Every finding on record at Accura Healthcare of New Hampton

Based on observation, clinical record review, resident interview, staff interview, and facility policy review the facility failed to maintain comfortable room temperatures and interventions to maintain resident comfort levels during a heating mechanism malfunction that lasted for an extended period of time for 5 of 5 residents reviewed (Resident #1, #2, #3, #5, and #6). The facility identified a census of 31 residents.Findings include: On 12/4/25 at 3:15 p.m., Resident #1 indicated he resided at the facility for two years and the facility dealt with heating/cooling issues about every six months. In this case, the system acted up for 1.5 weeks prior to Thanksgiving when it really felt cold. The resident indicated yesterday had been the first day the facility staff offered him to change rooms because his room lacked heat. The resident confirmed he would have moved sooner if offered because he felt cold. The resident indicated the facility offered more blankets, he had to ask for coffee/tea, the facility checked the temperatures in his room but never his body temperature. The resident verbalized concern for those residents that could not speak for themselves and how they felt with no heat. During an interview 12/4/25 at approximately 12:45 p.m., Resident #2, identified as not interviewable by the facility, confirmed it had been cold in the facility the past week and staff gave him extra blankets but he still felt cold. On 12/4/25 at 2:55 p.m., Resident #2 confirmed staff only asked him yesterday if he wanted to move to a different room which he refused. During that time the resident indicated the heat malfunctioned and he felt cold, even with blankets, and facility staff failed to offer him warm drinks. During an interview 12/4/25 at 3:35 p.m. Resident #3 confirmed it had been cold in the facility for the past week or so and it had not been until the last evening the facility repaired the heat. The resident indicated during the time the heat malfunctioned the facility staff placed space heaters in the hallways and gave residents more blankets but failed to offer warm/hot drinks and even with those interventions the resident remained cold. The resident confirmed the first time staff asked him if he wanted to change rooms to the warm area of the facility had been yesterday and he agreed however he would have moved sooner. During an interview 12/4/25 at 3:45 p.m., Staff A, [NAME] indicated the facility always provided coffee, tea, warm water, etc. to any resident who asked. However, they failed to set up an additional station for availability of said items to all residents at any time. During an interview 12/4/25 at 4:09 p.m., Staff B, Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA) confirmed she worked when the heat became nonfunctional and the temperatures in occupied resident rooms ran between 50 or 60 degrees, as noted from thermometers in the individual resident rooms. The staff member confirmed most of the resident complained of the cold. Staff gave residents more blankets but only moved residents that asked. The staff member confirmed staff only offered resident hot drinks during meals.During an interview 12/5/25 at 1 p.m., Staff C, CNA/CMA indicated she recalled an unknown occupied resident room temped out at 60 degrees F when the furnace broke. The staff member confirmed residents complained of the cold but no hot drinks were offered during that time span. During a tour and interview 12/4/25 at 12:45 p.m. Staff D, Maintenance Supervisor indicated the delay in the heating unit repair had been corporate approval as the situation entailed the circulation pump for hallways 100 and 300, which started to act up. Staff D further described the unit made noises on Wednesday, 11/26/25. On Thursday (Thanksgiving), himself and a local plumbing and heating repair person attempted to repair the system, however it only lasted three hours. The staff member indicated the heating system remained non-functional in the affected areas until 12/3/25. Staff D indicated the other staff moved the affected residents into the heated area of the facility, placed fans along with radiator type portable heaters in the hallways, increased the heating temperatures in the common areas and the hallways with heat (the 200 and 400 hallways) and the dining room . The tour continued as Staff D took the current temperatures in the resident rooms as identified below: room [ROOM NUMBER] = 65.8 F (room not in working order at current time) room [ROOM NUMBER] - 64.7 F on the window wall with room occupied by Resident #5. The resident indicated she felt cold a little bit, but better than the other day. The inside wall registered 70.1 F on inside wall where thermostat had been is located. room [ROOM NUMBER] - 62.8 F outside wall by window with the room occupied by Resident #6. The inside wall 72.7 F. The resident reported it had been very cold through the weekend but the facility offered blankets. Staff D indicated resident room should have stayed around 70 degrees F. On 12/4/25 at 1:32 p.m. Staff D indicated the facility had already started the process of corporate approval the week prior on the 18th, when the heating pump downstairs started making a noise and leaked, but remained functional. Review of the facilities Loss Of Heating System policy and procedure updated 4/2018 included the following nursing and food service directives:a. Extra blankets which included bath blankets.b. Grouped residents into rooms if possible. c. Provision of hot foods and drinks as applicable.

Based on staff interviews, employee job description, and Facility Assessment the facility failed to have the Infection Preventionist (IP) work at least part-time in the role. The facility reported a census of 40 residents.During an interview with the Infection Preventionist/Minimum Data Set Coordinator on 7/30/25 at 2:05 PM revealed she works in the IP role about an hour a week and has not completed staff competencies or audits related to infection control. She informed she does not have time to complete as she will get pulled to the floor or have to work on MDS's. She revealed she will look at the antibiotic resident line listing report to see what's going on but that is it. Review of the Facility Assessment Tool last reviewed on 1/7/25 instructed the Infection Preventionist need for the facility is one (1) employee who works part-time (3-8 hours). Review of Job Description: Quality Assurance & Infection Preventionist Nurse last revised non 11/16/2023 informed an essential job function of the role is to provide education related to infection prevention and control principles, policies, and procedures to staff, residents, and families (where appropriate). During an e-mail correspondence with the Administrator on 7/31/25 at 10:30 AM revealed the Infection Preventionist nurse would be expected to focus weekly on the infection control job duties focusing on the effectiveness of audits, education, and requirements for tracking/trending and implementation of the antibiotic stewardship program. During a follow up e-mail correspondence with the Administrator on 7/31/25 at 10:57 AM revealed the expectation of the Infection Preventionist is to work 3-8 hours. She does not have a set schedule, but is to work it into her schedule as it allows. During an interview with the Director of Nursing (DON) on 7/31/2025 at 11:20 AM revealed she does not think the Infection Preventionist is working 3-8 hours in that role a week, but maybe works a couple or 1-2 hours a week in that role.

Based on observation, policy review, 2022 United States (US) Food and Drug Administration (FDA) Food Code, and staff interviews, the facility failed to prevent soiled gloves or soiled utensils from coming into contact with food during food service for 34 of 40 residents served (Resident #2, #3, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #18, #20, #22, #23, #24, #25, #26, #27, #28, #29, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, and #42. The facility identified a census of 40 residents.Findings include: While under continuous observation on 7/29/25 from 12:02 PM to 12:11 PM Staff A, Dietary [NAME] after touching, the stove, a steam pan, thermometer, steam pan lid, applied gloves without washing her hands. She then rubbed the back of the left gloved hand on her left hip of her uniform and pulled her uniform top down in the back with both gloved hands. Staff A then touched bread with either the back of her left gloved hand, fingers of the left gloved hand or palm of her left gloved hand to move or hold bread in place on the plate so she could plate mash potatoes, roast beef and place a bowl of mixed vegetables on resident plates. Staff A continued this same manner of plating food for Resident #5, #7, #20, #24, #25 and #36.At 12:11 PM Staff A with her gloved hands pushed a tray cart of room trays toward the kitchen door to Staff B Dietary Aide. Staff A with gloved hands pushed a second tray cart and positioned the cart by the steam table. Staff A lifted a stack of plate covers by the steam table and moved the plate covers to the sink countertop, then walked to the walk-in refrigerator and opened with her left gloved hand. Staff A returned from the walk-in refrigerator with a covered bowl and placed on top of the steam table.At 2:12 PM Staff A continued to plate bread and move the bread on the plate with either the back of her left gloved hand, left gloved fingers or left gloved palm to plate additional food items on each resident plate for Resident's #3, #14, #16, #22, #23, #28, and #32.At 12:19 PM Staff A obtained a small bowl with her left gloved hand, rested the bowl against her apron while she walked to the dry pantry and placed cereal in the bowl. Staff A placed the bowl on the steam table, removed her gloves, then walked over and picked up her personal water bottle and drank. Staff A then applied gloves without washing her hands.Observation at 12:21 PM revealed Staff A continued to plate bread, touch utensils, then touch the bread with her left gloved hand to move on each resident's plate as she plated additional food items. The plates were served out to Resident's #12, #15, #18, #27, #29, #33, #34, and #35.Observation at 12:24 PM Staff A picked up a blue #16 scoop backwards in her right gloved hand, braced the scoop against her front apron to turn the scoop around, then utilized the scoop to plate pureed bread for Resident #15. Staff A also used the blue #16 scoop to also serve pureed bread to Resident's #6 and #8.At 12:29 PM Staff A opened the walk-in refrigerator with her left gloved hand and returned holding a plated salad with both gloved hands. Staff A then moved two meal tickets off of the prep table with her left gloved hand, then handled a stack of meal tickets in both gloved hands.Observation at 12:30 PM Staff A resumed plating bread and touching bread with soiled gloves for residents #8, #10, #13, #26, #37, #38, #39, #41, and #42.During an observation at 12:41 PM Staff A placed her left gloved thumb inside a bowl to move the bowl to the preparation table, then went back to plating bread and touching with the left gloved fingers and served the plates to Resident #2 and #9. At 12:44 PM Staff A steadied bread on the plate while she placed mash potatoes on the plate. The plate was served out to Resident #40.During an interview on 7/29/25 at 12:52 PM Staff A voiced the only training she received was from the prior staff member that had trained her. She reported she had not had any other type of training or video training on food handling or gloving.Interview completed 7/29/25 at 1:41 PM Staff B stated she didn't recall receiving much training on gloving but she had been trained to use gloves for only one task. If you switch tasks, you have to change your gloves and wash your hands between glove changes. You cannot touch other items or things while you are touching food with gloves.Interview on 7/29/25 at 1:46 PM Staff C, Dietary [NAME] explained once gloves are on you can only touched that one food item. You cannot touch your clothes, face, apron, or any other items/surfaces. If you do, you have to wash your hands and then apply new gloves before going back to touching food.During an interview on 7/29/25 at 2:05 PM the Certified Dietary Manager (CDM) explained they have provided education on how to use gloves and when to change gloves and wash hands. If staff are using utensils, they do not need to use gloves. The staff get into bad habits when they wear gloves all the time. She expects staff to use gloves for one task only. If they staff have to change tasks to touch anything else, they have to remove the gloves, wash their hands and put on new gloves. Gloves can only be used for one task and hand must be washed between gloved changes. The General Food Preparation and Handling Policy, dated 2021, directed bare hands should never touch ready to eat raw food directly. Disposable gloves are a single use item and should be discarded after each use. Employees should wash hands prior to putting gloves on and after removing gloves. Food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. Tongs or other serving utensils will be used to serve breads or other items to avoid bare hand contact with food. Staff will handle utensils, cups, glasses, and dishes in such a way as to avoid touching surfaces that food or drink will come in contact with.The Bare Hand Contact with Food and Use of Plastic Gloves Policy, dated 2021, documented Staff would use clean barriers such as single-use gloves, tongs, deli paper and spatulas when handling food. Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning work with food) and after removing single use gloves.The 2022 US FDA Food Code under 2-301.14 When to Wash (hands) directs food employees to clean their hands and exposed portions of their arms immediately before engaging in food preparation, after handling soiled equipment or utensils, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, before donning gloves to initiate a task that involves working with food, and after engaging in other activities that contaminate the hands. The Food Code at 3-301.11 Preventing Contamination from Hands directed food employees may not contact exposed, ready to eat food with their bare hands, and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves or dispensing equipment.

Based on staff interviews and record review the facility failed to ensure 1 of 1 residents current Preadmission Screening and Resident Review (PASRR) assessment reflected all current diagnoses and medications related to mental health (Resident #7). The facility reported a census of 40 residents. Record review of Resident #7 Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. The MDS informed she is not considered by the state to be a PASRR level II. Record review of Resident #7 current PASRR dated 6/26/2024 documented mental health diagnoses of depression and anxiety. The PASRR also documented she currently takes antidepressant medications. Record review of Resident #7 Order Summary Report signed by her Doctor on 6/16/2025 documented current mental health diagnoses of anxiety, insomnia, delusional disorders, personal history of adult neglect, depression, and hallucinations. It also documented she currently takes antipsychotic, antidepressant, and antianxiety medications. During an e-mail correspondence with the Administrator on 7/30/25 at 11:37 AM revealed the facility is planning to resubmit Resident #7 PASRR to reflect her current medications and diagnoses. During an interview with the Administrator on 7/31/2025 at 9:37 AM revealed the facility submitted a PASRR for review on 7/30/25 to reflect her current condition and are still waiting to hear back. Review of Resident #7 current Care Plan on 7/30/2025 documented the following focus care areas:a. Resident #7 has occasional behaviors of refusing/rejecting care that is necessary to achieve her goals for health and well being related to anxiety disorder and major depressive disorder.b. Resident #7 has impaired thought processes related to behavioral symptoms, delusional disorders, aging process, and hallucinations.

Based on observation, clinical record review, policy review and staff interview the facility failed to serve diets to meet the residents individualized needs for of 3 of 3 residents sampled (Resident #15, #23, and #34). The facility identified a census of 40 residentsFindings include:1. Resident #15's clinical record showed a 3/11/25 Physician Order for a regular diet, pureed texture, double protein. Resident #15's Potential Nutritional Problem Care Plan, revised 3/27/25, documented Resident #15 received a double portion with all three meals to aide in weight gain and directed the staff to serve the diet as ordered with double protein, pureed texture.On 7/28/25 the facility provided a Tuesday, Week 5 Menu signed by the Dietician which listed the following regular and pureed diet:a. Roast Beef 3 ounces, 1 servingb. Mash Potatoes 4 ounces (oz)c. Beef gravy 2 oz ladled. California blend vegetables 4 oze. Bread/margarine 1 eachA Facility provided 7/28/25, 10:34 AM Diet Order Tally Report listed four residents required a pureed diet (Resident #6, #8, #15 and #33).Observation on 7/29/25 at 11:33 AM Staff A, Dietary Cook, placed four, 3 oz servings of roast beef and four, 2 oz ladles of gravy into a food processor and blended into a pureed mixture. Staff A reported a total volume of 1 3/4 cups roast beef puree. Staff A checked the Pureed Diet Portion Sizes/Scoop Chart and stated the serving size for each resident was a #10 (3.25 oz) slightly heaping scoop. Staff A failed to prepare an extra serving of pureed roast beef for Resident #15.During an observation on 7/29/25 at 12:24 PM Staff A plated one #10 scoop of pureed roast beef on Resident #15's plate and served out the plate. Staff A as she moved Resident #15 meal ticket voiced she caught her mistake and had not served Resident #15 out a double protein portion. Staff A failed to serve out another #10 scoop serving of pureed roast beef or prepare another 3 oz serving of roast beef for Resident #15. Meal service ended at 12:47 PM and Staff A did not serve out a second portion of roast beef to Resident #15. Observation at this time revealed a small amount of pureed roast beef left in the steam pan.Resident #15's Lunch Meal Ticket documented a pureed diet and under the Notes/Alerts listed to provide double protein. 2. Review of Resident #23's clinical record showed a 3/27/24 Physician Order for a regular diet. Resident #23's Care Plan revised 5/01/25 identified a Potential Nutritional Problem and directed the staff to add extra butter and gravies to appropriate foods to increase caloric intake.Observation on 7/29/25 at 12:12 PM Staff A placed bread on Resident #23's plate, touched the bread with her left gloved hand to move on the plate as she placed mash potatoes and gravy on the plate. Staff A served out Resident #23's plate without additional servings of gravy or butter being added to the meal.Resident #23's 7/29/25 Lunch Meal Ticket documented a regular diet with thin fluids. The Meal ticket lacked documentation under Notes, Alerts or Standing orders of the need to provide extra butter or gravy to appropriate foods with meals.3. A 7/28/25 10:34 AM Diet Order Tally Report listed Resident #34 on a regular diet. Resident #34's Care Plan revised 6/03/25 documented a Potential Nutritional Problem and directed the staff to add extra butter/gravies to appropriate foods to increase caloric intake (initiation date 7/18/24; revised date of intervention 11/06/24).Observation completed 7/29/25 at 12:25 PM revealed Staff A plated roast beef, bread, mash potatoes with one 2 oz ladle of gravy, and vegetables and served out to Resident #34. Staff A failed to serve extra butter or gravy with the meal. Resident #34's Lunch Meal Ticket listed a Regular diet with thin liquids. Resident 34's Meal Ticket lacked any communication under Notes, Alerts or Standing Orders to provide extra butter or gravy on appropriate foods to increase caloric intake. Interview on 7/29/25 at 1:41 PM Staff B, Dietary Aide voiced the meal tickets are updated by the Certified Dietary Manager (CDM). Interview on 7/29/25 at 1:50 PM Staff B explained she didn't know how it was communicated from the care plans to the kitchen on which residents received extra gravy and butter with meals. It isn't on the meal tickets. Staff B directed to talk to the CDM as maybe she had not updated the meal tickets yet. They serve the resident diets as specified on the meal tickets.Interview on 7/29/25 at 1:46 PM Staff C, Dietary [NAME] reported the meal tickets are updated by the CDM. He refers any dietary changes or resident requests to the CDM. If a resident need anything special for their diet, it should be on the meal ticket. The cooks put the meal tickets on the resident meal trays so when the Certified Nursing Assistants serve the plates, they can double check the meal matches the ticket. They serve the diet as posted on the meal tickets.During an interview on 7/29/25 at 2:05 PM the CDM reported she is responsible for updating the meal tickets and thought she had all the meal tickets up to date. She reviewed Resident #34 care plan, then stated the Cooks would not know to serve the extra items if it wasn't on the resident's meal ticket. In regard to Resident #15, she expects the staff to serve out the resident diet as specified on the meal ticket. The meal tickets should specify the dietary needs of the residents and be followed. Care planned interventions would be communicated to the cook through the meal tickets. The Standardized Menus Policy, revised 2025, included a definition of Reasonable effort to assess the individual needs and preferences and demonstrate actions to meet those needs and preferences. The facility would make reasonable efforts to review, and/or adjust the menu and/or the individual resident's food plan to meet the nutritional needs and preferences of the resident. The Policy failed to address the use of resident meal ticket, how often meal tickets are updated and who has the responsibility to update the meal tickets.

Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interview the facility failed to complete a Minimum Data Set (MDS) Significant Change in Condition Assessment (SCSA) for 1 of 1 residents reviewed for bowel and bladder (Resident #3). The facility identified a census of 40 residents.Findings include:A Quarterly Nursing Assessment Progress Note dated 1/07/25 at 10:25 PM documented Resident #15 utilized the toilet to void, was always incontinent of urine and occasionally incontinent of bowel and required extensive assistance from staff for personal hygiene.Resident #3 1/08/25 Annual MDS Assessment showed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. The Resident had an upper extremity impairment (shoulder, elbow, wrist, hands) and a lower extremity impairment (hip, knee, ankle, foot) on one side of the body and utilized a walker. The MDS documented Resident #3 was independent in toileting hygiene and frequently incontinent of bladder and continent of bowel. The MDS listed diagnoses of non-traumatic brain dysfunction, benign prostatic hyperplasia (BPH, a condition in men where the prostate gland enlarges which can place pressure on the bladder and cause urinary problems), diabetes mellitus, thyroid disorder, Non-Alzheimer's Dementia, anxiety, bipolar disorder, retention of urine, unspecified and other disorder of the kidney and ureter.The 1/08/25 Urinary Incontinence Care Area Assessment (CAA) documented Resident #3 sas frequently incontinent of urine, wore pull up briefs and needed occasional assistance for incontinence care. The CAA Care Plan Considerations documented the overall objection was to improve the resident's urinary incontinence.A Quarterly Nursing Assessment Progress Note dated 4/08/25 at 2:43 PM documented Resident #15 as always incontinent of urine and frequently incontinent of bowel. The 4/09/25 Quarterly MDS Assessment showed a BIMS score of 15/15 indicating intact cognition. The MDS documented at GG0130C5 Toileting Resident #3 required substantial/maximal assistance (helper does more than half the effort. Helper lifts, holds trunk or limbs and provides more then half the effort). The MDS documented Resident #3 as always incontinent of urine and at H0400 always incontinent of bowel.A 4/09/25 MDS Assessment Validation Warnings Report documented a Significant Change Decline in section GG0130C5 and section H0400. The Validation Warning report was acknowledged by the MDS Coordinator on 4/18/25 at 9:33 AM.The Activities of Daily Living (ADL) Self-Care Performance Deficit Care Plan, revised 4/18/25, under toileting hygiene directed Resident #3 was incontinent of bowel and bladder, wore disposable pull up briefs and needed occasional substantial to maximal assistance of one staff person with incontinence cares.A 7/30/25 review of the April 2025 Documentation Survey Report V2 documented Resident #3 had 21 episodes of urinary incontinence (no episodes of being continent) and 19 episodes of bowel incontinence in the seven-day look-back period.A 7/30/25 review of Resident #3 MDS Tracking page revealed Resident #3 had not been set up for a Significant Change in Status MDS Assessment from January 2025 to July 2025.During an interview on 7/30/25 at 12:52 PM the MDS Coordinator explained she identifies a significant change in assessment if a resident goes on or comes off of hospice care services or if they have a decline or improvement in two areas of the MDS assessment. The MDS Coordinator reported after reviewing Resident #3 7/09/25 quarterly MDS to the 1/08/25 annual MDS, it warranted a significant change. She voiced she doesn't have a report she runs, she just relies on what she sees or what staff report to her. She had been working the floor a lot and it slipped through the cracks. She further voiced the facility did not have an MDS policy. She follows the MDS RAI User Manual for completing the MDS assessments. Interview 7/30/25 at 12:56 PM Staff D, Certified Nursing Assistant (CNA) reported Resident #3 had previously used the toilet and a urinal, but hadn't for a long time. Resident #3 never wants to get out of bed. He wears disposable briefs and has been dependent upon staff for check and changes for a long time. The CMS LTC RAI 3.0 User's Manual, Version 1.19.1 October 2024, Chapter 2, page 2-24 under Significant Change in Status Assessment (SCSA) directs the SCSA is a comprehensive assessment that must be completed when the interdisciplinary team (IDT) has determined that a resident meets the significant change guidelines for either a major improvement or decline. A Significant Change is defined as a major decline in a resident's status that:1.Will not normally resolve itself without interventions by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting.2. Impacts more than one area of the residents' health status; and3. Requires interdisciplinary review and/or revision of the care plan.When a resident's status changes and it is not clear whether the resident meets the SCSA guidelines, the nursing home may take up to 14 days to determine whether the criteria are met. After the IDT has determined that a resident meets the significant change guidelines, the nursing home should document the initial identification of a significant change in the resident's status in the clinical record. Under Some Guidelines to Assist in Deciding if a Change is Significant or Note the RAI include:a. Any decline in an ADL functioning area where a resident was newly coded as substantial/maximal assistance.b. Resident's incontinence pattern changes.

Based on clinical record review and staff interview the facility failed to follow the Care Plan for 1 of 3 residents reviewed (Resident #1). The facility identified a census of 42 residents. Findings include: A Care Plan for Resident #1 directed the facility staff the resident required the following Focus and Intervention areas as dated: a. An activities of daily living (ADL) self-care deficit related to (r/t) a stroke, type II Diabetes Mellitus, peg tube (gastrostomy tube), low vision in both eyes, obesity, hemiplegia on his left side (paralyzed), and respiratory failure. (initiated 1.15.25 and revised 4.11.25). 1. Dependent on two (2) staff members with bed mobility. (initiated 1.15.25 and revised 4.11.25) b. Impaired cognition r/t a Cerebral Infarct (stroke). The resident suffered from an inability to verbalize. (initiated 1.10.25 and revised 4.30.25) c. At risk for falls r/t a stroke, psychotropic medication use, hemiplegia, immobility, poor vision in both eyes, and obesity. (initiated 1.15.25 and revised 5.13.25) 1. Bed in lowest position when positioned in bed. (initiated 5.5.25) 2. Utilized a body pillow when repositioned. (initiated and revised 4.22.25) 3. Notification of the resident, family, and care givers of any new areas of skin breakdown. (initiated 1.15.25 and revised 4.30.25) According to a Progress Note entry dated 6.3.2025 at 8:50 p.m. the resident had been found on the floor beside his bed and sustained an abrasion to his right knee that measured 4 cm x 2 cm. The new intervention directed the facility staff to have performed 2 hour staff checks when they walked past his room. During an interview 6.4.25 at 12:45 p.m. Staff C, Licensed Practical Nurse (LPN) confirmed when she received report that morning the night shift staff informed her of the fall but failed to inform her of the abrasion to the resident's left knee or the every 2 hour staff walk by his room checks. According to a Progress Note entry dated 5.2.2025 at 2:29 p.m. the nurse walked into the resident's room and found the residents' bed in a high position and the resident positioned on the floor on the left side of his bed, towards the window and on his hands and knees. The resident sustained an abrasion (superficial open areas) to both his knees. During an interview 6.4.25 at 11:15 a.m. Staff C, LPN confirmed the resident's bed as not positioned all of the way to the floor prior to his fall on 5.2.25. During an interview 6.4.25 at 10:50 a.m. Staff A, Certified Nursing Assistant (CNA) confirmed she worked 5.2.25 and when she entered the resident's room she found him positioned on the floor on all fours and the bed not in it's lowest position. The staff member confirmed staff should have absolutely followed each individual resident's Care Plan. According to an email 6.4.23 at 10:33 a.m. the Administrator confirmed she expected staff to have followed the individual resident's Care Plans.

Based on clinical record review, staff interview, and facility policy review, the facility failed to properly assess and intervene for 1 of 3 residents following a fall. (Resident #1) The facility identified a census of 42 residents. Findings include: During an interview 6.4.25 at 12:45 p.m. Staff C, Licensed Practical Nurse (LPN) indicated she received report the resident had fallen last night (6.3.25) but there had been no report of an abrasion to Resident #1 knees. The staff member felt the fall occurred yesterday afternoon but on this day, sometime after 8 a.m., the Director of Nursing (DON) came to her and asked where the Incident Report had been located and Staff C told her she did not know as the Incident Report had not been in Point Click Care (PCC) at 5:45 a.m. During an interview 6.5.25 at 11:27 a.m. Staff D, LPN was aware Staff E, LPN documented her assessment in the Progress Notes around the 8 p.m. hour but failed to complete an Incident Report per facility policy. Staff D confirmed Staff E reported the abrasion located on the resident's right knee but not the intervention of staff to have walked by the resident's room every two (2) hours. Staff D also indicated she thought Staff E conducted four (4) sets of vitals but had not performed neurological (neuro) checks as she started the neuro sheet when she arrived at work. The staff member felt there had been times staff could have provided a more thorough report to oncoming staff members. A Neurological Assessment form dated 6.3.25 at 8:50 p.m. revealed nursing staff failed to assess the resident's neuro's as follows: a. Every 15 minutes times (x) three (3) immediately post the resident's fall. b. Every four (4) hours x one (1). c. Every eight (8) hours x 1. An observation 6.4.25 at 9:50 a.m. revealed a non-dated or initialed band aide on the right knee of Resident #1 with noted dark shadowing under the dressing with the appearance of sanguineous (bloody) drainage. Clinical record review 6.4.25 at 12:05 p.m. revealed no treatment to either knee. An observation 6.4.25 at 12 p.m. revealed the Director of Nursing (DON) as she removed the bandage with sanguineous drainage that covered the pad portion of the bandage itself. The open area to the knee appeared the size of a .50 cent piece. According to an email 6.4.25 at 2:21 p.m. the Administrator confirmed she expected staff to have completed an Incident Report form immediately post a fall. The Administrator indicated the nurse on duty during the fall had been newer and had not dealt with a fall so education had been provided that morning (6.4.25) when staff called her back into the facility to complete the form as expected. A Risk Management form updated 9.27.24 included the following: a. Neurological assessments must have been completed with every unwitnessed fall or/or possible head injury. b. All Incident Reports to be completed by the end of a nurses scheduled shift.

Based on observation, clinical record review, and staff interview, the facility failed to provide the Dietician recommended dietary interventions to prevent weight loss for 1 of 1 residents sampled (Resident #14). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating severe cognitive loss. The resident required supervision to touch assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for eating. The MDS listed a diagnosis of dementia with mild psychotic disturbance and documented Resident #14 with a significant weight loss (a significant weight loss is defined as a 5 percent (%) weight loss in 30 days or 10% weight loss in 6 months) and not on a prescribed weight loss regimen. The Care Plan revised 8/08/24 identified Resident #14 with a nutritional problem related to dementia, chronic kidney disease stage 3, hypertension and need for a mechanically altered diet. The Care Plan directed the following: a. Provide and serve supplements as ordered: Premier Protein shakes twice a day - provided by family. b. Provide and serve the diet as ordered. Monitor intake and record every meal. c. Registered Dietician to evaluate and make diet change recommendations as needed. An 8/08/24 Nutritional Progress Note documented Resident #14 with a 3% weight loss in 30 days, 7.8% in 90 days and 11.5% in 180 days. The Progress Note reflected Resident #14 received Premier Protein shakes twice a day. The Dietician documented Resident #14 intake is not likely meeting estimated needs with significant weight loss related to a sore mouth and poor intake of meals. Continue with the Premier protein shakes. Recommend to add ice cream to lunch and dinner for added calories. An 8/26/24 review of Resident #14 weights revealed a weight of 164.6 pounds on 4/10/24 and a weight of 144.2 pounds on 8/06/24 resulting in a 12.39% weight loss in less than 6 months. During an observation on 8/26/24 at 12:05 PM Staff D, Dietary [NAME] served out Resident #14 lunch meal. The lunch meal did not include ice cream. Observation 8/26/24 at 12:25 PM of Resident #14 table revealed no ice cream with Resident #14 lunch meal/dishes. During an interview on 8/27/24 at 3:15 PM a certified nursing assistant observed passing the afternoon snack cart. She reported she usually always tries to give Resident #14 an afternoon snack of applesauce or pudding. Ice cream is usually not on the afternoon snack cart. On 8/27/24 at 12:00 PM Resident #14 observed seated in the dining room with drinks in front of her waiting for lunch. Further observation at 12:10 PM revealed Resident #14 eating independently with supervision. Her lunch consisted of a pureed breakfast burrito, mashed potatoes, and a pureed apple crisp dessert. Resident #14 had not been served ice cream with her lunch meal. On 8/27/24 at 12:15 PM Staff A, Licensed Practical Nurse (LPN) reported Resident #14 receives protein shakes for her weight loss. They also try to give her afternoon snacks. She loves ice cream. Her son will take her out for ice cream and she will eat all of it. They give her ice cream for an afternoon snack if they have it on the snack cart. On 8/27/24 at 12:25 PM the Dietary Manager reported the Consulting Dietician is at the facility every other Thursday. The Dietician emails the dietary recommendations back to the facility after the Thursday visit, so recommendations come to the facility later. The recommendations from the Dietician are taken care of by the Director of Nursing (DON), Assistant Director of Nursing (ADON) or by her. An 8/27/24 review of Resident #14 lunch and dinner meal slips provided by the facility noted to provide ice cream. On 8/27/24 01:08 PM Staff E, Certified Nursing Assistant (CNA) voiced Resident #14 did not get her ice cream for lunch today (8/27/24). During an interview on 8/27/24 at 1:17 PM Staff D, [NAME] reported Resident #14 is to receive ice cream at lunch and supper. She reported it is her responsibility to serve the ice cream to Resident #14 and she had not served out the ice cream the past two days at lunch. Interview on 8/27/24 at 2:03 PM Staff A, LPN, reported she was not aware Resident #14 required ice cream at lunch and supper. She stated if she had seen a physician order for it, should/would ensure it got done. She reported she had only seen the Dietician twice since the Dietician started at the facility. She didn't know if the Dietician came weekly or bi-weekly, but she doesn't see the recommendations that the Dietician makes. She reported at one time the facility had said they were not going to offer out ice cream for all residents any more. The snack cart usually has yogurt, mandarin oranges, applesauce, and canned pudding. The snack carts are very limited. During an interview on 8/27/24 at 2:15 PM the DON reported if the Dietician recommends supplements, then they proceed with getting a physician order. If the recommendation is for ice cream, she will notify dietary to update the resident's meal slip. She reported she is responsible for overseeing the dietary recommendations are being done. The DON confirmed she expects the dietary staff to serve out the Dietician recommended items and the plan of care to be implemented. The Care Plan Development Policy dated 08/15 directed individualized, comprehensive care plan using the MDS assessment will be developed for each resident, and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, record review, resident and staff interviews, the facility failed to follow physician orders for 1 of 3 residents sampled (Resident #32). Facility reported a census of 38 residents. Findings include: Resident #32 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS documented Resident #32 received scheduled pain medication for a pain level of 7 out of 10 (a 1-10 pain scale, 10 being the worst possible pain). The MDS listed medical diagnoses of stroke, arthritis, and osteoporosis. The Care Plan initiated 7/31/24 identified Resident #32 with chronic pain related to osteoarthritis and osteoporosis. The Care Plan goal identified a goal Resident #32 would verbalize adequate relief of pain or the ability to cope with unrelieved pain. The Care Plan directed the staff to: 1. Monitor/document for side effects of pain medication. Observe constipation; new onset or increased agitation, restlessness, confusion, hallucination, dysphoria, nausea, vomiting; dizziness and falls. Report occurrences to the physician. 2. Monitor/record/report to the nurse any signs or symptoms of non-verbal pain: changes in breathing, mood/behavior, eyes, face and body. 3. Monitor/record/report to the nurse resident complaints of pain or requests for pain treatment. 4. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents' past experience of pain. A 7/29/24 Progress Note e-signed by the primary provider on 8/7/24 identified Resident #32 with on-going pain for active chronic osteoarthritis and low back pain. The provider ordered Resident #32 to continue treatment with Lidocaine external patch 5 percent (%). Resident #32 August 2024 Treatment Administration Record (TAR) documented the following pain levels on a 1-10 pain scale where the two-digit number (00-10) indicates by the resident as corresponding to the intensity of their worst pain, where zero is no pain and 10 is the worst pain imaginable. 8/13/24 6:00 AM 4 8/13/24 2:00 PM 10 8/14/24 6:00 AM 6 8/15/24 6:00 AM 3 8/16/24 6:00 AM 4 8/16/24 2:00 PM 4 8/17/24 6:00 AM 4 8/17/24 2:00 PM 4 8/18/24 6:00 AM 10 8/19/24 6:00 AM 2 8/23/24 6:00 AM 10 8/23/24 2:00 PM 3 The National Institutes of Health define pain levels as follows: a. Mild pain: 0-3 b. Moderate pain: 4-6 c. Severe pain 7-10 Resident #32 identified a moderate level of pain 6 times and a severe level of pain 3 times when administered the incorrect dose of the prescribed medication. Observed on 8/26/24 at 7:21 AM, Staff A, Licensed Practical Nurse (LPN) place the Lidocaine external patch 4% on the lower back of Resident #32. Staff A, LPN failed to follow professional standards of medication administration (right patient, right drug, right time, right dose and right route). During an interview on 8/26/24 at 9:13 AM, Resident #32 revealed she has a lot of pain at times due to arthritis in her arms and back. Resident #32 rated her current pain level at a 3. During an interview on 8/26/24 at 9:16 AM, Staff A, LPN confirmed she applied the Lidocaine pain relief gel patch 4% patch to the lower back of Resident #32. The packaging for the Lidocaine pain relief gel patch 4% revealed the box contained 15 patches with 3 remaining patches in the box. During an interview on 8/27/24 at 9:10 AM Director of Nursing (DON) revealed physician orders are to be followed as prescribed. Staff B, DON revealed she was unaware of the discrepancy and was notified on 8/26/24 of the medication error. On 8/27/24 at approximately 9:30 AM DON revealed the facility lacked a policy for order verification/transcribing of physician orders. The DON voiced she expected the nurse will follow up with the pharmacy when a discrepancy is identified.

Based on observation, clinical record review, and staff interview the facility failed to have emergency equipment readily available at the bedside for 1 of 1 residents reviewed for tracheostomy care (Resident #22). The Facility identified a census of 38 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating a mild cognitive loss. The MDS documented Resident #22 with a tracheostomy (tracheostomy is an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia. A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. Breathing is done through the tracheostomy tube rather than through the nose and mouth) and a diagnosis of cancer. The Care Plan revised 6/19/24 documented Resident #22 utilized a tracheostomy related to a malignant neoplasm (cancer) of the supraglottis (the supraglottis is the upper part of the voice box, that's located above the vocal cords and includes the epiglottis) and directed the nursing staff in tube out procedure: keep extra tracheostomy tube and obturator (a curved rod that fits inside the tracheal cannula) at the bedside. If the tube is coughed out, open the stoma (a surgically created opening in the neck that goes into the windpipe and allows air to reach the lungs) with a hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate the head of the bed 45 degrees and stay with resident. Obtain medical help immediately. During an observation on 8/27/24 at 9:25 AM Staff C, Licensed Practical Nurse (LPN) provided Resident #22 his tracheostomy care as physician ordered. After tracheostomy care completion, Staff C was asked what emergency equipment was available in Resident #22 room. Staff C opened the closet door and stated Resident #22 had a bag with suction equipment in it. The suction equipment observed zipped inside a bag in the closet, not set up for emergency use. Staff C searched the closet all the way to the back of the close and the three drawer bin of tracheostomy equipment and reported she could not find a hemostat (a hemostat is a surgical tool, like pliers that is used to grasp skin to secure during procedures). She would have to check with the Director of Nursing (DON) as she didn't see a hemostat in the resident's room. On 8/27/24 at 9:44 AM Staff C asked the DON about a hemostat in Resident #22 room. Staff C reported she had looked in the resident's closet and bin with his tracheostomy equipment but couldn't find a hemostat. The DON at this time reported she would expect a hemostat to be in the room and they would get a hemostat in the room. She expected staff to follow the Care Plan. On 8/27/24 at 10:32 AM Resident #22 reported Staff C had not been back to his room with any equipment. Interview on 8/27/24 at 10:35 AM the DON reported the tracheostomy care kit has forceps in the kit and she would expect the nurses to use the forceps in the tracheostomy kit to open the airway in an emergency. Staff C stood by the DON and when asked if she would know in an emergency to go get the tracheostomy care kit and she reported, no. The DON verified the tracheostomy kits were not stored and accessible in Resident #22 room if there was an emergency. When asked about emergency tracheostomy training, the DON reported the nurses did not have documented emergency training. During an interview on 8/27/24 at 10:36 AM the DON reported she would be providing the nurses with emergency education yet this week. A review of the Facility Assessment updated 7/09/24 lacked documentation of emergency training regarding tracheostomy care. The Tracheostomy Care Procedure, undated, provided by the facility under accidental decannulation directed the following: 1. Call for assistance. 2. Replace the old tracheostomy tube with the new tube that is the same size. 3. Be prepared to manually ventilate the resident in whom respiratory distress develops. 4. Notify emergency personnel, if necessary. 5. Continue to manually ventilate until emergency personnel arrives and take over ventilation. The Procedure lacked direction of the emergency equipment that should be maintained at the bedside for emergency tracheostomy care.

Based on observation, clinical record review, and staff interview the facility failed to have eye protection readily available for enhanced barrier precautions (EBP) for 1 of 1 residents reviewed for tracheostomy care (Resident #22). The Facility identified a census of 38 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating a mild cognitive loss. The MDS documented Resident #22 with a tracheostomy (a tracheostomy is an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia. A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. Breathing is done through the tracheostomy tube rather than through the nose and mouth) and a diagnosis of cancer. The Care Plan revised 6/19/24 documented Resident #22 utilized a tracheostomy related to a malignant neoplasm (cancer) of the supraglottis (the supraglottis is the upper part of the voice box, that's located above the vocal cords and includes the epiglottis). The Care Plan included a revised intervention dated 4/17/24 which directed the nurse to utilize enhanced barrier precautions (EBP) for tracheostomy care. The Center for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multi-drug resistant Organisms (MDROs) Updated: July 12, 2022 under key points listed the following: 1. Multi-drug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated for residents with any indwelling medical devices, regardless of MDRO colonization status. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care Under the CDC Summary of Personal Protective Equipment (PPE) Use and Room Restriction When Caring for Residents in Nursing Homes directed gloves and gown to be worn prior to the high contact care activity, change PPE before caring for another resident, face protection may also be needed if performing activity with risk of splash or spray. During an observation on 8/27/24 at 9:25 AM Staff C, Licensed Practical Nurse (LPN) reported she wears a gown and gloves when she performs Resident #22 tracheostomy care. Staff C washed her hands, donned an isolation gown and gloves. Observation of the PPE isolation bin as Staff C donned her PPE revealed no goggles or face shield readily available in the isolation bin. Staff C proceeded to perform Resident #22 tracheostomy care cleansing with saline soaked cotton tipped applicators around Resident #22 stoma with Staff C within 10-12 inches of the resident while performing the tracheostomy care. Resident #22 covered his tracheostomy with his finger and verbalized sometimes he coughs during his tracheostomy care and secretions go flying all over as he started to chuckle. Staff C reported she had not been told to wear eye protection or a face shield when providing tracheostomy and no eye protection was present in the isolation bin for Resident #22 care. She would need to check with the Director of Nursing (DON). On 8/27/24 at 9:44 AM Staff C asked the DON about eye protection. The DON verbalized she would expect the nurses to wear a face shield if there was potential for droplet or airborne secretions. The DON informed Staff C face shields were in the basement with the COVID 19 personal protective equipment (PPE). During an interview on 8/27/24 at 1:36 PM the Infection Preventionist (IP) reported the facility has one resident on EBP due to tracheostomy care. The nurses wear a gown and gloves for EBP. The staff should probably wear a face shield in the event of sputum or droplets. Then the IP stated, now that I say it out loud, the staff should probably have face shields on. The IP verbalized the facility follows CDC guidelines.

Based on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The facility reported a census of 42 residents. Findings include: During an interview on 4/15/24 at 10:17 AM, the Administrator reported the Dietary Manager is not certified but currently enrolled in the course. During an interview on 4/15/24 at 1:38 PM, the Dietary Manager reported she is not certified, but currently enrolled in the course. She reported the dietician comes once a week.

Based on observation, staff interviews and policy review the facility failed to maintain sanitary practices by improperly storing clean dishes and maintaining a clean kitchen. The facility reported a census of 42 residents. Findings include: During initial kitchen observation on 4/15/24 at 9:45 AM, the following findings were identified. The dishes were stored on open shelving next to the prep area not inverted. The shelves were covered in dust and soiled dark spots. The front of the oven covered in dry food spills and stove top covered in dry food particles. The window in front of the prep area open with build up of dirt and dried leaves with the breeze blowing on the food on the counter. The large mixer with dried food particles on it. The open shelving next to the steam table dirty with food particles and stored dishes in which half were inverted and half were not. During an observation on 4/16/24 at 10:52 AM, the kitchen dirty areas and dishes stored improperly on 4/15/26 remained the same with no changes. Dirty window open and breeze blowing on the prep area in which the Dietary Manager was preparing the pureed food. During an interview on 4/16/24 at 1:00 PM, the Dietary Manger reported the kitchen staff have a cleaning schedule. She showed the cleaning schedule book with checklist. The last documented completed cleaning was done on 4/9/24. She reported she expected staff to do the cleaning daily and document upon completion. She reported she expects staff to store the dishes on the open shelves inverted. She reported the facility lacked a policy on kitchen sanitation or storing of dishes. Review of the facility's undated cleaning list titled Night Cook Tasks documents staff are to clean the stove top and outside of the oven. It lacked any direction for the shelves, how to store dishes and cleaning the large mixer.

Based on observation, staff interviews, record review and policy review the facility failed to check placement and elevate the resident's head of bed prior to flushing a g-tube for 1 of 1 resident reviewed (Resident #24); failed to follow physicians orders for insulin for 1of 1 resident reviewed (Resident #33); and failed to prime insulin pen prior to administering for 3 of 3 residents reviewed (Resident #24, #33 and #37). The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment for Resident #24 documented diagnoses of hypertension, cancer, malnutrition, gastrostomy status, and dysphasia. During an observation on 4/17/24 at 10:30 AM, Staff A, Licensed Practical Nurse (LPN) set up supplies on a barrier. She did hand hygiene and applied a gown and gloves. She then drew up 30 ml of warm water with the syringe, cleaned the port to the G-tube with an alcohol wipe, unclamped the tubing and flushed the line with syringe of warm water. She did not check placement of tube prior to doing so and resident was laying flat in bed with his head not elevated. Staff A, LPN reported she does need to check placement prior to flushing the tube. During an interview on 4/17/24 at 1:20 PM, the Director of Nursing reported she expects staff to elevate the resident to a semi-Fowler's position (elevated 30-45 degrees) and check the placement of the G-tube prior to flushing. Review of the Medication Administration Record for April documents the resident is to get his G-tube flushed twice a day with 30 milliliters (ml) of warm water. Review of the facility policy Medication Administration for enteral tubes dated 1/13 directed staff to verify that that the head of the bed is 30-45 degrees and to verify tube placement prior to flushing the tube. 2. 1. The MDS Assessment for Resident #33 dated 03/13/24 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented the resident diagnoses of hypertension, diabetes, and depression. During an interview on 4/15/24 at 12:26 PM, Resident #33 reports her blood sugars have been really high frequently. Review of Resident #33's February, March and April 2024 Medication Administration Records (MAR) document the resident's blood sugars are not consistent. It documented on 12 different occasions the resident either refused her insulin or the nurse held the insulin per nursing judgement. Review of Resident #33's Progress Notes lacked documentation of the physician being notified on the 12 different occasions of insulin refusal or being held. It further lacked any documentation of staff education of the risks of not taking the insulin as prescribed by the physician. During an interview on 4/16/24 at 2:10 PM Staff B, LPN reported Resident #33 is very noncompliant with her diabetes. Resident #33 will refuse meals but then snack on high sugar and high carbohydrate snacks in her room. She reported she has held Resident #33 insulin due to nursing judgement because the blood sugar level or she has refused to eat the meal. She documents the insulin being held on the MAR but not notify the physician. During an interview on 4/16/24 at 2:25 PM Staff C, Registered Nurse (RN) reports she will ask Resident #33 if she wants to take her insulin or not due to not always eating the meal. She reports she documents the refusal on the MAR. She reports any refusal or insulin being held the physician needs to be notified right away and documented. During an interview on 4/16/24 at 2:35 PM Staff D, LPN reports if a resident is refusing their insulin or the blood sugar is very low then she would notify the physician right away. The resident will need to be educated on the risks and it all needs to be documented. During an interview on 4/16/24 at 3:45 PM, the Nurse Consultant reports she expects staff to notify the physician right away if the insulin is not given or a resident refuse. It then should be documented in the resident's chart. During an interview on 4/17/24 at 9:08 AM, the DON reports the nurse should first look and see if the resident has parameters for holding the insulin. If it is held or the resident refuses then the physician needs to be notified right away and it should be documented in the resident's Progress Notes. Review of the facility policy Refusal of Medication or Treatment dated 5/14 directed staff to notify the Physician of the refusal. The policy lacked any direct to of holding medications per nursing judgement. 42441 3. The MDS dated [DATE] revealed Resident #24 had a diagnosis of type 1 diabetes mellitus (DM) and received insulin injections 7 out of the past 7 days. The Care Plan revised 3/19/24 revealed Resident #34 had DM and used insulin daily. The MAR dated April 2024 revealed Resident #24 had an order initiated 3/11/24 for Humalog (insulin) KwikPen solution 14 units subcutaneously in the morning. The MAR further revealed the resident had an order initiated 3/30/24 for 26 units subcutaneously solution pen-injector of Toujeo (insulin) one time a day On 4/17/24 at 9:05 AM, observed Staff A, LPN inject Resident #24 with 14 units of Lispro insulin and 26 units of Toujeo insulin and utilized insulin pen injectors. Staff A did not prime either insulin pen prior to the subcutaneous injections and left the insulin pens in place for approximately 2 seconds after both injections. 4. The MDS dated [DATE] revealed Resident #37 had a diagnosis of DM and received insulin 7 out of the past 7 days. The Care Plan revised 3/25/24 revealed Resident #37 had a diagnosis of DM and received insulin daily. The MAR dated April 2024 revealed Resident #37 had an order initiated 4/10/24 for 20 units Glargine insulin subcutaneously using a pen injector. The MAR further revealed the resident had an order initiated 4/10/24 for 15 units Fiasp insulin subcutaneously using a pen injector. On 4/17/24 at 9:15 AM, observed Staff A, LPN inject Resident #37 with 20 units of Glargine insulin subcutaneously using a pen injector and inject 15 units of Fiasp insulin subcutaneously using a pen injector. Staff A did not prime either insulin pen prior to administration of the insulin and held each pen in place for approximately 2 seconds after administration. 5. The MDS dated [DATE] revealed Resident #33 had a diagnosis of DM and received insulin injections 7 out of the past 7 days. The Care Plan revised 8/31/23 revealed Resident #33 had DM and used insulin daily. The MAR dated April 2024 revealed Resident #33 had an order initiated 3/14/24 for 56 units of Toujeo insulin subcutaneously using an insulin pen injector one time a day. The MAR further revealed the resident had an order for 30 units of Aspart insulin subcutaneously initiated 4/15/24 using an insulin pen injector one time a day. On 4/17/24 at 9:30 AM, observed Staff A, LPN inject Resident #33 with 56 units of Toujeo insulin and 30 units of Aspart insulin and utilize insulin pen injectors. Staff A did not prime either insulin pen prior to the subcutaneous injections and left the insulin pens in place for approximately 3 seconds after administration. During an interview 4/17/24 at 1:00 PM, Staff A LPN acknowledged priming of the insulin pens should have been completed and that she has been educated and moving forward she will be priming insulin pens. During an interview 4/17/24 at 1:17 PM the DON revealed it is an expectation insulin pens are primed 2 units prior to administration and kept in place for 10 seconds after administration of insulin. During an interview 4/17/24 at 1:24 PM Staff A, LPN revealed the expectation is to keep the insulin pen 10 seconds after administration of the insulin and revealed now that she had the knowledge she would do so in the future. During an interview 4/17/24 at 2:04 PM the DON revealed the 3 different insulin pens used for Residents #24, #33 and #37 had manufacturer's recommendations that mirrored one another. The DON provided a copy of the Levemir FlexPen manufacturer's recommendation. Review of the manufacturer's Quick Guide for the Levemir (insulin) FlexPen revealed the following: 3. Prime Your Pen: Before each injection, prime your pen by performing an airshot. Turn the dose selector to select 2 units. Holding your pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubble collect at the top of the cartridge. Press and hold the green push button. Make sure a drop of insulin appears at the needle tip. 5. Give your injection: Inject the dose by pressing the green push-button all the way in until the 0 lines up with the pointer. Keep the needle in the skin for at least 6 seconds, and keep the green push-button pressed all the way in until the needle has been pulled out.

Based on observation, photos, and provider contract review, and resident interview revealed the facility failed to maintain clean and safe oxygen concentrator filters for 2 residents reviewed on oxygen therapy (Resident #5 and #7). The facility identified a census of 42 residents. Findings include: 1. A Diagnosis Report form dated 3.19.24 indicated Resident #5 had diagnoses that included Parkinson's, combined Systolic and Diastolic Congestive Heart Failure, and Obstructive Sleep Apnea. A Treatment Administration Record (TAR) form dated 3.1.24 thru 3.31.24 indicated the resident as on continuous oxygen set at 2-3 liters per minute related to Acute Respiratory Failure with Hypercapnia with the physician's order dated 2.19.24 at 2:27 p.m. An observation 3.24.24 at 11:28 a.m. with a photo taken revealed the filter on the oxygen concentrator for Resident #5 full of dust, dirt, and debris. 2. A Diagnosis Report form dated 3.19.24 indicated Resident #7 had diagnoses that include Chronic Obstructive Pulmonary Disease (COPD, Occlusion and Stenosis of her Carotid Artery, Obstructive Sleep Apnea, and combined Systolic and Diastolic Heart Failure. A TAR dated 3.1.24 thru 3.31.24 indicated the resident with an as needed (PRN) oxygen order for shortness of breath dated 2.20.24 at 3:35 p.m. An observation 3.24.24 at 1:22 p.m. with a photo taken revealed the filter on the oxygen concentrator for Resident #7 full of dust, dirt, and debris. During an interview 3.14.24 at 1:15 p.m. the resident confirmed she utilized her oxygen when she needed it. Review of the Service Agreement with the provider of the oxygen products and the facility, effective 9/22/2022, page 2 states the oxygen product provider assumes full responsibility for proper maintenance and repair of all oxygen equipment rented to the facility.

Based on observation, photos, record review, staff interview and review of the facilities Resident Rights the facility failed to maintain an environment free of vermin. The facility identified a census of 42 residents. Findings include: 1. A photo dated 3.14.24 at 9:46 a.m. revealed multiple dead ants in random areas on the floor and along the base boards in room [ROOM NUMBER]. 2. A photo dated 3.14.24 at 9:51 a.m. revealed multiple dead ants in random areas on the floor and along the base boards in room [ROOM NUMBER]. 3. During an interview 3.14.24 at 2 p.m. Staff A, Certified Nursing Assistant (CNA) confirmed she observed ants in room [ROOM NUMBER], when it was occupied by Resident #1 and room [ROOM NUMBER] occupied by Resident #4 around the holidays when the residents received snacks and treats from their families and friends. During an interview 3.14.24 at 2:13 p.m. Staff B, CNA confirmed on 3.11.24 she observed live ants in room [ROOM NUMBER] as they climbed around a piece of food on the resident's floor. During an interview 3.14.24 at 2:53 p.m. Staff C, CNA confirmed she observed ants only in resident rooms which contained sweets and extra foods down hall 200. The staff member felt the ants could have been controlled if staff properly cleaned those resident rooms. 4. According to the facilities Resident Rights form contained in the resident's admission contract the facility assured the residents they provided a safe, clean, comfortable and homelike environment, which allowed the use of resident's personal belongings. 5. A facilities Pest Control policy revised 12.2019 included the following: The facility strived to protect the resident/patients, staff and visitors from insects and other pests by controlling infestations.

Based on observation, record review, resident, staff and family interview, and facility policy review the facility failed to report a suspected abuse allegation in a timely manner, within 2 hours, to the Department of Inspections, Appeals, and Licensing. The facility identified a census of 47 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 7.11.23 indicated Resident #1 had diagnoses that included bipolar disorder, problems related to life management, arthritis, and muscle weakness. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (moderately impaired cognitive skills and required extensive assistance of staff with transfers, ambulation in room, dressing, toilet use, personal hygiene, and bed mobility. A Care Plan identified the following Focus as dated: a. Impaired cognitive function and at risk for falls, increased depression and decreased socialization. (revised 6.21.22) A Progress Note entry dated 7.1.23 at 7:50 p.m. included the following information: a. The resident became upset with evening cares and stated a certified nursing assistant (CNA) would not take her to the bathroom and ripped her clothes off when positioned in bed. The CNA stated the resident normally requested that same CNA for cares. The resident called her daughter, the daughter called the facility and stated she planned to follow up on the incident. During an interview 7.7.23 at 11:30 a.m. a family member confirmed the resident called her last Saturday (7.1.13) at 8:02 p.m. for 17 minutes and reported having been so upset with Staff A, CNA. As the resident cried she reported having been tossed into bed. The resident also reported as the staff member wheeled her back to her room she stopped and talked to someone in the hallway so the resident asked why she stopped and chit chatted when she had to go to the bathroom and the staff member said that is your 1st mistake. The staff member then took her back to her room in her wheel chair and left her there with no call button or anything. The family member reported the resident yelled help, help me as Staff B, registered nurse (RN) came in and gave her meds and call light. Staff A re-entered and that had been when the resident stated she had to go to the bathroom when Staff A reported another resident occupied the shared restroom. The staff member stated you are going to bed right now as she forced the resident's clothes off and threw the resident into bed. The resident allegedly placed her hands out in defense and said she could call police as Staff A stated she could have charged the resident. During an interview 7.13.23 at 2:13 p.m. Staff B, confirmed when she walked past the resident's room that evening the resident called her by name at which time she noticed the resident's tray table and call light had not been positioned within reach. Staff A then entered the resident's room and provided HS cares. The next thing the staff member knew the resident's daughter called and reported the alleged incident. The staff member confirmed she failed to report the allegation to the Administrator right away. The staff member reported in hind sight she should have reported the incident to the Administrator. During an interview 7.13.23 at 1:04 p.m. Staff A confirmed on the way back from the dining room another resident told her a fall risk resident had been up independently in the hallway. As the staff member propelled the resident to her room she barely got her in the door and the staff member ran to the resident as he ambulated independently and as a means to have prevented the fall. Staff B entered the resident's room turned her around and gave her her call light. Staff C, CNA the other aide assigned to that hallway attempted to assist the resident with her hour of sleep (HS) cares but the resident refused and stated she preferred Staff A. When Staff A returned 5-10 minutes later she gave the resident a washcloth and assisted her with her pajamas. The staff member confirmed she failed to take the resident to the bathroom because someone else had been in the shared bathroom. The staff member also changed the resident's brief and provided perineal cares that night. The staff member denied she ever yanked the resident's shirt or ever touched her arms. During an interview 7.13.23 at 2:35 p.m. Staff C confirmed she observed Staff A as she propelled the resident back to her room. When the staff member dropped the resident off she requested assistance to bed right away but other residents required assistance at that time so the staff left the resident and cared for the other residents so she placed on her call light. Staff C responded and the resident requested Staff A so the staff member exited the resident's room. During an interview 7.13.23 at 1:51 p.m. the Administrator confirmed she found out about the alleged incident on 7.3.23 during morning review. The Administrator failed to grasp the extent of the allegation until she returned to work on 5th and the resident's family member had packed up her belongings and discharged her against medical advice, that is when the event had been reported and the staff member suspended. The administrator confirmed she failed to report incident timely. The facilities Abuse Prevention Program & Reporting Policy reviewed 8.2019 including the following directives on suspected abuse: a. Notification of the shift supervisor if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. b. Report the incident immediately to the administrator and director of nursing. c. Notification of the appropriate state agency immediately.

Based on observation and staff interview, the facility failed to maintain a clean, homelike environment with multiple visible stains on the carpet and walls in resident's rooms in need of repair. The facility reported a census of 44 residents. Findings Include: 1. Observations 10/25/22 at 11:35 AM revealed multiple visible stains on the carpet in the resident care area hallways. Review of the undated facility admission policy revealed the facility will provide a safe, clean, comfortable and homelike environment. The policy documented the facility is required to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. During an interview 11/2/22 at 9:31 AM, the Administrator revealed he would expect the carpet to be presentable and free of multiple large stains. During an interview 11/2/22 at 11:05 AM the Regional Director of Clinical Services revealed the expectation would be for the walls to be kept in good repair. During an interview 11/2/22 at 9:11 AM, the Regional Director of Clinical Services revealed there is not a facility policy specific to cleaning floors. 44972 2. During an environmental tour of the facility on 10/25/22 the following was identified: a. room [ROOM NUMBER]-2: wall beside bed was badly scratched b. room [ROOM NUMBER]-2: wall at the head of the resident's bed was badly scuffed c. room [ROOM NUMBER]: carpet on floor of the entire room was badly stained and black in color d. room [ROOM NUMBER]: carpet on the floor was stained e. Hallway outside room [ROOM NUMBER]: carpet on the floor had dark stains f. room [ROOM NUMBER]: bathroom doorframe and bathroom wall were badly gouged and scuffed g. Hallway outside room [ROOM NUMBER]: Carpet on the floor had a large dark stain h. room [ROOM NUMBER]: carpet on the floor had numerous dark stains i. Hallway outside room [ROOM NUMBER] - carpet on the floor had dark stains

Based on observation, clinical record review, policy review and resident and staff interviews, the facility failed to provide bathing as prescribed for 7 of 12 residents reviewed (Resident #13, #15, #21, #22, #35, #39, #41). The facility reported a census of 44 residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE], identified Resident #13 had a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS documented during the 7 day observation period for gathering of information for this MDS, the resident required the supervision of 1 staff for transfers and toileting, extensive assistance of 1 staff for personal hygiene and was totally dependent on 1 staff person for bathing. The MDS documented diagnosis that included seizure disorder, depression, schizophrenia, and mild intellectual disabilities. The care plan focus area revised 8/3/22 identified a need for assistance with activities of daily living including set up assistance with dressing and personal hygiene and assistance with TED hose. The POC (plan of care) Response History (electronic documentation by staff for care) with a look back of 30 days and printed on 10/31/22 at 10:58 AM, the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: - 10/5/22 at 8:55 PM not applicable - 10/12/22 at 9:14 PM physical help in part of bathing activity - 10/19/22 at 9:09 PM physical help in part of bathing activity Per documentation Resident #13 received 2 of 9 scheduled showers for the months of October. Resident #13 was to receive showers on Wednesdays and Saturdays. The facility lacked documentation of providing the resident with a shower on 10/1, 10/5, 10/8, 10/15, 10/22, 10/26, and 10/29 and there were no documented refusals. In an interview on 10/31/22 at 11:30 AM Resident #13 reported during a Resident Council meeting, she was to receive showers on Wednesdays and Saturdays. She stated staff frequently told her they do not give showers on the weekends or they did not have enough staff to give her a shower. 2. A MDS assessment dated [DATE], identified Resident #35 had a BIMS score of 15 indicating intact cognition. The MDS documented during the 7 day observation period for gathering of information for this MDS, the bathing activity had not occurred and the resident required extensive assistance of 2 staff for bed mobility, transfers, toileting and personal hygiene. The MDS documented diagnosis that included diabetes mellitus, anxiety disorder, depression, and schizophrenia. The care plan focus area revised 6/19/22 identified a need for assistance with activities of daily living including assistance of 2 staff with transferring back to the wheelchair and changing incontinency product, changing clothing, personal hygiene and assisting out of bed. Resident requested 3 showers per week. The POC Response History with a look back of 30 days and printed on 10/31/22 at 10:50 AM, the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: - 10/3/22 at 10:39 AM total dependence - 10/5/22 at 1:29 PM physical help in part of bathing activity - 10/10/22 at 10:34 AM physical help in part of bathing activity - 10/12/22 at 10:13 AM physical help in part of bathing activity - 10/17/22 at 1:59 PM physical help in part of bathing activity - 10/19/22 at 10:52 AM physical help in part of bathing activity - 10/21/22 at 11:48 AM physical help limited to transfer only - 10/24/22 at 10:32 AM physical help in part of bathing activity - 10/28/22 at 10:54 AM physical help limited to transfer only Per documentation Resident #35 received 9 of 13 scheduled showers for the month of October. Resident #35 was to receive showers on Mondays, Wednesdays and Fridays. The facility lacked documentation of providing the resident with a shower on 10/7, 10/14. 10/26, and 10/31 and there were no documented refusals. In an interview on 10/25/22 at 10:44 AM, Resident #35 stated he was to get showers on Mondays, Wednesdays and Fridays. He stated he got his shower most of the time but the facility was short staffed and they did not always have time to give it to him. 3. A MDS assessment dated [DATE], identified Resident #41 had a BIMS score of 12 indicating moderate cognitive impairment. The MDS documented during the 7 day observation period for gathering of information for this MDS, the resident was independent with bed mobility, transfers and toileting and required supervision with personal hygiene and bathing. The MDS documented diagnosis that included transient cerebral ischemic attack, depression, polyneuropathy and muscle wasting and atrophy. The care plan focus area revised 4/27/22 identified a need for assistance with activities of daily living including assistance of 1 staff for bathing, staff assistance with nail care on bath days, and to assist the resident with a sponge bath when a full bath or shower could not be tolerated. The POC Response History with a look back of 30 days and printed on 10/26/22 at 4:07 PM, the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in-out of tub/shower (excludes washing of back and hair) documented the following: - 9/28/22 at 9:13 PM supervision-oversight help only - 10/1/22 at 9:57 PM resident refused - 10/5/22 at 8:52 PM resident refused - 10/12/22 at 9:16 PM resident refused - 10/19/22 at 9:10 PM resident refused Per documentation Resident #41 received 1 of 8 scheduled showers for the 30 days reviewed. Resident #41 was to receive showers on Wednesdays and Saturdays. The facility lacked documentation of providing the resident with a shower on 10/8/22, 10/15/22, and 10/22/22. There were 4 documented refusals. In an interview on 10/26/22 at 9:32 AM, Resident #41 stated she had not received a shower for at least 2 weeks. She stated she felt they were too short staffed. In an interview on 10/27/22 at 2:55 PM, Resident #41 reported she had not been offered a shower for greater than 2 weeks. She denied she had been refusing showers. She stated they had not asked her until the previous night. She stated she did refuse as she was already in bed when they offered the shower. She requested one the next evening but the staff told her they may not have time or the staff to complete her shower at that time. 40907 4. A MDS dated [DATE], documented that Resident #22's MDS score was 13 out of 15 indicating her cognition was intact. It documented during the 7 day observation period for the gathering of information for this MDS, that the bathing activity had not occurred. On 10/25/22 at 3:34 PM, Resident #22 stated that she had gone 15 days before without a shower. She stated she should have gotten a shower on this morning but the CNA that was supposed to give her a shower went home with a fever. A review of this resident's POC Response History (electronic documentation by staff for care) revealed that on 10/25/22 resident refused a shower and this was documented by Staff A, CNA. On 10/27/22 at 12:41 PM, Staff A, CNA stated that Resident #22 declined her shower on 10/25/22. She stated that Resident #22 was offered a shower by another CNA and Resident #22 refused her shower. She stated that this resident liked her shower down very early in the morning, before 6:00 a.m. When told it was Staff A's signature on the Kardex that signed the refusal on 10/25/22, Staff A looked confused. Staff A then said that another CNA had told Staff A that Resident #22 refused her shower on 10/25/22. Staff A stated the other CNA went home sick that day and probably didn't sign the refusal before she left, so that's why this CNA would have signed the refusal. When asked if the other CNA was working on this day, Staff A said that the other CNA was not working as the other CNA was still off work sick. When asked about residents going without showers, Staff A stated that when there are only 3 CNAs instead of 4 it is difficult to get showers done. She said the following shift tries to pick them up or they try to pick up the showers the next day. When asked why the residents would say they haven't received their 2 showers a week, she repeated they try to give them their showers the next shift or next day if one is missed. When told there was greater than 7 days between some of the showers per the Kardex for Resident #22, Staff A stated that often agency staff are part of their daily staff and they do not document like they should. Staff A stated she had told the Director of Nursing (DON) about the lack of documentation by the agency staff. Staff A understood that it is a problem when the showers weren't documented, coupled with residents voicing that they are not receiving 2 showers a week. The POC (plan of care) Response History with a look back history of 30 days and printed on 10/25/22 at 4:09 P.M., the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: -9/27/22 at 1:48 P.M. physical help limited to transfer only -9/30/22 at 11:17 A.M. resident refused -10/2/22 at 10:08 A.M. not applicable -10/9/22 at 1:47 P.M. resident refused -10/18/22 at 1:46 P.M. physical help in part of the bathing activity -10/20/22 at 9:16 P.M. physical help in part of the bathing activity -10/25/22 at 1:59 P.M. resident refused 5. A MDS dated [DATE], documented that Resident #39's MDS score was 13 out of 15, which indicated this resident's cognition was intact. It documented during the 7 day observation period for the gathering of information for this MDS, that the bathing activity had not occurred. On 10/25/22 at 11:28 AM, Resident #39 stated she wanted showers every day or maybe every other day so she could use her body wash. She stated they give showers twice a week. Resident #39 stated one time she went without showers for 3 weeks. She stated that was 4 to 5 months ago. She didn't know why she went so long without a shower. She said now she received them twice a week and she was due for one the following day. The POC (plan of care) Response History with a look back history of 30 days and printed on 10/26/22 at 3:34 P.M., the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: -9/28/22 at 1:58 P.M. not applicable -10/5/22 at 1:32 P.M. not applicable -10/8/22 at 1:59 P.M. supervision-oversight help only -10/19/22 at 9:40 P.M. supervision-oversight help only On 11/1/22 at 4:31 p.m., the Director of Nursing (DON) stated the facility's expectation was that residents received showers twice a week unless they request less or more showers. She stated they try to honor the residents' choices. The DON stated she expected documentation of resident's showers would be done and that shower refusals would get documented. In an email correspondence on 11/7/22 at 10:51 A.M., Staff B responded that the NA (not applicable) response would likely indicate the shower wasn ' t completed. 42441 6. A MDS dated [DATE] documented Resident #15 had a BIMS score of 15 out of 15 indicating intact cognition. The MDS documented Resident #15 required extensive physical assistance of 1 staff with hygiene. During an interview 10/25/22 at 3:00 PM, Resident #15 revealed he received showers unless the facility didn't have enough staff. Resident #15 further stated he had to wait 1 1/2 weeks a couple weeks ago to get a shower. The POC Response History with a look back history of 30 days printed 10/31/22 at 10:22 AM with the prompt Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) documented the following: -10/4/22 at 12:11 PM total dependence -10/7/22 at 1:52 AM not applicable -10/11/22 at 10:46 AM total dependence -10/18/22 at 10:54 AM physical help limited to transfer only -10/21/22 at 1:59 PM total dependence -10/25/22 at 1:59 PM total dependence -10/28/22 at 12:26 PM total dependence 7. A MDS dated [DATE] documented Resident #21 had a BIMS of 15 indicating intact cognition. The MDS documented Resident #21 required extensive physical assistance of 1 staff for hygiene. During an interview 10/25/22 at 2:34 PM, Resident #21 revealed there was a time he wasn't getting showers but he was now. The POC Response History for Resident #21 with a look back history of 30 days printed 11/1/22 at 9:27 AM with the prompt: Bathing: Self Performance - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) lacked documentation in regards to completion of bathing. Review of facility protocol titled, Bathing, dated January 2013 revealed the purpose of bathing as the following: -Clean skin and shampoo hair -Increase circulation -Exercise body parts -Reduce tension -Promote comfort while maintain safety and dignity The Bathing protocol further directed staff to provide the resident the opportunity to bathe according to preference and facility procedure. During an interview 11/01/22 at 10:04 AM, the Director of Nursing and the Regional Director of Clinical Services acknowledged Resident #21 did not have a shower in the past 30 days and he had one that morning. The Regional Director of Clinical Services further acknowledged showers not being given is an issue. During an interview 11/01/22 at 9:17 AM, the Regional Director of Clinical Services revealed showers are expected to be documented if given.