Every finding on record at Windcrest Health and Rehab Inc

Based on observation, interview and facility document review, the facility failed to ensure that the food preparation equipment and environment were maintained in a clean and sanitary condition to prevent contamination and potential development of foodborne pathogens, one of one kitchens and one meal service observed. The findings include:Ice Machine During the initial tour of the kitchen on 06/08/2026 at 11:03 AM this surveyor asked the Dietary Consultant to perform a swipe test on the ice machine where the ice comes from the dispenser with a white paper towel. The Dietary Consultant described what came off on the white paper towel as brown and black specks. During an interview on 06/08/2026 at 11:15 AM, the [NAME] stated the ice machine was cleaned once a week. Review of the kitchen cleaning schedule on 06/09/2026 2:56 PM, revealed the ice machine was marked as cleaned on 06/02/2026 and 06/09/2026. Refrigerator During an observation of the left refrigerator on 06/08/2026 at 11:06 AM this surveyor observed a pork roast in a shallow pan in the bottom of the refrigerator labeled 06/01/2026. The Dietary Consultant informed this surveyor the date marked was the date the roast was pulled from the freezer. During a second observation of the left refrigerator on 06/08/2026 at 11:17 AM the pork loin was no longer observed in the refrigerator. The Dietary Consultant stated it had been thrown out due to being held to long. During an interview on 06/08/2026 at 11:20 AM, the Dietary Manager indicated that the pork loin have been in the refrigerator since it was pulled June first and should have been cooked yesterday for today's lunch (06/08/2026). Food Preparation Equipment During an observation on 06/09/2026 at 11:11 AM the [NAME] indicated a large cooking pot on the stove was used to fry foods. The pot was observed to have a brown murky oily substance in it with brown debris floating on top. The pot was black with buildup of charring on the outside and inside of the pot. The cook stated they would change [the oil] today after they fried the fish sticks and tater tots for lunch. During a follow up interview and observation on 06/10/2026 at 10:50 AM, the [NAME] stated the pot used to fry foods in holds about four gallons of grease. The [NAME] continued that the pot had been cleaned. This surveyor observed the inside of the pot to be amber and brown in color with heavy black areas. The outside of the pot continued to be black with a buildup of charring, with the same buildup on the inside of the pot; the buildup on the inside of pot appeared flakey. The [NAME] stated that the Dietary Manager performed in-services but could not recall when the last time one was received. During an interview on 06/10/2026 11:30 AM, Dietary Aide #10 stated, I have been here since October; I wash dishes, make drinks and snacks, and I clean the dish area every day. During an observation on 06/10/2026 at 11:45 AM, Dietary Aide #10 was observed pushing a cart with clean cups on it to the dish room to obtain additional clean cups. Dietary Aide #10 filled cups one at a time with tea, touched the outside of a plastic wrap box with their hands, touched the cup rim with a bare hand, covered the cup with plastic, and repeated the process for approximately 30 cups. No hand hygiene was observed during this process. During the lunch meal service Dietary Aide #10 was observed touching their clothing, touching the rim of their glasses, then touching coffee cup lids, the ice scoop and ice machine, and retrieving items from the fridge. No hand hygiene was observed to be performed between the times Dietary Aide #10 touched their personal items or dirty items in the kitchen and touching items that would be used by residents. During an interview on 06/10/2026 at 1:15 PM, Dietary Aide #10 stated, I don't wash my hands as often as I should. It does spread germs. During an observation and concurrent interview on 06/10/2026 at 12:45 PM, a black insect box was observed on the window seal directly above the food preparation area, another box was observed beside the microwave on the food preparation surface. This surveyor witnessed Night [NAME] #9 kill an insect with a rubber glove on the counter, throw the insect and the glove away, wash his hands, and continue with food preparation without sanitizing the food preparation area. Night [NAME] #9 indicated the insect he'd killed on the counter was an ant and that the boxes [on the window seal and beside the microwave] were for roaches. During an interview on 06/10/2026 at 1:30 PM, the [NAME] stated we do have a pest person who visits every week. During an interview on 06/10/2026 at 1:15 PM the Dietary Manager stated, I expect staff to wash their hands all the time. Examples of when to perform hand hygiene were going from dirty dishes to clean dishes, after touching clothing, when entering the kitchen at all times. The Dietary Manager indicated the pest company was coming out once a week for the last three weeks, to treat for ants and roaches, but we were not given instructions on additional steps to take [regarding the pests]. The Dietary Manager stated, I expect staff to clean the pot used for frying food when it has any floating particles in it. The Dietary Manager described the grease in the pot as cloudy and needs dumped. The Dietary Manager went on to describe the pan as having burnt on grease covering it and stated, it is only used for holding grease. The Dietary Manager indicated she did not have a regular schedule for in-services but held them when she needed to. She stated during the in-services she read the in-services to staff to ensure understanding and asked them if they understand the in-services before signing them. The Dietary Manager stated facility wide in services were held for every person once a year. Items we in-service on include hand washing, properly serving, and serving times, and sanitation. Dietary staff are trained by the cook and I pull the new people and talk to them as well. During an interview on 06/11/2026 at 12:53 PM, the Administrator stated the kitchen staff need to follow our policy on hand sanitizing. Review of the Food Handling and Safety In- Service dated 08/20/2025 instructed staff to wash their hands and surfaces often and sanitize surfaces. Do not touch the rim of the tumblers or cups. The in-service was signed by the dietary aid and night cook. Review of the Handwashing in service dated 06/08/2026 provided more specific examples of when to wash hands that included :Before starting to work, after break, touching any part of your body/clothing. The in-service was signed by the dietary aid and the night cook Review of a facility policy titled, Sanitation with a revised date of October 2008 revealed that all kitchens, kitchen areas, and dining areas shall be kept clean, free from liter and rubbish and protected from rodents, roaches, flies and other insects. The policy also indicated, All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Review of a facility policy titled, Ice Machines and Ice Storage Chests indicated containers will be drained, cleaned and sanitized by the manufacturer's instruction and facility policy.

Based on observation, interview and facility document review, the facility failed to ensure that the waste was properly contained in the dumpsters, and the area was free from debris. The findings include: During on observation of the dumpsters behind the facility, on 06/08/2026 at 11:10 AM, this surveyor observed the following behind and around the facility dumpsters: pieces of metal a broken bed side table top, one glove, behind the dumpster, two gloves at the front of the dumpster in the ground, and on the right side of the dumpster were four additional gloves on the ground. white plastic grocery bag various scraps of paper. an aluminum can, a Styrofoam cup. During a continuation of the observation behind the facility building this surveyor observed the following: - The commercial grease trap behind the building had two plastic chairs leaning on it, a plastic wheeled dolly was lying on top of the commercial grease trap along with a cooking thermometer. -A large tin can full of water and cigarette butts sat on the ground. -The top of the commercial grease trap had a thick black substance on the top of it. -The commercial grease trap was 104 inches from the back door and approximately six inches from the back of the building. During a second and third observation on 06/09/2026 at 7:45 AM and 06/10/2026 at 11:10 AM, this surveyor again observed the following behind and around the facility dumpsters: pieces of metal a broken bed side table top, one glove, behind the dumpster, two gloves at the front of the dumpster on the ground, and on the right side of the dumpster were four additional gloves on the ground. white plastic grocery bag various scraps of paper. an aluminum can, a Styrofoam cup. During interview on 06/10/2026 at 3:48 PM, the Maintenance Director confirmed the dumpster findings and stated, everyone pitches in and picks up the trash on a daily basis. It mostly blows in from other areas like the apartments next door. The gloves are facility trash. The Maintenance Director stated, I am responsible for the area around the dumpster and pick it up on a daily basis. The Maintenance Director confirmed and observed the commercial grease trap. The Maintenance Director stated the kitchen staff are responsible for this area, the facility has a company that empties the grease trap every couple of months. During an interview on 06/10/2026 at 3:07 PM, the Dietary Manager stated the cooks were responsible for taking out kitchen trash, and the dietary aides were responsible for taking out dish room trash. The Dietary Manager stated the whole facility uses the dumpsters, and everybody was responsible for keeping the area around the dumpster clean. The Dietary Manager went on to add that the kitchen staff had not been told they are solely responsible for the dumpster. When asked about the commercial grease trap, the Dietary Manager stated that maintenance cleans around the building, if the oil gets spilt on the container the person dumping the oil should clean it up. During an interview on 06/11/2026 at 12:53 PM, the Administrator stated staff need to follow the policy on the grounds and pick up trash on a daily basis depending on the weather. The Administrator stated, I drive around the building about three times a week to monitor the trash. This week I drove around on Tuesday, Wednesday, and today (Thursday). The Administrator indicated she did not document when she drove around the building, and the Maintenance Director did not document when he picked up trash on the grounds. Review of a facility policy titled, Sanitation with a revision date of October 2008, revealed kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily.

Based on observations, interviews and record review, the facility failed to maintain a safe, clean, homelike environment. Specifically, the facility failed to replace missing window blinds that compromised resident privacy during dressing; and failed to replace heavily soiled, stained bed linens and pillows that were left unchanged for multiple days in the resident rooms. The findings include: During an observation of room [ROOM NUMBER]-A on 06/08/2026 at 11:45 AM this surveyor observed a bed made with a bare pillow missing its pillowcase. The pillow itself was heavily soiled with a large, dark brown stain measuring approximately 8 inches in diameter across the center. During an observation on 06/09/2026 at 8:10 AM of room [ROOM NUMBER]-A, the surveyor observed that the bed linens at the foot of the bed were heavily soiled with a reddish-brown substance. Additionally, the floor fan was missing its protective safety cover, leaving the fan blades completely exposed to resident contact. During a follow-up observation of room [ROOM NUMBER]-A on 06/10/2026 at 9:21 AM this surveyor observed that the soiled bed sheets that had been noted on the previous days had still not been changed or laundered. During a concurrent observation of Resident #26's room and interview on 06/09/2026 at 9:02 AM, this surveyor noted there were no blinds on the room window to enhance privacy. Resident #26 stated that due to the missing window blinds they changed clothing in the corner. During an interview on 06/10/2026 at 8:55 AM, Certified Nursing Assistant (CNA) #11 stated they had not noticed the missing window blinds in Resident #26's room but noted that the resident was independent with dressing. CNA #11 observed the pillow in 401-B at this surveyor's request and stated the pillow was nasty and coved in brown stains. CNA #11 immediately discarded the pillow into the trash. During an interview on 06/10/2026 at 9:56 AM, Licensed Practical Nurse (LPN) #13 stated that bed sheets must be changed immediately anytime they become soiled. LPN #13 stated they were unaware that the window blinds were missing in Resident #26's room. During a follow up interview on 06/11/2026 at 11:11 AM, CNA #11 indicated that staff were supposed to report broken items by writing them down in the maintenance book or by verbally telling the maintenance department. During an interview on 06/11/2026 at 12:39 PM, the Director of Nursing (DON) revealed that broken items should be logged by staff in the maintenance book or reported by the CNAs to the charge nurse to notify maintenance. The DON stated that missing blinds should be reported immediately and verified that resident bed linens [NAME] be changed daily, or as needed if they become soiled. During an interview on 06/11/2026 at 11:16 AM, Charge Nurse LPN #14 revealed that all maintenance requests must be written in the facility maintenance log and stated that none of these specific environmental issues had been reported to them. During a follow-up interview on 06/11/2026 at 11:16 AM, the Maintenance Director indicated that they go from one work order to the next based on what staff write in the log or tell them verbally. The Maintenance Director stated they check the building every morning to ensure items are in working order but explicitly stated that nobody had reported the broken/missing blinds in room [ROOM NUMBER] to them.

Based on observation, record review, interview and facility policy review, the facility failed to ensure residents environment remained free form smoking hazards as evidence by two (Residents #29 and #41) of four resident observed had with cigarettes and lighters in their possession during smoke breaks. The findings include: Resident #41 On 06/08/2026 during the 2:00 PM smoke break, this surveyor observed Resident #41 with a lighter. An unidentified female staff member took the lighter from Resident #41. Resident #41 was observed again by a surveyor removing a second lighter from a personal bag observed on the resident when they were observed in the smoking area. The resident placed the second lighter back in their bag, and it was not given to the staff member to place in the container before the resident went back into the facility. On 06/08/2026, Resident #41 had a sign on the door which indicated surveyors were not allowed in the room. On 06/10/2026 at 2:08 PM, this surveyor was seated in a room facing windows to the smoking area. Resident #41 was observed entering the smoking area wearing a smoking apron with a black and pink pouch hanging on the right side of a wheelchair. Resident #41 opened the black and pink pouch, pulled out a green and white carton of cigarettes, opened the top, removed one cigarette placing the cigarette between their lips, and put the green and white carton inside the black and pick pouch. Resident #41 removed a small lighter from the same pouch and lit their cigarette and placed the lighter inside the black and pink pouch. This surveyor observed smoke coming from the cigarette and the resident's mouth. There was a female staff CNA, later identified as CNA #5, in the area handing cigarettes to other residents and lighting the other residents' cigarettes. CNA #5 did not give Resident #41 a cigarette or lighter during this smoke break. Resident #41 did not give the black and pink pouch to CNA #5 after leaving the smoking area. Resident #41 was observed later in the day on 06/10/2026 with the black and pink pouch hanging on the side of their wheelchair in the hallway as surveyor was walking to the conference room. Review of an admission record revealed Resident #41 admitted to the facility on [DATE] with diagnoses which included epilepsy and primary open-angle glaucoma in right eye, moderate stage and left eye, severe stage. Review of the Order Summary Report for Resident #41 revealed an order dated 05/19/2025 to admit to long term care. There was no order indicating Resident #41 had approval to keep smoking items in their possession. A review of Resident #41's Care Plan, with a review date of 05/13/2026, revealed Resident #41 was a smoker. Interventions included that Resident #41's smoking supplies were stored at the nurses' station. Interventions also include that Resident #41 required a smoking apron and supervision while smoking. A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 05/07/2026 for Resident #41 revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also included that Resident #41 was a current tobacco user. A review of Resident #41's nursing smoking safety screen and care plan form dated 05/04/2026 indicated the resident's cigarettes and lighter were kept at the nurses' station. During an interview on 06/10/2026 at 2:45 PM, Certified Nursing Assistant (CNA) #5 stated residents were not allowed to have their own cigarettes and lighters on their person, such as in a bag. She stated, But I will tell you that this has been an issue. There have been times that I have confiscated them on smoke break, put them in a box, come back the next day and they [residents] have them again. She stated the residents' smoking items are to be stored at the nursing station in a drawer. CNA #5 stated she did not give Resident #41 a cigarette or light Resident #41's cigarette during the 2 PM smoke break. She also stated Resident #29 was not supposed to have a lighter on their person. During an interview on 06/11/2026 at 10:45 AM with the Advance Practice Registered Nurse (APRN), she stated residents were not allowed to have their individual smoking paraphernalia. She stated for residents to receive consent to have smoking paraphernalia on them, providers would have to screen them. She stated she has not approved any residents to smoking paraphernalia in their possession. During an interview on 06/11/2026 at 1:45 PM, the Director of Nursing (DON) stated Resident #41 was not allowed to have smoking items on their person. He stated he was made aware on 06/11/2026 around 2:30 PM by the CNA who was scheduled for the smoke break [CNA #5] that Resident #41 had cigarettes and a lighter in their possession. During an observation and concurrent interview on 06/11/2026 at 5:15 PM, Licensed Practical Nurse (LPN) #6 she stated the smoking items were stored in the drawer and pointed this surveyor to an unlocked drawer in the nursing station. This surveyor opened the drawer and observed a clear container with white top with the word smokers' written in blue on the top. The container was not locked. There was no black and pink pouch observed in the drawer that contained smoking container. LPN #6 stated nurses and CNAs had access to the drawer with the smoking items. She stated it was important to keep cigarettes/lighters out of the hands of the residents, so they don't burn each other and for oxygen precautions. Resident #29 During an observation on 06/10/2026 at 2:10 PM during the 2:00 PM smoking break at the outdoor smoking area visible from the surveyor conference room window, Resident #29 was observed removing an oblong package from a black case on their lap. Resident #29 was observed removing a cigarette from this oblong box, then placed it in their mouth. Resident #29 removed a lighter from the same black case and lit the cigarette independently. Resident #29 replaced the cigarette pack and lighter into the black bag on their lap. Staff were present and walking around assisting the other residents with their smoking material.A review of the admission Record indicated that Resident #29 was admitted to the facility on [DATE] with diagnoses that included difficulty walking, neuralgia, neuritis, long term opioid use, polyneuropathy, muscle weakness, muscle wasting and atrophy, need for assistance with personal care, paranoid schizophrenia and bipolar disorder. A review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/09/2026, indicated that Resident #29 used tobacco. A review of a quarterly MDS with an ARD of 06/03/2026, indicated Resident #29 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. The MDS also included that Resident #29 used a wheelchair, walker and had prosthetics for an impairment of the lower extremities. A review of a Care Plan Report with an initiated date of 03/05/2026 indicated Resident #29 smoked, should have been made aware of the facility policy related to smoking. Resident #29 required a smoking apron when smoking, required supervision and their smoking supplies were to be stored at the nurse station. The care plan also included that Resident #29 was resistant to care and was a high risk for falls with a history of falls. Resident #29 was on anti-depressant medication, opioid and other controlled pain medication and that Resident #29 had impaired vision. A review of the Order Summary Report as of 06/11/2026 revealed Resident #29 had medication orders for a medication used to treat depression related to bipolar disorder to be given one time a day for depression, an opioid pain medication to be given 6 hours as needed for pain, a generic medication used to treat seizures and nerve pain to be given three times a day related to neuralgia and neuritis. A review of a nursing Smoking Safety Screen and Care Plan assessment with a review date of 06/01/2026 revealed Resident #29 needed the facility to store their cigarettes and lighter. Resident #29 required a smoking apron, supervision for safety, cigarettes and lighter would be kept at the nurse's station. The care planning decision intervention read in part Resident #29's smoking supplies would be stored at the nurse's station. This assessment was E-signed by LPN #1. A review of a Smoking Policy-Residents with a revised date of October 2023 revealed the facility had established and would maintain safe smoking practices. The policy interpretation and implementation indicated that 7. The resident smoking status was evaluated on admission to include on 7d. The assessment would determine the resident's ability to smoke safely with or without supervision. 9. The resident's ability to smoke safely would be re-evaluated quarterly, with significant changes and as needed. 10. The residents smoking privileges, restrictions and any concerns would be addressed on the plan of care, with all staff providing care for the residents being made aware of those issues. 12. Any resident that had smoking privileges requiring monitoring would have direct supervision of a staff, family member, visitor or volunteer at all times while smoking. 13. Any residents who had been assessed to have had independent smoking privileges were permitted to keep smoking material in their possession including disposable safety lighters. 14. The residents were not allowed to share smoking material with other residents. 15. Without independent smoking privileges, the residents were not allowed to keep smoking material except under direct supervision. 17. The facility maintained the right to confiscate any smoking material that was found to be in violation of the facility policy.

[NAME] SmithBased on observation, record review, interview, and facility policy review, the facility failed to recognize and/or assess risk factors that placed a resident at risk for receiving possible sexually inappropriate behaviors, and to implement guidance to maintain separation of affected residents, for one (Resident #40) of one resident reviewed.The findings include:A review of a reportable for Resident #40, dated 06/02/2026, indicated the Administrator received a report that Resident #50 had inappropriately touched Resident #40 during smoke break time.A review of a witness statement included in the reportable from Certified Nursing Assistant (CNA) #6 dated 06/01/2026 at 21:25 (9:25 PM) indicated [Resident #40] mentioned that [Resident #50] had touched them in the chest area while both residents were out on a smoke break. The witness statement indicated Resident #40 was very displeased and uncomfortable at the incident.A review of a witness statement included in the reportable from Licensed Practical Nurse (LPN) #8 dated 06/01/2026 indicated Resident #40 was brought to her by a CNA (not named) to report an incident from the smoke break. The witness statement indicated Resident #50 had touched Resident #40 inappropriately on the breast and other residents in the smoking area. There were no other residents named, or dates or times listed for the other incidents with the other residents.A review of in-services on types of abuse dated 06/02/2026, conducted by the Administrator with nursing, housekeeping, laundry, dietary and other staff members, revealed several names and titles. The in-service indicated sexual abuse was a non-consensual sexual act of any kind with an elderly person. The in-service also revealed if abuse is witnessed or reported to a staff member, the staff must report this to the Administrator/DON (Director of Nursing) immediately.A review of the Office of Long-Term Care (OLTC) Incident and Accident Report (I&A) 762-Findings and actions taken dated 6/9/2026 and completed by the Administrator indicated staff was instructed to keep Residents #40 and #50 separated during smoke times.A review of the admission record for Resident #40 indicated the facility admitted the resident on 02/23/2026 with diagnoses that included dementia and cognitive communication deficit.A review of the Order Summary Report for Resident #40 indicated admit to long term care with an order date of 02/23/2026.A review of the quarterly Minimum Data Set, with an Assessment Reference Date of 05/25/2026, for Resident #40 revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also indicated that Resident #40 did not use a mobility device.A review of Resident #40's care plan, with a reviewed date of 05/25/2026, revealed Resident #40 was a smoker and required supervision while smoking.A review of Resident #50's Order Summary Report revealed diagnoses of vascular dementia and other sexual disorders. An injectable medication, with a start date of 06/07/2026, related to the diagnosis of other sexual dysfunction, was to be given intramuscularly one time a day starting on the seventh and ending on the eighth of every month.A review of Resident #50's care plan, initiated 05/28/2026, revealed Resident #50 exhibits indicators of hypersexual behaviors: grabbing the CNAs (Certified Nursing Assistants) inappropriately and making sexually inappropriate comments. An intervention initiated on 06/10/2026 included an injectable medication.A review of Resident #50's admission MDS with an ARD of 06/02/2026 revealed a BIMS score of 15, which indicated the resident was cognitively intact. The MDS also indicated Resident #50 used a wheelchair for mobility.During an interview on 06/08/2026 at 2:30 PM, Resident #40 stated Resident #50 touched them, pointing to their chest area, while outside during a smoke break. Resident #40 asked if Resident #50 was going to jail and this surveyor stated they would have to refer to what was done by the facility.On 06/08/2026 at 3:13 PM, Resident #50 was lying awake in bed. During an interview, Resident #50 stated, I have not touched anyone period. Resident #50 stated they were spoken to by other staff members at the facility about this and was taken out to smoke at different times with no other residents present for a while but did not state how long this occurred of them smoking separately from other residents. During an observation on 06/10/2026 at 11:13 AM, this surveyor was seated in the room with other surveyors and looked out the window to observe the residents on smoke break. This surveyor observed Resident #50 seated to the immediate left of Resident #40 in the smoking area where the initial incident was alleged to have transpired. The residents were not speaking to each other. Resident #40 was looking straight across the area and did look down at one point. This surveyor went to Licensed Practical Nurse (LPN) #7 for assistance but she was not able to assist surveyor with an observation at the time. This surveyor then asked Certified Nursing Assistant (CNA) #2 for assistance identifying Resident #40. CNA #2 looked out the glass door to the smoking area and stated Resident #40 was in a blue shirt, seated on the left side of Resident #50. At 11:21 LPN #7 came to the area and stated those two residents were not to be seated next to each other. She called CNA #3 to the door and informed her of the situation. CNA #3 then moved Resident #50 to a different area.During an interview on 06/10/2026 at 11:55 AM, Resident #40 stated she was not happy that Resident #50 had been seated next to them. Resident #40 asked this surveyor if Resident #50 was going to jail, and this surveyor told Resident #40 the Administrator would have to speak to them about the concern of Resident #50 and jail.During an interview on 06/10/2026 at 12:15 PM, CNA #3 was interviewed and state she did not place the residents out in the smoking area for the 11 AM smoke break because she was on lunch break. She stated she was unaware that Residents #40 and #50 were seated next to each other. CNA #3 stated the Director or Nursing (DON), Assistant Director of Nursing (ADON) or Administrator had not informed her that Residents #40 and #50 were not to sit next to each other. CNA #3 stated she had been given the information by a coworker but could not recall who it was nor the date she had been told. During an interview on 06/10/2026 at 12:24 PM, CNA #4 stated she had placed Resident #50 to the right of Resident #40 during the 11 AM smoke break. She stated another CNA did tell her that these two residents were not to be seated next to each other, but she could not recall the date. She stated she placed Resident #50 by Resident #40 because, that was the only spot to put [Resident #50]. She stated that she forgot Resident #40 was sitting there and she was just helping out by bringing [the residents] out there. She stated she had not been told by the DON, ADON, or Administrator to keep Residents #40 and #50 separated.During a telephone interview on 06/11/2026 at 10:45 AM, the Advanced Practice Registered Nurse (APRN) stated she was made aware of the alleged incident on 06/02/2026 between Resident #40 and #50. She stated she was made aware that Residents #40 and #50 were to be separated and not sit together.During an interview on 06/11/2026 at 1:54 PM, the DON stated they did not have findings that gave them certainty of the occurrence [Resident #50 touching Resident #40]. He stated he believed keeping Residents #40 and #50 from sitting next to each other was the appropriate intervention.During an interview on 06/11/2026 at 2:21 PM, the Administrator stated he received a telephone call on his way to work on 06/02/2026 and was made aware of the allegations that Resident #50 had inappropriately touched Resident #40 during a smoke break. He stated after this incident, the residents were to be kept separate at all times. The Administrator stated it was not acceptable to place Resident #40 and #50 next to each other. He stated the DON or designee should have immediately instructed the nurses and CNAs to keep Resident #40 and #50 separated.A review of am Abuse Prevention Program policy, with a revision date of December 2016, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy indicated that the administration will protect their resident from abuse by anyone including but not limited to other residents.

49981 Based on observation, interview, and policy review, it was determined that the facility failed to ensure that residents had a clean, safe, homelike environment by not repairing water damaged ceiling, walls, light fixtures, and not keeping furniture and linens clean. The findings are: 1. On 10/28/2024 at 11:55AM, Resident #11's bedsheets were observed to have a brown, wet substance on them. Resident #11 confirmed she had an accident and needed assistance. A Certified Nursing Assistant (CNA) was called into the room to assist resident. a. On 10/29/2024 at 8:27AM, observed Resident #11 having the same bedsheets as the day before, and brown substance appeared to be dried on the sheets. 2. On 10/29/2024 at 8:31AM, in the hall of the secure unit, two ceiling tiles and a light covering appeared to have been wet by the appearance of brown ring stains, and a spot in the light covering that looked like liquid. 3. On 10/29/2024 at 8:48AM, rubber stripping that connects the floor with the wall in the dining room was peeled back and a hole was exposed in the wall. a. On 10/29/2024 at 8:49AM, in the dining room, above the exit sign, the ceiling tile was brown, as though it had been wet. b. On 10/29/2024 at 8:49AM, in the dining room, the wall had a lump in it and was spongy to touch. The rubber stripping that attaches the wall to the floor was not attached to the floor. The stripping was pulled up, and what appeared to be a wooden or cement wall was exposed, that looked like it had been wet. The wooden or cement surface had black and gray substance, and the bottom looked to be eroding and crumbling. 4. On 10/29/2024 at 8:59Am, in the secure unit of the facility, there was a chair in the dayroom that was observed to have several stains. The chair was a greenish gray color, and the stains were darker in color, as though there had been spills on it. 5. On 10/29/2024 at 11:44AM, an air conditioner was observed in a resident's room, that had a metal casing that attached it to the wall along with a puffy yellow substance around the edges where the air unit met the wall. 6. On 10/30/2024 at 8:45AM, a picture of the chair with stains, from the unit in the facility, was shown to the Administrator. The Administrator was asked if he would sit in the chair or have it in his home. The Administrator confirmed that the chair should not have been in the building, and it would be removed promptly. a. On 10/30/2024 at 8:47AM, a picture of Resident #11's bedsheets was shown to Administrator. Administrator was asked if the bedsheets needed to be changed. Administrator confirmed the bedsheets should not have been left on resident's bed in that condition. 7. On 10/30/2024 at 2:11PM, the surveyor observed in the secure unit of the facility, that the dirty chair with stains had been removed from the unit. Surveyor asked CNA #1 where the chair went and CNA #1 stated the chair was not even supposed to be in there, somebody came and took it out. 8. On 10/30/2024 at 2:13PM, Resident #11's bedsheets had been changed and resident was in bed taking a nap. 9. On 10/30/2024 at 2:15PM, Licensed Practical Nurse (LPN) #9 confirmed that resident's sheets are changed on bath day. LPN #9 confirmed CNAs are to change the bedsheets if needed or resident gets a bath. LPN #9 stated CNAs are assigned to residents, and it changes daily. There are no housekeeping chore assignments for the CNA's. 10. On 10/30/2024 at 2:45PM, the Administrator provided a copy of the Quality of Life-Homelike Environment Policy for the facility. The policy indicates that the residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 11. On 10/31/2024 at 7:30AM, upon entering facility the surveyor noticed several places in the dining room ceiling leaking a liquid onto the floor. Housekeeper #2 confirmed this happens often. Housekeeper #8 confirmed it happens every time it rains. a. On 10/31/2024 at 7:59AM, the Administrator confirmed the facility's roof leaks when it rains, and they have quotes to have the roof fixed and waiting for approval from owners. b. On 10/31/2024 at 9:52AM, the Maintenance Director (MD) confirmed the floors, walls, and rubber stripping were worn badly and needing repair. The MD said that new tile is on its way and when the new floor was laid, the walls and rubber stripping would be replaced. The MD also confirmed the roof leaks when it rains, and it was hard to seal the leaks when the roof was flat and stays wet from holding water. 12. On 10/28/2024 at 12:11PM, the air conditioning unit in room [ROOM NUMBER] had a yellowish tinge to the upper section where the cold air was dispersed. The same vent area showed a blackish brown substance adhered to the inside of the upper section and the vent fins. The vent joints contained a greyish-white, fuzzy substance. The wall directly to the left side of the window, behind the headboard and the wall to the right, where a resident ' s bed was pushed up against it, had gouges of paint missing. 13. On 10/28/2024 at 12:14PM, the 300-hall dayroom air conditioning unit, showed an approximate two-inch vertical accumulation of a dark brown, fuzzy-like unknown substance that clogged the right vent screen. The bottom screen near first vertical plastic stabilizer on the left side was approximately one and a half inches. The bottom screen, near the first vertical plastic stabilizer on the right side, had approximately one-third of the middle section clogged with a similar unknown dark brown, fuzzy-like substance. 14. On 10/28/2024 at 12:25PM, in room [ROOM NUMBER] the ceiling air vent near the window, directly above a resident's bed, contained several brown fuzzy objects hanging from the grating of the air vent. The wall air vent located by the door, where another resident ' s bed was pushed directly underneath the vent, contained a black grimy substance adhered to the air vent grid. 15. On 10/30/2024 at 7:33AM, a hallway 300 ceiling light cover contained what appeared to be various insect and spider carcasses, along with various black or brown specks. 16. On 10/31/2024 at 9:50AM, Maintenance Director, stated the air conditioning units were unable to be cleaned, but the facility was in the process of replacing them. The wall and ceiling air vents were maintenance responsibility to clean. The ceiling light covers were maintenance responsibility to clean. 17. On 10/31/2024 at 10:17AM, during an interview the Director of Nursing (DON) stated air filtration was a problem. Residents should not be exposed to the air coming out of dirty vents. It can exacerbate a lung diagnosis or increase a need for O2. All departments should be involved in observing and notifying maintenance or housekeeping to help keep air vents clean. 18. On 10/31/2024 at 10:23AM, during an interview Administrator stated, I need to get the housekeepers on deep cleaning ceiling vents and cleaning the air conditioning unit vent areas. The facility has been trying to replace the air conditioning units. 19. On 10/31/2024 at 10:30AM, the Nurse Consultant stated the facility does not have a housekeeping policy. 20. Review of a facility document, October 2024 housekeeping deep clean schedule showed October 1, 2024, room [ROOM NUMBER] and October 11, 2024, room [ROOM NUMBER] had been deep cleaned.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure medications were not pre-popped prior to administering medications to residents for 7 (Resident #5, #11, #15, #16, #26, #28, and #49) of 7 residents reviewed for preparation of medication administration. Findings include: A review of facility policy titled, Pharmacy Services Overview, revised in April 2007, stated pharmacy services were to provide feedback about performance and practices related to medication administration and medication errors. Services will collaborate with staff and practitioners to address and resolve medication problems. A review of facility policy titled, Administering Medications, revised April 2019, stated that medications will be administered in a safe, timely manner and as prescribed. Medications administered are to be verified with the resident ' s identity before administering medication and the person administering the medication must check the medication label three times to verify the correct resident, correct medication, correct dose, the right time and the right method. The person administering the medication was to sign the Medication Administration Record (MAR) after administering the medication and before administering any other resident ' s medication. During an observation on 10/30/2024 at 4:15 PM, Licensed Practical Nurse (LPN) #3 was noted to be placing empty medication cups on top of the medication cart. Some of the medication cups were noted to have initials on the outside of the cup and LPN #3 was holding a black marker. On 10/30/2024 at 4:24 PM, LPN #3 was observed taking a stack of cups that had medications in them and placed the cups in the top drawer of the medication cart. When LPN #3 was asked what was put in the medication cart, LPN #3 stated I was getting my medications together for the residents. LPN #3 confirmed medications were not to be pre-popped prior to giving and that medications were not supposed to be prepared that way. When asked why the medications had been pre-popped, LPN #3 stated, I thought you were gone. LPN #3 stated the Director of Nursing (DON) would not be happy about it. The DON walked out of the medication room behind the nurse ' s station, at that time and stopped at the medication cart. The DON was asked if it was known that LPN #3 was pre-popping medications and DON stated, No, and I am not happy about it. During an observation on 10/30/2024 at 4:33 PM, the DON went down the hall stating education was being provided for the rest of the nursing staff on duty. During an interview on 10/30/2024 4:34 PM, LPN #3 revealed staff had been educated on medication pass with lots of in-services. Confirmation was given that medications that had been pre-popped had been destroyed by crushing and putting the medications in the sharps container. LPN #3 described the proper way to prepare for medication administration was to confirm the right resident, look at the MAR, look at the medication card, make sure it was the right day scheduled, then pop the medication, go administer the medication and then come back and sign the medication off on the MAR. LPN #3 was asked what the importance was of not pre-popping medications and she stated, I know it is wrong, it is a bad habit. LPN #3 confirmed she had previously pre-popped medications and by stating, I know I did it yesterday too. LPN #3 stated the resident could die if they got the wrong medications. On 10/30/2024 at 4:46 PM, the DON informed the surveyor the facility was going to replace medications that had to be wasted at the facility ' s expense and that LPN #3 had been in-serviced and the Assistant Director of Nursing (DON) was observing medication administration with LPN #3. On 10/31/2024 at 11:04 AM, the DON stated she had no competencies on medication administration for LPN #3. The DON provided a list of the residents whose medications were observed being pre-popped on 10/30/2024, a list of what had been done to prevent recurrence of the same event and a copy of the Medication Administration Observation that had been completed on 10/30/2024 by the ADON. Two in-service records were provided by the DON titled, Preventing Medication Errors, dated 08/02/2024 and the in-service dated 10/30/2024 which stated, it is not best practice to pre-pop medications. Follow all steps for safe medication administration by preparing one resident at a time.

Based on observation, record review, and interview, the facility failed to ensure hot foods were served hot and cold dairy products were served cold to maintain palatability and encourage adequate nutritional intake for 1 of 1 meal observed. The findings are: 1. On 10/28/24 at 11:48 AM, Resident #30 stated the food was cold when served in the dining room and even colder if served in the resident's room. 2. On 10/30/24 at 12:38 PM, an unheated food cart was in the main dining room by the kitchen window. The first lunch tray for the unit was placed on a shelf in the unheated food cart by the Certified Nursing Assistant (CNA) #3. While CNA #3 was loading food trays in the unheated food cart, she left the door open. At 12:29 PM, as CNA #3 finished loading food trays onto the left side shelf of the food cart, she closed the door. The right side of the door remained open while she continued loading food cart. Once the right side was filled, she closed that door and delivered the food cart to the unit. The door was left open as the CNA #3 removed food trays from the food cart and served them to the residents in the unit dining room. At 1:13 PM, immediately after the last resident was served on the unit, the temperature of the food items on the test tray were taken and read by CNA #3 with the following results: a. Milk - 54.8 degrees Fahrenheit. b. Mashed potatoes - 108.1 degrees Fahrenheit. c. Pepper steak - 113 degrees Fahrenheit. d. Pureed pepper steaks with gravy - 111.7 degrees Fahrenheit. e. Sausage 107.4 degrees Fahrenheit. f. Ground sausage 98.7 degrees Fahrenheit. g. Fried potatoes - 109 degrees Fahrenheit. h. Fried Okra - 101.1 degrees Fahrenheit. i. Macaroni and Cheese - 110.1 degrees Fahrenheit. j. Vegetable blend - 110 degrees Fahrenheit. k. Pureed macaroni and Cheese - 95.9 degrees Fahrenheit. l. Pureed corn bread with milk - 97 degrees Fahrenheit. m. Pureed vegetable blend - 93 degrees Fahrenheit. n. Pureed ham and bean - 96.5 degrees Fahrenheit. 3. On 10/30/24 at 1:25 PM, CNA#3, was asked whether an unheated food cart should be left open when loading meal trays for lunch and when passing meal trays to the residents receiving their meal trays in dining room on the 100- hall (unit). CNA #3 mentioned that she had left the food cart open when passing the meal trays but had considered closing it. CNA#3 later confirmed she should have closed one side of the door.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure dish washing machine air vent was cleaned; floors, base boards, dish washer and kitchen walls were free of dirt; chipped floor tiles were replaced; a sanitary environment for food preparation was provided, and expired spices and leftover fruit items were promptly removed from stock for 1 meal observed. The findings are: 1. On [DATE] at 8:06 AM, the scoop holder on a wall by the ice machine in the kitchen had a gray, wet residue at the bottom of it. The scoop was directly touching the residue. The Lead Dietary [NAME] (LDC) was asked to wipe the gray residue at the bottom of the scoop holder. He did so, and the substance easily transferred to the paper towel. The LDC, when interviewed, stated, it [the residue] was gray in color. They use it [the ice machine] to fill beverages served to the residents at mealtimes, the CNAs (certified nursing assistants) use the ice for the water pitchers in the residents' rooms, and it is cleaned once a week. 2. On [DATE] at 8:07 AM, one container of leftover diced peaches, dated [DATE], was on a shelf in the refrigerator. The LDC stated it had been there too long. 3 On [DATE] at 8:09 AM, the wall around the water hose sink, on the dirty side of the dish machine, had discoloration of sage color. 4. On [DATE] at 8:13 AM, the base board, below the rack where clean pans were stored, was loose, the area that was exposed had sage color. 5. On [DATE] at 8:26 AM, the ceiling air vent, in the dish washing machine room, was rusty. 6. On [DATE] at 8:27 AM, the container of red pepper, on a shelf below the counter, had an expiration date of [DATE]. 7. On [DATE] at 11:27 AM, Dietary Aide (DA) removed crackers from a box under the counter for the residents. Without washing her hands, she picked up glasses by the rims and placed them on the tray to be used in serving beverages to the residents for lunch. 8. On [DATE] at 11:55 AM, the following observations were made in the kitchen. a. Dietary Aide, turned on the food preparation sink faucet, and filled a pitcher with water. Without washing her hands, she picked up glasses by the rims and placed them on the trays and poured beverages into each glass, to be served to the residents for lunch. b. The floor in front of the steamtable was chipped, exposing the concrete. c. There was a gap on the floor in front of the food preparation sink, exposing the cement. d. The floor, between the ice machine and the rack, where canned goods were stored in the storage room, was chipped, exposing the cement. e. [DATE] at 11:58 AM, the Dietary Aide removed a pitcher of tea from the refrigerator and placed it on the counter. Without washing her hands, she picked up glasses by the rims and poured beverages in them to be served to the residents for lunch. The Dietary Aide, when interviewed, stated she should have washed her hands. 9. A review of facility policy titled, Preventing Foodborne Illness -Employee Hygiene and Sanitary Practices, initiated [DATE], provided by the Administrator on [DATE] indicated, employees should wash their hands after engaging in other activities that contaminate the hands.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to shave, clean the hands and face, and change clothing for 1 (Resident #2) of 1 resident reviewed for dignity. Findings include: A review of a facility policy titled, Resident Rights, revised on 12/01/2016, indicated residents would have their existence dignified and would be treated with respect kindness and dignity. A review of Resident #2 ' s Admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain, and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed supervision or touching assistance with personal hygiene; and partial to moderate assistance with upper body dressing. A review of Resident #2 ' s Care Plan, initiated on 12/26/2023, revealed the resident had an ADL deficit. Interventions included extensive assistance by one staff for personal hygiene and oral care and extensive assistance by one staff for dressing. A review of an Activity of Daily living task listed in the Documentation Survey Report, Personal Hygiene, revealed Resident #2 had personal hygiene every shift and staff were to layer clothing instead of applying loose articles such as a lap blanket to accommodate feeling cold when up to wheelchair related to mental awareness. A review of the MDS Kardex Report, printed on 06/21/2024, indicated Resident #2 needed extensive assistance with personal hygiene and dressing. During an observation on 10/28/2024 at 1:28 PM, Resident #2 returned to room after noon meal in the dining room, the area around the mouth, chin and hands were covered in orangish-red sauce from meal and the tee shirt that was worn was stained with droppings from the noon meal. Resident #2 had the appearance of not being shaved for several days, as indicated by the hair growth on the cheeks and chin. During an observation on 10/29/2024 at 8:14 AM, Resident #2 ' s room was darkened due to the light being off. Resident #2 was sitting in wheelchair waiting to go to bed. Resident #2 in need of a shave due to facial hair growth on chin and cheeks. Droppings of food were noted on the shirt being worn at that time. During an observation on 10/29/2024 at 12:30 PM, Resident #2 was sitting at the dining room table eating lunch and was noted with long facial hair on chin and cheeks and the same shirt that Resident #2 was wearing at breakfast was still being worn with the same stains visible. During a concurrent interview and observation on 10/29/2024 at 1:47 PM, Resident #2 was made aware of the facial hair growth and the stains of food on the face, and beard and that the shirt had not been changed since breakfast and was still soiled with droppings of food from breakfast and lunch, and a large coffee stain around the neck of the shirt. When asked Resident #2 stated a preference to be clean and did not want to be dirty. During an interview on 10/30/2024 at 8:55 AM, the Certified Nursing Assistant (CNA) #4 stated Resident #2 did like to be shaved and that with dressing, it was extensive assistance that was needed. CNA #4 confirmed CNAs provide showers and sometimes Resident #2 will refuse to be shaved, only when not feeling good, but most of the time will allow staff to shave when it is needed. CNA #4 confirmed Resident #2 ' s face and hands should have been cleaned prior to leaving the dining room and the shirt should have been changed if Resident #2 agreed, and it should have been offered. During an interview on 10/30/2024 at 12:39 PM, Director of Nursing (DON) confirmed Resident #2 should have had his face and hands cleaned prior to leaving the dining room, and staff should have offered to change the soiled shirt.

Based on observations, interviews, record review, facility document review, and facility policy review it was determined that the facility failed to ensure accuracy of the assessments required for the Minimum Data Set (MDS) for 1 (Resident #2) of 2 residents reviewed for accuracy and assessment completion of the MDS. Findings include: A review of a facility policy titled, Certifying Accuracy of the Resident Assessment, revised on December 2009 indicated, any personnel completing any section of the MDS must sign and certify accuracy of that assessment portion. A review of the Admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed set up or clean up assistance with eating and oral care, supervision or touching assistance with personal hygiene; partial to moderate assistance with upper body dressing, toileting, bed mobility which included sit to lying, lying to sitting on the side of the bed, sit to stand position, and chair to bed transfer, toilet transfer and tub/shower transfer. A review of Resident #2 ' s Care Plan, dated on 12/26/2023, revealed the resident had an Activities of Daily Living (ADL) self-performance deficit. Statement in the care plan: the assistance needed for self-care performance fluctuates and Resident #2 may require more or less assistance, therefore the staff will provide the needed assistance at the time based on the circumstances. Interventions included being able to feed self after setting up, extensive assistance with oral care, personal hygiene, dressing, bed mobility, and transfers needed. A review of Resident #2 ' s MDS Kardex Report printed on 06/21/2024, indicated Resident #2 needed extensive assistance with personal hygiene and dressing. A review of an activity of daily living task in the Documentation Survey Report, bed mobility, revealed Resident #2 required partial to moderate assistance 3 out of 7 days and substantial to maximal assistance on 3 out of 7 days and total dependency on 1 out of 7 days. For the task of toileting, required substantial to maximal assistance 4 out of 7 days, 2 out of 7 days of total dependence and 2 out of 7 days for partial to moderate assistance. The task of transferring, 4 out of 7 days required substantial or maximal assistance, 3 out of 7 days required partial to moderate assistance and 1 day Resident #2 was independent with transfer. During an observation on 10/28/2024 at 1:28 PM, Resident #2 returned to room after noon meal in the dining room, the area around the mouth, chin and hands were covered in orangish-red sauce from meal and the tee shirt that was worn was stained with droppings from the noon meal. Resident #2 had the appearance of not being shaved for several days as indicated by the hair growth on the cheeks and chin. During an observation on 10/29/2024 at 8:14 AM, Resident #2 ' s room was darkened due to the light being off. Resident #2 was sitting in wheelchair waiting to go to bed. Resident #2 in need of a shave due to facial hair growth on chin and cheeks. Droppings of food were noted on the shirt that was being worn at that time. During an observation on 10/29/2024 at 12:30 PM, Resident #2 was sitting at the dining room table eating lunch and was noted with long facial hair on chin and cheeks and the same shirt that Resident #2 was wearing at breakfast was still being worn with the same stains visible. During a concurrent interview and observation on 10/29/2024 at 1:47 PM, Resident #2 was made aware of the facial hair growth and the stains of food on the face and beard and that the shirt had not been changed since breakfast and was still soiled with droppings of food from breakfast and lunch and a large coffee stain around the neck of the shirt. When asked, Resident #2 stated a preference to be clean and did not want to be dirty. During an observation on 10/30/2024, CNA#4 and CNA#5 transferred Resident #2 to bed after breakfast. A gait belt was placed around Resident #2 ' s waist, the wheelchair was placed beside the resident's bed on the left side. The resident ' s jacket was removed. CNAs were on either side of Resident #2 and resident was asked to lean forward, with the use gait belt, Resident #2 was brought to a standing position with body bent forward, scooted feet to pivot and was placed in a seated position on the side of the bed with CNA#4 and CNA #5 providing maximal support for Resident #2. Once on the side of the bed, both CNAs had to assist Resident #2 to scoot further up to the head of the bed, CNA#5 turned the top half of the body while CNA #4 brought Resident #2's legs up and placed on the bed. During an interview on 10/30/2024 at 12:14 PM, CNA #4 stated the closet care plan was used to determine what type of assistance was needed with care provided to Resident #2. CNA #4 confirmed Resident #2 needed assistance with cleaning up, shaving and changing clothing. Confirmation was given by CNA #4, that Resident #2 was an extensive transfer of 2 staff members. During an interview on 10/30/2024 at 12:14 PM, MDS Coordinator stated to complete the MDS, observations were made, staff and residents were interviewed, and the chart was reviewed. The MDS coordinator confirmed the care plan was updated once the MDS had been completed. The MDS coordinator stated Resident #2 must have had a significant change, and the resident would be reevaluated. The MDS coordinator gave confirmation that the MDS and the Care Plan did not match on Resident #2. During an interview on 10/30/2024 at 3:00 PM, DON stated the inaccuracy of MDS ' had been identified and were brought to the attention of the Quality Assessment and Assurance Committee in June 2024. An action plan was put into place which included 1) Interdisciplinary team members were in-serviced to make sure information was entered correctly on the MDS the first time, 2) MDS coordinator and DON/Assistant Director of Nursing (ADON) in-serviced to ensure accuracy prior to signing and/or submitting the MDS, 3) The MDS coordinator will ensure the care plan was updated when completing the MDS, 4) MDS sections will be audited weekly to ensure all sections were being completed timely and accurately by the DON or designee, 5) hire new MDS coordinator, and 6) sign MDS coordinator up for training. DON stated the issue of MDS ' was discussed in the morning meetings and t the Administrator would have the minutes. When asked how the staff would know what plan to follow when caring for the residents, since the care plan, the closet care plan and the MDS did not match; DON stated the staff had a fall binder which would tell the staff what interventions had been put into place and what assistance would be required. During an interview on 10/30/24 at 3:10 PM, Administrator was asked to review the morning meeting minutes to see if there was any information regarding MDS inaccuracy issues. From June 2024 to October 2024, the Administrator confirmed there was no mention of MDS inaccuracy or care plan issues. Administrator confirmed there was a mention of the MDS inaccuracy in the July 2024 Quality Assurance meeting, but no further follow-up was documented in the following months. Administrator stated the DON had sent an email, titled Corrections/Plans from Mock Survey, dated 09/11/24 at 3:55 PM, stating five care plans would be reviewed in the morning start up. During an interview on 10/30/24 at 3:52 PM, DON provided paperwork showing care plan reviews but described no issues or how those issues were corrected. Most of the pages had no dates, no last names of residents and only 100 hall were provided. No other forms were provided to support any evidence that ongoing reviews for MDS and care plan inaccuracies were being completed.

Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure care plans were updated with accurate information and failed to resolve care plans that were no longer needed for 1 (Resident #2) of 3 residents reviewed for Care Plans. The findings are: 1. A review of a facility policy titled, Resident Rights, revised December 2016, indicated residents have the right to be informed of and participate in care planning and treatment. 2. A review of Resident #2 ' s Admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed set up or clean up assistance with eating and oral care, supervision or touching assistance with personal hygiene; partial to moderate assistance with upper body dressing, toileting, and bed mobility which included: sit to lying, lying to sitting on the side of the bed, sit to stand position, and chair to bed transfer, toilet transfer and tub/shower transfer. A review of Resident #2 ' s Care Plan, dated on 12/26/2023, revealed resident had an Activities of Daily Living (ADL) self-performance deficit. Statement in the care plan: the assistance needed for self-care performance fluctuates and Resident #2 may require more or less assistance, therefore staff will provide the needed assistance at the time based on the circumstances. Interventions include being able to feed self after setting up, and extensive assistance with oral care, personal hygiene, dressing, bed mobility, and transfers. A review of Resident #2 ' s MDS Kardex Report printed on 06/21/2024, indicated Resident #2 needed extensive assistance with personal hygiene and dressing. A review of an activity of daily living task in the Documentation Survey Report, titled bed mobility, revealed Resident #2 required partial to moderate assistance 3 out of 7 days and substantial to maximal assistance on 3 out of 7 days and total dependency on 1 out of 7 days. For the task of toileting, required substantial to maximal assistance 4 out of 7 days, 2 out of 7 days of total dependence and 2 out of 7 days for partial to moderate assistance. The task of transferring, 4 out of 7 days required substantial or maximal assistance, 3 out of 7 days required partial to moderate assistance and 1 day Resident #2 was independent with transfer. During an observation on 10/28/2024 at 1:28 PM, Resident #2 returned to room after noon meal in the dining room, the area around the mouth, chin and hands were covered in orangish-red sauce from meal and the tee shirt that was worn was stained with droppings from the noon meal. Resident #2 had the appearance of not being shaved for several days as indicated by the hair growth on the cheeks and chin. During an observation on 10/29/2024 at 8:14 AM, Resident #2 ' s room was darkened due to the light being off. Resident #2 was sitting in wheelchair waiting to go to bed. Resident #2 in need of a shave due to facial hair growth on chin and cheeks. Droppings of food were noted on the shirt being worn at that time. During an observation on 10/29/2024 at 12:30 PM, Resident #2 was sitting at the dining room table eating lunch and was noted with long facial hair on chin and cheeks and the same shirt that Resident #2 was wearing at breakfast was still being worn with the same stains visible. During a concurrent interview and observation on 10/29/2024 at 1:47 PM, Resident #2 was made aware of the facial hair growth and the stains of food on the face and beard and that the shirt had not been changed since breakfast and was still soiled with droppings of food from breakfast and lunch, and a large coffee stain around the neck of the shirt. When asked, Resident #2 stated a preference to be clean and did not want to be dirty. During an observation on 10/30/2024, CNA#4 and CNA#5 transferred Resident #2 to bed after breakfast. A gait belt was placed around Resident #2 ' s waist, the wheelchair was placed beside the resident ' s bed on the left side. The resident ' s jacket was removed. CNAs were on either side of Resident #2 and resident was asked to lean forward, with the gait belt, Resident #2 was brought to a standing position with body bent forward, scooted feet to pivot and was placed in a seated position on the side of the bed with CNA#4 and CNA #5 providing maximal support for Resident #2. Once on the side of the bed, both CNAs had to assist Resident #2 to scoot further up to the head of the bed, CNA#5 turned the top half of the body while CNA #4 brought Resident #2 ' s legs up and placed on the bed. During an interview on 10/30/2024 at 12:14 PM, CNA #4 stated the closet care plan was used to determine what type of assistance was needed with care provided to Resident #2. CNA #4 confirmed that Resident #2 needed assistance with cleaning up, shaving and changing clothing. Confirmation was given that Resident #2 was an extensive transfer of 2 staff members. During an interview on 10/30/2024 at 12:09 PM, the MDS Coordinator stated the treatment nurse and dietary are responsible for reviewing and updating care plans for their areas. The MDS Coordinator confirmed that the care plan was updated once the MDS has been completed. The MDS Coordinator stated Resident #2 must have had a significant change, and that resident would be reevaluated. Confirmation from the MDS coordinator was given that the MDS and Care Plan did not match on Resident #2. During an interview on 10/30/2024 at 3:00 PM, the Director of Nursing (DON) stated the inaccuracy of MDS ' had been identified and were brought to the attention of the Quality Assessment and Assurance Committee in June 2024. An action plan was put into place which included 1) Interdisciplinary team members were in-serviced to make sure information was entered correctly on the MDS the first time, 2) MDS coordinator and DON/Assistant Director of Nursing (ADON) in-serviced to ensure accuracy prior to signing and/or submitting the MDS, 3) MDS coordinator will ensure care plan is updated when completing the MDS, 4) MDS sections will be audited weekly to ensure all sections are being completed timely and accurately by the DON or designee, 5) hire new MDS coordinator, and 6) sign MDS coordinator up for training. DON stated the issue of MDS ' was discussed in the morning meetings and the administrator would have the minutes. When asked how the staff would know what plan to follow when caring for residents, since care plan, closet care plan and MDS did not match, DON stated staff had a fall binder which would tell what interventions had been put into place and what assistance would be required. During an interview on 10/30/24 at 3:10 PM, the Administrator was asked to review the morning meeting minutes to see if there was any information regarding MDS inaccuracy issues. From June 2024 to October 2024, Administrator confirmed there was no mention of MDS inaccuracy or care plan issues. Administrator confirmed there was a mention of the MDS inaccuracy in the July 2024 Quality Assurance meeting, but no further follow-up was documented in the following months. The Administrator stated the DON had sent an email titled, Corrections/Plans from Mock Survey, dated 09/11/24 at 3:55 PM, stating five care plans would be reviewed in the morning start up. During an interview on 10/30/24 at 3:52 PM, the DON provided paperwork showing care plan reviews, but no issues were described and no details on how those issues would have been corrected. Most of the pages had no dates, no last names of residents and only 100 hall was provided. No other forms were provided to support any evidence that ongoing reviews for MDS and care plan inaccuracies were being completed.

Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure the care plans were updated within the appropriate time frame with accurate information and failed to resolve care plans that were no longer needed for 3 (Resident #2, #14, and #23) of 3 residents reviewed for Care Plans. The findings are: 1. A review of a facility policy titled, Resident Rights, revised December 2016, indicated, residents have the right to be informed of and participate in care planning and treatment. 2. A review of Resident #2 ' s Admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain, and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed set up or clean up assistance with eating and oral care, supervision or touching assistance with personal hygiene; partial to moderate assistance with upper body dressing, toileting, and bed mobility which included: sit to lying, lying to sitting on the side of the bed, sit to stand position, and chair to bed transfer, toilet transfer and tub/shower transfer. A review of Resident #2 ' s Care Plan, dated on 12/26/2023, revealed the resident had an Activities of Daily Living (ADL) self-performance deficit. Statement in Resident #2 ' s care plan: assistance needed for self-care performance fluctuates and Resident #2 may require more or less assistance, therefore staff will provide the needed assistance at the time based on the circumstances. Interventions include being able to feed self after setting up, and extensive assistance with oral care, personal hygiene, dressing, bed mobility, and transfers. A review of Resident #2 ' s MDS Kardex Report printed on 06/21/2024, indicated Resident #2 needed extensive assistance with personal hygiene and dressing. A review of an intervention/task, in the Documentation Survey Report, titled, bed mobility, revealed Resident #2 required partial to moderate assistance 3 out of 7 days and substantial to maximal assistance on 3 out of 7 days and total dependency on 1 out of 7 days. For the task of toileting, Resident #2 required substantial to maximal assistance 4 out of 7 days, 2 out of 7 days of total dependence and 2 out of 7 days for partial to moderate assistance. The task of transferring, 4 out of 7 days required substantial or maximal assistance, 3 out of 7 days required partial to moderate assistance and 1 day Resident #2 was independent with transfer. During an observation on 10/28/2024 at 1:28 PM, Resident #2 returned to room after noon meal in the dining room, the area around the mouth, chin and hands were covered in orangish-red sauce from meal and the tee shirt that was worn was stained with droppings from the noon meal. Resident #2 had the appearance of not being shaved for several days as indicated by the hair growth on the cheeks and chin. During an observation on 10/29/2024 at 8:14 AM, Resident #2 ' s room was darkened due to the light being off. Resident #2 was sitting in wheelchair waiting to go to bed. Resident #2 in need of a shave due to facial hair growth on chin and cheeks. Droppings of food were noted on the shirt being worn at that time. During an observation on 10/29/2024 at 12:30 PM, Resident #2 was sitting at the dining room table eating lunch and was noted with long facial hair on chin and cheeks and the same shirt that Resident #2 was wearing at breakfast was still being worn with the same stains visible. During a concurrent interview and observation on 10/29/2024 at 1:47 PM, Resident #2 was made aware of the facial hair growth and the stains of food on the face and beard and that the shirt had not been changed since breakfast and was still soiled with droppings of food from breakfast and lunch, and a large coffee stain around the neck of the shirt. When asked, Resident #2 stated a preference to be clean and did not want to be dirty when asked. During an observation on 10/30/2024, Certified Nursing Assistant (CNA) #4 and CNA #5 transferred Resident #2 to bed after breakfast. A gait belt was placed around Resident #2 ' s waist, the wheelchair was placed beside the resident ' s bed on the left side. The resident ' s jacket was removed. CNAs were on either side of Resident #2 and resident was asked to lean forward, with the gait belt, Resident #2 was brought to a standing position with body bent forward, scooted feet to pivot and was placed in a seated position on the side of the bed with CNA #4 and CNA #5 providing maximal support for Resident #2. Once on the side of the bed, both CNAs had to assist Resident #2 to scoot further up to the head of the bed, CNA #5 turned the top half of the body while CNA #4 brought Resident #2 ' s legs up and placed on the bed. During an interview on 10/30/2024 at 12:14 PM CNA #4 stated the closet care plan was used to determine what type of assistance was needed with care provided to Resident #2. CNA #4 confirmed Resident #2 needed assistance with cleaning up, shaving and changing clothing. Confirmation was given that Resident #2 was an extensive transfer of 2 staff members. 3. A review of Resident #14 ' s Admission Record, indicated the facility admitted Resident #14 with diagnoses that included cerebral infarction, cerebellar stroke syndrome, dementia, pain, and seizures. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/2024, revealed Resident #14 had BIMS score of 7 which indicated the resident had moderate cognitive impairment. Resident #14 required set up or clean up assistance with eating, supervision or touching assistance with oral care, upper and lower body dressing, required substantial or maximal assistance with showering/bathing and applying or removing footwear, partial to moderate assistance with bed mobility and personal hygiene. Resident #14 was dependent with toileting hygiene and transferring from one surface to another. A review of Resident #14 ' s Care Plan, initiated on 02/16/2018, indicated total dependence on staff for bathing and showering and transferring required 2 staff with the use of a mechanical lift. Resident #14 was able to feed self after setting up, and extensive assistance was required with bed mobility, personal hygiene and dressing. A review of Resident #14 ' s MDS Kardex Report, printed 06/20/2024, indicated Resident #14 required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and total dependence for transferring. A review of an Activity of Daily living task in, the Documentation Survey Report, bed mobility for August 2024 revealed Resident #14 required total assistance with bed mobility 5 out of 7 days and partial to moderate assistance 2 out of 7 days. Toileting: 4 out of 7 days required total assistance, substantial to maximal assist for 1 out of 7 days and 2 days with partial to moderate assistance were required. During an observation on 10/28/2024 at 1:31 PM, Resident #14 was assisted to room by staff and 1 staff member was noted to be taking a mechanical lift into the room to assist the resident to bed. During an observation on 10/29/24 at 8:07 AM, Resident #14 was eating breakfast in the dining room without assistance. During an interview on 10/30/2024 at 4:10 PM, CNA #7 confirmed Resident #14 was unable to dress self, was transferred with a mechanical lift, and could not position self in bed. 4. A review of Resident 23 ' s Admission Record, indicated the facility admitted Resident #23 with diagnoses that included encephalopathy (fluid on the brain), dependence on renal dialysis, chronic kidney disease, Stage 4 (severe), and acute metabolic acidosis. Review of 5-day Medicare Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/2024, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. Resident #23 was not marked for taking a high-risk drug, a diuretic. A review of Resident #23 ' s Care Plan, initiated 12/09/2022 revealed Resident #23 was on diuretic therapy related to hypertension. Interventions included administering the diuretic medication and monitoring for side effects and effectiveness, monitoring dose; and to monitor, document and report as needed any adverse reactions to the diuretic therapy. A review of the Order Summary Report, revealed Resident #23 did not have an order for any type of diuretic. During an observation on 10/28/24 at 1:00 PM, Resident # 23 was lying in bed on right side eating lunch and watching television. During an observation on 10/29/24 at 8:11 AM, Resident #23 was lying in bed, watching television and voiced no concerns. MDS coordinator confirmed Resident #23 was no longer on a diuretic and the care plan was last updated on 12/09/2022. MDS Coordinator stated according to the discontinued physician orders, the diuretic had been discontinued on 04/12/2023. During an interview on 10/30/2024 at 12:09 PM, MDS Coordinator stated, the treatment nurse and dietary are responsible for, reviewing and updating care plans for their areas. MDS Coordinator confirmed the care plan was updated once the MDS has been completed. Stated Resident #2 must have had a significant change, and that resident would be reevaluated. Confirmation was given by MDS Coordinator that MDS and Care Plan did not match on either Resident #2, #14, or #23, and had not been updated when the MDS had been completed. During an interview on 10/30/2024 at 3:00 PM, the Director of Nursing (DON) stated the inaccuracy of MDS ' had been identified and were brought to the attention of the Quality Assessment and Assurance Committee in June 2024. An action plan was put into place which included 1) Interdisciplinary team members were in-serviced to make sure information was entered correctly on the MDS the first time, 2) MDS coordinator and DON/Assistant Director of Nursing (ADON) in-serviced to ensure accuracy prior to signing and/or submitting the MDS, 3) MDS coordinator will ensure the care plan is updated when completing the MDS, 4) MDS sections will be audited weekly to ensure all sections are being completed timely and accurately by the DON or designee, 5) hire new MDS coordinator, and 6) sign MDS coordinator up for training. DON stated the issue of MDS ' was discussed in the morning meetings and that Administrator would have the minutes. When asked how the staff would know what plan to follow when caring for the residents, since care plan, closet care plan and MDS did not match, DON stated staff had a fall binder which would tell what interventions had been put into place and what assistance would be required. During an interview on 10/30/24 at 3:10 PM, the Administrator was asked to review the morning meeting minutes to see if there was any information regarding the MDS inaccuracy issues. From June 2024 to October 2024, the Administrator confirmed there was no mention of MDS inaccuracy or care plan issues. The Administrator confirmed there was a mention of the MDS inaccuracy in the July 2024 Quality Assurance meeting, but no further follow-up was documented in the following months. The Administrator stated the DON had sent an email, titled Corrections/Plans from Mock Survey, dated 09/11/24 at 3:55 pm, which stated five care plans would be reviewed in the morning start up. During an interview on 10/30/24 at 3:52 PM, the DON provided paperwork showing care plan reviews, but no issues were described and no details on how those issues would have been corrected. Most of the pages had no dates, no last names of residents and only 100 hall was provided. No other forms were provided to support any evidence that ongoing reviews for the MDS and care plan inaccuracies were being completed.

Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure resident was shaved, failed to clean resident ' s face and hands after meals and failed to assist resident with changing clothing after being soiled during meals for 1 (Resident #2) of 1 resident reviewed for activities of daily living. Findings include: A review of a facility policy titled, Activities of Daily Living (ADLs), Supporting, revised in March 2018, indicated, residents who were unable to independently carry out ADLs would receive services to maintain good nutrition, grooming and personal and oral hygiene. A review of Resident #2 ' s Admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain, and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed supervision or touching assistance with personal hygiene; and partial to moderate assistance with upper body dressing. A review of Resident #2's Care Plan, initiated on 12/26/2023, revealed Resident #2 had an ADL deficit. Interventions included extensive assistance by one staff for personal hygiene and oral care and extensive assistance by one staff for dressing. A review of an intervention/task on the Documentation Survey Report, revealed Resident #2 had personal hygiene every shift, and staff were to layer clothing instead of applying loose articles such as a lap blanket to accommodate feeling cold while up to wheelchair related to mental awareness. A review of Resident #2 ' s MDS Kardex Report , printed on 06/21/2024, indicated Resident #2 needed extensive assistance with personal hygiene and dressing. A review of an In-service Education Report, dated 08/02/2024, indicated staff were in-serviced on ADLs, baths, wheelchairs, transfers, and gait belts. During an observation on 10/28/2024 at 1:28 PM, Resident #2 returned to room after noon meal in the dining room, the area around the mouth, chin and hands were covered in orangish-red sauce from meal and the tee shirt that was worn was stained with droppings from the noon meal. Resident #2 had the appearance of not being shaved for several days as indicated by the hair growth on the cheeks and chin. During an observation on 10/29/2024 at 8:14 AM, Resident #2's room was darkened due to the light being off. Resident #2 was sitting in wheelchair waiting to go to bed. Resident #2 was in need of a shave due to facial hair growth on chin and cheeks. Droppings of food were noted on the shirt being worn at that time. During an observation on 10/29/2024 at 12:30 PM, Resident #2 was sitting at the dining room table eating lunch and was noted with long facial hair on chin and cheeks and the same shirt that Resident #2 was wearing at breakfast was still being worn with the same stains visible. During a concurrent interview and observation on 10/29/2024 at 1:47 PM, Resident #2 was made aware of the facial hair growth and the stains of food on the face and beard and that the shirt had not been changed since breakfast and was still soiled with droppings of food from breakfast and lunch, and a large coffee stain around the neck of the shirt. When asked, Resident #2 stated a preference to be clean and did not want to be dirty. During an interview on 10/30/2024 at 8:55 AM, Certified Nursing Assistant (CNA) #4 stated Resident #2 did like to be shaved and that with dressing, it was extensive assistance that was needed. CNA #4 confirmed CNAs provide showers and sometimes Resident #2 will refuse to be shaved, only when not feeling good, but most of the time will allow staff to shave when needed. CNA #4 confirmed Resident #2's face and hands should have been cleaned prior to leaving the dining room, and shirt should have been changed if Resident #2 agreed and that it should have been offered. During an interview on 10/30/2024 at 12:39 PM, Director of Nursing (DON) confirmed Resident #2 should have had his face and hands cleaned prior to leaving the dining room and staff should have offered to change the soiled shirt.

Based on observation, record review, and interview, the facility failed to ensure the environment was free of potential hazards as possible, as evidenced by failure to ensure medications were stored and contained for 1 (Resident #41) of 1 sampled resident; and failed to ensure mattress's fit the bed frame to prevent potential accidental injury for 1 (Resident#53) of 1 sampled resident. The findings are: 1. Resident #41 had a diagnosis of diabetes mellitus and chronic kidney disease. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The resident required limited to extensive assistance with activities of daily living (ADL's). A review of Resident #41 electronic health record revealed no order to self-administer medications and was not care planned to self-administer medications. On 10/30/23 11:55 AM Resident #41 lying in bed watching tv. A bottle of rubbing alcohol (green) observed in the wheelchair next to the bed. A pink pill and a white pill were observed on the floor. Resident #41 was asked, what do you use the alcohol for? Resident #41 stated, astringent. On 10/31/23 10:07 AM Resident #41 was sitting in wheelchair in room. A bottle of rubbing alcohol was observed sitting on the bedside table. On 11/01/23 10:06 AM Resident #41 was observed lying in bed. A bottle of green alcohol was observed sitting on the bedside table. Certified Nursing Assistant (CNA) #1 was asked, what does Resident #41 use the alcohol for? CNA #1 stated, not sure, that's the first time I have seen it. CNA #1 was asked, why should alcohol not be left out in the resident ' s rooms? CNA #1 stated, usually if it says, keep out of reach we keep it out of the resident ' s rooms and if it's used as a medication, it should be put up for the resident's safety. CNA #1 was asked, why should pills not be left in the floor? CNA #1 stated, in case a resident comes by and takes it. On 11/02/23 10:42 AM Licensed Practical Nurse (LPN) #1 was asked, why does Resident #41 have a bottle of alcohol at the bedside? LPN #1 stated, I have no idea, it has been removed and placed in the cart. LPN #1 was asked, why should resident ' s pills not be left on the floor in their room? LPN #1 stated, because whoever medication it is, won't get scheduled dose, and any resident could wander in and take it and have an adverse reaction. 2. Resident #53 had a diagnosis of dementia, falls, and low back pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The resident required partial/moderate supervision and set up assistance for activities of daily living (ADL's). On 10/30/23 02:24 PM Resident #53 was observed sitting on the edge of the bed. There is a space approximately one foot between the foot of the mattress and the foot of the bed with the bed frame exposed. Resident was asked, is this your bed. Resident stated, yes. Resident was asked, how long have you been sleeping on this bed? Resident stated, a couple of months. On 10/31/23 09:47 AM A space approximately one foot between the mattress and the foot of Resident #53 bed was observed with the bed frame exposed. On 11/01/23 10:19 AM Resident # 53 was observed sitting on the edge of the bed. There is a space approximately one foot between the foot of the mattress and the foot of the bed with the bed frame exposed. On 11/02/23 11:05 AM Maintenance #1 was asked, why is there a space between the mattress and the foot board on R#53 bed? Maintenance #1 stated, I really don't know why, but I can find out and let you know.

Based on observation, record review and interview, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior and improve the quality of life for 2 (Resident #18 and #40) of 2 sample residents. The findings are: 1. Resident #40 had a diagnosis of dementia and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe impairment. The resident required extensive to dependent assistance for activities of daily living (ADL's). On 10/30/23 12:13 PM, Resident #40 in bed an area behind Resident #40 bed is an area peeling. A hole in the wall approximately 2 centimeters (cm) in diameter was observed on the wall behind Resident #40 bed. On 10/31/23 10:05 AM, Resident #40 observed in bed. The wall area behind the resident's bed was torn and peeling. A hole in the wall approximately 2 cm in diameter was observed on the wall behind Resident #40 bed. On 11/01/23 09:30 AM, the Administrator was asked, if something needs to be fixed, where is this documented? The Administrator stated, in the maintenance book at the nurses station. On 11/01/23 10:02 AM, Resident #40 observed in bed. Certified Nursing Assistant (CNA) #1 was asked, why is the wall behind Resident #40 bed torn and peeling, and a hole in the wall? CNA #1 stated, the bed is usually pushed against the wall, it's happened before, and it was fixed. On 11/02/23 10:48 AM, Maintenance #1 was asked about the peeling wall and hole behind Resident #40 bed and stated, I replaced it as soon as I found out about it yesterday. Maintenance #1 was asked, did you know about the wall and hole on 10/30/23? Maintenance #1 stated, no. Maintenance #1 was asked who was responsible for ensuring that things that need fixed are reported? Maintenance #1 stated, everyone. 2. Resident #18 had a diagnosis of dementia and chronic kidney disease. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 6, which indicated severe impairment. The resident required extensive assistance for activities of daily living (ADL's). On 10/30/23 12:05 PM, Resident #18 assisted out of bed with staff assistance. Resident #18 mattress is torn and peeling with shreds of plastic hanging down. A picture was taken. On 10/31/23 09:56 AM, Resident # 18 was observed in bed. The mattress has strips of plastic pieces torn and shredded and hanging from the mattress. On 11/01/23 10:00 AM, Resident #18 was observed in bed. The plastic mattress cover is torn and peeling and has strips of plastic hanging from the mattress. Certified Nursing Assistant (CNA) #1 was asked to describe Resident #18 mattress. CNA #1 stated, it's a standard mattress and the plastic cover of the mattress is torn and peeling. CNA #1 was asked, has this been reported and to whom? CNA #1 stated, I have not reported it, but it would be reported to maintenance. On 11/02/23 10:57 AM, Maintenance #1 was asked about the mattress on R#18 bed. Maintenance #1 stated, it was torn, peeling and could cause skin tears. I replaced it yesterday.

Based on observation, interview, and record review, the facility failed to ensure residents were assessed and deemed safe to self-administer updraft treatments using a nebulizer for 1 (Resident #4) of 4 (#1, #2, #3, and #4) sample mix residents, to prevent the potential of accidental overdose and/or other respiratory complications. The findings are: 1. Resident #4 had diagnoses of Respiratory Failure, Pneumonitis, and Quadriplegia. The 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/23 documented the resident scored 12 (8-12 moderately impaired) on the Brief Interview for Mental Status (BIMS), required extensive assist of one person for bed mobility, dressing, and eating; and required extensive assist of two persons for transfers, toilet use, and personal hygiene; had an impairment to both sides of upper and lower extremities and was always incontinent of bowel and bladder. a. The Physician Order with a start date of 01/22/23 documented, .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 3 mg [milligrams]/3ml [milliliters] Ipratropium-Albuterol 3 ml inhale orally six times a day for shortness of breath . b. The Care Plan with an initiated date of 01/27/23 documented, .the resident has Pneumonia r/t [related to] CVA (Cerebrovascular Accident) .give medications as ordered. Monitor/document for side effects and effectiveness . c. On 03/30/23 at 12:32 p.m., Resident #4 was lying in bed in his room. The nebulizer mask covered his mouth and nose, and it was turned on and running. There were no staff in the room with him. d. On 03/30/23 at 12:35 p.m., Licensed Practical Nurse (LPN) #1 entered Resident #4's room. She turned the nebulizer off and removed the nebulizer mask from his face. e. On 03/30/23 at 12:36 p.m., the Surveyor asked LPN #1, Does Resident #4 self-administer updraft treatments? LPN #1 replied, No, I ran off to take the phone call. The Surveyor asked, Who is responsible for staying with the resident when administering an updraft treatment? LPN #1 replied, Me, I usually stay with them. The Surveyor asked, Why should the nurse stay with the resident when administering an updraft treatment? LPN #1 replied, Because they can't take it off when it's done, and to make sure it's administered right. f. On 03/30/23 at 2:21 p.m., the Surveyor asked LPN #2, Do you have anyone who self-administers updrafts? LPN #2 replied, I'm not sure. The Surveyor asked, Who is responsible for staying with the resident when they receive an updraft treatment? LPN #2 replied, The nurse. The Surveyor asked, Why should the nurse stay with the resident when receiving an updraft treatment? LPN #2 replied, Because it's medication, and to monitor for effectiveness. g. On 03/30/23 at 2:23 p.m., the Surveyor asked the Director of Nursing (DON), Do you have anyone who self-administers updrafts? The DON replied, No. The Surveyor asked, Who is responsible for staying with the resident while receiving an updraft treatment? The DON replied, The nurse. The Surveyor asked, Why should the nurse stay with the resident during an updraft treatment? The DON replied, It's administration of a medication. The Surveyor asked What are your expectations from your staff regarding following the facilities policy and procedures and following the Centers for Medicare and Medicaid Services (CMS) guidelines? The DON replied, That they will follow them. h. On 03/30/23 at 3:29 p.m., the Surveyor asked the Administrator, Who is responsible for staying with the resident while receiving an updraft treatment? The Administrator replied, The nurse. The Surveyor asked, Why should the nurse stay with the resident while receiving an updraft treatment? The Administrator replied, In case anything goes wrong. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and following the CMS guidelines? The Administrator replied, It's a must. i. The facility policy titled, Self-Administration of Medication, provided by the DON on 03/30/23 at 2:54 p.m. documented, .residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so . j. The facility policy titled, Administering Medications through a Small Volume Handheld Nebulizer, provided by the DON on 03/30/23 at 2:54 p.m. documented, .the purpose of this procedure is to safely and septically administer aerosolized particles of medications into the resident's airway .obtain a physician's order as needed .review the resident's care plan .remain with the resident for the treatment .

Based on observation, interview, and record review, the facility failed to ensure foods stored in the refrigerators, freezers, and dry storage were consistently dated & labeled of when received, opened and/or prepared, failed to ensure foods stored in refrigerators, freezers, and shelves were sealed/closed completely, failed to ensure left-over food products were used or discarded within 3 days, failed to ensure foods being prepared were kept free of contamination by insects to ensure foods were distributed in sanitary conditions, and failed to ensure dish washer sanitizer level was checked with test strips each shift to ensure dishes were washed in sanitary conditions to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen in facility. These failed practices had the potential to affect 57 residents who received meals from the kitchen, as documented by list of 1 resident NPO (nothing by mouth) 7/29/22 received from Assistant Director of Nursing. The findings are: 1. On 07/25/22 at 10:04 AM, During initial tour of kitchen with Dietary Manager (DM), the following was observed: a. On 07/25/22 at 10:05 AM, Dry storage room contained the following: - a Ziploc bag of cereal [cheerios] not dated of when opened. The DM was asked about open date and DM stated, Oh, I thought only perishable foods needed to have more than a received date. That is new to me. - a Ziploc bag of spaghetti noodles (uncooked) not dated when opened - a Ziploc bag of elbow noodles (uncooked) not dated when opened b. On 07/25/22 at 10:11 AM, Three door stainless freezer contained the following: - Ziploc bag of chicken tenders not dated when opened - Ziploc bag of oriental blend vegetables not dated when opened - Ziploc bag of tater tots not dated when opened - Ziploc bag of cookie dough not dated when opened - Ziploc bag of pancakes not dated when opened - Ziploc bag of dinner rolls not dated when opened - Ziploc bag of hash brown triangles not dated when opened - Ziploc bag of beef tips not dated when opened - Ziploc bag of diced chicken not dated when opened - Ziploc bag of pork rib patties not dated when opened - pork roasts (2) wrapped in plastic wrap and then aluminum foil not dated when opened c. Under prep counter in middle of kitchen contained a box dated 7/12/22 with a cantaloupe covered in black sunken in patches and white fuzzy patches. DM stated, That needs to be thrown out. They don't last long. d. On 07/25/22 at 10:18 AM, Three door stainless refrigerator contained the following: - plastic square storage container of strawberries in red liquid dated 7/8/22. Surveyor asked if the date was the received date, open date, or thaw date. DM stated, either the received date or thaw date. I'm not sure. - Ziploc bag of capri veggie blend with brown liquid at bottom of bag dated '7/21/22' and written 'use by 7/21/22'. The DM was asked, How long are left-overs good for? DM stated, 3 days. I'll throw that out. - Ziploc of shredded lettuce with brown discoloration on approximately 1/2 of the lettuce in the bag not dated received or opened - bag of broccoli dated 7/21/22. DM stated, Those both [lettuce and broccoli] need to be thrown out. - 3 bags of pork patties dated 7/19/22. The DM was asked what that date was. DM stated, Probably thaw date. e. On 07/25/22 at 10:23 AM, the DM was asked if dish washer was high or low temp machine. DM stated, It's a low temp machine with sanitizer and we add chlorine too. the DM was asked to check ppm level. DM stated, I need to get them from my office. The DM was asked, How often do you check the ppm levels? DM stated, We don't test the chlorine or sanitizer levels. We just have them [EcoLab] come out regularly. The last time was about 2 weeks ago. The DM was asked, How do you know it is accurately working? DM stated, They [EcoLab] check it when they come. DM checked ppm. Surveyor asked what it registered. DM stated about 40 or so. Just below 50. The DM was asked what it needed to be at. DM stated, it does not say on the bottle. Sticker on dish washer stated, 'wash min[imum] 155 degrees' and 'rinse min[imum] 180 degrees'. The DM was asked, Would you test the sanitizer solution in the bucket staff are using for the counter tops? DM tested the solution and it turned dark purple. DM stated, Oh, that is way too high. DM stated to kitchen staff You need to make new solution. The chlorine is way too strong. 2. On 07/25/22 at 10:45 AM, Surveyor entered kitchen to watch puree and line service. Surveyor obtained plastic spoons from DM. DS#1 asked when surveyor wished to check puree. DS#1 was informed that puree would be checked once he was completed and was ready to cover the containers. DS#1 began puree process stating he had 8 puree and 20 mechanical soft but he typically made enough for 10 and 24 respectively. DS#1 pureed spaghetti noodles from colander resting on edges of sink, with cold water running over it. Surveyor noted ants on prep counter and windowsill. Surveyor noted ants crawling on edge of colander with pasta and in and out of holes in colander containing pasta. Spaghetti completed and put in pan and left next to food processor. Meat sauce, garlic bread, and vegetable mix pureed. DS#1 wiped counter and food processor with sanitizer solution in between each food being processed; wiping ants from prep counter. a. On 07/25/22 at 11:01 AM, DS#1 moved the 4 containers of puree to the center prep table in middle of kitchen and was about to place lids on them. Surveyor dipped a plastic spoon into each puree and then felt texture. Surveyor noted round balls of pasta in the spaghetti puree. Surveyor asked DM to feel the puree texture and asked to describe it. DM stated, Oh, it has balls. Spaghetti is difficult to puree. DM stated to [NAME], We need to redo the spaghetti. It had lumps; not big lumps, but big enough that we have to get them out. b. On 07/25/22 at 11:04 AM, The DS#1 was asked if he noted the presence of ants. DS#1 stated, Yes a few and he again wiped off prep counter. The DS#1 was asked, Anywhere else? DS#1 stated, No. DS#1 began to scoop noodles out of colander to put in pan. The DM was asked if she noted the presence of ants. DM stated, we just had them [pest control] come out last week. Surveyor pointed to colander. DM stated, Good thing we are redoing the puree. DM informed DS#1 to get water to make new spaghetti. DM threw out spaghetti. c. On 07/25/22 at 11:24 AM DS#1 scooped spaghetti puree from pan back into food processor. Surveyor asked, What are you starting now? DS#1 stated, I need to puree this more to remove the lumps. The DS#1 was asked, Where did the pureed noodles come from? DS#1 stated, Ah [explicative], I didn't even think of that. d. On 07/25/22 at 11:26 AM Surveyor received Pest control receipt from 7/26/22 stated Kitchen .spot treatment .Ants from DM. 3. On 07/25/22 at 11:13 AM Received Chlorine PPM guidelines with general guidelines that health inspectors look for from Human Resources. 4. On 07/29/22 at 07:25 AM, Food Storage policy received from Assistant Director of Nursing (ADON) stated, .8. All foods stored in refrigerator or freezer will be covered, labeled, and dated (use by date) . a. On 07/29/22 at 12:41 PM, Surveyor went to DM office and asked for manufacturer guidelines for the PPM test strips used, as the ones previously given was for another brand and type of test strip. DM stated, Oh, yes that was for the other type of test strips. We changed companies. Let me get a hold of them and see if they can send me one. Surveyor stated, So to clarify, you do not have a reference in order to know if the ppm level is correct or not. DM shook her head. b. On 07/29/22 at 01:20 PM, Test strip manufacturer instructions received from DM stated, .recommended ppm .the level is 50-100 ppm .

Based on observation, record review and interview, the facility failed to follow and implement an appropriate plan of action to correct an identified quality deficiency cited on the 2021 Annual Survey to monitor, track, and evaluate the effectiveness of accurately coding the Minimum Data Set (MDS) Plan for their Quality Assurance Corrective Action/Performance Improvement Activities/Plan (QACAPIAP). This failed practice had the potential to affect 58 Residents residing in the facility according to the Resident Census and Condition of Residents provided by the Nurse Consultant on 7/25/22 at 11:02 AM. The findings are: a. The 2567 dated 5/7/21 showed, Based on observation, interview and record review the facility failed to ensure the Minimum Data Set was coded correctly for 1 (Resident #36) of 5 (Residents #10, 32, 35, 36 and 43) final sampled residents who wandered in the facility. b. On 7/29/22: Based on observation, record review and interview the facility failed to ensure the MDS was completed in a timely manner for 1 (Resident #1). The facility failed to ensure the MDS was accurately coded to reflect Resident status for 1 resident (Resident #31). The facility failed to ensure the MDS assessment accurately reflected medication use based upon pharmaceutical category for 1 (Resident #50) who had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 7/29/22 at 10:50 AM, during the QAA/QAPI Facility Task, the Surveyor asked the Administrator, Were you aware you had a MDS accuracy deficiency in 2021? He said, I was aware of the deficiency in 2021 when I started in December 2021 after I looked over their last Annual Survey. The Surveyor asked, Have you developed a QAPI plan to address the MDS accuracy deficiency? He said, No. d. The Quality Assurance and Performance Improvement (QAPI) Plan received by the Administrator on 7/29/22 at 12:31 PM showed, Policy Statement: The facility shall develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality and resolve identified problems. Policy Interpretation and Implementation: The objectives of the QAPI Plan are to: 1. Provide a means to identify and resolve present and potential negative outcomes related to resident care and services; 2. Reinforce and build upon effective systems and processes related to the delivery of quality care and services; 3. Provide structure and processes to correct identified quality and/or safety deficiencies; 4. Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome; 5. Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively and to delineate lines of authority, responsibility and accountability; 6. Provide a means to centralize and coordinate comprehensive QAPI activities in order to meet the needs of the residents and the facility; and 7. Establish systems and processes to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program.

Based on record review and interview, the facility failed to notify the Resident and/or Resident Representative in writing of the reason for transfer to hospital in a language they understand for 3 (Resident #8, 34 and 156) of 8 (Resident #34, 8, 56, 38, 5, 42, 156 and 16) sampled residents who were transferred/discharged to the hospital in the last 120 days. This failed practice had the potential to affect 11 residents who were transferred/discharged to the hospital in the last 120 days as documented on a list provided by the Administrator on 7/27/22 at 8:07 AM. The findings are: 1. R #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/22 showed a Staff Assessment of Mental Status (SAMS) score of 3 (a score of 3 indicates severe cognitive impairment). a. The Progress Note dated 6/11/2022 at 11:26 AM showed, Orders Administration Note Text: resident sent to hospital on 6/10/2022 b. The Progress Note dated 6/15/2022 at 09:58 AM showed, Nsg-General Note Text: This nurse spoke with Registered Nurse (RN) at facility concerning an anticipated DC 6/10/22 date from the hospital. RN states resident is being discharged to (Hospital) States she has been medically cleared for discharge and they are awaiting clearance from Hospital to admit . c. The Progress Note dated 6/23/2022 at 10:42 PM showed, Nsg-General Note Note Text: Resident arrived at approximately 2030 [10:30 PM] via Northwest Transport on a stretcher. She is positive for COVID-19, but asymptomatic and is on isolation. She is AO [Alert and Oriented] x1 and mostly nonverbal. She is incontinent of bowel and bladder and requires limited assistance x1. Her bowel sounds are present in all four quadrants. Her skin is warm, dry, and normal in color with a turgor of less than three seconds. She does not have any teeth. PERRLA [Pupils equal round, reactive to light and accommodation]. Peripheral pulses are palpable. Lung sounds are clear. Resident denied any pain. Medication administered and tolerated well. Resident is resting quietly in her room with her eyes closed at this time. WCTM [will continue to monitor]. d. The Notice of Transfer/discharge date d 6/13/2022 provided by the Business Office Manager on 7/26/2022 at 3:20 PM showed, A. Facility Initiated Transfer: Complete this form when a resident is temporarily transferred to an acute care hospital, emergency room or other location. A copy of this notice must be provided to the resident and resident representative at the time of transfer unless it is an emergency. If an emergency the facility will issue as soon as practicable. 1. Date of Notice: 6/13/22 2. Date of transfer or discharge 6/10/22 3. Reason for the transfer: a. (checked) The discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs .4. Resident was transferred or discharged : (checked) 1. Hospital .C. Method of Delivery: 1. The resident and the resident's representative must receive a copy of this notice. Please indicate below the method in which this notice was delivered. (checked) 1. Notice was hand delivered to the resident .(checked) 4. Notice was mailed to the resident's representative . 2. R #156 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 6/25/22 documented a Brief Interview of Mental Status (BIMS) score of 1 (a score of 0 - 7 indicates severe cognitive impairment). a. The Progress Note dated 7/17/2022 04:04 PM showed, Nsg-I&A Note Physician Contact (Who/When): On [APN] notified @ 0105 [1:05 AM]. Family Contact (Who/When): R #156 Responsible Party, notified @ 0135 [1:35 AM]. Incident Description: Called to unit per Certified Nursing Assistant (CNA). Resident on the floor in her room lying on her right side. Resident denies hitting her head. No visible injuries observed. Resident stated she got up and her leg gave away and she fell . Resident was rubbing the outer area of her left upper thigh and stated it was hurting. ROM [Range of Motion] to extremity WNL. [Within Normal Limits] After getting resident up into a semi-sitting position and onto her bedside she was rubbing the outer area of her right upper thigh and stated it was hurting. Upon checking ROM resident would place her hand on the right outer area of her upper thigh. Resident moving upper and LLE [left lower extremity] without difficulty, PEARL [Pupils equal round and reactive to light]. Immediate Intervention: Sent to [emergency room ]. Vitals: 97.4, 68, 14, 120/100 . b. The Progress Note dated 7/19/2022 at 3:15 PM showed, Nsg-Admission Summary Note Text: Resident transferred to this facility from Hospital and arrived via stretcher to Rm #103B. Transferred to her bed x4 staff. MD/APN [Medical Doctor/Advanced Practical Nurse] notified that resident returned. Daughter and son aware that she has returned. admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The Facility Initiated Transfer Form dated 7/17/2022 provided by the Business Office Manager on 7/26/2022 at 3:20 PM showed, A. Facility Initiated Transfer: Complete this form when a resident is temporarily transferred to an acute care hospital, emergency room or other location. A copy of this notice must be provided to the resident and resident representative at the time of transfer unless it is an emergency. If an emergency the facility will issue as soon as practicable. 1. Date of Notice: 7/18/2022 2. Date of transfer or discharge 7/17/2022 3. Reason for the transfer: a. (checked) The discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs .4. Resident was transferred or discharged : (checked) 1. Hospital .C. Method of Delivery: 1. The resident and the resident's representative must receive a copy of this notice. Please indicate below the method in which this notice was delivered. (checked) 1. Notice was hand delivered to the resident .(checked) 4. Notice was mailed to the resident's representative . 3. R #34 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 6/6/2022 did not document a BIMS or a Staff Assessment of Mental Status (SAMS). The MDS showed, .Feeding tube .While a Resident .Proportion of total calories the resident received through [MEDICATION(S)] or tube feeding .51% or more . a. R #34 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. R #34 Care Plan last reviewed 12/2/2017 showed, .Focus: The resident requires tube feeding r/t [related to] late effects of [CONDITION(S)] [[CONDITION(S)] accident] .Interventions: The resident needs total assistance with tube feeding and water flushes. See MD orders for current feeding orders . c. Progress noted dated 5/20/2022 10:52 PM showed, .CNA reported to this nurse that PEG tube fell out of abdomen when changing patient. PEG tube appears intact and completely out of abdomen with deflated balloon. Skin appears intact. No signs of distress seen. Non emergent northwest transport notified. PEG tube and face sheet with patient upon transport . d. Progress note dated 5/21/2022 01:45 PM showed, .MD at NWMC ER notified this reporter that they will be admitting resident at this time due to ER unable to replace peg tube and it will have to replaced later this morning/today . e. Progress note dated 5/21/2022 at 1:57 PM showed, .Resident returned from hospital, having had PEG tube replaced. No s/sx [signs and symptoms] of pain or distress noted at this time, VSS [vital signs stable], feeding started at this time. WCTM [will continue to monitor] . f. R #34 The Notice of Transfer/discharge date d 5/21/2022 provided by the Nurse Consultant on 7/27/2022 at 11:30 AM showed, A. Facility Initiated Transfer: Complete this form when a resident is temporarily transferred to an acute care hospital, emergency room or other location. A copy of this notice must be provided to the resident and resident representative at the time of transfer unless it is an emergency. If an emergency the facility will issue as soon as practicable. 1. Date of Notice: 5/21/2022 2. Date of transfer or discharge 5/20/2022 3. Reason for the transfer: a. (checked) The discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs .4. Resident was transferred or discharged : (checked) 1. Hospital .C. Method of Delivery: 1. The resident and the resident's representative must receive a copy of this notice. Please indicate below the method in which this notice was delivered. (checked) 1. Notice was hand delivered to the resident .(checked) 4. Notice was mailed to the resident's representative . 4. On 7/27/2022 at 3:40 PM, the Surveyor asked the Business Office Manager, Who is responsible for the Hospital Transfer/Discharge Notices sent to the Resident's and/or their Responsible Parties? She stated, I am. The Surveyor asked, Where on these forms you have provided for R #8, #34 and #156 is the reason for transfer/discharge in a language they can understand documented? She stated, It's not, just documented that their discharge/transfer was necessary for wellbeing and the facility cannot meet the resident's needs.