Every finding on record at The Waters of Cheatham, LLC

Based on policy review, Centers for Medicare & Medicaid Services guidelines, Infection Prevention Control Officer Training certificate review, and interview, the facility failed to ensure employment of a qualified Infection Control Preventionist to monitor and maintain the facility's Infection Prevention and Control Program. This could have affected 54 out of 54 residents residing in the facility. The findings include: 1. Review of the undated facility policy titled, Infection Prevention and Control-Policy and Procedure (IPCP), revealed .It is the policy of the facility to ensure that a comprehensive system is in place that prevents, identifies, investigates reports, records, and controls infections and prevent the development and transmission of communicable disease processes for residents/ care providers, staff, visitors, and others within the facility to include those providing contractual services in an effort to provide a safe, sanitary, comfortable environment. Further, to determine the most effective practices to reduce infection rates as well as identifying ways to integrate these practices into the everyday workday to create a culture of safety as related to Infection Control.There will be an appointed person to spearhead the Infection Prevention and Control Program. This person will be a licensed nurse.This person will be the Infection Preventionist for the facility.The Infection Preventionist will make facility wide rounds at least weekly to identify any breaches visible within the physical environment. 2. Review of the Centers for Medicare & Medicaid Services factsheet titled, Updated Guidance for Nursing Home Resident Health and Safety, dated June 29, 2022, revealed .Requires facilities have a part-time Infection Preventionist (IP) .The IP must physically work onsite and cannot be an off-site consultant or work at a separate location .IP role is critical to mitigating infectious diseases through an effective infection prevention and control program .IP specialized Training is required and available . The facility was unable to provide documentation that the facility had an ICP at least part-time. The current interim Director of Nursing (DON) was unable to provide documentation, and the newly hired Assistant Director of Nursing (ADON) as of 3/25/2026, was currently taking the course and had only completed 7 of the 12 required modules. The Regional DON was able to provide the required training certificate but did not physically work part-time at the facility. The facility failed to ensure there was an ICP at least part time to assess, develop, monitor, and manage the facility's IC program. During interview on 3/25/2026 at 7:30 AM, the Interim DON confirmed that she had completed infection control training for Infection Preventionist many years ago but was unable to provide the documentation. During an interview on 3/25/2026 at 9:52 AM, with the Regional DON and newly hired ADON revealed, the ADON has completed 7 of the 12 modules required to receive certificate, and the Regional DON had the required certificate, but does not work at this facility the minimal part time required.

Based on policy review, medical record review, observation, and interview the facility failed to ensure wound assessments and treatments were completed correctly as ordered by the physician for 2 of 4 (Resident #8 and #51) sampled residents reviewed for pressure ulcers/wounds. The findings include: 1.Review of the facility's policy titled GUIDELINES FOR PREVENTION / TREATMENT OF PRESSURE INJURIES . dated 10/9/2023, revealed .It is the intent of the facility to recognize the following information and to act on it in such a way as to practice evidence-based recommendations for the prevention/treatment of pressure injuries to the residents who reside in the facility .A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing .Pressure injuries are significant health issues and one of the biggest challenges for long term care facilities . Review of the facility's policy titled GUIDELINES FOR PHYSICIAN ORDERS- (FOLLOWING PHYSICIAN ORDERS), dated 6/18/2023, revealed .It is the policy of the facility to follow the orders of the physician .All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Diabetes, Pressure Ulcer Sacral Stage 4, and Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region. Review of the Care plan dated 2/25/2026 revealed, .Focus .I have a pressure ulcer to .Stage IV Sacrum POA [present on admission] .Interventions .Treatment per physician orders . Review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, and was admitted with 1 stage 4 pressure wound. Review of the March Physician orders revealed, .Stage 4 sacral wound cleanse with Dakin's 1/4 solution, [is a solution used to cleanse wounds to remove dead tissue] pat dry, apply medihoney [promotes for faster wound healing and offers protection against invading bacteria .] to calcium alginate [an absorbent dressing used to maintain a moist environment that promotes healing] pack wound, apply border foam dressing daily every day shift for Sacral wound .Order Date 02/17/2026 .Start Date .2/18/2026 . Review of the Medication Administration Record (MAR) dated 3/1/2026 - 3/31/2026, revealed no treatments were completed on the following days: a. 3/6/2026 b. 3/13/2026 c. 3/14/2026 d. 3/15/2026 e. 3/20/2026 f. 3/22/2026 The facility failed to ensure the wound treatments were provided as prescribed and in accordance with facility policy. During an interview on 3/26/2026 at 10:25 AM, the Assistant Director of Nursing (ADON) was shown Resident #8's March MAR for wound care and was asked should there be blanks on the MAR for wound care. The ADON stated, .no .I tried to put all the wounds at night .the new NP [Nurse Practitioner] moved some to days .I think that's what happened .I moved them back to nights .just not marking them off . The ADON was asked should physician orders be followed. The ADON stated, .yes . During an interview on 3/26/2026 at 12:31 PM, the Director of Nursing (DON) was asked should there be blanks in the MAR for wound care. The DON stated, Is the expectation that the MAR's and TAR's [Treatment Administration Record] should be filled out . The DON was asked how often was wound care ordered for the stage 4 sacrum. The Interim DON stated, The order says every day shift . The DON was shown Resident #8's MAR and was asked if wound care was provided on the 6th, 13th, 14th, 15th, 21st, and 22nd. The DON stated, .on the MAR you cannot prove that they did it .it shows care was not delivered. 3. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Vascular Dementia, Psychosis, Morbid (Severe) Obesity, and Diabetes. Review of the quarterly MDS dated [DATE], revealed a BIMS assessment score of 15, which indicated she was cognitively intact. Resident #51 had impairment on both sides to lower extremities that required substantial to maximal assist with rolling left and right and was dependent on staff for sit to lying and chair/bed to chair transfer. Review of the Wound assessment dated [DATE] revealed an In-house Acquired Pressure Injury to Sacrum Stage 3 that was identified on 2/15/2026 and staged as a 3 due to being a previous stage 3 wound. Review of the Physician Order dated 2/25/2026 revealed Cleanse wound to sacrum with NS [Normal Saline] pat dry, apply collagen [used in wound healing] sheet and border foam dressing daily and PRN [as needed] every day shift for wound . Review of the TAR dated 2/1/2026 - 2/28/2026 revealed staff failed to provide wound care to Resident #51's Stage 3 sacrum wound as ordered on the following dates: a. 2/27/2026 b. 2/28/2026 Review of the TAR dated 3/1/2026 - 3/31/2026 revealed staff failed to provide wound care to Resident #51's Stage 3 sacrum wound as ordered on the following dates: a. 3/1/2026 b. 3/6/2026 c. 3/8/2026 d. 3/12/2026 e. 3/13/2026 f. 3/14/2026 g. 3/16/2026 The facility failed to ensure the wound treatments were provided as prescribed and in accordance with facility policy. During an interview on 3/26/2026 at 1:15 PM, the ADON was asked if there should be blanks on the TAR for a resident that has orders for a wound treatment daily. She replied, .no, I'm sure the treatment was done, they just didn't click it off, and I know if you don't chart it .it didn't happen . During an interview on 3/26/2026 at 1:45 PM, the Interim DON was asked if there should be blanks on the TAR for a resident that has orders for a wound treatment daily. She replied, .No .

Based on Quarterly Payroll Based Journal (PBJ) review, facility staffing information review, and interview, the facility failed to submit accurate staffing data for Quarter 1 for PBJ 2026 (October 1, 2025- December 31, 2025) reviewed for staffing data. The findings include: 1. Review of the Centers for Medicare & [and] Medicaid Services Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual dated June 2025, revealed . Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. 2. Review of the PBJ (Payroll-Based Journal) Staffing Data Report for Quarter 1 of 2026 (October 1, 2025 - December 31, 2025) revealed excessively low weekend staffing. 3. Review of LICENSURE STAFFING REQUIREMENTS for the following dates between October 1, 2025 - December 31, 2025, revealed the weekend staffing percentages as follows:a. 10/4/2025 - 3.65% (percent) b. 10/5/2025 - 3.32% c. 10/11/2025 - 3.18% d. 10/12/2025 - 3.12% e. 10/18/2025 - 2.81% f. 10/19/2025 - 2.93% g. 10/25/2025 - 3.0% h. 10/26/2025 - 3.23% i. 11/1/2025 - 2.96% j. 11/2/2025 - 2.93% k. 11/8/2025 3.52% l. 11/9/2025 - 2.93% m. 11/15/2025 - 2.25% n. 11/16/2025 - 2.92% o. 11/22/2025 - 3.39% p. 11/23/2025 - 3.80% q. 11/29/2025 - 3.86% r. 11/30/2025 - 2.77% s. 12/6/2025 - 3.23% t. 12/7/2025 - 3.21% u. 12/13/2025 - 2.57% v. 12/14/2025 - 2.37% w. 12/20/2025 - 2.97% x. 12/21/2025 - 3.04% y. 12/27/2025 - 2.83% z. 12/28/2025 - 3.04% The facility's Licensure Staffing documentation indicated the Quarter 1 PBJ information was reported inaccurately. During an interview on 3/16/2026 at 11:47 AM, the Administrator was asked why the PBJ report for Quarter 1 was triggered for excessive low weekend staffing. The Administrator stated, .our DON (Director of Nursing) at the time was not calculating the information correctly.the system we use does not calculate the hours based on timeclock punches correctly immediately.it could be 1 or 2 days later. The Administrator confirmed that the Quarter 1 PBJ information reported was incorrect.

Based on facility policy review, observations and interviews, the facility failed to ensure nurse staffing information for licensed and unlicensed staff responsible for resident care was posted daily for 3 of 3 (3/23/2026, 3/24/2026, and 3/25/2026) days reviewed. The findings include: Review of the facility policy titled, Guidelines for BIPA [Benefits Improvement and Protection Act] Staffing Posting Requirements, dated 7/24/23, revealed It is the policy of the facility, in cooperation with Medicare/Medicaid Services.to comply with the requirement of daily posting of nursing staff in the facility.must post daily, at the beginning of each shift, the facility specific shift schedule for the 24 hour period, the number and category of nursing staff employed or contracted by the facility for each 24 hour period.the total number of hours worked by licensed [unlicensed] and licensed nursing staff who are directly responsible for resident care. Observations at the nurse's station on 3/23/2026 at 9:55 AM, 1:30 PM, and 4:35 PM, revealed the daily number of licensed and unlicensed nursing staff was not posted. Observations at the nurse's station on 3/24/2026 at 7:30 AM, 1:45 PM and 3:15 PM revealed the daily number of licensed and unlicensed nursing staff was not posted. Observations at the nurse's station on 3/25/2026 at 7:35 AM, 10:00 AM, and 2:45 PM revealed the daily number of licensed and unlicensed nursing staff was not posted. During an interview on 3/25/2026 at 3:00 PM, the Interim Director of Nursing (DON) was asked if the daily number of licensed and unlicensed nursing staff should be posted daily. She replied, .yes, it is the expectation that staffing information will be posted daily. During an interview on 3/26/2026 at 8:16 AM, the Administrator was asked if the daily number of licensed and unlicensed nursing staff should be posted daily. She replied, .yes.

Based on facility policy review, medical record review, and interview, the facility failed to provide an ongoing program of activities designed to meet the interests, physical, mental, and psychosocial well-being for 7 of 10 sampled residents (Resident #5, #9, #22, #26, #29, #41, and #54) reviewed for activities. The findings included: 1. Review of the undated facility policy titled, Your Rights and Protections as a Nursing Home Resident, revealed, .Be Treated with Respect.Participate in Activities: You have the right to participate in an activities program designed to meet your needs. Review of the undated facility policy titled, Activities Program, revealed, .It is the policy of the facility to provide an ongoing program of Activities designed to meet, in accordance with.the interests and the physical, mental and psychosocial well-being of the residents.Facility will provide a 1:1 program for residents who are unable or who desire not to attend or join group activities.All staff will assist in transporting residents to/from activities. 2. Review of the medical record revealed Resident #5 admitted to the facility on [DATE], with diagnoses which included Congestive Heart Failure, Chronic Pulmonary Edema, Cognitive Communication Deficit, and Hypertension. Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. Review of the Care Plan with target date of 4/13/2026 revealed, .Engage me in simple, structured activities per my preference that avoid overly demanding tasks.Reminisce with me using photos of family and friends. Review of the medical record revealed there was no documentation Resident #5 had been provided or offered activities from 2/23/2026 to 3/24/2026. During a telephone interview on 3/23/2026 at 1:58 PM, Resident #5's representative stated, .he loves bingo, but I am not sure if he is getting to go. During an observation and interview on 3/25/2026 at 9:27 AM, Resident #5 stated, .I use to play bingo.I enjoyed it. Continued observation revealed no television (TV) was playing or radio beside bed for music stimulation. 3. Review of the medical record revealed Resident #9 admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease, Anxiety Disorder, and Major Depressive Disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #9 had a staff assessment for mental status that revealed poor short term and long term memory recall. Review of the Care Plan with target date of 4/27/2026 revealed, .Provide Facility Low Functioning Activity Programming.Provide individual-focused 1:1 sessions with emphasis on sensory and environmental awareness, integration and stimulation.Provide diversionary activities. Review of the medical record revealed there was no documentation Resident #9 had been provided or offered activities from 2/23/2026 to 3/24/2026. Observation on 3/23/2026 at 10:13 AM, Resident #9 was sleeping, no TV playing or radio beside her bed for music. Observation on 3/25/2026 at 9:45 AM and 3/26/2026 at 10:55 AM, Resident #9 laying supine in her bed facing the wall. No TV on or radio beside her bed for music. 4. Review of the medical record revealed Resident #22 admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Vascular Dementia, Anxiety Disorder, and Major Depressive Disorder. Review of the quarterly MDS dated [DATE], revealed Resident #22 had a BIMS score of 14 which indicated no cognitive impairment. Review of the Care Plan with target date of 3/31/2026 revealed, .Engage me in simple, structured activities per my preference that avoid overly demanding tasks.Provide a program of activities that accommodates my abilities. Review of the medical record revealed there was no documentation Resident #22 had been provided or offered activities from 2/23/2026 to 3/24/2026. Observation on 3/23/2026 at 10:25 AM, Resident #22 was sleeping. No TV playing or radio beside the bed for music. 5. Review of the medical record revealed Resident #26 admitted to the facility on [DATE], with diagnoses which included Type Diabetes Mellitus, Cognitive Communication Deficit, and Major Depressive Disorder. Review of the quarterly MDS dated [DATE], revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated no cognitive impairment. Review of the Care Plan with target date of 4/26/2025, revealed, .Provide friendly visits to establish a relationship and encourage increased participation and interaction.Provide diversionary activities. Review of the medical record revealed there was no documentation Resident #26 had been provided or offered activities from 2/23/2026 to 3/24/2026. During an interview on 3/25/2026 at 9:33, Resident #26 was asked about her activity involvement. She stated, .I can't get up without someone helping me, I sleep most of the day. Resident #26 was asked if the Activity Director comes by and visits with her or sits and talks with her. Resident #26 stated, .I don't think she comes by and sees me.no one comes and talks with me. Continued observation revealed no radio beside bed for music. 6. Review of the medical record revealed Resident #29 admitted to the facility on [DATE], with diagnoses which included Anemia, Hyperlipidemia, Hypertension, and Anxiety Disorder. Review of the quarterly MDS dated [DATE], revealed a Brief Interview for Mental (BIMS) Status score of 14 which indicated no cognitive impairment. Review of the Care Plan with target date of 5/5/2026 revealed, .Activities.Interventions/Tasks.enjoys going on walks outside, people watching, playing games, bingo, baking, and volunteering her services.provide friendly visits.enjoys going outside in the courtyard. Review of the medical record revealed there was no documentation Resident #29 had been provided or offered activities from 2/23/2026 to 3/24/2026. During an interview on 3/23/2026 at 10:33 AM, Resident #29 stated, .nothing to do here on the weekends, yesterday I wanted to go outside, no one could go outside with me.I don't like to go out with the smokers I don't want to be around the smoke. During an interview on 3/26/2026 at 11:00 AM, Resident #29 stated, .if you're a nonsmoker going outside with smokers you get that smell on you.we never get to go anywhere.we manage to have a little money, would be nice to go shopping.makes you feel like a shut in. 7. Review of the medical record revealed Resident #41 admitted to the facility on [DATE], with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Major Depressive Disorder, and Anxiety Disorder. Review of the annual MDS dated [DATE], revealed Resident #41 had a BIMS score of 10 which indicated moderately impaired cognition. Review of the Care Plan with target date of 4/8/2026 revealed, .Focus.Prefers to be in bed most of the day.Provide Facility Low Functioning Activity Programming.Provide individual-focused 1:1 sessions with emphasis on sensory and environmental awareness, integration and stimulation.Reminisce with me using photos of family and friends. Review of the medical record revealed there was no documentation Resident #41had been provided or offered activities from 2/23/2026 to 3/24/2026. Observation on 3/23/2026 at 10:48 AM and 3/26/2026 at 10:58 AM, Resident #42 was sleeping in bed. No TV playing or radio beside her bed. 8. Review of the medical record revealed Resident #54 admitted to the facility on [DATE], with diagnoses which included Hemiplegia and Hemiparesis, Cerebral Infarction, Major Depressive Disorder, and Anxiety Disorder. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 14 which indicated no cognitive impairment. Review of the Care Plan with target date of 5/31/2026 revealed, .Reminisce with me using photos of family and friends. Review of the medical record revealed there was no documentation Resident #54 had been provided or offered activities from 2/23/2026 to 3/24/2026. Observation on 3/23/2026 at 10:49 AM and 3/26/2026 at 10:59 AM revealed Resident #54 sleeping no TV playing or radios beside her bed. During an interview on 3/26/2026 at 9:40 AM, the Activity Director was asked about activity participation charting and where it is charted in the electronic medical record. The Activity Director stated, .the CNA charts it in [Named electronic charting system] . at one time we put it on individual sheets. This surveyor asked the Activity Director to provide activity participation over the last month. The Activity Director brought six sheets of paper with handwritten last names of residents with dates from 2/23/2026 to 3/24/2026. The handwritten list had no name for activity provided or how the residents responded to the activity. The Activity Director stated, .without documentation I can't prove it happened.I understand. The Activity Director was asked if any activities were provided for the weekends. She stated, .we have management on duty for the weekend.they try to do something, but nothing is charted. During an interview on 3/25/2026 at 3:00 PM, the Social Service Designee was asked where the charting for daily activities would be in the electronic charting record. The SSD stated, .the CNAs have an activity tab to chart . SSD was asked if any residents had brought concerns to her related to activities. SSD stated, .some have asked about going outside, don't want to go around the smoke . The SSD was asked about activities over the weekends. The SSD stated, .they have complained about no activities on the weekend . During an interview on 3/26/2026 at 12:38 PM, the Director of Nursing (DON) was asked if she would expect residents who elect not to come to the group activities to be provided with 1 on 1 activities. The DON acknowledged that a resident should be provided with 1 on 1 activities. The DON was given the 6 handwritten sheets the Activity Director provided for activity participation. The DON stated, .that is just names on a paper doesn't tell you anything.what activity it was. The DON was asked if a resident requests to go outside should they be allowed to go out. The DON stated, .yes, they should be able to go out.

Based on facility policy review, review of the Administrator's Job Description, review of the TELS (telephone communication system designed for healthcare environments to handle maintenance) work orders, Previous Maintenance Director employee file, medical record review, observations and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for 2 of 8 (400 Hall women's communal bathroom and 400 Hall men's communal bathroom) communal bathrooms observed. The findings include: 1. Review of the undated facility policy titled, Your Rights and Protections as a Nursing Home Resident, revealed, .As a nursing home resident, you have certain rights and protections under Federal and state law that help ensure you get the care and services you need. Review of the facility policy titled, ENVIRONMENTAL CARE POLICIES AND PROCEDURES MANUAL, dated 8/12/2015 revealed, .RESTROOM - DAILY CLEANING PURPOSE.To maintain a clean, orderly and attractive environment for residents.that prevents the spread of infection.General Inspection.Inspect and report any equipment damage or needed repairs. 2. Review of the Administrator's signed Job Description dated 1/20/2026, revealed, .the Administrator leads and directs the overall operations of the facility in accordance with resident needs .Monitor each department's activities .Conduct regular round to ensure resident needs are being addressed, monitor operations of all departments, cleanliness and appearance of facility . 3. Review of the Work Orders in the TELS system revealed, .May 21, 2025 .Mens restroom on 400 hall is LEAKING BAD .replaced gaskets and tighten connections . Review of the Work Orders in the TELS system revealed, .Dec. [December] 27,2024 .Womens restroom [ROOM NUMBER] .Floor wet from leaking toilet/back toilet .2/9 [2/9/2026] .[Named Maintenance Director] .Completed . Review of the Work Orders in the TELS system revealed, .Apr. [April] 7,2025 .Both toilets are leaking from the back of toilet .1/26 [2026] [Named Maintenance Director] .Completed . Review of the Work Orders in the TELS system revealed, .May.20,2025 .Mens Bathroom [ROOM NUMBER] hall .Toilet Leaking .1/26 [2026] [Named Maintenance Director] .Completed . 4. Review of the Previous Maintenance Director's employee file revealed a voluntary termination on 3/5/2026. 5. The following 6 residents were affected by the malfunctioning toilets in the 400 Hall women's communal bathroom and 400 Hall men's communal bathroom. a. Review of the medical record revealed Resident #3 admitted to the facility on [DATE], with diagnoses which included Chronic Respiratory Failure, Chronic Pulmonary Embolism, and Abnormalities of Gait and Mobility. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #3 had a Brief Interview for Mental Score (BIMS) of 10, which indicated moderate impaired cognition. During an interview on 3/26/2026 at 12:00 PM, Resident #3 was asked about using the men's communal bathroom on the 400 Hall. Resident #3 stated, .Yea, I have used it before .water was in the floor .my wheelchair was soaked in water .I don't use it anymore .I come up to the 100 hall and use the bathroom now . b. Review of the medical record revealed Resident #29 admitted to the facility on [DATE], with diagnoses which included Anemia, Hyperlipidemia, Hypertension, and Anxiety Disorder. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 14, which indicated no cognitive impairment. Resident #29 was dependent for toileting. During an interview on 3/23/2026 at 10:33 AM, Resident #29 stated, .the women's bathroom on the Hall [400 Hall women's communal bathroom] only has one commode working.I have to go up front and use the employee bathroom because someone will be in their or it will be to dirty. The 400 Hall women's communal bathroom has 2 commodes, with only 1 in operation. During an interview on 3/24/2026 at 12:25 PM, Resident #29 was asked about the 2nd commode being bagged in the women's communal bathroom. Resident #29 stated, .it first started leaking, then it got stronger, and now we can't use it .really need them working .we have to wait our turn or try to find another bathroom .hopefully it will get fixed soon .it has been at least a month . c. Review of the medical record revealed Resident #41 admitted to the facility on [DATE], with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Muscle Weakness, and History of Falling. Review of the annual MDS assessment dated [DATE], revealed Resident #41 had a BIMS score of 10, which indicated moderate impaired cognition. Resident #41 required partial/moderate assistance with toileting. d. Review of the medical record revealed Resident #43 admitted to the facility on [DATE], with diagnoses which included Cerebral Infarction, Aphasia, Hypertension, and Muscle Weakness. Review of the quarterly MDS dated [DATE], revealed Resident #43 has a BIMS score of 10, which indicated moderate impaired cognition. Resident #43 required partial/moderate assistance with toileting. e. Review of the medical record revealed Resident #53 admitted to the facility on [DATE] with diagnosis which included Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure, and History of Falling. Review of the annual MDS dated [DATE] revealed a BIMS score of 00, which indicated severe cognitive impairment. Resident #53 required substantial/maximal assist with toileting. f. Review of the medical record revealed Resident #54 admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis, Difficulty in Walking, and Repeated Falls. Review of the quarterly MDS dated [DATE] revealed Resident #54 had a BIMS score of 14, which indicated no cognitive impairment. Resident #54 was dependent for toileting. Observation on 400 hall in the women's communal bathroom on 3/23/3036 at 10:52 AM, 3/24/2026 at 7:35 AM, and 3/24/2026 at 11:37 AM, revealed only one commode available for use. The second commode next to the wall had a plastic bag wrapped around it with a plunger bagged laying on top of the commode. Observation on the 400 hall in the men's communal bathroom on 3/23/2026 at 10:54 AM, 3/24/2026 at 7:33 AM, and 3/24/2026 at 11:35 AM, revealed the bathroom light was dim, and the above fluorescent light bulb was out. Continued observation in the bathroom revealed a wet towel sitting under the 1st commode. The second commode next to the wall had a wet shower cape folded under the toilet with mold noted to the adjacent wall of the commode. The commode is visibly leaking at the top of the plumbing, extending down the side of the commode, and dripping onto the floor. During an interview on 3/24/2026 at 11:47 AM, the Housekeeping Supervisor was asked why the 2nd commode in the women's communal bathroom had bags wrapped around the toilet. The Housekeeping Supervisor stated, .I don't know why . The Housekeeping Supervisor was asked to verify the 1st commode would flush and he stated, .yes it will flush but it is leaking at the back of the commode .we don't have a Maintenance director right now.he handed me the keys and said he was done. During an interview on 3/24/2026 at 11:50 AM, the Housekeeping Supervisor was asked about the light fixture in the men's communal bathroom. The Housekeeping Supervisor stated, .the bulb needs to be changed .may need a new balance . The Housekeeping Supervisor was asked why the 1st and 2nd commodes in the men's communal bathrooms had a towel and folded shower cape under the commodes. The Housekeeping Supervisor flushed the first bathroom stall and stated, .it is leaking at the top of the commode . The Housekeeping Supervisor acknowledged the commode in the 2nd stall of the men's communal bathroom was leaking at the top and he was unsure of how long it had been leaking. The Housekeeping Supervisor stated, .the tile should not be molded .we had a Maintenance Director he quit he handed me the keys and said he was done . During an interview on 3/24/2026 at 12:15 PM, Licensed Practical Nurse (LPN) A stated, .I don't know how long the women's commode has been bagged up but I have a certified nursing assistant that will know . During an interview on 3/24/2026 at 12:25 PM, Certified Nursing Assistant (CNA) B was asked how long the women's commode in the 2nd stall had been out of use with bags placed over it. CNA B stated, .about a month . CNA B was asked how long the men's communal bathroom commodes had been leaking. The CNA stated, .a couple of months. CNA B was asked who uses the women's communal bathroom on the 400 hall. CNA B stated, .I know 3 residents do.[Resident #29, Resident #41, Resident #53].[Resident #29] and [Resident #41] sometimes goes on their own but I have to assist [Resident #53].1-2 males use the men's bathroom [Resident #43] takes himself, he is a very private man, I try to check on him frequently when he is in the bathroom.[Resident #3] uses it sometimes on his own when he is in the dining room. During an interview on 3/24/2026 at 2:30 PM, CNA B was asked if she was concerned about the commodes leaking. The CNA stated, .it could cause the residents to fall. During an interview on 3/24/2026 at 3:15 PM, the Administrator was asked if the communal bathrooms were the only bathrooms on the 400 hall. She stated, .yes . The Administrator was asked should the communal bathrooms on the 400 hall be in good working condition. The Administrator stated, .according to him [previous Maintenance Director] it was, I don't use those bathrooms so I didn't know .He [Maintenance Director] would say he completed projects .I would go behind him and see things he hadn't completed .he turned his keys in and walked out . The Social Service Director walked into the room and the Administrator asked her when the Maintenance Director left and she stated, .3/5/2026 . During a telephone interview on 3/24/2026 at 8:17 PM, CNA C was asked if she had ever seen any issues with the 400 hall men and women communal bathrooms. CNA C stated, .always issues with the female bathroom the toilet closes to the wall leaks a lot, and men's bathroom we had to put towels or bath blankets down under both commodes because they both leaked .the light bulbs would stay out in the men's bathroom . The CNA was asked how long the bathrooms have needed repair and she stated, .I know it has been over a month . Observation on 3/25/2026 at 8:05 AM and 9:52 AM, the men's communal bathroom on the 400 hall has an out of order sign on the door. Observation on 3/25/2026 at 9:53 AM, the women's commode next to the wall continues to be bagged and the 1st commode continued to leak. Observation on 3/26/2025 at 11:55 AM, the men's communal bathroom on the 400 hall has an out of order sign on the door. Observation on 3/26/2026 at 11:56 AM, the women's commode next to the wall continues to be bagged and the 1st commode continued to leak. During an interview on 3/26/2026 at 12:43 PM, the Director of Nursing (DON) was asked if a homelike environment would include bathrooms in good working condition. The DON stated, .Yes .

Based on policy review, medical record review, and interview, the facility failed to have an accurate and updated Baseline Care Plan for 4 of 5 sampled residents (Resident #2, #3, #4, and #5) reviewed for Baseline Care Plan. The findings include: 1. Review of the facility's policy titled Baseline Care Plan Assessment/Comprehensive Care Plans, revised 3/23/2021, revealed .It is the policy of the facility to ensure that every resident has a Baseline Care Plan completed and implemented within 48 hours of Admission. The Baseline Care Plan is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission .The Baseline Care Plan will continue to be updated with changes in risk factors, goals and interventions until the Comprehensive Care Plan is completed .Upon admission to the facility, the admitting nurse will initiate the Baseline Care Plan Assessment to establish an initial plan of care to identify potential problems and to initiate appropriate goals and interventions. The Baseline Care Plan Assessment will be completed within 48 hours of admission and will address areas of imminent concern .Observations, interview[s] with the resident and/or their representative, information obtained from the physician as well as review of the available medical records on admission will be reference points for development of the Baseline Care Plan Assessment .The Baseline Care Plan will continue to be revised until the final completion of the Comprehensive Care Plan . 2. Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses Anxiety, Stage 4 Metastatic Lung Cancer, Malignant Neoplasm Bone and Prostate, Severe Protein Calorie Malnutrition, Chronic Obstructive Pulmonary Disease, and Depression. Review of the Baseline Care Plan dated 3/22/2023 and signed by RN #1, revealed .Presence of pain yes . There was no documentation for interventions and include non-pharmaceutical interventions or goals for pain. Under the section titled Mental health needs, it was blank with no documentation. Review of Resident #2's Nurse's note dated 3/22/2023 at 10:23 PM, revealed .Communicates verbally all needs and concerns. Appears very depressed and anxious. PRN [as needed] anxiety medication given and ineffective. Resident unable to calm down even with the presence of wife/spouse at bedside. Resident was unable to sleep for more than 30-minute waking up to make sure spouse was still at beside . Review of Resident #2's Nurse's note dated 3/23/2023 at 5:50 AM, revealed .Appears very depressed and anxious. PRN anxiety medication given and ineffective. Resident unable to relax and had daughter calling the facility numerous times to check resident's O2 [oxygen] levels or check on patient because he kept calling her . Review of the physician's order dated 3/23/2023, revealed .Lorazepam 0.5 mg [milligrams] 1 by mouth every 6 hours as needed for anxiety/agitation . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed cognition was not assessed. Resident #2's activities of daily living (ADL) needs bed mobility and transfer between surfaces required extensive assistance and two-person physical assist, dressing extensive assistance one person physical assist. Review of Resident #2's Kardex (communication from Baseline Care Plan to Certified Nursing Assistant's ADL tool) dated as of 5/17/2023, revealed no documentation of resident's pain or anxiety, goals, or interventions. During an interview on 5/16/2023 at 2:00 PM, Minimum Data Set (MDS) nurse stated, . My office was near his room. He [Resident #2] was very anxious. He would keep the pulse ox (device that measures oxygen saturation in the blood) on his finger and if it fell off or got lost in the covers of the bed, he would get so anxious .He required constant reassurance . During an interview on 5/16/2023 at 2:40 PM, Regional Nurse Consultant #1 confirmed the 3/22/2023 Baseline Care Plan had no documentation of anxiety or depression, goals, interventions, and no documentation of goals and interventions for pain. She stated, .I don't see anything .I will call our regional MDS . During an interview on 5/17/2023 at 8:00 AM, Regional Nurse Consultant #2 confirmed no documentation of goals and interventions for pain, and no documentation of anxiety or depression with goals and interventions. She stated, .You are right . During an interview on 5/17/2023 at 8:00 AM, when asked how the Baseline Care Plan information is communicated to the CNAs, the Regional Nurse Consultant #1 stated, .The Baseline Care Plan information populates to the CNA's Kardex . When asked is there any documentation of communication to the CNA about Resident #2's anxiety and pain, the Regional Nurse Consultant #1 stated, .No . During an interview on 5/17/2023 at 8:55 AM, MDS Regional Consultant confirmed no documentation of anxiety on the Baseline Care Plan with goals and interventions pharmaceutical and non-pharmaceutical, and not updated from admission. She stated, .No, there was no documentation of anxiety, interventions and goals .No, the Baseline Care Plan was not updated to reflect anxiety . 3. Medical record revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses Chronic Obstructive Pulmonary Disease, Hypertension, Diabetes Mellitus Type 2, Depression, Dementia, Chronic Pain, and Adult Failure to Thrive. Review of Resident #3's Baseline Care Plan with admitted [DATE], revealed .Medications resident is taking . no check mark in the box labeled psychotropic medication. Review of the physician's order dated 3/28/2023, revealed .Paroxetine Hydrochloride 20 mg 1 tab by mouth one time a day r/t [related to] depression . Review of Resident #3 Baseline Care Plan revealed .Admission 3/28/2023 .signed by [nurse's name] .signed date 1/5/2023 . During an interview on 5/17/2023 at 8:30 AM, Licensed Practical Nurse (LPN) #1 was asked if the document titled Baseline Care Plan with Resident #3's name, the facility name, Resident #3's room number and admitted [DATE] accurate, and LPN #1 stated .Yes . When asked to confirm at the bottom of the page was signed and dated as 1/5/2023, LPN #1 stated .Yes . When asked how the document can be an admitted [DATE] but signed on 1/5/2023, LPN #1 did not reply. 4. Medical record review revealed Resident #4 was admitted to the facility on [DATE], with diagnoses of Diabetes Mellitus Type 2, Cirrhosis Liver, Malignant Neoplasm Bronchus and Lung, Melanoma Skin, Hypertension, Anxiety and Chronic Pain. Review of the physician's order dated 2/25/2023, revealed .Oxycodone HCL [hydrochloride] 10-325 mg 1 by mouth every 4 hours prn pain .Oxycodone HCL 100 mg/ml give 0.25 ml every hour as needed for shortness of breath/pain . Review of Resident #4's Baseline Care Plan signed 2/25/2023, revealed Presence of Pain yes . There was no documentation of goals, interventions, and non-pharmaceutical interventions for pain. Review of Care Plan note dated 3/2/2023 at 6:52 PM, revealed .Family has concerns about his anxiety .Resident got emotional talking about how he is forgetful of things at times and that causes his anxiety . Review of the admission MDS dated [DATE], revealed Resident #4 scored a 13 on the BIMS which indicated cognitively intact for daily decision making. Review of the Baseline Care Plan, revealed the care plan was completed on 3/9/2023. There was no documentation of an update to reflect anxiety, goals, and interventions. 5. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses After Care Fracture Femur, Chronic Obstructive Pulmonary Disease, Depression, Diabetes Mellitus Type 2, Hypertension, Osteoporosis, Peripheral Vascular Disease, Infection Clostridium Difficle and Atrial Fibrillation. Review of the admission MDS dated [DATE], documented the resident scored a 15 on the BIMS which indicated cognitively intact for daily decision making. Review of the physician's order dated 4/25/2023, revealed .Escitalopram Oxalate 20 mg 1 by mouth daily for depression . Review of Resident #5's Baseline Care Plan dated 4/25/2023, revealed under the section titled Social Services-Mental health needs-Depression screening the area was blank with no documentation. Under the section titled, Safety risk, it was documented, .yes history of falls .yes fall in the last month prior to admission . Thee was no documentation of goals and interventions for falls. During an interview on 5/17/2023 at 8:00 AM, Regional Nurse Consultant #2 stated, .You are right the Baseline Care Plans are not patient specific and doesn't include patient specific goals and interventions . During an interview on 5/17/2023 at 8:55 PM, when asked are the Baseline Care Plans being updated or revised to reflect the needs or changes occurring prior to development of the comprehensive care plan, the MDS Regional consultant stated, .No they are not .they should be to reflect needs or changes occurring prior to development of the comprehensive care plan .but no .we will be doing more education .

Based on Centers for Disease Control (CDC) guidelines, policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 7 staff members (Certified Nursing Assistant (CNA) #1) observed failed to properly don (to put on) Personal Protective Equipment (PPE) for 3 of 64 residents (Resident #40, #37, and #43) observed during dining; when 1 of 3 staff members (Licensed Practical Nurses (LPN) #2) failed to clean nebulizer equipment and a reusable syringe properly for Resident #22 and #54 during medication administration; when 1 of 1 staff member (CNA #2) was observed entering a Transmission Based Precautions (TBP) room without the proper PPE; when the facility failed to ensure continuous TBP status for 1 of 2 sampled residents (Resident #60) in TBP; and when 2 of 2 staff members (CNA #9 and CNA #10) were observed not performing hand hygiene after testing themselves for COVID-19. The findings include: Review of the CDC guidelines titled, SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT ., updated 2/2/2022, revealed .MASK .Fit flexible band to nose bridge . Observation in the resident's room on 4/24/2022 at 1:00 PM, revealed CNA #1 entered Resident #40's room with her surgical mask below her nose. Observation in the resident's room on 4/24/2022 at 1:05 PM, revealed CNA #1 entered Resident #40's and Resident #43's room with her surgical mask below her nose. Observation in the resident's room on 4/24/2022 at 1:13 PM, revealed CNA #1 entered Resident #37's room with her surgical mask below her nose. Review of the facility's undated policy titled, Enteral Tube Medication Administration, revealed .Separate piston syringe from barrel, rinse and allow to air dry . Observation in the resident's room on 4/25/2022 at 4:25 PM, revealed LPN #2 administered a nebulizer treatment to Resident #22, removed the nebulizer mask, placed it in a plastic bag without cleaning the mask or medication reservoir. Observation in the resident's room on 4/26/2022 at 7:22 AM, revealed LPN #2 removed Resident #54's piston syringe from a plastic bag, checked placement of the PEG (Percutaneous Endoscopic Gastrostomy) tube (a tube inserted in the stomach to administer medication or food) and administered the medications through the PEG tube. LPN #2 rinsed the plunger and barrel of the syringe, placed them back in the plastic bag, and failed to allow the barrel and plunger to dry. Water particles were visible in the plastic bag. During an interview on 4/26/2022 at 5:20 PM, the Director of Nursing (DON) was asked how a nebulizer mask should be stored until the next time it was used. The DON confirmed it should be cleaned, dried, and placed back in the bag. The DON confirmed an enteral feeding syringe should be cleaned, dried, and placed back in the bag until the next use. The DON was asked how staff should wear their mask. The DON confirmed the mask should be worn over the nose and mouth. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #60 received antibiotics. Observation outside Resident #60's room on 4/24/2022 at 11:01 AM and 4:13 PM, on 4/25/2022 at 8:27 AM, 12:58 PM, and 4:07 PM, and on 4/26/2022 at 2:05 PM revealed Resident #60 was not in isolation. Observation in the resident's room on 4/27/2022 at 10:56 AM, revealed Certified Nursing Assistant (CNA) #2 entered Resident #60's room wearing only goggles and a surgical mask. Observation on the 400 Hall outside of Resident #60's room on 4/27/2022 at 10:57 AM, revealed a sign on the door that read Stop Contact Precautions Everyone must clean hands .before entering and when leaving room. Providers and Staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . During an interview on 4/27/2022 at 11:07 AM, LPN #3 stated, I did an in-and-out catheter on her, and she had ESBL [Extended Spectrum Beta-Lactamase] [a bacteria in the urine] and was in isolation . LPN #3 confirmed Resident #60 was on Intravenous antibiotics for 10 days, and the isolation was discontinued over the weekend, prior to obtaining a repeat urinalysis. LPN #3 confirmed Resident #60 was not supposed to be out of isolation until the urine was returned. LPN #3 confirmed staff were supposed to wear a mask, goggles, gown, and gloves when entering the room. During an interview on 4/27/2022 at 11:55 AM, the Nurse Practitioner (NP) confirmed Resident #60 had been on antibiotics since December for Urinary Tract Infections ([CONDITION(S)]). The NP confirmed Resident #60 was started on an antibiotic on 4/11/2022, a repeat urine sample was collected on 4/26/2022, and Resident #60 should have remained in isolation until the results were returned. The NP confirmed Resident #60 should not have been removed from isolation. The facility's policy titled, COVID-19 Residents and Staff Testing, .dated 3/31/2022, revealed .During specimen collection, facilities must maintain proper infection control . Observation at the screening area in the lobby on 4/25/2022 at 5:59 PM, revealed CNA #9 and CNA #10 were performing COVID-19 tests on themselves. CNA #9 and CNA #10 did not perform hand hygiene after completing the test. During an interview on 4/25/2022 at 6:06 PM, CNA #9 confirmed she had not washed her hands after performing the COVID-19 test on herself. During an interview on 4/25/2022 at 6:08 PM, CNA #10 confirmed she had not washed her hands after performing the COVID-19 test on herself. During an interview on 4/26/2022 at 5:20 PM, the DON confirmed staff should perform hand hygiene after they perform a COVID-19 test on themselves.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 3 of 7 staff members (Certified Nursing Assistant (CNA) #1, CNA #5, and CNA #6) failed to perform proper hand hygiene for 13 of 64 residents (Resident #7, #12, #15, #17, #37, #40, #43, #47, #49, #51, #56, #57, and #59) observed during meal service. The findings include: Review of the facility's undated policy titled, Hand Hygiene Guidelines, revealed .The scope of this guideline includes all interdisciplinary members .and individuals that partake in the resident plan of care .Procedure .When hands are visibly soiled, exposure to a spore forming organism has been suspected .before and after eating .hands should be washed . Observation on the 200 Hall on 4/24/2022 beginning at 1:00 PM, revealed CNA #1 entered Resident #40's room, donned a glove on her left hand, moved Resident #40's urinal from his over bed table to his nightstand, removed the glove and prepared his meal tray, without performing hand hygiene. CNA #1 returned to the meal cart, poured coffee in a cup, delivered and prepared Resident #47's meal tray, without performing hand hygiene. CNA #1 returned to the meal cart, poured coffee in a cup, and delivered Resident #43's meal tray, without performing hand hygiene. Resident #40 and #43 both requested a sandwich, in place of their meal. CNA #1 exited the residents' room, went to the Nutrition Room, obtained 3 sandwiches from the refrigerator, and returned to Resident #40 and #43's room, without performing hand hygiene. CNA #1 returned to the meal cart, obtained Resident #15's meal tray, delivered the tray and prepared it for the resident without performing hand hygiene. CNA #1 returned to the meal cart, obtained Resident #57's meal tray, delivered the tray and prepared it, without performing hand hygiene. CNA #1 returned to the meal cart, obtained Resident #37's meal tray, delivered the tray and prepared it, without performing hand hygiene. CNA #1 returned to the meal cart, obtained Resident #12's meal tray, took it to his room and placed it on his over the bed table. CNA #1 exited the room, went to the clean linen cart, obtained 2 towels and a chair from the hallway, and returned to the resident's bedside. CNA #1 donned gloves, without performing hand hygiene, assisted Resident #12 up in bed, sat down, and placed a towel over the Resident's chest and shoulders. CNA #1 prepared Resident #12's meal tray and assisted the resident to eat the meal, while wearing the same gloves used to move the resident up in bed. CNA #1 failed to perform hand hygiene during the entire meal service. Observation on 4/25/2022 at 5:04 PM, CNA #5 wore a surgical mask and eye protection, donned a gown and gloves, and delivered Resident #51's meal tray. CNA #5 raised the head of the resident's bed, using the bed controls, opened the resident's silverware and napkin, touched the cornbread and dessert bar with the gloved hand that had been used to adjust the bed controls. Observation on the 100 Hall on 4/25/2022 at 5:25 PM, revealed CNA #6 delivered Resident #49's meal tray and touched her dessert bar and cornbread with her bare hands. Observation on the 100 Hall on 4/25/2022 beginning at 5:27 PM, revealed CNA #1 retrieved Resident #7's meal tray from the meal cart, placed the tray on his over bed table, raised the bed using the bed controls, went to the door, and asked another staff member for assistance. CNA #1 and CNA #3 moved the resident up in bed. CNA #1 exited the room, went to the clean linen cart, retrieved a towel, and returned to Resident #7's room, without performing hand hygiene. Observation on the 100 Hall on 4/25/2022 at 5:40 PM, revealed CNA #1 touched the handle of a wheelchair, pushed the meal cart to the Dining Room, poured 2 cups of coffee, opened the meal cart, and served Resident #59's tray, without performing hand hygiene. Observation in the resident's room on 4/25/2022 at 5:46 PM, revealed CNA #1 entered Resident #56's room, obtained a carbonated beverage from the refrigerator, and opened it for the resident. CNA #1 returned to the meal cart, obtained Resident #17's tray, delivered the tray and prepared it for the resident, without performing hand hygiene. During an interview on 4/26/2022 at 5:19 PM, the Director of Nursing confirmed staff should wash their hands between each resident when passing trays, should perform hand hygiene after touching inanimate objects, and should not touch the residents' food with their bare hands.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unsecured and not attended by authorized staff, open, undated, and expired in 4 of 9 medication storage areas (100 Hall Medication Cart, 300 Hall Medication Cart, 200 Hall Medication Cart, and ,d+[DATE] Hall Medication Room) reviewed. The findings include: Review of the facility's undated policy titled, MEDICATION STORAGE IN THE FACILITY, revealed .Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Outdated .will be immediately withdrawn from stock . Observation during medication administration at the 100 Hall Medication Cart on [DATE] at 8:02 AM, revealed Licensed Practical Nurse (LPN) #1 removed a [MEDICATION(S)] 5 percent (%) patch ( a non-medicated pain patch) for Resident #29, handed the patch to the surveyor, walked away from the medication cart, and stated, I got to get some scissors, and entered the Plant Operations Office, leaving the [MEDICATION(S)] 5% patch in the hands of the surveyor, unsecured and not attended by authorized staff. Observation at the 300 Hall Medication Cart on [DATE] at 12:18 PM, revealed the following: a. 1 multi dose vial of [MEDICATION(S)] R (Regular) Insulin (medication used to decrease blood glucose levels) open and undated b. 6 [MEDICATION(S)] Syringes with an expiration date of ,d+[DATE] During an interview on [DATE] at 12:36 PM, Registered Nurse (RN) #1 confirmed staff should put an opened date on medications when they are opened, and no medication should be stored past its expiration date. Observation of the 200 Hall Medication Cart on [DATE] at 12:44 PM, revealed 2 bottles of Acetic Acid Irrigation (used to cleanse infected wounds) 1000 milliliters (ml) open and undated Observation in the ,d+[DATE] Hall Medication Room on [DATE] at 12:50 PM, revealed 1 multidose vial of [MEDICATION(S)] 1 ml (medication used to detect [CONDITION(S)]) open and undated in the refrigerator. During an interview on [DATE] at 12:50 PM, Licensed Practical Nurse (LPN) #4 confirmed medications should be dated when opened. During an interview on [DATE] at 1:57 PM, the Director of Nursing (DON) confirmed that staff should date medications when opened, and no medications should be stored past the expiration or use by dates. She confirmed medications should be stored under lock and key and secured.

Based on policy review, medical record review, and interview the facility failed to ensure 5 of 16 sampled residents (Resident #29, #49, #52, #56, and #60) or their families were invited to participate in planning their care. The findings include: Review of the facility's policy titled Baseline Care Plan Assessment/Comprehensive Care Plans, dated 11/25/2017, revealed .Social Service Director .will notify the resident's responsible party either by letter or phone call to inform them of the scheduled Care Plan Conference to include the date and time. This notification will continue for subsequent Care Plan Conferences. The notifications will be documented for reference .Social Service Director .will invite and encourage the resident to attend . Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #29 was cognitively intact for making decisions. Review of the medical record, revealed no documentation Resident #29 was included in her Care Plan meetings. During an interview on 4/26/2022 at 2:24 PM, the Social Service Director was asked if Resident #29 should have been invited to attend her Care Plan meeting. The Social Service Director stated, We didn't have a 72-hour Care Plan meeting, we didn't have one . Review of the medical record, revealed Resident #49 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS dated [DATE], revealed Resident #49 had moderate cognitive impairment. Review of the Care Plan Meeting Notes dated 4/20/2022, revealed Resident #49 or their family was not invited to a Care Plan meeting and did not participate in a Care Plan meeting. During an interview on 4/26/2022 at 2:26 PM, the Social Service Director was asked if Resident #49 or a family member should have been invited to attend her Care Plan meeting. The Social Service Director confirmed they did not have a Care Plan meeting for Resident #49. Review of the medical record, revealed Resident #52 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan Meeting Notes dated 8/4/2021, revealed Resident #49 or family was not invited to a Care Plan meeting and did not participate in the Care Plan meeting. Review of the significant change MDS dated [DATE], revealed Resident #52 had severe cognitive impairment. Review of the medical record, revealed Resident #56 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #56 was cognitively intact for making decisions. Review of the medical record, revealed no documentation Resident #56 attended her Care Plan meeting. During an interview on 4/26/2022 at 2:23 PM, the Social Service Director confirmed no 72-hour or quarterly Care Plan meetings were held. Review of the medical record, review revealed Resident #60 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS dated [DATE], revealed Resident #60 had intact cognition for making decisions. During an interview on 4/24/2022 at 4:17 PM, Resident #60 confirmed she had not been invited to attend Care Plan meetings. During an interview on 4/26/2022 at 2:23 PM, the Social Service Director confirmed the required Care Plan meetings were not conducted. During an interview of 4/26/2022 at 5:35 PM, the Director of Nursing (DON) confirmed residents or their responsible party should be invited to attend Care Plan meetings.

Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect when 4 of 7 staff members (Certified Nursing Assistant (CNA) #1, #2, and #4, and Licensed Practical Nurse (LPN) #3) failed to use courtesy titles, stood over a resident when assisting with a meal, and failed to knock when entering the residents' rooms for 14 of 64 residents (Resident #3, #7, #12, #17, #18, #20, #23, #29, #31, #33, #34, #40, #56, and #214) observed. The findings include: Review of the facility's undated policy titled, Dignity, revealed .Staff will be polite and respectful at all times .When addressing a resident, staff will refrain from calling the resident names like .Sweetie .Honey .as this can be interpreted as undignified . Dining observation outside the resident's room on 4/24/2022 at 1:00 PM, revealed CNA #1 failed to knock on the door or announce herself prior to entering Resident #40's room to serve a meal tray. Dining observation outside the resident's room on 4/24/2022 at 1:14 PM, revealed CNA #1 failed to knock on the door or announce herself prior to entering Resident #12's room to serve a meal tray. Dining observation on the 300 Hall on 4/25/2022 at 5:03 PM, revealed CNA #2 delivered Resident #214's meal tray. CNA #2 stated, I have your tray, honey .I think so, sweetie .You're welcome, honey . Dining observation on the 300 Hall on 4/25/2022 at 5:05 PM, revealed CNA #2 delivered a meal tray to Resident #33. Resident #33 stated, I am supposed to get a grilled cheese . CNA #2 stated, I don't know baby, let me go back to Kitchen .what you say, honey I can't hear you .let me deliver some more trays . CNA #2 delivered Resident #20's meal tray and stated, Hey sleeping beauty .hey baby I have your tray .I got your tray baby .it's your supper tray, [NAME] . and exited the room. CNA #2 sanitized her hands, removed a meal tray from the meal cart, walked down the hall to the Dining Room and delivered a meal tray to Resident #23. CNA #2 placed the meal tray on the table in front of the resident and stated, I got your tray sweetie . Dining observation outside of the resident's room on 4/25/2022 at 5:28 PM, revealed CNA #1 failed to knock on the door or announce herself prior to entering Resident #3's room to serve a meal tray. Dining observation outside of the resident's room on 4/25/2022 at 5:29 PM, revealed CNA #4 failed to knock on the door or announce herself prior to entering Resident #29's room to serve a meal tray. Dining observation outside of the resident's room on 4/25/2022 at 5:30 PM, revealed CNA #1 failed to knock on the door or announce herself prior to entering Resident #31's room. Dining observation in the resident's room on 4/25/2022 at 5:31 PM, CNA #1 delivered Resident #7's tray and stated, I think he's a feeder if I'm not mistaken . CNA #1 went to the linen cart, obtained a towel, and returned to the resident's room. CNA #1 failed to knock or announce herself, and assisted the resident with his meal, standing at his bedside. The bed was in the low position. Dining observation outside of the resident's room on 4/25/2022 at 5:32 PM, revealed CNA #4 failed to knock on the door or announce herself prior to entering Resident #18's room to serve a meal tray. Dining observation outside of the resident's room on 4/25/2022 at 5:34 PM, revealed CNA #1 failed to knock on the door prior to entering Resident #17's room to serve a meal tray. Dining observation in the resident's room on 4/25/2022 at 5:40 PM, revealed CNA #4 replaced CNA #1 during dining, and assisted Resident #7 with his meal, standing at his bedside. The bed was in the low position. Dining observation outside of the resident's room on 4/25/2022 at 5:41 PM, revealed CNA #1 failed to knock on the door prior to entering Resident #56's room to serve a meal tray. Observation at the 400 Hall Medication Cart on 4/26/2022 at 9:00 AM during medication administration, revealed LPN #3 stated to Resident #34, Hey, Honey. During an interview on 4/26/2022 at 5:19 PM, the Director of Nursing (DON) confirmed staff should knock prior to entering a resident's room, should not stand when assisting a resident with their meal, and should use courtesy titles when addressing a resident.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure residents were free from a significant medication error for 1 of 5 sampled residents (Resident #60) reviewed for medications. Resident #60 received her scheduled Insulin (a medication that lowers blood glucose levels) when her blood glucose was outside the ordered parameters. The findings include: Review of the facility's undated policy titled, Policy and Procedure-Pharmacy Recommendations, revealed .objective being to ensure that the residents are receiving medications that are effective and safe .Recommendations as a result of the reviews will be provided to the Director of Nursing upon exit interview by the Pharmacy Consultant .This process will begin within 72 hours of the receipt of the Pharmacist Consultant's report .a response as to the action to be taken regarding the Pharmacy Consultant's recommendation will be documented within 7 days of the receipt of the recommendation .potential to be of an emergent concern or has the potential for negative outcome for the resident will be addressed immediately . Review of the facility's undated policy titled, Policy and Procedure Insulin Administration, revealed .Review the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Remove the medication from the drawer and read the label carefully .When removing Insulin from the drawer .Before withdrawing Insulin or dialing Insulin dose on flex pen .Before administration of Insulin to the resident . Review of the medical record, revealed Resident #60 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Pharmacy Review for Resident #60 dated 2/2/2022, revealed .Insulin (70/30) was administered on 1/1/22 [2022] despite hold order for BG [Blood Glucose] < [less than]110. Please address with staff .(2/1/2022) Feb [February] 2022 .2/1-104 & [and] admin [administer] [Named Licensed Practical Nurse (LPN) #3] 2/2-108 & admin [Named LPN #3] 2/7-80 & admin [Named LPN #3] . Review of the Order Review Report revealed, .Insulin NPH [MEDICATION(S)] & Regular Suspension (70-30) 100 UNIT/ML [Milliliter] Inject 10 unit subcutaneously three times a day for diabetes before meals Hold if BGL [blood glucose level] <110 . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .Insulin .(70-30) .three times a day .Hold if BGL <110 . Review of the 1/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A. On 1/26/2022, Resident #60's blood glucose was 82, and the scheduled 10 units of 70-30 insulin were administered. B. On 1/31/2022, Resident #60's blood glucose was 107, and the scheduled 10 units of 70-30 Insulin were administered. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .Insulin .(70-30) .three times a day .Hold if BGL <110 . Review of the 2/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A. On 2/1/2022, Resident #60's blood glucose was 104, and the scheduled 10 units of 70-30 Insulin were administered. B. On 2/2/2022, Resident #60's blood glucose was 108, and the scheduled 10 units of 70-30 Insulin were administered. C. On 2/7/2022, Resident #60's blood glucose was 80, and the scheduled 10 units of 70-30 Insulin were administered. D. On 2/14/2022, Resident #60's blood glucose was 90, and the scheduled 10 units of 70-30 Insulin were administered. Review of the MEDICATION ERROR REPORT dated 2/15/2022, revealed, .2/1/22 [2022] .Insulin 70/30 .10 units .physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[LPN #3's] signature .2/2 [2022] .70/30 Insulin .10 unit .physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[LPN #3's] signature .2/7 [2022] .Insulin 70/30 .10 unit .physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[LPN #3's] signature . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .Insulin .(70-30) .three times a day .Hold if BGL <110 . Review of the 3/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A. On 3/8/2022, Resident #60's blood glucose was 107, and the scheduled 10 units of 70-30 Insulin were administered. B. On 3/10/2022, Resident #60's blood glucose was 86, and the scheduled 10 units of 70-30 Insulin were administered. C. On 3/13/2022, Resident #60's blood glucose was 107, and the scheduled 10 units of 70-30 Insulin were administered. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .Insulin .(70-30) .three times a day .Hold if BGL <110 . The April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A. On 4/2/2022, Resident #60's blood glucose was 97, and the scheduled 10 units of 70-30 Insulin were administered. B. On 4/5/2022, Resident #60's blood glucose was 93, and the scheduled 10 units of 70-30 Insulin were administered. C. On 4/8/2022, Resident #60's blood glucose was 76, and the scheduled 10 units of 70-30 Insulin were administered. D. On 4/22/2022, Resident #60's blood glucose was 86, and the scheduled 10 units of 70-30 Insulin were administered at 11:30 AM. E. On 4/22/2022, Resident #60's blood glucose was 76, and the scheduled 10 units of 70-30 Insulin were administered at 4:30 PM. During an interview on 4/27/2022 at 11:15 AM, LPN #3 was asked about the Insulin administration for Resident #60 and if it was administrated outside the ordered parameters. LPN #3 stated, .I didn't sign off that I held it due to low sugar, so I got written up for that. The former Director of Nursing (DON) talked with me .She [Resident #60] can tell you when it gets low. She never had to go out for low sugar . During an interview on 4/27/2022 at 11:55 AM, the Nurse Practitioner (NP) was asked about Resident #60's Insulin administration. The NP stated, I was not aware of the Insulin, what happened . The NP was asked if she expected nursing staff to follow parameters.Yes, I would think they would .

Based on policy review, medical record review, and interview, the facility failed to develop a Baseline Care Plan within 48 hours of admission that included the initial goals and needs for 2 of 5 sampled residents (Resident #29 and #213) reviewed. The findings include: Review of the facility's policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, updated 11/25/2017, revealed .Upon admission to the facility, the admitting nurse will initiate the Baseline Care Plan Assessment to establish an initial plan of care to identify potential problems and to initiate appropriate goals and interventions. The Baseline Care Plan Assessment will be completed within 48 hours of admission . Review of the medical record, revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #29 did not have a Baseline Care Plan developed within 48 hours of admission that addressed the initial goals and needs of the resident. The Baseline Care Plan was completed on 3/7/2022. During an interview on 4/27/2022 at 9:37 AM, the Director of Nursing (DON) confirmed the Baseline Care Plan was not completed within 48 hours. Review of the medical record, revealed Resident #213 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #213 did not have a Baseline Care Plan developed within 48 hours of admission that addressed the initial goals and needs of the resident. The Baseline Care Plan was completed 4/26/2022. During an interview on 4/27/2022 at 9:35 AM, the DON confirmed the Baseline Care Plan should be completed with 48 hours of admission. She confirmed Resident #213's Baseline Care Plan was not completed in a timely manner.

Based on policy review, medical record review, and interview, the facility failed to permit a resident to return to the facility after a hospitalization for 1 of 2 residents (Resident #163) reviewed for hospitalization . The findings include: Review of the facility's undated policy titled, Transfer and Discharge Policy and Procedure, revealed, .The facility shall permit each resident to remain in the facility unless such transfer or discharge is made in recognition of the resident's rights to receive considerate and respectful care; to receive necessary care and services and to participate in the development of the Comprehensive Care Plan .Non-emergency transfers or discharges not within the same certified facility will receive notice 30 days before transfer or discharge. Notice will be given to the resident/responsible party .The written notice will include .A statement that the resident has the right to appeal the action to State Department of Health including a current phone number of the Department .The name, address and telephone number of the State Long Term Care Ombudsman . Review of the medical record, revealed Resident #163 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #163 had moderately impaired cognition, had no behaviors, required extensive assistance for bed mobility, transferring, and toilet use, required limited assistance for walking in the corridor, dressing, and personal hygiene, was independent with eating, and was always continent of bladder and bowel. Review of the Progress Notes revealed that on 2/23/2022, Resident #163 hit another resident in the arm with a hanger. On 3/8/2022, Resident #163 walked into the Main Dining Room and began making faces and hand gestures at other residents, verbally told them to shut up, and threw a bag across the Dining Room floor in the direction of other residents. On 3/17/2022, Resident #163 became aggressive toward staff, threw trash and dirty briefs at staff, and was swinging at staff. Review of the Progress Notes revealed Resident #163 was sent to the emergency roiagnom on [DATE] due to his aggressive behavior toward staff. Review of an undated Physician's statement, signed by the Physician, revealed, .On the morning of 03/17/22 at approximately 10AM [10:00 AM] resident became verbally and physically aggressive towards staff that was attempting to clean resident's room. Resident's behavior continued to escalate and was non redirectable. EMS [Emergency Medical Services] was notified and resident was sent out for Psych [Psychiatric] Evaluation .Resident is a harm to himself and others due to escalating physical and verbal threats towards staff and residents. Resident is not able to understand or has the ability to understand the effects of his behaviors and is in need of psych consultation. Resident is not [no] longer appropriate for this kind of facility setting at this time . Review of the TRANSFER/DISCHARGE REPORT dated 3/17/2022, revealed .physical aggression towards others . There was no documentation in the TRANSFER/DISCHARGE REPORT of the specific needs which could not be met at the facility, attempts made by the facility to meet those needs, or the services another facility could provide. Review of the Discharge MDS dated [DATE], revealed .Discharge - return anticipated . During an interview on 4/27/2022 at 5:10 PM, the Administrator was asked if the facility had notified the resident and the resident's representative, in writing, of the reason for the discharge to the hospital and had sent a copy of the notice to the Ombudsman. The Administrator stated, .not in writing . The Administrator was asked if the facility had provided a notice of discharge to the resident or his representative and had the facility sent a copy of the notice to the Office of the Long-Term Care Ombudsman. The Administrator stated, .I don't believe it was in writing . The Administrator was asked if Resident #163 was permitted to return to the facility. The Administrator stated, .No, he was not a good fit .because he was unsafe .the behaviors had escalated .

Based on policy review, employee personnel file review, and interview, the facility failed to ensure employees were screened for a history of abuse, neglect, and exploitation of resident property prior to being hired for 2 of 6 sampled employees (Director of Nursing (DON) and Dietary Aide #1) reviewed. The findings include: Review of the facility's policy titled, Abuse Prevention Program, dated 1/2017, revealed .It is the policy of this facility to prevent abuse, neglect, mistreatment and misappropriation of resident property .Before any person who will be providing direct patient care is hired .a background check using .the state abuse registry, and the state abuse registries for states in which the prospective employee has lived in the previous 7 years according to Public Chapter 1084 . Review of the DON's personnel file revealed there was no abuse registry check included in the file. The DON's hire date was 3/21/2022. Review of Dietary Aide #1's personnel file revealed there was no abuse registry check included in the file. Dietary Aide #1's hire date was 3/4/2022. During an interview on 4/27/2022 at 10:54 AM, the Human Resources/Assistant Business Office staff member confirmed the DON and Dietary Aide #1 did not have an abuse registry check in their files. During an interview on 4/27/2022 at 4:27 PM, the Administrator confirmed the abuse registry should be checked on every employee prior to hiring.

Based on policy review, medical record review, and interview, the facility failed to monitor for behaviors for 3 of 5 (Resident #12, #16, and #67) sampled residents reviewed for unnecessary medications. The findings include: 1. The facility's undated [MEDICAL CONDITION] MEDICATIONS Behavior Management Meetings policy documented, .Nursing .Monitors [MEDICAL CONDITION] drug use .Monitors for presence of target behaviors on a daily basis and documenting same . 2. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED] a. .[MEDICATION NAME] .(antidepressant) .Capsule 10 MG (milligrams) Give 4 capsule by mouth at bedtime . b. .DULoxetine .(antidepressant) Capsule .60 MG .Give 1 capsule by mouth one time a day . c. [MEDICATION NAME] (antianxiety) .Tablet 7.5 MG Give 1 tablet by mouth two times a day . Review of the (MONTH) 2019 MAR indicated [REDACTED]. Interview with the Administrator on 10/22/19 at 3:00 PM, in the Conference Room, the Administrator stated, I don't have it (Behavioral monitoring for [MEDICAL CONDITION] medications). 3. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MAR for the month of (MONTH) 2019 documented the following: a. .[MEDICATION NAME] (antidepressant) .Tablet 100 MG Give 100 mg .by mouth at bedtime .give with 75 mg to equal 175 mg . b. .[MEDICATION NAME] (antidepressant) .50 mg Give 1 TABLET .AT BEDTIME . Review of the (MONTH) 2019 MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 10/22/19 at 3:00 PM, in the Conference Room, the DON stated, There is no behavior monitoring . 4. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MAR for (MONTH) 2019 documented, .[MEDICATION NAME] (antidepressant) 5 mg .every day . Review of the (MONTH) 2019 MAR indicated [REDACTED]. Interview with the Administrator on 10/22/19 at 4:33 PM, in the Conference Room, the Administrator confirmed there was no behavioral monitoring for Resident #67's [MEDICAL CONDITION] medications.

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 3 of 18 (Resident #42, #270 and #277) sampled residents were uncovered and exposed, and 5 of 15 (Certified Nursing Assistant (CNA) #1, #2, #3, #4, and #5) CNAs were observed standing to feed residents. The findings include: 1. The facility's undated DIGNITY policy documented, .Staff will not stand to feed a resident .Staff will provide privacy for residents during any personal care and/or treatment. The privacy curtain must be pulled anytime that the resident needs to have privacy .Residents are to have all aspects of their dignity maintained by staff regardless of the resident's cognitive level or ability to realize or understand what is being said or done by others . 2. Observations in Resident #277's room on 10/20/19 at 12:07 PM, revealed CNA #2 assisted Resident #277 with the bedpan and changed Resident #277's brief without providing privacy. The privacy curtain was not pulled between Resident #277 and the roommate during the personal care. Interview with the Director of Nursing (DON) on 10/23/19 at 8:27 AM, in the DON office, the DON was asked if residents should be assisted with the bedpan and have a brief changed without closing the privacy curtain. The DON stated, No. Observations in Resident #270's room on 10/21/19 at 8:13 AM and 10/22/19 at 8:08 AM, revealed Resident #270 uncovered with his brief exposed. The door to the room was open, and Resident #270 could be observed from the hallway. Interview with the DON on 10/23/19 at 8:27 AM, in the DON office, the DON was asked if residents should be in public view when they are uncovered, exposed and wearing a brief. The DON stated, No. Observations in Resident #42's room on 10/21/19 at 9:47 AM and 10/22/19 at 7:54 AM, revealed Resident #42 lying in bed, uncovered, wearing only a shirt and brief. The door to the room was open, and Resident #42 could be observed from the hallway. Interview with CNA #1 on 10/22/19 at 6:15 PM, in the 400 Hall, CNA #1 confirmed that Resident #42 frequently uncovers herself and stated, She should have pants on because she does that. Some (staff)do (put pants on the resident), some don't. I try to keep pants on her when I'm here. 3. Observations in Resident #40's room on 10/20/19 beginning at 12:55 PM, revealed CNA #4 standing to feed Resident #40. Observations in Resident #48's room on 10/20/19 beginning at 12:55 PM, revealed CNA #3 standing to feed Resident #48. Observations in Resident #40's room on 10/21/19 at 6:10 PM, revealed CNA #5 standing to feed Resident #40. Observations in Resident #32's room on 10/22/19 at 8:17 AM, revealed CNA #1 standing to feed Resident #32. Interview with the DON on 10/23/19 at 8:33 AM, in the DON office, the DON was asked if staff should stand to feed residents. The DON stated, No.

Based on medical record review and interview, the facility failed to ensure assessments were accurate for 1 of 21 (Resident #71) sampled residents reviewed. The findings include: Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurses' Note dated 8/1/19 revealed Resident #71 was discharged home with family. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] documented Resident #71 was discharged to an acute care hospital. Interview with the MDS Coordinator on 10/23/19 at 10:17 AM, in the Conference Room, the MDS Coordinator confirmed Resident #71 had been discharged home, and the MDS was inaccurate.

Based on medical record review and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for 1 of 18 (Resident #58) sampled residents reviewed. The findings include: Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].hospice referral-hospice to evaluate and treat as needed . Medical record review revealed there was no Significant Change MDS assessment completed after Resident #58 was referred to hospice services. Interview with the MDS Coordinator on 10/23/19 at 8:05 AM, in the Medical Records Office, the MDS Coordinator confirmed Resident #58 was receiving Hospice services. The MDS Coordinator was asked if Resident #58 should have had a Significant Change MDS assessment completed related to hospice services. The MDS Coordinator stated, Yes .