Every finding on record at Avir at Comfort

Based on observation, interview and record review, the facility failed to ensure residents received an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 3 of 3 residents (Residents #1, #2, and #-3) reviewed for activities. The facility failed to ensure residents #1, #2, and #3 had the option of participating in daily, organized activities to meet the residents' psychosocial needs and preferences during May 2026. This failure could result in decreased psychosocial well-being or decreased quality of life. Findings included:Record review of the activities calendar dated May 2026 reflected SELF-DIRECTED ACTIVITIES [sic] listed on every Saturday and Sunday of the month, totaling 10 days. Record review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included bipolar disorder (a mental health disorder characterized by severe mood swings). Record review of Resident #1's quarterly MDS submitted 3/5/2026 reflected a BIMS score of 15, which indicated intact cognition. In an interview on 5/27/2026 at 9:45 AM, Resident #1 said the activities posted on the monthly calendar were frequently cancelled without notice, and the only consistent activities were hosted by members of the community. She said the coffee social scheduled at 10:00 AM on 5/27/2026 and most other weekdays would not occur because the event was never actually hosted by the facility. She said the self-directed activities on the weekends in May meant there was nothing scheduled for residents to do on the weekends except watch television. She said this had been occurring for several months, and the lack of activities made her feel terrible. Record review of Resident #2's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (decreased ability of the left side of the body because of neurological damage from a blood clot in the brain).Record review of Resident #2's quarterly MDS submitted 4/06/2026 reflected a BIMS score of 15, which indicated intact cognition.In an interview on 5/27/2026 at 11:58 AM, Resident #2 said he was satisfied with the activities program, but he wished there were activities on the weekends to help the time pass. Record review of Resident #3's Face Sheet reflected an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's disease (a progressive neurological disorder that affects memory, thinking, and behavior). Record review of Resident #3's quarterly MDS submitted 4/30/2026 reflected a BIMS score of 12, which indicated moderately impaired cognition. Record review of Resident #3's Activities- Quarterly/Annual Participation Review dated 5/18/2026 reflected the following: .2. Describe resident's favorite activities, special accomplishments, and/or new interests.Resident loves crafting unique crafts/art, bingo, social gatherings, manicures/makeup, family visits, music, movies, most all activities [sic]. She enjoys going on outings and visiting with friends and family .Resident #3 declined to participate in an interview on 5/27/2026 at 12:15 PM. In an interview with CNA A on 5/27/2026 at 10:10 AM, she said there was no coffee social or other organized activity occurring at the facility at that time. She said the activities calendar did not reflect which activities were actually hosted at the facility, and residents frequently reported that they were bored due to lack of activities. She said she felt like residents were at risk for becoming sad or depressed due to not having consistent activities. In an interview with the AD on 5/27/2026 at 1:42 PM, she said she was unsure if the coffee social scheduled for 10:00 AM that day had occurred because she was late to work and had not yet arrived by that time. She said she had not called anyone to ask them to host the event in her absence. She also said approximately 2 to 3 scheduled activities were cancelled per week due to various reasons, and her back-up activities consisted of an activity cart with snacks and independent activities on it. She said that she scheduled the weekend activities as self-directed due to a conflict with a resident regarding the type of activities on weekends. She said she prepares activity packets on Friday afternoons for any interested residents to use for entertainment, and the corporate company of the facility was displeased with her decision to include self-directed activity on the calendar for the weekends. She felt residents were receiving adequate stimulation through activities, and the potential harm of not having enough activities to meet residents' needs was decreased quality of life. In an interview with the Admin. on 5/27/2026 at 2:54 PM, she said was aware the scheduled activity for every weekend in May 2026 was self-directed. She said she had not approved of this activity and had seen the schedule when the calendar was posted by the AD. She said this activity did not meet the standards of the facility, but she did not discuss the deficiency with the AD due to ongoing performance issues. She said the AD had been on a performance improvement plan since January 2026 due to complaints from residents and staff about lack of activities, poor communication, and inconsistent efforts to engage residents in activities, and the AD had resigned effective June 2026. Record review of the facility policy titled Activity Programs dated June 2018 reflected the following: . 6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's psychosocial needs for 3 of 3 residents (Residents #1, 2, and 3) reviewed for comprehensive care planning. The facility failed to ensure residents' preferences for activities and leisure were addressed in the comprehensive care plans for Residents #1, 2, and 3. This failure could result in decreased quality of life. Findings included: Record review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included bipolar disorder (a mental health disorder characterized by severe mood swings). Record review of Resident #1's quarterly MDS submitted 3/5/2026 reflected a BIMS score of 15, which indicated intact cognition. Record review of Resident #1's Activities- Quarterly/Annual Participation Review dated 10/14/2025 reflected the following: .2. Describe resident's favorite activities, special accomplishments, and/or new interests.Arts and Crafts [sic], Coloring [sic], Gardening [sic]. Resident is very involved in all matters of activities at the facility and frequently becomes creative with the Activities Director to assist in facilitation of activities . Record review of Resident #1's Care Plan Report undated/ printed 5/27/2026 did not reveal person-centered care planning related to Resident #1's preferences of activities. Record review of Resident #2's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (decreased ability of the left side of the body as a result of neurological damage from a blood clot in the brain). Record review of Resident #2's quarterly MDS submitted 4/06/2026 reflected a BIMS score of 15, which indicated intact cognition. Record review of Resident #2's Activities- Quarterly/Annual Participation Review dated 1/07/2026 reflected the following: .2. Describe resident's favorite activities, special accomplishments, and/or new interests.Loves all activities . Record review of Resident #2's Care Plan Report undated/printed 5/27/2026 did not reveal person-centered care planning related to Resident #2's preferences of activities. Record review of Resident #3's Face Sheet reflected an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's disease (a progressive neurological disorder that affects memory, thinking, and behavior). Record review of Resident #3's quarterly MDS submitted 4/30/2026 reflected a BIMS score of 12, which indicated moderately impaired cognition. Record review of Resident #3's Activities- Quarterly/Annual Participation Review dated 5/18/2026 reflected the following: .2. Describe resident's favorite activities, special accomplishments, and/or new interests.Resident loves crating unique crafts/art, bingo, social gatherings, manicures/makeup, family visits, music, movies, most all activities [sic]. She enjoys going on outings and visiting with friends and family . Record review of Resident #3's Care Plan Report undated/printed 5/27/2026 did not reveal person-centered care planning related to Resident #3's preferences of activities. In an interview on 5/27/2026 at 9:50 AM, the LSW said the Activities Director did not attend routine care plan conferences. He said the conferences reviewed residents' preferences for activities, but the inclusion of that information into the care plan is performed by the DON. In an interview on 5/27/2026 at 1:42 PM, the AD said the facility procedure for care plan conferences did not include her. She was unsure if residents' preferences for activities were reviewed during these conferences. She was unsure if residents' care plans included preferences and/or accommodations needed for activities. She said allowing residents the options to participate in activities they enjoyed was important to their overall well-being and healing. In an interview on 5/27/2026 at 2:54 PM, the Admin said the facility was undergoing a progress change for care plan conferences that would include the activities department. She said the current process was the care conferences were attended only by the LSW and DON, and all care areas were reviewed. She said the staff were aware of residents' activities preferences because the census was small and the staff had become familiar with the residents over time. In an interview on 5/27/2026 at 3:45 PM, the DON said she was responsible for creating resident's care plans. She said residents' preferences and needs were reviewed during care plan conferences, but the facility was instituting a new process that would include the Activities Director at all care plan conferences. She said the care plans did not include specific preferences, but she made the preferences known to staff during routine, weekly staff meetings. Record review of the facility policy Care Plans, Comprehensive Person-Centered dated 2001, revised March 2022 reflected the following: .7. The comprehensive, person-centered care plan: . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on interview and record review the facility failed to use the services of a registered professional nurse at least 8 consecutive hours a day, 7 days a week for 1 of 1 facilities reviewed for nursing services. The facility did not utilize the services of an RN on 2/22/25, 2/23/25, 3/1/25, 3/30/25, 4/13/25, 4/20/25, 4/27/25, 5/4/25, 6/1/25, 6/8/25, 6/15/25, 6/29/25, 7/6/25, 7/13/25, 7/20/25, 7/27/25, 8/3/25, 8/10/25, and 8/17/25 for a total of 19 days. This failure could place residents at risk of not receiving needed care and services.The findings were: Review of the PBJ staffing data report for FY quarter 2 2025 (January 1 - March 31) with a run date of 8/14/25 revealed the facility triggered for no RN hours for Saturday 2/22/25, Sunday 2/23/25, Saturday 3/1/25, and Sunday 3/30/25. Review of the facility time sheets for RNs revealed the facility had no RN coverage for Saturday 3/1/25. Review of the facility time sheets for RNs revealed the facility had no RN coverage for Sundays on 3/30/25, 4/13/25, 4/20/25, 4/27/25, 5/4/25, 6/1/25, 6/8/25, 6/15/25, 6/29/25, 7/6/25, 7/13/25, 7/20/25, 7/27/25, 8/3/25, 8/10/25, and 8/17/25. In an interview on 8/22/2025 at 12:35 p.m. the Administrator stated the facility lost their Sunday nurse and had been doing well with RN hours prior to that. The Administrator stated they had been actively seeking an RN for the weekends and just hired a new weekend nurse, and she had been training this week. The Administrator stated she felt the staff were competent and her licensed nurses (LVNs) were well equipped to deal with situations. The Administrator stated she was unsure of any possible consequences of not having an RN for 8 consecutive hours a day 7 days a week due to always having competent licensed nursing staff on duty and the DON was on call 24/7 and there was also physician telehealth available 24/7 but she understood it was better to have an RN on-site for assessment. In an interview on 8/22/25 at 1:07 p.m. the DON stated the possible consequences of not having an RN 8 hours a day 7 days a week could be not having the advanced assessment and skill set but she was available 24/7 by phone and all staff and many families had her cell phone number plus she had a group chat with all staff that she starts every Monday. Review of the facility policy on nursing services for RN hours implemented 7-2025 indicated It is the policy of the facility to comply with Registered Nursing staffing requirements as per the Social Security Act. 1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #3) reviewed for quality of care. CNA A transferred Resident #3 using a mechanical lift without the assistance of another staff member. This failure could place residents at risk of accidents, injury, and pain. The findings were: Record review of Resident #3's face sheet dated 8/22/25 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE]. The resident's diagnoses included Wernicke's encephalopathy (an acute, life-threatening neurological emergency caused by a severe thiamine (Vitamin B1) deficiency, most often due to chronic alcohol abuse but also associated with poor nutrition or malabsorption. Its classic symptoms include loss of muscle coordination), generalized muscle weakness, muscle wasting and atrophy not elsewhere classified unspecified site (wasting or loss of muscle tissue), and Transient Ischemic Attack (TIA - short period of symptoms similar to those of a stroke. It's caused by a brief blockage of blood flow to the brain). Record review of Resident #3's annual MDS assessment dated [DATE] revealed the resident had a BIMS score of 13 out of 15 indicating the resident was cognitively intact, used a wheelchair, and required extensive assistance of a 2- person physical assist for bed mobility, and transfers. Record review of Resident #3's undated care plan revealed a problem with a start date of 6/6/25 edited on 6/17/25 for ADL function that the resident required a mechanical lift, with a goal of safe travels and an approach to maintain safe transfers. In an observation and interview on 8/21/25 at 10:04 a.m. CNA A opened the door to Resident #3's room and exited the room pushing the mechanical lift out in to the hallway. Resident #3 was in his wheelchair in his room with the mechanical lift sling underneath him. There were no other staff members in Resident #3's room. CNA A stated no one had helped her transfer the resident. CNA A stated she transferred Resident #3 from his bed to his wheelchair alone with the mechanical lift. CNA A stated she was not supposed to transfer the residents with the mechanical lift alone. CNA A stated she did not ask anyone for assistance with the mechanical lift as when she looked down the hall, she did not see anyone and went ahead and transferred the resident without the assistance of another staff member. In an observation and interview on 8/21/25 at 10:08 a.m. Resident #3 was sitting in his room in his wheelchair with the mechanical lift sling underneath him. Resident #3 stated CNA A had transferred him using the mechanical lift by herself without the assistance of another staff member and stated there were no issues with the transfer and he felt safe during the transfer. Resident #3 stated the facility staff including CNA A did not usually use the mechanical lift to transfer him without the assistance of another staff member but he had wanted to get up. In an observation on 8/21/25 at 10:10 a.m. the DON was in-servicing staff on 2-person transfers using mechanical lifts. In an interview on 8/22/25 at 12:00 p.m. the DON stated it was important to use 2-persons for a mechanical lift to ensure control of the mechanical lift, ensure the resident was properly positioned, and for proper guidance of the lift and the resident. The DON stated the possible consequences of not using 2-persons for a mechanical lift could be the resident could fall or sustain an injury from not guiding the resident's legs up and or hitting something. Review of CNA A's training skills checklist revealed she was trained and had passed a 2-person mechanical lift on 3/25/25 and did not need improvement. Review of the facility policy on safe resident handling and transfers with an implementation date of 7-2025 indicated It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and to provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. 10. Two staff members must be utilized when transferring residents with a mechanical lift.

Based on interview and record review the facility failed to provide nursing care with a sufficient number of nursing personnel on a 24-hour basis to all residents in accordance with resident care plans for 1 out of 4 days (04/07/25) reviewed for sufficient nursing staff. The facility failed to have sufficient staff available to provide resident care for approximately 5 hours during the 2P-10P shift on 04/07/25. This failure could put residents at risk of not receiving necessary care to maintain their highest practicable physical, mental and psychosocial wellbeing. Findings include: Record review of Resident #2's face sheet, accessed 04/18/25, reflected a [AGE] year-old female initially admitted [DATE], with diagnoses to include dementia (group of symptoms affecting memory, thinking and social abilities), unsteadiness of feet, and generalized muscle weakness. Record review of Resident #2's quarterly MDS assessment, dated 04/05/25, reflected Resident #2 was partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for chair/bed-to-chair transfers and had a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #2's care plan, last reviewed 03/24/25, reflected I have a history of fall R/T impaired mobility and impaired balance with intervention resident is educated to wait for staff to supervise with transfers., dated 03/31/25. Record review of Resident #3's face sheet, accessed 04/18/25, reflected a [AGE] year-old female initially admitted [DATE], with diagnoses to include insomnia, dementia (group of symptoms affecting memory, thinking and social abilities), lack of coordination, major depressive disorder, and need for assistance with personal care. Record review of Resident #3's annual MDS assessment, dated 01/16/25, reflected Resident #3 was substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for chair/bed-to-chair transfers and was dependent (Helper does ALL of the effort) to wheel her wheelchair 50 feet with two turns and wheel 150 feet. It further revealed Resident #3 had a BIMS score of 13 out of 15, indicating intact cognition. Record review of Resident #3's care plan, last reviewed 03/24/25, reflected [Resident #3] is at risk for disturbed sleep patter R/T insomnia with intervention Encourage resident to go to bed at the same time everyday and wake up at the same time everyday., dated 03/27/24. Record review of Resident #4's face sheet, accessed 04/18/25, reflected a [AGE] year-old female initially admitted [DATE], with diagnoses to include age-related physical debility, lack of coordination, muscle weakness, and need for assistance with personal care. Record review of Resident #4's quarterly MDS assessment, dated 02/07/25, reflected Resident #4 was had a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #5's face sheet, accessed 04/18/25, reflected a [AGE] year-old female initially admitted [DATE], with diagnoses to include cerebral palsy (group of permanent neurological disorders that affect body movement and muscle coordination), need for assistance with personal care, moderate intellectual disabilities, and depression. Record review of Resident #5's quarterly MDS assessment, dated 01/24/25, reflected Resident #5 had a BIMS score of 02 out of 15, indicating severely impaired cognition. It reflected Resident #5 had frequent urinary incontinence and frequent bowel incontinence and needed substantial/maximal assistance (helper does MORE THAN HALF the effort) to roll left and right. Record review of Resident #5's care plan, last reviewed 03/24/25, reflected Urinary Incontinent Care with an intervention To assess resident incontinence and protect skin integrity, dated 03/31/25. Interview on 04/16/25 at 09:50AM, Resident #2 revealed last Monday, 04/07/25, there were no CNAs after a certain time on the 2PM-10PM shift. She revealed her call light was not answered when she wanted to transfer herself from her wheelchair to bed. (Resident #2 was unable to recall any specific times related to using her call light and transferring herself.) She revealed she transferred herself without falling. She revealed her roommate Resident #3 went to bed around 11PM on 04/07/25, when Resident #3 typically went to bed around 7PM. Interview on 04/16/25 at 04:23PM, CNA A revealed last Monday 04/07/25 he knew from Resident #2 about CNAs not being in the facility. He stated the Staffing Coordinator said there were no CNAs scheduled from 2PM-10PM. He stated that was not typical for the facility. Interview on 04/16/25 at 05:19PM, LVN F revealed he worked Monday 04/07/25 2PM-10PM. He further revealed they were without a CNA from 5PM-10PM. He revealed the nurses did everything to include passing out medications, wound care, feeding, and answering call lights. He revealed there was nothing he knew of that was missed, but that some residents went to bed later than planned. Interview on 04/16/25 at 06:33PM, the DON revealed on Monday 04/07/25 CNA A was at the facility until about 5:30PM. She revealed Nurse Aide E was originally on the schedule to cover 5PM-10PM time frame but had left at 5PM instead. The DON revealed she was switching to 12-hour shifts, so she could have a pool of nursing staff she could call in to work if that happened again. She revealed to make sure resident care was not missed on this evening, the nursing staff talked about grievances in the morning huddle, and she went into everyone's rooms to make sure residents were fine. She revealed she found there was no effect on resident care at that time. Interview on 04/18/25 at 11:40AM, the DON revealed it was important to make sure there were CNAs scheduled throughout the day. She revealed she scheduled 2 CNAs for the 2PM-10PM shift and at least 3 for the 6AM-2PM shift. She further revealed it was important to have enough CNAs so there was not a delay in care and so this did not affect nursing duties like medication pass when the nurses may need to help CNAs or do CNA work instead. Interview on 04/18/25 at 12:50PM, Nurse Aide E revealed she was not aware that she was scheduled to work on 04/07/25 on the 2P-10P shift. She revealed she left the facility at 5PM. Interview on 04/18/25 at 05:40PM, Resident #3 revealed she typically went to bed at 7PM but she was put to bed at 10P or 11P on 04/07/25. She revealed she preferred going to bed at 7PM after she took her medications because they made her drowsy. Interview on 04/18/25 at 05:43PM, Resident #4 revealed the call lights were not being answered on 04/07/25 evening. She revealed her roommate, Resident #5 had her call light on but was never responded to. Resident #4 revealed she had to change Resident #5's brief because she was wet. Resident #5 was present during this interview and unable to be interviewed. Record review of the Facility Assessment Tool reflected the total minimum number needed or average or range of nurse aides were 2 on afternoon shift. Record review Punch Detail Report, dated 04/07/25, reflected Nurse Aide E clocked out at 5PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected Nurse Aide H clocked out at 5PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected Nurse Aide I clocked out at 5PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected Nurse Aide J clocked out at 5PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected CNA A clocked out at 5:06PM on 04/07/25. Record review Punch Detail Report, dated 04/07/25, reflected CNA G clocked in at 10:07PM on 04/07/25. Record review of facility's policy Staffing, revised July 2021, reflected Our center provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the center assessment . 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services.

Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plan for 1 of 5 Residents (Resident #1) whose records were reviewed, in that: Resident #1's Care Plan still reflected resident was a 1 person transfer when she was a 2-person transfer. The deficient practices could affect any resident and could result in the inaccuracy of assessments and contribute to residents not receiving care for identified care needs. The findings were: Record review of Resident #1's face sheet, accessed [DATE], reflected an [AGE] year-old female admitted [DATE] and expired [DATE], with diagnoses to include hemiplegia and hemiparesis (paralysis and partial weakness of one side), cerebral infarction (necrotic tissue in the brain), and dementia (group of symptoms affecting memory, thinking and social abilities). Record review of Resident #1's quarterly MDS assessment, dated [DATE], reflected Resident #1 was substantial/maximal assistance (helper does MORE THAN HALF the effort) for chair/bed-to-chair transfers and had a BIMS score of 09 out of 15, indicating moderate cognitive impairment. Record review of Resident #1's care plan, last reviewed [DATE], reflected ADLs functional status/rehabilitation potential with intervention Ambulation/Transfers amount of assist:1 person, dated [DATE]. It further reflected The following tasks will be documented in POC CareAssist with intervention 2 person assist with transfers, dated [DATE]. Interview on [DATE] at 04:49PM, CNA A had been working at the facility since October or [DATE]. He revealed Resident #1 was transferred with a mechanical lift. He revealed there was a cheat sheet that told the nursing staff how residents were transferred to include 1 person, 2 person, or mechanical lift. He revealed it was important to know how to care for residents so he could help them out more. Interview on [DATE] at 12:30PM, LVN B revealed Resident #1 was transferred with a mechanical lift and 2 people were needed for this transfer. She revealed she did not read care plans and the information about resident care was reported verbally amongst nursing staff. She revealed she would let the DON know to update care plan when a resident needed something different like transfers. She further revealed it was important to update care plans for resident care. She revealed if the nursing staff did not know what to do for a resident, then they would refer to the care plan to figure it out. Interview on [DATE] at 01:03PM, LVN C revealed Resident #1 was transferred via mechanical lift most of the time. She revealed 2 people were needed for a mechanical lift. She revealed the nursing staff relayed information about resident care via word of mouth. Interview on [DATE] at 11:00AM, CNA D revealed Resident #1 was a 2-person mechanical transfer. She revealed she read the residents' care plans to know how to care for the residents. Interview on [DATE] at 02:16PM, the DON reviewed the care plan screen and that it reflected a 1-person transfer for Resident #1, which needed to be updated so the resident was not inappropriately transferred since Resident #1 was a mechanical lift that required a 2 person transfer The DON further revealed she oversaw that care plans were updated as needed. Record Review of the facility policy, revised [DATE], Care Plans, Comprehensive Person-Centered, reflected, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 20 days (1/1/24, 1/6/24, 1/13/24, 1/14/24, 1/20/24, 1/27/24, 2/3/24, 2/4/24, 2/10/24, 2/17/24, 4/6/24, 4/21/24, 5/11/24, 5/12/24, 6/1/24, 6/2/24, 6/8/24, 6/9/24, 6/15/24, and 6/16/24), reviewed for nursing services. The facility had no RN coverage for 1/1/24, 1/6/24, 1/13/24, 1/14/24, 1/20/24, 1/27/24, 2/3/24, 2/4/24, 2/10/24, 2/17/24, 4/6/24, 4/21/24, 5/11/24, 5/12/24, 6/1/24, 6/2/24, 6/8/24, 6/9/24, 6/15/24, and 6/16/24. (20 days from January 2024 to June 2024) This failure could result in residents not receiving the required services to meet their needs. The findings were: Record review of the CMS PBJ staffing data report run date 7/3/24 for quarter 2 (January 1 through March 31st) revealed the facility triggered for no RN hours on 1/1/24, 1/6/24, 1/13/24, 1/14/24, 1/20/24, 1/27/24, 2/3/24, 2/4/24, 2/10/24, and 2/17/24. Record review of the facility timesheets revealed no RN coverage for 1/1/24 (Monday), 1/6/24 (Saturday), 1/13/24 (Saturday), 1/14/24 (Sunday), 1/20/24 (Saturday), 2/3/24 (Saturday), 2/4/24 (Sunday), 2/10/24 (Saturday), 2/17/24 (Saturday), 4/6/24 (Saturday), 4/21/24 (Sunday), 5/11/24 (Saturday), 5/12/24 (Sunday), 6/1/24 (Saturday), 6/2/24 (Sunday), 6/8/24 (Saturday), 6/9/24 (Sunday), 6/15/24 (Saturday), 6/16/24 (Sunday), and 5 hours of coverage on 1/27/24 (Saturday). During an interview on 7/7/24 at 11:30 a.m. the DON stated she worked at a minimum of 40 hours a week Monday through Friday but often worked outside her normally scheduled hours but is salaried and does not clock in or out. During an interview on 7/10/24 at 9:30 a.m. the HRC stated there were other RN's the facility used that are no longer employed but she and her corporate contact were unable to access their timesheets. During an interview on 7/10/24 at 12:30 p.m. the Administrator stated the facility had been without a weekend RN supervisor but hired one in June 2024 and has had no issues since that time with RN coverage. The Administrator stated she was unsure of the consequences of not having an RN on duty at the facility because the nurses had immediate access to the DON by phone, the clinical resource nurse (RN), the physician's group, and 911 for emergencies and pointed across the street to the city EMS services building and stated EMS was across the street. Review of the facility policy for staffing revised July 2021 indicated . 4. Direct care staffing information per day including agency and contract staff is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter. Review of another facility policy for staffing revised 9-28-23 indicated . 4. The facility utilizes the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure staff wore hair restraints to cover hair when in the kitchen. The facility failed to ensure staff with facial hair was covered by a hair restraint. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 07/07/2024 at 9:13 a.m. during initial tour of the kitchen revealed CNA A entered the kitchen and washed hands at the sink without a hair net. During an interview on 07/07/24 at 9:23 a.m. CNA A revealed she should have had a hair net on due to contamination. CNA A further stated she had just come in from taking some trash and had something on her hand and was trying to find the nearest sink to wash her hands. CNA A stated a hair net should be always worn when you are in the kitchen or entering the kitchen due to contamination risk. Observation and interview on 07/08/2024 at 3:17 p.m. revealed upon entry to the kitchen the DM not wearing a hair net or a beard restraint. The DM was observed to have been standing next to the stove and the prep table at the time of entry to the kitchen not wearing a hair net or a beard restraint. The DM quickly went into the dietary office and returned with a cook bonnet that ties in the back along with a beard restraint which was only covering his beard not his mustache. The DM revealed by not wearing the hair restraints it could cause contamination of food items in the kitchen The DM further stated the reason for the need to cover the mustache was due to bacteris was not easily washed off and his mustache could carry bacteria. During an interview on 07/10/2024 at 10:46 a.m. the DM revealed regarding the incident on 07/08/2024 when he was observed not wearing a hair net and beard restraint that he had just entered the kitchen, pulled a pot and the meat from thawing to begin preparation, had not put on his hair restraints yet. The DM further stated it was important to wear them as they kept hair out of the food due to hair potentially carrying bacteria. The DM stated hair getting into the food had the potential of causing sickness or illness. The DM stated hair restraints should be worn at all times when in the kitchen. During an interview on 07/10/2024 at 11:05 a.m. the ADM revealed staff were to wear hair restraints every time they go in the door of the kitchen. The ADM further stated by not wearing them it could be an infection control issue and that the hair restraints are worn so hair did not get on the food. Review of facility's policy Personnel Guidelines, not dated, read Dress Code and Appearance: Wear hair restraints that are designed to effectively keep hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service or single-use articles. This helps prevent hair from contacting food and food-contact surfaces and to deter team members from touching their hair. Hair restraints may include hair bonnets and nets, beard restraints and clothing that covers body hair. Hair should be fully covered with hair restraints within the department. Other hair restraints require approval from the Dietitian or designee. Hair coverings should completely restrain hair, should not be worn outside the kitchen and remain clean. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 16 residents (Resident #13) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #13. This deficient practice could affect any resident and keep them from calling for help as needed. The findings were: Record review of Resident #13's face sheet, dated 07/10/2024, revealed she was admitted to the facility on [DATE] with diagnoses which included: other specified chronic obstructive pulmonary disease, essential hypertension, dementia in other diseases classified elsewhere, unspecified severity, with anxiety, unspecified macular degeneration, shortness of breath, and localized edema. Record review of Resident #13's Admission MDS assessment, dated 06/29/2024, revealed the resident's BIMS score was 12, which indicated moderate cognitive impairment. The Admission MDS assessment further revealed Resident #13 required substantial/maximal assistance (helper does more than half the effort) for lower body dressing, putting on/taking off footwear, sit to stand, chair/bed-to-chair transfer, dependent (helper does all the effort) for upper body dressing and partial/moderate assistance (helper does less than half the effort) for personal hygiene. Record review of Resident #13's care plan, revision date of 07/02/2024, revealed Resident #13 had a problem of Category: Falls. Falls/Safety/Elopement Risk and approach revealed Encourage use of call light. Keep call light within reach. Observation and interview on 07/07/2024 at 10:35 a.m. revealed Resident #13's call light on the floor at the foot of the bed near privacy curtain with Resident #13 at bedside sitting in her wheelchair. Resident #13 stated she wished she could get someone who could help her turn her light on. Resident #13 stated she did not know where her call light was, but she only knew of the string to her light over her bed. During an interview and observation on 07/07/2024 at 10:42 a.m. LVN B revealed Resident #13 did not have her call light within reach and would need to get a stuffed animal on it because they usually have one on them as she placed the call light from the floor to the bed. LVN B stated Resident #13 would not have been able to reach the call light. Resident #13 took the string in her hand. LVN B further stated everyone was responsible to place the call light within reach. Observation and interview on 07/10/2024 at 10:55 a.m. revealed Resident #13 in her room with over the bed table next to her while sitting in her wheelchair next to her bed which ran across the wall under the over bed light with the call light on the other side privacy curtain in the chair next to the other bed in the room. The DON was preparing Resident #13's medications for administration as Resident #13 called to her to please come in the room. The DON was observed entering and visited with her, explained to her the medications being received. The DON as she prepared to leave room and had answered resident's questions, she noticed call light and placed it beside Resident #13 with the teddy bear sitting it on her lap which was attached to the call light. The DON informed Resident #13 she was placing the call light on her lap. When DON exited Resident #13's room she stated the call light was out of reach and stated it was everyone's responsibility to ensure call lights were within reach. The DON further stated it was important for call lights to be within reach, so residents were able to call for assistance or alert staff to their needs. Record review of facility's Answering the Call Light policy, revised date March 2021, read Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines 5. When the resident is in bed or confined to a chair be the call light is within easy reach of the resident.

Based on observation and interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 4 of 8 days (7/4/24, 7/5/24, 7/6/24, and 7/7/24) prior to and during the survey period, reviewed for nursing services. The daily staff posting was not posted on 7/4/24, 7/5/24, 7/6/24, and 7/7/24. (4 days) This failure could result in residents and visitors being unaware of facility staffing levels. The findings were: During an observation on 7/7/24 at 8:53 a.m. 07/07/24 the daily staffing was posted on wall to left of nursing station in a clear plastic holder and was dated 7/3/24, the sheet behind that was dated 7/4/24. There were no other daily staffing sheets observed. During an observation on 7/7/24 at 10:50 a.m. the daily staffing was posted on wall to left of nursing station in a clear plastic holder and was dated 7/3/24, the sheet behind that was dated 7/4/24 and had not been updated. In an interview on 7/7/24 at 8:58 a.m. LVN B stated she was not sure who was responsible for posting the daily staffing but thought it was the DON and on the weekends their weekend supervisor but she was not there today. In an interview on 7/7/24 at 10:52 a.m. the DON stated any one of the nursing staff was responsible for posting the daily staff posting. In an interview on 7/10/24 at 10:55 a.m. the Administrator stated the DON was responsible for posting the daily staffing sheet. The Administrator stated not posting the daily staffing could possibly result in residents and visitors not being aware of the staffing levels for that day. In an interview on 7/10/24 at 11:05 a.m. the DON stated she made the daily staffing sheet and placed them behind the other and any nurse on duty was to rotate the daily staffing sheet to the appropriate date. Review of the facility policy on staffing revised July 2021 indicated . 6. Staffing levels for direct care staffing is updated each shift and posted in a public area.

Based on observations and interviews, the facility failed to post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility for 2 of 4 days (7/7/24 and 7/8/24), observed for postings. The facility did not have the survey results available and accessible to residents and visitors without having to ask for them on 7/7/24 and 7/8/24 during the survey period. This failure resulted in residents, family members, and legal representatives of residents being unable to access prior survey results without having to ask to see them. The findings were: During an observation on 7/7/24 at 8:50 a.m. there was a picture framed, and carved sign on the wall in the entrance of the facility and read the annual survey results were in the lobby for viewing. No survey results were observed in the lobby, common area, or on the nurses station desk. During an observation and interview on 7/7/24 at 12:30 p.m. No survey results were observed in the lobby, common area, or on the nurses station desk. The HRC stated she was unable to locate the survey result binder at that time. During an observation on 7/8/24 10:50 a.m. No survey results were observed in the lobby, common area, or on the nurses station desk. During a resident council group meeting on 07/08/24 at 11:10 a.m. some residents stated the survey binder with results was available to the residents in the front area near the desk at the front door. In an interview on 7/8/24 at 2:00 p.m. the HRC had the survey results binder near the nurses station and stated it was located behind the nurses station with other binders. In an interview on 7/10/24 at 10:55 a.m. the Administrator stated the survey results had been in a plastic pocket on the wall in the entrance but had fallen off and the plastic pocket had not been repaired yet and why the results were not where they normally were and the Administrator was unsure of when it had broken. The Administrator stated this could create the possibility of the survey results not being easily accessible to residents and visitors that wanted to read them. Review of the facility policy on examination of survey results revised October 2021 policy statement indicated copies of survey results are maintained in an accessible location 2. The location of the survey reports will be posted in a public area of the center as required by state regulations

The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #10) reviewed for infection control. The facility failed to post a sign on Resident #10's door to indicate she was on Contact Isolation (any of the techniques used in addition to standard precautions that decrease the likelihood of infection by microorganisms transmitted through direct or indirect contact with the patient or patient care items, e.g., methicillin-resistant Staphylococcus aureus). This deficient practice could affect staff, residents, and visitors who may enter Resident #10's room without the appropriate PPE and expose them to infection. The findings included: Record review of Resident #10's electronic face sheet (undated) reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: partial intestinal obstruction (happens when the intestines are partially blocked), toxic encephalopathy (neurologic disorder caused by exposure to toxic substances that damage the brain), dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), methicillin resistant staphylococcus aureus infection (a type of bacteria that's resistant to a number of widely used antibiotics), and unspecified site, carrier or suspected carrier of methicillin resistant staphylococcus aureus (may be a carrier of the bacteria and can spread or transmit the bacteria to others). Record review of Resident #10's quarterly MDS assessment with an ARD of 02/23/2024 reflected she scored an 11/15 on her BIMS which signified she was moderately cognitively impaired. She could understand and be understood. She required extensive assistance with her ADL's. Record review of Resident #10's comprehensive care plan revised 02/29/2024 reflected Problem, has a pressure ulcer infection on sacrum, Approach, use principles of universal/standard precautions for contact precautions per facility policy. Record review of Resident #10's physician orders dated 02/29/2024 reflected Pt to have contact isolation due to positive MRSA to nares until her ABT therapy done in 10 days. Special Instructions: Pt to maintain isolation status x 10 days. Start dated 02/26/2024. Observation on 02/28/2024 at 10:00 a.m. of Resident #10's door revealed she had a bin sitting outside against the wall with masks, gloves, and gowns in the drawers (PPE). There was no sign on her door. Observation on 02/29/2024 at 08:00 a.m. of Resident #10's door revealed she still had a bin outside of her door, and there was no isolation sign posted. In an interview on 02/29/2024 at 09:30 a.m. with the DON, she stated she informed the staff to set up isolation for Resident #10 when she returned from the hospital on 02/21/2024 and the positive MRSA nasal swab was noticed in her lab work. She stated that staff who collaborated with the resident were informed she was on contact isolation. She stated there should have been a sign on Resident #10's door which indicated she was on contact isolation. In an interview on 02/29/2024 at 1:24 p.m. with C NA A, she stated she was informed that Resident #10 was on contact isolation, but there was no sign on the door. She stated the PPE was available and they wore a gown and gloves when they collaborated with the resident. In an interview on 02/29/2024 at 1:30 p.m. with LVN B, she stated she was informed that Resident #10 was on contact isolation, but that a sign was not on the door because of HIPAA rules. Record review of the facility policy and procedure titled Isolation-Categories of Transmission-Based Precautions revised January 2012 reflected 8. Signs - The facility will implement a system to alert staff to the type of precaution resident requires.

Based on interview and record review, the facility failed to develop and implement a Baseline Care Plan for resident 1 of 3 (Resident #6) who was admitted on hospice to the facility for respite care on 8/31/2023. The facility failed to initiate a Baseline Care Clan within 48 hours of admitted on 8/31/2023 to include information for the resident's stay for respite, for her hospice care, and for her stage 2 left heel wound while at the facility. This failure could place the resident at risk of not receiving person-centered care that is needed for communicating with staff to ensure the resident's needs are met. Findings include: Record review of Resident #6's face sheet on 2/28/2024 at 3:25PM revealed she was an [AGE] year old woman admitted to facility 8/31/2023 with diagnoses which include: Parkinson's disease, hypotension (low blood pressure), and Rhabdomyolosis (breakdown of muscle that release a damaging protein- myoglobin into the blood that can cause kidney damage). Record review of Resident #6's MDS assessment dated [DATE] revealed she had a BIMS score of 9 and required extensive assistance with ADLs. During an interview with the DON on 2/29/2024 at 12:11PM she stated ,a Baseline Care Plan should be done within 48 hours of admission. It lets the nurses know the need of the resident and how to care for the resident. Based on record review of the facility's policy for admissions on 2/29/2024 at 3:15PM titled- Care Plans- Baseline and dated 12/2016 (revised) revealed: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. Policy interpretation stated in part: the baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to ensure the facility fryer was clean and old oil discarded. 2. The facility failed to ensure homemade Jell-O was discarded after 3 days. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness. The findings were: 1. In an observation on 6/4/2023 at 9:45 a.m. of the facility fryer located in the facility kitchen revealed there were two separate [NAME] with oil. Further inside the oil [NAME] revealed the well on the right was dark and was unable to see the bottom of the pan. Further review of the kitchen fryer revealed there was a thick splatter of oil on the outside of the fryer and on the table the fryer was sitting on. In an interview on 6/4/2023 at 9:52 a.m. with the FSS revealed they used only the fryer on the left and used the right side for run off from the fried food item. The FSS reported he had changed the oil in the well on the left side but had not had a chance to change out the well on the right side. He also noted he was aware of the oil splatters on the outside of the well and on the table. 2. In an observation on 6/4/2023 at 9:52 a.m. of the reach-in refrigerator located in the facility kitchen was a 1/4 container of facility-made Jell-O with a made by date of 5/29/2023. In an interview on 6/4/2023 at 9:52 a.m. with the FSS revealed any food that came from a can was discarded after 7 days and any food made at the facility was discarded after 3 days. The FSS stated the Jell-O should have been discarded. Record review of the facility policy, Basics for Handling Food Safety, revised August 2013, revealed, Safe steps in food handling, cooking, and storage are essential to prevent foodborne illnesses and to keep food safe, Clean-Wash hands and surfaces often. Record review of the facility policy, Subject: Administrator Orientation Manual; Guideline: Weekly Administrator Kitchen Sanitation Rounds; Approval date: July 2010 revealed, Administrator will make weekly kitchen sanitation rounds to ensure sanitation meets regulatory requirements. Record review of the facility policy, Food Storage, dated 2018, under the heading, Refrigerator revealed, e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.

Based on interview and record review the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for 19 of 31 facility staff reviewed for trainings on infection control, in that; The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with trainings on infection control. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the undated excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: ADM, PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN P, LVN B or CNA E. Review of ADM's personnel record had a hire date of 9/10/2021, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of DON's personnel record had a hire date of 12/2/2022, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of SW's personnel record had a hire date of 5/23/2023, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of PT's personnel record had a hire date of 1/01/2019, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of OT L's personnel record had a hire date of 12/06/2022, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of OT M's personnel record had a hire date of 12/07/2018, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of CNA H's personnel record had a hire date of 5/1/2023, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of RN P's personnel record had a hire date of 5/16/2023, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of LVN B's personnel record had a hire date of 4/26/2023, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of CNA E's personnel record had a hire date of 10/10/2022, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of DA Q's personnel record had a hire date of 12/31/2015, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of ACT DIR's personnel record had a hire date of 7/29/2020, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of LVN D's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of RN N's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of LVN C's personnel record had a hire date of 7/15/2020, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of LVN O's personnel record had a hire date of 11/10/21, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. Review of Lead CNA J's personnel record had a hire date of 12/03/2002, with annual training in-services provided by the facility that did not include evidence of trainings on infection control. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and CNA Lead J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 2:45 PM, LVN D stated she was hired at the height of the pandemic and started when the facility was experiencing a significant COVID-19 outbreak among residents and staff. LVN D stated she did not complete any orientation or training before starting work on the floor. LVN D stated the facility was stretched extremely thin, and it was chaos when she started. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was a being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/8/2023 at 8:30 AM, the RRN stated because of the lack of proof of training, she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. In step 5.) Training topics .e.) Infection prevention and control program standards, policies, and procedures. In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record. Review of Abuse Prevention Program policy, revised June 2021, reveled the following Policy Statement 4.) Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. Under the Policy Interpretation and Implementation heading, in [DATE].) Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

Based on interview and record review the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for 4 (Lead CNA K, CNA E, CNA F, and CNA G) of 6 staff, in that; The facility failed to provide an annual performance review and subsequent trainings based on the outcome of the review for 4 (Lead CNA K, CNA E, CNA F, and CNA G) of 6 nurse aides reviewed for competencies. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: Lead CNA K, CNA F, CNA G. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: CNA E. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of annual performance review and subsequent trainings based on the outcome of the review. Review of CNA E's personnel record had a hire date of 10/10/2022, with annual training in-services provided by the facility that did not include evidence of an annual performance review and subsequent trainings based on the outcome of the review. Review of CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of an annual performance review and subsequent trainings based on the outcome of the review. Review of CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of an annual performance review and subsequent trainings based on the outcome of the review. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and CNA Lead J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was a being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/8/2023 at 8:30 AM, the RRN stated because of the lack of proof of training, she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record. Review of Abuse Prevention Program policy, revised June 2021, reveled the following Policy Statement 4.) Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. Under the Policy Interpretation and Implementation heading, in [DATE].) Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 19 of 31 facility staff reviewed for trainings consistent with their expected roles, in that; The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with trainings consistent with their expected roles. Findings included: Review of the undated excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: ADM, PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN P, LVN B or CNA E. Review of ADM's personnel record had a hire date of 9/10/2021, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of DON's personnel record had a hire date of 12/2/2022, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of SW's personnel record had a hire date of 5/23/2023, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of PT's personnel record had a hire date of 1/01/2019, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of OT L's personnel record had a hire date of 12/06/2022, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of OT M's personnel record had a hire date of 12/07/2018, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of CNA H's personnel record had a hire date of 5/1/2023, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of RN P's personnel record had a hire date of 5/16/2023, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of LVN B's personnel record had a hire date of 4/26/2023, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of CNA E's personnel record had a hire date of 10/10/2022, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of DA Q's personnel record had a hire date of 12/31/2015, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of ACT DIR's personnel record had a hire date of 7/29/2020, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of LVN D's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of RN N's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of LVN C's personnel record had a hire date of 7/15/2020, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. Review of LVN O's personnel record had a hire date of 11/10/21, with annual training in-services provided by the facility that did not include evidence of trainings consistent with their expected roles. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and CNA Lead J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 2:45 PM, LVN D stated she was hired at the height of the pandemic and started when the facility was experiencing a significant COVID-19 outbreak among residents and staff. LVN D stated she did not complete any orientation or training before starting work on the floor. LVN D stated the facility was stretched extremely thin, and it was chaos when she started. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was a being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/8/2023 at 8:30 AM, the RRN stated because of the lack of proof of training, she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. In step 4.) Training .appropriate to the level of education and expected roles of those attending. In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record. Review of Abuse Prevention Program policy, revised June 2021, reveled the following Policy Statement 4.) Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. Under the Policy Interpretation and Implementation heading, in [DATE].) Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

Based on interview and record review the facility failed to include effective communications as mandatory training for 17(DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O) of 31 direct care staff reviewed for trainings, in that; The facility failed to provide the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with effective communications as mandatory training. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN P, LVN B or CNA E. Review of DON's personnel record had a hire date of 12/2/2022, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of SW's personnel record had a hire date of 5/23/2023, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of PT's personnel record had a hire date of 1/01/2019, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of OT L's personnel record had a hire date of 12/06/2022, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of OT M's personnel record had a hire date of 12/07/2018, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA H's personnel record had a hire date of 5/1/2023, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of RN P's personnel record had a hire date of 5/16/2023, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN B's personnel record had a hire date of 4/26/2023, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA E's personnel record had a hire date of 10/10/2022, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of ACT DIR's personnel record had a hire date of 7/29/2020, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN D's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of RN N's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN C's personnel record had a hire date of 7/15/2020, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN O's personnel record had a hire date of 11/10/21, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and CNA Lead J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 2:45 PM, LVN D stated she was hired at the height of the pandemic and started when the facility was experiencing a significant COVID-19 outbreak among residents and staff. LVN D stated she did not complete any orientation or training before starting work on the floor. LVN D stated the facility was stretched extremely thin, and it was chaos when she started. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was a being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/8/2023 at 8:30 AM, the RRN stated because of the lack of proof of training, she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. In step 5.) Training topics .a.) Effective communication with residents and family (direct care staff). In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record. Review of Abuse Prevention Program policy, revised June 2021, reveled the following Policy Statement 4.) Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. Under the Policy Interpretation and Implementation heading, in [DATE].) Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

Based on interview and record review the facility failed to ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents 19 (ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O) of 31 facility staff reviewed for education records, in that;:: The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with education on the rights of the resident and the responsibilities of a facility to properly care for its residents. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the undated excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: ADM, PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN P, LVN B or CNA E. Review of ADM's personnel record had a hire date of 9/10/2021, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of DON's personnel record had a hire date of 12/2/2022, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of SW's personnel record had a hire date of 5/23/2023, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of PT's personnel record had a hire date of 1/01/2019, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of OT L's personnel record had a hire date of 12/06/2022, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of OT M's personnel record had a hire date of 12/07/2018, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of CNA H's personnel record had a hire date of 5/1/2023, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of RN P's personnel record had a hire date of 5/16/2023, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of LVN B's personnel record had a hire date of 4/26/2023, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of CNA E's personnel record had a hire date of 10/10/2022, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of DA Q's personnel record had a hire date of 12/31/2015, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of training education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of ACT DIR's personnel record had a hire date of 7/29/2020, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of LVN D's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of RN N's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of LVN C's personnel record had a hire date of 7/15/2020, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of LVN O's personnel record had a hire date of 11/10/21, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and CNA Lead J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 2:45 PM, LVN D stated she was hired at the height of the pandemic and started when the facility was experiencing a significant COVID-19 outbreak among residents and staff. LVN D stated she did not complete any orientation or training before starting work on the floor. LVN D stated the facility was stretched extremely thin, and it was chaos when she started. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was a being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/8/2023 at 8:30 AM, the RRN stated she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. In step 5.) Training topics .b.) Resident rights and responsibilities. In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record. Review of Abuse Prevention Program policy, revised June 2021, reveled the following Policy Statement 4.) Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. Under the Policy Interpretation and Implementation heading, in [DATE].) Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

Based on interview and record review the facility failed to ensure that staff members are educated on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting incidents, and dementia management and resident abuse prevention, for 19 (ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O) of 31 facility staff reviewed for education, in that; The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with training that education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: ADM, PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN P, LVN B or CNA E. Review of ADM's personnel record had a hire date of 9/10/2021, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of DON's personnel record had a hire date of 12/2/2022, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of SW's personnel record had a hire date of 5/23/2023, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of PT's personnel record had a hire date of 1/01/2019, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of OT L's personnel record had a hire date of 12/06/2022, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of OT M's personnel record had a hire date of 12/07/2018, with annual training in-services provided by the facility that did not include evidence education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of CNA H's personnel record had a hire date of 5/1/2023, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of RN P's personnel record had a hire date of 5/16/2023, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of LVN B's personnel record had a hire date of 4/26/2023, with annual training in-services provided by the facility that did not include evidence education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of CNA E's personnel record had a hire date of 10/10/2022, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of DA Q's personnel record had a hire date of 12/31/2015, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of CNA F's personnel record had a hire date of 4/29/2019, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of CNA G's personnel record had a hire date of 2/21/2022, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of ACT DIR's personnel record had a hire date of 7/29/2020, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of LVN D's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of RN N's personnel record had a hire date of 8/12/2021, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of LVN C's personnel record had a hire date of 7/15/2020, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. Review of LVN O's personnel record had a hire date of 11/10/21, with annual training in-services provided by the facility that did not include evidence of education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. In a group interview on 6/07/2023 at 1:58 PM with CNA E, CNA G, CNA I and CNA Lead J, all denied being behind on required trainings. CNA I stated the trainings are an automated process, where they are alerted via company email to complete specified trainings. CNA I stated that upon passing the test, a certificate of completion is provided and automatically sent to the ADM. Lead CNA J stated the trainings show up in your email with a link, that tells you what the deadline is. Lead CNA J stated there is usually plenty of time to complete the required trainings. Lead CNA J no one has been told by management they cannot work until trainings are completed. Lead CNA J stated sometimes there are in person In-Service trainings in addition to the mandatory computer courses. In an interview on 6/07/2023 at 2:45 PM, LVN D stated she was hired at the height of the pandemic and started when the facility was experiencing a significant COVID-19 outbreak among residents and staff. LVN D stated she did not complete any orientation or training before starting work on the floor. LVN D stated the facility was stretched extremely thin, and it was chaos when she started. In an interview on 6/07/2023 at 3:30 PM with RVP and RRN, the RVP stated he had just learned the system the company uses to push training notices directly to staff was not engaged properly for this facility's direct care staff. The RVP stated that it was a being fixed immediately. The RVP stated, all direct care staff should be up to date with mandatory trainings as part of their normal duties. The RVP stated he was not sure why or how long the system was not engaged properly. In an interview and record review on 6/8/2023 at 8:30 AM, the RRN stated she had started on 6/06/2023 In-Service trainings to direct care staff on the following topics: Blood Borne Pathogens, Restraints, Falls, Abuse and Neglect, Dementia trainings, Ethics, Infection control, Emergency Preparedness and Behavior Health. This was signed by 10 staff members which included the RRN, an illegible signature and title, CNA I, Lead CNA J, LVN C, the BOM, an illegible signature with title OT, an illegible signature with title Dietary Manager, an illegible signature with title RN, an illegible signature with no discernable title and the ADM. Review of Staff Development Program policy, revised June 2021, revealed statement, All personnel must participate in initial orientation and regularly scheduled in-services training classes. Under the Policy Interpretation and Implementation heading, in step 2.) .ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. In step 5.) Training topics .c.) Preventing abuse, neglect, exploitation .(1) Activities that constitute abuse, neglect, and exploitation .(2) Dementia management and resident abuse prevention. In step 6.) .CNAs are required to complete no less than 12 hours annually of in-service training. In step 8.) Classes attended by the employee are entered on the respective employee's Employee Training Attendance Record. Review of Abuse Prevention Program policy, revised June 2021, reveled the following Policy Statement 4.) Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. Under the Policy Interpretation and Implementation heading, in [DATE].) Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

Based on interview and record review, the facility failed to ensure that a resident received CPR (Cardio [MEDICAL CONDITION] Resuscitation) in accordance with Professional Standards of Practice for one (Resident #1) of 5 Residents reviewed for CPR, in that; RN A and RN B failed to initiate CPR for a Resident who was a Full Code status. The resident expired in the facility. These failures could affect all Full Code Residents who could need CPR by placing them at risk of death. The findings included: Record review of Resident #1's Face Sheet, undated, revealed he was [AGE] years old and admitted to the facility [DATE]. [DIAGNOSES REDACTED]. Further review of the resident's face sheet revealed, There are no Advance Directives selected for this resident and that his Code Status was Full Code. Record review of Resident #1's closed medical record revealed the resident was in the hospital on [DATE]. Further review of the hospital records revealed physician progress notes [REDACTED].#1 was diagnosed with [REDACTED]. Record review of Resident #1's re-admission orders [REDACTED]. Record review of the Provider Investigation Report (PIR) dated [DATE] PM revealed Resident #1 was found unresponsive [DATE] at 6:15 AM and CPR procedures were delayed until 6:35 AM. The Provider Investigation Report (PIR) further documented that on [DATE] at 6:15 AM CNA D notified RN A that Resident #1 appeared pale, cold to touch and she was not able to awaken the resident. The report went on to say RN A and RN B went to the resident's room to assess the resident and determined he did not have a pulse. RN A returned to the nurses' station, opened Resident #1's chart to attain contact numbers for the resident's physician and responsible party from the face sheet and attempted to call the physician and responsible party. At 6:35 AM LVN C entered the facility for his shift, was informed Resident #1 was unresponsive, identified the resident was Full Code and went to his room and began CPR. At that time RN A called 911 and RN B retrieved the crash cart and took it to the residents room. At 6:40 AM EMS arrived in the facility, conducted an EKG and determined the resident had no pulse. At 6:44 AM the hospital physician called the facility and gave RN A order to pronounce Resident #1's death. The PIR included a written statement by CNA D, who had checked on Resident #1 at 4:45 AM and he was still breathing and waved at the CNA when she talked to him. The PIR included a written statement by RN A revealing after CNA D notified her of Resident #1's condition she went to assess the resident and noted he was pale, had no pulse and would not respond to her. RN A said she went back to the nurses' station and called the resident's physician to get an order to pronounce his death and to call the residents responsible party to let him know the resident had passed. The RN further noted after LVN started CPR she called 911. Record review of Resident #1's nurses' progress note dated [DATE] and completed by RN A revealed at approximately 5:45 AM CNA D had alerted her of Resident #1's condition. The note further revealed she and LVN B went in to check Resident #1 and reported he was pale, his hands were cold and he was unresponsive. The RN wrote she went back to the nurses station and left a message with the resident's physician she needed an order to pronounce Resident #1's death. The RN wrote she then called the resident's responsible party and told him the resident had passed. The note went on to say Resident #1 was identified as full code, CPR was started by LVN D and RN A called 911. RN A's progress note revealed 10 minutes later RN A spoke to the resident's physician and received an order to pronounce Resident #1's death. Record review of PIR revealed a statement by CNA D that RN A was notified that Resident #1 shook his hand in a back and forth motion but it was not as fast as he has been and his eyes had a glaze over them. CNA D reported that RN A continued to sit at the nurses station and when she got up to check on him (Resident #1) she did not have anything in her hands such as vital sign supplies. RN A walked down the hall, to Resident #1 door and look in at him but did not go inside of his room. RN A then came back to the nurses station and as she walked by CNA D she said 'yes, he does look bad, poor guy, please check on him again before you leave' . CNA D agreed to check on him again before she left. CNA was later notified by HK that Resident #1 was not breathing. Record review of an EMS report dated [DATE] and located in the PIR revealed EMS received the call at 6:39 AM and were assessing Resident #1 by 6:40 AM. The report went on to say a cardiac monitor was placed on the resident and he was asystolic, a flatline EKG, with no pulse and he was not breathing. Record review of an Employee Termination/Separation Form located in the PIR dated [DATE] and signed by RN B and the Administrator revealed the RN confirmed she had not checked the code status for Resident #1 on the morning of the incident. Record review of an Employee Termination/Separation Form located in the PIR dated [DATE] and signed by the Administrator revealed RN A confirmed she had not checked the code status for Resident #1 on the morning of the incident. Further review of the form revealed RN A refused to provide any additional information and the form was documented that RN A refused to sign the form. Interview on [DATE] at 3:40 PM with the Administrator revealed each residents paper chart was clearly marked with an 8 inch X 11 inch card at the front of the chart. The Administrator reported if the resident was Full Code a green card with the words Full Code was placed in the chart. The Administrator went on to say if the resident had requested no resuscitation and completed an Out of Hospital Do Not Resuscitate Form a red card was placed in the front of the medical chart that read, DNR. The Administrator stated the charge nurses were responsible for placing the green or red cards in the residents record to represent if the resident was full code or DNR. The Administrator confirmed Resident #1 had a green Full Code card at the front of his medical chart. Interview on [DATE] at 11:15 AM with RN B revealed she had gone into Resident #1's room with RN A after being alerted the resident was non-responsive. The RN B reported she had placed her hands on the resident and said a prayer but did not fully assess the resident. RN B confirmed she had not checked the resident's chart for code status and CPR was not started. RN B stated when they discovered Resident #1 was full code she brought the crash cart and AED (Automated External Defibrillator) to Resident #1's room while LVN C was performing CPR. RN B reported the AED indicated not to shock the resident. Attempted an interview on [DATE] at 3:08 PM with RN A but she refused to comment. Record review of record located with the PIR revealed the facility did an audit of all residents records for code status. Review of in-service training reports dated [DATE] at 6:30 PM, [DATE] at 5:07 PM, [DATE] at 12:24 PM, [DATE] at 6:15 PM, [DATE] at 3:25 PM and [DATE] at 4:10 PM revealed the facility did mock code blue drills. Review of in-service training report dated [DATE] revealed all staff were in-serviced on code status, AED procedures and Abuse/Neglect. Review of facility policy, Basic Life Support (CPR) revised ,[DATE] revealed, It is the policy of this facility to provide basic life support, including CPR -cardiopulmonary resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order [REDACTED]. Further review of the policy, under the heading, Procedure, 4. Identify code status/advance directive preferences. Review facility education and training on abuse and neglect, revised [DATE] revealed, Neglect - The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. This may include the failure to provide staff, supplies, services, policies, training, or staff supervision and oversight to meet the resident's needs.

Based on observation, record reviews, and interviews the facility failed to monitor acceptable parameters of nutritional status such as body weight and failed to provide interventions to prevent severe unintended weight loss for Resident # 2 out of 15 residents (Residents # 1 - # 15) reviewed for weight loss in that: - The facility failed increase the rate of Resident #2's tube feeding from 60 cc's to 80 cc's per hour for 18 hours a day as recommended by the dietician in both June and July 2011. Resident # 2 experienced a 5.6 % weight loss in those two months. These failures to monitor nutritional status and provide interventions caused severe unintended weight loss for Resident # 2 and put other residents at risk for unintended weight loss. The findings were: Review of Resident # 2's clinical record revealed a facesheet, dated 4/7/11, with [DIAGNOSES REDACTED]. A History and Physical dated 4/13/11 revealed Resident # 2 had been in the hospital 2/7/11 through 3/31/11. He was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident # 2's clinical record revealed a 2011 "Yearly Weight Record" with an admission weight of 174 for March, 174 for April, 167 for May, 161 for June, and 157 for July. July had weekly weights of 157 on 7/1, 153 on 7/19 and 152 on 7/26. The resident's August weight was 154. Resident # 2 had a 20 pound weight loss of 11.49% in 5 months from his admission in March 2011 to August 2011. Resident # 2 was sent to the hospital on [DATE] and returned on 6/18/11. The recorded weight upon his return was 160, as recorded on the Nutrition Risk Evaluation form dated 6/23/11. Review of the Registered Dietician's Nutrition Risk Evaluation (NRE) dated 6/23/11, revealed the recommendation to increase the resident's rate of the feeding from 60 cc's per hour for 18 hours to 80 cc's per hour for 18 hours. The resident's weight was recorded as 160 # on 6/21/11 on the NRE form. The form also noted Significant Weight Loss was circled "Y" with the note "13 # since March 2011 (almost 7.5 % in 3 months". No [MEDICATION NAME] laboratory values were noted on the NRE or in Resident #2's clinical record. The Registered Dietician noted the resident with the current feedings was receiving > 51 % of his calories with the formula, which equaled to 1296 Calories and 60 Grams of Protein. A section of the form questioned the resident's nutrient and fluid needs and if they were being met. The Registered Dietician answered this section with the following: Fluids 1464-1830 - Not Met, Calories 1760-1920 - Not Met, and Protein 73 - Not Met. The Registered Dietician wrote the recommendations: "-Increase [MEDICATION NAME] 1.2 TF (tube feeding) to 80 cc/hr x 18 hrs to provide 1728 calories, 81 g (grams) protein, 1166 cc free water to better meet nutrition needs. -monitor TF tolerance and residuals -will follow as needed." Record review also revealed the same recommendations were written on a MNT (Medical Nutrition Therapy) form for the month of June 2011. This form was to be sent to the physician for signature so the recommendations would be transcribed into an order to be followed by the staff. Further record review revealed the Registered Dietician wrote a follow up Progress Note dated 7/16/11. She noted Resident # 2's weight was down 6 #s since June and he was only receiving 74 % of the KCal and 82 % of the Protein needs with the current formula still infusing at 60 cc's per hour. She repeated the same recommendations (from 6/23/11) to increase the feeding to 80 cc per hour over 18 hours, on at 3 p.m. and off at 9 a.m. The Registered Dietician also wrote the follow up recommendation on the MNT form for the month of July 2011 to be sent to the physician for signature. Observation of Resident # 2 on 8/2/11 at 3 p.m. revealed the feeding rate was set at 60 cc's per hour. The staff was asked to weigh Resident # 2 and his weight was 154 #s on 8/2/11. Interview with the DON on 8/2/11 at 3:38 p.m. revealed the facility procedure was that the dietary recommendations were given to the DON and then to the Treatment Nurse to fax to the MD. Once the signed recommendation was returned to the facility, it was to be given to the Treatment Nurse to write the order. The DON stated she did not know what happened to the June 2011 recommendations for Resident #2 and that she did not know what to do with the July 2011 recommendations because she thought they were her copies until yesterday (8/1/11). During interview with RN F and the DON on 8/3/11 at 9:50 a.m., RN F stated the facility got behind in handling the recommendations written, and the July 2011 recommendations (including the recommendation for Resident # 2, dated 7/16/11) were sent to the MD on Monday 8/1/11. The DON stated she did not know what happened with the June 2011 recommendations since she had only been in the position for one month. Review of the facility policy for Weight Change Procedures dated and signed 2/24/11, Section # 3, revealed "A significant change in weight is defined as 5% in one month, 7.5 % in three months, and 10 % in six months. WHEN SIGNIFICANT WEIGHT CHANGE OCCURS, PROCEED WITH THE FOLLOWING: Nursing should inform the Dietary Manager, and notify the physician, requesting laboratory studies if none have been done in the last three months. Document if the physician does not want lab work..." "...The Dietician will be notified at the next scheduled visit. Nutrition intervention or diet change recommendations will be discussed with the Dietary Manager and Nursing and implemented as needed..." "...A newly-identified significant unplanned weight change will trigger reassessment..." "...Weight change will be recorded weekly on residents with significant weight change until stable..." The policy also had a Weight Change Notification form that listed the weight, diets and supplements, and had an area for the physician to sign. The policy directed that the the form was to be left in the chart. Review of Resident # 2's chart revealed this form was not in the clinical record. The CMS form 672 dated 8/2/11 identified 4 residents as receiving tube feedings and 2 residents as experiencing unplanned significant weight loss/gain.