**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility to provide a notice and/or an accurate notice of the discharge to the resident, resident family and/or the receiving facility to ensure a safe and orderly continuance of care. This was true for Resident #99 on two (2) of three (3) of her transfers to an acute care facility. Resident identifier: #99. Facility Census: 115. Findings include: a) Resident #99 A review of Resident #99's chart on 12/11/24 at 9:24 AM found she was discharged to an acute care facility on 07/19/24, 09/25/24 and 10/05/24. Further review of the record found a transfer form dated 09/25/24. On this form the date of the transfer was listed as 07/19/24. Further review of the record found there was no transfer form for the discharge date of 07/19/24. During an interview with the Director of Nursing (DON) in the afternoon of 12/16/24 she confirmed, there was not a transfer form completed for Resident #99's discharge on [DATE] and the transfer form for 09/25/24 listed the incorrect transfer date.

Based on record review and staff interview, the facility failed to ensure an accurate accounting of bed - hold days was provided to Resident #99's healthcare decision maker when the resident was discharged from the facility to an acute care hospital. This was true for three (3) of three (3) discharges reviewed. Resident identifier: #99. Facility Census: 115. Findings include: a) Resident #99 A review of Resident #99's chart on 12/11/24 at 9:24 AM, found the resident was discharged to an acute care facility on 07/19/24, 09/25/24 and 10/05/24. On 12/16/24 the facility was asked to provide the bed -hold notice for each of the three (3) discharges. The facility provided the notices. The notices were blank except for a nurse's signature, the resident's name, medical record number and the state abbreviation. The number of Medicaid bed - hold days available was not completed. The price per day of the bed hold was not completed and there was no indication notice was provided and/or reviewed with Resident #99's responsible party. Therefore, it was not noted if the person responsible wished to pay bed- hold or declined to pay bed- hold. Further review of the record found Resident #99 was staying at the facility under Medicaid services. When asked how many bed - hold days Resident#99 had used for the year in the afternoon of 12/16/24, the Nursing Home Administrator (NHA) stated, she has used six (6) of her 12 days for the year. An interview with the NHA in the evening of 12/16/24 confirmed they had no other documentation showing the resident's son was made aware of how many bed -hold days Resident #99 had left upon discharge from the facility to the hospital on each of the three (3) occasions she was discharged .

Based on record review and staff interview, the facility failed to identify diagnoses for two (2) of three (3) residents reviewed for the area of pre admission screening and resident review (PASARR). Resident identifiers: #55 and #18. Facility census: 115 a) Resident #18 A diagnosis of Bipolar Disorder and Post-Traumatic Stress Disorder (PTSD) were not identified on the most recent PASARR dated 11/14/23 for Resident #18. On 12/17/24 11:45 AM, the State Surveyor reviewed and confirmed the discrepancies with the orders, care plan and PASARR with the Director of Nursing. b) Resident 55 Record review on 12/10/24 at 01:15 PM revealed the following medical diagnoses Schizoaffective Disorder Anxiety Disorder Biploar Disorder Further record review on 12/10/24 revealed the Pre admission Screening and Resident Review (PASRR) did not identify Bipolar disorder Corporate Registered Nurse # 155 confirmed the PASRR did not identify Bipolar disorder.

Based on resident interview record review and staff interview the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities by failing to identify religious preferences in the care plan. This failed practice was found to be true for one (1) of three (3) residents reviewed under the activities care area during the Long-Term care survey process. Facility census:115 Resident identifier:#48 Findings include: a) Resident #48 On 12/09/24 At 12:34 PM An interview with Resident #48 who stated I can't say anyone comes to invite me to anything, I have gone to a church service and they do ask about bingo but I don't believe in gambling and I don't do that. I can turn on preaching on Sundays, I used to me a minister before i came here Record review completed on 12/10/24 at approximately 10:00 am revealed resident #48's care plan revealed no preferences to religion and being of the Baptist faith or history of being a minister. On 12/10/24 at 12:05 PM the Administrator confirmed the activity care plan did not identify resident religious preferences or history of being a minister.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview and observation, the facility failed to evaluate Resident #10's hearing impairment. This was true for one (1) of three (3) residents reviewed under the care area of activities of daily living. Resident identifier: #10. Facility Census: 115. Findings Include: a) Resident #10 On 12/10/24 at approximately 11:30 AM, the resident was interviewed and found to be hard of hearing. A record review found the care plan recognized impaired communication due to impaired hearing. The medical record was not found to have any information regarding a hearing test or an assessment for hearing aids. On 12/16/24 at 5:15 PM, the Director of Nursing (DON) confirmed the resident did have impaired hearing and a hearing assessment had not been performed since admission to the facility on [DATE] .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure residents receive proper treatment and care to maintain mobility and good foot health. This was true for one (1) of four (4) residents reviewed for activities of daily living during the long-term care survey process. Resident identifier: #97. Facility Census: 115. Findings include: a) Resident #97 An observation of Resident #97, on 12/10/24 at 9:06 AM, found she had long toenails on each foot. The nails extended out from the tip of the toe and were curled on the ends. A review of Resident #97's medical record, on 12/11/24, found Resident #97 was admitted to the facility on [DATE]. The resident did not have any diagnosis which would prevent the staff from providing nail care to the resident. There was no indication in the medical record that the resident had ever seen the podiatrist at the facility. An observation with the Director of Nursing (DON) on 12/11/24 at 8:38 am confirmed the residents toe nails were long and needed trimmed. A follow up interview, with the DON at 9:19 AM on 12/11/24, confirmed the resident had not seen the podiatrist recently and was placed on the list for next week. The DON stated, I told my wound care nurse and he has already trimmed her toe nails.

Based on observation, record review and staff interview, the facility failed to wear proper personal protective equipment (PPE) with Resident #12 during activities of daily living (ADL) and wound care while in Enhanced-Barrier Precautions (EBP). This was a random opportunity for discovery. Resident identifier: #12. Facility Census: 115. Findings included: a) Resident #12 On 12/12/24 at 9:41 AM, Nurse Aide (NA) #35 was observed providing ADL care for Resident #12. The resident is in EBP due to wounds, suprapubic catheter and a feeding tube. When the resident is in EBP, the staff must wear gown and gloves while providing dressing, bathing, providing hygiene, changing linens, changing briefs and wound care. NA #35 was not wearing PPE while providing the ADL care. Upon entering the room to observe wound care, Registered Nurse (RN) #102 and Licensed Practical Nurse (LPN) #1 did not donn PPE prior to providing wound care. On 12/12/24 at 11:25 AM, the Director of Nursing (DON) was asked to come to the resident's room. Upon arrival, the EBP signage was turned backward and could not be seen prior to entering the room. The DON stated, I don't know how the sign got turned around .the staff should have worn the proper PPE while providing ADL care as well as wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident Interview and Record review the facility failed to ensure the resident environment was clean and in good repair. This was true for three (3) resident rooms on the 400 and 500 halls. Room identifiers: #404, #407, and #500. Facility census: 115. Findings Include: a) Resident Rooms During and initial tour of the facility on 12/09/24 the following issues were identified in resident rooms: room [ROOM NUMBER] - The blind had brown stains on it. The floor had a pink substance which was not able to be wiped up. The top of the toilet tank did not fit the tank appropriately and the sink was not affixed to the wall completely. room [ROOM NUMBER]- The light fixture in the bathroom was dislodged from the ceiling and was hanging down. The light fixture was also covered in dust. room [ROOM NUMBER]- Resident #24 who resided in room [ROOM NUMBER] stated she had been asking them for a year to paint over the flowers they have stuck to the wall. She stated she did not like them and wanted them covered up. She also pointed to the ceiling and stated, There are brown spots on the ceiling too. She indicated she had told them about them and she wishes they would clean them or paint over them because she is tired of looking at them. The surveyor observed the flowers on the wall and the brown spots the resident referred to. The surveyor also noted her fan which was sitting on the bed table was covered in dust. The light in the bathroom was also covered in dust. A tour with a Corporate Registered Nurse (CRN) in the afternoon of 12/11/24 confirmed the above issues. She stated, I will get these taken care of.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview and observation, the facility failed to provide an accurate Minimum Data Set (MDS) for five (5) of 34 residents. MDS issues were found with Resident #10's hearing assessment, Resident #99's intravenous (IV) access, a cancer diagnosis for Resident #93, the use of insulin for Resident #79 and Resident #56's dental status. Resident Identifiers: #10, #99, #93, #79 and #56. Facility Census: 115. Findings include: a) Resident #10 On 12/10/24 at approximately 11:30 AM, the resident was interviewed and found to be hard of hearing. A record review found the care plan recognized impaired communication due to impaired hearing. The MDS section B dated 12/04/24 indicated the resident's ability to hear is adequate. The medical record was found to not have any information regarding a hearing test or an assessment for hearing aids. On 12/16/24 at 5:15 PM, the Director of Nursing (DON) confirmed the resident did have impaired hearing and a hearing assessment had not been performed since admission to the facility on [DATE] . b) Resident #99 On 12/11/24 at 9:30 AM, a record review was completed for Resident #99. The review found the MDS section O dated 11/22/24 did not indicate the resident had intravenous (IV) access for antibiotic therapy. The resident was noted with an implanted right subclavian port. On 12/11/24 at 11:50 AM, the Corporate Registered Nurse (RN) #155 confirmed the resident did have an implanted right subclavian port. Corporate RN #155 confirmed the MDS was incorrect. c) Resident #93 On 12/11/24 at 10:15 AM, a record review was completed for Resident #93. The review found the MDS section I dated 11/08/24 did not indicate the resident's diagnosis of polycythemia vera (blood cancer). On 12/11/24 at 11:55 AM, the Corporate RN #155 confirmed the diagnosis of polycythemia vera was not indicated on the MDS. d) Resident #79 On 12/11/24 at 10:50 AM, a record review was completed for Resident #79. The review found the resident was noted for taking insulin for diabetes. The MDS section N dated 10/04/24 indicated the resident was receiving insulin. However, the review found the resident was prescribed Ozempic. Ozempic is a once-weekly injection used to treat diabetes as well as assist with weight loss. However, Ozempic is not an insulin. On 12/11/24 at 1:30 PM, the Corporate RN #155 confirmed the resident was not receiving insulin. e) Resident #56 During an observation of Resident #56, on 12/09/24 at 2:30 PM, during the initial phase of the Long term care survey process it was noted Resident #56 had multiple missing teeth and the teeth remaining were in poor repair. An observation completed with the Director of Nursing (DON) on 12/11/24 at 3:00 PM found the resident had multiple missing teeth but did have some teeth remaining. Review of the residents record found a dental consultation dated 04/19/24. This consult indicated the resident had the following missing teeth 1, 2, 7-10, 13-19, 21-32. This indicated teeth 3-6, 11, 12, and 20 were not missing. A review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/26/24 indicated Resident #56 was edentulous under section L. Dental Status. This incorrect MDS was confirmed with the Director of Nursing (DON) on 12/11/24 at 3:00 PM.

c) Resident #366 Resident #366 did not have a food allergy for strawberries care planned. The State Surveyor asked the DON how food allergies were care planned and the DON stated, I would have to look. No further information given. d) Resident #61 Resident 361 did not have a food allergy for fish care planned. The State Surveyor asked the DON how food allergies were care planned and the DON stated, I would have to look. No further information given. e) Resident #103 Resident #103 did not have a food allergy for shellfish care planned. The State Surveyor asked the DON how food allergies were care planned and the DON stated, I would have to look. No further information given. f) Resident #70 Resident #70 did not have a food allergy for pecans care planned. The State Surveyor asked the DON how food allergies were care planned and the DON stated, I would have to look. No further information given. Based on record review and interviews the facility failed to develop and implement comprehensive care plans. This was found true for 12 of 34 residents' care plans reviewed. Resident identifiers: #48, #26, #366, #61, #103, #70, #102, #12, #99, #93, #65, and #98. Facility census:115. Findings include: a) Resident #26 A record review on 12/16/24 revealed care plan stated no blood pressure (b/p) or lab stick to right extremities (RE). Further record review of the care plan contained a plan of care for not taking b/p in RE. Focus Resident at risk for decreased ability to perform ADL's in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting, related to: recent illness, hospitalization resulting in fatigue, activity intolerance. Goal Resident will improve current level of function in: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting by next review as evidence by improved ADL scores. Interventions - No BP(Blood Pressure) or Lab sticks to RE(Right Extremity) Further record review of the documented blood pressures revealed on 13 occasions where b/p were being documented as taken in the RE. the following dates were documented: -12/09/24 (Lying r/arm{right/arm}) -11/27/24 (Lying r/arm{right/arm}) -11/24/24 (Lying r/arm{right/arm}) -11/22/24 (Lying r/arm{right/arm}) -11/21/24 (Lying r/arm{right/arm}) -11/17/24 (Lying r/arm{right/arm}) -11/16/24 (Lying r/arm{right/arm}) -11/15/24 (Lying r/arm{right/arm}) -11/14/24 (Lying r/arm{right/arm}) -11/13/24 (Lying r/arm{right/arm}) -11/10/24 (Lying r/arm{right/arm}) -11/10/24 (Lying r/arm{right/arm}) -11/08/24 (Lying r/arm{right/arm}) During an interview on 12/16/24 at 6:30 PM the Director of Nursing (DON) confirmed the care plan was not being followed. b) Resident #48 On 12/09/24 At 12:34 PM during an interview with Resident #48 the resident stated, I can't say anyone comes to invite me to anything, I have gone to a church service and they do ask about bingo but I don't believe in gambling and I don't do that. I can turn on preaching on Sundays, I used to me a minister before i came here Record review completed on 12/10/24 at approximately 10:00 am revealed resident #48's care plan revealed no preferences to religion and being of the Baptist faith or history of being a minister. On 12/10/24 at 12:05 PM the Administrator confirmed the activity care plan did not identify resident religious preferences or history of being a minister. g) Resident #102 On 12/16/24 at 11:45 AM, a record review was completed for Resident #102. The record review found the resident was noted with significant weight loss. Upon reviewing the care plan, an intervention was noted to monitor intake of all meals, offer alternate choices as needed, alert dietician and physician to any decline in intake. An additional review of the meal intake from October, 2024-December, 2024 was completed. The following dates did not include all intake of meals during this timeframe: -11/29/24 two (2) meals were documented -12/02/24 two (2) meals were documented -12/04/24 zero (0) meals were documented -12/08/24 one (1) meal was documented -12/08/24 one (1) meal was documented -12/09/24 two (2) meals were documented -12/11/24 two (2) meals were documented -12/12/24 two (2) meals were documented -12/15/24 two (2) meals were documented On 12/16/24 at 12:50 PM, Corporate Registered Nurse (RN) #156 confirmed all meals were not documented and the care plan was not implemented. Corporate RN #156 stated, we have issues with documentation. h) Resident #12 On 12/16/24 at 10:00 AM, a record review was completed for Resident #12. The record review found the resident was noted with significant weight loss. Upon reviewing the care plan, an intervention of monitor for changes in nutritional status (changes in intake, changes in tube feeding tolerance, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated was noted . An additional review of the meal intake from October, 2024-December, 2024 was completed. The following dates did not include all intake of meals during this time: -10/04/24 two (2) meals were documented -10/05/24 one (1) meal was documented -10/14/24 two (2) meals were documented -10/15/24 two (2) meals were documented -11/28/24 one (1) meal was documented -11/29/24 zero (0) meals were documented -12/04/24 two (2) meals were documented -12/05/24 two (2) meals were documented -12/06/24 two (2) meals were documented -12/07/24 two (2) meals were documented -12/08/24 one (1) meal was documented -12/09/24 zero (0) meals were documented -12/10/24 zero (0) meals were documented -12/12/24 two (2) meals were documented -12/13/24 zero meals were documented -12/15/24 one (1) meal was documented -12/16/24 two (2) meals were documented On 12/17/24 at 11:30 AM, Corporate RN #156 confirmed all the meal intake was not documented and the care plan was not implemented. Corporate RN #156 stated, we have issues with documentation. i) Resident #99 On 12/11/24 at 1:00 PM, a record review was completed for Resident #99. The review found the resident had a diagnosis of epilepsy. Upon further review, the care plan had not been developed regarding the epilepsy diagnosis. On 12/11/24 at 1:30 PM, Corporate RN #156 confirmed the diagnosis of epilepsy was not developed on the care plan. j) Resident #93 On 12/11/24 at 9:00 AM, a record review was completed for Resident #93. The review found the resident has a diagnosis of cirrhosis and polyneuropathy. Upon reviewing the care plan, the diagnoses had not been developed. On 12/11/24 at 10:41 AM, Corporate RN #155 confirmed the diagnoses were not developed on the care plan. k) Resident #98 A review of Resident #98's care plan found the following focus statement: Resident is at risk nutritional risk r/t (related to) AMS (altered mental status) Goal Read as follows: Resident will maintain a stabilized weight without any significant changes through next review. Interventions included: - Monitor intake at all meals Review of the residents meal percentages from 07/29/24 through 08/29/24 found the following: No documentation for any meals on 07/29/24, 08/02/24, 08/03/24, 08/04/24, 08/07/24, 08/09/24, 08/10/24, 08/12/24, 08/14/24, 08/16/24, 08/17/24, 08/26/24, 08/27/24, and 08/28/24. No documentation for breakfast and lunch on the following dates: 07/30/24, 07/31/24, 08/15/24, 08/18/24, and 08/19/24. No documentation for dinner on the following dates: 08/08/24, 08/11/24, 08/13/24, and 08/25/24. Review of the resident meal percentages from 10/01/25 through current on 12/16/24 found the following missing documentation: No Documentation for any meals 10/02/24, 10/07/24, 10/08/24, 10/12/24, 10/13/24, 10/28/24, 10/31/24, 11/01/24, 11/04/24, 11/05/24, 11/07/24 -11/10/24, 11/13/24, 11/21/24- 11/27/24, and 12/05/24. She was missing breakfast and lunch documentation on 10/01/24, 10/09/24, 10/28/24, 11/2/24, 11/11/24, 11/14/24, 11/18/24, 12/05/24, 12/12/24. She was missing documentation for the Breakfast and dinner meal on 11/15/24, 11/28/24. She was missing documentation for dinner on 11/19/24, 12/09/24, 12/13/24, 12/14/24, 10/14/24, 10/18/24, 10/26/24, 10/30/24. She was Missing documentation for Breakfast on 10/11/24 and 10/29/24. During an interview with the Director of Nursing on 12/16/24 at 3:45 PM she was made aware of the above findings. At the conclusion of the survey no other information was provided. l) Resident #65 A review of Resident #65's medical record found the following care plan focus statement: - Resident is at nutritional risk r/t related to advanced age and mechanically altered diet consistency. Goal Read as follows: Resident will consume 75 percent or greater of 3 meals every day through next review Interventions included: - Monitor for changes in nutritional status (changes in intake ) as indicated. A review of Resident #65's meal documentation from admission to current found the following: No documentation for any meals on 09/09/24, 09/14/24, 09/15/24, 09/18/24, 09/19/24, 09/22/24, 09/23/24, 09/24/24, 09/27/24, 10/02/24, 10/07/24, 10/08/24, 10/12/24, 10/13/24, 10/25/24, 10/27/24, 11/01/24, 11/02/24, 11/04/24, 11/05/24, 11/06/24, 11/07/24, 11/08/24, 11/09/24, 11/10/24, 11/13/24, 11/19/24, 11/21/24, 11/22/24, 11/23/24, 11/24/24, 11/25/24, 11/27/24, 11/29/24, 12/07/24, 12/13/24, 12/14/24 and 12/15/24. No documentation for breakfast and lunch on the following dates: 09/10/24, 09/21/24, 09/25/24, 09/28/24, 10/01/24, 10/09/24, 10/28/24, 11/11/24, 11/12/24, 11/14/24,11/18/24,11/28/24,12/02/24, 12/05/24 and 12/12/24. No Documentation for breakfast and dinner on the following dates: 09/20/24, 09/26/24, 10/26/24, 10/31/24 and 11/15/24. No documentation for breakfast on the following dates: 09/16/24 and 10/11/24, No documentation for lunch on the following dates: 09/11/24 and 12/01/24. No documentation for dinner on the following dates: 09/13/24, 09/30/24, 10/14/24,10/18/24, 10/29/24, 10/30/24 and 12/09/24. Resident #65 was missing 52% of her meal percentage documentation since admission. During an interview with the Director of Nursing on 12/16/24 at 3:45 PM she was made aware of the above findings. At the conclusion of the survey no other information was provided.

d) Resident #55 During record review on 12/10/24 at 01:15 PM revealed the following medical diagnoses as written SCHIZOAFFECTIVE DISORDER, UNSPECIFIED ANXIETY DISORDER, UNSPECIFIED BIPOLAR DISORDER, UNSPECIFIED Further record review on 12/10/24 revealed the Pre admission Screening and Resident Review (PASRR) did not identify Bipolar disorder. however did have Major depressive disorder marked with no medical diagnosis of Major Depressive disorder. Corporate Registered Nurse # 155 confirmed major depressive disorder was not revised in the care plan. Based on record review and staff interview, the facility failed to revise the care plan for five (5) of 34 residents reviewed during the survey process. Care plan revisions were notdone for Resident #31's actual fall, a house supplement for Resident #266, an incorrect diagnosis for Resident #79 and psychiatric diagnoses for Resident #55. Resident Identifiers: #31, #266, #79 and #55. Facility Census: 115. Findings Include: a) Resident #31 On 12/14/24 at 2:08 PM, a record review was completed for Resident #31. The review found the care plan focus of at risk for falls: decreased mobility. However, the resident did have an actual fall on 12/09/24. On 12/16/24 at 12:19 PM, the Administrator was notified and confirmed the care plan had not been revised regarding the actual fall. b) Resident #266 On 12/14/24 at 3:30 PM, a record review was completed for Resident #266. The review found an intervention under the focus of nutritional risk due to advanced age, therapeutic and mechanically altered diet and dysphagia as house supplement daily as ordered. A further review on the Medication Administration Record (MAR) found the resident had a physician's order for Nourishment two (2) times a day (Name of Supplement). On 12/16/24 at 4:00 PM, the Director of Nursing (DON) was notified and confirmed the care plan had not been revised regarding the supplement twice daily. c) Resident #79 On 12/11/24 at 4:00 PM, a record review was completed for Resident #79. The review found the care plan had a focus area of diagnosis of diabetes: Insulin Dependent. Upon further review, the resident does not have a physician's order for insulin. On 12/12/24 at 8:57 AM, Corporate Registered Nurse (RN) #155 was notified and confirmed the resident was not receiving insulin.

Based on record review and staff interview the facility failed to ensure Resident #97 who is dependent on staff for showering received at least two showers per week as scheduled. This was true for one (1) of four (4) residents reviewed for the care area of Activities of Daily Living (ADLS) during the long term care survey process. Resident Identifier: 97. Facility Census: 115. Findings Include: a) Resident #97 A review of Resident #97's medical record on 12/11/24 at 1:11 PM, found Resident #97 was scheduled to receive a shower twice a week on Monday and Thursday. From 09/01/24 through 12/11/24 the resident should have received 29 showers. She only received 10 showers; she refused one shower on 12/02/24. She received a shower on the following dates: 09/02/24 09/09/24 10/03/24 10/07/24 10/24/24 10/25/24 11/04/24 11/07/24 11/21/24 and 11/25/24. An interview with corporate Registered Nurse #155 on 12/11/24 at 1:20 PM confirmed Resident #97 did not receive her showers as scheduled. A follow up interview with the Director of Nursing at 1:50 PM on 12/11/24 confirmed if a resident was not scheduled for a shower they should receive a bed bath. A review of the record found Resident #97 only received the following bed baths: 09/16/24 09/17/24 09/26/24 10/03/24 10/08/24 10/13/24 10/14/24 10/29/24 10/31/24 11/04/24 11/11/24 11/24/24 11/28/24 11/29/24 12/03/24 12/04/24 12/09/24 12/10/24 and 12/11/24. Resident #97 should have received two (2) showers per week and five (5) bed baths per week for a total of 29 showers and 72 bed baths from 09/01/24 through the time of this review on 12/11/24. Resident #97 received 10 showers and had one refusal and received 19 bed baths with no documented refusals. The DON at 1:50 PM on 12/11/24 confirmed Resident #97 was not receiving her showers and/or bed baths as scheduled.

d) Resident #26 A record review on 12/16/24 revealed an order of no blood pressure (b/p) to right extremities (RE). Further record review of the care plan contained a plan of care for not taking b/p in RE. A review of the documented blood pressures revealed on 13 occasions where b/p were being documented as taken in the RE. the following dates were documented: 12/09/24 (Lying r/arm{right/arm}) 11/27/24 (Lying r/arm{right/arm}) 11/24/24 (Lying r/arm{right/arm}) 11/22/24 (Lying r/arm{right/arm}) 11/21/24 (Lying r/arm{right/arm}) 11/17/24 (Lying r/arm{right/arm}) 11/16/24 (Lying r/arm{right/arm}) 11/15/24 (Lying r/arm{right/arm}) 11/14/24 (Lying r/arm{right/arm}) 11/13/24 (Lying r/arm{right/arm}) 11/10/24 (Lying r/arm{right/arm}) 11/10/24 (Lying r/arm{right/arm}) 11/08/24 (Lying r/arm{right/arm}) During an interview on 12/16/24 at 6:30 PM with the Director of Nursing (DON) who confirmed the care plan and orders for no blood pressure to right extremity was not being followed. c) Resident #89 On 12/09/24 at approximately 2:00 PM, the resident was observed wearing a right hand splint. On 12/14/24 at 11:52 AM, a record review was completed for Resident #89. The review did not find a physician's order for the right hand splint. The care plan was reviewed and the right hand resting splint was listed. On 12/16/24 at 12:20 PM, the Administrator was notified and confirmed there was no physician's order regarding the hand splint . Based on record review, observation, resident interview and staff interview the facility failed to ensure residents were provided with the care and services to enable them to maintain and/or attain their highest practicable physical, mental and psychosocial well being. This was true for four (4) of 34 sampled residents. Resident identifiers: #98, #99, #89 and #26. Facility Census: 115. Findings Include: a) Resident #98 During an interview with Resident #98 on 12/09/24 at 12:36 PM, she stated she had a lot of trouble with being Compacted in her bowels and it causes her pain. She stated, I don't know why they can not just give me stool softeners or anything to help with it. A review of Resident #98's medical record on 12/17/24, found the resident on 4 occasions since the beginning of September found on the following occasions Resident #97 went more than three (3) days without having a bowel movement those dates are as follows; 09/17/24, 09/18/24, 09/19/24 10/21/24, 10/22/24, 10/23/24, 10/24/24 11/03/24, 11/04/24, 11/05/24,11/06/24 11/23/24, 11/24/24, 11/25/24, 11/26/24, 11/27/24, 11/28/24,11/29/24. A review of Resident #98's physician orders found the following orders related to the lack of a bowel movement: -- Milk of Magnesia (MOM) Give 30 milliliters (ml) by mouth as needed for constipation as needed at bed time for no bowel movement in 3 days. -- Dulcolax Suppository 10 MG if no result from MOM. -- Fleet Enema 7-19 gram Insert one dose rectally as needed for constipation if no result from the dulcolax within two hours. A review of Resident #98's medication administration records for the months of 09/2024, 10/2024, and 11/2024 found none of the orders mentioned above were initiated when the resident had gone three (3) days or longer without a bowel movement. An interview with the Director of Nursing (DON) in the afternoon of 12/17/24 confirmed the bowel protocol had not been followed. She stated, it would have been documented on the MAR if they had followed the orders above. b) Resident #99 A review of Resident #99's medical record found she had an indwelling Foley catheter which was added to her care plan in 02/2024. A review of Resident #99's care plan found the following related to her indwelling catheter: Focus Statement: Resident requires indwelling catheter due to neuromuscular dysfunction of bladder. This care plan focus was initiated on 02/29/24. Goal: Resident will have no signs and symptoms of urinary tract infection x 90 days. Date Initiated: 02/29/2024 with a target date of 02/20/25. Interventions Included: -- Record Output Date Initiated: 02/29/2024 -- Monitor output for odor, color, consistency, and amount Date Initiated: 02/29/2024 The facility was asked to provide the output records for 09/2024, 10/2024, 11/2024, and 12/2024 on the morning of 12/16/24. At 12:37 pm on 12/16/24, the Nursing Home Administrator confirmed they had not been documenting on the medical record the residents output. She stated, We added that task today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure nutritional maintanence was maintained for Resident #266, #102, #12, #65 and #98. This was true for five (5) of six (6) residents reviewed under the care area of nutrition. Resident Identifiers: #266, #102, #12, #65 and #98. Facility Census: 115. a) Resident #266 On 12/16/24 at 3:25 PM, a record review was completed for Resident #266. The record review found the resident was noted to have significant weight loss. The care plan focus area was at nutritional risk related to advanced age, therapeutic and mechanically altered diet and dysphagia. An intervention listed house supplement day as ordered. (Typed as written.) However, the resident was scheduled to receive the house supplement twice daily. Upon further review, the documentation on the Medication Administration Record (MAR) from November, 2024 through December, 2024 indicated zero (0) % was taken on the following dates: --11/09/24 PM --11/10/24 AM and PM --11/12/24 AM and PM --11/23/24 AM --11/24/24 AM and PM --11/25/24 AM and PM --11/26/24 AM and PM --11/27/24 AM and PM --11/28/24 AM and PM --11/29/24 AM --12/16/24 AM On 12/6/24 at 4:10 PM, the Director of Nursing (DON) confirmed the resident did not take the house supplements. The DON stated, the intervention would be reviewed. b) Resident #102 On 12/16/24 at 11:45 AM, a record review was completed for Resident #102. The record review found the resident was noted with significant weight loss. Upon reviewing the care plan, an intervention of monitor intake of all meals, offer alternate choices as needed, alert dietician and physician to any decline in intake. An additional review of the meal intake from October, 2024-December, 2024 was completed. The following dates did not include all intake of meals during this time: --11/29/24 two (2) meals were documented --12/02/24 two (2) meals were documented --12/04/24 zero (0) meals were documented --12/08/24 one (1) meal was documented --12/08/24 one (1) meal was documented --12/09/24 two (2) meals were documented --12/11/24 two (2) meals were documented --12/12/24 two (2) meals were documented --12/15/24 two (2) meals were documented On 12/16/24 at 12:50 PM, Corporate Registered Nurse (RN) #156 confirmed all meal intake was not documented. Corporate RN #156 stated, we have issues with documentation. c) Resident #12 On 12/16/24 at 10:00 AM, a record review was completed for Resident #12. The record review found the resident was noted with significant weight loss. Upon reviewing the care plan, an intervention of monitor for changes in nutritional status (changes in intake, changes in tube feeding tolerance, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. An additional review of the meal intake from October, 2024-December, 2024 was completed. The following dates did not include all intake of meals during this time: --10/04/24 two (2) meals were documented --10/05/24 one (1) meal was documented --10/14/24 two (2) meals were documented --10/15/24 two (2) meals were documented --11/28/24 one (1) meal was documented --11/29/24 zero (0) meals were documented --12/04/24 two (2) meals were documented --12/05/24 two (2) meals were documented --12/06/24 two (2) meals were documented --12/07/24 two (2) meals were documented --12/08/24 one (1) meal was documented --12/09/24 zero (0) meals were documented --12/10/24 zero (0) meals were documented --12/12/24 two (2) meals were documented --12/13/24 zero meals were documented --12/15/24 one (1) meal was documented --12/16/24 two (2) meals were documented On 12/17/24 at 11:30 AM, Corporate RN #156 confirmed all the meal intake was not documented. Corporate RN #156 stated, we have issues with documentation. 692 d) Resident #98 A review of Resident #98's medical record found the following weights recorded for the previous six (6) months: 05/30/24 - 141.6 pounds (Lbs) 06/26/24 - 135 Lbs 07/03/24 - 135.2 Lbs 07/10/24 - 130.4 Lbs 07/17/24 - 133.6 Lbs 07/24/24 - 133.2 Lbs 07/30/24 - 131.6 Lbs 08/07/24 - 129.1 Lbs 08/14/24 - 127.8 Lbs 08/27/24 - 129.1 Lbs 09/25/24 - 128 Lbs 11/26/24 - 122.4 Lbs The resident did not have a weight in October because she refused to be weighed. The following formula determines percentage of weight loss and was used to calculate the weight loss percentages for Resident #98 at the 30 day, 90 day, and six (6) month mark the results are as follows: Formula : % of body weight loss = (usual weight - actual weight) / (usual weight) x 100 30 day: un able to calculate because the weight for 10/2024 was not available. 90 day: 129.1-122.4/129.1x100 = 5.12 percent. This was not a significant or Severe weight loss. Six (6) months: 141.6 - 122.4/141.6 X100 = 13.56 percent. This is considered a severe weight loss according to federal regulation. Further review of the medical record found Resident #98 was last seen by the Registered Dietician (RD) on 12/11/24. In this assessment the RD indicated Resident #98's meal intakes are usually between 50 % to 100 %. However in the 30 days prior to this note the resident was missing documentation for 35 of 90 meals for a percent of 39 % of the time. Resident #98 was also seen by the RD on 08/29/24 at which time she again stated, Resident is consuming 100 % of most meal per documentation. However the meal intake percentages for the previous 30 days was incomplete. However in the 30 days prior to this note the resident was missing documentation for 45 out of 75 meals consumed in the facility for a percentage of 60 %. The resident was at an acute care hospital from [DATE] to 08/24/24 those dates were excluded from this review. Review of the residents meal percentages from 07/29/24 through 08/29/24 found the following: No documentation for any meals on 07/29/24, 08/02/24, 08/03/24, 08/04/24, 08/07/24, 08/09/24, 08/10/24, 08/12/24, 08/14/24, 08/16/24, 08/17/24, 08/26/24, 08/27/24, and 08/28/24. No documentation for breakfast and lunch on the following dates: 07/30/24, 07/31/24, 08/15/24, 08/18/24, and 08/19/24. No documentation for dinner on the following dates: 08/08/24, 08/11/24, 08/13/24, and 08/25/24. Review of the resident meal percentages from 10/01/25 through current on 12/16/24 found the following missing documentation: No Documentation for any meals 10/02/24, 10/07/24, 10/08/24, 10/12/24, 10/13/24, 10/28/24, 10/31/24, 11/01/24, 11/04/24, 11/05/24, 11/07/24 -11/10/24, 11/13/24, 11/21/24- 11/27/24, and 12/05/24. She was missing breakfast and lunch documentation on 10/01/24, 10/09/24, 10/28/24, 11/2/24, 11/11/24, 11/14/24, 11/18/24, 12/05/24, 12/12/24. She was missing documentation for the Breakfast and dinner meal on 11/15/24, 11/28/24. She was missing documentation for dinner on 11/19/24, 12/09/24, 12/13/24, 12/14/24, 10/14/24, 10/18/24, 10/26/24, 10/30/24. She was Missing documentation for Breakfast on 10/11/24 and 10/29/24. During an interview with the Director of Nursing on 12/16/24 at 3:45 PM she was made aware of the above findings. At the conclusion of the survey no other information was provided. e) Resident #65 A review of Resident #65's medical record found the following weights recorded: 09/08/24 - 112 pounds (Lbs) 09/18/24 - 111.2 Lbs 09/25/24 - 108 Lbs 10/02/24 - 115.6 Lbs 10/09/24 - 115.8 Lbs 10/16/24 - 114.2 Lbs 10/23/24 - 114 Lbs 11/06/24 - 106.4 Lbs 11/13/24 - 107.8 Lbs 11/20/24 - 108 Lbs 11/26/24 - 112.4 Lbs 12/04/24 - 103.4 Lbs 12/11/24 -104.6 Lbs. The following formula determines percentage of weight loss and was used to calculate the weight loss percentages for Resident #65 at the 30 day and 90 day mark. Resident #65 was not admitted to the facility until 09/25/24 therefore a six (6) month weight loss percentage was not completed. The results are as follows: Formula : (usual weight - actual weight) / (usual weight) x 100 =% of body weight loss 30 day: (107.8-104.6)/(107.8)X100= 2.97%. This was not a significant or severe weight loss for 30 days. 90day: (112-104.6)/(112)x100= 129.1-122.4/129.1x100 = 6.61 %. This was not a significant or Severe weight loss. However the residents weight is on a downward trend. Further review of the medical record found Resident #65 has been seen by the Registered Dietician five (5) times since her admission to the facility. The RD assessed the resident on 09/10/24 this was the residents admission assessment. The RD noted the resident indicated her appetite had been improving. The RD noted consuming 75-100% of meal per resident. No intakes documented. The RD assessed the resident 10/24/24. The RD noted this was a significant weight change review. This RD noted the resident had a greater than 5 % weight gain in the last 30 days. The RD noted the resident is consuming 50-100 % meals per documentation. The RD assessed the resident on 11/07/24. The RD noted this was significant weight change review. Resident with a 5 % weight loss in 30 days. The RD noted the resident was consuming 50-75 % of most meals per documentation. Noted resident is a picky eater. The RD assessed the resident on 11/14/24. The RD noted this was a significant weight change review and the resident had lost greater than 5% in 30 days. Noted Resident with a recent weight gain. Resident is consuming 50-75 % of most meals per documentation. The most recent time assessment by the RD was on 12/12/24. This was quarterly assessment. The RD noted the resident is consuming 50-75% of her meals per documentation. The RD noted on all the assessments pertaining to Resident #65 her meal consumption per the documentation. However review of Resident #65's meal documentation found the documentation to be incomplete. A review of Resident #65's meal documentation from admission to current found the following: No documentation for any meals on 09/09/24, 09/14/24, 09/15/24, 09/18/24, 09/19/24, 09/22/24, 09/23/24, 09/24/24, 09/27/24, 10/02/24, 10/07/24, 10/08/24, 10/12/24, 10/13/24, 10/25/24, 10/27/24, 11/01/24, 11/02/24, 11/04/24, 11/05/24, 11/06/24, 11/07/24, 11/08/24, 11/09/24, 11/10/24, 11/13/24, 11/19/24, 11/21/24, 11/22/24, 11/23/24, 11/24/24, 11/25/24, 11/27/24, 11/29/24, 12/07/24, 12/13/24, 12/14/24 and 12/15/24. No documentation for breakfast and lunch on the following dates: 09/10/24, 09/21/24, 09/25/24, 09/28/24, 10/01/24, 10/09/24, 10/28/24, 11/11/24, 11/12/24, 11/14/24,11/18/24,11/28/24,12/02/24, 12/05/24 and 12/12/24. No Documentation for breakfast and dinner on the following dates: 09/20/24, 09/26/24, 10/26/24, 10/31/24 and 11/15/24. No documentation for breakfast on the following dates: 09/16/24 and 10/11/24, No documentation for lunch on the following dates: 09/11/24 and 12/01/24. No documentation for dinner on the following dates: 09/13/24, 09/30/24, 10/14/24,10/18/24, 10/29/24, 10/30/24 and 12/09/24. Resident #65 was missing 52% of her meal percentage documentation since admission. During an interview with the Director of Nursing on 12/16/24 at 3:45 PM she was made aware of the above findings. At the conclusion of the survey no other information was provided.

Based on resident interview, staff interview and record review, the facility failed to ensure three (3) of four (4) resident's food allergies were acknowledged. food the Resident (#103) was allergic to was not served and the Resident #70 and #61 tray cards were accurate for documented food allergies. This was true for three (3) of four (4) residents with food allergies. Resident indentifiers: #103, #70, #61. Census: 115. a) Resident #103 Resident #103 reported she was served shrimp on 11/10/24 for the lunch meal. Documentation and patient report stated the resident was allergic to shellfish. On 12/16/ 24 3:08 PM the resident reported she had a severe reaction to shellfish. The resident reported her face swells, she gets puffy patches on skin and her skin is itchy. The resident stated, If severe, I have problems breathing. In the past, I had to go to the hospital. The resident presented the State Surveyor a picture of a meal served 11/10/24 from lunch. The resident was served shrimp which was touching all other foods on the plate per photograph and verbal report. According to the lunch menu for that date, shrimp and grits with capri vegetables and cornbread were served as an alternate. b) Resident #70 Resident #70's tray card did not have the food allergy to pecans listed. c) Resident # 61 Resident #61's tray card had allergy to fish and shellfish on the tray card. Only fish is listed on the resident's list of allergies on the medical record. Food allergies for Resident #103, #70. and #61 were not documented on the care plan. On 12/16/24 5:20 PM, DON reported other staff member's are notified by nursing (dietary and activities). The DON stated, They just ask. The State Surveyor asked the DON how food allergies were care planned and the DON stated, I would have to look. No further information was given. d) On 12/16/24 12:50 PM, the State Surveyor interviewed the Certified Dietary Manager (CDM). The CDM reported the allergies to food are printed on the tray ticket in bold and black. CDM said, The unit manager lets me know about allergies and we verify the diet with the tray ticket.

Based on observation, record review and staff interview, the facility failed to store and label food and store utensils and in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 115 Findings confirmed by the Certified Dietary Manager (CDM) on 12/09/24 during the initial kitchen investigation initiated at 11:00 AM included: a) A Ziploc bag of soup was opened and not labeled or dated. b) An opened pie crust was not dated. c) A trash bag of French bread loaves tied in a knot that were not labeled or dated. d) Serving utensils were stored in a drawer in the dining room with handles all turned different ways. The CDM reported the cook likes to keep her serving utensils in the drawer. The CDM stated, She keeps this drawer. The Certified Dietary Manager (CDM) stated, At one point there were dates. I'll go throw these out. concerning the food items found in the freezer.

Based on observation, record review and staff interview, the facility failed to properly dispose of garbage in accordance with professional standards for food service safety and to ensure garbage was not hanging out of the trash can and onto clean pots and pans in the surrounding area. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 115 Findings included: a) Observations made on 12/09/24 at 11:00 AM revealed the following: Garbage from the trash can was overflowing under the handwashing sink in the kitchen beside clean pots and baking sheets. Garbage from the trash can was on the storage rack with clean pots and baking sheets. CDM asked if he should remove the trash can. Food was on tables and floor with dirty napkins and straws in the dining room. The CDM reported housekeeping cleans this after dinner. Dirty silverware on table. The CDM reported breakfast was not served in the dining room. The CDM picked up some of the food and trash off the floor. The kitchen staff were preparing for lunch at this time. These findings were confirmed by the Certified Dietary Manager (CDM) on 12/09/24 during the initial kitchen investigation initiated at 11:00 AM.

c) Resident #55 Record review on 12/11/24 at 10:19 AM revealed the Pre admission Screening and Resident Review (PASRR) was coded to have Major Depressive Disorder however there was not diagnosis for Major depressive disorder in the Medical Diagnosis or care plan During an interview with Corporate Registered Nurse (CRN) #155 the CRN stated, I'm not sure where that diagnosis came from, I'll get this check out now confirming there was no order for Major Depressive Disorder. d) Resident #14 On 12/16/24 at 1:00 PM, a record review was completed for Resident #14. The review found no documentation regarding current vaccinations, such as influenza and COVID-19. On 12/16/24 at 2:45 PM, an interview was held with the Infection Preventionist Registered Nurse (IPRN) #91. IP RN #91 stated, We have contacted the Medical Power of Attorney (MPOA) on 10/14/24, 10/16/24 and 10/18/24 with no response. IPRN #91 was asked, Did you document the attempts to reach the MPOA? IPRN #91 stated, No, we didn't. Based on record review and staff interview the facility failed to ensure the resident record was complete and accurate for four (4) of 34 sampled residents reviewed during the long term care survey. Resident identifiers: #99, #56, #14 and #55. Facility Census: 115. Findings Include: a) Resident #56 During an observation, of Resident #56, on 12/09/24 at 2:30 PM, during the initial phase of the Long term care survey process it was noted Resident #56 had multiple missing teeth and the teeth remaining were in poor repair. An observation completed with the Director of Nursing (DON) on 12/11/24 at 3:00 PM found the resident had multiple missing teeth but did have some teeth remaining. Review of the residents record found a dental consultation dated 04/19/24. This consult indicated the resident had the following missing teeth 1, 2, 7-10, 13-19, 21-32. This indicates teeth 3-6, 11, 12, and 20 were not missing. The most recent oral health evaluation contained in Resident #56's medical record was dated 11/24/23. This assessment indicated Resident #56 was edentulous. This incorrect assessment was confirmed with the Director of Nursing (DON) on 12/11/24 at 3:00 PM. The DON also confirmed there was not a more recent dental assessment. b) Resident #99 A review of Resident #99's medical record found a physician order which indicated the resident was NPO (Nothing by Mouth) and strictly fed by a feeding tube. Further review of the record found Resident #99 had meal percentages documented in her medical record. The following dates had documented meal percentages: -- 10/03/24 -- 10/04/24 -- 10/05/24 -- 10/15/24 -- 10/17/24 -- 10/18/25 -- 10/21/24 . -- 10/26/24 -- 10/28/24 -- 11/14/24 -- 11/18/24 -- 11/26/24 -- 11/28/24 -- 12/03/24 -- 12/08/24 -- 12/14/24 During an interview with the Director of Nursing (DON), on 12/16/24 at 2:00 PM, DON confirmed this was an inaccurate medical record and they have disabled that task in the Nurse aides documentation.

. Based on record review and staff interview, the facility failed to document the correct discharge destination of Resident #123. This is true for one (1) of two (2) residents reviewed under the care area of hospitalization. Resident Identifier: #123. Facility Census: 113. Findings Included: a) Resident #123 On 10/31/23 at 1:00 PM, a record review was completed for Resident #123. The review found the Minimum Data Set (MDS) Discharge Return Not Anticipated dated 09/05/23 listed the discharge destination of acute hospital. However, the resident was discharged to home with family. The following progress note dated 09/05/23 at 5:07 PM states, Resident discharging home at this time via (Name of ambulance company). Daughter at bedside. Went over discharge paperwork including medication list, no questions concerns. No s/s (signs/symptoms) of acute distress prior to leaving. No complaints/needs. In good spirits. Medications called into (Name of pharmacy) per request. Skin clean, warm, dry with no acute changes. On 10/31/23 at 2:10 PM, Clinical Care Reimbursement (CCR) nurse #129 confirmed the MDS discharge destination was incorrect. No further information was obtained during the long-term survey process. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to coordinate with the appropriate, State-designated authority, to ensure individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs.This is true for one (1) of two (2) residents reviewed during the survey process. Resident Identifier: 12. Facility Census: 113. Findings Included: a) Resident #12 At approximately 2:40 PM on 10/31/23, a review of Resident #12's records were conducted. During this review, it was determined the resident was admitted to the facility on [DATE] with no diagnosis of a Level II mental illness. Record review indicated Resident #12 was diagnosed with Major Depressive Disorder on 3/13/17 and the PASARR was not revised to reflect this diagnosis. At approximately 3:09 PM on 10/31/23, an interview was conducted with the Interim Director of Nursing (IDON) #28 and the Administrator #70. The administrator and IDON confirmed Resident #12 had been diagnosed with Major Depressive Disorder since 3/13/17 and the PASARR for the resident had not been revised.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to develop a care plan regarding a wound infection and intravenous (IV) antibiotic therapy for Resident # 329. This is true for one (1) of 26 residents reviewed during the survey process. Resident #329. Facility Census: 113. Findings Included: a) Resident #329 On 11/01/23 at 12:30 PM, a record review was completed for Resident #329. The review found a care plan had not been developed regarding a wound infection and IV antibiotic therapy for Resident #329. The resident was admitted to the facility on [DATE]. The resident arrived to the facility with a physician's order for Ertapenem Sodium Injection Solution 1 (one) Gram use 500mg (milligram) IV every day through 11/17/23 for an infection which was chronic multifocal osteomyelitis of the left foot and ankle. On 11/01/23 at 1:37 PM, the Interim Director of Nursing (IDON) was notified and confirmed the care plan was not developed regarding the wound infection nor the IV antibiotic therapy. No further information was obtained during the long-term survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to revise the comprehensive care plan when residents' needs and conditions changed. This deficient practice had the potential to affect two (2) of 26 residents reviewed in the long-term care center. Resident identifiers: #54 and #70. Facility census: 113. Findings included: a) Resident #54 Resident #54 had diagnoses of cerebral palsy, aphasia, and severe intellectual disabilities. Review of Resident #54's comprehensive care plan showed a focus related to activities. An intervention was, I enjoy watching/listening TV. [Typed as written.] Resident #54 was observed on the following days and at the following times: - 10/31/23 at 11:59 AM - 11/01/23 at 10:34 AM - 11/01/23 at 2:07 PM The resident's television was turned off at the time of these observations. Resident #54's Recreation Comprehensive assessment dated [DATE] stated it was very important for the resident to watch or listen to television. Resident #54's activity participation record was reviewed for October 2023. Movies/TV was marked as important. However, the participation record showed the resident did not watch or listen to television this month. During an interview on 11/01/23 at 3:25 PM, the Activities Director stated television viewing was no longer a preferred activity for Resident #54. She stated the resident became overstimulated with television, which caused him agitation and behaviors such as yelling out. She confirmed the resident's care plan had not been updated to reflect that television viewing was no longer an activity he preferred. b) Resident #70 On 10/30/21 at 12:30 PM, an initial interview was conducted with Resident #70. The resident was noted to be sitting up and moving herself around in bed. A record review was completed on 10/31/23 at 8:24 AM. The review found the care plan listed the resident as needing extensive assistance of two (2) staff members for bed mobility. On 10/31/23 at 2:31 PM, an additional interview was held with Resident #70. The resident stated, I can move myself in bed .I can roll from side to side and get myself to the top of the bed. On 10/31/23 at 2:35 PM, Licensed Practical Nurse (LPN) #85 was asked can Resident #70 move independently in bed? LPN #85 stated, (Name of resident) can move independently in bed. On 10/31/23 at 2:43 PM, the Interim Director of Nursing (IDON) was notified and confirmed the care plan had not been revised regarding bed mobility. No further information was obtained during the long-term survey process.

Based on record review, resident interview, and staff interview, the facility failed to ensure residents receive proper treatment and assistive devices to maintain vision and hearing abilities, by failing to make appointments and arrange transportation to and from the office of the practitioner. This is true for one (1) of two (2) residents reviewed during the survey process. Resident Identifier: #424. Facility Census: 113. Findings Included: a) Resident #424 At approximately 12:55 PM on in 10/30/23, an interview with Resident #424 revealed they had been trying to obtain an appointment with an audiologist for almost a year. Resident #424 states they have hearing problems and it is critical they see an audiologist in a timely manner and they want to go outside of the facility to see the audiologist. Resident #424 stated, they had brought the appointment to the attention of the nurses, nursing aides, and social worker, but had been unable to obtain an appointment up to this point. At approximately 3:15 PM on 10/31/23, an interview was conducted with Social Services Director (SSD) #28 regarding the audiologist appointment for Resident # 424. SSD #28 confirmed, they were aware of the need for an appointment, and the resident ' s desire to see a provider outside of the facility. SSD #28 stated, they had been aware of the need for an appointment for a couple of months but was unsure if it was made, due to another employee being in charge of scheduling appointments. At approximately 10:57 AM on 11/01/23, An interview was conducted with Unit Clerk (UC) #66 in which they stated they believed the audiologist appointment for Resident #424 to be made. UC #66 provided a handwritten note which stated the appointment was made. At approximately 11:05 am on 11/01/23, this surveyor called the audiologist office to confirm the appointment. The employee from the audiologist office stated, no appointment was made for Resident # 424. The employee confirmed no appointment had been made or canelled. At approximately 11:10 AM on 11/01/23, An interview was conducted with UC #66, informing them the audiologist office did not have an appointment for Resident #424. UC #66 confirmed, they had no way of verifying an appointment was made or the audiologist had been contacted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to dispose of expired over-the-counter(OTC) medications appropriately and store medication in a safe and secure location. These were random opportunities for discovery. Facility Census: 113. Findings Included: a) Expired Medication On [DATE] at 8:13 AM, while observing medication administration, Licensed Practical Nurse (LPN) #79 needed an over-the-counter (OTC) medication from central supply. While in central supply, an observation found four (4) unopened bottles of Calcium Citrate which expired in July, 2023. On [DATE] at 8:15 AM, LPN #79 confirmed the OTC medication was expired. On [DATE] at 8:20 AM, the Interim Director of Nursing (IDON) was notified and confirmed the medication should have been disposed of upon expiration. b) Unsecured Medication On [DATE] at 8:20 AM on the Blue hall, one (1) bottle of Zinc was found sitting on top of the medication cart. There was no staff member near the medication cart. Upon discovery, the IDON was at the nurse's station on the unit where the medication was found. On [DATE] at 8:20 AM, the IDON was notified and confirmed the medication should have been locked in the medication cart. No further information was obtained during the long-term survey.

. Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for Resident #41. This is true for one (1) of two (2) residents reviewed under the care area of hospitalizations. Resident Identifier: #41. Facility Census: 113. Findings Included: a) Resident #41 On 10/31/23 at 1:00 PM, a record review was completed for Resident #41. The review found the resident had been transferred to an acute care facility multiple times. Upon reviewing the transfer forms, the following had an incorrect date and time of transfer: --05/02/23 at 1:42 PM had the incorrect transfer date and time of 04/29/23 at 10:40 PM --05/29/23 at 6:53 AM had the incorrect transfer date and time of 05/02/23 at 2:19 PM --07/02/23 at 5:30 PM had the incorrect transfer date and time of 06/15/23 at 7:50 PM --07/09/23 at 7:40 AM had the incorrect transfer date and time of 07/02/23 at 5:44 PM On 10/31/23 at 1:30 PM, the Interim Director of Nursing (IDON) was notified and confirmed the transfer dates and times were incorrect. No further information was obtained during the long-term survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to provide a safe, sanitary, and homelike environment. Resident room walls were in disrepair. This was a random opportunity for discovery. Room identifier: #500, # 618 and #316. Facility census: 113. Findings included: a) room [ROOM NUMBER] An observation on 10/30/23 at 1:40 PM, revealed the back wall behind bed B, had large scrapes with deep grooves. An interview on 11/01/23 at 9:58 AM, with the Maintenance Director confirmed this should have been fixed. He stated, the wall was damaged by the power bed. b) room [ROOM NUMBER] An observation on 10/30/23 at 2:12 PM, revealed the back wall behind bed B, had large scrapes with deep grooves. An interview 11/01/23 at 10:07 AM, with the Maintenance Director confirmed this should have been fixed. He stated, the wall was damaged by a wheelchair. c) Room # 316 On 10/30/23 at 12:14 PM, the bathroom for room [ROOM NUMBER] was noted to be scraped and have missing paint on the door and the wall to the left of the bathroom entrance. During an interview on 11/01/23 at 9:55 AM, the maintenance director confirmed the bathroom for room [ROOM NUMBER] had damage. He stated the damage was caused by Resident #93's wheelchair. He stated the bathroom had been repaired before and confirmed it was currently in need of repair. No further information was provided through the completion of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview, record review and policy review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward the resolution. This was true for four (4) of four (4) residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #45, #6, #2 and #10. Facility census: 113. Findings Included: a) Facility Policy Record review of the facility's policy titled, Grievance / Concern, revision dated 07/19/23, showed: -Upon receipt of grievance/concern, the Grievance/Concern form will be initiated by the staff member receiving the concern. -Upon receipt of the Grievance/Concern Form, the Administrator or designee will document the grievance/concern on the Grievance/Concern Log. -Notify the person filing the grievance of the resolution in a timely manner. -Completed Grievance /Concern forms will be reviewed and retained by the Administrator for a period of no less than three (3) years from the issuance of the grievance decision to assure the patient's interests have been addressed. b) Resident #45 On 10/30/23 at 3:14 PM during an interview and observation, Resident #45 stated she reported a blanket missing. Resident #45 stated, the facility brought her a blanket from lost and found with another resident's name on it. She stated, they just covered up the other name with hers. An observation found this to be a true statement. 10/31/23 a record review of missing items /grievances revealed, no documentation from Resident #45's grievance. During an interview with the Guest Service Director on 10/31/22 at 2:10 pm, she stated, she was not aware of the missing blanket. She verified the grievance policy was not followed when Resident #45 reported her blanket missing. c) Resident #6 On 10/30/23 at 3:26 PM, during an interview, Resident #6 stated, she reported missing multiple rock band shirts (Beatles, Pink [NAME], etc.). She stated, she reported them missing but the facility did not do anything about it. She also stated, a staff member that works in the facility went out with her own money and bought her a couple band shirts to replace some that were missing. 10/31/23 a record review of missing items /grievances revealed, no documentation from Resident #6's grievance. During an interview with the Guest service Director on 10/31/22 at 2:10 pm, she stated, she was aware of the missing rock band shirts. She also verified that the facility nurse replaced a couple shirts for her. She verified the grievance policy was not followed. No further information was provided prior to the end of the survey on 10/02/23 at 11:30 AM. d) Resident #2 At approximately 3:08 PM on 10/30/2023, an interview was conducted with Resident #2. During this interview Resident #2 reported, they were missing multiple items of clothing from their room. Resident #2 stated, they had brought this to the attention of multiple staff members and nothing had been followed up on. Resident #2 revealed, their items had not been recovered and they had never been instructed to fill out a grievance form pertaining to the missing items. At approximately 2:37 PM on 10/31/2023, an interview was conducted with the Guest Services Director (GSD) #56 in which they confirmed, the facility does not have residents fill out grievance forms immediately, and only do so when an issue reported by a resident is unresolved. GSD #56 supplied the facility ' s policy on grievances, which indicates a grievance form must be filled out immediately after a resident reports missing items. e) Resident #10 At approximately 8:43 AM on 10/31/2023, an interview was conducted with Resident #10. During this interview Resident #10 reported, they were missing multiple items of clothing from their room. Resident #10 stated, they had brought this to the attention of multiple staff members and nothing had been followed up on. Resident #10 revealed their items had not been recovered and they had never been instructed to fill out a grievance form pertaining to the missing items. At approximately 2:37 PM on 10/31/2023, an interview was conducted with the Guest Services Director (GSD) #56 in which they confirmed, the facility does not have residents fill out grievance forms immediately, and only do so when an issue reported by a resident is unresolved. GSD #56 supplied the facility's policy on grievances, which indicates a grievance form must be filled out immediately after a resident reports missing items.

. Based on observation and staff interview the facility failed to have the cabinet under the steam table cleaned and sanitized. This has the potential to affect all residents who receive their nutrition from the kitchen. Facility Census: 113. Findings included: a) Steam Table The second kitchen tour on 10/31/23 at 12:05 PM found under the steam table to be unclean and in disrepair. The contact paper was pealing, the plywood was exposed, there was sticky food debris, and an unidentifiable black substance. During an interview with the kitchen manager and corporate dietary manager they confirmed the steam table was not clean was in disrepair. They indicated the kitchen had notified the maintenance department but the issue has not yet been fixed. During an interview on 11/01/23 at 9:45 AM the Maintenance Director verified under the steam table would be hard to clean and sanitize. He stated, he would get it fixed this day.

. Based on facility record review and interview the facility failed to explain the Binding Arbitration Agreement in a form and manner residents or Resident Representatives can understand. This has the potential to affect all residents or Residents Representatives that sign a Binding Arbitration Agreement. Facility Censes: 113. Findings included: a) Binding Arbitration Agreement A facility record review found multiple Residents or Residents Representatives had signed a Binding Arbitration Agreement. During an interview 11/01/23 at 2:30 pm, the admission Coordinator was unable to explain a Binding Arbitration Agreement accurately. She stated, the Resident could not consult or obtain a lawyer, there was only one Arbitrator, genesis health care would choose the Arbitrator and they were giving up their right for a lawyer. When the admission Coordinator was asked questions about Binding Arbitration Agreement, she was unable to explain. The admission Coordinator at this time stated, Residents don't usually ask questions about the form. She continued to say she would better familiarize herself with the Agreement.

. Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The glucometer was not cleaned with a cleaning solution approved by the manufacturer. This deficient practice had the potential to affect residents residing in the unit who receive blood glucose monitoring by fingerstick. Resident identifiers: #324, #178, #179, #51. Facility census: 113. Findings included: a) Glucometer cleaning The facility's procedure titled Fingerstick Glucose Measurement, with an effective date of 01/01/04 and revision date of 06/15/22, stated, Clean and disinfect the blood glucose meter after use with EPA [environmental protection agency] approved disinfectant, following manufacturer's instructions. On 11/01/23 at 8:19 AM, Licensed Practical Nurse (LPN) #8 was observed performing fingerstick blood glucose monitoring using a glucometer. The glucometer brand was EVENCARE G2. Following the completion of the procedure, LPN #8 brought the glucometer back to the medication cart. She cleaned the glucometer with an alcohol pad before placing the glucometer into a drawer in the cart. The EVENCARE G2 glucometer manual, available on-line at Medline.com, was reviewed. The manual gave the following instructions: The following products are validated for disinfecting the EVENCARE G2 Meter: - Dispatch Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8) - Medline Micro-Kill+ (Trademark) Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: 59894-10) - Clorox Healthcare Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12) - Medline Micro-Kill (Trademark) Bleach Germicidal Bleach Wipes (EPA Registration Number: 69687-1) - Other EPA Registered wipes may be used for disinfecting the EVENCARE G2 system, however, these wipes have not been validated and could affect the performance of the meter On 11/01/23 at 9:00 AM, LPN #8 verified she had cleaned the glucometer with an alcohol pad. She provided one of the alcohol pads used, which was 70% isopropyl alcohol, manufactured by Medline. On 11/01/23 at 9:30 AM, the Director of Nursing provided the facility's EVENCARE G2 glucometer manual pursuant to the surveyor's request. The DON confirmed 70% isopropyl alcohol pads were not a cleaning solution approved by the manufacturer according to the manual. No further information was provided through the completion of the survey process.

. Based on observation and staff interview the facility failed the provide a resident the right to a dignified existence. This was a random opportunity for discovery. Resident identifier: Resident # 15. Facility census 121. Findings included: a) Resident #15 During an observation on 03/23/22 at 4:24 AM, Resident # 15 was seen from the hallway in the bed closest to the door, with lights on, no covering, wearing only a brief. The door was fully opened, and the privacy curtain was not pulled to prevent exposing Resident #15. On 03/23/22 at 5:06 AM, Nurse Aide #32 was asked if Resident # 15 should be exposed to anyone walking by. NA #32 placed a blanket over Resident # 15. On 03/23/22 at 5:13 AM, the Administrator was informed of the above observations for Resident # 15. The Administrator stated it would not be a dignity issue if Resident # 15 wished to be exposed. An interview on 03/23/22 at 6:15 AM, the Director of Nursing stated Resident # 15 has the right to expose himself, because he does not want the curtain, or the door closed. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to complete the Minimum Data Set (MDS) to accurately reflect Resident #112's discharge status. For Resident #49 the MDS did not accurately reflect the residents dental status. This was true for two (2) of sampled residents reviewed during the Long Term Care Survey Process. Resident Identifier: #112 and #49. Facility census 121. Findings Included: a) Resident #112 A record review of the discharge Minimum Data Set (MDS) with an Assessment reference Date (ARD) 02/05/22, found the MDS was marked in Section A, discharge date [DATE] to an acute hospital. Further review of the notes dated 02/04/22 at 12:00 AM {typed as written} Discharge Facility Course: This resident just admitted to {facility name} and nursing notified me that now resident's family has chosen to take her home. Resident lives with her son and has support from multiple children / family. Resident only had her therapy evaluations but they are ok with her going home with family support. Resident was previously active with {home health name} and she was instructed to follow up with her PCP in the next week. In an interview with the Administrator on 03/23/22 at 6:45 am she verified the assessment was inaccurate and Resident #112 was discharged to home and not to an acute care hospital. b) Resident # 49 On 03/21/22 at 1:15 PM, This surveyor observed Resident #49, to have several teeth broken and several teeth which were missing. A review of the medical records found an assessment note dated 1/31/22 at 7:36 PM, Assessment Note: An oral health evaluation was completed. Lips appear healthy. Tongue appears healthy. Gums and tissues appear healthy. Saliva appears healthy. Pt is edentulous (lacking teeth). Pt oral cleanliness results: food particles/tartar/plaque in 1-2 areas of mouth or on dentures broken and decayed teeth Pt has no verbal or non-verbal signs of dental pain. No oral health issues have been identified. A further review of the medical record reveals a Progress noted dated for 01/31/22 signed by the facility Physician that read .Oral health Pt. (patient) is edentulous, resident has decay/missing teeth A continued review of the medical record reveals a on 1/31/2022 at 7:36 PM, a Nursing Documentation Note that read as follows: .Oral health reviewed. Pt. is edentulous. resident has decay/missing teeth A review of the MDS (Minimum Data Set) section L Oral/Dental Part B dated for 2/07/22 was marked as follows: No natural teeth or tooth fragment (s) (edentulous) On 03/23/22 at 9:03 AM, This surveyor and Registered Nurse (RN) # 45 observed Resident # 49 oral cavity. RN # 45 confirmed Resident #49 had multiple teeth of which several were broken. On 03/23/22 at 9:12 AM, in an Interview with RN #82 regarding Resident #49's MDS section L. RN #82 stated I just pulled the information from the nursing evaluation. I did not go and look at the Resident. On 03/23/22 at 9:30 AM, the Administrator acknowledged the MDS coordinator should assess the Resident when filling out the MDS form. .

. Based on record review, staff interview and observation the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards care. Resident did not have instructions or goals for oxygen use. This was true for (1) of two (2) Residents reviewed during the long term care process. Resident Identifier # 323 Facility Census 121 Findings Included: a) Resident 323 On 03/21/22 at 2:45 PM, this surveyor observed Resident # 323 in bed with 4L/NC (liters/ nasal cannula) in use. On 03/21/22 2:50 PM, Licensed Practical Nurse (LPN) #117 acknowledged Resident #323 was using 4L/NC of Oxygen. After review of Resident # 323's orders LPN #117 acknowledged Resident # 323 did not have an order or a care plan for Oxygen use. On 03/22/22 at 8:30 AM, the Administrator acknowledged Resident # 323 did not have a care plan regarding oxygen care. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to develop a clear and accurate care plan on how to safely transfer a resident. This was true for one (1) out of 28 reviewed for care plans. Resident identifiers: Resident # 162. Facility census 121. Findings included: a) Resident #162 Review of medical records revealed Resident #162 was admitted on [DATE] with a new Facture of neck of left femur, as a result received a rod and pins surgically to repair the femur. In addition, the local hospital discharge report stated Resident #162 suffered a compression fracture to his Lumbar spine location L2. These injuries were from a fall at the home of Resident #162. Resident #162 is also blind and has dysphagia from a previous cerebral infarction. A review of the Care Plan created by the facility revealed the following: Focus Statement: -Resident requires assistance for Actives of Daily Living (ADL), care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, ambulation, locomotion, and toileting related to: Recent illness, fall with injury, hospitalization. Goal related to this focus statement: -- Resident will improve current level of function in: bathing, grooming/personal hygiene, dressing, eating, bed mobility, transfers, ambulation, locomotion, as evidenced by improved ADL scores. Interventions related to this goal included: -For Your Information: Resident is hard of hearing and is legally blind. -Provide extensive to dependent assist x1 with locomotion on/off unit. -Provide patient with 1-2 assist with transfers. -Provide resident with extensive assist of 1-2 for bed mobility. -Provide resident with extensive assist of 1-2 for toileting. During an interview on 03/23/22 at 10:26 AM, the Director of Nursing (DON) was asked who makes the decision of using one (1) person or two (2) people to transfer Resident # 162. The DON stated, the decision would be based on how Resident #162 was able to do for herself. DON went on to say Resident # 162 might only need one (1) person to help her in the morning and might be tired and need a two (2) person assist in the evening. The DON was then asked who was responsible for making this decision on how many people it would take to safely transfer Resident # 162. The DON did not provide an answer to this question. .

. Based on resident interview, record review and staff interview the facility failed to administer medications in accordance with the physician orders. This was true for one (1) of 28 sampled residents reviewed during the long term care survey. Resident Identifier: #24. Facility Census: 121. Findings Included: a) Resident #24 On 03/21/22 at 1:00 PM, Resident #24 stated I haven't gotten my medication for my lip. On 03/22/22 at 12:00 PM the record was reviewed. A progress note dated 03/22/22 at 9:39 AM stating .the medication is not available at this time, called pharmacy to obtain an approximate time of arrival, pharmacy stated they had to order it into their facility. Medication should be on their truck sometime today, Pharmacy will deliver as soon as they receive their delivery. FNP (Family Nurse Practitioner) notified, Order received to HOLD until arrival. Noted. [Typed as written.] The Medication Administration Record (MAR) for March 2022 was reviewed and noted a physician's order with the order date of 03/21/22 for Acyclovir Cream 5% (a medication to treat herpes simplex) apply to upper lip area tropically five times a day for 4 (four) days. The MAR was marked with a check indicating the medication was administered on 03/21/22 at 6:00 PM, 10:00 PM and on 03/22/22 at 6:00 AM. On 03/22/22 at 12:15 PM, the Assistant Director of Nursing (ADON) #12 confirmed the medication was not available from the pharmacy and was not in the medication cart. The ADON #12 stated the medication is not here and I had her [nurse] call the pharmacy. ADON #12 also verified a check mark indicates the medication was administered. ADON #12 stated I don't know why it is marked. On 03/22/22 at 2:22 PM the ADON #12 stated the nurses were contacted and [they] stated it was a documentation error. They will be here today to fix it. On 03/23/22 at 12:03 PM, ADON #12 verified the Acyclovir Cream 5% was received on 03/22/22 and was available on the medication cart. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on policy review, Resident family interview, Resident interview, record review, and staff interview the facility failed to ensure the resident environment of which it had control remained as free from accident hazards as possible. Resident #162 was transferred inappropriately by a nurse aide (NA). This was a random opportunity for discovery. Resident Identifier: Resident #162. Facility census 121. Findings included: a) Facility Policy Facility policy titled, NSG234 Resident Handling/Transfer Equipment, revision date: 10/01/21. - Gait belt use should be evaluated if the patient has any of the following: - back fracture b) Resident #162 Review of medical records revealed Resident #162 was admitted on [DATE] with a new Fracture of neck of left femur, as a result received a rod and pins surgically to repair the femur. In addition, the local hospital discharge report stated Resident #162 suffered a compression fracture to her Lumbar spine location L2. These injuries were from a fall at the home of Resident #162. Resident #162 is also blind and has dysphasia from a previous cerebral infarction. During an interview on 03/21/22 at 1:12 PM, Resident #162 was noted to be in the bed moaning and asking for pain medication. The daughter of Resident #162 said, about 10 minutes ago Nurse Aide (NA), (called NA #106 by name) had just put her mother in the bed. The daughter went on to say NA #106 hurt my mother. NA #106 hurt her when he had Resident #162 give him a hug around his neck and he squeezed her around her whole body and hurt her ribs and back. Daughter said, even when my mother yelled out and said you are squeezing me and hurting me, NA #106 did not stop. Resident #162 was asked if a nurse had come in to assess her pain. The Daughter said, she cannot find a nurse to tell. On 03/21/22 at 1:21 PM, this surveyor located Licensed Practical Nurse # 117 (LPN) and informed her of what Resident #162 reported. LPN# 117 stated she was not aware that NA #106 had hurt Resident # 162 and will check her out. LPN#117 went to the room of Resident #162 and asked the daughter how was Resident #162 supposed to be transferred? LPN #117 asked the daughter is she a one or two person assist or is she a lift patient? The daughter said, I don't know what you are asking me? I don't have any medical training, so I don't know what any of that means. A review of medical records revealed the facility Attending Physician made changes to the pain medication for Resident #162 after being informed of the increased pain after the transfer from wheelchair to bed on 03/21/22. The following medication were changed on 03/21/22: -Hydrocodone-Acetaminophen 10-325 MG, give 1 tablet by mouth every 4 hours as needed for pain for 14 days. Start date was 03/08/22 and end date 03/22/22. This was discontinued on 03/21/22 at 3:47 PM, -Ibuprofen 800 mg by mouth one time now for pain. Started on 03/21/22. -Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet two times a day for pain. Started on03/21/22. -Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet every 8 hours as needed for pain. Started on 03/21/22. On 03/21/22 at 4:30 PM, the Director of Nursing (DON) provided copies of the reportable which was started on 03/21/22 at 3:48 PM. This was reported to the facility staff on 03/21/22 at 1:21 PM. The following statements were collected (the statements are typed as written.) Nurse Aide Registry Immediate fax reporting of Allegations Incident date: 03/21/22 Alleged Perpetrator: (Named) NA#106 Allegation: Allegation by family member that when staff transferred resident, he squeezed too hard possibly causing injury. NA #106 written statement: dated 03/21/22: 401A Resident's family requested the resident be transferred from chair to bed. I positioned the bed and wheelchair accordingly. Then I transferred resident to the bed. The resident made noise during the transfer. I carefully placed resident in the bed and resident complained about pain. I checked resident for injury but found none. I proceeded to change resident's brief and cleaned her up. Once done, I checked resident one more time. Then informed the nurse. No further complaints. LPN #117 written statement: Dated 03/21/22: State Surveyor approached me in the hall and asked what I would do if one of my residents was injured. State Surveyor informed me that (named) Resident #162 had been complaining of pain after being transferred back to bed by CNA (NA). Informed State Surveyor I was unaware of situation, immediately assessed resident for signs of bruising in area of pain (said ribs). Obtained VS (vital signs), WNL (within normal limits), notified nursing unit supervisor and (Named facility nurse practitioner), (FNP). No s/s (sign or symptom) of acute distress at this time, no redness, intercostal areas, lung sounds clear. FNP ordered x-ray of right rib series. Made family aware. Social Worker (SW) #14 statement: No date on statement This (LSW) spoke with resident and resident's daughter this date r/t (related to) to their allegation the (CNA) NA squeezed resident too hard when transferring her and could've caused injury. Resident's daughter stated that resident told CNA she was in pain and CNA did not stop the transfer and continued transferring her onto the bed. Resident's daughter stated that CNA was bear hugging resident and holding her so tightly that she was afraid resident had broken ribs. Social Worker (SW) #14 and Administrator interview statement: No date on statement LSW interviewed resident with Administrator present, no family at bedside. LSW asked resident if CNA (named NA #106) had hurt her during transfer. Resident responded no, but I hurt all the time being so old. LSW asked resident if she ever felt abused by (named NA #106), to which she responded no. She stated that all staff are good to her and pain medicine has been helping. This was signed by SW #14 and Administrator. A review of the Care Plan created by the facility revealed the following: Focus Statement: -Resident requires assistance for Actives of Daily Living (ADL), care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, ambulation, locomotion, and toileting related to: Recent illness, fall with injury, hospitalization. Goal related to this focus statement: -- Resident will improve current level of function in: bathing, grooming/personal hygiene, dressing, eating, bed mobility, transfers, ambulation, locomotion, as evidenced by improved ADL scores. Interventions related to this goal included: -For Your Information: Resident is hard of hearing and is legally blind. -Provide extensive to dependent assist x1 with locomotion on/off unit. -Provide patient with 1-2 assist with transfers. -Provide resident with extensive assist of 1-2 for bed mobility. -Provide resident with extensive assist of 1-2 for toileting. During an interview on 03/23/22 at 10:26 AM, the Director of Nursing (DON) was asked who makes the decision of using one (1) person or two (2) people to transfer Resident # 162. The DON stated, the decision would be based on how Resident #162 was able to do for herself. DON went on to say Resident # 162 might only need one (1) person to help her in the morning and might be tired and need a two (2) person assist in the evening. The DON was then asked who was responsible for making this decision on how many people it would take to safely transfer Resident # 162. The DON did not provide an answer to this question. A review of the facility form titled, Occupational Therapy OT initial Evaluation, dated 03/09/22 did not contain the diagnosis of the L2 Compression fracture. This diagnosis was included on the hospital discharge summary and the progress note written by the Family Nurse Practitioner. In the sections of this evaluation form that determined the type of assistance Resident #162 would require for the area of functional transfers the following was contained: - Moderate assistance Care area of bed mobility: -Moderate Care area of toileting with use of toilet/commode: -Maximal assistance The above OT evaluation was the only one provided to the survey team. An interview on 03/23/22 at 10:30 AM, with Occupational Therapist, Registered (OTR) #133, was asked what did it mean if a resident was evaluated to need moderate assistance for transfers. OTR #133 stated it means the staff should use a Hoyer lift when transferring the resident. During an interview on 03/23/22 at 10:44 AM, with the Director of Physical Therapy (DPT) when asked to explain what the term Moderate Assist meant. The DPT was looking at Resident #162's record. The DPT said the term moderate means the facility nursing staff, nurses and/or Nurse Aides should be using a lift such as a Hoyer lift to transfer Resident #162. A further review of the electronic medical record revealed on 03/18/22 the DON made a change to the level of assistance needed for Resident #162 for transfers from moderate to minimal assist. During an interview on 03/23/22 at 10:50 AM, the DON was asked why the level of assistance for transfers was changed on 03/18/22. The DON Stated the, Certified Occupational Therapy Assistant (COTA) #143 verbally told her too. The DON went on to say COTA #143 also trained the staff on how to transfer Resident #162 on this day. The DON did not know if it was a formal training or/not with having the staff sign saying they were trained. The DON was asked if she could provide an evaluation form from the physical therapy department that would reflect Resident #162 had improved and now required a lower level of assistance for transfers. The DON stated, No it was all verbal. On 03/23/22 at 11:18 AM, the DON, the DPT, and COTA #143 entered the room to tell this surveyor more information. The DPT said we (the therapy department) were not aware COTA #143 had re-evaluated Resident #162 and had failed to update the physical therapy records. At the above time COTA #143 was asked if he trained the staff on how to safely transfer Resident #162? COTA #143 nodded his head to indicate yes. COTA #143 was asked to demonstrate how the staff was instructed to assist Resident #162 during transfers. COTA #143 demonstrated on DPT. He held his arms out straight and said the staff would only have to place their hands or forearm on the trunk of the body only to stabilize and support Resident #162 and would not lift or pull-on the resident. The DPT was then asked if it was acceptable to transfer any resident using the Bear hug technique? The DPT stated NO, because this is a no lift facility. The DPT was asked if it would be appropriate to transfer a resident by wrapping your arms around a resident if the resident had a diagnosis of a lumbar spine compression fracture. The DPT said, NO. On 03/24/22 at 7:45 AM, the Administrator provided a typed paper titled, Education/In-service Training sign-in sheet. Facility name, dated: 03/18/22 Topic: Safe transfers Resident #162 (named resident) requires extensive assistance of 1-2 people. She may require more or less assistance depending on pain level or fatigue. She requires sequencing of events prior to transfers (ie. We are going to stand up and take two steps to the chair.). (Called resident by name) is legally blind and requires frequent reorientation to her surroundings. She requires a gait belt and front wheeled walker for transfers. Attendees Name: Title/department: shift: date: There were two (2) staff members who had signed this paper. Licensed Practical Nurse # 117 shift: 7a-7p, date: 03/18/22 Nursing Aide # 106, Shift: 7a-7p, date: 03/18/22 No other staff were listed. During a phone interview on 03/24/22 at 8:30 AM with all surveyors present, NA #106 was asked to please describe step by step how Resident #162 was transferred from the wheelchair on 03/21/22. NA #106 stated, first he bent over and asked the resident to hug him around the neck, then he placed his arms around the resident's waist and back, securely holding her body to his, picked her up and placed her from the wheelchair to the bed. NA# 106 was asked to clarify did he wrap his arms around the body of Resident #162 and pick her up to put her in the bed? NA #106 stated, yes, I did. NA #106 was asked when did he last receive training on how to transfer Resident #162? NA #106 stated he was trained on patient transfers in Nurse Aide classes. NA #106 was asked if he was trained on how the transfer Resident #106 on 03/18/22? NA #106 said, No I did not even work in that area of the facility on 03/17, or 03/18/22 he was pulled to Blueridge side, (which is located on the opposite side of the facility). NA #106 was asked if he signed a paper on 03/18/22 about transfers for Resident #162? NA #106 said, No I have not signed any paper on that day or any other day about that. .

. Based on observation, policy review and staff interview the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The facility failed to anchor the Foley catheter and use proper hand hygiene after peri care. This was true for two (2) of two (2) Residents reviewed during the long term care process. Resident Identifier # 18 and # 63 Facility Census 121 Findings Included: a) Resident #18 On 03/22/22 at 09:15 AM, this surveyor observed Nursing Aide (NA) #18 perform peri care on Resident #18. After peri care NA #18 applied a barrier ointment to Resident #18's clean skin with out performing hand hygiene or changing gloves. On 03/22/22 at 9:39 AM, the Director of Nursing (DON) acknowledged NA #18 should have changed gloves and performed hand hygiene after peri care before applying the barrier ointment. b) Resident #63 During observation of catheter care on 03/22/22 at 11:40 AM, with Nurse Aide #113 it was found there was no secure anchored device on Resident # 63. NA #113 said she would inform the unit nurse. On 03/22/22 at 12:03 PM, the Director of Nursing was informed of the above information. No further information was provided. .

. Based on record review, staff interview, observation and resident interview, the facility failed to maintain an accurate and complete medical record for Resident #24's medication administration record and documenting an injury for Resident #49. This was true for two (2) of 28 records reviewed during the long term survey process. Resident Identifiers: #24 and #49. Facility Census: 121. a) Resident #24 On 03/21/22 at 1:00 PM, Resident #24 stated I haven't gotten my medication for my lip. On 03/22/22 at 12:00 PM the record was reviewed. A progress note dated 03/22/22 at 9:39 AM stating .the medication is not available at this time, called pharmacy to obtain an approximate time of arrival, pharmacy stated they had to order it into their facility. Medication should be on their truck sometime today, Pharmacy will deliver as soon as they receive their delivery. FNP (Family Nurse Practitioner) notified, Order received to HOLD until arrival. Noted. [Typed as written.] The Medication Administration Record (MAR) for March 2022 was reviewed and noted a physician's order with the order date of 03/21/22 for Acyclovir Cream 5% (a medication to treat herpes simplex) apply to upper lip area tropically five times a day for 4 (four) days. The MAR was marked with a check indicating the medication was administered on 03/21/22 at 6:00 PM, 10:00 PM and on 03/22/22 at 6:00 AM. On 03/22/22 at 12:15 PM, the Assistant Director of Nursing (ADON) #12 confirmed the medication was not available from the pharmacy and was not in the medication cart. The ADON #12 stated the medication is not here and I had her [nurse] call the pharmacy. ADON #12 also verified a check mark indicates the medication was administered. ADON #12 stated I don't know why it is marked. On 03/22/22 at 2:22 PM the ADON #12 stated the nurses were contacted and [they] stated it was a documentation error. They will be here today to fix it. On 03/23/22 at 12:03 PM, ADON #12 verified the Acyclovir Cream 5% was received on 03/22/22 and was available on the medication cart. b) Resident #49 On 03/21/22 at 1:15 PM, This surveyor observed Resident #49 to have a bruise over his right eye. In an interview with Nurse Aide (NA) # 20 regarding Resident # 49's bruising over his right eye. NA # 20 stated I do not know what happened as Resident # 49 was just transferred to this unit. A review of the medical record reveals a progress note dated for 02/22/22 at 8:08 AM, that reads as follows: During morning medication pass, resident found laying on back, on fall mat, between bed and bed side commode on left side of bed with head at top of the bed and feet towards the end of bed. full body assessment complete with no injuries noted or pain reported by resident On 03/21/22 at 3:00 PM, the Administrator produced a RMS Event Summary Report dated 2/22/22 at 8:18 AM, that read as follows: Resident was found lying on his back on fall mat between bed and BSC (bed side commode). Resident is unable to provide a sequence of event, r/t (related to ) baseline mental status of confusion d/t (due to ) AMS (altered mental status). Assessment completed. No injuries noted at this time. Bruise noted to right eye, no other concerns noted at this time 03/23/22 07:45 AM, The Administrator acknowledged the right eye bruising was not charted in the medical record nor was it followed in the skin check assessments. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, and a clean safe homelike environment. This was a random opportunity for discovery and was true for rooms 200, 201, 400, 409, and the resident sitting area on Cherry Lane. Facility census 121. Findings included: a) room [ROOM NUMBER] An observation of room [ROOM NUMBER] on 03/21/22 at 12:36 PM, found: - bubbled up paint on the wall behind bed B measuring over one foot by one foot, a white plastic outlet cover was missing a screw on the top, causing the cover to fall, and not covering a hole in the wall. -Trash under bed-B, cups, cookie wrappers, cotton balls, a paper towel and a dark substance which appeared to be spilled on the floor. Under and around bed A: -Tissues, empty chip bags, and medication cups. Floor appeared soiled and made a sticky sound when walked on. Maintenance Supervisor (MS) was shown all the issues in room [ROOM NUMBER] on 03/21/22 at 1:00 PM. At this time MS checked the temperature of the room, which was 67 degrees. Resident in bed A was complaining about being cold. The above findings were verified by Nurse Aide (NA) #4 on 03/21/22 at 12:56 PM. On 03/21/22 at 1:26 PM, the Administrator was informed of the above findings of the condition of the rooms. On 03/22/22 at 11:40 AM. a gray wash basin was discovered in the resident bathroom of room [ROOM NUMBER]. The wash basin was full of feces. The Fecal matter was over the sides of the basin and dripping onto the floor and on the toilet. Also, on the bottom of the privacy curtain around bed-A was a large amount brownish unidentifiable substance. In addition, the observations mentioned on 03/21/22 were still present and appeared to be untouched from the previous day. On 03/22/22 at 11:41 AM, NA #113 stated that the facility is not as clean as it could be because there were only two (2) housekeepers left after six (6) quit on the same day last week. On 03/22/22 at 12:00 PM, the above findings were verified with Social Worker #14. b) room [ROOM NUMBER] On 03/21/22 at 12:43 PM, during an observation of room [ROOM NUMBER] the following was found: - floors appeared soiled, and sticky. - Trash on floors, paper towels, plastic wraps, a clear plastic kitchen bowl under the bed. -The room smelled of urine and feces. The above findings were verified by Nurse Aide # 4 on 03/21/22 at 12:56 PM. c) room [ROOM NUMBER] During a resident interview on 03/21/22 at 1:08 PM, it was noted the privacy curtain between bed-A and bed-B was heavily soiled with a white substance and a dark in color substance. On 03/21/22 at 1:10 PM, the above was verified by NA #103. d) room [ROOM NUMBER] During an observation on 03/22/22 at 10:36 AM, it was discovered that in room [ROOM NUMBER] a large amount of sticky brown substance was on the floor and on the base of the Pole holding the tube feeding pump. Licensed Practical Nurse (LPN) # 102 was present at the time and stated, housekeeping must scrap the brown substance off the floor after it dries. LPN #102 said it was from the tube feeding drippings on the floor. e) Resident sitting area on Cherry Lane On 03/21/22 at 12:59 PM, LPN # 117 was asked what all of the large boxes and plastic bags was piled up on the floor. LPN# 117, stated it was a Christmas trees and decorations. LPN #117 confirmed the area was a sitting area for the residents. On 03/21/22 at 1:26 PM, the Administrator was informed of the above findings and the conditions of the rooms. No further information was provided. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, resident interview and staff interview the facility failed to provide the assistance with dining, grooming and bathing required to maintain nutritional status and hygiene to residents who were dependent for Activities Of Daily Living (ADL) care. The facility al failed to provide Resident #2 with clean bed linen when needed. Resident identifiers: #2, #323, #32 and #107. Facility census: 121 Findings included: a) Resident #2 During an interview on 03/21/22 at 12:59 PM Resident # 2 stated, I am unable to see due to my cataracts, they won't feed me and I cant see to eat. I have to beg them to feed me. I have asked the nurse to cut my nails they are digging into my hand and I need a shave. An observation on 03/21/22 at 12:59 PM Residents #2's blanket had ravioli sauce from lunch meal he was presently eating, at the bottom of the blanket near his feet, green beans were on his left upper arm and on his bed sheet. Resident #2's face was unshaved and his hair was disheveled . Resident #2 asked Nurse Aide (NA) #74 to order him a hamburger so he could eat something. During an interview on 03/22/22 at 8:30 AM Resident #2 stated thanks so much for your help, I got shaved and my nails cut. I got a bed bath too. I am unable to feed myself I can eat like sandwiches and stuff like that I don't have to look for. Therapy says I can feed myself, but I cant see the food not that I cant do it. (NA #27 name) helped me with my breakfast. An observation on 03/22/22 at 8:30 AM Resident #2's blanket still had the ravioli stain at the bottom of the blanket near the Residents feet. During an interview on 03/22/22 at 8:32 AM NA #27 stated (Resident #2 name) does good with finger foods, but I had to feed him this morning because it was scrambled eggs, he wasn't able to chase those eggs around. On 03/22/22 at 8:33 AM NA #27 verified Resident #2's blanket was soiled. NA #27 stated I didn't work yesterday so I am not sure why they weren't change, but I will as soon as I finish picking up trays, I will change them. During an interview on 03/22/22 at 9:55 AM NA #116 and NA #96 stated, a bed bath consisted of washing full body, changing sheets and blankets, shaving and nail care. We do showers daily, their is no shower aide we do our own, some of them refuse so they get bed baths. During an interview on 03/22/22 at 10:53 AM the Director of Nursing (DON) stated when the NA gives a bed bath they are to change the sheets also. This surveyor informed the DON Resident #2 had documentation stating he received a bed bath on 03/21/22. Resident #2's bed sheets were soiled during the 03/21/22 lunch meal. The DON stated, I talked to LPN #75, this morning and she said she will look at him, he probably needs a order for finger foods instead. During an interview with 03/23/22 at 9:10 AM, Therapy Director #132 stated Residents name had physical, occupational and speech therapy evaluations, he refuses to let them evaluate him, throws things at them when they come in. We tried when he was readmitted on [DATE] and again on 03/04/22. During an interview on 03/23/22 at 10:00 AM, the Occupational Therapist (OT) #133, the Speech Therapist(ST) #134 and this surveyor was with Resident #2 in his room. Resident #2 got irritated with us asking him any questions, refused to answer any of the OT #133 and ST #134 questions. Resident #2 stated I do better with finger foods, now leave. b) Resident #323 An observation on 03/21/22 at 1:08 PM, found Resident #323 was laying in bed and her hair was disheveled and greasy, with a tiny ponytail on top of her head. During an interview on 03/21/22 at 1:08 PM Resident #323 stated, I have not had a shower since I've been here, they wash you off if that's what you call it. Look at this grease clot hair. They change your clothes everyday but that's it. Nursing Documentation for task of Bathing had the following days and times checked for a bed bath: --Bed Bath on 03/14/22 at 2:21 PM --Bed Bath on 03/15/22 at 3:42 AM --Bed Bath on 03/15/22 at 9:51 AM --Bed Bath on 03/20/22 at 2:57 PM --Bed Bath on 03/21/22 at 2:59 PM Nursing Documentation for task of Bathing had the following days and times checked for resident refused: -- Resident Refused on 03/17/22 at 10:59 PM --Resident Refused on 03/18/22 at 6:59 AM During an interview on 03/22/22 at 11:31 AM the DON stated we asked her if she wanted a shower and she refused, she will get a bed bath and her hair washed today. c) Resident #32 During an interview on 03/21/22 at 12:34 PM, Resident #32 was unshaven and disheveled. The resident stated, I don't know when I shaved last. Observations on 03/22/22 at 9:38 AM, found the resident remained unshaven. Resident #32 stated, I need a shave don't I. Observations on 03/23/22 at 9:06 AM, found the resident remained unshaven. Assistant Director of Nursing (ADON) #12 confirmed the resident had not been shaved and appeared disheveled. On 03/23/22 at 9:11 AM, ADON #12 stated the resident is getting shaved now. d) Resident #107 During an observation on 03/21/22 at 12:34 PM, Resident #107 was unshaven and disheveled. Resident #107 has a Brief Interview for Mental Status (BIMS) score of 5 (five) which indicates the resident is severely impaired cognitively. Resident #107 was unable to verbalize his needs regarding activities of daily living (ADLs). On 03/22/22 at 9:38 AM, during observation the resident remained unshaven and disheveled. On 03/23/22 at 9:06 AM, the Assistant Director of Nursing (ADON) #12 confirmed the resident had not been shaved and appeared disheveled. On 03/23/22 at 9:11 AM, ADON #12 stated the resident is getting shaved now. .

. Based on resident interview, observation, staff interview, and record review, the facility failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s). This was true for four (4) out of four (4) residents reviewed for foot care during the long term care survey process. Resident identifiers: #93, #27, #32 and #107. Facility census 121. Findings included: a) Resident #93 During an interview on 03/21/22 at 1:24 PM, Resident # 93 said, her right big toe hurts. Observation of the right great toe, found an unknown type of purple stain on the toe. The toenail was growing up from the nail bed instead of outward and appeared to be very long and thick. In addition, there was dried crusted, brownish substance on the inner side of the great toe. After further observation all of the toenails were very long and not clean. A review of medical records found Resident # 93 had not been on the schedule to be seen by the facility podiatrist in the last six (6) months. Also, there was not any nursing notes about the toe being stained purple or having any dried crusted areas on the toe. Nursing skin assessments were completed on 03/03/22, 03/10/22, and 03/17/22. The right great toe was never mentioned. On 03/22/22 at 2:29 PM, the Director of Nursing (DON) observed the right great toe. The DON agreed there was dried drainage of some sort on the toe. The DON did not know what the purple staining was on the toe. The DON also agreed the toenails were very long and should have been trimmed. On 03/22/22 at 3:00 PM, the DON provided a piece of paper with names of Residents and a space by the names for handwritten notes. Beside of Resident # 93's name said, needs cut long. The DON stated this was a toenail audit and that it was completed on 03/15/22. The DON was then asked why the skin assessments completed on 03/03/22, 03/10/22, and 03/17/22 did not mention anything about the purple stain on her right great toe. The DON did not have a response. On 03/23/22 at 2:15 PM, the DON and Facility Nurse Practitioner (FNP) told this surveyor the purple stain on the toe of Resident #93 was Gentian Violet, and a family member had put it on her toe. The family have been told they cannot do toe care. The FNP was asked how long it had been on the toe. The FNP did not remember and indicated she did not write a note about it. When asked about the dried crust area on the inside of the residents toe the FNP stated, I was not told about that, I will go immediately and evaluate the toe. On 03/23/22 at 4:37 PM, FNP stated she cleaned Resident #93's right toe. She said, she did not think it was infected at this time. On 03/24/22 at 10:45 AM, FNP said she has scheduled an appointment for Resident #93 to be sent out to see a local Podiatrist, instead of having the resident wait to be seen in May. b) Resident #27 On 03/21/22 at 12:43 PM, during an interview with Resident#27, the resident's toe nails were observed to be long. ADON #12 confirmed his toe nails needed trimmed. Resident stated I haven't seen the podiatrist. On 03/22/22 at 2:00 PM, the ADON #12 confirmed the podiatrist was at the facility on 03/14/22. ADON #12 stated I don't know why he wasn't seen. On 03/22/22 at 2:20 PM, SW #14 stated the resident didn't request to see the podiatrist. I will add him to the list. The podiatrist will be here on 05/16/22. c) Resident #32 During an interview on 03/21/22 at 12:34 PM, Resident #32 stated, My toe nails are so long they are like talons. The podiatrist was here last week .they came in and never came back. I don't know why they didn't come back. On 03/22/22 at 2:00 PM, he Assistant Director of Nursing (ADON) #12 confirmed the resident's toe nails needed trimmed. ADON #12 stated The podiatrist was here on 03/14/22. I don't know why he wasn't seen. On 03/22/22 at 2:20 PM, Social Worker (SW) #14 stated the resident didn't request to see the podiatrist. I will add him to the list. The podiatrist will be here on 05/16/22. d) Resident #107 During observation on 03/21/22 at 12:34 PM, Resident #107 was noted with long toenails. Resident #107 has a Brief Interview for Mental Status (BIMS) score of 5 (five) which indicates the resident is severely impaired cognitively. Resident #107 was unable to verbalize his needs regarding activities of daily living (ADLs). On 03/22/22 at 12:34 PM, the Assistant Director of Nursing (ADON) #12 confirmed the resident's toe nails needed trimmed. ADON #12 stated The podiatrist was here on 03/14/22. I don't know why he wasn't seen. On 03/22/22 at 1:24 PM, the Director of Nursing (DON) confirmed the podiatrist was in the facility on 03/14/22. The DON provided the consultant paperwork from the podiatrist dated 03/14/22 stated was not seen due to time constraint. On 03/22/22 01:30 PM, the DON stated I will check and see about next appointment. The DON also stated if the podiatrist doesn't see the resident due to a time constraint that's not our responsibility. On 03/22/22 2:20 PM, SW #14 stated the podiatrist will be back on 05/16/22. The podiatrist is responsible for not seeing the resident due to a time constraint. I'll make sure he is on the list. .

. Based on observation, record review and staff interview the facility failed to ensure respiratory care consistent with professional standards of practice. Resident #312 did not have oxygen running as ordered by the physician, Resident #323 did not have an order for oxygen use despite the fact they were using oxygen, and Resident #322's Tracheotomy (trach) care was not done per standard of care. This was true for three (3) of three (3) Residents reviewed during the long term care process. Resident Identifiers # 312, #323 and #322. Facility Census 121 Findings Included: a) Resident #312 A review of the medical record revealed an order dated 03/18/22 at 3:14 PM, which read as follows: Oxygen at 5 L/min (liters/ minute) via Nasal Cannula continuously. On 03/21/22 at 2:30 PM, this surveyor observed Resident #312 with Oxygen via Nasal Cannula running at 3l/min via nasal cannula. On 03/21/22 at 3:40 PM, Licensed Practical Nurse (LPN) # 114 confirmed Resident # 312's Oxygen was running at 3l/NC (nasal cannula). Upon Review of Resident #312's orders LPN# 114 acknowledged that Resident # 312's oxygen was ordered for 5l/min via nasal cannula. On 03/21/22 at 3:24 PM, The Administrator acknowledged oxygen should run at the physician prescribed order. b) Resident #323 On 03/21/22 at 2:451 PM, this surveyor observed Resident # 323 in bed with 4L/NC (liters/ nasal cannula) in use. On 03/21/22 at 2:50 PM, Licensed Practical Nurse (LPN) #117 confirmed Resident #323 was using 4L/NC of Oxygen. After review of Resident # 323's orders LPN #117 acknowledged Resident # 323 did not have an order for Oxygen use. On 03/21/22 at 3:24 PM, in an interview the Administrator acknowledged Resident # 323 should not be using oxygen with out a physician order. c) Resident # 322 A review of the facility policy named Tracheotomy Care with an effective date of 01/01/04 a Review date of 07/15/21 and a Revision date of 07/15/21 read as follows: .3. Gather supplies 7. Evaluate patient's heart rate, respiratory rate, breath sounds, pulse oximetry, and cough effort. Evaluate sputum amount, color and consistency. 8. perform hand hygiene 14. Remove gloves. Discard in waste bag and cleanse hands. 34. Evaluate patient's respiratory rate, heart rate, heart rate, breath sounds, pulse oximetry, and cough effort 35. Remove PPE and perform hand hygiene On 03/22/22 at 11:125 AM, this surveyor observed trach care on Resident # 322 by Licensed Practical Nurse (LPN) #114. During the changing of the inner cannula LPN #114 attempted to to replace the inner cannula with an inner cannula that was to large in size. LPN #114 stated oh that is not a number 5 shiley. LPN#114 then tossed the inner cannula into the trash and obtained the right size inner cannula from the bedside table drawer. LPN#114 placed the spot vital sign machine on Resident #322 before trach care to monitor Resident # 322's oxygen saturations. When LPN #114 was changing out the inner cannula's the vital spot machine went blank and then went off . LPN #114 did not make any attempt to turn the machine back on during the procedure. LPN#114 failed to evaluate Resident's 322's heart rate or breath sounds before or after trach care. LPN #114 failed to evaluate Resident # 322's pulse oximetry after trach care. LPN#114 failed to perform hand hygiene (HH) before, during or after trach care. LPN # 114 failed to perform HH before or after any glove changes during Trach care. LPN#114 failed to perform HH after discarding the used procedure tray from the bedside table and failed to wiped down bedside table after use. After removal of the vital sign spot machine from Resident # 322 hand LPN #114 placed the machine back in the hall way for use without any decontamination of the machine. On 03/22/22 at 12:14 PM, in an interview with the DON and Administrator regarding trach care, they acknowledged LPN# 114 should have had the right size inner cannula ready before the start of care and it is policy to assess the Resident before and after the procedure. The DON and Administrator acknowledged Hand Hygiene was not performed per policy or CDC guidelines. .

. Based on observation, policy review, resident interview, and staff interview the facility failed to serve food that was palatable and at an accurate temperature. The failed practice had the potential to affect all residents currently receiving nutrition from the facility ' s kitchen. Resident Identifiers: #323 Facility Census: 121 Finding Included: During an interview on 03/21/22 at 1:08 PM Resident #323 stated the food is terrible, I ate my lunch because I was starving. The food is cold and Kool-aid and milk are warm. l would love to have some iced tea. Can we not have some ice for our drinks. On 03/22/22 at 12:53 PM, temperatures were obtained on the lunch meal tray for Resident #73 at the time of service. The following temperatures were obtained by the District Account Manager(DAM) #160 using her thermometer: --fish filet on a bun: 99 degrees Fahrenheit (F) --potato wedges: 100.4 degrees F --peaches: 63.4 degrees F --lemon mayo: 66 degrees F --Kool-aide: 63 degrees F -- Ice tea: 81.7 degree F --Coffee: 143 degree F On 03/22/22 at 12:57 PM the DAM #160 stated hot foods should be 124 degrees and cold should be 41 degrees at time of service. The CNA's have ice on the halls they can put ice in the drinks. The previous Administrator done away with all the hot plates and we have had all the (Company's name) buildings with food temps issues. A review of the facility policy titled Food: Quality and Palatability with an original date of 05/14 and revision date 09/17 found the following: .Food will be palatable, attractive and at a safe and appetizing temperature. A review of the facility polity titled Food Preparation with an original date of 05/17 and a revision date of 09/17 found the following: .13. All foods will be held at appropriate temperatures, greater than 135 degrees F for hot holdings and less than 41 degree F for cold holding. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, policy review and staff interview the facility failed to store food in a safe and sanitary manner, the food stored in the kitchen and nourishment refrigerators were not labeled correctly. The facility also failed to keep kitchen equipment clean and refrigerator and freezer temperatures were not correctly recorded. This failed practice had the potential to affect more than a limited number of residents currently receiving nutrition from the facility's kitchen. Facility Census:121. Findings Included: During the initial tour of the kitchen with the Account Manager (AM) #129 at 11:31 AM on 03/21/22 found the following items were not dated with the the items opened date or date of discard: a) Food Storage in the Kitchen and Nourishment Rooms Reach in Refrigerator: --5 trays of several individual servings bowls of red Jell-O, the AM #129 stated its for lunch it has a date on the tray. The AM pulled out the tray of Jell-O to show this surveyor the date sticker on the tray, a lid from one of the Jell-O bowls fell on the kitchen floor. The AM picked up the lid off the floor and placed it back on the bowl of Jell-O and proceeded to push the tray back in the refrigerator. -- Cheese slices with no opened date. --2 pitchers of tea with no prepared date. --one bottle of coke AM stated it is staff's. --one bottle of flavored coffee creamer, AM stated it is staff's. Walk in Refrigerator: --A plastic tote with employee only wrote on it which contained a diet Pepsi, 3 diet coke and a diet mountain dew, AM stated that's all staff and labeled in this tote. --a opened box of sausage with no open date --opened box of bacon with no open date --Roast Beef, wrapped in foil laying on the bottom shelf without a drip-proof container --Ground Turkey laying on the bottom shelf without a drip-proof container. --a bottle of lemon juice with no open date --a bottle of lime juice with no open date Walk In freezer: --Open container of 4 cupcakes with no open date. Dry Pantry: --Opened bag of pancake mix with no open date. A review of the facility policy titled Food Storage: Cold Foods with an original date of 05/14 and a revision date of 09/17 and 04/2018 found the following: .5. All foods will be stored wrapped or in a covered containers, labeled and dated . A review of another facility policy titled Food: Preparation with an original date of 05/14 and a revision date of 09/17 found the following: .Thawing in the refrigerator, in a drip proof container, and in a manner that prevents cross-contamination On 03/21/22 at 12:15 PM the Administrator was informed about all the kitchen issues including the jell-o. The Administrator stated I will make sure the Jell-o is taken care of and thrown away. During the a tour of the nourishment rooms with AM #129 at 9:25 AM on 03/22/22 found the following foods did not present a resident's name and/or a brought in date: Blueridge Pantry: --4 individual packages Jell-o with Resident's room number and no brought in date. --2 individual packages applesauce with Resident's room number and no brought in date. --4 bottles of ensure with Resident's room number and no brought in date. --A bag of cubed cheese with Resident's room number and no brought in date. --A opened Bottle of Ranch with no Resident name and no brought in date. --A opened bottle of coffee creamer with Resident's room number and no brought in date. --7 frozen pizzas with Resident's room number and no brought in date. A tour on 03/22/22 at 9:32 with AM #129 of the Cherry Lane Pantry found the following items: --A bottle of Carmel coffee creamer with Resident's room number and no brought in date. --A bottle of honey mustard dressing with Resident's room number and no brought in date. --A bottle of hazelnut coffee creamer no name and no brought in date. --A individual onion in a plastic bag with Resident's room number and no brought in date. --3 individual cartons of premier protein drink no name and no date. --A carton of almond milk with Resident's room number and no brought in date. --A frozen meal of macaroni and cheese with no name or no date. --A frozen protein bowl meal with no name and no date. The AM notified Registered Nurse #7 the items needed discarded. A tour on 03/22/22 at 9:37 AM with AM #129 of the [NAME] Garden Lane Pantry found the following items: --2 opened container french onion dip with Resident's room number and no brought in date. --A jar of pickles with Resident's room number and no brought in date. --5 individual packages of applesauce with Resident's room number and no brought in date. --4 individual packages of peaches with Resident's room number and no brought in date. --2 Diet Coke with Resident's room number and no brought in date. --A plastic bag with two plastic containers with no name or date. --A opened container of ice cream with Resident's room number and no brought in date. --Lean Cuisine frozen meal with Resident's room number and no brought in date. --Healthy Choice frozen meal with Resident's room number and no brought in date. --A bag of frozen cauliflower with Resident's room number and no brought in date. The AM notified Nurse Aide #65 the items needed discarded. A review of the facility policy titled Guidelines for food brought in for individual patients/residents with a date 11/28/16 found the following: .Food items that require refrigeration must be labeled with patient's/resident's name and date the food was brought in . b) Cleaning of equipment During the initial tour of the kitchen with the AM #129 at 11:31 AM on 03/21/22 the flat top griddle had pancake batter from the breakfast meal spilled down the side and pancake debris all over the flat top. The AM stated he will clean it before he leaves, he ran out of time and had to start lunch A review of the facility policy titled Equipment with a original date of 05/14 and a revision date of 09/17 found the following: .3. All food contact equipment will be cleaned and sanitized after every use . c) Refrigerator and Freezer Temperatures During the initial tour of the kitchen with the AM #129 at 11:31 AM on 03/21/22 found the refrigerator and freezer temperatures logs were void of temperatures. Refrigerator temperature was void of temperatures on the following dates: --03/18/22 AM & PM --03/19/22 AM --03/20/22 AM --03/21/22 AM Freezer temperature was void of temperatures on the following dates: --03/18/22 AM & PM --03/19/22 AM --03/20/22 AM --03/21/22 AM The AM acknowledged the void temperatures for the freezer and refrigerator those days. A review of the facility policy titled Food Storage: Cold Foods with an original date of 05/14 and a revision date of 09/17 and 04/18 found the following: .4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections including COVID - 19. These failed practices found were Feces left in a basin in a resident's bathroom for an extended amount of time. Foley catheters on the floor. Soiled brief on the floor. Using clean linen to care for residents that was being stored on the soiled linen cart and using the same peri cleansing foam on multiple residents. Staff picking up drink glasses for the residents by the rim. Staff not wearing Personal Protective Equipment in an area of quarantined residents. Trash in the floor overflowing from the trash can. Failure to use hand hygiene during trach care. Resident Identifiers: #76, #15, #92, #76, and #322. Facility census 121. Findings included: a) Resident #76 During an observation of catheter care for the roommate of Resident #76, on 03/22/22 at 11:40 AM. A gray basin was discovered in the resident bathroom. The plastic basin was full of feces. The Fecal matter was over the sides of the basin and dripping into the floor and on the toilet. After a brief interview on 03/22/22 at 11:49 AM, with Resident #76, it revealed the fecal matter was from when Licensed Practical Nurse (LPN) #88 emptied the colostomy bag prior to him going to dialysis. Resident #76 let the facility for dialysis treatment outside of the facility on 03/22/22 at 5:10 AM. Nurse Aide (NA) #113 was the person to find the pan filled with feces, while emptying urine from a foley catheter. On 03/22/22 at 12:00 PM, Social Worker (SW) #14 was asked to verify the pan of feces in the bathroom. SW#14 stated, that is totally unacceptable for anyone to do that. b) Resident #15 During an observation on 03/23/22 at 4:11 AM, Resident #15 was laying in bed in room [ROOM NUMBER]. Their foley catheter was not hanging on the bed, but was instead lying on the floor beside of the bed. Nurse Aide #32 was shown the catheter collection bag was on the floor. NA #32 hung the collection bag on foot board of the bed. The foot board was approximately 20 inches higher than the mattress on the bed. It was pointed out to NA #32 that urine cannot flow up hill to the collection bag and could cause the urine to back flow back into the bladder (which has the potential to cause a bladder infection). The above finding was shared with Administrator on 03/23/22 at 5:30 AM. c) Resident #92 On 03/22/22 at 9:27 AM, a soiled brief was observed laying on the floor with no barrier. Nurse Aide (NA) #95, stated it shouldn't be on the floor. On 03/22/22 at 9:30 AM, the Assistant Director of Nursing (ADON) #12 was notified of the breach of infection control. d) Resident #76 On 03/23/22 at 4:23 AM, Resident #76's urinary catheter bag was observed hanging on the bed. The bed was in the lowest position and the urinary catheter bag was touching the floor. Licensed Practical Nurse (LPN) #38 confirmed the urinary catheter bag was touching the floor. On 03/22/22 at 9:30 AM, the ADON #12 was notified of the breach of infection control. e) Hallway On 03/23/22 at 4:25 AM, the dirty linen cart was observed with the lid up due to being full. Dirty linen was observed laying on top of the dirty linen cart. Nurses Aide (NA #32) confirmed the dirty linen cart was full and the dirty linen was on top of the linen cart. On 03/23/22 at 4:50 AM, an additional dirty linen cart was observed with a stack of clean folded wash cloths and a bottle of peri-care cleaner on top of the lid. NA #32 confirmed they were using the same bottle of peri-care cleaner on each resident during incontinence care.Also, a box of clean gloves were observed sitting on top of the lid of the trash can which was sitting next to the dirty linen cart. NA #32 was interviewed regarding this observation. NA #32 was asked if this is how you were trained. NA #32 stated Yes. NA #32 stated she was unaware this was an infection control breach. On 03/23/22 at 5:15 AM, the Administrator was notified of the above infection control issues. No further information was obtained during the long term survey process. f) Dining room observation During a dining room lunch meal observation on 03/22/22 at 12:21 PM Nurses Aide (NA) #107 picked up a glass of juice at the rim of the glass instead of on the side. During an interview on 03/22/22 at 12:22 PM NA #107 stated I should not have picked up the glass that way I will not be doing this that way again. g) admission Observation Unit face shields and N95 An observation on 03/23/22 at 4:20 AM upon entering the AOU (in this unit it is required to wear a N95 mask and a face Shield). The Licensed Practical Nurse (LPN) #119 was not wearing a N95 mask or a face shield. LPN #119 stated my mask just broke do you know if they have any up front. An observation on 03/23/22 at 4:23 AM (Nursing Aide) NA #118, was not wearing the required Face Mask. Then LPN #119 unwrapped a face mask for himself and NA #118 to wear. During an interview on 03/23/22 at 5:15 AM The Executive Director was notified of the issues found on AOU and no other information provided. A review of the facility policy titled Use of Googles, Face Shields and N95 Respirators on and off units dated 02/28/22 found the following: .Staff must wear a face shield along with an N95 respirator . h)Blueridge Pantry Garbage An observation on 03/23/22 at 4:29 AM of the Blueridge Nourishment Room found the room had a foul odor, the garbage was overflowing, all the Resident's items not dated that were discarded from the refrigerators and freezers on 03/22/22 were stacked on the floor. During an interview on 03/23/22 at 5:15 AM The Executive Director was notified of trash in the Blueridge Pantry stated I will take care of it right now. i) Resident # 322 A review of the facility policy named Tracheotomy (Trach) Care with an effective date of 01/01/04 a Review date of 07/15/21 and a Revision date of 07/15/21 reads as follows: .8. perform hand hygiene 14. Remove gloves. Discard in waste bag and cleanse hands. 35. Remove PPE and perform hand hygiene LPN#114 failed to perform hand hygiene (HH) before, during or after trach care. LPN # 114 failed to perform HH before or after any glove changes during Trach care. LPN#114 failed to perform HH after discarding the used procedure tray from the bedside table and failed to wiped down bedside table after use. After removal of the vital sign spot machine from Resident # 322 hand LPN #114 placed the machine back in the hall way for use without any decontamination of the machine. On 03/22/22 at 12:14 PM, in an interview the DON and Administrator acknowledged Hand Hygiene was not performed per policy or CDC guidelines. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to ensure staff possessed the appropriate competencies required 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. These failed practices had the potential to affect all residents currently residing in the facility. The staff failed to ensure appropriate foot care, Activities of Daily Living Care (ADL), trach care and the failure to ensure residents are transferred in a safe manner. Resident Identifiers: #93, #27, #32, #107, #2, #323, #322, and #162. Facility Census: 121. Findings Included: a) Foot Care 1. Resident #93 During an interview on 03/21/22 at 1:24 PM, Resident # 93 said, her right big toe hurts. Observation of the right great toe, found an unknown type of purple stain on the toe. The toenail was growing up from the nail bed instead of outward and appeared to be very long and thick. In addition, there was dried crusted, brownish substance on the inner side of the great toe. After further observation all of the toenails were very long and not clean. A review of medical records found Resident # 93 had not been on the schedule to be seen by the facility podiatrist in the last six (6) months. Also, there was not any nursing notes about the toe being stained purple or having any dried crusted areas on the toe. Nursing skin assessments were completed on 03/03/22, 03/10/22, and 03/17/22. The right great toe was never mentioned. On 03/22/22 at 2:29 PM, the Director of Nursing (DON) observed the right great toe. The DON agreed there was dried drainage of some sort on the toe. The DON did not know what the purple staining was on the toe. The DON also agreed the toenails were very long and should have been trimmed. On 03/22/22 at 3:00 PM, the DON provided a piece of paper with names of Residents and a space by the names for handwritten notes. Beside of Resident # 93's name said, needs cut long. The DON stated this was a toenail audit and that it was completed on 03/15/22. The DON was then asked why the skin assessments completed on 03/03/22, 03/10/22, and 03/17/22 did not mention anything about the purple stain on her right great toe. The DON did not have a response. On 03/23/22 at 2:15 PM, the DON and Facility Nurse Practitioner (FNP) told this surveyor the purple stain on the toe of Resident #93 was Gentian Violet, and a family member had put it on her toe. The family have been told they cannot do toe care. The FNP was asked how long it had been on the toe. The FNP did not remember and indicated she did not write a note about it. When asked about the dried crust area on the inside of the residents toe the FNP stated, I was not told about that, I will go immediately and evaluate the toe. On 03/23/22 at 4:37 PM, FNP stated she cleaned Resident #93's right toe. She said, she did not think it was infected at this time. On 03/24/22 at 10:45 AM, FNP said she has scheduled an appointment for Resident #93 to be sent out to see a local Podiatrist, instead of having the resident wait to be seen in May. 2. Resident #27 On 03/21/22 at 12:43 PM, during an interview with Resident#27, the resident's toe nails were observed to be long. ADON #12 confirmed his toe nails needed trimmed. Resident stated I haven't seen the podiatrist. On 03/22/22 at 2:00 PM, the ADON #12 confirmed the podiatrist was at the facility on 03/14/22. ADON #12 stated I don't know why he wasn't seen. On 03/22/22 at 2:20 PM, SW #14 stated the resident didn't request to see the podiatrist. I will add him to the list. The podiatrist will be here on 05/16/22. 3. Resident #32 During an interview on 03/21/22 at 12:34 PM, Resident #32 stated, My toe nails are so long they are like talons. The podiatrist was here last week .they came in and never came back. I don't know why they didn't come back. On 03/22/22 at 2:00 PM, he Assistant Director of Nursing (ADON) #12 confirmed the resident's toe nails needed trimmed. ADON #12 stated The podiatrist was here on 03/14/22. I don't know why he wasn't seen. On 03/22/22 at 2:20 PM, Social Worker (SW) #14 stated the resident didn't request to see the podiatrist. I will add him to the list. The podiatrist will be here on 05/16/22. 4. Resident #107 During observation on 03/21/22 at 12:34 PM, Resident #107 was noted with long toenails. Resident #107 has a Brief Interview for Mental Status (BIMS) score of 5 (five) which indicates the resident is severely impaired cognitively. Resident #107 was unable to verbalize his needs regarding activities of daily living (ADLs). On 03/22/22 at 12:34 PM, the Assistant Director of Nursing (ADON) #12 confirmed the resident's toe nails needed trimmed. ADON #12 stated The podiatrist was here on 03/14/22. I don't know why he wasn't seen. On 03/22/22 at 1:24 PM, the Director of Nursing (DON) confirmed the podiatrist was in the facility on 03/14/22. The DON provided the consultant paperwork from the podiatrist dated 03/14/22 stated was not seen due to time constraint. On 03/22/22 01:30 PM, the DON stated I will check and see about next appointment. The DON also stated if the podiatrist doesn't see the resident due to a time constraint that's not our responsibility. On 03/22/22 2:20 PM, SW #14 stated the podiatrist will be back on 05/16/22. The podiatrist is responsible for not seeing the resident due to a time constraint. I'll make sure he is on the list. B) ADL Care 1. Resident #2 During an interview on 03/21/22 at 12:59 PM Resident # 2 stated, I am unable to see due to my cataracts, they won't feed me and I cant see to eat. I have to beg them to feed me. I have asked the nurse to cut my nails they are digging into my hand and I need a shave. An observation on 03/21/22 at 12:59 PM Residents #2's blanket had ravioli sauce from lunch meal he was presently eating, at the bottom of the blanket near his feet, green beans were on his left upper arm and on his bed sheet. Resident #2's face was unshaved and his hair was disheveled . Resident #2 asked Nurse Aide (NA) #74 to order him a hamburger so he could eat something. During an interview on 03/22/22 at 8:30 AM Resident #2 stated thanks so much for your help, I got shaved and my nails cut. I got a bed bath too. I am unable to feed myself I can eat like sandwiches and stuff like that I don't have to look for. Therapy says I can feed myself, but I cant see the food not that I cant do it. (NA #27 name) helped me with my breakfast. An observation on 03/22/22 at 8:30 AM Resident #2's blanket still had the ravioli stain at the bottom of the blanket near the Residents feet. During an interview on 03/22/22 at 8:32 AM NA #27 stated (Resident #2 name) does good with finger foods, but I had to feed him this morning because it was scrambled eggs, he wasn't able to chase those eggs around. On 03/22/22 at 8:33 AM NA #27 verified Resident #2's blanket was soiled. NA #27 stated I didn't work yesterday so I am not sure why they weren't change, but I will as soon as I finish picking up trays, I will change them. During an interview on 03/22/22 at 9:55 AM NA #116 and NA #96 stated, a bed bath consisted of washing full body, changing sheets and blankets, shaving and nail care. We do showers daily, their is no shower aide we do our own, some of them refuse so they get bed baths. During an interview on 03/22/22 at 10:53 AM the Director of Nursing (DON) stated when the NA gives a bed bath they are to change the sheets also. This surveyor informed the DON Resident #2 had documentation stating he received a bed bath on 03/21/22. Resident #2's bed sheets were soiled during the 03/21/22 lunch meal. The DON stated, I talked to LPN #75, this morning and she said she will look at him, he probably needs a order for finger foods instead. During an interview with 03/23/22 at 9:10 AM, Therapy Director #132 stated Residents name had physical, occupational and speech therapy evaluations, he refuses to let them evaluate him, throws things at them when they come in. We tried when he was readmitted on [DATE] and again on 03/04/22. During an interview on 03/23/22 at 10:00 AM, the Occupational Therapist (OT) #133, the Speech Therapist(ST) #134 and this surveyor was with Resident #2 in his room. Resident #2 got irritated with us asking him any questions, refused to answer any of the OT #133 and ST #134 questions. Resident #2 stated I do better with finger foods, now leave. 2. Resident #323 An observation on 03/21/22 at 1:08 PM, found Resident #323 was laying in bed and her hair was disheveled and greasy, with a tiny ponytail on top of her head. During an interview on 03/21/22 at 1:08 PM Resident #323 stated, I have not had a shower since I've been here, they wash you off if that's what you call it. Look at this grease clot hair. They change your clothes everyday but that's it. Nursing Documentation for task of Bathing had the following days and times checked for a bed bath: --Bed Bath on 03/14/22 at 2:21 PM --Bed Bath on 03/15/22 at 3:42 AM --Bed Bath on 03/15/22 at 9:51 AM --Bed Bath on 03/20/22 at 2:57 PM --Bed Bath on 03/21/22 at 2:59 PM Nursing Documentation for task of Bathing had the following days and times checked for resident refused: -- Resident Refused on 03/17/22 at 10:59 PM --Resident Refused on 03/18/22 at 6:59 AM During an interview on 03/22/22 at 11:31 AM the DON stated we asked her if she wanted a shower and she refused, she will get a bed bath and her hair washed today. 3. Resident #32 During an interview on 03/21/22 at 12:34 PM, Resident #32 was unshaven and disheveled. The resident stated, I don't know when I shaved last. Observations on 03/22/22 at 9:38 AM, found the resident remained unshaven. Resident #32 stated, I need a shave don't I. Observations on 03/23/22 at 9:06 AM, found the resident remained unshaven. Assistant Director of Nursing (ADON) #12 confirmed the resident had not been shaved and appeared disheveled. On 03/23/22 at 9:11 AM, ADON #12 stated the resident is getting shaved now. 4. Resident #107 During an observation on 03/21/22 at 12:34 PM, Resident #107 was unshaven and disheveled. Resident #107 has a Brief Interview for Mental Status (BIMS) score of 5 (five) which indicates the resident is severely impaired cognitively. Resident #107 was unable to verbalize his needs regarding activities of daily living (ADLs). On 03/22/22 at 9:38 AM, during observation the resident remained unshaven and disheveled. On 03/23/22 at 9:06 AM, the Assistant Director of Nursing (ADON) #12 confirmed the resident had not been shaved and appeared disheveled. On 03/23/22 at 9:11 AM, ADON #12 stated the resident is getting shaved now. c) Tracheotomy Care 1. Resident # 322 A review of the facility policy named Tracheotomy Care with an effective date of 01/01/04 a Review date of 07/15/21 and a Revision date of 07/15/21 read as follows: .3. Gather supplies 7. Evaluate patient's heart rate, respiratory rate, breath sounds, pulse oximetry, and cough effort. Evaluate sputum amount, color and consistency. 8. perform hand hygiene 14. Remove gloves. Discard in waste bag and cleanse hands. 34. Evaluate patient's respiratory rate, heart rate, heart rate, breath sounds, pulse oximetry, and cough effort 35. Remove PPE and perform hand hygiene On 03/22/22 at 11:125 AM, this surveyor observed trach care on Resident # 322 by Licensed Practical Nurse (LPN) #114. During the changing of the inner cannula LPN #114 attempted to to replace the inner cannula with an inner cannula that was to large in size. LPN #114 stated oh that is not a number 5 shiley. LPN#114 then tossed the inner cannula into the trash and obtained the right size inner cannula from the bedside table drawer. LPN#114 placed the spot vital sign machine on Resident #322 before trach care to monitor Resident # 322's oxygen saturations. When LPN #114 was changing out the inner cannula's the vital spot machine went blank and then went off . LPN #114 did not make any attempt to turn the machine back on during the procedure. LPN#114 failed to evaluate Resident's 322's heart rate or breath sounds before or after trach care. LPN #114 failed to evaluate Resident # 322's pulse oximetry after trach care. LPN#114 failed to perform hand hygiene (HH) before, during or after trach care. LPN # 114 failed to perform HH before or after any glove changes during Trach care. LPN#114 failed to perform HH after discarding the used procedure tray from the bedside table and failed to wiped down bedside table after use. After removal of the vital sign spot machine from Resident # 322 hand LPN #114 placed the machine back in the hall way for use without any decontamination of the machine. On 03/22/22 at 12:14 PM, in an interview with the DON and Administrator regarding trach care, they acknowledged LPN# 114 should have had the right size inner cannula ready before the start of care and it is policy to assess the Resident before and after the procedure. The DON and Administrator acknowledged Hand Hygiene was not performed per policy or CDC guidelines. d) Resident Transfer 1. Facility Policy Facility policy titled, NSG234 Resident Handling/Transfer Equipment, revision date: 10/01/21. - Gait belt use should be evaluated if the patient has any of the following: - back fracture 2. Resident #162 Review of medical records revealed Resident #162 was admitted on [DATE] with a new Fracture of neck of left femur, as a result received a rod and pins surgically to repair the femur. In addition, the local hospital discharge report stated Resident #162 suffered a compression fracture to her Lumbar spine location L2. These injuries were from a fall at the home of Resident #162. Resident #162 is also blind and has dysphasia from a previous cerebral infarction. During an interview on 03/21/22 at 1:12 PM, Resident #162 was noted to be in the bed moaning and asking for pain medication. The daughter of Resident #162 said, about 10 minutes ago Nurse Aide (NA), (called NA # 106 by name) had just put her mother in the bed. The daughter went on to say NA #106 hurt my mother. NA #106 hurt her when he had Resident # 162 give him a hug around his neck and he squeezed her around her whole body and hurt her ribs and back. Daughter said, even when my mother yelled out and said you are squeezing me and hurting me, NA #106 did not stop. Resident #162 was asked if a nurse had come in to assess her pain. The Daughter said, she cannot find a nurse to tell. On 03/21/22 at 1:21 PM, this surveyor located Licensed Practical Nurse # 117 (LPN) and informed her of what Resident #162 reported. LPN# 117 stated she was not aware that NA #106 had hurt Resident # 162 and will check her out. LPN#117 went to the room of Resident #162 and asked the daughter how was Resident #162 supposed to be transferred? LPN #117 asked the daughter is she a one or two person assist or is she a lift patient? The daughter said, I don't know what you are asking me? I don't have any medical training, so I don't know what any of that means. A review of medical records revealed the facility Attending Physician made changes to the pain medication for Resident #162 after being informed of the increased pain after the transfer from wheelchair to bed on 03/21/22. The following medication were changed on 03/21/22: -Hydrocodone-Acetaminophen 10-325 MG, give 1 tablet by mouth every 4 hours as needed for pain for 14 days. Start date was 03/08/22 and end date 03/22/22. This was discontinued on 03/21/22 at 3:47 PM, -Ibuprofen 800 mg by mouth one time now for pain. Started on 03/21/22. -Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet two times a day for pain. Started on03/21/22. -Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet every 8 hours as needed for pain. Started on 03/21/22. On 03/21/22 at 4:30 PM, the Director of Nursing (DON) provided copies of the reportable which was started on 03/21/22 at 3:48 PM. This was reported to the facility staff on 03/21/22 at 1:21 PM. The following statements were collected (the statements are typed as written.) Nurse Aide Registry Immediate fax reporting of Allegations Incident date: 03/21/22 Alleged Perpetrator: (Named) NA#106 Allegation: Allegation by family member that when staff transferred resident, he squeezed too hard possibly causing injury. NA #106 written statement: dated 03/21/22: 401A Resident's family requested the resident be transferred from chair to bed. I positioned the bed and wheelchair accordingly. Then I transferred resident to the bed. The resident made noise during the transfer. I carefully placed resident in the bed and resident complained about pain. I checked resident for injury but found none. I proceeded to change resident's brief and cleaned her up. Once done, I checked resident one more time. Then informed the nurse. No further complaints. LPN #117 written statement: Dated 03/21/22: State Surveyor approached me in the hall and asked what I would do if one of my residents was injured. State Surveyor informed me that (named) Resident #162 had been complaining of pain after being transferred back to bed by CNA (NA). Informed State Surveyor I was unaware of situation, immediately assessed resident for signs of bruising in area of pain (said ribs). Obtained VS (vital signs), WNL (within normal limits), notified nursing unit supervisor and (Named facility nurse practitioner), (FNP). No s/s (sign or symptom) of acute distress at this time, no redness, intercostal areas, lung sounds clear. FNP ordered x-ray of right rib series. Made family aware. Social Worker (SW) #14 statement: No date on statement This (LSW) spoke with resident and resident's daughter this date r/t (related to) to their allegation the (CNA) NA squeezed resident too hard when transferring her and could've caused injury. Resident's daughter stated that resident told CNA she was in pain and CNA did not stop the transfer and continued transferring her onto the bed. Resident's daughter stated that CNA was bear hugging resident and holding her so tightly that she was afraid resident had broken ribs. Social Worker (SW) #14 and Administrator interview statement: No date on statement LSW interviewed resident with Administrator present, no family at bedside. LSW asked resident if CNA (named NA #106) had hurt her during transfer. Resident responded no, but I hurt all the time being so old. LSW asked resident if she ever felt abused by (named NA #106), to which she responded no. She stated that all staff are good to her and pain medicine has been helping. This was signed by SW #14 and Administrator. A review of the Care Plan created by the facility revealed the following: Focus Statement: -Resident requires assistance for Actives of Daily Living (ADL), care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, ambulation, locomotion, and toileting related to: Recent illness, fall with injury, hospitalization. Goal related to this focus statement: -- Resident will improve current level of function in: bathing, grooming/personal hygiene, dressing, eating, bed mobility, transfers, ambulation, locomotion, as evidenced by improved ADL scores. Interventions related to this goal included: -For Your Information: Resident is hard of hearing and is legally blind. -Provide extensive to dependent assist x1 with locomotion on/off unit. -Provide patient with 1-2 assist with transfers. -Provide resident with extensive assist of 1-2 for bed mobility. -Provide resident with extensive assist of 1-2 for toileting. During an interview on 03/23/22 at 10:26 AM, the Director of Nursing (DON) was asked who makes the decision of using one (1) person or two (2) people to transfer Resident # 162. The DON stated, the decision would be based on how Resident #162 was able to do for herself. DON went on to say Resident # 162 might only need one (1) person to help her in the morning and might be tired and need a two (2) person assist in the evening. The DON was then asked who was responsible for making this decision on how many people it would take to safely transfer Resident # 162. The DON did not provide an answer to this question. A review of the facility form titled, Occupational Therapy OT initial Evaluation, dated 03/09/22 did not contain the diagnosis of the L2 Compression fracture. This diagnosis was included on the hospital discharge summary and the progress note written by the Family Nurse Practitioner. In the sections of this evaluation form that determined the type of assistance Resident #162 would require for the area of functional transfers the following was contained: - Moderate assistance Care area of bed mobility: -Moderate Care area of toileting with use of toilet/commode: -Maximal assistance The above OT evaluation was the only one provided to the survey team. An interview on 03/23/22 at 10:30 AM, with Occupational Therapist, Registered (OTR) #133, was asked what did it mean if a resident was evaluated to need moderate assistance for transfers. OTR #133 stated it means the staff should use a Hoyer lift when transferring the resident. During an interview on 03/23/22 at 10:44 AM, with the Director of Physical Therapy (DPT) when asked to explain what the term Moderate Assist meant. The DPT was looking at Resident #162's record. The DPT said the term moderate means the facility nursing staff, nurses and/or Nurse Aides should be using a lift such as a Hoyer lift to transfer Resident #162. A further review of the electronic medical record revealed on 03/18/22 the DON made a change to the level of assistance needed for Resident #162 for transfers from moderate to minimal assist. During an interview on 03/23/22 at 10:50 AM, the DON was asked why the level of assistance for transfers was changed on 03/18/22. The DON Stated the, Certified Occupational Therapy Assistant (COTA) #143 verbally told her too. The DON went on to say COTA #143 also trained the staff on how to transfer Resident #162 on this day. The DON did not know if it was a formal training or/not with having the staff sign saying they were trained. The DON was asked if she could provide an evaluation form from the physical therapy department that would reflect Resident #162 had improved and now required a lower level of assistance for transfers. The DON stated, No it was all verbal. On 03/23/22 at 11:18 AM, the DON, the DPT, and COTA #143 entered the room to tell this surveyor more information. The DPT said we (the therapy department) were not aware COTA #143 had re-evaluated Resident #162 and had failed to update the physical therapy records. At the above time COTA #143 was asked if he trained the staff on how to safely transfer Resident #162? COTA #143 nodded his head to indicate yes. COTA #143 was asked to demonstrate how the staff was instructed to assist Resident #162 during transfers. COTA #143 demonstrated on DPT. He held his arms out straight and said the staff would only have to place their hands or forearm on the trunk of the body only to stabilize and support Resident #162 and would not lift or pull-on the resident. The DPT was then asked if it was acceptable to transfer any resident using the Bear hug technique? The DPT stated NO, because this is a no lift facility. The DPT was asked if it would be appropriate to transfer a resident by wrapping your arms around a resident if the resident had a diagnosis of a lumbar spine compression fracture. The DPT said, NO. On 03/24/22 at 7:45 AM, the Administrator provided a typed paper titled, Education/In-service Training sign-in sheet. Facility name, dated: 03/18/22 Topic: Safe transfers Resident #162 (named resident) requires extensive assistance of 1-2 people. She may require more or less assistance depending on pain level or fatigue. She requires sequencing of events prior to transfers (ie. We are going to stand up and take two steps to the chair.). (Called resident by name) is legally blind and requires frequent reorientation to her surroundings. She requires a gait belt and front wheeled walker for transfers. Attendees Name: Title/department: shift: date: There were two (2) staff members who had signed this paper. Licensed Practical Nurse # 117 shift: 7a-7p, date: 03/18/22 Nursing Aide # 106, Shift: 7a-7p, date: 03/18/22 No other staff were listed. During a phone interview on 03/24/22 at 8:30 AM with all surveyors present, NA #106 was asked to please describe step by step how Resident #162 was transferred from the wheelchair on 03/21/22. NA #106 stated, first he bent over and asked the resident to hug him around the neck, then he placed his arms around the resident's waist and back, securely holding her body to his, picked her up and placed her from the wheelchair to the bed. NA# 106 was asked to clarify did he wrap his arms around the body of Resident #162 and pick her up to put her in the bed? NA #106 stated, yes, I did. NA #106 was asked when did he last receive training on how to transfer Resident #162? NA #106 stated he was trained on patient transfers in Nurse Aide classes. NA #106 was asked if he was trained on how the transfer Resident #106 on 03/18/22? NA #106 said, No I did not even work in that area of the facility on 03/17, or 03/18/22 he was pulled to Blueridge side, (which is located on the opposite side of the facility). NA #106 was asked if he signed a paper on 03/18/22 about transfers for Resident #162? NA #106 said, No I have not signed any paper on that day or any other day about that. .