**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of clinical record, and review of facility policy and procedures, the facility failed to ensure wounds were adequately assessed and monitored for one resident. The deficient practice could result in the clinical team not being fully aware of a resident's wound status and could lead to a delay of care for a worsening or non-healing wound.Findings include:Resident #10 was admitted to the facility December 10, 2024, with diagnoses that included atherosclerosis of native arteries of extremities with gangrene of left leg, polyneuropathy, and hypertension. The resident re-admitted to the facility on [DATE], with a new diagnosis of acquired absence of left leg below knee.A quarterly minimum data set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not assessed for Resident #10.A physician order dated June 12, 2025, and discontinued July 18, 2025, indicated to complete a skin check weekly.A care plan dated April 11, 2025, revealed Resident #10 had a skin impairment, with interventions to have a weekly skin assessment completed by a licensed staff, and to monitor, document, and report any changes in skin status to the physician.A Weekly Skin check and Wound assessment dated [DATE], revealed this was the first skin check of the resident's stay. The assessment revealed Resident #10 had the following skin impairments: Right toe(s): wound vac in place. There was no evidence of any other wounds, any measurements, or any other descriptors of the wounds to include color, odor, exudate, or tissue.A Weekly Skin check and Wound assessment dated [DATE], revealed the resident had the following skin impairments:Left toe(s): wound vac in place and functioning properlyLeft ankle (outer): treatment applied to open areasRight ankle (outer): treatment applied to open areasHowever, the assessment revealed no evidence of any measurements of the wounds, or any other descriptors of the wounds to include color, odor, exudate, or tissue.A Weekly Skin check and Wound assessment dated [DATE], revealed the following:Left toe(s): wound vac changed today. No drainage noted during dressing change, and wound appears smaller in size.Right ankle (outer): small open area healing well, and no drainage.Left lower leg (rear): serous drainage noted when dressing taken off.However, the assessment revealed no evidence of any measurements of the wounds.A Weekly Skin check and Wound assessment dated [DATE], revealed the following:Left toe(s): wound vac in place and functioning properly. No drainage noted during dressing change, and no odor.Right ankle (outer): small open area with no drainage noted, and area appears smallerLeft lower leg (rear): moderate amount of serosanguinous drainage noted on old dressing, and wound is moderate in size.However, the assessment revealed no evidence of any measurements of the wounds.A Weekly Skin check and Wound assessment dated [DATE], revealed the following:Left toe(s): wound vac intact and was changed today. Serosanguinous drainage noted, and wound appears smaller in size.Right ankle (outer): small open area with no drainage noted, and area appears to be healing and smaller in sizeLeft lower leg (rear): Serous drainage noted on dressing, and area appears to be healing well and is smaller in size.However, the assessment revealed no evidence of any measurements of the wounds.A Weekly Skin check and Wound assessment dated [DATE], revealed the following:Left toe(s): wound vac intact and was changed today. Serosanguinous drainage noted, and wound appears smaller in size.Right ankle (outer): small open area with no drainage noted, and area appears to be healing and smaller in sizeLeft lower leg (rear): Serosanguinous drainage noted on dressing, and foul odor noted.However, the assessment revealed no evidence of any measurements of the wounds.A Progress Note dated July 15, 2025, relayed that a surgical clinic called and stated that Resident #10 came in for an appointment and the results of the MRI show new osteomyelitis of the left 2nd toe and proximal space, and instructed to send the resident to the emergency room for treatment.A Weekly Skin check and Wound assessment dated [DATE], revealed this was the first skin check of the resident's stay, and that Resident #10 had a small open area to right calf and ankle, and additionally, a left below knee amputation surgical site. The assessment revealed no evidence of any measurements of the wounds, or any other descriptors of the wounds to include color, odor, exudate, or tissue.The clinical record was reviewed for Resident #10, and revealed no evidence of any other weekly wound assessments or measurements for the timeframe of June 12, 2025 through July 15, 2025.A facility Staff List revealed that the Assistant Director of Nursing (ADON / Staff #19) was hired on June 30, 2025.An interview was conducted with a Unit Manager and Licensed Practical Nurse (LPN / Staff #22) on August 26, 2025, at 11:57 am. Staff #22 stated that the ADON is taking on the role of wound nurse, and that the floor nurses do the daily wound treatments. Staff #22 stated that nurses monitor wounds to see if they are getting worse or better by completing weekly skin assessments and by observing the wounds during daily dressing changes and wound care. Staff #22 stated that signs of a healing wound include decreased drainage from the wound, decreased redness, and decreased size and odor. Staff #22 additionally stated that skin assessments include measurements of the wounds from week to week and that nurses use that to compare wound status, and that there could be risks to a resident if the wounds were not being measured.An interview was conducted with an LPN (Staff #3) on August 26, 2025, at 12:21 p.m. Staff #3 stated that nurses monitor wounds to determine if they are getting better or worse by completing weekly skin assessments. Staff #3 stated that the weekly skin assessment entails completing a full skin check, and making notes if anything is found. Staff #3 stated that she would know if a wound was getting smaller by doing a visual assessment and comparing the wound to something of a comparable size, such as size of a dime. Staff #3 stated that she believed that the ADON was taking measurements of the wounds with the provider. A telephonic interview was attempted with the ADON (Staff #19) on August 26, 2025, at 1:30 p.m. A voicemail was left for a return call. The staff did not return the call.An interview was conducted with the DON (Staff #85) on August 26, 2025, at 2:17 p.m. The DON stated that if a resident has wounds, nurses monitor to determine if they are getting better or worse by completing weekly skin assessments, and the ADON does weekly rounding on complex, extensive, or changing wounds. The DON stated that residents with wounds being measured would have the measurements recorded in the clinical record, if the measurements were taken prior to July 2025. The DON stated that signs that a wound is healing or worsening could include changes in size, borders, pain, and swelling, and that a nurse would know if the wound was getting smaller because the ADON does wound measurements upon the resident's admission. The DON stated that the floor nurses visualize the wounds and complete measurements if needed, but for complex wounds or pressure ulcers the staff would complete weekly wound measurements. The DON stated that if a skin assessment is not done completely or weekly, as ordered by the physician, then the risk to a resident could be not capturing skin integrity changes. The interview with the DON continued, and the clinical record was reviewed for Resident #10. The Weekly Skin and Wound assessment dated [DATE] was reviewed, and the DON stated that there were no measurements in that assessment because the facility accepted the wound measurements from the discharging hospital, which were stated by the DON as:Left posterior calf: 13.0 cm x 9.0 cm x 0.1 cmLeft posterior heel: 2.5 cm x 3.0 cm x 0.0 cmLeft posterior upper calf: 3.0 cm x 1.0 cm x 0.2 cmLeft medial ankle: 6.0 cm x 2.0 cm x 0.1 cmRight lower leg: 6.0 cm x 4.0 cm x 0.1 cmRight distal calf: 1.5 cm x 2.5 cm x 0.0 cmThe DON stated that it would not meet her expectation that the Weekly Skin and Wound Assessment from June 12, 2025 only listed wounds on the right toes, and that the assessment should have included the other wounds. The DON stated that she could not tell from the assessment what size the wounds were, if there was drainage or not, or if there were any odors, and that there is a possibility that something could have been missed.An interview was conducted with a clinical resource (Staff #40) on August 26, 2025, at 2:47 p.m. Staff #40 stated that weekly skin and wound assessments should have descriptors and measurements to delineate healing or nonhealing process.Review of the facility policy titled Wound Management Program, dated 2014, revealed that a thorough head to toe assessment of each resident's skin will be completed on admit and at least weekly thereafter. Residents with wounds are to be assessed weekly and reviewed in the skin and weight meeting while the wound is active and for two weeks after complete wound healing. Each wound will be monitored and progress documented at least weekly by the wound care team into the Electronic Health Record (EHR). Documentation to include type, location, measurements, exudate, odor, description of wound bed, periwound assessment and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, resident and staff interviews, the facility failed to ensure that one resident (#11) was discharged in a manner that prevented accident hazards. The deficient practice resulted in a resident being inadvertently discharged with a Peripherally Inserted Central Catheter (PICC) line in place, which could pose a risk of infection or potential misuse of the PICC line.Findings include:Resident #11 was admitted to the facility on [DATE] with diagnoses that included encephalitis and encephalomyelitis, extradural and subdural abscess, alcohol abuse with withdrawal, and generalized muscle weakness.Review of the care plan revealed a problem focus, dated April 19, 2025, which revealed that Resident #11 was receiving IV antibiotic medication. The goal in place for this focus was that the resident would not have any complications related to IV therapy. Interventions included administering IV per order via PICC line, changing the dressing per order, usage of EBP during high-contact care, and monitoring/documenting/reporting/ any signs of infection at the site.Review of the physician orders revealed the following orders:Ertapenem Sodium Injection Solution Reconstituted 1 GM (Ertapenem Sodium) Use 1 gram intravenously one time a day for CEREBRITIS until 05/20/2025 23: 59 - (Ordered 4/19/25)Discontinue IV/PICC line after completion of IV ABX and provider approval. one time only for ABX for 1 Day - (Ordered 4/19/25)Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also indicated that Resident #11 was receiving IV medications while a resident.Review of the NP note dated May 19, 2025 revealed that Resident #11 was receiving IV antibiotics with an anticipated end date of May 20, 2025.Review of a Medication Administration Note dated May 20, 2025 revealed that Resident #11's end date for his ordered Ertapenem was May 20, 2025. The note indicated that pharmacy would need an updated order to continue this medication, and that the provider was notified of this.Review of the discharge summary indicated that Resident #11 was discharged to the community and to his private home or apartment on May 21, 2025 at 8:00AM. The discharge summary indicated that Resident #11 was not going to receive home health services or medical equipment at home. There was no evidence found in the summary or the progress notes that the resident's PICC line was removed or was offered to be removed.Review of the Discharge MDS, dated [DATE], revealed that Resident #11 was not receiving any IV medications at discharge.Telephone interview was conducted on July 1, 2025 at 11:34AM with Resident #11, who confirmed that he was discharged from the facility with his PICC line still in his arm. The resident also claimed that he had told staff that he needed his PICC line removed while preparing to discharge, but the resident stated that he felt the staff were rushing him to discharge home and failed to remove it. Resident #11 also explained that he did not know what to do with the PICC once home. He explained that he could not shower because he knew he could not get the PICC line wet. The resident also stated that he eventually went to the hospital closest to him to get it addressed, though it took him several days to make arrangements to go to the hospital. The resident expressed frustration at the situation, and stated that he did not believe the facility assisted him at all with removing the PICC line or the costs associated with his subsequent hospital visit.Interview was conducted on July 1, 2025 at 1:04PM with a Licensed Practical Nurse (LPN/Staff #4), who stated that PICC lines should always be removed before discharging a resident, especially if they have drug-seeking behavior. The LPN identified the risks of discharging a resident without removing their PICC line to be that it is an infection risk, and the resident could put drugs into the PICC line. The LPN denied ever discharging a resident with a PICC still in place, but she thought it may have happened because she recalled receiving an in-service training about it recently.Interview was conducted on July 1, 2025 at 2:06PM with the Director of Nursing (DON/Staff #26), who stated that doctor's orders should be followed when determining if a resident can discharge with a PICC line or not. When asked about Resident #11, the DON stated that Resident #11 was not supposed to discharge with his PICC in place, and there were orders in place to remove the PICC line. The DON stated that Resident #11's family was rushing to leave with the resident. The DON also stated that the nurse had attempted to convince the resident to stay so that the PICC could be removed, but the family insisted on leaving. The DON explained that there was not an RN in the building at the time that the resident was trying to discharge with family, so the nurse had attempted to convince them to wait until an RN arrived to remove the PICC. When asked when the facility discovered that the resident discharged with the PICC, the DON stated that the resident reached out to the facility shortly after discharging. The DON explained that the resident chose to go to the hospital to remove the PICC line. When asked what impact this could have on the resident, the DON stated that she did not feel this had any impact or adverse reaction on the resident, and that the resident just wanted it out as he felt it was a bother.Interview was conducted on July 1, 2025 at 2:34PM with the Executive Director (ED/Staff #7), who stated that he first became aware that a resident had discharged with a PICC line in place on May 23, 2025 after receiving a call from a hospital. The ED stated that the hospital had informed him that Resident #11 had discharged with his PICC line still in place. Upon learning of this, the ED stated he reported the incident to the appropriate agencies, including the state agency. After investigating, the ED stated that he discovered that Resident #11 had discharged earlier in the day than what is standard, and that the discharge was rushed. The ED said that the family was rushing to take the resident, and the nurse seemed rushed, so this was how it was missed. The ED explained that the facility coordinated with the hospital to remove the resident's PICC. The ED also stated that he had called the resident after he went to the hospital, and that the resident was worried that it was in his arm, but he was happy that the facility was helping him. When asked about the risks of a resident discharging with a PICC line, the ED explained that he was not a clinician, but stated that it was a safety risk, as there would be risks for substance abuse or infection.Review of the facility policy titled, Admissions/Transfer/Discharges: Transfer or Discharge - Preparing a Resident for Discharge, revealed that residents should be prepared in advance for discharge. The policy listed that nursing services are responsible for tasks including: obtaining orders for discharge, including recommended discharge services and equipment; preparing the discharge summary; and preparing the medications to be discharged with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure one resident (#326) was treated with respect and dignity. The deficient practice could lead to psychosocial harm of a resident. -Findings include: Resident #326 was admitted to the facility on [DATE], with diagnoses that included hypotension, unsteadiness on feet, degeneration of nervous system due to alcohol, and unspecified dementia. A Health Status Note dated November 8, 2021, by a Registered Nurse (RN / Staff #112), revealed Resident #326 had a smoker's patch in place on the right arm. The resident stated rudely, If you people would let me smoke and let me out of here, I would be content!, as the resident raised his hand at the nurse. Staff #112 was startled and told the resident to please settle down and stop acting like a a**. Staff #112 offered to make the resident a sandwich, but, he settled with yogurt, and drank water. The resident was then resting peacefully. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. A facility Reportable Event Record / Report dated November 23, 2021, revealed in the evening of November 8, 2021, Staff #112 was in Resident #326's room while the resident was in bed resting, and was startled when the resident raised his arm abruptly and yelled at the staff member. The staff member was caught off guard and surprised and used language that was inappropriate for use around a resident. The resident did not take offense to what was said, and Staff #112 was able to calm the resident by offering food and something to drink. The resident was calmed and peaceful and had all of his needs met. There were no other incidents noted of similar behavior. The language used by the staff member was the result of being startled and was not meant in a personal or attacking way toward the resident. It is still not considered appropriate so the staff member was suspended and educated about customer service and appropriate behavior toward residents. Upon interview, Staff #112 explained that the language used was not meant to be personal to the resident, and was sorry for using it. The resident was also interviewed and stated to not have had any problem with a staff member or feel that he has been spoken to inappropriately or treated poorly. He was pleasant and happy with his care. An interview was conducted on May 20, 2025 at 10:31 AM, with a Certified Medication Assistant (CMA / Staff #66) who stated that if a staff member was overheard to speak to a resident disrespectfully, she would first ensure resident safety, then remove the staff who was doing that to the resident, contact the Director of Nursing (DON), and let the charge nurse know. Staff #66 stated that if a staff member was overheard saying stop acting like an a** to a resident, that would be inappropriate. Additionally, Staff #66 stated in a case where there is suspected verbal abuse, the facility's policy is to first, examine the picture for safety, then report it to the abuse coordinator right away. An interview was conducted on May 20, 2025, at 12:13 PM, with a Licensed Practical Nurse (LPN / Staff #72) who stated if a staff member speaks to a resident disrespectfully, Staff #72 would be expected to intervene, and ask the offending staff member to take a break, and Staff #72 would then take over the situation. Staff #72 stated that in cases of alleged abuse, staff have a 2 hour timeframe to report. Staff #72 stated if a staff member was overheard saying stop acting like an a** to a resident, that would be super inappropriate. An interview was conducted with the Director of Nursing (DON / Staff #56) on May 20, 2025, at 2:50 PM, who stated if she overheard a staff member speak to a resident disrespectfully, she would remove that staff from the patient care area and meet with the staff, then initiate an immediate investigation. The DON stated that if a staff member was overheard saying stop acting like an a** to a resident, that would be considered inappropriate. Review of the facility policy titled Code of Conduct, 2014, revealed standards of professional conduct are expected to be demonstrated by all employees. The following list is provided as examples of behavior that will result in disciplinary action up to and including termination and is not all- inclusive: violation of any zero-tolerance policy, abuse, disrespect of superiors, coworkers, residents or guests, harassment of all forms, fighting or instigation, substandard work, the violation of any Company policy or procedure presently in force, and violation of the Code of Conduct. Review of the facility policy titled Resident Rights, revised December 2016, revealed employees shall treat all residents with kindness, respect, and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, facility documentation and policy, the facility failed to ensure that one resident's (#47) consent was given prior to the administration of a psychotropic medication. The deficient practice could result in the resident not being informed of the risk and benefits of proposed care and not being given the opportunity to choose the care option of care he or she prefers. Findings include: Resident # 47 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, dementia with mood disturbance, anxiety, muscle weakness, and cognitive communication deficit. The admission Minimum Data Set (MDS) dated [DATE], revealed the resident had a brief Interview for Mental Status (BIMS) of 10 indicating the resident had impaired cognition. In addition, the Resident Mood Interview screening, revealed the resident scored a 0, indicating no concerns of depressive symptoms over the past two weeks. The MDS revealed no evidence of high-risk drug classes for anti-anxiety and antidepressants in the data set. The care plan for Antidepressant Medication, related to depression, was initiated on May 7,2025, with interventions that included to administer antidepressant medications as ordered by the physician. An order for one Bupropion HCL Extended release tablet for anxiety was dated May 11, 2025, three days prior to the psychotropic consent was signed. Review of the Informed Consent: Psychotropic Medication revealed consent for Bupropion an antidepressant for depression was declined by the resident's representative May 13, 2025 and witnessed by the facility representative the same day. According to the Medication Administration Record (MAR), 150 mg of Bupropion HCL ER was given once a day to the resident for anxiety on May 11, 2025 - May 13, 2025. An interview was conducted on May 19, 2025 at 9:30 a.m., with the resident's representative. The representative revealed concerns the resident was given an antidepressant without consent. The representative revealed it was the family's wish and decision to hold off on the antidepressant in order to not impede the resident's plan to re-introduce turmeric and curcumin into the medication regimen. The representative expressed discontent upon discovering the resident was given medication without consent. An interview was conducted with Licensed Practical Nurse (LPN/Staff #72) 05/19/25 at 10:36 a.m., revealed consent for psychotropics are done prior to the medication being given. This prevents the resident from receiving medications they may not want. A panel discussion was conducted on May 20, 2025 at 9:20 a.m. with the clinical resource (Staff # 250 , and the Director of Nursing (DON/Staff #56). Both parties reviewed the psychotropic consent and the Bupropion administration dates during the interview. The parties agreed that consents should be obtained before administration of meds, just in case the resident refuses the medication. Both parties agreed the facility expectation was not met expectation for this resident. The facility expectation is to get the consent signed before administration, as the facility mandates psychotropics consents are obtained prior to given the medication. The facility's Resident's Rights/Dignity policy, effective January 1, 2024, revealed the resident is to be informed and participate in his or her care planning and treatment. The facility's Psychotropic Medication Use policy, effective January 1, 2024, revealed the resident has the right to decline treatment with psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record, staff interviews, review of facility documentation, policy and procedures and the State Agency (SA) database the facility failed to implement their policy regarding conducting thorough investigation of abuse/neglect allegation and protecting residents from further abuse for two residents (#26 and #171). The deficient practice could result in abuse/neglect continuing and not being prevented. Findings include: Regarding resident #26 (alleged victim) -Resident #26 was admitted to the facility on [DATE] with diagnoses that included hypotension, chronic kidney disease, and nocturia. Review of the SA database revealed that a self-report was submitted by the facility on January 4, 2023. The report indicated an allegation of neglect. However, it did not detail information on what occurred nor did it indicate who the alleged perpetrator was. The report did not identify that the perpetrator was a staff member and whether the staff member was suspended pending an investigation. However, review of the resident's clinical record did not reveal any progress notes related to the incident. Additionally, there was no indication that the resident was assessed or that notifications to the provider, and other required agencies were made. Review of the 5-day investigation report dated January 20, 2023 indicated that an allegation of neglect was reported regarding a Certified Nursing Assistant (CNA/staff #666) related to resident #26. It was alleged that staff #666 told resident #26 that he should not use the call light for at least an hour since she just got him situated. The report revealed that the facility's investigation did not include interviews of residents and staff members. The report did not include witness statements. Although there was a summary of interview of the alleged victim, alleged perpetrator, and witness, it did not state when the interviews were conducted nor did it identify who the witness was. Further review of the 5-day investigation report also revealed that the facility did not indicate what action was taken after they were notified of the allegation. The investigation concluded that resident neglect did not occur. However, the report noted that the alleged perpetrator was on an improvement plan due to incidents of poor customer service and unprofessional conduct, but never anything that was seen as abuse or neglect. Regarding staff #666 (alleged perpetrator) Review of staff #666's personnel file revealed a job description for a Certified Nursing Assistant (CNA) dated September 30, 2022. Among the tasks and responsibilities identified stated that the CNA will provide direct care and assist residents with activities of daily living including dressing, eating, grooming, communicating, ambulation, toileting, and personal hygiene. A corrective Action Form signed January 12, 2023 documented that staff #666 had a history of complaints pertaining to patient care. The form documented instances in which staff #666 failed to provide ADL care/services to residents who needed her assistance resulting in her placement on Written Warning for Professional Conduct/Poor Performance. Review of the Corrective Action Form signed January 16, 2023 revealed that on January 13, 2023 a resident's daughter reported staff #666 for failure to assist resident with her meal and instead was observed with her feet propped up on the resident's bed playing a game on her phone. This incident resulted in staff #666 being terminated. A 5-day investigation report dated January 20, 2023 included an undated interview summary conducted with staff #666. The interview summary indicated that per staff #666 she was misheard and was only trying to educate the resident on appropriate call light usage after she had assisted him with his personal care. The report noted that staff #666 was on an improvement plan due to incidents of poor customer service and unprofessional conduct. An interview with a Certified Nursing Assistant (CNA/staff #29) was conducted on May 20, 2025 at 9:51 a.m. Staff #29 stated that neglect can encompass not checking on residents, not providing needed care and services, and not supporting them with their ADL (activities of daily living) needs. The CNA noted that the importance of not neglecting residents is for their safety and comfort. The potential impact of neglect is that residents can feel unsafe, depressed, and discomfort. Staff #29 stated familiarity with resident #26. However, the CNA stated that she could not recall an incident of neglect involving the resident. Regarding resident #171 (alleged victim) -Resident #171 was admitted to the facility on [DATE] with diagnoses that included monoplegia, chronic heart failure, and depression. Review of the SA database revealed that a self-report was submitted by the facility on November 9, 2022. The report indicated an allegation of family to resident verbal abuse. The report did not indicate whether the family member was separated from the resident and not allowed access to the resident pending an investigation. A progress note dated November 9, 2022 revealed that shouting was heard from the resident's room. Staff found resident and husband arguing. The note indicated that the resident was separated from the spouse and that the spouse was asked to leave. The note documented that the resident was visibly upset, had to be comforted, and given time to express feelings. The note also indicated that the physician, administrator, and DON was informed of the incident. Further review of the resident's clinical record revealed a progress note dated November 10, 2022 which documented that the resident stated that she was really depressed in part since her husband blames her for putting herself in the facility. The note indicates suicidal ideation as a result. However, there was no mention regarding the prior day's incident with the husband. Furthermore, there was no indication that resident's interaction with husband will be monitored or that visitation is limited pending investigation. Review of the undated 5-day investigation report submitted by the facility on November 15, 2022 revealed that the facility's investigation did not include interview with the alleged perpetrator (family member) or potential witnesses. The report did not contain witness statements. Although there was a summary of interview of the alleged victim and a witness, the summary did not indicate when the interviews were conducted nor did it identify who the witness was. An interview with a Certified Nursing Assistant (CNA/staff #29) was conducted on May 20, 2025 at 9:51 a.m. Staff #29 stated that in instances of abuse, the staff will separate the resident from the alleged perpetrator to ensure safety. This is important in order to maintain the resident's dignity and safety. According to the CNA, the impact of resident abuse is trauma which can lead to behaviors. Staff #29 said that following the policy regarding conducting a thorough investigation of allegations of abuse/neglect and protecting residents from further abuse/neglect is important to ensure that the facility is doing its due diligence to investigate and ensure the safety of residents. The impact of not following the policy regarding conducting a thorough investigation and protecting residents from further abuse is that residents would feel like they could not speak up when something happens, feel like the abuse/neglect will happen again, and assume that the facility does not follow-through on allegations. The CNA stated that she was not familiar with resident #171. During an interview with a Licensed Practical Nurse (LPN/staff #72) conducted on May 20, 2025 at 12:21 p.m., staff #72 stated that following the policy for conducting a thorough investigation and protecting residents from further abuse/neglect is important since you do not want the abuse/neglect to continue or happen to others. The LPN stated that the impact of not following the policy regarding conducting a thorough investigation and protecting residents from further abuse/neglect is that it can create tension, and not have a healthy environment in which residents do not feel safe. Staff #72 stated familiarity with resident #26 but was unfamiliar with the incident. Additionally, the LPN said that she was unfamiliar with resident #171. An interview with the Director of Nursing (DON/staff #56) was conducted on May 20, 2025 at 1:03 p.m. Staff #56 stated that her expectation is that staff defer to the policy and refer to it to ensure they are touching all the points. This is important to ensure that all steps are followed and that they are not missing a bullet point. According to the DON the impact of not following policies is the possibility of missing a step that can affect the outcome. The facility policy titled Abuse revision 0622 indicated that the facility strives to prevent abuse of all their residents. According to the policy, abuse also included the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The Reporting and Investigation section of the policy stated that a minimum of three residents will be interviewed to determine if there is a trend. Interviews may also include the alleged perpetrator, witnesses, and staff members as applicable. The policy noted that if the alleged perpetrator is an employee, they will be immediately suspended pending the result of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, staff interviews, and review of facility process and policy the facility failed to ensure that all transfer/discharge notifications were made for one resident (#176). The deficient practice could lead to notifications of resident transfer/ discharge not being made to all required parties. Findings include: Resident #176 was admitted to the facility with diagnoses that included hyperlipidemia, bipolar disorder, anxiety disorder, and gastro-esophageal reflux disease. Review of the resident's face sheet revealed that the resident #176 had a Public Fiduciary identified as his responsible party, guardian, and emergency contact. The face sheet also listed the contact information for the responsible party which included an office number, fax number, and e-mail address. A Discharge assessment dated [DATE] revealed the reason for the assessment as hospital transfer. The section Parties notified prior to transfer? indicated a check mark that responsible party was notified but did not annotate who was notified and when. A discharge Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has modified independence regarding cognitive skills for daily decision making. Review of the Order Summary Report did not reveal any order for the resident to be sent to the hospital or indicate that responsible party was notified. An IDT (Interdisciplinary Team) Care Plan Conference note dated August 4, 2022 documented that resident did not attend the conference due to being COVID (Coronavirus) positive. The note indicated that the fiduciary wanted to speak with the resident. The note documented that the facility would set up a video call meeting to enable them to talk later. The note indicated that the resident as having difficulties breathing and was sent to the ER (emergency room) but has since returned. However, review of the resident's Census List indicated that when the resident discharged on August 4, 2022, the resident did not return to the facility until August 21, 2022. Additionally, review of resident #176's progress notes did not reveal any documentation regarding the resident being sent and admitted to the hospital. Furthermore, there was no documentation that the fiduciary was notified that the resident was sent and admitted to the hospital. Review of an ER report dated August 4, 2022 revealed that resident #176 presented to the ER, COVID positive, with oxygen saturation of 83%, productive cough, body aches, and headache. The report indicated that the resident was being admitted due to concern of bacterial process overlying his COVID-pneumonia. Review of a complaint intake submitted to the State Agency (SA) on August 5, 2022 revealed a complaint from the resident's responsible party/public fiduciary regarding transfer/discharge notification. The complaint alleges that during a care conference convened on August 4, 2022, the responsible party was informed that the resident was in his room following an ER visit for breathing issues. The responsible party asked to have a video conference scheduled later that day so he can discuss the resident's plan of care. However, later on, the responsible party was informed that he could not speak with resident #176 since he was still in the hospital. The responsible party alleges that he was not notified of the resident's transfer to the hospital until the care conference and that the facility did accurately inform him of the resident's status. Review of resident #176's hospital progress notes revealed that he was admitted to the hospital on [DATE]. His disposition was documented as poor prognosis and expected prolonged hospital stay. Further review of the progress notes revealed that the resident was not discharged back to the facility until August 21, 2022. An interview was conducted with a Certified Nursing Assistant (CNA/staff #29) on May 20, 2025 at 9:51 a.m. Staff #29 stated that when a resident is transferred/discharged , the responsible party/public fiduciary is notified by the nurse prior to the transfer. The CNA said that the notification is documented on the assessment as well as on the progress notes. Staff #29 noted that notification of the responsible party/public fiduciary is important so that they can be informed of what is happening with the resident and be there for support, especially if the resident is unable to communicate well. According to the CNA, the impact of not notifying the responsible party/public fiduciary is frustration from lack of communication. Staff #29 said that she was not familiar with resident #176. During an interview with a Licensed Practical Nurse (LPN/staff #72) conducted on May 20, 2025 at 12:21 p.m., staff #72 stated that in the event that a resident need to be transferred to the hospital, the public fiduciary is notified. The LPN said that the notification is documented in a progress note. The note should document that notification was made or that the fiduciary could not be reached. Staff #72 stated that it is inappropriate to not notify the public fiduciary because they need to be notified. The LPN noted that it is important to notify the responsible party/public fiduciary so that they can be aware of the resident's status. The impact of not notifying the responsible party/public fiduciary is that the resident could end up at a place that the responsible party/public fiduciary does not approve of or not prefer. Additionally, the resident will be alone and not have the support of the responsible party/public fiduciary if they are unaware of resident's status. The LPN indicated that she is not familiar with resident #176. An interview with the Director of Nursing (DON/staff #56) was conducted on June 17, 2025 at 1:03 p.m. Staff #56 stated that the POA (power of attorney)/family member/public fiduciary is normally notified about transfers unless the resident or they request not to be notified. The notification is normally documented on the discharge assessment or the progress note. The scenario pertaining to resident #176 was presented to the DON and she indicated that it was inappropriate that the public fiduciary was not notified. Staff #56 said that it is important to notify POA/public fiduciary specifically if they need to be involved in the decision making in order for them to know how to support the resident, and to be able to act as the resident's support when the resident is outside of the facility. The DON indicated that the impact of not notifying the POA/public fiduciary is that it can cause a possible issue with assistance, decision making, and would not be there to assist the resident. A policy titled Admissions/Transfers/Discharges: Transfer or Discharge Documentation indicated that when a resident is transferred or discharged from the facility, information that an appropriate notice was provided to the resident and/or legal representative will be documented in the medical record. Review of the facility policy titled Admissions/Transfers/Discharges: Transfer or Discharge - Emergency indicated that if it becomes necessary to make an emergency transfer or discharge to a hospital or other related institution, the facility will notify the representative or other family member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to accurately complete a comprehensive Minimum Data Set (MDS) assessment within the required timeframe for one resident (#34). The deficient practice could result in delayed identification of potential risks and care needs. Findings include: Review of resident #34's hospital records prior to his admission to the facility revealed a progress note dated January 10, 2023 which documented that the resident is incompetent to make his own decision. The note indicated that the resident has a public fiduciary. A hospital progress note date January 24, 2023 documented that the resident had a history of cognitive impairment. The note indicated that resident was inpatient status at the hospital and needed long term care that can accommodate his needs. The note stated that the hospital was waiting on public fiduciary for assistance to place resident in a facility. Resident #34 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of mandible, tempomandibular joint disorder, and severe protein-calorie deficit. A speech therapy eval dated February 3, 2023 documented that the resident had a history of cognitive impairment and had a guardian. A progress note dated February 6, 2023 documented that the resident was a poor historian, had cognitive impairment, and had cognitive communication deficit. However, review of the resident's MDS assessments revealed that an admission assessment conducted in February 7, 2023 did not contain a Brief Interview for Mental Status (BIMS) score. The cognitive patterns section was left blank regarding whether the resident could be interviewed to determine a BIMS score. Additionally, the section pertaining to staff assessment for mental status was also left blank. During an interview with a Certified Nursing Assistant (CNA/staff #29) conducted on May 20, 2025 at 9:51 a.m., staff #29 stated that resident #34 has some confusion. The CNA stated recalling the incident in which resident #34 left the facility and was found walking on the road. Staff #29 said that the resident was found up the road, about a mile away. The CNA said that when the resident was asked what he was doing, resident #34 stated that he was walking. Staff #29 said that the way resident #34 presented was misleading and so the staff did not realize that his cognition was not as good as it seemed. An interview with a Licensed Practical Nurse (LPN/staff #72) was conducted on May 20, 2025 at 12:21 p.m. Staff #72 stated that as part of the assessment, they also review information from where the resident is coming from such as hospital records. Information such as fall risk, elopement risk, and cognition. Accurate assessment is important because for example if a resident is cognitively impaired but ambulatory, they can be an elopement risk and need to be monitored/supervised. Otherwise, there could be a risk of the resident eloping and getting hurt. The LPN indicated familiarity with resident #34. Staff #72 stated that resident #34 is ambulatory and loves to walk around. The LPN said that resident #34 has episodes of confusion. During an interview with the Director of Nursing (DON/staff #56) conducted on May 20, 2025 at 1:03 p.m., staff #56 stated that it is important to assess a resident's cognition and know the cognition level of a resident. The DON indicated that depending on the level of cognition there is a criterion that triggers for an elopement risk. Staff #56 noted that it is important to accurately assess residents to protect them from risks and possible dangerous situation. The DON said that the impact of not accurately assessing residents is the possibility of negative/dangerous situation. Review of the facility's Wander Risk Eval revealed that among the areas that are factored in in determining a wandering risk scores is Orientation and Behavior/Mood. Review of the RAI manual, dated October 2019, revealed that the primary purpose of the MDS assessment tool is to identify resident care problems that are addressed in an individualized care plan. The manual included that the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD), and there can be no more than 366 days between comprehensive assessments. The facility policy titled Behavioral Assessment, Intervention and Monitoring revise December 2016 indicated that as part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness. Additionally, the policy noted that a part of the comprehensive assessment, the staff will evaluate, based on input from the resident, family, caregivers, review of medical records and general observation the resident's usual patterns of cognition, mood, and behavior. The policy indicated that the interdisciplinary team will evaluate behavioral symptoms to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Furthermore, the policy noted that the care plan will incorporate findings from comprehensive assessment and be consistent with current standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure that one resident's (#34) cognitive communication deficit was appropriately care planned and implemented. The deficient practice could result in a plan of care that does not meet the resident's needs. Findings include: Review of resident #34's hospital records prior to his admission to the facility revealed a progress note dated January 10, 2023 which documented that the resident is incompetent to make his own decision. The note indicated that the resident has a public fiduciary. Resident #34 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of mandible, tempomandibular joint disorder, and severe protein-calorie deficit. A speech therapy eval dated February 3, 2023 documented that the resident had a history of cognitive impairment and had a guardian. A progress note dated February 6, 2023 documented that the resident was a poor historian, had cognitive impairment, and had cognitive communication deficit. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #34 has difficulty communicating some words or finishing thoughts but is able if prompted or given time. The MDS also noted that the resident misses some part/intent of message but comprehends most conversation. Further review of the admission MDS dated [DATE] did not contain a Brief Interview for Mental Status (BIMS) score. The cognitive patterns section was left blank regarding whether the resident could be interviewed to determine a BIMS score. Additionally, the section pertaining to staff assessment for mental status was also left blank. The assessment also indicated that the resident is ambulatory and does not use any mobility device. A communication care plan initiated on February 12, 2023 revealed that the resident has jaw carcinoma impacting his ability to communicate. Interventions included to anticipate/meet needs, monitor effectiveness of communication strategies, and use communication techniques which enhance interaction. However, further review of the care plan did not indicate that the resident's cognition impairment was addressed. There was no evidence that the facility had interventions in place to mitigate issues/concerns his impaired cognition could cause. Additionally, review of the resident's clinical record did not reveal any indication that the resident's cognition impairment was addressed or interventions put in place to mitigate issues/concerns his impaired cognition could cause. A progress note dated March 9, 2023 revealed that the resident was found ambulating on the street with a walker. The note indicated that a staff member escorted resident #34 back to the facility. According to the progress note, the resident stated that he was walking in the parking lot and took a wrong turn. The note documented that a wander guard was placed on the resident. A progress note dated March 10, 2023 documented that resident #34 was found down the street from the facility. According to the progress note a staff member drove to where the resident was located and escorted the resident as he walked to guide him back to the facility. The note documented that the resident stated that he got confused while walking and had to confirm with the staff as he walked which direction to go. An interview with a Licensed Practical Nurse (LPN/staff #72) was conducted on May 20, 2025 at 12:21 p.m. Staff #72 stated that a care plan is important in order to have a plan in place for a resident's known issues, deficits, and impairments. The impact of not having a care plan is that the condition would not be address and appropriate interventions not put in place. An example would be for elopement risk, if it is not properly care planned, the resident can get hurt. The LPN indicated familiarity with resident #34 and noted that he was confused at times. During an interview with the Director of Nursing (DON/staff #56) conducted on May 20, 2025 at 1:03 p.m., staff #56 stated that it is important to assess a resident's cognition and know the cognition level of a resident. The DON indicated that depending on the level of cognition. Staff #56 noted that it is important to accurately assess residents to have interventions in place to protect them from risks and possible dangerous situation. The DON said that the impact of not having interventions in place is the possibility of negative/dangerous situation. The facility policy titled Assessments/Care Planning: Care Plans, Comprehensive Person-Centered indicated that it is the facility's policy to include measurable objectives and timetable to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Furthermore, assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The facility policy titled Behavioral Assessment, Intervention and Monitoring revise December 2016 indicated that as part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness. Additionally, the policy noted that a part of the comprehensive assessment, the staff will evaluate, based on input from the resident, family, caregivers, review of medical records and general observation the resident's usual patterns of cognition, mood, and behavior. The policy indicated that the interdisciplinary team will evaluate behavioral symptoms to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Furthermore, the policy noted that the care plan will incorporate findings from comprehensive assessment and be consistent with current standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident's comprehensive care plan was reviewed and revised to meet the resident's needs for one resident (#324). The deficient practice could lead a resident not receiving care and services to meet their needs, which could lead to harm or injury. -Findings Include: Resident #324 was re-admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, personal history of traumatic brain injury, dementia, unspecified abnormality of gait and mobility, cognitive communication deficit, anxiety disorder, and need for assistance with personal care. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) assessment that was not completed. Section J revealed the resident had two or more falls with injury since admission, re-entry, or prior assessment. A care plan initiated February 6, 2023, revealed Resident #324 was at risk for falls or had an actual fall. Interventions included to follow the facility fall protocol, follow Falling Leaf Program, be sure the call light is in reach and encourage the resident to use it for assistance, anticipate and meet the resident's needs, therapy evaluations and treatments as ordered or as needed, and encourage the resident to participate in activities that promote exercise, physical activity, strengthening, and improved mobility. An additional care plan intervention was initiated on February 9, 2023, to have a Call Don't Fall as a reminder. Following this update, there was no evidence of any further care plan updates to address the resident's falls from February 9, 2023 until March 4, 2023. An admission Evaluation - Nursing note dated February 6, 2023, revealed Resident #324 admitted from acute hospital via wheelchair for fracture of left humerus. The resident was alert and oriented x 1, and highly confused. An Alert Charting Change of Condition Summary, dated February 6, 2023, revealed the resident was found on the floor. He was attempting to ambulate without assistance. The resident is very confused and very forgetful. No injuries noted at this time. Notifications to appropriate parties were made. A Daily Skilled Evaluation dated February 7, 2023, revealed Resident #324 was found outside of the building and was wandering around on the sidewalk. Resident was redirected to the nursing station for supervision and had a wander guard applied to his right ankle. Resident is alert, but only oriented to himself, he does not say much. He was squirming around in the bed, so he was transferred to his wheelchair to avoid a fall. The resident then made it outside as mentioned above. A Fall Incident Report dated February 8, 2023, revealed the resident was found lying on the floor in his room by a Certified Nursing Assistant (CNA), with no injuries observed at this time, and the resident was placed back in his wheelchair. A provider Encounter note dated February 9, 2023 revealed the resident has had multiple falls since admission. Ongoing falls will be a challenge, and they are using one-to-one staffing on the overnight hours while he is sundowning and seems to be more agitated. Unfortunately, regardless of treatment plan he remains at high risk for ongoing falls and injuries. We will continue all current interventions. Additionally, a memory care unit may be more appropriate. A Health Status Note dated February 9, 2023, revealed Resident #324 is again 1:1 on night shift for safety as he continues with agitation, restlessness, and unable to stay in his bed. The resident continues ability to self-propel wheelchair in hallways, and wanders into other resident's rooms unless 1:1 observation is provided. Will continue to monitor. A Daily Skilled Evaluation note dated February 9, 2023, revealed the resident fell out of wheelchair at 10:25 AM. The resident is very confused, and no skin issues noted, no injuries or complaints of pain, and range of motion within normal limits. Notifications to appropriate parties were made. A Health Status Note dated February 10, 2023, revealed the resident's call light within reach but the resident is unable to use due to confusion. The resident's bed in low position and frequent room monitoring due to decreased safety awareness, and to address needs as they arise. A Daily Skilled Evaluation note dated February 10, 2023, revealed Resident #324 fell this shift at 1:25 PM. The resident was in his room with his back to his bed pushing his wheelchair and fell backwards onto his bed. Fall was witnessed by this writer, and no injuries noted and neuro checks started. An Alert Charting Change of Condition Summary dated February 11, 2023, revealed CNAs were wheeling the resident back from the nursing station in his wheelchair, and said the resident had a fall with positive head strike, so neuro checks were needing to be re-started. The resident was sitting in his chair looking around, unable to answer questions (which is his baseline). The resident was then assessed. Neuro checks were initiated, skin assessed for any injuries, and the resident was kept at the nursing station for observation and supervision. The physician was notified and elected to send the resident via ambulance to be evaluated at the hospital with concerns of hypotension and increased confusion following head strike. An Alert Note dated February 12, 2023, revealed the resident is very confused. He has been getting out of bed and sliding to the ground. Resident has been wandering to other resident's room as well as between the hallways trying to get outside. Resident would benefit as a one on one candidate. An additional Alert Note dated February 12, 2023, revealed the resident continues to push self and hyperextend his body out of his wheelchair. Resident can self-propel throughout the hallway and is not easily redirected. During previous shift, the resident had a fall and pulled out his foley catheter with balloon still inflated. Resident continuously monitored this shift while out in hallway. Resident attempted to place self on floor numerous times. The resident was helped to bed, lights turned off, heater on, and covered up to help promote sleep, with the bed lowered to the floor, and fall matt placed on floor beside bed. Approximately 30 minutes after being helped to bed, the resident was already observed on the floor in his doorway. The resident had crawled from his bed to the doorway. In addition to crawling out of bed, the resident pulled his foley catheter out with balloon still inflated for the 2nd time today. The resident was helped back into bed, with CNA at bedside. The resident would benefit from psychiatric evaluation and 1:1 supervision. A Health Status Note dated February 13, 2023, revealed that 911 was called to send the resident to the ED for evaluation related to fall and signs and symptoms of possible injury. A Baseline Care Plan note dated February 14, 2023 revealed the resident was found on the floor in the bathroom, he is unable to let his needs be known. The only injuries noticed are a skin tear to the right forearm, and neuro checks have started. A Behavioral Health Services Encounter Summary dated February 27, 2023, revealed the resident presents for new patient psych eval. Th resident was admitted with diagnosis of Parkinson's and multiple recent falls with subsequent fractures, and presents today as lying in bed, confused, alert and oriented to self. He is able to communicate needs, and states doing ok today. Limited history available and most information gathered from chart and staff interview. The resident has a history of behavioral disturbances and treatment, and staff report resident has been doing ok and redirectable at this time. An Alert Charting Change of Condition Summary dated February 28, 2023, revealed the resident was attempting to self-transfer to bed and slipped onto the floor. The resident denies pain at this time. Event paperwork started. An Incident Note dated March 3, 2023, revealed the resident was on the floor beside the bed. He had tried to get out of bed and fell on the floor, and hit the back of his (unspecified body part), but no apparent injury noted at this time. Assisted getting him back in bed. No other injuries observed. Notifications were made, and neuro checks initiated. An Alert Charting Change of Condition Summary dated March 8, 2023, revealed the resident was observed by a CNA sitting on floor mat at bedside, his head resting on his bed, and bed in low position. No new injuries noted, and the resident does not appear to be in pain. An interview was conducted on May 20, 2025, at 11:10 AM, with a Registered Nurse (RN / Staff #3) who stated that to prevent future falls from occurring, the staff would notify the Director of Nursing of concerns about falls, especially if the resident tended to get up and walk on their own. Staff #3 also stated that interventions would be put in place, that could include moving the resident's bed up against the wall, putting the bed in the lowest position, placing fall mats at bedside, and implementing frequent checks every 15 -20 minutes that would be put into the care plan and monitored by staff filling out a form and signing off that frequent checks were completed. Staff #3 stated that sometimes the facility would implement 1:1 supervision for residents. An interview was conducted on May 20, 2025, at 12:13 PM, with a licensed practical nurse (LPN / Staff #72). Staff #72 stated she was not familiar with care planning, and that she is not involved in that process. An interview was conducted on May 20, 2025, at approximately 2:15 PM, with the Director of Nursing (DON / Staff #56) who stated that if a resident has repeated falls, the facility prevents ongoing future falls by assessing the root cause of the fall and updating the care plan with appropriate interventions after each fall. The DON stated that there are many interventions the facility can employ to prevent falls, and that the facility can provide 1:1 supervision, however it is usually done as a last resort as it could cause the resident to be more restless. The clinical record and care plan of Resident #324 were reviewed together and the DON stated the care plan for addressing ongoing falls for Resident #324 was missing updates during the timeframe of February 9, 2023 through March 4, 2023, during which time the resident had repeated ongoing falls, and that this would not meet her expectation for fall prevention for Resident #324. Review of the facility policy titled Assessments/Care Planning: Care Plans, Comprehensive Person-Centered, effective January 1, 2024, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. The comprehensive, person-centered care plan: includes measurable objectives and timeframes and reflects currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; and when the resident has been readmitted to the facility from a hospital stay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff interviews, and facility policy and process, the facility failed to ensure pain medications as needed (PRN) was administered within the Pain Parameters for one resident (#54). The deficient practice could result in residents being overmedicated. Findings include: Resident #54 was admitted to the facility on [DATE] with diagnoses that included hepatic encephalopathy and alcoholic cirrhosis of the liver with ascites The order summery included Morphine Sulfate (concentrate) Solution 20 mg/ml give 5 mg by mouth every 3 hours as needed for pain 7-10 ordered April 25, 2025. The medication administration record (MAR) dated May 2025 revealed that Morphine Sulfate (concentrate) Solution 20 mg/ml give 5 mg by mouth every 3 hours as needed for pain 7-10 was administered on May 16, 2025 three times for a pain level of 6, 3, 6. An interview was conducted on May 20, 2025 at 11:33 a.m. with the registered nurse (RN/staff #3), who stated that an order for pain medication as needed (PRN) requires the dosage, frequency, and a pain scale. He also stated that when the pain medication is administered, he documents the level of pain and if the medication was effective on the medication administration record (MAR). He reviewed the MAR dated May 2025 and stated that the Morphine Sulfate (concentrate) Solution 20 mg/ml give 5 mg by mouth every 3 hours as needed for pain 7-10 and stated that the medication was given outside of parameters on May 16, 2025 for pain scale of 6, 3, and 6. He stated that there is a risk of overmedicating, slower breathing, and the resident becoming unconscious when administered outside of the pain scale parameters. An interview was conducted on May 20, 2025 at 11:50 a.m. with the Director of Nursing (DON/staff # ), who stated that an order for a pain medication PRN requires the dosage, frequency, and pain scale. It is her expectation that nurses' document the pain level and if the pain medication was effective on the MAR. She stated that if a pain medication is administered outside of the pain parameters, there is a risk of the resident being overmedicated. The DON reviewed the MAR dated May 2025 and stated that the Morphine Sulfate (concentrate) Solution 20 mg/ml give 5 mg by mouth every 3 hours as needed for pain 7-10 was administered outside of parameters on May 16, 2025 for pain scale of 6, 3, and 6. The facility policy titled, Medications: Administering Medications, revealed that medications are administered in accordance with prescriber orders, including any required time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, facility documentation and policy, the facility failed to ensure that one resident (#94) did not receive medications against their wishes. This deficient practice can result in not respecting the rights of the resident. Findings include: Resident # 94 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, dementia with mood disturbance, anxiety, muscle weakness, and cognitive communication deficit. The admission Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. An order for one Bupropion HCL Extended release tablet for anxiety was dated May 11, 2025. According to the Medication Administration Record (MAR), 150 mg of Bupropion HCL ER was given to the resident for anxiety on May 11, 2025 - May 13, 2025. A progress note dated May 13, 2025, revealed the antidepressant was considered a good option and was started. The note further explains that the medication was to be discontinued because the family wanted to take the non-pharmacological route. The informed consent for psychotropic medication use was declined by the resident's representative on May 13, 2025, after the resident received three doses of the medication. The clinical record fails to reflect the resident giving consent prior to starting the antidepressant. An interview was conducted on May 19, 2025 at 9:30 a.m., with the resident's representative. The representative stated displeasure that the facility administered the anti-depressant without proper consent, and against the family's request. An interview was conducted on May 19, 2025 at 1:39 p.m. with Registered Nurse (RN/Staff # 410). The RN stated that if a resident was to receive a medication without their consent, that will be a violation of their rights. A panel discussion conducted with the Clinical Resource (Staff # 250) and the Director of Nursing (DON/Staff #56) on May 20, 2025 at 9:20 a.m. Both parties reviewed the resident's clinical record and stated that the resident received the medication without consent, and that this failed to meet the facility expectations. The Clinical Resource stated that the facility was to obtain consent, before administering a psychotropic. The facility's Psychotropic Medication Use policy, effective January 1, 2024, revealed the resident has the right to decline treatment with psychotropic medications.

Based on observations, interviews, facility documentation and policy, the facility failed to ensure that two of four sampled medication carts had medications stored according to professional standards. The deficient practice can result in cross-contamination of medications and medication errors. Findings include, During medication cart storage observation with the Director of Nursing (DON/Staff # 56), the following was observed on March 19, 2025 at 8:09 a.m. : Medication Cart # 1: -An unrefrigerated vial of Lorazepam 2 mg/ml , with the affixed label stating keep refrigerated, was located in the narcotic storage area of the cart. -A pink like solution was crusted on the outside of a Geri-Tussin bottle. -Product crusting was present on an opened and unlabeled sixteen-ounce bottle of Milk of Magnesia. - A bottle of Wild Cherry Pro-Stat with the open date of April 5, 2025 had a crusted solution extending down the sides of the bottle. - Geri-Lanta bottle was opened but not dated. -Pepto Bismol Ultra was opened and not dated. Medication Cart # 2 -A medicine cup, contained two tablets, labeled as Zofran 4 mg was found in the medication cart drawer. An interview was conducted with the DON on March 19, 2025 at approximately 8:20 a.m. The DON revealed that it was against facility policy to store medications in the medication cart that was not in the original container. She further stated that the medication should have been disposed of if the resident was not available to receive the medication. The DON also stated that the facility expectation would be to refrigerate narcotics if indicated and should have been properly stored, in order to preserve the drugs potency. She stated that opened bottles of medication should be dated, and all bottles and containers should be clean and sanitary to prevent contamination. During a resident council meeting conducted on May 19, 2025 at 2:30 p.m., the attendees revealed that they would expect and are very confident that the staff are preparing their medications in a clean and safe environment. During an interview with Registered Nurse (RN/Staff # 3) revealed that during medication pass, it is important that the medication cart stays clean and orderly to reduce the chance of spreading disease or cross contaminating. During a panel discussion held on May 20, 2025 at 2:30 p.m. with the Clinical Resource Director (Staff # 250) and the DON, both parties stated that the facility expectation was not met during the medication cart audit the day prior. Staff # 250 stated the facility expectations are to keep the medication carts and room in clean and sanitary conditions, and to store medications according to facility policy. The facility's Medication Labeling and Storage policy effective date January 1, 2024, revealed medications are to be stored in the containers they are received. In addition, the staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Also, medications requiring refrigeration are stored in a refrigerator at a secured location.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate for one resident (#324) The deficient practice could lead to care team members not being aware of a resident's status, and could lead to missed or delayed treatment. -Findings Include: Resident #324 was re-admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, personal history of traumatic brain injury, dementia, unspecified abnormality of gait and mobility, cognitive communication deficit, anxiety disorder, and need for assistance with personal care. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) assessment that was not completed. Section J revealed the resident had two or more falls with injury since admission, re-entry, or prior assessment. Review of the clinical record revealed no evidence of any neuro check logs for Resident #324 for the time frame of his facility admission starting February 6, 2023. An Alert Charting Change of Condition Summary, dated February 6, 2023, revealed the resident was found on the floor. He was attempting to ambulate without assistance. The resident is very confused and very forgetful. No injuries noted at this time. Notifications to appropriate parties were made. A Fall Incident Report dated February 8, 2023, revealed the resident was found lying on the floor in his room by a Certified Nursing Assistant (CNA), with no injuries observed at this time, and the resident was placed back in his wheelchair. There was no evidence of a progress note in the resident's medical record regarding this fall. A Daily Skilled Evaluation note dated February 10, 2023, revealed Resident #324 fell this shift at 1:25 PM. The resident was in his room with his back to his bed pushing his wheelchair and fell backwards onto his bed. Fall was witnessed by this writer, and no injuries noted and neuro checks started. There was no evidence in the medical record that notifications to the medical provider and resident's family were made. An Alert Note dated February 12, 2023, revealed the resident is very confused. He has been getting out of bed and sliding to the ground. Resident has been wandering to other resident's room as well as between the hallways trying to get outside. Resident would benefit as a one on one candidate. There was no evidence in the medical record that notifications to the medical provider and resident's family were made. An additional Alert Note dated February 12, 2023, revealed the resident continues to push self and hyperextend his body out of his wheelchair. Resident can self-propel throughout the hallway and is not easily redirected. During previous shift, the resident had a fall and pulled out his foley catheter with balloon still inflated. Resident continuously monitored this shift while out in hallway. Resident attempted to place self on floor numerous times. The resident was helped to bed, lights turned off, heater on, and covered up to help promote sleep, with the bed lowered to the floor, and fall matt placed on floor beside bed. Approximately 30 minutes after being helped to bed, the resident was already observed on the floor in his doorway. The resident had crawled from his bed to the doorway. In addition to crawling out of bed, the resident pulled his foley catheter out with balloon still inflated for the 2nd time today. The resident was helped back into bed, with CNA at bedside. The resident would benefit from psychiatric evaluation and 1:1 supervision. There was no evidence that notifications to the medical provider and resident's family were made. A Baseline Care Plan note dated February 14, 2023 revealed the resident was found on the floor in the bathroom, he is unable to let his needs be known. The only injuries noticed are a skin tear to the right forearm, and neuro checks have started. There was no evidence that notifications to the medical provider and resident's family were made. An Alert Charting Change of Condition Summary dated February 28, 2023, revealed the resident was attempting to self-transfer to bed and slipped onto the floor. The resident denies pain at this time. Event paperwork started. There was no evidence that notifications to the medical provider and resident's family were made. An Alert Charting Change of Condition Summary dated March 8, 2023, revealed the resident was observed by a CNA sitting on floor mat at bedside, his head resting on his bed, and bed in low position. No new injuries noted, and the resident does not appear to be in pain. There was no evidence in the medical record that notifications to the medical provider and resident's family were made. An interview was conducted on May 20, 2025, at 11:10 AM, with a Registered Nurse (RN / Staff #3) who stated that if a resident falls, the nurse will assess the resident to see if there are any injuries, perform a head to toe assessment, start vitals and neuro checks, notify all applicable parties including the medical provider and family. Staff #3 stated that this would be documented in a progress note and an incident report, and that a fall risk assessment would be completed. An interview was conducted on May 20, 2025, at 12:13 PM, with a licensed practical nurse (LPN / Staff #72). Staff #72 stated that if a resident falls, the nurse will assess the resident, notify the provider, and other applicable parties, and the incident is documented in a progress note and an incident report, also called a risk management report. An interview was conducted on May 20, 2025, at approximately 2:15 PM, with the Director of Nursing (DON / Staff #56) who stated that if a resident falls in the facility, the nurse will complete an assessment of the resident and document it in the medical record, and complete an incident report. Additionally, if a resident has repeated falls, the facility prevents ongoing future falls by assessing the root cause of the fall and updating the care plan with appropriate interventions after each fall. The clinical record and incident reports of Resident #324 were reviewed together and the DON stated that the fall on February 8, 2023, had an incident report but did not have any indication in the medical record, and that a number of the resident's falls were missing documentation that the provider and family were notified. Additionally, the DON confirmed that there was no evidence of neuro check logs for the falls during the resident's admission. Review of the facility policy titled Documentation: Charting and Documentation, effective January 2024, revealed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record may be electronic, manual or a combination. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided; the name and title of the individual(s) who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment; whether the resident refused the procedure/treatment; notification of family, physician or other staff, if indicated; and the signature and title of the individual documenting.

Based on observations, interviews, facility documentation and policy, the facility failed to ensure a clean, sanitary, and safe environment in the residents' shower rooms, and in shared resident bathroom on the 200-Hall. The deficient practice could result in the spread of infection and the failure to achieve a home-like environment. Findings include: A facility walkthrough was conducted with the Maintenance Supervisor (Staff #302) and the Maintenance Manager (Staff #31) on May 19, 2025 at 08:58 a.m. to observe a resident shared restroom on the 200-Hall. All parties observed feces stuck to the inside of the commode, feces on the handrail, feces on the floor, dust and calcification in the toilet bowl, and a used and stained urinal (occupants of both rooms were females). During a facility walkthrough on May 19, 2025 at 9:15 a.m. with the Maintenance Supervisor (Staff #302), an unlabeled blue chemical in a squirt bottle was observed on the handle near the commode in the 200-Hall shower room. The shower drains had soap scum and multiple strands of hair. The shower room vent was covered in a thick layer of black and grayish substance. An interview was conducted with resident #271 on May 18, 2025 at at 2:44 p.m. The resident voiced discontent about sharing the toilet with three other people. The resident stated They know that four people are using this toilet, I went in there today and feces was on the floor and yesterday, there were feces all over the place! The resident revealed that staff was alerted about the state of the toilet. However, there was no action taken to resolve her concern. An interview was conducted with the Maintenance Supervisor (Staff #302) and the Maintenance Manager (Staff #31) on May 19, 2025, at approximately 9:00 a.m. Both parties revealed the facility had no official housekeeping manager and that the maintenance manager was covering that position. After observing the resident restroom, both parties agreed that the smell and condition of the restroom was unacceptable. They noted that it will be taken care of immediately with housekeeping. In an interview with Staff #302 conducted on May 19, 2025 at 9:15 a.m., staff #302 acknowledged that it is unsafe for cleaning products to be within residents' reach. Staff #302 stated that he was going to send housekeeping to do a deep cleaning of the shower room to include the air vents. Review of the facility's Environmental Services Manager job description indicated that the the individual must have a knowledge of all areas of facility maintenance. The job description indicated that this individual is responsible for the cleanliness and appearance of the physical environment, including offices, common areas, and resident rooms. The facility's Housekeeper job description revealed that the Housekeeper works under the direct supervision of the Environmental Services Manager. This Housekeeper maintains the facility, resident rooms, and all common areas in a cleanly, welcoming, and homelike environment Review of the undated Environmental/Maintenance policy revealed that it is the responsibility of the facility to provide residents, guests, and staff a safe and functional environment. In addition, the facility directed that any hazardous and/or emergency findings are to be reported to the management staff. Review of the Infection Control: Cleaning and Disinfection of Environmental Surfaces policy, with an effective date of January 1, 2024, indicated that housekeeping surfaces will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Additionally, the policy directed that environmental surfaces will be disinfected on a regular basis and when surfaces are visibly soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure an allegation of abuse was reported timely to required entities for one resident (#326). The deficient practice could lead to ongoing abuse leading to harm of a resident. -Findings include: Resident #326 was admitted to the facility on [DATE], with diagnoses that included hypotension, unsteadiness on feet, degeneration of nervous system due to alcohol, and unspecified dementia. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. A Health Status Note dated November 8, 2021, by a Registered Nurse (RN / Staff #112), revealed Resident #326 had a smoker's patch in place on the right arm. The resident stated rudely, If you people would let me smoke and let me out of here, I would be content!, as the resident raised his hand at the nurse. Staff #112 was startled and told the resident to please settle down and stop acting like a a**. Staff #112 offered to make the resident a sandwich, but, he settled with yogurt, and drank water. The resident was then resting peacefully. Review of State Agency records revealed the facility called the reporting hotline on November 16, 2021, and reported an allegation that a staff member verbally abused Resident #326. A facility Reportable Event Record / Report dated November 23, 2021, revealed in the evening of November 8, 2021, Staff #112 was in Resident #326's room while the resident was in bed resting, and was startled when the resident raised his arm abruptly and yelled at the staff member. The staff member was caught off guard and surprised and used language that was inappropriate for use around a resident. The resident did not take offense to what was said, and Staff #112 was able to calm the resident by offering food and something to drink. The resident was calmed and peaceful and had all of his needs met. There was no other incident noted of similar behavior. The language used by the staff member was the result of being startled and was not meant in a personal or attacking way toward the resident. It is still not considered appropriate so the staff member was suspended and educated about customer service and appropriate behavior toward residents. Upon interview, Staff #112 explained that the language used was not meant to be personal to the resident, and was sorry for using it. The resident was also interviewed and stated to not have had any problem with a staff member or feel that he has been spoken to inappropriately or treated poorly. He was pleasant and happy with his care. An interview was conducted on May 20, 2025 at 10:31 AM, with a Certified Medication Assistant (CMA / Staff #66) who stated that if a staff member was overheard saying stop acting like an a** to a resident, that would be inappropriate. Additionally, Staff #66 stated in a case where there is suspected verbal abuse, the facility's policy is to first, examine the picture for safety, then report it to the abuse coordinator right away. An interview was conducted on May 20, 2025, at 12:13 PM, with a Licensed Practical Nurse (LPN / Staff #72) who stated that in cases of alleged abuse, staff have a 2 hour timeframe to report. Staff #72 stated if a staff member was overheard saying stop acting like an a** to a resident, that would be super inappropriate. An interview was conducted with the Director of Nursing (DON / Staff #56) on May 20, 2025, at 2:50 PM who stated if she overheard a staff member speak to a resident disrespectfully, she would remove that staff from the patient care area and meet with the staff, then initiate an immediate investigation and report it. The DON stated that if a staff member was overheard saying stop acting like an a** to a resident, that would be considered inappropriate. Review of the facility policy titled Abuse Policy, revealed abuse is the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well- being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, mental abuse including abuse facilitated or enabled through the use of technology, and misappropriation of property. Potential abusers can be residents, employees, family members, visitors, venders, or any other person who comes into the facility. None of these types or sources of abuse are condoned in Haven Health facilities. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse. If abuse is witnessed or suspected, or an injury of unknown origin is identified, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse. If abuse is witnessed or suspected, reporting and investigation will take place in this manner: Executive Director (ED) will be notified. ED and witness who is reporting will notify the following entities: Adult Protective Services, Ombudsman, State Survey Agency, Law enforcement when applicable. Suspected abuse will be reported in accordance with timeframes and standards required by CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records, review of facility documentation, review of the State Agency (SA) database, staff interviews and review of policy and procedure facility failed to ensure two allegations of abuse (resident #171& #326) and an allegation of neglect (resident #26) were fully investigated. The deficient practice could result in allegations of abuse and neglect not being investigated and abuse/neglect occurring in the facility. Findings include: Regarding Resident #26 -Resident #26 was admitted to the facility on [DATE] with diagnoses that included hypotension, chronic kidney disease, and nocturia. A report was received by the State Agency on January 4, 2023 regarding an allegation of neglect. However, the report did not identify the alleged perpetrator. Review of the SA database revealed that the facility failed to submit a thorough investigation of the allegation to the SA. Furthermore, review of the facility's 5-day investigation report dated January 20, 2023 revealed that the investigation did not include interviews of residents and staff members. The report did not include witness statements. Although there was a summary of interview of the alleged victim, alleged perpetrator, and witness, it did not state when the interviews were conducted nor did it identify who the witness was. An interview with a Certified Nursing Assistant (CNA/staff #29) was conducted on May 20, 2025 at 9:51 a.m. Staff #29 stated that neglect can encompass not checking on residents, not providing needed care and services, and not supporting them with their ADL (activities of daily living) needs. The CNA noted that the importance of not neglecting residents is for their safety and comfort. The potential impact of neglect is that residents can feel unsafe, depressed, and discomfort. Regarding resident #171 -Resident #171 was admitted to the facility on [DATE] with diagnoses that included monoplegia, chronic heart failure, and depression. A report was received by the State Agency on November 9, 2022 indicated that resident #171 had a family-to-resident verbal abuse incident. The resident's clinical record revealed a progress note dated November 10, 2022 which documented that the resident stated that she was really depressed in part since her husband blames her for putting herself in the facility. The note indicates suicidal ideation as a result. However, there was no mention regarding the prior day's incident with the husband. Furthermore, there was no indication that resident's interaction with husband will be monitored or that visitation is limited pending investigation. Review of the undated 5-day investigation report submitted by the facility on November 15, 2022 revealed that the facility failed to conduct a thorough investigation that included witness interviews, perpetrator interview and staff interviews (potential witnesses). The report did not contain witness statements. Although there was a summary of interview of the alleged victim and a witness, the summary did not indicate when the interviews were conducted nor did it identify who the witness was. Further review of the undated 5-day investigation report revealed that the facility does not believe that abuse has occurred. An interview with a Certified Nursing Assistant (CNA/staff #29) was conducted on May 20, 2025 at 9:51 a.m. Staff #29 said that conducting a thorough investigation of allegations of abuse/neglect is important to ensure that the facility is doing its due diligence to investigate and ensure the safety of residents. The impact of not conducting a thorough investigation is that residents would feel like they could not speak up when something happens, feel like the abuse/neglect will happen again, and assume that the facility does not follow-through on allegations. During an interview with a Licensed Practical Nurse (LPN/staff #72) conducted on May 20, 2025 at 12:21 p.m., staff #72 stated that conducting a thorough investigation is important since you do not want the abuse/neglect to continue or happen to others. The LPN stated that the impact of not conducting a thorough investigation is that it can create tension, and not have a healthy environment in which residents do not feel safe An interview with the Director of Nursing (DON/staff #56) was conducted on May 20, 2025 at 1:03 p.m. Staff #56 stated that her expectation is that staff defer to the policy and refer to it to ensure they are touching all the points. The DON stated that conducting a thorough investigation is important to ensure that allegation is looked into and that safety is made a priority. According to staff #56 the impact of conducting a thorough investigation is that there is a possibility of continued inappropriate actions. The facility policy titled Abuse revision 0622 indicated that the facility strives to prevent abuse of all their residents. According to the policy, abuse also included the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The Reporting and Investigation section of the policy stated that a minimum of three residents will be interviewed to determine if there is a trend. Interviews may also include the alleged perpetrator, witnesses, and staff members as applicable. The policy noted that if the alleged perpetrator is an employee, they will be immediately suspended pending the result of the investigation. Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure an allegation of abuse was thoroughly investigated for one resident (#326). The deficient practice could lead to ongoing abuse leading to harm of a resident. -Findings include: Resident #326 was admitted to the facility on [DATE], with diagnoses that included hypotension, unsteadiness on feet, degeneration of nervous system due to alcohol, and unspecified dementia. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. A Health Status Note dated November 8, 2021, by a Registered Nurse (RN / Staff #112), revealed Resident #326 had a smoker's patch in place on the right arm. The resident stated rudely, If you people would let me smoke and let me out of here, I would be content!, as the resident raised his hand at the nurse. Staff #112 was startled and told the resident to please settle down and stop acting like a a**. Staff #112 offered to make the resident a sandwich, but, he settled with yogurt, and drank water. The resident was then resting peacefully. Review of State Agency records revealed the facility called the reporting hotline on November 16, 2021, and reported an allegation that a staff member verbally abused Resident #326. A facility Reportable Event Record / Report dated November 23, 2021, revealed in the evening of November 8, 2021, Staff #112 was in Resident #326's room while the resident was in bed resting, and was startled when the resident raised his arm abruptly and yelled at the staff member. The staff member was caught off guard and surprised and used language that was inappropriate for use around a resident. The resident did not take offense to what was said, and Staff #112 was able to calm the resident by offering food and something to drink. The resident was calmed and peaceful and had all of his needs met. There was no other incident noted of similar behavior. The language used by the staff member was the result of being startled and was not meant in a personal or attacking way toward the resident. It is still not considered appropriate so the staff member was suspended and educated about customer service and appropriate behavior toward residents. Upon interview, Staff #112 explained that the language used was not meant to be personal to the resident, and was sorry for using it. The resident was also interviewed and stated to not have had any problem with a staff member or feel that he has been spoken to inappropriately or treated poorly. He was pleasant and happy with his care. The report revealed no witness statements, and no evidence of other resident interviews to establish a trend. An interview was conducted on May 20, 2025 at 10:31 AM, with a Certified Medication Assistant (CMA / Staff #66) who stated that if a staff member was overheard saying stop acting like an a** to a resident, that would be inappropriate. An interview was conducted on May 20, 2025, at 12:13 PM, with a Licensed Practical Nurse (LPN / Staff #72) who stated if a staff member was overheard saying stop acting like an a** to a resident, that would be super inappropriate. An interview was conducted with the Director of Nursing (DON / Staff #56) on May 20, 2025, at 2:50 PM who stated if she overheard a staff member speak to a resident disrespectfully, she would remove that staff from the patient care area and meet with the staff, then initiate an immediate investigation, and report it. The DON stated that if a staff member was overheard saying stop acting like an a** to a resident, that would be considered inappropriate. Review of the facility policy titled Abuse Policy, revealed abuse is the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well- being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, mental abuse including abuse facilitated or enabled through the use of technology, and misappropriation of property. Potential abusers can be residents, employees, family members, visitors, venders, or any other person who comes into the facility. None of these types or sources of abuse are condoned in Haven Health facilities. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse. If abuse is witnessed or suspected, or an injury of unknown origin is identified, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse. If abuse is witnessed or suspected, reporting and investigation will take place in this manner: Executive Director (ED) will be notified. ED will begin investigation immediately and complete within 5 working days using the Abuse Investigation Packet. A minimum of three residents will be interviewed in order to determine if there is a trend. Interviews may also include the Alleged Perpetrator, Witnesses and Staff Members as applicable. Suspected abuse will be reported in accordance with timeframes and standards required by CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to assess and monitor the activities for one resident (#24). Findings include: Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, acquired absence of right leg above knee, depression, and anxiety disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. The activities care plan dated February 6, 2025 revealed that the resident spends his day in bed either watching TV, playing games on his phone or visit with family. Interventions included: -provide leisure supplies for self-directed pursuits. -introduce to other resident with similar interests, disabilities, and/or limitation. -modify daily schedule, treatment plan as needed to accommodate activity participation. -offer a variety of activity types and locations. -reassess the resident as needed for changes in activity preferences. Review of the task sheets for talking-conversing, pet therapy, one-to-one intervention program, and movie/TV for the last thirty days did not reveal any documentation. Review of the activities tracking for April 2025 revealed that the resident watched movies/TV daily and talked/conversed with others eight days out of the month. Review of the activities tracking for May 2025 revealed that the resident participated in a group activity, Bingo, daily from the first of May through the 20th of May 2025. Review of the Activity Manager job description for the Activity Manager (staff #65) dated October 3, 2023 revealed that the tasks and responsibilities included to actively involve each resident in an ongoing program of activities that appeals to his or her interests and enhances the resident's highest practicable level of physical, mental and psychosocial well-being and to actively monitor the residents' responses and evaluate these responses to the programs in order to determine if the activities meet the assessed needs of the resident. The facility provided documentation stating that the Activities Manager walked the Executive Director through the process of documenting a resident's participation in activities. It was determined that there was an error in the documentation process and the system did not save the documentation. A work order has been completed to fix the error. An interview was conducted on May 19, 2025 at 10:33 a.m. with the Activities Manager (Staff #65), who stated that she has been the Activity Manager since October 2023. She stated that the resident could attend group activities, such as Bingo, if he was willing to get out of bed and he had attended Bingo one time since being admitted . She stated that the system for documenting activity participation just got up and running, so she didn't have any documentation on activities for any of the residents. She did provide documentation of an activities list that showed how many residents attended each activity each day, but had no way of knowing which residents attended. She stated that she did not know that she had to document each residents participation in activities. She stated that the purpose of activities is so the residents keep their dignity, feel more comfortable and at home, to assist with ADLs and to get back to normalcy. Also, it helps with depression. She stated that if a resident is not attending activities, it may indicate that something is wrong, such as depression, and if it continued, there may be a trend, but acknowledged that she wouldn't be able to tell because she had no activity documentation to review. An interview was conducted on May 20, 2025 at 7:54 a.m. with the Administrator (staff #74) and 2. Stock [NAME], the [NAME] President of Operations (staff #83). Staff #72 stated that he supervises the Activity Manager (staff #65) and it is his expectation that she maintains the activity schedule, sets up activities, knows who is attending activities, attends the morning meetings, provides feedback and works with the volunteers. He stated that he has watched staff #65 use the software to document if a resident attended an activity, was sleeping or refused to attend once or twice. He stated that the reason for documentation is because they want to know the residents are up and participating whenever they can and to show when residents are not attending. The data could show a trend when a resident is not attending activities and the facility would want to look into the reason why the resident is not attending. However, there are some resident who don't want to engage as much or don't want to attend activities, such as resident #24. He stated that the Activity Manager should be reviewing the activity data and they meet at least monthly to review the how many people are attending each activity, what is popular, and go over the activity calendar. He stated that he has not reviewed activity documentation for a specific resident. He stated that the purpose of activities are to keep the residents engaged and socializing. It is possible that if someone refuses to attend, there may be some type of emotional/mental concern, such as depression going on and documentation is needed so you can see if there are any changes with the resident. During an interview conducted on May 20, 2025 at 1:48 p.m. with resident #24, he stated that he may want to attend some group activities depending what it is. An Activity Calendar was not observed in the resident's room. He asked what activities are going on. During a second interview conducted on May 20, 2025 at 1:49 p.m. with the Activities Manager (staff #65), she reviewed the activities tracking for April 2025 and May 2025 for resident #24 and stated that she had just completed the activity documentation/data to the best of her memory. The facility policy, Activity Programs - Staffing states that the activity programs are staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident. The Activity Director/Coordinator shall at least monitor and evaluate the resident's responses to activities and revise the approaches as appropriate; and develop, implement, supervise and evaluate the activity program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate supervision to prevent elopement for one resident (#34); and, failed to ensure one resident (#324) was free from preventable accidents of repeated falls. The deficient practice could result in avoidable accidents and/or decline in fuction. Findings include: - Regarding resident #34 Review of resident #34's hospital records prior to his admission to the facility revealed a progress note dated January 10, 2023 which documented that the resident is incompetent to make his own decision. The note indicated that the resident has a public fiduciary. Resident #34 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of mandible, tempomandibular joint disorder, and severe protein-calorie deficit. A speech therapy eval dated February 3, 2023 documented that the resident had a history of cognitive impairment and had a guardian. A progress note dated February 6, 2023 documented that the resident was a poor historian, had cognitive impairment, and had cognitive communication deficit. Another progress note also dated February 6, 2023 documented that it was hard to determine the resident's cognition due to the resident being quiet and not speaking much. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #34 has difficulty communicating some words or finishing thoughts but is able if prompted or given time. The MDS also noted that the resident misses some part/intent of message but comprehends most conversation. Further review of the admission MDS dated [DATE] did not contain a Brief Interview for Mental Status (BIMS) score. The cognitive patterns section was left blank regarding whether the resident could be interviewed to determine a BIMS score. Additionally, the section pertaining to staff assessment for mental status was also left blank. The assessment also indicated that the resident is ambulatory and does not use any mobility device. Review of resident #34's clinical record did not reveal any evidence that a care plan was initiated to address the resident's cognition impairment. There was no evidence that the facility had interventions in place to mitigate issues/concerns his impaired cognition could cause. A progress note dated March 9, 2023 revealed that the resident was found ambulating on the street with a walker. The note indicated that a staff member escorted resident #34 back to the facility. According to the progress note, the resident stated that he was walking in the parking lot and took a wrong turn. The note documented that a wander guard was placed on the resident. Review of an Incident Report for elopement dated March 9, 2025 revealed that resident #34 was found in the street walking. The report documented that per the resident he was walking in the parking lot and took a wrong turn which resulted in him ending up on the street. The report indicated confused as a predisposing physiological factor for the elopement. The report also documented that an off-duty aide notified the facility about the resident ambulating alone in the street. A progress note dated March 10, 2023 documented that resident #34 was found down the street from the facility. According to the progress note a staff member drove to where the resident was located and escorted the resident to guide him as he walked back to the facility. The note documented that the resident stated that he got confused while walking. The note also indicated that the resident had to confirm with the staff which direction to go as he walked. A physician order dated March 10, 2023 prescribed the use of wander guard at all times. The order also directed to check the bracelet is on properly and functional every shift. A behavioral care plan initiated on March 10, 2023 revealed that the resident has wandering/exit-seeking behavior. Interventions included the wear of wander guard and minimize disruptive behavior by offering tasks to divert attention. Review of resident #34's clinical record revealed that a Wandering Risk Eval was not completed until March 31, 2023. The assessment revealed a risk score of 9 indicating that the resident was a moderate risk for wandering. A request for resident #34's Supervision/Monitoring log was submitted on May 18, 2025. The facility annotated on the request form that there was none available. A request for the investigation file regarding resident #34's elopement was submitted on May 18, 2025. The facility annotated on the request form that there was none available. An interview with a Certified Nursing Assistant (CNA/staff #29) was conducted on May 20, 2025 at 9:51 a.m. Staff #29 stated that staff round on residents every 2-hours or as needed. She indicated that during the initial admission assessment it will document whether a resident has a history of risks such as elopement. The CNA said that staff communicate for frequent checks. If the resident is new, staff is in the room a lot for the first few days if they are having cognitive communication deficit. According to staff #29 it is important to round on residents routinely for safety and to ensure that they are comfortable, not at risk for falls and/or elopement which they try to mitigate. The CNA noted that if residents are not rounded on routinely they can end up with preventable accidents such as falls or elopement. Staff #29 described resident #34 as sometimes confused. The CNA recalled the incident in which resident #34 left the facility and was found walking on the road. Staff #29 said that the resident was found up the road, about a mile away. The CNA said that when the resident was asked what he was doing, resident #34 stated that he was walking. Staff #29 said that the way resident #34 presented was misleading and so the staff did not realize that his cognition was not as good as it seemed. A wander guard was placed on the resident to prevent further incidents. During an interview with a Licensed Practical Nurse (LPN/staff #72) conducted on May 20, 2025 at 12:21 p.m., staff #72 stated that during assessment they review information from where the resident came from such as hospital records. Information such as fall risk, elopement risk, and cognition are reviewed. Accurate assessment is important because for example if a resident is cognitively impaired but ambulatory, they can be an elopement risk and need to be monitored/supervised. If not, then the resident can go outside, get him, and the facility would not know where or what happened to the resident. There could be a risk of the resident eloping and getting hurt. The LPN indicated familiarity with resident #34. Staff #72 stated that resident #34 is ambulatory and loves to walk around. The LPN said that resident #34 has episodes of confusion. During an interview with the Director of Nursing (DON/staff #56) conducted on May 20, 2025 at 1:03 p.m., staff #56 stated that it is important to assess a resident's cognition and know the cognition level of a resident. The DON indicated that depending on the level of cognition there is a criterion that triggers for an elopement risk. Staff #56 noted that it is important to accurately assess residents to protect them from risks and possible dangerous situation. The DON said that the impact of not accurately assessing residents is the possibility of negative/dangerous situation. Staff #56 stated that although she is familiar with the resident, she is unfamiliar with the incident. Review of the facility policy titled Elopements revised December 2007, revealed that the staff shall investigate and report all cases of missing residents. The policy noted that when the resident returns to the facility, the DON or Charge Nurse has to examine the resident for injuries, notify the physician, resident's legal representation, complete/file Report of Incident/Accident, and document the event in the resident's medical record. The facility policy titled Behavioral Assessment, Intervention and Monitoring revise December 2016 indicated that as part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness. Additionally, the policy noted that a part of the comprehensive assessment, the staff will evaluate, based on input from the resident, family, caregivers, review of medical records and general observation the resident's usual patterns of cognition, mood, and behavior. The policy indicated that the interdisciplinary team will evaluate behavioral symptoms to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Furthermore, the policy noted that the care plan will incorporate findings from comprehensive assessment and be consistent with current standards of practice. Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure one resident (#324) was free from preventable accidents of repeated falls. The deficient practice could lead to injury to a resident and/or a decline in function. -Findings Include: Resident #324 was re-admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, personal history of traumatic brain injury, dementia, unspecified abnormality of gait and mobility, cognitive communication deficit, anxiety disorder, and need for assistance with personal care. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) assessment that was not completed. Section J revealed the resident had two or more falls with injury since admission, re-entry, or prior assessment. A care plan initiated February 6, 2023, revealed Resident #324 was at risk for falls or had an actual fall. Interventions included to follow the facility fall protocol, follow Falling Leaf Program, be sure the call light is in reach and encourage the resident to use it for assistance, anticipate and meet the resident's needs, therapy evaluations and treatments as ordered or as needed, and encourage the resident to participate in activities that promote exercise, physical activity, strengthening, and improved mobility. An additional care plan intervention was initiated on February 9, 2023, to have a Call Don't Fall as a reminder. Following this update, there was no evidence of any further care plan updates to address the resident's falls from February 9, 2023 until March 4, 2023. A Fall Risk Evaluation dated February 7, 2023, revealed the resident scored 17.0 indicating high risk for falls. A physician order dated February 13, 2023 indicated may send patient to ED (emergency department) for eval related to fall. An additional physician order dated March 11, 2023, indicated may send patient to ED for eval and treatment related to fall. Review of the clinical record revealed no evidence of any neuro check logs for Resident #324 for the time frame of his facility admission starting February 6, 2023. An admission Evaluation - Nursing note dated February 6, 2023, revealed Resident #324 admitted from acute hospital via wheelchair for fracture of left humerus. The resident was alert and oriented x 1, and highly confused. An Alert Charting Change of Condition Summary, dated February 6, 2023, revealed the resident was found on the floor. He was attempting to ambulate without assistance. The resident is very confused and very forgetful. No injuries noted at this time. Notifications to appropriate parties were made. A Daily Skilled Evaluation dated February 7, 2023, revealed Resident #324 was found outside of the building and was wandering around on the sidewalk. Resident was redirected to the nursing station for supervision and had a wander guard applied to his right ankle. Resident is alert, but only oriented to himself, he does not say much. He was squirming around in the bed, so he was transferred to his wheelchair to avoid a fall. The resident then made it outside as mentioned above. A Fall Incident Report dated February 8, 2023, revealed the resident was found lying on the floor in his room by a Certified Nursing Assistant (CNA), with no injuries observed at this time, and the resident was placed back in his wheelchair. There was no evidence of a progress note in the resident's medical record regarding this fall. A provider Encounter note dated February 9, 2023 revealed the resident has had multiple falls since admission. Ongoing falls will be a challenge, and they are using one-to-one staffing on the overnight hours while he is sundowning and seems to be more agitated. Unfortunately, regardless of treatment plan he remains at high risk for ongoing falls and injuries. We will continue all current interventions. Additionally, a memory care unit may be more appropriate. A Health Status Note dated February 9, 2023, revealed Resident #324 is again 1:1 on night shift for safety as he continues with agitation, restlessness, and unable to stay in his bed. The resident continues ability to self-propel wheelchair in hallways, and wanders into other resident's rooms unless 1:1 observation is provided. Will continue to monitor. A Daily Skilled Evaluation note dated February 9, 2023, revealed the resident fell out of wheelchair at 10:25 AM. The resident is very confused, and no skin issues noted, no injuries or complaints of pain, and range of motion within normal limits. Notifications to appropriate parties were made. A Health Status Note dated February 10, 2023, revealed the resident's call light within reach but the resident is unable to use due to confusion. The resident's bed in low position and frequent room monitoring due to decreased safety awareness, and to address needs as they arise. A Daily Skilled Evaluation note dated February 10, 2023, revealed Resident #324 fell this shift at 1:25 PM. The resident was in his room with his back to his bed pushing his wheelchair and fell backwards onto his bed. Fall was witnessed by this writer, and no injuries noted and neuro checks started. An Alert Charting Change of Condition Summary dated February 11, 2023, revealed CNAs were wheeling the resident back from the nursing station in his wheelchair, and said the resident had a fall with positive head strike, so neuro checks were needing to be re-started. The resident was sitting in his chair looking around, unable to answer questions (which is his baseline). The resident was then assessed. Neuro checks were initiated, skin assessed for any injuries, and the resident was kept at the nursing station for observation and supervision. The physician was notified and elected to send the resident via ambulance to be evaluated at the hospital with concerns of hypotension and increased confusion following head strike. An Alert Note dated February 12, 2023, revealed the resident is very confused. He has been getting out of bed and lidding to the ground. Resident has been wandering to other resident's room as well as between the hallways trying to get outside. Resident would benefit as a one on one candidate. An additional Alert Note dated February 12, 2023, revealed the resident continues to push self and hyperextend his body out of his wheelchair. Resident can self-propel throughout the hallway and is not easily redirected. During previous shift, the resident had a fall and pulled out his foley catheter with balloon still inflated. Resident continuously monitored this shift while out in hallway. Resident attempted to place self on floor numerous times. The resident was helped to bed, lights turned off, heater on, and covered up to help promote sleep, with the bed lowered to the floor, and fall matt placed on floor beside bed. Approximately 30 minutes after being helped to bed, the resident was already observed on the floor in his doorway. The resident had crawled from his bed to the doorway. In addition to crawling out of bed, the resident pulled his foley catheter out with balloon still inflated for the 2nd time today. The resident was helped back into bed, with CNA at bedside. The resident would benefit from psychiatric evaluation and 1:1 supervision. A Health Status Note dated February 13, 2023, revealed that 911 was called to send the resident to the ED for evaluation related to fall and signs and symptoms of possible injury. A Baseline Care Plan note dated February 14, 2023 revealed the resident was found on the floor in the bathroom, he is unable to let his needs be known. The only injuries noticed are a skin tear to the right forearm, and neuro checks have started. A Behavioral Health Services Encounter Summary dated February 27, 2023, revealed the resident presents for new patient psych eval. Th resident was admitted with diagnosis of Parkinson's and multiple recent falls with subsequent fractures, and presents today as lying in bed, confused, alert and oriented to self. He is able to communicate needs, and states is doing ok today. Limited history available and most information gathered from chart and staff interview. The resident has a history of behavioral disturbances and treatment, and staff report the resident has been doing ok and redirectable at this time. An Alert Charting Change of Condition Summary dated February 28, 2023, revealed the resident was attempting to self-transfer to bed and slipped onto the floor. The resident denies pain at this time. Event paperwork started. An Incident Note dated March 3, 2023, revealed the resident was on the floor beside the bed. He had tried to get out of bed and fell on the floor, and hit the back of his (unspecified body part), but no apparent injury noted at this time. Assisted getting him back in bed. No other injuries observed. Notifications were made, and neuro checks initiated. An Alert Charting Change of Condition Summary dated March 8, 2023, revealed the resident was observed by a CNA sitting on floor mat at bedside, his head resting on his bed, and bed in low position. No new injuries noted, and the resident does not appear to be in pain. An interview was conducted on May 20, 2025, at 10:31 AM, with a CNA and Certified Medication Assistant (CMA /Staff #66) who stated that if a resident falls, CNAs would first ensure the resident is ok, then would get the nurse to assess and observe the resident. Staff #66 stated that the procedure is to leave the resident where they are at while getting the nurse, because the nurse needs to assess the situation correctly. An interview was conducted on May 20, 2025, at 11:10 AM, with a Registered Nurse (RN / Staff #3) who stated that if a resident falls, the nurse will assess the resident to see if there are any injuries, perform a head to toe assessment, start vitals and neuro checks, notify all applicable parties including the medical provider and family. Staff #3 stated that this would be documented in a progress note and an incident report, and that a fall risk assessment would be completed. Staff #3 stated that to prevent future falls from occurring, the staff would notify the Director of Nursing of concerns about falls, especially if the resident tended to get up and walk on their own. Staff #3 also stated that interventions would be put in place, that could include moving the resident's bed up against the wall, putting the bed in the lowest position, placing fall mats at bedside, and implementing frequent checks every 15 -20 minutes that would be put into the care plan and monitored by staff filling out a form and signing off that frequent checks were completed. Staff #3 stated that sometimes the facility would implement 1:1 supervision for residents, but that the facility is not really equipped for that level of care. Staff #3 stated that he did not believe the facility would hire sitters, that if the resident required a sitter, then the resident would be discharged to a higher level of care. An interview was conducted on May 20, 2025, at 12:13 PM, with a licensed practical nurse (LPN / Staff #72). Staff #72 stated that if a resident falls, the nurse will assess the resident, notify the provider, and other applicable parties, and the incident is documented in a progress note and an incident report, also called a risk management report. Staff #72 stated she was not familiar with care planning, and that she is not involved in that process. Staff #72 stated that if a resident was confused and disoriented and keeps trying to get up without staff assistance, then staff check on the resident frequently an could move the resident's room closer to the nurse's station. Staff #72 stated that the facility does not employ one to one supervision due to staffing issues, and that the facility had a resident who needed one to one supervision and that intervention was not implemented. An interview was conducted on May 20, 2025, at approximately 2:15 PM, with the Director of Nursing (DON / Staff #56) who stated that if a resident falls in the facility, the nurse will complete an assessment of the resident and document it in the medical record, and complete an incident report. Additionally, if a resident has repeated falls, the facility prevents ongoing future falls by assessing the root cause of the fall and updating the care plan with appropriate interventions after each fall. The DON stated that there are many interventions the facility can employ to prevent falls, and that the facility can provide 1:1 supervision, however it is usually done as a last resort as it could cause the resident to be more restless. The clinical record and care plan of Resident #324 were reviewed together and the DON stated the care plan for addressing ongoing falls for Resident #324 was missing updates during the timeframe of February 9, 2023 through March 4, 2023, during which time the resident had repeated ongoing falls, and that this would not meet her expectation for fall prevention for Resident #324. Review of the facility policy titled Resident Safety: Accident and Incidents - Investigating and Reporting, effective January 1, 2024, revealed all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the facility premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident form: the date and time the accident or incident took place; the nature of the injury/illness (e.g., bruise, fall, nausea, etc.); the circumstances surrounding the accident or incident; where the accident or incident took place; the name(s) of witnesses and their accounts of the accident or incident; the injured person's account of the accident or incident; the time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions; the date/time the injured person's family was notified and by whom; the condition of the injured person, including his/her vital signs; the disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); any corrective action taken; follow-up information; other pertinent data as necessary or required; and the signature and title of the person completing the report. The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. The director of nursing services shall ensure that the administrator receives a copy of the Report of Incident/Accident form for each occurrence. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review of the facility policy titled Falls/Falls Risk: Falls and Fall Risk, Managing, effective January 1, 2024, revealed that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Resident conditions that may contribute to the risk of falls include: delirium and other cognitive impairment, lower extremity weakness, medication side effects, functional impairments, visual deficits, and incontinence. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. Review of the facility policy titled Assessing Falls and Their Causes, revised March 2018, revealed the purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. After a Fall: If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. Obtain and record vital signs as soon as it is safe to do so. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. Notify the resident's attending physician and family in an appropriate time frame. Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. Refer to resident-specific evidence including medical history, known functional impairments, etc. When a resident falls, the following information should be recorded in the resident's medical record: the condition in which the resident was found (e.g., resident found lying on the floor between bed and chair), assessment data, including vital signs and any obvious injuries, interventions, first aid, or treatment administered, notification of the physician and family, as indicated, completion of a falls risk assessment, appropriate interventions taken to prevent future falls, and the signature and title of the person recording the data.

Based on staff interviews and review of facility documentation and policy, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 67 and the sample was 20. The deficient practice could result in residents not receiving advanced care activities to meet their needs. Findings include: The Facility assessment dated of May 25, 2021, revealed an average daily census range of 38 - 42, with full capacity being 80 residents. Staffing planning included one FT (full time) DON (director of nursing), wound nurse, admission nurse, unit manager, and, an MDS (minimum data set) nurse. Per the assessment there should be at least one RN per 24-hour period; individual nursing staff assignments was based on patient care needs and individual staff needs/training; and that, nursing shifts are twelve hours with a goal of consistent assignments. The following dates were reviewed of the punch detail for registered nurses: -November 23 - 27, 2023; -February 16 - 19, 2024; -May 24 - 27, 2024; -August 30 - 31, 2024 -September 2. 2024; -November 2 - December 2, 2024; -May 16 - 18, 2025 The punch detail revealed no evidence of RN coverage on the following dates: - May 25, 2024 - August 30, 2024, August 31, 2024 and - May 16, 2025, May 17, 2025 An interview was conducted with the Staffing Coordinator (staff #29) on May 19, 2025 at 12:45 p.m. The Staffing Coordinator admitted that one RN is needed to work in the facility at least one 8-hour shift daily. She additionally stated that if a registered nurse (RN) was not available to provide the RN coverage that the DON would cover on occasion in the role of an RN floor nurse. The staffing coordinator also stated that the LPN, unit manager and herself will cover shifts if they could not find coverage. She is aware of the need to have RN coverage for 8 hours every day, the facilities expectations are not met if they do not meet the RN coverage need. She verbalized the risk to the residents could be a situation could occur that is out a an LPN ' s scope of practice, that could lead to resident harm. An interview was conducted with the Director of Nursing (DON) (staff # 56) on May 20, 2025 at 3:15 p.m. with the Clinical Resource (staff #250) and the Executive Director (staff # 74) in attendance. The DON stated that it did not meet the the facility expectations to not have an RN coverage for 8 hours every day and the risk could result in staff not being able to adequately cover that position. The Clinical Resource (Staff #250) stated that they have less staff compared to our competitors, this is due to low RN hours on the weekends, but they have higher LPN hours compared to other facilities and that this will be addressed in upcoming quality performance discussions. According to Centers for Medicare & Medicaid Services, The requirements for long-term care facilities require that a skilled nursing facility provide 24-hour licensed nursing services, an RN for 8 consecutive hours a day, 7 days a week (more than 40 hours a week), and that there be an RN designated as Director of Nursing on a full time basis.

Based on observations, interviews, facility documentation and policy, the facility failed to ensure safeguards and systems were in place to ensure accurate reconciliation and accounting for all controlled substances. The deficient practice could result in inventory loss, and potential diversion. Findings include: An observation of the Medication Cart # 1 narcotic logbook was conducted on May 19, 2025 at approximately 8:09 a.m. with the Director of Nursing (DON/Staff # 56). The Shift to Shift Narcotic Sheet & Card Verification revealed the following for May 1 to May 19, 2025: - Count inconsistencies from May 1, 2025 through May 3, 2025. - 6 missed staff signature entries - Duplicate signature entries on May 18, 2025. - The date of May 2020 is written on the log sheet with the entries for May 17 - May 19. An interview was conducted with the DON on May 19, 2025 at approximately 8:09 a.m. The DON revealed the expectation is to have two licensed nurses to sign the log once narcotic count has been completed accurately. In an interview conducted on May 19, 2025 at 10:10 a.m. the Clinical Resource (Staff #250) reviewed the narcotic count logs, and revealed the missing signatures did not meet facility expectation. The resource staff revealed two nurses are instrumental in ensuring proper count of narcotics, to avoid the possibility of missed medications. In an interview conducted with RN (Staff # 3) on May 19, 2025 at approximately 1:39 p.m. revealed that nurses do narcotic counts at the beginning and end of each shift. The off going shift refers to the narcotic book and the oncoming nurse will count the cards and medications. As long as there are no discrepancies, both nurses will then sign to validate the counts were correct. The facility's Medication Therapy policy revealed the facility shall review medication-related issues as part of its quality assurance and performance improvement committee and activities. The facility's Administration Medications Policy effective date January 1, 2024, revealed the DON supervises and directs all personnel who administer medications and/or have related functions.

Based on observations, staff interviews, and a review of facility documentation and policies, it was found that the facility failed to incorporate food safety, storage and hygiene. Findings Include: -Regarding food storage and expired food items: A kitchen observation was conducted with the morning cook (staff #20) on April 18, 2025 at 9:53 AM and revealed the following: - food items found in the refrigerator were beyond their use by date and food items were not sealed properly. -Within the large, three-door refrigerator,cooked bacon was discovered wrapped in tinfoil and lacked any date labeling. - A full one-pound plastic container of strawberries contained two strawberries exhibiting approximately one-inch diameter white colored substance. - A one-gallon plastic bag of lettuce was observed to be brown and wilted, and the bag was undated. - A second plastic bag of spring lettuce was unsealed and bore an illegible date. - A 32 ounce bag of green onions was unsealed and bore a May 2, 2025. - A carton containing multiple heads of green lettuce was observed, with a significant number of leaves appearing wilted and brown. -A staff member discarded a tinfoil of bacon in the trash, then retrieved the tinfoil of bacon. Without washing hands or wearing gloves, they stirred a pan of broccoli with their bare right hand using a large spoon. This spoon was then placed on a plate, with the handle touching a butcher knife. -A staff member did not perform hand hygiene. -Regarding the Mixer, ice machine & Gas Range: An observation of the ice machine in the kitchen was conducted with the morning [NAME] during kitchen observation and the interior frame of the ice machine was observed with dirt and dust buildup, and the exterior of the machine appeared dirty, dust was observed on the vent of the ice machine, covering the filter. An observation of a large mixer was conducted with Dietary Aide (staff #30) on April 18, 2025 at 10:27 AM, and the large mixer located to the right of the ice machine was visibly dirty with food splatter in multiple areas. An observation of the gas range in the kitchen was conducted with the morning cook (staff # 20) on April 18, 2025 at 10:58 AM, the range was observed with a buildup of grease and dust sitting under and on both sides of the gas range. Cleaning logs provided for March 2 to April 27, 2025, show that the refrigerators and ice machine were last cleaned on March 30, 2025. -Regarding vents and lights: An observation of the ceilings, vents and lights in the kitchen was conducted with Dietary Aide (staff # 30) on April 18, 2025 at 10:45 AM, and the ceilings, vents, and lights were found to be covered in dust and dirt. Additionally, the ceilings and tube lights in the freezer room (located between the storage room and kitchen) had numerous cob webs. An interview was conducted with the morning [NAME] (staff #20) on April 18,2025 at 9:53 AM, who stated that sealing and dating food prevents residents from receiving spoiled items. The cook further acknowledged that serving moldy foods poses a risk of resident illness and that failing to perform hand hygiene creates a risk of cross-contamination. The cook also stated that each shift cook is responsible for checking for and discarding spoiled food during their shift. Furthermore, the cook stated that each shift cook is responsible for checking for and discarding spoiled food, but noted there's no supervisory schedule or sign-off sheet to verify these checks. An interview conducted with a Dietary Aide (staff # 30) on April 18, 2025 at 10:27 AM, who stated that unopened food items risk freezer burn and acknowledged the freezer's lack of cleanliness, committing to a weekly cleaning schedule. The Dietary Aide further stated that there was an unsealed open plastic bag of frozen sausage in the freezer and a significant accumulation of dust in the freezer handles' crevices. Another interview was conducted with the morning [NAME] (staff # 20) on April 18,2025 at 11:00 AM , who ran a finger along the inside lining of the ice machine, revealing a dark and wet substance that transferred to their finger. The Staff member confirmed the presence of dust on the plastic vent covering the ice machine's filter, but asserted that it does not impact the filter's function. The cook stated that maintenance last cleaned the ice machine the previous Thursday. The cook further stated that grease buildup on the stove increases the risk of fire, and that the night cook is responsible for cleaning it. An interview conducted with the Maintenance Manager (staff # 10) on April 18,2025 at 11:20 AM, who stated that the maintenance team was responsible for calling a vendor to clean ceiling vents. However, staff #10 then clarified that maintenance cleans the kitchen's ceiling vents every two months, with the last cleaning occurring a month prior. The staff member also confirmed that the maintenance team is responsible for cleaning lights when covers need removal, and that kitchen staff would submit orders for these cleanings. The Maintenance Manager also stated that kitchen staff are responsible for cleaning the stove, fridges, and freezers, and that the kitchen manager ensures the kitchen ceilings are clean. An interview conducted on April 20 ,2025 at 08:18 AM with the Director of Nursing (DON/Staff #40) who stated that the ice machine maintenance protocols included that kitchen staff clean the interior and exterior, while housekeeping and maintenance handle general external cleanliness and dust prevention. The DON also stated that kitchen staff also clean the kitchen vents, but maintenance changes the filters. The DON further stated that kitchen staff are responsible for visual cleanliness and that they have a contract company that conducts quarterly kitchen cleanliness inspections, with reports sent to the Executive Director. The DON stated that if the ice in the ice machine is determined to be contaminated it should be discarded and the machine cleaned and that internal contamination requires a third-party vendor to clean. The DON stated that all opened food must be dated, properly sealed, and discarded when necessary, adhering to storage policies. The DON further stated all kitchen staff must follow the general policy, washing hands before and after tasks, and cleaning surfaces. the DON stated that to prevent cross-contamination, staff should wash hands between handling contaminants and changing gloves. The DON emphasized that moldy produce must be immediately discarded, and wilted or discolored produce should not be served, as this falls short of her expectations. She also stated that improperly sealed food could result infoodborne illnesses, and serving freezer-burned food is unacceptable due to its potential to cause resident illness. The DON stated that the kitchen staff are responsible for cleaning all their equipment, including the ice machine, large mixers, gas range, and refrigerators including handles. An interview was conducted on April 20 ,2025 at 08:18 AM with the Dietary Manager (Staff # 50) who stated that the large mixer is rarely used, and is cleaned bi-weekly. She also stated that all kitchen staff are responsible for cleaning, with visual oversight and that dietary aides clean the stove weekly. Tje Dietary Manger stated that kitchen aides clean the stove vents weekly, while maintenance cleans other vents during filter changes, though this isn't documented. She also stated that refrigerators are checked daily and thoroughly cleaned weekly by dietary aides. The Dietary Manager further stated that kitchen staff clean the ice machine's exterior and internal dust daily and they clean behind the ice machine as needed and maintenance also cleans the ice machine. The Dietary Manager stated that when ice in the ice machine would become contaminated, the ice would be discarded and replaced with bagged ice. She also stated that mainenance is responsible for cleaning the kitchen ceilings and lights. The Dietary Manager stated that staff are requiree to immediately date and label opened food packages and practice thorough hand hygiene at a sink, using hot water and soap for at least 20 seconds. She further stated to prevent cross-contamination, they emphasize using more utensils and expressed strong disapproval for staff touching garbage then food without handwashing, deeming it an unacceptable risk and would lead to retraining. She also stated that refrigerators are checked daily for spoiled/expired food, and moldy produce must be immediately discarded. An interview was conducted on April 20 ,2025 at 11:22 AM with the Executive Director (ED/Staff #60) who emphasized that food storage must be orderly, fresh, and rotated, requiring cooks to conduct daily refrigerator inspections and immediately date all opened food items. The ED stated that expired or improperly sealed food poses a significant risk of bacterial growth and foodborne illness, necessitating that it is immediately discarded to protect residents. The ED added that improperly sealed meat risks freezer burn and spoilage, and wilted produce must be discarded. He also stated that kitchen staff are responsible for cleaning all equipment, including freezers (and handles), ice makers, ceilings, vents, and tube lights, noting that dust on handles can cause cross-contamination. The ED also stated that staff failing to perform hand hygiene creates an unacceptable cross-contamination risk, and that serving ice from a dusty ice maker risks foodborne illness, a practice he would personally avoid. A faciltiy policy titled, Food storage and Date Marking, revealed that all the food items must be stored and dated properly. A facility policy titled, Cleaning Instructions:Ice Machine and Equipment, revealed that the ice machine should be cleaned and sanitized on a regular basis to maintain a clean, sanitary condition. The steps include removing the ice, washing the interior thoroughly using a detergent solution. Rinse and drain the interior with clean hot tap water and pay close attention to the crevices. A facility policy titled, Cleaning Instructions: Refrigerators, revealed that the refrigerators will be cleaned thoroughly inside and outside with a detergent and followed by a sanitizer at least once every month , or as needed. Spills and leaks will be cleaned as they occur. A facility policy titled, Cleaning Instructions:Stoves, revealed that the cooktops will be cleaned after every use. A facility policy titled, General HACCP Guidance for Food Safety, revealed that staff should wash hands prior to working with food, after using the restroom or soiling hands in any way. The facility was not able to provide a policy for cleaning the kitchen ceiling / lights.

The facility failed to ensure that staff followed appropriate infection control practices. The deficient practice could result in a spread of preventable illness to residents and staff. Findings included: On May 19, 2025 at 11:03AM, a Certified Nursing Assistant (CNA/Staff #64) was observed completing a resident's vitals near a nursing station. It was observed that Staff #64 did not sanitize or wash his hands before and after obtaining the resident's vital signs. Upon exiting the room the CNA was observed to write the vital signs of the resident on a clipboard and set the clipboard on the nursing station. Staff #64 was then observed entering another resident;s room without first sanitizing his hands. An interview was conducted on May 19, 2025 at 11:19AM with Staff #64, who stated that the facility's expectations regarding hand hygiene was to perform handwashing before and after providing care or coming in direct contact with a resident. Staff #64 also stated that hand hygiene and infection control practices are expected when obtaining the vitals of a resident. Staff #64 stated he did not complete proper hand hygiene while obtaining the vitals of the resident, and stated that he did not complete proper hand hygiene before and after obtaining vitals, and did not sanitize his hands when he entered another resident's room immediately after obtaining the vital signs. Staff #64 stated that the facility's expectation is to perform hand hygiene before and after obtaining vital signs, as well as disinfecting the devices that had been utilized to obtain the vital signs, due to the risk of spreading germs, illnesses, and diseases. An interview was conducted with another CNA (Staff #20) on May 19, 2025 at 2:50 PM, who stated that hand hygiene is to be completed before and after patient care, and to ensure handwashing is to be completed every few times after hand sanitizing. Staff #20 also stated that the facility's expectation is to ensure appropriate infection control practices are followed due to the risk of spreading infections from resident to resident and to the staff. Staff #20 had also stated that when obtaining labs, the facility's expectation is to ensure appropriate infection control practices are followed. Staff #20 then demonstrated what devices are to be disinfected and where the disinfectant can be found, as infection control practices included hand hygiene and disinfecting the devices utilized to obtain a resident's vital signs. An interview was conducted with the DON/IP (Director of Nursing/Infection Preventionist/Staff #56) and a Clinical Resource (Staff #250) on May 19, 2025 at 3:50PM. Staff #56 stated that hand hygiene is expected to be completed before and after patient care, whether that may be bringing in a tray of food or providing a patient with medications. The DON/IP also stated that obtaining vitals is considered patient care and that hand hygiene is expected to be completed before and after obtaining the vitals. The DON/IP stated that when obtaining vitals, disinfecting the devices and equipment with appropriate disinfectant is just as important as hand hygiene. A policy titled, 'Infection Control, Handwashing/Hand Hygiene' stated that the facility considers hand hygiene the primary means to prevent the spread of infection. It also stated that hand washing should be done after hands are visibly soiled, and after contact with a resident with an infectious diarrhea. The policy also stated that the use of an alcohol-based hand rub can be used before and after coming on duty, coming in contact with residents, handling medications, any non-surgical invasive procedures, handling invasive devices, before donning sterile gloves, handling clean or soiled dressings, moving from a contaminated body site to a clean site during resident care, after contact with a resident's intact skin, bloody or bloodily fluids, dressings and contaminated equipment and objects in the immediate vicinity of the resident, after removing gloves, before and after entering isolation precaution settings, eating or handling food, assisting a resident with heir meals and after the personal use of the toilet or conducting personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#2) was provided care and services to meet professional standards regarding following physician orders for assessment of a resident post-fall. The deficient practice could lead to an injury being missed and a delay of care provided to a resident. -Findings include: Resident #2 was admitted to the facility January 10, 2025, and re-admitted to the facility on [DATE], with diagnoses that included pneumonia, end-stage renal disease, acute pulmonary edema, hemiplegia and hemiparesis affecting the left side, and dysarthria. An admission MDS (minimum data set) assessment, dated January 16, 2025, revealed the resident had a brief interview for mental status (BIMS) score of 12, indicating the resident had moderately impaired cognition. A physician order dated March 4, 2025, indicated for an x-ray of Resident #2's right arm to rule out a fracture. A progress note dated March 4, 2025, revealed a Certified Nursing Assistant (CNA) called the nurse to the resident's room stating that the resident had rolled out of bed. The resident stated that he rolled out of bed and hit his right arm and back. The resident reported having mild discomfort. Additionally, the resident was having difficulty moving the right arm over his head. The provider was notified, and a new order for an x-ray was placed. An eMar-Medication Administration note dated March 5, 2025, revealed no xray this date regarding the right arm x-ray. Review of the clinical record revealed no evidence that the right arm x-ray was completed. A Progress Note dated April 2, 2025, revealed the provider was made aware that the resident's x-ray was not completed, and that there were no new orders. An interview was conducted on April 2, 2025, at 3:49 PM, with the Medical Records Manager (Staff #20), who stated that there was no x-ray for Resident #2. An interview was conducted with a Licensed Practical Nurse (LPN / Staff #35) on April 2, 2025, at 4:11 PM. Staff #35 stated that the facility's process for getting an x-ray is that staff receives an order from the provider, that it is printed out and sent to a mobile x-ray company. Then, the mobile x-ray company is called, and the x-ray is scheduled. The clinical record was reviewed at this time, and Staff #35 stated that the x-ray for Resident #2's right arm was not done, and that she believed she made an error when she charted that the x-ray was not done on March 5, 2025, as the order goes away once it is charted on. Staff #35 stated that she just found out today that if an order is charted on, then it disappears. An interview was conducted with the Director of Nursing (DON / Staff #15) on April 3, 2025, at 10:15 AM. The DON stated that staff should follow physician orders as they are entered, and that if physician orders are not followed, that depending on the order, it could cause a delay of care, or a resident not receiving what is ordered. The DON stated that Resident #2 has had 2 falls during his admission to the facility, and that an x-ray for the right arm was ordered on March 4, 2025. The DON stated that it was brought to her attention yesterday that Resident #2 did not get the x-ray, and that it was a documentation issue from the floor nurse. The DON stated that the nurse was provided education on the issue, and that the provider was notified that the resident did not get the x-ray as ordered. Review of the facility policy titled Medication Orders, revised November 2014, revealed that a current list of orders must be maintained in the clinical record of each resident. Treatment orders must specify the treatment, frequency, and duration of the treatment. Review of the facility policy titled Medications: Documentation of Medication Administration, dated January 1, 2024, revealed a medication administration record is used to document all medications administered, and that administration of medication is documented immediately after it is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure the medical record was complete, accurate, and readily accessible for one resident (#55). The deficient practice could lead to care team members not having accurate, complete, and current resident information to coordinate care, which could lead to a decreased quality of care for residents. -Findings include: Resident #55 was admitted [DATE], and re-admitted [DATE], with diagnoses that included encounter for surgical aftercare following surgery on the genitourinary system, urinary tract infection, functional quadriplegia, depression, anxiety disorder, post-traumatic stress disorder, and conversion disorder. An admission MDS (minimum data set) assessment dated [DATE], revealed the resident had a BIMS (brief interview for mental status) score of 12, indicating the resident had moderately impaired cognition. A care plan dated February 18, 2025 for the resident experiencing impacts of distressing or traumatic events had interventions that included refer to mental health professional for trauma assessment and treatment. A Progress Note dated March 9, 2025, revealed the resident's physical and mental status seems to have changed since coming back from the hospital. The resident is no longer showing any signs of being a quadriplegic, and is now transferring herself from bed to wheelchair without any assistance. The resident is bringing random items from her room into the main room, and has been removing rocks from the plantar and placing them around the facility. Additionally, the resident has been taking towels, using them, and placing them in garbage bags, and putting the bag in the nursing cart garbage. The Director of Nursing (DON) and provider were notified. Staff tried to remove any items from her room that could harm her. A History and Physical note from the resident's medical provider dated March 9, 2025, indicated to consult the psychiatric (psych) provider for Resident #55. A Behavior Note dated March 10, 2025, revealed Resident #55 was awake all night long self-transferring and going to the water/coffee area, getting cups of water, and taking one sip and throwing the full cup of water away. Resident used up the entire bucket of water and a lot of cups every time. The resident was talking in the third person. Resident kept wheeling herself around the entire building as fast as she could. A Behavior Note dated March 12, 2025, revealed the resident was observed taking other resident's food apart and trying to feed him. The resident was asked not to do that and educated on the importance of asking certified nursing assistants (CNAs) and nurses for help. An additional Behavior Note dated March 14, 2025, revealed the resident had multiple episodes of crying and yelling at staff, and would start yelling at staff that she had needs, but then was unable to verbalize her needs and states she just wants to be taken care of and feel better. Staff provided emotional support and active listening. A Discharge Summary note dated March 17, 2025, revealed the resident left the facility against medical advice. There was no evidence in the clinical record that a psych provider was consulted for Resident #55, or that the resident was evaluated, or what interventions were recommended by a psych provider. A Medical Records Progress Note dated March 26, 2025, at 11:39 AM, revealed Resident #55 had a telehealth visit with the contracted psych provider on March 11, 2025. A call was placed to the provider on March 14, 2025 to request the visit notes. A follow up call was made on March 26, 2025, at approximately 11:00 AM to request the records. A Medical Records Progress Note dated March 26, 2025, at 1:44 PM, revealed the psych provider records had been received and uploaded into the resident's electronic medical record. An interview was conducted with a CNA (Staff #19) on March 26, 2025, at 10:48 AM. The CNA stated that she is in charge of scheduling appointments for the facility. Staff #19 stated that she was familiar with Resident #55, and that the resident started demonstrating behaviors when she returned from the hospital. Staff #19 stated that the resident was referred to a contracted psych provider, and was set up for a telehealth appointment on Monday, March 10, 2025. The CNA stated that she assisted the resident with setting up the electronic device for the telehealth appointment, but was not present for the resident's appointment visit. An interview was conducted on March 26, 2025, at 10:56 AM, with the Medical Records Manager (Staff #30), who stated that she had called the contracted psych provider for Resident #55's appointment visit notes, however had still not received the medical records. Staff #30 stated that she will re-request the records. An interview was conducted with the DON (Staff #72) on March 26, 2025, at 12:51 PM. The DON stated that the importance of having a complete medical record for a resident would be for the facility to track incidences and occurrences regarding that resident's care, and additionally to allow the interdisciplinary team (IDT) to ensure care is completed and followed-up appropriately. If the medical record was not complete for a resident, the DON stated that this could negatively impact different aspects of residents' care and services. The clinical record for Resident #55 was reviewed at this time, and the DON stated that there was no evidence of any psych consultations or visit notes. The DON stated that this would still meet her expectation, because the facility had reached out to the psych provider to receive those notes. An interview as conducted with the [NAME] President of Clinical Operations (Staff #41) on March 26, 2025, at 1:53 PM. Staff #41 stated that the facility has no policy specifying a required time frame of when consults and visit notes need to be uploaded into the medical record. Review of the facility policy titled Charting and Documentation, dated January 1, 2024, revealed that all services provided to the resident, progress toward the care planned goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the IDT members regarding the resident's condition and response to care. Review of the facility policy titled Medical Records: Retention of Medical Records, dated January 1, 2024, revealed medical records shall be retained by the facility in accordance with current applicable laws. Review of federal regulation 483.70 (i) revealed a facility must maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized. Medical records must be retained for the period of time required by State law; or five years from the date of discharge when there is no requirement in State law. The medical record must contain a record of the resident's assessments, the comprehensive plan of care and services provided, and physician, nurse, and other licensed professionals progress notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that a resident received care and services according to physician orders regarding weight monitoring for one resident (#10). The deficient practice could result in a residents not receiving treatment to meet their needs. -Findings include: Resident #10 was admitted on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, dysarthria, dysphagia, acute respiratory failure with hypoxia, and methicillin susceptible staphylococcus aureus infection. A care plan dated February 1, 2025, revealed that the resident was at risk for nutritional problems with an intervention to monitor weights per orders. A physician order dated February 1, 2025, indicated for an enteral feed of Osmolite 1.5 to start at 35 ml/hr to increase by 10 ml/r until goal of 65 ml/hr and 90 ml of free water flushes every 2 hours. A physician order dated February 1, 2025, indicated for Weekly Weights: On admission and then follow facility protocol of weekly x 4 weeks. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed a brief interview for mental status (BIMS) score of 4 indicating the resident had severely impaired cognition. Section GG revealed the resident was dependent on caregivers for oral and personal hygiene, toileting, dressing, bed mobility, transferring from sitting to standing, and transfers from bed to chair. The resident was unable to ambulate. Section I revealed the resident had malnutrition or was at risk for malnutrition. Additionally, the resident had a feeding tube. The medication and treatment administration record for February 2025 revealed no evidence of weekly weights taken. The Weights Summary log revealed one entry: -2/3/2025: 182.9 Lbs, taken on a standing scale, entered by a dietary consultant (Staff #6). The facility logs of weekly and monthly weights for February 1-February 17, 2025 were reviewed, with no evidence of any weights taken for Resident #10. Review of the Certified Nursing Assistant (CNA) Task log for Weights revealed no evidence that the resident refused any weights taken. A Nurse Practitioner progress note dated February 17, 2025, revealed patient with mouth breathing and work of breath not relieved by O2 and that the resident was sent to higher level of care. A Discharge summary dated [DATE], revealed the resident was transferred to the emergency department. An interview was conducted on February 27, 2025, at 10:50 AM with a CNA (Staff #12), who stated that the facility's process for taking residents' weights was that the facility has hoyer lift scales and wheelchair scales that a wheelchair can be rolled up on. Staff #12 also stated that a resident could walk up onto the wheelchair scale and be weighed that way. Staff #12 further clarified that a resident could not just stand up on the wheelchair scale, that several steps would need to be taken by the resident to be able to get on the scale. The CNA stated that the CNAs or nurses are the ones that take the residents' weights, that it is charted in the electronic medical record in a Weights log. Staff #12 stated that if a resident refuses to have a weight taken, then that would be documented as a refusal under the Weights Task log. A telephonic interview was conducted on February 27, 2025, at 11:28 AM, with a Registered Dietician (RD / Staff #19), who stated that she had been consulted to review Resident #10's tube feed order, to ensure that the resident was getting enough calories. The RD stated that the order was for the resident to start at 35 ml/hour and go up to 65 ml/hour. She stated that she uses the weight measurements that the facility has entered in the medical record to determine the resident's caloric needs, and that if there are no weights entered, that she will review the hospital records. The RD stated that she recalled a nursing director contacting her to review the resident's tube feed prescription because the resident's mouth was dry. A telephonic interview was conducted with a dietary consultant (Staff #6) on February 27, 2025, at 11:50 AM. The dietary consultant stated that all the work that she does with the facility is remote, that she does not come to the facility. She stated that if she notices that a resident does not have a weight assessment completed, that she will look in the past medical records from the discharging hospital and enter in the most recent weight she can find into the medical record. She stated that this is intended to be a place holder weight until the facility can get the weight assessment done. Staff #6 stated that if the facility did not weigh a resident, then it would not trigger any weight changes, and the resident may get missed for review. Staff #6 stated that there would be risks if the resident did not get weighed, and that the facility needed to establish a baseline weight, and monitor for weight gains or weight losses. Regarding Resident #10, the dietary consultant confirmed that she did not weigh the resident, rather that she entered a previously taken weight from the hospital into the medical record. An interview was conducted with a CNA (Staff #20) on February 27, 2025, at 12:33 PM, who stated that it is the CNAs who are in charge of getting resident weights. Additionally, the CNAs document the weights on a piece of paper that notifies them which residents need to be weighed, and then enter the weight into the medical record during their shift. On February 27, 2025, at 12:34 PM, an interview was conducted with another CNA (Staff #31) who stated that CNAs are given paper lists of which residents need to be weighed, both weekly and monthly. An interview was conducted with the Director of Nursing (DON / Staff #3) on February 27, 2025, at 1:43 PM, who stated that she has been the DON at the facility for two days. She stated that the staff follow the facility policy for monitoring residents' weights. She additionally stated that it was her expectation that staff would follow physician orders for weight monitoring. The clinical record of Resident #10 was reviewed together and the DON confirmed that the resident had a weight monitoring order to be weighed weekly for four weeks. The DON also confirmed that only one weight was entered in the medical record which was the weight entered by the dietary consult (Staff #6), and that she would have to speak with staff to see what happened. An additional interview was conducted at this time with the former DON and current clinical resource (Staff #29), who stated that it looked like staff missed getting Resident #10's weight, and that it would not meet her expectation. Staff #29 stated that there are risks of missing residents' weight assessments: there could be potential weight loss for the residents or that the facility would not identify weight loss in a timely manner. Staff #29 stated that the facility would be taking steps to correct the issue. Review of the facility policy titled Nutrition/Hydration: Weight Assessment and Intervention, dated January 1, 2024, revealed that resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. Weights are recorded in the individual's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, observations, policy review and the State Agency (SA) complaint tracking system, the facility failed to ensure that two residents (#1 and #2) received treatment and care in accordance with professional standards of practice by failing to provide wound care as ordered by a physician. The sample size was 5. The deficient practice could lead to residents acquiring wound infections. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that include osteoporosis, acute post-hemorrhagic anemia, and chronic obstructive pulmonary disease (COPD). A review of a Minimum Data Set (MDS) assessment dated [DATE], indicated resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of the physician's orders revealed resident #1 was to have wound care by cleaning the Right surgical area with normal saline, pat dry, and apply dressing at the surgical site once a day every three days. Review of a weekly skin assessment dated [DATE] at 12:31 PM noted that resident #1 had a surgical dressing on the right lower leg with instructions in place until November 22. After that time, the dressing would need to be changed every three days. A review of the November 2024 Medication Administration Record (MAR) revealed, that between November 19, 2024 and November 30, 2024, wound care was provided three times (November 20, 23, and 30). A review of the December 2024 MAR revealed, that between December 1, 2024 and December 4, 2024, wound care was provided once (December 3, 2024) by staff #18. An interview was conducted with resident #1 on December 4, 2024 at 12:40 PM in her room. The resident indicated the wound bandage had not been changed in five day and she was not sure if the wound was getting better. She also indicated that the nurse was supposed to change it every few days. An interview was conducted on December 4, 2024 at 12:57 PM with Registered Nurse (RN/Staff #63). Staff #63 confirmed that she was the wound care nurse for the facility. She explained that her responsibility was to see residents, who receive wound care, once a week and to document in the skin assessments. Staff #63 continued to explain that she sees resident #1 once a week and when she last saw the resident, there were no concerns with her wounds. Staff #63 indicated that she last changed resident #1's wound bandage on November 29, 2024 and had not yet seen her since that date. Staff #63 also added that resident #1 often tells her that her bandage has not been changed in a week so she would go and change her bandage to make her happy. On December 4, 2024 at 1:54 PM, the [NAME] President of Clinical Operations (VP/Staff #9) was observed exiting resident #1's room. At that time, Staff #9 was asked to return to the resident's room with the State Surveyor (SS). Resident #1 was observed to be sitting on her wheelchair with a bandage exposed on her lower right leg. When asked what the date was on the bandage, Staff #9 responded November 29. When asked what that would indicate to the staff member, Staff #9 explained that she would have to look at the orders but it told her that the dressing was last changed on November 29, 2024. RN Staff #63 reached out to SS on December 2, 2024 at 2:21 PM. She explained that she took a look at resident #1's wound bandage and that the date on there was November 29, 2024. When asked what that mean, staff #63 stated that it meant she was the last person to change the bandage and that was on November 29, 2024. When asked what the risks to the resident would be if bandages are not changed as ordered, Staff #63 indicated that wound could potentially get infected. An interview was conducted with RN/Staff #18 on December 4, 2024 at 2:25 PM. Staff #18 confirmed that he worked on December 3, 2024 and that he sometimes provides wound care to residents. Staff #18 explained that when he provides wound care, he documents it on the MAR. When asked if he provided wound care to resident #1 on December 3, 2024, he stated that he did not. SS showed staff #18 the December MAR and asked him if he had signed off on wound care for resident #1. He looked at the MAR and explained that he did sign off on it but he did not provide the care as he thought he might have gotten distracted. When asked what the risks were if wound care is not provided to the resident as ordered, he indicated that if one wound care was missed, nothing would happen but if it were to be missed frequently then the wound could get infected. Related to resident #2: Resident #2 was admitted to the facility on [DATE] with diagnoses of osteomyelitis of vertebra, sacral, and sacrococcygeal region, type 1 diabetes, and cellulitis of both the right and left lower limb. Review of the last completed MDS, dated [DATE], did not have a completed BIMS assessment, however it was noted that the staff assessment for mental status was modified independence. Review of physician's orders found an order dated November 8, 2024 for wound care to the right ankle. The order indicated the wound was to be cleansed with saline, apply calcium alginate to wound and cover with clean dry dressing every three days and as needed. The December MAR was reviewed and it was noted that wound care to the right ankle was provided on December 3, 2024 by staff #18. On December 4, 2024 at 2:58 PM, Resident #2 was observed with a bandage with blood soaked through on his right ankle. Licensed Practical Nurse (LPN/Staff #17) was present in the room when the observation was made and indicated that the date on the bandage was November 28 and that told her that the bandage was needing to be changed. Staff #17 explained that she had just come onto the floor as they recently did a shift change and that the outgoing nurse had told her that resident #2 needed a bandage changed because the nurse was not able to get to it during her shift. An interview was conducted on December 4, 2024 at 4:38 PM with staff #9. When what could be a possible risk to the residents if wound dressings are not changed as ordered by a provider. Staff #9 indicated there could be a possible infection of the wound. When asked what transpired with Resident #1 and Staff #9 explained that SS had made a true observation that her wound dressing was not changed,. Staff #9 continued to explain that the dressing should have been changed according to the schedule and it had not. She also indicated that the MAR showed that it was signed off but the actual care was not done. Staff #9 added that staff were not to be documenting care until it was provided. The policy titled, Skin/Wound Management: Wound Care was reviewed on December 4, 2024. The policy went into effect on January 1, 2024. The policy stated that the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. The documentation section of the policy indicated that the date and time the wound care was given should be recorded in the resident's medical record. This indicated that documentation was to be done after providing wound care. The policy titled, Documentation: Charting and Documentation stated All services provided to the resident . shall be documented in the resident's medical record,. The policy also indicated that documentation in the medical record will be complete and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure a thorough investigation for a resident to resident complaint. The deficient practice could result in residents not being protected from further abuse and appropriate corrective action not taken. Findings include: Resident #1 was admitted on [DATE] with diagnosis including anemia, dysphagia, protein-calorie malnutrition, pulmonary fibrosis, macular degeneration, insomnia, intervertebral disk degeneration-lumbar region, anxiety disorder, spinal stenosis-lumbar region, radiculopathy-lumbar region, mild cognitive impairment, age related osteoporosis, chronic kidney disease, palmar fascial fibromatosis and depression. A review of the quarterly MDS (minimum data set) dated November 4, 2022 revealed a BIMS (brief interview of mental status) score of 15, suggesting the resident was cognitively intact. The facility final incident report dated January 10, 2023 revealed that an alleged incident of resident to resident abuse had occurred involving resident #1. It was alleged that the roommate of resident #1 had hit the leg of resident #1 while she was sleeping. It was further documented that staff separated the residents and moved the alleged perpetrator out of the room to another room on a different hall. It was further noted that the incident was immediately reported and an investigation started. The report revealed that there were no witnesses and all staff that were on shift reported no issues between the two residents prior to the incident. The report, however, did not include any staff interviews. Skin assessments observed within the electronic health record for resident #1, revealed no evidence of injury or bruising from the alleged encounter. On May 16, 2024 at 8:33 A.M staff #45 (DON-director of nursing) stated that the facility was unable to locate the interviews for the final report regarding the resident to resident abuse allegation. An interview was conducted with resident #1 at 8:55 A.M. on May 16, 2024. Resident #1 stated that she did recall her roommate hitting her last year in January. She stated that her roommate would just stare at her at the end of the bed, which prompted her to reach out to the previous administrator, staff #91 to report the issue. She stated that the previous administrator responded by saying he would move her roommate, but before the move could take place, the resident stated that her roommate hit her on the right leg with her fist. She stated that she reported the incident to the administrator and that she had suffered no injuries or bruises from the encounter. She further stated that her previous roommate had been moved and that she currently felt safe in the facility. A telephone call was placed on May 16, 2024 at 9:30 A.M. to staff #25 LPN (licensed practical nurse) noted to have been on duty on the date of the alleged resident to resident abuse allegation. Staff #25 stated that she did not recall any incidents of resident to resident abuse with regard to resident #1. An interview was conducted on May 16, 2024 at 9:38 A.M. with staff #45 (DON). Staff #45 stated that that she was unable to find the interviews for the resident to resident abuse investigation for resident #1. Staff #45 stated that the expectation is that all investigative interviews are thoroughly completed and documented. She stated that the risk of not completing them is the potential for more of a wide-spread issue and not identifying the root cause. A review of the facility policy entitled Abuse version 0622 with a copyright date of 2022 revealed that an investigation of abuse will be conducted immediately and completed within 5-days to include a minimum of three resident interviews for trending purposes and interviews may also include the alleged perpetrator, witnesses and staff members; however, the facility had no record of additional resident or staff interviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of facility documentation, and policy, the facility failed to ensure that the electronic health record for resident #2 was complete and accurately documented. The deficient practice could result in incomplete and/or inaccurate clinical records. Findings include: Resident #2 was admitted on [DATE] and discharged on September 21, 2023 with diagnosis including pleural effusion, alcoholic cirrhosis of the liver with ascites, congestive heart failure, thrombocytopenia, hypothyroidism, dorsalgia, anxiety disorder, gastrointestinal hemorrhage, hepatorenal syndrome, urinary tract infection, chronic kidney disease, and paroxysmal atrial fibrillation. A review of the MDS (minimum data set) dated September 6, 2023 revealed a BIMS (brief interview of mental status) score of 13 suggesting that the resident was cognitively intact. A review of the electronic health record for resident #1 revealed no evidence of a personal inventory form at admission or subsequent prior to discharge. The facility's final incident report, regarding the missing funds complaint, revealed that the facility was replacing the $55.00 in cash that had allegedly gone missing from her wallet; however, there was no documented evidence that the resident had received the funds from the facility. A telephone call was placed on May 15, 2024 at 2:51 P.M. to resident #2. A fax machine answered the call and no alternate phone numbers were available to leave a message. An interview was conducted on May 16, 2024 at 7:25 A.M. with staff #46 (LPN-licensed practical nurse). Staff #46 stated that the personal inventory form is generally filled out by CNA's (certified nursing assistants) at admission and updates to the inventory form can be completed throughout the resident's stay by any staff member. Staff #46 stated that regardless of who completes the form, each resident has to have a personal inventory form. Staff #46 stated that the risk of not having an inventory form in place, could include not knowing what property the resident had to begin with, which would impact the ability to efficiently track any missing items. An interview was conducted on May16, 2024 at 8:15 A.M with staff #52 (CNA). Staff #52 stated that at admission a resident inventory form is completed by CNA's or nurses in conjunction with the resident and or resident's family. He stated that valuables to include money are locked away for safe-keeping for each resident. Staff #52 stated that at discharge, the inventory form is verified with the items that the resident is taking home to ensure that residents have all their property. He stated that if items were brought in after the initial inventory form had been completed, any new items are added to the form. An interview was conducted on May 16, 2024 at 9:38 A.M with staff #45 (DON-director of nursing). Staff #45 stated that the facility was unable to locate a personal property inventory form for resident #2. She stated that the expectation is that inventory forms and receipts for petty cash utilized for reimbursement are completed, documented and retained. She stated that the risk would be the inability to track whether a resident brought items into the facility and match that report with the inventory form at discharge. For the missing petty cash receipt documenting the reimbursement to resident #2, the risk would be the inability to document and or prove that funds were dispersed as reported. A review of the facility policy entitled Resident Rights-Personal Property dated January 1, 2024 revealed that the resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary; however, per record review and interviews, there was no evidence that resident belongings were inventoried at the time of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure there was a physician order for the use of an indwelling catheter for one resident (#172). The deficient practice could result in inappropriate use of an indwelling catheter for residents who do not need them. Findings included: Resident #172 was admitted on [DATE], with diagnoses of acute cystitis without hematuria and acute kidney failure. The Minimum Data Set (MDS) assessment included that indwelling catheter was not coded for resident #172. The nursing admission evaluation on April 2, 2024 revealed the resident was oriented to person, place, and situation and had bowel and bladder incontinence. The care plan dated April 3, 2024 included that the resident had an indwelling catheter for bladder outlet obstruction. Interventions included to change catheter as ordered and catheter care every shift. Review of the catheter evaluation dated April 3, 2024 revealed the justification for use of indwelling catheter was bladder outlet obstruction; and that, the catheter order included to change Foley catheter as needed and catheter care every shift and as needed. The history and physical progress note dated April 3, 2024 included that the resident had complicated cystitis. The documentation did not include the resident had indwelling catheter on. The physiatry progress note on April 5, 2024 included that Foley catheter was in place. Despite documentation that the resident had indwelling catheter, the clinical record revealed no physician order for the indwelling catheter from April 2 through April 10, 2024. The physician order dated April 11, 2024 included for Foley catheter size 16Fr (French)/30 cc (cubic centimeter) balloon and to change Foley catheter as needed for leaking, soiling, blockage or as ordered. An observation was conducted on April 10, 2024 at 1:44 p.m. with a certified nursing assistant (CNA)/staff #67) who completed indwelling Foley catheter care for resident #172. The resident had an indwelling catheter with a privacy bag that covered the Foley catheter bag. An interview was conducted with a licensed practical nurse (LPN)/staff #9) on April 11, 2024 at 1:22 p.m. The LPN stated obstruction would be one of the reasons for a Foley indwelling catheter placement. The LPN said that when a resident had indwelling catheter, she would ensure to get an order from the provider and there was a reason for the indwelling catheter use. During the interview, a review of the electronic record was conducted with the LPN who stated there was no order for the catheter use and she needed to get an order for the resident's Foley catheter. In an interview conducted with the Director of Nursing (DON) on April 11, 2024 at 2:54 p.m., the DON said that a physician order was needed if the resident was using and indwelling catheter. The DON said that there should be specific diagnosis for the use of indwelling catheter such as neurogenic bladder, or urine outlet obstruction. The DON also said that it was her expectation that staff would check the admission orders if a resident had a Foley catheter; and that, to call the physician if there was admitting order for the use of an indwelling catheter. Further, the DON stated that if the Foley catheter care did not appear in the MAR/TAR (medication administration record/treatment administration record) the staff should find out the reason and then contact the physician. The facility policy on Urinary/Renal Conditions: Catheter Care, Urinary dated on January 1, 2024, revealed that to review and document the clinical indications for catheter use prior to inserting, nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and policy and procedures, the facility failed to ensure that one resident (#41) received nail care as needed and showers, and one resident (#12) received assistance with showers as needed. The deficient practice could result in poor hygiene and infection. Findings include: Resident #41 was admitted on [DATE] with diagnoses that included chronic kidney disease, Type II diabetes, and acquired absence of the left leg below the knee. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 8 indicating the resident had a moderate impairment. The assessment also included that the resident needed substantial/maximal assistance with bathing. Review of the care plan dated March 12, 2024 revealed that the resident was at risk for functional self-care deficits. Interventions included the resident required substantial/max-total assist to bathe. Review of the shower task sheet for the month of March 2024 revealed that the resident received a shower on March 1, 8, 12, 19, 22, 26, and 29, 2024. The resident only received one shower the week of March 8 and March 12, 2024. The shower task sheet for the month of April 2024 revealed that the resident received a shower on April 2 and 9, 2024. The resident only received one shower per week. The shower sheets for March and April 2024 also revealed that fingernail care was a part of the bathing process. Further review of the shower sheet forms revealed no documentation that the resident received or refused showers/bathing or was offered nail care for the month of March and April 2024. During an observation conducted on April 9, 2024 at 2:34 p.m., the resident's fingernails were observed to be too long, stained, and had dirt under the nails. An interview was conducted on April 11, 2024 9:22 a.m. with a Direct Care Coordinator/certified nursing assistant (CNA/staff #43) who stated that showers were scheduled twice a week; and, showers included washing hair, shaving, and clipping/cleaning fingernails. She stated that staff were supposed to complete a shower sheet form and document services provided including resident refusals. The CNA also stated that the staff were to document that the resident received assistance with showers on the shower task sheet. Further, The CNA said that the DON (Director of Nursing) was responsible for monitoring the shower sheet forms and the task sheets. During the interview, an observation of resident #41 was conducted with the CNA (staff #43) who stated that the resident's the fingernails on the left hand were too long, past the fingers, and had black debris was under the nails. The right hand was under the blanket, so it could not be observed. In an interview with the Medical Records Manager (staff #37) conducted on April 11, 2024 at 9:37 a.m., staff #37 said that she did not have any shower sheet forms for resident #41 for the last two weeks. During the interview, staff #37 checked in the DON's office and the nurse stations to see if there were any shower sheet forms; and, staff #37 stated that she could not find any shower sheets for the last two weeks resident #41. An interview was conducted on April 11, 2024 at 9:53 a.m. with the DON who stated the residents were scheduled for two showers a week; and that, the resident can ask for more. The DON said that showers/bathing were documented on the task sheet and on the shower sheet form; and, both forms of documentation were currently being used because staff were forgetting to document on the task sheet. The DON said that the facility was working on ensuring that the shower sheet forms were collected. She stated that nail cutting and cleaning was a part of nail care and if the resident refuses nail care, it should be documented on the shower sheet form and the resident had to sign it. She stated that Direct Care Coordinator (CNA/staff #43) was responsible for reviewing the task sheets and shower sheet forms; however, staff #43 had been working on the floor because she was needed to assist with the residents. The facility's policy, Bathing and Showers dated 2022 stated a purpose to promote cleanliness, provide comfort to the resident and to observe the condition of the skin. Do not trim the resident's toenails or fingernails unless otherwise instructed by the supervisor. The following information should be documented in the resident's record: date and time of shower, skin observations, refusals, and how the bath/shower was tolerated by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, facility policy and procedures, and CMS (Centers for Medicare and Medicaid Certification) guidance, the facility failed to ensure that staff used appropriate enhanced barrier precautions (EBP) for two residents (#23 and #172). The deficient practice could result in the transmission of infections to residents and staff. Findings include: -Resident #172 was admitted on [DATE], with diagnoses of acute cystitis without hematuria and acute kidney failure. The Minimum Data Set (MDS) assessment included that indwelling catheter was not coded for resident #172. The nursing admission evaluation on April 2, 2024 revealed the resident was oriented to person, place, and situation and had bowel and bladder incontinence. The care plan dated April 3, 2024 included that the resident had an indwelling catheter for bladder outlet obstruction. Interventions included to change catheter as ordered and catheter care every shift. An observation was conducted on April 10, 2024 at 1:44 p.m. with a certified nursing assistant (CNA)/staff #67) who completed indwelling catheter care for resident #172. The CNA washed her hands by the nurses' station before entering the resident's room. She brought with her a clean urinal, donned clean gloves, emptied the foley catheter bag and emptied the urinal in the bathroom. She then disposed of the urinal into a trash bag, washed her hands with soap and water and donned new gloves. She carried the trash can with plastic lining cover with her gloves on then proceeded to lowering the head of the bed. She uncovered the resident, unstrapped her brief, wiped down the resident's abdominal folds, groin area and labia using a clean wipe each time. The CNA wiped the area where the catheter was exiting the urethra, grabbed the catheter from the exit from urethra and wipe 3-4 inches down; and after the catheter care, she re-strapped the resident's brief, doffed the gloves and washed her hands with soap and water. For the duration of the observation, the CNA was not wearing a gown. -Resident #23 was admitted on [DATE] with diagnoses of generalized muscle weakness, unspecified urinary incontinence, and obesity. The Foley catheter care plan dated July 27, 2023 included interventions to check tubing for kinks each shift and to provide catheter care each shift. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. An observation was conducted on April 9, 2024 at 12:17 p.m. There were no signs posted outside or in the resident's (#23) room to indicate what personal protective equipment (PPE) was needed during catheter care. An interview with resident #23 was conducted during the observation. The resident stated that staff wear gloves during catheter care and wash hands at sink, but they do not wear gowns. During an interview conducted with a certified nursing assistant (CNA/staff #62) on April 10, 2024 at 10:00 a.m., the CNA stated that she checks the resident's catheters every two hours and empties the bags as needed. She also said that when she empties the bags, she wears gloves, doff them when she was done, and wash her hands. A catheter care observation for resident #23 was conducted with (CNA/staff #62) on April 10, 2024 at 1:15 p.m. The CNA washed her hands, doffed gloves, placed a paper towel on the floor, and placed a urinal on the paper towel. The CNA then disconnected the tip/tubing from the urinal bag and wiped the tip with an alcohol wipe before emptying the catheter bag into the urinal. Once the bag was empty, she cleaned the tip/tubing with a clean alcohol wipe and reconnected it to the bag, and placed the bag in a privacy bag. The CNA then threw the paper towel away, emptied the urinal, doffed her gloves and washed her hands with soap and water. For the duration of the observation, the CNA was not wearing a gown. In an interview conducted with the CNA immediately following the observation, the CNA stated that she never wears a gown unless the resident was on isolation. An interview was conducted on April 10, 2024 at 2:30 p.m. with the Director of Nursing (DON) and the [NAME] President of Clinical Operations (staff #105). The DON stated that she was also the Infection Control Preventionist and she has not provided staff with PPE training requirements on high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their multidrug-resistant organism (MDRO) status, such as central/IV lines, trach's, catheters and wounds. Staff #105 stated that they were not aware of the new enhanced barrier precautions and will begin training immediately and ensuring that PPE is available. The facility policy, Infection Control Program dated 2013 states that all facility staff will be educated on hand hygiene, infection control, and isolation precautions on hire and annually. This education may also be required on an ad hoc basis as deemed appropriate by the ICC. The CMS guidance on Enhanced Barrier Precautions (QSO-24-08-NH) dated March 20, 2024 included that EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their MDRO status. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gowns and gloves during high-contact resident care activities that provide opprotunities for transfer of MDROs to staff hands and clothing. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use e.g. urinary catheter and wound care: any skin opening requiring a dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy and procedures, the failed to ensure one resident (#1) received showers at the scheduled frequency. The census was 59. The deficient practice could result in residents not receiving the care needed to maintain good hygiene. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, unspecified dementia, and type II diabetes. The admissions minimum data set (MDS) dated 18, 2023 included that the resident required supervision when bathing. Review of documentation revealed a care plan dated January 17, 2023 for an activities of daily living self-care performance deficit related to impaired mobility, weakness, and multiple medical problems. The interventions included to monitor/document/report to MD as needed any changes, any potential for improvement, reasons for self-care deficits, expected course, and declines in function. The clinical record revealed that the resident was scheduled to shower on Monday and Thursday during the 2:00 p.m. to 10:00 p.m. shift. Shower documentation revealed the following: During the week of January 22 through January 28, 2023, the resident only received one shower. There was no documentation that the resident refused showers this week. During the week of February 5 through February 11, 2023, the resident only received one shower. There were no documented refusals. During the week of February 12 through February 18, 2023, the resident only received one shower. There were no documented refusals. During an interview conducted on March 2, 2023 at 8:11 a.m. with the Director of Nursing (DON/staff #5), she stated that the facility has a schedule for residents to shower/bath twice a week and staff are supposed to complete a shower form, which has a skin assessment on it. She stated that if the resident refuses to shower, staff should ask the resident to co-sign on the form that they refused. An interview was conducted on March 2, 2023 at 10:21 a.m. with the Administrator (#7), who stated that the facility doesn't have any shower forms for the resident and the only documentation regarding bathing has already been provided. An interview was conducted on March 2, 2023 at 10:31 a.m. with a licensed nursing assistant (LNA/staff #23), who stated that the staffing coordinator schedules two showers a week for each resident. He stated that once he if finished helping a resident with a shower, he documents that shower was done under the task section for bathing. He stated that if a resident refuses to shower, he completes a shower form and asks the resident to sign it. The facility's policy, Activities of Daily Living (ADLs), Supporting, revised March 2018 states that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and review of the clinical record, the facility failed to ensure a resident (#98) had means to communicate with staff, by failing to ensure the call device was accessible to the resident. The sample size was 19. The deficient practice can result in residents' needs not being met in a timely manner. The findings include: Resident #98 was admitted to the facility on [DATE] with diagnoses that included repeated falls, and acute kidney failure, and unsteadiness on feet. The admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 which indicated the resident had moderate impaired cognition. A review of the care plan initiated on September 28, 2022 revealed the resident was at risk for falling related to deconditioning and gait/balance problems. Interventions included ensuring the resident's call light is within reach, encouraging the resident to use the call light for assistance, and promptly responding to all requests for assistance. Review of the care plan initiated on September 28, 2022 revealed the resident had a communication problem related to a hearing deficit. Interventions included having the call light within reach. A care plan initiated on September 28, 2022 revealed the resident had an Activities of Daily Living self-care performance deficit related to activity intolerance, impaired balance, and limited mobility. Interventions included encouraging the resident to use the call light to call for assistance. During the initial observation conducted on November 14, 2022 at 10:26 a.m. of resident #98, the call light was observed hanging on the wall, not within the resident's reach. An additional observation was conducted on November 16, 2022 at 12:50 p.m. The call light cord was observed coiled up hanging on the wall. An interview was conducted at that time with resident #98 who stated assistance was needed from staff to use the bathroom. On November 16, 2022 at 1:34 p.m., staff was observed assisting resident #98 back to the room. The staff left the resident's room and the call light cord remained coiled up on the wall. An interview was conducted on November 16, 2022 at 12:56 p.m. with a certified nurse assistant (CNA/staff #38). According to the CNA, residents will press the call light when they need assistance from staff. Staff #38 stated that for those residents who forgets how to use a call light, she would remind them how to use it. An interview was conducted on November 16, 2022 at 1:10 p.m. with a licensed practical nurse (LPN/staff #48). According to the LPN (#48), residents press the call bottom if they need assistance. The LPN stated that if they do not press the call light or are unable to, the staff will check on them every hour. She added, if residents are unable to press the call light due to cognitive impairment she would check on them every hour to ensure their needs are being met. Staff #48 also stated that the call lights are attached to the sheets, and for residents who are cognitively impaired the call light is attached to their gown. The LPN added that some residents have a pad attached to them but resident #48 is not one of those residents. An interview was conducted on November 16, 2022 at 2:16 p.m. with the Director of Nursing (DON/staff #25). According to the DON, when residents need assistance they use a call bell. She stated that part of the CNA training is that the call lights are to be within reach of the resident. Also, she included that the risk of the call lights not being within reach of the resident is that the staff would not know if residents needed assistance and help. In the past, she added, residents would yell for help if they cannot reach the call light. The DON stated that sometimes the call lights fall to the ground which is why staff is supposed to do frequent checks on the residents. Regarding resident #98, the DON stated that because the resident does not like the call light clipped to her, it is clipped to the sheet or her pillow. The DON then verified where the call light is, the wires were coiled up and hanging on the wall and she stated that it should not be there and she placed it on the resident's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #45 was admitted on [DATE] with a diagnosis of age-related Osteoporosis with current Pathological fracture. A review of a health status note dated October 30, 2022 at 9:50 PM indicated the resident had increased edema to the left hand and forearm, with no redness, pain, or warmth. Then at approximately 9:00 PM, the resident had a wet cough with increased respirations of 40 using accessory muscles. The on-call Nurse Practitioner (NP) was notified and said to send the resident to the Emergency Room. The resident's spouse was notified. A Health Status Note dated October 30, 2022 at 11:00 PM stated the resident was admitted to the hospital. A review of the clinical record did not reveal a notice of transfer was provided to the resident/representative in writing for the reason for the transfer/ discharge to the hospital. An interview was conducted with the [NAME] President of Clinical Operations (staff #68) on November 17, 2022 at 3:20 PM. Staff #68 stated that they failed to meet the requirement of providing the resident/representative written notice of the transfer. A facility policy regarding transfer or discharge revealed that when a resident is transferred or discharged from the facility, information documented in the clinical record would include that appropriate notice was provided to the resident and/or legal representative. Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to notify two residents (#1 and #45) and residents' representatives in writing of the reason for the transfer/discharge. The sample size was 2. The deficient practice could result in residents not knowing their discharge rights. Findings include: -Resident #1 was admitted to the facility on [DATE] with diagnoses that included acute on chronic systolic congestive heart failure, atrial fibrillation, hypertensive urgency, and urinary tract infection. Review of a nurse's progress note dated November 5, 2022 included that the resident had a change in level of consciousness, low blood pressure, and a low heart rate. The note included the resident's family member was present in the room. The Nurse Practitioner was notified and an order was received to send the resident to the emergency room for evaluation. The note stated the resident left the facility and was admitted to the hospital. Review of the resident's census list revealed a transfer to the hospital on November 5, 2022. Review of a discharge, return anticipated, Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an unplanned discharge to the hospital. However, review of the clinical record did not reveal that written information regarding the transfer was provided to the resident/representative. An interview was conducted on November 17, 2022 at 3:16 p.m. with the [NAME] President of Clinical Operations (staff #68). She stated that she was aware that the resident/representative was required to be provided transfer information in writing at the time of discharge or transfer from the facility. She stated the required written information was not provided to resident #1, or their representative, at the time of transfer to the hospital on November 5, 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #45 was admitted on [DATE] with a diagnosis of age-related Osteoporosis with current Pathological fracture, vertebra (E) subsequent encounter for fracture with routine healing. A review of a health status note dated October 30, 2022 at 9:50 PM indicated the resident had increased edema to the left hand and forearm, with no redness, pain, or warmth. Then at approximately 9:00 PM, the resident had a wet cough with increased respirations of 40 using accessory muscles. The on-call Nurse Practitioner (NP) was notified and said to send the resident to the Emergency Room. A Health Status Note dated October 30, 2022 at 11:00 PM stated the resident was admitted to the hospital. A review of the clinical record indicated that bed hold policy was not provided to the resident/representative in writing. An interview was conducted with the [NAME] President of Clinical Operations (staff #68) on November 17, 2022 at 3:20 PM. Staff #68 stated the bed hold notice was not provided to the resident/representative and that they failed to meet this requirement. A facility policy regarding bed hold and returns revealed that prior to transfers, and therapeutic leaves, residents or the resident representative will be informed in writing of the bed hold and return policy. Based on clinical record reviews, staff interviews, and review of policy and procedure, the facility failed to notify the residents and/or the residents' representatives of the facility policy for bed hold at the time of discharge/transfer from the facility for two residents (#1 and #45). The sample size was 2. The deficient practice could result in residents not being informed of the bed hold policy. Findings include: -Resident #1 was admitted to the facility on [DATE] with diagnoses that included acute on chronic systolic congestive heart failure, atrial fibrillation, hypertensive urgency, and urinary tract infection. Review of a nurse progress note dated November 5, 2022 revealed the resident left the facility and was admitted to the hospital. Review of the resident's census list included a transfer to the hospital on November 5, 2022. Review of a discharge return anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an unplanned discharge to the hospital. Review of the clinical record did not reveal that the bed hold policy was provided to the resident/representative at the time of transfer/discharge. An interview was conducted on November 17, 2022 at 3:19 p.m. with the [NAME] President of Clinical Operations (staff #68). She stated that she was aware of the required documentation that was to be provided to a resident/representative at the time of transfer/discharge from the facility. She stated the bed hold policy was not provided to resident #1 or their representative at the time of transfer to the hospital on November 5, 2022. She stated it was important to provide the information because it gave the resident/representative information on the conditions of discharge, information if the bed would be available on return, and included the resident's rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#14) had a referral for a Level II PASRR (pre-admission screening and resident review form). The sample size was 2. The deficient practice could result in resident's not receiving needed care in the facility. Findings include: Resident #14 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, post-traumatic stress disorder, schizoaffective disorder, anxiety disorder, depression and sleep terrors. Review of the clinical record revealed a Level I preadmission screening and resident review form (PASRR) dated September 6, 2022 from an acute care hospital. Upon review of the document, the box indicating that the resident qualified for a 30-day convalescent care was selected. No selections regarding mental illness in section B were selected. The remainder of the form was blank. The form was signed and dated. An additional Level 1 PASRR dated October 10, 2022 revealed a 30-day respite for convalescent care was selected. The remainder of the form was blank. The form was signed and dated. Review of the clinical record revealed no evidence that the Level 1 PASRR was updated or another completed, or a referral for a Level II PASRR was completed once the resident's stay exceeded 30-days. An interview was conducted with the resident relations staff member (staff # 22) on November 17, 2022 at 8:16 AM. She stated that she was learning the PASRR process and was working under the resident relations director (staff #65). She stated that she reviewed all new residents' PASRR level 1 documents upon admission. She stated that she noted if they were completed in their entirety as well as verify details such as diagnoses and demographics. She stated that she had not done a level 2 PASRR request for any resident since being in this position as one had not yet been required. She stated that the current process was that her supervisor reviewed all forms that she reviewed or filled out to ensure accuracy. Staff #22 stated that she had never answered yes to section D for a Level II referral and she stated that she did not know what qualifies a resident for a level II referral. An interview was conducted with the director of nursing (DON/staff #25) November 17, 2022 at 12:07 PM. The DON stated that she is aware that a PASRR is for mental health however, she does not know the purpose of the PASRR form. Review of the facility policy Pre-admission Screening and resident review (PASRR, 2020) revealed that if a resident had a diagnosis for mental illness, a Level II PASRR referral must be submitted. It is the responsibility of the facility to make the referral or to ensure the referral is completed by the resident's case manager. A resident is considered to be positive for mental illness if the resident had a diagnosis of a mental illness in addition to having functional impairments, receiving intensive treatment for the diagnosis or has had a significant disruption to their normal living situation within the last 2 years.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and review of facility policy and procedure, the facility failed to develop the person-centered care plan to include the resident's medication/medical needs for one resident (#14). The sample was 19. The deficient practice could result in an incomplete plan of care for the resident. Findings include: Resident #14 was readmitted on [DATE] with an original admission date of September 6, 2022 with diagnoses to include diabetes mellitus type 2, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), nicotine dependence, chronic post-traumatic stress disorder (PTSD), schizoaffective disorder, depression, anxiety disorders and sleep terrors. Review of the admission assessment dated [DATE] revealed the resident was incontinent of bowel and bladder, had shortness of breath while lying flat and upon exertion, used oxygen, was a current smoker and had hypokalemia (low potassium level). Review of the admission minimum data set (MDS) assessment dated [DATE] revealed the resident scored 15 on the brief interview for mental status (BIMS) indicating that the resident was cognitively intact. Review of the history and physical dated October 23, 2022 revealed the resident had transferred to the facility from an acute care hospital. The resident underwent treatment for mild hypokalemia, minimal exacerbation of COPD, diabetes and PTSD. Review of the comprehensive care plan revealed no focus area or interventions related to the diagnoses of diabetes mellitus type 2, chronic respiratory failure with hypoxia, COPD, nicotine dependence, PTSD, schizoaffective disorder, depression, anxiety disorders and sleep terrors. Review of the IDT (interdisciplinary team) Care Plan Conference note dated November 3, 2022 revealed the care plan was reviewed and remained appropriate. An interview with the director of nursing (DON/staff #25) was conducted on November 17, 2022 at 12:07 PM. The DON stated that the resident's needs including the use of oxygen should be on the comprehensive care plan. The comprehensive care plan should be used as a guide to provide resident care. Review of the facility policy Care Plans, Comprehensive Person-Centered (revised 12/2016) revealed the comprehensive care plan should incorporate identified problem areas and associated risk factors. The policy further revealed that the comprehensive care plan is to include a description of the services furnished to attain or maintain the residents highest practicable physical, mental and psychosocial wellbeing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and resident and staff interviews, the facility failed to fully assess one resident's (#97) nutritional status and needs by not obtaining a baseline weight. The sample size was two residents. The deficient practice could result in unmet nutritional needs and unidentified weight loss. Findings include: Resident #97 was admitted to the facility on [DATE] with diagnoses that included biventricular heart failure, hyperlipidemia, anemia, and hypo-osmolality and hyponatremia. Review of the physician's orders revealed: -November 5, 2022 orders for: A regular diet, regular texture, thin liquids consistency, fluid restrictions, fortified foods; and weights per facility protocol. -A November 10, 2022 order for Pro-stat supplement 30 milliliters (ml) one time a day. -A November 15, 2022 order for Ensure clear nutritional supplement two times a day for weight management. Review of a Nutritional Data Collection and assessment dated [DATE] revealed no weight for the resident, that the goal weight was 160-196, that the resident ate 50-75% of food and was on a fluid restriction. Review of the resident's care plan initiated on November 10, 2022 included a focus that the resident had or was at risk for nutritional problems related to increased nutrient requirements, at risk for hydration/nutrition related to a fluid restriction, potential for weight fluctuations related to diuretic treatment for heart failure, resident self-directed diet, and variable meal intake. The focus was updated on November 15, 2022 revealed the resident had a decreased appetite and did not like sweet supplements so the supplement was changed. The goal was that the resident would consume more than 75% of meals and 100% of the supplement. The interventions stated weights per orders. A Skin and Weight Review dated November 15, 2022 revealed the estimated needs were based on a recent weight of 86 kg (189.59 pounds) and revealed the resident had a potential for weight fluctuations related to heart failure and diuretic use. However, review of the clinical record did not reveal the facility had obtained any weights for this resident. A physician's order dated November 15, 2022 stated Ensure clear nutritional supplement two times a day for weight management. An interview was conducted on November 15, 2022 at 9:15 a.m. with the resident. The resident stated that he had lost weight but was unclear if the weight loss occurred at the facility. An interview was conducted on November 16, 2022 at 12:39 p.m. with the Director of Nursing (DON/staff #25). She stated that resident #97 came to the facility on November 5, 2022 and should have been weighed by facility staff on admission. The DON reviewed the clinical record and stated that she found a weight from the hospital, but that the facility had not weighed the resident so they needed to obtain a weight. She stated that skilled residents should be weighed weekly after the admission weight and that resident #97 was a skilled resident. The DON reviewed her tiger text and stated that she had been notified that there was no weight on the resident on November 8 and 14, 2022. She stated at that time she should have had staff obtain a weight on the resident. The DON stated there is a risk the facility could miss potential weight loss or a change in condition related to weight if a baseline weight and weekly weights were not obtained. An interview was conducted on November 16, 2022 at 12:40 p.m. with the contracted Dietician (staff #69). She stated the facility had not obtained a weight for resident #97. She stated the diet technician would have notified the facility staff at the time of assessment that there was no weight documented. She stated she based her assessment on review of the clinical record, the hospital weight, and an interview with the resident. She stated that if there is no weight, there is a risk that she would not be able to determine if the resident was getting adequate nutrition, at risk for malnutrition, or had a weight loss since admission. She stated she would not be able to identify a significant weight loss without a baseline weight. An interview was conducted on November 16, 2022 at 12:41 p.m. with the [NAME] President of Clinical Operations (staff #68). She stated that there was an oversight by the facility when a weight was not obtained on resident #97. She stated the facility should have weighed the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one resident (#14) had an order for oxygen use. The sample size was 2. The deficient practice could result in residents receiving oxygen without a physician order. Findings include: Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, post-traumatic stress disorder, schizoaffective disorder, anxiety disorder, depression and sleep terrors. Review of the admission note dated September 9, 2022 revealed the resident used oxygen at home for chronic COPD as well as during the stay at the acute care hospital prior to admission to the facility. The nursing admission note on this date stated that respiratory equipment (oxygen) was in place. Review of the clinical record revealed several head to toe evaluations dated September 9, 2022, October 2, 2022 and October 28, 2022 that the resident was using oxygen. Review of the daily skilled nursing evaluations dated September 10, 2022, October 17, 2022, October 31, 2022 and November 4, 2022 included a note that oxygen was in use by the resident. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed that the resident used oxygen both while a resident and also while she was not a resident. Review of the comprehensive care plan did not reveal an entry for oxygen use. Review of the clinical record did not reveal an order for oxygen. During an observation conducted on November 14, 2022 at 2:49 P.M. The resident was observed receiving oxygen via nasal cannula. The resident stated that she had been receiving oxygen as needed via nasal cannula since admission to the facility. An additional observation of the resident on November 17, 2022 was conducted and the resident was receiving oxygen via nasal cannula. The oxygen was set at 4 liters. The resident stated that the facility increased the oxygen delivery to 4 liters to assist with breathing. The resident stated that it helped the breathing but the cannula was drying out her nose. An interview was conducted on November 17, 2022 at 2:07 PM with the director of nursing (DON/staff #25). She stated that If a resident is using oxygen, an order should be located in the resident's clinical record. The DON further stated that there should be an order for all oxygen, including as needed treatments. She stated that there are potential issues with a resident receiving oxygen without an order such as the tubing would not be changed regularly, and it does not allow the staff to ensure that the appropriate amount of oxygen is being given to the resident. The DON stated that in addition to an order, oxygen should be on the resident's comprehensive care plan. The DON further stated that this should be a standing order however she did not find any order for oxygen in the resident's clinical record. She stated oxygen should not be in the resident's room available for use without an order. Review of the facility policy Medication Orders (2014) revealed that an oxygen order should include the flow rate, the route and the rationale.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to complete behavior monitoring for one resident (#14). The sample size was 2. The deficient practice could result in the resident not receiving appropriate care and services to attain their highest practicable mental and psychosocial well-being. Findings include: Resident #14 was readmitted on [DATE] with an original admission date of September 6, 2022 with diagnoses to include diabetes mellitus type 2, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), nicotine dependence, chronic post-traumatic stress disorder (PTSD), schizoaffective disorder, depression, anxiety disorders and sleep terrors. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed the resident scored 15 on the brief interview for mental status (BIMS) indicating the resident was cognitively intact. Review of the physician note dated October 26, 2022 revealed the resident was being seen for a new psychiatric evaluation. The evaluation revealed that the resident was diagnosed with adjustment disorder with depressed mood, schizoaffective disorder, depressive disorder, anxiety disorder, sleep terror disorder and chronic PTSD (post-traumatic stress disorder). The note revealed that the resident was on medication for frequent nightmares and was to be closely monitored for behaviors and psychosis, cognition, depression and anxiety, Review of the orders and the medication administration record (MAR) and the treatment administration record (TAR) for November 2022 revealed no evidence of behavior monitoring or an order for behavior monitoring. An interview was conducted with a licensed practical nurse (LPN/staff #48) on November 17, 2022 at 9:44 AM. She stated that the resident gets agitated, refuses care such as brief changes and showers or bed baths. Staff #48 stated that the resident's relative will visit and assist with the resident's care. She stated that the resident does have PTSD and is claustrophobic so the resident's door should always be open and the TV should be on at all times for background noise per the resident request. Staff #48 further stated that the resident was not being monitored for night terrors and was not currently monitoring for behaviors. The LPN stated that the resident may have been monitored for behaviors at some point but could not find any documentation of behavior monitoring in the clinical record. On November 17, 2022 at 12:07 PM, an interview was conducted with the director of nursing (DON/staff #25). She stated that if a resident exhibited behaviors or was on medications for any type of behavior, the resident should have behavior monitoring. She stated a resident that is monitored for behaviors should have an order in the clinical record and that order should be transferred to the TAR. The DON stated monitoring should be charted on every shift in the TAR. She stated any resident that was taking any psychotropic medications or had any diagnoses that may exhibit behaviors including PTSD related night terrors should have behavior monitoring in their clinical record. Review of the facility policy Behavioral Assessment, Intervention and monitoring (revised December 2016) revealed that behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. The policy further revealed that nursing staff will identify, document, and inform the physician about specific details regarding changes in the resident including onset, duration, intensity and frequency of behavioral symptoms.

Based on observation, staff interview, and policy review, the facility failed to ensure expired food was not available for consumption. The deficient practice could cause food-borne illness. Findings include: During the initial kitchen walk-thru on November 14, 2022 at 9:47 a.m. with the dietary manager (staff #43) a reach-in refrigerator was observed to contain two pudding-like in disposable mini cups with a lid labeled peanut butter pudding with a use by date of November 7, 2022. A large clear square graduated container with apple sauce was observed labeled use by November 10, 2022. Staff #43 stated that they must have been mislabeled. They were not disposed of at that moment. At 11:02 a.m. that same day, the food items were observed still in the refrigerator. This time staff #43 was observed disposing of them immediately. An interview was conducted on November 17, 2022 at 7:32 a.m. with staff #43. She stated that she conducts inventories every Thursday after food deliveries are made and that she attempts to check every day for expired food. Staff #43 stated there is a risk of getting sick from contaminated food and expired food, and that the expired pudding and applesauce should have been thrown away. Review of the facility's policy titled, Food Safety and Sanitation revealed, Perishable foods with expiration dates should be used prior to the use by date on the package. When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to develop and implement a policy to ensure two residents (#9 and #1) were administered influenza and pneumococcal immunizations. The sample size was 5. The deficient practice could result in residents not receiving immunizations. Findings include: -Resident #9 was admitted to the facility on [DATE] with a diagnosis of moderate protein-calorie malnutrition. Review of the clinical record revealed the resident received the influenza vaccine in 2016. Continued review of the clinical record revealed the resident was educated and offered the influenza vaccine, and the consent was signed October 25, 2022. Additional review of the clinical revealed the vaccine was added to the schedule but not administered. Further review of the clinical record revealed the resident had received the pneumococcal (PCV13) vaccine October 15, 2013. Review of the clinical record revealed the resident was educated and offered the pneumococcal vaccine, the consent was signed October 25, 2022, and the pneumococcal (PPSV23) vaccine was added to the schedule. However, review of the clinical record did not reveal any evidence that the resident was administered the vaccine. -Resident #1 was admitted to the facility on [DATE] with a diagnosis of acute chronic systolic congestive heart failure. Review of the clinical record revealed the resident had received the influenza vaccine October 26, 2020. Continued review of the clinical record revealed the influenza vaccine was offered on November 3, 2022, and added to the schedule. However, no evidence was revealed that the resident was administered the influenza vaccine. Review of the clinical record revealed the resident had received the pneumococcal (PCV13) in 2013. Continued review of the clinical record revealed the pneumococcal vaccine was offered on November 3, 2022, and that pneumococcal (PPSV23) vaccine was added to the schedule to be administered. However, no evidence was revealed that the resident received that pneumococcal vaccine. During an interview conducted with the Director of Nursing (DON/staff #25) and the Corporate [NAME] President of Nursing Operations (staff #68) on November 17, 2022 at 1:19 PM, the DON stated that upon admission residents are asked if they would like the influenza or pneumococcal vaccines. She stated that if the resident requests the vaccines, she or another manager will educate the resident about the vaccine and offer it as soon as they can. The DON stated that tracking is done via a dashboard in point click care and it is reviewed daily. In an interview conducted with staff #25 and staff #68 on November 17, 2022 at 3:43 PM, the DON stated that she did not think that there had been follow-up with the pharmacy since the request on September 7, 2022. Staff #86 agreed that it was longer than the facility expected and that she would see if there had been any other requests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to develop and implement policies and procedures to ensure two residents (#9 and #1) received the COVID vaccine. The sample size was 5. The deficient practice could result in residents not receiving the COVID vaccine per their request. Findings include: -Resident #9 was admitted to the facility on [DATE] with a diagnosis of moderate protein-calorie malnutrition. Review of the clinical record revealed the resident received a COVID vaccine series on March 11, 2021 and April 5, 2021. Continued review of the clinical record revealed the resident was educated and offered the COVID booster, and the consent was signed October 25, 2022. Additional review of the clinical revealed the vaccine was added to the schedule but not administered. -Resident #1 was admitted to the facility on [DATE] with a diagnosis of acute chronic systolic congestive heart failure. Review of the clinical record revealed the resident had received the primary series of a COVID vaccine. Continued review of the clinical record revealed that on November 3, 2022, the COVID booster was offered and requested from the pharmacy. However, no evidence was revealed that the resident was administered the COVID booster. An interview was conducted with the Director of Nursing (DON/staff #25) and the Corporate [NAME] President of Nursing Operations (staff #68) on November 17, 2022 at 1:19 PM. The DON stated that upon admission, residents are asked if they would like the COVID vaccine. She stated that if the resident requests the vaccine, she or another manager will educate the resident about the vaccine and offer it as soon as they can. The DON stated that tracking is done via a dashboard in point click care and it is reviewed daily. Another interview was conducted with the staff #25 and staff #68 on November 17, 2022 at 3:43 PM. The DON stated that they had not received the COVID vaccine and that she did not think that there had been follow-up with the pharmacy since the request on September 7, 2022. Staff #86 agreed that it was longer than the facility expected and that she would see if there had been any other requests. Review of the facility's COVID Immunization Policy and Procedure stated the recommendation is to provide education for all staff and residents on COVID immunizations, availability, and then allow them to each make an informed decision on whether to take or decline the COVID immunization. The policy also stated that when the COVID vaccine is available to the facility, each resident is offered the COVID vaccine unless the immunization is medically contraindicated or the resident has already been immunized. The policy revealed the resident's clinical record includes documentation that indicated each dose of COVID vaccine administered to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #147 was admitted on [DATE] with diagnoses including wedge compression fracture of the lumbar vertebra, immunodeficiency due to drugs, long term use of anticoagulants and a non-pressure chronic ulcer on lower leg. The admission evaluation dated November 11, 2022 revealed the resident had moderate hearing and vision difficulty, skin discoloration with edema and left lower extremity weakness. A progress note dated November 12, 2022 revealed the resident had an elevated INR (international normalized ratio) lab result and should be monitored every shift for signs and symptoms of bleeding, brushing and hemorrhage related to the use of anticoagulants. A change of condition note dated November 12, 2022 at 3:16 pm revealed the resident had a hematoma on the left forearm and complaints of pain related to that area. The resident was sent to the acute care hospital at 10:30 am. Review of a note dated November 12, 2022 at 11:17 pm revealed the resident was transferred back to the facility. Review of the clinical record revealed that the record did not include a baseline care plan for the resident. An interview with the vice president of clinical operations (staff # 68) was conducted on November 17, 2022 at 3:52 pm. She stated that there was no baseline care plan for this resident. Staff #68 stated that the fact that there was no baseline care plan completed for this resident was a concern as the baseline care plan is used as a guide to provide care to the resident. Review of the policy Care Plans - Baseline (revised 12/2016) revealed that a baseline care plan is to be developed within 48 hours of admission. The baseline care plan is used to ensure that the immediate care needs of the resident are met and maintained. Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to develop a complete baseline care plan that included the instructions needed to provide effective and person-centered care for three residents (#97, #102, and #147). The sample size was 19. The deficient practice could result in resident care needs not being met. Findings include: -Resident #97 was admitted to the facility on [DATE] with diagnoses that included biventricular heart failure, lobar pneumonia, acute respiratory failure with hypoxia, pleural effusion, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and pulmonary hypertension. Review of the admission evaluation dated November 5, 2022 revealed the resident exhibited shortness of breath while lying flat, with exertion, and while sitting at rest and used oxygen (O2). Review of the November 5, 2022 physician's orders included: -O2 at 0-5 liters per minute (LPM) as needed to keep O2 saturation above 89%. -Albuterol Sulfate hydrofluoroalkane (HFA) aerosol solution 108 micrograms (mcg)/actuation breath inhale 1 puff orally every 4 hours as needed for wheezing. Review of the weights and vitals summary/oxygen saturation summary from November 5 through 15, 2022 had documentation on 9 out of 11 days and included the use of O2 via nasal cannula (NC) at each check. Review of an admission progress note dated November 7, 2022 revealed the resident was noted to have diminished respiratory volumes and increased inspiratory: expiratory ratio consistent with COPD. Diagnoses included acute on chronic congestive heart failure, pneumonia, acute and chronic respiratory failure with hypoxia, severe pulmonary hypertension. Review of a provider's initial history and physical, dated November 8, 2022, included the resident had significant medical illnesses including oxygen dependent COPD, a recent diagnosis of heart failure, along with non-alcoholic fatty liver and coronary artery disease. The note included the resident was at high risk for decompensating anytime soon requiring hospitalization and that they would need to follow very closely on a medical basis. Review of the initial and baseline care plan did not reveal a focus, goal, or interventions that addressed the resident's chronic and acute respiratory diagnoses or the ongoing oxygen use. An interview was conducted on November 16, 2022 at 1:02 p.m. with a Licensed Practical Nurse (LPN/staff #48). She stated that if a resident reports shortness of breath or need for oxygen, she would check the resident's O2 saturations, raise the head of the bed, have the resident raise their arms and place the resident on O2 per standing or resident specific orders. She stated she would expect oxygen use and respiratory conditions to be included in the resident's care plan. She stated that resident #97 received oxygen, had respiratory conditions, and was at risk for respiratory complications. The LPN stated the resident should have a care plan for respiratory conditions/O2 use. The nurse reviewed the resident's care plan and noted the respiratory conditions/O2 use were not included on the care plan. She stated it was important to be on the care plan so staff would know the resident's history and what interventions were needed for the resident. The LPN stated it was especially important for nurses that did not know the resident because the facility used a lot of agency staff. An interview was conducted on November 17, 2022 at 9:58 a.m. with the Director of Nursing (DON/staff #25). She stated on admission of a resident, the admitting nurse starts the baseline care plan with the admission assessment/evaluation which includes assessment questions in areas such as O2 use, presence of a Foley, and incontinence. She stated that she, the assistant DON, or MDS nurse would review the baseline care plan with the resident including the physician's orders. The DON stated she would not expect oxygen use/acute respiratory conditions to be addressed in a care plan focus, goal, or intervention on the baseline care plan for a resident with altered respiratory status and using oxygen. She stated the oxygen order and use would be included in the review of the physician's orders. -Resident #102 was admitted to the facility on [DATE] with diagnoses that included COVID-19, cardiomegaly, acute and chronic respiratory failure with hypoxia, and acute pulmonary edema. Review of the physician's orders dated November 7, 2022 revealed: -Enoxaparin Sodium (anticoagulant) Solution Prefilled Syringe 40 milligrams (mg)/0.4 milliliters (ml), Inject 0.4 ml subcutaneously one time a day for clot prevention. -Monitor for signs and symptoms of bleeding/hemorrhage/bruising every shift for anticoagulant therapy. Notify the doctor if present. Review of the baseline care plan did not reveal that anticoagulant use/risk for abnormal bleeding was addressed in a care plan focus, goal, or intervention. An interview was conducted on November 17, 2022 at 7:59 a.m. with a Registered Nurse (RN/staff #39). She stated that the admission process in essence creates the baseline care plan. She stated that if she notes a concern (i.e. no teeth) she can fill out the care plan section of the admission assessment and the problem would carry over into the actual care plan. She stated if a resident was on an anticoagulant, there would need to be a baseline care plan for anticoagulant use which included monitoring for signs and symptoms of bleeding, bruising, blood in stool or vomit, etc. so that the care needs would be available to all caregivers, resident, and families. She stated that the resident would get a copy of the care plan. The RN reviewed the record for resident #102 and stated the resident had orders for anticoagulant use and that bleeding risk should have been included on the care plan for the related risks. The RN stated the anticoagulant use was not addressed on the resident's care plan. An interview was conducted on November 17, 2022 at 9:58 a.m. with the DON (staff #25). She stated the baseline care plan and physician's orders would be reviewed with the resident and would include the order for an anticoagulant and monitoring for abnormal bleeding. She stated the nurse caring for the resident would know what medication was being given and what to monitor for from the administration records, including anticoagulant use and monitoring for abnormal bleeding. She stated she would not expect the use of an anticoagulant and the risk for abnormal bleeding to be addressed in a focus, goal, or intervention of the baseline care plan. An interview was conducted on November 17, 2022 at 10:23 a.m. with the [NAME] President of Clinical Operations (staff #68). She stated the process for baseline care plans was that the initial goals were created off of the admission assessment. She stated that as part of the baseline care plan, a summary of all of the physician's orders would be reviewed with the resident/representative, which would include the prescribed medications, monitoring of behaviors and side effects related to medications, and any treatments or other services ordered. Staff #68 stated the reviewed documentation was scanned into the resident's chart after review with the resident to use by the facility staff to guide care.

Based on observations, clinical record reviews, staff interviews, and review of policy and procedures, the facility failed to implement appropriate standard and transmission-based precautions. The deficient practice could result in transmission of infection. Findings include: An interview was conducted on November 14, 2022 at 10:07 a.m. with the Director of Nursing (DON/staff #25). She stated the residents in the rooms marked with signs were COVID-19 positive residents. She stated that you would need to don personal protective equipment (PPE), gown, gloves, N95 mask, and eye protection, from the supply cart in the hallway prior to entering the marked transmission-based precautions (TBP) rooms. She stated when you are finished in the TBP room, the PPE should be doffed and put in the receptacles in the hallway. The DON indicated an open trash can which contained discarded PPE including face shields, masks and gloves and a covered canister marked gowns only. She stated if the eye protection is to be re-used it would need to be disinfected with the provided disinfecting wipes. The DON stated the facility is in a COVID-19 outbreak. A resident who was positive for COVID room was marked with a contact precaution sign which stated: Everyone must clean their hands, including before entering and when leaving the room. Put on gloves before room entry. Discard gloves before room exit. Put on a gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. An observation was conducted on November 14, 2022 at 10:28 a.m. of a Licensed Practical Nurse (LPN/staff #66) leaving the resident's room wearing an isolation gown, eye protection, gloves, and a mask. The nurse passed two rooms on the same side of the hall and three rooms on the opposite side of the hall in the process of disposing of the used PPE. She disposed of the gloves in the open trash can which was immediately to the left of the clean PPE cart, disposed of the gown in the covered canister marked gowns only, and wiped down her eye protection which she then hung on the clean PPE cart. Next to the canister marked gowns only there were two larger covered containers; one with a sign for soiled gown only and one with a sign for clean gowns only. An interview was conducted with the LPN (staff #66) immediately following the observation. She stated she was told by the DON to wear the PPE used in a TBP room, out into the hallway and to dispose of them in the provided canisters/trash cans. A second interview was conducted on November 14, 2022 at 11:04 a.m. with the LPN (staff #66). She stated there were three rooms on isolation precautions/TBP for COVID. The LPN stated she thought one of the residents, room was off of isolation that day, but wanted to clarify. An observation was conducted on November 14, 2022 at approximately 12:15 p.m. A staff member came out of one of the resident's rooms on precautions wearing PPE, an isolation gown, gloves, mask, and eye protection. The staff member removed the PPE in the hallway and disposed of the PPE in the receptacles in the hallway. The resident room had a Special Droplet/Contact Precautions sign on the door that included: In addition to standard precautions, only essential personnel should enter this room. If you have questions, ask the nursing staff. Everyone, including visitors, doctors, and staff must clean hands when entering and leaving the room. Wear mask, fit tested N-95 or higher required when doing aerosolizing procedures. Wear eye protection, face shield or goggles. Gown and glove at the door. Keep the door closed. Use dedicated or disposable equipment. Clean and disinfect shared equipment. Review of 7 occupied rooms in the immediate hallway revealed: -one resident who had received the initial COVID vaccine doses and two boosters; -one resident who had received the initial COVID vaccine doses and one booster; -two residents who had received the initial COVID vaccine dose(s) and no boosters; -one resident who had declined the any COVID vaccinations; -and two residents with recent COVID infection; -and two residents with an active COVID infection. An interview was conducted on November 17, 2022 at 7:59 a.m. with a Registered Nurse (RN/staff #39). She stated the rooms that were on isolation/TBP for COVID had isolation bins outside of the rooms and the big pails that contained the reusable gown. She stated she would don PPE, gown, mask, gloves, and most of the time her prescription eyeglasses or a smaller face shield outside of the room. The RN stated that her prescription eye glasses were adequate eye protection as long as the infected resident was not coughing. She stated she would doff her PPE in the room and dispose of it in the room or in the hallway, wherever the receptacle was located. She stated the non-disposable gowns had to be put into the receptacle for reusable gowns located in the hallway. The RN stated that if she wore the PPE out of the TBP room to doff and discard, there was a risk for transmission of infection to others in the building if the infectious agent was released into the air. An interview was conducted on November 17, 2022 at 5:05 p.m. with the [NAME] President of Clinical Operations (staff #68). She stated that she had received specialized training in infection prevention. For rooms with TBP, she stated staff should don PPE, appropriate for the precaution type, prior to entering the room. She stated staff should doff and discard the PPE inside of the room and perform hand hygiene. She stated any reusable equipment should be disinfected per manufacturer's instructions. Staff #68 stated the observations of staff removal of PPE in the hallway after leaving TBP rooms did not meet her expectations. She stated that by exiting wearing PPE that was used to care for a resident on TBP would result in potential contamination to the hall and risk transmission of infection to the residents in that hallway. Staff #68 stated prescription eyeglasses were not considered to meet the requirement in rooms in isolation that required eye protection and the staff member would not be wearing adequate PPE. Regarding terminal cleaning of a COVID-19 TBP room: An observation was conducted on November 14, 2022 at 11:12 a.m. of a resident's room. The room door was marked with a special droplet/contact precaution sign that stated: In addition to standard precautions, only essential personnel should enter this room. If you have questions, ask the nursing staff. Everyone including visitors, doctors, and staff, must clean their hands when entering and leaving the room. Wear mask, fit tested N-95 or higher required when doing aerosolizing procedures. Wear eye protection, face shield or goggles. Gown and glove at the door. Keep the door closed. Use dedicated or disposable equipment. Clean and disinfect shared equipment. Supplies outside of the room included gowns, gloves, surgical masks, and disinfectant wipes. An observation of a housekeeping staff member (staff #32) was conducted on November 14, 2022 at 11:12 a.m. doing a terminal cleaning of a resident's room who was coming off of isolation precautions. The staff member was outside of the resident's room with a cleaning cart. Staff #32 donned a gown, blue gloves from the cart, a surgical mask over an existing N95, and a face shield. She then entered the room with the cleaning cart and closed the door. At 11:57 a.m., the housekeeper came out of the room and removed and discarded the gown and eye protection into an uncovered trash can next to the clean PPE cart/supplies. She then touched the outside of the doorframe and moved bagged clean linens from one surface to another. She then rolled the cleaning cart out of the room and placed a bag of bagged linens from the surface of the cart into a large covered gray bin in the hallway. Staff #32 then mopped the room. She then picked up the bag of clean linens from the hallway, opened the bag, and made the bed. She was not observed to change gloves or do hand hygiene between mopping and handling the clean linens. At 12:16 p.m., she removed her gloves and put them in the open trash can in the hallway. She was not observed to do hand hygiene. She wheeled the cleaning cart to an environmental services room and exited the room without the cart. An interview was conducted on November 17, 2022 at 7:46 a.m. with the housekeeping staff. She stated that up to the time of the observation she had been directed to take the cleaning cart into the room to deep clean an isolation/TBP room after the resident was removed from isolation precautions. She stated that after the terminal cleaning of the room, she was directed to park the cleaning cart outside of the room and leave the door open when doing the terminal cleaning. She stated she dons a gown, gloves, 2 masks, and a face shield to go into an isolation room. She stated when coming out of the room, she would take off the PPE and discard the 2nd mask and gloves into the uncovered bin outside the door. Staff #32 stated she would put the gown into the covered bin. She stated she would disinfect the eye protection for 5-10 minutes with the disinfectant wipes, but that she did not do that at the time of the observation as she just wiped it down briefly. She stated she disinfected and wiped down the cart before removing it from the room using the appropriate dwell time. She stated she had also switched her gloves while she was in the room but not after taking out the cart and garbage and mopping the room. Staff #32 stated that she used the same gloves to make the bed with clean linens. She stated she was aware that she did not maintain infection control during the observation and was educated. An interview was conducted on November 17, 2022 at 5:05 p.m. with the [NAME] President of Clinical Operations (staff #68). She stated that when a resident completed infectious isolation/TBP, the resident would be showered. Staff #68 stated that if the resident would be returning to the same room, the room would be terminally cleaned prior to the resident's return or further resident placement. She stated a terminal room cleaning included separation curtain removal and bagging of all linens with placement into a yellow bag. The yellow bag would alert laundry to know the linens came from an infection isolation room to be processed per protocol. Staff #68 stated the room would then be cleaned with an EPA approved cleanser by housekeeping staff wearing the required PPE. She stated the cleaning cart would be left outside of the room. She stated there should be a separate bag for the mop cloth and rags and that the PPE worn in the room should be removed in the room and discarded into the trash bag. She stated the staff member should return to the room after waste and linens are disposed of/taken to the laundry to set up the bed, hang a new curtain, and place clean trash liners. Staff #32 stated the observation of the terminal cleaning of the room did not meet her expectations as the housekeeper moved from a dirty task to a clean task without a glove change/hand hygiene and doffed the used PPE from an infection isolation room in the hallway and discarded it into an open trash can in the hallway when it should have been doffed and discarded in the room prior to exit. She stated there was a risk of a resident in the hallway reaching into the open garbage can that contained used PPE from the infection isolation room. She stated the cleaning cart should not have been taken into the infection isolation room for the terminal cleaning as there would not be a way to adequately disinfect/decontaminate the cart and supplies. She stated the observed concerns presented a risk of transmission of infection. Review of the facility's COVID-19 Environmental Cleaning policy revealed it is the policy of the facility to protect the health and wellbeing of the resident and staff during infectious disease outbreaks. All non-dedicated, non-disposable medical equipment used for resident care should be cleaned and disinfected according to manufacturer's instructions and facility policies. Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Recommended PPE should be worn by environmental services personnel who clean and disinfect rooms of residents with suspected or active COVID-19. PPE should be removed upon leaving the room, immediately followed by performance of hand hygiene. Review of the facility's Infection Control Policies and Procedures: Coronavirus (COVID-19) policy revealed hand hygiene should be performed before and after all resident contact, contact with infectious material and before and after removal of PPE, including gloves. Dedicated or disposable resident care equipment should be used. If the equipment must be used for more than one resident, it will be cleaned and disinfected before use on another resident, according to the manufacturer's recommendation.

Based on staff interviews and facility policy, the facility failed to designate a qualified individual as the Infection Preventionist (IP) on an ongoing basis. The deficient practice could result in improper infection prevention practices in the facility. Findings include: An interview was conducted with the [NAME] President of Clinical Operations (staff/#68) and telephone interview with the Registered Nurse/Infection Preventionist (RN/IP/staff #9) on November 17, 2022 at 11:26 AM. The IP stated that she comes in once a month to do rounds and the last time she was in the facility was at the end of September 2022. It was then stated that the Director of Nursing (DON/staff #25) is overseeing the day to day infection control and education. They stated the DON is not certified. A policy regarding Infection Control included that the facility will identify one or more individuals with training in infection control to provide on-site management of the infection prevention control program.