Every finding on record at Main West Postacute Care

Based on interview and record review, the facility failed to provide Physical Therapy (PT-a health professional trained to evaluate and treat people who have conditions or injuries that limit their ability to move and do physical activities) and Occupational Therapy (OT- a health professional that provides services to increase and/or maintain a person's capability to participate in everyday life activities) for five of five residents (Residents 1, 2, 3, 4 and 5) when Residents 1, 2, 3, 4, and 5 did not receive PT and OT treatments ranging from 1/5/26 to 2/4/26 that had been prescribed by their physician. These failures had the potential to result in a decline in the range of motion, decreased functional status, loss of gains and overall weakness for Residents 1, 2, 3, 4 and 5.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive (the mental processes of perception, thinking, learning, memory, reasoning, and judgment) Assessment, dated 12/30/25, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation and memory recall) score was 15, indicating Resident 1 had no cognitive impairment.During a review of Resident 1's order summary report titled Medication Review Report for December 2025, the Medication Review Report indicated PT and OT orders were prescribed on 12/26/25.During a review of Resident 1's PT and OT evaluation and plan treatment, dated 12/26/25, the PT and OT plan indicated Resident 1's diagnosis of muscle weakness. PT and OT would work with Resident 1, five times a week for four weeks daily from 12/26/25-1/22/26. Resident 1 did not receive PT and OT for the weeks of 1/5/26, 1/12/26 and 1/19/26 for a total of eight missed PT treatments and eight missed OT treatments.During a review of Resident 2's MDS Assessment, dated 10/20/25, the MDS indicated Resident 2's BIMS score was 15, indicating Resident 2 had no cognitive impairment.During a review of Resident 2's order summary report titled Medication Review Report for January 2026, the Medication Review Report indicated PT and OT orders were prescribed on 1/20/26.During a review of Resident 2's PT evaluation and plan treatment, dated 1/21/26, the PT plan indicated Resident 2's diagnosis of muscle weakness. PT would work with Resident 2, five times a week for four weeks daily from 1/21/25-2/4/26. Resident did not receive PT for the weeks of 1/26/26 and 2/2/26 for a total of 7 missed PT treatments. Resident 2 did not have an OT evaluation or treatments documented.During a review of Resident 3's MDS assessment, dated 12/30/25, the MDS indicated Resident 3's BIMS score was 7, indicating Resident 3 had severe cognitive impairment.During a review of Resident 3's order summary report titled Medication Review Report for December 2025, the Medication Review Report indicated PT and OT orders were prescribed on 12/26/25.During a review of Resident 3's PT and OT evaluation and plan treatment, dated 12/28/25, the PT and OT plan indicated Resident 3's diagnosis of muscle weakness. PT and OT would work with Resident 3, five times a week for four weeks daily from 12/28/25-1/24/26. Resident 3 did not receive PT and OT for the weeks of 1/5/26, 1/12/26 and 1/19/26 for a total of thirteen missed PT treatments and fifteen missed OT treatments.During a review of Resident 4's MDS assessment, dated 12/25/25, the MDS indicated Resident 4's BIMS score was 4, indicating Resident 4 had severe cognitive impairment.During a review of Resident 4's order summary report titled Medication Review Report for December 2025, the Medication Review Report indicated PT and OT orders were prescribed on 12/21/25.During a review of Resident 4's PT evaluation and plan treatment, dated 12/23/25, the PT and OT plan indicated Resident 4's diagnosis of abnormalities of gait and mobility. PT and OT would work with Resident 4, five times a week for four weeks daily from 12/23/25-1/19/26. Resident 4 did not receive PT and OT for the weeks of 1/5/26, 1/12/26 and 1/19/26 for a total of thirteen missed PT treatments and fifteen missed OT treatments.During a review of Resident 5's assessment, dated 10/20/25, the MDS indicated Resident 5's BIMS score was 13, indicating Resident 1 had no cognitive impairment.During a review of Resident 5's order summary report titled Medication Review Report for December 2025, the Medication Review Report indicated PT and OT orders were prescribed on 12/13/25.During a review of Resident 5's PT evaluation and plan treatment, dated 12/15/25, the PT and OT plan indicated Resident 5's diagnoses of a pelvic and other abnormalities of gait and mobility. PT and OT would work with Resident 5, five times a week for four weeks daily from 12/15/25-1/11/26. Resident 5 did not receive PT and OT for the weeks of 1/5/26 for a total of five missed PT treatments and five OT treatments.During an interview on 2/4/26 at 4 p.m., with Consultant Administrator (CA), the CA stated their third-party consultant group is currently assisting the Skilled Care Facility (SNF) transition from contracted therapy services (a strategic arrangement where healthcare facilities hire external, third-party companies or independent therapists to provide specialized, temporary, or ongoing rehabilitation services)to in-house therapy services (direct employment of therapist by the facility without outside contractors or agencies to provide rehabilitation services). CA stated PT and OT services should have continued without disruption after 1/5/26 when the contracted therapy services ended. CA stated the actual PT and OT services did not restart until after 1/22/26. CA stated she could not speak to how no PT and OT services affected the residents in the facility.During an interview on 2/4/26 at 4:07 p.m., with the Director of Nurses, the DON stated therapy services are provided for residents to ensure rehabilitating services are provided as ordered by the physician. The DON stated, during our transition from contracted to in-house therapy services, services were not available for PT and OT from 1/5/26 to 1/22/26. The OT was hired on 1/20/26 and the PT was hired on 1/22/26. The DON stated potential outcomes for residents not receiving or finishing their prescribed therapy services include weakness, loss of gains and potential contractures.During an interview on 2/5/26 at 4 p.m., with the PT, the PT stated he was hired on 1/22/26 to provide therapy services as ordered. The PT stated he previously worked with the contracted therapy services, so he was familiar with the residents in the facility prior to coming on board for in-house therapy services. The PT stated that the residents did not receive therapy services from 1/5/26 to 1/22/26 because there was no one hired to do so. The PT stated it was concerning how the facility went about terminating the contracted services without having staff hired prior to the contract termination to ensure there wasn't any disruption in PT services for the residents. The PT stated potential outcomes for residents not receiving services included loss of strength, decline in functional status and potential risk for falls.During an interview on 2/6/26 at 10:37 a.m., with the ADM, the ADM stated in total there were five residents who did not have continued services or evaluations for PT and OT rehab services from 1/5/26 to 1/22/26.During an interview on 2/6/26 at 10:45 a.m., with the DON, the DON stated PT and OT services should be evaluated and assessed by the PT or OT within 72 hours of orders. The licensed nurses are responsible for ensuring notifications are made to the therapy department for evaluations to be conducted. The DON stated from X to X there was not a PT or OT available to conduct the evaluations or continue the current treatment plans for the five residents in the facility. The DON stated it is important for PT and OT services to continue or for the residents to be evaluated to ensure a decline does not occur and functional mobility remains.During an interview on 2/6/26 at 10:59 a.m., with the ADM, the ADM stated the plan of care and orders for Residents 1,2,3,4 and 5 were not followed according to the physician orders and treatment plans within the medical record. The ADM stated potentially these residents could have experienced increased weakness due to the lack of therapy services. The ADM stated policy for Therapy services were not followed and it was the expectation that the consulting group would assist the facility with a smoother transition, but this did not occur. ADM stated the primary physician should have been notified of the delays and orders should have been clarified to readjust treatments for Resident's 1,2,3,4 and 5.During an interview on 2/6/26 at 11:18 a.m., with the OT, the OT stated she recently got hired on 1/20/26 and prior to that date, she could not speak about what the facility was doing to ensure services for OT. The OT stated currently she is assisting the facility via telehealth (the provision of healthcare provided remotely by means of technology) as she is in Florida. The OT stated that she instructs the staff to assist her with the telehealth with exactly how to perform the necessary assessments while overseeing the movements online. The OT stated OT services are important to ensure residents become stronger to be more independent with self-care, contracture management, and overall quality of life. The OT stated that without oversight, potential quality of life detriment could occur.During a review of the facility's policy and procedures (P&P) titled, Scheduling Therapy Services, dated Jan. 2018, the P&P indicated, .Therapy services shall be scheduled in accordance with the resident's treatment plan. the therapist shall interview the resident and consult with the attending physician as to the type of treatment to be administered. therapy is scheduled in coordination with nursing service and is documented in the resident medical records. residents receiving therapy is posted at each nurses station. The listing contains: the name of the resident, the room number of the resident, the type of therapy scheduled, the time therapy is scheduled, where the therapy is scheduled,. nursing service shall be responsible for preparing and escorting the resident to the therapy area.During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, dated Jan. 2018, the P&P indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person centered care plan will.include measures objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident highest practicable physical, mental and psychosocial well-being.incorporate identified problem areas. incorporate risk factors associated with identified problems. reflect treatment goals, timetables and objectives. assessments of residents are ongoing and care plans are revised as information about the residents and the residents condition change.

Based on observation and interview, the facility failed to ensure discarded items were secured inside of a dumpster. This deficient practice had the potential to affect all 96 residents who resided in the facility. Findings included: During an observation of the rear of the facility on 03/05/2025 at 10:19 AM, there was a cluttered area that contained 13 bags of clothing items, seven mattresses that were stained brown and stacked on top of a bed, a dusty plate warmer, and pallets. During an interview on 03/05/2025 at 10:25 AM, the Housekeeping Supervisor stated the items located at the rear of the facility had been there for three to six months and the maintenance staff were responsible for cleaning the area. During an interview on 03/05/2025 at 10:29 AM, Laundry Staff #5 stated the clutter of items had been located in the same area since she started working at the facility in 08/2024. During an interview on 03/05/2025 at 10:30 AM, the Maintenance Assistant (MA) stated some of the items were trash and other items were spart parts. Per the MA, every six to eight months, the facility rented a dumpster to throw away the items as the facility only had one dumpster and all the items would not fit in the dumpster. The MA stated the items that would be placed in the dumpster included wood pieces, mattresses that were stacked on top of a bed, wheelchair frames, chairs, headboards, a stack of 30 side rails, old shower chairs, fitted sheets for residents' beds, and an old bed. During an interview on 03/05/2025 at 11:00 AM, the Maintenance Director stated the cluttered area contained either items that needed to be repaired or items that needed to be discarded that could possibly attract pests. During an interview on 03/07/2025 at 7:32 AM, the Director of Nursing stated the area needed to be cleaned. During an interview on 03/07/2025 at 10:14 AM, the Administrator stated the area contained spare parts or items that needed to be disposed of. Per the Administrator, the area was not accessible to residents or their family but should be cleaned and without clutter.

Based on observation, interview, record review, and facility policy review, the facility failed to implement enhanced barrier precautions (EBP) for 2 (Resident #93 and Resident #252) of 21 sampled residents. Findings included: A facility policy titled Enhanced Barrier Precaution, dated 06/2022, revealed, Enhanced Barrier Precautions expand the use of PPE [personal protective equipment] and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [multidrug-resistant organism] to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact activities. The policy specified, 1. Enhanced Barrier Precautions can be applied to residents with any of the following: a. Wounds or indwelling medical devices, regardless of MDRO colonization status such as but not limited to central line, urinary catheter, feeding tubes, tracheostomy/ventilator care). B. Infection or colonization with an MDRO. 2. Use EBP for high-contact resident care activities by using gown and glove during: a. Dressing b: Bathing/showering c. Transferring d. Provide hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care of use: central line, urinary catheter, feeding tube, tracheostomy/ventilator h. Wound care: any skin opening requiring a dressing. 1. An Admission Record revealed the facility admitted Resident #93 on 10/22/2024. According to the Admission Record, the resident had a medical history to include type 2 diabetes mellitus, direct infection of the left ankle and foot, and acquired absence of other left toes. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/26/2025, revealed Resident #93 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had an infection of the foot, other open lesion(s) of the foot, and a surgical wound. Resident #93's Care Plan Report included a focus area initiated 01/09/2025, that indicated the resident had a surgical incision to the left transmetatarsal amputation site. Interventions directed staff to cleanse the surgical incision to the left transmetatarsal amputation site with normal saline, pat dry, apply a debriding agent/abdominal dressing and wrap with a sterile gauze every shift. During an observation on 03/05/2025 at 8:30 AM, the Treatment Nurse provided wound care to Resident #93's left foot and did not wear a gown. During an interview on 03/05/2025 at 9:25 AM, The Treatment Nurse acknowledged she did not wear a gown when she performed wound care for Resident #93. The Treatment Nurse stated she did not wear a gown because the resident's wound was not draining. Per the Treatment Nurse, she was aware of EBP and the only time she needed to implement EBP was when a resident had an open wound, a catheter, a tube feeding, or an intravenous line. During an interview on 03/07/2025 at 9:02 AM, the Director of Nursing (DON) stated if a resident had an opened wound, staff should implement EBP when care was provided. The DON stated staff would be expected to wear a gown and gloves for any wound care treatments. During an interview on 03/07/2025 at 9:57 AM, the Administrator stated if a resident was on EBP, staff should wear a gown and follow precautions. 2. An Admission Record revealed the facility admitted Resident #252 on 02/28/2025. According to the Admission Record, the resident had a medical history to include a diagnosis of dysphagia (difficulty swallowing). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2025, revealed Resident #252 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident had a feeding tube. Resident #252's Care Plan Report included a focus area initiated 03/02/2025, that indicated the resident was on enhanced barrier precautions related to a gastrostomy tube. During a concurrent observation and interview on 03/05/2025 at 4:30 PM, Licensed Vocational Nurse (LVN) #12 administered medications to Resident #252 by way the resident's gastrotomy tube. LVN #12 donned gloves but did not wear a gown. LVN #12 stated it was her mistake that she did not wear a gown. During an interview on 03/06/2025 at 3:14 PM, the Director of Staff Development (DSD) stated it had been explained to staff that if a resident had a gastrotomy tube, a catheter, or a wound, staff should wear a gown and gloves when they provide care to the resident. The DSD stated staff should wear the appropriate personal protective equipment, a gown and gloves, when they administer medications to a resident by of a resident's gastrostomy tube. During an interview on 03/07/2025 at 9:02 AM, the Director of Nursing stated it was expected of staff to wear a gown and gloves when they administer medications to a resident through the resident's gastrostomy tube. During an interview on 03/07/2025 at 9:57 AM, the Administrator stated if a resident was on EBP, staff should wear a gown and follow precautions.

Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 1 (Resident #42) of 3 sampled residents reviewed for preadmission screening and resident review (PASARR). Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, dated 01/2018, revealed, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and verify the accuracy of that portion of the assessment. An Admission Record revealed the facility admitted Resident #42 on 05/03/2019. According to the Admission Record, the resident had a medical history that included diagnoses of schizophrenia and major depressive disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2024, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was not currently considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. Per the MDS, the resident had active diagnoses to include depression and schizophrenia. Resident #42's Care Plan Report included a focus area, initiated 07/01/2021, that indicated the resident had impaired cognitive function related to diagnoses of schizophrenia and depression. During an interview on 03/06/2025 at 9:38 AM, the MDS Nurse stated she began employment with the facility on 01/27/2025 and count not speak to any MDS assessments done before 01/27/2025. During an interview on 03/06/2025 at 2:48 PM, the Director of Nursing stated she was not aware of any MDS assessment that were not accurate. During an interview on 03/07/2025 at 9:32 AM, the Administrator stated the expectation was for the MDS assessment to be accurate.

Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of a preadmission screening and resident review (PASARR) for 1 (Resident #84) of 3 sampled residents reviewed for PASARR. Findings included: A facility policy titled, Preadmission Screening and Resident Review, with a release date of 01/2018, indicated, The completed Level I screening form must be reviewed by the Admissions Coordinator or designated staff to verify completeness and accuracy. An Admission Record indicated the facility admitted Resident #84 on 03/29/2023. According to the Admission Record, the resident had a medical history to include a diagnosis of unspecified psychosis, schizophrenia, major depressive disorder, bipolar disorder, and anxiety disorder. Resident #84's Preadmission Screening and Resident Review Level I Screening, dated 08/07/2023, revealed the resident did not have a serious diagnosed mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disturbance. During an interview on 03/05/2025 at 9:06 AM, the Director of Nursing (DON) stated Resident #66's PASARR dated 08/07/2023 was not filled out correctly. The DON stated the admissions person was responsible to review the PASARR for accuracy. During an on 03/07/2025 at 10:36 AM, the DON stated the expectation was that the PASARR was completed accurately. She stated she was not sure why Resident #84's PASARR was not completed accurately. During an interview on 03/07/2025 at 11:12 AM, the Administrator stated he expected the PASARR to be accurate. He stated that the person responsible should double check themself to ensure accurate completion of the PASARR. The Administrator stated there was no one at the facility at the present time to check the PASARR for accuracy.

Based on observation, interview, and record review, the facility failed to ensure licensed nurses stayed with a resident to ensure all medication was administered as ordered by the physician for 1 (Resident #8) of 21 sampled residents. Findings included: An Admission Record revealed the facility admitted Resident #8 on 09/23/2024. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, acute bronchitis, chronic respiratory failure, and acute respiratory failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/08/2025, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #8's Care Plan Report, included a focus area initiated 08/26/2024, that indicated the resident had chronic obstructive pulmonary disease with multiple comorbidities. Interventions directed staff to administer ipratropium-albuterol inhalation solution and albuterol-ipratropium as ordered. Resident #8's Order Summary Report that contained active orders as of 03/10/2025, revealed an order dated 09/10/2024, for ipratropium-albuterol inhalation solution 0.5-2.5 milligrams (mg)/3 milliliters (ml), inhale 3 ml orally every six hours for shortness of breath related to chronic obstructive pulmonary disease with acute exacerbation. During a concurrent observation and interview on 03/04/2025 at 8:30 AM, Resident #8 was observed lying in their bed with a breathing treatment in place and aerosol vapor was observed coming from the end of the mouthpiece/mask. There was not a nurse present and Resident #8 acknowledged they was doing their breathing treatment. During a concurrent observation and interview on 03/05/2025 at 7:58 AM, Resident #8 was noted sitting on the edge of their bed. The resident's nebulizer machine was on and there was aerosol vapor coming from the mouthpiece/mask which was in the resident's mouth. Resident #8 stated they had just woken up and were taking their breathing treatment before their breakfast. The resident stated the night shift nurse left the breathing treatment for them to administer. During an interview on 03/05/2025 at 11:09 AM, Resident #8 stated the nurses put the medication in the machine for them and they took it when they woke up in the morning. During an interview on 03/07/2025 at 8:41AM, Registered Nurse (RN) #3 stated that around 5:15 AM to 5:30 AM, she placed medication in the nebulizer machine for Resident #8. She stated when the treatment was done, she would go back in the room, wipe out the mask, and put the nebulizer and tubing back into the bag to cover it. When asked about the 03/04/2025 and 03/05/2025 of the resident with the nebulizer treatment in place, RN #3 stated the resident must not have finished all the medication and then turned the machine back on themself. RN #3 stated she knew it was the nurse's responsibility to ensure a resident had taken all the medication, whether it was a pill or nebulizer treatment. During an interview on 03/05/2025 at 12:47 PM, Licensed Vocational Nurse (LVN) #4 stated she had given Resident #8 a breathing treatment at noon and had placed the medication in the cup of the mouthpiece and handed it to the resident to administer. LVN #4 stated she did not stay in the room with the resident for the entire ten to fifteen minutes until the treatment was complete. LVN #4 stated she went back a little later to see if the resident finished the treatment. During an interview on 03/07/2025 at 8:35 AM, the Director of Nursing (DON) stated she was not aware Resident #8 administered their own nebulizer treatments without the nurses present. The DON stated it was her expectation that the nurses stay with the resident when giving nebulizer treatments and to follow the policy for medication administration.

Based on interview, record review, document review, and facility policy review, the facility failed to implement the pharmacist's recommendation for 1 (Resident #93) of 5 sampled residents reviewed for unnecessary medications. Findings included: An undated facility policy titled, Consultant Pharmacist Reports, revealed, The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing and the attending physician, and if appropriate, the medical director and/or the administrator. The policy further revealed, G. Recommendations are acted upon and documented by the facility staff and or the prescriber. 1) Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. An Admission Record revealed the facility admitted Resident #93 on 10/22/2024. According to the Admission Record, the resident had a medical history to include a diagnosis of constipation. A quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 01/26/2025, revealed Resident #93 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident had intact cognition. Resident #93's Care Plan Report, included a focus area initiated 10/22/2024, that indicated the resident had constipation related to decreased mobility. Interventions directed staff to administer senna, polyethylene glycol and docusate sodium as prescribed. The Consultant Pharmacist's Medication Regimen Review for recommendations created between 11/17/2024 and 11/18/2024, revealed Resident #93 was currently on Colace (docusate sodium), polyethylene glycol 3350 (a laxative), and senna and Please add to the order: Hold for loose stools. The follow-through section of the Consultant Pharmacist's Medication Regimen Review for the recommendation to add to the medication order hold for loose stools had a check mark and was notated done. Resident #93's Medication Review Report, which contained medication orders on or after 03/05/2025, revealed an order dated 10/22/2024, for polyethylene glycol 3350 oral packet 17 grams, give one packet by mouth two times a day for bowel care management, mix with 4-8 ounces of water. The order did not indicate to hold the medication for loose stools. During an interview on 03/05/2025 at 3:33 PM, Licensed Vocational Nurse (LVN) #12 stated that the charge nurses did not do anything with the pharmacy reviews (recommendations). Per LVN #12, if something were needed to be done, it would be done by the registered nurse (RN) supervisor or the Director of Nursing (DON). During an interview on 03/05/2025 at 3:44 PM, the DON stated the charge nurses and the supervisors were in charge of following up any nursing pharmacy recommendations. During an interview on 03/07/2025 at 8:38 AM, RN #17 stated she assigned pharmacy recommendations to the night shift supervisors to complete. RN #17 stated she was familiar with Resident #93 but had not worked on any pharmacy recommendations for the resident. RN #17 stated the recommendations should be followed. According to RN #17, if the physician agreed with the recommendation, it should have been done within one to two days. During an interview on 03/07/2025 at 9:57 AM, the Administrator stated pharmacy recommendation should be followed and if it was recommended to hold a stool softener, the staff should have added it to the medication order.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to address dental needs for 1 (Resident #39) of 1 sampled resident reviewed for dental. Findings included: A facility policy titled, Availability of Services, Dental, dated 01/2018 indicated the following, Oral healthcare and dental services will be provided to each resident. PROCESS 1. Dental services are available to all residents requiring routine and emergency dental care. The policy continued, 3. Social services will be responsible for making necessary dental appointments. 4. All requests for routine and emergency dental services should be directed to social services to assure that appointments can be made in a timely manner. An Admission Record indicated the facility admitted Resident #39 on 02/15/2024. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #39's Care Plan Report, included a focus area initiated 02/22/2024, that indicated the resident had oral/dental health problems related to poor oral hygiene and the resident having missing and broken teeth. The care plan goal was for the resident to get regular dental checkups as feasible. Resident #39's Order Summary Report, with active orders as of 03/07/2025, revealed an order dated 09/27/2024, for dental consult and treatment as indicated. During a concurrent observation and interview on 03/03/2025 at 9:33 AM, Resident #39 stated they had problems with their teeth and had asked the social worker for assistance with taking care of their teeth and that it had not been done. Some of the resident's teeth were observed broken, discolored, and some were missing. Resident #39's Oral Health Care Patient Notes, dated 04/22/2024, indicated the resident had a new patient examination, an oral cancer exam, and a hard/soft tissue exam, which were all within normal limits. The Oral Health Care note indicated that bridge #9 through 11 needed to be replaced with an outside dentist. There was no evidence in Resident #39's record to indicate the recommendation for the resident's bridge to be replaced had been completed. Resident #39's Oral Health Care Patient Notes, dated 11/18/2024, indicated an intraoral examination was completed and found to be within normal limits. The Oral Health Care note had a handwritten note on the document that indicated a referral to an oral surgeon was needed for multiple extractions with an outside dentist. There was also a handwritten note that indicated x-rays would be performed at the next visit to assess if the extraction could be done in facility. There was no evidence in Resident #39's record to indicate the recommendation for the extractions had been completed. A Psychosocial Note, dated 11/26/2024 at 12:48 PM, indicated Resident #39 was seen by the facility's dental provider on 11/18/2024. The note indicated that the dental provider suggested that the resident go outpatient for extractions. The note indicated that the social worker shared that due to the resident being a gurney patient, local dental offices were unable to accommodate the resident. A Psychosocial Note, dated 02/05/2025 at 3:50 PM, indicated that Resident #39 came to visit the social worker inquiring about seeing a dental specialist, and that the social worker reached multiple barriers for the resident's dental care due to dental offices not being equipped to transfer the resident from a wheelchair to a dental medical procedure chair. The note indicated that the resident's only known option for receiving dental work was in an alternate county; however, they experienced high volume of patients and were booked for the year 2025. Resident #39's Oral Health Care, note dated 02/11/2025, indicated a recommendation for full mouth extractions. There was no evidence in Resident #39's record to indicate the recommendation for the extractions had been scheduled. During an interview on 03/04/2025 at 10:47 AM, Resident #39 stated that they were still waiting to see a dentist, they sometimes felt pain but had no pain currently. The resident stated they could not remember the date when they last had dental pain. During an interview on 03/04/2025 at 12:05 PM, the Interim Social Service Director stated that a referral had been sent for Resident #39 and the vendors had said they could not accommodate the resident due to the resident being in a wheelchair. During an interview on 03/04/2025 at 2:38 PM, the Director of Nursing (DON) stated that social services should set up appointments with the dentist right away. The DON stated that for Resident #39, a dental appointment should have been scheduled. During a follow-up interview on 03/07/2025 at 10:25 AM, the DON stated that if there were any complaints about dental problems, staff should assess the pain and notify the doctor. She stated her expectation was that they obtain the dental consult as soon as possible. She said her expectation was to address the concern right away and then follow up as needed until the concern was resolved. The DON stated if the in-house vendor was not able to meet the resident's needs, social services was supposed to arrange a dental appointment with another dentist. The DON said social services should have arranged the appointment for Resident #39 earlier and should have found an outside dentist when the recommendation was made the first time. During an interview on 03/07/2025 at 11:04 AM, the Administrator stated his expectation was that staff make sure dental needs were provided either in-house or by outside sources if needed. He stated if dental needs were not able to be completed in-house, staff should get the appointment as soon as they were able. The Administrator stated for Resident #39, staff should have continued to follow up and reaching out to different sources to obtain the appropriate dental care.

Based on interview, record review, document review, and facility policy review, the facility failed to report allegations of abuse to facility management and to the state survey agency for 2 (Resident #57 and Resident #69) of 3 sampled residents reviewed for abuse. Specifically, facility staff failed to report allegations of abuse after becoming aware of the allegation when a police officer reported to staff that Resident #57 called and said a staff member restrained the resident; and when a police officer reported to staff that Resident #69 called and reported that a certified nursing assistant (CNA) pushed them. Findings included: A facility policy titled, Abuse and Neglect Prohibition Policy, dated 06/2022, revealed, It is the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents through the following: Screening of potential hires; Training of employees (both new employees and ongoing training for all employees); Prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Reporting of incidents, investigations, and the facility's response to the results of their investigations; The policy continued, 1. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect or exploitation the Administrator or designee will perform the following: i. All alleged violations-Immediately but not later than: 1. 2 hours-if the alleged violation involves abuse or results in serious bodily injury. 1. An Admission Record indicated the facility admitted Resident #57 on 01/24/2025. According to the Admission Record, the resident had a medical history that included diagnoses of insomnia, and depression. A 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2025, revealed Resident #57 had a Brief Interview For Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #57's Care Plan Report, included a focus area initiated 01/28/2025, that indicated the resident had a history of traumatic events related to being physically and/or emotionally abused. Interventions directed staff to assess for possible triggers related to said trauma, create a trauma-sensitive environment, and encourage the resident to inform staff when they are uncomfortable with staff or resident interaction. The Care Plan Report also included a focus area initiated 01/28/2025, that indicated the resident had behaviors that included getting upset when not getting attention and getting verbally aggressive when they did not get their own way. Interventions directed staff to encourage the resident to appropriately express all feelings and concerns, listen attentively, and attempt to resolve all areas and conflict and to monitor the resident for fabricating stories. A nursing Progress Note, dated 03/03/2025 at 7:00 AM, indicated that at around 7:00 AM, a police officer came to the facility and informed the nurse that Resident #57 called 911 and stated one of the workers was restraining them. During an interview on 03/03/2025 at 1:41 PM, Resident #57 stated they made a call to the police on 03/03/2025 and the police came to the facility. The resident stated during the night a staff person grabbed them from behind and threw them down on the bed. During an interview on 03/03/2025 at 3:05 PM, the Administrator stated he was not aware of any allegations of abuse in the last 24 hours. The Administrator stated he was the Abuse Coordinator. He stated any allegations of abuse should have been reported to him right away, and that he was not aware of an incident with Resident #57. The Administrator stated the allegation of abuse should have been reported within two hours. During an interview on 03/03/2025 at 3:14 PM, the Director of Nursing (DON) stated if a CNA or a nurse were aware of an allegation of abuse they should report the allegation of abuse to the Administrator. During an interview on 03/05/2025 at 2:09 PM, Registered Nurse (RN) #9 stated they were Resident #57's charge nurse on the date of the incident. RN #9 stated the police entered the facility and spoke to Resident #57, then spoke to her. RN #9 stated the police reported to her that Resident #57 called the police and stated they were held from the back by a staff person. RN #9 stated she was aware of care that was provided to the resident's roommate but was not aware of any abuse. RN #9 stated she told the DON about the residents' behavior after 9:00 AM on 03/03/2025. During a follow-up interview on 03/07/2025 at 10:45 AM, the DON stated herself and the Abuse Coordinator should have been notified right away of the incident and she was not sure why staff had not notified administration. During a follow-up interview on 03/07/2025 at 11:18 AM, the Administrator stated his expectation was for allegations of abuse to be reported. He stated when police came into the building, staff were to notify the supervisor and the Administrator. The Administrator stated staff should have notified the DON and himself right away. 2. An Admission Record indicated the facility admitted Resident #69 on 11/09/2023. According to the Admission Record, the resident had a medical history that included diagnoses of obstructive sleep apnea, major depressive disorder, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/15/2024, revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #69's Care Plan Report, included a focus area initiated 12/03/2024, that indicated the resident had insomnia. Interventions directed staff to provide a quiet environment during sleep hours. The Care Plan Report also included a focus area initiated 01/21/2025, that indicated the resident became upset when staff went into their room to care for their roommate, especially at night, threw stuff at staff when upset, fabricated stories about staff and residents to get their way, and told visitors things about the facility staff and residents that were false. Interventions directed staff to educate the resident about staff needing to come into their room to tend to other residents. During an interview on 03/03/2025 at 1:44 PM, Resident #69 stated that staff attacked them and threw them against the wall about one month ago. Resident #69 stated they reported it, the police came to the facility, and that the facility staff investigated the incident. During an interview on 03/05/2025 at 4:30 PM, Resident #69 stated they called the police officer the day after the incident. Resident #69 stated they did not report the incident to anyone at the facility. Resident #69 stated they were not sure if the male staff still worked at the facility because they had not seen the staff since the incident. An investigation packet provided by the facility included an undated typed document, signed by the Director of Nursing (DON) that revealed a paragraph that indicated that on 01/20/2025 around 10:45 PM, a certified nursing assistant (CNA) reported Resident #69 was assisted to the floor. The document indicated in a separate paragraph that around 3:00 PM, a police officer was called to the facility by Resident #69, who reported that a CNA pushed the resident the prior night. There was no evidence included in the facility's investigation packet that the allegation of abuse was reported to the Administrator or to the state agency. During an interview on 03/05/2025 at 5:01 PM, the Administrator stated Resident #69 stated that a staff pushed them down, but per the staff that did not happen, but instead the staff rushed to brace the resident's fall. During a follow-up interview on 03/05/2025 at 5:08 PM, the Administrator stated that the state agency was not notified of the allegation because it was not abuse per interviews with the staff.

Based on interview, record review, document review, and facility policy review, the facility failed to identify and thoroughly investigate an allegation of abuse for 1 (Resident #69) of 3 sampled residents reviewed for abuse. Specifically, facility staff failed to investigate an allegation of abuse for Resident #69 once they became aware of the allegation when a police officer came to the facility on [DATE] and reported to staff that Resident #69 called and reported that a certified nursing assistant (CNA) pushed them. Findings included: A facility policy titled, Abuse and Neglect Prohibition Policy, dated 06/2022, revealed, It is the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents through the following: Screening of potential hires; Training of employees (both new employees and ongoing training for all employees); Prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Reporting of incidents, investigations, and the facility's response to the results of their investigations; The policy continued, 5. When an abuse is identified, the appropriate steps to protect residents from additional abuse will be implemented immediately, which will include: i. Conducting a thorough investigation of the alleged abuse. An Admission Record indicated the facility admitted Resident #69 on 11/09/2023. According to the Admission Record, the resident had a medical history that included diagnoses of obstructive sleep apnea, major depressive disorder, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/15/2024, revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #69's Care Plan Report, included a focus area initiated 12/03/2024, that indicated the resident had insomnia. Interventions directed staff to provide a quiet environment during sleep hours. The Care Plan Report also included a focus area initiated 01/21/2025, that indicated the resident became upset when staff went into their room to care for their roommate, especially at night, threw stuff at staff when upset, fabricated stories about staff and residents to get their way, and told visitors things about the facility staff and residents that were false. Interventions directed staff to educate the resident about staff needing to come into their room to tend to other residents. During an interview on 03/03/2025 at 1:44 PM, Resident #69 stated that staff attacked them and threw them against the wall about one month ago. Resident #69 stated they reported it, the police came to the facility, and that the facility staff investigated the incident. During an interview on 03/05/2025 at 4:30 PM, Resident #69 stated they called the police officer the day after the incident. Resident #69 stated they did not report the incident to anyone at the facility. Resident #69 stated they were not sure if the male staff still worked at the facility because they had not seen the staff since the incident. An investigation packet provided by the facility included an undated typed document, signed by the Director of Nursing (DON) that revealed a paragraph that indicated that on 01/20/2025 around 10:45 PM, a certified nursing assistant (CNA) reported Resident #69 was assisted to the floor. The document indicated in a separate paragraph that around 3:00 PM, a police officer was called to the facility by Resident #69, who reported that a CNA pushed the resident the prior night. There was no evidence included in the facility's investigation packet that the allegation of abuse was reported to the Administrator or to the state agency. During an interview on 03/07/2025 at 10:45 AM, the DON stated for abuse allegations investigations should begin right away and the staff member should be suspended until the investigation was completed. The DON stated that interviews of the staff that were present during the time of the incident should be conducted, to include the supervisor, the resident involved, and any other alert and oriented residents who witnessed the incident. During an interview on 03/05/2025 at 5:01 PM, the Administrator stated Resident #69 stated that staff pushed them down, but per the staff that did not happen, but instead the staff rushed to brace the resident's fall. During a follow-up interview on 03/07/2025 at 11:18 AM, the Administrator stated that his expectation was for allegations of abuse to be reported.

Based on interview, record review, and facility policy review, the facility failed to ensure staff reported a resident's grievance to the designated Grievance Officer so that an investigation could be initiated for 1 (Resident #66) of 21 sampled residents. Findings included: A facility policy titled, Grievances/Complaints, Recording & Investigating, dated 01/2018, revealed, All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). Policy Interpretation and Implementation 1. The Administrator has assigned the responsibility of investigating grievances and complaints to the Social Services Department if applicable, otherwise, 2. 2. Upon receiving a grievance and complaint report, designated Grievance Officer will begin an investigation into the allegation. 3. The Department Director(s) of any named employee(s) will be notified of the nature of the complaint that an investigation is underway. 4. The investigation and report will include, as applicable: a. the date and time of the alleged incident; b. the circumstances surrounding the alleged incident; c. the location of the alleged incident; d. the names of any witnesses and their accounts of the alleged incident; e. the resident's account of the alleged incident; f. the employees account of the alleged incident; g. Accounts of any other individuals involved (i.e. employee's supervisor, etc.); and h. recommendations for corrective action. An Admission Record revealed the facility admitted Resident #66 on 05/03/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of pneumonia. A 5-Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/04/2024, revealed Resident #66 had a Brief Interview for Mental Status score of 14, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for all activities of daily living (ADLs) and had moderately impaired vision. During an interview on 03/03/2025 at 9:47 AM, Resident #66 stated the staff were eating their candy bars. According to Resident #66, when the staff gave them a candy bar, the staff either took some for themselves or took the candy bar at night when they were asleep, without their permission. Resident #66 stated they were completely out of their candy bar and they thought a male nurse took them. During an interview on 03/04/2025 at 2:10 PM, Certified Nurse Assistant (CNA) #1 stated she did not remember the day, but either 02/27/2025 or 02/28/2025, Resident #66 told her that they were missing chocolate candy bars out of their snack drawer. CNA #1 stated she reported to a nurse that Resident #66's chocolate candy bars were not in the resident's snack drawer. According to CNA #1, either on 02/27/2025 or 02/28/2025, when the resident asked for a chocolate candy bar, there were four in the resident's snack drawer and she gave the resident two. CNA #1 stated when the resident asked for a chocolate candy bar on 03/04/2025, there were none in the snack drawer. CNA #1 stated she only reported the resident's missing chocolate candy bars to the nurse. During an interview on 03/04/2025 at 2:17 PM, Licensed Vocational Nurse (LVN) #2 stated Resident #66 told him they were missing chocolates and that he tried to help find the chocolate candy bars, but they were not in the resident's snack drawer. LVN #2 stated he thought he might have talked with the resident's family, but did not remember when. According to LVN #2, the resident's family visited the resident on 03/04/2025 and brought some more chocolate candy bars for Resident #66. LVN #2 acknowledged he did not do anything else about the resident's missing chocolate candy bars because the resident's family brought more to the resident. LVN #2 stated he did not notify anyone of the resident's missing chocolate candy bars. During an interview on 03/05/2025 at 3:47 PM, the Interim Social Services Director (SSD) stated the grievance process was when a resident complained, they did an investigation on how it happened and tried to produce a solution within 48 hours. The Interim SSD stated she expected staff to have notes on what was told to them with the time and a complete description of what happened, and for them to tell her as soon as possible. The Interim SSD stated she had not received any grievances recently regarding missing candy for Resident #66. During an interview on 03/07/2025 at 8:40 PM, the Director of Nursing (DON) stated her expectation was if anyone voiced a grievance, a grievance form was to be filled out right away and the charge nurse was to be notified so the facility could follow the policy going forward and address the issue at hand. During an interview on 03/07/2025 at 9:57 AM, the Administrator stated he expected staff to follow the grievance process.

Based on interview, record review, document review, and facility policy review, the facility failed to complete a comprehensive assessment at least every 366 days for 4 (Residents #9, #23, #66, and #89) of 22 sampled residents reviewed for resident assessment. Findings included: A facility policy titled, MDS [Minimum Data Set] Completion and Submission Timeframes, dated 01/2018, revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy specified, 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, revealed Comprehensive Assessments OBRA [Omnibus Budget Reconciliation Act]-required comprehensive assessments include the completion of both the MDS and the CAA [care area assessment] process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required. They consist of: *Admission Assessment *Annual Assessment *Significant Change in Status Assessment [[NAME]] *Significant Correction to Prior Completion Assessment [SCPA]. Per the User's Manual, The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless a SCSA or an SCPA has been completed since the most recent comprehensive assessment was completed. 1. An Admission Record revealed the facility admitted Resident #89 on 01/13/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of dementia. Resident #89's medical record revealed the last comprehensive MDS was an admission MDS with a date of 01/20/2024. There was no evidence to indicate another comprehensive assessment was completed after 01/20/2024. 49044 2. An Admission Record revealed the facility admitted Resident #9 on 01/12/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease. Resident #9's medical record revealed the last comprehensive MDS was an annual MDS with a date of 01/19/2024. There was no evidence to indicate another comprehensive assessment was completed after 01/19/2024. 3. An Admission Record revealed the facility admitted Resident #23 on 03/21/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of metabolic encephalopathy. Resident #23's medical record revealed the last comprehensive MDS was a significant change in status MDS with a date of 01/22/2024. There was no evidence to indicate another comprehensive assessment was completed after 01/22/2024. 28193 4. An Admission Record revealed the facility admitted Resident #66 on 05/03/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of pneumonia. Resident #66's medical record revealed no evidence to indicate an admission MDS had been completed. During an interview on 03/06/2025 at 9:38 AM, the MDS Nurse stated her first day of employment with the facility was 01/27/2025. The MDS Nurse stated when she started, she knew there were a lot of MDS assessments that were either late or not done. Per the MDS Nurse, the plan going forward was for her to catch up on the incomplete assessments, but there was a lot to do. The MDS Nurse stated Resident #9 and Resident #23 were overdue for an annual MDS, the last quarterly MDS for Resident #89 in 01/2025 should have been an annual MDS, and an admission MDS should have been done for Resident #66 in 11/2024. During an interview on 03/06/2025 at 2:48 PM, the Director of Nursing stated she was not aware there were MDS assessments that had not been completed. During an interview on 03/07/2025 at 9:32 AM, the Administrator stated the expectation for the staff was to follow the RAI Manual and complete the MDS assessment timely.

Based on interview, record review, document review, and facility policy review, the facility failed to complete a quarterly Minimum Data Set (MDS) at least every 92 days for 3 (Residents #24, #66, and #93) of 22 sampled residents reviewed for resident assessment. Findings included: A facility policy titled, MDS [Minimum Data Set] Completion and Submission Timeframes, dated 01/2018, revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy specified, 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, revealed The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. Per the User's Manual, The MDS completion date must be no later than 14 days after the ARD [assessment reference date]. 1. An Admission Record revealed the facility admitted Resident #24 on 10/28/2011. According to the Admission Record, the resident had a medical history that included a diagnosis of dementia. Resident #24's medical record revealed the last comprehensive MDS was an annual MDS dated [DATE]. There was no evidence to indicate a quarterly MDS assessment was completed in 01/2025. 28193 2. An Admission Record revealed the facility admitted Resident #66 on 05/03/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of pneumonia. Resident #66's medical record revealed the last MDS was a quarterly MDS dated [DATE]. There was no evidence to indicate a quarterly MDS assessment was completed in 01/2025. 49044 3. An Admission Record revealed the facility admitted Resident #93 on 10/22/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. Resident #93's medical record revealed an admission MDS dated [DATE]. Further review revealed, a quarterly MDS with an Assessment Reference Date (ARD) of 01/26/2025, revealed the MDS was signed as being completed by the Director of Nursing (DON) on 03/04/2025. During an interview on 03/06/2025 at 9:38 AM, the MDS Nurse stated her first day of employment with the facility was 01/27/2025. The MDS Nurse stated when she started, she knew there were a lot of MDS assessments that were either late or not done. Per the MDS Nurse, the plan going forward was for her to catch up on the incomplete assessments, but there was a lot to do. The MDS Nurse stated Resident #24 was overdue for a quarterly MDS and a quarterly MDS had not yet been started for Resident #66. During an interview on 03/06/2025 at 2:48 PM, the DON stated she was not aware there were MDS assessments that had not been completed. During an interview on 03/07/2025 at 9:32 AM, the Administrator stated the expectation for the staff was to follow the RAI Manual and complete the MDS assessment timely.

7. Resident #31's electronic medical record revealed a quarterly MDS with an Assessment Reference Date (ARD) of 01/23/2025 had a status of Export Ready. The screen did not indicate the assessment completion date. During an interview on 03/06/2025 at 9:38 AM, the MDS Nurse stated Resident #31's quarterly MDS with an ARD of 01/23/2025 was completed on 02/06/2025 and was not submitted until 03/04/2025 (26 days after the assessment completion date). She stated the status of export ready meant the assessment was locked and ready to be submitted but had not yet been sent over or transmitted to CMS. 8. Resident #79's electronic medical record revealed a quarterly MDS with an Assessment Reference Date (ARD) of 01/10/2025 had a status of Export Ready. The screen did not indicate the assessment completion date. During an interview on 03/06/2025 at 9:38 AM, the MDS Nurse stated Resident #79's quarterly MDS with an ARD of 01/10/2025 was completed on 01/24/2025 but was not submitted until 03/04/2025 (39 days after the assessment completion date). She stated the status of export ready meant the assessment was locked and ready to be submitted but had not yet been sent over or transmitted to CMS. 9. Resident #88's MDS transmission revealed a quarterly MDS with an Assessment Reference Date (ARD) of 01/17/2025 had a status of Export Ready. The screen did not indicate the assessment completion date. During an interview on 03/06/2025 at 9:38 AM, the MDS Nurse stated Resident #88's quarterly MDS with an ARD of 01/17/2025 was completed on 02/12/2025 but was not submitted/accepted until 03/04/2025 (20 days after the assessment completion date. She stated the status of export ready meant the assessment was locked and ready to be submitted but had not yet been sent over or transmitted to CMS. During the interview on 03/06/2025 at 9:38 AM, the MDS Nurse discussed her experience, training, and process with the facility's MDS assessments. She stated she had been working at the facility since 01/27/2025. She indicated she was aware there were a lot of MDSs that were late or not completed and had been told it was due to gaps in MDS Coordinators. The MDS Nurse stated she was receiving her training from the corporate office and Directors of Nursing and MDS Coordinators from other facilities, all while trying to create and maintain a current MDS schedule going forward. She stated she had been trying to work on the late or incomplete assessments little by little while doing the assessments that were currently due. For scheduling of the MDSs and to know what type of MDS to complete next, she stated she was relying on the facility's electronic medical record software to guide her. During an interview on 03/06/2025 at 2:48 PM, the Director of Nursing (DON) stated she had been employed as the DON since 11/16/2024. She stated when she became the DON, there was a registered nurse (RN) in the role of MDS Coordinator who locked and submitted her own assessments. The new MDS Nurse was a licensed vocational nurse (LVN), so when she was finished with the assessments, she asked the DON to sign and lock them for her. The DON stated she was not made aware of any MDSs that were not complete or not sent in. She stated the prior MDS Coordinator left in January of 2025, and the new MDS Nurse started at the end of January 2025. She stated she was notified just the previous week that she would need to sign and lock the MDSs going forward; however, she was not made aware that she needed to sign assessments that were completed prior to the new MDS person starting. The DON stated she was new to the process and was learning with the new person what to do. She could not state how to check which MDSs were due or which MDSs needed to be completed. She stated the MDS Nurse was still new and was still learning, but her expectation was that the facility stay up to date with the MDS assessments. During an interview on 03/07/2025 at 9:32 AM, the Administrator stated he had started with the company in November of 2023. He stated his expectation was for the MDS to be transmitted timely within 14 days. He indicated the facility should follow the MDS schedule and the RAI Manual. 35314 Based on record review, interview, facility policy review, and review of the Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and (&) Medicaid Services (CMS) system within 14 days after the assessments were completed for 9 (Residents #15, #31, #33, #41, #55, #60, #71, #79, and #88) of 22 sampled residents reviewed for resident assessment. Findings included: A facility policy titled, MDS Completion and Submission Timeframes, released 01/2018, indicated, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy also specified, 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QiES [Internet Quality Improvement and Evaluation System] Assessment Submission and Processing (ASAP) System in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual (RAI). The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, effective 10/2024, indicated, The MDS must be transmitted (submitted and accepted into iQIES) electronically no later than 14 calendar days after the MDS completion date [Item #] (Z0500B + 14 calendar days). 1. Resident #41's electronic medical record Minimum Data Set (MDS 3.0) Summary screen revealed a quarterly MDS with an Assessment Reference Date (ARD) of 01/17/2025 was completed on 01/31/2025 but was not transmitted and accepted until 03/04/2025 (33 days after completion). During an interview on 03/06/2025 at 9:38 AM, the MDS Nurse confirmed that Resident #41's MDS was completed on 01/31/2025 and locked/accepted by CMS on 03/04/2025. 2. Resident #55's electronic medical record Minimum Data Set (MDS 3.0) Summary screen revealed a quarterly MDS with an ARD of 01/24/2025 was completed on 02/07/2025 but was not transmitted and accepted until 03/04/2024 (26 days after completion). During an interview on 03/06/2025 at 9:38 AM, the MDS Nurse confirmed that Resident #55's MDS was completed on 02/07/2025 and locked/accepted on 03/04/2025. 49044 3. Resident #60's electronic medical record Assessment History screen revealed a quarterly MDS with an Assessment Reference Date of 01/25/2025 was accepted on 03/04/2025 (39 days after the assessment date). The screen did not indicate the completion date. During an interview on 03/06/2025 at 9:38 AM, the MDS Nurse stated for Resident #60, the quarterly MDS with an ARD of 01/25/2025 was completed on 02/08/2025 and was locked/accepted on 03/04/2025 (24 days after the assessment was completed). 52274 4. Resident #19's electronic medical record Minimum Data Set (MDS 3.0) Summary screen revealed a quarterly MDS with an Assessment Reference Date (ARD) of 01/22/2025 was completed on 02/05/2025 but was not locked and accepted by the CMS System until 03/04/2025 (27 days after the assessment completion date). During an interview on 03/06/2025 at 9:38 AM, the MDS Nurse confirmed Resident #18's quarterly MDS with an ARD of 01/22/2025 was completed on 02/05/2025 and not locked/accepted by CMS until 03/04/2025. 5. Resident #35's electronic medical record Minimum Data Set (MDS 3.0) Summary screen revealed a quarterly MDS with an Assessment Reference Date (ARD) of 01/23/2025 was completed on 02/06/2025 but was not locked/accepted by the CMS System until 03/04/2025 (26 days after the assessment completion date). During an interview on 03/06/2025 at 9:38 AM, the MDS Nurse confirmed Resident #35's quarterly MDS with an ARD of 01/23/2025 was completed on 02/06/2025 but was not locked/accepted by CMS until 03/04/2025. 6. Resident #49's electronic medical record Minimum Data Set (MDS 3.0) Summary screen revealed a quarterly MDS with an Assessment Reference Date (ARD) of 01/21/2025 was completed on 02/04/2025 but was not locked and accepted by the CMS System until 03/04/2025 (28 days after the assessment completion date). During an interview on 03/06/2025 at 9:38 AM, the MDS Nurse stated Resident #49's quarterly MDS with an ARD of 01/21/2025 was completed on 02/04/2025 and not locked/accepted by CMS until 03/04/2025.

Based on observation, interview, and document review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 17 (Rooms 6 through 11 and Rooms 17 through 27) of 43 resident rooms in the facility. Findings included: During an observation on 03/03/2025 at 9:52 AM, three residents resided in room [ROOM NUMBER], Rooms 8 through 11, and Rooms 17 through 27. The Client Accommodations Analysis dated 03/06/2025, revealed the following: - In room [ROOM NUMBER], there was 78.7 sq ft for each resident. - In room [ROOM NUMBER], there was 77.4 sq ft for each resident. - In room [ROOM NUMBER], there was 77.3 sq ft for each resident. - In room [ROOM NUMBER], there was 77.3 sq ft for each resident. - In room [ROOM NUMBER], there was 77.3 sq ft for each resident. - In room [ROOM NUMBER], there was 77.8 sq ft for each resident. - In room [ROOM NUMBER], there was 76.2 sq ft for each resident. - In room [ROOM NUMBER], there was 77.3 sq ft for each resident. - In room [ROOM NUMBER], there was 77.3 sq ft for each resident. - In room [ROOM NUMBER], there was 77.5 sq ft for each resident. - In room [ROOM NUMBER], there was 78.4 sq ft for each resident. - In room [ROOM NUMBER], there was 77.3 sq ft for each resident. - In room [ROOM NUMBER], there was 77.3 sq ft for each resident. - In room [ROOM NUMBER], there was 77.3 sq ft for each resident. - In room [ROOM NUMBER], there was 77.3 sq ft for each resident. - In room [ROOM NUMBER], there was 77.3 sq ft for each resident. - In room [ROOM NUMBER], there was 75.6 sq ft for each resident. During an interview on 03/07/2025 at 9:02 AM, the Director of Nursing stated she expected that the residents have as much room as needed in their room and for the facility to request the waiver for any rooms that did not meet the requirements. During an interview on 03/07/2025 at 9:30 AM, the Maintenance Director acknowledged the facility did have 17 resident rooms that were less than the required square footage, there was a waiver for those rooms, and three residents resided in each of the 17 rooms. During an interview on 03/07/2025 at 9:57 AM, the Administrator acknowledged the facility did have rooms that did not meet the required square footage.

Based on observation, interview and record review, the facility failed to ensure the interventions indicated in the plan of care were being provided by the nursing staff for Resident 1 in accordance with professional standards of practice for one of four sampled residents (Resident 1), when Resident 1 ' s splint and finger sleeve was not available for Resident 1. This failure failed to meet the medical needs of Resident 1 and had the potential to contribute to contractures (perment tightenting of joints that casues stifness) Resident 1 ' s right hand. Findings: During a review of Resident 1's Admission Record (AR) (document containing resident demographic information and medical diagnosis), dated 1/27/25, the AR indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included but are not limited to .TYPE 1 DIABETES MELLITUS WITH UNSPECIFIED DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) .ESSENTIAL PRIMARY HYPERTENSION (HTN-high blood pressure) .STIFFNESS OF RIGHT HAND, NOT ELSEWHERE CLASSIFIED PAIN IN JOINTS OF RIGHT HAND (discomfort in a joint) . OTHER MUSCLE SPASMS (occur when your muscle involuntarily and forcibly contracts uncontrollably and can't relax) During a review of Resident 1's Admission MDS assessment, dated 12/14/24, the Admission MDS assessment indicated, Resident 1's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation, and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had no cognitive impairment. During a concurrent observation and interview on 1/27/25 at 4:10 p.m., with Licensed Vocational Nurse (LVN) 1, Residents 1 was observed sitting on his bed while in his room. Resident 1 did not have a finger sleeve on his right index finger or a splint on his right hand. LVN 1 stated Resident 1's sleeve and splint should have been applied. LVN 1 stated if the splint is indicated in the care plan the intervention should be done. During a concurrent interview and record review on 1/27/25 at 4:25 p.m., with LVN 1, Resident 1 ' s care plan dated 9/20/24 was reviewed. LVN 1 stated interventions indicate .Date initiated 09/20/2024 .Monitor for placement of elastic finger sleeve to amputated [right] index finger . Wrist extension splinting, and finger extension pan with wrist flexion and finger extension with progressive wrist extension splinting . LVN 1 stated staff failed to provide items listed on care plan interventions. LVN 1 stated failing to do so placed Resident 1 at risk for potential contractures to his right hand. LVN 1 stated staff failed to follow interventions for the right hand after Resident 1 ' s right index finger amputation. During a concurrent interview and record review on 1/27/25 at 4:39 p.m., with Licensed Vocational Treatment Nurse (LVN Tx) , Resident 1 ' s care plan dated 9/20/24 was reviewed. LVN Tx stated she was the nurse who placed the interventions in the care plan but did not indicate stop dates on interventions or communicate to staff the interventions put in place. LVN Tx stated Resident 1's splinting apparatus was ordered but never received and there was no follow up to ensure Resident 1 ' s plan of care was implemented. LVN Tx stated nursing staff failed to follow plan of care and interventions. During an interview on 1/27/25 at 5:12 p.m., with the Administrator (ADM), the ADM stated his expectations are that all residents care plans and orders should be followed. ADM stated nursing staff failed to follow policies according to care plans as well as their job descriptions for their nursing responsibilities. During a concurrent interview and record review on 2/5/24 at 1 p.m., with the Director of Nurses (DON), Resident 1 ' s care plan dated 9/20/24 was reviewed. The DON stated all nursing staff are responsible to follow physian orders and interventions placed in care plans. The DON stated it is her expectations that orders and interventions are followed.The DON stated staff were not following care plan interventions for Resident 1. The DON stated there was confusion on the splinting and everyone failed to follow up on ordering the apparatus in order to provide Resident 1 the appropriate splinting required and to screen Resident 1 by the therapy department. The DON stated it was everyone ' s responsibilities to work as a team in order to meet the needs of the resident and follow the interventions post amputation of his right index finger and they failed to do so. A review of the facility policy and procedure, titled, Care Plans, Comprehensive Person-Centered, dated Jan. 2018, indicated .The comprehensive, person-centered care plan will: include measurable objectives and timeframes; describe the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being . build on residents strengths . reflect treatment goals, timetables and objectives in measurable outcomes .identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. A review of the facility policy and procedure, titled, Activities of Daily Living (ADL ' s), Supporting, dated Jan. 2018, indicated .Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical conditions demonstrate that the diminishing ALDs are unavoidable .appropriate care and services will be provided for residents who are unable to carry out ADLs independently .Care and services to prevent and/or minimize functional decline will include appropriate management . A review of the facility Human Resource Manual Job Description for the LVN Tx. Nurse, titled Licensed Vocational Nurse sign and dated 8/13/2018, indicated .Responsibilities .Care planning . contributes to establishing individualized patient goals .assists in developing interventions to achieve goals . implements the plan of care . evaluates effectiveness of interventions to achieve patient goals and minimize re-hospitalization s . participates in review and revision of plan of care . communicates pertinent date to RN and or physician . documents accurately and thoroughly .

Based on interview, record review, and observation, the facility failed to ensure sufficient preparation and orientation for a safe and orderly discharge from the facility for one of one sampled resident (Resident 1) when the facility planned to discharge Resident 1, a [AGE] year-old female with medical and physical needs, to a homeless shelter. This failure resulted in emotional stress, increased anxiety, an increase in antipsychotic medication (used to treat mental health disorders), and near daily episodes of mood swings as evidenced by angry outbursts from Resident 1 and potential for an unsafe discharge. Findings: During a review of Resident 1 ' s Admission Record (AR), dated 8/6/24, the AR indicated Resident 1 was a [AGE] year-old female admitted to the facility six years ago. Resident 1 ' s diagnoses included Multiple Sclerosis (MS, a chronic neurological disorder), Type 2 Diabetes Mellitus (chronic condition regarding the inability to control blood sugar), Chronic Obstructive Pulmonary Disease (COPD, a condition caused by damage to the airways), Hypertension (high blood pressure, when the force of the blood pushing against the walls of the blood vessels is too high), Generalized Anxiety Disorder (persistent feeling of anxiety or dread), Bipolar Disorder (mental illness that causes unusual shifts in a person ' s mood, energy, activity levels, and concentration), Major Depressive Disorder (mood disorder, causing severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working), Glaucoma (eye disease that gradually deteriorates vision), Hyperlipidemia (too much cholesterol, a waxy, fat-like substance, in the blood, Hypothyroidism (thyroid gland does not produce enough hormones which are used to regulate several body functions), Muscle Weakness, Edema (an accumulation of excess fluid in the body), Pain, Abnormalities of gait and mobility (difficulties with walking and getting from place to place), and Suicidal Ideations (thoughts of ending one ' s life). During a review of Resident 1 ' s Order Summary Report (OSR), dated 8/6/24, the OSR indicated Resident 1 had physician ' s orders that included: quetiapine twice a day (antipsychotic medication used to regulate chemicals in the brain), clonazepam four times a day (an anti-anxiety medication), oxygen to be administered via nasal canula (through a tube inserted into Resident 1 ' s nose), ipratropium-albuterol four times a day, inhaled from a nebulizer (a machine that requires electricity and turns the liquid medication into a fine mist), insulin aspart, (a hormone that helps regulate blood glucose levels, injected by a needle and syringe into the fatty tissue of the body), insulin glargine every night at bedtime - (a long-acting insulin), lisinopril (medication used to lower blood pressure), tramadol (a pain reliver for moderate to moderately severe pain), baclofen (a muscle relaxer), gabapentin (used to relieve pain by changing the way pain is perceived in the brain), furosemide (used to make the body get rid of extra fluid through the kidneys and increases urination), levothyroxine (a thyroid gland hormone replacement). During a review of Resident 1 ' s Progress Notes (PN), dated 6/26/24, at 2:55 PM, the PN indicated the facility had [R]eceived email from . residents insurance, stating they will no longer cover her stay beyond July 31st [2024]. SSD [Social Services Director] notified resident and asked her what her income was, resident stated I have a headache and I can not talk about this right now. During a review of a follow-up email from Resident 1 ' s insurance provider, dated 7/3/24, at 2:44 PM, and addressed to the facility ' s SSD, the email indicated Resident 1 . does not have needs that require this level of care [care required by a Skilled Nursing Facility] . the member is appropriate to discharge to a lower level of care. During a review of Resident 1 ' s PN dated 7/15/24, at 2:40 PM, the PN indicated, SSD found a place for [Resident 1 to] rent. SSD presented information to resident. SSD reminded her d/c [discharge] is coming up at the end of this month. During a review of Resident 1 ' s PN dated 7/16/24, at 10:11 AM, the PN indicated, the SSD had located a room and board facility for the resident. The PN indicated, SSD will present information to the resident. During a review of Resident 1 ' s PN dated 8/2/24, at 2:55 PM, the PN indicated a Licensed Vocational Nurse (LVN) . monitored [Resident 1 ' s oxygen saturation without the use of oxygen. [Oxygen saturation] steadily declined and after around 20 minutes [Resident 1 ' s oxygen saturation] dropped to 87[%]. During a review of Resident 1 ' s PN dated 8/5/24, at 12:54 PM, the PN indicated, SSD and DON [Director of Nursing] went to speak with resident to confirm discharge plans for 8/6/24. SSD and DON reminded resident that resident does have safe discharge tomorrow, SSD secured a bed for resident at [name of a shelter]. Resident stated, I am not leaving tomorrow. SSD spoke with [Resident 1 ' s insurance provider agent] to notify that resident has a safe discharge location and is refusing to discharge tomorrow. During a review of Resident 1 ' s Notice of Transfer/Discharge (NTD), dated 8/5/24, the NTD indicated Resident 1 was given a 30-day notice that she was to be discharged from the facility to [name of shelter], a homeless shelter located at [address of shelter], on 9/4/24. The NTD indicated Resident 1 refused to sign the document. During a review of the website for above named shelter in the discharge, at https://turlockgospelmission.org, the website indicated the facility Helps the Homeless and Hurting, and Services Provided - A Warm Bed, Clothing & Hygiene, Cooling and Warming Shelter, Meal Services, Case Management, Community Service and Diversion Services Opportunities, A safe environment during the day .a positive alternative to the parks. During a review of Resident 1 ' s PN dated 8/5/24, at 4:33 PM, the PN indicated, SSD, joined by DON, issued resident 30 day notice for discharge [due to] Residents health has improved sufficiently that the resident no longer needs the services provide by this facility. Resident has until 9/4/24 to cooperate with SSD for discharge. Resident refused to sign notice. SSD and DON signed notice at witnesses. During a concurrent observation and interview on 8/6/24, at 10:50 AM, with Resident 1, in her room at the facility, Resident 1 was a female who appeared her age, lying in her bed, a wheelchair was bedside. Resident 1 was receiving supplemental oxygen delivered to her nose through a tube connected to an oxygen concentrator. Noted on her bed was a nebulizer machine for her prescribed breathing treatments. Resident 1 had many possessions near her bed. Resident 1 stated she was very upset about the 30-day discharge to a homeless shelter. Resident 1 stated she has never been homeless before. Resident 1 stated the nursing staff give her breathing treatments four times a day and perform blood glucose checks four times day. Resident 1 stated the facility planned to switch her insulins to oral medication for her diabetes, and stated, How is that going to work? Resident 1 stated she could transfer herself from her bed to her wheelchair, to the toilet and back again, but that was all, can could not walk outside of her room. Resident 1 stated, I have MS. Throughout the interview, Resident 1 appeared anxious, wringing her hands, spoke with pressured and halting speech, moving head from side-to-side, often placing her hands up in the air in a gesture of frustration, and at times seemed near tears. During an interview on 8/6/24, at 11:10 AM, with the SSD, the SSD stated Resident 1 was issued a 30-day notice yesterday, she has until 9/4/24. She would be financially responsible for costs after 8/31/24. [Resident 1 ' s health insurance] denied her because they reviewed her MDS [a comprehensive, standardized assessment tool], showed member is overall high functioning, independent with ADLs [activities of daily living], continent [able to use the toilet], no wound, [assessment screening] negative for serious mental illness. No behaviors or wandering. [name of shelter] is a homeless shelter. [Resident 1] told ombudsman that she used to be homeless, so that is where her current discharge location is. The SSD stated she was aware Resident 1 has been a resident of this facility continuously for the last six years and was admitted to the facility in August 2018. The SSD stated, The Ombudsman told me she had been homeless before admission here, but [Resident 1] doesn ' t really talk to me much anymore. Home health would follow her at homeless shelter, 3 or 4 times a week. I recommended to [Resident 1] she consider switching to oral diabetic agents. But no physician has ordered this. If she were to be discharged , nursing staff would teach her how to do her own [blood glucose monitoring], self-administer her meds. She would be discharged to homeless shelter with a portable oxygen concentrator. All the medications would be sent with her. She would self-medicate with that. I don ' t know if she self-medicates now. During an interview 8/6/24, at 10:20 AM, with the DON, the DON stated she was aware Resident 1 was prescribed many different medications, including continuous oxygen, blood glucose monitoring with insulin injections four times a day. The DON stated, I think she can do it herself at the homeless shelter. We can train her to [administer all her medications]. I understand she has been her for six years. During an interview on 8/6/24, at 1:30 PM, with Resident 1, Resident 1 stated she feels like she has been in a cognitive decline. I ' m not as sharp as I used to be. During an interview on 8/6/24, at 1:45 PM, with Resident 1 ' s Family Member (FM 1), FM 1 stated Resident 1 was never homeless. FM 1 stated she talks to Resident 1 frequently and Resident 1 is very stressed out over this. She is overwhelmed. During an observation and interview on 8/6/24, at 2:05 PM, in Resident 1 ' s room, with Resident 1, the DON, and the SSD, Resident 1 was noted to be anxious and upset, tearful, appearing short of breath. The SSD and DON were discussing with Resident 1 an updated discharge plan that did not include a homeless shelter. When asked if they thought Resident 1 was anxious and distraught during the conversation, the DON and SSD nodded their heads and stated, Yes. During a review of Resident 1 ' s Medication Administration Record (MAR) for June 2024, the MAR indicated Resident 1 had a physician ' s order for quetiapine, dated 1/24/23, in the amount of 75 mg to be given every evening at bedtime. The MAR indicated on 6/29/24, the facility nursing staff began to monitor Resident 1 every shift for mood swings as evidence by angry outbursts. The MAR indicated Resident 1 received 120 blood glucose checks during the month and required insulin 119 times. During a review of Resident 1 ' s MAR for July 2024, the MAR indicated on 7/24/24, Resident 1 had a physician ' s order to increase her quetiapine dose to include an additional 25 mg to be given every morning. The MAR indicated that on 7/30/24, the 25 mg morning dose of quetiapine was doubled to 50 mg to be given every morning, for a total of quetiapine 50 mg every morning, and quetiapine 75 mg to be given every evening. The MAR indicated Resident 1 was documented to have begun having mood swings as evidence by angry outbursts on 7/24/24, and continued on 7/25/24, 7/26/24, 7/27/24, 7/28/24, 7/30/24, and 7/30/24 (some days having multiple episodes). The MAR indicated Resident 1 received 124 blood glucose checks during the month and required insulin 124 times. During a review of Resident 1 ' s PN dated 7/30/24, at 10:21 AM, the PN indicated Resident 1 was seen by a Nurse Practitioner on 7/29/24. The PN indicated the facility ' s Interdisciplinary Team (usually comprised of facility staff representing nursing, social services, dietary, and activity departments) recommended increasing Resident 1 ' s [morning] dose of quetiapine to 50 mg, and resident had [history] of bipolar and experiences sudden mood swings. During a review of Resident 1 ' s MAR dated through 8/23/24, the MAR indicated Resident 1 was documented to have mood swings as evidence by angry outbursts on 8/1/24, 8/2/24, 8/3/24, 8/6/24, 8/7/24, 8/8/24, 8/9/24, 8/12/24, 8/14/24, 8/15/24, 8/16/24, 8/17/24, 8/18/24, 8/19/24, 8/22/24 (some days having multiple episodes). The MAR indicated Resident 1 received 86 blood glucose checks from 8/1/24 to 8/23/24 and required insulin 84 times. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized, comprehensive assessment tool), dated 6/11/24, the MDS indicated at Question C500 - Brief Interview for Mental Status, a score of 15 out of a possible 15, which indicated Resident 1 was cognitively intact. During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated at Question GG0170 FF - Tub/Shower transfer: The ability to get in and out of a tub/shower, a score of 1, which indicated Resident 1 required a Helper who does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required to complete the activity. During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated at Question GG 0170 J - Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns, a score of 6, which indicated Resident 1 was Independent - Resident completes the activity by themselves with no assistance from a helper. During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated at Question GG 0170 K - Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space, a score of 6, which indicated Resident 1 was Independent - Resident completes the activity by themselves with no assistance from a helper. During a concurrent interview and record review on 8/13/24, at 10:23 AM, with the DON, Resident 1 ' s MDS dated [DATE] was reviewed. The DON stated she knew Resident 1 could walk in her room, but I don ' t know about 50 or 150 feet. I don ' t know why it was coded that way. During an interview on 8/15/24, at 9:45 AM, with Resident 1, Resident 1 stated, I ' ve not walked up and down the hallway in years. I can walk a little bit from the wheelchair to the bathroom, and I need oxygen to do that. I ' ve never walked up and down the hallway ever since I ' ve been here. I need help showering and getting dressed. I can ' t do my hair or nothing. I can get from my bed to my wheelchair myself. During an interview on 8/23/24, at 9:06 AM, with the Medical Records Director (MRD), the MRD stated she has known Resident 1 for many years. The MRD stated, I ' ve not seen her walk outside her room, not in hallway, no. No, honestly, I have not. During an interview on 8/23/24, at 9:25 AM, with the DON, the DON stated, I ' ve not seen her walk 50 feet with two turns, or 150 feet, only in her room. During an interview on 8/23/24, at 9:40 AM, with Registered Nurse (RN) 1, RN 1 stated she has worked at the facility for six years and was familiar with Resident 1. RN 1 stated, I ' ve never seen her walk in hallway, only in wheelchair. I ' ve only seen her walk in her room. She ' s been like that for the whole 6 years she ' s been here. During an interview on 8/23/24, at 9:45 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated she has worked at the facility or 3 years and was familiar with Resident 1. CNA 1 stated, Resident 1 only walks in her room, not in the hallway. Maybe 10-20 feet in room. Always been like that, for the 3 years I ' ve been here. Sometimes she bathes herself, but usually we help her. One person needs to be with her at all times, she may fall or slip. One person with her at all times while she bathes, for safety. Once in the shower room, she can mostly bathe herself, but she does need help with her hair. During an interview on 8/23/24, at 9:50 AM, with CNA/Restorative Nursing Assistant (CNA/RNA), the CNA/RNA stated she has worked at the facility for about seven years and was familiar with Resident 1. CNA/RNA stated, I ' ve only seen [Resident 1] walk in her room. From bed to closet to bathroom. Never in hallway. She ' s never walked in hallway since I ' ve been here. During an interview on 8/29/24, at 12:37 PM, with the [NAME] County Ombudsman, the Ombudsman stated she recalled talking with Resident 1 and the facility about ever having a history of homelessness. The Ombudsman stated Resident 1 ' s information conflicted and was unsure if Resident 1 was ever homeless or not. During a concurrent interview and record review on 8/29/24, at 1:03 PM, with the DON, Resident 1 ' s MARs dated 6/24, 7/24, and 8/24, were reviewed. The DON verified the documentation as accurate.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) had an accurate Minimum Data Set Assessment (MDS, a set of comprehensive, standardized assessments), when her MDS assessment dated [DATE] was not accurate. This failure had to potential to affect the care and facility placement of Resident 1. Findings: During a review of Resident 1 ' s Admission Record (AR), dated 8/6/24, the AR indicated Resident 1 was a [AGE] year-old female admitted to the facility six years ago. During a review of an email from Resident 1 ' s insurance provider, dated 7/3/24, at 2:44 PM, and addressed to the facility ' s Social Services Director, the email indicated Resident 1 . does not have needs that require this level of care [care required by a Skilled Nursing Facility] . the member is appropriate to discharge to a lower level of care. During a review of Resident 1 ' s Progress Notes (PN), dated 8/5/24, at 4:33 PM, the PN indicated, SSD, joined by DON [Director of Nursing], issued resident 30 day notice for discharge [due to] Residents health has improved sufficiently that the resident no longer needs the services provide by this facility. During an interview on 8/6/24, at 11:10 AM, with the SSD, the SSD stated Resident 1 was issued a 30-day notice yesterday, she has until 9/4/24. [Resident 1 ' s health insurance] denied her because they reviewed her MDS which showed [Resident 1] is overall high functioning, independent with ADLs [Activities of Daily Living]. The SSD stated she was aware Resident 1 was admitted to the facility in August 2018 and has been a resident of this facility continuously for the last six years. During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated at Question GG 0170 Mobility - J - Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns, a score of 9, which indicated Not applicable - Not attempted and the resident did not perform his activity prior to the current illness, exacerbation [worsening] or injury[.] During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated at Question GG 0170 Mobility - K - Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space, a score of 9, which indicated Not applicable - Not attempted and the resident did not perform his activity prior to the current illness, exacerbation [worsening] or injury[.] During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated at Question GG 0170 Mobility - J - Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns, a score of 6, which indicated Resident 1 was Independent - Resident completes the activity by themselves with no assistance from a helper. During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated at Question GG 0170 Mobility - K - Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space, a score of 9, which indicated Not applicable - Not attempted and the resident did not perform his activity prior to the current illness, exacerbation [worsening] or injury[.] During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated at Question GG 0170 Mobility - J - Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns, a score of 6, which indicated Resident 1 was Independent - Resident completes the activity by themselves with no assistance from a helper. During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated at Question GG 0170 Mobility - K - Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space, a score of 6, which indicated Resident 1 was Independent - Resident completes the activity by themselves with no assistance from a helper. The MDS dated from 12/19/23 to 6/11/24 indicated an significant improvement in Resident 1 ' s ability to walk 50 feet with two turns, and to 150 feet. During a concurrent interview and record review on 8/13/24, at 10:23 AM, with the DON, Resident 1 ' s MDS dated [DATE] was reviewed. The DON stated she knew Resident 1 could walk in her room, but I don ' t know about 50 or 150 feet. I don ' t know why it was coded that way. During a concurrent interview and record review on 8/13/24, at 4:45 PM, with the MDS Consultant (MDS-C), Resident 1 ' s MDS dated [DATE], 3/18/24, and 6/11/24 were reviewed. The MDS-S confirmed the entries at Question GG 0170 Mobility - K and J. The MDS-C stated that after six years in the facility, a sudden improvement should have been verified by facility staff. During an interview on 8/15/24, at 9:45 AM, with Resident 1, Resident 1 stated, I ' ve not walked up and down the hallway in years. I can walk a little bit from the wheelchair to the bathroom, and I need oxygen to do that. I ' ve never walked up and down the hallway ever since I ' ve been here. I can get from my bed to my wheelchair myself. During an interview on 8/23/24, at 9:06 AM, with the Medical Records Director (MRD), the MRD stated she has known Resident 1 for many years. The MRD stated, I ' ve not seen her walk outside her room, not in hallway, no. 150 feet? How far is 150 feet? [Stated to the MRD that 150 feet was half a football field]. No, honestly, I have not. During an interview on 8/23/24, at 9:25 AM, with the DON, the DON stated, I ' ve not seen [Resident 1] walk 50 feet with two turns, or 150 feet, only in her room. During an interview on 8/23/24, at 9:40 AM, with Registered Nurse (RN) 1, RN 1 stated she has worked at the facility for six years and was familiar with Resident 1. RN 1 stated, I ' ve never seen her walk in hallway, only in wheelchair. I ' ve only seen her walk in her room. She ' s been like that for the whole 6 years she ' s been here. During an interview on 8/23/24, at 9:45 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated she has worked at the facility or 3 years and was familiar with Resident 1. CNA 1 stated, Resident 1 only walks in her room, not in the hallway. Maybe 10-20 feet in room. Always been like that, for the 3 years I ' ve been here. During an interview on 8/23/24, at 9:50 AM, with CNA/Restorative Nursing Assistant (CNA/RNA), the CNA/RNA stated she has worked at the facility for about seven years and was familiar with Resident 1. CNA/RNA stated, I ' ve only seen [Resident 1] walk in her room. From bed to closet to bathroom. Never in hallway. She ' s never walked in hallway since I ' ve been here. During a concurrent interview and record review on 8/23/24, at 11:30 AM, with the DON, Resident 1 ' s MDS dated [DATE], Question GG 0170 Mobility - K and J was reviewed. The DON stated, It can be an error. I will check with the data and if it is not accurate, we will do a correction.

Based on observation, interview and record review, the facility failed to follow the policy and procedure titled, Hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) Program for one of three sampled residents (Resident 1) when the facility failed to collaborate with the facility and hospice provider regarding Resident 1 ' s request to receive HIV (human immunodeficiency virus - virus that attacks cells that help the body fight infection) treatment. This failure resulted in Resident 1 not receiving HIV treatment and increasing his chances of weakened immunity (protecting the body against an infectious). Findings: During an interview on 5/7/24 at 2:00 p.m. with Family (FM 1), FM 1stated that the facility informed him that hospice was responsible to provide HIV medication. FM 1 stated when he spoke to hospice they informed him that the facility was responsible to provide the HIV medication and that there was no reason that he couldn ' t receive it. During a concurrent interview and record review on 5/7/24 at 2:52 p.m. with Registered Nurse (RN) 1 Resident 1 ' s Admission Record (document containing resident demographic information and medical diagnosis) undated was reviewed. The admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis included HIV. RN 1 stated Resident 1 has had the diagnosis of HIV since 2017. RN 1 stated that Resident 1 was currently not receiving any medication for HIV. RN 1 stated that Resident 1 ' s father had told him that Resident 1 wanted HIV treatment. RN 1 stated he had not called the primary physician to inform him of Resident 1 ' s request for HIV treatment. RN 1 stated the Director of Nurses (DON) told him that hospice needed to provide HIV treatment. During a telephone interview on 5/7/24 at 2:56 p.m. with hospice Director of Patient Care Services (DPS), DPS stated Resident 1 was eligible to receive HIV treatment. DPS stated the facility has not reached out to them regarding Resident 1 ' s request for HIV treatment. During an interview on 5/7/24 at 3:18 p.m. with the DON, the DON stated the hospice and the facility had to collaborate with each other when prescribing medications. The DON stated that a hospice nurse caring for Resident 1 informed the facility that Resident 1 was not able to receive HIV treatment unless he was taken off hospice care. The DON stated the facility has not collaborated with Resident 1 ' s primary physician and hospice physician in regard to Resident 1 ' s request to receive HIV treatment. The DON stated she has not called Resident 1 ' s primary physician because she assumed that he will instruct them to call the hospice physician since hospice would be the one to prescribe the medication. During a concurrent observation and interview on 5/7/23 at 3:47 p.m. with Resident 1, in Resident 1 ' s room, Resident 1 was seated his wheelchair. Resident 1 stated he would like treatment for HIV but the facility was not providing him medication. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment scored was 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a review of the facility P&P titled Hospice Program, dated 1/20178 , the P&P indicated, in general, it is the responsibility of the facility to meet the resident ' s personal care and nursing needs and coordination with the Hospice representative, and ensure that the level of care provided is appropriately based on the individual resident ' s needs . Administering prescribed therapies, including those therapies determined appropriate by the Hospice and delineated in the Hospice plan of care . ensuring that the LTC [long term care] facility communicates with the Hospice medical director, the resident ' s attending physician, and other practitioners participating in the provision of care to the resident as needed to coordinate the Hospice care with the medical care provided by other physicians . During a review of the professional reference titled HIV Treatment dated 11/21/23 found at https://www.cdc.gov/hiv/basics/livingwithhiv/treatment.html#:~:text=If%20you%20skip%20your%20HIV,stay%20healthy%20and%20protect%20otherswas reviewed. The professional reference indicated, What are the benefits of taking my HIV treatment as prescribed? . HIV treatment reduces the amount of HIV in the blood . If you skip your HIV treatment, even now and then, you are giving HIV the chance to multiply rapidly. This could weaken your immune system, and you could become sick .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) maintained acceptable parameters of nutritional status when the Registered Dietitian (RD) was not notified of Resident 1's weight loss of 6.8 pounds (9.6%) in 3 weeks and by mouth (PO) intake was 60% to obtain recommendations to prevent unplanned and further weight loss. As a result of this failure, Resident 1's compromised nutritional status was not addressed which had the potential to lead to further medical complications. Findings: During a review of Resident 1's Admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included hypertension (high blood pressure), long term use of insulin (controls amount of sugar in the body) and muscle weakness. During a review of the facility document titled, Weights and Vitals Summary (WVS), dated 4/29/24, indicated the following weights and comparisons for Resident 1: 1/16/24 159.28.2 lbs (pounds., unit of measurement) 1/21/24 158.4 lbs 1/30/24 151.6 lbs 2/4/24 144 lbs (-5.0% change [comparison weight 1/16/24, 195.3 lbs, - 9.6%, -15.3 lbs] -7.5% change [comparison weight 1/16/24, 159.3 lbs, -9.6%, -15.3 lbs] 2/12/24 137.8 lbs (10.0% change [comparison weight 1/16/24, 159.3 lbs, -13.5%, 21.5 lbs] -5.0% change [comparison weight 1/16/24, 159.3 lbs, -13.5%, -21.5 bs] During a review of the facility document titled Order Summary Report (OSR), dated 1/17/24 indicated, NAS [no added salt], CCHO [Controlled Carbohydrate Diet (CCHO - a diet for people with diabetes (disorder in which the body does not produce enough or respond normally to insulin [hormone that regulates the amount of glucose in the blood], causing blood sugar (glucose) levels to be abnormally high) to help stabilize blood glucose levels [sugar in the blood]);] diet regular texture, regular liquids consistency. During a review of the Nutrition assessment dated [DATE], the RD documented the resident had risk for unintended weight loss, was a high nutrition risk and estimated needs were 1800 to 2150 calories, and 75 to 85 grams of protein per day. The RD documented the nutrition diagnosis was increased protein needs related to wound healing as evidenced by surgical wounds to right hip/thigh and diabetic ulcers to right and left knee/leg. The weight goal was weight maintenance. The RD inventions were to recommend: no added salt to current diet order and start a [brand name] wound healing supplement twice a day. During a concurrent telephone interview and record review on 5/17/24 at 10:03 a.m. with the RD, Resident 1' s Interdisciplinary (IDT) Weight Meeting dated 1/30/24 was reviewed. The IDT indicated, .Lost 6.8# in a week .Meal intake .in the last week 60% .Resident has a 6.8# weight loss in a week. PO [by mouth] intake is 60% he eats in his room and is able to feed himself .Continue to monitor weekly weights . The RD stated she completes monthly weight assessment no later than the 10th of every month. The RD stated she conducted her assessment on 2/7/24 with recommendations of sugar free health shakes to provide extra calories when she reviewed the weight report. The RD stated she was unaware of the IDT meeting on 1/30/24 and the continued weight loss. The RD stated if she was notified on 1/30/24 meeting she would have recommended the health shake at that time. The RD stated the facility conducted weekly weight meetings but she only attends the monthly meetings. The RD stated a wight change of 3 lb or 2% would trigger a review. The RD stated Resident 1 would need to eat 100% of his meals to meet his nutritional needs. During a review of Resident 1's percentage of meals eaten from 1/17/24 to 1/29/24, showed on average the resident ate 60% of meals, with 2 meals resident refused. During a review of Resident 1's RD Progress Note dated 2/7/24 indicted, .Significant weight loss of 15.3# 9.6% x 1 month .37% PO intake x 5 days .significant weight loss .possibly d/t [due to] variable to per PO intake .given poor PO intake, resident may benefit from health shakes and weekly weights x 4 weeks .Recommend 4 [ounce-unit of measure two times daily] between meals give recent weight loss (provides 400 kcal [kilocalorie-unit of measure]/12 [gram-unit of measure] protein . During a review of the facility Nutritional Breakdown of the menu, undated, indicated for the CCHO diet it provided 1994 calories and 96 grams of protein per day. During a telephone interview on 5/17/24 at 11:01 with the Dietary Supervisor (DS), the dietary supervisor stated the IDT meetings were held weekly and monthly. The DS stated the RD was only present during the monthly meetings, the RD had access to review weights in the clinical record. The DS stated she was in the IDT weight meeting on 1/30/24 but did not notify the RD because the RD had access to review weights. The DS stated the weight IDT comprised of the Infection Prevention nurse, Social Service Director, Activity Director and herself. The DS stated the recommendation on 1/31/24 IDT meeting was to continue weekly weights because Resident 1 was a new admit, had recent surgery and was on antibiotics. During a concurrent telephone interview and record review on 5/17/24 at 11:04 a.m. with the Director of Nurses (DON), the facility policy and procedure (P&P) titled Weight Assessment and Intervention dated 03/2021 was reviewed. The policy indicated, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .The Dietitian will review the unit Weight Record to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether of not the criteria for significant weight change has been met . The DON stated the RD should be notified when there is a significant weight change. During a review of the American Academy of Family Physician journal, indicated .Elderly patients with unintentional weight loss are at higher risk for infection, depression and death .Involuntary weight loss can lead to muscle wasting, .depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year . (February 15, 2002/Volume 65, Number 4 www.aafp.org/afp American Family Physician)

Based on observation, interview, and record review, the facility failed to maintain a safe, comfortable and homelike environment for 62 of 74 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 69, 73, and 74) when the ambient (the surrounding area or environment) temperatures in resident rooms, including the main halls, and station one and two's medication room, reached 86.3 degrees Fahrenheit (F- unit of temperature) (safe and comfortable temperature is 71 to 81 degrees F) on 7/30/21 at 2:57 p.m. and continued to rise to 88.5 degrees F by 5:15 p.m. which affected Residents 1 through 37, Residents 39 through 48, Resident 59, Resident 69, and Residents 73 through 74. In the new wing of the building, the ambient room temperatures registered as low as 59 degrees F, which affected Residents 49 through 58 and Resident 60. The facility administration and nursing staff had previous knowledge of the excessive hot and cold temperatures and did not implement effective interventions to identify and address the unsafe and uncomfortable temperatures in the facility. These failures placed residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 59, 69, 73 and 74) at risk for dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake), heat related illnesses, compromised skin integrity and wound healing, reduced their ability to participate in their normal activities to preserve their highest practical physical, mental, and psychosocial well-being and resulted in unsafe storage of medications potentially affecting medication strength and stability and placed residents (Residents 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, and 60) in uncomfortable and unsafe cold temperatures. Because of the potential serious harm to residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 69, 73, and 74) related to excessive heat and heat related illnesses such as heat exhaustion (condition whose symptoms may include heavy sweating and a rapid pulse, a result of your body overheating), dehydration, heat stroke (a condition caused by your body overheating), hypothermia (the condition of having an abnormally low body temperature) and the failure to maintain safe and comfortable ambient temperatures in the facility, an Immediate Jeopardy (IJ) situation (a situation that involves immediate action to remove the threat of harm or potential harm) was called with a scope and severity K under 42 CFR §483.10(i)(6), F584 on 7/30/21 at 10:54 p.m. with the Facility Administrator (ADM), Director of Nurses (DON), and Clinical Director (CD). The facility was provided the IJ template which indicated the need to submit an acceptable written Plan of Removal that addressed the need for immediate action for the IJ situation. The facility submitted an acceptable IJ Plan of Removal (Version 3) on 7/31/21 at 8:30 pm., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1. Develop a monitoring tool and document room temperatures to ensure the ambient temperatures are safe, comfortable and within the required range (71 to 81 degrees F). 2. Immediately train and in-service staff for awareness of resident safety and comfortable temperature levels and signs and symptoms of heat stroke, heat exhaustion, dehydration, and/ or hypothermia. 3. Rounds (act of visiting each of a number of people or places)/monitoring of residents in the affected areas and document. 4. Immediately ensure the chillers (component of the heating, ventilation and air conditioning system that uses water or refrigerant to cool air)/cooling systems are professionally checked & maintained to ensure the system is functioning properly. 5. The facility needs to immediately implement measures to maintain the temperatures of 71 to 81 degrees F. The components of the IJ Plan of Removal were validated through observations, interviews, and record review. The IJ was removed on 8/1/21 at 4:58 p.m. with the facility ADM. Findings: During concurrent observation and interview on 7/30/21, at 2:15 p.m., at the facility entrance and visitor COVID-19 (an infectious respiratory illness) screening area, with the DON, the ambient temperatures in the screening area and adjacent (next to) hallways were hot and humid. Three high velocity industrial fans (heavy duty air circulating fan) and five portable air-cooling units (moveable device that cools air) located in the immediate hallways were in use. Wind from the circulating air and fan noise echoed through the hallway corridors. Notable in the hallways were three-drawer plastic storage containers, stocked with isolation gowns (protects the wearer from the splashing and soiling) at the entrance of each room. The DON stated every resident in the facility was on transmission-based precautions (help stop the spread of germs) after being exposed to staff who tested positive for coronavirus (germ that causes COVID-19 illness) and visitors were required to wear a respirator mask (disposable air filtering facepiece) and eye protection (face shield or goggles) while in the facility to minimize transmission (transfer of germs). The DON stated the facility was hot and fans and air-cooling units were placed in the hallways to cool temperatures. During an interview on 7/30/21, at 2:30 p.m., in the ADM's office, with the ADM, the ADM stated he worked for the facility since 7/1/21. The ADM stated the air-cooling units located in the hallways were portable swamp coolers (a device that cools air through the evaporation of water) that were implemented before he started (7/1/21). The ADM stated he encountered past complaints from residents regarding the facility's environment being stuffy, not hot. The ADM stated he instructed the Maintenance Supervisor (MS) and housekeeping staff to check the ambient temperatures and swamp coolers daily and add ice and water to the coolers as needed. The ADM stated temperatures in the facility should be maintained between 71 degrees F and 81 degrees F. During a concurrent observation and interview on 7/30/21, at 2:34 p.m., with Resident 40 and Resident 33, in the ADM's office, Resident 40 and Resident 33 abruptly entered the office. Resident 40 was tearful and yelled, It's so hot in here . I'm miserable . check our rooms, it's nice in here [ADM office] but not our rooms . they [administration] all go home . we're stuck here and have closed doors . I've never seen a fan . I came to this place and didn't plan for this. Resident 33 stated, [Resident 40]'s right . it's so hot I can't breathe . I have [CONDITION(S)] [[CONDITION(S)]- a long [MEDICATION(S)] inflammation of the lungs that blocks airflow]. Resident 40 stated multiple residents complained about the hot temperatures in the facility. Resident 40 stated, I've told everyone . and with the right index finger pointed at the ADM and stated, I told that man . him. During a review of Resident 40's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 6/1/21, the MDS assessment indicated, Resident 40 was cognitively intact with a Brief Interview for Mental Status (BIMS-an evaluation of attention, orientation, and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During a review of Resident 33's MDS assessment, dated 6/1/21, the MDS assessment indicated, Resident 33 had moderate cognitive impairment with a BIMS score of 9. During an interview on 7/30/21, at 2:41 p.m., with the MS, the MS stated he checked and documented ambient temperatures in the facility. The MS stated he checked temperatures at 10:30 a.m. every morning. The MS stated temperature checks included the hallways and common areas of the facility. The MS stated he did not check resident rooms as part of his daily routine. The MS stated nurses checked the ambient temperature in residents' rooms. During a review of the facility's Maintenance Log (Name of Facility), dated May 2021 and June 2021, the Maintenance Log indicated temperatures were taken in the facility's dayroom, dining room, men's hall, Cross Hall, PT [Physical Therapy] all, women's hall, and new wing. The Maintenance log did not include resident rooms. During concurrent observation and interviews on 7/30/21, at 2:57 p.m., in the medication room of station one and station two, with the MS and Licensed Vocational Nurse (LN) 1, LN 1 accessed the medication room. The ambient temperature in the medication room was hot and humid. LN 1 acknowledged the hot temperature and stated the facility was usually hot for the summer. LN 1 pointed to the analog tube thermometer (tube filled with liquid that expands as it gets hotter) on the wall in the medication room and stated nurses used the wall thermometer to check the temperature in the medication room. LN 1 stated, Look it's says the temperature is 86 degrees or 88 degrees [F]. The ambient room temperature was taken with the industrial infrared temperature gun (tool that can measure temperatures of an object from a distance and with no contact necessary). The ambient temperatures in the room ranged between 85.7 degrees F and 86.3 degrees F. LN 1 and the MS acknowledged the temperature registered on the infrared temperature gun was comparable to the analog thermometer on the medication's room wall and determined the temperatures registered on the infrared gun were accurate. LN 1 stated the medication room stored additional over the counter medications, nutritional supplements, and enteral tube feedings (special liquid food mixture containing protein, carbohydrates [sugar], fats, vitamins, and minerals, given through a tube into the stomach) prescribed for the residents. LN 1 stated excessive heat can ruin the medications and cause the medications to lose their effectiveness. LN 1 opened the cabinets in the medication room and itemized each medication, nutritional supplement, and nutritional product on the shelves. LN 1 stated the cabinets contained six bottles (100 tablets [pills] each) of acetaminophen (drug to relieve pain and reduce temperature) 325 milligrams (mg- unit of measurement of mass), four bottles (100 tablets each) of aspirin (drug to reduce inflammation) 325 mg, five bottles (100 tablets each) of [MEDICATION(S)] (reduce fever and inflammation and treat pain) 200 mg, two bottles (100 capsules [dissolvable gelatin container to hold medicine] each) of stool softener 250 mg, one bottle (200 tablets) of stool softener 100 mg, four bottles (60 tablets each) of stimulant (raises activity in the body) [MEDICATION(S)] (relieves constipation) 8.6 mg, three bottles (200 tablets each) [MEDICATION(S)] 8.6 mg, one bottle (96 caplets) of anti-diarrheal (control symptoms of diarrhea) medication 2 mg, five bottles (90 capsules each) of [MEDICATION(S)] (natural chemical substance that helps control and regulate activity in the body, including sleep) 5 mg, one box (110 pieces) of [MEDICATION(S)] (replacement to help stop the urge to smoke) 200 mg, one box (14 patches) [MEDICATION(S)] transdermal patch (medicated adhesive patch that is placed on the skin to deliver medicine) 7 mg, one 16 ounce (oz- a unit of capacity) bottle of liquid iron (a mineral important in making red blood cells, which carry oxygen around the body) 220 mg/(per) 5 milliliters (ml- unit of volume), four bottles (100 tablets each) of [MEDICATION(S)] sulfate (iron) 325 mg, three bottles (100 tablets each) of calcium [MEDICATION(S)] with Vitamin D (calcium [mineral] replacement), one bottle (100 tablets) of Vitamin D 125 (builds and maintain healthy bones) microgram (mcg- unit of mass)/ 400 international units (units- amount of a substance), one bottle (250 tablets) of [MEDICATION(S)] (helps to make new cells in the body, improved neurological [brain] function) 400 mcg, two bottles (100 tablets each) of [MEDICATION(S)] 1 mg, four bottles (100 tablets each) of Vitamin C (necessary for the growth, development, and repair of all body tissues) 250 mg, one bottle (100 tablets) of [MEDICATION(S)] (helps the body convert foods into energy) 100 mg, four bottles (120 capsules each) of Vitamin D3 (builds and maintain healthy bones) 25 mcg, one box (500 tablets) antacid (for heartburn and stomach upset) 420 mg, one bottle (100 tablets) of [MEDICATION(S)] (converts foods to energy, prevents cell damage) 500 mg, two bottles (100 capsules each) cranberry juice extract (helps prevent bladder infections) 425 mg, five- eight ounce boxes of Health Shake 1 (nutritional supplement), and eight- eight ounce boxes of Health Shake 2 (nutritional substance) prescribed to residents with diabetes (DM-long [MEDICATION(S)] illness in which the body cannot regulate blood sugar). During a professional reference review of Lexicomp (professionally recognized evidence-based online drug referential manual), last updated 8/10/21, the directions for the acetaminophen indicated, Storage/ Stability . oral formulations: Store at 20°C [Celsius-units of measurement] to 25°C (68°F- 77°F); avoid excessive heat (40°C [104°F] . Avoid high humidity . During a professional reference review of Lexicomp, last updated 8/9/21, the directions for aspirin indicated, Storage/ Stability . Store oral dosage forms (caplets, tablets, capsules) at room temperature; protect from moisture . Hydrolysis (chemical breakdown) of aspirin occurs upon exposure to water or moist air . During a professional reference review of Lexicomp, last updated 8/11/21, the directions for [MEDICATION(S)] indicated, Storage/ Stability .Tablet: Store at 20°C to 25°C (68°F to 77°F . During a professional reference review of Lexicomp, last updated 7/1/21, the directions for stool softener/ [MEDICATION(S)] medication indicated, Storage/ Stability . Tablet: Store at 20°C to 25°C (77°F); excursions (temperature outside of manufacturer's recommended ranges) are permitted between 15°C and 30°C (59°F- 86°F) . During a professional reference review of Lexicomp, last updated 8/6/21, the directions for anti-diarrheal medication indicated, Storage/ Stability . Store between 20°C to 25°C (68°F and 77°F) . During a professional reference review of Lexicomp, last updated 8/6/21, the directions for [MEDICATION(S)] indicated, Storage/ Stability . Store at room temperature . During a professional reference review of Lexicomp, last updated 8/3/21, the directions for liquid iron supplement indicated, Storage/ Stability . Room temperature .Protect from excessive heat . During a review of [product] manufacturer's guidelines for Storage and Directions for Use for Health Shake 1 and Health Shake 2, undated, the guidelines indicated, . Store in a cool dry place . [and] Best served chilled . During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, undated, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Medications requiring storage at room temperature are kept at temperatures ranging from 15°C (59°F) to 30°C(86°F) . Medication storage areas are kept . free of clutter and extreme temperatures . During a review of the facility's document titled, Refrigerator/ Med Room Temperature Log dated May 2021, the documented temperature readings for the AM (morning) and PM (afternoon) shift (24-hour period) on 5/4/21, 5/11/21, 5/12/21, 5/17/21, 5/21/21, 5/28/21, and 5/31/21 exceeded 77 degrees F. During a review of the facility's document titled, Refrigerator/ Med Room Temperature Log dated June 2021, the documented temperature readings for the AM and PM shift (24-hour period) on 6/1/21, 6/2/21, 6/6/21, 6/7/21, 6/8/21, 6/9/21, 6/10/21, 6/11/21, 6/12/21, 6/13/21, 6/15/21, 6/17/21, 6/18/21, 6/20/21, 6/21/21, 6/22/21, 6/23/21, 6/24/21, 6/25/21, 6/26/21, 6/27/21, 6/28/21, 6/29/21, and 6/30/21 exceeded 77 degrees F. During a review of the facility's document titled, Refrigerator/ Med Room Temperature Log dated July 2021, the documented temperature readings for the AM and PM shift (24-hour period) exceeded 77 degrees F each day, 7/1/21 through 7/30/21. During a review of the facility's document titled, Midnight Census Report dated 7/30/21, the census report indicated station one and station two housed 48 of 74 residents. Of the 48 Residents, 40 residents (Residents 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 17, 18, 19, 20, 21, 22, 23, 25, 26, 27, 29, 31, 32, 33, 34, 35, 37, 39, 40, 41, 42, 43, 44, 45, 69, 73, and 74) were prescribed medications and nutritional supplements stored in the medication room. During a review of Resident 1's Order Summary Report (OSR- a document that provides a list of all orders placed within specific time periods for a resident), dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [stool softener] 100 MG Give 1 capsule by mouth every 12 hours as needed Start date 3/24/20 . During a review of Resident 2's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [Health Shake] two times a day Give Sugar free . Start date 7/6/21 . During a review of Resident 3's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . Iron Tablet 325 (65Fe) MG ([MEDICATION(S)] Sulfate) give 1 tablet by mouth one time a day related to iron deficiency (shortage) .Start date .4/16/21 . During a review of Resident 4's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [Health Shake] with meals Start date 2/5/21 . [stool softener] 100 MG Give 2 tablet one time a day for Bowel Care Management related to constipation . Start date 8/5/20 . [[MEDICATION(S)]] Tablet 8.6 MG (Sennosides- used to treat constipation) Give 1 tablet by mouth one time a day for constipation . Start date 8/5/20 . During a review of Resident 5's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [stool softener] 100 MG Give 2 capsule by mouth one time a day related to Constipation Start date 5/23/21 . [MEDICATION(S)] sulfate 325 mg (65 Fe) Give 1 tablet by mouth one time a day for supplement . Start date 6/5/20 . [[MEDICATION(S)]] Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth one time a day for Bowel care Management related to Constipation . Start date 12/29/20 . During a review of Resident 7's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 .[MEDICATION(S)] Sulfate 325 (65 Fe) MG Give 1 tablet by mouth one time a day for supplementation Start date .1/21/21 . During a review of Resident 8's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [stool softener] 100 MG Give 1 tablet by mouth every 12 hours as needed for Constipation Start date 4/1/21 . [MEDICATION(S)] Tablet 1 MG Give 1 tablet three times a day for supplement . During a review of Resident 9's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [MEDICATION(S)] Sulfate [MEDICATION(S)] 220 (44Fe) MG/5ML Give 7.5 ml by mouth one time a day related to Iron Deficiency [CONDITION(S)] (condition in which the blood doesn't have enough healthy red blood cells) Start date 12/11/19 . [[MEDICATION(S)]] Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth at bedtime related to Constipation . Start date 7/7/19 . During a review of Resident 10's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [Health Shake] three times a day Give Sugar free health shake between meals Start date 8/25/20 . [[MEDICATION(S)]] Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth one time a day for Bowel Care Management related to Constipation . During a review of Resident 11's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [[MEDICATION(S)]] Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth two times a day for Bowel Care Management Start date 11/16/20 . During a review of Resident 12's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [stool softener] Capsule 250 MG Give 2 capsule by mouth one time a day for Bowel Care Management Start date 6/2/20 . During a review of Resident 13's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [stool softener] Capsule 250 MG Give 1 capsule by mouth one time a day for Bowel Care Management Start date 9/25/20 . [MEDICATION(S)] Sulfate Tablet 325 (65Fe) MG Give 1 tablet by mouth one time a day related to [CONDITION(S)] . start date 4/8/21 . During a review of Resident 15's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [Health Shake] with meals Give 4 oz health shake TID [three times a day] .Start date 5/31/21 . [stool softener] Tablet 100 MG Give 1 tablet by mouth one time a day related to constipation . Start date 6/11/21 . During a review of Resident 17's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [Health Shake] with meals Start date 6/7/21 . [stool softener] Capsule 250 MG Give 2 capsule by mouth one time a day for Bowel Care Management related to Constipation . Start date 5/30/20 . During a review of Resident 18's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [stool softener] Capsule 100 MG Give 1 capsule by mouth one time a day related to Constipation . [acetaminophen] Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours for pain . Start date 7/31/19 . During a review of Resident 19's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [Health Shake] after meals for Weight Monitoring Start date 3/11/21 . Cranberry Capsule 425 MG Give 1 capsule by mouth one time a day for supplement . Start date 5/23/21 . During a review of Resident 20's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [stool softener] Tablet100 MG Give 1 tablet by mouth at bedtime for Bowel Care Management related to Constipation . Start date 11/17/20 . [MEDICATION(S)] Sulfate [MEDICATION(S)] 220 (44Fe) MG/ 5ML Give 7.5 ml by mouth one time a day related to Iron Deficiency [CONDITION(S)] . Start 5/23/21 . [MEDICATION(S)] Tablet 1 MG Give 1 tablet by mouth one time a day for supplement . Start date 4/24/20 . [MEDICATION(S)] HCL ([MEDICATION(S)]- most common salt used to formulate medication) Tablet 100 MG Give one tablet by mouth one time a day for supplement . Start date 5/23/21 . During a review of Resident 21's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [MEDICATION(S)] Tablet 1 MG Give 1 tablet by mouth one time a day for supplement . Start date 9/6/19 . [[MEDICATION(S)]] Tablet 8.6 MG (Sennosides) Give 2 tablet by mouth every 24 hours as needed for constipation . Start date 9/5/19 . Vitamin B1 Tablet 100 MG ([MEDICATION(S)] HCL) Give 1 tablet by mouth one time a day for supplement . Start date 9/6/19 . During a review of Resident 22's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . Acetaminophen Tablet 325 MG Give 2 tablet by mouth four times a day for Chronic (long [MEDICATION(S)]) Pain related to Scoliosis (where the spine twists and curves to the side) . Start date 3/ 12/19 . [MEDICATION(S)] Acid Tablet (vitamin C) 500 MG Give 1 tablet by mouth two times a day for supplement . Start date 7/22/20 . [MEDICATION(S)] HCL Tablet 100 MG Give 1 tablet by mouth on time a day for supplement . Start date . 7/1/15 . During a review of Resident 23's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [Health Shake] three times a day give between meals . Start date 5/18/21 . [stool softener] Capsule 250 MG Give 1 capsule by mouth one time a day for constipation Start date 11/17/20 . [MEDICATION(S)] Sulfate Tablet 325 (65Fe) MG Give 1 tablet by mouth one time a day for supplementation . Start date 7/21/20 . [[MEDICATION(S)]] Tablet 8.6 MG (Sennosides) Give 2 tablet by mouth at bedtime for Constipation . Start date 12/28/20 . During a review of Resident 25's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [MEDICATION(S)] Sulfate Tablet 325 (65Fe) MG Give 1 tablet by mouth one time a day for supplementation . Start date 6/1/21 . During a review of Resident 26's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . Aspirin Tablet 325 MG Give 1 tablet via G-Tube (gastrostomy tube - tube inserted through the wall of the abdomen directly into the stomach) one time a day for [CONDITION(S)] ([CONDITION(S)] or stroke- loss of blood flow to the brain prophylaxis [action to prevent illness]) . Start date 6/30/20 . During a review of Resident 27's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [stool softener] Capsule 100 MG (stool softener) Give 2 capsule by mouth one time a day for Constipation . Start date 11/17/20 . [acetaminophen] tablet 325 MG (Acetaminophen) Give 2 tablet by mouth two times a day for pain . Start date 10/14/20 . During a review of Resident 29's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [MEDICATION(S)] Tablet 1 MG Give 1 tablet by mouth one time a day for supplementation . Start date 12/11/20 . [MEDICATION(S)] HCL Tablet 100 MG Give 1 tablet by mouth one time a day for supplement . Start date 12/11/20 . [acetaminophen] Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours for pain . Start date 7/ 12/21 . During a review of Resident 31's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [stool softener] Tablet 100 MG Give 2 tablet by mouth one time a day for Bowel Care Management Start date 11/17/20 . [MEDICATION(S)] Tablet 200 MG Give 2 tablet by mouth every 8 hours for pain . Start date 5/28/21 . Iron Tablet 325 (65Fe) MG ([MEDICATION(S)] Sulfate) Give 1 tablet by mouth one time a day related to [CONDITION(S)] . Start date 4/20/21 . During a review of Resident 32's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [Health Shake] with meals give 4OZ health shake with breakfast, Lunch and Dinner . Start date 3/3/21 . [[MEDICATION(S)]] Tablet 8.6 MG (Sennosides) Give 2 tablet by mouth at bedtime for Constipation . Start date 12/14/20 . During a review of Resident 33's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [stool softener] Tablet 100 MG Give 2 tablet by mouth one time a day to prevent constipation . Start date 4/15/21 . [MEDICATION(S)] Sulfate Tablet 325 (65Fe) MG Give 1 tablet by mouth on time a day related to [CONDITION(S)] . Start date 12/11/19 . During a review of Resident 34's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [Health Shake] three times a day Give Sugar free 4 oz. health shake . Start date 7/6/21 . During a review of Resident 35's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [stool softener] Tablet 100 MG Give 2 tablet by mouth one time a day for constipation . Start date 5/30/20 . During a review of Resident 37's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [stool softener] Tablet Give 200 mg by mouth one time a day for Bowel care Management . Start date 11/17/20 . During a review of Resident 39's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [Health Shake] three times a day 4oz between meals . Start date 6/14/21 . [stool softener] Tablet 100 MG Give 2 tablet by mouth one time a day for Bowel Care Management . Start date 11/17/20 . During a review of Resident 40's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . Iron Tablet 325 (65Fe) MG ([MEDICATION(S)] Sulfate) Give 1 tablet by mouth one time a day related to [CONDITION(S)] . Start date 4/8/21 . [acetaminophen] Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth one time a day for Pain . Start date 3/13/21 . During a review of Resident 41's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [acetaminophen] Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for Pain . Start date 4/13/21 . During a review of Resident 42's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [Health Shake] three times a day . between meals . Start date 1/11/21 . Vitamin B- 1 Tablet 100 MG ([MEDICATION(S)] HCL) Give 1 tablet by mouth one time a day for supplement . Start date 3/11/20 . During a review of Resident 43's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours for pain . start date 4/16/19 . [MEDICATION(S)] Sulfate Liquid 220 (44 Fe) MG/ ML Give 7.5 ml by mouth one time a day . Start date 12/11/19 . Sennoside [[MEDICATION(S)]] Tablet 8.6 MG Give 1 tablet by mouth every 24 hours as needed for Constipation .Start date 9/20/19 . During a review of Resident 44's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . Cranberry Capsule Give 425 MG by mouth one time a day for Prophylaxis . Start date 4/8/21 . [stool softener] Capsule 250 MG Give 2 capsule by mouth on time a day . Start date 6/2/20 . During a review of Resident 45's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [Health Shake] three times a day . Start date . 7/17/21 . [acetaminophen] Tablet 325 mg (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for pain . Start date 6/18/21 . During a review of Resident 69's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [stool softener] Tablet 100 MG Give 4 tablet by mouth one time a day . Start date 6/3/20 . [MEDICATION(S)] Sulfate [MEDICATION(S)] 220 (44 Fe) MG/ 5 ML Give 7.5ml by mouth one time a day . Start date 4/30/21 . [acetaminophen] Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours for pain . Start date 8/1/18 . During a review of Resident 73's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [MEDICATION(S)] Sulfate [MEDICATION(S)] 220 (44 Fe) MG/ 5 ML Give 7.5ml by mouth one time a day . Start date 12/11/19 . [acetaminophen] Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth three times a day related to Muscle Weakness . Start date 7/14/21 . During a review of Resident 74's OSR, dated 7/31/21, the OSR indicated, Active Orders As Of: 7/31/21 . [Health Shake] give with meals . Start date 11/16/20 . [MEDICATION(S)] Tablet 1 MG Give 1 tablet by mouth one time a day for Supplement . Start date 9/6/19 . During an observation on 7/30/21, at 3:27 p.m., in the men's hall, the ambient temperature in Resident 10, Resident 11, and Resident 12's room ranged between 82 degrees F and 86.3. degrees F, on the infrared temperature gun depending on the area within the room. During a review of Resident 10's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 7/30/21, the AR indicated, Diagnosis information . [CONDITION(S)] Disease (CVD- a group of conditions that affect blood flow and the blood vessels in the brain) . Diabetes Mellitus .Acute Ischemic Heart Disease (range of conditions associated with sudden, reduced blood flow to the heart) . Major Depressive Disorder (mood disorder) . Constipation . Malnutrition (reduced nutritional status) . During a review of Resident 11's AR, dated 7/30/21, the AR indicated, Diagnosis information . Cerebral Infarction (referred to as stroke; damage to tissues in the brain due to a loss of oxygen) . Flaccid [CONDITION(S)] (severe or complete loss of motor function on one side of the body) . Athero[TRUNCATED]