assessment, or in the provider assessment completed on 8/22/24, or the admission nutrition assessment completed on 8/24/24. On 11/13/24 at 9:11 AM, an interview was conducted with the DON who stated staff were made aware of resident food allergies by what was printed on the resident's meal ticket. The DON stated meal trays were checked by the nurses and CNAs as well as the kitchen staff. The DON stated having the nurses check the meal tickets was initiated after the kitchen was struggling to catch food allergies and preferences on the resident's meal ticket. The DON stated when a resident was admitted , allergies should be on the resident's history and physical, and from that, the information was put in the resident's medical record and on the resident's meal ticket. The DON stated the Dietary Manager (DM) should be filling out a form with the resident about allergies and food preferences, but was unsure if that was being done. The DON was asked about resident 38 and the Benedryl that was provided to him on 10/18/24. The DON stated she did not remember the exact situation and as far as she was aware, there had not been any incidents of residents having a reaction as a result of a food allergy. The DON stated staff should be documenting why they were administering allergy medication and what the symptoms were when the medication was provided. The DON also stated allergy testing was ordered for all residents with food allergies so the reactions could be documented. 3. Resident 16 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to embolism of left middle cerebral artery, cognitive communication deficit, diabetes mellitus and major depressive disorder. On 11/5/24 at 1:00 PM, an interview was conducted with resident 16. Resident 16 stated he would die if he ate tomatoes. Resident 16 stated as a little kid thought he had one. Resident 16 stated the facility served him tomatoes. Resident 16 stated he was able to see if he had tomatoes were on his tray and did not eat them. Resident 16 stated he told staff Hello, tomatoes Die. Resident 16 stated that staff said they were sorry but did not stop sending him tomatoes. Resident 16's medical record was reviewed. Resident 16 had allergies listed as Penicillin and Tomato. A Diet Type Report dated 11/3/24 revealed resident 16 had additional directions of double protein portions, extra 8 ounces fluid with each meal, per patient report highly allergic to tomatoes. On 10/8/24 at 9:08 PM a nursing progress note revealed, Resident extremely upset that his tray had tomatoes. He says he will 'die' if he eats it. added allergy to profile. On 11/5/24 at 6:08 PM, an observation was made of RN 1 at the 300 hallway meal cart. RN 1 was observed to look at resident 16's meal ticket and then lifted the lid of the tray. There was marinara sauce on the tray. RN 1 was observed to hand it to a CNA. The CNA was observed to take the tray to resident 16's room and place it on his bed. Resident 16 was not in his room. On 11/5/24 at approximately 6:30 PM, an interview was conducted with RN 1. RN 1 stated that she checked all the residents meal tickets and their meals to make sure they were not served foods they were allergic to or food they did not like. RN 1 stated that resident 16 was allergic to tomatoes but was not sure what his allergy was. RN 1 stated that marinara sauce was made of tomatoes and resident 16 should have not been served the sauce. On 11/5/24 at 7:15 PM, an interview was conducted with resident 16. Resident 16 nodded yes when asked if he was allergic to all tomatoes. Resident 16 stated, raw die. Resident 16 made a quarter-sized circle with his hand and pointed to the circle and stated, there, die. Resident 16 was asked if he could eat marinara sauce, and he responded, love marinara, raw die. On 11/5/24 at 11:34 AM, an interview was conducted with the Registered Dietitian (RD). The RD stated the DM or ADM updated food preferences a minimum of once per year. The RD stated if a resident went to the hospital then their allergies and preferences were reviewed upon readmission. The RD stated upon admission, there was admission paper work the nurse completed to let the kitchen know there was a resident with a food allergy. The RD stated she was not sure if resident 16 had food allergies but the kitchen should not serve the resident foods they were allergic to.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review for 4 of 65 sampled residents, the facility did not ensure each resident received drinks, including water and other liquids, consistent with the residents' needs and preferences and sufficient to maintain resident hydration. Specifically, water was not being provided to residents between meals, residents had to seek out staff to obtain fresh water and resident water mugs were not being cleaned regularly. Resident identifiers: 26, 27, 55 and 120. Findings include: 1. Resident 26 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, facioscapulohumeral muscular dystrophy, unspecified protein-calorie malnutrition, hyperlipidemia, hypomagnesemia, hypo-osmolality and hyponatremia, and weakness. Resident 26's meal ticket revealed an alert to encourage fluids. A review of resident 26's care plan revealed the following: a. Focus: Potential for Health Maintenance related to: Facioscapulohumeral muscular dystrophy, malnutrition, hyperlipidemia, hypomagnesemia, hyponatremia, headache, hx [history] of falling, osteopenia, palpitations, weakness, nausea, hx of nicotine use. Date Inititiated: 6/26/23 b. Interventions: Administer medications as ordered by the physician Date initiated: 6/26/23 Assess for and provide adaptive equipment/assistive devices as needed Date initiated: 6/26/23 Educate resident on identifying signs and symptoms of worsening health conditions/disease processes and reporting them to staff Date initiated: 6/26/23 Elevate HOB [head of bed] PRN [as needed] for comfort Date initiated: 6/26/23 Monitor for increased pain and report to nurse/MD [medical doctor] Date initiated 6/26/23 Monitor labs per physician order Date initiated: 6/26/23 Offer and encourage fluid intake Date initiated: 6/26/23 Provide assistance with ADLs [activities of daily living] as needed Date initiated: 6/26/23 Refer to therapy to evaluate and treat as indicated Date initiated: 6/26/23 Report changes from baseline function/change of condition to MD Date initiated: 6/26/23 On 11/3/24 at 3:20 PM, an interview was conducted with resident 26. Resident 26 stated that she was not receiving water during the day. Resident 26 stated she had to ask for water or go out to the nurse's station to ask someone there for water. Resident 26 stated the kitchen did not have clean mugs for her to use. Resident 26 stated that she had to buy smaller mugs to fit in her sink so that she could wash them herself. Resident 26 stated she washed the mugs with hand soap at first, but was able to buy some dish soap. 2. Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, aftercare following joint replacement surgery, difficulty in walking, muscle weakness, type 2 diabetes mellitus with hyperglycemia, major depressive disorder, anxiety disorder, essential hypertension, unsteadiness on feet, and history of falling. A review of resident 27's care plan revealed the following: a. Focus: Risk for falls related to Arthritis, anxiety, Fatigue, weakness, Incontinence, Pain, Use of Antidepressants and Use of Narcotic analgesics. Date initiated: 7/22/20 Revision on: 10/12/22 b. Interventions: Ensure that resident is wearing appropriate non-skid footwear when transferring, ambulating or mobilizing in w/c [wheelchair]. Date initiated: 7/22/20 Revision on: 9/23/22 I prefer to keep all needed items like water pitcher, tissue box, urinal, etc, within reach Date initiated: 7/22/20 I would like staff to keep furniture in locked position during transfers and nursing care. Date initiated: 7/22/20 I would like staff to provide me a safe environment: even floors, free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls Date initiated: 7/22/20 Offer me toileting assistance every 2-3hours [sic] while awake and PRN. Date inititiated: 7/22/20 Revision on: 7/22/20 Please avoid repositioning the furniture in my room. Date initiated 7/22/20 On 11/04/24 8:22 AM , an interview was conducted with resident 27. Resident 27 stated that she had to get water for herself down at the nurse's station because she was not provided water throughout the day and call lights were not answered. On 11/6/24 at 5:30 PM, an observation was made of resident 27 walking down the hallway towards the nurse's station. Resident 27 asked Certified Nurse Aide (CNA) 6 for some water. 3. Resident 120 was admitted to the facility on [DATE] with diagnoses which included, but not limited to lymphedema, superficial mycosis, cellulitis of right lower limb, activated protein c resistance, cellulitis of left lower limb, and morbid (severe) obesity due to excess calories. A review of resident 120's care plan revealed the following: a. Focus: Potential for altered skin integrity related to: incontinent, skin moisture, morbid obesity Date initiated: 9/17/24 b. Interventions: Administer treatments for skin impairment per physician order. Notify MD is skin impairment does not respond to current treatment regimen or resident experiences and adverse reaction. Date initiated: 9/17/24 Encourage good nutritional and oral fluid intake Date initiated: 9/17/24 Encourage/prompt resident to change positions regularly to offload pressure points. Resident is able to make major and frequent position changes without staff assistance. Date initiated: 9/17/24 Nurses to perform weekly skin assessment, Notify MD of any new skin impairments and obtain treatment orders as indicated. Date initiated: 9/17/24 Staff will help promote clean skin by encouraging/assisting resident to bathe regularly. Dry skin thoroughly after bathing. Keep skin moisturized by applying lotion as indicated. Date initiated: 9/17/24 Staff will provide prompt peri-care after incontinent episodes and may apply barrier cream as a skin protectant. CNAs may apply unmedicated barrier creams. Date initiated: 9/17/24 On 11/3/24 at 2:37 PM, an interview was conducted with resident 120. Resident 120 stated that the facility was not providing her with water throughout the day and that if she wanted water she had to go to the nurse's station and request water. 4. Resident 55 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with dyskinesia without mention of fluctuations, chronic obstructive pulmonary disease, type 2 diabetes mellitus, tremor, and personal history of other infectious and parasitic disease. On 11/4/24 at 8:45 AM, an interview was conducted with resident 55. Resident 55 stated there were no beverages offered between meals. On 11/12/24 at 10:24 AM, an interview was conducted with resident 55. Resident 55 stated he got beverages with meals but not between meals. Resident 55 stated he had his own bottled water in his closet. Resident 55 stated he went shopping with a friend to buy the bottled water he stored in his closet. Resident 55's medical record was reviewed. Resident 55's care plan dated 5/28/24 revealed, The resident has nutritional problem r/t [related to] enteral feedings, difficulty swallowing, poor intake. The goal was The resident will maintain adequate nutritional status as evidenced by no unplanned/undesired significant weight changes, no s/s [signs and symptoms] of malnutrition, and adequate nutritional intake at meals through review date. Some of the interventions included Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated and RD [Registered Dietician] to evaluate and make diet change recommendations PRN. A physician's order dated 7/1/24 revealed weekly cmp [comprehensive metabolic panel]/cbc [complete blood count] with auto diff [automatic differentiation] for monitoring of kidney function. One time a day every Mon [Monday] for monitoring. Laboratory results were reviewed. Labs were completed 9/32/24 and 11/4/24. It should be noted there was an order to have a CMP and CBC weekly. On 9/23/24 resident 55's Blood Urea Nitrogen (BUN) was 22 which was high with a reference range of 8/22 milligrams per deciliter (mg/dL) and a Creatinine level of 1.56 which was high with a reference range of 0.77-1.35 mg/dL. Resident 55's Glomerular filtration rate (GFR) was high at 50 milliliters per minute/1.73 m to the power squared (mL/min/1.73sq m2). On 11/4/24 resident 55's BUN was 29 which was high, Creatinine was 1.48 which was high and GFR was 53 which was low. On 11/12/24 at 11:08 AM, an interview was conducted with CNA 8. CNA 8 stated CNA's completed rounds and asked residents about water and snacks. CNA 8 stated some residents came to ice stations and asked for waters. CNA 8 stated she usually provided water when residents asked for it. CNA 8 stated residents had their own mugs or the kitchen provided reusable ones. CNA 8 stated she changed out the mugs when mugs looked dirty or if the resident requested a new one. A resident was observed walking to the ice station asking staff for water. CNA 8 stated that was how most residents got their water mugs filled was by asking at the ice station. On 11/6/24 at 8:51 AM, an interview was conducted with CNA 5. CNA 5 stated that when she started a shift at work that she would check residents to see if they wanted water, but that was the only time she would ask. On 11/6/24 at 9:38 AM, an interview was conducted with CNA 6. CNA 6 stated that in the past the kitchen staff would get the resident mugs cleaned and ready for resident use, but that had not been happening. CNA 6 stated that he tried his best to provide water to the residents, but that it did not always happen. On 11/7/24 at 9:15 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that residents were supposed to be provided provided water at 10:00 AM and 2:00 PM. LPN 2 stated that CNA's and nurses helped to pass the water to residents. LPN 2 stated that most of the residents just go to the nurse's station and asked for water. On 11/7/24 at 10:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the CNA's would go around as part of their rounding and check with the residents and see if they would like water. The DON stated that rounding was done every two hours and the residents should be asked if they wanted something to drink. The DON stated that the residents got a new mug every morning and staff would take the dirty mugs away to get them clean. The DON stated that the nursing staff should be checking water cups throughout the day and making sure that residents were getting fluid. The DON stated that residents could go to the nurse's station and ask for water and that it was typical of residents to do that. The DON stated residents families provided water mugs for residents to have in their rooms. On 11/13/24 at 9:52 AM, a follow up interview was conducted with the DON. The DON stated fluid intake was monitored for residents that had catheters or were on a fluid restriction. The DON stated the amount of brief changes and lab work were monitored for dehydration. The DON stated a CBC and CMP would be obtained to determine hydration status. The DON stated staff would also look for physical signs of dehydration like skin turgor. The DON stated resident 55 did not have weekly labs in his medical record since 9/23/24 as ordered by the physician to determine kidney function.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Resident 26 was admitted to the facility on [DATE] with diagnoses which include facioscapulohumeral muscular dystrophy, unspecified protein-calorie malnutrition, hyperlipidemia, hypomagnesemia, hypo-osmolality and hyponatremia, and weakness. On 11/3/24 at 3:30 PM, an interview was conducted with resident 26. Resident 26 stated that she was never offered snacks, but if you asked certain CNA's they would go and look to see if they had any snacks. Resident 26 stated that on occasion there would possibly be yogurt or string cheese available. 10. Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include difficulty in walking, muscle weakness, type 2 diabetes mellitus with hyperglycemia, major depressive disorder, anxiety disorder, essential hypertension, unsteadiness on feet, and history of falling. On 11/4/24 at 8:06 AM, an interview was conducted with resident 27. Resident 27 stated that she had asked for snacks and had been told on multiple occasions that there were not any snacks available. Resident 27 stated that the staff knew her family brought in food and snacks for her and that was why she was rarely asked if she wanted a snack. 11. Resident 53 was admitted to the facility on [DATE] with diagnoses which included, osteomyelitis of vertebra, anxiety disorder, type 1 diabetes mellitus with hyperglycemia, unspecified protein-calorie malnutrition, sepsis, psoas muscle abscess, alcohol abuse, and major depressive disorder. On 11/6/24 at 1:26 PM, an interview was conducted with resident 53. Resident 53 stated that she was a diabetic and needed snacks when her blood sugar got low and this happened quite often. Resident 53 stated that she had to have family provide her with snacks because the facility had not offered any to her. 12. Resident 120 was admitted to the facility on [DATE] with diagnoses which included lymphedema, superficial mycosis, cellulitis of right lower limb, activated protein c resistance, cellulitis of left lower limb, and morbid (severe) obesity due to excess calories. On 11/3/24 at 5:39 PM, an observation was made of resident 120 knocking on the kitchen door and asking the kitchen staff if she could have some snacks. On 11/3/24 at 5:40 PM, an interview was conducted with resident 120. Resident 120 stated that she was hungry and the kitchen staff only had some string cheese that they could provide her with. Resident 120 stated that this occurred quite often. Resident 120 stated that snacks were not provided unless she went to the kitchen and asked. On 11/5/24 at 12:53 PM, an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated that resident 29's biggest complaint was not getting enough food. CNA 6 stated that the snacks available for residents were chips, cheese sticks, and yogurt. CNA 6 stated that it depended on if it was available and they had those snacks about 80% of the time. CNA 6 stated that if there were no snacks they recommended to the residents that they provide their own snacks. CNA 6 stated that otherwise they tell the residents that they had to wait for the next meal. CNA 6 stated that they use to have sandwiches available for snacks but none recently due to the staff fluctuations in the kitchen. CNA 6 stated that they provided snacks at 8:00 AM, 10:00 AM, 3:00 PM, and 8:00 PM. CNA 6 stated that they wanted to keep snacks available to those times so it stays a snack an not a meal. On 11/5/24 at 1:32 PM, an interview was conducted with CNA 5. CNA 5 stated that the facility snacks were graham crackers, Oreo cookies, chips, pudding, yogurt, and string cheese. CNA 5 stated that she could get a ham and cheese sandwich or a peanut butter and jelly sandwich from the kitchen but there were times that those items were not available. CNA 5 stated that snacks were offered at 10:00 AM, 2:00 PM, and 8:00 PM. On 11/5/24 at 2:46 PM, an interview was conducted with staff member 1 who stated meals were not being served at regular times and sometimes as late as 9:00 PM. Staff member 1 also stated that residents needed scheduled meals due to having diabetes and needed a certain amount of time between their meals to sustain blood sugar levels. Staff member 1 stated snacks were provided once in a while. Staff member 1 stated at night between dinner and breakfast, there was nothing in the hydration room because dietary staff did not deliver them. Staff member 1 stated often the snacks provided were not appropriate for the residents. On 11/12/24 at 10:54 AM, an interview was conducted with CNA 8. CNA 8 stated there were specific times for snacks. CNA 8 stated the kitchen was slow to getting snacks to the CNA's us, so it was hard to offer the snacks. CNA 8 stated the hydration room should be stocked with chips, yogurt, applesauce but they were usually empty. CNA 8 stated staff had to go to kitchen to obtain snacks. CNA 8 stated she offered residents snacks, but then told residents she could not guarantee that there was a snack. CNA 8 stated if she offered a snack or a resident asked for a snack, then she went to hydration room for a snack. CNA 8 stated if there were no snacks in the hydration room then she went to the kitchen for a snack. CNA 8 stated sometimes the kitchen did not have snacks and she went back to the residents and apologized to the resident that there were no snacks. CNA 8 state it was hard to get rounds done, snacks delivered, meals done and showers with 2 people because there was not enough staff. On 11/5/24 at 3:47 PM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated that there was a list posted with the snacks that were available to residents. The ADMIN stated that whenever he looked snacks were available. The ADMIN stated that snacks were located in the nutrition rooms. The ADMIN stated that snacks are available at anytime, but mostly at night. The ADMIN stated that he had heard some residents say that there were not snacks available. On 11/5/24 at 4:46 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that snacks were available to residents. The DON stated that the CNA's went around and offered snacks to the residents. The DON stated that snack times had changed since meal times have changed. The DON stated that there were sandwiches, chips, and fruit cups available to residents for snacks. The DON stated that all residents should be asked if they wanted a snack at the designated snack time. The DON stated that typically there was one snack per resident so that not everyone was taking all the snacks. The DON stated the snack program meant that residents who wanted to be asked if they wanted a snack. The DON stated residents usually wanted to be offered a snack. The DON stated she could not think of a time when the facility ran out of snacks. The DON stated there were sugar free snack options for diabetic residents. The DON stated she had not heard of any residents having to go and buy their own snacks. The DON stated typically one snack per resident was offered to ensure that they did not run out. On 11/7/24 at 9:20 AM, an interview was conducted with the facility Registered Dietitian (RD). The RD stated she did not know how the snack program worked. The RD stated she would be surprised if there was a snack program at the facility. On 11/12/24 at 2:55 PM, a follow-up interview was conducted with the DON. The DON stated some people have preferences for their own snacks and staff had not asked what snacks residents want. The DON stated that would be a good idea to look at residents preferences. The DON stated resident's should not have to buy their own snacks. A review of the facility resident council minutes revealed the following: a. May 2024: .Items to be addressed at next meeting with the new dietary manager include allergies/dietary restrictions being accommodated, snacks available, . b. June 2024: .Want to get issues resolved, once we have a manager: cheese sticks and pudding are usually available, missing often are: sandwiches, yogurt, juice, chips, cookies, crackers, etc. For some, they prefer to take their pills with these as a medium or are used for 'quick fixes' with low blood sugar #s [numbers] . c. October 2024: .Many residents commented that snacks are not available or there is very little variety, most days . On 11/6/24 at 3:00 PM, the facility resident council was attended. Several residents in attendance stated that they were not offered or given snacks. (Cross Refer to F725, F802 and F803) Based on observation, interview and record review it was determined, for 12 of 65 sampled residents, the facility failed to provide each resident with 3 meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Additionally, snacks were not provided to residents who wanted to eat at non-traditional times or outside of the scheduled meal service times and consistent with the resident plan of care. Specifically, meals were not served according to meal times, meal times were changed without resident input, snacks were not being provided regularly. Resident identifiers: 9,13, 16, 26, 27, 29, 32, 49, 53, 55, 60, and 120. Findings include: 1. Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included heart failure, renal insufficiency, depression, and hypertension. On 11/3/24 at 5:33 PM, an interview was conducted with resident 9 who stated the food was cold 90% of the time. Resident 9 stated dinner came at 6 or 7 or whenever. Resident 9 stated there were no snacks available in the evenings. Resident 9 stated occasionally there would be a cheese thing or a small bag of chips, if they have them. 2. Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, muscle weakness, major depressive disorder, and chronic pain. On 11/4/24 at 11:07 AM, an interview was conducted with resident 13 who stated meals were coming late regularly. 8. Resident 29 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included drug induced secondary Parkinsonism, adult failure to thrive, dementia, bipolar disorder, anxiety disorder, drug induced akathisia, suicidal ideation, post-traumatic stress disorder, nephrogenic diabetes insipidus, hyperparathyroidism, chronic kidney disease, schizoaffective disorder, hyperlipidemia, Meniere's disease, non-ST elevation (NSTEMI) myocardial infarction, obstructive sleep apnea, cognitive communication deficit, insomnia, hypertension, and chronic pain. On 11/3/24 at 2:21 PM, an interview was conducted with resident 29. Resident 29 stated that the facility was short on snacks and quite often they did not have snacks available. Resident 29 stated that she had informed staff of this problem. Resident 29 stated that the new guy in the kitchen said he would work on it. Resident 29 stated that both day and night time snacks were not available. Resident 29 stated that when they did have snacks they went fast, and they did not have enough for everyone. Resident 29 stated that staff did not offer snacks and the residents had to ask for them. Resident 29's medical record was reviewed. On 5/1/24, resident 29's diet order was Regular diet Regular texture, Thin liquids consistency. On 9/30/24, resident 29's care conference summary documented under the food and nutrition summary, RT [resident] states that combinations of items has been weird. The assessment documented that resident 29 wanted to participate in the snack program and would like snacks delivered at 10:00 AM, 3:00 PM, and 8:00 PM. 3. Resident 16 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to embolism of left middle cerebral artery, cognitive communication deficit, diabetes mellitus, major depressive disorder. On 11/5/24 at 9:23 AM, an interview was conducted with resident 16. Resident 16 stated he was not served enough food because the portion sizes were too small. Resident 16 stated he should be getting double portions all the time. Resident 16 stated he was hungry. Resident 16 stated he had been hungry for about a year and a half. Resident 16 stated he did not get snacks and was told that corporate did not give snacks. Resident 16 stated he had to go to the kitchen to get food because if he asked anyone else they told him to wait a minute and did not get food. Resident 16 stated he was always told to wait a minute when asked for food. Resident 16 stated he had not been offered a snack last night and had gone to the kitchen yelling for food that morning. Resident 16 state he had not been served breakfast. Resident 16 was observed to have 3 cans of Campbell's chicken noodle soup, a bag with some rice in it, bag of small candy and a bag of spicy nacho chips. Resident 16 stated his sister had to bring him snacks all the time. 4. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral infarction, cognitive communication deficit, type 2 diabetes mellitus, and major depressive disorder. On 11/4/24 at 8:22 AM, an interview was conducted with resident 32. Resident 32 stated the meals were always late. Resident 32 stated last night he was not sure what the food was, so he only ate the dessert. Resident 32 stated he had diabetes and he was provided applesauce and chips if he got snacks. Resident 32 stated he use to get snacks but not anymore. Resident 32 stated last night he was offered Oreo's for a snack before bed. Resident 32 stated his blood sugars were usually good so he did not need protein with his carbohydrate before going to bed. Resident 32's medical record was reviewed. A Care Conference Summary Form dated 9/20/24 and locked on 10/3/24 revealed 32 wanted to participate in the snack program and be offered a snack at 10:00 AM, 3:00 PM, 8:00 PM. 5. Resident 49 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, paroxysmal atrial fibrillation, heart failure, and chronic kidney disease. On 11/3/24 at 6:39 PM, an interview was conducted with resident 49. Resident 49 stated snacks were a joke. Resident 49 stated if you did not get enough to eat and tried to get a snack, you have to find out who to trust at the facility. Resident 49 stated for example he asked staff for snacks and they said there was nothing but then he saw other residents with sandwiches and chips. Resident 49's medical record was reviewed. On 8/15/24 a Care conference revealed, Small Portions diet, Regular texture, Thin liquids consistency. Meal times are inaccurate and not according to schedule provided. Resident 49 wanted to participate in the snack program and desired to be offered a snack at 10:00 AM, 3:00 PM and 8:00 PM. 6. Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, type 2 diabetes mellitus, tremor, and atrial fibrillation. On 11/4/24 at 8:43 AM, an interview was conducted with resident 55. Resident 55 stated he was not offered snacks consistently. On 11/12/24 at 10:25 AM, an interview was conducted with resident 5. Resident 5 stated he was not offered snacks and meals were late. 7. Resident 60 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, gastroesophageal reflux disease, dysphagia, history of falling, constipation and dementia. On 11/3/24 at 03:57 PM, an interview was conducted with resident 60. Resident 60 stated he did not get enough food. Resident 60 stated no snacks were offered and he would like snacks especially before bed. Resident 60 stated prior to admission he ate a snack before bed. Resident 60's medical record was reviewed. A Care Conference dated 8/27/24 and locked on 9/4/24 revealed a care conference was held on 9/2/24 revealed that resident 60 did not want to participate in the snack program and he would provided his own snacks. On 11/6/24 at 9:04 PM, a phone interview was conducted with the Resident Advocate (RA). The RA stated he was in charge of getting the care conference scheduled with the family and then filled out the form. The RA stated he asked each resident if they had any needs or concerns with the dietary department. The RA stated he asked residents if the food was palatable food and then triggered it to a grievance form. The RA stated he did not know why resident 60 had it documented that he would provide his own snacks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident 26 was admitted to the facility on [DATE] with diagnoses which include, but not limited to, facioscapulohumeral muscular dystrophy, unspecified protein-calorie malnutrition, hyperlipidemia, hypomagnesemia, hypo-osmolality and hyponatremia, and weakness. Resident 26's record was reviewed on 11/7/24. Resident 26's progress notes revealed the following: a. On 12/6/23 at 2:42 PM, a nutrition/dietary note documented: Late Entry: Note Text: NAR: [Resident 13] WEIGHT LOSS OF 7.1 LBS. CURRENT WEIGHT: 255.9 IWR: 107.8-145.6 BMI:43.9 OBESE CLASS III PO [oral] INTAKE NSA,REG [regular],THIN; <50%INTAKE SUPLEMENT [sic]: CHOLECALCIFFEROL [sic] 1250MCG [sic], B12 500MCG. MEDS [medications]: MORPHINE INCREASE TO 15 MG. FUROSOMIDE [sic] 20 MG FOR 1 WEEK. NO NEW LABS EDEMA NOTED DISCUSS AT NAR MEETING: TIME THE WEIGHTS TAKE PLACE, CHANGE WEIGHT DUE TO BEING PREVIOUS TO INFUSION OR AFTER. RESIDENT HAS STATED WOULD LIKE TO LOOSE WEIGHT. NEW MEDICATIONS FOR EDEMA b. On 2/28/24 at 10:37 AM, a physician progress note documented,Note Text: [Name Redacted] Name: [Resident 29] Sex: FeMale [sic] DOB [DATE of birth ]: [redacted] Age: [redacted] Yrs Service Date: 02/28/2024 Provider: [name redacted] Chart#: [number redacted] Chief Complaint: [Resident 29] presents for a comprehensive assessment of chronic conditions. History Of Present Illness: [Resident 29] is . On 11/12/24 at 3:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident charts were routinely audited for inaccurate information. The DON stated that other resident information should not be in resident 26's electronic medical record. 5. Resident 371 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included paraplegia, cognitive communication deficit, and pressure ulcer of sacral region. Resident 371's medical record was reviewed 11/12/24 through 11/13/24. On 7/12/24 at 1:00 AM, a physician documented in resident 371's chart detailing why the resident was sent out for a blood transfusion for a low hemoglobin. On 11/13/24 at 2:39 PM an interview was conducted the the DON. The DON stated that resident 371 did not have a low hemoglobin and was not sent out for a transfusion. The DON stated there was a resident in the facility similar to 371 and that it would have be easy to mix them up. The DON confirmed that the physicians progress note was in regards to a different resident in the facility and the progress note was inaccurate for resident 371. Based on interview and record review, the facility did not ensure that, for 6 of 65 sample residents, medical records were complete and accurately documented. Specifically, neuro checks were not documented in the resident's medical record, records were not obtained after a resident went to and returned from the hospital, a resident's medical information was found in another resident's medical record, and a physician documented a progress note in the wrong resident's medical chart. Resident identifiers: 10, 13, 26, 220, 221 and 371. Findings include: 1. Resident 221 was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, paraplegia, infection and inflammation due to indwelling urethral catheter, and extended spectrum beta lactamase resistance. Resident 221's medical records were reviewed between 11/3/24 and 11/13/24. On 10/18/24 at 8:07 PM, an alert charting progress note revealed, At 7:00 PM CNA [Certified Nursing Assistant] informed me that resident was acting really wierd [sic]. I came into the room and resident apeared [sic] asleep but breathing. I rubbed his arm and said his name, he responded with than you, please, I asked him if he knew where we are, he responded with thank you I asked him how old he was he said thank you please. He would only open his eyes when asked to and would close them shortly after. Upon shining my pen light on his pupils they constricted only slightly going from 7 mm [millimeters] to 4 mm. Residents vital signs were normal with a low grade fever of 99.5 which later jumped to 100.5 F [Fahrenheit]. Upon auscultation lungs were clear, heart rate was rapid, and I wasn't able to tell but it may have sounded abnormal. Upon contacting [name redacted] the DON [Director of Nursing] we determined we should send him to the hospital. [ambulance provider] was called and came. The Paramedics assessed him and also agreed his was needing to go to the hospital. Resident was taken to the hospital. On 10/19/24 at 3:07 AM, an alert charting progress note revealed, Resident returned to facility from ER [emergency room] visit via [ambulance provider] at 2:05 AM. Resident yelling out oh god oh god repeatedly. Usually wants several pillows used for positioning of arms and legs in bed, refused to allow staff to place any of them. Refused podis boots. Went to sleep only a few minutes after EMS [emergency medical services] left. Nurse [name redacted] at [hospital] called in report and stated resident was given IV [intravenous], catheter and ostomy changed, wound dressings changed and CT [computer tomography] of head negative. Reports resident is alert and oriented to self and date only. DC [discharge] paperwork lists diagnoses as: decubitus ulcers, chronic indwelling foley catheter, h/o [history of] brain tumor, paraplegia and anemia. tests performed while at ER: CBC [complete blood count], CMP [complete metabolic panel], drug of abuse screen-urine toxology, free T4 [free thyroxine], lactic acid-plasma, PT/INR [protime/international normalized ration], Sars-CoV-2 [Severe acute respiratory syndrome-Corona Virus-2], Flu [influenza], RSV [Respiratory syncytial virus] by RT PCR [real time polymerase chain reaction], serum drug tox [toxicity] screen, TSH [thyroid]stimulating hormone] with reflex free T4, UA [urinalysis] with micro [microscopic], CT brain/head without contrast, and ECG [electrocardiogram] 12 lead. No new orders. It should be noted that no hospital summary or discharge documentation, laboratory tests, or CT test results could be found in resident 221's medical record. 2. Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, muscle weakness, major depressive disorder, and chronic pain. On 5/27/24 at 4:45 AM, an alert charting progress note revealed, Found pt [patient] laying on her bed with a hematoma on her forehead. Pt with a laceration to her nose. Severe pain to her right shoulder and pain and bruising to her left knee. Pt states that her pant leg got caught on her electric w/c [wheelchair] and she fell forward. Pt got herself up into her bed and then called for assistance. Pt requested to go to ER for evaluation of her right shoulder. Non-emergent ambulance called. Notified physician on call and pt's daughter. Pt sent out at this time. On 5/27/24 at 4:48 AM, a discharge progress note revealed, Date/time of discharge/transfer: 5-27-24 at 4:35 AM; Discharge/transfer location: [hospital]; Mode of transportation at time of discharge/transfer: non-emergency ambulance; Reason for transfer/discharge: severe pain to right shoulder-possible fracture; Discharge teaching/instructions completed during discharge/transfer process: [blank]; Discharge paperwork released with resident at time of discharge/transfer: Transfer/discharge record, order summary, face sheet; Resident's response to discharge/transfer process: Pt wanting to go to the ER; How were resident's personal effects stored/handled at time of discharge/transfer?: Personal items left in her room. Pt took her phone and phone charger with her; Name of individual to whom report was provided at new location: [blank]; Name of resident representative notified (if resident is not self-responsible): [family member]; Name of physician notified: [name redacted] on call for [name redacted]. On 6/4/24 at 6:46 PM, an alert charting progress note revealed, Pt re-admitted to facility via facility transport. A/O [alert and oriented] x 4. Able to verbalize needs. Continent of bowel and bladder. Resident using sling to R [right] shoulder. Has bruises to: forehead, L [left] knee, Rt [right] shoulder, LFA [left forearm] L elbow, 2 small bruises to bilat [bilateral] ankle, RFA [right forearm]. She has small scan on bridge of nose. Incision to R chest area intact, no s/s [signs/symptoms] of infection. Uses motorized w/c for mobility. Las BM [bowel movement] 6/3/24. C/O [complains of] pain to R shoulder Oriented to facility. Call light is within reach. On 8/18/24 at 4:31 PM, an alert charting progress note revealed, upon entering the room resident sitting in the floor. stating I went down the floor to pick up a something and I could not get up. called for assistance to help transfer resident during assessment no injuries noted at this time. resident alert and oriented x 4. Neuro checks started. educated resident on the importance to ask for assistance. Dr. Notified. On 8/18/24 at 6:01 PM, an alert charting progress note revealed, upon continuous assessment resident complaining of dizziness and headache post fall. Dr. called provided this information. resident requested to go to the hospital. [ambulance provider] called. On 8/18/24 at 11:04 PM, an alert charting progress note revealed, Resident returned from [hospital] ED [emergency department] at 8:51 PM. No findings found on CT OR X-ray. VSS [vital signs stable]. On 8/29/24 at 9:37 AM, an alert charting progress note revealed, Resident was in the Therapy room using a balloon when she tried to reach for the balloon and fell on her face on the floor bleeding from the nose. Used towel and applied ice pack. Called 911. Resident is alert and oriented to person, time, situation. Waiting for ambulance. On 8/29/24 at 9:51 AM, an alert charting progress note revealed, [ambulance provider] arrived and resident decided to go to ER to be checked. V/S [vital signs] BP [blood pressure] 170/84, PR [pulse rate] 95, RR [respiration rate] 18, T [temperature] 98.2, O2 sat[oxygen saturation] 93 RA [room air]. Called the daughter to inform her of the incident and she appreciates the call. On 8/29/24 at 2:53 PM, an alert charting progress note revealed, Resident came back from [hospital] with an order for Ibuprofen 600 mg [milligrams] TID [three times daily] for 7 days. PCC [medical record software] updated. On 9/23/24 at 9:01 AM, an alert charting progress note revealed, resident had a witnessed fall, resident reported losing her balance when walking in room. resident hit head and neuro checks started. resident alert and oriented x 4. Vs [vital signs] stable. resident appears to have a repetitive behavior continue to be lack of self-limitations and safety. reported to Dr [educated]. educated resident on safety measures, daughter no answer on phone, unable to leave message to report this concern. On 9/23/24 at 7:22 PM, an alert charting progress note revealed, resident returned from infusion appointment. no changes noted. On 9/23/24 at 10:46 PM, an alert charting progress note revealed, Pt with fall this morning. Pt was in another pt's room. Pt states that she fell forward and hit her face. Pt with bruising under both eyes. Pt continues to c/o pain to legs. Pt went to ER after infusion appointment today. Pt was afraid that she had a DVT [deep vein thrombosis], but no DVT, just inflammation from fluid in her legs. Pt stated that her doctor's are working on a plan of what to do. It should be noted, hospital records could not be found in resident 13's medical record for this hospital visits on 5/27/24, 8/18/24, 8/29/24, and 9/23/24. 3. Resident 10 was admitted to the facility on [DATE] with diagnoses that included personal history of traumatic brain injury, type 2 diabetes, bipolar disorder, post-traumatic stress disorder, morbid obesity, major depressive disorder, anxiety disorder, and cognitive communication deficit. On 11/10/24 at 2:29 PM, a behavior progress note revealed, Guardian contacted about sending to b med [behavior medicine] to get stabilized on medications due to refusals of medications and care. Guardian [name redacted] stated that she was okay with that plan to help him stabilize his mental health and requested that he be sent to the hospital. Spoke with resident about plan and he stated he was just going to leave AMA [against medical advice]. Reassured resident and allowed him to verbalize feelings about this decision. He agreed to be sent to be stabilized and was taken to hospital via [ambulance service]. On 11/10/24 at 7:07 PM, an alert charting progress note revealed, Attempted to do a nurse to nurse and a doc to doc and the hospital refused to do so. No interventions taken and he was medically and psychiatrically cleared to come back to the facility. They stated he was only not taking Gabapentin which didn't constitute an admission. I educated the nurse that wasn't the case. He said there was nothing they could do for him and he was already on his way back. It should be noted that hospital documentation for 11/10/24 was not found in resident 10's medical record. On 11/7/24 at 11:59 AM, an interview was conducted with the Minimum Data Set (MDS) coordinator who stated the hospital records for resident 13 were not in the medical records. The MDS stated typically the resident returned from the hospital with a history and physical. The MDS stated he was not sure why it was not in the residents medical records. The MDS stated when a resident returned from the hospital, the nurse should go over the paperwork, put in a progress note, and put the documents in a manager's folder that went to the DON. The MDS stated the DON would be reviewed and then to go medical records and scanned into the resident's medical record so there was a date associated with it. On 11/12/24 at 1:22 PM, an interview was conducted with the DON who stated typically hospital documentation comes back from the hospital with the resident. The DON if the hospital records did not come back with the resident, she was able to pull the records from the hospital medical records. The DON stated she would obtain the records, print them off for medical records and it could take about a week to upload. The DON stated nurses could call for order changes, or the hospital would call you. The DON stated the expectation she has is that discharge orders from the hospital would be in the resident's medical records. The DON stated 90% of the time, resident's came back with orders and documentation. The DON stated the nurse or the DON were responsible for obtaining documentation from the hospital. 4. Resident 220 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included polyneuropathy, cognitive communication deficit, anxiety disorder, acute respiratory failure with hypoxia, congestive heart failure, panic disorder, chronic obstructive pulmonary disease, morbid obesity, major depressive disorder, and chronic kidney disease. Resident 220's medical records were reviewed between 11/3/24 and 11/13/24. On 10/5/24 at 1:41 AM, an alert charting progress note revealed, Resident A & O x 3-thinks it is 2012. Equal hand grips, sluggish pupil response, Equal hand drift. States she feels 'not normal'. On 10/5/24 at 2:18 AM, an alert charting progress note revealed, Neuro checks completed on resident. Left pulses diminished. Lung sounds clear. Skin cold and dry. Still very confused. Called [ambulance provider] to be sent to the ED [emergency department]. It should be noted that no neuro check documentation could be found in resident 220's medical record and the facility was unable to provide the documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 3 of 5 sampled residents, that the facility did not ensure that residents were offered the COVID-19 immunization and that the medical records included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, three residents did not have immunization documentation in their medical records. Resident identifiers: 49, 61, and 269. Findings included: 1. Resident 49 was admitted to the facility on [DATE] with diagnoses which included dementia, paroxysmal atrial fibrillation, heart failure, cognitive communication deficit, and pain. On 11/12/24 resident 49's medical records were reviewed. No documentation could be found for the administration or declination for the COVID-19 vaccine for the current season. 2. Resident 269 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, severe sepsis, cognitive communication deficit, dementia, anxiety disorder, cardiac arrhythmia, acute respiratory failure, rhabdomyolysis, and acute kidney failure. On 11/12/24 resident 269's medical records were reviewed. No documentation could be found for the administration or declination for the COVID-19 vaccine for the current season. 3. Resident 61 was admitted to the facility on [DATE] with diagnoses which consisted of fibromyalgia, dementia, hypertension, edema hypothyroidism, and insomnia. On 11/12/24 resident 61's medical records were reviewed. No documentation could be found for the administration or declination for the COVID-19 vaccine for the current season. On 11/12/24 at 9:21 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that they already offered the Respiratory syncytial virus (RSV) vaccine, Hepatitis B vaccine, Hepatitis A vaccine, influenza vaccine, COVID vaccine, pneumonia vaccine, and Human papillomavirus (HPV) for the current season. The DON stated that she had not filed the paper copies of the vaccines administered into the resident medical records yet. On 11/12/24 at 1:22 PM, the DON stated that resident 269 and resident 61 had declined the vaccine and wanted to discuss it with their POA (Power of Attorney) first. The DON stated that she was going to approach them again later. The DON stated that resident 49 had initially consented but on the day of the vaccine clinic he declined. The DON stated that she had no documentation of resident 49's refusal. On 11/13/24 at 9:02 AM, a follow-up interview was conducted with the DON and the Regional Nurse Consultant (RNC) 1. The DON stated she should have had documentation of the resident 269, resident 61 and resident 49's vaccine declinations. The DON stated that the immunization clinic was held the first Tuesday in October.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 3 of 65 residents sampled, that the facility did not adequately equip residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities. Specifically, resident's bedside and toilet call lights were not in working condition or were not present at all. Resident identifiers: 44, 51, and 55. Findings included: 1. Resident 51 was admitted to the facility on [DATE] with diagnoses which included intracerebral hemorrhage, hemiplegia and hemiparesis of left side, neurologic neglect syndrome, chronic kidney disease, hypertension, congestive heart failure, cognitive communication deficit, aphasia, visual loss both eyes, and insomnia. On 11/03/24 at 2:48 PM, an interview was conducted with resident 51. Resident 51 stated that she had fallen previously in the morning when attempting to get up and toilet herself. Resident 51 stated that sometimes she had to change her brief because the staff did not come to help her. Resident 51 stated that the call light did not always work either. Resident 51 stated that she could put a pull up brief on by herself but she could not put the tab briefs on by herself. It should be noted that resident 51 had hemiplegia and hemiparesis of the left side that limited her ability to perform toileting tasks independently. Resident 51 stated that she waited 2 hours the other night for assistance. Resident 51's call light was pushed at the bedside and in the bathroom and both were observed not functioning. On 10/9/24, resident 51's MDS Assessment documented a BIMS score of 14, which indicated that the resident was cognitively intact. The assessment documented that the resident was a one-person limited assist for bed mobility and eating, and a one-person extensive assist for transfers and toilet use. The assessment documented that the resident was not on a urinary or bowel toileting program. Review of the Daily Maintenance Log for Station B for September and October 2024 documented the following: a. On 9/23/24 at 10:25 AM, bed remote is broken room [ROOM NUMBER]. b. On 9/30/24 at 10:30 AM, call lights do not work bedroom and bathroom in room [ROOM NUMBER]. c. On 10/2/24 at 1:24 PM, call light still does not work, please fix in room [ROOM NUMBER] B. d. On 10/13/24 at 4:00 PM, the TV was broken in room [ROOM NUMBER] B. e. On 10/14/24 at 6:54 PM, the call light wont turn off in room [ROOM NUMBER]. f. On 10/17/24 at 4:01 PM, call light wont turn off in room [ROOM NUMBER]. g. On 11/7/24 at 9:48 AM, call light not working in room [ROOM NUMBER] B. Review of the Daily Maintenance Log for Station A for October and November 2024 documented the following: a. On 10/8/24 at 11:00 AM, call lights did not turn on in room [ROOM NUMBER]. b. On 10/13/24 at 5:01 PM, the call light was stuck in room [ROOM NUMBER]. c. On 10/22/24, the call light wont turn off in room [ROOM NUMBER]. On 11/05/24 at 12:53 PM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated that resident 51 required one-person assist for incontinence care due to vision issues and paralysis in left arm. CNA 6 stated that resident 51 was incontinent of bowel and bladder and she would let staff know when she needed a brief change. On 11/07/24 at 9:35 AM, a follow-up interview was conducted with CNA 6. CNA 6 stated that resident 51 had maybe 4 falls since she was admitted and none with any injuries. CNA 6 stated resident 51 would call for assistance to get out of bed, but if staff did not come immediately she would try to do it herself and would fall. CNA 6 stated that interventions to prevent falls were to encourage the resident to call for help when getting up. CNA 6 stated that the call light system was difficult at times, and sometimes they would do a system reset. CNA 6 stated that the last time the call light system was not working was approximately 4 weeks ago. CNA 6 was observed to push resident 51's bedside call light and it did not alarm. CNA 6 was observed to attempt to activate the call light from resident 51's bathroom and it did not alarm. CNA 6 stated that the bathroom light was not working either. CNA 6 stated that maybe it was resident 51's roommate that was calling for help for resident 51. CNA 6 stated that things were difficult with maintenance and they just hired a new maintenance staff. CNA 6 stated that they would document any maintenance issues in a binder and the maintenance staff should look at it daily to see what needed to be fixed. CNA 6 stated that according to the maintenance binder it looked like resident 51's call light was documented not functioning 5 times prior. On 11/13/24 at 10:24 AM, an interview was conducted with the Maintenance Supervisor (MS). The MS stated that he started at the facility approximately 2 weeks ago. The MS stated that the process for maintenance requests or repairs was that staff would text him in an emergency situation and if it was not an emergency, staff would write it in the daily maintenance log. The MS stated that he checked the log daily, Monday through Friday. The MS stated that he documented in the log any issues that were resolved or passed off to another department. The MS stated that the service technician for the company that installed and repaired the call light system walked him through the process of repairing and trouble shooting the call lights. The MS stated that it depended on what the issue was with the call light. The MS stated that if it was a ripped cord then he would just replace the cord. The MS stated that if the call light did not alarm he would check the ID on the back of the call light to verify that it registered in the system. The MS stated that each call light ID had to be registered in the system for that specific location or room. The MS stated that sometimes in the past staff would take call lights from other rooms to replace non-functioning lights. The MS stated that this solution did not work because then the light would not register correctly in the system. The MS stated that resident 51's call light was repaired at the bedside and in the bathroom. The MS stated that the bathroom was broken and had to be replaced completely. The MS stated that resident 51's call light at the bed registered to another room location and he replaced it. The MS stated the bedside call light also had black electrical tape on it from being frayed. The MS stated that he had a lot of call lights that needed repair and that needed to be correctly registered in the system. The MS stated that he found approximately 5 call lights that needed to be repaired or registered. The MS stated that he did not verify with the maintenance logs the reports of the broken call lights. The MS stated that he did daily rounds to verify that the call lights were in working condition. The MS stated that he repaired the call lights in rooms 106, 116, 117, 318, 319, 322, 323, 327, 329, 338, 337, 401, 403, and 507 on 11/7/24 when he was informed that they were not working. It should be noted that resident 51's call light was repaired on 11/12/24 according to the new maintenance log. The MS stated that he would have to locate the previous maintenance logs and he did not know who removed and replaced them. [Cross-refer F689 and F690] 2. On 11/3/24 at 4:27 PM, an observation was made of room [ROOM NUMBER] B. Resident 23 resided in room [ROOM NUMBER] B. There was no call light cord for bed B. There was a 1 call light cord to bed A. 3. On 11/3/24 at 4:33 PM, an observation was made of room [ROOM NUMBER] A. Resident 44 resided in 321 A. There was no call light cord for the A bed. There was 1 call light cord from the call to the B bed. An interview was immediately conducted with CNA 11. CNA 11 stated resident 44 resided in room [ROOM NUMBER] A. CNA 11 stated that resident 44 did not use a his call light but was able to use a call light. CNA 11 was observed to look at room [ROOM NUMBER] A and stated she did not know why resident 44 did not have a call light cord. CNA 11 stated all residents should have call lights cords available. 4. On 11/3/24 at 4:18 PM, an observation was made or room [ROOM NUMBER] A. Resident 55 resided in room [ROOM NUMBER] A. There was no call light cord observed to bed A. There was one call light cord from the wall to bed B. On 11/12/24 at 10:32 AM, a follow-up observation of room [ROOM NUMBER] was conducted. There was only one bed for 307 B. There was one call light cord that was attached to the wall. There was one hole for a call light cord and not 2 call light cords. On 11/12/24 at 10:26 AM, an interview was conducted with resident 55. Resident 55 stated he moved rooms because his other room did not have a call light. Resident 55 stated he did not know why he did not have a call light. Resident 55 stated there was not a call light. Resident 55 stated when he needed assistance, he used his roommate's call light or asked his roommate to use the call light for him. Resident 55 stated he felt abandoned when he did not have a call light. Resident 55 stated that he had not had any accidents as a result of not having a call light. On 11/12/24 at 1:41 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was room change papers that was filled out with the reason for the move. The DON stated resident 55 was able to use a call light. The DON stated every resident should have a call light to call for staff. The DON stated she was not aware that resident 55 did not have a call light. The DON stated resident 55 requested a room move but could not remember why. The DON stated if resident 55 did not have a call light, then that was probably why he did wanted to move rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 30 of 65 sampled residents, that the facility did not provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Specifically, meals were served late, menus were not meeting nutritional needs, portion sizes were not appropriate, food was not palatable, resident food allergies and preferences were not honored, beverages were not offered between meals, therapeutic diets were not followed, snacks were not provided, adaptive equipment was not provided, and the kitchen was not sanitary. In addition, weights and nutritional assessments were not being completed. Resident identifiers: 1, 3, 5, 4, 9, 10, 12, 13, 14, 15, 16, 22, 24, 26, 27, 28, 29, 30, 32, 36, 38, 44, 49, 50, 52, 53, 55, 60, 65 and 120. Findings include: 1. Based on observation, interview and record review it was determined, for 17 of 65 sampled residents, that the facility did not employ sufficient staff with the appropriate competencies and skills set to carry out the function of the food and nutrition services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, meals were observed to be served over an hour later than the posted meal times, a resident was observed to be yelling he was hungry, residents were in the hallways waiting for food, residents were upset in the dining room waiting for meals and residents council minutes revealed complaints of late meals. Resident 16 will be cited at a harm level. Resident identifiers: 9, 13, 14, 22, 24, 26, 27, 30, 32, 36, 38, 44, 50, 52, 55 and 120. (Cross refer F802) 2. Based on observation, interview and record review it was determined, for 3 of 65 sampled residents, that the facility did not have menus that met the nutrition needs of residents in accordance with established nutritional guidelines. Specifically, menus were not followed and correct portion sizes were not provided to residents. Resident identifiers: 15, 16 and 55. (Cross refer to F803) 3. Based on observation, interview and record review it was determined, for 11 out of 65 sampled residents, that the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that was palatable, attractive, and at an appetizing temperature. Specifically, there were multiple complaints from residents about the quality of food, there were multiple resident council complaints about the flavor of food, and when surveyors pulled a test tray during the lunch meal, the food was found to be lacking in flavor and appearance. Resident identifiers: 9, 12, 16, 22, 26, 27, 28, 32, 50, 55, and 120. (Cross Refer to F804) 4. Based on observation, interview and record review it was determined, for 6 of 65 sampled residents, that the facility did not ensure that each resident received the food and drink that accommodated the resident allergies, intolerances, and preferences. Specifically, residents with food allergies and intolerances were served food containing identified allergens, and one resident who was admitted on [DATE] had not been questioned about food allergies until 11/5/24. Resident identifiers: 1, 10, 16, 26, 28, and 38. (Cross Refer to F806) 5. Based on observation, interview and record review for 4 of 65 sampled residents, the facility did not ensure each resident received drinks, including water and other liquids, consistent with the residents' needs and preferences and sufficient to maintain resident hydration. Specifically, water was not being provided to residents between meals, residents had to seek out staff to obtain fresh water and resident water mugs were not being cleaned regularly. Resident identifiers: 26, 27, 55 and 120. (Cross Refer to 807) 6. Based on observation, interview and record review, it was determined for 1 of 65 sampled resident, that the facility did not provide therapeutic diets as prescribed by the attending physician. Specifically, a resident with a physician's order for thickened liquids was observed to have thin water at the bedside. Resident identifier: 60. (Cross Refer to 808) 7. Based on observation, interview and record review it was determined, for 12 of 65 sampled residents, the facility failed to provide each resident with 3 meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Additionally, snacks were not provided to residents who wanted to eat at non-traditional times or outside of the scheduled meal service times and consistent with the resident plan of care. Specifically, meals were not served according to meal times, meal times were changed without resident input, snacks were not being provided regularly. Resident identifiers: 9,13, 16, 26, 27, 29, 32, 49, 53, 55, 60, and 120. (Cross Refer to 809) 8. Based on observation, interview, and record review, it was determined for 1 of 65 sampled residents, that the facility failed to provide special eating equipment and utensils for residents who needed them to ensure that the resident could use the assistive devices when consuming meals and snacks. Specifically, one resident was not provided with a lipped plate when identified as needing one. Resident identifier: 5. (Cross Refer to 810) 9. Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the kitchen was dirty with spills and dried food down near the burners, the large mixer had a white substance on the arms that hold the bowl and under the mixer, the oven floor was caked with spilled food on the bottom, food items in the walk-in freezer were open to air, food items in the reach in refrigerator were not labeled, and food items in the dry storage room were open to air. Additionally, staff with facial hair were not wearing a beard cover, personal phones were in the food preparation area, there was damage to several areas of the wall, tiles missing around the baseboard, and there was crumbs and food particles under the dish machine, stove and oven. (Cross Refer to 812) 10. Based on observation, interview and record review, for 4 of 65 sampled residents, the facility did not ensure residents maintained acceptable parameters of nutritional status. Specifically, residents meal portion sizes were not adequate, residents weights were not obtained and residents nutrition assessments were not being completed. Resident identifiers: 3, 4, 55, 60, and 65. (Cross Refer to 692) On 11/3/24 at 1:15 PM, an interview was conducted with the Dietary Manager (DM). The Dietary Manager (DM) who stated he was trying to find the old cleaning schedules so that he could create new ones. The DM stated, This place looks like a mess right now, but it is far better than when I came. On 11/5/24 at 11:03 AM, an interview was conducted with the Registered Dietitian (RD)who stated she had worked at the facility since September and had started making suggestions in the kitchen. The RD stated she learned quickly that the staff were doing their best to get the food out to the residents, but the kitchen was a disaster. The interview also revealed: a. The RD stated the current Dietary Manager (DM) had only been at the facility for a short time. The RD stated the Assistant Dietary Manager (ADM) was acting as the DM prior to bringing on a new DM. The RD stated the current DM had a lot of experience, was very knowledgeable and had been through a survey many times in the past. The RD stated the DM was working on putting things in the facilities QAPI (Quality and Performance Improvement) program. The RD stated the DM was working on cleanliness in the kitchen, labeling and dating food items, menus, and staffing. The RD stated a lot of areas needed work. b. The RD stated she was only doing resident assessments when the residents were admitted . The RD stated the facility medical software was not populating quarterly assessments. The RD acknowledged that she needed to start doing the quarterly assessments that had not been done by the previous dietitian. The RD stated the facility did not even have an annual assessment form for documenting. The RD stated when she did admission assessments, if there were recommendations they would be on the bottom of the assessment and she would notify the Director of Nursing (DON) of her recommendations. The RD stated she met with residents when they were admitted . The RD stated if a resident had a special request, she would meet with them. The RD stated resident goals were communicated to the staff verbally through the DON. c. The RD stated kitchen audits should be completed once a month, but she had not completed one since the beginning of her employment. The RD stated the information from a kitchen audit should be given to the DM or the administrator. The RD stated during a kitchen audit the refrigerators and freezers should be checked for food being labeled and dated, cleanliness and proper temperatures. The RD stated during a kitchen audit an overall observation should be done of the kitchen for cleanliness, proper food temperatures, that the dish machine is functioning properly to sanitize the dishes, and that staff were following proper food handling techniques including wearing hair nets and wearing clean aprons. The RD stated she had not done any audits because she did not have anyone to address the problems with before the new DM was hired. The RD stated she did not know if the ADM had any training. The RD stated she did not know who should be providing education to the dietary staff. The RD stated if she identified something that needed to be fixed she would tell the administrator about it, but she did not provide the education. The RD stated the process for fixing problems in the kitchen should be that she would tell the DM and then the administrator. The RD stated she reviewed some things with the current DM and his response to her was that he was working on it. The RD stated a week ago she went through the kitchen with a corporate nurse and identified problems with the cleanliness in the kitchen, that the shelving in the store rooms were not 6 inches off the floor and when stock was delivered it was left sitting on the floor of the refrigerator or freezer. The RD stated she was making sure all staff were wearing hair nets. The RD stated she did not know if there was a cleaning schedule for the kitchen. The RD stated she has not been monitoring the temperature logs for the dish machine, refrigerator, freezer, or trayline. d. The RD stated she had not completed a tray audit since she was hired. The RD stated the process to complete a tray audit was to ask for a test tray, take the temperature of the food, taste the food and evaluate the presentation and if it was following the menu and was meeting the nutritional needs of the residents. The RD stated if a substitution needed to be made to the menu she had the ability to go into the dietary software and substitute food items in and out of the menu. The RD stated if substitutions were being made they should be posted. The RD stated there should also be a record kept of the substitutions and the record should be kept for a year. The RD stated the DM did not have to contact her if he wanted to make a substitution to the menu. The RD stated the software would make suggestions for alternations to the menu. The RD stated she sort of knew that the kitchen was not following the posted menu. The RD stated depending on what came on the delivery truck, a substitution could be necessary. The RD stated she did not know who trained the DM on the kitchen software and she was not sure if that was part of her role. The RD stated she was new to using that particular software herself. The RD stated she thought the DM should be self-monitoring what is going on in the kitchen. The RD stated when looking at the substitutions, she would look for adequate protein, vegetables, if the menu was meeting the 5 a day guidelines and requirements for vitamin A for the week. The RD stated she had not looked at the menu for that particular week. The RD stated there should be a seasonal rotation being used. e. The RD stated she did not know if there was a schedule for providing snacks or how the residents would receive a snack. The RD stated the DM could call or text her any time and that they have worked together for a long time. The RD stated the DM did not have a problem asking questions. The RD stated the DM should be assessing residents for their food preferences and that the preferences should be updated once a year. The RD stated the residents should also be assessed again after coming back from a hospital stay. f. The RD stated food allergies should be addressed when a resident was admitted and that the information should be communicated to the kitchen to be put on the resident's meal ticket. The RD stated she had not heard of any residents having a problem with food allergies or had any resident complaints. The RD stated she had not seen resident 16, who had a food allergy. The RD stated in a perfect world she would assess the residents every 90 days. The RD stated she needed to set up a schedule so the resident assessments would be getting done. The RD stated she had observed meal service at the facility. The RD stated not many residents were eating in the dining room. The RD stated the benefits of eating in the dining room were that the resident could get out of their room, a different food item could be obtained right away if needed, dietary staff could be communicated with more easily and the meal service would go faster. The RD stated the meal service had been off and it was brought to her attention 2 weeks ago. The RD stated it was a struggle to get dinner and breakfast out in a timely manner. The RD stated she did not know if there was enough dietary support in the kitchen and that it would be a good question for the DM. The RD stated she was not aware that residents had expressed concerns that meals were being delivered late. g. The RD stated under the previous dietary manager kitchen supplies were not being ordered, things were not coming in and the staff were doing a lot of running to the store for supplies. The RD stated she did not know if there were enough pellets to keep meals hot. The RD stated she did not know why residents were receiving food in Styrofoam bowls, or if kitchen staff were using those to cut down on the time it takes to do the dishes. h. The RD stated her contract was for 8-12 hours per week, and that was the number of hours she was currently working at the facility. The RD stated when she was hired the census was significantly lower. The RD stated with a higher census she would need at least 20 hours per week to complete resident visits and get the quarterly assessments up and going. The RD stated that would not include kitchen duties.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 26 was admitted to the facility on [DATE] with diagnoses which include, but not limited to, facioscapulohumeral muscular dystrophy, unspecified protein-calorie malnutrition, hyperlipidemia, hypomagnesemia, hypo-osmolality and hyponatremia, and weakness. On 11/3/24 at 3:20 PM, an interview was conducted with resident 26. Resident 26 stated that the kitchen used to clean the mugs that residents used on a daily basis. Resident 26 stated that mugs were not getting clean and she began to wash the mugs she received with hand soap prior to using them. Resident 26 stated that washing the mugs in her bathroom sink was difficult due to size and that she purchased her own smaller mugs to use. Resident 26 stated that she purchased dish soap and washed the mugs in her bathroom sink because clean mugs were not provided to her. Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the kitchen was dirty with spills and dried food down near the burners, the large mixer had a white substance on the arms that hold the bowl and under the mixer, the oven floor was caked with spilled food on the bottom, food items in the walk-in freezer were open to air, food items in the reach in refrigerator were not labeled, and food items in the dry storage room were open to air. Additionally, staff with facial hair were not wearing a beard cover, personal phones were in the food preparation area, there was damage to several areas of the wall, tiles missing around the baseboard, and there was crumbs and food particles under the dish machine, stove and oven. Findings included: 1. On 11/3/24 at 1:15 PM, an initial walk-through of the kitchen was conducted. In the reach in refrigerator, hash brown patties were in a pan and were covered, but not labeled. There was no thermometer in the reach in refrigerator, and no temperature log on the outside. The walk in freezer had a temperature of -4 degrees Fahrenheit on the outside, but no thermometer could be found inside. A box of frozen dinner roll dough was open to air and a box of sausage patties was open to air. In the dry storage room, a bag of granulated sugar was open to air, and a container of graham cracker crumbs was open to air. In the food service area, there were 2 bags of cold cereal on top of a tray rack that were open to air. The large mixer had a white substance on the arms that hold the bowl and on the floor underneath. The burner plates on the stove were dirty, and crumbs were down around the burners. There was a large amount of crumbs and spills on the floor of the oven. There was rust around the drain behind the ice machine. Tiles were missing around the baseboard outside the freezer, and there was a loose tile along the wall behind the meal carts. The wall behind where the meal carts were stored was damaged and there was a white substance on the floor beneath the carts. On 11/3/24 at 1:20 PM, an observation was made of the cook and dietary aid serving the lunch meal. A cell phone was sitting above the steam table playing music. The cook, who had facial hair, was not wearing a beard cover. On 11/3/24 at 5:49 PM, an observation was made of the kitchen during the time the dinner meal was being plated. The large mixer had a white substance on the arms that hold the bowl, and there was a white substance on the floor beneath the large mixer. A tray on the tray cart had a brown substance on it and a piece of plastic wrap. The burner plates on the stove were dirty with crumbs down around the burners. There was food splatter on the front of the griddle and stove. On 11/5/24 at 6:02 PM, an observation was made of the kitchen during dinner meal service. The large mixer had a white substance on the arms that hold the bowl and below the mixer. Inside the large bowl was some dough that was covered with plastic wrap. The plastic wrap was labeled S.D. 11/5. There were apple slices on the floor, and a white substance that looked like dough on the floor that had been stepped on. A personal cell phone was above the steam table playing music. There was food crumbs and spills on the floor of the oven. On 11/7/24 at 1:35 PM, an observation was made of the kitchen during lunch service. A personal cell phone was above the steam table playing music while food was being plated. The cell phone was observed to fall into the macaroni and cheese below it. The Assistant Dietary Manager (ADM) who was serving the food removed the phone and continued to serve the meals. On 11/8/24 at 10:06 AM, an additional walk-through the kitchen was conducted. The large mixer was observed to have a white substance on the arms that hold the bowl and under the mixer. The stove and griddle had dried food splatter on them, the splash panel behind the griddle and stove was not clean. Temperature logs were observed outside of the walk in refrigerator and freezer, and the reach in refrigerator. The logs had been filled out through the beginning of November. In the reach in refrigerator, a bag of cheese and a bag of meat were observed to not be labeled, there was a container of red onions that were not labeled or dated. There were 12 Styrofoam bowl with what appeared to be dry cereal in them that were not labeled or dated, and a bag of lettuce that was not dated. In the dry storage room, a large bag of oats was not sealed or covered, sea salt caramel toffee sauce was not dated, and canned roasted red pepper strips were not labeled. In the walk in refrigerator, a bucket of chicken base was not dated. There was a leaking pipe that was dripping on a bottle of sea salt caramel toffee syrup that was not labeled and on the top shelf. There were bowls of what appeared to be pudding that were covered but not dated. A package of provolone cheese was observed to be open to air on the shelf and was not dated. A bag of cheddar cheese was not dated. There was chicken on the bottom shelf that was not dated. A box of raw bacon was open to air, and 2 bags of chives were not dated. In the walk in freezer, two boxes of frozen hash browns were open to air, a package of tater tots was not dated. Two boxes of frozen cookie dough were open to air, a box of whole frozen strawberries was open to air, a box of turkey franks was open to air, pork sausage links were open to air, a package of what appeared to be large sausage franks was open to air. There was ice on top of the back shelf, and icicles hanging from a hose in the freezer. The wall near the hand washing sink was damaged and the dry wall was exposed. The wall behind the mixer was damaged with the dry wall exposed. The drain behind the dish machine was rusty and dirty. There was a white substance on the wall behind the ice machine. The drain under the 3 sink area had rust around it and the drain under the defrost sink was rusty. Boxes of butter packets, jelly packets, sweetener, moist towelettes and a silverware holder with spoons and a paring knife was observed to be on the floor. The wall was dirty behind the coffee machine On 11/3/24 at 1:15 PM, an interview was conducted with the ADM who stated she was checking the dish machine temperatures after she finished all the dishes for the meal. The ADM stated if the temperature did not meet appropriate levels, she would report it to the Dietary Manager (DM). The ADM stated the dish machine was a low temperature machine. The ADM stated she was not positive as to what the appropriate temperature should be while running the dish machine, but had been going by 100 degrees Fahrenheit. The ADM was unable to find strips to check the chemical sanitizer level and stated the staff had not been checking it. The ADM stated they had not been keeping a log of the dish machine. On 11/8/24 at 10:37 AM, an interview was conducted with the ADM. The ADM stated she knew the dishes were being sanitized because the sanitizer, soap and rinse aid were visible dropping into the machine. The ADM stated she did not know what the required temperature should be for the dish machine. The ADM stated if the temperatures were not meeting requirements there was no way to verify that the dishes were being sanitized. The temperatures observed after several cycles of the dish machine were 74 degrees for the wash cycle, and 90 degrees for the rinse cycle. The ADM stated she did not know where the strips were to check the sanitizer in the dish machine. The ADM stated when the company who serviced the machine came last, the chemicals were adjusted and checked but the staff had not been checking since then. After the additional walk-through of the kitchen, the DM was not available for an interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 11/6/24 at 7:54 AM, a medication pass was observed with Registered Nurse (RN) 2. RN 2 was observed to come out of room [ROOM NUMBER] with a food tray, placed it in the meal cart, and then went to the medication cart and poured medication into a cup. No hand hygiene was performed. RN 2 prepared the rest of resident 20's medications and then went into room [ROOM NUMBER]. No hand hygiene was performed. RN 2 poured resident 20's water into the cup with the liquid medication. Resident 20 took all the liquid medication and other oral medications. RN 2 proceeded to instill eyedrops into both of resident 20's eyes. No hand hygiene was performed. On 11/6/24 at 8:21 AM, a medication pass was observed with RN 2. RN 2 went into resident 46's room and turned off her call light. RN 2 left the room and went to the medication cart. No hand hygiene was performed. RN 2 proceeded to pull out resident 46's medications and put them into a medication cup. RN 2 was observed to open and close different medication drawers, used keys to open a locked drawer, and use the computer keyboard. RN 2 went into room [ROOM NUMBER] and handed the resident her medications in the medication cup. Resident 46 took the medications. RN 2 left room and went back to the medication cart, no hand hygiene was performed. RN 2 pulled out a requested pain medication from the cart and placed it in a medication cup. RN 2 was observed to rub her nose. No hand hygiene was observed. RN 2 went back into room [ROOM NUMBER] and handed resident 46 the medication cup and a cup of water. No hand hygiene was performed. Resident 46 took the medication and RN 2 left the resident's room. On 11/6/24 at 1:47 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated hand sanitizer should be used before and after going in each resident's room. LPN 4 stated hand hygiene should be performed at every interaction with a resident even if you do not touch anything. On 11/6/24 at 2:06 PM, an interview was conducted with RN 2. RN 2 stated you should hand sanitize between each resident and wash your hands after using hand sanitizer three times. On 11/7/24 at 4:17 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was to perform hand hygiene in between each resident during medication pass, before entering a room, and before preparing medications. Based on observation, interview and record review it was determined, for 2 of 65 sampled residents, that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of staff not performing hand hygiene during meal service and medication pass, food was delivered to resident rooms uncovered, and the facility did not have a Legionella prevention and monitoring plan in their water management program. Resident identifiers: 20, 46. Findings included: 1. DINING OBSERVATIONS On 11/03/24 at 1:35 PM, an observation was made of the lunch meal service. Certified Nurse Assistant (CNA) 2 was observed to deliver a lunch tray to room [ROOM NUMBER] A. The tray contained one chicken leg, mashed sweet potatoes, green beans, a roll, and a pie dessert with the chocolate topping melted. The dessert was not covered and was walked from the nurse's station down the hallway to the end of the hall for delivery. On 11/05/24 at 6:17 PM, an observation was made of CNA 12 during meal service. At 6:19 PM, CNA 12 delivered the dinner tray to room [ROOM NUMBER]. CNA 12 did not perform hand hygiene and was wearing gloves. At 6:19 PM, CNA 12 delivered the dinner tray to room [ROOM NUMBER] A. CNA 12 was observed wearing gloves and touched their face. No hand hygiene was performed. On 11/12/24 at 1:46 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that her expectation with hand hygiene during meal service was that staff should perform hand hygiene after exiting a resident room and in between passing food trays. 2. On 11/13/24 at 10:24 AM, an interview was conducted with the Maintenance Supervisor (MS). A copy of the facility Legionella prevention and monitoring plan was requested. The MS stated that he was not in charge of the Legionella system, had not heard anything about it and did not know what it was. The MS stated that he was not aware of the facility water maintenance plan to prevent contaminants or measures to reduce the risk of Legionella. The MS stated that the facility had an emergency water agreement with a supplier but could not recall who that supplier was. The MS stated that they did not have a water management plan and he had not seen one in all the documentation left from the previous Maintenance Supervisor. It should be noted that the MS was newly hired and had only been on the job for approximately two weeks. No additional information was provided by the facility about the water management program. Review of the facility Water-borne Contaminants policy documented, The maintenance director or designee is responsible to identify the facility's risk for water-borne contaminants, including Legionella growth and spread, using a designated risk assessment tool approved and to implement appropriate prevention measures, including Legionella testing as indicated based on the risk assessment outcome. The policy was adopted on 12/16/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, for 1 out of 32 sampled residents, a resident that was a fall risk did not have a baseline care plan developed within 48 hours of the admission. Resident identifier: 47. Findings included: Resident 47 was admitted to the facility on [DATE] with diagnoses which include, but were not limited to, pneumonitis due to inhalation of food and vomit, abnormalities of gait and mobility, dysphagia, protein-calorie malnutrition, chronic obstructive pulmonary disease, opioid dependence, cognitive communication deficit, low back pain, essential hypertension, repeated falls, pain in right shoulder, and esophageal obstruction. Resident 47's medical record was reviewed on 6/26/23. On 4/5/23 at 3:53 PM, a Baseline Care was opened in resident 47's medical record but never completed. On 6/28/23 at 11:19 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 47 was very independent. LPN 2 stated that the floor nurses did the baseline care plans. On 6/28/23 at 11:35 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nurses on admission would open the baseline care plan and start them. The DON stated the Minimum Data Set (MDS) coordinator would finish the baseline care plans. The DON stated that resident 47's baseline care plan had been opened but not completed. The DON stated that the baseline care plan should be closed within 72 hours. The DON stated a care plan should be completed within two weeks of admission. The DON stated if a resident had a fall a risk assessment would be completed and the interdisciplinary team would meet. The DON stated that she would update the care plan for falls and nutrition at risk. The DON stated the Assistant Director of Nursing would update the care plan for wounds and the MDS coordinator would update all other areas of the care plan. The DON stated that the safety interventions in place for resident 47 included straightening up his room and encouraging him to use his call light. The DON stated that when resident 47 was admitted he did not want to be a [NAME] on staff and the staff have had to encourage resident 47. The DON stated that resident 47 understood that now and would use his call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, for 1 out of 32 sampled residents, a resident that had care areas trigger on the Minimum Data Set (MDS) Care Area Assessment (CAA) Summary did not have a care plan developed and implemented in a timely manner. In addition, the care plan was not updated with safety interventions after the resident had four falls. Resident identifier: 47. Findings included: Resident 47 was admitted to the facility on [DATE] with diagnoses which include, but were not limited to, pneumonitis due to inhalation of food and vomit, abnormalities of gait and mobility, dysphagia, protein-calorie malnutrition, chronic obstructive pulmonary disease, opioid dependence, cognitive communication deficit, low back pain, essential hypertension, repeated falls, pain in right shoulder, and esophageal obstruction. Resident 47's medical record was reviewed on 6/26/23. An admission MDS assessment dated [DATE], documented that resident 47 required supervision of one person for bed mobility, transfer, walk in room, walk in corridor, locomotion on and off unit, and dressing. Resident 47 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 indicated that resident 47 was intact cognitively. The CAA and Care Planning section documented that falls was a triggered care area and falls were addressed in the care plan. [Note: A care plan for resident 47 was not developed until 5/30/23.] On 4/14/23 at 5:40 AM, a Health Status Note documented Note Text: Resident pressed his call light and was found in bed alert and oriented. He stated he fell in the bathroom when he was trying to urinate and hit the left side of his head on the bathroom floor. There is a small laceration on the left side of his head, that has coagulated blood there, no active bleeding. Assessed resident for other injuries, none noted. No c/o [complaints of] pain at this time. Neuro [Neurological] checks done, B/p [blood pressure] 108/61, HR [heart rate] 69, temp [temperature] 97.6, resp [respirations] 18. Will continue to monitor. [Note: A care plan was not developed and no new interventions were implemented.] On 4/16/23 at 12:11 PM, a Health Status Note documented Note Text: Patient was reaching for something at the side of his bed and fell onto his left side out of bed as per patient. Patient states that he did not hit his head. This nurse found patient on floor attempting to get up. Assisted patient back to bed. This nurse assessed patient, no apparent injuries. Vitals [vital signs] taken, BP: 117/68 HR: 78 O2% [oxygen saturation percentage]: 97 RR [respiratory rate]: 14. MD [Medical Director], DON [Director of Nursing], ADON [Assistant Director of Nursing] and Administrator notified. [Note: A care plan was not developed and no new interventions were implemented.] On 4/28/23 at 10:54 PM, a Health Status Note documented Note Text: Pt [Patient] had pressed his call light and was found sitting on his bed with blood on his floor. Pt had blood in his hair on the left side of his head. When asked what happened, Pt stated that he was trying to stand up and walk to his chair when his feet got caught in his blankets and he tripped over them and hit his head. Pt stated he then got back up and sat in bed and pressed his call light to let us know. HR: 74 BP: 134/72 Temp: 98.4 RR: 18 O2 [oxygen]: 98 head injury assessed and cleansed. Vitals taken and neuros assessed with no signs of concussion or other trauma. MD notified and DON notified, pt stated no one needed to be contacted for him. [Note: A care plan was not developed and no new interventions were implemented.] On 5/4/23 at 6:32 PM, an Incident Note documented Note Text: Heard resident calling out, entered room, resident observed laying on the floor on L eft [sic] in fetal position, small amount of frank blood noted to head and on floor. Resident awake and able to converse with staff. Sat resident up, denied serious pain, nausea, or dizziness. assisted to stand with 2 person assist and to get in bed. Resident denies pain in legs, hips, knees with standing. Laceration noted to L [left] eyebrow, cleansed with wound cleanser, 2 steri-strips applied, superficial abrasion to outer R [right] ankle, tender to touch, no swelling. Initially stated he didn't know how he ended up on the floor, then stated he stood up and his L leg just gave out. Neuros initiated. VS [vital signs]: [blood pressure] 134/80, HR 74, RR 16, [temperature] 97.4, [oxygen] 93% on room air. [Name of MD removed] notified. Resident states no one needs notified on his behalf. Resident tearful and repeatedly apologizing. Re-assured resident that staff is here to help him. [Note: A new intervention was developed but not initiated until 5/30/23, when the care plan was developed.] A care plan Focus initiated on 5/30/23, documented The resident is at risk for falls r/t [related to] difficulty maintaining sitting balance, impaired balance during transitions, use of psychotropic and opioid medications, anemia, visual and hearing impairment, cognitive impairment and pain. A care plan goal documented The resident will not sustain serious injury through the review date. Interventions were initiated on 5/30/23, and included: a. 5/4/23, Staff shall assist to provide the resident with a safe environment to reduce the risk for falls: Declutter room. b. Anticipate and meet the resident's needs. Keep frequently used items within reach. c. Educate and encourage the resident to wear appropriate footwear, such as nonskid socks or shoes, when ambulating/mobilizing. d. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. e. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. [Note: Resident 47 had four falls prior to a care plan with safety measures being implemented. Three of the falls resulted in resident 47 hitting his head and causing lacerations.] On 6/28/23 at 11:15 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that resident 47 required minimal cares and resident 47 did a lot on his own. CNA 2 stated that resident 47 had good and bad days. CNA 2 stated that resident 47 was able to toilet himself. CNA 2 stated that he had never known resident 47 to have fallen here at the facility. CNA 2 stated that resident 47 was very knowledgeable and required reassurance with the call light. CNA 2 stated that resident 47 would fall asleep with food in his mouth and the nurses were adjusting medications. CNA 2 stated that resident 47 would go from using the walker to not using the walker but resident 47 was not a risk taker. On 6/28/23 at 11:19 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 47 was very independent. LPN 2 stated that the floor nurses did the baseline care plans. On 6/28/23 at 11:35 AM, an interview was conducted with the DON. The DON stated that the nurses on admission would open the baseline care plan and start them. The DON stated the MDS coordinator would finish the baseline care plans. The DON stated that resident 47's baseline care plan had been opened but not completed. The DON stated that the baseline care plan should be closed within 72 hours. The DON stated a care plan should be completed within two weeks of admission. The DON stated if a resident had a fall a risk assessment would be completed and the interdisciplinary team would meet. The DON stated that she would update the care plan for falls and nutrition at risk. The DON stated the ADON would update the care plan for wounds and the MDS coordinator would update all other areas of the care plan. The DON stated that the safety interventions in place for resident 47 included straightening up his room and encouraging him to use his call light. The DON stated that when resident 47 was admitted he did not want to be a [NAME] on staff and the staff have had to encourage resident 47. The DON stated that resident 47 understood that now and would use his call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, for 1 out of 32 sampled residents, facility staff did not promptly respond with a resident presented with signs and symptoms of a UTI and they did not ensure the resident received an antibiotic susceptible to the organism causing the UTI. Resident identifier: 3. Findings included: Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right, chronic obstructive pulmonary disease, urinary tract infection, and overactive bladder. Resident 3's medical record was reviewed on 6/26/23. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 3 was frequently incontinent of bladder and occasionally incontinent of bowel. Resident 3 was not on a toileting program. In addition, resident 3 required extensive assistance of two persons for toileting. A care plan Focus initiated on 4/29/16, documented I am at risk for Urinary Tract Infection, hx [history recurrent UTI, incontinent of B&B [bowel and bladder]. Interventions included: a. Encourage adequate fluid intake. Date Initiated: 4/29/16. b. Give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 4/29/16. c. Monitor/document/report to MD [Medical Director] PRN [as needed] for s/sx [signs and symptoms] of UTI: Frequency, Urgency, Malaise, foul smelling urine, dysuria, Fever, nausea and vomiting, flank pain, Supra-pubic pain, Hematuria, Cloudy urine, Altered mental status, Loss of appetite, Behavioral changes. Date Initiated: 4/29/16. d. Obtain and monitor lab [laboratory]/ diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 4/29/16. e. Obtain vital signs as ordered/facility protocol. Date Initiated: 4/29/16. On 5/13/23 at 11:15 PM, a Health Status Note documented Note Text: CNA [Certified Nursing Assistant] reported red blood in brief from urine. Red blood visualized in brief and resident confirmed tenderness/discomfort in labia/meatus area. One time order received from MD for straight cath [catheter] to obtain UA [urinalysis] with C&S/micro [culture and sensitivity microbiology]. CNA's assisted nurse with keeping clean field and to comfort resident, . Tolerated well and straight cath urine sample obtained on first attempt with 16FR [French] pre-lubricated sterile straight catheter to specimen cup. Urine is brown/red brick color with no unusual odor. genital folds had dark pink rash with c/o [complaints of] itching and discomfort. Afebrile. HX of chronic urinary tract infections. Catheter UA sample will be properly stored in specimen fridge until lab can pick up tomorrow. Continue to monitor and observe for s/sx of worsening infectious disease process. Report acute findings to MD. On 5/14/23 at 2:19 AM, a Health Status Note documented Note Text: Resident has had multiple episodes of increased paranoia close to being hysterical d/t [due to] UTI. Call light used multiple times an hour as well as calling out. Verbalized that she just wanted some comfort as 'someone is putting a bomb in my room'. Continue with emotional support and calming distractions. On 5/14/23 at 12:15 AM, UA was completed by the lab. The urinalysis microscopic documented the urine white blood cells (WBC) were greater than 30 high, urine red blood cells (RBC) were greater than 30 high, and urine bacteria 2 plus. The lab was printed on 5/19/23 at 2:45 PM, by the Director Of Nursing (DON). [Note: The lab was received by the DON five days after it was completed by the lab.] On 5/15/23 at 12:13 AM, a Health Status Note documented Note Text: Pt. [Patient] with red tinged urine. Urine sample has been collected and waiting to be picked up by the lab. On 5/19/23 at 2:45 PM, the urine culture was received by the DON. On 5/23/23 at 10:10 AM, a physician's order documented Macrobid Oral Capsule 100 MG [milligrams] (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day for UTI for 7 Days. [Note: The antibiotic was initiated 10 days after the onset of symptoms and four days after the urine culture was received by the facility.] On 5/23/23 at 6:51 PM, an Orders -Administration Note documented Note Text: Macrobid Oral Capsule 100 MG Give 1 capsule by mouth two times a day for UTI for 7 Days Awaiting shipment from pharmacy. [Note: The first dose of Macrobid was not administered. Resident 3 received 6 and a half days of the Macrobid instead of the seven days ordered by the physician.] On 5/28/23 at 11:29 PM, a Health Status Note documented Note Text: ABX [antibiotic] Charting: Pt. continues on macrobid for UTI. No adverse reaction noted. Pt. continues to have red tinged urine. No c/o pain this shift. Pt. incontinent of bowel and bladder. Pt. gets brief changed. On 5/29/23 at 11:58 AM, a Health Status Note documented Note Text: ABX CHARTING: Resident continues on Macrobid for UTI. No complaints of adverse reaction noted. Resident continues to have some blood in brief at this time. No c/o pain with voiding. On 5/29/23 at 11:21 PM, a Health Status Note documented Note Text: ABX charting: Pt. continues to be on abx for UTI. No adverse reactions noted. Pt. continues to have red tinged uringe [sic]. Pt. incontinent of bowel and bladder. Pt. changed on a regular basis. On 5/30/23 at 9:25 AM, a Health Status Note documented Note Text: ABX CHARTING: resident continues on her abx therapy. She has had some loose stools, pro-biotics were started today. No complaints of burning with voiding, still some blood in brief with changes. On 6/14/23 at 4:02 AM, a Health Status Note documented Note Text: Pt with confusion this am, accusing staff of shaking fists at her all night, told nurse she stole her breakfast tray at 0300 [3:00 AM] this am, reported to pt that it wasn't time for breakfast and pt kept telling nurse she took her breakfast. pt than demanding her synthroid at 3 am and a pain pill. When nurse explained it was only 3 am she said she knew it but than refused to take anything for pain and refused her synthroid. nurse took 2 CNAS into her room to try to redirect pt and also ask her if she would take her pain medicine as pt was hollering out and could not be redirected. pt also refused for other staff in room as well. call light in pt reach. On 6/14/23 at 5:21 AM, a Health Status Note documented Note Text: pt more alert at this time, pt given her synthroid at this time as ordered. more pleasant with staff, states having bad morning and apologized to staff for her behavior earlier, allowed pt to vent and educated pt that staff is here to help and assist here. On 6/15/23 at 7:00 PM, a Health Status Note documented Note Text: At 1900 [7:00 PM] pt was pale, shaky, and labored breathing. O2 [Oxygen] and HR [heart rate] were variable. Put on O2 and color improved, and HR and O2 levels stabilized. Pt seems confused and struggling to find words to explain needs. On 6/16/23 at 4:17 PM, a Health Status Note documented Note Text: Resident has altered mental state. Attempt x2 for straight cath assessment of urine unsuccessful. 500 ml [milliliter] infusion order provided. 22 g [gauge] IV [intravenous] started L [left] hand. Will attempt straight cath after infusion completed. On 6/17/23 at 6:26 AM, a Health Status Note documented Note Text: UA collected this morning. Urine is viscous, brown/red in color and has a foul odor. Pt has had generalized pain and pain to vagina, SOB [shortness of breath] and tremors in her hands. [Note: A UA was obtained three days after resident 31 presented with s/sx of a UTI.] On 6/17/23 at 8:26 AM, the UA results were received from the lab. The urinalysis microscopic documented the urine WBC were greater than 30 high, urine RBC were greater than 30 high, urine bacteria 4 plus, and urine mucus 3 plus. On 6/17/23 at 9:01 AM, a Discharge Progress Note documented . Discharge/transfer location: Transferred to [name of medical center removed] ER [Emergency Room] . Reason for Transfer/discharge: Lethargic, episodes of confusion, low blood pressure, hematuria. On 6/28/23 at 10:49 AM, an interview was conducted with the DON. The DON stated that the UA collected on 5/13/23, from resident 31 was received from the lab on 5/19/23. The DON stated that was the struggle she was having with the lab and sometimes it took a long time to get the cultures back. On 6/28/23 at 11:23 AM, a follow up interview was conducted with the DON. The DON stated if a resident presented with s/sx of a UTI she would notify the MD and ask if the staff could collect a UA. The DON stated the facility used the McGeer's criteria to determine if they needed a UA. The DON stated that whenever a UA was sent to the lab the staff requested a culture. The DON stated it would depend if the lab would run the culture, the lab often stated that they did not see the culture indicated on the lab slip. The DON stated the facility was having problems with the lab. The DON stated it could take five to six days to get the culture back from the lab. The DON stated that she was able to call the lab or log into the lab system. The DON stated she would call the lab after 48 hours of no results. The DON stated they would wait to start an antibiotic after they got the lab results and the results were sent to the MD. The DON stated that time to time they would start an antibiotic prior to getting the culture back but she would try to deter that until they received the culture. The DON stated that not everything needed an antibiotic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure residents who displayed or were diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Specifically, for 1 out of 32 sampled residents, the facility was unable to demonstrate implementation of interventions for managing a residents dementia with behavioral disturbances. The resident had uncontrolled anxiety and agitation for two months that resulted in a fall with a fracture. Resident identifier: 164. Findings included: Resident 164 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Parkinson's disease, insomnia, vascular dementia, and osteoporosis without current pathological fracture. Resident 164's medical record was reviewed on 6/26/23. A care plan Focus initiated on 12/27/22, documented Elopement risk/wanderer r/t [related to] vascular dementia and confusion. The interventions included, but were not limited to, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: [sic]. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 164 had a Brief Interview for Mental Status (BIMS) score of 3. A BIMS score of 0 to 7 suggests severe impairment A care plan Focus initiated on 1/4/23, documented Impaired cognitive function r/t Dementia. A care plan Goal documented The resident will be able to communicate basic needs on a daily basis through the review date. Interventions were initiated on 1/4/23, and included: a. Administer medications as ordered. Monitor/document for side effects and effectiveness. b. Ask yes/no questions in order to determine the resident's needs. c. Communicate with the resident/family/caregivers regarding residents capabilities and needs. d. Communication: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues stop and return if agitated. e. Cue, reorient and supervise as needed. f. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. g. Monitor/document/report as needed any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. h. Present just one thought, idea, question or command at a time. i. Reminisce with the resident using photos of family and friends. j. Use task segmentation to support short term memory deficits. Break tasks into one step at a time. On 12/21/22 at 5:33 PM, a Health Status Note documented Note Text: Hospice nurse, [name removed] in to see resident at time of admit. Reconciled medications. Resident placed on mechanical soft diet d/t [due to] no teeth but is able to eat things such as PB&J [peanut butter and jelly] sandwiches. Resident is very anxious about being in a new place and is very worried about the fact that she will forget most of what she is told at least at first. Changed call light to a pressure button d/t resident with contractures to both hands and is really only able to use thumb and index finger on both hands. On 12/22/22 at 3:40 AM, a Health Status Note documented Note Text: Resident is oriented to self only, frequently forgets and confuses where she is and when it is. Shows many signs of anxiety and fearfulness r/t new facility and new living situation. Is weight bearing. Vital signs WNL [within normal limits]. Will continue to be monitored and looked after closely as she transitions to staying here. On 12/22/22 at 5:49 PM, a Health Status Note documented Note Text: Resident is alert and oriented to self only. Requires frequent re-direction and re-assuring. High anxiety and paranoia. Wandered into another resident's room and urinated on the floor shortly after a staff member had taken her to the restroom. Enjoyed time in activities today and enjoyed eating meals in the dining room. On 12/23/22 at 5:55 PM, a Health Status Note documented Note Text: Resident continues to be restless and paranoid. Needs frequent re-direction. Needs fed unless finger foods. Must be prompted to use the restroom. Does not like to be alone at any time. Spoke with her daughter for at least an hour this morning. Only oriented to self. Enters other resident's rooms. On 12/24/22 at 3:58 PM, a Health Status Note documented Note Text: Resident is alert and oriented x1 [oriented to person] self only. Takes pills whole. Continent b/b [bowel and bladder] as long as she is prompted to use the restroom. Requires assistance eating, toileting and transferring. Very restless and anxious. Does like to participate in activities and go to the dining room to eat. On 12/29/22 at 2:56 PM, a Health Status Note documented Note Text: Resident alert and oriented to self only. Continues have high anxiety. Really does not like to be in her room alone, prefers to be around other people and having someone to talk to. Does not understand or remember how to use call light, instead calls out for help frequently. Resident able to walk with a shuffling gait and does wander into other resident's rooms at times. Continent of b/b. Resident able to feed self if food is able to be eaten with hands, otherwise needs to be fed as she cannot use silverware. Eats lunch and dinner in the dining room, participates in activities. On 1/3/23 at 8:55 AM, a Hospice Nursing Clinical Note documented . Pt [Patient] is more confused which is adding agitation. Pt is very emotionally unstable today. On 1/6/23 at 11:25 AM, a Hospice Nursing Clinical Note documented . Pt very anxious today but cooperative. On 1/6/23 at 11:36 AM, a Social Service Note documented Note Text: Called and notified resident's POA [Power of Attorney] regarding her move, to room [ROOM NUMBER] so she can be closer to the nurse's station. Received verbal consent. On 1/11/23 at 1:15 PM, a Hospice Nursing Clinical Note documented . Pt continues to have episodes of anxiety and repetitive behavior and questions. On 1/14/23 at 1:15 PM, a Hospice Nursing Clinical Note documented . Pt was in wheel chair by nurses station asking to go to her room upon sn [skilled nursing] arrival. pt was agitated and anxious. On 1/19/23 at 7:30 AM, a Health Status Note documented Note Text: Resident had stuck her hands in her brief and got BM [bowel movement] on them and licked her fingers before CNA [Certified Nursing Assistant] could stop her. Assisted resident to wash hands and brush teeth. On 1/19/23 at 10:31 AM, a Health Status Note documented Note Text: Resident reporting to BOM [Business Office Manager] that a young man had come in her room and threw her to the ground. No one has been witnessed in resident room and resident unable to get self off floor. Administrator notified of resident's statements. Resident's baseline is oriented to self only. On 1/19/23 at 3:25 PM, a Health Status Note documented Note Text: Resident's hospice nurse in to see her today. Reports that today is the calmest and happiest she has ever seen resident in all the time she has taken care of her. On 1/27/23 at 3:36 PM, a Health Status Note documented Note Text: Resident very anxious today. Constant supervision required. Report that resident was wandering into other resident rooms during the night. Repetitive statements. On 2/19/23 at 6:30 PM, a Health Status Note documented Note Text: Pt with constant hollering out, unable to redirect pt. pt upsetting other residents, wandering into other residents rooms. other residents using foul language due to her increased behaviors. unable to spend 1:1 [one on one] with resident. unable to redirect. pt urinating on floors and having episodes of defecating on the floor in her room and or the hallway. notified pt hospice nurse [name removed] of pt uncontrollable hollering and behaviors. Nurse reports she will reach out to the sister again and notified the hospice physician regarding behaviors. notified management of pt condition. On 2/20/23 at 1:26 PM, a Health Status Note documented Note Text: Pt has multiple anxious episodes, which are evident by her repeated calling out, wondering when not answered and increase in agitation. Pt has now started to scream loud and become angry when extremely anxious. On 2/20/23 at 6:00 PM, a physician's order documented LORazepam Intensol Oral Concentrate 2 MG/ML [milligrams per milliliters] (Lorazepam) Give 1 ml [milliliter] by mouth at bedtime for anxiety. The order was discontinued on 2/23/23 at 1:24 PM. On 2/20/23 at 6:30 PM, a physician's order dated LORazepam Intensol Oral Concentrate 2 MG/ML (Lorazepam) Give 0.5 ml by mouth every 4 hours as needed [PRN] for anxiety/anxious behaviors. The February 2023 Medication Administration Record was reviewed. Resident 164 received PRN lorazepam on 2/21/23 at 11:34 AM, 2/23/23 at 1:55 AM, 2/24/23 at 3:35 AM, 2/24/23 at 8:02 PM, 2/25/23 at 4:03 AM, and 2/25/23 at 10:59 PM. [Note: Resident 164 had documented anxiety and agitation since admission on [DATE]. The lorazepam for anxiety and anxious behaviors was initiated two months after resident 164's admission.] On 2/21/23 at 6:27 PM, a Health Status Note documented Note Text: pt was taken from dining room and placed at nurses station in her wheelchair due to increased anxiety. nurse visiting with pt and trying to calm resident. pt requiring 1:1 attention. unable to calm pt, yelling at staff, other residents. pt given her hs [take at bedtime] medications at this time. pt sitting at nurses station so staff could watch her due to impulsive behavior. pt attempts to ambulate without assist [assistance]. pt has unsteady gait. asked pt to sit at station and visit with other residents at this time. visitors in facility and had a dog and family let [resident 164] pet and visit with the dog. seemed to calm pt for a little while. nurse went to another pt room to assist with cares. pt in w/c [wheelchair] at nurses station visiting with other residents and dog in the building. On 2/21/23 at 7:00 PM, a Health Status Note documented Note Text: pt still at nurses station in her w/c. continues with agitation. staff visiting with [resident 164] to try to calm her. pt given hs snack, cheezits. pt happy with her snack. On 2/21/23 at 7:30 PM, a Health Status Note documented Note Text: CNA found nurse in another pt room and reported [resident 164] is laying on the floor by the nurses station. Pt was laying on her back with rt [right] leg extended in front other and her left leg bent at the knee in front of her. Her w/c was behind her. pt baseline is confused and disoriented due to diagnosis of severe dementia. Pt was hollering loudly that she was in pain. Pt unable to describe what happened. Residents at nurses station reports she stood and fell. pt continued to yell and cry out in pain. pt pupils reactive to light, no red or raised areas noted to head. body assessment performed by nurse. pt able to extend her right leg, no rotation of leg or hip noted. pt unable to extend rt leg, kept in bent position. no rotation of hip noted. no other [sic] red or raised areas noted to other body parts. pt logged roll with assist times 3 using blanket into her bed. pt continues to scream out in pain. vitals [vital signs] [blood pressure] 112/69, [pulse] 84, [respirations] 18, [temperature] 97.2, oxygen sats [saturations] at 95 room air. noresp [nonrespiratory] distress noted. mental status appears at baseline. pt always confused and disoriented. Notified [name of hospice removed] of pt fall and screaming in pain. asked [name removed] hospice nurse if nurse needed to call pt daughter, [name removed] reported no she would call her. Asked [name removed] protocol for fall while pt on hospice services. Explained to hospice nurse that felt pt had a broken left hip and or leg. [Name removed] reports to nurse that no they do not send the pt to the hospital and that she would be out to facility to assess, evaluate pt at this time. pt was give prn morphine as ordered through hospice for extreme pain to left hip area. tol [tolerated] well. pt calm after receiving prn morphine. vital signs after morphine [blood pressure] 110/64, [pulse] 71, [respirations] 16, [temperature] 97.6, room air sats at 96. pt continues to guard left hip area. pt able to relax left leg after receiving prn morphine. [Note: Resident 164 received one PRN dose of lorazepam on 2/21/23 at 11:34 AM. Resident 164 had documented anxiety and agitation throughout the day on 2/21/23, prior to the fall.] On 2/21/23 at 7:46 PM, a Health Status Note documented Note Text: Received call back from Hospice nurse [name removed] reporting she notified pt daughter [name removed] and that the daughter was very upset that nurse had given her mother morphine for pain. Hospice nurse reports that she would not be out to assess the pt as the daughter was very upset and was on her way to take the pt, her mother to the ER [Emergency Room] herself. explained to the hospice nurse that the daughter should not take her in a car to the ER if pt has suspected injuries or broken hip. Nurse at [name of Long Term Care (LTC) Facility removed] notified the DON [Director of Nursing] of [name of Hospice removed] of situation and nurse was instructed to send the pt to the ER via [name of Ambulance company removed] if injury suspected and not to allow daughter to take the pt to the hospital. Explained to DON of hospice company that daughter is very upset and unable to calm her daughter and explained pt was in severe pain and gave morphine under pt prn orders. DON told [name of LTC Facility removed] he would reach out to the daughter and his hospice nurse regarding the situation. Nurse at [name of LTC Facility removed] notified pt daughter [name removed] that we would be sending the pt via [name of Ambulance company removed] to [name of hospital removed] for eval [evaluation] and treatment. daughter yelling at nurse on phone so loudly that other staff could hear her, daughter upset that none of the staff here would be accompanying her mother in the ambulance to the hospital. explained we dont do that and that she would be with the EMTs [emergency medical technicians] and that the daughter could meet her at the hospital. daughter continued to raise her voice at nurse at [name of LTC Facility removed] demanding to know why her mother fell. explained to daughter that we can not provide constant 1:1 services and that [resident 164] does require a lot of supervised attention and care and cant be redirected and is a fall risk. daughter continued to be upset over prn morphine. educated daughter that pt pain non-controllable and was not going to let her suffer and cry out in pain and morphine was ordered by her hospice physician and that pt was calm after giving to her and that her vitals stable after getting this medication. daughter allowed nurse to hang up at this time as nurse needed to notify [name of Ambulance company removed] for transport to hospital. On 2/21/23 at 11:30 PM, a Health Status Note documented Note Text: Nurse called ER to check on status of pt. [Name removed] RN [Registered Nurse] reported to nurse that pt had a fractured pelvis and that they were going to finish xray to left shoulder because pt with complaints of pain to left shoulder. On 2/21/23, an Emergency Department (ED) note documented ED COURSE: Patient seen and evaluated has history of Parkinson's and also dementia by report is approximately baseline patient received morphine before coming in seems the pain at this point is controlled. CT [computed tomography] head and cervical spine were obtained which shows no acute injury she does have old compression fractures of T1 [thoracic vertebra] with T3-5 age-indeterminate but no acute abnormality of the cervical spine CT head is unremarkable x-ray of the hip obtained which shows a superior and inferior inferior [sic] pubic rami fracture but no acute hip fractures. X-ray of the shoulder is negative for any acute injury there is degenerative changes. Ortho [Orthopedics] recommends weight-bear as tolerating and follow-up with them in clinic. Patient is in a nursing home already and is already on hospice given that she is in a SNF [Skilled Nursing Facility] I think she is okay for discharge . On 2/21/23 at 11:35 PM, a Health Status Note documented Note Text: Daughter called facility and reported that left shoulder not broken and that [resident 164] was ready to be transported back to facility at this time. On 3/4/23 at 11:35 PM, a Change of Condition documented Note Text: Resident passed peacefully with dignity and respect. On 6/27/23 at 1:28 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated if a resident was admitted to the facility on hospice services the hospice company would bring the medications to the facility for the resident. LPN 1 stated if patients were close to death and only receiving comfort medications the facility staff would administer lorazepam for anxiety and morphine for pain. LPN 1 stated that if the resident was on other medications they would be scheduled. LPN 1 stated that she would contact the hospice company if the resident did not already have something in place for agitation and the hospice company would prescribe something. LPN 1 stated that if a resident was wandering the protocol would be to take the resident back to their room, deescalate the situation, and LPN 1 would give the PRN medication if needed. LPN 1 stated it was usually on the MAR to observe for the behaviors for medications. On 6/27/23 at 1:35 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 164 was confused a lot and always yelled help me. CNA 1 stated that resident 164 could walk with help and the walker. CNA 1 stated the other CNAs would say that resident 164 could not walk. CNA 1 stated if you asked resident 164 questions she was coherent enough to answer. CNA 1 stated that resident 164 was really anxious but pleasant and if you went in to calm resident 164 down she would be fine. CNA 1 stated that she would put resident 164 in the recliner and put a lap blanket on resident 164's lap because it made resident 164 feel safe. CNA 1 stated that resident 164's daughter always had snacks for resident 164. CNA 1 stated that resident 164 did not have medications for anxiety and resident 164's daughter did not want resident 164 on anything. CNA 1 stated it took a lot of talking to calm resident 164 down and it was all about your approach with resident 164. CNA 1 stated that she was not on shift when resident 164 fell. CNA 1 stated that she felt bad after resident 164 fell because it hurt her so bad to change her. On 6/27/23 at 1:52 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that resident 164 was legally blind or mostly blind. The ADON stated that resident 164 was a very anxious resident and had a hard time tracking faces but recognized voices and shadows. The ADON stated that resident 164 was very impulsive and had very poor safety awareness. The ADON stated that resident 164 spent a lot of time at the nurses station so staff could keep an eye on her. The ADON stated that the night of the fall resident 164 had an impulsive event where she got up and fell. The ADON was asked about treating resident 164's anxiety and agitation. The ADON stated that in this environment they could not chemically restrain residents. The ADON stated that resident 164 was a constant challenge. On 6/28/23 at 8:43 AM, an interview was conducted with the DON. The DON stated that resident 164 admitted to the facility on hospice services and was really anxious. The DON stated that the staff tried not to sedate resident 164. The DON stated that resident 164 was moved to a room closer up the hall near the nurses station and staff would keep resident 164 parked by the water fountain. The DON stated that another resident would sit with resident 164 so staff could come and go. The DON stated that resident 164 would ask for PB&J sandwiches often. The DON stated that resident 164 was always in a wheelchair and would try to and ambulate on her own with a blanket. The DON stated that resident 164 would also try and ambulate with the wheelchair as a walker. The DON stated that the night of the fall resident 164 was alone at the nurses station. The DON stated that a resident was not with resident 164 and the nurse had just left the station to pass a medication when resident 164 had gotten up and fallen. The DON stated that resident 164 was unsupervised for two to three minutes. The DON stated that resident 164's daughter was the POA and did not want hospice to give any Ativan or morphine until the end. The DON stated that usually when a resident was on hospice services Ativan and morphine were medications that were the usual regimen. The DON stated that resident 164 had melatonin and valerian root at night that the daughter gave resident 164 for anxiety. The DON stated that she was told on admission that the daughter did not want those medications from the hospice provider. The DON stated that resident 164 did not have pain prior to the fall. The DON stated other distractions for anxiety that the facility implemented for resident 164 included a digital picture frame and television shows that resident 164 liked to watch. The DON stated that once those ran the course they would bring resident 164 out to sit with staff. The DON stated that resident 164 ate in the dining room. The DON stated that nonpharmalogical interventions were used for resident 164 and the staff could be better at documenting those interventions. The DON further stated that resident 164 did not want to be isolated in her room and resident 164 had a hard time seeing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 25 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, but not limited to, quadriplegia, acute and chronic respiratory failure, morbid obesity due to excess calories, urinary tract infection, pressure ulcer of unspecified buttock stage 3, and major depressive disorder. Resident 25's medical record was reviewed on 6/26/23. Resident 25's progress notes were reviewed and documented the following UTI entries: a. On 3/11/23, a health status note stated, pt looked up his UA lab results per nurse request and were sent to [name of doctor removed]. pt has elevated BP when s/s of UTI present, bp 129/101, flank pain, cloudy urine with multiple sediment present. foul odor to urine present upon flushing catheter. many bacteria present, increased WBC, blood in urine. notified [name of doctor removed]. orders to start on macrobid 100 mg po [by mouth] BID x 5 days pending C [culture] and S [sensitivity] results. pt given first does from pyxis maching [sic]. [Note: The culture and sensitivity was unable to be located within resident 25's medical record.] b. On 3/14/23, a health status note stated, Resident is on antibiotics for UTI. No adverse effects noted. No sob [shortness of breath], respirations even and unlabored. catheter is draining to gravity. Urine is yellow. c. On 3/16/23, a health status note stated, Pt continues with Macrobid for UTI. No adverse reactions noted. d. On 3/18/23, a health status note stated, pt finished with macrobid. no adverse reactions noted. e. On 3/19/23, an alert note stated, ABX NOTE: Resident finished Macrobid last night. Urine looks clear in catheter, flushes easily. Resident is afebrile. His BP is up and down like at baseline. Resident has not complained of shoulder pain this morning. Resident 25's care plan was reviewed and a focus area stated resident 25 had a UTI related to painful urination. Interventions identified included: 1. Give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness. 2. Monitor/document/report to MD PRN [as needed] for s/sx [signs and symptoms] of UTI: Frequency, Urgency, Malaise, foul smelling urine, dysuria, Fever, nausea and vomiting, flank pain, Supra-pubic pain, Hematuria, Cloudy urine, Altered mental status, Loss of appetite, Behavioral changes. 3. Obtain and monitor lab/ diagnostic work as ordered. Report results to MD and follow up as indicated. The care plan was initiated on 4/4/23. On 6/28/23 at 10:02 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated resident 25 was at an increased risk for UTI because of his indwelling catheter. LPN 3 stated there was a protocol they followed when a resident had UTI symptoms. LPN 3 stated resident 25 presented with atypical UTI symptoms such as his face often got flushed and red when his catheter was flushed. LPN 3 stated there were certain criteria that needed to be met on a resident's UA sample before a culture and sensitivity was done. LPN 3 stated the WBC's needed to be above a certain amount and nitrites need to be present for a urine culture to be ordered. LPN 3 stated the urine culture resulted within 48 to 72 hours and it let the provider know which antibiotics were susceptible to the organism found in the resident's urine. LPN 3 stated they tried to steer away from starting antibiotics based on the UA results because they did not want to start and stop an antibiotic midway due to the resident being prescribed the wrong antibiotic initially. LPN 3 stated they had a feeling the lab had lost resident's UA and urine culture results for march 11. On 6/28/23 at 11:23 AM, an interview was conducted with the DON. The DON stated there was a protocol the nurses followed if a resident was having UTI symptoms. The DON stated the nurses notified the MD and obtained an order to collect a UA. The DON stated anytime they obtained a UA, they also ordered a urine culture to be done. The DON stated their lab was not the best. The DON stated staff often need to call the lab after 48 hours of not seeing results to make sure the lab had seen the urine culture request. The DON stated sometimes a doctor would prescribe antibiotics without a urine culture but stated they tried to deter the doctor from doing that because a resident could be treated with the wrong antibiotics. The DON stated not everything thing needed an antibiotic and they had enough multi-drug resistant organisms. The DON stated they remember the nurse practitioner at the time had ordered resident 25 antibiotics without a urine culture. The DON stated they were unsure why a urine culture was not done. Based on interview and record review, it was determined, the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, for 2 out of 32 sampled residents, a resident with a Urinary Tract Infection (UTI) was started on an antibiotic and the culture and sensitivity (C&S) was never received which indicated to repeat the culture. In addition, a resident with a UTI was started on an antibiotic and a C&S was not completed per physician's orders. Resident identifiers: 25 and 31. Findings included: Resident 31 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus, mild intellectual disabilities, cognitive communication deficit, obstructive and reflux uropathy, retention of urine, essential hypertension, presence of urogenital implants, hydronephrosis, and history of falling. Resident 25's medical record was reviewed on 6/28/23. On 5/14/23 at 3:59 PM, a Health Status Note documented Note Text: Patient DD [down drain] bag is draining large amounts of blood, emptied 550 ml [milliliters] from DD bag, bag is clotting at bag connection tube. Patient states that she is not feeling well today and has not been out of bed. She usually goes to church on Sunday's but was not able to today. Vitals [Vital signs] are BP [blood pressure]: 160/80, Temp [temperature]: 98.4 O2 Sats [oxygen saturations]: 95% HR [heart rate]:75. Securement device on patients leg came loose from last application, left a skin tear and a blister on her left inner thigh. Prepped skin with skin prep, replaced with a different type of tape. Patient tolerated well. MD [Medical Director] notified. On 5/16/23 at 11:53 AM, a physician's order documented Cipro Oral Tablet 500 MG [milligrams] (Ciprofloxacin HCl [hydrochloride]) Give 1 tablet by mouth two times a day for bladder infection for 7 Days. On 5/16/23 at 3:21 PM, a Health Status Note documented Note Text: UA [Urinalysis] collected and sent to lab [laboratory] yesterday. Practitioner on site today ordered to start cipro 500 BID [twice a day] x [for] 7 days while awaiting C&S results. Down drain bag draining slightly cloudy yellow urine, No evidence of hematuria visible at this time. Resident OOB [out of bed] and attended activities of the day. On 5/16/23 at 10:22 PM, a Health Status Note documented Note Text: pt [patient] started on cipro for s/s [signs and symptoms] of UTI. first dose taken from pyxis. urine is amber, some sediment present in down drain bag. denies any abd [abdominal] pain at this time. cath [catheter] cares provided. pt offered fluids. On 5/17/23 at 10:48 AM, the UA results were received from the lab. On 5/18/23 at 4:54 AM, a Health Status Note documented Note Text: Pt has been compliant with oral abx [antibiotic] at this time. No complaints of UTI symptoms or abdominal pain. Urine is draining from foley catheter well with no issues. urine is dark yellow, clear, no odor noted. On 5/18/23 at 10:14 AM, a Health Status Note documented Note Text: Resident on oral ABX/UTI. No complaints of UTI symptoms or abdominal pain. Supra-pubic catheter patent, dark yellow urine is draining well. Resident is tolerating well medication no adverse reactions note. Encourage fluid as tolerated. On 5/18/23 at 7:31 PM, a urine culture documented Mixed Gram Positive and Gram Negative Organisms Multiple organisms, probable contamination, please repeat culture. [Note: The Director of Nursing (DON) provided the urine culture to the State surveyors. The culture was not located within resident 31's medical record. A repeat culture was unable to be located within resident 31's medical record.] On 5/21/23 at 9:32 PM, a Health Status Note documented Note Text: Pt continues on Cipro for UTI. no adverse reactions noted. urine is amber, some sediment present no bleeding noted to urine. supra-pubic cath cares provided. fluids encouraged. On 5/23/23 at 12:04 AM, a Health Status Note documented Note Text: pt continues on cipro for UTI. no adverse reactions noted. urine is amber, small particles present, characteristic odor. fluids encouraged. On 5/23/23 at 9:46 PM, a Health Status Note documented Note Text: pt given last dose of Cipro for UTI. No adverse reactions noted. urine to down drain, amber in color, small sediment noted. characteristic odor. cath cares provided. On 6/28/23 at 11:23 AM, an interview was conducted with the DON. The DON stated if a resident presented with s/s of a UTI she would notify the MD and ask if the staff could collect a UA. The DON stated the facility used the McGeer's criteria to determine if they needed a UA. The DON stated that whenever a UA was sent to the lab the staff request a culture. The DON stated it would depend if the lab would run the culture, the lab often stated that they did not see the culture indicated on the lab slip. The DON stated the facility was having problems with the lab. The DON stated it could take five to six days to get the culture back from the lab. The DON stated that she was able to call the lab or log into the lab system. The DON stated she would call the lab after 48 hours of no results. The DON stated they would wait to start an antibiotic after they got the lab results and the results were sent to the MD. The DON stated that time to time they would start an antibiotic prior to getting the culture back but she would try to deter that until they received the culture. The DON stated that not everything needed an antibiotic. The DON stated there was no repeat culture done for resident 31. The DON stated that the Nurse Practitioner started resident 31 on Cipro for a bladder infection and hematuria. The DON stated that yes she would need the C&S to ensure resident 31 was on the appropriate antibiotic. The DON stated she had never received the lab or the fax for resident 31.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 3 sampled residents, that the facility did not have evidence that the allegations of abuse were thoroughly investigated. Specifically, a Certified Nurse Assistant (CNA) was witnessed to hit a resident and shove incontinence wipes inside the resident's mouth and the facility did not immediately assess and monitor the resident for injuries. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis (MS), systemic lupus erythematosus, paraplegia, type 2 diabetes mellitus, hypertension, chronic obstructive pulmonary disease, cognitive communication deficit, pain in right hip, urge incontinence, major depressive disorder, anxiety disorder, insomnia, hypothyroidism, and polyosteoarthritis. The facility abuse investigation report documented the description of the incident as, On 8/16 C.N.A [name of CNA 1 omitted] reported that C.N.A [name of CNA 3 omitted] had asked her to help change [resident 1's name omitted] brief. It was reported that [resident 1] became combative and scratched the arm of C.N.A [CNA 3], it is reported that [CNA 3] then hit the resident 3 times. The resident then tried to bite [CNA 3], at this time it is alleged that [CNA 3] shoved wipes into her mouth and said 'bite these'. The report documented that CNA 3 was interviewed and denied hitting resident 1, or stuffing any wipes in her mouth. CNA 3 reported that resident 1 was combative and was resisting cares and that she was inappropriate with how she spoke to the resident. The report then documented that resident 1 was interviewed and stated that she did not like CNA 3 and had stated that morning CNA 3 had grabbed her arm and hurt it. The report documented that another CNA, not identified, had heard a commotion and entered resident 1's room. The unidentified CNA stated that CNA 3 was inappropriate with how she was speaking to the resident, but did not see her hit the resident and did not see any wipes in or around the resident's mouth. The report documented that staff and residents were interviewed and no other concerns or incidents were identified involving CNA 3. The facility determination of the investigation findings was to substantiate the allegation of abuse and CNA 3 was terminated. On 8/16/22, the ADM documented a typed note that identified 8 staff members that were interviewed related to the allegation of abuse. The note stated that none of the staff interviewed had ever witnessed or heard of CNA 3 hitting or being physically abusive with residents. The note further documented that it was identified that CNA 3 could be very direct and bold with how she speaks to residents and that it can upset them sometimes, but otherwise they had no concerns about the care that she provided outside of this alleged incident. On 8/16/22, the ADM documented a second typed note that identified 6 residents that were interviewed related to concerns with staff or the cares provided. The note documented that CNA 3 was not identified in the resident interviews. The note documented that one resident identified a concern related to a night aide who did not provide care due to not being assigned to the resident. The resident stated that the incident had been addressed by the ADM and there were no additional problems. On 1/26/23 resident 1's medical records were reviewed. Review of resident 1's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/23/22 documented that resident 1's Brief Interview for Mental Status (BIMS) score was a 12, which would indicate moderately cognitively impaired. The assessment documented that resident 1 had hallucinations with physical and verbal displays of the behavior occurring daily. The assessment documented that resident 1 was a two person extensive assist for bed mobility, transfers, toileting and personal hygiene; a limited 2 person assist for dressing; and a limited 1 person assist for eating. On 8/16/22 at 2:47 PM, resident 1's progress note documented, Per CNA, pt [patient] is combative today. CNA reports scratching and biting type behavior. Pt has also refused to have adult brief changed. Full linen change of bed required. Bed linens soaked roughly 90% of entire fitted sheets. No documentation could be found of a skin assessment of resident 1 after the allegation of abuse was reported. On 1/26/22 at 8:44 AM, an interview was conducted with the Administrator (ADM). The ADM stated that the witness to the alleged incident was CNA 1 and CNA 2. The ADM stated that CNA 2 entered resident 1's room upon hearing a commotion from the hallway. The ADM stated that CNA 2 had not witnessed anything but overheard loud noises. The ADM stated that he did not recall any exact statements that were reported or what CNA 2 had heard from the hallway. On 1/26/23 at 10:31 AM, a follow-up interview was conducted with the ADM. The ADM stated that at the time he was the only person who conducted the abuse investigation, but the Director of Nursing (DON) sat in on the interviews with CNA 1 and CNA 3. The ADM stated that no other staff conducted interviews for the investigation. The ADM stated that CNA 1 reported that CNA 3 asked for help in providing incontinence care to resident 1. CNA 1 reported that during that care resident 1 scratched CNA 3's arm and CNA 3 responded by hitting the resident 3 times, on the arm and shoulder area. The ADM stated that it was described as 3 fast hits. The ADM stated that CNA 1 then reported that resident 1 had tried to bite CNA 3 and CNA 3 responded by shoving incontinence wipes inside resident 1's mouth. The ADM stated he did not know who removed the wipes from resident 1's mouth. The ADM stated that CNA 3 confirmed that resident 1 had scratched her arm. The ADM stated that CNA 3 denied hitting resident 1 or stuffing wipes in her mouth, but admitted that she may have been too bold or forward in her approach to get resident 1 to cooperate with her cares. The ADM could not say what bold or forward meant nor what was said exactly by CNA 3. The ADM stated that CNA 3 had said she was concerned about resident 1 refusing cares and had gone in with the attitude of we are going to get you cleaned up. The ADM stated that CNA 3 did not say, and he did not ask, what was said to resident 1. The ADM stated that CNA 3's demeanor and descriptions were that resident 1 needed this done and they were going to get it done. The ADM stated that he discussed the residents rights to refusal with CNA 3 and if they did refuse care to report it to the nurse, and to reapproach later. The ADM stated that he did not recall what was said exactly and did not recall any other information provided in the interview. The ADM stated that he then interviewed CNA 2. The ADM stated that CNA 2 reported hearing loud voices from the hall, but he did not recall if she heard what was said. The ADM stated that when he interviewed CNA 3 she admitted in the altercation that she was bold and sometimes upset the residents. The ADM stated that he did not recall if he asked CNA 3 how her behavior upset residents. I'm sure I asked how it upset the resident, but I don't recall. The ADM stated that he did not have any other documentation of the staff interviews other than the abuse investigation report. The ADM stated that he then interviewed resident 1. The ADM stated that initially resident 1 had reported no concerns or problems with staff, but when asked directly about CNA 3 resident 1 had said she did not like CNA 3. The ADM stated he asked resident 1 why she did not like CNA 3 and the resident replied that CNA 3 had grabbed her arm forcefully. The ADM stated he did not recall if anyone assessed resident 1 after the incident, but if they did it would be documented in the resident's electronic medical record. The ADM stated that it was part of their practice to have a nursing evaluation on any residents with allegations of abuse. On 1/26/23 at 11:22 AM, the DON entered the interview with the ADM. The DON stated that Registered Nurse (RN) 1 was assigned to resident 1 on the day of the incident. The DON stated she did not interview resident 1 after the incident, nor did she conduct any assessments or evaluations of resident 1 after the incident. The DON stated that a weekly skin check might have been done. The DON stated that she did not instruct RN 1 to perform a skin evaluation. The DON stated that she believed that RN 1 was aware of the incident. The DON stated that the process for investigating allegations of physical abuse was that staff should inform the ADM and DON; find the responsible person and conduct interviews; take that person off the floor away from the situation; make sure there's no physical harm to either party; make sure the resident did not have any injuries; and make notifications to the state, police, and the physician. The DON stated that she did not recall if resident 1 was evaluated for any injuries. The DON stated that documentation of the evaluation for injuries would be in the resident's progress note or risk management. The DON was observed to review resident 1's skin assessments and progress notes and stated that there was no documentation of the incident. The DON stated that there were no incident reports or risk management notes that were initiated for the allegation. The DON stated that there was not an assessment of resident 1 for injuries after the incident. The DON stated that she would have been the person who notified the MD of the incident through the facility messaging app, but did not have documentation of the notification. The DON stated she recalled notifying the physician shortly after the incident was reported, and the physician ordered to monitor the resident. The DON stated that they would have monitored for any injuries to the arms or any adverse reaction to the wipes being inside the mouth. The DON stated that documentation of the monitoring should be on alert charting but they did not do any alert charting. The DON stated that she does not recall if she informed the staff of the physicians orders to monitor resident 1. The DON stated that the incident occurred when RN 1 was new and this was one of his first shifts working on his own. On 2/1/23 at 11:04 AM, a telephone interview was conducted with RN 1. RN 1 stated that he was not present for the incident between resident 1 and CNA 3, but was informed within an hour after it had occurred. RN 1 stated that it was his understanding that there was some fighting or combative behavior by resident 1 during a brief change and CNA 3 had negative words towards the resident. RN 1 stated that one of the other aides reported the incident to him, but that he did not recall who that person was as he had just started working at the facility. RN 1 stated that he did not do anything at that time, because he had heard that it was reported to leadership or the CNA Supervisor. RN 1 stated he recalled thinking someone is going to take care of it and I don't know what to do. RN 1 stated that negative words were reported to him, but does not recall what was said only that it was harsh words. RN 1 stated that what was reported was harsh in the tone and the words used. RN 1 stated that he did not have any concerns with abuse at the time, and understood the frustration. RN 1 stated that now with more experience he would characterize the report as abuse and would require leadership involvement. RN 1 stated that the process for reporting allegation of abuse was to file a grievance and give it to the grievance officer, and then notify the DON and ADM. RN 1 stated that after the incident was reported he did not immediately assess resident 1. RN 1 stated that he checked on resident 1 later, and she was still combative. RN 1 stated that resident 1 was holding her stuffed animal and did not want to be assessed or talked to. RN 1 stated that he did not perform a physical assessment of the resident, because she would not allow it. RN 1 stated that no one in administration had talked to him about the incident, but he thought he may have spoken to the CNA Supervisor about it. Review of the facility Abuse Policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish or deprivation of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being. The policy documented that all occurrences of resident abuse, suspected abuse, neglect and injuries of unknown source shall be promptly reported to the facility abuse coordinator for investigation. The policy stated that should an incident of resident abuse be reported, the Administrator, shall conduct an investigation of the alleged incident, and if abuse happened the nurse shall assess and treat the victim. The policy was last revised on 12/2016. [Cross-refer F600]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined, for 1 of 52 sampled residents, that the facility did not ensure that the resident had the right to receive services in the facility with reasonable accommodation of the resident's needs and preferences. Specifically, a resident requested a refill of toilet paper for 2 days and when she received the toilet paper the two rolls were placed out of reach and not in the toilet paper dispenser. Resident identifier: 6. Findings included: Resident 6 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, neuropathy, pressure ulcer of left heel, major depressive disorder, anxiety disorder, osteoarthritis, low back pain, pain in right hip, edema, and obesity. On 9/15/21 at 9:14 AM, an interview was conducted with resident 6. Resident 6 stated that she informed housekeeping yesterday that she needed toilet paper. Resident 6 stated that she was low and would run out today. Resident 6 stated that she was going to the nurse's station to inform them again that she needed toilet paper. On 09/15/21 at 2:47 PM, resident 6 was observed in the 300 hallway talking to Licensed Practical Nurse (LPN) 1. Resident 6 was heard stating to LPN 1 that she still had not received any new toilet paper. On 9/15/21 at 3:08 PM, an interview was conducted with housekeeper 1 at the end of the 300 hallway. Housekeeper 1 stated that she normally worked 7:00 AM to 3:00 PM, but today she arrived at 7:30 AM and was staying until 3:30 PM to help the other housekeeper out. Housekeeper 1 stated that she normally worked on the 100 hallway, but right now there were only 2 housekeepers for the entire building. Housekeeper 1 stated that her day started with cleaning the nurse's station, employee bathroom, and then emptying the garbage. Housekeeper 1 stated that she would then proceed to clean the bistro, front end of the building, coffee room and then the therapy room. Housekeeper 1 stated that after this was completed she would start cleaning the resident rooms on the 100 hallway. Housekeeper 1 stated that between the two housekeepers one of them would work Monday through Friday and the other would work Saturday through Thursday, that way there was one person present every day and some days they would overlap. Housekeeper 1 stated that the majority of the rooms were cleaned daily, but that if a room was not cleaned that day those were the rooms that they started with the following day. Housekeeper 1 stated that when they cleaned the resident rooms they emptied the garbage, swept, made the bed, wiped down the tables, mopped and cleaned the bathroom. On 9/16/21 at 11:53 AM, a follow-up interview was conducted with resident 6. Resident 6 stated that the night nurse obtained two rolls of toilet paper at 10 PM last night for her. Resident 6 stated that the rolls were placed on the back of the toilet seat and not in the dispenser. Resident 6 stated that she had arthritis in her hips and hands and she had a hard time reaching around to grab the toilet paper. Resident 6 also stated that she had cataract surgery on her right eye yesterday and was not supposed to bend over or it would increase the pressure in her eye. Resident 6 stated that housekeeping had not come in yet today, and it was easier to use the toilet paper if it was placed in the dispenser. An immediate observation was made of resident 6's bathroom. One roll of toilet paper was observed located on the back of the toilet tank. A second roll was observed located on a storage cart next to the toilet and was against the back wall next to the tank. Both rolls were observed behind the seat. The toilet paper dispenser on the wall was observed empty. On 9/16/21 at 12:26 PM, an interview was conducted with the Maintenance/Housekeeping Director (HD). The HD stated that the facility had two housekeepers dedicated to cleaning, except one was pulled from cleaning to do laundry on Mondays. The HD stated that each room was scheduled to be cleaned every other day, and they needed a third housekeeper for each room to be cleaned daily. The HD stated that they terminated the third housekeeper a week ago because that individual was not cleaning each room daily. That individual was previously responsible for resident 6's room. The HD stated that housekeeper 2 was now picking up the terminated staff members assignments and that she was completing the work and adding it in when she could. The HD stated that he needed to confirm if resident 6's room had been cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 52 sampled residents, that the facility did not immediately consult with the resident's physician when there was an accident involving the resident which resulted in injury and the potential for requiring physician intervention. Specifically, a resident fell out of bed onto the floor between the bed and the window. The resident's Foley catheter bag was hung on the opposite side of the bed, putting tension on the catheter. Resident Identifier: 36. Findings included: Resident 36 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic respiratory failure, acute on chronic diastolic (congestive) heart failure, chronic kidney disease stage 4 (severe), hypertension, benign prostatic hyperplasia, insomnia, chronic arterial fibrillation, and chronic pain syndrome. On 9/13/21 at 3:54 PM, an interview was conducted with resident 36. Resident 36 stated he had fallen out of bed and was sent to the hospital. Resident 36 stated he did not remember anything about the fall or being transferred to the hospital. On 9/14/21, resident 36's medical record was reviewed. An Incident Report dated 8/20/21 9:20 PM revealed resident 36 had an unwitnessed fall from his bed to the floor. Resident 35 was found lying supine on the floor between the bed and the wall. Resident 36's Foley catheter bag was hung on the opposite side of the bed from where the resident fell putting a lot of tension on the tubing. The catheter bag was immediately moved to resident 36's side to alleviate strain. Resident was assessed. No injuries were observed. The Incident report revealed that the prior Director of Nursing (DON) was notified on 8/20/21 at 9:22 PM. The incident Report noted that resident 36's physician was notified on 8/23/21 at 10:17 AM. [Note: The physician was notified 2 days after resident 36's fall on 8/20/21.] On 9/15/21 at 2:55 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC confirmed that resident 36's 8/20/21 Fall Incident Report noted that resident 36's physician was not notified until 8/23/21. No other information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 52 sampled residents, that the facility did not inform each resident periodically during the resident's stay, of services available in the facility and of charges for those services not covered under Medicare or Medicaid or by the facility's per diem rate. Specifically, a resident was not issued a Notice of Medicare Non-coverage (NOMNC) form when the Medicare part A services were terminated. Resident identifier: 98. Findings included: Resident 98 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, anxiety disorder, hyperlipidemia, idiopathic peripheral autonomic neuropathy, and hypertension. Resident 98's medical record was reviewed on 9/13/21 through 9/16/21. Resident 98 was discharged to home on 7/18/21. On 9/15/21 at 3:30 PM, the Administrator was emailed a copy of the Skilled Nursing Facility Beneficiary Protection Notification Review form and asked to complete one for resident 98 and two additional residents. The Administrator was asked to return the completed forms along with the NOMNC for all three residents. On 9/15/21 at 6:52 PM, an email was received from the Administrator containing 2 NOMNC forms. There was no NOMNC form for resident 98. On 9/16/21 at 1:53 PM, the Administrator was interviewed. The Administrator stated he was unable to find a NOMNC form for resident 98.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 3 of 52 sample residents, that the facility did not ensure prompt resolution of residents' grievances. Specifically, one resident had filed a grievance about his clothes getting bleached in the laundry, which had not been resolved, and one resident was missing clothing that had not been found or replaced. Resident Identifiers: 9, 15, and 149. Findings include: On 9/15/21, the Resident Council Meeting minutes were reviewed for 6/30/21, 7/28/21 and 8/25/21. • The 6/30/21 Resident Council Meeting minutes documented Residents are complaining that they're not getting their personal clothes back in a timely manner. This was referred to the prior Administrator with a note that read, Unresolved • The 8/25/21 Resident Council Meeting minutes documented that resident 149's clothes were getting bleached, and resident 15's clothes were getting bleached and they were missing several clothing items. This was referred to the current Administrator and the Maintenance/Housekeeping Director (HD). On 9/16/21 at 3:52 PM, the Grievance Report Forms were reviewed. Resident 15 had three documented grievances. 1. Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia, Cervical (C)5-C7 incomplete, neuromuscular dysfunction of bladder, gastro-esophageal reflux disease, anxiety disorder, insomnia, hypotension, pressure ulcer of right buttock and sacral region, stage 4, acute and chronic respiratory failure and major depressive disorder. Resident 15 was the facility's Resident Council President. On 9/16/21 at 9:54 AM, an interview was conducted with resident 15. The three documented grievances were reviewed with resident 15. a. A grievance report form dated 4/21/21 revealed, resident 15's clothes were getting bleached in the laundry room. There were no additional notes on the Grievance Report Form related to investigating, confirming or resolving this grievance. Resident 15 stated that this grievance had not been resolved. Resident 15 stated he had continued to receive clothes back from the laundry that had been bleached. Resident 15 pointed at the shirt he was wearing, which appeared purple in color. Resident 15 stated that it was blue when he purchased it. b. A grievance report form dated 5/18/21 revealed, resident 15's clothes had been bleached and it had likely ruined multiple pairs of clothing. The Grievance Report Form revealed that staff had received additional training regarding laundry. Weekly meetings had been established with housekeeping/laundry. A follow up 5/19/20 in weekly meeting to review scheduling, cleaning checklists and bleach cycle. The Grievance Report Form included the date resolved as 5/18/21 and had signatures included resident 15, the Grievance Officer and the Administrator. Resident 15 stated he had continued to receive clothes back from the laundry that had been bleached. c. A grievance report form dated 6/16/21 revealed, resident 15 did not have clean clothing to wear for two days in a row and had to wear hospital gowns while out of bed. There were no additional notes on the Grievance Report Form related to investigating, confirming or resolving this grievance. Resident 15 stated that this grievance had not been resolved. Resident 15 stated as recent as two weeks ago, he had to wear a hospital gown because he had no clothes in his closet. Resident 15 stated he had personally discussed this grievance with the new current Administrator and was told by the Administrator that more laundry staff were being hired. 2. Resident 149 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, abnormalities of gait and mobility, cognitive communication deficit, asthma, chronic pain syndrome, hypertension, gastro-esophageal reflux disease, osteoarthritis, fibromyalgia and bipolar disorder. The facility had no documented Grievances Report Forms from resident 149. On 9/16/21 at 10:32 AM, an interview was conducted with resident 149. Resident 149 stated she had clothes come back bleached from the laundry, but was not sure if she had filled out a Grievance Report Form when her clothes were bleached. On 9/16/21 at 4:37 PM, an interview was conducted with the Administrator. The Administrator stated he did not know about resident 149's clothes getting bleached. The Administrator stated that he was aware that the HD was working on a new process to prevent missing clothes. On 9/16/21 at 4:43 PM, an interview was conducted with the Housekeeping/Laundry Manager. The Housekeeping/Laundry Manager stated he had been investigating what was broken in the process. The Housekeeping/Laundry Manager stated he had not implemented any new processes yet to resolve missing clothing or prevent clothes from being bleached. 3. Resident 9 was admitted to the facility on [DATE] with diagnoses which included heart failure, osteoporosis, chronic kidney disease, and depression. On 9/14/21 at 9:52 AM, resident 9 stated that she had missing clothing while at the facility that were never found or replaced. Resident 9 stated that she had completed grievances for her missing items. On 9/16/21, resident 9's medical record review was completed. On 3/23/21, a Grievance Report Form was completed by resident 9. Resident 9 stated that she was given an expensive pair of pajamas for Christmas that were missing. The report revealed that this grievance was investigated and staff could not locate the pajamas. Follow-up actions were to change the garbage bags in resident 9's room. Resident 9's nursing notes revealed that on 8/7/21 at 7:13 PM, resident filed a grieve[ance] with laundry. She is very upset that her clothes are not being returned form laundry. Resident is missing a white pair of pants, gray stripe on side pants, and blue pair of pants. Resident is very upset about her clothes. Tried to go find them for her but had no luck on fining them. Review of the grievances completed for resident 9 revealed that no grievance was completed by staff members for these missing clothing. On 9/15/21 at 12:25 PM, the Resident Advocate (RA) was interviewed. The RA stated that she assisted residents with filling out the Grievance Report Form and then assigned the task to the director in charge. For missing laundry the RA stated that the director was the Housekeeping Director (HD). The RA stated that every day she followed up with the director to determine when the grievance was resolved. The RA stated that the resolved grievances were placed in a binder. On 9/16/21 at 9:44 AM, laundry aide (LA) 1 was interviewed. LA 1 stated that there was extra clothing in the laundry room for residents who had no clothing or if clothing was not labeled. A labeler was located on the north wall of the laundry room. LA 1 stated that clothing was labeled before they were washed, with the label placed in the collar of shirts, or the waistband of pants. LA 1 stated that she was aware that residents had complained about missing laundry, but the items were not located. LA 1 stated that some of the Certified Nursing Assistants (CNAs) reported to her that the laundry bags may have been thrown away. On 9/15/21 at 2:55 PM, an interview was conducted with the HD. The HD stated that when he was given a grievance for missing laundry, the laundry staff would search for the missing item. The HD stated that he had been in charge of laundry for two months and was not aware of any missing items before he started. On 9/15/21 at 3:13 PM, the Administrator (ADM) was interviewed. The ADM stated that after the HD searched for missing clothing, the ADM would talk to the resident to determine how they would like the situation to be handled. The ADM stated that if no grievance was completed for a resident's missing items, he did not receive a report about it, and therefore did not do anything about it. If there was a grievance completed, the ADM stated that he worked with the resident and their family to replace it. The ADM stated that the grievance forms are at each nurses' station and in the RA's office, and grievance forms could be completed by any staff members. The ADM stated that resident 9's missing clothing were not replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 52 sample residents, that the facility did not conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity, not less than once every 12 months. Specifically, resident's annual Minimum Data Set (MDS) assessments were not completed every 12 months. Resident identifiers: 6 and 11. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses which included diabetes, anxiety, and depression. Resident 6's medical record was reviewed on 9/16/21. Resident 6's MDS assessments were reviewed and revealed an admission MDS dated [DATE]. There was an in progress annual MDS dated [DATE]. The MDS was not completed or submitted. 2. Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] which diagnoses which included type 2 diabetes mellitus, hypertension, heart disease, chronic pain syndrome, anxiety and major depressive disorder. Resident 11's medical record was reviewed on 9/16/21. Resident 11's MDS assessments were reviewed and revealed an annual MDS dated [DATE]. There was an in progress annual MDS dated [DATE]. The MDS was not completed or submitted. On 9/16/21 at 8:16 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that there were a lot of July MDS's that had not been submitted. The RNC stated that the previous Director of Nursing (DON) was behind with the MDS's.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 45 was admitted to the facility on [DATE] with diagnoses which included chronic inflammatory demyelinating polyneuritis, gout, anoxic brain damage, chronic pain, and gastroparesis. Resident 45's medical record was reviewed 9/13/21 through 9/16/21. Resident 45's MDS indicated the resident was on a tube feed due to weight loss. On 9/13/21 at 2:26 PM, resident 45 was interviewed. Resident 45 was observed and did not have a tube feeding or equipement for a tube feeding. Resident 45 stated the he was on a tube feeding but it had been discontinued a couple of months ago. A Nutrition (Dietary) note dated 7/15/21 at 10:31 AM stated, Stop tube feed bolus dt (due to) weight gain. On 9/15/21 at 5:49 PM, the Regional Nurse Consultant (RNC) was interviewed. The RNC stated resident 45's July 2021 MDS would reflect the updated information. 2. Resident 24 was admitted to the facility on [DATE] with diagnoses which consisted of traumatic brain injury (TBI), spastic hemiplegia right dominant side, epilepsy, pseudobulbar affect, adjustment disorder with mixed anxiety, dysphagia, aphasia, osteoporosis, healed traumatic fracture, hypertension, multiple sclerosis, muscle wasting wasting, and unspecified psychosis. On 9/14/21 resident 24's medical records were reviewed. Review of resident 24's progress notes revealed the following: a. On 9/3/2020 at 11:02 PM, the note documented that resident 24 was dependent for activities of daily living (ADLs) including bedside incontinence cares. b. On 11/26/2020 at 1:03 PM, the note documented the presence of a brief for bowel and bladder incontinence. c. On 6/3/21 at 5:30 PM, the note documented that resident 24 was incontinent of bladder and bowel and staff changed the resident at routine intervals. Review of resident 24's Quarterly MDS Assessment on 6/3/21 documented the functional status [Section G] for toilet use was total dependence with a two person assist. The assessment defined toilet use as how the resident used the toilet room, commode, bedpan, or urinal; transferred on/off toilet; cleansed self after elimination; changed pad; managed ostomy or catheter; and adjusted clothes. The assessment documented the resident was always continent of bowel and bladder [H0300 and H0400]. The Annual MDS Assessment on 3/3/21 documented the urinary continence [H0300] as frequently incontinent with 7 or more episode of urinary incontinence but 1 episode of continent voiding, and the bowel incontinence was always incontinent with no episodes of continent bowel movements. The Quarterly MDS Assessment on 12/1/2020 and 8/31/2020 documented always incontinent of bladder and bowel [H0300 and H0400] for resident 24. On 9/15/21 at 11:19 AM, an interview was conducted with CNA 2 and Licensed Practical Nurse (LPN) 2 . CNA 2 stated that resident 24 required a 2 person assist for all cares for the safety of the staff and resident because she hit, yelled and screamed with any care provided. The CNA stated that it was hard to determine what resident 24's needs and wants were and that was why they had her on a scheduled 2 hour rounds. She can't tell us what she needs so we check on her frequently. The CNA stated that it would take 2 to 3 staff to complete a brief change on resident 24 for incontinence care. Based on observation, interview and record review it was determined, for 3 of 52 sample residents, that the facilities did not complete assessments accurately to reflect the resident's status. Specifically, a resident was assessed as having a ventilator but did not have one. Another resident's bowel and bladder function was not assessed correctly. In addition, another resident was assessed as having a feeding tube or weight loss but did not have either. Resident identifiers: 11, 24 and 45. Findings include: 1. Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes mellitus, hypertension, heart disease, history of pulmonary embolism and anxiety disorder. Resident 11's medical record was reviewed on 9/16/21. Resident 11's quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 11 used an invasive mechanical ventilator. On 9/16/21 at 4:17 PM, an interview was conducted with resident 11. Resident 11 stated he had never used on a ventilator. Resident 11 was observed to not have markings on his neck for a ventilator. On 9/15/21 at 9:52 AM, an interivew was conducted with Certified Nurses Assistant (CNA) 2. CNA 2 stated resident 11 did not use a ventilator and had not ever used one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 52 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident with depression had a care plan to monitor symptoms that was not implemented. Resident identifier: 13. Findings include: Resident 13 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, obesity, chronic pain, breast cancer, and lymphedema. During her stay at the facility, resident 13 was also diagnosed with major depression, cognitive communication deficit, post-traumatic stress disorder (PTSD), and adjustment disorder with depressed mood. On 9/14/21 at 9:16 AM, resident 13 stated that she had experienced severe depression at the facility. Resident 13 stated that sometimes she had refused cares. Resident 13 stated that she had visited with a counselor, but resident 13 stated that she was still struggling. On 9/14/21 at 9:16 AM, resident 13's room smelled strongly of urine. On 9/16/21 at 2:47 PM, resident 13's room smelled strongly of urine. On 9/16/21, resident 13's medical record review was completed. Resident 13's care plans included the following: a. Focus: Self care deficit related to: decreased motivation, energy deficit, environmental barriers. Resident will participate as able in ADL's (activities of daily living) and have all basic self care needs met at all times through next 90 day review. Initiated 2/17/21. Interventions included assist patient in accepting necessary amount of dependence, encourage resident to do as much self care as possible, encourage use of commode or toilet as soon as possible .maintain regular toileting at set intervals and/or continence programs .support the resident to come to his or her own conclusions and offer alternatives to interventions that the resident insist he or she will not comply with. Negotiate autonomy and decision making. Adapt the plan as needed. b: Focus: Potential for complication related to depression, behaviors, refusal of cares/services, initiated 2/17/21. Interventions: Interventions as appropriate and required (a) out of room daily b) encourage participation in activities c) facilitate verbalization of fears/frustrations .Targeted behaviors monitored daily a) withdrawal from activities b) tearfulness/crying c) verbalization of sadness, and refusal of cares/personal hygiene etc ). c. Focus: Resident has mental health diagnoses: Adjustment disorder with depressed mood and PTSD and requires the use of anti-depressant and anti-anxiety medications, initiated 2/22/21. Interventions: .Document target symptoms Q (every) shift. Notify MD (Medical Doctor) of any new/worsened symptoms of mental illness that are not effectively managed with current pharmacological and non-pharmacological interventions. Follow PASRR (Preadmission Screening and Resident Review) level II recommendations .Staff should use the following non-pharmacological interventions to help manage resident's behavioral symptoms. Interventions: 1) Provide opportunities for socialization 2) Provide encouragement, support and active listening 3) Encourage resident to follow her self-identified approaches on her safety plan 4) Resident likes to have a sense of control over care. Honor resident's preferences for care provision to the extend possible. If she refuses care, return and offer care again later. d. Focus: Refusing care as evidenced by: delaying/stalling or not permitting routine skin assessment, poor hygiene or infrequent bathing; reluctance to accept help when help offered, initiated on 5/14/21. Interventions included: Discuss topics of interest to resident during care Identify root cause of refusal . e. Activities/Recreation Therapy: The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, immobility, initiated on 2/6/21. Interventions included .The resident needs assistance/escort to activity functions. Provide 1:1 visits prn (as needed). f. Focus: The resident has an ADL self-care performance deficit related to mental illness, refusal of or delayed self care, poor motivation to participate in self care, initiated on 8/25/21. Interventions included .Encourage the resident to discuss feelings about self-care deficit . Nursing notes revealed the following: On 5/3/21 at 3:43 AM, Resident still has not gotten OOB (out of bed). Room has strong foul odor, urine saturating clothing and bedding and running on to floor. On 5/4/21 at 4:15 PM, CSW (Clinical Social Worker) in resident room to complete MDS (minimum data set), The room had a foul odor. Resident was in bed and there were about five flies moving around her body. CSW asked when she showered last and she reported last Tuesday. CSW let her know that it was time to shower again. CSW opened the window to air the room out. Education provided on hygiene and health concerns. Resident said she can shower herself and would get it done tonight. CSW told her I would f/u (follow up) in the morning . On 5/5/2021 at 6:16 PM, Resident did not get up during the whole shift. The odor was so strong the urine was seeping through the bed. Unable to do wound treatment. Will continue to encourage resident to comply with wound care and personal hygiene. On 5/8/21 at 5:37 PM, Resident, again, did not get OOB this entire shift despite several promises to get up and shower. Resident has refused all attempts by several staff members to assist her with hygiene cares. Bedding is severely soiled all around resident. Linens had to be placed at foot of residents bed to stop urine from running across floor. Multiple flies are in room. Odor from room is so severe a resident across the hall had to change rooms d/t (due to) odor causing nausea. Resident's window is opened in effort to air out room. On 5/14/21 at 4:46 PM, a skin/wound note documented that resident 13's last wound assessment was on 3/18/21. On 6/2/21 at 5:59 PM, Resident has refused all attempts by staff to assist her with hygiene cares. Has refused to get OOB this entire shift to use the bathroom or to clean herself. Bed is noticeably soiled . On 6/3/21 at 2:43 PM, Resident has yet to get OOB and shower despite promises . Nurse with resident that she appears to be stalling like she usually does and resident stated, 'I know and I'm just disgusted with myself but I can't help it.' Resident then began crying and asked to be left alone . On 6/4/21 at 5:28 PM, Resident got out of bed today. She had dripping feces coming out of her [pant] leg. Feces in the bed and on the floor. We got her to the bath room and showered her off. Had to wash over her body 3 or 4 times to get the feces off her skin. She has skin break down all over her body . On 6/4/21 at 5:42 PM, Wash her heel look at the heel some skin loss due to sitting in feces . On 6/5/21 at 2:42 PM, .She has sore[s] all over due to sitting in her feces . On 6/6/21 at 9:44 AM, resident complaining of pain due to pressure ulcers all over her body.she is at risk for sepsis due to sitting gin her feces and refusing to get changed for over three weeks . On 6/6/21 at 2:33 PM, Open sores on both hips, down the back of both legs, on her bottom and between her thighs. On 6/25/21 at 8:21 PM, resident 13 had MASD (moisture associated skin damage) on thigh. Completed an application for psych evaluation. On 6/30/21, resident 13 refused to get up. There was a smell in hallway. On 7/4/21, Resident did not get up from her chair during the whole shift. There is urine dripping from resident chair to the floor. The mal odor is coming from resident room can be smelled in the hallways and the nursing station . On 7/8/21, Patient remains sitting in recliner soiled with urine and feces. Wound doctor here, patient refused wound cares. On 7/9/21, .Resident had crying bouts for 1/2 hour about how she is scared to get up and how she worries all the time . On 7/10/21, Resident cried a little, said it is really hard to get up everyday she feels anxious all the time and has down days where she just wants to sleep all day . On 7/16/21, Resident got up after sitting in her feces for 4 days refusing any changing and refusing to get up and get showers. She has sores running down her bottom . On 7/18/21 at 5:14 PM, Resident refused wound treatment during this shift. She did not get out of her chair during this shift. Will continue to encourage resident to be complaint with care. On 7/21/21 resident 13 was referred to a counselor. On 7/24/21, Resident decided to get out of bed and take a shower. Her bed was soaking with urine and BM (bowel movement). residents clothes were also soaked. She has refused every shift for 4 days . A skin and wound note from 7/24 revealed .She feels down and doesn't feel good enough to get up. Resident has not been up or changed in over 4 days. Resident just sits in her feces and refuses to get up. Resident stated that she had called her behavior med counselor and tried to cancel it because she was not out of bed. counselor came anyways. Resident stated she wanted to get up after lunch . On 8/1/21 at 5:43 PM, Resident did not get out of her chair during this shift. Was unable to do wound care. Explain the risk and benefits. Resident verbalized her understanding and keep promising that she will get up but it did not happened. Will continue to encourage resident to be complaint with hygiene and wound care. On 8/6/21, resident refused to get up . She said she was feeling down and anxious today. Resident was feeling overwhelmed and tired. She has been sitting in her chair for three days. She is sitting in her feces and urine. The odor is strong and other residents are complaining about the smell . On 8/7/21, . Resident has been sitting in her feces and urine for 4 days. odor was strong. Chair resident sits in is soak[ed] with urine and feces. Management is aware of the situation with the chair. Her wounds have reopened up and are bleeding . On 8/13/21, a behavioral note revealed Resident was sitting in her urine and feces for three days. She refused to get up. Resident stated she wasn't doing well mentally and couldn't take care of her self. So decided to just sit in her urine . She has sores all up and down her legs and in between her bottom. resident refused to see the wound doctor yesterday .Resident had an appt (appointment). with councilor today. It went well resident stated. she feels better mentally and physically today . Resident 15 refused to get out of her chair on 8/15/21. In September 2021, resident 13 refused to get out of her chair on 9/5, 9/7, and 9/12. On 9/2/21, resident 13 refused care by the wound doctor. On 9/3/21, the wound specialist dismissed resident 13 from services due to refusal of assessments. On 9/14/21 at 8:33 AM, Resident refused to allow staff to assist her to get cleaned up. On 9/16/21 at 8:51 AM, Certified Nursing Assistant (CNA) 9 was interviewed. CNA 9 stated that resident 13 did not ask for help often, so she did not help her. CNA 9 stated that she did not know what assistance resident 13 needed. On 9/16/21 at 9:01 AM, CNA 6 was interviewed. CNA 6 stated that resident 13 did not push her call light for assistance, so CNA 6 brought resident 13 her meals, but did not assist resident 13 otherwise. On 9/16/21 at 9:07 AM, CNA 2 was interviewed. CNA 2 stated that resident 13 did not ask for help, but had depression. CNA 2 stated that the CNAs attempted to get resident 13 out of her room, but she refused to go to activities. On 9/16/21 at 11:40 AM, the Resident Advocate (RA) was interviewed. The RA stated that she did not know resident 13. On 9/16/21 at 11:48 AM, the Activities Director (AD) was interviewed. The AD stated that resident 13 liked to color in her room. The AD stated that when resident 13 remained in her room, resident 13 became depressed. The AD stated that she was scheduled to do one-on-one activities with resident 13 once weekly, but the AD was very busy, so she only went to resident 13's room about once every other week. The AD stated that residents who remained in their rooms were being neglected with their activities. On 9/16/21 at 12:04 PM, the Regional Nurse Consultant (RNC) was interviewed. The RNC stated that there had been a lot of turnover in staffing, and the new staff members were still getting to know the residents. The RNC stated that resident 13 was receiving social services, but did not have behavioral health services provided by the staff. The RNC stated that monitoring of resident 13's feelings of hopelessness was the most critical monitor, but all the monitoring in resident 13's care plan was not being completed. The RNC stated that resident 13 had refused cares, most likely due to depression.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 34 sample residents, based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility did not provide necessary resident's care and services for hygiene-bathing, dressing, and grooming. Specifically, a resident had long fingernails, greasy hair and soiled clothing. Resident identifier: 34. Findings include: Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included mood disorder, epilepsy, aphasia, impulse disorder, and traumatic brain injury. On 9/13/21 at 3:45 PM, an observed was made of resident 34. Resident 34 was in bed with dirty hair and long fingernails. On 9/15/21 at 10:00 AM, an observation was made of resident 34. Resident 34 was observed in the hallway. Resident 34 was sitting in his wheelchair that was soiled. Resident 34 was observed to have long fingernails with dark substance under them and food splatter on his pants. Resident 34's medical record was reviewed on 9/15/21. An annual Minimum Data Set, dated [DATE] revealed personal hygiene required limited 1 person assistance. Resident 34's required 1 person physical help in part of bathing activity. Resident 34 was further assessed as having limited range of motion to one side of his upper extremities. A care plan dated 6/25/2020 revealed, I have an ADL Self Care Performance Deficit and Impaired Mobility related to: Dementia, Impaired balance and unstable gait. The goal developed was I will maintain my current self care and mobility status through next review. Interventions developed were BATHING: I require 1 staff physical assistance with bathing and BATHING: I would like staff to check nail length and trim and clean on bath day and as necessary. Please report any changes to the nurse. An additional intervention dated 6/30/2020 was In addition: BATHING: I would like staff to provide me with short, simple instructions such as: Hold your washcloth in your hand. Put soap on your washcloth. Wash your face, etc. to promote independence. On 9/15/21 at 9:31 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated resident 34 was compliant for most part with Activities of Daily Living (ADL). CNA 2 stated resident 34 had not refused showers or personal hygiene care. CNA 2 stated that resident 34 had not refused nail care. CNA 2 stated nail care and trimming was done every Sunday. CNA 2 stated a podiatrist came in once a month to do toenails. CNA 2 stated resident 34 received afternoon showers. CNA 2 stated that CNA 6 was in charge of showering resident 34. CNA 2 stated there was a book that had which residents showered and what shift. CNA 2 stated that resident 34 was to be showered in the morning Monday, Wednesday and Friday. CNA 2 stated she did not know if resident 34 had been showered. On 9/15/21 at 9:40 AM, an interview was conducted with CNA 6. CNA 6 stated she had completed showers for residents assigned to her. CNA 6 stated resident 34 was not on her list to shower. CNA 6 stated she looked at the wrong form and did not know resident 34 was assigned to be showered Monday, Wednesday and Friday in the morning. CNA 6 was unable to determine when resident 34 last had a shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic respiratory failure, acute on chronic diastolic heart failure, chronic kidney disease, hypertension, benign prostatic hyperplasia, insomnia, chronic arterial fibrillation, and chronic pain syndrome. On 9/13/21 at 3:54 PM, an interview was conducted with resident 36. Resident 36 stated that the facility had no activities for him. Resident 36 stated he did not leave his room and did not participate in group or one-on-one activities. On 9/14/21, resident 36's medical record was reviewed. Resident 36's care plan dated 12/28/2020 and revised on 12/8/2020 revealed Activities/Recreation Therapy: The resident has little or no activity involvement r/t Physical Limitations, resident wishes not to participate. The goal developed was Will accept at least 1 1:1 (one-on-one) visit per week for social engagement/leisure involvement [times] 90 days. An intervention developed was Offer in room visits to provide social and sensory stimulation, assess for leisure needs and requested leisure resources. Resident prefers in room/independent leisure. Provide 1:1 visits weekly. On 9/15/21 at 9:53 AM, an interview was conducted with the AD. The AD stated she started as the AD at the end of May 2021. The AD stated she tries to conduct one-on-one activities for residents that stay in their rooms and are not able to join the group activities. The AD stated that sometimes she was only able to conduct one-on-one activities every other week because she was busy doing group activities. The AD stated she documented her one-on-one resident visits in her Activity Log binder. The AD's notes revealed she visited one-on-one with resident 36 on 8/31/21, 9/9/21 and 9/13/21. On 9/15/21 at 10:42 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated she would have expected the AD to make weekly one-on-one activities visits with resident 36 as outlined in his care plan. 4. Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia, C5-C7 incomplete, neuromuscular dysfunction of bladder, anxiety disorder, insomnia,pressure ulcer of right buttock and sacral region, acute and chronic respiratory failure and major depressive disorder. Resident 15 was the facility's Resident Council President. On 9/14/21 at 10:22 AM, an interview was conducted with resident 15. Resident 15 stated that the prior Administrator would not give the AD a budget for any activities and was giving the AD so many duties unrelated to resident activities that she did not have time to conduct activities with residents. Resident 15 stated that two months ago, when the current Administrator started, the AD was freed up to conduct activities with residents again and was also given a budget to purchase items for resident activities. Resident 15 stated the AD had been doing a great job and that he had enjoyed the group activities she had conducted with residents. On 9/15/21 at 5:46 PM, an interview was conducted with the AD. The AD stated that the prior Administrator was having her be the transport driver, schedule outside appointment for residents and train the Business Office person. The AD stated that the prior administrator was having her do 4 different jobs and she did not have time to do any activities with residents other than weekly group Bingo and sometimes take residents outside. The AD stated she often had to cut the resident's time outside short because she had to transport a resident to his dialysis treatments three days a week. The AD stated that the facility went a long time without someone to schedule appointments for resident that they started to back up. The AD stated the prior Administrator pressured her to catch up on making appointments for resident, which took even more time away from resident activities. The AD stated that she had asked the prior Administrator for a budget to use for resident activities, but he would not tell her how mush she could spend and told her that she needed to get approval for all purchases from him. The AD stated she was not able to purchase items for their group Bingo games. The AD stated that when the current Administrator started two months ago that he freed her up from all the other duties and gave her a budget for resident activities. The AD stated she had been able to do many more activities with residents since then. On 9/16/21, the Activities calendars were reviewed and revealed the following: [Note: The AD highlighted the activities that were completed on the calendar.] a. May 2021 - 133 activities were listed on the calendar. 23 activities were highlighted as conducted. b. June 2021 - 116 activities were listed on the calendar. 39 activities were highlighted as conducted. c. July 2021 - 109 activities were listed on the calendar. 24 activities were highlighted as conducted. d. August 2021 - 108 activities were listed on the calendar. All scheduled activities were conducted. 2. Resident 13 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, chronic pain, a history of breast cancer, lymphedema, osteoarthritis, and opioid dependence. During resident 13's stay, additional diagnoses included post-traumatic stress disorder (PTSD), adjustment disorder, depression, and cognitive communication disorder. On 9/14/21 at 9:16 AM, resident 13 stated that she had experienced severe depression at the facility. Resident 13 stated that sometimes she had refused cares. Resident 13 stated that she had visited with a counselor, but she was still struggling. On 9/16/21, resident 13's record review was completed. Resident 13 had a care plan for Activities/Recreation Therapy initiated on 2/6/21. The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t (related to) Cognitive deficits, Immobility, Physical Limitations Interventions included: a. Offer in room visits and provide the resident with materials for individual activities as desired and socialization. b. The resident needs assistance/escort to activity functions. Provide 1:1 visits prn (as needed). On 7/16/21 at 2:45 PM, the AD was interviewed. The AD stated that resident 13 went into a bit of a depression when she stayed in her room. The AD stated that resident 13 did not come out often, and resident 13 was scheduled for in-room activities. The AD stated that resident 13 should have had activities in her room once weekly, but there were 33 people who had one-on-one activities, so the best the AD could do was to visit resident 13 every other week. The AD stated that she's requested additional staff to help. The AD stated that there were meetings on Tuesdays, and Thursdays was the day to buy supplies and do care conferences, so those days were out. Additionally, group activities were held six days each week. Scheduled times for one-on-one activities on the AD calendar for Monday from Noon to 1:00 PM, Wednesday from 11:00 AM to Noon, and Friday from 11:00 AM to 1:00 PM. The one-on-one visit times on Tuesdays and Thursdays conflicted with other meetings. The AD stated that visits as needed were as often as the resident felt they needed a visit, within reason. The AD stated that she felt the residents that were bed bound or stayed in their rooms were being neglected. Based on observation, interview and record review it was determined, for 4 of 52 sample, that the facility did not provide activities based on the comprehensive assessment, care plan and the preferences of each resident. The choice of activities were not designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. Specifically, residents that were bed bound were not provided activities. Resident identifiers: 11, 13, 15 and 36. Findings include: 1. Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, heart disease, history of pulmonary embolism, chronic pain syndrome, anxiety disorder, major depressive disorder, and opioid dependence. On 9/14/21 at 11:26 AM, an interview was conducted with resident 11. Resident 11 stated that previous activities were really good and activity staff brought snacks to residents. Resident 11 stated that the activity staff went to the store for him and now were only able to get him stuff once a month. Resident 11 stated there were no snack activities or birthday celebrations. Resident 11 stated that the activity calendar was hung in his room on 9/13/21. Resident 11 stated that the calendar was hung on his bathroom door and he did not get out of bed. An observation was made of the facility calendar that was across the room and not visible from resident 11's bed. On 9/16/21 at 3:59 PM, an interview was conducted with resident 11. Resident 11 stated that there was nothing for residents that were bed bound. Resident 11 stated that activity staff use to come around for a few minutes and talk to the residents that were bed bound. Resident 11 stated there were 2 to 3 activity staff members that went around to each room and talked to resident for a few minutes and provided a snack or treat. Resident 11 stated there was 1 activity staff member and she tried to talk with every bed bound resident but was to busy to visit more than every other week. Resident 11's medical record was reviewed on 9/16/21. Resident 11 had annual Minimum Data Set (MDS) opened but was not completed dated 7/30/21. The previous annual MDS dated [DATE] revealed it was very important for resident 11 to take care of his personal items and have a phone. It was also documented that it was important for resident 11 to choose what type of bathing, snacks available and to choose bedtime. It was somewhat important to have family or friends involved in his care. It was Somewhat important for resident 11 to keep up on the news, pets, do favorite activity, listen to music, and lock up things to keep them safe. A care plan dated 10/14/19 and updated on 5/25/2020 revealed Activities/Recreation Therapy: I am minimally involved in the life of the facility and demonstrate limited social interaction. I prefer in room leisure. A goal developed was Will accept at least 1 1:1 (one on one) visit per week for social engagement/leisure involvement [times] 90 days. Interventions developed were to Assess my strengths and abilities. Encourage independence by allowing resident to make his own leisure choices. RT (Recreation Therapy) will support and give praise and Encourage continued family support and involvement and Offer in room visits to provide social and sensory stimulation, leisure resources and to assess my leisure needs. Staff will shop for resident as needed. Provide 1:1 visits 1x per week. On 9/15/21 at 8:52 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that when COVID-19 started and activities were shut down, all group activities were canceled. LPN 2 stated that one on one activities were provided when group activities were canceled. On 9/16/21 at 10:52 AM, an interview was conducted with the Activities Director. The AD stated that she had 33 residents that wanted one on one visits. The AD stated she had been asking for an assistant for a couple of week. The AD stated that she felt the residents that were bed bound were being neglected. The AD stated the Therapeutic Recreational Therapist (TRT) had not been in the building and she met with the TRT every Friday over video chat. The AD stated that resident 11 did not want to do anything besides talk about video games and movies. The AD stated that she tried to spend as long as possible with him. The AD stated that she usually spent 30 minutes every other week talking to resident 11.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 52 sample resident, that the facility did not ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM motion to prevent further decrease in ROM. Specifically, a resident with limited ROM to in his fingers was not provided treatments. Resident identifier: 34 Findings include: Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included mood disorder, traumatic brain injury, anxiety disorder, dementia with behavioral disturbance, and impulse disorder. On 9/15/21 at 9:13 AM, an observation was made of resident 34 in the hallway. Resident 34 was observed in the hallway with his right hand turned in at the wrist and fingers were pressed into the palm of his hand. Resident 34 used his legs to wheel himself through the hallway. Resident 34's medical record was reviewed on 9/16/21. An annual Minimum Data Set (MDS) dated [DATE] revealed resident 34 had limited ROM to one side of his upper extremities. Resident 34's care plan dated 9/4/2020 revealed The resident has acute pain r/t (related to) Disease process (Spinal compression fractures). One of the goals developed was The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. An intervention developed was Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care. A list was provided of residents that had a contracture or limited ROM. Resident 34's name was not on the list. On 9/15/21 at 9:21 AM, an interview was conducted with Certified Nursing Assistant (CNA) 8. CNA 8 stated that there was no restorative nursing program. CNA 8 stated there were no residents receiving active or passive ROM exercises. CNA 8 stated if a resident had Medicare or Medicaid they received therapy services. CNA 8 stated resident 34 did not have a brace or sprint. On 09/15/21 at 9:31 AM, an interivew was conducted with CNA 2. CNA 2 stated that there was no restorative nursing program since August 2020. CNA 2 stated therapy worked with residents every quarter for 30 days but there was nothing provided between the quarters. CNA 2 stated if there was a sudden change in condition then the resident might be provided therapy services. CNA 2 stated that therapy measured residents with limited ROM. CNA 2 stated resident 34 did not receive therapy. CNA 2 stated that resident 34 was compliant with cares and would be compliant with range of motion exercises. On 9/15/21 at 3:12 PM, an interview was conducted with the Director of Therapy (DOT). The DOT stated therapy staff depended on nursing staff to report if a resident had a decreased ROM or a change in ROM. The DOT stated resident 34 was not receiving therapy services and did not have limited ROM. An observation was made of resident 34 with the DOT. The DOT was observed to move resident 34's fingers, hands, legs, and feet. The DOT stated resident had little limited ROM in fingers 2nd and 3rd digits on his right hand. The DOT stated resident 34 had a flexion contracture in his second and third digits. The DOT stated resident 34 recently had a therapy screening completed. The DOT stated that resident 34 did not wake up long enough to complete the screening. The DOT stated that therapy staff usually measured contractures. The DOT stated that resident 34 was missing knuckles and pinky on the left hand. The DOT stated if there was a change then measurements were taken and documented. The DOT stated that resident 34 did not have admission measurements for a baseline. The DOT stated she thought nursing staff would notice if his contracture was getting worse. The DOT stated there was not a restorative nursing program. The DOT stated if there was a change then therapy would perform exercises. The DOT stated she had discussed re-starting the restorative nursing program with the Administrator but there was had not been a response.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 2 of 52 sample residents, that the facility did not ensure that residents who were incontinent received appropriate treatment and services to prevent urinary tract infections (UTI) and to restore continence to the extent possible. Specifically, a dependant resident developed a UTI and perineal care was performed incorrectly, and a dependent resident with a history of chronic UTIs did not receive timely incontinence care. Resident identifiers: 24 and 26. Findings included: 1. Resident 24 was admitted to the facility on [DATE] with diagnoses which consisted of traumatic brain injury (TBI), spastic hemiplegia right dominant side, epilepsy, pseudobulbar affect, adjustment disorder with mixed anxiety, dysphagia, aphasia, osteoporosis, healed traumatic fracture, hypertension, multiple sclerosis, muscle wasting, and unspecified psychosis. On 9/14/21 resident 24's medical records were reviewed. Review of resident 24's progress notes revealed the following: a. On 6/3/21 at 5:30 PM, the note documented that resident 24 was incontinent of bladder and bowel and staff changed the resident at routine intervals. b. On 9/11/21 at 3:00 PM, the note documented that resident 24 was notably lethargic and was much less vocal/agitated during cares. The resident had a poor appetite which was unusual and was afebrile. An order was obtained to collect a urine sample via straight catheterization (cath) for a urinalysis (UA) with culture and sensitivity (C & S) to rule out a UTI. c. On 9/11/21 at 4:30 PM, the note documented that resident 24's guardian was informed of the resident's change in condition and the order for a UA via straight cath. The guardian gave consent to the order and requested a follow-up with the test results. Resident 24 was administered Alprazolam 0.5 milligrams (mg) as needed (PRN) at 3:30 PM in preparation for the straight cath procedure. The urine sample was collected via straight cath using sterile technique with a 4 staff member assist. The urine was documented as cloudy. d. On 9/12/21 at 5:02 PM, the note documented that resident 24 was alert and vocal this shift per her normal baseline. The UA results were received and faxed to the primary care provider, 2+ bacteria was present with a negative nitrate. Fluids were encouraged. e. On 9/13/21 at 7:03 PM, the note documented that the Physician's Assistant (PA) was at the facility in the morning and a copy of the UA results were provided to him and forwarded to his office by fax. The note documented that they were awaiting the susceptibility results. On 9/14/21 resident 24's medical records did not contain copies of the UA with the C & S report. On 9/15/21 the urine C & S report was reviewed and documented the organism identified was Escherichia coli (e-coli) and was sensitive to the antibiotic Bactrim. The report documented that the specimen was obtained on 9/11/21. The results were finalized on 9/13/21. The report documented that the results were faxed to the facility on 9/14/21 at 8:30 AM, and were reviewed by the PA on 9/15/21 at 10:00 AM. Review of resident 24's physician orders revealed an order for Bactrim DS Tablet 800-160 mg (Sulfamethoxazole-Trimethoprim), give 1 tablet by mouth two times a day for UTI for 10 Days. The order was initiated on 9/15/21. Review of resident 24's Medication Administration Record (MAR) revealed that the Bactrim order was scheduled to be administered on 9/15/21 at 8:00 PM for the first dose. Review of resident 24's care plan revealed the following focus areas with interventions: a. A focus area for Activities of Daily Living (ADL) Self Care Performance Deficit and Impaired Mobility related to musculoskeletal impairment, limited mobility, disease process (TBI), physical inactivity, and cognitive impairment was initiated on 5/14/18 and revised on 8/8/19. The interventions documented that the resident required total assistance with personal hygiene care and required 1 staff participation to use toilet. The intervention was revised on 8/26/2020. b. A focus area for Current Continence Status was incontinent of bowel and bladder, and was initiated on 5/14/18 and revised on 2/16/21. The interventions documented were to change clothes/linens/pads and/or briefs promptly when wet, provide peri-care after each involuntary episode to keep clean and dry, and evaluate and monitor for pressure ulcer potential. Review of resident 24's Quarterly Minimum Data Set (MDS) Assessment on 6/3/21 documented the functional status [Section G] for toilet use was total dependence with a two person assist. The assessment defined toilet use as how the resident used the toilet room, commode, bedpan, or urinal; transferred on/off toilet; cleansed self after elimination; changed pad; managed ostomy or catheter, and adjusted clothes. The assessment documented the resident was always continent of bowel and bladder [H0300 and H0400]. The Annual MDS Assessment on 3/3/21 documented the urinary continence [H0300] as frequently incontinent with 7 or more episode of urinary incontinence but 1 episode of continent voiding, and the bowel incontinence was always incontinent with no episodes of continent bowel movements. The Quarterly MDS Assessment on 12/1/2020 and 8/31/2020 documented always incontinent of bladder and bowel [H0300 and H0400] for resident 24. On 9/15/21 at 11:19 AM, an interview was conducted with Certified Nurse Assistant (CNA) 2 and Licensed Practical Nurse (LPN) 2 . CNA 2 stated that resident 24 required a 2 person assist for all cares for the safety of the staff and resident because she hit, yelled and screamed with any care provided. The CNA stated that it was hard to determine what resident 24's needs and wants were and that was why they had her on a scheduled 2 hour rounds. CNA 2 stated She can't tell us what she needs so we check on her frequently. The CNA stated that it would take 2 to 3 staff to complete a brief change on resident 24 for incontinence care. LPN 2 stated that resident 24's history surrounding the TBI was traumatic and because of this resident 24 did not like to be touched at all, not even by her family/guardian. On 9/15/21 at 2:31 PM, an interview was conducted with with LPN 1. LPN 1 stated that resident 24 was acting differently from her baseline and that was what prompted the UA. LPN 1 stated that resident 24 could communicate a little bit and could say owie. LPN 1 stated that the facility had a standing order to complete a UA for signs and symptoms of a UTI. LPN 1 stated that she was not aware of the results of resident 24's UA and was not aware that the resident had an order to start antibiotic therapy today. LPN 1 stated that the medication did not pop up in the MAR and did not show to administer on her shift. LPN 1 stated that this was something that was usually reported in change of shift report and this information was not relayed to her. LPN 1 stated that they had Bactrim available in the emergency kit (E-kit) if the pharmacy did not deliver it. LPN 1 stated that the person who gave report should have passed off this information in report this morning that resident 24 would be starting the antibiotic today. LPN 1 stated that the information was also not listed on the 24 hour report or in alert charting. LPN 1 stated that if the UA was finished on 9/13 and faxed to the facility on 9/14 it should have been reported to the provider right away ideally. LPN 1 stated that if it was sent on 9/15/21 it could have been buried in the faxed reports on the fax machine. LPN 1 stated that it was the licensed nurse's responsibility to follow-up on the laboratory results. LPN 1 stated that if it did not get passed off in shift report then she had no idea that they did the UA. On 9/15/21 at 3:42 PM, an observation was made of CNA 1 and the Hospitality Aide (HA) providing resident 24 with incontinence care. Resident 24 was observed to hit and yell the entire time care was provided. Resident 24 was positioned in bed and rolled on the left lateral side towards CNA 1. The HA was observed to clean and wipe away a large, soft bowel movement with backward wipes toward the back. A new cleansing wipe was used for each pass by the HA. CNA 1 was observed to clean after the HA. CNA 1 was observed to wipe resident 24's anus with a cleansing wipe multiple times before obtaining a new wipe. During the entire process of providing incontinence care to resident 24, the resident was observed to strike the back of CNA 1 with a full swinging force of the left arm. The impact of the blows were mostly observed on the lower back and upper thigh area of CNA 1. Resident 24 was then rolled to her back and the clean brief was brought between the resident's knees and secured on both sides. The residents pants were pulled up and the blankets were draped over the residents torso. Upon completion of the task the resident calmed down and stopped yelling. No cleaning was observed completed of resident 24's labia. Upon exit of the room an interview was conducted with CNA 1. CNA 1 stated that resident 24 would not open her legs from the front to allow for cleaning of the labia and genitalia. CNA 1 stated that she cleaned the labia from the back when the resident was side lying, and wiped forward as the resident would not allow the aides to part her legs to clean her labia. CNA 1 stated because of her past history she would not let people touch the front labia to clean her properly. CNA 1 stated that she identified the changes in resident 24's behavior that prompted a UA and the identification of the current UTI. CNA 1 stated that the resident was more tired and more quiet and that was what prompted her to think she had an infection. On 9/16/21 at 10:01 AM, a follow-up interview was conducted with CNA 2. CNA 2 stated that resident 24 squeezed her legs together too tight and they tried as best as they could to clean her when providing incontinence care. CNA 2 stated that resident 24 did not allow them to clean the labia. CNA 2 stated that when cleaning resident 24 during incontinence care they roll her to the side and wiped as best they could from the front to the back. CNA 2 stated that if there were 3 staff members they could pry the residents knees apart, with one staff on each leg while one staff wiped and cleaned the resident. CNA 2 stated that this was done if a bowel movement had gotten in there. On 9/16/21 at 12:56 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that the infection control trends that she could see developing for the current month were related to facility acquired UTIs with an e-coli trend. The RNC stated that typically when she identified trends she would conduct audits for Peri care to determine if cross contamination had occurred and to see if it was being completed correctly. The RNC stated that she would also look at the residents that were incontinent to ensure that staff were checking them more frequently so organisms did not migrate into the urinary tract and that those resident did not sit in wet briefs for prolonged periods of time. The RNC stated that resident 24 had behaviors with cares and was resistant. The RNC stated that this made it difficult for staff to provide cares for resident 24. The RNC stated that she did not know how staff were adequately cleaning resident 24. The RNC stated that resident 24 was more guarded with cleaning the front labia area. The RNC stated that she had a care conference with resident 24's guardian and she was aware of the difficulties with proper cleaning of the resident with peri cares. 2. Resident 26 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which consisted of hemiplegia and hemiparesis following a cerebrovascular accident, osteoarthritis of knee, morbid obesity, idiopathic peripheral autonomic neuropathy, edema, autistic disorder, chronic obstructive pulmonary disease, atrial fibrillation, atrial septal defect, hypothyroidism, and overactive bladder. On 9/13/21 at 2:25 PM, an interview was conducted with CNA 5. CNA 5 stated that resident 26 was on contact precautions for Carbapenem-resistant Acinetobacter baumannii (CRAB) in the coccyx wound. On 9/13/21 at 2:44 PM, an interview was conducted with LPN 3. LPN 3 stated that resident 26 was on contact isolation precautions for Extended Spectrum Beta-Lactamase (ESBL) in the urine and Carbapenem-resistant Enterobacterales (CRE) in the skin. LPN 3 stated that resident 26 was colonized with both infections and could come out of her room after she performed hand hygiene. LPN 3 stated that resident 26 was incontinent of bladder and bowel and wore a brief. On 9/14/21 at 10:25 AM, an interview was conducted with resident 26. Resident 26 stated that her wound originated on the upper thigh and buttocks and was caused by the brief rubbing. Resident 26 stated that she also had yeast in there and that it was a bad place to have a brief rubbing. Resident 26 stated that the wound was still present on the left leg, but that the right leg had healed completely. Resident 26 stated that the wet briefs and incontinence caused her pain and the urine burned the wound. Resident 26 stated that staff changed her brief 2 times a shift and one of those times was usually right before they go off shift. Resident 26 stated that the staff were required to make rounds and provide incontinence care before the shift ended, but sometimes they did not get around to doing this with everyone that needed assistance. Resident 26 stated that she had left sided paralysis due to an old stroke and required incontinence care. Resident 26 stated that sometimes the staff forgot to put the call light within reach and she would have to wait until shift change for assistance or she would just have to yell and call out for help. Resident 26 stated that she had waited up to 30 minutes for assistance in the past. Resident 26 stated that she might need assistance with getting something to drink, a medication, or the other night she needed the nurse to check the wound on her buttocks because it was causing her pain. Resident 26 stated that she informed the CNA on the night shift that she needed the nurse and was told that the nurse was busy. Resident 26 stated that she asked the same aide 30 minutes later for the nurse and was again told that the nurse was on break. Resident 26 stated that she felt like the aides were filtering the messages to the licensed nurses and she was not able to get the care she needed from them. Resident 26 stated that she tried to be partners with her staff but that she did not think they had a care mentality. Resident 26 stated that she knew when she was not okay, and the aides should not be in charge of deciding what messages were relayed to the nurse. On 9/14/21 at 7:19 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 26 had a lot of moisture associated skin damage (MASD) on the posterior thigh region and the buttocks. RN 1 stated that in the past the resident had a Foley to allow the wounds to heal. RN 1 stated that when the catheter was discontinued the wounds would reappear again. RN 1 stated that the MASD was caused by sweat and urine. RN 1 stated that resident 26 goes through periods of times where she refused cares. RN 1 stated that they tried to maintain clean chucks and ensured she remained dry. RN 1 stated that the resident did not have any dressings to the wounds and that she just had cream applied to the wounds during incontinence care. Review of resident 26's physician orders revealed the following: a. Contact precautions for ESBL, Carbapenem resistant Acinetobacter (CRAb (sic), skin colonization). CRE gastrointestinal (GI) colonization dated 7/23/18 every shift for CRA/CRE colonization. Resident may exit room when: 1. Resident was assisted to complete hand hygiene 2. High touch surfaces of power wheelchair were disinfected 3. Resident and clothing was clean and unsoiled. The order was initiated on 9/14/21. b. If resident refused shower CNAs to wash buttocks area with soap and water and pat dry. Nurses to oversee CNAs and make sure it was being done every day shift every on Tuesday and Friday. The order was initiated on 4/19/19. c. Furosemide Tablet 20 milligrams (MG), give 1 tablet by mouth one time a day for hypertension. Hold for systolic blood pressure (SBP) less than (<) 100 or heart rate (HR) <60. Call Medical Doctor (MD) if patient was symptomatic. The order was initiated on 11/24/18. Review of resident 26's care plan revealed the following focus areas with interventions: a. A focus area for at risk for UTI, history of recurrent UTI, and incontinent of bladder and bowel was initiated on 4/29/16 and revised on 6/2/2020. Interventions identified included Encourage adequate fluid intake; Give antibiotic therapy as ordered, monitor/document for side effects and effectiveness; Monitor/document/report to MD (Medical Doctor) as needed for signs and symptoms of UTI: Frequency, Urgency, Malaise, foul smelling urine, dysuria, Fever, nausea and vomiting, flank pain, Supra-pubic pain, Hematuria, Cloudy urine, Altered mental status, Loss of appetite, Behavioral changes; Obtain and monitor laboratory/ diagnostic work as ordered; Report results to MD and follow up as indicated; and Obtain vital as ordered/facility protocol. b. A focus area for resistive to care related to refusing medications, treatments, refusing brief changes, and incontinence cares was initiated on 5/4/16 and revised on 4/13/2020. Interventions identified included Allow the resident to make decisions about treatment regime, to provide sense of control; Encourage as much participation/interaction by the resident as possible during care and/or activities; Give clear explanation of all care activities prior to AND as they occur during each contact; If possible, negotiate a time for activities of daily living (ADLs) so that the resident participates in the decision making process and return at the agreed upon time; Provide consistency in care to promote comfort with ADLs; Maintain consistency in timing of ADLs, caregivers and routine, as much as possible; and Provide resident with opportunities for choice during care provision. c. A focus area for diuretic therapy related to hypertension was initiated on 1/10/2020 and revised on 10/5/2020. Interventions identified included Administer medication as ordered; Many other medications may interact with antihypertensives to potentiate their effect (Levodopa, Nitrates). Monitor for Interactions/Adverse Consequences; May cause dizziness, postural hypotension, fatigue, and an increased risk for falls; Observe for possible side effects every shift; Monitor Dose; Monitor for any signs or symptoms of fluid deficit and relay findings to physician; and Report pertinent lab results to MD. d. A focus area for potential for complications related to incontinence was initiated on 4/27/21. Interventions identified included Assess skin after each episode of incontinence-notify nurse with any problems CNA; Begin trial use of UriCap (external female urinary collection device); Monitor for placement and function; Clean peri area thoroughly after each episode of incontinence; and Use calm, matter of fact approach to maintain dignity. Review of resident 26's Annual MDS Assessment on 6/5/21 documented the functional status [Section G] for toilet use was total dependence with a two person assist. The assessment defined toilet use as how the resident used the toilet room, commode, bedpan, or urinal; transferred on/off toilet; cleansed self after elimination; changed pad; managed ostomy or catheter, and adjusted clothes. The assessment documented that the urinary continence was not rated, resident had a catheter (indwelling, condom) urinary ostomy, or no urine output for the entire 7 days look back period. The bowel incontinence was documented as always incontinent with no episodes of continent bowel movements. On 9/15/21 at 8:16 AM, a continuous observation started outside of resident 26's room. On 9/15/21 at 9:17 AM, CNA 6 entered resident 26's room and obtained a cup of water. No incontinence care was provided. On 9/15/21 at 9:19 AM, CNA 6 returned to resident 26's room with a cup of ice. No incontinence care was provided. On 9/15/21 at 10:37 AM, the Activities Director (AD) entered resident 26's room to answer a call light. No incontinence care was provided. On 9/15/21 at 10:41 AM, CNA 2 entered resident 26's room and closed the resident's door. On 9/15/21 at 10:50 AM, an interview was conduced with the CNA 2 upon exit of resident 26's room. CNA 2 stated that she provided incontinence care and resident 26 was incontinent of bladder. CNA 2 stated that the resident had an area of redness on the right leg crease between the upper thigh and the buttocks. The CNA stated that the area was red but was not open, and that she applied barrier cream to the area. CNA 2 stated that resident 26 did not have any other wounds in the groin or coccyx area. CNA 2 stated that resident 26 was unable to tell if she was wet, and that was why she was checked every 2 hours or more frequently. CNA 2 stated that she usually checked resident 26 more often because she knew resident 26 also took a diuretic. It should be noted that resident 26 was observed to wait 2 hours and 25 minutes for incontinence care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 52 sample residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. Specifically, a resident with a continuous positive airway pressure (CPAP) machine was not provided the supplies and cleaning to use the machine. Resident identifiers: 11. Findings include: Resident 11 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, chronic pain syndrome, anxiety disorder, opioid dependence and major depressive disorder. On 9/14/21 at 11:21 AM, an interview was conducted with resident 11. Resident 11 stated that he had a bandage on face from blister from CPAP machine. Resident 11 stated that the bandage was used for protection to prevent blisters. Resident 11 stated he had not been using the CPAP because the machine had not been cleaned and supplies were not changed. Resident 11 stated his CPAP machine had not been cleaned for a month or a month and a half. Resident 11 stated that the CPAP machine needed to be cleaned with a vinegar solution but the staff used water when cleaning. On 9/15/21 at 8:25 AM, an observation was made of resident 11. Resident 11 was observed to be in bed with eyes closed. Resident 11 was observed to have a nasal cannula with an oxygen concentrator. Resident 11 was not observed to be using the CPAP machine next to his bed. Resident 11's medical record was reviewed on 9/15/21. A quarterly Minimum Data Set, dated [DATE] revealed that resident 11 required oxygen and an invasive mechanical ventilator. A care plan dated 10/28/19 and revised on 11/19/19 revealed, I have altered respiratory status/difficulty breathing related to Sleep Apnea. A goal revealed, I will have no complications related to shortness of breath though next review date. An intervention developed was, CPAP settings: 11-13 cm (centimeters) H2O (water) via full-face mask for NOC (night). A physician's order dated 6/27/21 revealed, Resident to wear CPAP auto set 11-13cmH20 full face mask CPAP for NOC. at bedtime for Respiratory health. Another physician's order dated 3/14/21 revealed, Wash CPAP tubing and outside of machine with warm water and soap weekly. Let air dry. at bedtime every Sun (Sunday) for CPAP maintenance. According to the September 2021 Medication Administration Record (MAR) resident refused to wear the CPAP 9/2, 9/3, 9/4, 9/9, 9/10 and 9/11. [Note: A nurse documented that resident 11 wore his CPAP machine on 9/15/21.] On 9/16/21 at 9:38 AM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated that resident 11 had a great personality. CNA 6 stated she had not had any problems with resident 11 refusing cares. CNA 6 stated that he told her how to care for him. CNA 6 stated resident's cognition was fine. On 9/15/21 at 9:52 AM, an interivew was conducted with CNA 2. CNA 2 stated she cleaned out, rinsed and made sure nothing was clogged with CPAP machines. CNA 2 stated she took out the tray on the CPAP machine, rinsed it, let it air dry and put it back in the machine. CNA 2 stated she thought that tubing and masks were replaced every month. CNA 2 stated that resident 11 did not use his CPAP machine and she did not know when his machine had been cleaned last.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 52 sample residents, that the facility did not ensure that residents, who use psychotropic drugs, received gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, a resident who received multiple psychotropic drugs, did not have a 2nd GDR attempted within the last 12 months. Resident identifier: 35. Findings include: Resident 35 was admitted to the facility on [DATE] with diagnoses that included calculus of ureter, type 2 diabetes mellitus, hypertension, neuromuscular dysfunction of bladder, gout, chronic viral hepatitis C, morbid obesity due to excess calories, acute pyelonephritis, bipolar disorder, insomnia, chronic pain syndrome, opioid dependence, anxiety disorder and major depressive disorder. On 9/14/21, resident 35's medical record was reviewed. Review of resident 35's physician orders revealed the following prescribed psychotropic drugs: a. Buspirone HC (hydrochloride) 15 MG (milligrams) - Give 1 tablet by mouth two times a day for anxiety. Order Date was 3/18/20 and discontinued on 1/22/21. Buspirone HC 15 MG - Give 1 tablet by mouth two times a day for anxiety until 1/26/2021. The medication was ordered on 1/22/21. Buspirone HCl Tablet 5 MG - Give 2 tablet by mouth two times a day for anxiety for 7 Days. The medication was ordered on 1/22/21. b. Fluoxetine HCl [Prozac] Capsule 40 MG - Give 2 capsule by mouth one time a day for Depression related to MAJOR DEPRESSIVE DISORDER. The medication was ordered on 3/12/20. c. Vraylar Capsule 1.5 MG (Cariprazine HCl) - Give 1.5 mg by mouth in the morning for treat mood disorder related to BIPOLAR DISORDER. The medication was ordered on 8/6/21. Review of resident 35's September 2021 Medication Administration Records (MAR) revealed resident 35 was administered the psychotropic drugs as ordered. The facility's Psychotropic [Drug] Review Meeting Forms were reviewed and revealed the following: a. 9/16/20 - Resident had three psychotropic drugs ordered and reviewed. Buspar 15 mg PO (by mouth) BID (twice-a-day) for Anxiety Fluoxetine 40 mg PO daily for depression Trazodone 100 mg at HS (at night) for depression Last GDR (Gradual Dose Reduction) attempted: 2/2020 If GDR was contraindicated, list the date that a physician documented rationale for GDR contraindication. NA (not applicable) was noted. [Note: No GDR attempted.] b. 1/19/21 - Resident had three psychotropic drugs ordered and reviewed. Buspar 15 mg PO (by mouth) BID (twice-a-day) for Anxiety Fluoxetine 40 mg PO daily for depression Trazodone 100 mg at HS (at night) for Insomnia Last GDR (Gradual Dose Reduction) attempted: 2/2020 If GDR was contraindicated, list the date that a physician documented rationale for GDR contraindication. NA was noted. [Note: GDR - Buspar was tapered and discontinued.] c. 2/9/21 - Resident had two psychotropic drugs ordered and reviewed. Fluoxetine 40 mg PO daily for depression Trazodone 100 mg at HS (at night) for Insomnia Last GDR (Gradual Dose Reduction) attempted: 1/22/21 Buspar taper to DC (discontinue) If GDR was contraindicated, list the date that a physician documented rationale for GDR contraindication. NA was noted. [Note: No GDR attempted.] d. 3/9/21 - Resident had two psychotropic drugs ordered and reviewed. Fluoxetine 40 mg PO daily for depression Trazodone 100 mg at HS (at night) for Insomnia Last GDR (Gradual Dose Reduction) attempted: 1/22/21 Buspar taper to DC If GDR was contraindicated, list the date that a physician documented rationale for GDR contraindication. NA was noted. [Note: No GDR attempted.] e. 7/21/21 - Resident had two psychotropic drugs ordered and reviewed. Fluoxetine 40 mg PO daily for depression Trazodone 100 mg at HS (at night) for Insomnia Last GDR (Gradual Dose Reduction) attempted: 1/22/21 Buspar taper to DC If GDR was contraindicated, list the date that a physician documented rationale for GDR contraindication. na was noted. [Note: No GDR attempted.] On 9/15/21 at 10:42 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The Psychotropic [Drug] Review Meeting Forms for resident 35 were reviewed. The RNC confirmed that resident 35 did not have a 2nd GDR attempted during the last 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 52 sampled residents, that the facility did not obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist. Specifically, a resident had 4 laboratory tests obtained without a physician order for the services. Resident identifier 25. Findings included: Resident 25 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included hypertrophic cardiomyopathy, obstructive and reflux uropathy, hypertension, seizures, hypothyroidism, hyperlipidemia, gastro-esophageal reflux disease, insomnia, peripheral neuropathy, hemorrhoids, syncope and collapse, opioid dependence, dyspnea, mild cognitive impairment, dysphagia, cognitive communication deficit, major depressive disorder, old myocardial infarction, edema, anemia, borderline personality disorder, arthropathy, and history of transient ischemic attack. On 9/14/21 resident 25's medical record was reviewed. Review of resident 25's laboratory results revealed the following: a. On 1/23/21 a Urine culture was obtained. b. On 2/24/21 a Complete Blood Count (CBC) and a Comprehensive Metabolic Panel (CMP) was obtained. c. On 4/28/21 a Thyroid Stimulating Hormone (TSH) was obtained. Review of resident 25's orders revealed no physician orders for the urine culture on 1/23/21, CBC and CMP on 2/24/21, and TSH on 4/28/21. On 9/15/21 at 9:17 AM, the Regional Nurse Consultant (RNC) emailed a response that stated she did not have any physician orders for the labs results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 52 sampled residents, that the facility did not maintain medical records on each resident that were complete, accurate, and readily accessible. The facility also did not keep confidential information contained in the resident's record. Specifically, hospice notes were not in the individual medical records and computer screens showing resident information were left unattended and readily observable by others not authorized to view the information. Resident identifier 46. Findings included: 1. On 9/15/21 at 1:32 PM, Registered Nurse (RN) 1 was observed at the 100 hall nurses' station medication cart, standing and typing on the laptop computer. RN 1 walked away from the computer but did not close it or lock the screen. It was observed that the computer screen was left open and displayed resident names, room numbers, and diagnoses. RN 1 sat at the nurses' station and typed on the desktop computer for 7 minutes. During that time, 2 maintenance staff, 2 Certified Nursing Assistants (CNA), and 1 resident walked past the open computer screen. On 9/16/21 at 4:08 PM, RN 2 was interviewed. RN 2 stated it was the nurses' responsibility to make sure the computers were locked so resident information was not visible to others. On 9/15/21 at 4:42 PM, RN 1 was observed at the 100 hall nurses' station med cart, standing and typing on the laptop computer. RN 1 walked away from the computer but did not close it or lock the screen. It was observed that the computer screen was left open and displayed resident names, room numbers, and prescribed medication. RN 1 sat at the nurses' station and typed on the desktop computer for 5 minutes. After 5 minutes the laptop computer screen went dark. During that time 2 residents walked past the open screen. On 9/16/21 at 4:49 PM, the laptop computer on the 100 hall med cart was observed open and unattended. The screen displayed resident names, birthdays, and room numbers. After 1 minute of observation, RN 2 was observed exiting the 100 hall bathroom and returning to the laptop computer. In her absence two CNAs and two residents walked past the open computer screen. On 9/16/21 at 4:55 PM, the Regional Nurse Consultant (RNC) was interviewed. The RNC stated, Our expectation is that every nurse locks the computer when they walk away. The RNC stated that if more than two instances were observed of nurses not locking the computer when they walk away it was a trend. 2. Resident 46 was admitted to the facility on [DATE] with diagnoses which consisted of pulmonary hypertension, cirrhosis of the liver, heart failure, post-traumatic stress disorder, perforation of intestine, generalized edema, central pain syndrome, morbid obesity, pleural effusion, gastrointestinal hemorrhage, chronic pulmonary embolism, obstructive sleep apnea, non-pressure ulcer of lower leg, emphysema, portal hypertension, and palliative care. On 9/14/21 resident 46 medical records were reviewed. Review of resident 46's physician orders revealed an order for hospice services for a terminal diagnosis of perforation of the intestine. The current certification period was 8/9/21 to 11/6/21. The name and phone number of the hospice provider was listed in the order. Review of resident 46's documents revealed a hospice certification and plan of care with a start of care date effective 8/9/21. No other hospice documentation could be located in resident 46's medical records. On 9/15/21 at 10:11 AM, an interview was conducted with the hospice Certified Nurse Assistant (CNA) 4. CNA 4 stated that she visited the resident one time a week and had been providing care for the resident for 4 weeks now. CNA 4 stated that today was the first time resident 46 allowed her to assist him with a shower. CNA 4 stated that the hospice nurse visited the resident two times a week and would be in the facility to see resident 46 today. On 9/15/21 at 4:10 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that they communicated with hospice by telephone and in person. LPN 1 stated that the hospice nurse was at the facility today. LPN 1 stated that the hospice nurse reported that the resident was calling family and reporting to his family that he had 2 hours to live. LPN 1 stated that the hospice nurse reported changes in resident 46's medications to her and changes were made to the resident's Lasix and potassium today. LPN 1 stated that the hospice nurse visited resident 46 one time a week and the CNA came in one to two times a week. LPN 1 stated that the CNA provided him with a shower sheet today for a skin assessment. LPN 1 stated that the hospice nurse would talk to the facility nurses and give any new orders. LPN 1 stated that she did not have any of the hospice nurse or CNA notes, that would be nice. On 9/16/21 at 9:07 AM, an interview was conducted with the RNC. The RNC stated that resident 46's medical records were incomplete, and all of the hospice notes since August 2021 had not been scanned into resident 46's medical records. The RNC stated that the medical records staff gave her notice last week and she was checked out. The RNC stated that the process was for the hospice provider to email the visit notes and assessment to the facility and the medical records staff scanned them into the resident's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 52 sampled residents, that the facility did not ensure that the hospice care furnished in the Long Term Care (LTC) facility through an agreement with the hospice provider had a written agreement with that hospice provider that was signed by the authorized representative of the hospice provider and an authorized representative of the LTC facility before hospice care was furnished to any resident. Specifically, the hospice agreement for services that were provided to a resident was not signed by the LTC facility representative. Resident identifier 46. Findings included: Resident 46 was admitted to the facility on [DATE] with diagnoses which consisted of pulmonary hypertension, cirrhosis of the liver, heart failure, post-traumatic stress disorder, perforation of intestine, generalized edema, central pain syndrome, morbid obesity, pleural effusion, gastrointestinal hemorrhage, chronic pulmonary embolism, obstructive sleep apnea, non-pressure ulcer of lower leg, emphysema, portal hypertension, and palliative care. On 9/14/21 resident 46 medical records were reviewed. Review of resident 46's physician orders revealed an order for hospice services for a terminal diagnosis of perforation of the intestine. The current certification period was 8/9/21 to 11/6/21. The name and phone number of the hospice provider was listed in the order. Review of resident 46's documents revealed a hospice certification and plan of care with a start of care date effective 8/9/2021. Review of the hospice agreement with resident 46's hospice provider documented that the contract was signed by the hospice provider on 10/1/17. The hospice agreement was not signed by the LTC facility representative. On 9/16/21 at 1:43 PM, an interview was conducted with the facility Administrator. The facility Administrator stated that he had not had to create a contract with a hospice provider for this facility yet, and does not know how it was done in the past. The Administrator stated that the contract should contain the parties involved, the services provided, dates of services, and any provisions for revising the contracts. The Administrator stated that the contract become effective once they were signed, and signatures were required by both the hospice provider and the facility. The Administrator stated that they should have verified that both parties had signed the contact.

Based on observations, interviews and record review it was determined that the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee that identified issues with respect to which Quality Assessment and Assurance activities were necessary. In addition, the QAA committee did not develop and implement appropriate plans of action to correct identified quality deficiencies. Specifically, the facility had repeat deficiencies cited from the previous recertification survey. Findings include: 1. Based on observation, interview and record review it was determined based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility did not provide necessary resident's care and services for hygiene-bathing, dressing, and grooming. Specifically, a resident had long fingernails, greasy hair and soiled clothing. This occurred for 1 out of 52 residents. Resident identifier: 34 Cross refer to F tag 676 2. Based on observation, interview and record review it was determined that the facility did not ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM motion to prevent further decrease in ROM. Specifically, a resident with limited ROM to in his fingers was not provided treatments. This occurred for 1 out of 52 residents. Resident identifier: 34 Cross refer to F tag 688 3. Based on observation, interview and record review it was determined that the facility did not ensure that a resident who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practical mental and psychosocial well-being. Specifically, one resident with severe depression was not provided behavioral care and services to meet her emotional or physical needs. Additionally, another resident did not receive counseling services. This occurred for 2 out of 52 residents. Resident identifiers: 11, and 13. Cross refer to F tag 742 4. Based on interview and record review, it was determined that the facility did not ensure that residents, who use psychotropic drugs, received gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these drugs. Specifically a resident, who received multiple psychotropic drugs, did not have a 2nd GDR attempted in the last 12 months. This occurred for 1 out of 52 residents. Resident identifier: 35. Cross refer to F tag 758 5. Based on interview and record review it was determined that the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not a employee a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Cross refer to F tag 801 6. Based on interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, areas in the kitchen were not cleaned and the sanitizer solution was not at the required amount. Cross refer to F tag 812 7. Based on observation, interview, and record review it was determined that the facility failed to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Additionally, the facility did not maintain a IPCP surveillance system. Specifically, observations were made of staff entering a room on contact precautions without performing hand hygiene and donning gloves and a gown, staff were observed inside the facility and resident areas without eye protection, and staff were observed wearing their surgical masks down below their nose and mouth, staff did not perform hand hygiene during meal service after touching multiple objects inside the resident's room, a meal tray was delivered to the wrong resident and then was taken from the wrong room to the correct room, and the facility tracking and trending log for surveillance of communicable diseases was incomplete. This occurred for 8 out of 52 residents. Resident identifiers: 5, 8, 25, 26, 27, 31, 33, and 42. Cross refer to F tag 880 On 9/16/21 at 5:04 PM, an interview was conducted with the facility's Administrator. The Administrator stated that his employment at the facility as the Administrator started July 2021. The Administrator stated he was unable to locate the QAA Committee meeting minutes. The Administrator further stated he was unable to find any evidence of performance improvement projects.

Based on interview and record review, it was determined that the facility did not have an active Quality Assessment and Assurance (QAA) Committee. Specifically, there were no QAA Committee meeting minutes for review. Findings include: On 9/16/21, the facility's Quality Assurance and Improvement (QAPI) Plan was reviewed. The QAPI Plan outlines who comprises the committee and that it met monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees. On 9/16/21 at 5:04 PM, an interview was conducted with the Administrator. The Administrator stated that his employment at the facility as the Administrator started July 2021. The Administrator stated he was unable to locate the QAA Committee meeting minutes. The Administrator further stated that he had not held a QAA Committee meeting since his arrival in July 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 29 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, intellectual disabilities, major depressive disorder, insomnia, and fatigue. On 9/13/21 at 3:30 PM, Resident 29 was observed wearing light pants, a light brown shirt with a pen in the left breast pocket, blue socks, and black shoes. On 9/14/21, 9/15/21, and 9/16/21 resident 29 was observed wearing the same clothing that he was wearing on the 9/13/21. Resident 29's medical record was reviewed on 9/13/21 through 9/16/21. Review of resident 29's progress notes revealed the following: a. On 6/3/21 at 5:23 PM, the note documented that staff must insist resident 29 put on clean clothes every day or he will wear the same dirty clothing for days at a time. b. On 6/4/21 at 3:44 PM, the note documented that staff must insist resident 29 put on clean clothes every day or he will wear the same dirty clothing for days at a time. c. On 6/5/21 at 3:42 PM, the note documented that staff must insist resident 29 put on clean clothes every day or he will wear the same dirty clothing for days at a time. d. On 6/6/21 at 2:56 PM, the note documented that staff must insist resident 29 put on clean clothes every day or he will wear the same dirty clothing for days at a time. Review of resident 29's care plan revealed the following focus areas with interventions: a. A focus area for Activities of Daily Living (ADL) Self Care Performance Deficit related to disease process (cerebral palsy), fatigue, and weakness was initiated on 7/21/16 and revised on 8/12/19. The interventions documented that the resident required sufficient time for dressing and undressing as the task can be tiring painful, difficult, and confusing. The interventions also documented that staff need to assist the resident to choose simple, comfortable clothing that maximizes the resident's ability to dress self. Both interventions were revised on 10/02/2020. Review of resident 29's Annual Minimum Data Set (MDS) Assessment on 6/10/21 documented the functional status [Section G] for dressing use was limited assistance with a one physical person assist. The assessment defined dressing as how resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED (Thrombo-Embolus Deterrent) hose, putting on, and changing pajamas and housedresses. The functional abilities and goals [Section GG] for upper and lower body dressing was partial/moderate assistance. The assessment defined upper and lower body dressing as the ability to dress and undress above and below the waist, including fasteners. On 9/16/21 at 3:52 PM, CNA 1 was interviewed. CNA 1 stated that resident 29 showered on Sundays and Wednesdays. On 9/16/21 at 3:53 PM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that resident 29 wore the same clothing even after he showered. LPN 1 stated that resident 29 changed out of his dirty clothes and puts on a new set of clean clothing on Sundays after he showered. On 9/16/21 at 4:01 PM, CNA 7 was interviewed. CNA 7 stated that resident 29 gets very upset when staff attempted to change his clothing. CNA 7 stated that it did more harm than good trying to get resident 29 to wear clean clothing because he gets too agitated. On 9/16/21 at 4:30 PM, resident 29 was observed wearing the same clothing he had been wearing all week. On 9/16/21 at 5:30 PM, resident 29 was observed in a new set of clean clothing. He had been changed out of his light pants, light brown shirt with a pen in the left breast pocket, and blue socks. Resident 29 was smiling and had a calm, pleasant demeanor. Based on observation, interview, and record review it was determined, for 6 out of 52 sampled residents, that the facility did not ensure that the residents had the right to a dignified existence and self-determination, and that each resident was treated with dignity and respect. Specifically, a resident was not allowed to keep a clothing protector and declined to be cleaned after a meal and these requests were not permitted or allowed. A resident was provided dining assistance while the staff was observed to stand over the resident and that staff was heard to refer to the resident as honey and darling. Multiple residents were observed to be served their meals in Styrofoam containers instead of plates. Lastly, a resident was observed to wear the same soiled clothing for four days in a row. Resident identifiers: 5, 10, 24, 27, 29, and 41. Findings included: 1. Resident 24 was admitted to the facility on [DATE] with diagnoses which consisted of traumatic brain injury (TBI), spastic hemiplegia right dominant side, epilepsy, pseudobulbar affect, adjustment disorder with mixed anxiety, dysphagia, aphasia, osteoporosis, healed traumatic fracture, hypertension, multiple sclerosis, muscle wasting, and unspecified psychosis. On 09/14/21 at 8:29 AM, an observation was made of resident 24 in the main dining room. Certified Nurse Assistant (CNA) 1 was assisting resident 24. CNA 1 was observed to remove the residents clothing protector and wipe the residents mouth. Resident 24 was observed to try to hold onto the clothing protector. CNA 1 was observed to struggle with resident 24 over the clothing protector and pulled the clothing protector out of resident 24's hands. The CNA attempted to wipe the cream of wheat from resident 24's face. Resident 24 was observed to pull away and turned her head away when CNA 1 attempted to wipe her mouth. Resident 24 was also observed to swing at and attempted to hit CNA 1. The resident became agitated and began to yell. CNA 1 was observed to forcefully wipe resident 24's face and then wheeled the resident out of the dining room back to their room. The resident was heard yelling down the hallway to their room. On 09/14/21 at 8:32 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 24 indicated that she had finished eating. The CNA stated that the resident did this by holding up a hand while she pointed at each item and asked if she was finished. This was how she knew she was finished. On 09/14/21 at 8:38 AM, an interview was attempted with resident 24. Resident 24 was observed laughing and making noises. The resident was non verbal when approached and was observed smiling. The resident was seated in their wheelchair while watching TV. On 09/15/21 at 1:25 PM, an observation was made of resident 24 yelling out in the main dining room and laughing at no one. CNA 2 approached resident 24 at eye level and said hi. The resident replied hi back and then returned to eating. On 09/16/21 at 1:53 PM, an interview was conducted with CNA 2. CNA 2 stated that when resident 24 was resistant to cares she would stop what she was doing and approach later or have another staff member attempt to provide those cares. CNA 2 stated that resident 24 sometimes responded to playing music as an intervention and that she enjoyed 80's hits. CNA 2 stated that often resident 24 continued to respond with outbursts or was resistive to cares even when they approached later or had another staff member attempt to provide those cares. CNA 2 stated that this was due to resident 24's TBI. CNA 2 stated that if resident 24 wanted to keep a clothing protector she would just let her keep it and obtain it later from the resident. CNA 2 stated that resident 24 would most likely throw the clothing protector on the ground after she was finished with it. CNA 2 stated that she would never struggle with resident 24 over a clothing protector. CNA 2 stated that resident 24 sometimes could clean her own face, sometimes she yelled out, and depending on her mood she may hit or pull away. CNA 2 stated that if resident 24 did not want her face cleaned she would leave her alone and try again later. On 09/16/21 at 2:18 PM, and interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that the best way to interact with resident 24 was to greet her, explain the care to be provided, and give her a break if she became resistant to the care. The RNC stated that resident 24's family member stated that resident 24 responded better if staff talked to her first before providing the care. The RNC stated that the staff would also need to determine the best time of day, in accordance with the resident's preferences, that care should be provided. The RNC stated that staff would need to approach the resident later if resident 24 refused care and not engage in a power struggle with the clothing protector. 2. Resident 27 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, hyperlipidemia, attention and concentration deficit, exposure keratoconjunctivitis, cataract, nystagmus, exothropia, thyrotoxicosis, hemiplegia and hemiparesis, dysphagia, pneumonitits, and gastrostomy. On 09/14/21 at 8:18 AM, an observation was made of CNA 3 assisting resident 27 with dining. CNA 3 was observed to stand over resident 27 while providing dining assistance and serving resident 27 bites of food. CNA 3 was heard calling the resident honey two times, and was heard to call the resident darling one time while providing dining assistance. 3. On 9/15/21 during the lunch meal service in the main dining room the following residents were observed to be served their meals in Styrofoam to go containers: a. At 1:01 PM, resident 24 was served turkey cutlets and green beans in a Styrofoam container. b. At 1:04 PM, resident 41 was served turkey cutlets, mashed potatoes with gravy, and green beans in a Styrofoam container. c. At 1:08 PM, resident 5 was served turkey cutlets, mashed potatoes with gravy, and green beans in a Styrofoam container. d. At 1:13 PM, resident 10 was served turkey cutlets, mashed potatoes with gravy, and green beans in a Styrofoam container. e. At 1:17 PM, resident 27 was served turkey cutlets, mashed potatoes with gravy, green beans, and a slice of bread in a Styrofoam container. On 9/15/21 at 1:20 PM, an interview was conducted with [NAME] 1. [NAME] 1 stated there were not enough lids for the plates. [NAME] 1 stated that Styrofoam containers were used for the last 7 to 8 residents served in the dining room. On 9/15/21 at 1:24 PM, an interivew was conducted with the Dietary Manager (DM). The DM stated that there were not enough lids if all the trays were not returned to be washed. The DM stated that if there were not enough clean lids then food was served in Styrofoam containers to residents in the dining room. The DM stated that she had ordered more lids but it took a while for them to be delivered. An invoice was provided for domes from the Administrator. The order date was 9/15/21 at 2:36 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 9/15/21, the Resident Council Meeting minutes were reviewed for 6/30/21, 7/28/21 and 8/25/21. Under the Business Office section in the minutes, it repeatedly documented, Nursing station A needs change [money] for weekends for the residents. So the residents can use the vending machine. In the June 2021 meeting minutes this was referred to the prior Business Office Manager and was noted, Unresolved. In the July and August 2021 meeting minutes, this was referred to the current Business Office Manager. On 9/15/21 at 3:30 PM, during the Resident Council Meeting, resident 8, 15 and 17 expressed frustration about not being able to access money from their trust accounts at the facility on weekends to use in the facility's vending machines. On 9/13/21 at approximately 2:00 PM, an observation was made of the BOM's office. The door was closed with a sign that revealed do not disturb. On 9/15/21 at 6:34 PM, an interview was conducted with the BOM. The BOM stated she had developed with a new process to help residents access money from their trust accounts over the weekend. The BOM stated that starting this coming Friday 9/17/21, 3 bank bags with cash/change, one for each resident hallway, would be kept at Nursing Station A over the weekend. The BOM stated that residents would be able to access money from the trust accounts during the weekend from these bank bags. The BOM stated that on Mondays, she would collect the bank bags from Nursing Station A and reconcile the residents' trust accounts for those residents, who accessed money over the weekend. On 9/16/21 at 9:58 AM, an interview was conducted with the BOM. The BOM stated that residents were able to get money Monday through Friday from her. The BOM stated that there was a receipt book and money was tracked through receipts. The BOM stated that the charge nurse at station A was able to provide money to residents on the weekends and it was tracked through the receipt book. On 09/16/21 at 10:05 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she worked weekends. RN 2 stated that she was not sure if there was petty cash available here. RN 2 stated that the BOM was in charge of the all the money for the residents. On 9/16/21 at 10:12 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated she worked weekends and stated I do not understand the money situation. LPN 1 stated there was some money in the narcotic room but did not know which residents could have money. LPN 1 stated if she provided money to residents, some of them have said they did not get money. LPN 1 stated that the BOM had the money but she was not sure how to access it on the weekends for residents. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses which included blindness, neuropathy, hypertension, abnormal gait, mild cognitive impairment, anxiety, and a history of poliomyelitis. On 7/16/21 at 2:58 PM, resident 3 was interviewed. Resident 3 stated that she never received money from the facility. Resident 3 stated that her sister paid for her to live in the facility, and that her sister would occasionally give her money. Resident 3 stated that she had never received a statement from the facility about money, and did not think the facility had any money for her. Resident 3's financial statement of her resident account revealed that resident 3 had $5,959.52 in her account. Based on interview and record review it was determined, for 5 of 52 sample residents, that the facility did not provide the resident the right to manage his or her financial affairs. Specifically, residents who had authorized the facility to manage any personal funds did not have reasonable access to those funds. In addition, resident's were not provided their $45 for 9 months. Resident identifiers: 3, 8, 11, 15 and 17. Findings included: 1. Resident 11 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, chronic pain syndrome, anxiety disorder, opioid dependence and major depressive disorder. On 9/14/21 at 10:42 AM, an interview was conducted with resident 11. Resident 11 stated he had not been getting his $45 per month. Resident 11 stated that he was told by the Business Office Manager (BOM) that he could not have his money because the prior company had his money. Resident 11 stated he used the money to purchase his own soda, snacks, chips and munchies. Resident 11 stated that the BOM told him another time that the government did not allow for him to get $45 a month. Resident 11 stated he was unable to access his money on the weekends. On 9/16/21, resident 11's Trust Transaction History statements were reviewed. The following was documented: a. The opening balance was $0.00. b. On 8/1/2020 revealed a deposit of $2542.20. c. On 8/13/2020, a withdrawal for patient liability of $832.00. A remaining balance $1,710.20. d. On 9/9/2020, deposit of $1,072.00. e. On 9/19/2020, a withdrawal for patient liability of $832.00. f. On 10/9/2020, a deposit $1072.00 g. On 10/19/2020, a withdrawal patient liability of $832.00. h. On 11/10/2020, a deposit of $1072.00. i. On 11/10/2020, a withdrawal patient liability of $832.00. j. On 12/18/2020, a deposit of $1072.00. k. On 12/18/2020, a withdrawal patient liability of $832.00. A remaining balance of $1,591.41 was documented. There were additional withdrawals totaling $1,487.85 from 12/18/2020 until 5/21/21. There were no deposits during that from those dates. l. On 5/21/21, a Misc. withdrawal correction of $6.00. m. On 5/28/21, a Misc withdrawal correction of $30.00. n. On 6/25/21, a deposit of $20.00. o. On 6/25/21, cash withdrawal correction $20.00. p. On 7/27/21, withdrawal correction from April 2021 for $20.00. r. On 7/14/21, deposit $20.00. s. On 7/27/21, Misc deposit correction. t. On 9/3/2021, a deposit of $9,744.00. u. On 9/13/21, a withdrawal patient liability of $7,614.00. v. On 9/16/21, a withdrawal for September dental was $975.00. The remaining balance was $1,193.29. Resident 11 was negative $11.71 from 6/25/21 until 6/30/21. Resident 11 did not receive a deposit from social security from January 2021 through August 2021. On 9/16/21 at 1:49 PM, an interview was conducted with the BOM. The BOM stated that when a resident had medicaid, there was a dental plan for $140.00 per month. The BOM stated that the social security came to the facility and the resident received $45.00 per month no matter what. The BOM stated that the new company took over about a year ago. The BOM stated that the Regional Business Office Manager (RBOM) knew more about the resident trust accounts. On 9/16/21 at approximately 2:00 PM, an interview was conducted with the RBOM. The RBOM stated that social security was hold money for a while for certain residents. The RBOM stated that the previous company had received extra pay and until the funds were paid back residents did not receive their money. The RBOM stated that resident 11's trust was audited when the BOM started working with the company in June 2021. The RBOM stated that receipts were checked against the withdrawals and there was only 1 mistake. The RBOM stated that the money was refunded. The RBOM stated that there was no interest during the time that the money was held but there will be interest provided for the $9,744.00 in September 2021. The RBOM stated that resident had stimulus money so none of the residents needed their $45.00 per months. The RBOM stated that if resident's needed something during that time the facility purchased it for them. The RBOM stated they provided resident 11 receipts and the audit in June or July 2021. The RBOM stated that other residents were affected by the social security not being provided. On 9/22/21 at 2:48 PM, a follow-up phone interview was conducted with the BOM. The BOM stated that she was not aware of why resident 11 had negative money in June 2021 and $8.29 in July and August 2021. The BOM stated she did not know why resident 11's balance was $1,193.29 after receiving the social security. The BOM stated that resident 11 received more than $45.00 per month. The BOM stated she would have to look into why resident 11's balance went from the negative to $1,193.29. The BOM did not provide additional information. On 9/16/21 at 4:09 PM, a follow up interview was conducted with resident 11. Resident 11 stated that the BOM did not want to talk to him and was very rude if she did talk to him.

Based on interviews and record reviews it was determined, for 2 of 52 sample residents, that the facility did not protect residents' rights to receive mail delivered to the facility on their behalf. Specifically, residents were not receiving mail unless they asked facility staff if there was any mail from them. Resident identifiers: 15 and 17. Findings include: On 9/15/21, 6/30/21, 7/28/21 and 8/25/21 Resident Council Meeting minutes were reviewed on 9/15/21. The 7/28/21 and 8/25/21 Resident Council Meeting minutes revealed under the Business Office section, Residents are requesting that the mail be delivered in a timely manner. This was referred to the Business Office Manger (BOM). In the 8/25/21 Resident Council Meeting minutes, resident rights were reviewed about mail. It revealed, The resident has the right to privacy in written communication, including the right to- 'Promptly' means delivery of mail or other materials to the resident within 24 hours of delivery by the postal service . On 9/15/21 at 3:30 PM during the Resident Council Meeting, resident 15 and resident 17 stated that mail had not been delivered timely or consistently unless they had asked about it. Resident 15 further stated that not all staff knew where the key was to check if there was mail. On 9/15/21 at 4:24 PM, an interview was conducted with the facility's Administrator. The Administrator stated that there had been confusion between the Business Office Manager (BOM) and the Activities Director (AD) about whose role it was to check and deliver mail to residents. The Administrator stated that he had a meeting with the BOM and the AD on 9/14/21 and the AD was given the assignment to check and deliver mail to residents. On 9/15/21 at 4:43 PM, an interview was conducted with the BOM. The BOM stated she had started working at the facility about 3 months ago and had never delivered mail to residents. The BOM stated it had always been the responsibility of the AD to distribute mail to residents. On 9/15/21 at 4:47 PM, an interview was conducted with the AD. The AD stated that she was hired mid-May 2021. The AD stated that the previous BOM had told her that it was the BOM's role to deliver mail to residents. The AD further stated that during a meeting with the Administrator and BOM on 9/14/21 that it was clarified that it would be her, the AD's responsibility, to check and deliver mail to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 9/15/21, the Resident Council Meeting minutes were reviewed for 6/30/21, 7/28/21 and 8/25/21. a. The 7/28/21 Resident Council Meeting minutes documented that resident 8's clothes shrunk. This concern was referred to the Administrator and the HD. There was a hand written note, which read, RESOLVED. b. The 8/25/21 Resident Council Meeting minutes documented resident 15's clothes are getting bleached and [was] missing several clothes. Resident 149's clothes are getting bleached, These concerns were referred to the Administrator and the HD. On 9/15/21 at 3:30 PM, during the scheduled Resident Council Meeting, resident 8 stated her clothes had come back from the laundry shrunk and had changed colors. Resident 15 stated he had clothes go missing, but had been reimbursed for them after giving the Administrator his receipts for the missing clothes. Resident 149 stated her clothes had come back bleached from the laundry. On 9/16/21 at 9:43 AM, an interview was conducted with resident 8. Resident 8 stated that a couple months ago she had clothes come back from the laundry that were shrunk and were too small to wear. On 9/16/21 at 9:54 AM, an interview was conducted with resident 15. Two formal grievances that resident 15 had submitted were reviewed. The first grievance was from 4/21/21, which revealed resident 15's clothes were getting bleached in the laundry. There were no additional notes from the facility on the Grievance Report Form related to investigating, confirming or resolving this grievance. The second grievance was from 5/18/21, which revealed resident 15's clothes had been bleached and it had likely ruined multiple pairs of clothing. Resident 15 stated he had continued to receive clothes come back from the laundry that had been bleached. Resident 15 pointed at the shirt he was wearing, which appeared purple in color. Resident 15 stated that it was blue when he purchased it. On 9/16/21 at 10:32 AM, an interview was conducted with resident 149. Resident 149 stated she had clothes come back bleached from the laundry. On 9/16/21 at 4:37 PM, an interview was conducted with the Administrator. The Administrator stated he did not know about resident's clothes getting bleached. The Administrator stated that he knew that the HD was working on a new process to prevent missing clothes. On 9/16/21 at 4:43 PM, an interview was conducted with the HD. The HD stated he had been investigating what was broken in the process, but had not implemented any new processes yet to resolve missing clothing or prevent clothes from being bleached. Based on observation, interview and record review it was determined, for 10 of 52 sample residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Additionally, residents who were missing personal items did not have those items located or replaced. Resident identifiers: 5, 6, 8, 9, 11, 15, 29, 40, 46, and 149. Findings included: 1. Resident 9 was admitted to the facility on [DATE] with diagnoses which included heart failure, osteoporosis, chronic kidney disease, and depression. On 9/14/21 at 9:50 AM, resident 9 was interviewed. Resident 9 stated that she had ants in her room that bit her on the hand. Resident 9 stated that her hand was swollen and painful for a few days. On 9/16/21, resident 9's medical record review was completed. Nursing notes for resident 9 revealed the following: a. On 9/3/21 at 1:01 PM, resident 9 reported ant bites when she was retrieving food from her drawer. Resident 9's left hand by the thumb was swollen and resident 9 complained of itching. Resident 9 had ice applied to the hand and a request was made for the physician to prescribe Benadryl. b. On 9/3/21 at 5:53 PM, a video chat was completed with the physician for treatment to left hand. Resident 9 was prescribed hydrocortisone cream for itching and an antibiotic. Resident 9's hand was warm to the touch. c. On 9/4/21 at 11:11 AM, resident 9's hand looked better than the previous day. d. On 9/5/21 at 6:42 PM, resident 9's hand was still a little bit swollen. e. On 9/8/21 at 6:07 PM, resident 9 continued antibiotics for infected ant bite to left hand . Left hand no longer swollen, slight discoloration present at thumb base f. On 9/9/21 at 6:22 PM, resident 9 continued to receive antibiotics for infected ant bite to left hand. On 9/16/21 at 1:52 PM, the Housekeeping Director (HD) was interviewed. The HD stated that the facility completed the pest control to spray for ants. The HD stated that the housekeeping staff who was assigned to the area that included resident 9's room did not always clean residents' rooms well, and had been let go. The HD produced the monthly extermination reports from the pest control company. The months of April, 2021 to present were reviewed and revealed that monthly spraying occurred. After the ant bite, an additional spraying was arranged. On 9/14/21 at 9:52 AM, resident 9 stated that she had missing clothing while at the facility that were never found or replaced. Resident 9 stated that she had completed grievances for her missing items. On 3/23/21, a Grievance Report Form was completed by resident 9. Resident 9 stated that she was given an expensive pair of pajamas for Christmas that was missing. The report revealed that this grievance was investigated and staff could not locate the pajamas. Follow-up actions were to change the garbage bags in resident 9's room. Resident 9's nursing notes revealed that on 8/7/21 at 7:13 PM, resident filed a grieve[ance] with laundry. She is very upset that her clothes are not being returned form laundry. Resident is missing a white pair of pants, gray stripe on side pants, and blue pair of pants. Resident is very upset about her clothes. Tried to go find them for her but had no luck on fining them. On 9/15/21 at 12:25 PM, the Resident Advocate (RA) was interviewed. The RA stated that she assisted residents with filling out the Grievance Report Form and then assigned the task to the director in charge. For missing clothing from laundry, the RA stated that the director was the Housekeeping Director (HD). The RA stated that every day she followed up with the director to determine when the grievance was resolved. On 9/16/21 at 9:44 AM, laundry aide (LA) 1 was interviewed. LA 1 stated that there was extra clothing in the laundry room for residents who had no clothing or their clothing was not labeled. A labeler was located on the north wall of the laundry room. LA 1 stated that clothing was labeled before they were washed, with the label placed in the collar of shirts, or the waistband of pants. LA 1 stated that she was aware that residents had complained about missing laundry, but the items were not located. LA 1 stated that some of the Certified Nursing Assistants (CNAs) reported to her that the laundry bags may have been thrown away. On 9/15/21 at 2:55 PM, an interview was conducted with the HD. The HD stated that when he was given a grievance for missing laundry, the laundry staff would search for the missing item. The HD stated that he had been in charge of laundry for two months and was not aware of any missing items before he started. On 9/15/21 at 3:13 PM, the Administrator (ADM) was interviewed. The ADM stated that after the HD searched for missing clothing, the ADM would talk to the resident to determine how they would like the situation to be handled. The ADM stated that if no grievance was completed for a resident's missing items, he did not receive a report about it, and therefore did not do anything about it. If there was a grievance completed, the ADM stated that he worked with the resident and their family to replace it. The ADM stated that the grievance forms were located at each nurses' station and in the RA's office, and grievance forms could be completed by any staff members. The ADM stated that he had not replaced resident 9's missing clothing. 2. Resident 6 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, neuropathy, pressure ulcer of left heel, major depressive disorder, anxiety disorder, osteoarthritis, low back pain, pain in right hip, edema, and obesity. On 09/15/21 at 9:14 AM, an interview was conducted with resident 6. Resident 6 stated that she informed housekeeping yesterday that she needed toilet paper. Resident 6 stated that she was low and would run out today. Resident 6 stated that she was going to the nurse's station to inform them again that she needed toilet paper. On 09/15/21 at 2:47 PM, resident 6 was observed in the 300 hallway talking to Licensed Practical Nurse (LPN) 1. Resident 6 was heard stating to LPN 1 that she still had not received any new toilet paper. On 9/15/21 at 3:08 PM, an interview was conducted with Housekeeper (HK) 1 at the end of the 300 hallway. HK 1 stated that she normally worked 7:00 AM to 3:00 PM, but today she arrived at 7:30 AM and was staying until 3:30 PM to help the other housekeeper out. HK 1 stated that she normally worked on the 100 hallway, but right now there were only 2 housekeepers for the entire building. HK 1 stated that her day started with cleaning the nurse's station, employee bathroom, and then emptying the garbage. HK 1 stated that she would then proceed to clean the bistro, front end of the building, coffee room and then the therapy room. HK 1 stated that after this was completed she would start cleaning the resident rooms on the 100 hallway. HK 1 stated that between the two housekeepers one of them would work Monday through Friday and the other would work Saturday through Thursday, that way there was one person present every day and some days they would overlap. HK 1 stated that the majority of the rooms were cleaned daily, but that if a room was not cleaned that day those were the rooms that they started with the following day. HK 1 stated that when they cleaned the resident rooms they emptied the garbage, swept, made the bed, wiped down the tables, mopped and cleaned the bathroom. On 9/16/21 at 11:53 AM, a follow-up interview was conducted with resident 6. Resident 6 stated that the night nurse obtained two rolls of toilet paper at 10 PM last night for her. Resident 6 stated that the rolls were placed on the back of the toilet seat and not in the dispenser. Resident 6 stated that she had arthritis in her hips and hands and she had a hard time reaching around to grab the toilet paper. Resident 6 also stated that she had cataract surgery on her right eye yesterday and was not supposed to bend over or it would increase the pressure in her eye. Resident 6 stated that housekeeping had not come in yet today, and it was easier to use the toilet paper if it was placed in the dispenser. Resident 6 stated that the last time housekeeping came to clean the room was a few days ago. Resident 6 stated that they had only been cleaning the room [ROOM NUMBER] time per week. Resident 6 stated that the rooms use to be cleaned daily but since the new owners changed it was cleaned 1 time a week. An immediate observation was made of resident 6's bathroom. One roll of toilet paper was observed located on the back of the toilet tank. A second roll was observed located on a storage cart next to the toilet and was against the back wall next to the tank. Both rolls were observed behind the seat. The toilet paper dispenser on the wall was observed empty. On 9/16/21 at 12:26 PM, an interview was conducted with the HD. The HD stated that the facility had two housekeepers dedicated to cleaning, except one was pulled from cleaning to do laundry on Mondays and that was Housekeeper (HK) 2. The HD stated that each room was scheduled to be cleaned every other day, and they needed a third housekeeper for each room to be cleaned daily. The HD stated that they terminated the third housekeeper a week ago because that individual was not cleaning each room daily. The HD stated that HK 1 was assigned to clean the resident rooms on the 100 and part of the 200 hall and the nurse's station. The HD stated that the HK 2 was assigned to clean the other part of the 200 hall, all of the 300 hall, and the activities room. The HD stated that the bistro was split between the two housekeepers. The HD stated that the terminated housekeeper was previously responsible for resident 6's room. The HD stated that HK 2 was now picking up the terminated staff members assignments and that she was completing the work and adding it in when she could. The HD stated that he needed to confirm if resident 6's room had been cleaned. The HD stated that the resident rooms should be swept, mopped, surfaces wiped down and the bathrooms cleaned. The HD stated that the housekeepers had cleaned resident 46's room. The HD stated that the CNAs and the housekeepers cleaned the wheelchairs and that there was no cleaning schedule or method of tracking that these were being completed. 3. Resident 46 was admitted to the facility on [DATE] with diagnoses which consisted of pulmonary hypertension, cirrhosis of the liver, heart failure, post-traumatic stress disorder, perforation of intestine, generalized edema, central pain syndrome, morbid obesity, pleural effusion, gastrointestinal hemorrhage, chronic pulmonary embolism, obstructive sleep apnea, non-pressure ulcer of lower leg, emphysema, and portal hypertension. On 9/14/21 at 8:56 AM, an observation was made of 3 dirty chuck pads and 2 briefs in resident 46's room on the floor. A area of wetness was noted on the floor directly in front of resident 46's recliner. On 9/15/21 at 10:11 AM, an interview was conducted with the hospice Certified Nurse Assistant (CNA) 4. CNA 4 stated that she had been visiting resident 46 for the last 4 weeks one time per week. CNA 4 stated that resident 46 had one wound on the left lower leg and redness in the groin. CNA 4 stated that resident 46 was continent of bowel and bladder and did not use urinals or briefs. CNA 4 stated that the resident used the briefs to place them in the groin folds to absorb moisture. CNA 4 stated that resident 46 discarded the used briefs on the floor afterwards. On 9/15/21 at 4:10 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 46 had weeping edema in his lower extremities, and that he was constantly vomiting because he ate and drank whatever he wanted. LPN 1 stated that resident 46 had one wound on the left lower extremity (LLE), and that wound was dripping water and puddles would pool on the floor in front of the resident. LPN 1 stated that they previously placed a dressing on the wound for the drainage, but now it was open to air. LPN 1 stated that resident 46 refused the wound dressing and just wanted to be comfortable. LPN 1 stated that resident 46 liked to place towels and pads on the floor for the weeping from his legs, and the weeping had so much drainage that it left wet areas on the floor. 5. On 9/16/21 at 4:17 PM, resident 11 was interviewed. Resident 11 stated the floor in his room was dirty. Observations were made of used towels and 4 used syringes to flush a urinary catheter in the corner of the room. A sign was posted that stated This is not trash pile or a laundry basket. Please remove soiled towels from room and throw dirty flush syringes in the trash can. Resident 11 stated he should not have to have a sign to throw things away. Resident 11 stated that the housekeeper had not been in his room for 3 weeks. Multiple dirty tissues were also observed on the floor. 6. On 9/13/21 at 3:45 PM, resident 40 stated that his room was cleaned twice a week. room [ROOM NUMBER] was observed with crumbs, debris, and black marks on the floor. Resident 34 was resident 40's roommate. Resident 34 stated their room had not cleaned. On 9/16/21 at 9:47 AM, an observation was made of room [ROOM NUMBER]. There was crumbs and debris on the floor. 7. On 9/16/21 at 9:50 AM, an observation was made of room [ROOM NUMBER]. room [ROOM NUMBER] had trash and debris on the floor. 8. On 9/14/21 at 10:33 AM, an observation was made of resident 5's wheelchair. Resident 5's wheel chair was soiled and the back of the wheelchair was cracked. Resident 5 stated the facility staff did not clean his wheelchair. Resident 5 stated he wanted to have his wheelchair cleaned. Resident 5 stated there was debris on the floor under the window for a day or so. Resident 5's toilet was observed full of toilet paper and a brown substance. The bathroom floor was observed covered in toilet paper with brown substance wiped on it. Resident 5 stated that the boss lady knew his toilet was clogged. Resident 5 stated he had stuffed the toilet with paper towels and the paper towels did not flush. An observation was made of a plunger next to toilet. 9. On 9/16/21 at 9:50 AM, an observation was made of resident 29. Resident 29's wheelchair was soiled and the cushion had a white substance on it. The wheelchair arm rests were soiled. On 9/16/21 at 3:42 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated she would expect for wheelchairs to be cleaned once a week. The RNC stated that it was the night shift CNAs that cleaned the wheelchairs. The RNC stated day shift CNAs were to spot clean wheelchairs. The RNC stated she expected wheelchairs to be washed in the showers so that they were fully cleaned and sanitized. On 9/16/21 at 12:27 PM, an interview was conducted with the HD. The HD stated he had one housekeeper for 5 days a week, another housekeeper for 4 day week. The HD stated that he needed another staff member for housekeeping to make sure resident rooms were cleaned daily. The HD stated a staff member was terminated for not cleaning daily. The HD stated that room [ROOM NUMBER] was cleaned 9/1/21. The HD stated that he did not know if room [ROOM NUMBER] was cleaned. The HD stated that wheelchairs were cleaned by CNAs and sometimes HK helped with cleaning them. The HD stated he did not have a wheelchair cleaning schedule. The HD stated HK staff reported to him if they cleaned a wheelchair. On 9/16/21 at 10:19 AM, an interview was conducted with HK 1. HK 1 stated she worked 5 days per week. HK 1 stayed that she cleaned as many rooms as she could in a day. HK 1 stated if she was unable to clean all the rooms in one day she started at the ones she missed the next day. HK 1 stated she was able to clean about 10 rooms a day depending on how messy the rooms were. HK 1 stated that the rooms had been really messy. HK 1 stated that there were 2 HK scheduled per day. HK 1 stated another HK and her worked together on the back half of the 300 hall. HK 1 stated that none of the HK worked on the weekends. HK 1 stated the rooms were messy on Mondays and Fridays. HK 1 stated she tried to play catch up on Monday and Fridays. HK 1 stated CNAs were responsible for spot cleaning on the weekends. HK 1 stated new admission, discharged and quarantine rooms were cleaned first and then the 300 hall rooms. HK 1 stated the 300 hall rooms were the ones that were not cleaned if there was not enough time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 11 of 52 sampled residents, that the facility did not assess a resident using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicaid and Medicare Services) not less frequently than once every 3 months. Specifically, residents quarterly review assessments were not completed within 3 months. Resident identifiers: 2, 3, 4, 7, 8, 9, 10, 12, 16, 17, and 45. Findings include: 1. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Lupus. Resident 2's medical record was reviewed on 9/15/21. Resident 2's annual Minimum Data Set (MDS) was completed on 4/8/21. There was a quarterly assessment in progress dated 7/9/21. The MDS was not completed or submitted. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses which included blindness, depression, neuropathy, hypertension, falls, osteoporosis, anxiety, and peripheral vascular disease. Resident 3's medical record was reviewed on 9/13/21 through 9/16/21. Resident 3's MDS quarterly assessment was due on 7/10/21. The quarterly assessment had been started and was in progress. The MDS was not completed or submitted. 3. Resident 4 was admitted to the facility on [DATE] with a diagnosis which included diabetes mellitus. Resident 4's medical record was reviewed on 9/15/21. Resident 4's quarterly MDS assessment was completed on 4/9/21. There was a quarterly MDS dated [DATE] that was in progress. The MDS was not completed or submitted. 4. Resident 7 was admitted to the facility on [DATE] with a diagnosis which included hereditary ataxia. Resident 7's medical record was reviewed on 9/15/21. Resident 7 had a quarterly MDS completed 4/14/21. A quarterly MDS dated [DATE] was in progress. The MDS was not completed or submitted. 5. Resident 8 was admitted to the facility on [DATE] with a diagnosis which included conversion disorder with seizures or convulsions. Resident 8's medical record was reviewed on 9/15/21. Resident 8 had an admission MDS dated [DATE]. A quarterly MDS dated [DATE] was in progress. The MDS was not completed or submitted. 6. Resident 9 was admitted to the facility on [DATE] with diagnoses which included Takotsubo syndrome, heart failure, osteoporosis, carcinoma, chronic kidney disease, anxiety, osteoarthritis and depression. Resident 9's medical record was reviewed on 9/13/21 through 9/16/21. Resident 9's MDS quarterly assessment was due on 7/17/21. The quarterly assessment was in progress. The MDS was not completed or submitted. 7. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis which included dementia. Resident 10's medical record was reviewed on 9/15/21. Resident 10 had an annual MDS completed 4/7/21. A quarterly MDS dated [DATE] was in progress. The MDS was not completed or submitted. 8. Resident 12 was admitted to the facility on [DATE] with diagnoses which included paraplegia, cortical age-related cataract, muscle weakness, and major depressive disorder. Resident 12's medical record was reviewed on 9/13/21 through 9/16/21. Resident 12's MDS quarterly assessment was due on 7/31/21. The quarterly assessment was in progress. The MDS was not completed or submitted. On 9/15/21 at 5:49 PM, the Regional Nurse Consultant (RNC) was interviewed. The RNC was shown resident 12's MDS section in the electronic medical record. The RNC stated, If it says it's overdue then it's overdue. The RNC stated she was catching up on the MDS records. The RNC stated that the previous facility Director of Nursing (DON) was the MDS Coordinator and she was covering the position until the new DON started. 9. Resident 16 was admitted to the facility on [DATE] with a diagnosis which included chronic systolic heart failure. Resident 16's medical record was reviewed on 9/15/21. Resident 16 had an annual MDS dated [DATE]. A quarterly MDS dated [DATE] was in progress. The MDS was not completed or submitted. 10. Resident 17 was admitted to the facility on [DATE] with a diagnosis which included cerebral infarction due to embolism of left meddle cerebral artery. Resident 17's medical record was reviewed on 9/15/21. Resident 17 had a quarterly MDS dated [DATE]. A quarterly MDS dated [DATE] was in progress. The MDS was not completed or submitted. 11. Resident 45 was admitted to the facility on [DATE] with diagnoses which included chronic inflammatory demyelinating polyneuritis, gout, anoxic brain damage, chronic pain, and gastroparesis. Resident 45's medical record was reviewed on 9/13/21 through 9/16/21. Resident 45's MDS was reviewed and it was revealed that the Quarterly Review Assessment was due on 7/24/21 and had not been submitted. On 9/16/21 at 8:16 AM, an interview was conducted with the RNC. The RNC stated stated that there were a lot of July MDS's that had not been submitted. The RNC stated that the previous DON completed MDS's.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 52 sampled residents, that the facility did not ensure that the Minimum Data Set (MDS) data was transmitted within 14 days after the resident's assessment was completed. Specifically, two residents were discharged from the facility and the MDS data was not transmitted to the Centers for Medicare and Medicaid Services System within 14 days. Resident identifiers: 1 and 14. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included low back pain, chronic kidney disease, type 2 diabetes, and hypertension. Resident 1's medical record was reviewed 9/13/21 through 9/16/21. Resident 1 was discharged to the local hospital on 5/20/21. Resident 1's MDS assessments was reviewed and it was revealed that the Discharge Assessment was completed but not yet transmitted. 2. Resident 14 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease of native coronary artery, hypertensive heart disease with heart failure, and end stage heart failure. Resident 14's medical record was reviewed 9/13/21 through 9/16/21. Resident 14 discharged to the local hospital on 6/28/21. Resident 14's MDS was reviewed and it was revealed that the Discharge Assessment was 66 days overdue. On 9/16/21 at 8:16 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated stated that there were a lot of July MDS's that had not been submitted. The RNC stated that the previous Director of Nursing (DON) completed MDS's.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 26 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which consisted of hemiplegia and hemiparesis following a cerebrovascular accident, osteoarthritis of knee, morbid obesity, idiopathic peripheral autonomic neuropathy, edema, autistic disorder, chronic obstructive pulmonary disease, atrial fibrillation, atrial septal defect, hypothyroidism, and overactive bladder. On 9/13/21 at 2:44 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 26 was incontinent of bladder and bowel and wore a brief. On 9/14/21 at 10:25 AM, an interview was conducted with resident 26. Resident 26 stated that her wound originated on the upper thigh and buttocks and was caused by the brief rubbing. Resident 26 stated that she also had yeast in there and that it was a bad place to have a brief rubbing. Resident 26 stated that the wound was still present on the left leg, but that the right leg had healed completely. Resident 26 stated that the wet briefs and incontinence caused her pain and the urine burned the wound. Resident 26 stated that staff changed her brief 2 times a shift and one of those times was usually right before they go off shift. Resident 26 stated that the staff were required to make rounds and provide incontinence care before the shift ended, but sometimes they did not get around to doing this with everyone that needed assistance. Resident 26 stated that she had left sided paralysis due to an old stroke and required incontinence care. Resident 26 stated that sometimes the staff forgot to put the call light within reach and she would have to wait until shift change for assistance or she would just have to yell and call out for help. Resident 26 stated that she had waited up to 30 minutes for assistance in the past. Resident 26 stated that she might need assistance with getting something to drink, a medication, or the other night she needed the nurse to check the wound on her buttocks because it was causing her pain. Resident 26 stated that she informed the Certified Nurse Assistant (CNA) on the night shift that she needed the nurse and was told that the nurse was busy. Resident 26 stated that she asked the same aide 30 minutes later for the nurse and was again told that the nurse was on break. Resident 26 stated that she felt like the aides were filtering the messages to the licensed nurses and she was not able to get the care she needed from them. Resident 26 stated that she tried to be partners with her staff but that she did not think they had a care mentality. Resident 26 stated that she knew when she was not okay, and the aides should not be in charge of deciding what messages were relayed to the nurse. Resident 26 stated that there had been a lot of staff turn over with the new company and provided examples of the cook, activities staff, aides, and maintenance. Resident 26 stated that she was not able to have the same diet as before. The previous cook would prepare her favorite split pea and ham soup. Resident 26 stated that if she did not have an order for yogurt she did not think she would have any protein in her diet now. Resident 26 stated that the new cook did not know what he was doing. Resident 26 stated that the previous activities staff member knew her personal likes and would make an effort to come and talk to her about her passion of basketball and the National Basketball Association (NBA) league. Resident 26 stated they would talk about their mutual favorite team and the upcoming games. Resident 26 stated that the previous maintenance staff was good at hanging her framed artwork on the wall. Resident 26 stated that she had 6 paintings that a family member had painted and they were hung on the walls. Resident 26 stated that the paintings had fallen down. Resident 26 stated that they had a new maintenance staff and she had asked for them to be hung back up. They are what keeps me sane, they are like old friends. Resident 26 was still waiting for the paintings to be hung on the walls. Review of resident 26's Annual MDS Assessment on 6/5/21 documented the functional status [Section G] for toilet use was total dependence with a two person assist. The assessment defined toilet use as how the resident used the toilet room, commode, bedpan, or urinal; transferred on/off toilet; cleansed self after elimination; changed pad; managed ostomy or catheter, and adjusted clothes. The assessment documented that the urinary continence was not rated, resident had a catheter (indwelling, condom) urinary ostomy, or no urine output for the entire 7 days look back period. The bowel incontinence was documented as always incontinent with no episodes of continent bowel movements. On 9/15/21 at 8:16 AM, a continuous observation started outside of resident 26's room. On 9/15/21 at 9:17 AM, CNA 6 entered resident 26's room and obtained a cup of water. No incontinence cares was provided. On 9/15/21 at 9:19 AM, CNA 6 returned to resident 26's room with a cup of ice. No incontinence care was provided. On 9/15/21 at 10:37 AM, the Activities Director (AD) entered resident 26's room to answer a call light. No incontinence care was provided. On 9/15/21 at 10:41 AM, CNA 2 entered resident 26's room and closed the resident's door. On 9/15/21 at 10:50 AM, an interview was conduced with the CNA 2 upon exit of resident 26's room. CNA 2 stated that she provided incontinence care and resident 26 was incontinent of bladder. CNA 2 stated that the resident had an area of redness on the right leg crease between the upper thigh and the buttocks. The CNA stated that the area was red but was not open, and that she applied barrier cream to the area. CNA 2 stated that resident 26 did not have any other wounds in the groin or coccyx area. CNA 2 stated that resident 26 was unable to tell if she was wet, and that was why she was checked every 2 hours or more frequently. CNA 2 stated that she usually checked resident 26 more often because she knew resident 26 also took a diuretic. It should be noted that resident 26 was observed to wait 2 hours and 25 minutes for incontinence care. On 9/15/21 at 3:13 PM, an observation was made of the hospitality aide (HA) entering resident 26's room. Resident 26's room had a contact isolation sign posted next to the door. The sign stated to perform hand hygiene, donn gloves, and donn a gown for all direct patient care or whenever clothing may contact surfaces in the room. The HA was observed to not donn gloves or a gown prior to entering the residents room and proceeded to touch the call light, side rail, and bed linens. The HA exited the room with resident 26's meal tray cover from the room. An immediate interview was conducted with the HA upon exit of the room. The HA stated that she was not aware that resident 26's room was on contact precaution. The HA stated she would only know about this if someone informed her, and no one had told her. The HA stated that she did not read the sign that was posted . The HA stated that she worked with an agency as a temporary hospitality aide and was not a CNA. The HA stated that she answered call lights, brought simple things to residents, did not transfer residents, delivered meal trays and water, and emptied the trash. On 9/16/21 at 9:55 AM, an interview was conducted with LPN 3. LPN 3 stated that the 300 hallway normally had 2 to 3 CNAs working on it. On 9/16/21 at 1:53 PM, a follow-up interview was conducted with CNA 2. CNA 2 stated that staffing for the 300 hallway was usually 3 CNAs, but sometimes there were only 2 on a shift. CNA 2 stated we still do pretty good, and we still manage to get things done. CNA 2 stated that if they were not able to complete tasks it was usually showers and it would get passed off to the next shift or done the next day. CNA 2 stated that this did not occur very often, but maybe one time per week they were not able to complete tasks. CNA 2 stated that she worked 12 hour shifts so she could spread the tasks out. CNA 2 stated that the 8 hours shift assignments seemed to get everything completed and she did not have to pick up work from the 8 hr shift from not completing their assigned tasks. It should be noted that resident 26 resided on the 300 hallway. [Cross Refer F690] 3. Resident 42 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included fracture of right femur, major depressive disorder, anxiety disorder, hemiplegia and hemiparesis following cerebral infarction, and chronic pain syndrome. On 9/15/21 at 10:24 AM, resident 42 was heard yelling from the hallway nurse, help me. On 9/15/21 at 10:26 AM, resident 42 turned the call light on. Resident 42 was heard again crying out, help me, nurse. On 9/15/21 at 10:32 AM, the call light was answered by CNA 2. Resident 42 waited 8 minutes for assistance. It should be noted that resident 42 resided on the 300 hallway. 4. Resident 15 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which consisted of quadriplegia cervical vertebrae (C5 to C7 incomplete), neuromuscular dysfunction of bladder, anxiety disorder, stage 4 pressure ulcer right buttocks, stage 4 pressure ulcer sacral region, and encounter for attention to colostomy. On 9/15/21 at 10:32 AM, resident 15's call light on was observed turned on. On 9/15/21 at 11:02 AM, CNA 6 was observed to answer resident 15's call light. On 9/15/21 at 12:10 PM, an interview was conducted with CNA 6. CNA 6 stated that she was assisting resident 15 up to the wheelchair and that the facility Administrator was in the resident room assisting her with the transfer. CNA 6 stated that the Administrator entered the resident's room at the same time as she did to answer the call light. CNA 6 stated that the Administrator typically did not assist with transfers, but that he knew what to do with the transfer. Resident 15 waited 30 minutes for transfer assistance. It should be noted that resident 15 resided on the 300 hallway. 5. Resident 46 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included pulmonary hypertension, cirrhosis of the liver, heart failure, post-traumatic stress disorder, perforation of intestine, generalized edema, central pain syndrome, morbid obesity, pleural effusion, gastrointestinal hemorrhage, chronic pulmonary embolism, obstructive sleep apnea, non-pressure ulcer of lower leg, emphysema, and portal hypertension. On 9/15/21 at 10:57 AM, resident 46 was heard calling out help water. CNA 2 was in the room next door to resident 46. No other staff member was observed nearby. The resident's call light was not turned on. Resident 46 was observed standing at the recliner, and then later ambulated to the restroom. No assistance was provided to the resident. It should be noted that resident 46 resided on the 300 hallway. 6. Resident 6 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, neuropathy, pressure ulcer of left heel, major depressive disorder, anxiety disorder, osteoarthritis, low back pain, pain in right hip, edema, and obesity. On 09/15/21 at 9:14 AM, an interview was conducted with resident 6. Resident 6 stated that she informed housekeeping yesterday that she needed toilet paper. Resident 6 stated that she was low and would run out today. Resident 6 stated that she was going to the nurse's station to inform then again that she needed toilet paper. On 09/15/21 at 2:47 PM, resident 6 was observed in the 300 hallway talking to LPN 1. Resident 6 was heard stating to LPN 1 that she still had not received any new toilet paper. On 9/15/21 at 3:08 PM, an interview was conducted with housekeeper 1 at the end of the 300 hallway. Housekeeper 1 stated that she normally worked 7:00 AM to 3:00 PM, but today she arrived at 7:30 AM and was staying until 3:30 PM to help the other housekeeper out. Housekeeper 1 stated that she normally worked on the 100 hallway, but right now there were only 2 housekeepers for the entire building. Housekeeper 1 stated that between the two housekeepers one of them would work Monday through Friday and the other would work Saturday through Thursday, that way there was one person present every day and some days they would overlap. Housekeeper 1 stated that the majority of the rooms were cleaned daily, but that if a room was not cleaned that day those were the rooms that they started with the following day. On 9/16/21 at 11:53 AM, a follow-up interview was conducted with resident 6. Resident 6 stated that the night nurse obtained two rolls of toilet paper at 10 PM last night for her. Resident 6 stated that the rolls were placed on the back of the toilet seat and not in the dispenser. Resident 6 stated that housekeeping had not come in yet today, and it was easier to use the toilet paper if it was placed in the dispenser. An immediate observation was made of resident 6's bathroom. One roll of toilet paper was observed located on the back of the toilet tank. A second roll was observed located on a storage cart next to the toilet and was against the back wall next to the tank. Both rolls were observed behind the seat. The toilet paper dispenser on the wall was observed empty. It should be noted that resident 6 resided on the 300 hallway. On 9/16/21 at 12:26 PM, an interview was conducted with the Maintenance/Housekeeping Director (HD). The HD stated that the facility had two housekeepers dedicated to cleaning, except one was pulled from cleaning to do laundry on Mondays. The HD stated that each room was scheduled to be cleaned every other day, and they needed a third housekeeper for each room to be cleaned daily. The HD stated that they terminated the third housekeeper a week ago because that individual was not cleaning each room daily. The HD stated that individual was previously responsible for resident 6's room. The HD stated that housekeeper 2 was now picking up the terminated staff members assignments and that she was completing the work and adding it in when she could. The HD stated that he needed to confirm if resident 6's room had been cleaned. [Cross Refer to F558 and F584] Based on observation, interview and record review it was determined that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, resident's were observed to not receive incontinence care for over 2 hours, call lights were observed alarming for 30 minutes, and residents were not provided supplies they needed. Resident identifiers: 6, 11, 15, 26, 42 and 46. Findings include: 1. Resident 11 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, chronic pain syndrome, anxiety disorder, opioid dependence and major depressive disorder. On 9/14/21 at 11:11 AM, an interview was conducted with resident 11. Resident 11 stated that he was incontinent of bowel and had a super pubic catheter for urine. Resident 11 stated he was unable to feel when he had a bowel movement. Resident 11 stated that he wanted to be checked every 2 hours to make sure he was not setting in a soiled brief. Resident 11 stated that he had skin breakdown on buttocks in the past because staff did not fully clean the bowel movement. Resident 11 stated that he normally could not feel being wiped but he was able to feel when he had skin breakdown. On 9/15/21 at 8:12 AM, a continual observation was made of resident 11. Resident 11 was in his room in bed with the door open. At 10:34 AM, an observation was made of the Activities Director (AD). The AD was observed to enter resident 11's room. The AD was interviewed immediately. The AD stated that resident 11 was sleeping. The AD was observed to close the door to resident 11's room. At 11:30 AM, the continual observation was completed. There were no staff observed to enter resident 11's room during the observation. Resident 11's medical record was reviewed on 9/15/21. A quarterly Minimum Data Set (MDS) dated [DATE] revealed, resident 11 had an indwelling catheter and was always incontinent of bowel. A care plan dated 9/19/19 and revised on 11/10/2020 with revealed I have potential for/an actual impairment to skin integrity r/t (related to) diagnoses type 2 diabetes, morbid obesity, and polyneuropathy. Excoriation to left lower buttocks (resolved) R thigh shearing 8/23/20 (resolved). An intervention developed was Resident will continue to have skin intact. Interventions developed were Keep skin clean and dry. Use lotion on dry skin. On 9/16/21 at 4:57 PM, resident 11's skin was observed. There was no redness or open areas. Resident 11 was observed to be clean when his brief was changed. Resident 11 stated that since he had a brief change about 5:00 PM, he would not be changed until the morning. Resident 11 stated there were not enough staff. On 9/15/21 at 8:53 AM, Licensed Practical Nurse (LPN) 2. LPN 2 stated that all residents on a bowel and bladder program were checked every 2 hours by Certified Nursing Assistant (CNAs). LPN 2 stated that there were some resident's that did not want to be bothered every 2 hours. LPN 2 stated that an alert was provided to the radios for CNAs to check residents every 2 hours. On 9/16/21 at 9:35 AM, an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated that she did not check resident 11 until 1:30 PM before the end of her shift. CNA 6 stated that he did not have wounds and he used a lot of creams. CNA 6 stated that she was told by other staff not to check on him until 1:30 PM. CNA 6 stated she did not remember who told her that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the function of the food and nutrition services. In addition, the facility must provide sufficient support personnel to safely and effectively care out the functions of the food and nutrition services. Specifically, meals were observed to be served 11 to 47 minutes past the posted meal time. Findings include: Review of the posted scheduled Meal Times documented the following: a. Breakfast 100-200 Hall 6:45 AM to 7:07 AM 300 Hall 7:05 AM to 7:25 AM Dining Hall 7:30 AM b. Lunch 100-200 Hall 11:45 AM to 12:05 PM 300 Hall 12:05 PM to 12:25 PM Dining Hall 12:30 PM 1. On 9/14/21 the following observations were made of the breakfast meal service delivery on the 300 hallway by Certified Nurse Assistant (CNA) 3: a. At 7:36 AM room [ROOM NUMBER] tray was served. b. At 7:40 AM room [ROOM NUMBER] tray was served. c. At 7:41 AM room [ROOM NUMBER] A tray was served. d. At 7:42 AM room [ROOM NUMBER] B tray was served. e. At 7:43 AM room [ROOM NUMBER] B tray was served. It should be noted that the first meal served was 11 minutes after the posted scheduled meal time and the last meal served was 18 minutes after the posted scheduled meal time. On 9/14/21 at 7:50 AM, an interview was conducted with CNA 1. CNA 1 stated that the residents that required assistance were served in the large dining room because there were so many residents that required assistance with dining. 2. On 9/14/21 the following observations were made of the breakfast meal service delivery in the main dining room: a. At approximately 7:55 AM, eleven residents were observed seated in the main dining room waiting for service. b. At 8:07 AM, resident 24's meal was served by Registered Nurse (RN) 1. It should be noted that this was 37 minutes after the posted scheduled meal time for the dining hall. c. At 8:17 AM, resident 299's meal was served. It should be noted that this was 47 minutes after the posted scheduled meal time for the dining hall. d. At 8:18 AM, resident 27 was provided dining assistance by CNA 3. It should be noted that this was 48 minutes after the posted scheduled meal time for the dining hall. 3. On 9/15/21 the following observations were made of the lunch meal service delivery on the 300 hallway: a. At 12:26 PM, the 300 hall trays were delivered to the hallway. b. At 12:27 PM, room [ROOM NUMBER] tray was served by CNA 6. c. At 12:28 PM, room [ROOM NUMBER] tray was served by CNA 6. d. At approximately 12:30 PM, room [ROOM NUMBER] A tray was served by CNA 6. e. At 12:32 PM, room [ROOM NUMBER] tray was served by CNA 6. f. At 12:33 PM, room [ROOM NUMBER] tray was served by CNA 6. g. At 12:34 PM, resident 15's tray was delivered to the small dining room on the 300 hallway by CNA 3. h. At 12:37 PM, room [ROOM NUMBER] tray was served by CNA 6. i. At 12:39 PM, room [ROOM NUMBER] tray was served by CNA 2. It should be noted that the last meal served was 14 minutes after the posted scheduled meal time. 4. On 9/15/21 at 12:36 PM, CNA 8 was observed passing hall trays at lunch. CNA 8 was observed to pass the hall tray to room [ROOM NUMBER]. a. At 12:40 PM, CNA 8 took a lunch tray to room [ROOM NUMBER]. b. At 12:41, CNA 8 took a lunch tray to room [ROOM NUMBER]. c. At 12:43, CNA 8 took a lunch tray to room [ROOM NUMBER]. d. At 12:45, CNA 8 took a lunch tray to resident to a resident in room [ROOM NUMBER]. e. At 12:47, CNA 8 took a lunch tray to the other resident in room [ROOM NUMBER]. It should be noted that the final tray on the 300 hall was provided 22 minutes after the scheduled time. 5. On 9/15/21 at 12:58 PM, the kitchen staff were observed to finish serving the last lunch tray for the residents in the dining room. The following observations were made of the lunch meal service delivery in the main dining room: a. At 12:45 PM, all residents were seated in the main dining room waiting for service. b. At 12:59 PM, first tray was served by CNA 2. c. At 1:01 PM, resident 24's meal was served. d. At 1:04 PM, resident 41's meal was served. e. At 01:08 PM, resident 5's meal was served. f. At 1:13 PM, resident 10's meal was served by CNA 2. g. At 1:17 PM, resident 27 was provided dining assistance by CNA 2. It should be noted that the first meal served was 29 minutes after the posted scheduled meal time and the last meal served was 47 minutes after the posted scheduled meal times. On 9/16/2021 at 1:30 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that meals were not late every day but it depended on what came up during the meal. The DM stated that there were days that the menu was more difficult.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 2 of 52 sample residents, that the facility did not have menus that were prepared in advanced and were followed. Specifically, the food portions were not followed according to the menu and resident's needs. Resident identifiers: 6 and 26. Findings include: 1. Resident 26 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which consisted of hemiplegia and hemiparesis following a cerebrovascular accident, osteoarthritis of knee, morbid obesity, idiopathic peripheral autonomic neuropathy, edema, autistic disorder, chronic obstructive pulmonary disease, atrial fibrillation, atrial septal defect, hypothyroidism, and overactive bladder. On 9/14/21 at 10:40 AM, an interview was conducted with resident 26. Resident 26 stated that the food was not really ., if I didn't have an order for yogurt, I don't think I'd have any protein. Resident 26 stated that the new cook did not know what he was doing. Resident 26 stated that everything was battered and deep fried. Resident 26 stated that she was supposed to have extra protein. Resident 26 stated she had a Boost breeze one time a day. Resident 26 stated that the previous cook use to make a split pea and ham soup that she really liked. Resident 26's medical records were reviewed. Review of resident 26's physician orders revealed the following: a. Breeze one time a day for Supplement 237 milliliters (mls). The order was initiated on 5/22/21. b. No Added Salt (NAS) with Supplemental Nutrition Program (SNP) diet, Regular texture, Thin liquids consistency. The order was initiated on 2/9/21. On 5/6/21 resident 26's last recorded weight was 303.5 pounds (lbs.). Review of resident 26's most recent quarterly dietary profile on 10/13/2020 documented a regular diet and regular fluid. The texture documented that the resident liked her food cut for her. Nutritional supplements were Liquacel in the afternoon and Boost Breeze with breakfast. Appetite was documented as fair with regular portions. No food dislikes were documented. The assessment documented that the resident had some chewing problems and required partial eating assistance. No other dietary profile was found in resident 26's medical records. 2. Resident 6 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, neuropathy, pressure ulcer of left heel, major depressive disorder, anxiety disorder, osteoarthritis, low back pain, pain in right hip, edema, and obesity. On 9/16/21 at 11:59 AM, an interview was conducted with resident 6. Resident 6 stated that the food was not cooked right. Examples given were that the cream of wheat was like water, and today the eggs were like rubber. Resident 6 stated that today she only had one piece of bacon instead of two, and the portion size should have been two pieces. Resident 6 stated that she had worked in kitchens before and knew she would have been fired if she sent out that food. Resident 6 stated that she reported at the Interdisciplinary Meeting that the food was not edible half of the time, but felt that nothing had changed. Resident 6's medical records were reviewed. Review of resident 6's physician orders revealed the following: a. Consistent Carbohydrate (CCHO) diet, Regular texture, Thin liquids consistency. The order was initiated on 7/14/2020. On 8/12/21 resident 6's last recorded weight was 177.5 lbs. Review of resident 6's most recent quarterly dietary profile on 10/22/2020, documented a CCHO diet and regular fluid. At the time of the dietary profile the nutritional supplement listed was Liquacel two times a day 30 mls and Med pass four times a day, 60 mls. Food allergies were shrimp and dislikes were lima beans, spinach, beets, and white bread. No other dietary profile was found in resident 6's medical records. 3. On 9/15/21 at 12:20 PM, an observation was made of the kitchen staff plating the lunch meal. There was sliced turkey, masked potatoes, gravy, green beans, slice of bread, and lemon bar or sugar cookie. The cook used a blue handled scoop for mashed potatoes, gray handled scoop for the green beans, blue handled scoop for ground chicken, and a 4 ounce (oz) ladle was used for the gravy. At 12:53 PM, an observation was made of [NAME] 1. [NAME] 1 was observed to serve the last green beans. [NAME] 1 was observed to get a large can of green beans and open it. [NAME] 1 scooped out green beans into a bowl. Dietary Aide (DA) 1 was observed to place the green beans into the microwave. There was no observation of seasoning applied to the green beans. DA 1 was observed to heat 7 servings of green beans in the microwave. A spreadsheet provided by the Dietary Manager (DM) was reviewed on 9/15/21. According to the Spreadsheet there was turkey cutlets with mustard cream sauce and the portion size was 3 oz (ounces) of meat and 1 oz of sauce. The serving size for the mashed potatoes was a #8 scoop with 1 oz of gravy. The herded whole green beans serving size was a #8 scoop. The bread or roll was served with 1 teaspoon of butter and a creamy lemon bar sized 3 inch by 2 inch. On 9/15/21 at 1:00 PM, an interview was conducted with [NAME] 1. [NAME] 1 stated that the gray handled scoop was a #8 which was used to serve green beans. [NAME] 1 stated the blue handled scoop was a #16 scoop used to serve mashed potatoes. [NAME] 1 was observed to weigh the meat. The meat was different sizes. [NAME] 1 stated he would weigh a small piece and then a large piece. The small piece was observed to be 2.5 oz and the large piece was 4.9 oz. [NAME] 1 stated that the green beans served from the steam table were from the fridge and were prepared the day before with seasoning. [NAME] 1 stated he did not season the green beans that were opened at lunch. [NAME] 1 further stated that there was not an alterative vegetable to serve. [NAME] 1 stated that if a resident wanted an alterative vegetable there was V8 juice. On 9/15/21 at 1:24 PM, an interview was conducted with the DM. The DM stated that Certified Nursing Assistants asked residents what they wanted to order. The DM stated that the kitchen served the residents the food they ordered. The DM stated that she had a spreadsheet with the serving sizes posted on the trayline for the cooks to reference. The DM stated that the scoops used were not the appropriate serving size according to the spread sheet.

Based on observation and interview it was determined, for 7 of 52 sample residents, that the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, resident's complained of food quality and a test tray was observed to not be palatable. Resident identifiers: 6, 8, 11, 13, 19, 26 and 40. Findings include: 1. On 9/14/21 at 8:20 AM, an interview was conducted with resident 19. Resident 19 stated that the food was cold and not cooked. 2. On 9/16/21 at 11:59 AM, an interview was conducted with resident 6. Resident 6 stated that the food was not cooked right. Resident 6 stated that the cream of wheat tasted like water. Resident 6 stated that the eggs were like rubber today. Resident 6 stated that today we only got one piece of bacon instead of 2, it should be 2 pieces. Resident 6 stated that she had worked in kitchens before and she would have been fired if she sent out that food like the kitchen did. Resident 6 stated that she had reported the food quality during her care conferences. Resident 6 stated that the food was not edible half the time and nothing had changed. 3. On 9/14/21 at 10:40 AM, an interview was conducted with resident 26. Resident 26 stated that the food was not really , if i didn't have an order for yogurt I don't think I'd have any protein. Resident 26 stated that the new cook did not know what they were doing. Resident 26 stated that everything was battered and deep fried. Resident 26 stated she was supposed to have extra protein. Resident 26 stated she had Boost breeze once a day. Resident 26 stated that the split pea and ham soup use to be good but not anymore. 4. On 9/14/21 at 12:00 PM, an interview was conducted with resident 8. Resident 8 stated last night the food was a green pepper, really spicy, and she was not able to eat it. Resident 8 stated all she ate was the cauliflower. Resident 8 stated if she ordered a sandwich she was unable to eat it. 5. On 9/14/21 at 10:48 AM, an interview was conducted with resident 11. Resident 11 stated that there was only 1 brand of yogurts which tasted awful. Resident 11 stated when the new company bought the facility they were no longer allowed to have macaroni and cheese. Resident 11 stated that he was unable to eat a lot of meat. Resident 11 stated that sandwich meat was sliced from regular meat and was not specifically lunch meat. Resident 11 stated that the lettuce for salads and sandwiches was usually brown. Resident 11 stated a sandwich was so bad one time that he thought it had been spit on. 6. On 9/14/21 at 9:15 AM, an interview was conducted with resident 13. Resident 13 stated that the food looks like cat food. Resident 13 stated that often, the food was too spicy for her to eat. Resident 13 stated that she spoke with the kitchen staff, but the food remained spicy. 7. On 9/13/21 at 3:40 PM, an interview was conducted with resident 40. Resident 40 stated he would rather eat anywhere but here. On 9/15/21 at 12:20 PM, the tray line for the lunch meal was observed. There was turkey, mashed potatoes, gravy, green beans, slice of bread and a lemon square or sugar cookie. An observation was made of [NAME] 1 opening a new can of green beans. [NAME] 1 was observed to heat the green beans in the microwave. [NAME] 1 was observed to serve the green beans to the last 7 residents. The gravy was observed to be water thin liquid. An interview was conducted with [NAME] 1. [NAME] 1 stated that there were not enough green beans so he opened another can. [NAME] 1 stated that he had heated up the green beans from the refrigerator because there was seasoning on them. [NAME] 1 stated he did not season the green beans for the last 7 resident's served. On 9/15/21 at 1:02 PM, a test tray was obtained. There was a slice of turkey, mashed potatoes, gravy, green beans, slice of bread and a lemon square. The temperature of the turkey was 132.2 degrees Fahrenheit and was warm to the taste. The temperature of the mashed potatoes and gravy was 120.5 degrees Fahrenheit. The mashed potatoes and gravy was warm to the taste with a strong starch flavor. The gravy was observed to have a consistency of water. The gravy was bland to the taste. The bread was served in a plastic baggy. The lemon square was served in a bowl. The lemon square tasted like a lemon square with a gel consistency. On 9/15/21 at 1:24 PM, an interview was conducted with the Dietary Manager (DM). The DM stated there was a food committee meeting monthly with resident council. The DM stated that residents provided food preferences at the food committee meeting. The DM stated she did not take minutes at the meeting. The DM stated that she noticed the gravy was very thin when she plated a few meals.

Based on interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, areas in the kitchen were not cleaned and the sanitizer solution was not at the required concentration. Findings include: 1. On 9/13/21 at 2:08 PM, an initial tour was conducted of the facility kitchen. The following was observed: a. There was brown substance splattered on the ceiling above the food preparation area. b. There was dust around a vent on the ceiling above the food preparation area. c. There was a bag of brown lettuce in a bag in the reach-in refrigerator. d. There was a white substance behind the oven. e. The floor in the dish machine room was soiled with a black substance. f. A white trash can was soiled with brown and black substance on the outside. g. There were large white bins containing rice, cake mix, salt and sugar that were soiled with a black substance on the sides and the clear lids had substance on them. 2. [NAME] 2 was observed to check the sanitizer solution. [NAME] 2 stated the sanitizer was changed at 1:00 PM. [NAME] 2 was observed to place a sanitizer testing strip into the bucket. The strip was observed to not change colors. [NAME] 2 stated then stated that the sanitizer was the one she had just changed. [NAME] 2 was observed to ask Dietary Manager (DM) if she was using the correct strips. [NAME] 2 stated that the the strip changed color when there was enough sanitizer. 3. On 9/15/21 at 1:00 PM, a follow up kitchen tour was conducted. The above items were again observed. An interview was immediately conducted with the DM. The DM stated that the ceiling needed to be cleaned. The DM stated the areas identified needed to be cleaned. The DM stated that the facility administrator had hired an new DM so that she was able to focus on completing her Certified Dietary Manager training and assist the new DM. The DM stated she would have more time to focus on cleaning the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** #. Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia, C5-C7 incomplete, neuromuscular dysfunction of bladder, gastro-esophageal reflux disease, anxiety disorder, insomnia, hypotension, pressure ulcer of right buttock and sacral region, stage 4, acute and chronic respiratory failure and major depressive disorder. Resident 15's Care Plan has a Focus Area for Altered respiratory status/difficulty breathing related to Sleep Apnea. It includes goals and an intervention to use his Bipap with specific settings. Resident 15 also has a physician order to wear his CPAP at night. On 9/16/21, the facility's Appointment Log was reviewed. On 9/16/21 at 9:54 AM, an interview was conducted with resident 15. The Appointment Log was reviewed with resident 15. a. There was an appointment in the Appointment Log for 5/4/21 for resident 15 to go to the Alpine Medical Equipment store because his Bipap machine was not working. Resident 15 stated that the facility did not transport him as requested to the store. Resident 15 stated Alpine Medical was located near the facility, so when he decided he did not want to wait for the facility to transport him, he took his Bipap machine on his electric wheel chair to Alpine Medical himself. He stated, Alpine Medical gave him a new machine and supplies and he then returned to the facility in his electric wheel chair. b. Resident 15 stated that he had asked the prior Director of Nursing (DON) a month ago to schedule an appointment at the Infusion Clinic because he had a PICC (peripherally inserted central catheter) line that was getting hard to flush. This request was not in the Appointment Log. c. Resident 15 also stated that an employee of his physician told him that he would schedule an urology appointment for resident 15. This request was not in the Appointment Log. On 9/16/21 at 12:16 PM, the Maintenance/Housekeeping Manager (MM) came stating that Licensed Practical Nurse (LPN) 2 had informed him that resident 15 needed an urology appointment. The MM stated he had just spoken with resident 15, who told him about also needing an appointment to the Infusion Clinic. The MM stated he would get those two appointments scheduled. On 9/16/21 at 4:42 PM, an interview was conducted with the MM, who now has the responsibility to make resident appointments and transport residents. TheMM stated that appointments were made several different ways and there had been some communication issues, which have caused confusion with scheduling appointments. The MM stated he was investigating the process but had not implemented any new processes to assure appointments get scheduled as requested. Based on observation, interview, and record review it was determined, for __ of 52 sample residents, that the facility did not timely arrange outside services that met professional standards. Specifically, one resident did not have an eye appointment, a resident had a missing tooth and a dental appointment had not been arranged for the resident. Resident identifiers: 9, 15, and 43. Resident 9 was admitted to the facility on [DATE] with diagnoses which included heart failure, osteoporosis, chronic kidney disease, and depression. On 9/14/21 at 9:50 AM, resident 9 was interviewed. Resident 9 stated that she had requested to go to the eye doctor several times. Resident 9 stated that her vision had changed and she needed to go to an eye doctor. On 9/16/21, resident 9's medical record review was completed. An Appointment Request for a vision check was initiated by resident 9 on 6/21/21. On 7/16/21 at 12:03, a Social Service Note revealed that resident 9 wore glasses and stated a need for vision care. On 9/15/21 at 11:45 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that if a resident needed a doctor's appointment, the nurse would fill out a request in the appointment book. RN 1 stated that the Housekeeping Director (HD) would schedule the appointments and provide a list to the nursing staff each week. On 9/15/21 at 11:51 AM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that nurses were responsible to put the follow-up appointments or patient-requested appointments in the appointment book, then the HD made the appointment and transported the resident to their appointment. LPN 1 stated that the HD provided a list to the nursing staff, but the nursing staff did not make appointments. LPN 1 stated that when the previous HD worked at the facility, he was behind on making appointments, but the new HD was catching up. LPN 1 stated that the Administrator had recently told staff only to make necessary appointments. LPN 1 stated that an eye appointment was necessary. On 9/15/21 at 12:12 PM, the HD was interviewed. The HD stated that he received requests from various sources, including nursing staff, residents, follow-up appointment reminders, social services staff, hospitals and doctors. The HD stated that sometimes families or nurses made appointments for the residents, so he requested those schedules so he could transport the resident to their appointment. The HD stated that he had called the eye doctor for resident 9 and thought that they had examined resident 9 previously, so he did not make a new appointment. The HD stated that when he started, he called the doctors and made sure residents had made it to their appointments, but the staff was still working on communication. The HD stated that he recently started using a calendar to keep track of appointments. On 9/16/21 at 7:47 AM, the Regional Nurse Consultant (RNC) was interviewed. The RNC stated that there was no record of resident 9 having an eye appointment or having her eyes checked. The RNC stated that an appointment was made on 9/15/21. +. Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, anxiety disorder, and major depressive disorder. On 9/14/21 at 11:08 AM, an interivew was conducted with resident 11. Resident 11 stated that he wanted to see an eye doctor since he was admitted . Resident 1 further stated he wanted to see a dentist outside of the facility. Resident 11 stated he appointments for testing that was ordered from a urologist. A quarterly MDS dated [DATE] revealed that resident did not have broken or loosely fitting full or partial dentures and no mouth pain or discomfort or trouble chewing. A social services note dated 4/27/21 revealed, . [Resident 11] is oriented and verbally responsive. BIM (sic) (Brief Interview of Mental Status) Score is 10. Resident appears to be frustrated with his level of care, he lists many complaints and unresolved concerns. He wants an appointment with an optometrist scheduled, He stated he has asked and is waiting for two years for eye appointment. A nursing progress notes dated 6/23/21 revealed, Received and order to refer to counselor/social worker on regular basic. And to follow up urologist appt. (appointment) Note on appt book. A progress note dated 7/27/21 revealed, Referral received from [name of physician] for plastic surgery: please evaluate for panniculectomy and treat as indicated. Request given to facility transport to schedule An appointment request book was located at the nurses station. The following appointments were requested with no follow up information: a. On 3/16/21, resident 11 had a request for a urology referral for hematuria. The time frame was as soon as possible (ASAP). There was not appointment documented. b. On 4/27/21, resident 11 had a request for an optometrist appointment. There was no follow up documented. c. On 5/18/21, resident 11 had an appointment request for urology institute for a hematuria. Appointment timeframe was as soon as possible (ASAP). The requested were crossed out. b. On 6/23/21, resident 11 had a note Please make an (sic) urology appt [and] if already make disregard it. c. On 7/23/21, resident 11 had the following entry, There is a referral for vascular surgeon for consult regarding vein therapy and treat as needed. There was no date for appointment. A progress note dated 6/23/21 revealed resident 11 returned from cardiologist. A progress note dated 8/20/21, 8/26/21 revealed that resident 11 returned from urology appointment. On 9/16/21 at 7:45 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that there were no appointments for resident 11. The RNC stated the staff were making the appointments today.

Based on interview and record review, it was determined that the facility did not sustain a Quality Assurance and Performance Improvement (QAPI) Program during transitions in leadership and staff. Specifically, there were no Quality Assessment and Assurance (QAA) Committee meeting minutes and the facility could not provide documentation to demonstrate evidence of its ongoing QAPI Program. Findings include: On 9/16/21, the facility's QAPI Plan was reviewed. The QAPI Plan outlined the objectives, authority, implementation, and evaluation of their QAPI Program. On 9/16/21 at 5:04 PM, an interview was conducted with the Administrator. The Administrator stated that his employment at the facility as the Administrator started July 2021. The Administrator stated he was unable to locate the QAA Committee meeting minutes. The Administrator further stated he could not locate documentation of the facility's ongoing quality improvement efforts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Additionally, the facility did not maintain a IPCP surveillance system. Specifically, observations were made of staff entering a room on contact precautions without performing hand hygiene and donning gloves and a gown, staff were observed inside the facility and resident areas without eye protection, and staff were observed wearing their surgical masks down below their nose and mouth, staff did not perform hand hygiene during meal service after touching multiple objects inside the resident's room, a meal tray was delivered to the wrong resident and then was taken from the wrong room to the correct room, a staff member was observed placing soiled gloves in her pocket, and the facility tracking and trending log for surveillance of communicable diseases was incomplete. Resident identifiers: 5, 8, 25, 26, 27, 31, 33, and 42. Findings included: 1. Resident 26 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which consisted of hemiplegia and hemiparesis following a cerebrovascular accident, osteoarthritis of knee, morbid obesity, idiopathic peripheral autonomic neuropathy, edema, autistic disorder, chronic obstructive pulmonary disease, atrial fibrillation, atrial septal defect, hypothyroidism, and overactive bladder. On 9/13/21 at 2:18 PM, an observation was made of a Personal Protective Equipment (PPE) cart located outside of resident 26's room. A contact isolation sign was posted next to resident 26's door. The sign by the door stated to perform hand hygiene, donn gloves, and donn a gown when providing patient care or coming into contact with anything in the resident's room. On 9/13/21 at 2:25 PM, an interview was conducted with Certified Nurse Assistant (CNA) 5. CNA 5 stated that resident 26 was on contact precautions for Carbapenem-resistant Acinetobacter baumannii (CRAB) in the coccyx wound. On 9/13/21 at 2:44 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 26 was on contact isolation precautions for Extended Spectrum Beta-Lactamase (ESBL) in the urine and Carbapenem-resistant Enterobacterales (CRE) in the skin. LPN 3 stated that resident 26 was colonized with both infections and could come out of her room after she performed hand hygiene. LPN 3 stated that resident 26 was incontinent of bladder and bowel and wore a brief. Review of resident 26's physician orders revealed the following: a. Contact precautions for ESBL, Carbapenem resistant Acinetobacter (CRAb, skin colonization). CRE gastrointestinal (GI) colonization dated 7/23/18 every shift for CRA/CRE colonization. Resident may exit room when: 1. Resident was assisted to complete hand hygiene 2. High touch surfaces of power wheelchair were disinfected 3. Resident and clothing was clean and unsoiled. The order was initiated on 9/14/21. Review of resident 26's care plan revealed a focus area for isolation contact precautions related to multiple drug resistant organism (MDRO): skin colonization CRAb; CRE. The care plan was initiated on 8/29/18 and was revised on 1/29/21. On 9/14/21 at 9:08 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that if staff entered resident 26's room they needed to perform hand hygiene, donn gloves, and wear a gown if they were touching anything in the room or were providing any resident care. On 9/15/21 at 9:17 AM, an observation was made of CNA 6 entering resident 26's room. CNA 6 did not perform hand hygiene or donn a pair of gloves prior to entering the room. CNA 6 exited resident 26's room carrying a cup of water from the resident's bedside. CNA 6 did not perform hand hygiene upon exit of the room. On 9/15/21 at 9:19 AM, CNA 6 returned to resident 26's room with a cup of ice. CNA 6 did not perform hand hygiene, donn gloves or a gown prior to entering the room. CNA 6 was observed to remove resident 26's breakfast tray from the room. The tray was held on CNA 6's forearm and in the CNA's left hand. The tray was observed to rest against CNA 6's torso, touching her clothing. On 9/15/21 at 12:10 PM, an interview was conducted with CNA 6. CNA 6 stated that she did not see the precaution signs on resident 26's door, and was not aware that the resident was on contact precautions. CNA 6 stated that rooms that were on transmission based precautions (TBP) had a PPE cart outside the resident room and a sign posted to notify staff. CNA 6 stated that she may have been going too fast and did not look up and see the posted sign. On 9/15/21 at 12:36 PM, CNA 8 was observed passing hall trays at lunch. CNA 8 was observed to have her procedure mask below her nose. CNA 8 was observed to put her left hand in her pocket, then handle a lunch tray with both hands and enter the room of resident 26, who was on contact precautions. CNA 8 was observed to touch resident 26's tray table, the hand rail on resident 26's left side with her right hand, her own hair with her left hand, and resident 26's bed spread with her left hand. CNA 8 then left resident 26's room, and went to the tray cart in the hallway without sanitizing. After exiting resident 26's room, CNA 8 took a lunch tray to resident 33, then to resident 8, then to resident 31, then to resident 25, and then to resident 42 before hand sanitizing and walking to the dining room at 12:48 PM. On 9/15/21 at 12:58 PM, CNA 8 was interviewed. CNA 8 stated that contact precautions for resident 26 were only required if the resident was touched. CNA 8 stated that to deliver a meal tray, she did not need to wear PPE. CNA 8 stated that she usually used hand sanitizer when delivering trays. On 9/15/21 at 3:13 PM, an observation was made of CNA 1 and the hospitality aide (HA) entering resident 26's room. Neither staff member performed hand hygiene, donned gloves, or donned a gown prior to entering the resident's room. The HA was observed to touch the call light, side rail, and the resident's bed linens. The HA exited the resident room carrying the resident's lunch meal tray cover. Neither staff member was observed to perform hand hygiene upon exit of the resident's room. An immediate interview was conducted with the HA. The HA stated that she was not aware that resident 26's room was on contact precaution. The HA stated that she was from an agency and she would know that a resident was on precautions because a facility staff member would report it to her. The HA stated that no one told her that resident 26 was on contact precautions. The HA stated that she did not read the posted sign next to resident 26's door prior to entering the room. The HA stated that she was not a CNA and her duties were to answer call lights, deliver meal trays and water, take out the trash and assist the CNAs with resident care. 2. On 9/13/21 at 1:10 PM, an interview was conducted with the Admissions Director during the screening process. The AD stated that there were no current COVID positive staff or residents at the facility, and the facility was not in outbreak status. An observation was made of the front lobby with cubbies filled with eye protection. Each cubby was labeled with a staff member's name. The lobby was sectioned off from the remainder of the building by a corridor separated by a door. The lobby contained two staff offices for the AD and the business office manager. An observation was made of RN 3 and RN 4 entering the lobby from inside the building to obtain face shields from the stored PPE cubbies. The staff were exiting the building to obtain the PPE. On 9/15/21 at 8:22 AM, an interview was conducted with CNA 2. CNA 2 stated that she entered the building through main entrance and obtained her PPE from the cubby located there. CNA 2 stated that they were universally wearing a surgical mask and eye protection while inside the building. The CNA was observed wearing a surgical mask and a face shield. On 9/14/21 at 7:19 AM, an observation was made of RN 1 on the 300 hallway at the medication cart. RN 1 was speaking to resident 33. Resident 33 was not wearing a face mask. RN 1 was observed with their surgical face mask down below the nose and mouth while speaking with resident 33. On 9/14/21 at 9:08 AM, RN 1 was observed outside of resident 26's room. RN 1 provided instructions on the contact isolation guidelines in place for resident 26. RN 1 was observed with a surgical face mask down below his nose and chin. On 9/15/21 at 9:43 AM, an observation was made of CNA 6. CNA 6 was observed at the nurses station with her mask down and face shield on. CNA 8 was observed sitting at the nurses station with her mask below her nose. The HD was observed with his nose exposed while in the hallway. At 10:36 AM, the HD was observed walking the 300 hall with his nose exposed and his mask below his nose. At 10:46 AM, the HD was observed with his face shield on his forehead and mask down with nose exposed within 6 feet of 3 residents. The 3 residents were not wearing masks. At 10:54 AM, observed the HD to have mask below nose and face shield not covering nose in the 300 hallway within 6 feet of 2 residents. The 2 residents were not wearing masks. At 10:57 AM, the HD was observed with his mask below nose and upper lip with face shield above mouth and nose. There were 2 residents not wearing masks within 6 feet of the HD. On 9/15/21 at 10:25 AM, an observation was made of RN 1. RN 1 was sitting at the nurses stated with RN 3 next to him. RN 1 was observed to have his mask around his chin with his nose and mouth exposed. On 9/15/21 at 11:00 AM, an observation was made of the facility Administrator in the 300 hallway. The Administrator was observed to not be wearing a face shield. There were residents in the 300 hallways without masks within 6 feet of the Administrator. The Administrator was observed to enter room [ROOM NUMBER]. On 9/15/21 at 11:02 AM, an interview was attempted with CNA 6. CNA 6 stated that she needed to assist the Administrator who was in room [ROOM NUMBER]. CNA 6 was observed obtaining a hoyer mechanical lift and entered room [ROOM NUMBER]. CNA 6 was observed wearing a surgical mask and eye protection. LPN 2 stated that the Administrator was in the room and that the CNA needed to assist him. An observation was made of the Corporate Administrator with a face shield in his hand. The Corporate Administrator was observed to hand the face shield into room room [ROOM NUMBER]. On 9/15/21 at 12:03 PM, an observation was made of the facility Housekeeping Director (HD). The HD was observed with their surgical face mask down below the nose and mouth. On 9/15/21 at 3:08 PM, an interview was conducted with Housekeeper 1. The housekeeper stated that they screened in at the beginning of the shift at the main entrance and obtained their surgical mask there. Housekeeper 1 stated that she purchased her own goggles and they were cleaned with bleach wipes. Housekeeper 1 stated that she stored the goggles in the storage closet along with the housekeeping supplies. The housekeeper was observed to remove the goggles at the beginning of the interview and propped them on top of her head. The goggles remained there for the duration of the interview. On 9/15/21 at 4:35 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that all staff entered the facility from front entrance and screened in with a symptom assessment and a temperature check. The RNC stated that all PPE was stored up front in the lobby. The RNC stated that all staff should be wearing a surgical mask and eye protection, either a face shield or goggles. The RNC stated that staff should not be inside the facility behind the lobby doors without PPE on. On 9/16/21 at 10:23 AM, an interview was conducted with LPN 1. LPN 1 stated that all staff should be universally wearing a surgical mask and a face shield. LPN 1 stated that the face shield was cleaned with bleach after exiting an isolation room and the surgical mask was changed after exiting a room on droplet precautions. An observations was made of CNA 6 with their surgical mask down below the nose. LPN 1 stated that staff should not have their mask down below their nose and when they touch their mask they need to perform hand hygiene. LPN 1 stated that when they went to lunch they changed their mask prior to returning to the floor. LPN 1 stated that the facility had a sufficient supply of masks, they are everywhere. On 9/16/21 at 10:30 AM, an interview was conducted with the HD. The HD stated that the masks did not fit properly, and because of this he was mindful and constantly adjusting it. The HD stated he had received education on the proper placement of the mask, and that it should cover the nose and mouth. On 9/16/21 at 12:13 PM, an observation was made of Housekeeper 1 on the 300 hallway with her eye protection resting on the top of her head. On 9/16/21 at 12:56 PM, a follow-up interview was conducted with the RNC. The RNC stated that she was aware of the PPE not being worn, and that she had similar observations of staff not wearing PPE correctly. The RNC stated that not everyone was wearing eye protection and they thought they should only be wearing eye protection in an outbreak status. Review of the facility Policy and Procedure for PPE Coronavirus 2019, Prevention and Control documented the best way to prevent COVID-19 was to avoid being exposed to the virus. Strategies identified to reduce the risk for exposure included staff wearing a surgical facemask and gloves when entering a resident room or when having direct contact with a resident for any reason. The policy further stated that visual alerts would be posted to instruct the staff on how to use the facemask to cover the nose and mouth, and how to perform hand hygiene. The policy was last revised on 2/1/21. It should be noted that the policy did not address the county positivity rate or community transmission level in relation to the use of PPE and the need for eye protection. Review of the facility Positivity Rate Tracking Log 2021 revealed that the facility had been in a high county positivity rate since 7/5/21 when the rate was greater than 10%. Review of the Centers for Disease Control and Prevention (CDC) COVID Data Tracker revealed that the facility's Community Transmission Level on 9/13/21 was High. https://covid.cdc.gov/covid-data-tracker/#county-view|Utah|49053|Risk|community_transmission_level Review of the CDC guidance Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic stated under Implement Source Control Measures that a well-fitting facemask should cover a person's mouth and nose to prevent the spread of respiratory secretions when they were breathing, talking, sneezing or coughing, and could be used for the entire shift unless soiled or damaged. The guidance further stated that source control and physical distancing was recommended for everyone in the healthcare setting regardless of vaccination status in counties with substantial to high community transmission. The guidance also stated that for facilities in counties with substantial or high transmission eye protection (goggles or face shield) should also be used during all patient care encounters. The guidance was last updated on September 10, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html 3. The following observations were made during the meal service delivery: a. On 9/14/21 at 7:36 AM, CNA 3 delivered the breakfast tray to room [ROOM NUMBER] and opened the milk carton for the resident. No hand hygiene was performed upon entrance to the room nor upon exit of the room. CNA 3 was observed to pull down their mask to speak to this surveyor. b. On 9/14/21 at 7:36 AM, CNA 3 was observed to pull down their facemask to speak to resident 5. The CNA was not socially distanced and was face to face with the resident. Resident 5 was not wearing a face mask. c. On 9/14/21 at 7:40 AM, CNA 3 delivered the breakfast tray to room [ROOM NUMBER]. No hand hygiene was performed upon entrance to the room nor upon exit of the room. d. On 9/14/21 at 7:41 AM, CNA 3 delivered the breakfast tray to room [ROOM NUMBER]A and opened the milk carton for the resident. No hand hygiene was performed upon entrance to the room nor upon exit of the room. e. On 9/14/21 at 7:42 AM, CNA 3 delivered the breakfast tray to room [ROOM NUMBER]B. CNA 3 was observed to touch their hair, the resident's phone, and pulled down their face mask to talk to the resident. No hand hygiene was performed upon entrance to the room nor upon exit of the room. f. On 9/14/21 at 7:43 AM, CNA 3 delivered the breakfast tray to room [ROOM NUMBER]B. CNA 3 was observed to touch the footboard of the bed, grabbed a towel at the bedside and placed on the resident as a clothing protector, and moved items on the bedside table. CNA 3 was observed to perform hand hygiene upon exit of the room. g. On 9/14/21 at 8:14 AM, CNA 1 was observed in the main dining room with their facemask down below the nose. h. On 9/14/21 at 8:18 AM, CNA 3 was observed in the main dining room assisting resident 27 with their breakfast. CNA 3 was observed to pull down their facemask to talk to resident 27, and the resident was not wearing a facemask. CNA 3 did not perform hand hygiene prior to assisting resident 27 with his meal. i. On 9/15/21 at 12:27 PM, CNA 6 delivered the lunch tray to resident 8. No hand hygiene was performed upon entrance to the room nor upon exit of the room. CNA 6 removed an old tray from the room and transported it to the kitchen. Approximately a few minutes later resident 8 approached CNA 6 in the hallway to inform her that the meal tray that she delivered did not belong to her. CNA 6 was observed to enter resident 8's room, obtain the meal tray that was just delivered, consult with CNA 2 who instructed her on the location of the resident, and then CNA 6 delivered the same meal tray to room [ROOM NUMBER]A. No hand hygiene was performed upon entrance to either room nor upon exit of either room. j. On 9/14/21 at 7:34 AM, an observation was CNA 6. CNA 6 was observed to deliver a tray to the resident in room [ROOM NUMBER]. CNA 6 was observed to ask the resident if he wanted his urinal emptied. CNA 6 placed the meal tray on the over bed table next to the urinal that was full. CNA 6 was observed to put on gloves, emptied it into the toilet and replaced the urinal on the over bed table. CNA 6 was observed to place the used gloves in the pocket of her scrubs. CNA 6 was observed to return to the breakfast meal cart and pick up another tray. CNA 6 did not perform hand hygiene. 4. On 9/16/21 at 8:14 AM, an interview was conducted with the RNC. The RNC stated that the infection control tracking and trending log only had tracking for February 2021 and September 2021. The RNC stated that she contacted the previous Director of Nursing (DON) and was informed that she had left an electronic copy on a flash drive. The RNS stated that the flash drive was blank. On 9/16/21 the facility IPCP surveillance tracking log was reviewed. Review of the tracking log revealed the following: a. February 2021 listed 2 facility acquired Urinary Tract Infections (UTIs). No documentation was found that identified the resident's name, the organism identified, and the antibiotic treatment ordered. b. September 2021 listed 4 facility acquired UTIs. All organisms identified were Escherichia coli (e-coli). Review of the facility policy on Infection Prevention and Control Program documented the elements of the IPCP program consisted of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection and employee health and safety. The policy further stated that the data gathered during surveillance was used to oversee infections and spot trends. The infection preventionist was responsible for surveillance, analysis of data and trends, and intervening as appropriate based on any identified trends. The policy was last revised in July 2016. On 9/16/21 at 12:56 PM, a follow-up interview was conducted with the RNC. The RNC stated that the data that was entered for the February tracking was incomplete. The RNC stated that September 2021 was not yet finished but that she had already identified a trend with facility acquired e-coli UTIs. The RNC stated that the plan now that the trend had been identified was to address staff education with perineal (peri) care, identify any possibly cross contamination, demonstrate proper pericare technique, identify incontinent residents and increase monitoring so organisms did not migrate into the urinary tract, and so resident did not sit in wet briefs for prolonged periods of time.

Based on interview and record review it was determined, for 4 out of 5 sampled facility staff members, that the facility did not ensure that testing of all facility staff for COVID-19 was completed based on the parameters set forth by the Secretary. Specifically, routine testing of unvaccinated staff members, based on the county positivity rate, was not completed two times a week. Staff identifiers: Staff 1, Staff 2, Staff 4, and Staff 5. Findings included: Review of the facility County Positivity Rate Tracking Log for 2021 documented that the testing frequency was twice weekly and had been since 7/5/21 when the county positivity rate increased above 10 %. On 9/15/21 the facility surveillance testing log for August 2021 and September 2021 were reviewed. Staff testing was reviewed for the following unvaccinated staff members: a. Staff 1 surveillance testing was completed on 8/6/21, 8/12/21, 8/13/21, 8/20/21, 8/27/21, 9/10/21. All tests results were Polymerase Chain Reaction (PCR) and all results were negative. Staff 1 was missing the second surveillance test for weeks 8/1/21 to 8/7/21, 8/15/21 to 8/21/21, 8/22/21 to 8/28/21, and 9/5/21 to 9/11/21. No testing was completed for the week of 8/29/21 to 9/4/21. b. Staff 2 surveillance testing was completed on 8/10/21, 8/13/21, 8/17/21, 8/20/21, 8/24/21, 8/27/21, 8/31/21, 9/3/21, 9/10/21, and 9/14/21. All tests were PCR and all results were negative. Staff 2 was missing both surveillance tests for week 8/1/21 to 8/7/21 and the the first surveillance test for the week of 9/5/21 to 9/11/21. c. Staff 4 surveillance testing was completed on 8/2/21, 8/6/21, 8/10/21, 8/13/21, 8/20/21, 8/24/21, 9/3/21, and 9/10/21. All tests were PCR and all results were negative. Staff 4 was missing the second test for week 8/15/21 to 8/21/21, 8/22/21 to 8/28/21, 8/29/21 to 9/4/21, and 9/5/21 to 9/11/21. d. Staff 5 did not have any record that surveillance testing had been completed for either month. Review of the staff schedules for August 2021 and September 2021 revealed the following: a. Staff 1 was scheduled to work on 8/4/21, 8/5/21, 8/6/21, 8/11/21, 8/12/21, 8/13/21, 8/14/21, 8/18/21, 8/19/21, 8/20/21, 8/25/21, 8/26/21, 8/27/21, 9/1/21, 9/2/21, 9/3/21, 9/4/21, 9/8/21, 9/9/21, and 9/10/21. b. Staff 2 was scheduled to work on Monday through Friday 6:00 AM to 2:00 PM. c. Staff 4 was scheduled to work on 8/2/21, 8/3/21, 8/6/21, 8/7/21, 8/9/21, 8/13/21, 8/14/21, 8/16/21, 8/20/21, 8/21/21, 8/23/21, 8/24/21, 8/27/21, 8/28/21, 8/30/21, 8/31/21, 9/3/21, 9/4/21, 9/6/21, and 9/10/21. d. Staff 5 was scheduled to work on 8/4/21, 8/5/21, 8/6/21, 8/9/21, 8/11/21, 8/12/21, 8/13/21, 8/14/21, 8/15/21, 8/16/21, 8/18/21, 8/19/21, 8/20/21, 8/23/21, 8/24/21, 8/25/21, 8/26/21, 8/30/21, 8/31/21, 9/1/21, 9/2/21, 9/3/21, 9/7/21, 9/8/21, 9/9/21, and 9/10/21. On 9/15/21 at 7:05 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that she spoke to the facility Administrator and he reported that the staff were so burned out that if it was not their scheduled day to work that day, and they were off on a testing day, they were not coming into the facility to be tested two times a week. Review of the facility Policy for Coronavirus 2019, Testing documented that routine testing shall be based on the extent of the virus in the community as indicated by the county positivity rate in the prior week, or most recent available data. If the county positivity rate increased to a higher level of activity, the facility would begin testing staff at the frequency shown in Table 1 as soon as the criteria for the higher activity was met. The table indicated that for a county positivity rate of greater than 10% minimum testing frequency was twice a week. The policy documented under staff refusal for routine testing, The facility will follow occupational health and local jurisdiction policies with respect to any asymptomatic staff who refuse routine testing. If there are no existing occupational health or local jurisdiction policies in place, staff shall be permitted to continue working until such a time as they are subject to testing requirements under symptomatic testing or outbreak testing. The policy was last revised in March 2021. On 9/16/21 at 8:23 AM, a follow-up interview was conducted with the RNC. The RNC stated that she did not have documentation of staff testing two times a week for Staff 1, Staff 2, Staff 4, and Staff 5. The RNC stated that Staff 5 was on vacation on 8/1/21 and 8/2/21. On 9/15/21 at 8:22 AM, an interview was conducted with Staff 1. Staff 1 stated that staff surveillance testing was done on Tuesdays and Fridays and was completed at the end of 400 hallway. Staff 1 stated that the 400 hallway had a separate entrance to the testing room, and that testing was done between 7:00 AM and 3:00 PM. Staff 1 stated that the testing was done by an outside laboratory and the test was a PCR test. On 9/15/21 at 4:35 PM, an interview was conducted with the RNC. The RNC stated that the testing room was located on the 400 hallway. The RNC stated that the outside contracted laboratory set up testing in a room down that hallway on Tuesdays and Fridays. The RNC stated that the surveillance testing was completed for all staff that were not vaccinated for COVID-19.

Based on interview and record review it was determined, for 5 out of 5 staff members sampled, that the facility did not ensure that that each staff member was provided education regarding the benefits and risks and potential side effects associated with the vaccine before offering the COVID-19 vaccine. Specifically, the facility did not maintain documentation that staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine and that staff were offered the COVID-19 vaccine unless medically contraindicated or the staff member had already been immunized. Staff Identifier: Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5. Findings included: On 9/15/21 the facility employee vaccination records for COVID-19 were reviewed. The vaccination records documented that Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5 had refused the COVID-19 vaccination. No documentation was found of when the vaccine was offered or if the vaccine was contraindicated. No documentation was found that the staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. Review of the facility Policy and Procedure on COVID-19 Vaccine documented that all employees who had no medical contraindication to the vaccine would be offered the COVID-19 vaccine. The policy stated that prior to the vaccination, the employee would be provided information and education regarding the benefits and potential side effects of the COVID-19 vaccine. Provisions of such education would be documented in the employee's medical record or file. The policy was adopted on 1/1/21. On 9/15/21 at 7:05 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that there was no documentation for the unvaccinated staff members that showed that they were provided education on the benefits and risks of the COVID-19 vaccine.

Based on interview and record review it was determined that the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not a employee a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings include: On 9/13/21 at 2:08 PM, an interview was conducted with the Dietary Manager (DM). The DM stated she had been the dietary manager for two and a half years. The DM stated that the Administrator hired a new DM with a CDM (Certified Dietary Manager) certification. The DM stated that the new DM was scheduled to start in about 2 weeks. The DM stated that after the new DM was hired, she planned to work on getting her CDM. There was no documentation regarding the full time DM having requirements to serve as the director of food and nutrition services. On 9/16/21 at approximately 2:00 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that a staff member with a CDM had been hired and had been to the facility a couple times. The RNC confirmed the staff with the CDM had not been in the facility full time.