Every finding on record at Hilltop Manor Health and Rehabilitation Center

Based on interviews, record review, and facility policy review the facility failed to act upon and resolve repeated Resident Council grievances related to food quality, staff attitudes, unanswered call lights, delayed assistance with care, housekeeping services, and the availability of ice water for eight (8) of 12 residents in the Resident Council meeting. Resident #13, Resident #15, Resident #17, Resident #23, Resident #32, Resident #38, Resident #41, and Resident #49 Findings Include:Review of the facility policy titled Resident and Family Grievances revised 11/14/25 revealed under, Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal .Policy Explanation and Compliance Guidelines: . 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; . 4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (long term care) facility stay .Record review of the Resident Council Minutes dated 7/8/26 revealed, Food is pointless to talk about this topic because nothing ever changes, flavor, smell, presentation, everything in general is horrible, nasty. According to the residents, the shift from 11 PM to 7 AM sleep by the vending machines. Residents reported that the CNA's enter their rooms, turn off the call light, and inform them that they will return in 1 (one) minute to provide assistance. However, residents stated that CNAs never come back. (Resident #38 )stated that the CNAs never change her bed. (Resident #23) stated that the CNAs do not help her with her bath. She also stated that when they do assist her, they have a bad attitude toward her during care. Residents report that bathrooms are not cleaned daily and items are not moved when sweeping or mopping. Residents report that all trash cans in their rooms need to be cleaned. There was no indication the facility addressed the residents' concerns.During the Resident Council meeting held on 8/12/26 at 12:10 PM, residents stated they knew how and with whom to file a grievance and they confirmed that they have told everyone about their concerns and nothing gets done. Resident #15 stated, It doesn't do any good to file a grievance, you might as well be talking to that T.V. on the wall, as she pointed to the television. Residents #13, #15, #23, #38, and #49 stated they met monthly for council meetings, but their concerns were never addressed or resolved, stating, Nothing ever gets done. All stated they believed their concerns would remain unresolved after the meeting. Residents #15, #17, #32, and #38 stated the aides had attitudes when asked to provide assistance. Resident #17 stated, They treat us poorly acting really nasty toward us and not willing to help us. Resident #38 stated, Nobody ever comes to my room to check on me; I could be lying dead in my bed. She stated, I do everything for myself; I can't even get them to change my sheets. She added, They haven't been changed in three (3) weeks. Resident #13 stated the aides did not enter her room to check on her and that she changed her own sheets. She stated this was becoming more difficult because she had trouble moving around the bed and bending to apply the fitted sheet. Resident #13 stated she wanted the aides to change her sheets, but they would not. Residents #13 and #15 stated call lights remained on for hours. Resident #13 stated she activated the call light for her roommate, who required assistance, but no one came. She stated call lights took 30 to 45 minutes or longer to be answered and stated, It's terrible; We can't get any aides or nurses on that end (of the building) when we need them. She stated her roommate waited almost an hour for staff to clean her and change her brief. Resident #15 stated the aides Are ridiculous and stated none of them Are worth a d***; You will see them one time at the beginning of the shift and you'll never see them again. She stated staff repeatedly turned off her call light and told her, It will be a minute, but did not return. Resident #15 stated she remained wet for more than an hour because staff did not respond to her call light. She stated these concerns had been discussed during prior council meetings, but nothing happened and these things did not get resolved. Resident #17 stated she was not receiving showers and had waited up to one hour and 30 minutes to be changed. Resident #49 stated he received a shower because he completed it himself. He stated the aides gave him trouble and did not want to assist him, so he showered independently. Resident #38 stated call lights were not answered at night because the aides slept near the drink machines at the end of the hall. Residents #13, #17, and #38 stated aides also pulled chairs into the hallway near therapy, placed their legs in wheelchairs, and slept. Resident #38 stated ice water was not passed on any shift. Other residents agreed this concern had been discussed during previous council meetings and continued to be a problem. Residents #13, #15, #23, #38, and #49 stated the food was awful. Residents #13 and #23 stated the food was always cold, and Resident #17 stated food served in her room was also often cold. Resident #15 stated the facility repeatedly served the same foods. Resident #23 stated mashed potatoes were served seven days a week and that hot dogs were served without condiments. Resident #41 stated, I don't like to eat breakfast because the bacon and sausage are too greasy and the grease is all on the plate. Resident #38 stated the kitchen sent burnt food and expected residents to eat it. Resident #23 stated housekeeping did not properly clean resident rooms, empty the trash, or fully mop the floors.An interview with the Activities Director on 8/12/26 at 1:50 PM confirmed she was aware of the Resident Council concerns and that they had been complaining to her in each meeting. She stated residents also told her they believed nothing was ever going to get done. She stated call lights, extended wait times for care, staff attitudes, and food were the primary recent concerns. The Activities Director stated she reviewed all concerns from the meeting with the Administrator and provided a copy of the minutes to each department. She stated each department was responsible for addressing the concerns. She stated the dietary department usually attended the meetings but missed the previous meeting. She confirmed the residents' concerns had not been addressed due to changes in administration and that their concerns were still ongoing. The Activity Director confirmed that the previous Resident Council meeting minutes prior to the 07/08/26 date do not reflect the concerns that the residents have voiced but she did confirm that they have told her about these same concerns for months. She confirmed that it was her job to get the grievances to the appropriate departments in order to get these grievances resolved.An interview with the Dietary Manager on 8/12/26 at 3:01 PM revealed she usually attended Resident Council meetings to address food concerns. She stated Residents #13 and #15 were picky eaters and that nothing she did would please them, stating, I have tried. She stated the facility followed an ordering guide and menu, and many residents could not have certain foods or spices. She stated she had a budget she could not exceed and sometimes modified menu items. The Dietary Manager stated money was an issue and it was impossible to make 60 people happy. She stated alternate meals were available and staff would prepare foods residents liked if the foods were available.An interview with the Administrator on 8/13/26 at 1:40 PM revealed she was aware of the residents' concerns from the meeting. She stated she had been in the position for only a few months and that the Director of Nursing and Assistant Director of Nursing left the facility without notice. She stated the new Director of Nursing began work on Monday, and she was waiting to address the nursing concerns with the new Director of Nursing. The Administrator confirmed the residents' concerns should be acted upon and resolved timely and should not be recurring problems during monthly meetings and that they had failed to do that.Record review of the admission Record revealed the facility admitted Resident #13 on 12/10/25 with medical diagnoses that included Parkinson's Disease, History of Falling, Tremor, and Need for Assistance with Personal Care.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/3/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #13 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #15 on 12/11/25 with medical diagnoses that included Bipolar Unspecified, Other Specified Disorders of Bladder, and Presence of Right Artificial Hip Joint.Record review of the MDS with an ARD of 6/15/26 revealed under section C, a BIMS summary score of 15, indicating Resident #15 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #17 on 4/15/26 with medical diagnoses that included Guillain-Barre Syndrome.Record review of the MDS with an ARD of 7/10/26 revealed under section C, a BIMS summary score of 15, indicating Resident #17 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #23 on 1/19/26 with medical diagnoses that included Parkinson's Unspecified.Record review of the MDS with an ARD of 7/06/26 revealed under section C, a BIMS summary score of 15, indicating Resident #23 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #32 on 4/13/23 with medical diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side.Record review of the MDS with an ARD of 5/14/26 revealed under section C, a BIMS summary score of 15, indicating Resident #32 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #38 on 4/01/26 with medical diagnoses that included Chronic Obstructive Pulmonary Disease.Record review of the MDS with an ARD of 5/11/26 revealed under section C, a BIMS summary score of 15, indicating Resident #38 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #41 on 5/15/26 with medical diagnoses that included Hydrocephalus Unspecified.Record review of the MDS with an ARD of 7/14/26 revealed under section C, a BIMS summary score of 15, indicating Resident #41 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #49 on 6/10/25 with medical diagnoses that included Chronic Obstructive Pulmonary Disease with Acute Exacerbation.Record review of the MDS with an ARD of 7/20/26 revealed under section C, a BIMS summary score of 15, indicating Resident #49 was cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to provide a safe smoking environment by failing to ensure protective smoking aprons were worn during smoking activities for two (2) residents reviewed for smoking safety (Resident #4 and Resident #45) for three (3) of four (4) smoking activities observed. Findings Include:Record review of the facility policy titled, Policies and Procedures under Subject: Smoking-Supervised with an effective date of 6/1/2025 revealed, The Center will provide a safe, designated smoking area for residents.The Center will have safety equipment safety equipment available in designated smoking areas including; .smoking aprons . 2. If a resident is identified during the smoking evaluation to require assistance or supervision with smoking, the Center will include the appropriate information in the care plan . 4.During designated smoking times staff will be assigned to assist or supervisor residents whose care plans indicate assistance or supervision is required while smoking .Resident #4An observation on 8/11/26 at 4:00 PM revealed Resident #4 was seated in the designated smoking area and was smoking without wearing a smoking apron.Record review of the admission Record revealed the facility admitted Resident #4 on 7/29/24 with medical diagnoses that included Alzheimer's Disease, muscle wasting and atrophy, and unspecified lack of coordination.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 03, indicating Resident #4 was severely cognitively impaired.Resident #45During an observation and interview on 8/11/26 at 9:46 AM, Resident #45 was seated in his wheelchair and was wearing sweatpants with visible burn holes. Resident #45 acknowledged he was a smoker and stated he did not wear a smoking apron over his clothes when smoking.An observation on 8/11/26 at 4:00 PM revealed Resident #45 was seated in the designated smoking area and was smoking without wearing a smoking apron.Record review of the admission Record revealed the facility admitted Resident #45 on 5/21/25 with medical diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and lack of coordination.Record review of the MDS with an ARD of 5/26/26 revealed under Section C, a BIMS summary score of 15, indicating Resident #45 was cognitively intact.During an interview and observation on 8/11/26 at 4:10 PM, Certified Nurse Aide (CNA) #1 acknowledged she was responsible for the smoke break that day and Resident #4 and Resident #45 were smoking without wearing smoking aprons.During an observation and interview on 8/12/26 at 10:32 AM, Resident #4 and Resident #45 were seated in the designated smoking area and were wearing smoking aprons. CNA #2 stated she put smoking aprons on all the residents to ensure they did not burn themselves. Unsampled Resident #1 stated, I only wear an apron if you put one on me, which isn't all the time.During an interview on 8/12/26 at 1:05 PM, the Director of Nursing (DON) stated the unit manager was responsible for completing smoking assessments upon admission and quarterly. The DON stated the smoking assessments evaluated the residents' ability to hold a cigarette, dispose of ashes, and whether the resident needed to wear a smoking apron for safety. The DON stated she was unaware of any incidents or accidents involving Resident #4 or Resident #45 while smoking.During an interview on 8/12/26 at 1:25 PM, Registered Nurse (RN) #1 stated she was one of the unit managers and was responsible for conducting smoking assessments upon a resident's admission and quarterly. RN #1 stated all residents were required to wear smoking aprons for their safety, so they did not burn themselves. RN #1 stated Resident #4 and Resident #45 were supposed to wear smoking aprons for their safety. RN #1 further stated Resident #45 was slow to flick his ashes and that it was a big safety concern for him.During a subsequent observation and interview on 8/13/26 at 2:34 PM, Resident #4 and Resident #45 were seated in the designated smoking area and were smoking without wearing smoking aprons. CNA #2 and RN #3 were present and confirmed the residents were not wearing smoking aprons.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents were treated with respect and dignity by providing reasonable accommodation for residents' needs and preferences related to incontinence care and protection of their beds, wheelchairs, and recliners for three (3) of 20 sampled residents. Resident #13, Resident #15, and Resident #49 Findings Include:Record review of the facility policy titled Resident Rights revealed under, .4. Respect and Dignity: The resident has a right to be treated with respect and dignity, including: . c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences .An observation and interview with Resident #13 on 8/11/26 at 10:39 AM revealed she was lying in bed. Resident #13 stated she was incontinent at times, especially at nighttime, although she did not require assistance from staff because she did everything on her own. She stated the facility no longer allowed residents to have incontinence pads to use at night due to the cost. Resident #13 stated residents received only an incontinent brief and a sheet. She stated the briefs were thin and did not hold up, allowing urine to leak throughout the night and it soaked her bed sheets and mattress. Because the facility no longer allowed incontinent bed pads, she cut up garbage bags and placed it under her fitted sheet to prevent the mattress from getting wet. Resident #13 stated she had to change her own sheets if they became wet because the aides never entered her room to do anything. She stated the facility sometimes ran out of sheets, and she had to use regular flat sheets instead of fitted sheets. Resident #13 stated she was told the company was no longer purchasing the incontinent pads and she had to make do the best way she could.Observations of the laundry carts on 8/11/26 and 8/12/26 revealed there were no washable or disposable incontinence pads.An interview with Certified Nurse Aide (CNA) # 4 on 8/12/26 at 8:24 AM revealed the facility removed all washable bed pads some time ago, but she was unsure why. She stated the aides folded a sheet and placed it under residents for positioning. CNA #4 stated some residents were heavily incontinent with urine and staff might have to change the entire bed and the mattress might be soaked. She stated many residents were unhappy about the removal of the incontinent pads, but there was nothing anyone could do.An interview with Registered Nurse (RN) #2 on 8/12/26 at 8:49 AM revealed the company discontinued the incontinent pads that the staff and residents used for their beds and wheelchairs to protect them from urine, but she was unsure why, stating, If I had to guess it would be the cost. She confirmed residents had voiced concerns about not having the incontinent pads and stated, They would rather have them.An observation and interview with Resident #15 on 8/12/26 at 11:54 AM revealed she was sitting in her wheelchair in the hallway on a thick, white, folded blanket. Resident #15 stated she used the folded blanket because the briefs provided by the facility leaked urine. She stated the facility no longer purchased reusable or disposable incontinent pads, so she used the blanket to protect her wheelchair from urine.An interview with Resident #49 on 8/12/26 at 12:06 PM revealed he regularly sat and watched television in his recliner and slept in it at night. Resident #49 stated he was incontinent at times and required protection under him to prevent soiling the recliner from urine. He stated the facility stopped purchasing the incontinent pads to reduce costs, so he had to purchase his own disposable pads for the recliner, stating You can't get them here. An interview with the Housekeeping/Laundry Supervisor on 8/12/26 at 2:44 PM revealed he had worked at the facility since December 2025 and was told the facility was no longer purchasing or using incontinence pads. He stated the aides were expected to use briefs and sheets to protect the mattresses and wheelchairs from incontinence. He believed the change occurred after the new company purchased the facility in October 2025. He confirmed the facility did not provide any type of disposable incontinence pads.An interview with the Director of Operations on 8/13/26 at 1:18 PM revealed the company discontinued purchasing washable incontinence pads and did not purchase disposable incontinent pads. He stated the aides should use draw sheets under residents instead. He acknowledged this practice could create a dignity concern for the residents.Record review of the admission Record revealed the facility admitted Resident #13 on 12/10/25 with medical diagnoses that included Parkinson's Disease, History of Falling, Tremor, and Need for Assistance with Personal Care.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/3/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #13 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #15 on 12/11/25 with medical diagnoses that included Bipolar Unspecified, Other Specified Disorders of Bladder, and Presence of Right Artificial Hip Joint.Record review of the MDS with an ARD of 6/15/26 revealed under section C, a BIMS summary score of 15, indicating Resident #15 was cognitively intact. Section H indicated Resident #15 was frequently incontinent of bladder.Record review of the admission Record revealed the facility admitted Resident #49 on 6/10/25 with medical diagnoses that included Chronic Obstructive Pulmonary Disease with Acute Exacerbation.Record review of the MDS with an ARD of 7/20/26 revealed under section C, a BIMS summary score of 15, indicating Resident #49 was cognitively intact.

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure cleaning and disinfection of resident wheelchairs was completed for three (3) of 20 sampled residents reviewed. Resident #23, Resident #29, and Resident #43Findings include: Record review of policy titled, Cleaning and Disinfection of Resident-Care Equipment, with a revision date of 11/13/2025 revealed .c. direct care staff are responsible for cleaning single-resident equipment when visibly soiled and according to routine schedule . An observation on 08/11/2026 at 9:42 AM, and again on 08/12/2026 at 9:30 AM revealed Resident #29's wheelchair was noted to have a thick brown substance on bilateral rear wheels, spokes, entire wheelchair frame, and brakes. An observation on 08/11/2026 at 9:44 AM and again on 08/12/2026 at 10:00 AM revealed Resident #43's wheelchair was noted to have a thick brownish gray substance on the entire wheelchair frame and bilateral rear wheels. An observation 08/11/2026 at 11:00 AM and again on 08/12/2026 at 10:55 AM revealed Resident #23's wheelchair was noted to have a thick gray substance and small food particles on the entire wheelchair frame, the bilateral rear wheels, including the spokes. An observation and interview on 08/12/2026 at 1:50 PM revealed Resident #23 sitting in her wheelchair in her room. She revealed that her wheelchair was filthy and needed to be cleaned. She further revealed that her daughter had discussed this situation with the previous Director of Nursing (DON) and still nothing had been done. Resident #23 revealed that she had been in the facility for nearly two years and her wheelchair had never been cleaned. Resident #23 further stated, This wheelchair is awful looking and I want it cleaned. During an observation and interview on 08/12/2026 at 4:22 PM with the DON, she confirmed that Resident #23, Resident #29, and Resident #43's wheelchairs were dirty and needed to be cleaned. She revealed that there was a cleaning schedule posted at the nurse's desk that included cleaning wheelchairs on the night shifts. She revealed that they divided the wheelchairs up between three days so that all wheelchairs were cleaned weekly. She revealed that residents had the right to have a clean environment and this included clean equipment. She stated, I like to have a clean vehicle, and I know they do too. Record review of the facility, 11-7 Cleaning Schedule revealed: Sunday: CNAs (Certified Nursing Assistant) to clean and return south hall wheelchairs and Geri chairs. Monday: CNAs to clean and return north hall wheelchairs and Geri chairs.Tuesday: CNAs to clean and return middle hall wheelchairs and Geri chairs.Record review of Resident #23's admission Record revealed an admission date of 07/15/24 with diagnoses that included Unspecified Parkinsonism and Muscle Weakness.Record review of Resident #23's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/06/26 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that she was cognitively intact. Record review of Resident #29's admission Record revealed an admission date of 08/25/22 with diagnoses that included Unspecified Heart Failure and Unspecified Muscle Weakness.Record review of Resident #29's MDS with ARD of 08/03/26 under Section C revealed a BIMS score of 15 which indicated that she was cognitively intact. Record review of Resident #43's admission Record revealed an admission date of 08/23/22 with diagnoses that included Primary Generalized Osteoarthritis and Unspecified Heart Failure.Record review of Resident #43's MDS with ARD of 07/13/26 under Section C revealed a BIMS score of 99 which indicated that she was unable to complete the interview.

Based on resident and staff interviews, record review and facility policy review the facility failed to develop an Activities of Daily living (ADL) care plan for Resident's #24 and #33 and failed to implement care plan interventions for Resident #42's ADL needs and failed to implement smoking aprons required for Resident's #4 and #45, for five (5) of 20 sampled residents reviewed. Findings include: Review of facility policy and procedures, Comprehensive Care Plans, revision date 11/14/2025, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs . Resident #4 Record review of Resident #4's Care Plan Report revealed under, Focus: Smoker – Mr. (Proper last name of the resident' is a smoker) .Interventions/Tasks.He requires a smoking apron while smoking. On 8/11/2026 at 4:00 PM an observation revealed Resident #4 sitting in the smoking area, smoking; the resident was not wearing a smoking apron. Record review of the admission Record revealed the facility admitted Resident #4 on 7/29/24 with medical diagnoses that included Alzheimer's Disease, Muscle wasting and atrophy, and unspecified Lack of Coordination. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 03, indicating Resident #4 was severely cognitively impaired. On 8/11/2026 at 4:10 PM, during an interview Certified Nurse Aide (CNA) #1 acknowledged she was responsible for the smoke break today. She lit the residents' cigarettes and kept the lighter and cigarettes in a box. An observation revealed that Resident #4 was not wearing a smoking apron. An interview on 8/12/2026 at 1:05 PM, with the Director of Nursing (DON) revealed that the residents' plan of care for safely smoking was not being followed regarding wearing the smoking apron. During an interview on 8/12/2026 at 3:45 PM, the Minimum Data Set (MDS) Coordinator revealed that if Resident #4 was not wearing the smoking apron, then the smoking plan of care for the resident was not being followed. Resident #24 Record review of Resident #24's Activities of Daily Living (ADL) Care Plan Report revealed under, Focus: ADL's – Mr. Proper last name of the resident' admitted with an ADL deficit R/T (related to) muscle weakness, decreased mobility, lower ext. (extremity) ulcers. The interventions were that the resident was dependent on staff assistance for toileting hygiene. The care plan did not include specific care instructions, such as the transfer method, required equipment, number of staff needed, toileting schedule, clothing and hygiene preferences, or safety measures. During an observation and interview with Resident #24 on 8/11/26 at 10:34 AM, he was sitting in his wheelchair in his room. Resident #24 stated the aides did not take him to the restroom as they were supposed to. He stated staff had to use a lift because he could not stand. He stated he asked staff to take him to the restroom, and stated, They just will not do it. He stated one of his biggest concerns was being able to use the toilet. He also stated he had to wait hours for help and staff did not want to help him and stated, I have a hard time getting someone to help me. An interview with the MDS Nurse on 8/13/26 at 2:10 PM revealed she was unsure how often Resident #24 was toileted, how he transferred, or how much assistance he required and would have to ask the aides. She confirmed the ADL care plan was copied from the MDS section GG assessment and lacked the individualized, person-centered approaches needed to instruct staff how to care for Resident #24. She confirmed the care plan was not developed so that anyone could review it and know how to care for him. Record review of the admission Record revealed the facility admitted Resident #24 on 11/29/25 with medical diagnoses that included History of Falling, Reduced Mobility, and Stiffness of Right and Left Knee. Record review of the MDS with an ARD of 6/3/26 revealed under section C, a BIMS summary score of 15, indicating Resident #24 was cognitively intact. Resident #33 Record review of Resident #33's ADL Care Plan Report revealed under, Focus: ADL's – Mr. 'Proper last name of the resident' has an ADL self-care performance deficit R/T dementia. The care plan listed Resident #33 as independent with showering/bathing and personal hygiene. Although the care plan identified an ADL self-care deficit, the interventions consisted of the copied section GG functional status entries from the MDS and did not instruct staff how to ensure Resident #33 received assistance with bathing, hair care, and other personal hygiene needs. Under Interventions, the care plan indicated Weekly nail care. During an observation of Resident #33 on 8/11/26 at 9:44 AM, he was lying on his bed with his head at the foot of the bed and his eyes closed. A foul body odor was noticeable in the hallway outside his room. After a knock on the door, Resident #33 sat on the edge of his bed and appeared disheveled and unkempt. He had a foul body odor; his hair was oily, greasy, and slicked down to his scalp; and he was barefoot. His fingernails and toenails were approximately one-half (1/2) to three-fourths (3/4) inch long. During an observation and interview with CNA #4 on 8/13/26 at 9:26 AM, she confirmed Resident #33 had long nails, oily hair, and a foul body odor. CNA #4 indicated Resident #33 had not been showered. An interview with the MDS Nurse on 8/13/26 at 2:20 PM revealed Resident #33 refused his showers; however, she was unable to provide documentation from the nurses or aides showing that he refused. She stated Resident #33 was independent with bathing according to section GG. However, after the MDS Nurse questioned CNA #6, she indicated Resident #33 required cueing and supervision while showering and was never left unattended. The MDS Nurse confirmed the ADL care plan was copied from the MDS section GG assessment and lacked the individualized, person-centered approaches needed to instruct staff how to care for Resident #33. She also confirmed that his nail care plan was not followed. Record review of the admission Record revealed the facility admitted Resident #33 on 10/10/24 with medical diagnoses that included Unspecified Dementia and Autistic Disorder. Record review of the MDS, with an ARD of 6/15/26, revealed under Section C, a BIMS summary score of 15, indicating Resident #33 was cognitively intact. Resident #42 Record review of Care Plan Report, revealed ADL self-care performance deficit related to Muscle Wasting and Atrophy of Bil (bilateral) arm, L(Left) side weakness/impairment, needs assist with ADL's. During an observation and interview on 08/11/2026 at 9:41 AM revealed Resident #42 sitting up in his wheelchair with a full one-half inch beard. Resident #42 stated that staff have not shaved him in 2-3 weeks and that he does not wish to grow a beard. He also revealed that he could not shave himself if he tried due to decrease use of his arms. Resident #42 stated that he had required assistance with his shaving and other care since he was admitted to the facility, and he revealed that he wanted to be shaved. On 08/12/2026 at 12:30 PM an interview Registered Nurse (RN) #2, revealed that shaving was part of Resident #42's personal hygiene and grooming needs and should be addressed on bath or shower days three times a week and as needed. An interview on 08/13/2026 at 9:07 AM with MDS nurse revealed person centered care plan should tell how to take care of the resident. She stated that he did need assistance with ADLs to include shaving and if it was not done then his care plan was not followed. Record review of Resident #42's admission Record revealed an admission date of 08/25/2023 with diagnoses Muscle Wasting and Atrophy of Right and left Upper Arm and Need for Assistance with Personal Care. Record review of Resident #42's MDS with ARD of 06/09/26 revealed a BIMS score of 15 which indicated that he was cognitively intact. Resident #45 Record review of Resident #45's Care Plan Report revealed under, Focus: Smoker – Mr. Proper last name of the resident' is a smoker under Interventions/Tasks. Revealed, Observe clothing and skin for signs of cigarette burns. Resident requires a smoking apron while smoking. On 8/11/2026 at 9:46 AM, during an observation and interview it was noted that Resident #45, was seated in his wheelchair, was wearing sweatpants with visible burn holes. Resident #45 acknowledged he was a smoker and did not wear a smoking apron over his clothes when smoking. On 8/11/2026 at 4:00 PM an observation revealed Resident #45 sitting in the smoking area, smoking; the resident was not wearing a smoking apron. Record review of the admission Record revealed the facility admitted Resident #45 on 5/21/25 with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, and Lack of Coordination. Record review of the MDS with an ARD of 5/26/26 revealed under section C, a BIMS summary score of 15, indicating Resident #45 was cognitively intact. An interview on 8/12/2026 at 1:05 PM, the DON revealed that the residents' plan of care for safely smoking was not being followed regarding wearing the smoking apron. During an interview on 8/12/2026 at 3:45 PM, the MDS Coordinator revealed that if Resident #45 was not wearing his smoking apron, then the smoking plan of care for the resident was not being followed.

Based on observation, staff interview, record review, and facility policy review, the facility failed to administer enteral flushes according to physician orders for one (1) of seven (7) residents reviewed during medication administration observations. Resident #50Findings Include:Review of the facility policy titled Medication Administration via Enteral Tube, revised 11/7/25, revealed Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines .Procedure a. Verify physician orders for medication and enteral tube flush amount .Record review of Resident #50's August 2026 Medication Administration Record (MAR) revealed an order dated 8/30/24, Enteral feed order every shift flush with 60 cc (cubic centimeters) of water before and after meds.During an observation of a medication pass with Registered Nurse (RN) #4 on 8/11/26 at 4:36 PM, RN #4 crushed and administered Resident #50's evening medications through the feeding tube. RN #4 did not flush the tube with the ordered 60 cc of water before or after administering the medications. When asked whether the resident's tube should have been flushed with water before and after the medications, RN #4 replied, I think its 30 before and after meds. RN #4 confirmed she did not give the flush. She stated the resident was NPO (nothing by mouth) and received all fluids from nursing staff through the feeding tube. RN #4 acknowledged the resident could become dehydrated if the ordered amount of water was not given.An interview with the Director of Nursing (DON) on 8/12/26 at 10:40 AM revealed she expected nurses to read the MAR and know the flush orders before entering the resident's room. This would ensure the resident received the physician ordered flush amount.Record review of the admission Record revealed the facility admitted Resident #50 on 8/30/24 with medical diagnoses that included Other Paralytic Syndrome following Cerebral Infarction Affecting Left Non-Dominant Side, Gastrostomy Status, and Unspecified Protein-Calorie Malnutrition.Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/18/26, revealed under Section C a Brief Interview for Mental Status (BIMS) summary score of 13, indicating Resident #50 was cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure residents requiring assistance received the necessary activities of daily living (ADL) care. This was evidenced by failure to provide timely toileting assistance (Resident #24), shower and nail care (Resident # 33) and facial shaving (Resident #42) for three (3) of the 53 residents reviewed for activities of daily living. Findings include: Review of facility policy titled, Activities of Daily Living (ADL's) with a revision date of 11/07/2025, revealed, .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene . Resident #24 An observation and interview with Resident #24 on 8/11/26 at 10:34 AM revealed he was sitting in his wheelchair in his room. Resident #24 stated the aides did not take him to the restroom as they were supposed to. He stated staff had to use a lift because he could not stand. He stated he asked staff to take him to the restroom, but, They just will not do it. He stated one of his biggest concerns was being able to use the toilet. He also stated he had to wait hours for help and staff did not want to help him. An observation on 8/11/26 at 11:38 AM revealed Resident #24 was sitting in his wheelchair in his room. His covered lunch meal was in front of him, and he was not eating. When asked why he was not eating lunch, Resident #24 stated, I am waiting on the trays to be passed and picked up so I can go to the bathroom. He stated staff told him they could not assist him to the toilet while meal trays were out. He stated he had been waiting for assistance and added, This is all the time; I have a hard time getting someone to help me. An interview on 8/11/26 at 11:41 AM with Certified Nurse Aide (CNA) #3 revealed staff knew Resident #24 needed assistance. CNA #3 stated staff could not assist residents to the toilet while meal trays were out and confirmed Resident #24 was told he would have to wait. An interview with the Director of Nursing (DON) on 8/11/26 at 11:46 AM revealed she expected staff to assist Resident #24 with toileting when needed. She confirmed the resident should not have to wait during a meal or until he had an accident. She stated this was an unacceptable practice and residents who needed assistance during mealtimes should receive the required care. An observation and interview with Resident #24 on 8/12/26 at 9:33 AM revealed he was sitting in his wheelchair in the hallway. He stated he had been waiting 30 minutes to use the bathroom. He stated, A girl with a nose ring walked by, and he told her he needed to use the bathroom. He stated she said OK and walked away. Resident #24 stated, It's like this every day, I can't get anyone to help me. An interview with the DON on 8/12/26 at 10:02 AM, she was notified that Resident #24 continued to wait for toileting assistance. The DON went into the hallway to find someone to assist him. Resident #24 was taken to the shower room and assisted to the toilet. The DON confirmed the aide who was initially notified of Resident #24's need should have stopped and obtained help to assist him. She confirmed all staff, including nurses, should address his needs timely. An interview with the Long-Term Care District Ombudsman on 8/13/26 at 11:02 AM revealed Resident #24 had voiced care concerns to her during previous visits to the facility. She stated Resident #24 reported that staff would not help him get dressed and that he experienced extended wait times for care. The Ombudsman stated she spoke with the Administrator and notified her of Resident #24's concerns. Record review of the admission Record revealed the facility admitted Resident #24 on 11/29/25 with medical diagnoses that included History of Falling, Reduced Mobility, and Stiffness of Right and Left Knee. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #24 was cognitively intact. Section GG revealed he was dependent with toileting. Resident #33 An observation of Resident #33 on 8/11/26 at 9:44 AM revealed he was lying on his bed with his head at the foot of the bed and his eyes closed. A foul body odor was noticeable in the hallway outside his room. After a knock on the door, the resident sat on the edge of his bed and appeared disheveled and unkempt. The resident had a foul body odor; his hair was oily, greasy, and slicked down to his scalp; and he was barefoot. His fingernails and toenails were approximately one-half (1/2) to three-fourths (3/4) inch long. An observation and interview with CNA #4 on 8/13/26 at 9:26 AM revealed Resident #33 was on the 3-11 PM shift shower schedule and should receive a shower on Monday, Wednesday, and Friday. CNA #4 confirmed the resident had long nails, oily hair, and a foul body odor. An observation and interview with Registered Nurse (RN) #2 on 8/13/26 at 9:48 AM confirmed that Resident #33 was not receiving showers or nail care. RN #2 stated any staff member could provide nail care because the resident was not diabetic. She stated long nails could cause a skin injury if the resident scratched himself. An interview with CNA #6 on 8/13/26 at 10:02 AM revealed the 3-11 PM shift was not providing showers to any residents and that this had been happening for a while. An interview with the DON on 8/13/26 at 10:16 AM revealed she expected residents to receive showers on their scheduled days and staff to provide nail care when needed. Record review of the admission Record revealed the facility admitted Resident #33 on 10/10/24 with medical diagnoses that included Unspecified Dementia and Autistic Disorder. Record review of the MDS, with an ARD of 6/15/26, revealed under Section C, a BIMS summary score of 15, indicating Resident #33 was cognitively intact. Resident #42 An observation and interview on 08/11/2026 at 9:41 AM revealed Resident #42 sitting up in his wheelchair with a full one-half inch beard. Resident #42 stated that staff have not shaved him in two to three weeks and that he does not wish to grow a beard. He also revealed that he could not shave himself if he tried due to decrease use of his arms. Resident #42 stated that he had required assistance with his shaving and other care since he was admitted to the facility, and he revealed that he wanted to be shaved. An interview on 08/12/2026 at 12:30 PM with RN #2, revealed that shaving was part of Resident #42's personal hygiene and grooming needs and should be addressed on bath or shower days three times a week and as needed. An interview on 08/12/2026 at 12:50 PM with the DON revealed that Resident #42 should have been shaved at least once a week but should be offered a shave on his regular scheduled bath or shower days. She revealed that not receiving his scheduled care was unacceptable and she would address this issue and ensure improved care. She further stated that she wanted these residents to be clean and feel good about themselves and that they would come up with a plan to ensure this wasn't missed again. Record review of Resident #42's admission Record revealed an admission date of 08/25/2023 with diagnoses that included Muscle Wasting and Atrophy of Right Hand, Right and Left Upper Arm and Need for Assistance with Personal Care. Record review of Resident #42's MDS with an ARD of 06/09/26 under Section C revealed a BIMS score of 15 which indicated that he was cognitively intact.

Based on observation, staff interview, and facility policy review the facility failed to ensure that medication carts were locked and secured while unattended for one (1) of two (2) medication carts observed. North HallFindings include: Record review of facility policy titled Medication Storage, revised 11/7/25 revealed .1. a. All drugs and biologicals will be stored in locked compartment (i.e., medication carts, cabinets, drawers, refrigerators, medication room) . An observation on 8/12/26 at 12:45 PM revealed a medication cart on the North Hall that was unlocked and unattended. An observation on 08/12/2026 at 12:50 PM revealed Registered Nurse (RN) #2 exit ed room [ROOM NUMBER]B and approached her unlocked mediation cart. An interview at that time with RN #2 confirmed that the medication cart was not locked and stated it was important to keep it locked when she was away from it to prevent residents or others from getting medications out of cart which could possibly harm them. RN #2 revealed that she normally kept the medication cart locked when she was away from it but had forgotten. An interview on 08/12/2026 at 12:50 PM with the Director of Nursing (DON) revealed that all medications should be locked in the medication carts when unattended by staff. She revealed that by not storing medications properly, anyone could walk up to the cart and take what they wanted. DON also confirmed that they had wandering residents and those with Dementia who could have taken medications they did not need, and her number one goal was to keep these residents safe.

Based on interview, record review, and facility policy review, the facility failed to provide adequate supervision to prevent a cognitively impaired resident with a history of wandering from exiting the facility unattended for one (1) of three (3) residents reviewed for elopement risk, Resident #1.Findings Included:Record review of facility policy titled, Missing Patient/Resident, revealed An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk of harm or injury.Record review of the facility investigation revealed on 3/22/26 at approximately 1:09 PM, a visitor observed Resident #1 standing near the front door. The visitor exited the facility and did not realize the resident followed him outside. At approximately 1:15 PM staff located Resident #1 on the front porch and escorted him back into the facility. The investigation determined Resident #1 was outside unattended for approximately five (5) minutes.Record review of the admission Record revealed Resident #1 was admitted [DATE] and readmitted from geriatric psychiatric hospitalization on 11/26/25 with diagnosis including Dementia with agitation.Record review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/27/26 revealed a Brief Interview for Mental Status (BIMS) score of three (3), indicating severe cognitive impairment.Interview with Licensed Practical Nurse #1 (LPN) on 3/30/26 at 2:00 PM, revealed that staff alerted her that Resident #1 was missing and she assisted with locating the resident. She stated Resident #1 ambulated in the halls and had not previously attempted to exit the building.Interview with Certified Nursing Assistant #1 (CNA) on 3/30/26 at 2:30 PM, revealed she located Resident #1 outside the front door on the porch and returned him to the facility at approximately 1:15 PM.Interview with the Director of Nursing (DON) on 3/30/26 at 3:00 PM, revealed Resident #1 had a history of wandering. She stated the interdisciplinary team previously determined the resident was not at risk for elopement. She verified that following the incident the resident was reassessed, and a wander guard was applied.The facility implemented corrective actions prior to State Agency entrance including completion of an elopement assessment for Resident #1, application of a wander guard, completion of elopement risk assessments for all residents, auditing of high-risk elopement interventions, staff education on elopement risk and missing resident procedures, updating the elopement binder, checking magnetic door locks, changing door codes on 3/23/26, conducting a Quality Assessment and Performance Improvement (QAPI) meeting with the interdisciplinary team, and conducting elopement drills on all shifts. Quality monitoring will include the Maintenance Director will conduct Elopement Drills weekly times four (4) weeks, then monthly times two (2) months, the ADM will monitor door locks to ensure visitors, family members and vendors do not have the code by observing five (5) per week during exiting times 4 weeks, then monthly times 2 months. The Interdisciplinary team (IDT) will have a QAPI meeting on 4/8/26 and 5/6/26 to review the monitoring process to ensure compliance is met and substantiated. Based on the implementation of the facility's corrective actions on 3/23/36, the deficient practice was determined to be past noncompliance, and the facility was found in compliance effective 3/24/26.Validation:The SA validated on 3/30/26, through interview and record review that all corrective actions had been implemented as of 3/23/26, and the facility was in compliance as of 3/24/26, prior to the SA's entrance on 3/30/26.

Based on observations, staff and resident interviews, record review and facility policy review, the facility failed to provide an activities program seven (7) days a week as evidenced by a lack of structured activities on weekends for five (5) of six (6) residents at the Resident Council meeting, with the potential to affect all residents. Resident #8, #13, #36, #37 and #40. Findings Included: A record review of a facility policy, titled Group Activities with no revision date revealed Group activities are scheduled to enhance the resident's well-being and self-esteem . During a Resident Council meeting on 12/4/24 at 9:45 AM, Residents #8, #13, #36, #37, and #40 stated that church services are provided on Sundays, but no other activities occur on the weekends. The residents explained that the Activity Director leaves activity/coloring pages and puzzles for them, and occasionally Resident #40 plays the piano. Residents #36 and #37 noted that there are no scheduled weekend activities because no activity staff are present, and other staff do not assist with any activities. They expressed a desire for structured activities on weekends. A review of the September, October, and November 2024 activity schedules revealed that Saturday activities included providing coloring, puzzles, movies, arts, and dominoes for the residents to do on their own and Sunday activities were limited to a church service. During an interview with the Activity Director (AD) on 12/4/24 at 10:00 AM, she confirmed there are no scheduled activities on the weekends. She stated that she is scheduled to work Monday through Friday, with no activity staff assigned on weekends. She confirmed that she leaves puzzles and activity/coloring pages for residents to use during the weekend and encouraged staff to put on movies. She mentioned that some residents play the piano on weekends but verified that no structured activities occur beyond the Sunday church service. She acknowledged that residents have expressed interest in additional weekend activities and stated she reported this to the Administrator. The AD emphasized that having activities seven (7) days a week is important for preventing boredom, encouraging socialization, and promoting residents' well-being. In an interview with the Administrator on 12/4/24 at 10:25 AM, he stated that the Restorative Certified Nursing Assistant (RCNA) is responsible for facilitating activities on weekends if residents request them. He agreed that the lack of weekend activities could negatively impact residents' well-being and quality of life. An interview with the RCNA on 12/4/24 at 11:00 AM revealed that she works Saturdays conducting restorative exercises. She explained that if time permits, she may organize an activity such as singing while a resident plays the piano. However, she noted that her responsibilities also include transportation and covering staff shortages, leaving her unavailable to consistently provide activities. She confirmed that she does not work on Sundays. Record review of the Admission Record revealed that the facility admitted Resident #8 on 12/25/17 with a diagnosis of Borderline Intellectual Functioning. Record review of Resident #8's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 9/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident is cognitively intact. Record review of the Admission Record revealed that the facility admitted Resident #13 on 1/27/23 with a diagnosis of Major Depressive Disorder. Record review of the MDS with an ARD of 10/28/24 revealed Resident #13 had a BIMS score of 15 indicating that the resident is cognitively intact. Record review of the Admission Record revealed that the facility admitted Resident #36 on 7/29/24 with a diagnosis of Major Depressive Disorder. Record review of Resident #36's MDS with an ARD of 8/29/24 revealed a BIMS score of 15 indicating that the resident is cognitively intact. Record review of the Admission Record revealed that the facility admitted Resident #37 on 11/29/19 with a diagnosis of Major Depressive Disorder. Record review of Resident #37's MDS with an ARD of 9/25/24 revealed a BIMS score of 15 indicating that the resident is cognitively intact. Record review of the Admission Record revealed that the facility admitted Resident #40 on 10/7/20 with a diagnosis of Blindness Right Eye. Record review of Resident #40's MDS with an ARD of 10/21/24 revealed a BIMS score of 15 indicating that the resident is cognitively intact.

Based on observation, resident and staff interview, and facility policy review, the facility failed to provide a resident with a clean, comfortable, and homelike environment when the facility failed to change the dirty, stained linen for (1) one of 53 residents' bed linens observed. Resident # 20 Findings include: A review of the facility policy titled, Making a bed, with no revision date revealed that all linens, including mattress pad, blanket, and bedspread should be replaced, if necessary . The pillowcase should also be checked for soiling and replaced as needed . Bed linens are regularly changed at least once a week. In an interview with Resident # 20 on 12/02/24 at 1:00 PM, she revealed she would like to have her bed linen changed, stating I can't remember the last time they were changed. An observation of the linen with Resident #20 revealed the bottom sheet to be dingy white, the top sheet had a baseball size brown stain which the resident stated was from a bowel movement. The pillowcase was covered in small dark dried stains which the resident stated were dried blood stains. An observation of Resident # 20's bed linen on 12/03/24 at 11:34 AM, revealed the bed linen remained dingy in appearance with a brown stain on the top sheet, and numerous small dark stains on the pillowcase. An observation and interview with Registered Nurse (RN) # 1 on 12/03/24 at 11:37 AM, she confirmed the sheets on Resident # 20's bed were dirty in appearance and dingy white, the top sheet had a brown stain on it, and the pillow had numerous dark stains that she identified as dried blood spots. RN # 1 then confirmed that the linens did not appear to have been changed recently, and stated the linen should have already been changed. It is a sanitization concern. In an interview with the Director of Nursing (DON) on 12/03/24 at 11:45 AM, she revealed the resident's beds should be made daily and linen changed weekly and each time the linen is soiled. She then confirmed that it was a sanitization problem. Review of the Admission Record revealed Resident #20 was admitted by the facility on 2/27/24. Record review of Resident #20's Section C of the Minimum Data Set (MDS) revealed that on 9/17/24 the Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact.

Based on staff interview, record review, and Resident Assessment Instrument (RAI) review, the facility failed to ensure that Minimum Data Set (MDS) was coded accurately for one (1) of 18 sampled residents. Resident #5. Findings included: Record review of the facility policy, titled MDS with a revision date of 9/25/17 revealed Policy .Each person completing a section or portion of the MDS signs the Attestation Statement indicating its accuracy . A record review of the Admission Record revealed Resident # 5 was admitted by the facility on 12/24/20 with a diagnosis of Bipolar Disorder. Record review of Resident #5's Significant Change MDS with an Assessment Reference Date (ARD) of 7/30/24, revealed Section A 1500 coded as No, Is the resident currently considered by the state level II PASRR (Preadmission Screening and Resident Review) process to have serious mental illness and/or intellectual disability or a related condition? Record review of Resident # 5's Summary of Findings Report, from the PASRR Office, dated 12/30/20 under Mental Health revealed the individual meets criteria for having a diagnosis of mental illness as defined by PASRR. During an interview with the MDS Nurse on 12/4/24 at 9:30 AM, she verified that the MDS was coded incorrectly and agreed that the importance of correctly coding MDS was to ensure residents received care they needed. An interview with the Director of Nursing (DON) on 12/4/24 at 12:00 PM, she agreed that it was her expectation that the MDS would be coded correctly.

Based on staff interview, record review, and facility policy review, the facility failed to accurately submit a resident's information for Preadmission Screening and Resident Review (PASRR) for a Level II evaluation for (1) one of (4) four residents reviewed for PASRR. Resident #54 Findings include: Review of the facility policy titled, Preadmission Screening and Resident Review (PASRR), with a revision date of 11/8/21 revealed, Policy: The center will assure that all Serious Mentally Ill (SMI) . residents receive appropriate pre-admission screenings according to the Federal/State guidelines. The purpose is to ensure that the residents with SMI .receive the care and services they need in the most appropriate settings. Record review of the Admission Record revealed Resident #54 was admitted by the facility on 5/24/24 with diagnoses of Brief Psychotic Disorder and Anxiety Disorder. A record review of Resident #54's May 2024 Order Summary Report, revealed that Divalproex sodium delayed release tablet 500 mg (milligrams): give two tablets by mouth twice daily for behaviors and hydroxyzine pamoate 100 mg capsule: give one capsule three times daily for anxiety with an order date of 5/24/24. Record review of Resident #54's intake information for PASRR dated 5/24/24 revealed, Section J: Disease Diagnoses: the admitting diagnoses of Anxiety and Brief Psychotic Disorder were not listed as an active diagnosis . Section L: Referral Questions: 31.) Does Resident # 54 have any history of mental illness? answered No .32.) Does Resident #54 take, or have a history of taking, psychotropic medications? answered No. In an interview with the Social Service staff #1 on 12/3/24 at 2:45 PM, she revealed after reviewing Resident #54's intake information for Level II PASRR evaluation she confirmed that Resident #54's active admission diagnoses for mental illness and use of psychotropic medications were not listed. She stated the inaccurate completion resulted in an inaccurate depiction of the resident's mental health status. This resulted in Resident #54 not being referred for a level II PASRR evaluation. She stated that the concern from not completing the initial PASRR correctly is that a resident with mental illness may not be appropriate for nursing home stay and may need specialized mental health services.

Based on observations, resident and staff interviews, record reviews, professional standards of practice, and facility policy review the facility failed to provide Peripherally Inserted Central Catheter (PICC) care for one (1) of four (4) residents with intravenous access. Resident #10. Findings include: Record review of the facility policy titled Central Vascular Access Device (CVAD) Dressing Change, effective date 6/1/24 revealed the guidance: Perform sterile dressing changes using Standard-Aseptic Non-Touch Technique (ANTT) at least weekly. Review of the professional standard of practice Checklist for Prevention of Central Line Associated Blood Stream Infections published by the Centers for Disease Control (CDC) revealed change semipermeable dressings at least every seven days. During an observation on 12/2/24 at 12:00 PM, Resident #10 was noted to have a PICC line inserted to the right arm with a transparent dressing dated 11/21/24. The resident stated that she had been on intravenous (IV) antibiotics, which were completed on 11/29/24, and was unsure why the PICC line had not been removed. She also stated that the dressing had not been changed. In an observation, interview and record review with Registered Nurse (RN) #2 on 12/2/24 at 12:20 PM, she verified that the PICC line dressing for Resident #10 was dated 11/21/24. She revealed after reviewing Resident #10's Order Summary Report that there were no orders for dressing changes to the PICC line, but there should have been. In an interview with the Director of Nursing (DON) on 12/2/24 at 1:00 PM, she confirmed that there should have been an order for Resident #10's PICC line dressing to be changed. The DON confirmed that Resident #10's PICC line dressing had not been changed and acknowledged that dressings should be changed every seven days. She stated that failure to do so could result in adverse effects, such as infection. Record review of the Admission Record revealed that the facility admitted Resident #10 on 8/30/24 with a diagnosis of Diabetes Mellitus. Record review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 11/28/24 revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact.

Based on observation, resident and staff interview, record review and facility policy review, the facility failed to ensure that medications were securely stored as evidenced by medications observed on the bedside table for two (2) of 53 residents reviewed. Resident #13 and #22. Findings Include: Review of the facility policy titled, Medication and Medication Supply Storage and Disposal, with no revision date revealed, Central storage of medications is required for prescription, prescribed over-the-counter medications .Will be kept in a locked area .Procedure :1.) Storage is required for the following situations and will be locked with limited access: If the facility administers or assists with self-administration of medication . Resident # 13 An observation on 12/2/24 at 2:30 PM revealed a bottle of Travoprost 0.004% eye drops sitting on Resident #13's overbed table. The resident stated that she puts the drops in her eyes herself at night and had been using the medication for [AGE] years. A record review of assessments revealed that Resident #13 did not have a Self-Administration of Medication assessment. A record review of the Order Review Report dated 12/3/24 for Resident #13 revealed that there was no physician's order for Travoprost 0.004%, nor an order to self-administer medications. An interview with Registered Nurse (RN) #3 on 12/3/24 at 1:25 PM, she stated that she was not aware of any medication that Resident #13 was self-administering. She verified that the resident did not have an order for Travoprost 0.004%. An observation and interview with RN #3 on 12/3/24 at 1:28 PM, she verified that there was a bottle of Travoprost 0.004% eye drops still sitting on residents over bed table. An interview with the Director of Nursing (DON) on 12/3/24 at 1:31 PM, she verified that Resident #13 did not have an assessment or a physician's order to self- administer any medications and did not have an order for the eye drops. She stated that the resident had been on the eye drops prior to her last hospitalization and felt they may not have been reordered upon her return. She agreed that the resident should be assessed for self-administration of mediation for safety. She agreed the resident could have adverse effects, such as drug interactions, from using a medication that was not ordered and agreed the medication should not be on the bedside table. Record review of the Admission Record revealed that the facility admitted Resident #13 to the facility on [DATE] with a diagnosis of Unspecified Glaucoma. Record review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 10/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. 47157 Resident #22 An observation of Resident #22's room on 12/02/24 at 11:10 AM revealed a box sitting on the bedside table titled Hydrocortisone 1% cream. Resident #22 stated that he uses that cream for a rash on his arm. He stated that the treatment nurse gave him a full box of hydrocortisone and told him to apply it every day. In an observation of Resident #22's room with Registered Nurse (RN) #1 on 12/03/24 at 11:00 AM, she confirmed the box on Resident #22's bedside table was Hydrocortisone cream. A continued record review of Resident #22's Order Summary Report dated 12/3/24 revealed that the resident had no orders for the Hydrocortisone cream. RN #2 confirmed Resident #22 did not administer his medications and the cream should not have been in the room. In an interview with the Treatment Nurse on 12/03/24 at 11:10 AM, she revealed the box of Hydrocortisone in Resident # 22's room was facility stock medication. She stated she did not give the resident the box of hydrocortisone and confirmed he did not have an order for it. She then revealed the medication should not be in the resident's room because he could apply too much of the hydrocortisone and have a potential adverse reaction. In an interview with the Director of Nursing (DON) on 12/03/24 at 11:15 AM, she confirmed Resident #22 did not have an assessment to self-administer medications and confirmed the medication should not have been left in the room. The DON stated the cream should have been stored in a locked medication/treatment cart. Record review of the Admission Record revealed Resident #22 was admitted by the facility on 3/21/24 with diagnosis of End-stage Renal Disease. Record review of Resident #22's Section C of the quarterly MDS with an ARD of 11/26/24 revealed a BIMS score of 15, indicating the resident was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent the possible transmission of infections when staff failed to use enhanced barrier precautions (EBP) during catheter care for one (1) one of (4) four direct care areas observed. (Resident #12) Findings include: Review of the facility policy titled, Enhanced Barrier Precautions, with a revision date of August 2022 revealed, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents . Policy Interpretation and Implementation: EBP's employ targeted gown and glove use during high contact resident care activities . Examples of high contact resident care activities g. device care .urinary catheter . An observation of catheter care for Resident #12 on 12/03/24 at 2:10 PM, revealed Certified Nurse Assistant (CNA) #1 and the Restorative CNA provided catheter care for Resident #12 and both CNAs failed to apply a gown before performing catheter care. In an interview with CNA #1 on 12/03/24 at 2:20 PM, she revealed she did not realize she had not used EBP. She then revealed that all residents with indwelling devices are on enhanced barrier precautions. In an interview with the Restorative CNA on 12/03/24 at 2:25 PM, she revealed that she had forgotten EBP and confirmed she knew she was supposed to. She then revealed the purpose of EBP is to reduce the risk of spread of infections for residents at increased risk of infection. Record review of the Order Summary Report for Resident #12 revealed an active order for Catheter care every shift and as needed, dated 11/18/24. In an interview with the Infection Control Nurse on 12/03/24 at 2:35 PM, she confirmed that the CNAs should have implemented EBP to provide a layer of protection to prevent the spread of infection for residents at increased risk. Review of the Admission Record revealed Resident #12 was admitted by the facility on 8/20/20 with Encounter for Surgical Aftercare Following Surgery On The Genitourinary System. Record review of Resident #12's Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/24 revealed in Section: H-Bladder and Bowel: H0100 was coded Indwelling catheter.

Based on observations, resident and staff interviews, and facility policy review the facility failed to maintain an effective pest control program to prevent flying insects for four (4) of four (4) survey days. Findings Included: Record review of the facility policy titled Pest Control with an effective date of 11/30/2014 revealed under, Policy: The facility will maintain a pest control program, which includes inspection, reporting, and prevention. Also revealed under, Procedure: . 3. Treatment will be rendered as required to control insects and vermin. 4. Any unusual occurrence or sighting of insects should be reported immediately to the Supervisor (See policy- Maintenance Repair Request Form). Proper action will be taken . An observation on 7/31/23 at 11:15 AM, of the main dining room during the lunch meal revealed seven residents eating their meal with five to six flies flying over and landing on the tables and trays. Residents observed swatting at flies with their hands while trying to eat. An observation on 7/31/23 at 11:20 AM, revealed a fly over the uncovered cornbread on the steam table. Dietary staff was alerted, and they covered the cornbread. An observation on 07/31/23 at 12:16 PM, revealed Resident #47 lying in bed and was non-verbal. The Survey Agent (SA) observed two flies hovering over the resident and landing on the resident and the bedside table in the room. An observation on 8/01/23 11:01 AM, down the main entry corridor, revealed two to three flies swarming around the front door entry area. During an observation of medication pass on South Hall on 8/02/23 at 8:02 AM, Survey Agent (SA) observed several flies and gnats flying around the medication cart. An observation on 8/2/23 at 11:00 AM, revealed five (5) flies in the kitchen around the food prep table. An observation of Resident # 50 on 8/02/23 at 2:10 PM, revealed the resident lying in bed with eyes closed and two flies hovering and landing on the resident's side rail and bed linen. An interview with Resident # 14 on 8/02/23 3:45 PM, revealed they have issues in the dining room with numerous flies while they're trying to eat. She revealed she had noticed four to five flies flying around while the residents were trying to eat. An interview with the Administrator (ADM) on 8/3/23 at 8:40 AM, confirmed that the facility had an issue with flies. He revealed that the facility used Eco-Lab for pest control. He revealed that Eco Lab came out to the facility about 2 weeks ago but did not address the flies because at that time, flies were not an issue. He revealed he had one insect light in the kitchen to address the flies. An observation and interview, on 08/03/23 at 09:04 AM, with the Dietary Manager (DM) confirmed flies in the kitchen. She stated that they come in every time someone opens the back door. The DM confirmed six (6) flies on a pipe above the food prep table and others flies around the sink and window. She stated that flies are nasty and carry disease. An interview on 08/03/23 at 10:00 AM, with the ADM confirmed that he was aware of the fly problem. He stated the kitchen has one insect light and he had thought about a fan for the back door but had not gotten one. 47874

Based on observations, resident and staff interviews, record review and facility policy review the facility failed to maintain a clean environment that was free of odors as evidenced by dirty walls and siderails and provide a sufficient supply of clean linen for two (2) of four (4) survey days. Findings include: Record review of the facility policy titled Cleaning and Disinfection of Environmental Surfaces undated revealed, Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen Standard. Policy Interpretation and Implementation: 1 . c. non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical environmental surfaces include bed rails, some food utensils, bedside tables, furniture and floors. 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled . An observation on 7/31/23 at 11:05 AM, revealed a strong smell of urine as soon as you reach the nurses station that lingered between the North and South hallways and that smell extended all the way down the South hallway of the building. An observation on 7/31/23 at 3:00 PM, walking from the front door revealed a strong smell of urine as soon as you get to the nurse's station and continued down the South hallway. An interview on 8/1/23 at 8:51 AM, with Certified Nurse Assistant (CNA) #1 revealed that the facility only has one laundry staff member, and they are off on Tuesday's and Wednesday's, so they run out of towels and washcloths. She stated that when the staff came in this morning they were out of clean towels and wash cloths, so a CNA took it upon themselves to start a load of laundry. An observation and interview with Laundry & Housekeeping Supervisor on 8/1/23 at 9:25 AM in the laundry room revealed there were no clean towels or wash clothes available now. The Laundry & Housekeeping Supervisor stated that they have a laundry staff person that works 6AM-2PM every day except Tuesday and Wednesday, but on those days, he helps and does some washing. He revealed he was currently washing bath cloths and towels, but the staff come to the laundry room and stock their linen carts and take them to the halls. An observation on 8/1/23 at 9:40 AM, of the linen cart on the South Hall revealed there were only 3 wash cloths and no towels. CNA #1 confirmed this observation. An observation and interview with CNA #2 on 8/1/23 at 9:45 AM, confirmed the linen cart on the North Hall had no washcloths or towels and CNA #2 revealed that they still had about three baths to give and that they had given all the baths they could with the washcloths and towels that they had. During the resident council meeting on 8/1/23 at 2:00 PM, Residents #21, Resident #41 & Resident #28 complained that the facility runs out of towels and wash clothes often and all agreed that their baths had been postponed or delayed due to no clean washcloths or towels at that time. An interview on 8/1/23 at 3:30 PM, with the Activities Director and CNA #7 confirmed they run out of clean wash cloths and towels and revealed that when they run out of towels and wash clothes, they tell housekeeping. An interview on 8/1/23 at 4:30 PM, with the Activities Director stated that since the facility stopped letting the staff use wet wipes, they have started running low on wash cloths and towels and that has been going on for the last couple of weeks. An interview on 8/2/23 at 2:15 PM, with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) stated that they knew about the issue with the staff running out of washcloths and towels, and knew there were extra in storage, but staff have been washing some at night and during the day to try and have enough to give baths. When the State Agent (SA) ask if the staff would have known about the extra linens in storage the DON revealed the staff would have notified her or the ADON and they would have notified laundry. The DON admitted that the washcloth and towel situation had gotten worse since they decided to take the wet wipes away because a resident had been flushing the wipes down the toilet and it stopped up the town's sewer system. An observation on 7/31/23 at 11:20 AM, revealed that Resident #21's room had a strong smell of urine in the room. An observation and interview on 08/01/23 at 9:00 AM, revealed that Resident #21's room had a strong smell of urine. The resident stated that he gives himself a bath when they aren't out of towels and wash clothes, and they run out quick. Record review of Resident #21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/14/23 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Record review of Resident #28's MDS with an ARD of 4/25/23 revealed under Section C a BIMS score of 13, which indicated the resident is cognitively intact, Record review of Resident #41's MDS with an ARD of 5/22/23 revealed under Section C a BIMS score of 15, which indicated the resident is cognitively intact. 47874 An observation of Resident #50 on 07/31/23 at 11:20 AM, revealed him lying in bed eating lunch. The resident's left and right inner side rails noted with a brown substance adhering. The wall located beside the bed was noted with a brown substance smeared down the wall in the resident's view. The brown substance on the wall measured approximately 10 inches in length x 5 inches in width. An interview with the DON on 8/01/23 at 3:05 PM, confirmed that Resident # 50 had a brown substance smeared on the wall and on both inner side rails. She confirmed that this was not a sanitary environment for the resident to reside in. She revealed it was housekeeping's responsibility to ensure the residents' side rails and walls were cleaned. An interview with the Regional Housekeeping Director on 8/01/23 at 3:10 PM, confirmed the brown substance on the wall and on Resident #50's side rails. He revealed that if the brown substance was bodily fluids, the nursing department would be responsible for cleaning. He confirmed that this was not a sanitary environment for the resident. Record review of the Admission Record for Resident # 50 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Nontraumatic Intracerebral Hemorrhage, Type 2 Diabetes Mellitus and Heart Failure.

Based on observations, resident and staff interviews and record review the facility failed to provide sufficient staff to provide the care needed to the individual residents for two (2) of four (4) days of survey. Findings Include: Review of the typed statement on facility letterhead dated August 2, 2023, and signed by the Administrator revealed, . (Proper Name of Facility) does not have a policy on staffing. Facility Staffing is based off of the acuity of the residents as described in the Facility Assessment. Review of the typed statement on facility letterhead revealed the facility does not have a policy on answering of call lights and was signed by the Administrator. Resident #46 An observation and interview on 07/31/23 at 11:05 AM with Resident #46 revealed a strong urine odor in the room. The resident revealed he needs someone to come empty his urinal, but he cannot reach his call light. This observation revealed the resident's call light was laying in the floor behind his bed and his urinal was full of urine. He stated they never come when you need them. An observation and interview on 7/31/23 at 11:30 AM revealed Resident #46's urinal was still full of urine and his call light was within reach. The resident revealed the staff came in and turned his call light off but did not empty the urinal. Record review of Resident #46's Admission Record revealed he was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction and Need for Assistance with Personal Care. Record review of Resident #46's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/27/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact and in Section G that the resident needed extensive assistance with ADL's. An interview on 7/31/23 at 11:15 AM, with Certified Nurse Assistant (CNA) #1 revealed they are always short staffed, and three (3) CNAs called in today. She stated, she had been asking for help all morning and no one would come help, but as soon as the State Agency walked in everyone came out of their offices and started helping. She revealed that Resident #36 had been on his call light ever since she got here at AM, because he wanted to get up and 11 PM-7 AM shift is supposed to get him up, but they did not probably because they were shorthanded. She stated that she explained to the resident that she had to pass breakfast trays and had some resident's she needed to get up for therapy and he understood. She revealed that the Director of Nurses (DON) walked past Resident #36's room with the call light on and told me that resident needed me, and I told her I knew that but had not had a chance to get to him and she kept on walking. She stated they have 3 CNAs on duty with 58 residents in the building. She stated that she has 20 residents assigned to her, ten (10) must be gotten up for therapy and about 20-25 are supposed to get baths today. She stated she has several that must be turned and have incontinent care and it is hard to do those rounds every two (2) hours since she is alone. She revealed she is asked to work overtime a lot and usually volunteers to do so and works six (6) days a week normally. She stated that the facility just does not have enough help. An interview on 8/1/23 at 3:30 PM, with the Activities Director confirmed she is working the South Hall this afternoon because they only have one aid. She stated that staffing is an issue because there are a lot of call ins. She revealed that some things do not get done such as showers because we do not have enough staff. Resident #36 An observation and interview on 07/31/23 at 12:43 PM with Resident #36 revealed that this facility needs staff bad. Resident #36 stated they do not have enough people to take care of us. He revealed he is supposed to get up every morning around 5:00 AM but he rarely does and its usually because they do not have enough staff. He revealed it was 10 AM before a staff member was able to get him up this morning. He stated, I cannot get myself out of bed and don't have use of my left arm. An interview on 8/1/23 at 1:10 PM with CNA #1 confirmed that Resident #36 likes to have his baths early of the morning and likes to stay up after that, so he is scheduled for his bath on the 11 PM-7 AM shift. She revealed about 2-3 times a week that does not happen, and they must do his bath and get him up on the 7 AM-3 PM shift. An interview on 8/3/23 at 8:20 AM with the Director of Nurses (DON) confirmed that Resident #36 has made the request to be got up and bath given on the 11 PM-7 AM shift. She confirmed there are times that he is not able to be gotten up on the 11 PM-7 AM shift and it is usually due to staffing. Record review of Resident #36's MDS with an ARD of 5/26/23 revealed under Section C a BIMS score of 15, which indicated that the resident was cognitively intact and under Section G that the resident needed extensive assistance for transferring. Resident Council Meeting On 8/1/23 at 2:00 PM, during the Resident Council Meeting, Resident's #9, Resident #14, Resident #21, and Resident #41 revealed that the facility is short staffed a lot. Resident #41 stated that you hear the aides and nurses talking about being short staffed all the time. Resident #14 revealed it takes the staff a long time to answer the call light, that she has had to wait an hour before for them to answer the call lights. Resident #28 revealed he has had to wait 2 hours before for the staff to answer the call light. Record review of Resident #9's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/4/23 revealed under Section C a Brief Interview for Mental Status score of 13, which indicated the resident is cognitively intact. Record review of Resident #14' MDS with and ARD of 7/11/23 revealed under Section C a BIMS score of 14, which indicated that the resident is cognitively intact. Record review of Resident #21's MDS with an ARD of 6/14/23 revealed under Section C a BIMS score of 15, which indicated the resident is cognitively intact. Record review of Resident #28's MDS with an ARD of 4/25/23 revealed under Section C a BIMS score of 13, which indicated the resident is cognitively intact. Record review of Resident #41's MDS with an ARD of 5/22/23 revealed under Section C a BIMS score of 15, which indicated the resident is cognitively intact. Resident #49 On 07/31/23 at 11:15 AM, in an interview with Resident # 49 , revealed she had not been getting her bath as scheduled on Monday, Wednesday, and Friday. She revealed her last bed bath was given last Monday. She revealed she was told last Wednesday and Thursday that there was not enough staff to do it, and on Friday she was told the facility ran out of towels and wash cloths. The resident revealed, at one point, therapy was helping complete her baths due to the shortage of staff. She revealed call ins were the main concern with staffing. On 8/01/23 at 2:25 PM, an interview with the DON , confirmed that Resident # 49's bathing task revealed missing documentation supporting that resident was not given a bath. She stated, I really couldn't say whether she had a bath those days or not. She revealed that the aides sometimes leave after their shift without documenting. She stated, It goes back to the staffing issue; When we have two or three aides on the floor, it's hard to find the time to document. She confirmed that if it's not documented, then it's no way to prove the bath was done. Record review of the MDS with an ARD of 04/28/23 revealed under section C a BIMS score of 14, which indicated Resident #49 was cognitively intact. Resident #52 An observation on 7/31/23 at 11:10 AM of Resident #52's room revealed his room smelled strong of urine. An interview and observation on 08/01/23 at 9:56 AM with Resident #52 revealed that he has prosthetic legs and when he is in bed without his legs on and uses his urinal, he calls for them to come empty it and the resident revealed that the staff sometimes takes 2-3 hours to come, or they will come and turn his light off and never empty the urinal. An interview on 8/1/23 at 1:53 PM, with Resident #52 revealed he must use his call light to have staff come clean him up when he uses the bathroom, and it usually takes them a long time to get to him especially on the night shift. He revealed if they don't show up in time then he tries to clean himself. He stated that the staff now know they would be better off to come clean me themselves because I make a mess. He stated, I just wish they would answer my call light quicker instead of going to take care of someone else while I've been waiting 30-45 minutes. Record review of Resident #52's MDS with an ARD of 5/23/23 revealed in Section C a BIMS score of 14, which indicates the resident is cognitively intact and under Section G that the resident needed extensive assistance for toileting, personal hygiene, and bathing. An interview and review of the staffing grid for the last 14 days with the DON and the Assistant Director of Nurses (ADON) on 8/2/23 at 2:15 PM, revealed staffing is an issue. They both admitted that they have plenty of staff but have a lot of trouble with call ins. The ADON revealed they had 5 CNA's and 1 LPN call in on Monday 7/31/23, 5 CNAs called in on Tuesday, and 2 CNAs called in this morning. The DON stated they just do not know what to do to make people come to work. When reviewing the staffing grid for the past 14 days, it was documented that they had 4 CNAs on duty 7 AM-3 PM on 7/31/23. When the State Agent ask about the documented 4 CNA's because there were only 3 on duty when we entered the building at 11:00 AM on 7/31/23 the ADON admitted that 2 CNAs had called in for the 7 AM-3 PM shift Monday and CNA #7 went to work the floor after their morning meeting. When the SA asked what time the morning meeting was over, she revealed it ended around 10:30 AM, When the SA ask what time the majority of baths were completed, both the DON and ADON admitted they would be done between 7 AM-11 AM. The ADON stated that she thought 2 CNAs were coming in late and they usually are here by 9 AM, so she assumed they had already come in and no one told her any different Review of the facilities list of CNA'S revealed the facility had 24 CNAs with five (5) being full time and 19 being As Needed (PRN). The ADON stated that she admits there are things that don't get done due to not having enough staff such as baths. The DON agreed with the ADON and stated, we just try to do what's needed the most with the staff we have. An interview and review of the Facility Assessment with the Administrator on 8/2/23 at 11:15 AM, revealed on page 8 under Staffing Plan 3.2. Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time and in the staff, graph revealed that the facility needed 8 LPN's, 14-15 CNAs, and 3 other nursing personnel. During this interview the Administrator revealed that the graph information under Staffing Plan in the Facility Assessment that showed the facility needed eight (8) LPN's and 14-15 CNA's and 3 other nursing personnel was for a 24-hour period. Record review of the Staffing Grid for the past 14 days with the DON and the ADON revealed there were two days where the facility failed to provide sufficient staff to meet the needs of the residents. An interview on 8/2/23 at 1:45 PM, with the Administrator confirmed that the facility has issues with staffing especially CNA's. He revealed he is not sure how to make these people come to work but agreed it is not the resident's fault and they were needed for resident care. An interview with the DON on 8/01/23 at 2:50 PM, confirmed that the facility had been struggling with staffing issues for a while. She stated, Especially the CNA's. She revealed yesterday (7/31/23) they had 3 aides for the entire building with a census of 58, making each aide responsible for 19 or 20 residents. She revealed that they had 5 aides on the schedule and one aide called in and one aide called and said she would be late, but never showed. She revealed the nurses from the office usually come out to help when the aides are short but confirmed that the office staff failed to come out and help yesterday with only three aides. She stated, We should have been helping. 47874

Based on observation, resident and staff interview, record review and facility policy review the facility failed to honor the choice of a resident to get up early for one (1) of 23 residents in the sample. Resident #36 Findings Include: Record review of the facility policy titled, Policies and Procedures: Resident and Patient Rights with a revision date of 09/01/2017 revealed, Policy .It is the policy of the company that all employees will conduct themselves in a professional manner at all times, respecting the rights of each resident or patient to privacy, personal care, self-respect and confidentiality . An observation and interview on 07/31/23 at 12:43 PM, with Resident #36 revealed he was sitting up in his wheelchair in his room and the resident revealed that this facility needs staff bad. Resident #36 stated they do not have enough people to take care of us. He stated that he is supposed to get up every morning around 5:00 AM but he rarely does, and it is usually because they do not have enough staff. He revealed it was 10 AM before a staff member was able to get him up this morning. He stated, I cannot get myself out of bed and don't have use of my left arm. An interview and review of the bath schedule on 8/1/23 at 1:06 PM with Licensed Practical Nurse (LPN) #1 confirmed that Resident #36 likes to get up early and his bath is scheduled on the 11 PM-7 AM shift. A review of the bath schedule with LPN #1 confirmed the resident was scheduled for a bath on the 11 PM-7 AM shift. An interview, on 8/1/23 at 1:10 PM with Certified Nurse Assistant (CNA) #1 confirmed that Resident #36 likes to have his baths early in the morning and likes to stay up after that, so he is scheduled for his bath on the 11 PM-7 AM shift. She revealed about 2-3 times a week that does not happen, and they must do his bath and get him up on the 7 AM-3 PM shift because they don't have the staff to bath him at that time and get him up. An interview, on 8/3/23 at 8:20 AM with the Director of Nurses (DON) confirmed that Resident #36 has made the request to be gotten up and his bath to be given on the 11 PM-7 AM shift. She confirmed there are times that he is not able to be gotten up on the 11 PM-7 AM shift and it is usually due to staffing. She confirmed that a resident's choices should be honored though. Record review of Resident #36's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Unspecified. Record review of Resident #36's Documentation Survey Report v2 for July 2023 revealed under ADL (Activity of Daily Living) - for transferring there were five times in the last two weeks where the resident did not get out of bed on the 11PM-7AM shift for his bath. Record review of Resident #36's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/23 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact and under Section G that the resident needed extensive assistance for transferring.