Every finding on record at Oakpark Health and Rehabilitation Center

Based on interviews and record reviews, the facility did not ensure one resident (#1) out of three residents reviewed received appropriate treatment and services for mental disorders to attain the highest practicable mental and psychosocial well-being.Findings included: Review of Resident #1's hospital medication discharge instructions, dated [DATE], showed the resident received Nuplazid 34 mg daily. Review of Resident #1's facility physician orders showed:-Nuplazid Oral Capsule 34 MG (Pimavanserin Tartrate). Give 1 capsule by mouth one time a day for delusions. Dated 11/30/25. Review of Resident #1's Medication Administration Record (MAR) for December 1st-19th 2025 showed Nuplazid was not administered and was documented as waiting on delivery from pharmacy on 12/6, 12/7, 12/10, 12/11, 12/12, 12/13, 12/14, and 12/17/25. Nuplazid was signed off as being administered on 12/1, 12/2, 12/3, 12/4 12/5, 12/8, 12/9, 12/15, 12/16, 12/18, 12/19/25. Behavior monitoring on the MAR showed the only documented behaviors from 12/1-12/16/25 were three instances of insomnia and 1 instance of wandering. On 12/17, 12/18, and 12/19/25 the resident was documented to have aggressiveness and avoidance/resisting care. Review of admission Records showed Resident #1 was admitted on [DATE] with diagnoses including Parkinson's disease, major depressive disorder, anxiety disorder, dementia, and amnestic disorder due to known physiological condition. Review of Resident #1's Care plan showed a focus area of resident has an alteration in/risk for alteration in neurological status related to Parkinson's, dementia, dated 12/1/25. Interventions included Give medication as ordered. There was an additional focus area of resident has a mood problem, dated 12/1/25. Interventions included administered medication as ordered, behavioral health consults as ordered/indicated, and monitor/record/report to doctor as needed significant changes in signs and symptoms of depression, anxiety, sad mood, as indicated. Review of Resident #1's progress notes showed:12/17/25 11:31 a.m. Patient with agitation, hitting and kicking staff. Nuplazid cannot be delivered due to high cost, Psych services aware awaiting new orders.12/17/25 1:23 p.m. [Family member] was called to supply Nuplazid, no answer message was left for call back. Review of Resident #1's medical record did not show any documentation the resident was seen by psychiatry while in the facility. There was no documentation of a follow-up with psych related to the progress note on 12/17/25. An interview was conducted on 1/12/26 at 2:10 p.m. with a representative from the facility's pharmacy. The representative reviewed all medications ordered and delivered to the facility for Resident #1. The representative said a three-day supply of Nuplazid was delivered on 11/29/25 and that was the only time the medication was delivered to the facility for Resident #1. The representative said there were two notes in their system on 11/20/25 and 12/11/25 saying the Director of Nursing (DON) called and said not to send the Nuplazid. An interview was conducted on 1/12/26 at 1:48 p.m. with the DON. The DON reviewed Resident #1's medical record and confirmed the resident did not receive the ordered Nuplazid for several days in December 2025. She said the expectation was that the facility get the ordered medication from the pharmacy and administer it to the resident. She said the family would not have been required to bring the medication to the facility. The DON confirmed there was no documentation psychiatry saw Resident #1 during his stay at the facility. When asked if Resident #1 should have been seen by psychiatry since he was not being administered his ordered medications for delusions; the DON stated she saw the documented behaviors, but he wasn't taken off the medication, he was taking it intermittently. An interview was conducted on 1/12/26 at 2:30 p.m. with the Nursing Home Administrator (NHA). The NHA said they checked with psychiatry and confirmed the Resident #1 was not seen in the facility. She said psychiatry attempted to see him on 12/11/25 but he was sleeping. The NHA said if a resident needed to see psychiatry other than their regular visit time, she said there is no reason that couldn't have happened. She said they did psychiatry telehealth visits when needed. The NHA said her expectation was that the facility obtained and administered the ordered medications, even high-cost medications.The NHA said the facility did not have a policy related to psychiatry services or mental health care. Review of a facility policy titled Physician Orders, reviewed 1/2024, showed:Guideline: Orders and administration of medications and treatments will be consistent with principles of safe and effective order writing.Procedure:1. Medications shall be administered upon the written order of a person duly licensed and authorized to prescribe such medications in this state as soon as practicable.9. Physician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated.10. The resident will be informed of medication changes as they occur. If the resident is deemed incapable of making health care decisions, the resident's responsible party will be informed of medication changes as they occur.

Based on interview and record review, the facility failed to provide a sufficient number of certified nurse assistants (CNAs) for four night shifts (4/6, 4/12, 4/26, and 6/21) of the twenty-seven night shifts reviewed. Findings:An interview was conducted with Resident #93 on 12/08/2025 at 11:18 a.m. The resident stated they must wait awhile for assistance to get a brief changed. The resident stated the staff do not bring water unless the residents ask for water. The resident stated they asked to have water a week ago at approximately 9:00 pm and it took until 2:00 a.m. to receive it. An interview was conducted with Staff B, Registered Nurse (RN) on 12/09/2025 at 4:25 p.m. She stated each unit usually has six Certified Nursing Assistants (CNAs) and two nurses. She said if somebody calls out for their shift, Then we try our best. She stated the Director of Nursing (DON), and nurses on the units communicate staffing needs to the Staffing Coordinator based on census. Staff B stated she is a unit manager, and she fills in if there are not enough nurses.An interview was conducted with Staff Q, CNA on 12/09/2025 at 5:00 p.m. He stated he is usually assigned 10-12 residents for the 3 pm to 11 pm shift. He stated there are usually six CNAs on each unit at night. He said the Staffing Coordinator creates the schedules. He stated he is always busy, but he helps people. He stated he remembers one day with a CNA shortage, and he has worked there for one year.An interview was conducted with Staff W, CNA on 12/10/2025 at 8:23 a.m. She stated she is the Staffing Coordinator, and she also works as a CNA when needed. She confirmed the schedule is based on the census. She said she has a cheat sheet she uses to ensure requirements for staffing. She stated the facility is well covered with CNAs, and they are focused on hiring nurses. She said the facility is currently using agency nursing staff to meet the requirements. She stated they just started using the agency again a few days ago, but they prefer to use their own staff first. Staff W stated they have six CNAs on each unit, and never less than five CNAs on a unit. She said they know the residents' needs ahead of time, because most of the residents have been in the facility for a while. Staff W noted the facility tries to have an RN on every shift.Review of the Daily Schedule Reports for April 2025 through June 2025, with a comparison to the Raw Punch Reports, revealed the following data: -The facility staffing plan consists of 15-18 CNAs and 6 LPNs or RNs for the facility per shift.-The minimum regulatory requirement for staffing is a ratio of 40 residents to every licensed nurse, and 20 residents to every licensed CNA. -The night shift on the 4/6/2025, 4/12/2025, 4/26/2025, and 6/21/2025 did not meet this minimum staffing requirement. On 4/6/2025, the staffing numbers for the 174 resident census were seven CNAs and six licensed nurses. On 4/12/2025, the staffing numbers for the 175 resident census were seven CNAs and six licensed nurses. On 4/26/2025, the staffing numbers for the 173 resident census were seven CNAs and five licensed nurses. On 6/21/2025, the staffing numbers for the 171 resident census were seven CNAs and six licensed nurses.

Based on observations, interviews, and record review, the facility failed to ensure proper infection control practices were implemented related to: 1) personal protective equipment (PPE), contact precautions, hand hygiene, soiled linen, and resident bathrooms on two out of three resident units observed; and 2) failed to properly sanitize the heel protector boot for one resident (#2) out of thirty-three sampled residents.Findings Included: An observation was conducted on 12/8/25 at 9:56 a.m. of the 100 unit shower room. The shower room was observed to have dirty linens in a pile on the floor, hanging on the shower chair, and on the rails in the shower. A Certified Nursing Assistant (CNA) was observed wheeling a resident into the shower room to have a shower prior to it being cleaned. An observation was conducted of the 100 hall lunch service on 12/8/25 at 12:18 p.m. A staff member was observed removing a tray from the tray cart, taking it into a resident room and setting the tray up for the resident. The staff member then returned to the tray cart and retrieved a tray for another resident without performing hand hygiene. A second staff member was observed removing a tray from the tray cart, taking it to a resident room, moving the resident's over bed table, and arrange the food and table items. The staff member exited the room, returned to the tray cart and retrieved another resident's tray without performing hand hygiene. An observation was conducted on 12/8/25 at 2:18 p.m. in room [ROOM NUMBER] of a toilet that had what appeared to be feces on the front of the toilet, around the rim, and splattered on the floor. A family member in the room said neither resident can use the bathroom independently, so a staff member had to assist them. The family member was upset and said it was disgusting because the residents had to use that bathroom. An interview was conducted on 12/8/25 at 2:30 p.m. with the Director of Nursing (DON). She reviewed photos of the toilet in room [ROOM NUMBER] and said it was not acceptable, and a staff member should have cleaned that up after taking the resident to the bathroom. The DON said she would have housekeeping go clean it immediately. An observation and interview was conducted on 12/9/25 at 2:00 p.m. Water cups in multiple resident rooms were observed with no names or labels. A family member stated they had come in multiple times and their family member's over bed table had been switched with the roommates. They said the cups had no label on them, but he assumed the resident's cups were switched with the tray tables. An observation was conducted on 12/9/25 at 3:13 p.m. of a contact precaution sign hanging on the door of room [ROOM NUMBER]. A CNA observed to be in the room with only gloves on moving around the resident bed and tray table. As the CNA exited the room no hand hygiene was performed and she proceeded down the hall entering another door. Photographic Evidence Obtained. An interview was conducted on 12/9/25 at 3:18 p.m. with Staff A, CNA. Staff A confirmed she was in room [ROOM NUMBER] without Personal Protective Equipment (PPE) on and the room had a contact precaution sign. Staff A said she was not providing direct care to the resident, so she did not need to wear PPE. She said contact precautions and enhanced barrier precautions were pretty much the same. Staff A said some of the precaution signs have a D or W on them, which indicated which bed (door or window) in that room was on precautions. An observation was conducted on 12/10/25 at 1:41 p.m. of two staff members entering room [ROOM NUMBER] with no PPE on. The contact precautions sign remained on the door at that time. An interview was conducted on 12/11/25 at 10:23 a.m. with Staff Z, Licensed Practical Nurse (LPN). Staff Z said for a room on contact precautions staff wore a gown and gloves and for Enhanced Barrier Precautions (EBP), staff only wore gloves. An interview was conducted on 12/11/25 at 10:29 a.m. with Staff C, CNA. Staff C said if a resident was on contact precautions, staff wore a gown anytime they go in the room and EBP staff only had to wear gloves. An interview was conducted on 12/11/25 at 10:41 a.m. with Staff D, CNA. Staff D said when a resident is on contact precautions staff only wore gown and gloves when you were touching the resident and that only applied to the resident with the contact precaution orders not both residents in the room. On 12/09/2025 at 8:49 a.m., Resident #2 was observed sitting on the side of the bed. The resident stated they had an infection on their feet. The resident stated the heel protector boots have never been cleaned. Observed soiled areas on the right heel protector boot. The resident gave permission for surveyor to photograph the feet. Review of admission Records showed Resident #2 was initially admitted to the facility on [DATE] with diagnoses including but not limited to: other sequelae of cerebral infarction (I69.398), Hemiplegia, unspecified affecting right dominate side (G81.91), Dysphagia following cerebral infarction (I69.391). Review of the psychiatry progress note, dated 12/02/2025, revealed a Brief Interview for Mental Status (BIMS) score of two. This BIMS score indicated that the resident's cognition was severely impaired. An interview was conducted with Staff V, Licensed Practical Nurse (LPN) on 12/10/2025 at 3:12 pm. She stated Resident #2 has been seen by wound care, and they change the dressings on the resident's feet. She stated nurses are also removing the dressings on the resident's feet every shift. The nurses would clean the boot and sanitize daily when doing wound care. An interview was conducted with Staff U, Registered Nurse (RN) a wound care nurse, on 12/10/2025 at 3:20 pm. She stated Resident #2 has pressure sores on his elbows, left ankle, right foot and the sacrum. She said the resident is very confused and agitated all the time. She said there have been no changes in his pressure wounds. She stated, We wipe the boots every day with blue wipes. She said she monitors the resident, to ensure the boots stays on their feet. When discussing the photograph of the soiled boot, the wound care nurse stated it should have been cleaned. She noted she will wipe the boots, but she is not sure if they can be washed. Review of Resident #2's December 2025 Medical Administration Record (MAR)/Treatment Administration Record (TAR) revealed the following wound care order: Apply skin prep to bilateral heels every shift as tolerated for 14 days. The start date was 11/29/2025 at 1445. The day shift on 12/9/2025 had no treatment administration documented. An interview was conducted on 12/11/25 at 5:01 p.m. with the Director of Nursing (DON)/Infection Preventionist (IP). The DON/IP said for a resident on contact precautions; staff sanitized their hands and put on gowns and gloves prior to entering the room. She said after providing care PPE was removed prior to exiting the room and hand hygiene was completed. The DON/IP said if a resident was on EBP staff hand sanitized prior to entering the room and wore a gown and gloves if they provided direct care to the resident. Prior to leaving the room staff removed PPE and performed hand hygiene. The DON/IP said she knew some staff did not put PPE prior to entering room and they would put it on at bedside. She said education was provided in October 2025 because the facility noticed inappropriate PPE use. The DON/IP said for hand hygiene while passing trays staff are educated to wash their hands every third tray if they are just handing the tray to someone, but if they are setting the tray up or moving anything, they should was hands after every tray. The DON/IP said used linen in the shower rooms should be bagged up and taken to the dirty laundry. She said occasionally staff take a resident back to the room, then come clean up prior to bringing another resident in. The DON/IP said she educated staff to spray down the shower chairs then take the used linen with them when they leave the room to take the resident out. She said this allows the proper dwell time for the sanitizing and the room is ready for the next shower. The DON/IP reviewed photos of the used linen in the shower room. She said it should not have been left like that and it obviously was not ready for the next resident to be showered. The DON also reviewed photos of Resident #2's hell protector boot. She said it was disgusting and should have changed out immediately. The DON/IP said the boot looked like it had feces on it and would be an infection risk because Resident #2 had a wound on his foot. Review of a facility policy titled Transmission Based Precautions, revised 2/2024 showed: Guideline: All staff receive training on transmission-based precautions upon hire and at least annually. Procedure: 2. Contact Precautions- a. Intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. b. Make decisions regarding private room on a case-by-case basis after considering infections risks to other residents in the room and available alternatives. c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens. Review of a facility policy titled Infection Prevention and Control Program, revised 1 /2024, showed: Standard: An infection prevention and control program (IPCP) are established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Guideline: The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is based on accepted national infection prevention and control standards in accordance with local, state, and federal regulations and guidelines. Elements: 1. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Prevention of Infection 1. Important facets of infection prevention include: a. identifying possible infections or potential complications of existing infections; b. instituting measures to avoid complications or dissemination; c. educating staff and ensuring that they adhere to proper techniques and procedures; d. communicating the importance of standard precautions and cough etiquette to visitors and family members; e. enhancing screening for possible significant pathogens; f. immunizing residents and staff to try to prevent illness; g. implementing appropriate isolation precautions when necessary; and h. following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC (Centers for Disease Control)). Review of a facility policy titled Hand Hygiene and Infection Control, revised 6/2023, showed: Standard: Hand hygiene is the single most important measure for preventing the spread of infection. Guideline: This facility shall require facility personnel use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated. Hand hygiene is a general term that applies to washing hands with water and either plain soap or thoroughly applying an alcohol-based hand rub (ABHR). Procedure: The facility acknowledges the CDC (Centers for Disease Control) guidelines to improve adherence to hand hygiene in health care settings. The hand hygiene guidelines are part of an overall CDC strategy to reduce infections in health care settings to promote resident safety. These guidelines state that hand washing is necessary when healthcare personnel's hands are visiblv soiled. When the hands are not visibly soiled, the CDC recommends the use of alcohol-based hand rubs by health care personnel for resident care to address the obstacles that health care professionals face when taking care of residents. Situations that require hand hygiene include, but are not limed to: When coming on duty When hands are visibly soiled (hand washing with soap and water) Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) Before and after performing any invasive procedure (e.g., fingerstick blood sampling) Before and after entering isolation precaution settings Before and after eating or handling food (hand washing with soap with water) Before and after assisting a resident with meals Before and after assisting a resident with personal care (e.g., oral care, bathing) Before and after handling peripheral vascular catheter and other invasive devices Before and after inserting indwelling catheters Before and after changing a dressing Upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse or blood pressure, and lifting a resident) After personal use of the toilet (hand washing with soap and water) Before and after assisting a resident with toileting After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C.difficle (hand washing with soap and water) After blowing or wiping nose After handling soiled or used linens, dressings, bedpans, catheters and urinals. After handling soiled equipment or utensils After removing gloves or aprons After completing duty

Based on observations, interviews, and record review, the facility failed to maintain essential facility equipment in a clean and safe manner within the resident environment related to 1) failing to ensure the Packaged Terminal Air Conditioners (PTAC) system filters were clean and free of debris for four resident room PTAC systems (rooms 364, 266, 272, and 210) out of seven systems observed; 2) failing to ensure the PTAC system was free from leaks in one resident room PTAC system (room [ROOM NUMBER]) out of the seven systems observed; and 3) failing to ensure the ice machines were free of bio growth in one unit ice machine (300 unit) out of four ice machines observed. Findings included:On 12/8/2025 at 10:58 a.m., the PTAC unit in room [ROOM NUMBER] was observed with a puddle of water under the unit. Photographic evidence obtained.On 12/11/2025 at 10:06 a.m. observed another large puddle of water under the PTAC unit in room [ROOM NUMBER]. Photographic evidence obtained.On 12/11/2025 at 10:06 a.m. the PTAC filters in room [ROOM NUMBER] were observed to be caked with dust and debris.On 12/11/2025 at 3:00 p.m. the PTAC filters in rooms [ROOM NUMBER] were observed with dust and debris. The vents were also noted to have dust and debris. Photographic evidence obtained.On 12/11/2025 at 10:13 a.m. an interview was conducted with Staff C, Certified Nursing Assistant (CNA). She stated the facility has a place on the computer where they can report broken machines. She said she tells maintenance directly. She stated she did not notice the leaking unit the morning of 12/11/2025 when she dropped off the food tray in room [ROOM NUMBER].An interview was conducted with the Maintenance Director on 12/11/2025 at 2:40 p.m. She said housekeeping texts her with any maintenance issue because they do not have access to The Equipment Lifecycle System (TELS). TELS is the facility's work order system. She stated all other staff use TELS or can come to her directly. She prefers they send her the info in the TELS system. She said the PTAC filters are cleaned once a month. Review of the record labeled PTAC Air Filters Washed, revealed the 300-unit filters were last cleaned on 11/23/2025 and the 200-unit filters were last cleaned on 11/21/2025.On 12/09/2025 at 1:06 p.m. debris that appeared to be black bio growth in the 300-unit ice machine was observed. The ice machine is stored in the nourishment room for the 300 unit. The bio growth was located on the interior surface of the ice machine chute where the ice is dispensed from the machine. Black bio growth was wiped from the interior of the machine with a clean napkin during this observation. Photographic evidence obtained. An interview was conducted with the Maintenance Director on 12/09/2025 at 4:28 p.m. She stated maintenance performs monthly cleanings of the ice machines. She revealed there are cleaning logs adhered to the side of each ice machine. Review of the cleaning log for the 300 unit ice machine revealed the last cleaning was completed on 11/12/2025.

Based on observations, record reviews and interviews, the facility failed to ensure skin checks were completed for three Residents (# 6, #14, #35) out of eight residents sampled for skin integrity. Findings included: 1. On 12/09/2025 11:30 a.m. and at 3:00 p.m. Resident # 14 was observed lying down in bed with her call light within reach. She was observed groomed with no odors and no signs of distress. Review of an admission Record dated 12/11/2025 revealed Resident # 14 was admitted to the facility on [DATE] with diagnoses to include but not limited to Parkinson's disease without dyskinesia, without mention of fluctuations, bipolar disorder, current episode mixed, moderate, major depressive disorder, recurrent, moderate. Review of Resident # 14's order summary revealed: Weekly skin checks every Friday for skin assessment. Dated 10/10/2025 Review of Resident # 14's Treatment Administration Record (TARSs) revealed: October 2025 Weekly skin checks were not documented as 1 out of 4 scheduled times completed December 2025 Weekly skin checks were not documented as completed On 12/10/2025 at 12:12 P.M an interview was conducted with Staff BB, RN. Staff BB stated she is not a full-time nurse at the facility so she can't explain why Resident # 14's skin checks were not completed as physician ordered. On 12/10/2025 at 12:30 P.M., an interview was conducted with Staff Y, License Practical Nurse/ Unit Manager. Staff Y stated her skin checks should be completed as ordered. If a nurse could not administer treatment, then they should document in the medical record the reason and notify the resident provider. 2. On 12/08/2025 at 10:42 a.m., Resident #35 was observed sitting in bed with the call light in his hand. A slight urine odor observed. A clean brief was observed on the chair next to resident. Observed a bandage on right side of his forehead, dated 12/6. The resident had sores on the forehead above the eyebrows. Review of admission Records showed Resident #35 was admitted to the facility on [DATE] with diagnoses including but not limited to parkinson's disease without dyskinesia without mention of fluctuations , adult failure to thrive, Weakness, Unspecified protein-calorie malnutrition, unspecified dementia, unspecified severity, without behavioral disturbance , psychotic disturbance, mood disturbance and anxiety. Review of Resident #35's Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of three indicating impaired cognition. Review of Skin Conditions, showed one stage II pressure ulcer and one stage III pressure ulcer. Review of the wound evaluations for Resident# 35's Stage III pressure ulcer on the sacrum revealed the following measurements: On 11/12/2025, the ulcer measured 3.0 cm in length, 1.7 cm in width, and 0.2 cm in depth. On 11/19/2025, the ulcer measured 1.9 cm in length, 1.7 cm in width, and 0.1 cm in depth. On 12/10/2025, the ulcer measured 7.1 cm in length, 2.1 cm in width, and 0.1 cm in depth. An interview was conducted with Staff G, CNA on 12/10/2025 at 10:54 a.m. She stated the CNAs usually do rounds every two hours. She said the care provided depends on the resident, and some may have to be checked every hour. She explained that if residents have pressure ulcers, then it is important they check often to make sure the residents are dry. Staff G said she would notify the nurse if sores were not healing or worsening An interview was conducted with Staff T, CNA on 12/10/2025 at 8:45 a.m. She said she would notify the nurse if there were a skin condition. The residents are rotated every 2 hours. She stated if residents refuse care, then she would tell the nurse. The policy is not to touch the resident if they refuse care. We let the nurse know. An interview was conducted with the Assistant Director of Nursing (ADON) on 12/10/2025 at 11:04 a.m. The ADON stated she is also a wound care nurse. She stated the wound care nurses round weekly for pressure injuries, with a Physician's Assistant (PA) from a wound care consultant. She said the PA will give recommendations if there is no progress, then she will make changes to care. She stated the facility has a wound care nurse daily. The ADON treats wounds during the week and Staff U, RN completes wound care on weekends. The ADON noted that bandage changes depend on the wound type. She said skin tears are better covered and bandages are changed three times a week. The ADON said pressure sore bandages are changed every day. She noted that Resident #35's facial wound and pressure sores were present on admission. She stated it was due to be changed today, 12/10/25. The order for the wound dressing change is three times a week. It falls on Monday, Wednesdays, and Saturdays. She thinks training for wound care is completed at least annually. She said she is not sure when the last training was completed. An interview was conducted with Staff U, RN, a wound care nurse on 12/10/2025 at 3:20 pm. Resident #35's bandages are changed every Monday, Wednesday, and Saturdays or as needed. She confirmed that on Monday, 12/8/25, the bandage on the resident's face was not changed. She confirmed the nurses can change bandages as well if the wound care nurse is not available. Review of Resident #35's November and December 2025 Medical Administration Record (MAR)/Treatment Administration Record (TAR) revealed the following wound care orders: Order: Treatment as follows; clean sacrum with normal saline, apply calcium alginate and cover with super absorbent dressing (SAD) every day shift. Order start date was 11/10/2025 at 6:45 a.m, and discontinue date was 12/07/2025 at 4:52 p.m. The following dates had no treatment administration documented: 11/17/2025, 11/26/2025. Order: Treatment as follows; clean right second toe with normal saline, apply calcium alginate, absorbent dressing (ABD) and wrap with kerlix every evening shift on Monday, Wednesday, Friday, and Sunday for would care. Start date was 11/09/2025 at 2:45 p.m. and discontinue date was 11/19/2025 at 9:07 a.m. The following date and times had no treatment administration documented: 11/9/2025 Order: Apply skin prep to bilateral heels as tolerated every shift as tolerated for 14 days. The start date was 11/08/2025 at 10:45 p.m. The evening shift on 11/9/2025 had no treatment administration documented. Order: Encourage and assist resident with turning and repositioning when in bed as tolerated every shift. The start date was 11/08/2025 at 10:45 p.m. The following evening shifts on 11/9/2025, 11/26/2025, 12/2/2025 and day shift on 12/9/2025 had no treatment administration documented. Order: Monitor the scab on the right side of the forehead, notify the doctor for any drainage or signs and symptoms of infection every shift. The start date was 11/09/25 at 2:45 p.m. and discontinue date was 11/15/2025 at 11:31 am. The following shift had no treatment administration documented: Evening shift on Sunday 11/9/2025 and Day shift on Saturday 11/15/2025. Order: Treatment as follows: clean lower back with normal saline, apply xeroform and cover with super absorbent dressing every day shift every Monday, Wednesday, Friday and Sunday. The start date 12/08/2025 at 6:45 a.m. No treatment was documented for 12/08/2025. Order: Clean open scab for right temporal area with normal saline, apply calcium alginate and cover with dry dressing. Change 3 times a week, every Monday, Wednesday, and Saturday. The start date was 11/22/2025 at 6:45 a.m. No treatment was documented for day shift on 12/08/2025. Order: Clean left ankle with normal saline, apply calcium alginate, ABD, and wrap with kerfix every day shift Monday, Wednesday, Friday and Sunday. The start date was 12/08/2025 at 6:45 a.m. No treatment was documented for day shift on 12/08/2025. Order: Treatment as follows; clean sacrum with normal saline, apply honey hydrogel, and cover with super absorbent dressing every day shift. Start date 12/08/2025 at 6:45 a.m. and discontinue date of 12/10/2025 at 7:56 p.m. No treatment was documented for day shift on 12/08/2025. 3. An interview was conducted on 12/9/25 at 11:29 a.m. with Resident #6. The resident said his tailbone hurt and that he previously had a wound there. He said it had been hurting for a little while, but the nurses did not do his skin checks. He said only the CNAs saw his buttock area when they changed him. Review of admission Records showed Resident #6 was admitted on [DATE] with diagnoses including quadriplegia and scoliosis. Review of Resident #6's physician orders showed: -Weekly skin check. Every evening shift every Thursday. Dated 5/1/25. -Apply skin prep to left outer ankle every shift. Dated 4/17/25. -Apply skin prep to right outer ankle every shift. Dated 4/17/25. Review of Resident #6's Treatment Administration Records (TARs) showed: September 2025 Weekly skin checks were not documented as completed 4 out of 4 scheduled times. Skin prep was not applied to the left and right outer ankle 22 out of 90 scheduled times. October 2025 Weekly skin checks were not documented as completed 3 out of 5 scheduled times. Skin prep was not applied to the left and right outer ankle 9 out of 90 scheduled times. November 2025 Weekly skin checks were not documented as completed 2 out of 4 scheduled times. Skin prep was not applied to the left and right outer ankle 10 out of 90 scheduled times. December 2025 Skin prep was not applied to the left and right outer 4 out of 23 scheduled times. An interview was conducted on 12/11/25 at 1:35 p.m. with Staff O, RN/Wound Care Nurse. Staff O said she was unaware skin checks were not being completed as ordered. She reviewed Resident #6's medical record and confirmed the skin checks were not completed as ordered. Staff O said those items should trigger a red notification on the charting system dashboard and Unit Managers (UM) should review those at the end of each shift to ensure they are completed. Staff O said she did audits previously but was then told by the Director of Nursing (DON) that the UM should be the ones auditing to ensure orders were completed. Staff O agreed it was a concern that orders were not completed. An interview was conducted on 12/11/25 at 2:53 p.m. with the DON. The DON said skin checks and treatment should be completed as ordered. She reviewed Resident #6's medical record and confirmed there was no documentation that the skin checks were completed as ordered. The DON said skin checks should be audited by Staff O, RN/Wound care nurse. The DON said she used to do audits at least. The DON said UM should also be doing audits to ensure orders are being completed and signed off in the medical record. The DON agreed it was a concern that skin checks and treatments were not completed as ordered and said she had not been aware it was a concern. Review of a facility policy titled Prevention of Skin Impairments/Pressure Injury, revised 1/2024 showed: Standard: The purpose of this policy is to provide information regarding identification of skin wound risk factors and interventions for specific risk factors. Guideline: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Factors: 1. Not all risk factors are fully modifiable or can be completely addressed. 2. Examples of these risk factors include, but are not limited to: a. Impaired/decreased mobility and decreased functional ability; b. Co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes mellitus; c. Drugs such as steroids that may afiect healing; d. Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency; e, Resident refusal of some aspects of care and treatment; f. Cognitive impairment; g. Exposure of skin to urinary and fecal incontinence; h. Under nutrition, malnutrition, and, hydration deficits; and The presence of a previously healed PU/PI. The history of any healed PU/PI, its origin, treatment, its stages [if known] is important assessment information since areas of healed Stage 3 or 4 PU/Pls are more likely to have recurrent breakdown. Prevention: 1. Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. 2. Based upon the assessment and the resident's clinical condition, choices and identified needs, basic or routine care could include, but is not limited to, interventions to: a. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); b. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; c. Provide appropriate, pressure-redistributing, support surfaces; d. Provide non-irritating surfaces; and e. Maintain or improve nutrition and hydration status, where feasible. Adverse drug reactions related to the resident's drug regimen may worsen risk factors for development of, or for non-healing PU/Pls (for example, by causing lethargy or anorexia or creating/increasing confusion) and should be identified and addressed. These interventions should be incorpora!ed into the plan of care and revised as the condition of the resident indicates. Monitoring/Documenting 1. Evaluate, report, and document potential changes in the skin. 2. Notify the physician and the resident/resident representative of changes in the skin. 3. Review the interventions and strategies for effectiveness on an ongoing basis. 4. Evaluate open areas (pressure/surgical areas) per physician orders.

Based on interviews and record reviews, the facility failed to ensure post fall interventions were implemented to prevent future falls for four residents (#20, #78, #138, #149) out of seven residents sampled for falls. Findings included: 1) Review of a facility provided incident log showed Resident #138 had falls on 11/26/25 and 12/8/25. Review of admission Records showed Resident #138 was admitted on [DATE] with diagnoses including essential sarcopenia, other symptoms and signs involving the musculoskeletal system, paroxysmal atrial fibrillation and syncope and collapse. Review of Resident #138's progress notes showed: 11/26/25 3:25 p.m. Alerted by CNA [certified nursing assistant] that Pt [patient] was on the floor. Pt observed laying flat on his back, on side of bed by window. Noted skin tear to left shoulder blade, pt c/o [complaints of] left side/hip pain. Pt states he did hit head but is not hurting, no redness or deformities noted. Pt was assisted into bed. Pt declining PRN [as needed] pain medcaitons [sic]. Pt noted with laborded [sic] breathing O2 85% on RA [room air], Pt placed on 2 L [liter] O2 and [NAME] TX given , O2 93%. MD, Family and DON aware 11/26/25 3:10 p.m. Fall Evaluation The following interventions and approaches have been implemented for the residents: Review footwear needs Call light re-orientation Review of Resident #138's Care Plan showed a focus area of being at risk for falls related to cognitive deficit, history of falls, unaware of safety needs, unsteady gait/poor balance, use of antihypertensives, and antidepressant medication. Review of the interventions did not show any interventions were added after the resident fell on [DATE]. The interventions for footwear needs and call light re-orientation were added as interventions in the care plan prior to the fall on 11/26/25. An interview was conducted on 12/11/25 at 2:53 p.m. with the Director of Nursing (DON). The DON reviewed Resident #138's medical record and confirmed no new fall interventions were added after the resident fell on [DATE]. The DON said interventions should have been added after that fall in an attempt to prevent future falls. Review of Resident #138's progress notes showed: 12/8/25 3:52 p.m. Notified by CNA that Pt. was on the floor. I observed Pt sitting on the floor by bathroom and wheelchair. Body audit complete, no injuries noted or reported. Pt states he was opening bathroom door and slid out of wheelchair. Pt denies hitting head, Pt denies any pain. VS wnl [within normal limits]. Pt assisted into wheelchair. Pt self propelled to dining room for Lunch. MD [medical doctor] and family notified. 2) On 12/09/2025 at 3:00 pm an observation was made revealing Resident # 20 sitting in her wheelchair propelling up and down the hallway. She was observed with no signs of distress On 12/11/2025 at 10:00 am an observation was made revealing Resident # 20 sitting up in her wheelchair, with no signs of distress. Review of Resident # 20 admission record revealed she was admitted to the facility on [DATE] with diagnoses to include but not limited to permanent atrial fibrillation, age-related osteoporosis without current pathological fracture, cognitive communication deficit. Review of Resident # 20's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07 which indicated Resident 20 is severely cognitive impaired. Review of a progress note dated 4/3/2025 revealed Resident # 20 was found on the floor. The progress note revealed an assessment was completed noting Resident # 20 had a Quarter sized bump on the left side of her head. Review of Resident # 20's fall care plan initiated on 12/24/2025 revealed no new interventions added after Resident # 20 fall on 4/3/2025. Review of Resident # 20's Medical Record reviewed on 12/ 11/2025 revealed no evidence of a quality of care note with the doctor's response to show Resident # 20 did not need a new intervention added after her fall on 4/3/2025. On 12/11/2025 at 3:00 pm., an interview was conducted with the Director of Nurses, DON. The DON stated that after every fall there is a new intervention put in place and added to the resident care plan. The only time they will not add a new intervention is if the doctor provides them with information that all interventions for the resident after a fall have been put in place. If the doctor provides them with that response, there would be documentation such as a quality of care note with the doctor's response. 3) An interview was conducted with Resident #143 on 12/08/2025 at 9:56 a.m. who stated Resident #78, had a bad fall recently. Resident #78 fell while using their walker because the wheels slipped out from under them. Resident #143 stated the doctor evaluated Resident #78 and decided to keep them in the facility. Review of admission Records showed Resident #78 was admitted to the facility on [DATE] with a diagnosis including but not limited to chronic kidney disease, stage three, unspecified. The resident has a diagnosis of unspecified dementia, unspecified severity without behavioral disturbance. The onset of dementia was documented as 8/15/2023. Review of Resident #78's Minimum Data Set (MDS), dated /15/2, Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of three. This BIMS score indicating the resident's cognition was moderately impaired. On 12/09/2025 at 4:50 p.m., Resident #78 was observed walking down the hall with a walker. The resident was walking quickly and appeared to have a steady gait. The resident was observed walking through the halls during the day. On 12/09/2025 at 5:10 p.m. Resident #78 was observed in their room standing next to the bed. A large bruise was observed on the right side of their forehead. Review of nursing progress notes dated 11/15/2025 at 4:08 p.m. revealed the resident had a large knot on her right forehead due to her fall. Review of the resident's care plan, with an initiated date of 08/26/2025, showed the care plan was not updated to address the fall by adding interventions to reduce future risk. An interview was conducted with the DON on 12/11/2025 at 6:33 p.m. The DON stated Resident #78 walks through the halls frequently throughout the day. She said the care plan should be updated after any resident falls. The DON confirmed the care plan was not updated for Resident #78. She revealed the plan was supposed to be updated with more rest periods for the resident. 4) Review of admission records showed Resident #149 was originally admitted on [DATE] and admission on [DATE], with diagnoses including metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), neuropathies, bipolar disorder, chronic pain, history of falling and major depressive disorder. Review of Resident #149's care plan Focus: the resident is at risk for falls related to (R/T) weakness, medication use, initiated on 6/9/25. Goal: the resident potential for sustaining a fall related injury will be minimized by utilizing fall precautions/ interventions through the next review date. Interventions: assist to toilet before and after meals- 12/10/25, offer toilet upon rising- 6/27/25, perimeter mattress- 11/6/25, encourage and assist resident to use bed in the lowest position as tolerated-6/9/25, encourage and remind resident to use call bell and wait for staff assistance with transfers, ambulation, toileting, etc., as indicated-6/9/25, encourage to transfer and change positions slowly-11/26/25, encourage and assist the resident to wear appropriate footwear such as rubber-soled shoes, non-skid bedroom slippers, non-skid socks., etc. when ambulating, transferring or mobilizing in wheelchair-. 6/9/25, physical and occupational therapy consult as needed- 6/9/25, educate/ discourage resident from unsafe activities, such as opening closed doors/ reaching in wheelchair; wait for staff to assist-9/15/25. Review of Resident #149's quarterly Minimum Data Set (MDS), dated [DATE] Section C, cognitive pattern showed a Brief Interview for Mental Status (BIMS) summary score 10, indicating moderate cognitive impairment. Section GG, functional abilities showed partial/ moderate assistance is needed for personal hygiene and sit to stand and substantial/ maximal assistance for chair to bed transfer. Resident #149's progress notes showed the following: A fall evaluation note, dated 11/24/25 at 11:40 PM, showed The following interventions and approaches have been implemented for the residents: Bed in lowest position Call light re-orientation . The fall risk evaluation was reviewed with the following people: Resident . Education was provided to the following people: Resident . The teaching methods used for the education provided was: Verbal Discussion. The outcome of the education provided was Verbalizes Understanding. An eINTERACT SBAR Summary for Provider note dated 11/24/24 at 11:42 p.m. showed Resident #149 fell. A progress note dated 11/29/25 at 12:15 a.m., this writer heard patient (pt) yelling, entered room and pt laying on her back on floor in between bed and window. asked pt what happened pt Stated I rolled out of bed. pt was assessed for injury and range of motion (ROM) pt denies hitting head assist of 2 back to bed pt able to stand neuro checks initiated .call bell was not activated. A progress note dated 12/7/25 at 6:29 p.m. showed Pt observed on floor, beside bed facing window wall. Pt unable to state how she got on floor. Pt obtained skin alteration on left upper arm. Assisted pt off the floor x 3, neurological check (neurocheck) within normal limits (wnl), vital signs (v/s) wnl. Pt was provided first aid to left arm and was referred to wound care. Notified the power of attorney (POA) and the advanced registered nurse partitioner (ARNP) placed pt on neuro checks. During an interview on 12/11/2025 at 3:10 p.m. the Director of Nursing (DON) said on 11/24/25 Resident # 149 was observed lying on the floor on the left side. She stated that no interventions related to the fall on 11/24/25 were added to the resident's care plan. She explained that after each fall, the IDT meets during the morning meeting to review the incident and assign responsibility for updating the care plan, typically to the MDS Coordinator During an interview on 12/10/25 at 10:40 a.m., the DON stated following a resident fall, staff are required to complete a skin assessment and a pain assessment. If the fall is unwitnessed, neurological checks are also performed. The manager added that employee statements are obtained as part of the post-fall investigation, and resident-specific interventions are reviewed, discussed, and implemented to help prevent future falls. The DON said on 12/8/25, the clinical team met to discuss Resident #149's fall that occurred on 12/7/25. During the meeting, the team decided to add an intervention instructing staff to toilet the resident before getting into bed and after getting out of bed. The Director of Nursing (DON) stated the MDS Coordinator should have updated the care plan with the new interventions. Review of facility policy titled, Standards and Guidelines: Falls-Managing, Preventing and Documentation, revise 9/2005, showed the following: Guideline: Each resident will have an individualized plan of care that will be reviewed and modified as needed to included fall interventions most appropriate to their individual needs and diagnosis. Definition: Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, OR as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. If there is a loss of balance during supervised therapeutic interventions and the resident comes to rest on the ground, floor or next lower surface despite the clinician's effort to intercept the loss of balance, it is considered a fall. Procedure: Fall Risk Factors 1. Some factors that may result in resident falls include, but are not limited to (a) Environmental hazards, such as wet floors, poor lighting, etc. (b)Unsafe or absent footwear and loose or improperly worn clothing; (c) Underlying chronic medical conditions, such as arthritis, heart failure, anemia and neurological disorders; (d)Acute change in condition such as fever, infection, delirium; (e)Medication side effects; (f) Orthostatic hypotension; (g) Lower extremity weakness; (h) Balance disorders; (I)Poor grip strength; (j) Functional impairments (difficulty rising from a chair, getting on or off toilet, etc.); (k) Gait disorders; (l) Cognitive impairment; (m) Visual deficits; (n)Pain; and (p) Refusals of with fall interventions, physician orders, plan of care, and/or staff assistance. Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e.to try one or a few at a time, rather than many at once). 3. Examples of initial approaches might include bed in lowest position, call light in reach, improving footwear, changing the lighting, etc. 4. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or until the reason for the continuation of the falling is identified as unavoidable. 6. Staff will identify and implement relevant interventions to try to minimize serious consequences of falling. 7. The facility is a restraint free environment. Meaning, bed alarms, chair alarms, side rails solely for fall prevention, and chemical interventions for fall prevention are not utilized. Monitoring Subsequent Falls and Fall Risk: 1.If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 2. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. Documentation: 1. Residents who experience a fall will have appropriate documentation completed in the facility risk management portal or on paper. 2. The residents care plan should be updated timely with the new interventions determined by the interdisciplinary team.

Based on observations, interviews, and record review, the facility failed to provide sufficient staffing to meet the needs of the residents related to dining and Activities of Daily Living (ADL) assistance with meals for three residents (#134, #50, and #168) observed in the dining room during three days (12/8/2025, 12/9/2025, and 12/10/2025) of three days dining was observed. Findings included: On 12/8/2025 at 12:50 p.m. the main dining room was observed during the lunch meal service. The main dining room revealed two sections, one large for residents who eat without assistance, and a smaller section where residents are assisted with their meals from staff. The smaller assistive section was observed with eight residents seated at various tables and with only one staff member in the room, who was Certified Nursing Assistant (CNA) Staff M. Staff M was observed seated at a table assisting a resident with eating assistance, where Resident #134 was also seated. Staff M was observed to only assist the table mate of Resident #134 with her lunch meal. Resident #134 was observed during the entire meal pushing most of her food off the plate and onto the table, as well as on her lap, and also observed picking up food from her plate with her fingers. Resident #134 was not served a meal that was finger foods. Resident #134 also picked up her juice cup and spilled it all over her plate with food, as well as most of it all over the table. Staff M continued to assist Resident #134's tablemate and did not intervene with Resident #134, nor cue her to stop pushing food off her plate. There were no other staff in the assistive section to assist. It appeared most of the eight residents in this assistive dining room needed some form of staff assistance to include either full eating assistance or cueing. Two residents #50 and #160 were observed seated at tables with their plates in front of them and were not eating, nor were they attempting to eat on their own. It was noted both needed either cueing supervision or limited eating assistance from staff. There were no other staff in the room from a timeframe of thirty-five minutes beginning at least 12:50 p.m. through to 1:25 p.m. Staff M confirmed she was the only staff member in the smaller room during that period of time and there are usually other staff in the room to assist. It was noted another staff member, who was the Assistant Director of Nursing (ADON), was assisting passing trays in the larger section of the dining room, as well as transporting tray carts from dining room to hallways, and from hallways to dining room. Interviews were attempted with Residents #134, #50, and #168. However, none were able to answer questions about their eating assistance, as they had cognitive impairments preventing them to be interviewed. On 12/9/2025 at 12:01 p.m. the main dining room assistive section was observed for the lunch meal service. There were twelve residents seated at various tables to include Residents #134, #50 and #169, and with only two staff members Certified Nursing Assistants (CNAs) Staff P and Q. All residents were already served and set up with their meals with Staff P was seated next to Resident #50 and Staff Q was seated next to Resident #168. It was observed Staff P and Staff Q were only providing eating assistance to Residents #50 and #168. There were ten others in the room to include Resident #134, who was not being assisted with cueing and eating assistance. Resident #134 appeared to have to wait until someone arrived to get them started with eating. Resident #134 was observed seated at a table with two other residents. Resident #134 picked up a clear plastic cup filled with a pink liquid and attempted to bring it to her mouth. While bringing the cup to her mouth, she spilled a large amount of liquid on her plate of food and also the table. There was no staff in the immediate area to intervene and assist her. Resident #134 continued to attempt to drink the liquid and put the cup down and continued to grab at her food items. She put food items in her mouth and did not use eating utensils. She continued to pick up food items with her fingers and food dropped on her lap and on the table. Resident #134 was observed to do this several times before she reached over and picked up her table mate's cup of pink liquid. At that time Staff P had to stop assisting with feeding Resident #50, got up and walked over to Resident #134 to intervene. Staff P grabbed the cup and placed it back to where Resident #134's table mate was at. She then went back to Resident #50 to finish assisting her with her meal. At 12:09 p.m. a staff member, who was a visiting Regional Dietary Manager, was observed to walk into the assistive dining section and sat down with Resident #134 to await further assistance from other staff. The Regional Dietary Manager is not an employee who regularly works at the facility, nor regularly sits to assist residents with their meals. At 12:10 p.m. Staff P finished assisting Resident #50 with her meal and then got up and walked over to Resident #134 to assist her with her meal.At 12:11 p.m. the ADON was observed to bring an empty tray cart into the room. After she did so, she immediately sat down next to Resident #134 after Staff P got up and began to assist her with eating. It was noted Resident #134 went from at least 12:01 p.m. through to 12:09 p.m. without any supervision, cueing and or eating assistance for eight minutes, resulting in spilled food and drink all over the table and plate of food. There were others in the room who needed assistance with eating and they too had to wait until Staff P and Q finished assisting Residents #50 and #168. Staff Q was observed to stop assisting Resident #168 with eating assistance three times and got up to either redirect other residents when spilling food/drink, or to assist with putting fork full of food to residents mouths. Staff Q would go back to Resident #168 each time after intervening with the other residents. At 12:33 p.m. an interview with Staff Q, who was now seated and assisting with eating with another resident at another table, revealed she does not normally help in the assistive dining room and was asked to do so today. She confirmed she and other staff had left Resident #134 without assistance for some time as she and others were passing and setting up meal trays for others. Staff P confirmed Resident #134 needs continued monitoring and assistance with her meal and confirmed she does grab at tablemate's food and utensils. At 12:36 p.m. an interview with Staff Q revealed he does not normally help with assisting residents with eating in the dining room. He mentioned it was his first time and was asked to come in the room to assist Resident #168 with his eating tasks. Staff Q confirmed there were others in the room who needs assistance with either cueing or full eating assistance. But he nor Staff P can assist with them all. Staff Q was not sure who else should be in the room to help. At 12:39 p.m. while in the 100 hallway, an interview was obtained with CNA Staff M. She confirmed she was assigned in the assistive dining room the day prior on 12/8/2025 and she was not assigned to help in that area today. She revealed she floats for assignments and there are times when she is in the dining room assisting and there are times when she assists in the hallways passing trays to residents while in their rooms. Staff M confirmed she was at a table in the assistive dining room the day before on 12/8/2025, and was assisting another resident at the same table where Resident #134 was at. Staff M confirmed she did not assist Resident #134 as she was assisting another resident at the table, and confirmed Resident #134 was spilling liquid in her food, and was pushing food off the plate to the table and her lap. Staff M again said she did not assist Resident #134 as she was not assigned to her at that time. Staff M confirmed Resident #134 needed constant supervision and eating assistance, but there was nobody else in the dining room at the time to assist. Staff M felt there should have been more help in the room to help all the residents who required eating assistance. On 12/10/2025 at 8:02 a.m. Resident #134 was noted in her room and lying flat in bed and under the covers. She was observed with her eyes closed and with the call light placed within her reach. The over the bed light was on only. The over the bed table was observed placed at bedside and with the breakfast meal tray placed on it. The lid was covering the plate. At 8:09 a.m. the floor nurse Staff N was at her medication cart just outside the resident's room and she confirmed the resident would be eating in her room and she does require total assistance with eating. Staff N was not sure who was assigned to her to assist with eating, but she did confirm that residents normally eat while in their rooms for breakfast. At 8:17 a.m. Resident #134 was still noted in her room and in bed with her breakfast meal tray placed on the over the bed table. Staff have yet to come in and assist her with eating. At 8:24 a.m. a Staff M was observed to go in the room and closed the door. At 8:30 a.m. the door was opened and Staff M was observed finishing with ADL care with Resident #134's room mate. She was observed to have changed clothes and bed linen for the room mate. Staff M revealed she will be assisting Resident #134 with her meal in a minute as she had to change the room mate's clothes and bed linen. Staff M confirmed the breakfast tray had been in the room for a little while but could not get to Resident #134 yet.It was found Resident #134 was not assisted with her breakfast meal until 8:36 a.m., which was thirty-two minutes after staff had originally placed the meal tray on the over the bed table. At 8:55 a.m. Staff M presented Resident #134's meal tray and it was found after she was assisted with her meal, she did consume 50% of her meal. Staff M confirmed Resident #134 needs assistance with eating and that most of the time she has to feed her, but she does try to cue the resident to pick up the utensil and eat on her own. Staff M confirmed Resident #134 will and does push food off her plate with her fingers and tries to pick up the food items with her fingers as well. It was found through three separate dining observations to include dates 12/8/2025, 12/9/2025 and 12/10/2025, Resident #134, #50, and #168 needed more than Supervision or Touching assistance with Eating Activity of Daily Living (ADL) tasks. It was also found there was not enough staff to provide ADL eating assistance in the (Assistive) dining room as there were residents who had to wait until staff finished with others. Residents in the (Assistive) dining room were not able to make their needs known and were not interviewable. On 12/11/2025 at 12:34 p.m. an interview with the 300 unit Medbridge nurse Staff R revealed she was knowledgeable of Resident #134 and revealed she requires eating assistance and cueing at times and has declined recently. Staff R revealed Resident #134 has Dementia and Alzheimer's and usually needs more than cueing. Staff R revealed she was not aware of lack of staff supervision and assistance for Resident #134 during meal services and explained the schedule of staff changes from day to day in the dining room. She confirmed when residents are in their room and requires assistance with eating, staff should not drop the tray off and leave and come back at a later time to assist. She confirmed the tray should be brought into the room at the same time the resident will be assisted. Staff R also revealed there should be a schedule for staff to assist residents while in the dining room. She revealed there are different staff on different days but does not know who was responsible for ensure those staff get to the dining room to assist. On 12/11/2025 at 12:40 p.m. an interview with the Assistant Director of Nursing (ADON) revealed she normally supervises and assists with meal service and tray pass for most meals, during the days she works. She revealed during the breakfast meal service, she oversees and assists with trays being passed to residents while in their rooms, as the dining room is not utilized during this meal service. She also revealed she assists with the lunch meal service and will receive and place meal carts from the kitchen to either hallways on Medbridge unit or in the main dining room. The ADON confirmed the main dining room has two sections with a smaller section for residents who require eating assistance or cueing with meals. The ADON revealed she normally supervises and assists in this assistive dining room section and will ensure those who need assistance, receives assistance. The ADON revealed there is a rotation of staff between the units with staff who assist with eating ADLs in the assistive dining room. She revealed one day there will be staff assigned and on another day there will be different staff assigned. She did not have a schedule for review. The ADON specified if a resident requires full eating assistance, a staff member must assist with only that resident. She revealed if a resident requires cueing, staff who are assisting residents, can cue other residents from where they are seated. The ADON revealed when staff are seated and assisting with eating for one particular resident, they are not to get up and leave the resident for any time to help others.The ADON revealed she was not aware that on 12/8/2025 and 12/9/2025 during the lunch meal service in the assistive dining room of staff getting up and leaving their assigned resident to help others, and was not aware Resident #134 was left with no one to assist her with eating assistance or cueing. She revealed she did have to assist and supervise meal tray pass in the hallway and in the main dining room (un assistive) section. The ADON confirmed there should have been more staff in the assistive dining room to assist 8-12 residents with eating. She confirmed there are usually more aides in the room to assist with these tasks. Review of Resident #134's medical record revealed she was admitted to the facility on [DATE]. Review of the advance directives revealed Resident #134 had a responsible party to make her medical and financial decisions. Review of the admission diagnosis sheet revealed diagnoses to include but not limited to: DMII, Alzheimer's disease, Anemia, Dysphagia, Conversion disorder with seizures, Insomnia, Depression. Review of the most current Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE], revealed; (Cognition/Brief Interview Mental Status or BIMS score 00 of 15, which indicated Resident #134 was not interviewable and would not be able to speak related to her medical care and services); (Activities of Daily Living related to EATING = Supervision and touching assistance). On 12/11/2025 at 5:00 p.m. the Director of Nursing did not have a specific Staffing the dining room policy and procedure for review. The Director of Nursing instead provided the Quality of Care, Standards and Guidelines: ADL Care and Services policy with a last review date 1/2024, for review. The policy revealed;Standard: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Guideline: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Procedure: 1. Residents will be provided with care, treatment, and services to e sure that their activities of daily living (ADLs) are met.4 . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with, including but not limited to: Dining (meals, hydration, snacks).

Based on interviews and record review, facility did not ensure a resident representative was contacted immediately upon a change in condition for one resident (#178) out of three residents reviewed for change of condition. Findings included: An interview was conducted on [DATE] at 3:49 p.m. with the resident representative (RR) for Resident #178. The RR said he had been at the facility on [DATE] in the evening and Resident #178 was doing about the same as she had been doing, but her breathing was a little labored. The RR said he went home that evening and was not contacted by staff until approximately 7:30 a.m. on [DATE] letting him know Resident #178 passed away. He said he went to visit the resident every day, and staff knew he stayed with her. He said he was not contacted early in the morning when Resident #178's condition declined drastically. Review of admission Records showed Resident #178 was admitted on [DATE] with diagnoses including chronic respiratory failure, heart failure, and unspecified convulsions. Review of Resident #178's progress notes showed: [DATE] 8:27 a.m. At approx [approximately] 0415 [4:15 a.m.] this writer was informed by the assigned CNA [certified nursing assistant], that the resident had an increased effort in breathing. V/S [vital signs] as followed BP [blood pressure] 123/79, HR [heart rate] 148, 02 [oxygen saturation] 68% 8L [liters] on nasal cannula, resident switched to non rebreather with an e-tank on 10L, RR [respiratory rate] 24, temp[temperature] 98.1. Resident had been on a constant decline for the past month. Resident was repositioned to an upright position to attempt to ease her breathing, attempted suctioning with no success. Call made out to [primary care provider's] office spoke with [name] ARNP [Advanced Registered Nurse Practitioner], received new orders to obtain a CXR [chest x-ray] and administer a dose of solu-medrol 125mg [milligram] IM [intramuscular], orders implemented. Resident expired at approx 0647 [6:47 a.m.]. [name] DON, [name] ARNP, and [RR name] were all notified. IV, G-tube, catheter all removed. An interview was conducted on [DATE] at 9:51 a.m. with Staff B, Registered Nurse (RN)/Unit Manager (UM). Staff B said when a resident had a change of condition the nurse should assess the resident, call the doctor and then call the family. She said notification should happen immediately after the change of condition. Staff . said if a resident is declining and/or near death the RR should be called immediately in case they want to come be with the resident. An interview was conducted on [DATE] at 11:55 a.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). They said when a change of condition occurred the facility staff called the family immediately. They said if a change of condition happened in the middle of the night, staff continued to call if they didn't get an answer. The NHA and DON reviewed Resident #178's medical record and confirmed there was only documentation showing the RR for Resident #178 was called after the resident passed away. They both agreed the resident declined significantly at 4:15 a.m. on [DATE] and the RR should have been notified. The DON said she thought the nurse mentioned calling the family, but was not positive and there was no documentation showing a call was made prior to Resident #178 passing. Review of a facility policy titled Change in Resident Condition or Status-Resident Rights, revised 6/2023, showed: Standard: Facility shall notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).Guideline: To ensure the facility provides timely notification in accordance with State and Federal Regulations as it pertains to residents' rights.Procedure: 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting);3. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source;b. There is a significant change in the resident's physical, mental, or psychosocial status;c. There is a need to change the resident's room assignment;d. A decision has been made to discharge the resident from the facility; and/ore. It is necessary to transfer the resident to a hospital/treatment center.

Based on observations, record reviews and interviews, the facility failed to maintain the use of a heart monitor per physician orders for one Resident ( # 138) out of twenty-four residents sampled.2- An observation was conducted on 12/8/25 at 11:57 a.m. of Resident #138's room. On the bedside table there was a round silver metal device with what appeared to be electrodes on a adhesive bandage. The resident was not present in the room at the time. Review of admission Records showed Resident #138 was admitted on [DATE] with diagnoses including essential hypertension, paroxysmal atrial fibrillation and syncope and collapse. Review of Resident #138's orders showed:12/4/25-Do not remove heart monitor. Cardiorenal vision will remove in 14 days. Press button on patient chest if he has a syncopal episode. Review of Resident #138's progress notes did not show any documentation as to why the monitor was no longer in place or that a provider was notified. An interview and observation was conducted on 12/10/25 at 3:15 p.m. with Resident #138. The resident was sitting in his wheelchair at his bedside. He was pleasantly confused. When asked if he had a monitor or anything on his chest, he said he didn't think so. He was observed feeling his chest and looking down his shirt saying he didn't feel anything. An observation and interview was conducted on 12/10/25 at 3:25 p.m. with Staff E, LPN. Staff E confirmed she was assigned Resident #138 that day as well as 12/8/25, the day the monitor was observed on the bedside table. When asked if Resident #138 had a heart monitor on she said, I almost forgot about that. Staff E said she was pretty sure he only had that on for two days and it had been completed. Staff E was observed reviewing Resident #138's physician orders and said, oh it is for 14 days. Staff E said the order was from 12/4/25 and the resident should have still had the heart monitor in place, but she did not know if he did. Staff E was observed entering Resident #138's room and checking him for his heart monitor. Staff E confirmed the resident did not have a heart monitor in place. An interview was conducted on 12/10/25 at 3:31 p.m. with the Director of Nursing (DON) and Staff B, Registered Nurse (RN)/Unit Manager (UM). When asked about Resident #138 having a heart monitor in place the DON said she believe the monitor was ordered but had no come in yet. Staff B said she believed cardiology put the monitor on the resident when they saw him. The DON reviewed Resident #138's medical record and confirmed the heart monitor was placed on the resident 12/4/25 and was to remain on for 14 days. The DON said the monitor should have remained in place and not been removed. She reviewed the photo of the device seen on the resident's bedside table on 12/8/25 and said that it was the heart monitor. An interview was conducted on 12/10/25 at 3:43 p.m. with the Cardiology Nurse Practitioner (NP). The NP confirmed she placed a heart monitor on Resident #138 on 12/4/25 due to him having episodes of syncope. She said the monitor should have remained in place for 14 days, not coming off for showers or any reason. The NP said the device is very difficult to remove and she had never had one come off or a resident be able to remove it. The NP said the round silver metal disc stored the data from the heart and the device was sent to the company who produced a report for the data. She said the device should not have been removed from the resident and she was never contacted by the facility letting her know the device was no longer on the resident. The NP said she would be in the facility the next day and would have to try to locate the monitor. She said she did not know if they would have to begin the test over because this has never happened before. The NP was going to assess the resident and go from there. Review of a facility policy titled Standards and Guidelines: Physician Orders, revised 1/2024, showed:Guideline: Orders and administration of medications and treatments will be consistent with principles of safe and effective order writing.Procedure:9. Physician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated. Photographic evidence obtained

Based on observations, record review and staff interviews, the facility failed to maintain and promote dignity for two of seventy-nine sampled residents (#134 and #13), related to: 1. Staff leaving resident with meal tray in front of her for long periods of time without assistance, and leaving resident and table soiled with liquid and food for long periods of time during four of four meals observed on 12/08/2025, 12/09/2025, 12/10/2025, and 12/11/2025; and 2. Not providing or assisting with provision of clothing leaving resident to wear hospital gowns every day. Findings included: 1. On 12/8/2025 from 12:50 p.m. through to 1:25 p.m. Resident #134 was observed seated at a table in the assistive dining room. She was seated at a table with a table mate and with one staff member, Staff M Certified Nursing Assistant (CNA) in the room. Staff M was observed assisting with eating with Resident #134's tablemate. At 12:50 p.m. Resident #134 had already been served and set up with her meal and most of her food had already been pushed off the plate by her hands. Resident #134 also picked up a clear plastic cup of pink liquid and spilled it on the remaining food items on her plate. A large amount of liquid spilled all over the table, leaving a section of the tablecloth soiled. Resident #134 also had food items on her lap. There were no other staff in the room to assist and intervene with Resident #134's dining experience, and Staff M continued to assist Resident #134's tablemate only. Resident #134 sat at the table with no eating assistance or cueing, and with food and liquid all over the table and herself for over thirty-five minutes. Interview with Staff M at 12:55 p.m. revealed she was in the dining room to assist Resident #134's tablemate and did not realize Resident #134 spilled drink and pushed food off the plate. She confirmed she was seated at the same table with Resident #134 and could not answer why she did not notice what happened with the food and liquid. The tablecloth under and surrounding Resident #134's plate was soaked with liquid. Staff M did not do anything to clean up the mess, nor was she observed assisting or redirecting the resident with her meal and the mess she made. On 12/9/2025 at 12:01 p.m. Resident #134 was again observed seated at a table in the assistive section of the dining room with two other residents. She had already been served her meal and was left to eat on her own. Resident #134 grabbed at food items on her plate with her fingers and then dropped it on the floor, table and her lap. She also picked up a plastic cup of pink liquid and spilled it on her lap while attempting to drink from it. She picked up her tablemate's cup of liquid, and she spilled some of it on her plate with food items. Resident #134 was left with liquid all over her lap and food dropped on her lap for long periods of time and throughout the entire dining service. There were two other staff members in the assistive dining room Staff P, CNA and Staff Q, CNA. Both had to get up from assisting Residents #50 and #168 several times to assist other residents, leaving Residents #50 and #168 without eating assistance for several periods of time. Residents #50 and #168 were not able to be interviewed related to their meal service. On 12/9/2025 at 12:33 p.m. Staff P stated she does not normally help in the assistive dining room and was asked to do so today. She confirmed she and other staff had left Resident #134 without assistance for some time as she and other staff were passing and setting up meal trays for others. Staff P confirmed Resident #134 needs continued monitoring and assistance with her meal and does grab at tablemate's food and utensils. On 12/10/2025 at 8:02 a.m. Resident #134 was observed in her room lying flat in bed under the covers with her eyes closed. The over the bed table was observed placed at bedside with the breakfast meal tray placed on it. The lid was covering the plate and the meal appeared untouched. At 8:09 a.m. Saff N, Licensed Practical Nurse (LPN) confirmed Resident #134 would be eating in her room and requires total assistance with eating. Staff N was not sure who was assigned to Resident #134 to assist with eating and stated residents normally eat while in their rooms for breakfast. At 8:24 a.m. Staff M, CNA was observed to go in the room and closed the door. At 8:30 a.m. the door was opened and Staff M was observed finishing with ADL care with resident #134's roommate. Staff M revealed she will be assisting Resident #134 with her meal in a minute as she had to change the roommate's clothes and bed linen. Staff M confirmed the breakfast tray had been in the room for a little while but could not get to Resident #134 yet. Resident #134 was not assisted with her breakfast meal until 8:36 a.m., which was thirty-four minutes after staff had originally placed the meal tray on the over the bed table. At 8:55 a.m. Staff M confirmed Resident #134 needs assistance with eating and that most of the time she has to feed her, but she does try to cue the resident to pick up the utensil and eat on her own. Staff M confirmed Resident #134 does push food off her plate with her fingers and tries to pick up the food items with her fingers as well. Staff M was not sure if Resident #134 had been seen by a Speech Therapist. On 12/11/2025 at 9:00 a.m. Resident #134's was observed sitting on the side of her bed and with her breakfast meal tray placed on the over the bed table, which was positioned behind her on the other side of the bed and at the window wall. The tray could not be reached by the resident. The meal tray was still covered and appeared to not have been touched or set up by staff. At 9:16 a.m. another observation revealed the resident was still seated in the same position in bed and with her breakfast meal tray placed behind her and still not touched or assisted with set up. At 9:25 a.m. Staff P, CNA was observed going into Resident #134's room and asked Resident #134 if she wanted to eat. The resident told her, Yes. Staff P brought the tray around to the front of the resident and she sat down and set up the meal tray and began to both cue and at times assist her with eating. Resident #134 was not able to answer questions related to her dining services. Interview with Staff P at 9:40 a.m. revealed she was not able to get to Resident #134 to assist her with her meal as she had to pass trays to other residents. She confirmed the tray was in the room for a long period of time without set up and assistance and usually residents who require assistance with their meals are served and set up last. Review of Resident #134's medical record revealed she was admitted to the facility on [DATE]. Review of the advance directives revealed Resident #134 had a responsible party to make her medical and financial decisions. Review of the admission diagnosis sheet revealed diagnoses to include but not limited to: DMII, Alzheimer's disease, Anemia, Dysphagia, Conversion disorder with seizures, Insomnia, Depression. Review of the most current Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE], revealed; (Cognition/Brief Interview Mental Status or BIMS score 00 of 15, which indicated Resident #134 was not interviewable and would not be able to speak related to her medical care and services); (Activities of Daily Living related to EATING = Supervision and touching assistance). On 12/10/2025 at 1:10 p.m. an interview with the Director of Rehabilitation (DOR) confirmed Resident #134 does need ADL eating assistance from staff and she has been continuing with Speech Therapy since her admission. The DOR could not say how many nursing staff assist residents with eating in the assistive dining room. She did confirm it depends on what type of assistance each resident requires. The DOR confirmed Resident #134 should not be left alone with her meal to eat on her own, and does require supervision with some assistance with eating. She revealed Resident #134 has dementia and Alzheimer's and needs the extra cueing. 2. During an interview on 12/08/2025 at 1:42 p.m., Resident #13 revealed he would like some clothing. He said he had spoken to staff members, and he had told them that he would like to be transported to dialysis with clothing on instead of the hospital gown but he doesn't have any. He stated the staff members have told him multiple times they would get this done but he is still without clothing and he is transported to dialysis in a hospital gown. It was observed he was in a soiled hospital gown during this interview. An observation on 12/08/2025 at 4:00 p.m., revealed Resident #13 was still in a hospital gown and his closet was open and empty. An observation on 12/9/2025 at 1:42 p.m., Resident #13 Had no clothing in his closet. An observation on 12/10/2025 at 9:30 a.m., Resident #13 was in a hospital gown and did not have any clothing in his closet. An observation on 12/11/2025 at 11:28 a.m., and again at 6:10 p.m., Resident #13 was in a hospital gown and did not have any clothing in his closet. Resident #13 stated again he has told people he doesn't have clothes, but they haven't done anything about it he said he was not sure who else to tell. During an interview with Staff M, (CNA) on 12/10/2025 at 12:49 p.m., Staff M stated Resident #13 is in and out of the hospital a lot and he goes to Dialysis three times a week and he always wears his hospital gown. She stated that she knew he did not have any clothing and had reported it before, but she had seen no results, no clothing. She reports anything to the nurse in charge that day. Staff M provided details on how they have donated clothing residents will leave behind that can be used for anyone at any time. During an interview on 12/10/2025 at 1:13 p.m., Staff L, LPN stated that she is aware he has no clothing, and she has not reached out to the social worker about it, but she said that is a good idea and that she would do that now. Interview on 12/11/2025 at 6:00 p.m., with the Director of Activities, she stated she was not aware Resident #13 did not have any clothing. She said the process would be to contact family and see if they could bring some clothing over, but she is not sure if that has happened with this resident and she would follow up. During an interview on 12/11/2025 at 7:08 p.m., the Social Services Director said she was unaware that any resident did not have any clothing it had not been reported to her. She stated the expectation of this facility is if a resident comes in without clothing they would get involved and find clothing for the resident. Resident #13 has not been reported to her prior to this time. During an interview on 12/11/2025 at 7:20 p.m., the Director of Nursing (DON) reported she was not aware Resident #13 did not have any clothing. The expectation is the CNA's report that to her. Record review of Resident #13's admission Record revealed Resident #13 was re-admitted [DATE] with diagnoses to include; nonrheumatic aortic valve stenosis, end stage renal disease, hemodialysis 3x week, chronic diastolic congestive heart failure, type 2 diabetes, depressive disorder, generalized anxiety disorder, and insomnia. Review of the Minimum Date Set (MDS) assessment, dated 11/07/2025, revealed in Section C (Cognitive Patterns) the resident had a Brief Interview for Mental Status (BIMS) score of a 13 out of 15 score indicating the resident was cognitively intact. Review of the medical record revealed the Task Response History for Dressing, over the dates between 09/01/2025 - 12/10/2025 revealed Resident #13 needed extensive to total dependence assistance daily. Review of the Care Plan record for Resident #13 revealed that his Activities of Daily Living (ADL) care does not mention ADL for dressing or clothing. Review of Resident #13's Valuables Listing inventory sheet on last intake on 06/06/2025 did not indicate he had any clothing items listed. Review of the policy titled Resident Rights policy and procedure, with a last reviewed date of 1/2024 for review revealed; Standard: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. Guideline: Employees shall treat all residents with kindness, respect, and dignity. Procedure to include but not limited to: 1. Federal and State laws guarantees certain basic rights to all residents of this facility. These rights include the resident's right to: a. A dignified experience, b. Be treated with respect, kindness, and dignity, h . Be supported by the facility in exercising his or her rights.

Based on observations, interviews and record review, the facility failed to provide two of seventy-nine sampled residents, (#134 and #153) with Activities of Daily Living tasks to include 1. lack of Eating assistance during three meal observations and 2. lack of assistance with getting out of bed. Findings included: 1. On 12/8/2025 from 12:50 p.m. through to 1:25 p.m. Resident #134 was observed seated at a table in the assistive dining room. She was seated at a table with a table mate and with one staff member, Staff M Certified Nursing Assistant (CNA) in the room. Staff M was observed assisting with eating with Resident #134's tablemate. At 12:50 p.m. Resident #134 had already been served and set up with her meal and most of her food had already been pushed off the plate by her hands. Resident #134 also picked up a clear plastic cup of pink liquid and spilled it on the remaining food items on her plate. A large amount of liquid spilled all over the table, leaving a section of the tablecloth soiled. Resident #134 also had food items on her lap. There were no other staff in the room to assist and intervene with Resident #134's dining experience, and Staff M continued to assist Resident #134's tablemate only. Resident #134 sat at the table with no eating assistance or cueing, and with food and liquid all over the table and herself. There were no other staff observed in this section of the dining room other than Staff M. Interview with Staff M at 12:55 p.m. revealed she was in the dining room to assist Resident #134's tablemate and did not realize Resident #134 spilled drink and pushed food off the plate. She confirmed she was seated at the same table with Resident #134 and could not answer why she did not notice what happened with the food and liquid. The tablecloth under and surrounding Resident #134's plate was soaked with liquid. Staff M did not do anything to clean up the mess, nor was she observed assisting or redirecting the resident with her meal and the mess she made. On 12/9/2025 at 12:01 p.m. the main dining room was entered and there were two sections. There was a larger section of the room that had residents dining without staff assistance, and there was a smaller section that were with residents who were being assisted by staff with setting up and eating. The smaller assistive dining room area was observed with approximately 12 residents and with two staff members in seated and assisting with feeding. Resident #134 was observed seated at a table with two other residents and with no staff seated at the table or in the immediate area. Resident #134 and the two table mates were already served and set up with their lunch meal trays. Resident #134, who required more than supervision and in need for cuing and some eating assistance, was observed without staff assistance/monitoring and was grabbing at her food items with her fingers and hands. She picked up a cup full of pink liquid and was trying to bring it to her mouth and as she was doing that, liquid spilled onto the plate of food. She did not use the eating utensils that were placed next to her plate. Resident #134 then was observed to drop food from her hands onto the table and then to her lap. She was observed to pick up and drop some food at least three times. Resident #134 grabbed at her table mates silverware and Staff P, CNA, walked over to the table and asked Resident #134 to not take from her table mate and to use her own eating utensils. Staff P walked away and immediately Resident #134 reached out and grabbed her tablemate's cup of pink liquid and started to drink out of it. There were no staff seated and around the table to assist and monitor Resident #134 and others at the table. There were only two staff in the dining area to include CNAs Staff P and Q, and they were either assisting passing trays to others in the room, or were seated at a table and helping to assist with feeding a resident. At 12:19 p.m. a CNA Staff P sat down to assist Resident #134 with both cueing and eating assistance. However, Staff P was observed to leave Resident #134 after assisting for about two minutes. At 12:13 p.m. the Assistant Director of Nursing was observed to bring a meal tray cart in the room and then walked over to sit next to Resident #134. She immediately began to pick up the eating utensil and brought food to Resident #134's mouth. Resident #134 accepted the bites and she was also observed to use the eating utensil with cueing. It was observed Resident #134 required both eating cueing and eating assistance, and needed full supervision so the resident would not continue to reach out and take her tablemate's food, drink and eating utensils. It was noted Resident #134 went without any supervision, cueing and or eating assistance for eight minutes, which resulted in resident spilling food and drink all over the table and spilling drink into her food. At 12:33 p.m. an interview with Staff P, CNA, who was now seated and assisting with eating with another resident at another table, revealed she does not normally help in the assistive dining room and was asked to do so today. She confirmed she and other staff had left Resident #134 without assistance for some time as she and other staff were passing and setting up meal trays for others. Staff P confirmed Resident #134 needs continued monitoring and assistance with her meal. On 12/10/2025 at 8:02 a.m. Resident #134 was observed in her room lying flat in bed under the covers with her eyes closed. The over the bed table was observed placed at bedside with the breakfast meal tray placed on it. The lid was covering the plate and the meal appeared untouched. At 8:09 a.m. the floor nurse Saff N was at her medication cart just outside the resident's room and she confirmed Resident #134 would be eating in her room and she does require total assistance with eating. Staff M was not sure who was assigned to her to assist with eating. At 8:55 a.m. Staff M confirmed Resident #134 needs assistance with eating and that most of the time she has to feed her, but she does try to cue the resident to pick up the utensil and eat on her own. It was found through three separate dining observations to include dates 12/8/2025, 12/9/2025 and 12/10/2025, Resident #134 needed more than Supervision or Touching assistance with Eating Activity of Daily Living (ADL) tasks. It was found Resident #134 had declined with Eating ADLs since last assessed. Review of Resident #134's medical record revealed she was admitted to the facility on [DATE]. Review of the advance directives revealed Resident #134 had a responsible party to make her medical and financial decisions. Review of the admission diagnosis sheet revealed diagnoses to include but not limited to: diabetes, Alzheimer's disease, anemia, dysphagia, conversion disorder with seizures, insomnia, depression. Review of the most current Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE], revealed; (Cognition/Brief Interview Mental Status or BIMS score 00 of 15, which indicated Resident #134 was not interviewable and would not be able to speak related to her medical care and services); (Activities of Daily Living related to EATING = Supervision and touching assistance). Review of the current month (12/2025) Physician's Order Sheet revealed orders to include but not limited to: CCHO (Consistent Carbohydrate) diet, Mechanical Soft texture, Thick consistency liquids with Fortified foods at meals, with an order date 10/31/2025; Speech Therapy clarification: 3-5 x/week x 60 days of Treatment of speech, language, voice, communication, and/or auditory processing disorder and Treatment of swallowing dysfunction and/or oral function for feeding, Group Therapy and Cognition, with an order date of 10/31/2025; Weight within 72 hours of admission then weekly x 3 and then monthly, with an order date of 11/1/2025. Review of the [NAME] Admission/readmission Nursing Evaluation dated 10/31/2025 revealed in section a part D ADL/Function, Resident #134 required Limited assistance with Eating. Review of the 10/31/2025 admission Nutrition assessment revealed Resident #134 had a diagnosis of Calorie Malnutrition and Alzheimer's, admission weight of 152 lbs., no changes in weight, usual PO intake 76% 0 100%, independent with feeding assistance, and is at risk of malnutrition. Review of the Hospital Discharge assessment (form 3008), dated 10/30/2025 revealed under section Q Nutrition/Hydration – Resident requires assistance with eating. Review of the nurse progress notes dated from admission on [DATE] through to current date 12/10/2025 revealed; 1. 11/6/2025 15:55 Summary of Skilled Services note revealed; Patient eats at the alcove dining room for more oversight and assistance with meals. 11/12/2025 15:47 Summary of Skilled Services note revealed; Patient eats at the alcove dining room for more oversight and assistance with meals. 11/14/202520:06 Summary of Skilled Services note revealed; Patient fed by staff with good consumption. 11/15/2025 15:29 Summary of Skilled services note revealed; Patient requires assistance with meals. 11/25/2025 15:40 Summary of Skilled services note revealed; Patient eats at the alcove dining room for more oversight and assistance with meals. 12/2/2025 16:23 Summary of Skilled services note revealed; Patient eats at the alcove dining room for more oversight and assistance with meals. Review of the current care plans with an initiated date of 10/31/2025 and with next review date 1/30/2025, revealed the following but not limited to problem/care areas; a . Resident is at risk for alteration nutrition/hydration r/t dementia, Hypertension, Hyperlipidemia, Diabetes, Hyponatremia, Anemia, poor dentation, weight loss, with interventions in place to include but not limited to: Mechanical altered diet at meals, Speech Therapy/Occupational Therapy to evaluate and screen as needed or ordered; Weights as ordered. b . Resident is at risk for aspiration and or history of Aspiration r/t poor dentation, with interventions in place to include but not limited to: Encourage and assist resident to eat in upright position, Speech therapy screen/evaluation/treatment as indicated/ordered. c . Resident is participating in physical, occupational or speech therapy with a goal to improve their functional level, with interventions in place to include but not limited to: Observe for changes in Resident's Functional Abilities, Provide therapy interventions as ordered/indicated. d . Resident is at risk and or have actual impaired cognitive function/impaired thought process related to Alzheimer's dementia, with interventions in place to include but not limited to: Provide cueing and reorientation as need, Speech therapy evaluation and treatment as indicated/ordered. e . Resident has a potential for ADL self care deficit r/t ADL needs and participation vary, Fatigue, chronic medical conditions, with interventions in place to include but not limited to: Encourage and Educate resident with increased independence as tolerated and assist with all ADL tasks as indicated, including locomotion/ambulation, bathing, bed mobility, transfers, toileting, meals, etc.; EATING; The resident needs SUPERVISION verbal cues and/or touching steadying of hands to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. On 12/10/2025 at 1:00 p.m. an interview with a Speech Therapist Staff J, revealed she was knowledgeable of Resident #134 and that she has dementia/Alzheimer's, with very low cognition. Staff J explained Resident #134 has been on Speech Therapy case load since her admission and between herself and Speech Therapist Staff L, they do see her on caseload. Staff J revealed Speech Therapy will make resident assessment for eating to include chewing and swallowing safety as well as consumption and utilization of eating/drinking equipment. Staff J revealed during the times therapy is not with Resident #134, nursing staff to include aides and nurses provide eating assistance. She was not sure how many staff are in the assistive dining room during meals to assist residents with their meals. Staff J revealed based on the resident's assistive or cueing needs, direct care staff should know what they need to do assist the resident. On 12/10/2025 at 1:10 p.m. an interview with the Director of Rehabilitation (DOR) confirmed Resident #134 does need ADL eating assistance from staff and she has been continuing with Speech Therapy since her admission. The DOR could not say how many nursing staff assist residents with eating in the assistive dining room. She did confirm it depends on what type of assistance each resident requires. The DOR confirmed Resident #134 should not be left alone with her meal to eat on her own, and does require supervision with some assistance with eating. She revealed Resident #134 has dementia and Alzheimer's and needs the extra cueing. 2. On 12/09/2025 at 10:23 a.m., Resident # 153 was observed lying down in bed with her call light in reach, and no signs of distress. She stated the staff doesn't get her up when she wants to get up because they don't have enough Hoyer pads available. Resident # 153 stated she has complained to staff about it and filed a grievance, but no one at the facility addressed her concerns On 12/09/2024 at 3:00 p.m. Resident # 153 was observed lying down in bed sleeping with her call light in reach. Review of an admission Record dated 12/11/2025 revealed Resident # 153 was originally admitted to the facility on [DATE] with diagnoses to include but not limited to acute diastolic (congestive) heart failure, essential (primary) hypertension, unspecified glaucoma Review of a Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident # 153 is cognitively intact. Review of Resident # 153 care plan dated 9/25/2024 revealed a focus for Activity of Daily Living (ADL) revealed Resident #153 has a potential for ADL self- care deficit related to (r/t) ADL needs and participation vary, chronic medical conditions, fatigue, impaired balance, limited mobility, Musculoskeletal impairment, history of coccyx fracture. Review of the care plan intervention revealed Resident # 153 transfers using a Mechanical Lift and requires two staff assistance with transfer. On 12/10/2025 at 11:38 a.m, an interview was conducted with Staff AA, CNA. Staff AA stated she is a new employee and has worked at the facility for 1 month. She has worked with Resident # 153 for the last couple of weeks and is familiar with her care. She said she gets her up every day using a Hoyer Pad/Sling. She said the only day the resident could not get up was when there was a fire in the facility, and on last Sunday when her Hoyer Pad/ Sling was in the laundry. Staff AA stated when Resident # 153 Hoyer Pad was sent to laundry, she did not have another pad available at that time to get her up. Staff AA stated the unit manager informed her today they purchased another Hoyer pad/ Sling for the resident and it's located in the shower room. On 12/10/2025 at 11:48 a.m an interview was conducted with Staff BB, Registered Nurse, RN. Staff BB stated she works at the facility as needed, and floats to different units. Staff BB said she is assigned to Resident # 153 today and her expectation is if a resident wants to get up then staff should meet the needs and desires of the resident. On 12/10/2025 at 11:54 a.m. an interview was conducted with Staff Y License Practical Nurse, LPN /Unit Manager. Staff Y stated her expectation is every resident should get out the bed. On the weekend if a resident wants to rest then it's okay for them to stay in bed. She said they have four residents on [NAME] Unit that uses the Hoyer lift. If a resident Sling/ Hoyer Pad is sent to the laundry room, then they always have extra Slings in the shower room. Staff Y stated if a staff member reports they can't get a resident up because the resident Hoyer Pad/ Sling is in laundry, then they should find someone in charge to locate one for them. A resident sling being in laundry is not an excuse to keep a resident in bed. Review of a facility policy titled, Standards and Guidelines: ADL Care and Services Revision dated 01/2024, revealed, Standard: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living ( ADLs). Guideline: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) are met. 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including, but not limited to b. Mobility (transfer, ambulation, wheelchair, splint/brace); d. Dining (meals, hydration, snacks).

Based on interviews and record review the facility did not ensure preadmission screening for mental disorders was completed accurately for three residents (#3, #149, and #88) out of thirty-three sampled residents.Findings included: 1. Review of admission Records showed Resident #3 was admitted on [DATE] with diagnoses including dementia, depression, and bipolar disorder. Review of Resident #3's PASRR Level I Screen, dated 7/23/25, indicated the resident had depressive disorder and bipolar disorder. However, Section II was marked No for the question Does the individual have validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease)? An interview was conducted on 12/11/25 at 7:14 p.m. with the DON. The DON reviewed Resident #3's medical record and PASRR Level I screen. She confirmed Resident #3 had a dementia diagnosis and she should have indicated that in Section II. The DON confirmed Resident #3's PASRR Level I screen was completed inaccurately. 2. Review of the admission record showed Resident #149 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia – 6/4/25, anxiety disorder – 6/4/25, major depressive disorder – 6/4/25, and bipolar disorder –6/4/25. A review of the Level I PASRR for resident #149, dated 8/28/25, revealed dementia as a secondary diagnosis was not selected. The review showed the Level I PASRR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. During an interview on 12/10/25 at 10:40 a.m., the Director of Nursing (DON) said on admission she reviews Level 1 PASRR's with the social worker and updates are added by the DON. The DON reported that they had reviewed Resident # 149's Level 1 PASRR and determined the resident did not meet the criteria for a Level II referral. The DON stated that the Resident #149 does not have a serious mental illness and bipolar disorder is not considered a serious mental illness. 3. Review of the admission record showed Resident #88 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia – 8/27/25, anxiety disorder – 9/24/25, major depressive disorder – 8/27/25, bipolar disorder –9/24/25 and panic disorder 9/24/25. A review of the Level I PASARR for resident #88 dated 8/28/25 revealed not all qualifying diagnoses were selected. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. During an interview on 12/11/25 at 3:33 p.m. the DON said new diagnoses should have been added to Resident #88's PASARR during the monthly gradual dose reduction (GDR) meeting. On 12/10/25 at 3:15 p.m. the Nursing Home Administrator (NHA) said the facility did not have a policy related to PASRRs, they follow the federal regulations.

Based on observations, interviews and facility policy, the facility failed to report an allegation of abuse for two (2) residents (# 20, #166) out of five (5) residents sampled.Findings included:On 12/09/2025 at 3:00 p.m. an observation was made of Resident #20 sitting in her wheelchair propelling up and down the hallway. Resident # 20 presented a little confused but stated she had no concerns.On 12/11/2025 at 10:00 a.m. an observation was made of Resident # 20 sitting in her wheelchair propelling up and down the hallway. She said she was getting ready to go to an activity.Review of Resident # 20 admission record revealed she was admitted to the facility on [DATE] with diagnoses to include but not limited to permanent atrial fibrillation, age-related osteoporosis without current pathological fracture, cognitive communication deficit.Review of Resident # 20's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07 which indicated Resident #20 is cognitively impaired.On 12/10/2025 at 4:00 pm an interview was conducted with Resident # 20's daughter the complainant. She stated her mother was crying when she called her on Sunday evening. The daughter stated her mother reported to her a cna was screaming at her and her roommate. She said the roommate spoke with her to confirm that the cna was yelling at her mother. The daughter said after she spoke with her mom, she called the facility around 8:57 p.m. and spoke to a staff member on the unit where her mother resided to report her concerns. She stated she told the staff what her mother and the roommate reported to her and stated she did not want the aid to return to her mother's room. The daughter stated the staff she spoke to told her they would report her concern to the nurse.2.On 12/10/2025 at 2:30 p.m. and at 5:00 p.m., an observation was made revealing Resident # 166 sitting in her room in her wheelchair, she was observed with no signs of distress.Review of Resident # 166 admission record revealed she was admitted to the facility on [DATE] with diagnoses to include but not limited to sarcopenia, endocrine disorder, unspecified, major depressive disorder.Review of Resident # 166 Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #166 is Intact cognitivelyOn 12/10/2025 at 2:50 p.m. an interview was conducted with Resident # 20 and her roommate Resident # 166. Resident # 20 stated Sunday night a staff member, she could not recall the name, came into her room and yelled at her and her roommate. Resident # 20 started crying when explaining the situation, stating that she had never been treated that way since she came to the facility. Resident # 20 said she couldn't remember all the details because she got so upset but she did tell her nurse that night what happened and the nurse told her she was going to investigate it. The roommate Resident # 166 remembered the details of the event, stating that every night she help's Resident # 20 get situated in the bed by tucking in her feet and putting an extra blanket over her legs. On Sunday night she stated that she was doing her usual routine, helping Resident # 20, when a staff member came into the room and got in her face yelling and telling her that she could not touch the resident. Resident # 166 stated the staff member pointed her finger forcefully and told her she needed to go to bed. She told the staff member that she always helps her roommate before she goes to sleep and stated the staff continued to yell at her saying that she is not to help the roommate and she needed to either go to bed or go sit in her chair. She stated that she also became emotional and started to cry because she didn't understand why she was being yelled at and felt that she had done nothing wrong. Resident # 166 stated she did not know what happened with that staff member but two ladies, she did not know their names or what their roles were, came into the room the next day and told them the staff member they had the incident with would never be assigned to them again. On 12/11/2025 at 10:26 a.m. an interview was conducted with Staff X, License Practical Nurse, (LPN). Staff X said she was the nurse assigned to Resident # 20 on Sunday night. Staff X stated Resident # 20 and # 166 did not report to her a staff member yelled at them.On 12/11/2025 at 10:30 a.m., an interview was conducted with the Director of Nursing, DON. The DON said Staff Y, the unit manager, reported to her that she overheard one of the nurses saying she did not know anything about Resident # 20 having any issues with a staff member on Sunday night. The DON said Staff Y told her she might want to speak to Resident # 20 about a concern. The DON said Resident # 20 reported to her she was upset because a staff member was talking loudly in the hallway, but she felt safe in the facility. The DON stated she knows who the cna is the resident felt were talking loudly. She stated the cna voice carries whenever she talks, and she is very loud. The DON said they have had multiple conversations with the cna concerning her loud tone and how it could come across wrong to others.On 12/11/2025 at 11:33 a.m. an interview was conducted with Staff Y, LPN /Unit Manager on the west unit. Staff Y said she overheard one of the Registered Nurses say they did not know anything about Resident # 20 having any concerns over the weekend with her aid. Staff Y said once she overheard the conversation, she asked the Director of Nurses if she was aware of anything that happened to Resident #20 over the weekend. Staff Y stated she told the DON and maybe she should speak to the residents to see what happened. Staff Y said if she was made aware or witnessed one of the staff yelling at any of the residents, she would immediately remove the resident, remove the staff and immediately notify the Administrator or Director of Nurses. Staff Y said if a staff were yelling at a resident, it is considered verbal abuse and should be reported.On 12/11/2025 at 11:40 a.m. An interview was conducted with the Director of Nursing and the Nursing Home Administrator. The NHA stated she would have reported the certified nursing assistant if staff had reported to her the cna was yelling at Resident # 20 and #166. The DON stated she spoke to Resident # 20 yesterday and was told by the resident staff was talking loudly in the hallway. The DON said she asked Resident # 20 was she scared or harmful during her interview and was told by the resident she felt safe in the facility. The DON said she did not talk to the roommate to ask if anything happened to her because she was only told to talk to Resident # 20. The NHA said she did call Resident # 20 daughter today. The NHA stated when she spoke to the daughter, she was informed the daughter called the facility Sunday night to report to staff that her mother was crying about a cna yelling at her and her roommate. The NHA stated the daughter reported she told staff she did not want the cna assigned back to her mother. The NHA said this was the first time she was told this information. If her staff had made her aware of the incident she would have started an investigation and submitted a report.On 12/11/2025 at 12:30 p.m., an observation and interview were conducted in Residents # 20 and #166 room with the Director of Nursing and Resident # 166. The Director of Nursing asked Resident # 166 about the incident reported to them about a staff yelling at her and Resident # 20. During the interview Resident # 166 stated on Sunday she was trying to assist Resident # 20 in bed. She stated a staff member came from out the bathroom and started yelling at her and Resident # 20. She stated the staff came over to her and put her finger in her face and yelled at her, telling her to leave Resident # 20 alone, and that she should go sit down. The DON asked Resident, 166 did she tell anyone. Resident # 166 replied, I did not tell anyone because I was so upset. Resident # 166 stated two ladies came down to their room that night to tell the residents they were going to take care of the situation and the staff member who yelled at them will not be allowed back in their room.Review of the facility policy titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI), Revision dated 03/2025, revealed Standards: The resident had the right to be free from abuse, neglect, exploitation, misappropriation or resident property, mistreatment, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents' medical symptoms.Initial Reporting: 1. In accordance with CFR 483.12 (c ) (1) , with response to allegation of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that causes the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the vent that causes the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other official ( including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures.

Based on observation, record review, and interview, the facility failed to provide sufficient staffing to adequately meet the residents' needs for nine residents (#131, #117, #26, #147, #144, #80, #72, #537, and #128) out of 63 residents sampled. Findings Included: 1. On 7/30/2023 at 9:10 a.m., an interview was conducted with Resident #131's family member. The family member said the 11:00 p.m.-7:00 a.m. shift was constantly understaffed, which had an impact on Resident #131 because he was always wet when she visited him in the morning. She said that she visited him before the morning shift started their assigned shift, so she knew that it was the night shift who left the resident wet. A review of the staffing assignment sheet, dated 7/30/2023, revealed Staff K, Registered Nurse (RN) worked as a nurse and a Certified Nursing Assistant (CNA) on the 11:00 p.m.-7:00 a.m. on the Medbridge unit. A review of the staffing assignment sheet, dated 7/31/2023, revealed Staff L, Licensed Practical Nurse (LPN) and Staff K, RN worked as nurses and CNAs from 11:00 p.m.-7:00 a.m. on the Medbridge unit. On 8/1/2023 at 12:00 p.m., an interview was conducted with Staff N, CNA. Staff N said she had been working at the facility for [AGE] years. She said sometimes they had enough staff and sometimes they did not. She reported she used to help out on 11:00 p.m.-7:00 a.m. shifts, but she stopped because they had a lot of call offs on that shift and it was too much for one CNA to have to work on the unit by themselves. She said last night they only had one CNA on for the 300 hall (Medbridge Unit) for 38 residents. On 8/1/2023 at 1:00 p.m., an interview was conducted with Staff K, RN. She said she worked as a CNA and a nurse for her shift from 11:00 p.m.-7:00 a.m. last night. She said that she and another nurse (Staff L, Licensed Practical Nurse [LPN]) and a CNA divided up the assignment. They gave the CNA 20 residents and both she and the other nurse had nine residents a piece. She said it was hard, but they made it through the night. Review of the CNA Assignment Sheet for 11(p.m.) to 7:00 (a.m.) for the Medbridge Unit showed Staff L, LPN was assigned rooms 301-321, Staff K, RN was assigned rooms 339-349 and 354-356 and Staff O, CNA was assigned rooms 322 - 338 and 357 - 373. and review of the census showed 36 residents on this unit. On 8/1/2023 at 1:38 p.m., an interview was conducted with Staff L, LPN. Staff L reported she worked as a CNA and a nurse last night and the night before due to staff calling out. She said she and Staff K worked as both nurses and CNAs for the whole night on the Medbridge unit. On 8/1/2023 at 1:45 p.m., an interview was conducted with Staff M, CNA. Staff M reported she was not able to provide dining assistance for her residents because they were always working short staffed at the facility. On 8/1/2023 at 4:00 p.m., an interview was conducted with Staff O, CNA. Staff O confirmed that she worked as a full time CNA on the 11:00 p.m.-7:00 a.m. shift on the Medbridge Unit. She confirmed she was the CNA who worked with both Staff L, LPN and Staff K, RN on the 11:00 p.m.-7:00 a.m. shift when they both worked as nurses and CNAs. She said they were short staffed often but she was able to manage her workload. On 08/02/23 at 9:42 a.m., an interview was conducted with Staff R, Staffing Coordinator. Staff R said she determined staffing in the facility by the census, and not by acuity. Whenever there was a call out and she was not in the building, the charge nurse was responsible to make sure there was coverage for the shift. She said they used agency but just for nurses, however after today, they had signed an agreement for agency CNAs. A review of the Facility Assessment, undated, showed: Requirements, Nursing facility will conduct, document, and annually review a facility-wide assessment, which includes both their resident's population and the resources the facility needs to care for their residents. Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using competency- based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychological well-being. The intent of the facility assessment is for the facility to evaluate its resident's population and identify the resources needed to provide the necessary person- centered care and services the resident requires. Staffing Plan 3.2 Based on our resident population, acuity of residents and the duties of the day-to-day operations - the following staffing plan is in place to meet those needs. The ratio of registered and license practical nurses to aids shall be sufficient to assure professional guidance and supervision in the nursing care of the residents. 37999 2. The Admission Record for Resident #117 identified admitted s of 1/20/22 and 5/31/2023. The record included diagnoses not limited to unspecified anxiety disorder, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 8/1/23 at 9:41 a.m., during an observation of medication administration, Resident #117 informed Staff S, LPN, of not getting a shower last night and that staff had told the resident they didn't have time. On 8/2/23 at 9:29 a.m., during an interview with Resident #117 she stated the staff were not very nice when giving a shower, they were rushed, and had an attitude. The resident stated when she did not receive a shower the staff would tell her they were too busy. A review of the Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. A review of the shower day schedule showed Resident #117 was to receive a shower during the 3:00 p.m.-11:00 p.m. shift on Monday and Thursday. A review of the Certified Nursing Assistant (CNA) documentation showed on Monday on 7/3/23 at 2:59 p.m., Resident #117 received a sponge bath, on 7/31/23 at 10:30 a.m., in addition at 9:14 p.m. the documentation indicated the resident had refused. 41015 3. During an interview on 07/30/23 at 1:11 p.m., Resident #26 stated the facility needed the staff to answer the call lights faster and not make residents wait long periods of time. Resident #26 stated they had to wait 45 minutes to an hour for someone to come answer the call light. 4. During an interview on 07/30/23 at 11:40 a.m., Resident #147 stated a concern with call light response time. Resident #147 stated the other night, I was so thirsty and put the call light on. Resident #147 stated it took staff over an hour to answer the call light just to get a drink of water. 5. During an interview on 07/30/23 at 12:05 p.m., Resident #144's family member stated the other day he looked for staff and could not find anyone. Resident #144's family member stated he did not know if it was the time of day of the visit but, there was a concern about staffing. A review of the facility's Resident Council minutes showed: -07/17/23- Old Business- Followed up with nursing with call lights and showers. - 07/03/23- Residents report slow call light response at times on 11-7 shift. - 06/05/23- Followed up with nursing regarding all lights. During an interview on 08/02/23 at 9:33 a.m., Staff A, Activities Therapist (AT) stated the Activity Director was charge of Resident Council. Staff A stated based on the Resident Council minutes notes she was not able to identify when the first complaint about call light response times started but would check more into the question since the Activity Director was out of the facility. Staff A stated when a concern was addressed at Resident Council , the Activity Director wrote a grievance immediately and took it to the social services department to take care of. During an interview on 08/02/23 at 10:00 a.m., Staff A stated the first call light concern identified in Resident Council was on 05/08/23. Staff A stated there was a grievance written corresponding to the identified concern made in the Resident Council meeting on 05/08/23. On 8/2/23 at 12:30 p.m., the Resident Council President (RCP) stated the issue, mentioned in the Resident Council minutes, was that call lights were not answered efficiently then clarified that it took staff to long to answer. A review of the facility's Grievance Log showed concerns related to call bell response times. The Grievance Log showed as followed: 05/08/23- Concern of call bell timeliness - Call bells not timely 11-7. 05/22/23- Concern of call bell- Call bell on 11-7 last weekend. Dinner was late last weekend too. 07/03/23 - Concern call bell- Report times call bell is slow. A review of the facility's Grievance Form with facility response was reviewed related to call bell response times. The Grievance Forms showed as followed: - Dated 05/08/23 the grievance showed, slow call light response at times on 11-7 shift (East and West). An in-service was provided to staff regarding call lights and answering call lights timely. Since staff education patients report its better. The in-service was conducted to all staff on 05/11/23 titled Customer Service. - Dated 05/22/23 the grievance showed, long call light response wait times on 11-7 shift and on weekends. An in-service was provided about call light response times. The in-service was conducted on 05/22/23 titled Call Light Response. -Dated 07/03/23 the grievance showed, slowed call light response at times. Occasionally it took a longer time to get a CNA to answer call lights promptly. An in-service was provided on call light response times. The in-service was conducted on 07/10/23 titled Call Bell Response. During an interview on 08/02/23 at 3:10 p.m., the Nursing Home Administrator (NHA) stated staff were educated regarding call bell response times after each grievance related to call bell concerns. 39866 6. An interview was conducted on 7/30/23 at 10:30 a.m. with Resident #80's family member. The family member stated, The only thing they [the facility] can improve on is always having someone available that can help because, if the person that is assigned to you is on break; the staff will say oh, I'm not your nurse, or I'm not your CNA [Certified Nursing Assistant] you have to wait till they get back. [Resident #80] can't use the call light but if I put the call light on, they don't answer that. It's worse on the night shift there's never any one around or at the nurse's station. 7. An interview was conducted on 7/30/23 at 12:00 p.m. with Resident #72's family member. She stated, If you push the call light it will take 30-45 minutes for anyone to even answer the call lights and that's not including the time it takes for them to do what you were calling them in to do. 8. An interview was conducted on 7/30/23 at 10:05 a.m. with Resident #537. She stated, I put my call light on the other night, I forgot what I needed, but I put the call light on and it took them 45 minutes to answer it and I asked the girl why and she said she starts at one end of the hall and works her way down. I told her what if I was having a heart attack? I could be dead by the time she got to me. Review of Resident #537's Admission MDS, dated [DATE], Section C- Cognitive Patterns revealed a BIMS score of 15 out 15 indicating the resident is cognitively intact. 9. An interview was conducted on 7/30/23 at 11:25 a.m. with Resident #128, she stated, The only concern I have is I think they have had too many cutbacks. The girls [CNAs] here used to have nine patients, now they each have 11. They are very nice, and I don't let them miss any of my care because I will go out into the hall and just yell until I get what I want. They are very nice, but they just wiz in and out of the rooms because they just don't have the time to spend with anyone like they used to. Review of Resident #128's Quarterly MDS, dated [DATE], Section C- Cognitive Patterns revealed a BIMS score of 15 out of 15 indicating the resident is cognitively intact.

Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed and four errors were identified for two residents (#186 and #95) of six residents observed. These errors constituted a 11.43% medication error rate. Findings included: 1. On 7/31/2023 at 8:30 a.m., an observation of medication administration with Staff B, Registered Nurse (RN), was conducted with Resident #186. Staff B dispensed medications scheduled at 9:00 a.m. which included but not limited to the following medications: - Oyster Shell Calcium 500 mg (milligrams) - 3 tablets. During the observation Staff B searched the medication cart, dispensing three Oyster Shell Calcium tablets identifying the tablets contained calcium carbonate. Staff B reported they had contacted the pharmacy this morning about the resident's Sodium Bicarbonate and was told they were out of it, and the physician was notified already. Staff B documented, med not available at this moment, pharmacy notified and MD notified this am, waiting for MD call back for update order. The July 2023 Medication Administration Record (MAR) showed Resident #186 was to receive at 9:00 a.m. on 7/31/23 the following medications: - Calcium Carbonate Oral wafer 500 (200 Ca) mg - Give 3 tablet by mouth every 8 hours for supplement during the observation, which Staff B had documented as given. - Sodium Bicarbonate 650 mg oral tablet (Sodium Bicarbonate (Antacid)) - Give 3 tablet by mouth two times a day for supplement. On 7/31/23 at 10:53 a.m., a review of progress notes and assessments for Resident #186 did not show the physician or pharmacy had been contacted prior to the medication administration observation with Staff B. The Electronic Medication Administration Record (eMAR) notes, dated 07/27 at 5:20 p.m., 07/28 at 8:02 a.m., and 7/29/23 at 5:36 p.m. showed waiting for delivery, 7/30 at 10:45 a.m. not aval (available), and 7/30/23 at 5:49 p.m. called pharmacy will deliver. On 7/31/23 at 5:15 p.m., a list of over-the-counter (OTC) medications was reviewed with Staff R, Staffing Coordinator/Central Supply. Staff R stated she would have to check with the wound care nurse that they knew more about it (available OTC medications). Staff R stated on 7/31/23 at 5:40 p.m. the highlighted items on the OTC list could be ordered. The list identified Sodium Bicarbonate tablets were highlighted and listed as (pharmacy) Do NOT Send. During an interview on 7/31/23 at 5:42 p.m. the Regional Nurse Consultant (RNC) stated the facility would contact the pharmacy for OTCs; would just need authorization from the Director of Nursing (DON) or Nursing Home Administrator (NHA) (for pharmacy) to bill the facility; could also order from supplier. Staff R stated medications only take a couple of days to receive from the supplier. The RNC stated the facility could also go to the nearby pharmacy and buy it if a resident had it ordered and we did not have it. On 8/2/23 at 11:27 a.m., Staff F, Registered Nurse/Unit Manager (RN/UM), stated Oyster Shell Calcium was not the same as Calcium Carbonate and identified it as a name brand Antacid. Staff F stated they could go get some (medication) and should have let her know of the missing medications (regarding Sodium Bicarbonate). On 8/2/23 at 11:29 a.m., Staff H, Wound Care/Registered Nurse (RN) stated not all house stock (OTC) were available. Staff H reported the facility calls the pharmacy if they do not have house stock and requests a form for the DON to sign, then the pharmacy sends it. 2. On 7/31/2023 at 5:17 p.m., an observation of medication administration with Staff C, Registered Nurse (RN), was conducted with Resident #95. Staff C dispensed medications which included: - Ferrous Sulfate 325 milligram (mg) tablet - Multi-Vitamin with minerals tablet - Vitamin D3 25 microgram (mcg) tablet - Calcium + D3 600 mg/10 mcg tablet - Memantine 10 mg tablet - Novolog FlexPen 4 units. Staff C confirmed dispensing 5 tablets. During the dispensing Staff C searched the medication cart and could not find the following medication scheduled to be administered with the above medications: ICaps Oral Capsule (Multiple Vitamins with minerals) - Give 1 capsule by mouth in the afternoon for supplement. Staff C confirmed ICaps tablet was not administered and documented the medication was not available. A review of Resident #95's Medication Administration Record (MAR) identified the resident had a physician order to administer Caltrate +D Plus minerals 600/800 mg-unit. According to the website, https://www.caltrate.com/calcium-supplement-products/600d3-plus-minerals/, Caltrate 600+D3 Plus Minerals contained 600 mg of Calcium and 800 International Unit (IU) of Vitamin D3. Medscape.com indicated that 10 mcg (that was administered) = 400 IU. On 8/2/23 at 11:29 a.m., Staff F, Registered Nurse/Unit Manager (RN/UM) reported ICaps was a (brand name) eye vitamin and mineral supplement. Staff H, Wound Care/RN, reviewed Resident #95's medications and stated the resident had duplicate medications that needed to be reviewed but did not identify the resident did not receive the 800 international units of Vitamin D as ordered. The policy titled, Medication Shortages/Unavailable Medications, undated, showed When medications are not received or are unavailable for the customers, the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. The procedure portion of the policy documented the following: - If a medication shortage is noted at the time of medication administration (Med-Pass), the licensed nurse or certified medication assistant must immediately initiate action to obtain the medication and not wait until the med pass is completed. The policy documented if a medication was noted during normal pharmacy hours a licensed nurse was to notify the pharmacy and speak to the pharmacist to determine the status of the order and if not order, place the order or re-order to be sent with the next scheduled delivery. The facility link may also be utilized to order or re-order. The policy documented if a medication shortage is noted after normal pharmacy hours a licensed nurse obtains the medication from the emergency stock supply and if unavailable, calls the pharmacy and requested to speak the on-call pharmacist. If an emergency delivery is not feasible a licensed nurse contacts the attending physician to obtain orders or directions which may include holding the dose/doses, use of an alternative medication available from the emergency stock supply, and/or change in order (time of administration or medication). Review of document titled, The Medication Dispensing System, undated, showed, All medications will be prepared (blister card, vials, [brand name] box) and administered in a manner consistent with the general requirements outlined in this policy. The procedure identified that prior to Medication Administration staff were to Verify each medication preparation that the medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right customer.

Based on observation, interview, and record review, the facility failed to ensure an as needed psychotropic medication was limited to 14 days for one resident (#125) out of six residents reviewed for unnecessary medication. The facility also failed to ensure three residents (#128, #40, and #286) out of six residents reviewed for psychotropic medications had documented corresponding diagnoses for ordered medications. Findings included: 1. Review of Resident #125's Admission Record revealed she was readmitted to the facility on [DATE] from hospice. Resident #125's medical diagnoses included but were not limited to senile degeneration of the brain and dementia without behaviors or mood disturbances and anxiety disorder. An observation of Resident #125 was conducted on 7/30/23 at 11:29 a.m. The resident was observed to be clean, lying in bed, with her eyes closed. During an observation conducted on 7/31/23 at 3:50 p.m., Resident #125 was observed to be lying in bed, her eyes were closed, and music was playing in her room. Review of Resident #125's physician orders active as of 8/2/23 revealed an order for Ativan oral tablet 0.5mg to be given every 4 hours as needed for anxiety and agitation which started on 6/21/23 without an end date. Review of Resident #125's Admission Minimum Data Set (MDS), Section I - Active Diagnoses, dated 5/6/23, revealed Resident #125 did not have any Psychiatric/Mood Disorders including the resident did not have anxiety disorder. Review of Resident #125's June and July 2023 Medication Administration Record (MAR) revealed the resident received her as needed Ativan 4 times from 6/21/23 to 7/31/23. One of the four Ativan administrations was administered on 7/15/23 at 2:45 p.m. which was 24 days after the medication was ordered. Review of Resident #125's pharmacy recommendation reviews for June 2023 revealed no recommendations. An interview was conducted with the facility's Regional Nurse Consultant on 8/01/23 at 3:29 p.m. She confirmed she reviewed Resident #125's Ativan order and confirmed it was ordered for longer than 14 days and the pharmacist just sent her an email for the July (2023) review and the resident did not have any recommendations. 2. Review of Resident #128's Admission Record revealed she was readmitted to the facility on [DATE]. The resident's medical diagnoses included heart failure, encephalopathy, cognitive communication deficit, cellulitis of left lower limb, morbid obesity (severe) obesity due to excess calorie, sepsis, type 2 diabetes mellitus with diabetic polyneuropathy. Her medical diagnoses did not include depression. Review of Resident #128's physician orders active as of 8/2/23 showed an order which started on 6/11/22 for Duloxetine HCL capsule Delayed Release Particles 60mg (milligrams), give 1 capsule by mouth one time a day for depression. Review of Resident #128's July 2023 MAR showed the resident received her ordered Duloxetine for depression. Review of Resident #128's Quarterly MDS, Section I-Active Diagnoses, dated 4/18/2023, showed the resident did not have any Psychiatric/Mood Disorders including the resident did not have depression. Review of Resident #128's Pharmacist reviews for the month of June 2023 did not show recommendations related to Resident #128 having ordered medications for diagnoses that were not documented. A phone interview was conducted with the facility's Consulting Pharmacist on 8/02/23 at 2:40 p.m. He stated, Residents are reviewed once a month and then if anyone needs a review in between we will do that too. We do look at medications and make sure there are corresponding diagnoses and as needed psychotropics should be limited to 14 days. 37999 3. Review of Resident #286's Admission Record showed the resident was admitted on [DATE]. The resident's medical diagnoses included syncope and collapse, unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The MDS assessment, dated 7/29/23, showed Resident #286 had a Brief Interview of Mental Status score of 3 out of 15, which indicated severe cognition impairment. The MDS showed the resident had an active diagnosis of Non-Alzheimer's Dementia and did not include any psychiatric/mood disorder diagnoses and received 4 days of antipsychotic and 3 days of antidepressant medications. The active Order Summary Report as of 8/2/23 for Resident #286 showed the resident was receiving the following psychotropic medications: - Escitalopram Oxalate 10 milligram (mg) - Give 1 tablet by mouth one time a day for depression; - Quetiapine Fumarate 25 mg - Give 1 tablet by mouth at bedtime for agitation/anxiety. The acute facility's History and Physical report, which showed a date of admission of 7/23/23, indicated Resident #286 had a diagnosis significant for dementia with behavior disturbance. The Physician/Practitioner progress note, dated 7/31/23 at 12:53 p.m., included diagnoses for Resident #286 of vascular dementia (vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety) and showed to continue supportive care. During the observation of medication observation with Staff D, Registered Nurse (RN), for Resident #286, on 7/31/23 at 8:04 a.m., the resident was observed lying in bed, pulling up the blankets that covered from the waist down. The resident informed the staff member to get rid of the five inches of water, lifting up the blankets indicating it (the water) was under there. The behavior monitoring for Resident #286 identified on 7/31/23 during the day shift Resident #286 did not have any episodes of behaviors. The Medication Administration Record (MAR) instructed staff to document behaviors, effectiveness, and non-pharmaceutical interventions. The care plan for Resident #286 indicated the following: - a focus was initiated, on 7/31/23, an identified the resident had a history of exhibiting the following behaviors agitated (and) anxious. The interventions instructed staff to Administer medications as ordered. Monitor/document for side effects and effectiveness. - a focus was initiated, on 7/31/23, an identified the resident was at risk for falls related to impaired mobility, use of psychotropic medications. - The resident uses antipsychotic medications related to (r/t) behavior management and instructed staff to administer antipsychotic medications as ordered by physician. - The resident uses antidepressant medication r/t depression and instructed staff to administer antidepressant medication as ordered by the physician. Staff J, Certified Nursing Assistant (CNA) stated on 8/1/23 at 4:48 p.m., that Resident #286 had no extra confusion noted, had never mentioned sitting in water, and that the resident was constantly dropping the water on the floor and when that happened staff changed the bed. During an interview that started on 8/1/23 at 5:00 p.m., Staff F, Registered Nurse/Unit Manager (RN/UM) reported understanding if a psychiatric consult was requested a Nurse Practitioner would come in. Staff F reported not noticing anything new with Resident #286's confusion. Staff F stated if the resident voiced lying in water that would be a behavior and should be noted on the behavior log. Staff F reviewed the medical diagnoses of the resident and stated the resident had dementia without behavioral disturbances then reviewed the hospital history and physical and identified it indicated the resident had a diagnosis of dementia with behaviors. Staff F reported the resident did not have a psych (psychiatric) consult. On 8/1/23 at 11:22 a.m., the Regional Director of Clinical Services (RDCS) stated the behavior monitoring should be included on the Medication Administration Record (MAR). The policy titled, Medication Utilization and Prescribing - Clinical Protocol, issued 10/14 and revised 10/22, showed the standard was To ensure medications are prescribed and utilized according to State and Federal guidelines. The assessment and recognition showed, When a medication is prescribed for any reason, the physician and staff will identify the indications (condition or problem for which it is being given, or what the medication is supposed to do or prevent), considering the resident's age, medical, and psychiatric conditions, risks, health status, and existing medication regimen. The assessment showed, Symptoms should be characterized in sufficient detail (onset, duration, frequency, intensity, location, etc.) to help identify whether a problem exists or whether a symptom is just a variation of normal. As part of the overall review, the physician and staff will evaluate the rational for existing medications that lack a clear indication or are being used intermittently on a PRN (as needed) basis. 41015 4. A review of Resident #40's Admission Record showed diagnoses of ataxic gait, unspecified dementia, anemia, essential hypertension, history of falling, sarcopenia, weakness, atherosclerotic heart disease, and other symptoms and signs of concerning food and fluid intake. Review of the active physician orders as of 8/2/23 showed a physician order, dated 01/31/23, showed, Escitalopram Oxalate Tablet 5 mg- Give 5 mg by mouth one time a day for depression give with 10 mg to equal dose of 15 mg. A second physician order, dated 01/31/23 showed, Escitalopram Oxalate Tablet 10 mg- Give 10 mg by mouth one time a day for depression give with 5 mg to equal dose of 15 mg. A third physician order, dated 11/02/22 showed, Buspirone HCI Oral Tablet 5 mg- Give 5 mg by mouth two times a day for anxiety. The Medication Administration Record (MAR) was reviewed for June 2023 and July 2023 and showed Escitalopram Oxalate Tablet 5 mg, Escitalopram Oxalate Tablet 10 mg, and the Buspirone HCI Oral Tablet 5 mg were given per the physician orders. The Quarterly Minimum Data Set (MDS), dated [DATE], showed a diagnosis of dementia but no diagnoses of anxiety or depression in Section I-Active Diagnoses of the MDS. The Quarterly Minimum Data Set (MDS), dated [DATE], showed the medications of antianxiety and antidepressants were administered all seven days during the seven day MDS day look back period. A review of Resident #40's care plan showed a focus diagnosis of dementia, initiated on 1/24/22, with appropriate goals and interventions. The care plan showed a second focus on adverse risks related to the use of antidepressant medications, initiated on 1/24/22, with appropriate goals and interventions. The diagnoses of anxiety and depression as the administration of antianxiety medications were not found on Resident #40's care plan. During an interview on 08/02/23 at 2:25 p.m., the Regional Nurse Consultant (RNC) stated the expectation of the facility was to have a resident diagnosis that corresponded with the medication ordered by the physician. Additional review of the facility policy titled, Medication Utilization and Prescribing-Clinical Protocol, issued 10/14 and revised on 10/2022, showed, Assessment and Recognition 1. When a medication is prescribed for any reason, the physician and staff will identify the indications (conditions or problem for which it is being given, or what the medication is supposed to do or prevent), considering the resident's age, medical and psychiatric conditions, risks, health status and existing medication regimen.

Based on observation, resident interview, and record review, the facility failed to 1. provide treatment and services to maintain or improve functional abilities for activities of daily living for one resident (#112) of two residents sampled and 2. failed to assist with meals and offer alternatives for one resident (#74) of seven residents sampled who required assistance with meals. Findings included: 1. A review of Resident #112's Admission Record revealed she was readmitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included morbid (severe) obesity, cellulitis of left lower limb, type 2 diabetes mellitus, and sciatica of the left limb. An observation and interview were conducted on 7/30/23 at 11:50 a.m. with Resident #112. She was observed lying in bed watching television. She stated her only concern was that when she first came to the facility in January, she was ordered therapy, but she had bilateral sciatic problems with her legs with unbearable pain and she could not participate in therapy. She stated, When you don't participate then they stop giving you therapy. I have a wound on my left leg and that is finally getting better now, and my sciatic nerve pain stopped, and the physicians wrote in their notes that I needed therapy, so I got occupational therapy [OT], but I never got PT [physical therapy]. I need physical therapy to get my arms stronger and build up my muscles so I can transfer myself in and out of my wheelchair, so I can go home. I have asked people if I can borrow the exercise bands or something to strengthen my arms, but no one will let me use them or give me therapy. I don't have to take up their time I can just do it in my bed if they would provide me with the equipment. I just want to go home. A review of Resident #112's Quarterly MDS, dated [DATE], Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. An interview was conducted with the facility's Rehabilitation Director on 8/01/23 at 4:13 p.m. She stated, We saw and screened her [Resident #112] on 6/20/23, no changes in ADLs [activities of daily living] and no change in mobility, no changes in eating or swallowing, no changes in pain, range of motion, sitting and positioning. When we do the screening, we see the patient. She [Resident #112] always says she needs therapy. When we assessed her, she has not had a decline or a change and she's not on therapy load. I can't tell you the last time she was in therapy because I don't have access to the old documentation. What I do know is that based on the quarterly assessment the therapist did not feel the resident would benefit from therapy services. There is recreational exercises that Activities does and the resident should know about that. The Rehabilitation Director confirmed it would be appropriate to start therapy services for someone who wanted to strengthen their arms to help assist in transfers. An interview was conducted on 8/01/23 at 4:26 p.m. with Staff Q, Physical Therapist. She said, I did not talk to the resident at the time of my assessment, but I did talk to the CNA [certified nursing assistant] and the nurse to see if there were any changes in mobility and there was no change. I'm pretty sure she has had OT in the last 6 months to a year and I'm pretty sure they gave her home therapy exercises but, there was no change functionally with her. She's not very mobile. She's rarely out of bed and I know in the past she was getting dressing changes for a wound. She's not highly motivated to get out of bed. 2. A review of the Admission Record showed Resident #74 was admitted on [DATE] and 6/14/23. The record included diagnoses not limited to sepsis due to escherichia coli (e.coli), pressure induced deep tissue damage of left buttock, unstageable pressure ulcer of right hip, and type 2 diabetes mellitus without complications. An observation on 7/30/23 began at 12:19 p.m. as the meal cart arrived on the unit. An unknown staff member removed a meal tray from the cart and placed it on the over-bed table for Resident #74. On 7/30/23 at 12:32 p.m., the covered meal continued to sit on the over-bed table with no staff observed entering the room. On 7/30/23 at 12:39 p.m., Resident #74's meal continued to sit on the table without staff entering the room to assist the resident. On 7/30/23 at 12:40 p.m., a staff member entered the resident's room, immediately left the room and shut the door. In an interview on 7/30/23 at 12:41 p.m., the resident said he did not know lunch was there and someone did assist him with his meals. On 7/30/23 at 1:00 p.m., Staff E, Registered Nurse (RN), entered the room and asked if the resident wanted to eat. Staff E lifted the plate cover and identified that it was meatballs and carrots. The resident stated No. Staff E stated the resident's family member brought him a fast food burger. Staff E removed the meal tray and did not offer the resident an alternative. The meal tray had been sitting on the resident's over-bed table for 21 minutes prior to a staff member entering the room then another 20 minutes before another staff member entered the room and asked the resident if he wanted to eat, leaving without offering an alternative. On 7/31/23 at 8:24 a.m., Staff I, Certified Nursing Assistant (CNA) was observed in Resident #74's room. The resident was informed the meal tray was on the over bed table and was asked if he was hungry, which the resident stated no to being hungry or thirsty. The staff member left the room with the meal tray, no alternative was offered. The Minimum Data Status (MDS), dated [DATE], showed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. The MDS showed the resident required extensive assistance from 1-person for eating. The care plan for Resident #74 showed the resident required assist with Activities of Daily Living (ADL) related to multiple factors and staff were to provide assistive devices as ordered/indicated and to encourage and assist with all ADL tasks as indicated, as tolerated by resident, including . meals, (and) personal /oral hygiene, cetera (etc.). The resident was identified as being at risk for alteration nutrition/hydration related to (r/t) diagnosis (dx) of Diabetes Mellitus (DM), wounds (and) infection. The interventions included but not limited to encourage and assist resident .as tolerated for meals and to explain and reinforce to the resident the importance of maintaining the diet as ordered, encourage the resident to comply, explain consequences of refusal, obesity/malnutrition risk factors. The CNA task of eating documentation showed from 7/4 to 8/1/23 Resident #74 was independent with eating after meal set up on 7/4, 7/5, 7/12, 7/13, 7/15, 7/16, 7/17, 721, and 7/29/23. The documentation showed the resident required limited assist from 1-person for meal(s) on 7/5, 7/6, 7/10, 7/12, 7/13, 7/14, 7/16, 7/20, and 7/26/23. The task showed the resident required extensive assist for a meal service from one-person on 7/6, 7/8, 7/9, 7/10, 7/11, 7/12, 7/13, 7/16, 7/17, 7/19, 7/22, 7/25, 7/29, and 7/30/23. The task showed the resident required total dependence from 1-person during meal service on 7/4, 7/5, 7/7, 7/8, 7/9, 7/11, 7/18, 7/20, 7/21, 7/23, 7/24, 7/25, 7/26, 7/27, 7/28, and 7/29/23. The facility provided evidence that menu alternatives of soup of the day, chef salad, yogurt or cottage cheese, seasonal fruit plate, grilled cheese sandwich, tuna or egg salad sandwich, peanut butter & jelly sandwich and deli sandwiches were available and baked sweet potato, hot dog, hamburger, and a baked potato was available if ordered 2 hours prior to the meal. Review of the facility's Activities of Daily Living (ADLs), Supporting policy, revised on March 2018, revealed: Policy Statement Residents will [be] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation 1. 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 condition(s) demonstrate that diminishing ADLs are unavoidable. a. The existence of a clinical diagnosis or condition does not alone justify a decline in a residence ability to perform ADLs. .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .c. Mobility (transfer and ambulation, including walking); . .e. Dining (meals and snacks) .5. A residence ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: .d. Extensive Assistance- while resident performed part of activity over the last 7 days, staff provided weight-bearing support. .6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 7. The resident's response to interventions will be monitored, evaluated and revised as appropriate.

Based on record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for four residents (#112, #286, #288, #42) of 30 residents sampled for PASARR Level II. Findings included: 1. Review of Resident #112's Admission Record revealed she was readmitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included but were not limited to anxiety disorder and bipolar disorder. Review of Resident #112's Preadmission Screening and Resident Review (PASARR), dated 1/19/22, revealed no qualifying mental health diagnosis and no PASARR Level II was required. Review of the Quarterly Minimum Data Set (MDS), dated [DATE] and 3/31/23, and an Admission MDS, dated [DATE], Section I, Active Diagnoses, showed psychiatric/mood disorder diagnoses of anxiety disorder and bipolar disorder. Review of the medical record revealed the resident was not assessed for a PASARR Level II. An interview was conducted with the Nursing Home Administrator (NHA) and the Regional Nurse Consultant on 8/02/23 at 11:40 a.m. They confirmed Resident #112 had an incorrect PASARR and would see if the resident had a different one. A follow up interview was conducted with the NHA on 8/02/23 at 12:20 p.m. She confirmed there was no other PASARRs in Resident #112's medical record and no other documents related to PASARR to provide. She confirmed there was a concern related to PASARRs. She said the DON (Director of Nursing) completed the PASARRs and all the nurses had access to the system to complete a PASARR. 2. A review of the Admission Record for Resident #286 showed he was admitted on [DATE] with diagnoses to include syncope and collapse, unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The Admission Record did not include any further diagnoses. The PASARR, completed by the acute care facility on 7/26/23, did not show Resident #286 had diagnoses related to mental illness or suspected mental illness with findings based on documented history, medications, and behavioral observations. The review of the medication list from the acute care facility, dated 7/26/23, for Resident #286 showed the resident was ordered Escitalopram 10 milligram (mg) daily (an antidepressant) and Quetiapine 25 mg every night (an antipsychotic). The acute care facility's History and Physical form showed the resident had been admitted on [DATE] and had a past medical history significant for dementia with behavior disturbance. The facility's active Order Summary Report as of 8/2/23 showed Resident #286 had the following physician orders: - Escitalopram Oxalate 10 mg - Give 1 tablet by mouth one time a day for depression, ordered 7/26/23. - Quetiapine Fumarate 25 mg - Give 1 tablet by mouth at bedtime for agitation/anxiety, ordered 7/26/23. A review of Resident #286's Minimum Data Set (MDS) showed a Brief Interview of Mental Status (BIMS) of 3, which indicated severe cognitive impairment. The MDS did not include any active diagnoses of psychiatric/mood disorders. The Medication section of the comprehensive assessment showed the resident had received four days of an antipsychotic and three days of an antidepressant. The Regional Nurse Consultant (RNC) stated on 8/2/23 at 2:35 p.m., [Resident #286's] PASARR should reflect (mental illness) diagnoses. 3. The Admission Record for Resident #288 showed the resident was admitted on [DATE] and 7/30/23. The record included diagnoses not limited to unspecified recurrent major depressive disorder. A review of Resident #288's PASARR, completed by an acute care facility on 7/24/23, did not indicate the resident had a mental illness or suspected mental illness based on documented history. 4. A review of Resident # 42's Admission Record showed she was admitted to the facility on [DATE], with diagnoses to include but not limited to dysphagia following cerebral infarction, aphasia following other cerebrovascular disease, bipolar disorder, unspecified, major depressive disorder, recurrent, unspecified. A review of Resident # 42's PASARR, dated 6/25/2023, revealed Section I: PASARR Screen Decision- Making, Section A. MI (mental illness) or Suspected MI, did not list Resident #42's mental illnesses. A review of the Admission MDS, dated [DATE], Section I- Active Diagnoses showed a Psychiatric/Mood Disorder of depression and bipolar disorder. On 08/01/2023 at 12:00 p.m., an interview was conducted with the Regional Clinical Director. She confirmed Resident # 42's PASARR was inaccurate and should have been revised to accurately reflect her mental disorders. A review of the facility policy titled, Admission Criteria, revised December 2016, showed, Our facility will admit only those residents whose medical and nursing care needs can be met. 7. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-Admission Screening and Resident Review program (PASARR) to the extent practicable. 8. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined ( through the preadmission screening program ) that the individual has a physical or mental condition the requires that level of services provided by the facility.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Review of the record for Resident # 1 revealed she was admitted to the facility on [DATE]. Review of the 3008 Hospital Transfer Form revealed no orders for Oxygen therapy. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission Minimum Data Set (MDS) assessment dated [DATE] showed: Section O Special Treatments and Programs - no documentation for Oxygen Therapy utilized. Review of Respiratory Assessments completed each shift revealed Oxygen Saturations were measured on room air until 1/20/22 at 3:29 pm. Continued review of the clinical record for Resident #1 revealed a nursing progress note dated 1/20/22, and written by Staff B, Licensed Practical Nurse (LPN). It stated: -1/20/22 at 1432 [2:32pm] Patient alert/pox (pulse oximetry) checked 82-83 % RA [Room Air]. Placed 02 [oxygen] via nc [nasal canula]. POX 94-95 % - continue to monitor status. An interview was conducted with Staff B, LPN on 03/04/2022 at 10:18am. She said the physical therapist told her Resident #1's 02 saturations were running low, and she rechecked them and put on oxygen via nasal canula. Staff B stated there was an oxygen concentrator in Resident #1's room at the time she placed the oxygen on the resident. Staff B said she did not call the physician to obtain orders for oxygen as Resident #1 already had the oxygen concentrator and a regular stand-up oxygen tank in her room. She stated the use of oxygen for Resident #1 was intermittent. Review of Physical Therapy documentation for 1/20/22 4:43pm, revealed She had 02 on was 93% during therapy. Review of Occupational Therapy documentation, dated 1/21/22 at 3: 24pm revealed: Tx [Treatment] Modifications: Treatment modifications to overcome barriers: patient provided oxygen, education on pacing self, proper breathing, patient 02 sats [saturations] were less than 90% (no on oxygen at start of session), placed on two liters, and 02 sats increased to over 90%, 24-hour report - nurse manager made aware. A phone interview was conducted with the Nurse Practitioner for Resident #1 on 3/4/22 at 12:15pm. He stated he did not recall receiving a call for Oxygen orders for Resident #1. He stated his expectation was to be notified when the resident needed oxygen and an order should be placed. I was not aware the resident needed to be put on oxygen before she was sent out and if she needed oxygen on 1/20/22, that is a working day, so I should have been notified. Review of a policy titled Oxygen Administration dated 3/2001, and updated on 7/2017, revealed: -Purpose: To describe method for delivering oxygen in order to improve tissue oxygenation, reduce risk for [CONDITION(S)], decrease work of breathing and reduce shortness of breath with activity. During a respiratory emergency it is appropriate for nursing to administer oxygen immediately and obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Procedure: 1. Verify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, record review, and Centers for Disease Control and Prevention (CDC) recommended infection control guidelines, the facility failed to ensure infection control practices during an active COVID-19 facility outbreak were followed related to 1) donning of personal protective equipment (PPE) prior to entering designated COVID-19 person under investigation (PUI) rooms (307, 312, and 357); and 2) ensuring all direct care staff wore a well-fitted face mask while inside of the facility on two (300 hall and East Wing) of three hallways observed. Findings included: 1. An observation on 08/12/21 at 5:36 a.m. revealed personal protective equipment (PPE) requirement signage posted on the double entrance doors into the 300-unit hallway. The signage stated an N95 & [and] Face Shield Required Prior to entering unit. Photographic evidence obtained of the signage. Upon entering the 300-hallway unit, an observation on 08/12/21 at 5:37 a.m., revealed Staff G, Certified Nursing Assistant (CNA) entering room [ROOM NUMBER]. Signage posted on the room door stated, AIRBORNE DROPLET PRECAUTION with instructions of Upon Entry into Room: -Gown - Face Shield - N95 Mask. IN Room: -Cleanse Hands - Apply Gloves for Direct Care - Offer Resident a Mask. BEFORE you EXIT Room: -Remove Gown & Gloves -Cleanse Hands. Photographic evidence was obtained. Staff G CNA wore a surgical mask; the staff member did not don an N95 mask or face shield. Upon entering the room, Staff G closed the door. An observation on 08/12/21 at 6:07 a.m., revealed Staff G, CNA walking down the 300-unit hallway without a face shield or N95 mask donned; Staff G, CNA was wearing a surgical mask. During an immediate interview with Staff G, CNA, she stated while working on the 300-unit an N95 mask and face shield are required. She further said upon entering a designated airborne droplet precaution room, the requirements are to don additional PPE of a gown and gloves. Staff G stated she has an N95 mask that the facility provides, which is stored in the front of the facility in a designated brown bag. Immediately following the interview on 08/12/21 at 6:07 a.m., Staff G, CNA was observed entering room [ROOM NUMBER] again which had the AIRBORNE DROPLET PRECAUTION signage still posted on the door and a PPE caddy placed outside the door with gowns. Staff G, CNA was overheard speaking to the resident stating she would be assisting with draining the catheter bag. Staff G, CNA was observed standing inside room [ROOM NUMBER]'s bathroom. Staff G, CNA did not don an N95 mask, face shield, or gown prior to entering the room. Staff G, CNA closed the room door. 2. An observation on 08/12/21 at 5:37 a.m. revealed Staff E, CNA walking in the 300-unit hallway without a face shield, or face mask of any kind covering her nostrils and mouth. Staff E was observed walking behind the nursing station prior to walking down the hallway and entering room [ROOM NUMBER], which had a call light turned on. An observation of room [ROOM NUMBER] revealed signage posted on the room door as AIRBORNE DROPLET PRECAUTION. Photographic evidence obtained. Staff E, CNA did not don any PPE, including a face shield, N95 mask, or gown, prior to entering room [ROOM NUMBER]. Staff E, CNA exited the room and walked back to the 300-unit nursing station. Staff E, CNA began speaking to Staff J, Licensed Practical Nurse (LPN) regarding how to turn off the doorbell alarm. Staff J, LPN provided Staff E, CNA with instructions on how to turn off the alarm prior to walking back to her medication cart. During this conversation, Staff E, CNA did not have on a face shield or face mask of any kind covering her mouth or nostrils. Staff J, LPN did not instruct Staff E, CNA to don the appropriate PPE requirements for the 300-unit hallway. During the continued observation on 08/12/21 beginning at 5:37 a.m., after speaking with Staff J, LPN, Staff E, CNA walked down the 300-unit hallway and entered room [ROOM NUMBER]. Staff E, CNA was overheard talking to a resident. Upon looking into the resident's room, Staff E, CNA was observed standing within 6 ft of the resident and was touching the resident's bed. Staff E, CNA was not wearing a face shield or mask of any kind while interacting with the resident. During an interview on 08/12/21 at 5:45 a.m., Staff E, CNA said sorry . I am doing a million things right now. Staff E stated she was unsure where she placed her face mask, N95 mask, and face shield. She stated she was currently assigned to 12 residents. She said upon arriving to the facility, the night supervisor provided instructions on what the PPE requirements were while working on the 300-unit. She stated she might have left her face shield and N95 mask in the bathroom. Finally, Staff E, CNA stated she went out to her car earlier and must have left her required PPE in the car. During this interview, Staff I, Registered Nurse (RN) was observed watching the interview while standing by a medication cart. 3. An interview on 08/12/21 at 5:52 a.m. with an assigned 300-hallway nurse, Staff I, Registered Nurse (RN), revealed that while working on the 300-unit a face shield and N95 mask are required due to residents that are actively infected with COVID-19. The requirement is that should a staff member be observed on the unit without a face shield or mask, they must be instructed to don the appropriate PPE. Staff I, RN stated he had not seen Staff E, CNA without PPE. An interview on 08/12/21 at 6:00 a.m. with Staff J, LPN revealed the PPE requirements while working on the 300-unit is to have an N95 mask and a face shield on. If a staff member is entering an airborne droplet precaution room, then they are required to don additional PPE of a gown and gloves. Staff J, LPN stated if a staff member were observed without any PPE on such as a N95 mask, surgical mask, or face shield then she would instruct the staff member to don the items and ask them if they needed assistance in finding an N95 mask and face shield. An interview on 08/12/21 at 7:04 a.m. with the Director of Nursing (DON) and Nursing Home Administrator (NHA) revealed there are COVID-19 positive residents in the facility. The PPE requirements for the 300-unit hallway is to always wear an N95 mask and face shield. The employees have personal bags stored in the dining room where they can keep their N95 mask and face shield. Those rooms designated as AIRBORNE DROPLET PRECAUTION are for residents considered to be persons under investigation (PUI) for COVID-19 due to being new admissions who have not been vaccinated for COVID-19. When entering one of these designated rooms, additional PPE of a gown and gloves are required. To ensure staff are wearing their PPE appropriately on the unit, the nurses on the floor are the main line of defense. 4. A record review of COVID-19 PREVENTION Please follow these tips when in our facility, not dated, revealed Maintain Social Distancing . Wear A Mask . A record review of Personal Protective Equipment Usage Guide, dated 06/17/21, revealed under section Mask revealed . N-95 Respirator . WHEN TO USE: Procedure masks or surgical masks are used for center/community staff under universal masking criteria N-95 respirators are used: . When providing care or services within (6) feet of patients with suspected or confirmed COVID-19 in transmission-based precautions including new admissions for quarantine period . Under section Face Shield/Goggles revealed . Full Face Shield . WHEN TO USE: Full-face shields are worn when providing direct care activities where splashes and sprays are anticipated as aerosol generating procedures or prolonged face-to-face or close contact with a potentially infections patient as with any patient in airborne droplet isolation. Must be used when providing care or services within six (6) feet of patients with suspected or confirmed COVID-19 in transmission-based precautions including new admissions for quarantine period . A policy review of Airborne Precautions, dated 07/2021, revealed Special air handling and ventilation required for airborne precautions is not routinely available in centers. Airborne transmission occurs by dissemination of either small [less than or equal to] 5 micron airborne droplet nuclei remaining suspended in the air for long periods of time or dust particles containing the infectious agent. Microorganisms carried in this manner can be widely dispersed by air currents and may become inhaled within the same room or over a longer distance depending on environmental factors . A policy review of Droplet Precautions, dated 07/2021, revealed Droplet transmission involves droplets generated by the individual during coughing, sneezing, and talking or during the performance of certain procedures, such as suctioning. Transmission occurs when droplets containing microorganisms generated from the infected person are propelled a short distance through the air and deposited on the susceptible conjunctiva, nasal mucosa, or mouth. Special handling and ventilation are not required . In addition to standard precautions, the following measures are necessary for droplet precautions . Mask . Wear a mask when within six (6) feet of the patient . Apply mask upon entering the patient room and remove mask upon exiting the patient's room and immediately wash hands with antimicrobial agent or use alcohol-based hand sanitizer. Avoid touching from of mask during removal as it is considered contaminated . Goggles . Wear goggles if likelihood of exposure during care . Remove goggles and immediately wash hands with an antimicrobial agent or use alcohol-based hand sanitizer. Avoid touching front of mask during removal as it is considered contaminated. A review of Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated March 29th, 2021, under section Personal Protective Equipment, revealed . Facilities should have policies and procedures addressing . Which PPE is required in which situations (e.g., residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection, residents placed in quarantine) .? The fit of the medical device used to cover the wearer's mouth and nose is a critical factor in the level of source control (preventing exposure of others) and level of the wearer's exposure to infectious particles. Respirators offer the highest level of both source control and protection against inhalation of infectious particles in the air. Facemasks that conform to the wearer's face so that more air moves through the material of the facemask rather than through gaps at the edges are more effective for source control than facemasks with gaps and can also reduce the wearer's exposure to particles in the air. Improving how a facemask fits can increase the facemask's effectiveness for decreasing particles emitted from the wearer and to which the wearer is exposed . Further review of the CDC Infection Control for Nursing Homes, updated March 29th, 2021, under sub-section Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection [COVID-19], revealed .Residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection do not need to be placed into an airborne infection isolation room (AIIR) but should be cared for HCP using an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown . 5. A tour of the facility east wing was conducted on 08/12/2021 at 05:50 a.m. Prior to entering the unit a double door with a signage STOP was posted. The signage read, MUST HAVE N95 Mask and Face shield Prior to Entering Unit. During the tour, an observation was made of Staff F, RN wearing a surgical mask. The mask was not covering her nose and was loose fitting around her ear. In addition, Staff F was not wearing a face shield. An interview was conducted on 08/12/2021 at approximately 05:51 a.m. with Staff F following the observation. Staff F, RN stated that she is aware of the signage posted, but she is not able to breathe effectively when wearing a N95 mask. She stated that she did not inform the facility of not being able to breathe when wearing a N95 mask. Staff F stated that she was not taking care of the resident on airborne precautions and did not think it was necessary to wear a face shield. On 08/12/21 at approximately 05:55 a.m. Staff E, Dietary Aide was observed entering facility lobby, she had no mask on. Staff E then opened the door to the main entrance of the facility to enter. Staff E was not wearing a mask upon attempt to enter the main entrance. In addition, she was not screened for signs and symptoms of COVID-19 upon entering the facility lobby. In an interview with the Staff E at approximately 5:56 a.m. on 08/12/2021. She stated that she has been working at the facility for a month and had never worn a mask upon entering the facility prior to getting to her assigned department. She stated that she usually does self-screening in the lobby area for COVID-19 but confirmed that this morning she did not. Signage was observed posted on the facility entrance related to cough etiquette, and face mask to be worn upon entrance to facility. On 08/12/21 07:17 a.m. an interview with the facility DON and the NHA revealed the expectation is for staff to wear the appropriate PPE in the designated areas. The DON and NHA stated that they expect staff and visitors to wear a mask upon entering the facility, and to be screened in the lobby area for COVID-19, before entering the main facility area.

Based on observation, interview and record review the facility failed to ensure one resident (Resident #1) of three residents sampled received care and services to ensure intact skin and to prevent a pressure wound from forming under a leg immobilizer. Resident #1 sustained a pressure related wound measuring 6.83 cm x 3.46 cm x 1 cm when licensed staff failed to obtain a physician order on admission for care of an immobilizer to the resident's leg. Resident #1 was last observed for skin integrity under the immobilizer on 12/29/20 when a wound was resolved on the right lateral calf. No staff observed the right leg under the immobilizer from 12/30/20 until 1/12/21 when a strong odor was noticed by a CNA (Certified Nursing Assistant) providing care. Findings Included: During a phone interview on 1/29/21 at 4:08 p.m. with Staff member A, CNA she stated she worked on 1/6/21 and 1/7/21. When she walked into the resident's room on 1/6/21 she stated the resident was new to her and she did not get report for the resident. The resident was sitting up in a chair and had an agency nurse caring for her that day. The resident was noted to have an odor noticed from her right leg when the lift was used with two CNA's. Staff member A, CNA said the odor was very strong and she notified the agency nurse. Staff member A, CNA was off work the 8th, 9th and 10th and returned to work on the 11th for the 3 to 11 shift. Staff member A, CNA said she lifted the resident's blanket during the shift and the smell was so strong that she could smell it through her surgical mask and faceshield. She confirmed she went to the unit manager as she could not believe no one did anything about the odor while she was off. Staff member A, CNA said she asked the unit manager to open the immobilizer due to the strong odor. Staff member A, CNA restated she could not believe that no one noticed the smell that she reported to the agency nurse on 1/6/21 until she returned on 1/11/21 as the odor was so much stronger on 1/11/21. During an interview with Staff member D, Unit manager on 1/29/21 at 2:45 p.m. she said the nurse caring for the resident on admission is responsible for making sure there is an order for [REDACTED]. Staff member D, unit manager said she opened the immobilizer and saw drainage to the right leg. The unit manager had to lift the leg to see the wound. The DON (Director of Nurses) was notified, Nurse practitioner, orthopedic doctor and the son. The unit manager stated she figured the wound was caused by the immobilizer due to the braces hard area that was going down the back of the leg. During an interview with Staff member E, CNA on 1/29/21 at 2:50 p.m. she stated she asked the agency nurse on an unknown day if she could remove the immobilizer for a shower and was told by the agency nurse not to remove the immobilizer due to an upcoming orthopedic appointment. During an interview with Staff member F, RN on 1/29/21 at 2:55 p.m. she stated she received the resident from another unit in the facility and was told by the nurse the resident was confused and did not have an order to remove the immobilizer. The nurse confirmed she completed a head to toe assessment and did not open or remove the immobilizer nor did she get an order for [REDACTED]. The body audits are done weekly and she confirmed they were done but without opening the immobilizer. The nurse confirmed she had recently been trained on calling the physician for an order if the resident has a brace or immobilizer so the skin can be viewed and documented. Review of Resident #1's 3008 transfer form from the hospital dated 12/9/20 revealed E. Primary [DIAGNOSES REDACTED]. Patient risk alerts: Pressure Ulcers and Falls. Review of the hospital discharge instructions dated 12/9/20 reflected: keep dressing dry right posterior leg, clean with saline apply foam gauze every 3 days. Non weight bearing right leg and reposition, immobilizer for pain management. Review of Resident #1's facility Admission Record Report revealed an admission date of [DATE] with a primary [DIAGNOSES REDACTED]. Review of Resident #1's admission assessment dated [DATE] revealed Resident #1 was admitted on [DATE] at 8:00 p.m. wearing an immobilizer for right trochanter femur fracture. Review of the facility physician orders regarding the right leg, wound and immobilizer revealed included: Follow up in 3 weeks with physician dated 12/10/20 Body audit every day shift for skin observation dated 12/10/20 Non weight bearing to right leg for 6 weeks total from date of injury added 12/21/20 wound care consult to right posterior leg dated 1/13/21 arterial doppler to right lower extremity due to wound dated 1/13/21 culture wound to right posterior calf dated 1/13/21 cleanse open area to posterior right calf with normal saline apply wound gel to wound bed. Cover wound bed with ABD (thick gauze pad) and wrap with [MEDICATION NAME] dated 1/13/21 Pressure relieve mattress, air mattress ordered 1/15/21 2 view x ray right knee prior to follow up with physician start date of 1/18/21 [MEDICATION NAME] 100 mg twice a day for 10 days dated 1/18/21 cleanse open area to posterior right calf with normal saline apply [MEDICATION NAME] to wound. Cover with abd and wrap with [MEDICATION NAME] dated 1/22/21 Review of Resident #1's treatment administration record reflected body audits were completed on 1/1/21 to 1/4/21 by Staff member J, LPN. On 1/5/21 and 1/6/21 no one signed off on the body audits. The dates 1/7/21, 1/8/21 and 1/11/21 were signed off by Staff member F, RN, 1/9/21 and 1/10/21 were signed off by Staff member K, LPN and 1/12/21 was not signed off by a staff member. Review of the skin worksheets completed by the CNA's included only 2 sheets: 1/6/20 (admitted in December 2020) bed bath given brace to right leg and red coccyx area notated checked as abnormal 1/9/21 resident refused bed bath, nothing documented Review of the NP (Nurse Practitioner) follow up note on 1/15/21 revealed the resident seen for new pressure ulcer to right posterior leg. She has been wearing an immobilizer due to condylar fracture and pressure ulcer developed underneath placement of immobilizer. Wound to right lower extremity is unstageable. Arterial ultrasound was obtained yesterday showing plaque/calcification however less than 50% stenosis. 5. Multiple wounds: she has nonhealing/slow healing wounds which are being monitored closely. Plan- Risk for development of ulcer is high as patient has suboptimal nutritional status, [MEDICAL CONDITION], poor bed mobility with history of fracture requiring immobilizer. Healing ability compromised. Review of the NP follow up on 1/18/21 revealed patient is seen today for follow up of pressure ulcer of right lower extremity. Wound culture positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) of wound. 5. [MEDICAL CONDITION] on maximum medical therapy with [MEDICATION NAME]. patient has history of leg wound with delayed healing. Review Resident #1's Skin and Wound Evaluation dated 1/12/21 at 2:12 p.m. revealed, wound 6.8 cm (centimeters) x 3.5 cm x 1.0 cm, wound bed: slough, % slough 50%, %Eschar 11%, evidence of infection None, Other: Bone, Progress: New. Review of wound care evaluation with photographs attached reflected: 12/11/20 right calf lateral, new abrasion - minutes old - acquired on admission measuring 2.87 cm x 1.16 cm, scab, healable. 12/18/20 right calf lateral, improving 7 days old, present on admission - measuring 2.26 cm x 1.06 cm, scab, surrounding tissue fragile, non [MEDICAL CONDITION] extends <4 cm around wound, intermittent pain, healable. 12/29/20 right calf lateral, resolved 18 days old, present on admission. 1/12/21 right calf lateral (photo shows posterior) new wound unknown age, present on admission, measuring 6.83 cm x 3.46 cm x 1 cm, wound 50% slough, other - bone, moderate exudate, no odor after cleansing. edges- non attached, surrounding tissue - [DIAGNOSES REDACTED] and fragile, pain of 3 at dressing. Progress is new. Nurse practitioner notified and responsible party. 1/20/21 right calf lateral (photo shows posterior) improving wound with age unknown, present on admission, measuring 7.73 cm x 2.24 cm x 1.5 cm, 70% granulation present, 30% slough present, and other bone documented. Moderate serosanginous drainage, edges non attached with pain of 2 at dressing. Goal of care is slow to heal. 1/27/21 right calf lateral (photo shows posterior), improving with age unknown, present on admission, measuring 4.21 cm x 1.99 cm x 0.8 cm, 90% granulation, 10% slough, no bone, moderate serosanginous, non attached edges, fragile skin, pain of 2 at dressing, goal of care is slow to heal, progress is improving. Review of the care plan revealed a focus area at risk for skin alteration in skin integrity related to impaired mobility, incontinence created on 12/9/20, revised on 12/18/20. Goal of care to decrease/minimize skin breakdown risks initiated on 12/9/20, created on 12/9/20. Interventions to administer treatment per physician orders initiated on 12/9/20, provide preventative skin care routinely and as needed initiated on 12/18/20. A focus area for alteration in musculoskeletal status related to non displaced femoral condyle fracture initiated on 12/10/20. Goal of care to remain free of complications related to fracture such as contracture formation, embolism and immobility initiated on 12/18/20. Interventions include following physician orders for and or therapy treatment initiated on 12/10/20. Review of the nursing progress notes dated 1/12/21 at 1:23 p.m. revealed a call placed to the orthopedic physician regarding the removal of the immobilizer to the right leg due to a wound on the back of right posterior calf. Orders obtained to remove immobilizer and x-ray of right knee, two views. To send x-ray results to appointment with resident. Spoke with son regarding appointment for 1/13/21 and he is unable to accompany to the appointment. Wound care as ordered. Review of the nursing progress notes dated 1/13/21 at 5:09 p.m. revealed a conversation with the NP regarding the wound on the right posterior leg. New orders for doppler of the right leg, wound culture and wound nurse to evaluate. Son spoken too about decline of the wound and new orders obtained. During an interview with the DON and the wound care nurse on 1/29/21 at 12:07 p.m. she said she was notified on the 12th of a new wound and went to look. The DON described the wound as about 3 inches long and 1 ½ wide, red with slough, and deep but not to the bone. Staff member H, wound care nurse stated the wound was quite large and would not have appeared over night. The DON stated the resident's skin integrity was last observed about two weeks prior by the wound care nurse. The DON confirmed her investigation with the nurses revealed they did incomplete body audits by not opening, observing the skin under the immobilizer and did not follow up with getting an order to do so. The DON confirmed the CNAs also did skin checks but did not remove the immobilizer as directed by the nursing staff. The DON stated the resident's wound care was completed in house by the wound care nurse and Nurse Practitioner (NP). The DON stated she had a conversation with the NP and Nursing home administrator and decided due to the resident's [MEDICAL CONDITION] and delayed healing of previous wounds which were resolved on 12/29/20, the wound Resident #1 sustained on 1/12/21 after her previous wounds healed was unavoidable. The DON confirmed the resident was having skin checks but the immobilizer was not removed and the skin integrity of the right leg was not observed from 12/30/20 to 1/12/21. The DON stated the resident is known to have a history of wounds from previous admission and is high risk for skin breakdown. An interview with Staff member H, RN Wound Care Nurse, on 1/29/21 at 12:03 p.m. revealed that with any new admission she completes a second body check and if new skin issues are observed she is notified. Staff member H, said Resident #1 had bilateral wound on both calf's on admission, the left leg was treated and healed then the right leg was treated and healed around 12/29/20. Once the wound is healed she no longer sees the resident. The resident was wearing an immobilizer the last time she saw her which was the day she evaluated and noted that a right lateral calf wound was resolved but did not lift the resident's leg to observe the back of it before closing the immobilizer. Staff member H, said she was notified by staff the day after they observed the new wound around 1/12/21 but was unsure of exact date. Resident #1 is currently getting a honey treatment and her wound is improving. Her dressing is changed every day and measurements are taken every week. Staff member H, stated the Nurse Practitioner saw it yesterday and has been watching the wound with her and adjusting the wound care accordingly. Resident #1 came with a soft foam immobilizer and we would remove the strap and complete the treatment. Staff member H, could not confirm the resident had an order for [REDACTED]. We do not remove the immobilizer but we could remove the strap and check the skin by opening the immobilizer looking at skin integrity and putting the strap back on. An interview conducted with Resident #1's Nurse Practitioner (NP) on 1/29/21 at 1:57 p.m. revealed the resident had advanced dementia, poor circulation and multiple skin tears with delayed healing from her assisted living. The NP stated her wound healing ability is compromised due to lack of blood flow and she had wounds that lingered for a long time but were finally resolved on this admission at the end of December. The NP confirmed that the nurses should have obtained an order for [REDACTED]. The NP said Resident #1 has pain from the fracture. Her pain is more with the repositioning. The NP confirmed when the wound was found she asked for a wound culture due to the residents history [MEDICAL CONDITION]. The wound was positive and has been debrided and treated for [REDACTED]. The NP stated there was no direction from the hospital on what to do for the immobilizer. The physician note stated to remain non weight bearing. Anytime there is a brace or splint we should have a clarification order for what to do with the immobilizer. The NP said we need expectation from the person who ordered the immobilizer and the facility did not do that. The DON confirmed on 1/29/21 at 12:46 p.m. that the facility did not have a do not remove order for the immobilizer and the nurses were responsible for calling the orthopedic doctor for the clarification of the immobilizer to maintain skin integrity. The resident was at high risk with newly resolved wounds and should have been getting daily body audits to include the entire body. The DON confirmed that approximately 5 nurses completed the body audits without removing or opening the immobilizer and did not follow up on getting an order. The DON's investigation did confirm the nurses were aware of the lack of orders and did not follow through to get clarification orders. Observation of Resident #1's wound care on 1/29/21 at 3:00 p.m. with Staff member H, and Staff member D assisting. The resident said her leg hurt but was unable to describe the pain. Staff member H, set up the supplies and removed the dressing. The wound on the right posterior calf was deep, pink with small amount of slough, clean with moderate drainage. During an interview with DON and NHA on 1/29/21 at 5:32 p.m. The DON said she told the NHA that since the resident was not eligible for surgery on that knee, the alignment should have been more important for healing. The DON confirmed the nursing staff did not attempt to contact the orthopedic physician for clarification of the immobilizer. The DON confirmed the facility never received orders related to the immobilizer, they reviewed the discharge instructions from the hospital that mentioned the immobilizer on the right leg. The DON confirmed the hospital record reflected to follow up with physician in three weeks and that did not happen. During an interview with the NHA and the DON on 1/29/21 at 6:31 pm they said that after reviewing the medical record, talking to the nurse practitioner and reviewing the doppler studies they believe the wound was unavoidable due to the client needing the brace, high risk for skin integrity problems, history of leg wounds. Review of the facility policy for braces/splints, revised 9/18 page one of one, revealed the procedure 1. Verify medical practitioners order. Order should specify what type of brace/splint should be used as well as wearing schedule. 9. carefully inspect skin and appearance of body part during and between applications. Review of the admission skin evaluation form page 9, dated 2013, reflected: After completion of the initial plan of care, the Patient information worksheet, kardex and task list are updated. A weekly skin evaluation is completed by the licensed nurse for those patients identified at risk for skin breakdown that do not have a pressure ulcer. Daily skin evaluations are completed by the licensed nurse for those patients with pressure ulcers. Documentation of skin evaluations is completed on the treatment administration record.