Every finding on record at Vandalia Healthcare & Senior Living

Based on interview and record review, the facility failed to provide dental services for 1 of 1 resident (R33) reviewed for dental services in the sample of 29. This failure resulted in R33's cavity and broken teeth going unaddressed and R33 acquiring an abscess requiring antibiotic treatment and ongoing pain. Findings include:R33's admission Record documents an admission date of 10/23/2013, with diagnoses including in part type 2 diabetes, longstanding persistent atrial fibrillation, and hypertension. R33's admission documents R33's payer source is listed as Medicaid. R33's Minimum Date Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) of 14, indicating R33's cognition is intact. R33's Physician's Order Summary documents R33 has and order for Acetaminophen 500 MG (milligrams) tablet, given 2 tablets orally as needed for mild pain up to 3 times a day, with a start date of 8/1/23. On 11/17/2025 at 11:20 AM, R33 stated he has had a tooth pain and a cavity for about a year that he has been asking to get fixed. R33 stated he has been asking since the beginning of the year. Doctors note, dated 5/14/25 written by V16 (Physician), documents under HPI (History of Present Illness); (R33) is complaining of a cavity in his right upper molar area. We are getting him setup to see a dental appointment. Doctors note, dated 7/2/25 written by V16, documents under HPI; (R33) complains of a dental cavity in his right lower jaw area. We are going to get him a dental appointment. Doctors Progress Note-Acute Care, dated 10/29/25 written by V17 (Nurse Practitioner), documents under History of Present Illness,(R33) presented with acute dental pain localized to the left lower gums, accompanied by gum swelling. Examination revealed broken and carious teeth. In the same document under Assessment/Plan, periapical abscess without sinus acute, new order for clindamycin 300 milligrams to be taken three times a day for seven days, refer to dental evaluation, and acetaminophen as needed. On 11/18/25 at 1:03 PM, V14 (Social Services Director) stated she doesn't make appointments, she gives the referral to V8 (Activities Director), and she makes the appointments. V14 stated she doesn't know anything about making R33 a dentist appointment, stating she would have made a note about it in his chart, while she searched through R33's chart and through her filling cabinet. V14 stated she can't find any evidence that she had been working on getting an appointment for R33. On 11/18/25 at 1:28 PM, V15 (Business Office Manager) stated she received a list of residents the week prior that V8 was having problems finding appointments for, and R33 was on it. V8 stated she hadn't started on trying to find a dentist for R33 yet. On 11/18/25 at 1:37 PM, V8 stated she was told the beginning of the prior week that R33 needed an appointment with a dentist, and she was trying to find a dentist that accepts his insurance. V8 stated she gave R33's name to V15 so she could help her fine a dentist. On 11/20/25 at 11:20 AM, V12 (Cook/Certified Nursing Assistant) stated she was the Activities Director/Transport until around the end of August, when she transferred to the kitchen as a cook. V12 stated she was first told to refer R33 to a dentist on 3/18/25, stated she called five different dentist offices, and they were either not taking new patients or would not take his insurance. V12 stated she called another dentist office the end of March and got an appointment for R33 on 4/24/25. V12 stated she took R33 to the dentist on 4/24/25, and they wouldn't see him because no one from the facility confirmed his appointment prior to his scheduled appointment, so the dental office canceled his appointment. V12 stated V13 (Former Administrator) was responsible for confirming R33's appointment and she did not do it. V12 stated they rescheduled R33's appointment for 8/6/25 and 8/20/25. V12 stated the dental officed called and canceled R33's appointment for 8/6/25 due to personal reasons, then the called again and canceled the other appointment for 8/20/25 due to the dentist had a family illness. V12 stated when the dental office called and canceled the appointment for 8/20/25, they stated they would call back with a new appointment, and they never called back, so on 9/12/25, she called to make another appointment, and the dental office would not schedule any appointment due to the dentist family illness. V12 stated on 9/12/25, she was no longer in the position to handle appointment, so she gave all of the information about R33 needing a dental appointment to a nurse, but she doesn't remember which nurse she gave it to. On 11/19/25 at 11:52AM, V2 (Director of Nursing) stated when a resident needs a dentist appointment, the referral should be made as soon as possible.

Based on observation, interview, and record review, the facility failed to notify the doctor and obtain treatment orders when the presence of a pressure area was detected for 1 of 3 residents (R4) reviewed for pressure areas in the sample of 29.R4's admission Record documents an admission date of 11/11/2024, with the following diagnoses in part: early-onset cerebellar ataxia, unspecified, sepsis, unspecified organism, and acute respiratory failure with hypoxia.R4's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 2, indicating R4 is severely cognitively impaired. R4's care plan documents a focus area of has impairment to skin integrity. with interventions including, Monitor/document/report PRN (as needed) any changes in current wound and/or skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection (such as redness, swelling, drainage, foul smell, decline in function) and reduced mobility, wound size (length X width X depth), stage. Report adverse findings to practitioner.R4's physician order sheet, dated 11/19/2025, documents an order for Right Hip - cleanse with wound cleanser and apply skin prep daily at bedtime for wound care, with an initiation date of 11/6/25. There were no additional orders noted for any other wounds located on R4's right buttock or back. R4's Treatment Administration Record (TAR) documents R4's right hip was cleansed with wound cleanser and skin prep was applied at bedtime on 11/18/25. R4's TAR does not document any treatment orders for any other wounds located on R4's right buttock or back. On 11/19/25 at 1:11 PM, observation of R4's right hip revealed a dressing dated 11/17 on R4's right hip and right upper buttocks/back also dated 11/17. V6 (Registered Nurse) removed the dressing to right hip; it was noted to have a scant amount of drainage on the bandage. There appeared to be some cream applied to the wound also. Wound bed was open. Bandage was removed from right upper buttocks/back, there was a quarter sized amount of drainage on the bandage and appeared to have cream on it. On 11/19/25 at 1:11 PM, V6 confirmed both wounds were open. On 11/19/25 at 1:45 PM, V6 confirmed there was no new documentation or dressing change orders for these two open areas. On 11/19/25 at 2:43 PM, V3 (Corporate Nurse) stated her expectation of nursing staff if they find a new wound would be to measure it and contact the physician for orders. V3 stated her expected timeline for that would be by the end of the shift. Facility Policy titled Prevention of Pressure Injuries, dated 2001, documents under the section titled Monitoring, Evaluate, report and document potential changes in the skin.Facility policy titled, Wound Care, dated 2001, documents under the section titled Preparation, Verify there is a physician's order.

Based on observation, interview, and record review, the facility failed to administrator intravenous medications safely for 1 of 1 (R25) resident reviewed for intravenous medication administration in a sample of 29. Findings include:R25's admission Record documents an admission date of 11/7/25, with diagnoses including in part infection following a procedure, encounter for surgical aftercare following surgery on the genitourinary system, peritoneal abscess, and long-term use of antibiotics. R25's Minimum Date Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) of 15, indicating R25's cognition is intact. R25's Care Plan documents implementation of enhanced barrier precaution due to R25 has surgical wounds with wound vacuum and/or dressing and secretions or excretions that are unable to be covered or contained and R25 is on intravenous medications and has a peripherally inserted central catheter (PICC) line related to wound infection. R25's Order Summary Report, dated 11/19/25, documents micafungin sodium intravenous solution reconstituted 100 milligrams (mg), use 100 mg intravenously in the afternoon for candidiasis with a start date of 11/9/25. Sodium chloride injection solution 0.9 % use 5 milliliters intravenously every day shift for PICC (peripherally inserted central catheter) line maintenance before and after intravenous infusion-micafungin with a start date of 11/8/25. The same Order Summary Report documents PICC line single lumen to upper extremity, monitor site for signs and/or symptoms of infection or migration with a start date of 11/7/25 and a discontinue date of 11/18/25 and PICC line double lumen to right chest, monitor site for signs and/or symptoms of infection or migration with a start date of 11/18/25. On 11/17/25 at 10:50 AM, R25's door did not have an enhanced barrier sign on it and there was no PPE available at the door or in the room. On 11/17/2025 at 10:58 AM, V6 (Registered Nurse) administered intravenous Micafungin Sodium reconstituted 100 mg medication to R25 through double lumen midline in R25's right chest. V6 cleaned her hands with hand sanitizer then donned gloves. V6 then mixed the IV medication, hung it on the IV pole, then programed the pump. V6 then removed the end cap on one lumen without changing her gloves and cleaned the end cap with alcohol, then attached a 10-milliliter syringe of normal saline and flushed the line then put the same end cap back on the lumen. Then V6 cleaned the other lumen end cap with alcohol without changing her gloves, attached a 10-milliliter syringe of normal saline, and flushed the line with the normal saline. After flushing the line, V6 removed the syringe and attached the medication intravenous line and started the medication at 100ml/hr. V6 did not pull blood back prior to administrating the medication on either lumen to check to patency, and V6 did not don a gown for this procedure. V6 did not change her gloves during this observation when moving to cleaning the catheter lumens and hooking up the IV line after programing the pump. On 11/17/25 at 2:20 PM, V2 (Director of Nursing) stated R28 was admitted with a single lumen PICC line in her upper extremity, but she wasn't sure which arm it was in. V2 was informed the line is in her chest and not her arm and it is a double lumen. V2 stated she wasn't sure what kind of line it was because she thought it was a PICC line in her arm. V2 stated she would try to find documentation on what type of line it is. On 11/19/25 at 11:52 AM, V2 stated V6 should be on enhanced barrier precautions due to her central line and a gown and gloves should be worn when administrating intravenous medication. V2 stated she was able to find that R25's line in her chest is a double lumen tunneled central catheter in her discharge documents from her recent hospital stay. On 11/20/25 at 10:45 AM, V2 stated prior to administrating intravenous medication into the central catheter in R25's chest, it should be flushed and aspirated for blood return prior to each infusion to check catheter patency. A facility policy titled Central Venous Catheter Flushing and Locking, dated June 2025, documents under General Guidelines, Frequency, 1. Flush the catheter and aspirate for blood return prior to each infusion to assess catheter function. Under Flushing when giving medications: 1. Perform hand antisepsis, don non-sterile gloves, 2. Disinfect needleless access device with disinfecting wipe, 3. Attach prefilled saline syringe to needleless access device, 4. Unclamp catheter or lumen, 5. Aspirate slowly for blood return to ensure patency of catheter.

Based on observation, interview, and record revied the facility failed to administration medication according to the standards of practice for 1 of 5 (R18) residents reviewed for medication administration in a sample of 29. Findings include:R18's admission Record documents an admission date of 7/28/25, with diagnoses including in part type 2 diabetes, hypertension, hypothyroidism, atrial fibrillation, weakness, chronic kidney disease, and depression. R18's Minimum Date Set (MDS), dated [DATE], documents a Brief Assessment of Mental Status (BIMS) of 14, indicating R18's cognition is intact. R18's Medication Administration Record (MAR), dated 11/1/25-11/30/25, documents R18 was given absorbic acid, levothyroxine, metoprolol succinate, modafinil, multivitamin, omeprazole, potassium chloride, sertraline, colace, eliquis, tylenol, and meclizine with his morning medication pass on 11/17/25. On 11/17/25 at 10:39 AM, there were cup of pills sitting on the bedside table beside R18's bed. R18 stated the nurse didn't wake him up to tell him they were there, so he doesn't know how long they've been sitting there. On 11/18/25 at 12:45 PM, V5 (License Practical Nurse) stated she doesn't usually wake R18 up when she takes him his medication if he is sleeping, and she will leave the cup of pills on his bedside table. V5 stated she usually would try to go back into R18's room to check to see if he took his pills, but on 11/17/25, she documented she gave the morning medication at 9:09 AM then she did not go back into the room until 11:21 AM to give his lunch time medication, and when she went in his room at 11:21 AM the pills were gone. On 11/19/25 at 11:52, V2 (Director of Nursing) stated if a resident is sleeping when the nurse goes to give them medication, they should be woken up and given directly to the resident and not left on the bedside table. A facility policy titled Administering Medication, dated April 2019, documents under Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. 20. For residents not in their rooms or otherwise unavailable to receive medications on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication.

Based on observation, interview, and record review, the facility failed to post enhanced barrier precaution signage and provide PPE (Personal Protective Equipment) for a resident and failed to follow proper infection control practices during resident care, for 2 of 2 residents (R4, R25) reviewed for infection control in a sample of 29. Finding include:1. R4's admission Record documents an admission date of 11/11/2024, with the following diagnoses: early-onset cerebellar ataxia, unspecified, sepsis, unspecified organism, and acute respiratory failure with hypoxia.R4's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 2, indicating R4 is severely cognitively impaired.R4's care plan documents a focus of Implementation of Enhanced Barrier, with an initiation date of 9/17/25, with interventions including Use enhanced barrier protection during high contact care activities. R4's Physician's order sheet documents an active order for Enhanced Barrier Precautions, with an initiation date of 7/31/25.On 11/18/25 at 2:56 PM, enhanced barrier precaution sign was posted outside of R4's door, Personal Protective Equipment was stored just inside the door. On 11/18/25 at 2:57 PM, wound care was observed on R4. Wound care was performed by V6 (Registered Nurse) and assisted by V5 (Licensed Practical Nurse). Neither V5 nor V6 donned a gown to perform wound care.On 11/18/25 at 3:15 PM, feeding tube flush was observed on R4. Flush performed by V5 (Licensed Practical Nurse) and assisted by V6 (Registered Nurse). Neither V5 nor V6 put on a gown to perform flush. V5 performed hand hygiene and applied gloves, V6 did not. On 11/19/2025 at 1:10 PM, V6 donned a gown before proceeding with R4's dressing change. V6 stated she was putting a gown on because R4 is on enhanced barrier precautions, and a gown should be worn when providing care for a resident who is on enhanced barrier precautions. 2. R25's admission Record documents an admission date of 11/7/25, with the following diagnoses: chronic kidney disease, stage 2 (mild), essential (primary) hypertension, and pseudomonas.R25's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 15, indicating R25 is cognitively intact. R25's care plan documents implementation of Enhanced Barrier Precaution, with an initiation date of 11/12/25. With interventions including, use enhanced barrier protection during high contact care activities.R25's Physician's order sheet does not document an order for enhanced barrier precautions. On 11/17/25 at 10:50 AM, R25's door did not have an enhanced barrier sign on it and there was no PPE available at the door or in the room.On 11/17/2025 at 10:58 AM, V6 (Registered Nurse) administered intravenous (IV) Micafungin Sodium reconstituted 100 mg medication to R25 through double lumen midline in R25's right chest. V6 cleaned her hands with hand sanitizer then donned gloves. V6 then mixed the IV medication, hung it on the IV pole, then programed the pump. V6 then removed the end cap on one lumen without changing her gloves, cleaned the end cap with alcohol, then attached a 10 ml syringe of normal saline and flushed the line then put the same end cap back on the lumen. Then V6 cleaned the other lumen with alcohol, attached a 10 ml syringe of normal saline, and flushed the line with the normal saline. After flushing the line, V6 removed the syringe and attached the medication IV line and started the medication at 100ml/hr. V6 did not pull blood back prior to flushing with normal saline on either lumen. V6 did not don a gown for this procedure. V6 did not change her gloves during this observation when moving to cleaning the catheter lumens and hooking up the IV line after programing the pump.On 11/19/25 at 11:52 AM, V2 (Director of Nurses) stated V6 should be on enhanced barrier precautions due to her central line, and a gown and gloves should be worn when administrating intravenous medication.Facility Policy titled, Enhanced Barrier Precautions, dated 2001, documents under Policy Interpretation and Implementation. 1. Enhance barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities.b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that cannot be covered or contained. 5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies Gloves and gown are applied prior to performing the high contact resident care activity. 17. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE (Personal Protective Equipment) required.

Based on observation, interview, and record review, the facility failed to ensure a resident's wound dressing was changed in accordance with physician's orders for 1 of 1 resident (R20) reviewed for wounds in the sample of 29. Findings include:R20's admission Record documents an admission date of 10/19/25, with diagnoses including in part cellulitis of right lower limb, local infection of the skin and subcutaneous tissue, morbid (severe) obesity due to excess calories, prediabetes, and personal history of methicillin resistant staphylococcus aureus infection. R20's Minimum data Set (MDS) documents a Brief Interview of Mental Status (BIMS) of 14, indicating R20's cognition is intact. R20's Care Plan documents R20 is on antibiotic therapy related to right leg cellulitis and R20 has actual impairment to skin integrity of right posterior lower leg related to cellulitis. R20's Order Summary documents, cleanse wound to right lower extremity with wound cleanser, apply zinc barrier cream, apply calcium alginate over open areas, wrap with gauze then (elastic compression) wrap daily and as needed at bedtime for wound care with a start date of 11/6/25.R20's Wound Assessment and Plan, dated 11/6/25, documents apply zinc barrier cream to periwound. Apply calcium alginate to open wound beds, then wrap lower extremity with kerlix and (elastic compression) wrap daily and as needed. R20's Wound Assessment and Plan, dated 11/13/25, documents apply moisturizing cream or ointment to intact skin of lower leg (such as A&D or vaseline). Cleanse wound beds with Dakins 1/4 strength solution. Apply calcium alginate to open wound beds, then wrap lower extremity with kerlix and elastic compression) wrap daily and as needed. On 11/19/25 at 2:14 PM, V6 (Registered Nurse) changed the dressing on R20's right lower extremity. V6 cleansed the wound with normal saline wound cleanser and gauze, wiped barrier cream in the wound on the wound bed and around the wound, placed calcium alginate over the barrier cream on the wound, then wrapped the leg with an (elastic compression) wrap. On 11/19/25 at 2:20 PM, V6 stated she put the barrier cream in the wound bed because she thought that was the treatment order. V6 looked at the treatment orders in the recent Wound Assessment and Plan, dated 11/13/25, and noted she should have used Dakins solution to cleanse the wound and not the normal saline wound cleanser and V6 stated the barrier creams should have been applied to the intact skin around the wound and not directly on the wound bed because the calcium alginate should be placed on the wound bed. V6 stated she did not round with the wound doctor on 11/13/25, so she doesn't know why the treatment order in the electronic medical record was not updated with the new orders. A facility policy titled Wound Care, dated October 2010, documents under Purpose, the purpose of this procedure is to provide guidelines for the care of wounds to promote healing.

Based in interview and record review, the facility failed to develop and implement new interventions to prevent falls for 1 of 3 (R6) residents reviewed for falls in a sample of 7.Findings included:Per admission Record, R6 was admitted to this facility on 5/18/2023, with diagnoses of dementia with moderate anxiety, unsteadiness on feet, and history of prostate cancer.R6's MDS (Minimum Data Set), dated 7/10/25, documented R6 has a BIMS (Brief Interview for Mental Status) score of 2 out of 15 total, which indicates R6 has severe cognitive impairment. This same MDS documented R6 is dependent on staff for all transferring and toileting, and needs partial to moderate assistance with showers.R6's Fall Risk Evaluation, dated 7/7/2025, documented R6 is at risk for fall.R6's Care Plan included a focus area of:1. Resident had an unwitnessed fall 7/31/25 with intervention of pressure alarm (to be used) all shifts (for R6). 2. Fall: (R6) has had an actual fall 7/2/2025 with intervention of nursing staff to remain present in dining room during meals. 3. Risk for falls r/t (related to) dementia, anxiety and history of falls (initiation date 8/28/2024) with interventions of assist resident with ambulation and transfers and keep environment tidy among others.R6's progress notes in his EHR (electronic health record) documented on 8/16/2025 at 10:39am, R6 had slipped out of his chair and had no visible injuries. R6's care plan does not include a plan of care or newly implemented interventions for this fall occurrence.R6's progress notes documented on 7/20/2025 at 6:20pm, R6 had an un-witnessed unintentional change in plane, which indicated R6 had fell. This same progress note documents R6 had no visible injuries. R6's care plan does not include a plan of care or newly implemented interventions for this fall occurrence.R6's progress notes document in part on 7/18/2025 at 6:30pm, R6 had an un-witnessed unintentional change in plane, which indicated R6 had fallen. This same progress note documents R6 had two small bruises and two small skin tears. R6's care plan does not include a plan of care or newly implemented interventions for this fall occurrence.On 8/27/2025 at 9:30am, V3 (Corporate Nurse) said all of R6's falls should have been addressed in his care plan, but they were not. V3 said new fall interventions should have been developed and implemented for R6, but they were not.The facility's Falls and Falls Risk Management policy, dated 2001, documented the following: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Staff will implement a resident-centered fall prevention plan to reduce falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions.

Based on interview and record review, the facility failed to maintain sufficient staff to meet the needs of the residents timely. This has the potential to affect all 37 residents currently residing at the facility. Findings Include: The facility Resident Matrix provided to this surveyor on 4/7/25 document 37 residents currently reside at the facility. 1. R2's Admission Record with a print date of 4/8/25 documents R2's admitted to the facility on [DATE] with diagnoses that include acute and chronic respiratory failure, heart failure, sleep apnea, diabetes, morbid obesity, and chronic obstructive pulmonary disease. R2's MDS (Minimum Data Set), dated 1/3/25, documents R2 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 requires substantial/maximal assistance for toileting. R2's current Care Plan documents a Focus Area of, ADL's (activities of daily living) Self care deficit-needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADL's R/T (related to): reduced mobility and Obesity. Date Initiated: 01/23/2024. This Focus area includes the intervention of, Assist Resident to transfer into wheelchair/Geri-chair/Broda chair and assist to position for comfort .Date Initiated 07/14/2024 .Assist with ADL's as necessary with staff assist of 1 .Date Initiated: 01/23/2024 . On 4/7/25 at 1:29 PM, R2 stated call lights aren't answered timely. R2 stated evenings and overnights are the worst. R2 stated this morning, he put on his call light on and it was 45 minutes before it was answered. R2 stated he put his call light on around 5:30 AM, and it didn't get answered until day shift arrived. R2 stated V6 (Certified Nursing Assistant/CNA) answered the call light and helped him get off the toilet. R2 stated he gets left on the toilet frequently. R2 stated they had cut CNA hours back on his unit. On 4/7/25 at 1:58 PM, V6 (CNA) stated she answers call lights as quickly as she can, but if she is in a room providing care, it may take a little longer. V6 stated this morning (4/7/25), R2's call light was going off when she arrived to the facility around 6:00 AM. V6 stated there were a few lights going off and she started answering them immediately. V6 stated she answered R2's bathroom light first, since she knew that was an instant need. V6 stated R2 said he had been waiting for assistance for awhile. When asked if it was typical to have call lights needing answered as soon as she got to the facility and for residents to say they had been waiting awhile, V6 stated the night shift staff were in a room providing care to another resident when she arrived, and it was a little different, so they must have had a rough night. V6 stated she felt like they were short staffed. V6 stated all of the needs were being met, it just took longer to meet them. V6 stated the average time it takes to answer a call light is fifteen minutes. On 4/7/25 at 1:45 PM, V5 (Licensed Practical Nurse/LPN) stated they have one nurse and four CNA's working today. When asked if that was enough staff to meet the needs of the residents timely, V5 stated, Sometimes. With our census being what it is, now it is better. V5 stated they had some residents pass away, and some were discharged home. V5 stated they have one resident in the hospital who has a lot of behaviors, and he should be discharged back to the facility any day now. V5 stated being the only nurse in the facility, she doesn't feel like she can get to the other side of the facility (to the locked dementia unit) if there is an emergency. V5 stated when she got to work this morning, R2 was on the commode and was yelling out, Hey, for assistance, which is what he does. V5 stated the day shift CNA's assisted R2 off the commode. V5 stated R2 didn't tell her how long he had been waiting for assistance. On 4/27/25 at 9:22 PM, V10 (LPN/Licensed Practical Nurse) stated she works night shift, and they don't always have enough staff to meet the needs of the residents timely. V10 stated they are supposed to have three CNA's and one nurse, but a lot of times they only have two CNA's, which is one CNA per unit and one nurse. V10 stated there are a few people who require assist of two for incontinence care. V10 stated if they have enough staff, they get residents up in the morning, but when they don't, they just get them dressed and leave them in bed. When asked if call lights are answered timely, V10 stated it probably takes longer to answer them during the morning routine. V10 stated she worked night shift beginning on 4/6/25 at 6:00 PM and ending on 4/7/25 at 6:00 AM. When asked if there were call lights that took longer to answer the morning of 4/7/25, V10 stated there was a bathroom call light (R2) going off, and it may have taken longer to answer it. V10 stated it took maybe 15-20 minutes. On 4/7/25 at 9:30 PM, V11 (CNA) stated they are not able to meet the needs of the residents timely. V11 stated when you don't have enough staff nothing gets done on time. When asked if she was aware of it taking 45 minutes to assist a resident off the commode, V11 stated R2. When asked why it took so long, V11 stated they don't have enough staff to get to it timely. V11 stated they are supposed to have two CNA's on unit two, and one on unit one, but sometimes is is just one CNA for the whole building. V11 stated they have residents who require assist of two for incontinence care. When asked how they provide incontinence care to those residents if they only have one CNA, V11 stated, The nurse sits on one unit while the CNA does the bed checks for the other unit, and will come help for the residents who require assist of two, and then goes back to the other unit to check on those residents. V11 stated she wasn't working, but she heard there was only one CNA working on night shift on 3/29/25, and she worked alone about a week before that. V11 stated it happens quite often. On 4/8/25 at 1:03 PM, when asked if she was aware of a resident sitting on a commode waiting for assistance for a long period of time, V17 (CNA) stated, Sometimes it takes longer to get to the them. V17 stated if they have enough staff, they answer the call lights almost immediately. 2. R3's Admission Record, with a print date of 4/8/25, documents R3 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation, heart failure, heart disease, disc degeneration, major depressive disorder, and restless leg syndrome. R3's MDS, dated [DATE], documents a BIMS score of 15, indicating R3 is cognitively intact. This same MDS documents R3 requires supervision or touching assistance for toilet hygiene. R3's current Care Plan documents a Focus area of ADL Function Rehab: resident is usually able to perform ADL's independently or with supervision. Date Initiated: 07/25/2024 This Focus area includes the intervention of, Encourage the resident to use bell to call for assistance .Date Initiated: 07/28/2024. R2's current Care Plan includes the Focus area of, Urinary Incontinence: the resident has MIXED bladder incontinence r/t impaired mobility. Date Initiated: 7/28/2024. This focus area includes the following interventions, Incontinent: Check every 2 house and as required for incontinence . Date Initiated: 07/28/2024. On 4/7/25 at 11:30 AM, R3 stated she hardly ever pushes her call light; she just goes and gets staff to assist her when needed. R3 stated when she does push it, they answer it timely. On 4/7/25 at 1:00 PM, V4 (Ombudsman) stated she attends Resident Council Meetings at the facility, and the residents voice concerns at every meeting that call lights aren't being answered timely. V4 stated R2 and R3 reported to her it is worse on evening shift and night shift. V4 stated R2 reported to her it takes up to 45 minutes to get assistance off the commode. V4 stated R3 reported she will go searching for help at times because she can't get anyone to answer the call light. On 4/7/25 at 2:07 PM, V7 (CNA) stated they don't have enough staff to meet the needs of the residents timely. V7 stated they changed some staff to as needed to lower the staffing numbers, and they have had to gradually bring more people back to the floor to assist with resident care. V7 stated they usually have staff call in, and sometimes only have two CNA's for unit two, and that isn't enough. When asked what care is delayed, V7 stated, resident care, toileting, weights, vital signs, and showers. V7 stated, I leave (at the end of her shift) feeling bad (due to delayed care). On 4/7/25 at 2:36 PM, V8 (CNA) stated they don't have enough staff to meet the needs of the residents timely. V8 stated call lights don't get answered timely when they are short staffed. V8 stated she usually works unit one (locked dementia unit), and they have eight residents with one CNA and a nurse that is shared with the other unit. On 4/7/25 at 2:56 PM, when asked if call lights were answered timely, V9 (CNA) stated it depends on staffing. V9 stated if there are only two CNA's working on side two, and one goes to lunch it gets rough. On 4/7/25 at 9:40 PM, V12 (CNA) stated they aren't able to answer call lights timely when they only have one CNA on each unit. On 4/8/25 at 12:23 PM, V15 (CNA) stated they didn't have enough staff to answer call lights timely. On 4/8/25 at 11:56 AM, V6 (CNA) stated she worked on 4/6/25, but had to leave around 9:30 AM for a family emergency. V6 stated she was working with two agency nurses, V15 and V16 (CNA's). On 4/8/25 at 12:23 PM, V15 (CNA) stated she worked on 4/6/25 with one CNA on each side of the facility. V15 stated no one came in to assist them. V15 stated she was working on unit one, and she felt bad for the CNA working (V16) working on the other unit. V15 stated they started their shift at 6 AM with three CNA's and two nurses. V15 stated V6 (CNA) had to leave early for a family emergency, and one of the nurses left at 2:00 PM. V15 stated it is unusual for them to have two nurses, they usually have one nurse and three CNA's. V15 stated they normally have one CNA on unit one and two on unit two. V15 stated if the CNA working unit one gives a resident a shower, the other residents are not being monitored. V15 stated the residents on that unit are all on 15 minute checks, and there are several who are fall risks. V15 stated one nurse and two CNA's are not enough to meet the needs of the residents. When asked what needs aren't met timely when they are short staffed, V15 stated, call lights, incontinence care, showers, all the important stuff. V15 stated they notified administration they were short staffed on 4/6/25, and V1 (Administrator) sent out a group message asking people to come in. V15 stated no one came in. On 4/8/25 at 12:51 PM, V16 (CNA) stated she worked on 4/6/25. V16 stated V15 was the CNA on unit one with an unknown agency nurse. V16 stated she and V6 were the CNA's on unit two, and V6 had to leave for a family emergency around 9:30 AM. V16 stated she was the only CNA on unit two until 6:00 PM. V16 stated they had two nurses working on 4/6/25, but one of them left at 2:00 PM. V16 stated that is not enough staff to meet the needs of the residents timely. When asked what needs weren't met, V16 stated, I mean, all of them. V16 stated she had worked night shift in the past as the only CNA, but not recently. V16 stated she knows night shift often only has one CNA. When asked if one CNA was enough to meet the needs of the residents timely on night shift, V16 stated, No. V16 stated V1 (Administrator) and the on call nurse V2 (Acting Director of Nurses/MDS Coordinator) were aware of them being short staffed on 4/6/25, and neither one came in to assist. On 4/8/25 at 1:53 PM, V2 (Acting Director of Nurses/MDS Coordinator) stated she was not aware of only one CNA working on any shift. V2 stated if for some reason staff call in and/or don't show up, one of the administration staff will come in. V2 stated, I am not going to leave them hanging. When asked if she was aware they were short staffed on 4/6/25, V2 stated she was out of town. When asked if one nurse and two CNA's were enough staff to meet the needs of the residents, V2 stated she would want more. On 4/8/25 at 1:35 PM, V1 (Administrator) stated two CNA's in the facility were enough to meet the needs of the residents on night shift when everyone was in bed. When asked about staffing on 4/6/25, V1 stated they didn't notify her there was an issue until later that day. V1 stated she put out two messages; one for a 10 AM to 6 PM shift and one for a 2 PM to 6 PM shift, and no one wanted to work. When asked if her offering a shift at 10 AM meant she knew at 10 AM they were short staffed, V1 stated it was probably a little before that. When asked if any administration came in to assist the staff in meeting the needs of the residents, V1 stated she didn't because she was out of town, and none of the other administration staff would answer the phones/messages. When asked if the residents would be safe with just one CNA on each unit, V1 stated, To a certain extent I would say yes, but I would like more. The facility undated Nurse Staffing policy documents, Policy: it is the policy of (name of an organization) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the (name of surveying agency).

Based on interview and record review, the facility failed to ensure residents were provided with a bedtime snack. This has the potential to affect all 37 residents who currently reside at the facility. Findings Include: The facility Resident Matrix provided to this surveyor on 4/7/25 documents 37 residents currently reside at the facility. On 4/7/25 at 1:00 PM, V4 (Ombudsman) stated she frequently attends the Resident Council Meetings at the facility. V4 stated R3 and R4 reported to her they were not getting snacks served at the facility unless the State Survey Agency was in the facility. On 4/7/25 at 11:30 AM, R3 and R4 stated they are served bedtime snacks. R3 and R4 stated they get them on the tray with their evening meal. On 4/7/25 at 1:29 PM, R2 stated he recently had an issue getting snacks, but after he complained he started getting them again. R2's Admission Record, with a print date of 4/8/25, documents R2's admitted to the facility on [DATE],3 with diagnoses that include acute and chronic respiratory failure, heart failure, sleep apnea, diabetes, morbid obesity, and chronic obstructive pulmonary disease. R2's MDS (Minimum Data Set) dated 1/3/25 documents R2 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R3's Admission Record, with a print date of 4/8/25, documents R3 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, heart failure, heart disease, disc degeneration, major depressive disorder, and restless leg syndrome. R3's MDS dated [DATE] documents a BIMS score of 15, indicating R3 is cognitively intact. R4's Admission Record, with a print date of 4/8/25, documents R4 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, chronic obstructive pulmonary disease, and diabetes. R4's MDS, dated [DATE], documents a BIMS score of 13, indicating R4 is cognitively intact. On 4/7/25 at 1:45 PM, V5 (LPN/Licensed Practical Nurse) stated residents used to be offered snacks, but they have been told it is no longer in the budget. V5 stated they get one snack at 8:00 PM that is served to them on their supper tray. V5 stated most of the residents eat it with supper, and then they don't have anything to eat at bedtime. V5 stated the kitchen is locked, so the staff will buy snacks for the residents to have. On 4/7/25 at 2:07 PM, V7 (CNA/Certified Nurse Aide) stated they used to get snacks at 10 AM and 2 PM, but they don't anymore. V7 stated the staff are buying snacks and bringing them in for the residents. V7 stated supper is served at 4:30 PM, and they don't get anything else to eat until the next morning when breakfast is served. On 4/7/25 at 2:36 PM, V8 (CNA) stated the kitchen never has snacks for the residents. On 4/7/25 at 9:22 PM, V10 (LPN/Licensed Practical Nurse) stated the facility is cutting back on snacks, so they pass them out with the supper trays. V10 stated they don't leave any snacks out for the staff to offer residents if they get hungry later. V10 stated they don't have access to the kitchen, and if there is a resident who is diabetic with a low blood sugar, she doesn't have much to choose from to offer them to eat. V10 stated she has the applesauce and pudding she uses to pass medications with that she can offer them. On 4/7/25 at 9:30 PM, V11 (CNA) stated the residents are served their 8:00 PM snack at 4:30 PM with their supper meal. V11 stated a lot of them eat it when it is served, and then they are hungry at bedtime. V11 stated they have a lot of residents who are diabetic and the kitchen is locked up. V11 stated they used to leave one door open for the night shift staff to access it if they needed to, but now it is locked, and they don't leave food out for the residents anymore. On 4/7/25 at 9:40 PM, V12 (CNA) stated snacks are passed to the residents on their supper tray. V12 stated they eat them with their supper meal, and then they go till breakfast the next morning with no snack. V12 stated the kitchen no longer leaves snacks out for them, and they lock the kitchen up. On 4/8/25 at 12:23 PM, V15 (CNA) stated they were told the company who purchased the facility cut the budget for the kitchen, so they are only allowed to have an 8:00 PM snack now. V15 stated if someone asks for a snack between meals she doesn't have anything to offer them. When asked if she was aware of snacks in the kitchenette/linen closet, V15 stated they only bring snacks for 8:00 PM, for each resident and it is served with their supper trays. V15 stated they don't put snacks in the kitchenette/linen closet for the residents. V15 stated there is one individual juice cup in the refrigerator on unit one that has been there for awhile, but other than that, she only has water and coffee to offer the residents. On 4/8/25 at 12:51 PM, V16 (CNA) stated residents get their bedtime snack with their supper and eat them with supper. V16 stated then they don't have anything for the rest of the night. V16 stated she usually works on side 2, and they don't have anything in the kitchenette to serve the residents. On 4/8/25 at 1:03 PM, V17 (CNA) stated they have multiple residents who ask for snacks, and they don't have anything to give them. V17 stated they used to stock the kitchenette/linen closet, but they don't do that anymore. V17 stated they were told it was a budget thing. On 4/8/25 at 10:33 AM, V14 (Dietary Manager) stated meals are served at 7:30 AM, 11:30 AM, and 4:30 PM. V14 stated they serve a house snack for 8:00 PM. When asked what a house snack was, V14 stated it is a snack served to everyone. V14 stated it is served to them on their supper trays or passed from room to room. V14 stated if they pass them from room to room, they are passed around 5:00 PM. V14 stated they pass them with supper or right around supper because some of the residents like to eat it at supper time. When asked if it is really an 8:00 PM snack if they are served it and eat it with supper, V14 stated, No. V14 stated they also keep snacks at both nurses station (kitchenette/linen closet), so if they get hungry at night they have options. V14 sated they have lunch meat, cheese, peanut butter, juice, koolaid, and water. When asked if the food options would be in the kitchenette/linen closet now, V14 stated yes it was in there at all times. V14 stated it gets refreshed three times daily. This surveyor walked with V14 to the linen closet on side one where the snacks were kept. There was a bottle of jelly in the refrigerator, along with one individual juice cup. There was thickener for drinks on the counter along with condiments and a few pudding cups. There was a can of peanut butter on top of the refrigerator and box of oatmeal on the counter. When asked where the bread was to make peanut butter and jelly sandwiches, V14 stated there was none. At 10:45 AM, this surveyor walked with V14 to the kitchenette located on side two. There were many bottles of water, soda, and juice noted in the refrigerator, as well as take out containers, and containers of food. None of these items were labeled, and V14 stated they were either staff food and drinks, or residents who had asked for them to be refrigerated. There was a can of peanut butter on top of the refrigerator; no pudding cups, no juice, a gallon jug of water in the refrigerator. V14 confirmed there was no bread and no jelly in this kitchenette. When asked about the individual packets of oatmeal on top of the refrigerator, V14 stated the residents get tired of the plain oatmeal, so staff will purchase the flavored oatmeal and bring it to the facility for the residents to have variety. V14 stated the nurses also have keys to the kitchen should they need anything after the kitchen staff have left for the day. V5 (LPN) was working as the nurse for side one and side two. With this surveyor and V14 observing, V5 attempted the keys on the nurses key ring and was not able to open the kitchen door. When asked if she had any concerns brought to her related to residents not getting snacks, V14 stated she had, but it was from CNA staff who she was concerned had been taking food from the kitchen for their personal use. This surveyor reviewed with V14 the observation of the kitchenette and linen closet where snacks are to be stored for resident use, and V14 stated she knew it looked bad, but the kitchen staff were probably just restocking them. V14 stated they used to pass snacks from a cart at 8:00 PM, but the residents were complaining the CNA staff didn't pass them out, so they started putting them on their dinner trays but some do eat them with their supper. On 4/8/25 at 11:00 AM, V1 (Administrator) stated the residents are supposed to be served snacks and the facility staff are supposed to restock the kitchenette/linen closet with snacks for the residents. The facility Evening Snack Policy, dated 10/15, documents, It is the policy of (name of an organization) to offer each resident an evening snack and document whether the resident accepted or declined the evening snack. Procedure: 1. An evening (H.S.) snack is incorporated into the daily menu. 2. Bulk snacks will be provided by the Food Service Department according to the number and types of diet being served. The snacks should be compatible with the resident's diet order and preference. 3. Appropriate snacks may include: assorted cookies, crackers, cakes, brownies, half sandwiches, fruit, ice cream, sherbet, and pudding. 4. Dietary staff will deliver H.S. snacks to the nursing units. 5. All residents will be offered an H.S. snack. 6. Acceptance of and/or declining of the H. S. snack is recorded by the CNA.

Based on interview and record review, the facility failed to ensure call lights were answered timely for 2 of 5 (R2 and R3) residents reviewed for call lights in the sample of 12. Findings Include: 1. R2's Admission Record, with a print date of 4/8/25, documents R2's admitted to the facility on [DATE], with diagnoses that include acute and chronic respiratory failure, heart failure, sleep apnea, diabetes, morbid obesity, and chronic obstructive pulmonary disease. R2's MDS (Minimum Data Set), dated 1/3/25, documents R2 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. This same MDS documents R2 requires substantial/maximal assistance for toileting. R2's current Care Plan documents a Focus Area of, ADL's (activities of daily living) Self care deficit-needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADL's R/T (related to): reduced mobility and Obesity. Date Initiated: 01/23/2024. This Focus area includes the intervention of, Assist Resident to transfer into wheelchair/Geri-chair/Broda chair and assist to position for comfort .Date Initiated 07/14/2024 .Assist with ADL's as necessary with staff assist of 1 .Date Initiated: 01/23/2024 . On 4/7/25 at 1:29 PM, R2 stated call lights aren't answered timely. R2 stated evenings and overnights are the worst. R2 stated this morning, he put on his call light on, and it was 45 minutes before it was answered. R2 stated he put his call light on around 5:30 AM, and it didn't get answered until day shift arrived. R2 stated V6 (Certified Nursing Assistant/CNA) answered the call light and helped him get off the toilet. R2 stated he gets left on the toilet frequently. R2 stated they had cut CNA hours back on his unit. On 4/7/25 at 1:58 PM, V6 (CNA) stated she answers call lights as quickly as she can, but if she is in a room providing care, it may take a little longer. V6 stated this morning (4/7/25), R2's call light was going off when she arrived to the facility around 6:00 AM. V6 stated there were a few lights going off, and she started answering them immediately. V6 stated she answered R2's bathroom light first, since she knew that was an instant need. V6 stated R2 said he had been waiting for assistance for awhile. When asked if it was typical to have call lights needing answered as soon as she got to the facility and for residents to say they had been waiting awhile, V6 stated the night shift staff were in a room providing care to another resident when she arrived, and it was a little different, so they must have had a rough night. V6 stated she felt like they were short staffed. V6 stated all of the needs were being met, it just took longer to meet them. V6 stated the average time it takes to answer a call light is fifteen minutes. On 4/7/25 at 1:45 PM, V5 (Licensed Practical Nurse/LPN) stated they have one nurse and four CNA's working today. When asked if that was enough staff to meet the needs of the residents timely, V5 stated, Sometimes. V5 stated when she got to work this morning, R2 was on the commode and was yelling out, Hey, for assistance which is what he does. V5 stated the day shift CNA's assisted R2 off the commode. V5 stated R2 didn't tell her how long he had been waiting for assistance. On 4/27/25 at 9:22 PM, V10 (LPN/Licensed Practical Nurse) stated she works night shift, and they don't always have enough staff to meet the needs of the residents timely. V10 stated it probably takes longer to answer them during the morning routine. V10 stated she worked night shift beginning on 4/6/25 at 6:00 PM and ending on 4/7/25 at 6:00 AM. When asked if there were call lights that took longer to answer the morning of 4/7/25, V10 stated there was a bathroom call light (R2) going off, and it may have taken longer to answer it. V10 stated it took maybe 15-20 minutes. On 4/7/25 at 9:30 PM, V11 (CNA) stated they are not able to meet the needs of the residents timely. V11 stated when you don't have enough staff, nothing gets done on time. When asked if she was aware of it taking 45 minutes to assist a resident off the commode, V11 stated, (R2). When asked why it took so long, V11 stated they don't have enough staff to get to it timely. On 4/8/25 at 1:03 PM, when asked if she was aware of a resident sitting on a commode waiting for assistance for a long period of time, V17 (CNA) stated, Sometimes it takes longer to get to the them. V17 stated if they have enough staff, they answer the call lights almost immediately. 2. R3's Admission Record, with a print date of 4/8/25, documents R3 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation, heart failure, heart disease, disc degeneration, major depressive disorder, and restless leg syndrome. R3's MDS, dated [DATE], documents a BIMS score of 15, indicating R3 is cognitively intact. This same MDS documents R3 requires supervision or touching assistance for toilet hygiene. R3's current Care Plan documents a Focus area of ADL Function Rehab: resident is usually able to perform ADL's independently or with supervision. Date Initiated: 07/25/2024 This Focus area includes the intervention of, Encourage the resident to use bell to call for assistance .Date Initiated: 07/28/2024. R2's current Care Plan includes the Focus area of, Urinary Incontinence: the resident has MIXED bladder incontinence r/t impaired mobility. Date Initiated: 7/28/2024. This focus area includes the following interventions, Incontinent: Check every 2 house and as required for incontinence . Date Initiated: 07/28/2024. On 4/7/25 at 11:30 AM, R3 stated she hardly ever pushes her call light; she just goes and gets staff to assist her when needed. R3 stated when she does push it they answer it timely. On 4/7/25 at 1:00 PM, V4 (Ombudsman) stated she attends Resident Council Meetings at the facility, and the residents voice concerns at every meeting that call lights aren't being answered timely. V4 stated R2 and R3 reported to her it is worse on evening shift and night shift. V4 stated R2 reported to her it takes up to 45 minutes to get assistance off the commode. V4 stated R3 reported she will go searching for help at times because she can't get anyone to answer the call light. On 4/7/25 at 2:07 PM, V7 (CNA) stated they don't have enough staff to meet the needs of the residents timely. When asked what care is delayed, V7 stated, resident care, toileting, and showers. V7 stated, I leave (at the end of her shift) feeling bad (due to delayed care). On 4/7/25 at 2:36 PM, V8 (CNA) stated they don't have enough staff to answer call lights timely. On 4/7/25 at 2:56 PM, when asked if call lights were answered timely, V9 (CNA) stated it depended on staffing. V9 stated if they only have two CNA's on unit 2, and one goes to lunch, then it takes longer to answer the call lights. On 4/7/25 at 9:40 PM, V12 (CNA) stated they aren't able to answer call lights timely when they only have one CNA on each unit. On 4/8/25 at 12:23 PM, V15 (CNA) stated they didn't have enough staff to answer call lights timely. On 4/8/25 at 1:35 PM, V1 (Administrator) stated two CNA's in the facility were enough to meet the needs of the residents on night shift when everyone was in bed. When asked if the residents were safe with just one CNA on each unit, V1 stated, To a certain extent I would say yes, but I would like more. On 4/8/25 at 1:53 PM, V2 (Acting Director of Nurses/MDS Coordinator) stated she would want more staff when asked if one nurse and two CNA's were enough staff to meet the needs of the residents timely. The facility Resident Council Minutes documents the following 1/30/25- Old Business .both shifts call lights a problem. 3/4/25 for [DATE] .Old Business: Any unresolved issues from last month: Call lights still an issue. The facility Answering the Call Light policy dated 9/2022 documents, .The purpose of this procedure is to ensure timely responses to the resident's requests and needs Steps in the Procedure: 1. Answer the resident call system immediately

Based on interview and record review, the facility failed to ensure residents who require assistance receive a shower for 3 (R2, R3, and R5) of 5 dependent residents reviewed for Activities of Daily Living assistance in the sample of 21. 1. R2's Admission Record documented an admitted [DATE], and included diagnoses of unspecified intellectual disabilities and muscle weakness. R2's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 00, indicating R2 has severe cognitive impairment. The MDS Section for Functional Abilities and Goals documented R2 as dependent for shower/bathing self. R2's Care Plan documented a Focus Area of: ADL's (Activities of Daily Living): Self care deficit-needs assist to complete quality care initiated on 12/28/24. Corresponding interventions include R2 will receive (showers) 2 times per week. Provide bathing, hygiene, dressing, and grooming per resident's preference as able. R2's Shower/Abnormal Skin reports (paper documentation) from January 2025 through 3/19/25 document R2 did not receive a shower on 03/13/25 due to being at the hospital. R2 received showers on 03/04/25, 02/17/25, 02/13/25, 01/29/25, 01/23/25, 01/18/25, 01/15/25, 01/08/25, 01/01/25 (bed bath noted). The Shower/Abnormal Skin Report for 01/30/25 has a staff signature, but does not indicate a shower or bed bath was given. R2's Electronic Health Record (EHR) documented no extra showers were provided to R2 other than the paper documentation previously listed. There were also no shower sheets with documented refusals provided for this time period. The undated facility shower schedule documents R2's showers are scheduled weekly on Monday in AM and Thursday in AM. 2. R3's Admission Record documented an admitted [DATE], and included diagnoses of hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, Alzheimer's, and type 2 diabetes mellitus. R3's MDS, dated [DATE], documented a BIMS score of 06, indicating R3 has severe cognitive impairment. The MDS Section for Functional Abilities and Goals documented R3 as dependent for shower/bathing self. R3's Care Plan documented a Focus Area of: ADL Function: Self care deficit-needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADLs initiated on 12/1/23. Corresponding interventions include in part: Will receive shower 2 times per week. Provide bathing, hygiene, dressing, and grooming per resident's preference as able. R3's Shower/Abnormal Skin reports (paper documentation) from January 2025 through 3/19/25 document R3 received bed baths on 03/13/25 and 03/04/25. R3 received showers on 02/17/25, 02/13/25, 01/30/25, 01/29/25, 01/27/25, and 01/23/25. A bed bath was given on 01/20/25, and R3 received showers on 01/16/25, 01/13/25, and 01/09/25. R3's Electronic Health Record (EHR) documented no extra showers were provided to R3 other than the paper documentation previously listed. There were also no shower sheets with documented refusals provided for this time period. The facility shower schedule undated documents R3's showers are scheduled on Monday in AM and Thursday in the AM. 3. R5's Admission Record documented an admitted [DATE], and included diagnoses of unspecified dementia, type 2 diabetes mellitus, overactive bladder, and muscle wasting. R5's MDS, dated [DATE], documented a BIMS score of 15, indicating R5 is cognitively intact. The MDS Section for Functional Abilities and Goals documented R5 as requiring partial/moderate assistance for shower/bathing self. R5's Care Plan documented a Focus Area of: ADL function/rehab: (R5) is usually able to perform ADL's with (specify assist level) hands on assist or weight bearing assist r/t (related to) . with a revision date of 10/20/24. Interventions include in part: Provide supportive care, assistance with mobility as needed. R5's Care Plan did not include information regarding the specific level of assistance needed or the rationale for the need for assistance. R5's Care Plan also did not document the frequency of showers scheduled per week. R5's Shower/Abnormal skin reports (paper documentation) from January 2025 through 3/19/25 document R5 received showers on 03/14/25, 02/28/25, 02/07/25, 01/30/25, 01/27/25, 01/23/25, 01/21/25, 01/18/25, 01/15/25, 01/08/25, and 01/01/25. R5's EHR regarding bathing self-performance was reviewed for the past 30 days from 03/18/25 and indicated additional showers were provided on 02/25/25 and on 03/04/25. There were no shower sheets with documented refusals provided for this time period. The undated facility document titled Shower Schedule documents R5's showers are scheduled on Tuesday in AM and Friday in AM. On 03/17/25 at 10:35AM, R5 stated she thinks she maybe gets one shower a week right now. R5 said she used to get 2 showers a week, and then the facility changed it. R5 said she doesn't know why they changed it, and she would like to go back to two showers a week. R5 said she doesn't really feel dirty because she is able to wash up and keep herself clean, but said she felt a lot cleaner when she was getting two showers a week. On 03/18/25 at 9:15AM, V7 (Certified Nurse Assistant/CNA) said all residents are supposed to get two showers weekly. V7 said when she is working, she tries to make sure her residents get their showers on their shower days. V7 said if she can't get it done, then she will pass it on to the next shift, or try to get it done that next day. On 03/18/25 at 10:06AM, V9 (CNA) stated all residents are to receive a shower two times a week. V9 said there have been times when she wasn't able to get all the resident showers done because they were running behind or don't have as much staff. V9 said she will try to get the shower done later in the week if she isn't able to get one done. V9 said they are to fill out a shower sheet every time they give a shower or when someone refuses. On 03/18/25 at 10:10AM, V10 (CNA) stated they do the best they can to get all the resident showers done that are on the shower schedule for the day. V10 said there have been days when they weren't able to get all the showers done in the day. V10 said they try to get the showers that weren't done completed on a different day in the week, but that doesn't always happen. On 03/18/25 at 11:30AM, V1 (Administrator) stated they didn't have any more shower sheets for R2, R3, and R5. V1 said without those shower sheets that document the shower was completed, it is possible the showers weren't done for those residents on those days. On 03/18/25 at 11:35AM, V2 (Regional Nurse) stated the facility does not have any more shower sheets on R2, R3, and R5. V2 said the shower sheets document when the showers were completed. V2 said without those shower sheets, it is possible that R2, R3, and R5's showers were not completed on the days that are missing. The facility policy titled Bath/Shower, with a revised date of 03/20/23, documents, To ensure adequate hygiene needs are met. A bath/shower is scheduled for all residents in the facility at least weekly.

Based on interview, observation, and record review, the facility failed to ensure the resident rooms and resident equipment were maintained in a state of good repair for 5 of 5 residents (R1, R2, R3, R4 and R12) reviewed for environment in a sample of 14. Findings include: 1. On 12/5/24 at 11:50AM, R1's bathroom was observed to have water leaking from the front of his toilet. R1's tiles behind his toilet were all laying on the floor away from the wall. R1's toilet was crooked and not positioned correctly and away from the wall. On 12/05/24 at 11:50 AM, R1 who was alert to person, place, and time, stated he knows the toilet leaks in the front and that the toilet is crooked. R1 said that he knows the tiles have fallen down behind the toilet as well. R1 said someone was supposed to be fixing it. 2. On 12/05/24 at 9:21AM, R2's bathroom toilet was observed was to not be secure to the floor and was easily moved around. R2's window sill in room had dust, dirt, debris along with cobwebs noted to top of the window. On 12/05/24 at 9:21AM, R2 who was alert to person, place, and time, stated he did not notice the toilet in his bathroom was not secure to the floor, and that it easily moved. R2 stated he didn't know if they clean the windows in his room or not. At that time, he did acknowledge there were cobwebs and debris along the window sill. 3. On 12/05/24 at 9:16AM, observed a sign going into R3's bathroom that stated, Do not enter this area it's closed at this time. When entering bathroom, 13 tiles were missing from floor, along with some water noted to the floor around toilet area. On 12/05/24 at 9:16AM, R3, who was alert to person, place, and time, stated he hasn't been able to use the bathroom in his room for several months. R3 said he has to go to the bathroom down the hall to use the restroom. R3 said it is a hassle to have to go down the hall to use the bathroom, and he has to wait at times to use that restroom. R3 said they were supposed to be fixing the bathroom. 4. On 12/05/24 at 11:55AM, observed R4's window sill in her room which had dirt, debris, and 5 dead leaves in window sill. On 12/05/24 at 11:55AM, R4 who is alert to person, place, and time, stated she used to have plants in her window sills, and she removed them a couple of weeks ago. R4 said she doesn't know the last time someone cleaned her window sill. 5. On 12/05/24 at 12:40PM, observed R12's bathroom which is adjoined to R3's room. Observed a sign on R12's bathroom door that states, Do not enter this area it's closed at this time Observed the bathroom with the 13 missing tiles from the floor and some water noted to floor. Window sill in R12's room had dirt and debris on it. On 12/05/24 at 12:40PM, R12, who was alert to person, place, and time, stated he hasn't been able to use his bathroom for over 6 months. R12 said he knows the bathroom is missing tiles, and the toilet doesn't work. R12 said they told him they couldn't get the part to fix the bathroom. R12 said it was a hassle to have to go down the hall to use the bathroom. R12 stated sometimes the restroom down the hall gets busy, and you have to wait. R12 said they come in his room and clean it often, but doesn't think they clean his windows. On 12/05/24 at 12:30PM, V3 (Certified Nurse Assistant/CNA) stated R3's and R12's bathroom hasn't been working for several months. V3 said they did have a maintenance man who was working on the toilet, but he was having to use his own money to fix things, and then he quit, so the toilet didn't get fixed. V3 said the tiles around the toilet in that bathroom are all up, and R3 and R12 have to use the shower room bathroom when they have to use the restroom. On 12/05/24 at 12:32PM, V4 (CNA) stated R3's and R12's bathroom hasn't worked in over several months. V4 said the maintenance man that quit a week ago was working on some of the toilets, but quit, and didn't finish repairing them. V4 said the maintenance man was using his own money to repair some of the things at the facility. On 12/05/24 at 12:35PM, V5 (CNA) said R3's and R12's bathroom hasn't worked for several months. V5 said R3 and R12 use the shower room bathroom when they have to use the restroom. V5 said the maintenance man was working on the toilets and some of the repairs at the facility, but was having to use his own money because he didn't have a budget. V5 said the maintenance man quit about a week ago. On 12/05/24 at 1:00PM, V6 (Housekeeping) said she was the only housekeeper working today. V6 said they are supposed to have 2 housekeepers working every day. V6 said they didn't have no housekeeper yesterday and the laundry worker was trying to clean rooms and keep up with laundry. V6 said she usually cleans the window sills when she can, but she only works 2 days a week most of the time, and she has had to work by herself a lot, and she is just trying to get done what she can. On 12/05/24 at 1:30PM, V2 (Maintenance/Therapy Assistant) stated he has been helping do the maintenance for over 2 years at the facility. V2 said he was aware R3's and R12's bathroom wasn't working. V2 said he wasn't aware of any work order to repair the bathroom. V2 wasn't aware of any other bathrooms needing repair. V2 said he thought the last maintenance man that worked at the facility looked at R3's and R12's toilet, and it needed a metal flange or something, and he needed to replace it. V2 said he usually will pay for the parts and then get reimbursed for his expenses. V2 said he didn't know if there was anything being done to fix the toilet in R3's and R12's room or not. V2 was not aware R1's toilet was leaking in the front of the toilet, and the toilet was crooked and the wall was missing tiles. V2 said he also was not aware R2's toilet was not secure to the floor and moved. V2 said he was going to go look at all of those toilets and see what he could do to fix them. V2 said he usually does a quick round in the morning to see what needs to be fixed. V2 said usually QA (Quality Assurance) will do round in the morning and midday of the resident's rooms, and let him know what needs fixed. On 12/05/24 at 2:20PM, V1 (Director of Nursing/DON) said she didn't know R3's and R12's bathroom was out of order. V1 said since she started at the facility, which was in August, she has always observed R3 and R12 using the shower room on the hall to go to the restroom. V1 was aware of R1's toilet leaking and being cracked along with the tiles missing. V1 said they tried to get R1 to move to a different room until they got his bathroom fixed, but he refused to move. V1 said she didn't know R2's toilet was not secure to the floor. V1 said she knows they do have several toilets ordered in bulk to fix several of the toilets at the facility. V1 was not sure which toilets were being replaced. V1 said she will make sure all the toilets are checked in the facility and make sure they all get fixed. A undated policy titled Physical Plant and Environmental Policy and Guidelines documents under the policy statement It is of the utmost importance to provide a safe, hospitable, clean, and organized facility and ground to ensure an environment that is conducive to providing the best care, comfort and home-like surrounding for residents. The policy statement also states The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA (National Fire Protection Association) codes.

Based on interview, observation, and record review, the facility failed to maintain safe water temperatures for 14 of 14 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for water temperatures in a sample of 14. Findings include: On 12/5/24 at 8:54 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method, and was accurate within +/_ 2 degrees Fahrenheit. 1. On 12/5/2024 at 9:12 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of the shared bathroom of R1 and R10, and registered 120.2 degrees Fahrenheit. On 12/5/24 at 9:12 AM, R1 who was alert to person, place, and time, stated the maintenance man told him a week ago the bathroom water temp was 118. R1 then stated the water is hot, but that it has never burned him. 2. On 12/5/2024 at 9:16 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of the shared bathroom of R3, R11, and R12, and registered 117.5 degrees Fahrenheit. This bathroom did have a sign on the door that stated, Do not enter this area it's closed at this time. The door was not locked and could be entered. On 12/5/24 at 9:16 AM, R3 who was alert to person, place, and time, stated he hasn't been able to use the bathroom for a while he said that sign has been on the door for several months. He said he has to go down the hall to use the restroom. He said it is a hassle to have to go down the hall and wait at times. 3. On 12/5/2024 at 9:20 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of bathroom of R13, and registered 117.6 degrees Fahrenheit. On 12/5/24 at 9:20 AM, R13 who was alert to person, place, and time, stated he uses the bathroom all of the time and stated the water was not too hot. R13 stated they did have some flooding on Monday, and they have to fix the water lines. 4. On 12/5/2024 at 9:21 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of the bathroom of R2, and registered 117.8 degrees Fahrenheit. 5. On 12/5/2024 at 9:23AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of room [ROOM NUMBER], which was empty, and registered 119.6 degrees Fahrenheit. 6. On 12/5/2024 at 9:30 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of the bathroom of R14, and registered 119.8 degrees Fahrenheit. 7. On 12/5/2024 at 9:35 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of the Shower Room of the E Hall, and registered 116.6 degrees Fahrenheit. At that time, the shower head in the shower was not working. 8. On 12/5/2024 at 9:38 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of room [ROOM NUMBER], which was empty, and registered 116 degrees Fahrenheit. 9. On 12/5/2024 at 9:50 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of the Shower Room on D Hall, and registered 122.5 degrees Fahrenheit. On 12/5/24 at 9:50 AM, V1 (Director of Nursing/DON) came into the Shower Room on D Hall to observe the water temperature taken at the handsink. As the temperature was being taken, V1 was asked what the temperature should be, and she said she thought not above when 110. As V1 was answering the question, the thermometer reading at the handsink was at 122.5 degrees Fahrenheit. V1 then stated they did have a maintenance man up until a week ago. She said he used to check the temps and keep logs. V1 stated V2(Maintenance Assistance/Therapy Assistant) the therapist has been trying to fill in as a maintenance man, and they have had the corporate maintenance man coming down when they had the pipes bust last week. V1 stated they really haven't had any complaints from residents other than R1, who said that the water was too hot and he got burned. V1 stated at that time, they investigated it, and every resident said the water temp was fine, including R1, and nothing more was ever said about the water being too hot. V1 stated she did do interviews and they did do testing of the water temps. Facility Incident Investigation Form, dated 11/8/24, documents R1 was asked the question, Have you had any issues with water temperature in this facility? R1's answer was, Yes, too hot. Never got burned by water. On 12/5/25 at 1:30 PM, V2 (Maintenance Assistance/Therapy Assistant) stated the last maintenance man left about a week ago, and he is the assistant. V2 stated he is the one that last took the water temperatures last week and this week, and documented on the log, and had found no issues with the temperatures. V2 stated he takes the water temperatures in 4 places to include both shower rooms and a room farthest away from the hot water heater. V2 said he uses a dial thermometer to take the temperatures, and he last calibrated back in November when one of the residents had complained of the water being too hot. V2 stated when he checked there were no issues. V2 stated the temperature range he is looking is to not go over 112, but likes to hit 110. V2 stated he would adjust the mixing valve if there was a problem. V2 stated no one had complained recently of the water being too hot. V2 stated the facility has 2 units, 1 unit has two hot water heaters, and so does the other. A list provided by V1 (DON), dated 12/5/24, of cognitively impaired and ambulatory residents included R1, R2, R3, R5, R6, R7, R8, and R9. On 12/05/24 at 2:30 PM, V1 (DON) stated one of the wandering cognitively impaired residents could have went into any of the shower rooms or bathrooms and turned on the sinks. V1 said they did have a plumber currently working on the hot water heater. V1 said they found a hole in the pipe leading to the hot water heater. V1 said they think the hole was causing the water heater to keep running and making the water too hot. V1 said the water heater was set at 110 degrees Fahrenheit. An undated Water Temperature Control Policy documents, It is the policy of (Name of Corporate) Health Care to maintain water temperature available to residents between 100 and 110 degrees Fahrenheit .

Based on observation, interview, and record review, the facility failed to provide nutritional supplementation as recommended for three (R3, R15, and R4) of six residents reviewed for nutrition in a sample of 27. This failure resulted in significant weight loss for R3. Findings include: 1. R3's face sheet documents an admitted [DATE], with diagnoses including: acute kidney failure, chronic atrial fibrillation, chronic venous hypertension with inflammation of bilateral lower extremity, anxiety disorder, hyperuricemia without signs of inflammatory arthritis and tophaceous disease, malignant neoplasm of colon, type 2 diabetes mellitus without complications, and osteoarthritis. R3's Care Plan documents a focus area titled Nutrition, dated 04/24/24, documents: the resident has potential nutritional problem r/t (related to) diet restrictions with an intervention dated 02/27/24 stating: RD (Registered Dietician) to evaluate and make diet change recommendations PRN (as needed). R3's Dietician Review, dated 03/22/24 at 10:05 AM, documents: risk factors for weight loss may include advanced age and restrictive diet order, BMI (Body Mass Index) is calculated as 22.8. BMI evaluation is > 65 y/o (years old), underweight (<23.0) factors affecting nutritional needs include: intake is fair-good, stage 3 wound left buttocks, left hip surgical wound, stage 2 wound coccyx, own teeth, ambulatory/wheelchair, normal weight, independent, alert, advanced age. (V14) (Regsitered Dietician/RD) reviewed evaluation of current condition includes: nutrition/weight does not require additional diagnosis at this time. Additional recommendations may be necessary. 2020 calories, 88 grams protein - 1.2 g/kg, 2020 ml fluids - 1 ml/calorie. V14 (RD) initial assessment. R3's Nutrition/Dietary Note, dated 05/24/24 at 10:44 AM, documents, Note text: weight loss note: Ht (height): 66 in (inches), wt (weight): 112 lbs (pounds) (mechanical lift) BMI (body mass index): 18.1 indicates underweight. Admission weight was 141.2 lbs (wheelchair). This indicates a weight loss of 21.1% (30 lbs) x 2 months. Spoke with (V3, Dietary Manager) regarding inconsistent weight methods. States that current weight seems accurate. Will monitor next month weight to assess weight trends. Current diet: CCD (consistent carbohydrate diet)/NAS (no added salt), regular texture and regular liquids, intakes are mostly 76-100% per documentation, feeds self, no reports of chewing/swallowing difficulties. Meds (medications), labs, and skin reviewed above. Pt (patient) has multiple wounds - stage 3 to left buttock, stage 2 coccyx and surgical wound. Per (V3) pt refuses supplements. Supplements recommended due to skin breakdown and weight loss. Goals: 1. Maintain adequate nutrition/hydration, 2. stable wt/<5% change within 1 mos (month) period, 3. Labs acceptable to MD (medical doctor) 4. Improved wound healing. Plans: 1 continue CCD-NAS/Reg (regular)/thin liquids. 2. Provide extra oz (ounce) protein with meals to aid with wound healing. 3. Monitor wt intake, labs, and skin 4. Refer to RD (Registered Dietician) PRN (as needed). R3's Nutrition/Dietary Note, dated 06/21/24 at 10:37 AM, documents, Note text: weight loss follow up/wound Note: Ht: 66 in, Wt: 110.4 lbs (mechanical lift) BMI: 17.8 indicates underweight. Admission weight was 141.2 lbs (wheelchair). This indicates a weight loss of 21.8% (30 lbs) x 4 months. Current diet: CCD/NAS, ground meat and regular liquids, intakes are mostly 76-100% per documentation, feeds self, no reports of chewing/swallowing difficulties. Meds, labs, and skin reviewed above. Pt has multiple wounds - stage 3 to left buttock, stage 2 coccyx and surgical wound. Per (V3) pt refuses supplement. Supplements recommended due to skin breakdown and weight loss. Goals: 1. Maintain adequate nutrition/hydration, 2 stable wt/<5% change within 1 mos period, 3. Labs acceptable to MD 4. Improved wound healing. Plans: 1 continue CCD-NAS/Reg /thin liquids. 2. Provide extra oz protein with meals to aid with wound healing. 3. Monitor wt intake, labs, and skin 4. Refer to RD PRN. R3's Nutrition/Dietary note, dated 07/19/24 at 11:51 AM, documents, Note text: weight loss follow up/wound note: Ht:66 in, Wt: 110.4 lbs (mechanical lift) BMI: 17.8 indicates underweight. No weight for July. Current diet: CCD/NAS, ground meat and regular liquids, intakes are mostly 76-100% per documentation, feeds self, no reports of chewing/swallowing difficulties. Meds, labs, and skin reviewed above. Pt has multiple wounds - stage 3 to left buttock, stage 2 coccyx and surgical wound. Per (V3) pt refuses supplement. Supplements recommended due to skin breakdown and weight loss. Goals: 1. Maintain adequate nutrition/hydration, 2. stable wt/<5% change within 1 mos period, 3. Labs acceptable to MD 4. Improved wound healing. Plans: 1 continue CCD-NAS/Reg /thin liquids. 2. Provide extra oz protein with meals to aid with wound healing. 3. Monitor wt intake, labs, and skin 4. Refer to RD PRN. R3's Order Summary Report, dated 8/1/24, under Dietary orders document active orders of regular diet, ground meat texture, regular/thin consistency, dated 04/24/24 and carb controlled diet/ no added salt, dated 3/14/24. There was no order for added protein noted on R3's Order Summary Report. The facility document titled, week 3 Monday documents: mechanical soft diet: 1 each ground pork fritter with gravy, sauce, 4 ounce scalloped potatoes, 4 ounces green beans, and 4 ounces peaches. On 07/29/24 at 12:10 PM, R3 received a #10 scoop (3.25 ounces) of ground pork fritter, R3 did not receive the extra ounce of protein with his meal. R3's dietary card did not document extra protein for R3. On 07/29/24 at 12:21 PM, V6 (Cook) stated they substituted mashed potatoes for the scalloped potatoes and the #10 scoop is what is listed for the mechanical soft residents to receive for the pork fritter. The facility document titled, week 3 Tuesday documents: mechanical soft diet: 3 ounces ground roast turkey with gravy, 2 ounces poultry gravy, #8 scoop mashed potatoes, 4 ounces Brussel sprouts, 1 each moistened roll/margarine, # 12 scoop warm blueberry cobbler. On 07/30/24 at 12:05 PM, R3 received 3 ounces of ground turkey. R3 did not receive extra protein with his lunch. The facility document titled, week 3 Wednesday documents: mechanical soft diet: 6 fluid ounces choice of juice, 1 serving moistened choice of cereal, 2 each eggs, 1 each soft cinnamon rolls with icing, 8 fluid ounces milk. On 07/31/24 at 8:12 AM, R3 received cereal and a cinnamon roll for breakfast. There were no eggs observed on R3's tray. R3's food intake record documents on 07/31/24 a 3 for breakfast indicating R3 consumed 75 - 100% of R3's breakfast. The facility document titled, week 3 Thursday documents: mechanical soft diet: 6 fluid ounces choice of juice, 1 serving moistened choice of cereal, 1 slice sausage breakfast pie with gravy, 1 slice softened toast, 1 teaspoon margarine/jelly, and 3 fluid ounces milk. On 08/01/24 at 8:04 AM, R3 received 2 sausage links and toast for breakfast. There were no eggs observed on R3's tray. On 07/29/24 at 1:17 PM, R3 stated, The food is horrible here. I will leave a note to tell staff to put my food on the table and wake me up if I'm sleeping and they will not do it. I will wake up and my food is sitting there and is cold, and it is already bad enough. The scrambled eggs are horrible, they are watery and make with that liquid egg stuff. The fried eggs are ok sometimes, sometimes they are brown, who knows what kind of oil they are using back there to cook with. Sometimes the omelets are ok, and sometimes not, it is not hard to make an omelet or fry an egg. R3 said he does not know where the cook learned to cook, but it's not right. He stated some of the food here is tough and he cannot chew it, he has no teeth, what do they expect? He eats what he can deal with. He feels like they are trying to starve him here, he is used to eating more. R3 was alert to person, place, and time. On 08/01/24 at 8:07 AM, V15 (Certified Nurse Aide/CNA) stated R3 did not get the eggs that were served because he does not like the scrambled eggs, she stated they do not bring anything else in place of the eggs if the resident does not want the eggs. R3 received two sausage links, the same as everyone else. On 08/01/24 at 9:39 AM, V27 (Dietary) stated she is not aware of any supplements for R3 or any extra protein; they do not offer him a different protein if he does not like the one they are serving. R3 does eat eggs, just not scrambled, he is ok with fried and omelets. On 08/01/24 at 11:07 AM, V3 (Dietary Manager) stated she is not aware R3 is supposed to receive extra protein with any meals. The extra protein is not on his dietary card because she was not aware of it, and no recommendation has been given to nursing by her to be given to the physician because she was not aware. She would have to look through his dietary notes and talk to V14 (Registered Dietician/RD) to find out about that. If the resident does not like scrambled eggs, they will send the plate out without the scrambled eggs, they do not put anything else in the place of them. They tried a few supplements with R3 once, super cereal, gelato and the health shake she believes, and he didn't like them. They tried all three on the same day and did not try them again. There was no order for them, or probably documentation because they just tried them once. V3 stated they substituted the eggs and sausage links breakfast for the sausage pie breakfast today, which was 2 eggs and 2 sausage links. On 08/01/24 at 2:20 PM, R3 stated he tried something similar to ice cream once, but it got melty while he was eating his food. It could have been better if it was frozen. On 08/01/24 at 11:40 AM, V22 (Registered Nurse) stated she believes any recommendation from V14 (Registered Dietician) goes to V3 (Dietary Manager) first, then to the nurse on duty who would then notify the doctor. On 08/01/24 at 12:20 PM, V3 stated any recommendations from the RD should come to her first then go to the nurse and then to the doctor. On 08/02/24 at 3:50 PM, V14 (Registered Dietician) stated she did put a recommendation in for an extra ounce for protein for R3 in May, she has the report where she sent it to V3 (Dietary Manager), when she generates her recommendations, the program automatically generates a report that can be sent to the physician by the facility. V14 stated with his weight loss and wounds, she would expect him to receive the extra protein, and she was not aware he was not. V14 stated she was unaware the supplements were only offered to R3 one time at the same time, she would have expected them to be offered more than once. V14 stated she would expect if there was a protein item being served that R3 did not like, she would expect something different offered in its place, especially since she recommended extra protein. V14 stated if a resident is not served the full meal and only receives a couple items of the meal, she would not consider that to be a 75 - 100% intake. She stated she uses all that information that is documented on a resident to make her recommendations. The facility policy, dated 10/13, titled, Nutrition Supplements and Nourishments documents; It is the policy of (this health care facility) to provide additional calories and/or protein to residents who cannot and/or are not capable of consuming adequate nutrients through their regular meals. It is also the policy of (this health care facility) to provide guidelines for the selection, ordering, use, and monitoring of nutrition supplements and nourishments. Procedure: 1. The need for a nutrition supplement and/or nourishment should be determined by the physician, nursing staff, dietitian, and/or interdisciplinary team (IDT). 5. Nutrition supplements and/or nourishments must be ordered by the physician and are part of the resident's diet order. Nutrition supplements are medical nutrition products and are to be served only with a physician's order. 8. The volume and frequency of supplement is based on the resident's needs. The policy titled, Resident Weight Monitoring, dated 03/19, documents: Procedure step 7. If there is an actual significant weight change (i.e. (in example) +/-5% x 1 month, +/-1 7.5% x 3 months, +/- 10% x 6 months), the resident, POAHC (Power of Attorney for Health Care)/family/guardian, physician and dietitian are notified. The physician shall be notified using the MD (physician) notification of weight change form. 8. The Food Service Manager and interdisciplinary team review the resident's weights and nutritional status, and make recommendations for intervention. 9. The Dietitian shall review and document all significant weight changes along with any recommended nutritional interventions in the dietary progress notes in the medical record monthly. 10. Nursing contacts the physician to convey recommendations from the interdisciplinary team and/or dietitian, and obtains any new orders. 11. Significant weight changes are reviewed in the weekly weight committee meeting. The weight committee will also identify and trends of gradual weight loss or gain. Significant changes in weights are documented in the care plan with goals and approaches/interventions listed. 48356 2. R15's Face Sheet, dated 08/01/24, documents R15 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, chronic kidney disease stage 3, major depressive disorder, anxiety, hyperlipidemia, and constipation. R15's Care Plan, with a revised date of 05/15/24, documents a focus area of ADL (Activities of Daily Living) function rehab: dependent for ADL's- assists only minimally. Not a candidate for restorative programming. Further decline in ability/participation likely due to cognition and end of life care. Documented interventions include serve diet as ordered and tolerated, see POS (Physician Order Sheets) or tray card for current diet, set up tray per R15 preference, feed R15 meal, record intake for each meal offer subs for foods not eaten. R15's Care Plan also documents a Focus area of Nutrition: the resident has a potential nutritional problem r/t (related to) dementia. Documented interventions include provide and serve supplements as ordered, provide, serve diet as ordered, monitor intake and record every meal, RD (Registered Dietitian) to evaluate and make diet change recommendations PRN (as needed). R15's Order Summary Report, dated 8/1/24, documents active orders of regular diet, mechanical soft texture, nectar/mildly thick consistency, dated 9/14/23, may participate in meal of the month, special occasion and holiday meals, using diet consistency, Lip plate for all meals, Supercereal at breakfast, Magic cup (Nutritional Supplement) at lunch and supper dated 8/23/23, 2.0 calorie Supplement three times a day 90 cc (cubic centimeters) dated 4/2/24, and Hospice care/services, dated 7/18/23. R15's Minimum Data Set (MDS), dated [DATE], documents in Section C, a Brief Interview for Mental Status (BIMS) score of 03, indicating R15 has severe impaired cognition. Section GG documents R15 is dependent for eating. R15's weight summary documents the following weights: 02/16/24 125.6 lbs. (pounds), 03/05/24 123.2 lbs., 04/02/24 118.8, 05/09/24 116.0 lbs., 06/03/24 114.9 lbs., and 07/04/24 116.5 lbs. On 07/29/24 at 11:50AM, R15 was served mechanical soft pork fritter, mashed potatoes with gravy, green beans, peaches with nectar thickened juice and water. There was no magic cup (Nutritional supplement) observed on R15's tray. On 07/30/24 at 11:45AM, R15 was served mechanical soft turkey, mashed potatoes with gravy, mixed vegetables, cobbler, nectar thickened water and juice. There was no magic cup (Nutritional supplement) observed on R15's tray. On 08/01/24 at 9:34AM, V3 (Dietary Manager) stated no resident on 07/29/24 and 07/30/24 received a nutritional supplement at lunch. V3 stated V27 (Dietary Aide) told her she forgot to send out the nutritional supplements on 07/29/24 and 07/30/24 at lunch. V3 said V27 talked to her about it, and told her she forgot the nutritional supplement both days at lunch meal. V3 said she educated V27 about making sure they are served. V3 said all residents who are to receive the nutritional supplement should have received them. V3 said R15 should have received her nutritional supplement, but stated she doesn't eat the nutritional supplement a lot. V3 stated R15 receives nutritional cereal at breakfast, and if R15 doesn't eat well, they will make her the nutritional cereal at lunch and supper as well. V3 said she knows R15 has had a weight loss, but R15 is on hospice care, and it is expected for her to lose weight. On 08/01/24 at 9:40AM, V27, (Dietary Aide) stated she did not serve any resident a nutritional supplement on 07/29/24 and 07/30/24 at lunch meal. V27 said on 07/29/24 she was nervous with serving, and she forgot all about the nutritional supplements. V27 stated on 07/30/24, the day was very crazy, and she didn't think about the nutritional supplement at all. 34201 3. R4's July 2024 Physician Orders document a diet order for a regular diet, pureed texture, pudding thick liquids, and high calorie/high protein supplement BID (twice a day) served with lunch and supper. On 7/29/24 at 12:08 PM, R4 was sitting up in a reclining wheeled chair being fed by V8 (CNA). R4's meal consisted of pureed pork fritter, mashed potatoes with gravy, green beans, peaches, pudding thick cranberry juice and water. R4 did not have a high calorie/high protein supplement, which V8 confirmed. On 7/30/24 at 12:30 PM, R4 was being fed by V16, CNA. R4's meal consisted of pureed turkey, mashed potatoes with gravy, peas, cake, dinner role, pudding thick tea and water. V16 stated R4 gets a high calorie/high protein supplement at times, and had one last night for supper. V16 confirmed R4 did not receive a supplement at lunch today. On 7/30/24 at 12:35 PM, V6 (Cook) stated R4 gets the high calorie/high protein supplement at supper, but V6 was not aware R4 was supposed to get it at lunch too. On 7/31/24 at 8:44 AM, V14 (Registered Dietician) confirmed R4 is to be receiving the ordered nutritional supplements BID due to a history of weight loss.

Based on observation, interview, and record review, the facility failed to provide an accessible call system for residents in the shower room or the community bathroom. This failure has the potential to affect all 33 residents residing at the facility. Findings include: On 07/29/24 at 1:35 PM, the hall bathroom/shower room on E-Hall was noted to have a call light box on the wall, but no pull cord was observed to be attached to the toggle switch. Thus, the call light near the toilet was not accessible as it could not be reached from the toilet or the floor without a pull cord. The shower stall in this bathroom/shower room also did not contain any call system. On 07/29/24 at 1:39 PM, the hall bathroom/shower room on the D-Hall was noted to have a call light box on the wall, but no pull cord was observed to be attached to the toggle switch. Thus, the call light near the toilet was not accessible as it could not be reached from the toilet or the floor without a pull cord. The shower stall did not contain any call system. On 07/29/24 at 2:17 PM, the hall bathroom/shower room on A-Hall did not have an accessible call light system in the shower stall. On 08/01/24 at 9:10 AM, the hall bathroom/shower room on E-Hall was noted to have a call light box on the wall, but no pull cord was observed to be attached to the toggle switch. Thus, the call light near the toilet was not accessible as it could not be reached from the toilet or the floor without a pull cord. The shower stall did not contain any call system. On 08/01/24 at 9:13 AM, the hall bathroom/shower room on D-Hall was noted to have a call light box on the wall, but no pull cord was observed to be attached to the toggle switch. Thus, the call light near the toilet was not accessible as it could not be reached from the toilet or the floor without a pull cord. The shower stall did not contain any call system. On 08/01/24 at 9:17 AM, the hall bathroom/shower room on A-Hall did not have an accessible call light system in the shower stall. On 08/01/24 at 10:35 AM, V4 (Maintenance) stated he can put a string to make the call light accessible from the toilets in the bathroom/shower rooms on the D and E Hall bathrooms. He stated he will have to figure something out since the shower stalls do not have a call light system. He stated he does not know how long they have been without strings by the toilets, no one had told him about them. On 08/01/24 at 1:37 PM, V1 (Administrator) stated there are two bathrooms/shower rooms on this side of the building (D and E Halls) and one bathroom/shower room on the other side (A-Hall). V1 stated she does not know why they do not have call lights that are accessible from the toilets but she will have V4 fix them today. V1 said she will have to call someone about there not being a call system in the shower stalls for either shower rooms, but they will get it corrected. On 08/01/24 at 4:21 PM, V1 stated she does not have a policy on call light systems. The Long Term Care Facility Application for Medicare and Medicaid (Form CMS 671) dated 07/29/24 documents 33 residents residing at the facility.

Based on observation, interview, and record review, the facility failed to store and serve food in a safe and sanitary manner in accordance with professional standards. This has the potential to affect all 33 residents residing at the facility. Findings include: On 07/29/24 at 9:51 AM during the initial tour of the kitchen, there were three containers of thickened juice, one kiwi and strawberry flavored and two orange flavored, opened and in the refrigerator with no dates on them. There were two bags of cereal, one whole grain toasted oats and one bran flakes, that were opened with no dates on them. There was a bag of dried milk opened with no date on it. There were also two containers of liquid eggs opened with no dates on them and one package of lunchmeat ham opened with no date on it in the walk in cooler. On 07/29/24 at 9:51 AM during the initial tour of the kitchen, there was a scoop inside the sugar bin laying on top of the sugar and a scoop in the container of coffee laying on top of the ground coffee. On 07/29/24 at 11:35 AM during lunch service, V27 (Dietary) touched the counter, the cart, the plastic wrap box, a pad of paper, and the door handle and then transferred residents drinks by the rim where the resident drinks from. On 08/01/24 at 11:07 AM, V3 (Dietary Manager) stated the opened items in the kitchen, especially in the walk in cooler and refrigerator, should be dated, and there should be no scoops in any of the bins or containers. V3 stated staff shouldn't be transferring glasses by the rims, it should be by the middle or towards the bottom of the glass. The Long Term Care Facility Application for Medicare and Medicaid (Form CMS 671), dated 07/29/24, documents 33 residents residing at the facility.

Based on observation, interview, and record review, the facility failed to have a full time Director of Nursing and to ensure Registered Nurse coverage 8 consecutive hours a day, seven days a week. This failure has the potential to affect all 33 residents who reside at the facility. Findings Include: The facility's Social Service Need Notice, dated 6/12/24, documents residents concern of the Administrator not being out on the floor more. V28 (Former Administrator) documented on this form, the Administrator does make daily rounds however is needing to do other things due to V2 (Director of Nursing/DON) being on the floor. On 7/29/24 at 12:09 PM and 7/30/24 at 12:13 PM, V2 (DON) was working the floor as a floor nurse and passing medications to residents. V2 was the only nurse on the unit both days at these times. On 7/30/24 at 12:13 PM, V2 stated V2 used to be the DON, but has not had any office time as DON for two months due to working 12 hour days, 3 days a week on the floor as a floor nurse. V2 stated V2 recently submitted V2's resignation from that position due to not having time to do the duties of a DON. V2 also explained for the last two years, V2 has worked the floor as a nurse more than working as DON. On 7/31/24 between 8:30 AM - 3:30 PM, V2 was not in the building. During this time, V22 (Registered Nurse [RN]/Assistant Director of Nursing [ADON]) was working the floor as a nurse. On 7/31/24 at 11:12 AM, V1 (Administrator) confirmed V2 has not performed DON duties over the past couple of months due to working the floor. On 7/31/24 at 3:15 PM, V13 (Minimum Data Set/Care Plan Coordinator [MDS/CPC]) stated when V22 (RN) is in the building, V22 is working the floor as a nurse, as is V2. On 8/01/24 between 8:00 AM - 12:45 PM, V2 was not in the facility. During this time, V22 (RN/ADON) was working the floor as the nurse. On 8/02/24 at 11:03 AM, V22 (RN/ADON) stated V22 was just a regular floor nurse, not the ADON. The Facility Assessment, dated 7/31/23, documents the facility will have one full time DON and if the DON has other responsibilities, more RN's (Registered Nurses) will be added to the schedule to assist the DON as to equal a full time employee. The facility Room Roster, dated 7/25/24, documents 33 residents reside at the facility. 41610 On 07/30/24 at 10:20 AM, V1 (Administrator) stated the provided schedule was the up to date schedule for the facility. On 07/30/24 at 12:13 PM, V2 (DON) stated she has been working the floor due to not having enough RN's to work. The schedule, dated June 2024, documents no Registered Nurse hours worked for 6/2, 6/6, 6/13, 6/16, 06/19, and 06/30. The Long Term Care Facility Application for Medicare and Medicaid (Form CMS 671), dated 07/29/24, documents 33 residents residing at the facility.

Based on observation, interview, and record review, the facility failed to provide at least 80 square feet per resident bed in multible occupancy resident bedrooms. This failure affects four (R7, R10, R15, R21) of four residents reviewed for environment in the sample of 27. Findings include: Observations on 8/1/2024 at 9:00 AM, revealed R7 resided in a room certified for double occupancy. This room contained two beds, a dresser, two bedside tables and one over the bed table and had limited area to move around inside the room. V4 (Maintenance Director) used a tape measure and measured R7's bedroom. The bedroom measured 136 inches by 151 inches which equals 142.61 total square feet, and equals 71.31 square feet per resident bed. Observations on 8/1/2024 at 9:10 AM, revealed R10 resided in a room certified for double occupancy. This room contained two beds, two bedside tables, one over the bed table, three trash cans, one isolation supply cart, one bedside commode and one dresser, and had limited area to move around inside the room. V4 used a tape measure to measure R10's bedroom. The bedroom measured 141 inches by 151 inches, which equals 147.85 total square feet, and equals 73.93 square feet per resident bed. Observations on 8/1/2024 at 9:20 AM, revealed R15 resided in a room certified for double occupancy. This room contained two beds, two bedside tables, one over the bed table, a trash can, a geriatric reclining chair and a wheeled walking assistive device and had limited area to move around inside the room. V4 used a tape measure to measure R15's bedroom. The bedroom measured 142 inches by 151 inches, which equals 148.9 total square feet, and equals 74.45 square feet per resident bed. Observations on 8/1/2024 at 9:30 AM, revealed R21 resided in a room certified for double occupancy. This room contained two beds, two bedside tables, one dresser, one supply cart for personal belongings, one trash can and one wheelchair with limited area to move around inside the room. V4 used a tape measure to measure R21's bedroom. The bedroom measured 143 inches by 150 inches, which equals 148.96 total square feet, and equals 74.48 square feet per resident bed. On 8/1/2024 at approximately 10:15 AM, V1 (Administrator) was asked if residents were notified during admission that some of the rooms in the facility did not meet the requirement of having 80 square feet of floor space per resident. V1 stated no. V1 said rooms 3-14, 16-23 and 28-31 did not meet the required 80 square feet of floor space per resident bed, and all are certified for double occupancy. V1 stated none of these rooms currently had more than one resident residing in them, but that could change at any time. The facility's Daily Midnight Census sheet (undated) documents R7, R9, R10, R15, R21, R22, R26, R28 and R32 currently reside in the waivered rooms, and none were interviewable. Observations and measurements of these rooms during the survey determined adequate space exists to meet the medical and personal needs of the residents living in these waivered rooms. Resident Council Minutes from the past 6 months indicated no concerns related to the size of the rooms included in the waiver.

Based on interview and record review, the facility failed to honor resident choices regarding preferences for sleeping/waking schedules for one (R16) of one resident reviewed for Self-determination in a sample of 27. Findings include: R16's face sheet documents an admitted [DATE], with diagnoses that include depression and insomnia. R16's Minimum Data Set (MDS), dated [DATE], documents chair/bed-to-chair transfer: the ability to transfer to and from a bed to a chair (or wheelchair) as Dependent designating: helper does all of the effort, resident does none of the effort to complete the activity .or, the assistance of two or more helpers is required for the resident to complete the activity. On 07/29/24 at 1:53 PM, R16 was alert to person, place, and time and stated the one thing he just does not agree with at the facility is they get him up too early, then he will just sit in his room. R16 stated sometimes they will take him to the dining room at 5:00 AM, and he will sit down there with nothing to do until breakfast is delivered around 8:00 AM. R16 again stated he doesn't agree with having to get up that early to go to the dining room and sit in his chair longer, as he would prefer to sleep longer. On 07/30/24 at 11:40 AM, R16 stated this morning they got him up before 5:00 AM, it was probably close to 4:30 AM, and he just does not understand why he has to get up so early; he does not like it. On 08/01/24 at 9:37 AM, V17 (Licensed Practical Nurse/LPN) stated R16 is already in the dining room prior to him arriving for work at 6:00 AM. On 08/01/24 at 9:39 AM, V25 (Dietary) stated R16 and R11 are typically in the dining room when she comes in to work at 6:00 AM. On 08/01/24 at 10:31 AM, R11 stated he independently propels himself in his wheelchair and goes to the dining room early in the morning around 6:00 AM or before, and R16 is usually down there. R11's MDS, dated [DATE], documents a Brief Interview for Mental Status score of 13, indicating R11 is cognitively intact. On 08/01/24 at 10:42 AM, V15 (Certified Nurse Aide/CNA) stated R11 and R16 are usually in the dining room upon her arrival to work at 6:00 AM. On 08/01/24 at 10:59 AM, V29 (CNA) stated she gets to work at 6:00 AM, and R16 is usually in the dining room when she arrives. V29 stated the night shift usually gets R16 up between 5:00 AM and 5:30 AM. On 08/01/24 at 3:05 PM, V1 (Administrator) stated residents should be able to get up when they would like. V1stated she does not know if they have a policy for that, it would just be a resident's right.

Based on interview and record review, the facility failed to promote resident independence and dignity while providing care by neglecting to explain a task prior to beginning and allowing the resident time to perform the task independently for one (R31) of six residents reviewed for resident rights in the sample of 27. Findings Include: R31's MDS (Minimum Data Set), dated 6/28/24, documents R31 has moderate cognitive impairments. On 7/29/24 at 10:48 AM, R31 stated, Yesterday {7/28/24} around 2:00 PM, a bigger girl was very rough with me during cares. R31 explained R31 is normally able to turn over in bed by herself with just a little help but this bigger girl was in a hurry to get her job done and just pushed me over hard and fast. R31 stated this action caused R31 to yell out What are you doing? R31 stated a man across the hall must have heard R31 yell because the man yelled back, What are you doing to her? R31 explained there was also a supervisor present. R31 thought the girl might have gotten fired, but then was back today {7/29/24}. R31 also stated the big girl made it known that she was big, strong and in charge. On 7/31/24 at 10:57 AM, V8, CNA (Certified Nursing Assistant/CNA), stated on 7/26/24, V8 was working 6:00 PM - 12:00 AM, and V12 (CNA) came in to relieve V8 at 12:00 AM. Upon V12 entering the facility, V12 entered R31's room and started providing cares. V8 stated V8 was at the nurses station, which is down the hall from R31's room, with V9 (CNA) when V8 and V9 overheard V12 and R31 yelling at each other. V8 explained V8 could not make out what exactly was being said, but explained R31 is hard of hearing so V12 was probably talking loud to R31 so R31 could hear V12. However, V12 was not pausing to give R31 the opportunity to voice R31's concern without talking over R31. V8 stated V8 and V9 walked down to R31's room and stood in the doorway and observed R31 lying in bed facing the door, with V12 standing over R31 and reaching around R31 to change R31's brief and said, I have to change you. V8 explained at this time, R31 said something to the affect of, If you just give me time, I can do it myself or I can help you, but V12 kept changing R31. V8 stated R31 felt like R31 was being rushed and man-handled. On 7/31/24 at 11:06 AM, V1 (Administrator) stated V12 (CNA) is currently suspended due to the incident with R31 during cares. V1 stated that during V1's investigation, V12 admitted R31 became vocal during cares because R31 felt V12 was rough in handling R31 and didn't explain what was happening. V1 explained the facility does not feel like the incident was abuse, however, it was poor customer service, and stated V12 should have given R31 more time to assist in rolling over in bed, and V12 should have explained to R31 what cares were going to be completed before doing them.

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to ensure resident's safety, and to ensure overall care and needs were maintained. These failures affect all 32 residents residing in the facility. The Immediate Jeopardy began on 11/26/21 when there were not enough staff on duty to ensure residents were assisted out of bed, changed out of soiled adult briefs/clothing, and provided nursing care necessary to maintain the residents' highest physical, mental and psychosocial well-being and highest practicable level of functioning. Due to the residents' comorbidities, vulnerabilities, and need for 24-hour nursing care, this failure increases their risk of serious harm and possible death. This failure has the potential to affect all 33 residents that reside at the facility. V1 (Administrator) and V15 (Corporate Manager) were notified of the Immediate Jeopardy on 12/9/21 at 4:15 PM. The surveyors confirmed through observations, interviews and record reviews that the Immediate Jeopardy was removed on 12/11/21. The facility remains out of compliance at a severity level Two as the facility evaluates the implementation and effectiveness of their interventions put in place with their removal plan. Findings include: On 11/29/21 at 1:30 PM, V36 (Ombudsman) stated V36 received calls from several residents at the facility the day after Thanksgiving, 11/26/21, that there was only one Certified Nurse Aide (CNA) and 1 nurse working. V36 stated V36 went in to meet with the residents at 1:23 PM, and when C36 got to the facility, V36 saw there was only one CNA and one nurse working. V36 stated R1, R2, R3, R4, R5, and R6 all expressed concerns there wasn't enough staff to take care of their needs. V36 stated they reported to V36 several residents were not toileted for over 8 hours, and were left in their incontinent briefs they were in the night before. All stated leaving several residents in their incontinent briefs for that long caused a terrible urine odor in the facility. V36 stated R1, R2, R3, R4, R5 and R6 all stated some residents had been left on their bedpan for over 1 hour. V36 said these residents told V36 they weren't getting their showers, and all of them stated they wanted a shower and were upset they weren't getting them. V36 said R1, R2, R3, R4, R5 and R6 all stated not being bathed caused them to feel embarrassed. V36 also stated these same residents stated they don't get ice every day, and they have to wait several hours to get water. V36 said R1, R2, R3, R4, R5 and R6 stated they were very upset and worried about the facility's lack of staff and their basic needs not being taken care of. V36 said these residents also told V36 they were upset their rooms weren't being cleaned well, their trash cans were overflowing, and their bathrooms were dirty and smelled of urine. V36 stated due to having very little staff, the food trays weren't being delivered timely and residents' food was cold. On 12/13/21 at 3:00 PM, V36 stated V36 noticed the facility had a strong urine odor when V36 came in to have the resident council meeting on 11/26/21 at 1:00 PM. V36 stated some of the resident's hair was flat in the back and messy, as though it hadn't been combed. V36 stated V36 did notice body odor on some of the residents that came to the resident council meeting, and a few of the residents' clothing had food stains on them. V36 stated V36 noticed some of the other residents, not in the meeting, still had on clothing protectors with food all over them, and the dining room tables weren't cleared and cleaned, and this was around 2:30 PM. V36 stated V36 observed the hallways, and some of the resident rooms were dirty, sticky, and had tissues and other paper pieces in the floor. V36 said as V36 walked down the hallway, V36's shoes stuck to the floor. V36 also stated some of the bathrooms had a dried yellow substance around the commodes and smelled of urine, the commodes were nasty, and their trash cans were full and overflowing. On 11/29/2021 at 1:45 PM, V1 (Administrator) stated V1 knew there were some complaints that would be coming in, because V36 and others said there were complaints in the Resident Council meeting about several resident care issues. V1 said they have a DON (Director of Nursing) right now, but she (DON) is extremely part time because she (DON) has another full time job, and only comes in to assist with paperwork a few times monthly. V1 stated they have not had a full time DON at the facility for the past year. V1 stated the current census was 33, and the facility is currently not accepting new admissions at this time due to all of the construction. V1 said V1 has been Administrator-In-Training since 8/30/2021, and V15 (Corporate Manager) is a Licensed Nursing Home Administrator, and V15 is covering the facility. V1 said the facility currently has 3 full time day shift nurses and 3 full time night nurses. V1 stated they have a total of 6 full time CNAs (Certified Nurse Aides). V1 said there are some days during the week when there is only 1 nurse and 1 CNA assigned, and this makes it difficult to take care of 33 residents, many with bariatric needs for ADLs (Activities of Daily Living) and for use of the mechanical lifts. At 1:15 PM, V1 stated they don't have a Certified Nurse Aide scheduled for several days this week, and when V1 contacted the corporate office, they stated they didn't have anyone to send. V1 stated there have been many times when V1 has reached out to talk to someone at the corporate level about the staffing problems, and they won't answer their phones, and they never called V1 back. On 12/6/21 at 10:30 AM, V1 stated there were no CNA's in the building on Friday, 12/3/21, from 6:00 AM until 8:45 AM. V1 stated there were 3 unlicensed/uncertified staff, V14 (Social Services Director), V16 (Activity Director), and V7 (Housekeeping/Laundry Supervisor) attempting to do the CNA's tasks for the residents, because there was no one to work. V1 stated V1 wasn't there on Friday (12/3/21) because on V1's way to work, V1 was in a car accident and was in the emergency room . V1 stated V1 called V14 (Social Services Director) and told V14 V1 was in an accident, and then V1 called V15, and V15 just stated, Well, aren't you going to go into work? V1 stated V1 told V15 V1 had a concussion and a severe headache, and the doctor told V1 to go home and rest. On 11/30/21 at 10:30 AM, V9 (Licensed Practical Nurse/LPN) stated they have 5 residents that are morbidly obese, and it takes more than one CNA to turn them or hold them so someone can clean them. V9 stated a couple of the younger residents can turn themselves some, but none of them can stand or transfer. V9 stated they all have to have the mechanical lift to get up, and it takes at least 2 people to use the mechanical lift. V9 stated when there is 1 CNA and V9, medication pass is always late because V9 has to stop and help the CNA with residents who require 2 people for transfers, bed mobility, showers, bed baths, or whatever the residents need, and it is impossible to get the medications passed timely. On 11/30/21 at 11:25 AM, V12 (Certified Nurse's Aide/CNA) stated V12 and one nurse worked last Friday, 11/26/21, and V12 is the corporate float, and doesn't work at this facility all the time. V12 stated V12 got as many residents changed, toileted and up as V12 could, but no showers or bed baths were given. V12 stated the meal trays were very late on 11/26/21, but V12 couldn't go any faster, because other residents needed care. V12 stated V12 could do only what V12 could do, because the nurse was trying to get the medications passed and he tried to help, but then his medication pass was late. V12 stated V12 can't physically turn the bariatric residents by herself, and because V12 can't turn them, V12 can't put them on the bedpan or clean them up if they are incontinent, and if there was an emergency, V12 and one nurse could not get all them out of the building. On 12/01/21 at 10:35 AM, V13 (CNA) stated V13 came in to help, but works in a sister facility. V13 stated, This facility always has problems with staffing because the resident care is heavy. On 12/01/21 at 11:00 AM, V4 (Licensed Practical Nurse, LPN) stated V4 is just finishing up the 8:00 AM medication pass, and V4 had to stop doing the 8:00 AM medication pass so V4 can take care of the 11:00 AM insulin's that V4 gives before the noon meal. V4 stated a nurse called in this morning, and V4 is the only nurse working. V4 stated they can't get the medications out on time with only one nurse working the floor because they have to stop to help the CNAs. V4 stated V4 tries to help the CNA's, but sometimes V4 can't, and the residents don't get taken care of like they should. On 12/02/2021 at 10:30 AM, V15 (Corporate Manager) stated they have a DON (Director of Nursing) for the facility, V2 (Former DON). When V15 was asked about the DON position, V15 wasn't aware V1 told this surveyor V2 had another full time job and only comes in to assist with paperwork a few times monthly. V15 was also not aware the facility had numerous issues related to a lack of staff, including residents waiting for assist with transfer, late medication administration, Activities of Daily Living (ADL) care not being done in a timely manner, and a resident not being able to continue peritoneal [CONDITION(S)] in the facility due to a lack of daily RN (Registered Nurse) coverage. V15 stated V15 thought the facility had 2 RNs on staff; at least 1, whom was (V11) the MDS (Minimum Data Set) and Care Plan Coordinator. V15 stated they pay (V11) extra for RN duties to be performed. V15 said V15 would check this out. When V15 was asked if V15 was aware the facility currently had 5 residents who require bariatric care, and the facility does not have enough staff on duty to routinely transfer these residents or remove them from the facility quickly in case of an emergency, V15 stated that V15 did not know that, and the facility has always been known to V15 as the bariatric facility. V15 said they send residents from all over the state to the facility for bariatric care. When asked if the facility had an emergency evacuation plan for the 5 bariatric care residents, V15 did not answer. V15 stated they did not know what more they could do to get more staff. V15 said they have offered sign-on bonuses, increased pay, and advertised on social media and job sites. V15 said they have hired a new advertising agency. V15 stated they are also contracted with 2 staffing agencies, but they do not have available staff in this area. On 12/02/2021 at 1:30 PM, V15 stated V15 had misspoke about this being a bariatric facility, that V15 spoke with someone who said the facility has not been a bariatric facility for years. V15 stated V15 would also locate the facility's Emergency Plan book regarding evacuation of these residents. On 12/2/21 at 2:30 PM, V2 (Former Director of Nursing) stated V2 only comes in to flush a port for R7, and has no Administrative role. V2 stated V2 is not the Director of Nursing. On 12/6/21 at 9:00 AM, V17 (Medical Director/Attending Physician) was present in facility with V3 (Nurse Manager/Resident Care Coordinator) making Monday Rounds. At that time, V17 was asked if V17 was aware the facility residents have complained medications were being received late, and resident's blood sugar levels were being obtained at 6:00 AM, or earlier, and some residents do not receive their sliding scale or [MEDICATION(S)] (fast acting insulin) for more than 2 hours after their blood sugar is taken. V17 said receiving insulin late could cause blood glucose levels to be high. V17 indicated giving medications late, such as blood thinners, could also cause elevated Pro Times (prothrombin times). V17 indicated residents' medications should be received at the times ordered. On 12/10/2021 at 9:45 AM, V17 stated V17 does attend the QA (Quality Assurance) meetings at the facility on a quarterly basis. V17 stated V17 has been involved with evacuation planning for the facility's Emergency Plan. V17 also stated V17 is aware the facility has bariatric residents, yet V17 has never heard of a specific plan for the evacuation of the bariatric residents. V17 said, I never thought of it, but I should have. V17 stated, I hope they have a plan. V17 stated V17 was aware of other cases in other facilities where it presented safety issues. V17 stated V17 was aware the facility was currently having issues with staffing, but V17 didn't want to comment, since the facility's administration was actively trying to hire people. On 12/6/21 at 1:15 PM, V14 (Social Services Director) stated on Friday, 12/3/21 at 6:00 AM, V14 and V9 (LPN) were the only ones in the building to take care of the residents. V14 stated V14 tried several times to reach corporate staff, and no one would answer their phones, and no one called V14 back. V14 stated V35 (Corporate Director of Nursing) called V14 back much later in the day, and all V35 would say is what are you going to do? V14 stated V14 was very uncomfortable doing a CNA's job because V14 wasn't trained for that. V14 stated they did the best they could to get residents up and to the dining room, and when V14 was asked if V14 helped feed residents, V14 stated V14 did assist them because they needed to be fed. V14 stated V14 knew several of the residents were soaked with urine, but V14 couldn't help them. V14 stated around 8:30 AM, V16 (Activity Director) and V7 (Laundry/Housekeeping Supervisor) came in and helped, but they aren't licensed or certified, and then, a little later, V25 (Transportation Aide/CNA) came in and helped with resident care. V14 stated doing CNA work made V14 feel overwhelmed and nervous because V14 didn't feel comfortable doing something V14 wasn't trained to do. 1. On 12/09/2021 at 9:00 AM, V27 (Family) stated her [AGE] year old family member has been at the facility for a long time, and has recently become more dependent after a couple strokes. V27 stated R15 was previously in a room in the back of the building with R15's own bathroom. V27 stated due to repairs and renovations, R15 has been moved to the C Hall with a roommate. V27 said R15 cannot use the bathroom in R15's current room because the mechanical lift does not fit, so R15 must use the large common bathroom in the C Hall. V27 said R15 often must wait for that bathroom to be available, and for staff to be available for assistance with toileting. V27 said R15 has to wait sometimes for more than an hour, but does not want to complain. V27 said R15 tells V27, I've been through a lot worse in my lifetime. V27 stated V27 lives close by, and stops by the facility at least 3 times weekly. V27 said R15 has [NAME] of R15's skin, and sitting in wet adult incontinence briefs for long periods of time has made it worse. V27 said the facility has been short of staff and showers were not getting done. V27 said R15 has scheduled shower days for Wednesdays and Fridays. V27 stated, I usually have to tell them that she is supposed to have her shower. V27 said R15 is often asked to take R15's shower after 9:00 PM. V27 said V27 does not know of any [AGE] year old that wants to take their shower at 9:00 PM. 2. R1's Quarterly Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 11, which indicates R1 is moderately cognitively intact. Section G of R1's MDS - Functional Status, documents R1 requires limited assist of 1 person with bed mobility, locomotion on and off unit; extensive 1 person assist for dressing, bathing and personal hygiene. R1 requires set up only for eating, and total dependence of one person for toileting. R1 has no impairment of Range of Motion for upper or lower extremities. R1 uses a wheelchair for mobility. The facility's November 2021 shower log documents that R1 had 2 showers on November 4th and 29th. R1 stated R1 wanted R1's showers, and it really bothers R1 when R1 doesn't get them every week like R1's supposed to. On 11/29/21 at 2:00 PM, R1 was sitting up in R1's wheelchair in R1's room. R1 was awake, alert, oriented to person, place and time. R1 said it can take a long time to get assistance when there are not many staff working. R1 said R1 needs help to go to the bathroom and cannot always wait until someone can assist R1. R1 also said it can take an hour or longer to get R1's morning medications. On 12/1/21 at 9:42 AM, R1 was seated in R1's wheelchair at the door to R1's room, with the call light above the door illuminated and the call light beeping. R1 stated, Oh boy, my pants are wet. R1 was asked by surveyor if he was okay, and R1 replied, I got a problem, I'm wet. R1 was upset R1 was wet. R1 said R1 had R1's call light on for 30 minutes, but Couldn't make it. At 9:44 AM, a non-nursing staff said to R1, Ok, they're coming. It will be 1 second. I'll go get a CNA (Certified Nurse Aide). R1 responded, Okay. At 9:45 AM, a staff handed R1 an adult incontinent brief. R1 self-propelled R1's wheelchair to the bathroom entrance. At 9:49 AM, V13 (CNA) arrived to assist R1 to change R1's pants and get cleaned up. 3. R2's Minimum Data Set, dated dated [DATE], documents in Section C that R2 has a BIMS of 12, indicating R2 is cognitively intact with some forgetfulness. Section G of R2's MDS documents R2 requires limited assist of 1 for bed mobility, transfers, walking in her room, dressing, toileting, personal hygiene and bathing. The facility's shower log for November 2021 documents R2 only had showers on the 2nd, 10th, 11th, 15th and 27th of November. On 11/30/21 at 10:35 AM, R2 stated the facility doesn't have enough help, and the call lights don't get answered timely. R2 stated they do help R2 with R2's shower when they have time to give it to her. R2 stated R2 likes to be clean and when R2's not, R2 is very uncomfortable. R2 stated the call lights go off continuously for 1 to 2 hours. R2 stated R2 is supposed to get peritoneal [CONDITION(S)], but because they don't have a Registered Nurse to do her peritoneal [CONDITION(S)], R2 is going to have to go outside of the facility to get the [CONDITION(S)]. R2 stated going out of the facility puts R2 at higher risk to get Covid-19, and R2 really doesn't want to leave the facility to get it done, but R2 doesn't have a choice. On 12/2/21 at 10:00 AM, R2 stated they don't get ice in their water pitchers because the CNA and the nurse don't have time to pass ice and get water. R2 stated she can get her own water, but many of the other residents can't do that. 4. The facility's Shower log documents R3 hasn't had a shower since 11/15/21. R3's MDS, dated [DATE], documents R3 has a BIMS score of 12 indicating, R3 has some forgetfulness, but is alert and can recall information. R3's MDS in Section G, documents R3 is totally dependent and requires 2-assist for bed mobility, transfers, dressing and toileting and is totally dependent with 1 assist for locomotion on and off the unit, for personal hygiene and bathing. R3 requires limited assistance of 1 person to help feed R3. On 12/2/21 at 11:45 AM, R3 was lying far over to the left side of R3's bed. and was lying back very far, and R3's bed was not positioned correctly for R3 to eat R3's meal. R3's meal tray was in front of R3 on the bedside table, but there was no way R3 could comfortably feed R3, and no one came in to help R3 sit up or to help R3 eat. R3's gown was stained in the front, and R3 had whiskers on R3's chin. R3's hair was very oily and unkempt, and R3 had body odor. R3 stated the staff answer R3's call light, but it takes over 30 minutes most of the time. R3 said R3 gets a shower sometimes, but it's not always when R3 is supposed to. R3 stated R3 has a sore on the right side of R3's buttocks. R3 stated they do treatments, but doesn't remember when or how often they do them. R3 stated R3 hasn't been out of R3's bed in over a week, and R3 likes to get out of bed. On 12/13/21 at 10:15 AM, R3 was sitting up in R3's wheelchair in the dining room, and R3 had her hair washed and was wearing clean clothes. When asked if R3 had a shower this morning, R3 smiled and stated, I finally got a shower and it feels really good. At 12:05 on 12/13/21, V32 (CNA) stated V32 gave R3 a shower this morning, and R3 didn't have any excoriation, but R3 did have a pressure ulcer on R3's right buttock. 5. R4's MDS, dated [DATE], documents a BIMS score of 10, which indicates R4 has moderately impaired cognition. Section G of R4's MDS documents R4 is totally dependent on 2 persons for bed mobility, dressing, toileting, and bathing. R4 is totally dependent on 1 person for eating and personal hygiene. R4 is transferred to her wheelchair every day and is totally dependent of 2 staff for transfers. The facility's November 2021 Shower log documents R4 only had showers on the 3rd and 10th of November. On 12/3/21 at 1:30 PM, R4 was up in R4's wheelchair, still in a hospital gown. R4's hair was unkempt. R4 stated R4 just got back from the hospital, and R4 still doesn't feel well. R4 stated the facility doesn't have enough staff to help them get showers. R4 stated R4 doesn't always get a shower when R4 is supposed to, and not getting a shower makes R4 feel uncomfortable because R4 doesn't want to smell bad. R4 stated R4 rarely gets ice water, then R4 said they have to ask for it. R4 stated the staff are always working hard to take care of the residents, but they just don't have enough help. 6. R5's MDS, dated [DATE], documents under Section C that R5 has a BIMS score of 13 indicating R5 is cognitively intact, but has some forgetfulness. Section G of R5's MDS documents R5 is extensive assist of 2 for bed mobility and transferring. R5 is extensive assist of 1 for dressing. R5 is totally dependent of 2 persons for toileting, and only needs minimal assist of 1 person for locomotion on and off unit when up to R5's wheelchair. The facility's November 2021 Shower log documents R5 only had showers on November 2nd, 10th, 13th, 15th and 29th. On 11/29/21 at 2:00 PM, R5 stated, (V4 ) (Licensed Practical Nurse) puts my morning and noon meds together. I have high anxiety and I need that pill when I'm supposed to get it. R5 stated the facility does not have enough staff. If they would treat people right they would stay. R5 said, They make the laundry girl do all kinds of things they should have other staff doing. R5 stated, It's bad, it's really bad. Yesterday my bowels moved at noon, but there was nobody to help me, because the people here were busy passing trays. R5 said it was 4 hours before there was someone to assist R5 to get cleaned up, and R5 sat in a soiled incontinence brief all that time. R5 said, Now I have a sore there on my bottom. R5 said the staff know about it, and are treating R5's bottom. R5 said it doesn't happen every day, but it has happened 3 or 4 times. R5 said it usually takes them an hour to assist her. R5 said They just can't do it all. R5 said, It was difficult to get my showers done like they were supposed to be doing, and that really bothered me. On 12/2/21 at 10:30 AM, R5's call light was on for 25 minutes before it was answered. On 12/3/21 at 10:45 AM, R5 was up in R5's wheelchair, and had a sweatshirt on that had food spilled on the front. R5's shirt wasn't changed at 3:00 PM. R5 stated they are very short-staffed and they don't answer the call lights timely. R5 said, Sometimes people have to wait over an hour before someone gets to their light. R5 stated because there isn't enough help they get their meals late, and the food is cold. R5 also stated R6 usually has to ask for ice water. On 12/08/2021 at 1:40 PM, R5 stated R5 needed staff to assist R5 to clean up from a bowel movement, and to lay down in R5's bed from sitting up in the wheelchair. V24 (Corporate Float Pool Certified Nurse Aide/CNA) said V24 was waiting for V25 (Transportation CNA) to assist, and to obtain the mechanical sit to stand lift. V25 brought the lift to the room, and R5 said R5 did not want to use the lift, because it was easier for R5 to be transferred with the gait belt and both CNAs. On 12/08/2021 at 1:50 PM, R5 was transferred into bed, the bed was raised, and both CNAs assisted R5 to roll and to remove the soiled adult incontinence brief. R5 had a large watery BM (bowel movement) and the adult incontinent brief was fully saturated with moisture. V25 remarked R5's BMs were always like this. R5's skin was cleansed with warm washcloths and cleanser. The skin of R5's posterior upper thigh areas was reddened. There was a long, reddened area 5 - 6 inches' length, noted at R5's right inner buttock area. V25 stated V25 thought that might be a scar. R5's reddened upper thighs had multiple creases and indentation marks left from the incontinent brief. V24 stated it bothers V24 that everyone doesn't know how to properly put on R5's incontinent brief. R5 stated that R5's bottom was sore and tender. 7. R6's MDS, dated [DATE], documents in Section C that R6 has a BIMS score of 7, indicating R6 has some issues with memory and recall, but is alert and oriented and can communicate R6's needs. Section G of R6's MDS documents R6 is limited assistance of 1 for bed mobility and transfers, and R6 is extensive assistance with dressing, toileting, personal hygiene and bathing. The facility's November 2021 Shower log documents R6 only had showers on November 1st, 8th, 10th, 27th. On 11/29/21 at 2:10 PM, R6 said today R6 got a shower, but R6 doesn't know what R6's shower days are, because they don't give showers on a schedule, they just do it whenever they can. R6 said it does take a long time for the call light to get answered when there aren't many staff. R6 said the longest R6 has waited to get changed after having a soiled incontinence brief is about an hour. R6 said R6 doesn't have any sores, but R6's groin is reddened and tender. R6 said staff are aware. 8. R7's MDS, dated [DATE], documents R7 has [CONDITION(S)] (Severe), Migraines, Muscle Weakness, Neuromuscular Dysfunction of Bladder, Urogenital Implants, [CONDITION(S)], History of Urinary Tract Infections, Anxiety Disorder, Chronic Pain Syndrome, Irritable Bowel Syndrome and [CONDITION(S)]. R7's MDS documents in Section C that R7 has a BIMS score of 15, indicating R7 is cognitively intact. Section G of R7's MDS documents R7 is totally dependent with bed mobility, transfers, dressing, toileting, hygiene and bathing. R7's November 2021 Weight Record documents R7's weight at 387 pounds. R7's Care Plan, dated 11/24/21, documents under Problem/Need: Resident has risk factors that require monitoring and intervention to reduce potential for self-injury; weakness and inability to bear weight, need for total assistance with transfers and refusing to attempt bearing weight, refusing assistance of 2 staff and use of the sit to stand. R7's Care Plan does not address the need for assistance with her Activities of Daily Living. R7's Physicians orders, dated 11/29/21, documents V17 (Physician) ordered [MEDICATION(S)] 100 milligrams 1 tablet by mouth x 5 days for her [CONDITION(S)]. The facility's November 2021 Shower log documents R7 only had a shower on November 2nd. On 11/30/21 at 1:00 PM, R7 was sitting in R7's wheelchair, had on a gown, and the skin on R7's legs was very dry. R7 had just had lunch. R7 stated R7 has been in R7's wheelchair 2 hours, and has had R7's call light on for over an hour. At 1:00 PM on 11/30/21, R7's call light was on, and had been on for 45 minutes before a staff member came into R7's room to ask what R7 needed. R7 stated R7 is in severe pain, and R7 got R7's morning medications late, at 9:30 AM, and that happens a lot. R7 stated R7 also has inhalers R7 needs routinely, but doesn't get them. R7 stated R7 has to have help to turn side to side, and R7 wears an incontinent brief, and there are many times R7 needs help, and there's no one to help R7, so R7 sits in urine. R7 stated R7 has to hold R7's urine for as long as possible, and R7 has a history of Urinary Tract Infections ([CONDITION(S)]), and has a [CONDITION(S)] right now. R7 also stated R7 hasn't had a shower or bath since R7's admission on 11/2/21 because they don't have enough help. R7 stated R7 worries R7 smells bad, and R7's skin will break down from not being cleaned. R7 stated R7 gets ice if R7 asks for it, but they don't pass ice. R7 also stated R7's food is usually cold when R7 gets it, because they only have one CNA, and they send R7 foods R7 can't eat. R7 stated R7 is supposed to have more protein, but R7 isn't getting it, and they send spicy foods R7 can't eat. R7 states R7 worries about not getting taken care of and R7 said it makes me so anxious. 9. R8's MDS, dated [DATE], documents R8 has a BIMS score of 15, indicating R8 is cognitively intact. R8's MDS documents in Section G, R8 is extensive assist of 2 for bed mobility, extensive assist of 1 person for dressing, toileting, and bathing. R8's MDS documents R8 doesn't get out of bed independently, and when R8 does, R8 is transferred with a mechanical lift. The facility's November 2021 Shower log documents R8 only had showers on 2nd, 8th, and 17th. On 11/30/21 at 10:05 AM, R8's call light came on, and during continuous observation, was on for over 40 minutes before it was answered. On 11/30/21 at 1:35 PM, V20 (Family) was on Face-Time with R8, and stated the facility is very dirty because there was no one cleaning rooms. V20 stated R8's room is disgusting with dirt and food spilled on the floor. V20 stated R8's floor is sticky because it never gets mopped. V20 stated V20 came in a week ago, and an olive was still on the floor when V20 came in the next week. V20 stated V20 gets upset because they don't have enough staff to take care of all the residents. V20 stated there are many times when resident call lights are on for over an hour and a half. V20 stated R8 doesn't get bathed like R8, should and it is embarrassing to R8 and it upsets R8. V20 stated when R8 has to wait so long to be put on the bed pan and R8 can't hold her urine anymore, R8 ends up urinating in her bed, which makes R8 very embarrassed, and it makes R8 more depressed. On 11/30/21 at 1:35 PM, R8 stated the facility doesn't have enough staff, and it depends on who's working as to whether they get taken care of. R8 stated R8 has to have help to stay turned onto R8's side, and even though R8 can turn on R8's side, R8 can't clean herself and R8 has to rely on the CNAs to help R8. R8 stated R8 has urinated in R8's bed because no one would answer R8's call light, and it is very embarrassing. R8 stated R8 has had R8's call light on for over an hour, and it is very frustrating no one comes to see what R8 needs. R8 stated R8 has sensitive skin and has [CONDITION(S)] that causes R8 to have a lot of pain, and it takes a while to get R8's pain medication. R8 stated R8 doesn't get up to R8's wheelchair very often because the staff don't have enough help to use the mechanical lift. R8 stated, When they use the mechanical lift, it is frightening because the staff are smaller and (R8) wonders if they are skilled enough to lift (R8) without something going wrong. R8 stated the staff are always in a hurry because they don't have enough help to take care of the residents. When asked about ice and getting water, R8 stated they don't get ice every day, but they will get it if you ask them to, but it takes forever. R8 stated R8 hasn't had a shower in a month, and R8 hasn't had a good bed bath in a long time, and R8 worries R8 has a terrible body odor, and it is very embarrassing to R8. On 12/8/21 at 9:24 AM, R8 stated R8 was extremely concerned whether the facility has enough staff to safely evacuate everyone in the case of an emergency. R8 said R8 has only seen the facility conduct 1 emergency evacuation drill during the past 2 years. R8 said Covid-19 was part of the reason because they didn't want people outside and potentially exposed. R8 said R8 knows the staffing has been very low over the past few weeks, and it is a big concern. 10. R9's MD,S dated 7/3/2,1 documents R9 has a BIMS score of 15, indicating R9 is cognitively intact. R9's MDS in Section G documents R9 is limited assist of 1 for bed mobility, extensive assist of 1 for dressing, extensive assist of 1 for toileting and personal hygiene and extensive assist of 2 for bathing. The facility's

Based on observation, interview, and record review, the facility failed to provide necessary services to maintain cleanliness, personal hygiene, and toileting for 11 of 16 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R11, R15) reviewed for activities of daily living in the sample of 25. These failures resulted in R1, R2, R4, R5, R7, R8 and R9 experiencing feelings of discomfort, worry, embarrassment, anxiousness, and depression. Findings include: On 11/29/21 at 1:30 PM, V36 (Ombudsman) stated V36 received calls from several residents at the facility the day after Thanksgiving, 11/26/21, that there was only one Certified Nurse Aide (CNA) and 1 nurse working. V36 stated V36 went in to meet with the residents at 1:23 PM, and when V36 got to the facility, V36 saw there was only one CNA and one nurse working. V36 stated R1, R2, R3, R4, R5, and R6 all expressed concerns there wasn't enough staff to take care of their needs. V36 stated they reported to V36 several residents were not toileted for over 8 hours, and were left in their incontinent briefs they were in the night before. All stated leaving several residents in their incontinent briefs for that long caused a terrible urine odor in the facility. V36 stated R1, R2, R3, R4, R5 and R6 all stated some residents had been left on their bedpan for over 1 hour. V36 said these residents told V36 they weren't getting their showers, and all of them stated they wanted a shower and were upset they weren't getting them. V36 said R1, R2, R3, R4, R5 and R6 all stated not being bathed caused them to feel embarrassed. V36 stated R1, R2, R3, R4, R5 and R6 stated they were very upset and worried about the facility's lack of staff and their basic needs not being taken care of. On 12/13/21 at 3:00 PM, V36 stated V36 noticed the facility had a strong urine odor when V36 came in to have the resident council meeting on 11/26/21 at 1:00 PM. V36 stated some of the residents' hair was flat in the back and messy, as though it hadn't been combed. V36 stated V36 did notice body odor on some of the residents that came to resident council meeting, and a few of the residents clothing had food stains on them. V36 stated V36 noticed some of the other residents, not in the meeting, still had on clothing protectors with food all over them. 1. R5's Minimum Data Set (MDS), dated [DATE], documents R5 has a Brief Interview of Mental Status (BIMS) score of 13, indicating R5 is cognitively intact, but has some forgetfulness. This same MDS documents R5 is extensive assist of 2 for bed mobility, transferring, is extensive assist of 1 for dressing, and is totally dependent of 2 persons for toileting. The facility's November 2021 Shower log documents R5 had showers on November 2nd, 10th, 13th, 15th and 29th On 11/29/21 at 2:00 PM, R5 stated, It's bad, it's really bad. Yesterday my bowels moved at noon, but there was nobody to help me, because the people here were busy passing trays. R5 said it was 4 hours before there was someone to assist R5 to get cleaned up, and R5 sat in a soiled incontinent brief all that time. R5 said, Now I have a sore there on my bottom. R5 said the staff know about it, and are treating R5's bottom. R5 said it doesn't happen every day, but it has happened 3 or 4 times. R5 said it usually takes them an hour to assist R5. R5 said, It was difficult to get my showers done like they were supposed to be doing, and that really bothered me. On 12/3/21 at 10:45 AM, R5 was up in R5's wheelchair with a sweatshirt on, that had food spilled on the front, and R5's shirt still wasn't changed at 3:00 PM. On 12/08/2021 at 1:40 PM, R5 stated R5 needed staff to assist R5 to clean up from a bowel movement, and to lay down in R5's bed from sitting up in the wheelchair. R5 stated R5 waited about 25 minutes before the staff came in to help R5. V24 (Corporate Float Pool Certified Nurse Aide/CNA) said V24 was waiting for V25 (Transportation CNA) to assist, and to obtain the mechanical sit to stand lift. V25 brought the lift to the room, and R5 said R5 did not want to use the lift, because it was easier for R5 to be transferred with the gait belt and both CNAs. On 12/08/2021 at 1:50 PM, R5 was transferred into bed, the bed was raised, and both CNAs assisted R5 to roll and to remove the soiled adult brief. R5 had a large watery BM (bowel movement), and the adult incontinent brief was fully saturated with moisture. V25 remarked R5's BMs were always like this. R5's skin was cleansed with warm washcloths and cleanser. 2. R8's MDS, dated [DATE], documents a BIMS score of 15, indicating R8 is cognitively intact. R8's MDS also documents R8 is extensive assist of 2 for bed mobility, and extensive assist of 1 person for dressing, toileting, and bathing. R8's MDS documents R8 doesn't get out of bed independently, but when R8 does get up, R8 is transferred with a mechanical lift. The facility's November 2021 Shower log documents R8 had showers on the 2nd, 8th, and 17th, and none after these dates in November. R8's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/30/21 at 1:35 PM, R8 was sitting up in R8's bed talking to R8's sister on R8's computer. R8's hair was piled up on top of R8's head in a messy bun, and it was oily. R8's fingernails were long and had a brown substance underneath R8's nails, and there was a noticeable odor coming from R8. R8 stated the facility doesn't have enough staff, and it depends on who's working as to whether they get taken care of. R8 stated even though R8 can turn on R8's side, R8 has to have help to stay turned onto R8's side. R8 said R8 can't clean herself, and has to rely on the CNAs to help R8. R8 stated R8 has urinated in R8's bed because no one would answer R8's call light, and it is very embarrassing. R8 stated R8 has had R8's call light on for over an hour, and it is very frustrating that no one comes to see what R8 needs. R8 stated R8 hasn't had a shower in a month, and hasn't had a good bed bath in a long time. R8 said R8 worries R8 has a terrible body odor, and it is very embarrassing to R8. On 11/30/21 at 1:35 PM, V20 (Family) was on Face-Time with R8. V20 stated R8 doesn't get bathed like R8 should, and it is embarrassing to R8 and it upsets R8. V20 stated when R8 has to wait so long to be put on the bed pan and R8 can't hold her urine anymore, R8 ends up urinating in R8's bed, which makes R8 very embarrassed, and it makes R8 more depressed. 3. R7's MDS, dated [DATE], documents R7 has a BIMS score of 15, indicating R7 is cognitively intact. R7's MDS also documents R7 is totally dependent with bed mobility, transfers, dressing, toileting, hygiene and bathing. R7's November 2021 Weight Record documents R7's weight at 387 pounds. R7's Care Plan does not address the need for assistance with her Activities of Daily Living. The facility's November 2021 Shower log documents R7 had a shower on November 2nd, and none after the 2nd. R7's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/30/21 at 1:00 PM, R7 was sitting in R7's wheelchair, had on a gown, and the skin on R7's legs was very dry. R7 stated R7 has to have help to turn side to side, R7 wears an incontinent brief, and there are many times R7 needs help, but there's no one to help R7, so R7 sits in urine. R7 also stated R7 hasn't had a shower or bath since R7's admission on 11/2/21, because they don't have enough help. R7 stated R7 worries R7 smells bad and R7's skin will break down from not being cleaned. R7 states R7 worries about not getting taken care of and she said it makes me so anxious. 4. R1's Quarterly MDS, dated [DATE], documents a BIMS score of 11, which indicates R1 is moderately cognitively intact. R1's MDS also documents under Functional Status R1 requires extensive one person assist for dressing, bathing and personal hygiene. R1 is totally dependent on one person for toileting. The facility's November 2021 shower log documents R1 had 2 showers on November 4th and 29th. On 11/29/21 at 2:00 PM, R1 was sitting up in R1's wheelchair in R1's room. R1 was awake, alert, oriented to person, place and time. R1 said it can take a long time to get assistance when there are not many staff working. R1 said R1 needs help to go to the bathroom, and cannot always wait until someone can assist him. On 12/1/21 at 9:42 AM, R1 was seated in R1's wheelchair at the door to R1's room, with the call light above the door illuminated, and the call light beeping. R1 stated, Oh boy, my pants are wet. R1 was asked by surveyor if R1 was okay, and R1 replied, I got a problem, I'm wet. R1 was upset R1 was wet. R1 said R1 had R1's call light on for about 30 minutes, but Couldn't make it. At 9:44 AM, a non-nursing staff said to R1, Ok, they're coming. It will be one second. I'll go get a CNA. R1 responded, Okay. At 9:45 AM, a staff handed R1 an adult incontinent brief. R1 self-propelled R1's wheelchair to the bathroom entrance. At 9:49 AM, V13 (CNA) arrived to assist R1 to change R1's pants and get cleaned up. 5. R2's MDS, dated [DATE], documents a BIMS score of 12, indicating R2 is cognitively intact with some forgetfulness. R2's MDS also documents R2 requires limited assist of one for bed mobility, transfers, walking in her room, dressing, toileting, personal hygiene and bathing. The facility's shower log for November 2021 documents R2 had showers on the 2nd, 10th, 11th, 15th and 27th of November. R2's MAR, dated 12/2021, documents R2 takes [MEDICATION(S)] 0.5 milligrams , twice daily for anxiety, and [MEDICATION(S)] 15 mg 1 at night for depression. On 11/30/21 at 10:35 AM, R2 stated the facility doesn't have enough help, and the call lights don't get answered timely. R2 stated they do help R2 with R2's shower when they have time to give it to R2. R2 stated R2 likes to be clean and when R2's not, R2 worries R2 smells bad. R2 stated R2 can clean herself some, but that's not as good as a shower. 6. The facility's November 2021 Shower log documents R3 hadn't had a shower since 11/15/21. R3's MDS, dated [DATE], documents R3 has a BIMS score of 12, indicating R3 has some forgetfulness, but is alert and can recall information. R3's MDS also documents R3 is totally dependent, and requires 2 assist for bed mobility, transfers, dressing, and toileting, and is totally dependent with 1 assist for locomotion on and off the unit, and for personal hygiene and bathing. R3 requires limited assistance of 1 person with eating. On 12/2/21 at 11:45 AM, R3 was lying far over to the left side of R3's bed, and was lying back very far and R3's bed was not positioned correctly for R3 to eat R3's meal. R3's meal tray was in front of R3 on the bedside table, but there was no way R3 could comfortably feed herself. R3 stated R3 wasn't able to eat because of the position R3 was in. R3's gown was stained in the front, R3 had whiskers on R3's chin, R3's hair was very oily and unkempt, and R3 had body odor. R3 stated the staff answer R3's call light, but it takes sometimes over an hour. R3 said R3 gets a shower sometimes, but it's not always when R3 is supposed to, and R3 doesn't remember what day R3 last had a shower. R3 stated R3 hasn't been out of R3's bed for over a week. On 12/13/21 at 10:15 AM, R3 was sitting up in R3's wheelchair in the dining room, and R3 had R3's hair washed, and was wearing clean clothes. When asked if R3 had a shower this morning, R3 smiled and stated, I finally got a shower, and it feels really good. At 12:05 on 12/13/21, V32 (CNA) stated V32 gave R3 a shower this morning. 7. R4's MDS, dated [DATE], documents a BIMS score of 10, which indicates R4 has moderate cognitive impairment. R4's MDS also documents R4 is totally dependent on 2 persons for bed mobility, dressing, toileting, and bathing, is totally dependent of 1 person for eating and personal hygiene, is up to R4's wheelchair, and is totally dependent of 2 for transfers. The facility's November 2021 Shower log documents R4 had a shower on the 3rd and 10th of November. On 12/3/21 at 1:30 PM, R4 was up in R4's wheelchair, still in a hospital gown. R4's hair was unkempt. R4 stated R4 just got back from the hospital, and R4 still doesn't feel well. R4 stated the facility doesn't have enough staff to help them get showers. R4 stated R4 doesn't always get a shower when R4 is supposed to, and not getting a shower makes R4 feel uncomfortable because R4 doesn't want to smell bad. 8. R9's MDS, dated [DATE], documents a BIMS score of 15, indicating R9 is cognitively intact. R9's MDS also documents R9 is limited assist of 1 for bed mobility, extensive assist of 1 for dressing, extensive assist of 1 for toileting and personal hygiene, and extensive assist of 2 for bathing. The facility's November Shower log documents R9 had a shower on November 2nd. On 11/30/21 at 11:20 AM, R9 was lying in R9's bed with the head of the bed down. R9 was wearing a gown with food particles on the front, R9's hair was oily and unkempt, and R9's fingernails were long with a brown substance beneath them. R9 also had a noticeable body odor. R9 stated it takes 2 staff to get R9 on the mechanical lift, and they don't have enough staff to do the transfers, so R9 just stays in R9's bed. R9 stated they don't get showers or bed baths, and R9 doesn't remember the last time R9 had a shower. R9 stated R9 has had accidents even though she wears an incontinent brief, and even with a brief on, R9 is left wet a long time. R9 stated R9 gets depressed when no one comes to help R9 get cleaned up. 9. R11's MDS, dated [DATE], documents a BIMS score of 14, indicating R11 is cognitively intact. R11's MDS also R11 is totally dependent, and requires assistance of 2 persons with bed mobility, transferring, dressing, toileting, personal hygiene, and is totally dependent and needs 1 assist for bathing. The facility's November 2021 Shower log documents R11 had showers on November 2nd, 9th and 17th and none after these dates. On 11/29/21 at 12:40 PM, R11 was in R11's wheelchair, and had just had lunch. R11 stated R11 can't stand for very long, and they use the mechanical lift on R11 to get R11 into R11's wheelchair. R11 stated R11 can't turn himself in bed because R11 can't use R11's left arm. R11 stated it takes 30 minutes or more to get R11's call light answered because they don't have enough help. R11 stated when R11 wets on himself, it takes an hour sometimes to get cleaned up because they don't have enough CNAs. On 12/8/21 at 9:07 AM, R11 said it takes 2 staff to assist R11 with transfers in and out of bed. R11 stated it is not unusual to have to wait an hour or more for 2 available staff. 10. R6's MDS, dated [DATE], documents R6 has a BIMS score of 7, indicating R6 has some issues with memory and recall, but is alert and oriented, and can communicate R6's needs. R6's MDS also documents T6 is limited assistance of 1 for bed mobility and transfers, and R6 is extensive assistance with dressing, toileting, personal hygiene, and bathing. The facility's November 2021 Shower log documents R6 had showers on November 1st, 8th, 10th, 27th. On 11/29/21 at 2:10 PM, R6 said today R6 got a shower, but R6 doesn't know what R6's shower days are, because they don't give showers on a schedule, they just do it whenever they can. R6 said it does take a long time for the call light to get answered when there aren't many staff. R6 said the longest R6 has waited to get changed after having a soiled incontinent brief is about an hour. R6 said R6 doesn't have any sores, but R6's groin is reddened and tender. R6 said staff are aware. 11. R15's MDS, dated [DATE], documents a BIMS score of 12, indicating R15 is cognitively intact with some forgetfulness. R15's MDS also documents R15 requires supervision with set up help for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toileting, personal hygiene and bathing. On 12/09/2021 at 9:00 AM, V27 (Family) stated her 97-year- old family member has been at the facility for a long time, and has recently become more dependent after a couple strokes. V27 said R15 often must wait for staff to be available for assistance with toileting. V27 said R15 has to wait sometimes for more than an hour, but does not want to complain. V27 said R15 tells her, I've been through a lot worse in my lifetime. V27 stated V27 lives close by, and stops by the facility at least 3 times weekly. V27 said R15 has [NAME] of R15's skin, and sitting in wet adult briefs for long periods of time has made it worse. V27 said the facility has been short of staff and showers were not getting done. V27 said R15 has scheduled shower days for Wednesdays and Fridays. V27 stated, I usually have to tell them that she is supposed to have her shower. V27 said staff often ask R15 to take R15's shower after 9:00 PM. V27 said V27 does not know of any [AGE] year-old that wants to take their shower at 9:00 PM. On 11/30/21 at 11:25 AM, V12 (CNA) stated V12 and one nurse worked last Friday, 11/26/21, and V12 is the corporate float and doesn't work at this facility all the time. V12 stated V12 got as many residents changed, toileted, and up as V12 could, but no showers or bed baths were given. V12 stated the residents are supposed to have 2 showers per week normally. V12 stated the meal trays were very late on 11/26/21 but V12 couldn't go any faster, because other residents needed care. V12 stated V12 could do only what V12 could do, because the nurse was trying to get the medications passed and he tried to help, but then his medication pass was late. V12 stated V12 can't physically turn R7, R8, R9, R10, or R11 by herself, and because she can't turn them, V12 can't put them on the bedpan or clean them up if they are incontinent. On 12/02/21 at 1:30 PM, V5 (CNA) states one CNA can't do everything, and one nurse can't do their job either with the staff being short. V5 states V5 worries the residents aren't being taken care of right and they deserve better. V5 states the residents are supposed to get 2 showers every week, and there's no way to do that because there are at least 4-5 residents to shower every day. V5 states they don't get to a lot of their work, like passing ice and straightening the rooms, or cleaning up residents that are incontinent, but they try really hard to take care of them. The facility's policy on Bath/Shower, dated 1/2018, documents under Policy: To ensure adequate hygiene needs are met, a bath/shower is scheduled for all residents in facility at least weekly. The facility's policy on A.M. (morning) Care, dated 1/2018, documents under Policy: A.M. Care will be given to all residents daily. Under procedure for A.M. Care: #6. Give oral hygiene per resident's ability for self-care. #7. Allow resident to wash, rinse, dry if able. #8. Wash, rinse, dry underarms (also under female breasts). #9. Wash perineal and rectal areas with soap. Rinse and dry. #10. Dress or assist resident to dress in clean, comfortable clothing, including shoes, stockings, and underwear. #11. Provide nail care. #12. Provide/assist with shaving (male/female) as needed.

Based on observation, interview, and record review, the facility failed to maintain resident dignity for 12 of 16 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R11, R13, and R16) reviewed for resident care in the sample of 25. These failures resulted in feelings of worry, depression, anxiousness, embarrassment, and being uncomfortable for R1, R2, R4, R5, R7, R8 and R9. Findings include: On 11/29/21 at 1:30 PM, V36 (Ombudsman) stated V36 received calls from several residents at the facility the day after Thanksgiving, 11/26/21, that there was only one Certified Nurse Aide (CNA) and 1 nurse working. V36 stated V36 went in to meet with the residents at 1:23 PM, and when V36 got to the facility, V36 saw there was only one CNA and one nurse working. V36 stated R1, R2, R3, R4, R5, and R6 all expressed concerns there wasn't enough staff to take care of their needs. V36 said these residents told V36 they weren't getting their showers, and all of them stated they wanted a shower and were upset they weren't getting them. V36 stated R1, R2, R3, R4, R5, and R6 all said not being bathed caused them to feel embarrassed. On 12/13/21 at 3:00 PM, V36 stated when V36 came to the facility on [DATE] to meet with the residents, some of the residents' hair was flat in the back and messy, as though it hadn't been combed. V36 stated V36 did notice body odor on some of the residents that came to resident council meeting, and a few of the residents' clothing had food stains on them. V36 stated V36 noticed some of the other residents, not in the meeting, still had on clothing protectors with food all over them. 1. R5's Minimum Data Set, dated dated [DATE], documents R5 has a Brief Interview for Mental Status (BIMS) score of 13, indicating R5 is cognitively intact, but has some forgetfulness. This same MDS documents R5 is extensive assist of 2 for bed mobility and transferring. R5 is extensive assist of 1 for dressing. R5 is totally dependent of 2 persons for toileting. The facility's November 2021 Shower log documents R5 had showers on November 2nd, 10th, 13th, 15th and 29th. On 11/29/21 at 2:00 PM, R5 stated, It's bad, it's really bad. Yesterday my bowels moved at noon, but there was nobody to help me, because the people here were busy passing trays. R5 said it was 4 hours before there was someone to assist R5 to get cleaned up, and R5 sat in a soiled incontinent brief all that time. R5 said, Now I have a sore there on my bottom. R5 said the staff know about it and are treating R5's bottom. R5 said it usually takes them an hour to assist R5. R5 said, It was difficult to get my showers done like they were supposed to be doing, and that really bothered me. On 12/2/21 at 10:30 AM, R5's call light was on for 25 minutes before it was answered. On 12/3/21 at 10:45 AM, R5 was up in R5's wheelchair and had a sweatshirt that had food spilled on the front, and at 3:00 PM, R5's shirt had not been changed. On 12/08/2021 at 1:40 PM, R5 stated R5 needed staff to assist R5 to clean up from a bowel movement, and to lay down in R5's bed from sitting up in the wheelchair. R5 stated R5 waited about 25 minutes before the staff came in to help R5. V24 (Corporate Float Pool CNA) said V24 was waiting for V25 (Transportation CNA) to assist, and to obtain the mechanical sit to stand lift. V25 brought the lift to the room, and R5 said R5 did not want to use the lift, because it was easier for R5 to be transferred with the gait belt and both CNAs. On 12/08/2021 at 1:50 PM, R5 was transferred into bed, the bed was raised, and both CNAs assisted R5 to roll and to remove the soiled adult incontinent brief. R5 had a large watery BM (bowel movement), and the adult incontinent brief was fully saturated with moisture. V25 remarked that R5's BMs were always like this. 2. R8's MDS, dated [DATE], documents R8 has a BIMS score of 15, indicating R8 is cognitively intact. This same MDS documents R8 is extensive assist of 2 for bed mobility, and extensive assist of 1 person for dressing, toileting, and bathing. R8's MDS documents R8 doesn't get out of bed independently, and when R8 does, R8 is transferred with a mechanical lift. The facility's November 2021 Shower log documents R8 had showers on 2nd, 8th, and 17th, and none after these dates in November. On 11/30/21 at 10:05 AM, R8's call light came on, and during continuous oberservation, was on for over 40 minutes before it was answered. On 11/30/21 at 1:35 PM, R8 was sitting up in R8's bed talking to R8's sister on R8's computer. R8's hair was piled up on top of R8's head in a messy bun, and it was oily. R8's fingernails were long and had a brown substance underneath R8's nails, and there was a noticeable odor coming from R8. R8 stated the facility doesn't have enough staff, and it depends on who's working as to whether they get taken care of. R8 stated R8 has to have help to stay turned onto R8's side, even though R8 can turn on R8's side, R8 can't clean herself and R8 has to rely on the CNAs to help R8. R8 stated R8 has urinated in R8's bed because no one would answer R8's call light, and it is very embarrassing. R8 stated R8 has had R8's call light on for over an hour, and it is very frustrating that no one comes to see what R8 needs. R8 stated R8 hasn't had a shower in a month, and hasn't had a good bed bath in a long time. R8 said she worries R8 has a terrible body odor, and it is very embarrassing to R8. On 11/30/21 at 1:35 PM, V20 (Family) was on Face-Time with R8. V20 stated R8 doesn't get bathed like R8 should, and it is embarrassing to R8 and it upsets R8. V20 stated when R8 has to wait so long to be put on the bed pan and R8 can't hold R8's urine anymore, R8 ends up urinating in her bed, which makes R8 very embarrassed, and it makes R8 more depressed. 3. R7's MDS, dated [DATE], documents a BIMS score of 15, indicating R7 is cognitively intact. This same MDS documents R7 is totally dependent with bed mobility, transfers, dressing, toileting, hygiene and bathing. R7's November 2021 Weight Record documents R7's weight at 387 pounds. R7's Care Plan does not address the need for assistance with her Activities of Daily Living. The facility's November 2021 Shower log documents R7 had a shower on November 2nd and none after the 2nd. On 11/30/21 at 1:00 PM, R7 was sitting in R7's wheelchair, had on a gown, and the skin on R7's legs was very dry. R7 stated R7 has to have help to turn side to R7's side, and R7 wears an incontinent brief, and there are many times R7 needs help and there's no one to help R7, so R7 sits in urine. R7 also stated R7 hasn't had a shower or bath since R7's admission on 11/2/21, because they don't have enough help. R7 stated R7 worries R7 smells bad, and R7's skin will break down from not being cleaned. R7 states R7 worries about not getting taken care of, and R7 said it makes me so anxious. At 1:00 PM on 11/30/21, R7's call light was on, and had been on for 45 minutes. 4. R1's Quarterly MDS, dated [DATE], documents a BIMS score of 11, which indicates R1 is moderately cognitively intact. This same MDS under Functional Status, documents R1 requires 1 person assist for dressing, bathing and personal hygiene, and is totally dependent on one person for toileting. The facility's November 2021 shower log documents R1 had 2 showers on November 4th and 29th. On 11/29/21 at 2:00 PM, R1 was sitting up in R1's wheelchair in R1's room. R1 was awake, alert, oriented to person, place and time. R1 said it can take a long time to get assistance when there are not many staff working. R1 said R1 needs help to go to the bathroom, and cannot always wait until someone can assist R1. On 12/1/21 at 9:42 AM, R1 was seated in R1's wheelchair at the door to R1's room, with the call light above the door illuminated and the call light beeping. R1 stated Oh boy, my pants are wet. R1 was asked by surveyor if R1 was okay, and R1 replied, I got a problem, I'm wet. R1 was upset R1 was wet. R1 said R1 had his call light on for about 30 minutes, but Couldn't make it. At 9:44 AM, a non-nursing staff said to R1, Ok, they're coming. It will be one second. I'll go get a CNA. R1 responded, Okay. At 9:45 AM, a staff handed R1 an adult incontinent brief. R1 self-propelled R1's wheelchair to the bathroom entrance. At 9:49 AM, V13 (CNA) arrived to assist R1 to change R1's pants and get cleaned up. 5. R2's MDS, dated [DATE], documents a BIMS of 12, indicating R2 is cognitively intact with some forgetfulness. This same MDS documents R2 requires limited assist of 1 for dressing, toileting, personal hygiene and bathing. The facility's shower log for November 2021 documents R2 had showers on the 2nd, 10th, 11th, 15th and 27th of November. On 11/30/21 at 10:35 AM, R2 stated they do help R2 with R2's shower when they have time to give it to her. R2 stated R2 likes to be clean and when R2's not, R2 is very uncomfortable and worries R2 smells bad. R2 stated R2 could wash herself some, but it's not like getting a shower. 6. The facility's November 2021 Shower log documents R3 hasn't had a shower since 11/15/21. R3's MDS, dated [DATE], documents a BIMS score of 12, indicating R3 has some forgetfulness, but is alert and can recall information. R3's MDS also documents R3 is totally dependent, and requires 2 persons for toileting and totally dependent of 1 assist for personal hygiene and bathing. On 12/2/21 at 11:45 AM, R3's gown was stained in the front, R3 had whiskers on R3's chin, R3's hair was very oily and unkempt, and R3 had body odor. R3 stated the staff answer R3's call light, but it takes sometimes over an hour. R3 said R3 gets a shower sometimes, but it's not always when R3 is supposed to, and R3 doesn't remember what day R3 had a shower. R3 stated R3 hasn't been out of R3's bed for over a week. On 12/13/21 at 10:15 AM, R3 was sitting up in R3's wheelchair in the dining room, and R3 had R3's hair washed and was wearing clean clothes. When asked if R3 had a shower this morning, R3 smiled and stated, I finally got a shower and it feels really good. 7. R4's MDS, dated [DATE], documents a BIMS score of 10, indicating R4 has moderately impaired cognition. R4's MDS also documents R4 is totally dependent on 2 persons for bed mobility, dressing, toileting, and bathing. R4 is totally dependent of 1 person for personal hygiene. The facility's November 2021 Shower log documents R4 had a shower on the 3rd and 10th of November, and none after that. On 12/3/21 at 1:30 PM, R4 was up in R4's wheelchair, still in a hospital gown. R4's hair was unkempt. R4 stated R4 just got back from the hospital, and R4 still doesn't feel well. R4 stated the facility doesn't have enough staff to help them get showers. R4 stated R4 doesn't always get a shower when R4 is supposed to, and not getting a shower makes R4 feel uncomfortable because R4 doesn't want to smell bad. 8. R9's MDS, dated [DATE], documents a BIMS score of 15, indicating R9 is cognitively intact. R9's MDS also documents R9 is limited assist of 1 for bed mobility, extensive assist of 1 for dressing, extensive assist of 1 for toileting and personal hygiene, and extensive assist of 2 for bathing. The facility's November Shower log documents R9 had a shower on November 2nd. On 11/30/21 at 11:20 AM, R9 was lying in R9's bed with the head of the bed down. R9 was wearing a gown with food particles on the front, R9's hair was oily and unkempt, and R9's fingernails were long and had a brown substance beneath them. R9 also had a noticeable body odor. R9 stated it takes 2 staff to get R9 on the mechanical lift, and they don't have enough staff to do the transfers, so R9 just stays in R9's bed. R9 stated they don't get showers or bed baths, and R9 doesn't remember the last time R9 had a shower. R9 stated R9 has had accidents, even though she wears an incontinent brief, and even with a brief on, R9 is left wet a long time. R9 stated R9 gets depressed when no one comes to help R9 get cleaned up. 9. R6's MDS, dated [DATE], documents a BIMS score of 7, indicating R6 has some issues with memory and recall, but is alert and oriented and can communicate R6's needs. R6's MDS also documents R6 is limited assistance of 1 for bed mobility and transfers, and R6 is extensive assistance with dressing, toileting, personal hygiene and bathing. The facility's November 2021 Shower log documents R6 had showers on November 1st, 8th, 10th, 27th. On 11/29/21 at 2:10 PM, R6 said today R6 got a shower, but R6 doesn't know what her shower days are because they don't give showers on a schedule, they just do it whenever they can. R6 said it does take a long time for the call light to get answered when there aren't many staff. R6 said the longest R6 has waited to get changed after having a soiled incontinent brief is about an hour. R6 said R6 doesn't have any sores, but R6's groin is reddened and tender. R6 said staff are aware. 10. R11's MDS, dated [DATE], documents a BIMS score of 14, indicating R11 is cognitively intact. R11's MDS also documents R11 is totally dependent and requires assistance of 2 persons with bed mobility, transferring, dressing, toileting, personal hygiene, and is totally dependent and requires assistance of 1 person with bathing. The facility's November 2021 Shower log documents R11 had showers on November 2nd, 9th, and 17th, and none after these dates. On 11/29/21 at 12:40 PM, R11 was in R11's wheelchair, and had just had lunch. R11 stated R11 can't stand for very long, and they use the mechanical lift on R11 to get R11 into R11's wheelchair. R11 stated R11 can't turn himself in bed because R11 can't use R11's left arm. R11 stated it takes 30 minutes or more to get R11's call light answered because they don't have enough help. R11 stated when R11 wets on himself, it takes an hour sometimes to get cleaned up, because they don't have enough CNAs. R11 said it takes 2 staff to assist R11 with transfers in and out of bed. R11 stated it is not unusual to have to wait an hour or more for 2 available staff. 11. On 11/30/21 at 1:20 PM, R13's call light was on, and R13 was on the bed pan. R13's call light was on for 25 minutes, and no one went to answer R13's call light. At 1:45 PM, V9 (Licensed Practical Nurse, LPN) went into R13's room, turned off R13's light, and V9 stated R13 wasn't done using the bed pan. R13 turned R13's call light back on immediately after V9 left R13's room. This surveyor went in to see what R13 wanted, and R13 stated R13 wanted off of the bed pan, R13 was done. R13's call light was on for 20 more minutes until R13 was taken off of the bedpan. 12. On 12/1/21, R16's call light came on at 1:30 PM, and during continuous observation, was on until 2:30 PM, when a staff person finally entered R16's room to answer the call light and assist R16. On 11/30/21 at 11:25 AM, V12 (CNA) stated V12 and one nurse worked last Friday, 11/26/21, and V12 is the corporate float, and doesn't work at this facility all the time. V12 stated V12 got as many residents changed, toileted, and up as she could, but no showers or bed baths were given. V12 stated, The residents are supposed to have 2 showers per week, normally. V12 stated the meal trays were very late on 11/26/21, but V12 couldn't go any faster because other residents needed care. V12 stated V12 could do only what V12 could do, because the nurse was trying to get the medications passed and he tried to help, but then his medication pass was late. V12 stated V12 can't physically turn R7, R8, R9, R10, or R11 by herself, and because V12 can't turn them, V12 can't put them on the bedpan or clean them up if they are incontinent. On 12/01/21 at 10:35 AM, V13 (CNA) stated V13 came in to help, but works in a sister facility. V13 stated, This facility always has problems with staffing because the resident care is heavy. V13 stated the residents are supposed to have 2 showers per week, but the residents aren't getting them as scheduled. On 12/02/21 at 1:30 PM, V5 (CNA) states one CNA can't do everything, and one nurse can't do their job either with the staff being short. V5 states V5 worries the residents aren't being taken care of right, and they deserve better. V5 states the residents are supposed to get 2 showers every week, and there's no way to do that, because there are at least 4-5 residents to shower every day. V5 states they don't get to a lot of their work, like passing ice and straightening the rooms, or cleaning up residents that are incontinent, but they try really hard to take care of them. The facility's policy on Bath/Shower, dated 1/2018, documents under Policy: To ensure adequate hygiene needs are met, a bath/shower is scheduled for all residents in facility at least weekly. The facility's policy on A.M. Care, dated 1/2018, documents under Policy: A.M. Care will be given to all residents daily. Under procedure for A.M. Care: #6. Give oral hygiene per resident's ability for self-care. #7. Allow resident to wash, rinse, and dry if able. #8. Wash, rinse, dry underarms (also under female breasts). #9. Wash perineal and rectal areas with soap. Rinse and dry. #10. Dress or assist resident to dress in clean, comfortable clothing, including shoes, stockings, and underwear. #11. Provide nail care. #12. Provide/assist with shaving (male/female) as needed.

Based on observation, interview, and record review, the facility failed to develop and implement a plan of care for monitoring [MEDICATION(S)] ([MEDICATION(S)]) therapy, failed to follow physicians' orders to obtain repeat labs on 2/19/21 after receiving elevated PT/INR (pro time)/(international rate) levels, and/or failed to notify the physician of PT/INR results to obtain further orders for monitoring for 4 (R1, R5, R14, R15) of 4 residents reviewed for monitoring in regard to the use of blood thinning medications in a sample of 41. This failure has the potential to cause serious physical harm (uncontrolled bleeding), and the possibility of death for R1, R5, R14 and R15, all who receive blood thinning medication. These failures resulted in an Immediate Jeopardy which was identified to have began on 2/19/21 when the facility failed to obtain a follow-up lab for R1, that was ordered due to a high PT/INR that had been obtained on 2/04/21. On 3/11/21, it was discovered that R1 experienced a 2-hour nose bleed through the night that was difficult to stop, which was not immediately reported to the physician. These failures have the potential to affect all 4 residents (R1, R5, R14, R15) residing in the facility, who receive blood thinning medication. V1 (Administrator) was notified of the Immediate Jeopardy on 3/17/21 at 2:10 PM. The surveyors confirmed through observations, record review, and interview, that the Immediate Jeopardy was removed on 3/18/21, the facility remains out of compliance at a severity Level Two as the facility evaluates the implementation and effectiveness of their interventions put in place with their removal plan. The Findings Include: 1. R1's Profile Face Sheet documents that R1 readmitted to this facility most recently on 4/01/20, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's February 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan did not contain any documentation regarding the drug [MEDICATION(S)] (Anti Coagulant therapy), how to monitor this drug for potential side effects, or have any interventions in place. On 3/12/21 at 4:05 PM, V1 (Administrator) verified that R1's care plan does not contain any documentation regarding [MEDICATION(S)], how to monitor for side effects, or any interventions that may be necessary. R1's lab result dated, 2/04/21, documents a PT (pro time) level at 19.3 (normal range - 9.6 - 12.2) and INR (international rate) level at 1.8 (normal range - 0.9 - 1.1). Handwritten orders on this form indicated R1's PT/INR lab was to be repeated on 2/19/21 to re-check these elevated levels. R1's record did not have any PT/INR results for 2/19/21. On 3/11/21 at 9:18 AM, R1 is alert and oriented. R1's room has a blood-soaked hand towel on the floor next to his bed. When asked, R1 stated this is where he puts things that need to go to laundry. R1 continued to state he had a nose bleed through the night that took two hours to get stopped. R1 stated he had also blown out two large clots of blood on the bathroom floor when he was trying to get his nose to stop bleeding, which were also still present on R1's bathroom floor. R1 stated he wasn't sure what caused his nose bleed, guessed it might be dry, stating he felt fine. R1 added when V19 (CNA - Certified Nursing Assistant) came in to his room this morning, she said, Eeww, I'm not touching that, referring to the bloody towel and blood spots on the floor. R1 stated the housekeeper would take care of the dirty towel and blood when she gets to his room this morning. When asked if he had pushed his call light or called anyone to help during his nose bleed, he stated, No. It wouldn't have done any good anyway. On 3/11/21 at 11:18 AM, V2 (Resident Care Coordinator - RCC) confirmed V22 (Primary Care Physician - PCP) gave an order on 2/04/21 to repeat R1's PT/INR on 2/19/21, and this lab had documentation from three different LPNs and was still not followed up and completed. On 3/11/21 at 11:03 AM, V20 (Licensed Practical Nurse - LPN) stated she was not aware of R1's nose bleed and did not know if R1's lab was drawn on 2/19/21, but would try and find out. On 3/11/21 at 11:20 AM , V2 (Licensed Practical Nurse) stated staff were overwhelmed with changes in staffing, roles had recently changed, and this order for R1 just got missed. V2 confirmed R1's lab was not drawn on 2/19/21, and has not been drawn since. On 3/11/21 at 12:30 PM, V2 confirmed she was getting ready to call V22 back and get the order for R1. The process of the facility obtaining a STAT PT/INR lab for R1, from the time V2 was notified of the missed lab on 3/11/21 at 12:30 PM until the time the lab was drawn on 3/12/21 at 3:27 PM, took an additional 15 hours. On 3/11/21 at 11:28 PM, V18 (CNA) stated R1 does not have a history of nose bleed, but R1 did have one yesterday. V18 stated she did not notify anyone else about this. On 3/11/21 at 12:03 PM, V22 (PCP/Medical Director) stated, The facility obviously messed up by not following up on R1's PT/INR on 2/19/21 as ordered. It sounds like his nose bleed was significant, however, without a lab result to compare his levels, I cannot say whether this is a serious result at this point. His labs were trending down, but if the repeat comes back high, then we have a serious problem. I need to speak with the DON (Director of Nursing) now and order a STAT PT/INR. V22 was re interviewed on 3/16/21 at 8:00 AM, regarding the results of the PT/INR drawn on 3-12-21. V22 stated he was notified of R1's critical lab result on 3/12/21. V22 confirmed this was a serious oversight on the nursing home's part, having had the potential to be a life-threatening situation. On 3/12/21 at 11:40 AM, V26 stated she was told the lab was unable to draw blood on R1 last night (3/11/21) and this had not been done. V26 stated she re-ordered a STAT (immediately) lab (within 2 hours) at 11:30 AM. The PT/INR results dated, 3/12/2021 at 18:00, show a PT of 70.6 (Normal range 10.2-12.9 seconds) and an INR of 6.0 (Normal range 0.9-1.1) CRITICAL RESULT. Read back to V26 (LPN) at the facility on 3-12-21 at 1759. On 3/12/21 at 6:19 PM, V26 notified this surveyor of a critical lab result on R1 of INR - 6.0 and PT - 70.6. V26 stated V22 was informed and orders were given to administer Vitamin K 5mg po (by mouth), hold all [MEDICATION(S)], and repeat CBC (complete blood count), BMP (basic metabolic panel), and PT on Monday, 3/15/21. On 3/16/21 at 11:55 AM, V20 (Licensed Practical Nurse, LPN) stated she saw blood on R1's nasal cannula and the bloody towel in his room on the morning of 3/11/21 between 6:00 AM and 9:00 when she was passing medication. She stated he told her he had a nose bleed and she thought it might have been from a dry nose and oxygen and could be seasonal allergies. She confirmed she did not document this in R1's chart or call the physician regarding the nose bleed. V20 stated it did not occur to her this may be a side effect of [MEDICATION(S)]. When asked if anyone from the previous night shift had mentioned R1's nose bleed to her, she stated, Yes, V24 (LPN) saw it. On 3/17/21 at 11:18 AM, V24 (LPN) stated R1 had told her he had a nose bleed, but she did not see any blood. When asked if any other staff had mentioned this to her, she stated they might have, but she could not really remember. 2. On 3/17/21, R14's record was reviewed. R14's Profile Face Sheet documents an admission to this facility on 8/18/18. R14's March 2021 POS documents the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's March 2021 POS documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ½ tablet by mouth once a day for a total of 3.5 mg daily. R14's care plan was not in the care plan binder, was unable to be located, and at 4:05 PM on 3-12-21, V1 (Administrator) stated R14 did not have a care plan. R14 did not have any monitoring in place in regard to anticoagulant therapy. R14's most recent lab result, dated 3/03/21, documents an elevated PT/INR result of - PT - 20.8 (H) (normal range - 9.6 - 12.2 seconds) and INR - 1.9 (H) (normal range - 09.1 - 1.1). This lab report indicates the facility received these results via fax on 3/03/21 at 2:03 PM. There is no documentation in R14's record indicating V22 (PCP) was notified of the elevated lab values. The facility schedule documents V20 and V26 were working on 3/03/21 from 6:00 AM to 6:00 PM. On 3/17/21 at 12:07 PM, V20 (LPN) stated she did not notify V22 of R14's elevated lab work. V26 has not returned this surveyor's call at this time. On 3/17/21 at 12:15 PM, V22 stated he would expect the facility to notify him of any abnormal labs they receive. V22 stated for R14 he would have instructed the facility to continue with the current treatment and dose of [MEDICATION(S)] and repeat PT/INR in 1-2 weeks. 3. R5's Face sheet documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Physician Telephone Orders, dated on 1/19/2021, documents, Continue same dose of [MEDICATION(S)] and recheck [MEDICATION(S)] in 2 weeks. On 3/17/2021 At 10:00 AM, V1 and V4 were unable to find the 2/2/2021 follow up lab result in R5's chart, and finally called the reference lab to obtain a copy. R5's chart did not reference if the lab was done or if the physician was notified of the results. R5 has no current order for PT/INR follow up. Once this 2/2/21 lab report was obtained the resuts are as follows: PT 26.8 (H) (Normal range 9.6-12.2) INR 2.6 (H) (Normal Range 0.9-1.1.) R5's Quarterly Minimum Data Set, dated dated [DATE], documents his Brief Interview for Mental Status (BIMS) of 14, indicating cognitively intact. R5's Care Plan, last entry dated 9/3/2020, does not reference any monitoring in regard to anticoagulant therapy. On 3/17/2021 at 11:15 AM, R5 stated, I don't know if I take a blood thinner or not. Yes, they were checking my blood weekly for a while but it has been like 3 to 4 weeks since they checked it last. No, I don't have any abnormal bleeding or bruising. On 3/17/2021 at 12:10 PM, V4, The lab has been a problem since we switched. If the lab was not in the chart, we probably didn't get it called to the doctor. (V2) tracks the residents on [MEDICATION(S)] and she is not here. We don't have a standing order for PT/INR here, we call the doctor each time to get the orders. I don't see anything in the nurse's notes, or physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/17/2021 at 12:24 PM, V22 stated, The facility is having issues with the lab they use. I should have been notified. If I was notified, they should have made an entry in the resident's record documenting the date and time and reported the results. After reading the results of R5's 2/02/21 lab to V22, V22 further stated even though he would consider R5's INR to be within his desired therapeutic range, he should have been notified and would give the order to adjust or maintain the same [MEDICATION(S)] dose, and repeat the PT and INR in week. 4. R15's Profile Face Sheet documents re-admission to this facility on 3/27/18. R15's March 2021 POS documents the following in part - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An updated order dated 2/05/21 to include [MEDICATION(S)] 6 mg 1 tablet po daily. R15's care plan, dated 4/01/17 does not contain any documentation regarding [MEDICATION(S)], how to monitor for side effects, or any interventions that may be necessary. On 3/9/2021 at 2:45 PM, V2 (Acting Director of Nursing - DON/RCC - Resident Care Coordinator) stated, We don't have updated care plans and MDS's right now because the MDS nurse quit in November. Corporate is doing them now. A facility policy titled, Laboratory Tests, dated revised 1/16/17, documents the following in part - Policy: Appropriate laboratory monitoring of disease processes and medications requires consideration of many factors including concomitant disease(s) and medication(s), wishes of the resident and family and current standards of practice. Responsibility: .Licensed nursing personnel .Procedure: 1) Laboratory testing will be completed in collaboration with Medicare guidelines, pharmacy recommendations and physician orders. 2) Obtain laboratory orders upon admission, readmission and PRN for medication and condition monitoring per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The drugs.com website documents the following regarding the drug [MEDICATION(S)] ([MEDICATION(S)]) - .Warning: Oral route (tablet) - [MEDICATION(S)] can cause major or fatal bleeding. Regular monitoring of INR should be performed on all treated patients. Drugs, dietary changes, and other factors affect INR levels achieved with [MEDICATION(S)] sodium therapy. Instruct patients about prevention measures to minimize risk of bleeding and to report signs and symptoms of bleeding. Side Effects Requiring Immediate Medical Attention: Along with its needed effects, [MEDICATION(S)] (the active ingredient contained in [MEDICATION(S)]) may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention. Check with your doctor immediately if any of the following side effects occur while taking [MEDICATION(S)]: .nosebleeds . The Immediate Jeopardy that began on 2-19-2021 was removed on 3-18-2021 when the facility took the following actions to remove the immediacy as confirmed through observation, interview, and record review: Beginning March 17, 2021, all residents who require [MEDICATION(S)] therapy had the lab orders reviewed and verification of the lab results being obtained timely. This information was also placed on the [MEDICATION(S)] Tracking Form. This was completed on March 17, 2021 by V21 (Regional DON) and V4 (LPN). Beginning March 17, 2021, individual resident [MEDICATION(S)] tracking forms are being implemented which will allow at a glance review for resident history of labs and orders. Completed March 17, 2021 by V21 and V4. Effective March 17, 2021, all PT/INRs are now to be telephoned to the physician and not faxed. Training with all licensed nursing personnel began on March 17, 2021 and was completed March 18, 2021. This was completed by V30, V21, V32, V31, and V34. Beginning March 17, 2021, all care plans are being reviewed for appropriate interventions and for resident receiving [MEDICATION(S)]. This was completed on March 17, 2021. This was completed by V34 and V28. Beginning March 17, 2021 and ongoing, the night nurse will review all telephone orders for accuracy against the clinical record and will then give to DON/Designee for her/him to review. Beginning March 17, 2021, the Adverse Drug Reaction Policy was implemented and forms were provided to all licensed nursing staff. The in-service was conducted by V30, V21, V31 (Regional Marketing), V32 (Regional Training and Education), and V34 (Regional MDS/CPC) and completed on March 18, 2021. The Administrator and the Regional DON have initiated training of all nursing staff on the identification, assessment, notification, documentation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Education was initiated on 03/17/21 and will include 100% of all nursing staff and will include the following information: All Licensed Nursing personnel will be educated as to the monitoring of a resident's condition while receiving [MEDICATION(S)] therapy. These are to include, but not limited to, excessive bruising, frank bright red bleed, GI (gastrointestinal) bleeding, coffee ground emesis, dark tarry stools, abdominal pain, blood in urine, excessive nose bleeds and increased PT/INRs (any INR greater than 3.5) unless otherwise directed by the physician. Any signs of abnormal bleeding. This was completed by V30, V21, V32, V31, and V34. Beginning March 17, 2021, all licensed nursing staff will be in-serviced on the following policies for Pro Time tracking sheet which is being implemented, pharmacy medication orders and resident charts, guidelines for physician notification of resident change in condition, pharmacy stop orders, and notification of physician notification in resident change in condition, oral medication administration and medication administration, and conformance with physician medication orders. This was completed by V30, V21, V32, V31, and V34. As of March 18, 2021, all in-services were completed with all licensed nursing staff. Beginning March 17, 2021, all [MEDICATION(S)] and PT/INR orders will be reviewed by the QA committee weekly times three months, then monthly times three months, then quarterly. The Resident Care Coordinator will monitor this process. Beginning March 17, 2021, the Resident Care Coordinator will review nursing process daily and present findings during the Facility Morning QA meetings and as needed to verify compliance.