**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#11) was given an advance notice prior to a roommate change. The deficient practice could result in resident's preference to choose her roommate was not considered. -Resident #41 was admitted on [DATE] with diagnoses of metabolic encephalopathy, dementia and need for assistance with personal care.The NP (nurse practitioner note dated July 24, 2025 included that the resident had a BIMS score of 12 which was consistent with moderate cognitive impairment.The room/roommate change notice signed by resident #41 and social services and dated August 11, 2025 revealed that resident #41 was provided the notice that she was moving to the room of resident #11 and this change was effective August 12, 2025.The census list report revealed that resident #41 had room change on August 12, 2025. -Resident #11 was admitted to the facility on [DATE] with diagnoses that included chronic inflammatory demyelinating polyneuritis, calcific tendinitis of the right thigh, adjustment disorder, hypotension, reduced mobility, muscle weakness, need for assistance with personal care, and polyneuropathy.The progress note dated February 3, 2025 included the resident was alert and oriented x 4 and was able to make needs known.A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The census list report revealed that resident #11 had a room change on February 28, April 12, and July 1, 2025. Despite documentation that resident #41 was moving to the room of resident #11, there was no evidence found that resident #11 was notified of the roommate change on August 12, 2025. In a written statement signed by Director of Nursing (DON/Staff#120) and dated August 19, 2025 at 12:35 p.m., the DON wrote the facility did not have room change notifications for Resident #11. An interview was conducted on August 19, 2025, at 12:40 p.m. with Resident #11 who stated that on August 12, 2025, she received a new roommate without prior notice. She said she was not informed of the change until staff asked her, at the time of the new roommate's arrival, whether she had been notified; and, this made her realize that she should have been told in advance, but was not. Resident #11 said that the new roommate was very disruptive and screamed during the first two days, which caused her to have a panic attack. She stated that she informed the Director of Nursing (DON) that she had not been notified about the roommate change, and the DON told her it had slipped through the cracks. The resident also said the facility offered to move her to a different room or pair her with another roommate, if available.An interview with the Resident Relations Manager (RRM/Staff #60) was conducted on August 19, 2025, at 1:55 p.m. The RRM stated that the facility uses a roommate change form to notify residents of a room change, and the form should be provided as soon as the facility is aware of the change. The RRM said that both the resident being moved and the resident receiving a new roommate were required to receive this notification; and, the only exception was for new admissions, who do not receive prior notice. The RRM further stated that not providing this notification could result in the resident being unhappy and losing their right to choose or decline a roommate, as the form includes that option. During the interview, the RRM reviewed the clinical record and stated that there was no documentation of a roommate change notification for Resident #11; and, staff should have completed the notification but failed to do so in this case.During an interview with the DON (Staff #120) conducted on August 19, 2025 at 2:32 p.m., the DON stated that best practice would be to have nursing staff document room changes in the clinical record as a progress note. The DON further stated that her expectation was for social services to complete their documentation for roommate changes and upload the completed form into the record. Review of the facility policy titled, Resident Rights - Room Change/Roommate Assignment, was revised in January of 2024 revealed that resident room or roommate assignments may change if the facility deemed it necessary, but that resident preferences were taken into account when such changes were considered. The policy further revealed that prior to changing a room or roommate assignment, residents should have been given advance written notice of such change, and advance written notice of a roommate change would include why the change was being made. The policy also revealed that documentation of a room change should be recorded in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, facility documentation and policy review and the State Agency complaint tracking system, the facility failed to follow their abuse reporting policy following an allegation of abuse for one resident (#11). The deficient practice could result in continued abuse and neglect to residents. Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included chronic inflammatory demyelinating polyneuritis, calcific tendinitis of the right thigh, adjustment disorder, hypotension, reduced mobility, muscle weakness, need for assistance with personal care, and polyneuropathy.The care plan dated February 3, 2025 included that resident #11 had functional self-care deficits and/or functional mobility limitations related to malnutrition, pain and weakness and required assistance. The care plan revised on February 14, 2025 revealed that the resident had behavior problem related to recent admission, refusal of care and was verbally abusive to staff. Interventions included to administer medications as ordered and all personal care and interaction done in pairs.A late entry NP (nurse practitioner) note dated [DATE] revealed the resident was oriented x3 and had good insight and judgment.A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The late entry NP note dated [DATE] included the resident was oriented x 3, had organized thoughts, cooperative behavior and good insight/judgement.A behavior progress note dated [DATE] revealed that at approximately 9:00 p.m. the resident asked for a shower and when she was assisted in shower, she grew upset, started yelling, cursing, and was verbally abusive and insulting to the Certified Nursing Assistants (CNAs).There were no further documentation of this incident found in the clinical record and facility documentation.Review of the State Agency complaint tracking system revealed no evidence that the facility had submitted a self-report for Resident #11's allegation of staff-to-resident abuse and neglect on or about [DATE].An interview was conducted on [DATE], at 12:40 p.m. with Resident #11 who stated that on [DATE], she repeatedly requested a shower throughout the day, but staff kept telling her it would be done later. The resident said that, that evening, two CNAs (staffs #34 and #46) assisted her into the shower. The resident stated that when she asked for a washcloth, Staff #34 threw it into her lap more aggressively than usual. The resident reported that her showers typically last about 15 minutes, but that night she was left alone in the shower for over 30 minutes while she screamed for help. She said she was crying in pain and no one responded, except for a nurse who briefly entered to hand her an item that had fallen. The resident stated that when the two CNAs returned, the resident stated they began arguing with her; and, one CNA told her that if she continued behaving that way, no one would help her. The resident further stated that the CNAs left her naked in the shower while they went to the nurses' station, where she overheard them telling a nurse they were going to record her. She said that staff #34 mocked her, told her to get dressed on her own despite her pain, and placed her shoes in her lap saying, See, your arms aren't broken. Resident #11 stated that she reported the incident to the Executive Director (ED/Staff #29) by email the same day. However, she said no one from administration responded or visited her room until the afternoon of [DATE]. An interview was conducted on [DATE] at 12:52 p.m. with one of the alleged CNAs (staff #46) who stated that the timeframe for reporting was within 2 hours, and she did recall an incident between herself and Resident #11. Staff #46 said that at the beginning of her shift on [DATE], Resident #11 was already upset, and had requested a shower several times throughout the day. Staff #46 said that the resident was not in her group for showers, but she did shower the residents' roommate thinking that the other CNA (staff #34) would give Resident #11 her shower. Staff #46 stated that the CNA who intended to shower her left early that day, and by the end of the night they realized that Resident #11 had not gotten her shower yet, so they decided to set her up for one. Staff #46 said that they left the resident in the shower for 30 minutes, and at some point she thought that the nurse went into the shower room because the resident dropped something. Staff #46 further stated that after 30 minutes, they returned to the shower room because the resident was screaming, and they got her dressed and in her wheelchair before the resident told them she was going to report them. Staff #46 said that the resident immediately wheeled herself back to her room and sent an email to report them; and, the charge nurse texted the ED, Staff #29, to report it immediately. In an interview with the other CNA (staff #34) conducted on [DATE] at 1:30 p.m., staff #34 stated that allegations of abuse or neglect must be reported within two hours. She said that on [DATE], Resident #11 was not assigned to her shower group, as the CNA assigned to the resident had left early that day. Staff #34 said that the resident's shower was delayed, and although Resident #11 asked her twice for a shower, she was hesitant to assist due to completing last rounds at the end of her shift. Staff #34 said that eventually, she and another CNA (Staff #46) decided to help the resident shower to avoid further upset. Staff #34 stated that Resident #11 was crying on the way to the shower room. She denied throwing a washcloth at the resident, stating instead that she gently placed it on the shower chair's armrest. Staff #34 said that she and Staff #46 left the resident alone in the shower and did not return for about 30 minutes. She said that when they heard the resident screaming, they returned to the room and the resident immediately yelled, Get me the f*** out of here. Staff #34 said she asked the resident to calm down, but the resident became louder and used profanity, saying she had been left in the shower for over an hour. Staff #34 stated that she and Staff #46 told the resident to calm down so they could assist her, but then left the resident alone and naked again in the shower room to notify the nurse. Staff #34 stated that when the nurse was unavailable, they returned to the resident; and, after helping her get dressed, Staff #34 said the resident wheeled herself back to her room and said she was going to report the incident to the state. Staff #34 further stated that they discussed recording the resident at the nurses' station for their own protection but decided not to do so because Staff #46 was uncomfortable with it. Staff #34 stated that she reported the resident's allegations to the nurse immediately, who then notified the supervising nurse and the oncoming shift. She also noted that she was not suspended until [DATE], at 11:00 a.m. A phone interview was attempted on [DATE] at 2:20 p.m. with the Licensed Practical Nurse (LPN/Staff#91) who entered the shower to assist the resident, but there was no response. An interview was conducted with a Registered Nurse (RN/Staff#58) on [DATE] at 2:24 p.m. The RN said that per the facility's policy, the timeframe for reporting was immediately to the administrator; and, if an allegation were made outside of business hours, they would leave a message, try to reach the Director of Nursing (DON), and make sure the residents were safe. During an interview with the DON (Staff #120) and ED (Staff #29) conducted on [DATE] at 2:32 p.m. both the DON and the ED stated that the timeframe for reporting was 2 hours. Regarding the incident, the ED stated that they were notified over email on [DATE] at 10:16 p.m., the ED did not check her email immediately, and she did not see the email until around 10 a.m. on [DATE]. The ED stated that she read it, reviewed it, and the facility did the initial 2 hours of making sure the resident was safe before sending the aide home and suspending the other. The ED stated that they did a skin assessment and concluded that it was not substantial for abuse and neglect. The ED stated that she did not click the verification link sent to her email to submit the report to the Arizona Department of Health Services (AZDHS), and when she attempted to click the link it expired. The ED further stated that they would fix their reporting processes moving forward. Review of a policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, was revised in January of 2024 and revealed that all reports of abuse, neglect, or exploitation needed to be thoroughly investigated by facility management, and needed to be reported immediately, but within two hours to the state agency, ombudsman, resident's representative, Adult Protective Services (APS), law enforcement, the physician, and the medical director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#11) was reported to the State Agency (SA) within the required timeframe. The deficient practice could result in resident not protected from continued abuse. Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included chronic inflammatory demyelinating polyneuritis, calcific tendinitis of the right thigh, adjustment disorder, hypotension, reduced mobility, muscle weakness, need for assistance with personal care, and polyneuropathy.The care plan dated February 3, 2025 included that resident #11 had functional self-care deficits and/or functional mobility limitations related to malnutrition, pain and weakness and required assistance. The care plan revised on February 14, 2025 revealed that the resident had behavior problem related to recent admission, refusal of care and was verbally abusive to staff. Interventions included to administer medications as ordered and all personal care and interaction done in pairs.A late entry NP (nurse practitioner) note dated [DATE] revealed the resident was oriented x3 and had good insight and judgment.A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The late entry NP note dated [DATE] included the resident was oriented x 3, had organized thoughts, cooperative behavior and good insight/judgement.A behavior progress note dated [DATE] revealed that at approximately 9:00 p.m. the resident asked for a shower and when she was assisted in shower, she grew upset, started yelling, cursing, and was verbally abusive and insulting to the Certified Nursing Assistants (CNAs).There were no further documentation of this incident found in the clinical record and facility documentation.Review of the State Agency complaint tracking system revealed no evidence that the facility had submitted a self-report for Resident #11's allegation of staff-to-resident abuse and neglect on or about [DATE].An interview was conducted on [DATE], at 12:40 p.m. with Resident #11 who stated that on [DATE], she repeatedly requested a shower throughout the day, but staff kept telling her it would be done later. The resident said that, that evening, two CNAs (staffs #34 and #46) assisted her into the shower. The resident stated that when she asked for a washcloth, Staff #34 threw it into her lap more aggressively than usual. The resident reported that her showers typically last about 15 minutes, but that night she was left alone in the shower for over 30 minutes while she screamed for help. She said she was crying in pain and no one responded, except for a nurse who briefly entered to hand her an item that had fallen. The resident stated that when the two CNAs returned, the resident stated they began arguing with her; and, one CNA told her that if she continued behaving that way, no one would help her. The resident further stated that the CNAs left her naked in the shower while they went to the nurses' station, where she overheard them telling a nurse they were going to record her. She said that staff #34 mocked her, told her to get dressed on her own despite her pain, and placed her shoes in her lap saying, See, your arms aren't broken. Resident #11 stated that she reported the incident to the Executive Director (ED/Staff #29) by email the same day. However, she said no one from administration responded or visited her room until the afternoon of [DATE]. An interview was conducted on [DATE] at 12:52 p.m. with one of the alleged CNAs (staff #46) who stated that the timeframe for reporting was within 2 hours, and she did recall an incident between herself and Resident #11. Staff #46 said that at the beginning of her shift on [DATE], Resident #11 was already upset, and had requested a shower several times throughout the day. Staff #46 said that the resident was not in her group for showers, but she did shower the residents' roommate thinking that the other CNA (staff #34) would give Resident #11 her shower. Staff #46 stated that the CNA who intended to shower her left early that day, and by the end of the night they realized that Resident #11 had not gotten her shower yet, so they decided to set her up for one. Staff #46 said that they left the resident in the shower for 30 minutes, and at some point she thought that the nurse went into the shower room because the resident dropped something. Staff #46 further stated that after 30 minutes, they returned to the shower room because the resident was screaming, and they got her dressed and in her wheelchair before the resident told them she was going to report them. Staff #46 said that the resident immediately wheeled herself back to her room and sent an email to report them; and, the charge nurse texted the ED (staff #29), to report it immediately. In an interview with the other CNA (staff #34) conducted on [DATE] at 1:30 p.m., staff #34 stated that allegations of abuse or neglect must be reported within two hours. Staff #34 stated that she reported the resident's allegations to the nurse immediately, who then notified the supervising nurse and the oncoming shift. She also noted that she was not suspended until [DATE], at 11:00 a.m. An interview was conducted with a Registered Nurse (RN/Staff#58) on [DATE] at 2:24 p.m. The RN said that per the facility's policy, the timeframe for reporting was immediately to the administrator; and, if an allegation were made outside of business hours, they would leave a message, try to reach the Director of Nursing (DON), and make sure the residents were safe. During an interview with the DON (Staff #120) and ED (Staff #29) conducted on [DATE] at 2:32 p.m. both the DON and the ED stated that the timeframe for reporting was 2 hours. Regarding the incident, the ED stated that they were notified over email on [DATE] at 10:16 p.m., the ED did not check her email immediately, and she did not see the email until around 10 a.m. on [DATE]. The ED stated that she read it, reviewed it, and the facility did the initial 2 hours of making sure the resident was safe before sending the aide home and suspending the other. The ED stated that they did a skin assessment and concluded that it was not substantial for abuse and neglect. The ED stated that she did not click the verification link sent to her email to submit the report to the State Agency, and when she attempted to click the link it expired. The ED further stated that they would fix their reporting processes moving forward. Review of a policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, was revised in January of 2024 and revealed that all reports of abuse, neglect, or exploitation needed to be thoroughly investigated by facility management, and needed to be reported immediately, but within two hours to the state agency, ombudsman, resident's representative, Adult Protective Services (APS), law enforcement, the physician, and the medical director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an allegation of abuse for one resident (#5) was thoroughly investigated. The deficient practice could result in the appropriate State Agencies not being notified and allegations of abuse not being thoroughly investigated. Findings include:Findings include:Resident # 5 was admitted to the facility on [DATE], with diagnoses of polyneuritis, protein-calorie malnutrition, adjustment disorder, and insomnia. A comprehensive care plan dated February 7, 2025, revealed that Resident # 5 had behavioral problems due to recent admission including, refusal of care and being verbally abusive to staff. Interventions included all personal care and interactions done in pairs. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicates Resident # 5 is cognitively intact. Review of an email dated July 29, 2025, from Resident # 5 sent to Executive Director (ED/Staff # 3) and Resident Relations Manager (Staff # 9), revealed that an interaction with Licensed Practical Nurse (LPN/ Staff # 67) was manipulative. Resident # 5 additionally described the interaction as intimidation and a covert threat disguised as an apology. Review of the Facility Concern Log dated July 29, 2025, revealed a concern raised by Resident # 5 who was upset about a conversation she had with LPN # 67. No resolution date to this concern was given. An interview was conducted with Resident # 5 on August 4, 2025 at 3:00 p.m., revealed that Resident # 5 had made multiple complaints to the Facility regarding LPN # 67. She reported that she was not getting a response so she had sent an email to the corporate office. Resident # 5 stated that on July 29, 2025 LPN # 67 entered her room alone to apologize for the negative feedback, but went on to say he supports a stay-at-home wife and two children and depends on the job and does not want anyone getting him in trouble. Resident # 5 revealed she felt intimidated by the conversation and immediately emailed ED Staff # 3 and Staff # 9 along with the corporate office. Resident # 5 confirmed she felt it was abuse. Resident # 5 also revealed that after she reported the conversation with LPN # 67 she continued to see him in the facility and was concerned with her safety. Resident # 5 also revealed that she secretly recorded the conversation and sent it to the Facility attached to the email. An interview was conducted with a Certified Nurse Assistant (CNA/staff # 57) at 9:27 a.m., who stated that she felt that she worked well with Resident # 5. The CNA stated that Resident # 5 was crying and having a hard day and that she was able to console her but the resident would not tell her what was wrong. The stated that Resident # 5 told her about the concerns with LPN # 67 and that Resident # 5 had reported concerns to the Executive Director (ED Staff # 3) and reported to the State Agency. An interview conducted with a Licensed Practical Nurse (LPN/staff # 67) on August 5, 2025 at 9:39 a.m., who stated that he was aware that Resident # 5 had filed complaints about him regarding taking care of a roommate, sleeping on the job while taking a break, and long wait times. The LPN revealed that Resident # 5 did complain a lot regarding staff care, and that he did go to apologize to Resident # 5 on July 29, 2025. The LPN further revealed that he had a family and needs this job so that is why he apologized. The LPN denied any attempt at intimidation with regards to his apology, but was upset with the fact Resident # 5 had secretly recorded the conversation. An interview conducted with Resident Relations (staff # 9) on August 5, 2025 at 9:55 a.m., who stated that Resident # 5 came to her regarding several complaints regarding roommates that she did not like and other issues with residents. Staff # 9 reported that Resident # 5 informed her that Resident # 5 had a recording of malicious conversation with LPN (staff # 67). Staff # 9 reported that this conversation was also given to the Executive Director ( ED/staff # 3), and the ED addressed Resident # 5's concerns. Staff # 9 revealed that Resident # 5 requested a transfer from the facility on July 29th, 2025, and due to Resident #5's insurance local facilities do not have the availability. Staff # 9 stated that Resident # 5 refused to go away from the area and decided to stay at the facility. During an interview conducted with the Executive Director (ED/staff # 3) on August 5, 2025 at 10:38 a.m., who stated that if a resident claims abuse the Facility will first make sure the resident is safe then report to the appropriate agencies, start the investigation, and if the alleged abuse involves a staff member that staff member is suspended until the conclusion of the investigation. The ED stated that Resident # 5 sent an email on July 29, 2025 stating that she was unhappy with the conversation she had with LPN # 67. The ED stated that Resident # 5 did not claim abuse, however review of the revealed Resident # 5 described the incident as intimidation and a covert threat. The ED also revealed that an investigation of the incident on July 29, 2025, was not conducted because the ED believed there was nothing to investigate because she had the audio recording. A Policy and Procedure titled, Abuse Policy, dated 2022, revealed that by definition abuse is the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy also revealed that if abuse is witnessed or suspected the ED will notify: Adult Protective Services, Ombudsman, State Survey Agency, Law enforcement when applicable, and Facility Director of Nursing (DON) who will notify Physician, Responsible Parties, and VP of Clinical Operations. ED will begin investigation immediately and complete within 5 working days. Suspected abuse will be reported in accordance with the timeframes and standards required by Centers for Medicare and Medicaid Services (CMS). If the alleged perpetrator is an employee, they will be immediately suspended pending the results of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure an allegation of resident (#5) abuse was reported to all applicable state agencies.Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an allegation of resident (#5) abuse was reported to all applicable state agencies. The deficient practice could result in further allegations of abuse not being reported and investigated by the appropriate state agencies. Findings include: Resident # 5 was admitted to the facility on [DATE], with diagnoses of polyneuritis, protein-calorie malnutrition, adjustment disorder, and insomnia. A comprehensive care plan dated February 7, 2025, revealed that Resident # 5 had behavioral problems due to recent admission including, refusal of care and being verbally abusive to staff. Interventions included all personal care and interactions done in pairs. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicates Resident # 5 is cognitively intact. Review of an email dated July 29, 2025, from Resident # 5 sent to Executive Director (ED/Staff # 3) and Resident Relations Manager (Staff # 9), revealed that an interaction with Licensed Practical Nurse (LPN/ Staff # 67) was manipulative. Resident # 5 additionally described the interaction as intimidation and a covert threat disguised as an apology. Review of the Facility Concern Log dated July 29, 2025, revealed a concern raised by Resident # 5 who was upset about a conversation she had with LPN # 67. No resolution date to this concern was given. An interview was conducted with Resident # 5 on August 4, 2025 at 3:00 p.m., who stated that she made multiple complaints to the Facility regarding LPN # 67. She stated that she was not getting a response, so she sent an email to the corporate office. Resident # 5 stated that on July 29, 2025 LPN # 67 entered her room alone to apologize for the negative feedback, but went on to say he supports a stay-at-home wife and two children and depends on the job, and did not want anyone getting him in trouble. Resident # 5 revealed she felt intimidated by the conversation and immediately emailed the ED (staff # 3) and the Resident Relations Manager (staff # 9) along with the corporate office. Resident # 5 stated that she felt it was abuse. The resident also stated that after she reported the conversation with LPN (staff # 67), she continued to see him in the facility and was concerned with her safety. Resident # 5 also revealed that she secretly recorded the conversation and sent it to the facility attached to the email. An interview was conducted with a Certified Nurse Assistant (CNA/ Staff # 57) at 9:27 a.m., who that she felt that she worked well with Resident # 5. The CNA revealed that Resident # 5 was crying and having a hard day and that she was able to console her but the resident would not tell her what was wrong. The CNA further stated that the resident told her about the concerns with the LPN (staff #67), and that Resident # 5 had reported her concerns to the ED (staff # 3), and to the State Agency.An interview conducted with LPN # 67 on August 5, 2025 at 9:39 a.m., revealed that he was aware that Resident # 5 had filed complaints about him regarding taking care of a roommate, sleeping on the job while taking a break, and long wait times. LPN # 67 revealed that Resident # 5 did complain a lot regarding staff care. LPN # 67 revealed that he did go to apologize to Resident # 5 on July 29, 2025 alone. LPN # 67 revealed that he had a family and needs this job so that is why he apologized. LPN # 67 denied any attempt at intimidation with regards to his apology, but was upset with the fact Resident # 5 had secretly recorded the conversation. An interview conducted with Staff # 9 on August 5, 2025 at 9:55 a.m. revealed that Resident # 5 had come to her regarding several complaints with roommates that she did not like and other issues with residents. Staff # 9 reported that Resident # 5 had informed her that Resident # 5 had a recording of malicious conversation with LPN # 67. Staff # 9 reported that this conversation was also given to ED Staff # 3, and the ED was addressing Resident # 5's concerns. Staff # 9 revealed that Resident # 5 requested a transfer from the facility on July 29th, 2025, and Staff # 9 had been working on however due to her insurance local facilities do not have the availability. Staff # 9 stated that Resident # 5 refused to go away from the area and decided to stay at the facility. During an interview conducted with the ED Staff # 3 on August 5, 2025 at 10:38 a.m., it was revealed that if resident claims abuse the Facility will first make sure the resident is safe then report to the appropriate agencies, start the investigation, and if the alleged abuse involves a staff member that staff member is suspended until the conclusion of the investigation. ED Staff # 3 revealed that Resident # 5 sent an email on July 29, 2025 unhappy with the conversation with LPN # 67. ED Staff # 3 revealed that Resident # 5 did not claim abuse however review of the email it was revealed Resident # 5 described the incident as intimidation and a covert threat. ED Staff # 3 also revealed that an investigation of the incident on July 29, 2025, was not conducted because ED Staff # 3 believed there was nothing to investigate because she had the audio recording. A Policy and Procedure titled, Abuse Policy, dated 2022, revealed that by definition abuse is the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy also revealed that if abuse is witnessed or suspected the ED will notify: Adult Protective Services, Ombudsman, State Survey Agency, Law enforcement when applicable, and Facility Director of Nursing (DON) who will notify Physician, Responsible Parties, and VP of Clinical Operations. Suspected abuse will be reported in accordance with the timeframes and standards required by Centers for Medicare and Medicaid Services (CMS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure an allegation of resident (#5) abuse was investigated. Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an allegation of resident (#5) abuse was investigated. The deficient practice could result in residents being abused. Findings include:Resident # 5 was admitted to the facility on [DATE], with diagnoses of polyneuritis, protein-calorie malnutrition, adjustment disorder, and insomnia.A comprehensive care plan dated February 7, 2025, revealed that Resident # 5 had behavioral problems due to recent admission including, refusal of care and being verbally abusive to staff. Interventions included all personal care and interactions done in pairs. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicates Resident # 5 is cognitively intact.Review of an email dated July 29, 2025, from Resident # 5 sent to Executive Director (ED/Staff # 3) and Resident Relations Manager (Staff # 9), revealed that an interaction with Licensed Practical Nurse (LPN/ Staff # 67) was manipulative. Resident # 5 additionally described the interaction as intimidation and a covert threat disguised as an apology. Review of the Facility Concern Log dated July 29, 2025, revealed a concern raised by Resident # 5 who was upset about a conversation she had with LPN # 67. No resolution date to this concern was given. An interview was conducted with Resident # 5 on August 4, 2025 at 3:00 p.m., revealed that Resident # 5 had made multiple complaints to the Facility regarding LPN # 67. She reported that she was not getting a response so she had sent an email to the corporate office. Resident # 5 stated that on July 29, 2025 LPN # 67 entered her room alone to apologize for the negative feedback, but went on to say he supports a stay-at-home wife and two children and depends on the job and does not want anyone getting him in trouble. Resident # 5 revealed she felt intimidated by the conversation and immediately emailed ED Staff # 3 and Staff # 9 along with the corporate office. Resident # 5 confirmed she felt it was abuse. Resident # 5 also revealed that after she reported the conversation with LPN # 67, she continued to see him in the facility and was concerned with her safety. Resident # 5 also revealed that she secretly recorded the conversation and sent it to the Facility attached to the email. An interview with Certified Nurse Assistant (CNA/ Staff # 57) at 9:27 a.m., revealed that she had worked with Resident # 5 and felt that she worked well with Resident # 5. CNA # 57 revealed that Resident # 5 was crying and having a hard day and that she was able to console Resident #5 but Resident # 5 would not tell her what was wrong. CNA # 57 revealed that Resident # 5 had told her about the concerns with LPN # 67 and that Resident # 5 had reported concerns to ED Staff # 3 and reported to the State Agency.An interview conducted with LPN # 67 on August 5, 2025 at 9:39 a.m., revealed that he was aware that Resident # 5 had filed complaints about him regarding taking care of a roommate, sleeping on the job while taking a break, and long wait times. LPN # 67 revealed that Resident # 5 did complain a lot regarding staff care. LPN # 67 revealed that he did go to apologize to Resident # 5 on July 29, 2025 alone. LPN # 67 revealed that he had a family and needs this job so that is why he apologized. LPN # 67 denied any attempt at intimidation with regards to his apology, but was upset with the fact Resident # 5 had secretly recorded the conversation. An interview conducted with Staff # 9 on August 5, 2025 at 9:55 a.m. revealed that Resident # 5 had come to her regarding several complaints with roommates that she did not like and other issues with residents. Staff # 9 reported that Resident # 5 had informed her that Resident # 5 had a recording of malicious conversation with LPN # 67. Staff # 9 reported that this conversation was also given to ED Staff # 3, and the ED was addressing Resident # 5's concerns. Staff # 9 revealed that Resident # 5 requested a transfer from the facility on July 29th, 2025, and Staff # 9 had been working on however due to her insurance local facilities do not have the availability. Staff # 9 stated that Resident # 5 refused to go away from the area and decided to stay at the facility. During an interview conducted with the ED Staff # 3 on August 5, 2025 at 10:38 a.m., it was revealed that if resident claims abuse the Facility will first make sure the resident is safe then report to the appropriate agencies, start the investigation, and if the alleged abuse involves a staff member that staff member is suspended until the conclusion of the investigation. ED Staff # 3 revealed that Resident # 5 sent an email on July 29, 2025 unhappy with the conversation with LPN # 67. ED Staff # 3 revealed that Resident # 5 did not claim abuse however review of the email it was revealed Resident # 5 described the incident as intimidation and a covert threat. ED Staff # 3 also revealed that an investigation of the incident on July 29, 2025, was not conducted because ED Staff # 3 believed there was nothing to investigate because she had the audio recording. A Policy and Procedure titled, Abuse Policy, dated 2022, revealed that by definition abuse is the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy also revealed that if abuse is witnessed or suspected the 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.

**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 a resident (#10) was not abused by another resident (#15). The deficient practice could lead to psychosocial or physical harm of a resident. -Regarding Resident #10 (alleged victim): Resident #10 was admitted to the facility June 5, 2025, with diagnoses that included alcoholic cirrhosis of liver, hepatic encephalopathy, type 2 diabetes mellitus, portal hypertension, acidosis, hypertension, unspecified head injury, and alcohol dependence. An admission minimum data set (MDS) assessment was still in progress. An Alert Note dated June 15, 2025, revealed a therapist came to the nurse after Resident #10 reported another resident hit her while having lunch in the bistro area on the rehab unit. This writer separated both residents, and ensured everyone was safe. Resident #10 reported being hit in the arm, and having a fork and knife thrown at her, and reports being okay. The nurse observed the area of the arm with no skin issues noted, and no reports of pain or discomfort. The incident was reported to the administrator. -Regarding Resident #15 (alleged perpetrator): Resident #15 was admitted to the facility May 13, 2025, with diagnoses that included displaced intertrochanteric fracture of right femur, chronic obstructive pulmonary disease, atherosclerotic heart disease, left bundle-branch block, anemia, and other reduced mobility. An admission MDS assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment. A care plan dated May 22, 2025, revealed Resident #15 had impaired cognitive function/dementia or impaired thought processes due to dementia, and impaired decision-making, with interventions to administer medications as ordered and communicate with the resident and family / caregivers regarding the resident's capabilities and needs. There was no evidence in the care plan regarding behaviors. Further review of the care plan revealed no evidence of revised interventions related to behaviors regarding other residents. A Daily Skilled assessment dated [DATE], revealed Resident #15 was alert with confusion to place, time, and situation. The assessment indicated No behavior issues noted. No change of condition was noted today, and there was no evidence of additional notes or follow-up regarding the interaction with Resident #10. Review of Resident #15's clinical record revealed no evidence of a description of a resident-to-resident incident on June 15, 2025 or that the provider and family had been notified. An interview was conducted on June 18, 2025, at 9:17 AM, with Resident #10, who stated that on June 15, 2025, Resident #15 kept her meal tray at another table and kept coming over to Resident #10 and Resident #20 who were eating at a separate table. Resident #10 stated that Resident #15 just kept coming over, and saying I want to go home, and Resident #10 kept saying to her you need to eat to get your strength that way you can go home. Resident #10 stated that Resident #15 kept poking Resident #20, and then stated what's wrong with you? and why are you talking to me that way? Resident #10 stated that Resident #15 just got worse. Resident #10 stated that she got up and pushed Resident #15 in her wheelchair over to the table where Resident #15's meal tray was, and Resident #15 turned around really quickly and took an open hand and hit Resident #10's right arm, and that she did it out of her anger. Resident #10 stated that Resident #15 then came back to the table and said something like I'm going to get you. Resident #10 stated that she has post traumatic stress disorder because she was abused in her past, and that this situation made her feel triggered. Resident #10 stated that she then went to the nurses' station and asked the only staff there, who was a therapist, to move Resident #15 away. Resident #10 stated that she was shaken up, and additionally, that as she was sitting at the table, Resident #15 came back to her table and threw her butter knife and fork at the plate right in front of Resident #10. Resident #10 stated that she does not feel at peace because of this incident, and that she would feel better if Resident #15 stayed in a different part of the building. An interview was conducted with an Occupational Therapist (OT / Staff #41) on June 18, 2025, at 9:50 AM. Staff #41 stated that on Sunday, June 15, 2025, she went to the nurses' station to get records and make copies, when Resident #10 approached her and said she hit me and pointed to Resident #15. Staff #41 stated that she observed the situation, and saw that there was nobody in any immediate danger, and Resident #15 was in her wheelchair, wheeling out of the room. Staff #41 stated that she saw that Resident #10 was safely removed from the alleged perpetrator, approximately 50 feet apart, and then the nurse (Staff #80) came onto the unit and Staff #41 relayed the incident to her. A telephonic interview with a Licensed Practical Nurse (LPN / Staff #80) was attempted on June 18, 2025, at 10:04 AM. A voicemail was left for a return call. The staff did not return the phone call. A telephonic interview was conducted with the facility Administrator (Staff #62) on June 18, 2025, at 10:09 AM. The Administrator stated that she was still in the process of conducting the investigation into the incident between Resident #10 and Resident #15, and had conducted interviews, but that the Administrator was not comfortable with handing anything over to the State Agency at this point, and that she will submit the interviews with the facility 5-day report. A telephonic interview was conducted with a Certified Nursing Assistant (CNA / Staff #25) on June 18, 2025, at 10:11 AM, who stated that he was working in the facility on June 15, 2025, when the altercation between Resident #10 and Resident #15 had occurred. Staff #25 stated that after the altercation, Resident #15 was separated from Resident #10 and was moved to another unit, and at the end of the day, Resident #15 was returned to her original unit. An interview was conducted on June 15, 2025, at 10:17 AM with Resident #20, who stated on June 15, 2025, he was eating with Resident #10 in the dining area, and Resident #15 kept coming over to the table and bothering Resident #10. Resident #20 stated that Resident #10 took Resident #15 back to her table, and then he saw Resident #15 hit Resident #10 in the forearm and tried to hit Resident #10 with the fork and knife. Resident #20 stated that there was one staff behind the nurses' station and that we told her about the incident, and that Resident #20 left the area after that. Resident #20 stated that because of that incident, he does not want to eat in the dining area, that he wants to eat meals in his room and keeps to himself after that. An interview was conducted with the Director of Nursing (DON / Staff #51) on June 18, 2025, at 10:37 AM. The DON stated that she was told by staff that Resident #10 and Resident #15 were in the bistro area eating, and Resident #15 was having dementia-related behaviors and this was bothering Resident #10. Resident #10 told Resident #15 to go eat her food, and then Resident #15 hit Resident #10 in the arm and threw her silverware. The residents were separated, and Resident #15 was moved to another unit for the rest of the day. The DON stated that the residents were assessed and there were no signs of injury. The DON stated there was no doubt that the situation occurred, but that she would not call this incident abuse because Resident #15 is not aware of what she is doing. The DON also stated that the intention of hurting someone is not a requirement for the definition of abuse. The DON stated that the facility defines abuse as an infliction of injury with resulting physical pain or mental anguish, and that examples of abuse include hitting and kicking. Review of the facility policy titled Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated January 1, 2024, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: protect residents from abuse, neglect, exploitation or misappropriation of property by anyone, identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property, investigate and report any allegations within timeframes required by federal requirements, protect residents from any further harm during investigations.

**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 accurate and complete for one resident (#2). The deficient practice could lead to care team members not being aware of a resident's status and lead to a delay in care or missed treatment. Findings Include: Resident #2 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia, pulmonary fibrosis, type 2 diabetes mellitus, insomnia, anxiety disorder, and depression. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 8, indicating moderate cognitive impairment. A physician order dated February 21, 2025, indicated to complete a skin check weekly. A Weekly Skin Check and Wound assessment dated [DATE], revealed the resident had no new or ongoing skin impairments. An Alert Charting note dated April 27, 2025, revealed at around 2:15 PM, Resident #2 was found by a Certified Nursing Assistant (CNA) on the floor beside his bed. The resident was very much confused, and may have tried to get out from his bed as the resident is used to being independent when ambulating. The resident had been reported to have a change in condition since the previous shift. An Alert Charting note dated April 27, 2025, revealed that the nurse received an order from the provider on call to send Resident #2 out to the hospital for further evaluation post-fall for possible urinary tract infection and cellulitis on left arm. Paramedics came at 3:45 PM and took the resident to the hospital. A physician order dated April 30, 2025, indicated to send the resident out to the emergency department to rule out possible infection. The clinical record was reviewed, and revealed no evidence of any nursing assessment with description of a skin condition on the resident's left arm. An interview was conducted on May 12, 2025, at 1:20 PM, with a CNA (Staff #59), who stated that if a CNA were to notice a resident to have a new skin condition, that it would be reported to the nurse to assess. Staff #59 stated that he had observed Resident #2 to have an inflamed and purple-looking area on the resident's arm, and that he did not report it to the nurse because everybody knew about it. Staff #59 also stated that the resident was scratching and picking at it. A telephonic interview was conducted with a Registered Nurse (RN / Staff #36) on May 12, 2025, at 1:52 PM. Staff #36 stated that she recalled Resident #2, and that there was a red and swollen area on the resident's left arm. Staff #36 stated that on April 26, 2025, the day before the resident was sent out to the hospital, she had noticed that the skin condition had started, and that there was an open area on the resident's arm, and that it was not as swollen as the following day. On April 27, 2025, Staff #36 stated that the area on the resident's arm was more swollen, and that the resident kept trying to touch it, so Staff #36 then treated the arm and wrapped it. Staff #36 stated that another nurse called the provider, and Staff #36 was instructed to just observe the skin condition on Resident #2's arm. Later that day, Staff #36 stated that she was called by the provider, and instructed to send the resident to the hospital. An interview was conducted with a Unit Manager and Licensed Practical Nurse (LPN / Staff #70) on May 12, 2025, at 2:21 PM. Staff #70 stated that the facility's process if a new skin issue or rash is found on a resident would be to document it, to notify the Director of Nursing, notify the wound team, and to follow the provider's orders. Staff #70 stated that the last day that she worked in the facility before Resident #2 was sent out to the hospital was April 24, 2025, and that she had returned to work on April 28, 2025. The clinical record of Resident #2 was reviewed together, and Staff #70 stated that she had completed the Weekly Skin Assessment, dated April 27, 2025, that indicated that Resident #2 had no new or ongoing skin issues. Staff #70 also stated that she was not working in the facility on the day of April 27, 2025, and that she had completed the skin assessment the following date after the resident had already gone to the hospital. Staff #70 stated that there was no nursing assessment or description of the resident's left arm skin condition in the medical record. Staff #70 stated that I don't see there was anything inappropriate done, and that it was found there was a scratch on his arm and he was sent out to the hospital that day. A telephonic interview was conducted with the Director of Nursing (DON / Staff #42) on May 12, 2025, at 2:48 PM, who stated that her expectation for nurses is that assessments are completed timely and that if they are late, then nurses should do a late entry and document for the time that the assessment was actually done. The DON stated that it would be inappropriate for a nurse who did not actually look at a resident's skin to document an assessment, and to date it inaccurately. Review of the facility policy titled Documentation: Charting and Documentation, effective January 1, 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 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. Review of the facility policy titled Assessments/Care Planning: Resident Examination and Assessment, effective January 1, 2024, revealed the purpose of this policy is to examine and assess the resident for any abnormalities in health status. Notify the physician of any abnormalities such as, but not limited to: abnormal vital signs; change in cognitive, behavioral or neurological status from baseline; wounds or rashes on the resident's skin; and worsening pain, as reported by the resident. The following information should be recorded in the resident's medical record: the date and time the procedure was performed, the name and title of the individual(s) who performed the procedure, all assessment data obtained during the procedure, how the resident tolerated the procedure if the resident refused the procedure, the reason(s) why and the intervention taken, and the signature and title of the person recording the data.

**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 (#52) was treated with dignity regarding privacy of a foley catheter bag. The deficient practice could lead to a resident having psychosocial harm from lack of dignity. -Findings include: Resident #52 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, pneumonia, encephalopathy, post-traumatic stress disorder, schizophrenia, depression, and anxiety. An admission MDS (minimum data set) assessment, dated March 24, 2025, revealed the resident had a brief interview for mental status (BIMS) assessment code of 99, indicating the resident was unable to complete the interview. A physician order dated March 19, 2025, indicated for a foley catheter size, and to change foley catheter as needed for leaking, soiling, blockage, or as ordered by physician. A progress note dated April 7, 2025 revealed the resident had a foley catheter in place. An observation was conducted on April 6, 2025, at 1:40 PM, and the resident was observed lying in bed, with the foley catheter bag hanging from the side of the bed, with no cover on the bag, and urine clearly visible. An additional observation conducted April 9, 2025, at 7:15 AM, revealed from the hallway, the resident's door to the room was wide open. The resident was observed lying in bed, and the foley catheter bag was hanging on the side of the bed facing the doorway. The privacy curtain was open, and there was no privacy cover on the bag, and urine was clearly visible from the hallway. A final observation was conducted on April 9, 2025, at 10:18 AM. The resident was lying in bed, however now had a privacy bag covering the foley catheter bag. An interview was conducted on April 9, 2025, at 9:15 AM, with a Certified Nursing Assistant (CNA / Staff #81). The CNA stated that the facility staff ensures that dignity and privacy is maintained for residents who may have a drain or device collecting bodily fluids by covering the collection bag with a privacy bag, or with the residents clothing. If the resident prefers to stay in their room, then a privacy curtain would be used to ensure privacy and dignity. At this time, Resident #52's foley catheter bag was observed together in the resident's room. The CNA stated, this one is not covered in regard to the foley bag. The CNA stated that if the resident wanted her door open and privacy curtain open, then the foley bag should be covered to maintain dignity. An interview was conducted with a Licensed Practical Nurse (LPN / Staff #85) on April 9, 2025, at 10:42 AM. The LPN stated that the facility uses privacy covers on foley bags to maintain a resident's dignity to ensure bodily fluids are not exposed for others to see. The LPN stated that an impact on residents if their bodily fluids were exposed could be embarrassment, and that it is a dignity issue. An interview was conducted with the Director of Nursing (DON / Staff #90) on April 9, 2025, at 11:49 AM. The DON stated that the facility uses privacy bags on foley catheter bags so that bodily fluids are not exposed. The DON stated that a potential impact on residents if their bodily fluids were visible and exposed could be embarrassment. Review of the facility policy titled Resident Rights/Dignity: Resident Rights, dated January 1, 2024, revealed that residents have a right to a dignified existence, and to be treated with respect, kindness, and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, staff interviews, review of facility documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure a safe and appropriate transfer of one resident (#182). The deficient practice could result in residents not receiving appropriate care and services during the transition of care. Findings include: Resident #182 was readmitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, Type 2 Diabetes Mellitus, Chronic Respiratory Failure with Hypoxia, anxiety disorder and severe protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12.0 indicating moderately impaired and resident requires continuous oxygen therapy treatment. Review of orders revealed an order for oxygen at zero to five liters per minute as needed to keep oxygen saturation above eighty-nine percent. Review of care plan dated November 18, 2024 revealed resident has potential nutritional problem related to COPD, respiratory failure, dysphagia, protein calorie malnutrition, underweight Body Mass Index (BMI). The interventions dated November 22, 2024 included provide food preference within limits and encourage by mouth intake. Review of another care plan dated November 29, 2024 revealed resident has emphysema/COPD and respiratory failure. The interventions included to give oxygen therapy as ordered, head of bed to be elevated (semi-Fowlers to fowlers) or out of bed upright in a chair during episodes of difficulty breathing (Dyspnea) and monitor for signs and symptoms of acute respiratory insufficiency such as anxiety and confusion. Review of another care plan dated November 29, 2024 revealed resident have impaired cognitive function/dementia or impaired thought processes related to short term memory loss. Review of another care plan dated November 30, 2024 revealed resident is homeless (I choose to return to my previous living arrangement). The interventions included to assess future placement setting to determine if resident's needs can be met, coordinate transportation with resident and/or family, discuss with resident/Family/Representative discharge planning process and provide services according to care plans in an effort to enhance optimum functioning and well-being. Review of record titled, Daily Skilled Evaluation, dated December 26 and December 27, 2024 revealed respiratory therapy and services provided by nurse such as cough/deep breathing, aerosol treatments, incentive spirometry and a nursing evaluation that includes abnormal respiratory findings such as cough; resident exhibits shortness of breath while lying flat, with exertion, while sitting at rest; resident head of bed elevated to avoid shortness of breath while lying flat; and resident uses oxygen. Review of record titled, Social Services Progress Note, effective date December 30, 2024 revealed a progress note by Resident Relations Manager/Social Service/Staff #2 that stated that the resident was notified of last covered day for skilled services will be January 2, 2025. The Notice of Medical Non Coverage (NOMNC) was issued due to the fact that resident has no need for skilled services, resident refused to sign the NOMNC, resident had no interest in applying for Arizona Long Term Care Services (ALTCS), resident will return to prior living at the shelter, and the facility's Resident Relations had purchased a replacement power cord for resident's portable oxygen to ensure a safe discharge. Review of record dated December 30, 2024 revealed a nurse practitioner (NP) progress note: -On December 20, 2024: the progress note states that the resident was seen, resident states that resident would like to transition to long term care (LTC) at the facility and was encouraged to speak with case management regarding discharge plan; -On December 24, 2024: the progress note states that the resident was seen during rounds, resident is in good spirits, resident is feeling ok, resident states might stay in long term care (LTC) at this facility; and -On December 28, 2024: the progress note states that the resident with persistent leukocytosis, status post by mouth use of steroids, might be contributing to elevated white blood cell (WBC), Augmentin twice a day for 7 days for empiric coverage, pneumonitis from previous chest Xray, monitor, resident is appropriate for palliative care. Review of record titled, Discharge Orders, dated December 31, 2024 revealed an order to may discharge to shelter on January 3, 2025 or when arrangements are made and follow up appointments to a provider/mobil unit in one week. Review of record titled, Daily Skilled Evaluation, dated January 1 and January 2, 2025 revealed respiratory therapy and services provided by nurse such as cough/deep breathing, aerosol treatments, incentive spirometry and a nursing evaluation that includes abnormal respiratory findings such as cough; resident exhibits shortness of breath while lying flat, with exertion, while sitting at rest; resident head of bed elevated to avoid shortness of breath while lying flat; and resident uses oxygen. Review of record titled, NSG/SS Discharge Evaluation, dated January 2, 2025 revealed the discharge/transfer was initiated by facility Interdisciplinary Team (IDT), the IDT assessment includes to Discharge to the Community with Hospice Services, Homeless, and home health services is not going to be provided. Review of records titled, Discharge summary, dated [DATE] revealed a Discharge Summary progress note stating the discharge date and time is on January 3, 2025 at 1:00 PM. Resident discharged to a shelter of location of choice. Resident is homeless (shelter or location of choice). Resident discharged with medications. The brief summary of stay and medical history as related to the stay included an admission date of October 13, 2024 with a diagnosis of COPD exasperation, alert and oriented times four, worked with therapies on strengthening, compliant with all respiratory treatments, independent with activities of daily living (ADLs), propels self in wheelchair without incident, maintains oxygen saturation (Sp02 ) greater than 90% on 4 liters of oxygen per nasal cannula, no signs and symptoms of distress, and able to verbalize all needs. Education provided on current treatments that included respiratory treatments, and current reconciled medication list provided to the resident/representative. For health literacy, resident states sometimes needs help. For pain frequency: pain disturbs sleep, pain limited rehabilitation therapy and pain has limited activities. Review of the discharge MDS dated [DATE] revealed resident functional abilities requires a set up or clean-up assistance with oral hygiene and resident requires supervision or touching assistance in lower body dressing, putting on/taking off footwear, and personal hygiene. Review of record dated January 3, 2025 revealed a nursing progress note that stated resident was discharged to a shelter, transported by the facility's in-house driver and resident's prescriptions, home medications, and equipment were sent with the resident. Resident verbalized understanding of all discharge instructions, in good spirits, and no signs and symptoms of distress. Review of the State Agency complaint tracking system received on January 7, 2025 revealed a January 3, 2025 as the date of alleged event. The detail includes that Resident #182 was discharged from the facility to a homeless shelter. The resident had a portable oxygen concentrator but did not have a home/wall concentrator upon arrival to the shelter. And, the Resident was transferred to a hospital by ambulance for hypoxia and shortness of breath. An interview was conducted on April 7, 2025 at 11:20 AM with a registered nurse (RN)/wound nurse/Staff #200. Staff #200 stated that regarding discharge planning, Staff #200 stated that for residents getting discharge, she collaborates with the Interdisciplinary Team (IDT), for instance, she stated that for a resident needing wound care, the resident must have appropriate needed wound care supplies. Furthermore, she stated that a resident being discharged will be provided a three days worth of supplies for wound care. She stated that the social services sets up discharges such as home health and outpatient services, and it all depends on residents' insurance. She stated that she does not do actual discharges of residents. Resident discharges are done by the floor nurse which includes providing discharge paperwork such as their prescription scripts and discharge paperwork that includes follow up appointment and medication list. An interview was conducted on April 7, 2025 at 11:33 AM with a licensed poractical nurse (LPN)/Staff #68. Staff stated that the rehab unit is where residents comes in with skill needs such as physical therapy (PT)/occupational therapy (OT) to get the residents stronger. She stated that when residents are ready to go home, the social worker and the physical therapist plan the discharge. If the resident is not ready to go home by themselves, the PT determines assisted living due to not able to take care of themselves at home. If residents are unable to go to an assisted living or home, the social worker looks for long term care using a placement referral. She stated that regarding discharging residents back to their home, she receives a discharge notice from their social worker, if her resident still needs additional services, the PT/OT will address the resident's need by documenting a therapy note that states the resident will need to continue therapy through home health care referral. Another interview was conducted on April 7, 2025 at 11:43 AM with social service/Staff #2. Staff #2 stated that she does resident's care plan, discharge planning, setting up durable medical equipment (DME), home health referrals, and follow up appointments for residents. She stated that regarding home health, within a week of resident's admission, she figures out if a resident is appropriate for home health referrals, she will give the resident choice if they would like home health services and which home health agency to choose from. She will talk to the resident and family or representative about home health during first couple days of admission, and any DME needed, and as it gets closer to their discharge date . Staff #2 stated that regarding issuing a NOMC, it comes from the resident's insurance, she prints it out and takes it to the resident at least 2 days before the last day of coverage. She will explain the NOMC to the resident and will explain to the resident the right to appeal. An interview was conducted on April 7, 2025 at 03:19 PM with an LPN/Staff #73. Staff stated that her role is usually passing medications and doing admissions and discharges. Regarding admissions, she stated that when a resident is admitted to their facility, the resident signs paper work such as consents, advance directive, vaccines, and psychotropic medication consents. She stated that during a discharge, the care relation department will start the process of entering resident's appointments, and if residents are going with medication, she will give the resident a copy of their prescription script because their care relation department already had faxed the scripts to the resident's pharmacy, and then she will have the resident or their family sign the discharge paperwork. In addition, staff #73 stated that she has taken care of residents that are homeless. She stated that the care relations department sets the whole discharge planning for their homeless resident who will be discharged to a homeless shelter, and she will go over and explain what is written on the discharge paper work. She stated that usually regarding resident with oxygen, the care relation department will set the resident up with a portable oxygen tank brought in by a third party home care company to their facility and then the resident is discharged with the portable oxygen. Staff stated that a portable oxygen is one that a resident can carry. She stated that she has not seen a portable oxygen before and never use it because when the residents are admitted in to their facility, the facility uses a big portable tanks or concentrators for their resident's use. Another interview was conducted on April 7, 2025 at 04:02 PM with Resident Relations Manager/Social Service/Staff #2. Staff #2 stated that her role is to coordinate care plans, work with discharge planning, grievances, NOMC, and initial resident assessment. She stated that discharge planning starts on the day she does initial assessment. She will ask the resident where they previously lived, their discharge goal, home health services of choice based on insurance and then she narrows the choices down based on which home health agency is contracted with resident's insurance. She stated that regarding homeless resident, the residents are discharged at the homeless shelter, and home health agency can not see them at the homeless shelter, but the resident has the option of outpatient therapy if the resident chooses and if their insurance allows it. Regarding DMEs such as wheelchairs, she orders it prior to resident's discharging out of the facility. Regarding oxygen, she stated that the resident does not discharge with concentrators or portables, but she remembers a resident that had purchased his own portable oxygen, so when that resident discharged , the resident did not need a concentrator because he had his own portable oxygen. She stated that she had one resident but does not remember who the resident was. She stated that they work with a placement referral, an outside resource for discharge planning for placement to a group homes or assisted living for homeless resident. She stated that she remembered resident #182. She stated that Resident #182 was discharged to a homeless center, and is being seen by mobile physician provider that provides services to the homeless shelter. She stated that she had ordered a cable for Resident #182's portable oxygen because it was lost during resident's transfer from the homeless center to the hospital. An interview was conducted on April 7, 2025 at 04:21 PM with the director of nursing (DON)/Staff #90. The DON stated that regarding the nursing discharge evaluation of Resident #182, she stated that the discharge with hospice services is a misclick and should have been without hospice services, and home health was not provided to the resident because the resident was discharged to the homeless shelter and home health will not see Resident #182 in the homeless shelter. The DON stated that resident #182 was admitted from hospital for bad COPD severe exacerbation, resident #182 will call 911 a lot for shortness of breath, and resident #182 refused hospice. Staff #2 present during this interview stated that resident was refusing therapy and at the homeless shelter they can not have home health services. In addition, Staff #2 stated that she spoke about ALTCS with resident. During the DON and Staff #2 interview, both staffs were looking in resident's electronic record for documentation about placement referrals and ALTCS. The DON and Staff #2 stated that they do not see any documentation in Point Click Care (PCC) computer regarding placement referrals. The DON stated that depending on resident's insurance, they will get the home health set up, follow up with resident's primary care provider (PCP) or pulmonologist, but if the resident does not want it, it is the resident's rights. The DON stated that Resident #182 was discharged with his own portable oxygen. An interview was conducted on April 8, 2025 at 11:35 AM with LPN/Staff #137. Staff #137 stated that she works as a floor nurse; she passes medications; assess residents; do treatments, discharges and admission; and contacts providers for things needed for residents. Regarding discharges, she stated that she does the nursing/social service discharge evaluation assessment in the computer, have the resident sign paperwork, explain to the resident the discharge summary, and then sent paper copies to the resident. Regarding discharging resident to a shelter, she stated that it is the same process, which includes the resident is discharged with their medication list, generally not discharge anybody with medication, they are given their prescription copies because 99.9% their prescription has already been called in to their pharmacy. She stated that regarding Resident #182, resident was administered breathing medication treatments, resident was able to make needs known, and resident was short of breath a lot of times. In addition, when Resident #182 was discharged , Staff #137 stated that the resident came with his has own portable oxygen tank, own nebulizer, home medications, own electric wheelchair, and when resident was discharged , resident was sent out with an oxygen cylinder tank so when he gets there he would be able to set up his own portable oxygen. In addition, staff stated that Resident #182 has been in their facility several times and then resident is discharged back to the homeless shelter. The last two admissions for Resident #182 were related to COPD exacerbation. An interview was conducted on April 9, 2025 at 10:11 AM with the administrator/Staff #176. The administrator stated that the resident refused ALTCS application so the resident could stay at the facility longer. The administrator also stated that the facility bought a charger for the resident's portable oxygen and made sure that the resident had prescriptions of the medications, and based on resident's right, resident has the right to determine his discharge location. Review of facility's policy titled, Administrative Policies: Consultants, with an effective date of January 1, 2024 revealed (1) facility may use as needed outside resources to furnish specific services to residents and to the facility. Review of facility's policy titled, Admissions/Transfers/Discharges: Transfer or Discharge Documentation, in effect date of January 1, 2024 revealed 1. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless-b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was accurate for one resident (#80). The deficient practice could result in incorrect discharge tracking information and data that is not accurate for quality monitoring. Findings include: Resident #80 was admitted on [DATE] with diagnoses that included cellulitis in the left lower extremity, endocarditis and acute and chronic respiratory failure. A social service note dated March 5, 2025 revealed that the resident's PICC (peripherally inserted central catheter) line was removed so the resident could return home. The resident declined a referral for home health. A health status note dated March 5, 2025 revealed that the resident was discharged in a private vehicle with a friend. The note further revealed that the resident verbalized understanding of all discharge instructions. The Discharge summary dated [DATE] revealed that the resident was discharged to a private home/apartment. Review of the discharge MDS assessment dated [DATE] revealed that the resident was discharged on March 5, 2025 with no anticipation of return.The assessment was coded as a planned discharge to an acute care hospital, code 04. An interview was conducted with the Regional MDS Director (staff #62) on April 8, 2025 at 11:23 a.m. She stated that a discharge MDS assessment was completed anytime a resident leaves the building for 24 hours or more, is admitted to the hospital or returns home. She further stated that resident #80 returned to his home upon discharge per the clinical record. Upon concurrent review of the MDS, staff #62 stated that the residents discharge MDS was coded incorrectly to indicate the resident was discharged to a hospital and not to the residents home. Staff #62 stated that the MDS discharge information was being reported to CMS (Center for Medicare and Medicaid Services) and this discharge was inappropriately reported. Staff #62 further stated that this assessment was incorrect and she will ensure it is corrected and education will be provided to those staff involved with MDS assessments. Staff #62 further stated that there was no policy for MDS inaccuracies. She stated the RAI (resident assessment instrument) manual is the reference that the facility uses for MDS coding. Review of the RAI manual revealed that a review of the medical record should be completed including the discharge plan and discharge orders for documentation of the discharge location. Code 01 should be used for a discharge to the community, such as a private home or apartment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, staff interviews and review of facility policy and procedure, the facility failed to ensure that a Pre- admission Screening and Resident Review (PASRR) Level 2 referral was completed for one resident (#28). The sample size was 18. The deficient practice could lead to residents not receiving needed care and services. Findings include: Resident #28 was admitted on [DATE] with diagnosis including major depressive disorder, single episode, anxiety disorder, bipolar disorder, type 1 diabetes, and schizoaffective disorder. A review of the quarterly MDS (minimum data set) dated December 26, 2024 revealed no noted BIMS (brief interview of mental status) score. The MDS revealed no noted potential indicators of psychosis and no noted behaviors. The MDs revealed diagnosis including anxiety disorder, depression, bipolar disorder and schizophrenia. A review of the care plan revealed focus areas to include anti-psychotic medication use for schizoaffective disorder. The care plan revealed monitoring for potential side effects and adverse reactions to anti-psychotics. The care plan further revealed that the resident had a noted behavior problem of refusing medications. A review of the electronic health record revealed a PASRR dated July 2, 2024 indicating that the resident did not meet the criteria for convalescent / respite care. It was noted that the resident did not have a terminal illness, no primary diagnosis of dementia and no developmental disability. Section B of PASRR revealed that the resident was diagnosed with schizophrenia, major depression, bipolar disorder, and anxiety disorder. It was further documented that the resident was prescribed Olanzapine and Latuda; however, the PASRR noted that a referral for a level II PASRR was not necessary. An interview was conducted on April 8, 2025 at 8:22 AM with the Resident Relations Manager, staff #2. Staff #2 stated that a PASRR is received from the other facility or hospital upon admission or would have to be conducted in-house, if not received at the time of admission. Staff #2 stated that if the PASRR received from another facility was incorrect then it would have to be corrected. Staff #2 further stated that if the resident remains in the facility after 30-days or if there are significant changes another PASRR would have to be completed. The Resident Relations Manager stated that diagnosis that might warrant a referral for a level II PASRR would include schizophrenia, anxiety, or depression. Staff #2 stated that if the resident had a terminal illness or dementia then the resident would not be referred for a level II PASRR. Staff #2 reviewed the PASRR dated July 2, 2024 for resident #28 and stated that this PASRR did not go up the stated but should have gone to the state for a level II PASRR referral. Staff # stated that there was a spreadsheet utilized to track PASRR submissions to see which residents had been referred, but stated that resident #28 did not show as having been submitted on the spreadsheet. Staff #2 stated that the expectation is that level II PASRR referrals are submitted, as warranted. Staff #2 stated that risk would be that the referral to the stated would not take place. An interview was conducted on April 8, 2025 at 11:56 AM with the Executive Director, staff #176. Staff #176 stated that her expectation is that a level I PASRR would be in place at admission or the day of admission. She stated if a level I had not been provided at admission, her expectation would be that it is completed by the Resident Relations Manager as soon as possible. Staff #176 stated that the expectation for a level II referral would be sent up as required and per facility policy. She stated that the risk for not sending a level II PASRR referral timely would include an incomplete medical record and an inability to provide a thorough plan of care for the resident. A review of the policy entitled PASRR, version 0920 with copyright date of 2020 revealed that a PASRR level I screening is used to determine whether the individual has a diagnosis or other presenting evidence that suggests the potential for serious mental illness (MI) or an intellectual disability (ID). The policy notes that if a resident is positive for either MI or ID, a level II PASRR referral must be submitted. The policy indicates that the exemptions for a level II PASRR referral are a diagnosis of dementia and a secondary diagnosis of MI or ID, a terminal illness with a life expectancy of less than 6 months or a resident who has been diagnosed with severe illness to include brain-stem dysfunction, progressed ALS, progressed Huntington's, in a comatose states or ventilator dependent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, resident and staff interviews, facility documentation and policy and procedures, the facility failed to ensure showers were provided for one resident (#36). Findings include: Resident was admitted on [DATE] with diagnoses of bipolar disorder, hemiplegia, and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side. Review of the resident's care plan report did not reveal any concern regarding personal hygiene or rejection of care. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was unable to complete the Brief Interview for Mental Status (BIMS) evaluation. The MDS assessment indicated that the resident did not exhibit rejection of care behavior during the assessment period. The assessment also revealed that the resident required substantial/maximal assistance for shower/bathing activities. A progress note dated February 28, 2025 documented that resident requested a shower. However, due to family visit, the resident declined shower after the family left. Further review of the resident's clinical record did not reveal any other progress note documentation regarding resident's refusal for showers/bath. A care plan revised March 12, 2025 revealed that the resident has functional self-care deficits and functional mobility limitations. Interventions included skin inspections during routine cares and per bath schedule. Review of the shower schedule for the section where resident #36 resides revealed that resident #36 had scheduled showers on Tuesdays and Fridays. The February 2025 task log for Bathing revealed that the resident was provided a shower on February 21 and that the resident refused on February 26, 2025. Further review of the Bathing task log revealed that the scheduled showers/bathing did not occur on the following dates: - February 25, 2025 - coded as NA indicating that resident not assigned bathing during shift Review of the March 2025 task log for Bathing revealed that resident refused showers on the following dates: - March 8 (Saturday) - March 9 (Sunday) - March 11 (scheduled-Tuesday) - March 13 (Thursday) - March 15 (Saturday) - March 16 (Sunday) - March 18 (scheduled-Tuesday) - March 25 (scheduled--Friday) Further review of the Bathing task log revealed that the scheduled showers/bathing did not occur on the following dates: - March 4, 2025 (Tuesday) - coded as NA indicating that resident not assigned bathing during shift - March 7, 2025 (Friday) - coded as NA indicating that resident not assigned bathing during shift - March 14 2025 (Friday) - coded as NA indicating that resident not assigned bathing during shift - March 21, 2025 (Friday) - coded as NA indicating that resident not assigned bathing during shift - March 28, 2025 (Friday) - coded as NA indicating that resident not assigned bathing during shift The April 2025 Bathing task log revealed that the following: - April 1, 2025 (Tuesday) - coded as NA indicating that resident not assigned bathing during shift - April 4, 2025 (Friday) - coded as NA indicating that resident not assigned bathing during shift During initial screening of residents conducted on April 6, 2025 at 2:01 p.m., resident #36 was observed looking unkempt. His hair appeared greasy with buildup on his scalp clearly visible. The resident's nails looked like he had been biting them. However, a portion of his nails were long with dirt embedded in them. An interview with resident #36 was conducted on April 6, 2025 at 2:01 p.m. Resident #36 stated that he was not getting showers. He said that he was scheduled for Friday and Tuesday showers. However, it has been almost a month since he got a shower due to staffing shortage. Resident #36 said that he bites his nails because the staff does not cut his nails. A follow-up observation was conducted on April 8, 2025 at 2:47 p.m. Resident #36 appeared cleaner than previous observation. The resident's hair looked clean and did not appear greasy. During a follow-up interview with resident #36 conducted on April 8, 2025 at 2:47 p.m., resident #36 stated that he was offered a received a shower today. A clarification interview with resident #36 was conducted on April 9, 2025 at 8:49 a.m. Resident #36 said that he only refused a shower once due to timing but had not refused since. Resident #36 stated that he was not offered a shower since that refusal and did not get offered a shower again until yesterday. Copies of shower sheets for resident #36 was requested on April 9, 2025 at 7:15 a.m. The facility provided one shower sheet dated April 8, 2025 indicating that the resident received a shower. Further review of the shower sheet revealed that it had a section for resident's signature when shower is refused. An interview with a Licensed Practical Nurse (LPN/staff #411) was conducted on April 9, 2025 at 8:51 a.m. Staff #411 stated that it is standard requirement that shower sheets are completed and that it is also used to document when a resident declines showers/baths. The LPN said that without the shower sheet then there is missing proof that a shower/bath was done. Staff #411 said that the impact of not having the shower sheets is that brings to question whether the service was provided. Additionally, this means that skin observation was not done and a lot of things that relates to overall health can be affected. The LPN noted that resident #36 tends to refuse showers/bath. However, she did not become aware until today that shower sheets were not being completed for this resident. During an interview with a Certified Nursing Assistant (CNA/staff #81) conducted on April 9, 2025 at 9:14 a.m., staff #81 stated that resident #36 does not look like he has been showering. The CNA noted that resident #36's hair always looks greasy. Staff #81 indicated that she had inquired when the residents in the secured unit get showers but the nurse did not know the shower schedule. The CNA said that shower sheets are normally kept at the nurse's station with the shower schedule. Staff #81 stated that showers are documented on the shower sheet and on the task log in the resident's electronic record. The CNA indicated that shower sheets are still completed for refusals and that the resident has to sign the sheet to verify that the care was refused. Staff #81 said that the importance of getting showers and documenting that it was done is so residents are clean and can have the skin check completed/documented. The CNA stated that the impact of not documenting showers/providing showers is that without the sheet, there is no documentation of when the shower/bath was given. The residents can end up smelly, wounds can get worst, and resident will not like not getting showers/bath. An interview with the Director of Nursing (DON/staff #90) was conducted on April 9, 2025 at 11:19 a.m. The DON stated that her expectation is that shower sheets are completed the day that shower is given. Staff #90 said that both the nurse and the CNA have to sign the shower sheet to document that the resident accepted the shower and that a skin sweep of the resident was completed. The DON also noted that the shower sheet should also be completed when a resident refuses shower/bath and that the resident should sign sheet for refusal. Staff #90 said that shower are important in general for hygiene, and infection prevention. It is also important that the showers are documented and shower sheet is completed since if it is not documented then it did not happen. The DON said that shower sheets are helpful with skin assessment. Additionally, if shower sheets are not completed/not available it leaves the impression that it was not done or the document was misplaced. Staff #90 said that the impact of not providing showers is that it increases the resident's risk for infection such as UTI (urinary tract infection) and impacts resident's well-being. The DON noted that residents just feel better after taking a shower. Review of the facility policy titled Bathing and Showers version 0822 revealed that the purpose of the procedure is to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. The policy stated to notify supervisor if the resident refuses bath/shower. The policy directed that the following information to be documented in the resident's record: - Date and time shower /bath were performed - Skin observations - If the resident refused The facility policy titled Personal Care: Activities of Daily Living (ADL), Supporting version 051123 indicated that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. The policy noted that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Furthermore, the policy noted that refusal and information are documented in the resident's clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff and resident interviews and review of policies and procedures, the facility failed to ensure physician orders, for hydration, were followed for resident #383. The deficient practice could result in fluid overload, electrolyte imbalance and a detrimental impact on kidney function. Findings include: Resident #383 was admitted on [DATE] with diagnosis including unspecified dementia, psychotic disturbance, anxiety, essential hypertension, constipation, chronic kidney disease, cognitive communication deficit, reduced mobility and need for assistance with personal care. A review of the admission MDS (minimum data set) dated December 21, 2022 revealed a BIMS (brief interview of mental status) score of indicating moderate cognitive impairment. A review of the care plan revealed that the resident is to be assisted with meals as needed and to anticipate needs. It further revealed that the resident's PO (per os-referring to oral intake) intake is to be monitored and documented. A review of the POC (plan of care documentation revealed that on December 17, 2022 from 8:00 AM to 12:00 PM there was no evidence that fluids had been offered or any documented refusals. On December 24, 2022 there was no documented fluid intake or noted refusals from 12:00 PM through December 25, 2022 at 9:19 PM. The POC further revealed multiple duplicate entries and that the resident took in 480 ml on December 24, 2022 and 240 ml on December 25, 2022. A review of the facility documentation revealed no documented evidence that CNA's (certified nursing assistants) had notified a nurse regarding the resident's fluid intake. An interview was conducted on April 9, 2025 at 9:00 AM with CNA (certified nursing assistant, staff #81). The CNA stated that there is generally a pitcher placed in the room for resident hydration. She stated that in addition to providing the hydration to the residents, staff would gauge if the resident was hydrated by checking pallor and if they had dry or chapped lips. If there was concern regarding dehydration then it would be reported to the nurse. Staff #81 stated that hydration would be documented in the resident's POC in PCC (point click care-electronic health platform), the CNA further stated that not ensuring a resident receives proper hydration or nutrition is a form of neglect. The CNA stated that the risk of dehydration could include a UTI (urinary tract infection or even death). An interview was conducted on April 9, 2025 at 9:24 AM with LPN (licensed practical nurse, staff #137). Staff #137 stated that for hydration, she would monitor if there were special orders in place. She stated that her expectation would be that CNA's notify her if they had not been able to get the resident to drink fluids. The LPN stated that the risk for resident not taking in sufficient fluids would include dehydration, skin impairment, organ disruption as half of your body weight is fluids. She further stated that her expectation is that CNA encourage fluid intake of non-caffeinated beverages. Staff #137 reviewed the POC documentation, reviewing the hydration and stated that the missed timeframes would be a concern. An interview was conducted on April 9, 2025 at 9:36 AM with the DON (director of nursing, staff #90). The DON stated that that there should be no blank areas on the POC and that for hydration anything under 1200 ml should be reported to the nurse. The DON reviewed the resident's record, to see if a concern had been reported to the nurse and she stated that it had not. The DON further stated that the risk to the resident of not documenting hydration properly could include dehydration, fluid overload, vital changes and constipation. She stated that by not reporting concerns regarding dehydration to the nurse, it could further include a delay in intervention for the resident. A review of the policy entitled Resident Hydration and Prevention of Dehydration dated January 1, 2024 revealed that nurse's aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. It further stipulates that intake will be documented in the medical record and that aides will report intake of less than 1200ml /day to nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure pain medications were administered following the physician-ordered parameter of two residents (#3 and #133). The deficient practice could result in residents' pain not adequately managed. Findings include: -Resident #3 was admitted on [DATE] with diagnoses of quadriplegia, chronic pain syndrome, constipation and opioid dependence. The care plan dated December 24, 2022 revealed that the resident had or was at risk for pain related to stage 4 pressure area. Interventions included to anticipate the resident's need for pain relief, respond as soon as possible to any complaint of pain and opioid analgesic to treat pain per physician orders. The physician order dated December 24, 2022 included for pain evaluation using pain scale of 0-10 every shift. The care plan dated December 28, 2022 included that the resident had pain and takes opioid/non-opioid and/or analgesic related to general discomfort. Interventions included to administer medications as ordered and anticipate the resident's need for pain relief and respond as soon as possible to any complaint of pain. A physician order dated May 30, 2023 revealed of acetaminophen (analgesic) 325 mg (milligram) give 2 tablets by mouth every 4 hours as needed for fever or pain level of 1-5. The quarterly nursing summary dated September 7, 2023 included that the resident was quadriplegic, and had frequent complaints of severe pain. Per the documentation the resident used pain medications which did not help with the pain and rarely took the pain away completely. Review of the clinical record revealed no evidence that the order for acetaminophen was changed since May 30, 2023. The order for acetaminophen was transcribed onto the MAR (medication administration record) from May through September 2023. Continued review of the MAR for September 2023 revealed that Acetaminophen was administered outside of the physician ordered parameters on the following dates: -September 4 for pain level of 6; -September 6 for pain level of 7; and, -September 14 for pain evel of 8. The progress note dated September 13, 2023 revealed that some medications administrations were missed; and that, the physician and NP was notified. There was no evidence found in the clinical record of any reason why acetaminophen was administered outside of the physician-ordered parameters on September 4, 6 and 14, 2023; and that, the physician was notified. -Resident #133 was admitted on [DATE] with diagnoses of acute osteomylitis, cellulitis of right lower limb, cutaneous abscess of the right foot and chronic pain syndrome. The care plan dated May 24, 2023 included that the resident was on an opiate medication related to chronic pain and was at risk for falls related to opiate use. Interventions included to administer medication as ordered and to anticipate and meet the resident's needs. The physician order dated May 24, 2023 included for acetaminophen 325 mg give 2 tablets by mouth every 6 hours as needed for pain 1-5. The encounter note dated September 4, 2023 included a diagnosis of chronic and well-controlled back pain. The order for acetaminophen was transcribed onto the MAR from May through September 2023. The MAR revealed that acetaminophen was documented as administered outside the physician ordered parameters on multiple dates in September 2023. There was no evidence found in the clinical record of any reason why acetaminophen was administered outside of the physician-ordered parameters on these dates; and that, the physician was notified. In an interview conducted with the licensed practical nurse (LPN/staff #68) on April 8, 2025 at 10:35 a.m., the LPN stated that pain assessment was done every shift (8 hours) regardless of whether the resident was prescribed with pain medication or not and during medication pass. She stated that she would normally ask the resident for presence of pain before giving the medications to the resident; and, during the interaction with the resident, she would check for signs of pain such as facial grimacing, rigidity, restlessness especially residents with dementia. The LPN also said that she will administer the pain medications based on the pain level the resident had reported and administer the medications following the physician ordered parameters. She stated that after an hour of the medication administration, she will check for effectiveness and would document it in the clinical record. During medication pass observation conducted with another LPN (staff #84) on April 8, 2025 at 11:46 a.m., the LPN stated that she would assess the residents for pain if they have not asked for PRN (as needed) pain medications thru out the day. She stated that when she assess residents for pain, she would document the resident pain scale in the clinical record. She stated that she would administer scheduled pain medications as ordered and would also document the resident's pain level in the clinical record. She said that for newly admitted residents, she would call the hospital and ask them to medicate the resident before discharge; and that, there were no medications available upon the resident's arrival at the facility, she would get a one time order from the PA (physician assistant) The LPN said that the medications ordered should arrive in the evening if the medication/s got ordered in by 1:00 p.m. or 2:00 p.m. Further, she stated that nurses can pull medications from an e-kit without an issue up to 2-3 times; but, an order should be in place for all medications. An interview with a certified nurse assistant (CNA/staff #70) was conducted on April 8, 2025 at 1:39 p.m. The CNA stated that he knows when a resident was in pain either because the residents tells him or he see facial grimaces or the resident was restless. He said that if a resident is in pain or complain of pain, he will report to the nurse who will then document in the clinical record and administer the resident's pain medications as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to assist one resident (#40) in obtaining routine dental services. The deficient practice could result in the delay of dental services. Findings include: Resident #40 was admitted to the facility on [DATE] with diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, Type 2 Diabetes Mellitus, major depressive disorder, anxiety disorder, and mild protein-calorie malnutrition. Review of comprehensive care plan dated December 5, 2023 revealed resident is at risk for oral/dental health problems related to cerebrovascular accident (CVA) with right side weakness. The interventions include consult with dietician and change if chewing/swallowing problems are noted, coordinate arrangements for dental care, transportation as needed as ordered and observe, monitor, document, report to medical doctor as needed signs and symptoms of oral, dental problems needing attention such as pain (gums, toothache, palate), abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, tongue (black, coated, inflamed, white, smooth), ulcers in mouth, and lesions. Review of record titled, Order Summary Report, revealed an active order dated February 1, 2024 for may be seen by Podiatrist, Dentist, Eye doctor, wound care consultant, Physiatrist and Audiologist of choice as needed. Review of Minimum Data Set (MDS) Section C - Cognitive Patterns dated November 14, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15.0 indicating cognitively intact. On April 6, 2025 at 11:31 AM, Resident #40 was observed with missing teeth. Resident stated that she has dentures but is not using it because the dentures do not fit her mouth. Resident stated that she had mentioned it to staff and nothing is being done. An interview was conducted on April 9, 2025 at 09:09 AM with a certified nursing assistant (CNA)/Staff #16. Staff stated that when she comes to work, she gets report from the previous shift, then she does walking rounds to make sure everyone is okay. She also passes out meal trays. She stated that if she has a resident that has dentures, she still cleans her resident's mouth with sponges, their diet would be puree or go by their preference. In addition, she will brush their dentures, apply Fixodent, help them put it in their mouth or they put their dentures themselves. She stated that she had residents that has told her that their dentures do not fit, and when that happens, she will inform the nurse or she will send the resident to see the social service because the social service is the one that can arrange them to see a dentist or to have their dentures fixed. Staff stated that she has seen dentist coming in their facility. An interview was conducted on April 9, 2025 at 09:17 AM with resident relation/Staff #2. Staff #2 stated that her role includes setting up appointments including dental appointments. She would also reach out to the resident or their family if they have the dental coverage. Regarding their residents residing in their long term care unit, Staff #2 stated that she never sets up a dental service appointment because the facility's long term care residents receive dental services as long as the resident is enrolled in the facility's contracted plan, and the facility's dental service provider visits their facility monthly. The dental service provider comes once a month and brings the list of residents who are enrolled in their plan. If the resident is not enrolled under the facility's dental service plan provider, she will reach out to the resident's family members on how to proceed with getting the resident's dental services. In addition, Staff #2 stated that the resident has to qualify for Medicare in order to enroll in the facility's dental service plan provider. An interview was conducted on April 9, 2025 at 09:49 AM with the director of nursing (DON)/Staff #90. The DON stated that regarding dental services for their long term care residents, she stated that if a resident is interested and based on their health insurance, they will set them up to see a dental provider, and the social services handles their dental appointments. The DON stated that resident #40 is not a Medicare beneficiary. Furthermore, during the interview, the DON is still looking at Resident #40's electronic medical record looking for dental services documentation. An interview was conducted on April 9, 2025 at 10:55 AM with a CNA/Staff #37. Staff #37 stated that she has work on all the units. She stated that resident #40 requires a Hoyer lift, is a total care, and stated that she has not taken care of the resident, she has not had the chance to assist the resident as she has been so busy today. An interview was conducted on April 9, 2025 at 11:00 AM with an LPN/Staff #85. Staff stated that resident #40 can feed herself and resident needs set up assistance. Staff stated that she is not aware of any issues related to resident's eating, resident eats about 75-100% of her meal, and resident is on regular diet with thin liquids. Staff stated that she does not normally work on this unit and she is a as needed staff. On April 9, 2025 at 11:05 AM Surveyor 49399 requested documents relating to resident #40's dental services, dental appointments, dental consult, or dental referrals. On April 9, 2025 at 11:18 AM, [NAME] President of Clinical Operations/Staff #59 stated none in record. An interview was conducted on April 9, 2025 at 11:56 AM with the DON/Staff #90. The DON stated that the process for providing dental services to their residents is if their residents want to be seen or scheduled to be seen by a dental provider, it goes through their social services, then the social services contacts the dental provider to see the resident in the facility or schedule for an outside dental service. The DON stated that for a routine dental service, the social services assists with appointments, transportation, and for reimbursement under the state plan if eligible. The DON stated that she cannot find any dental service record for Resident #40. Furthermore, the DON stated that based on their policy regarding dental services, dental services are offered as needed in situations such as tooth abscess, tooth cleaning, or tooth extraction. She stated that they have residents with dentures, and for residents with dentures situations such as if dentures don't fit or any damage, the DON stated that the facility would still help their residents set up dental appointments. The DON stated that regarding Resident #40's dentures not fitting, she stated that she will schedule a dental appointment for resident. She stated that she can't find any documents in resident #40's medical record for any dental appointments, including routine dental schedule. Review of facility's policy titled, Personal Care: Dental Services, in effect January 1, 2024 revealed routine and emergency dental services are available to meet the resident's oral health services in accordance with resident's assessment and plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, facility documentation and policy review, the facility failed to educate and offer an influenza vaccine that the resident was eligible to receive in accordance with the current Centers for Disease Control and Prevention (CDC) guidelines for one resident (#42) out of 5 reviewed for immunizations. The deficient practice posed the risk of the resident contracting influenza and its associated complications. Findings include: Resident #42 was admitted on [DATE] with diagnosis including Alzheimer's Disease with late onset, unspecified dementia, encephalopathy, Parkinson's disease, hypertension and reduced mobility. A review of the MDS (minimum data set) dated January 16, 2025 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 revealed no evidence that the resident received an influenza immunization, nor did the record reveal evidence that the resident received influenza education or signed a declination form. An interview was conducted on April 8, 2025 at 9:35 AM with the DON (director of nursing, staff #90). Staff #90 confirmed that she was responsible for the oversight of the vaccinations. She further stated that there was no evidence in the medical record that the influenza vaccine had been administered, that education was provided or that resident #42 had declined the vaccine. Staff #90 stated that the vaccination for resident #42, in 2024, had been missed. She stated that her expectation was that documentation for either immunization or declination should be in the medical record. Staff #90 stated that the risk would include the possibility of contracting the Flu. Staff #90 stated that she would be conducting an immunization clinic the following week and would be offering it to the resident to either accept or decline the vaccination. An interview was attempted on April 9, 20225 at 7:10 AM with resident #42. Resident #42 refused the interview. A review of the policy entitled Influenza Vaccine dated January 1, 2024 revealed that between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. The policy additionally stated that prior to vaccination that residents are provided information and education regarding the benefits and potential side effects of the influenza vaccine. The policy further stated that if a resident refuses the vaccine, it shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record.

Based on review of resident council minutes, resident and staff interviews, and policy and procedures, the facility was unable to demonstrate their response and rationale to grievances and recommendations voiced during resident council meetings. The facility census was 82. The deficient practice could result in residents' concerns, views, grievances or recommendations not being considered or acted upon by facility staff. Findings include: During a resident council interview conducted on April 8, 2025, residents stated that the facility does not act promptly upon grievances and does not consistently provide rationale or explanation if no response if given. The resident council indicated that the Administrator/Executive Director (staff #176) sometimes do not get to their grievances for two months. One of the trending issues still unresolved is the long call light wait times. Review of the resident council meeting minutes dated November 10, 2024, December 29, 2024, and February 23, 2025 revealed that there were grievances reported during the meeting. However, it did not identify what the grievances were. The minutes indicated that the grievances were forwarded to appropriate caring professionals or Care Relations. Review of the Grievances revealed a report dated November 10, 2024 from resident #3 stating that call light times are still long. He always seem to be waiting on help. Additionally, resident # 3 noted on his report that it is especially hard on him since he cannot do anything for himself. The form indicated that the resolution was reviewed with nursing and that it was satisfactory. However, it did not indicate when the issue was resolved. The form was signed off by staff on November 11, 2024. Review of the November 2024 Grievance log revealed a concern reported November 10, 2024 marked from various with the grievance described as call light wait times taking too long. The resolution date was marked as November 11, 2024. A Grievance Report dated November 11, 2024 marked from various residents revealed a complaint about long call light wait times. The report noted that light times are too long. Additionally, the report said that residents sometimes hear talking, laughter or witness phone use (of staff) when others are calling for assistance. The report documented that Social Services and nursing reviewed/completed response which indicated call light audits and education on wait times. The report did not clearly indicate when the issue was resolved. The form was signed off by staff on November 11, 2024. Review of the December 2024 Grievance log revealed a concern reported December 29, 2024 regarding long call light times. The resolution date was marked as December 30, 2024. A Grievance Report dated December 29, 2024 marked from multiple documented concerns about showers. The form stated the response was reviewed/completed by nursing which indicated shower audit, tracked every day, more communication with staff on completion. The form was signed off by staff on December 30, 2024. Review of the February 2025 Grievance log revealed a concern regarding multiple residents continually yelling and screaming. The resolution date was documented as February 23, 2025. A Grievance Report dated February 23, 2025 marked as from various documented concerns about screaming resident, loud noises, and profanity causing discomfort, lack of sleep, and anxiety with residents subjected to these instances. The form did not indicate which department addressed the issue. However, the response indicated was to encourage quiet hours, and found activities for specific residents. The report did not clearly indicate when the issue was resolved. The form was signed off by staff on February 23, 2025. However, review of resident council meeting minutes from November 2024 through April 2025 revealed that it did not document the status of previously identified grievance or indicate whether there was a grievance from previous meetings. No other evidence was provided that the facility had provided responses, actions and rationale regarding the residents' concerns. During an interview with the Director of Nursing (DON/staff #90) conducted on April 9, 2025 at 11:19 a.m., staff #90 stated that her expectation is that regardless of how a grievance is reported that a resolution is found and the issue resolved. The DON said that the grievance form is the same form used for issues addressed during resident council meetings. Staff #90 stated that her expectation is that the everything is documented pertaining to intervention, resolution status, Resident Relations signs off, and that complainant is apprised of the outcome. The DON admitted that she is not sure if the status of grievances addressed during resident council meetings is reflected or addressed on the meeting minutes. Staff #90 said that it is important to address grievances for the comfort and reassurance of residents. The DON noted that the impact of not addressing grievances is that the residents will continue to make the same complaints and feel that they are not heard. An interview with the Activity Manager (staff #4) was conducted on April 9, 2025 at 11:51 a.m. Staff #4 stated that during Resident Council Meetings, if there are grievances brought up, it is discussed offline after the meeting. The Activity Manager said that there is a one-on-one meeting to fill out the grievance form, if there are various complainant then the form will be marked as various for the name of resident. The form is then routed to Care Relations, Director of Nursing and the Executive Director. According to staff #4, at times there is a response and she logs in into the book. However, the Activity Manager noted that the form does not always come back to Activities. Staff #4 stated that although Activities is the liaison to Resident Council, Activities is not directly given update regarding grievances addressed during resident council meetings. The Activity Manager noted that if the resolution is not mentioned in the Resident Council Meeting minutes, then it is because it was not provided or Activities was not informed of a resolution. Staff #4 admitted that she had never asked why she is not informed about the status/resolution of grievances brought up during resident council meetings. The Activity Manager stated that the importance of addressing resident's grievances is for the benefit of the residents. Staff #4 admitted that she assumes that if she does not hear anything regarding the grievance that it is now good. The Activity Manager stated that from a personal perspective, the impact could be frustration if the issue is not resolved. An interview with the Executive Director (ED/staff #176) on April 9, 2025 at 12:18 p.m. The ED stated concerns brought up during resident council meetings are documented on a grievance form which is tracked. If the issue comes from a group, then it is discussed in resident council. Staff #176 said that it is important to address grievances since this is the residents' home and it is important for residents to have a voice. The ED stated hat that impact of not addressing grievances is that the facility will not be able to fix problems and it can lead to frustrated residents. Staff #176 stated that she is emailed a copy of the Resident Council Meeting minutes the day of the meeting and signs off by the end of the week. The grievance forms are completed same day and concerns addressed. The ED indicated that every situation is different so the resolution depends but they resolve grievances as quickly as possible. A facility policy titled Grievance Policy version 0818 revealed that facility will make a prompt effort to resolve grievances as evidenced by acknowledgement of grievance and activities working towards resolution of the grievance. Furthermore, the policy noted that Resident Relations Manager will report resolution to the resident and document updates on the Grievance Report and Resolution form. The policy indicated that the facility should communicate its decisions to the resident and/or family group.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview, facility documentation and policy review, the facility failed to protect the rights of five residents (#132, #23, #283, #187 and #483) to be free from physical abuse by another resident. The deficient practice could result in further resident abuse. Findings include: Regarding residents #132 and #12: -Resident #132 was admitted on [DATE] with diagnoses of vascular dementia, cerebral infarction, stage 3 CKD (chronic kidney disease) and antiphospholipid syndrome. The care plan with revision date of January 16, 2013 included that resident had impaired cognitive function and behavior problem of cursing at other residents and staff related to dementia, history of CVA (cerebrovascular accident) and TIA (transient ischemic attack) and recent BIMS ((Brief Interview for Mental Status) score. Interventions included to administer meds as ordered; monitor/document /report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status; anticipate and meet the resident's needs; remove resident from situation if issue arise; and, refer to psychiatric provider for consultation as ordered. -Resident #12 was admitted on [DATE] with diagnoses of type II diabetes, chronic respiratory failure, acute on chronic systolic CHF (congestive heart failure) and hemiplegia and hemiparesis. The care plan dated November 29, 2024 included tat the resident had have impaired cognitive function/dementia or impaired thought processes related to dementia. Interventions included to keep routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion; and, monitor/document /report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. The NP (nurse practitioner) note dated April 2, 2025 revealed that nursing staff reported irritability and refusal of cares for resident #12. Per the documentation, the resident was oriented x 3, had a cooperative behavior and had a BIMS of 15 indicating the resident had intact cognition. Assessment included dementia without behavioral/psychotic/mood disturbance and anxiety. Recommended nonpharmacological methods of relieving anxiety/depression included being sociable, being out of bed as much as tolerated, getting regular outside time as weather permits, music therapy, aromatherapy, and physical therapy as insurance allows. The alert charting dated April 8, 2025 revealed that resident refused his medications was irritable and reported that he was hurting. Per the documentation the resident last received opioid pain medication at 5:54 a.m. and had decliend to take Tylenol (analgesic) as a breakthrough medication. An observation conducted on April 8, 2025 at 10:51 a.m. revealed resident #12 wheeled himself in the common TV area where resident #132 was watching television. Resident #12 started yelling and jammed his wheelchair into the wheelchair of resident #132. The licensed practical nurse (LPN/staff #68) immediately approached resident #12, told him that he cannot do that, separated him from resident #132 and took resident #12 into his room. The LPN then called for the help of another staff to check on and take resident #132 to her room. As resident #12 was being wheeled back to his room, he was cussing and was very upset with resident #132 who was calm and continued to watch the TV. The LPN stated that she will report the incident to the administrator and the family of resident #132. An interview with the LPN (staff #68) was conducted on April 8, 2025 at 11:25 a.m. The LPN stated that she did not see resident #12 wheeled himself in the TV area but she saw resident #12 pushed the wheelchair of resident #132 forcefully and hit resident #132 at the right side of the back of her head. She stated that normally resident #132 was the aggressor in a resident-to-resident incident and was usually the one removed from the area of the incident. However, she said that in this incident, resident #132 was calm and resident #12 was the one removed from the area. it is [NAME] who is aggressive and is the one that is taken out of the area. The LPN further stated that when resident #12 was taken back to his room after the incident, resident #12 told his roommate that he had hit resident #132. In an observations conducted on April 8, 2025 at 1:11 p.m., resident #12 was sitting in his wheelchair and was just outside of his room door. He had an assigned 1:1 female staff sitting across him outside of his room in the hallway. Resident #12 told his assigned 1:1 female staff that he was sorry and he should have not hit resident #132. An interview was conducted on April 8, 2025 at 1:39 p.m. with a certified nurse assistant (CNA/staff #70) who stated that if he witnessed a resident-to-resident altercation it could be abuse; and, will separate the involved residents to ensure that they were safe. He said that he will then report the incident to the nurse or the administrator because there was a window of time that an allegation of abuse/incident had to be reported. He said that allegations of abuse had to be reported within 2 hours of the incident. In an interview with an LPN (staff #73) conducted on April 8, 2025 at 3:35 p.m., she stated that when she receives a report of an allegation of abuse or have witnessed abuse, she will ensure that the residents were safe and would separate the involved residents. She would then report the incident to who was also the abuse coordinator; and that, she could also report the incident herself if needed. Regarding resident #132, she stated that resident #132 required total assistance but can say want she wants/needs, cusses and use inappropriate words, and was non-ambulatory. The LPN stated that resident #132 can interact nicely with other residents depending on the resident's mood. Regarding resident #12, she stated that resident #12 was alert and oriented x 3 and did not have any behaviors. Regarding residents #483 and #533: Resident #483 was admitted on [DATE] with diagnoses of Cerenral Ischemia, Cervicalgia and Dysphagia. The care plan with a revision date of November 25, 2023, included a behavior problem, impaired safety awareness, resistance to care, and verbal behavior. The goal was that his safety would be maintained. A recent BIMS (Brief Interview for Mental Status) score was 15 (cognitively intact). A Daily Skilled Evaluation - dated September 23, 2023, revealed that Resident #483 was showing agitation with other residents and was upset due to other residents trying to get into his room and eat his snacks. Per the documentation, the staff were redirecting other residents away from him. A Progress Note dated September 30, 2023, revealed, Resident #483 was calm, quiet, and was sitting in front of the nursing station in the long-term care side of the facility. The documentation included that Resident #533 ran his wheelchair into Resident #483's wheelchair and that Resident #533 grabbed the eyeglasses off of Resident #483's face and threw the eyeglasses on the floor. Per documentation, Resident #483 complained of his left eye hurting. Resident #533 was admitted on [DATE], with a diagnosis of Alzheimer's Disease. The care plan with a revision date of October 6, 2013, included that the resident had a behavior problem, impaired cognitive function, physical behaviors, resistance to care, and verbal behavior. The goal was to demonstrate effective coping and not harm himself or others. Interventions were to minimize the potential for disruptive behaviors, including physical and verbal aggression. A recent BIMS (Brief Interview for Mental Status) score was 3 (severe impairment). An interview with CNA#14 was conducted on April 8, 2025, at 9:38 am. The CNA said that if a physical altercation occurs between two residents, the residents would be separated, and the CNA would try to keep them separated. The CNA also said she would immediately notify the nurse, and if the resident has an injury like a scratch, it would be documented by the nurse. She said if the wound nurse is in the building, she would be notified to evaluate for wound care, and the CNAs would document the incident. An interview with a Registered Nurse (LPN#68) conducted on April 8, 2025, at 09:59 am, the RN stated that if two residents were arguing, the staff were to intervene, separate them, and notify the social worker. The RN said that if the behavior continued and both residents were in the same room, one resident would be moved if necessary, and the incident would be documented in the progress notes. The RN said if there was an injury to one of the residents, the facility would notify the resident's family, the Executive Director of the facility, and the facility's medical director, would be notified and incident reports would be completed. During the interview with Director of Nursing (DON#90) conducted on April 8, 2025, at 11:15 am, the DON said that if there is a resident-to-resident altercation, the facility will ensure safety, separate the residents, notify the facility's Executive Director, complete skin assessments on the residents, and check for witnesses. She stated that skin assessments are going to be done to look for any changes from the weekly skin assessment. In an interview with the Executive Director ED conducted on April 8, 2025, at 11:42 am, the ED said that for a resident-to-resident altercation, the facility ensures that the residents involved were safe. She said the staff would intervene and separate the residents. Once the residents were safe, the staff would call her. She said that she would then review the incident and conduct an investigation. She stated she would report the incident to the State agency, ombudsman, Adult Protective Services, and local law enforcement. Regarding the incident between Resident # 483 and Resident #533, she stated she was not employed at the facility during this incident, and she was unsure if the 5-day report was stored or submitted to the State agency by the ED at the time of the incident. An attempt to conduct a telephone interview with RN#5, who witnessed the incident between Resident #483 and #533, was conducted on April 8, 2025. The attempt was unsuccessful because there was no answer. A message was left, but the RN did not return the call. -Regarding resident #283 and resident #187 -Resident #283 was admitted on [DATE] and discharged on June 18, 2024 with diagnosis including Alzheimer's disease, unspecified symptoms and signs involving cognitive function and awareness, hypertension, schizoaffective disorder, generalized anxiety disorder and urinary tract infection. A review of the quarterly MDS (minimum data set) dated November 30, 2023 revealed a BIMS (brief interview of mental status) score of 99, indicating that the interview was not successfully completed. The MDS further revealed that there were no noted indicators of psychosis, but it did reveal other behavioral symptoms one to three days a week, rejection of care and wandering one to three days a week. A review of the care plan revealed that the resident was on anti-psychotic medications for which side effects and / or toxic symptoms were being monitored. The care plan further revealed that that the resident had an alteration in neurological status due to dementia with interventions including medications and monitoring for side effects. Other focus areas in the care plan noted that the resident had communication problems due to Alzheimer's/ Dementia), impaired cognitive function -expressive aphasia, and behavior problem to include wandering and kissing other male residents. A review of the resident's skin assessment on February 3, 2024 and February 10, 2024 revealed that skin was intact and revealed no new skin related issues. -Resident #187 was admitted on [DATE] and discharged on April 1, 2024 with diagnosis including cerebral infarction, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and urinary tract infection. A review of the 5-day MDS revealed a BIMS score of 15 indicating that the resident was cognitively intact. The MDS further revealed no potential indicators of psychosis and no noted behaviors. A review of the care plan revealed focus areas including impaired cognitive function and impaired thought processes, and history of cerebral vascular accident. Care plan revealed documented interventions for all focus areas. A review of the 5-day investigation, dated January 16, 2024 revealed that on February 10, 2024 resident #283 was observed to be walking toward the sofa in one of the bistro areas where resident #187 was sitting. As resident #287 approached the sofa to sit down, resident #187 became upset and pushed her walker into resident #283. Resident #283 then grabbed the walker in an effort to stabilize herself. It was noted that the residents were separated and redirected to other areas of the facility. Bother residents were noted to have been monitored throughout the night to ensure no further altercations occurred. Two staff members were noted to have observed the incident, staff #60 and staff #61 . An interview was conducted on April 7, 2025 at 11:45 AM with CNA (certified nursing assistant, staff #123). The CNA stated that abuse can include many different kinds of behavior, including verbal, physical and neglect. The CNA stated that aggressive behavior towards others and also constitute abuse. Staff #123 stated that if abusive behavior is observed, the CNA would intervene, separate the parties, make sure they are safe and report the incident to someone in charge. Staff #123 stated that in an abuse case the facility has 2 hours to report the incident to the state. The CNA stated that abuse training is frequent and that staff #123 has had a couple of abuse trainings since November 2024. An interview was conducte4d on April 7, 2025 at 11:54 AM with LPN (licensed practical nurse, staff #137). Staff #137 stated that aggressive behavior can be abuse if directed toward someone. The LPN stated that all incidents of abuse have to be reported, regardless if there is an injury involved or not. The LPN stated that post incident and investigation, other interventions would be put in place to ensure the safety of the residents, which could include moving a resident to another room or even another hall. Staff #137 stated that the expectation for staff is to follow facility protocol if there is an incident of alleged abuse. A telephone call was placed on April 7, 2025 at 1:30 PM to RN (registered nurse, staff #61). The number given by the facility was disconnected. The RN is no longer employed by the facility. A telephone call was placed on April 7, 2025 at 1:32 PM to CNA, staff #60. A message was left on the voicemail. No return call was received. An interview was conducted on April 7, 2025 at 1:43 PM with the DON (director of nursing, staff#90). The DON stated that she did recall the incident, but not the specifics. Staff #90 stated that her expectation is that resident to resident abuse does not occur. She stated that at the time the facility unsubstantiated the abuse allegation as no physical injury or psychological harm had occured. She further stated that the facility had unsubstantiated the allegation, she saw no risk to the residents. The facility policy entitled Abuse version 1219 with a copyright date of 2017 revealed that the facility definition of abuse includes infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. The policy further states that abuse includes verbal abuse, sexual abuse, physical abuse, neglect, mental abuse, including abuse enabled through the use of technology and misappropriation of property. The policy states that these types of abuse or sources of abuse are not condoned by the facility and that the objective is to provide a safe environment for residents through preventative measure that protect every resident's right to be free from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy and procedure, the facility failed to ensure that 2 residents (#29 and #37) out of 18 sampled, that were newly admitted , had a level I pre-screening to determine if the residents may have had an MI (mental illness) or ID (intellectual disability). The deficient practice could result in residents not receiving the necessary specialized services required. Findings include: Resident #29 was admitted on [DATE] with diagnosis including autistic disorder, depression, schizoaffective disorder, and bipolar disorder. A review of the 5-day MDS (minimum data set) dated March 20, 2025 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident was cognitively intact. The MDS revealed a mood severity score of 01, indicating minimal impact. There were no noted potential indicators of psychosis or behaviors. The MDS further revealed that the resident was on antidepressants and anticonvulsant medications. A review of the care plan revealed that the resident had a focus area related to use of sedative/ hypnotic medications as well as antidepressant medications and that the resident required a special care unit related to autism and depression. The care plan also noted that the resident/ representative had expressed a desire for continued/ long-term care placement. An interview was conducted on April 8, 2025 at 8:22 AM with the Resident Relations Manager, staff #2. Staff #2 stated that a PASRR is received from the other facility or hospital upon admission or it would have to be conducted in-house, if not received at the time of admission. Staff #2 stated that if the PASRR received from another facility was incorrect then it would have to be corrected. Staff #2 further stated that if the resident remains in the facility after 30-days or if there are significant changes another PASRR would have to be completed. The Resident Relations Manager stated that diagnosis that might warrant a referral for a level II PASRR would include schizophrenia, anxiety, or depression. Staff #2 stated that if the resident had a terminal illness or dementia then the resident would not be referred for a level II PASRR. Staff #2 reviewed the PASRR received for resident #29 and stated that it was not legible. Staff #2 stated that she has not requested it from the facility, but stated that because it was unreadable she would have to call and re-request it; however, the resident was admitted on [DATE] and there was no evidence of a legible level I PASRR in place for resident #29. A follow-up interview was conducted on April 8, 2025 at 10:58 AM with staff #2. The Resident Relations Manager stated that that a legible level I PASRR should have been in the electronic health record for this resident. She stated that the risk included potentially not being able to care for the resident appropriately and determine if there is a need for a level II referral. An interview was conducted on April 8, 2025 at 11:56 AM with the Executive Director, staff #176. Staff #176 stated that her expectation is that a level I PASRR would be in place at admission or the day of admission. She stated if a level I had not been provided at admission, her expectation would be that it is completed by the Resident Relations Manager as soon as possible. Staff #176 stated that the expectation for a level II referral would be sent up as required and per facility policy. She stated that the risk for not sending a level II PASRR referral timely would include an incomplete medical record and an inability to provide a thorough plan of care for the resident. A review of the policy entitled PASRR, version 0920 with copyright date of 2020 revealed that a PASRR level I screening is used to determine whether the individual has a diagnosis or other presenting evidence that suggests the potential for serious mental illness (MI) or an intellectual disability (ID). The policy notes that if a resident is positive for either MI or ID, a level II PASRR referral must be submitted. The policy indicates that the exemptions for a level II PASRR referral are a diagnosis of dementia and a secondary diagnosis of MI or ID, a terminal illness with a life expectancy of less than 6 months or a resident who has been diagnosed with severe illness to include brain-stem dysfunction, progressed ALS, progressed Huntington's, in a comatose states or ventilator dependent. Related to resident #37- Resident #37 was admitted to the facility on [DATE] with diagnosis that included diabetes type 2, major depressive disorder, post traumatic stress disorder (PTSD), and acute kidney failure. A review of the admission MDS, dated [DATE] revealed resident #37 had a BIMS score of 15 which indicated she was cognitively intact. The same MDS also revealed resident #37 completed a PHQ-9 and scored a 00 which indicated she was no to minimal depression at the time of the assessment. A review of the care plan revealed the resident had a focus area related to the use of antidepressant medications and interventions included administering medications as ordered, educating the resident and family about the risk and benefits of anti-depressant medications, and to monitor for behaviors and side effects of medications. A review Resident #37's Electronic Health Record (EHR) reveled a Pre-admission Screening and Resident Review (PASRR) level I form was completed by the hospital, on February 21, 2025, prior to the resident being admitted to the facility. However, the form was not completed in it's entirely. Further review of resident #37's EHR did not reveal an updated PASRR being completed upon admission. On April 8, 2025 at 10:31 AM a request was made to see the most recent completed PASRR for resident #37. The facility submitted the same hospital completed PASRR which was dated February 21, 2025. An interview was conducted on April 8, 2025 at 10:42 AM with the Resident Relations Manager (staff #2). Staff #2 explained that if a resident comes into the facility from the hospital, the hospital social worker will complete the PASRR. Staff #2 was asked to look at Resident #37's PASRR and to verify that it was accurate. Staff #2 reviewed the PASRR and explained that the middle section of the PASRR Level I was empty because the resident was not expected to be in the facility more than 30 days. She also explained that if a resident ends up staying more than 30 days, then a second PASRR Level I would be submitted by the facility. When asked if a second PASRR was completed for Resident #37 due to her being in the facility longer than 30 days, Staff #2 reviewed the EHR and indicated that she did not see an updated PASRR Level I for resident #37 and did not know why it was not completed. When asked which staff is responsible for ensuring PASRRs are completed for residents, Staff #2 indicated that she was. An interview was conducted on April 9, 2025 at 8:07 AM with the Executive Director (ED/Staff #176). Staff #176 confirmed that if a resident is in the facility more than 30 days, than a PASRR will be completed by the facility. Staff #176 reviewed residnet #37's EHR and shared that an updated 30 day PASRR was not in the resident's chart. She did note that an updated PASSR was completed on April 8, 2025 which was after surveyor's interview with staff #2. When asked what the risk would be to the resident if they did not have an updated PASRR in their EHR, Staff #176 indicated that the resident's medical record would be incomplete. On April 9, 2025 at 8:17 AM, Staff #176 informed surveyor that the updated 30 day PASRR for resident #37 was missed because staff was new and did not recognize the information from the hospital was not complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, observations, and policy review, the facility failed to ensure that two residents (#190 and #79) received treatment and care in accordance with professional standards of practice by failing to follow physician's orders for resident care. Findings include: Related to resident #190- Resident #190 was admitted to the facility on [DATE] with diagnosis that included aphasia, acute osteomyelitis of the right ankle and foot, type 2 diabetes, history of strokes, and cognitive communication deficit. Resident #190 was admitted to the facility from the hospital after an Open Reduction and Internal Fixation (ORIF) of the right ankle fracture and with discharge orders which included to follow up with orthopedic surgery for the broken right foot and broken wrist. Page 11 of the hospital documents indicated the follow-up was to take place 1 week following discharge and (to) maintain (the) wound VAC until then. The same document also indicated that an orthopedic appointment was scheduled for Resident #190 for Wednesday, February 1, 2023 at 2:15 PM. A review of the quarterly Minimum Data Set (MDS), dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident was moderately cognitively impaired. A review of the facility's orders for resident #190 did not include an order for an orthopedic appointment. A review of an encounter note, signed by a Physician (Staff #65), in Resident #190's Electronic Medical Record (EHR) revealed a note dated January 24, 2023 indicated that the resident had a cast and will have a follow-up with orthopedics. A progress note, dated March 15, 2023, noted that Resident #190 had an orthopedic follow up on April 28, 2023 regarding a cast removal related to foot fracture. Further review of progress notes did not reveal any notes that indicated why the orthopedic appointments scheduled for February 1, 2023 and April 28, 2023 did not take place. Review of a Physician Communication Form, dated May 1, 2023 at 1:30 PM indicated resident #190 went to an appointment to follow up with the right ankle ORIF. It was noted that at this appointment the splint and sutures were removed and x-rays indicated the fracture was healed. An interview was conducted on April 9, 2025 with the Resident Relations Manager (staff #2) at 9:45 AM. Staff #2 share that she recently started managing resident appointments. Staff #2 also explained that when a resident has discharge orders from the hospital, the orders will say if a resident has an appointment or if a follow-up appointment is needed. Then the nurses doing the admission will see the discharge orders and will get orders from the facility's physician and then staff #2 will schedule the appointment. Staff #2 was not able to explain why resident #190's orthopedic appointment was not completed by stating I'm going to be honest, I don't know why it was not documented. An interview was conducted on April 9, 2025 at 10:29 AM with Licensed Practical Nurse (LPN/staff #84). Staff #84 explained that when a resident is admitted to the facility from the hospital, they will come with discharge orders. Those discharge orders, including orders for appointments, will be put into the facility's EHR system. When asked what the risks to the residents might be if the orders are not put into the system, staff #84 indicated that residents might get an infection if something is not addressed due to not having an order. An interview was conducted on April 9, 2025 at 10:31 AM with LPN/staff #85. Staff #85 explained that she will look at the orders for the incoming resident and then would communicate and verify the orders with the facility's doctor. Staff #85 indicated that orders could include both medication orders and/or follow-up appointment orders. Once the orders are verified, in-house, she would then enter them into the facility's EHR. Staff #85 explained that risks to the residents for not having an order depends on the order itself. It could potentially cause them harm because we are not managing them or doing follow-up appointments. An interview was conducted on April 9, 2025 at 10:42 AM with the Director of Nursing (DON/staff #90). Staff #90 confirmed that incoming residents will come into the facility with orders 100% of the time. Staff #90 explained that incoming orders will go to her and she then reviews them. Once she approves the orders, the medical records will put the orders into the EHR but does not make the orders active as this is all done prior to the resident actually arriving to the facility. Once the residents do arrive, the nurses will review the orders and then makes them active in the EHR and staff #90 also reviews the orders again. Staff #90 also shared that the in-house provider will also review the orders upon admission. Staff #90 acknowledged that orders also could include orders for follow-up appointments. Staff #90 was asked to review resident #190's EHR to determine if there was an order for a follow-up orthopedic appointment and she confirmed there was no order in the system. Staff #90 also added that she was not in her current position when this took place and that they now had a process in place so this did not happen. She also shared that the risk to residents for not ensuring orders were put into the system was that the residents could develop infection, delayed healing, and a delay in treatment. A review of the facility's policy titled Orders/Receiving/Transcribing: Medication and Treatment Orders indicated the policy was last revised on January 1, 2024. The policy statement is as follows: Orders for medications and treatments will be consistent with principles of safe and effective order writing. There was no language regarding non-pharmacological order processes. Regarding Resident #79: Resident #79 was admitted to the facility on [DATE], with diagnoses that included sepsis, cystitis, urinary tract infection, Parkinson's disease, and epileptic seizures. An annual MDS (minimum data set) assessment, dated January 9, 2025, revealed the resident had a brief interview for mental status (BIMS) score of 14, indicating the resident had intact cognition. A care plan dated February 3, 2022, revealed the resident has a potential fluid deficit, with a goal for the resident to be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. An intervention revealed to monitor vital signs as ordered/per protocol and record, and to notify the provider of significant abnormalities. A physician order dated January 27, 2020, indicated to assess vital signs per facility protocol. A physician order dated November 25, 2023, indicated to monitor vital signs every 4 hours for 24 hours. The order was discontinued December 7, 2023. Review of the physician orders revealed no evidence of an order specifying a frequency for monitoring vital signs (other than per facility protocol) for Resident #79 for the time frame of December 7, 2023 through January 24, 2025. There was no evidence of a change of condition monitoring order for Resident #78 for January 23, 2025. An Incident Report dated January 23, 2025, at 9:43 AM, revealed the resident fell in her bathroom while trying to transfer from her wheelchair to the toilet. Upon assessment, no lumps, bumps, abrasions, bruising, or cuts observed. The resident fell into a hurdler's position with her left leg bent back. The pain assessment section was blank, the mental status assessment was blank, and there was no evidence of vital signs assessed. The report indicated that the resident called 911 to be sent to the hospital. A progress note dated January 23, 2025, revealed Resident #79 fell in her bathroom while trying to transfer from her wheelchair to the toilet. Upon assessment, no lumps, bumps, abrasions, bruising, or cuts observed. The resident fell into a hurdler's position with her left leg bent back. The resident was sent to the hospital for diagnostics. The resident returned to the facility at 4:30 PM. There was no evidence of vital signs assessed. Review of the clinical record revealed no evidence of vital signs, other than pain, assessed on January 23, 2025. A progress note dated January 24, 2025, at 11:00 PM, revealed the resident's husband stated that Resident #79 was having difficulty breathing. The resident's oxygen saturation was assessed between 87-89%. The resident was put on 2.5 liters of oxygen via nasal cannula, and the resident's oxygen saturation improved to 94%. The provider was notified. The clinical record was reviewed, and there was no evidence that the resident's respirations, blood pressure, and temperature, were assessed on January 24, 2025. An interview was conducted on April 8, 2025, at 1:27 PM, with a Licensed Practical Nurse (LPN / Staff #10), who stated that if a resident falls, that staff assess the resident and give medical attention required at that time. The resident's family and medical provider are notified, as well as the DON. Staff #10 stated that a risk management report is completed, and daily charting is completed. Additionally, the resident is placed on change of condition monitoring, and that staff monitor the resident, where each shift staff must observe, assess, and document the status of the resident for 3 days. Staff #10 stated that for long term care residents, vital signs are assessed once per month, and as needed. Additionally, Staff #10 stated that regarding Resident #79, that the resident had a fall and was sent out to the hospital. The resident returned, and had an injury to her right leg, and never recovered beyond that. An interview was conducted on April 8, 2025, at 2:04 PM, with the vice president of clinical operations (Staff #59), who stated that vital signs per facility protocol means for staff to follow what is in the orders, and that there would be a physician order specifying the frequency to assess vital signs. An interview was conducted on April 9, 2025, at 8:31 AM, with the Director of Nursing (DON / Staff #90), who stated that if a resident falls, the nurse should assess right away, then assess vital signs and check the resident's mental status. The nurse would complete a head to toe assessment, and if an injury is noted, then the nurse would further assess that area. If a resident is complaining of pain, then the resident is sent out to the hospital to get imaging. Additionally, after a fall, appropriate notifications to the resident's family and physician are made. The DON stated that the nurse's assessment at the time of the fall is documented in a progress note or an incident report, but preferably both. The DON stated that a fall is considered a change of condition for a resident, and that staff may perform neuro-checks or more frequent monitoring depending on the situation and the orders. Additionally, the DON stated that she expects vital signs to be assessed at the time of the fall, and in the subsequent days after a fall if there is a clinical change noted in a resident. The interview continued with the DON, who stated that she recalled Resident #79, and that the resident had a fall on January 23, 2025, at around 9:30 AM. The resident requested to be evaluated in the hospital and was sent out. The resident returned the same day at approximately 4:30 PM. There was a fracture in the resident's leg that was missed in communication during report from the hospital that day. On either January 24 or January 25, the resident was sent back out to the hospital to get a brace for the resident's leg. The DON stated that the resident was transitioned to hospice care on January 25, 2025. The clinical record was reviewed together, and the DON stated that she could not find any vital sign assessments completed for the resident on the day of her fall. Additionally, on the following day, January 24, the DON stated that she could see record of only oxygen saturation assessment, and no other vital signs assessed. The DON stated that the resident was receiving oxygen therapy on January 24, 2025, and that this was not usual for the resident. The DON stated that this would not meet her expectation of monitoring vital signs after a fall, and that the impact on a resident could be that an underlying condition could be missed. Review of the facility policy titled Resident Safety: Accidents and Incidents - Investigating and Reporting, dated January 1, 2024, revealed that the following data shall be included on the incident report form: the condition of the person, including his/her vital signs. Review of the facility policy titled Assessments/Care Planning: Resident Examination and Assessment, dated January 1, 2024, revealed that orders, including vital signs, are to be completed in accordance with physician orders. Vital signs for each resident shall be obtained in accordance with the standard of care required, and based on the resident's condition. For residents with lower acuity, vital signs may be assessed less regularly, but in accordance with physician order. Review of the facility policy titled Falls/Falls Risk: Falls - Clinical Protocol, dated January 1, 2024, revealed that nurses shall assess and document / report the following: vital signs, change in condition or level of consciousness, and pain. Additionally, the staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications have been ruled out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff and resident interviews and review of policies and procedures, the facility failed to ensure that one resident (resident #21) was assessed for self administration for medications. The deficient practice could result in an adverse event for the resident. -Regarding Resident #21 Resident #21 was admitted on [DATE] with diagnosis including heart disease, atrial fibrillation, nonrheumatic mitral valve insufficiency, presence of a prosthetic heart valve, symptomatic epilepsy and epileptic syndromes with complex partial seizures, malignant neoplasm of the brain, repeated falls, insomnia, osteoporosis, anxiety disorder, and depression. A review of the quarterly MDS (minimum data set) dated November 26, 2024 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident was cognitively intact. A review of the physician orders revealed no evidence of an order to self-administer medications or orders for Pepto Bismol, Aspercream, Equate-nasal spray or Rescue Remedy. A review of the electronic health record revealed no evidence that the resident was assessed to self-administer medications. A review of the care plan revealed no evidence of authorized medication self-administration. An observation was conducted on April 6, 2025 at 10:48 AM in room [ROOM NUMBER]-1 for resident #21. The observation revealed the following medications on the bedside table: Aspercream containing Lidocaine HCL 4%, Equate -generic nasal spray, Rescue Remedy Relief Drops, Rescue Remedy Spray and Pepto Bismol. Providine Iodine was observed on top of the resident's dresser. An observation on April 6, 2025 at 10:52 AM revealed a response to a call light test, in which CNA (certified nursing assistant, staff #111) entered the room in response to the call light. It was observed that the CNA did not remove any of the medication on the bedside table or on the dresser. An observation on April 6, 2025 at 11:50 AM revealed that all the medications, except the providine iodine solution, previously identified were still at the bedside table. An interview was conducted on April 6, 2025 at 11:15 AM with RN (registered nurse, staff #10). Staff #10 stated that medications are prescription based as well as over the counter. Staff #10 stated that lotions can be medications, and if they are they would not be allowed at bedside. Staff #10 stated that if medications are found at bedside, they have to be removed. Staff #10 stated that the risk for medications at bedside is that the resident could open and use them without the doctor's knowledge and that there might be a potential for allergies. An interview was conducted on April 6, 2025 at 11:52 AM with CNA (certified nursing assistant, staff #111). Staff #111 stated that a medication is anything that is prescribed by a doctor and given to a patient by a nurse. Staff #111 further stated that medications could also be over the counter and could include oral, intravenous or topical. Staff #111 stated that residents are not allowed to have medications at bedside. If medications are found at bedside, they have to be reported to the nurse, who would then remove the medication. Staff #111 stated that she is not aware of any resident have medications at bedside. Staff #111 stated that she checks for medications anytime she in the resident's rooms. She stated that the risk for medications at bedside could include overdose. An interview was conducted on April 6, 2025 at 12:06 PM with staff #10, RN and staff #111, CNA. It was shared with staff that resident #21 had medications at bedside. Staff #111 went to resident's room and removed the medications on the bedside table. The RN identified the medications as Aspercreme, Pepto Bismol Ultra-24 caplets, Barrier Cream, Rescue Remedy drops and nasal spray. Staff #10 stated that she had placed the providine iodine solution into the resident's dresser when she saw it about an hour ago, but had not seen the other medications on the bedside table. The RN stated that the risk to the resident includes that medical staff need to know what medications are being taken and that they are not overused. An interview was conducted on April 7, 2025 at 12:58 PM with the DON (director of nursing, staff #90). Staff #90 stated that in order for a resident to have medications at bedside an assessment would have to be done, self-administration would be care planned and the resident would receive a lock box or drawer where they could store the medication. Staff #90 stated that hospice had given permission for resident #21to have some of his medications at bedside. Staff #90 stated that she knew the permissions from hospice were verbal and after reviewing the record, stated that there was no evidence that the resident had been assessed for medication self-administration. The DON stated that there should be documentation in the file that the resident had been assessed to allow for medications at bedside. She stated that the risk could include a roommate potentially ingesting the medication, patients coming into the room and taking the medication, improper medication management, losing a medication and or the risk for potential medication interactions. A review of the policy entitled Self-Administration of Medications with an effective date of January 1, 2024 revealed that residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy further revealed that if it is deemed safe and appropriate, then this is documented in both the medical record and care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, facility documentation and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving appropriate care and treatment that they need. Findings include: The PBJ (Payroll-Based Journal) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing for all four quarters in 2024 and, the 1st quarter of 2025. Per the report, submitted weekedng staffing data was excessively low. The facility assessment reviewed on February 4, 2025 revealed that the facility was licensed to provide care for 112 residents, had an average daily census of 60-75 with 20-30+ of this census being short term stays, and, had an average number of admission and discharges of 25-35 per month Staffing plan included the following: -full time Director of Nursing (DON); -At least 1 registered nurse (RN) per 24 hour period; -Up to 6 certified nursing assistant (CNAs) for the AM shift (6:00 a.m. to 2:00 p.m.); -Up to 6 CNAs for evening shift (2:00 p.m. to 10:00 p.m.); and -Up to 4 CNAs for the NOC (night) shift (10:00 p.m. to 6:00 a.m.) The facility's staffing schedule were documented as follows: -3 shifts for nurses and CNAs for the rehab and long term care unit: AM shift (6:00 a.m. to 2:00 p.m.); evening shift (2:00 p.m. to 10:00 p.m.) and NOC shift (10:00 p.m. to 6:00 a.m.); and, -2 shifts for nurses and CNAs for the behavior unit: AM shift (6:00 a.m. to 6:00 p.m.) and PM shift (6:00 p.m. to 6:00 a.m.) The rehab and the long term care (LTC-also known as the east unit) were divided into front, middle and back. The daily staffing assignment with signatures for April 6, 2025 revealed the following information: -Two CNAs were scheduled in the rehab hall but there was only 1 CNA who signed in for the AM shift; -Three CNAs were scheduled in the LTC/East hall but there was only 2 CNAs who signed in for the AM shift; -One CNA was scheduled and signed in for the first shift in the Behavior unit; -Two CNAs on each hall (rehab and LTC/East) were scheduled for the evening shift. There was only 1 CNA who signed in -Two CNAs on each hall (rehab and LTC/East) were scheduled for the NOC shift. None of these CNAs documented that they signed in for the NOC shift in the rehab and LTC/East hall; -One CNA was scheduled for the second shift in the Behavior unit. The scheduled CNA did not document that she signed in for the 2nd shift in the Behavior unit. During resident interviews conducted during the initial pool on April 6, 2025, there were multiple with an alert and oriented residents who reported having to wait a long time before receiving assistance they needed. One male resident reported that he had to wait for up to an hour a couple of times a week before he receives help; and, there was no specific day or time of day that the issue was more prevalent. A female resident reported that she had to wait for 30-45 minutes for assistance; and that, staff were supposed to change her at 5:00 a.m. this morning but the staff were not able to. She stated that she ended up being wet all over including her bed sheets. Another female resident reported that she had to wait an hour to get the assistance she needed; and that's the reason why she requested for a bedside commode so she would not soil or wet herself. A female resident also reported that the facility was short-staffed during weekends. An observation of room tray delivery for the rehab unit, middle was conducted on April 6, 2025 at 12:00 p.m. The food cart containing the room tray meals arrived in the hallway at 12:10 p.m. There were two nurses and one CNA in the rehab unit and they were delivering the meal trays for the rehab unit front section. There were no staff delivering the meal trays for the resident rooms located in the rehab middle hall. At 12:27 p.m., a female staff took the food cart from the rehab middle hall, wheeled it to rehab back hall and started delivering the meal trays for residents in that hall. At 12:36 p.m., the same female staff took the food cart from the rehab back hall, wheeled the cart back to rehab middle hall and started delivering the meal trays into the resident rooms in rehab middle unit (approximately 26 minutes after the food cart was first delivered to rehab middle hall). In an interview with an alert and oriented male resident conducted on April 6, 2025 at 12:19 p.m., he stated that sometimes staff takes a long time to respond the room; and that. the facility was short-staff on yesterday (April 5, 2025). He stated that yesterday (April 5, 2025) staff was doing a bed change and moved him out of bed. He said that it took a long time for staff to change the bed; and, by the time he was moved back to his bed, the mattress was deflated. He further stated he was uncomfortable because it took the staff a long time again to fill the mattress back up. An interview was conducted on April 6, 2025 at 1:00 p.m. with a with a female resident who stated that she was placed on isolation because of an infection. She stated she did not have any problem being on isolation because she understood why. However, she stated that she felt very isolated because of low staffing, she had limited human interaction. She further stated that there was no one available staff to check on her or check on her needs frequently. During a family interview conducted on April 6, 2025 at 1: 33 p.m., the family member stated he had observed that there was really low staffing on the weekend and this resulted in delay in provision of care to his family who was a resident at the facility. In an interview with a licensed practical nurse (LPN/staff #68) conducted on April 8, 2025 at 7:07 a.m., she stated that there were 5 medications carts: 2 carts each in the rehab and LTC/east hall and 1 cart in the behavioral unit. In another interview with the LPN (staff #68) conducted on April 8, 2025 at 10:35 a.m., she stated that staffing/staffing ratios were based on the facility census; and, staffing/staffing ratios were the same for weekdays and the weekends. She stated that the typical staffing ratios were as follows: -Day and Evening shift in Rehab and East unit: One nurse for each cart in the rehab and east unit (total of 4); and, 2-3 CNAs each in the rehab and east unit (total of 4-6); -Day shift in the Behavior unit: One nurse and one CNA; and, -Night shift in Rehab, East and Behavior unit: One nurse for each unit (total of 3) and one CNA for each unit (total of 3). An interview with a CNA (staff #70) conducted on April 8, 2025 at 1:39 p.m. the CNA stated that The facility had shortage of staff; and that, the facility have incentives to ensure that the facility/unit was adequately staffed. He stated that regular staffing pattern includes usually 2 CNAs in the rehab, 2 CNAs in the east unit and 1 CNA in the BU (behavior unit) during day shift. He said at night, there is 1 CNA in the rehab unit, 1 CNA in the east unit and 1 CNA in the BU. He stated that this was the normal staffing ratio even in the weekend. He said that staff help each other so if one unit was short of a CNA, the unit that was not busy usually will help. During an interview with another LPN (staff #73) conducted on April 8, 2025 at 3:35 p.m., the LPN stated that on the avarage, there was 1 nurse on each cart in the rehab unit, east (LTC) unit and BU on both the day and night shift. She stated that there were at least 3 CNAs for the day shift in the rehab and LTC unit; and, 1 CNA in BU. She stated that the night shift, there is 2 CNAs in the rehab and LTC unit and 1 CNA in BU. She stated that this was the same staffing ratio for the weekends. The LPN stated that residents had complained of not having enough staff; and that, staff were not fast enough to come and assist when residents press the call light on. She stated that this staffing ratio had always been the same. She said that sometimes she has residents that were a 2-person assist or needed more time to assist them, so probably could use more staff. In a phone interview with a staffing coordinator (staff #93) conducted on April 9, 2025 at 10:40 a.m., she stated that the typical staffing pattern for weekdays and weekends were as follows: a) AM shift (6:00 a.m.-2:00 p.m.) in the rehab/east units: 3 CNAs on each unit, 2 nurses (RN or LPN) on each unit b) PM shift (2:00 p.m.-10:00 p.m.): 2 nurses on each unit and 3 CNAs on each unit c) NOC shift (10:00 p.m.-6:00 a.m.: 1 nurse for both the rehab and east units and 2 CNAs on both units She stated that the behavioral unit (BU) had a 12 hour shift. She said that the BU had 1 nurse and 1 CNA on both shifts and 1 [NAME] staff who was not a CNA and does not do CNA work. She stated that the [NAME] staff pass out ice water, answer call light and does not provide direct care. The staffing coordinator further stated that the facility had instances during the winter months when they had low staffing which mean that there were not enough CNA to work on the rehab/east unit. She stated that full staff meant there was 3 CNAs for the rehab/east unit; and that, not enough staffing meant that there were less than 3 CNAs on shift for the rehab/east unit. She said that the BU always had a full staff meaning there was always one CNA in the unit for both shifts. In a later interview with the staffing coordinator (staff #93) conducted on April 9, 2025 at 10:53 a.m., she stated that she was not involved with the staffing data submission to CMS. She said that the facility's corporate office was in-charge or involved with this. the facility had adequate staff to provide care to the residents. During an interview with the administrator conducted on April 9, 2025 at 11:27 a.m., she stated that the data that was submitted to CMS for the quarterly PBJ staffing report is directly taken from the data n their payroll software. She said that the payroll software have the data on who actually worked and the actual hours worked by staff for a specific date and time. She stated that she was working with their corporate to figure out why the facility was triggering for excessively low staffing on weekends because she believed that the facility had adequate staffing on the weekend. Regarding Resident Council: Review of the resident council meeting minutes dated November 10, 2024 revealed that there were grievances reported during the meeting. However, it did not identify what the grievances were. The minutes indicated that the grievances were forwarded to appropriate caring professionals or Care Relations. A cross reference with the Grievance log revealed a Grievance Report dated November 11, 2024 marked from various residents revealed a complaint about long call light wait times. The report noted that light times are too long. Review of the resident council meeting minutes dated December 29, 2024, and February 23, 2025 revealed that there were grievances reported during the meeting. A cross reference with the Grievance log revealed a Grievance Report dated December 29, 2024 marked from multiple documented concerns about showers. During a Resident Council interview conducted on April 8, 2025 at 1:02 p.m., residents present indicated that there are not enough staff members to take care of the resident's needs. The residents indicated that staffing impacts call light wait times. Further stating that the call light response time is so long that some residents forget what they called for. A male resident stated that at times it takes 45 minutes before a staff responds to call light. Two other male residents stated that staff will pop in and say that they will come back but never return. The residents commented that staff forgets about them. Furthermore, the residents stated that around mealtimes, staff do not respond to call lights because they are passing out trays or assisting with feeding residents. An interview with a Licensed Practical Nurse (LPN/staff #411) was conducted on April 9, 2025 at 8:51 a.m. Staff #411 stated that there is only one CNA (Certified Nursing Assistant) assigned in the secured unit. The LPN said that there is normally about 8-10 residents in the unit. Staff #411 stated that when the assigned CNA calls off, then the CNA from another unit covers. The LPN said that the CNA is pretty busy and that the ratio of staff-to-resident is tough. Staff #411 stated that patient needs are still met but in the secured unit, it is stressful for staff knowing that they only have one CNA. Staff #411 said that the unit has 2 residents that are 2-person assist and this means that the [NAME] or activities staff has to stay with the rest of the residents when those residents require assistance. The LPN noted that the [NAME] cannot provide any care for residents/touch residents. All they can do is provide beverages and do activities with the residents so if another resident requires care while the CNA and nurse is already assisting a 2-person assist resident, the other residents have to wait. An interview with a Certified Nursing Assistant (CNA/staff #81) was conducted on April 9, 2025 at 9:14 a.m. Staff #81 stated that there is normally 2 CNAs assigned for 15-20 residents. The CNA stated that there is not enough staffing to take care of the residents' needs. Staff #81 said that if they are assisting a Hoyer-lift resident, then the wait time for other residents can be at least 20-minutes. The CNA indicated that insufficient staff impacts patient care. Staff #81 said that staffing issues means long call light wait time and services such as showers gets cut off. The CNA noted that residents have reported not getting showers. Staff #81 reported that upon arriving for shift, residents are found soiled and have not been changed. Additionally, some residents get tired of waiting for staff to assist them so the resident is forced to get up by themselves to use the toilet or reach for bedside urinal and end up falling since they require assistance. The CNA indicated that staff normally gets a text on weekends to solicit for volunteer to work the shift. Staff #81 stated that weekend staffing is bad and that it has been months since staffing started getting worst. The CNA said that most nurses at the facility are travel nurse and the CNAs are registry. During an interview with a Licensed Practical Nurse (LPN/staff 85) conducted on April 9, 2025 at 10:14 a.m., staff #85 stated that there is usually 2 CNAs on shift for 26 residents. The LPN said that that number makes timelines for care really tight. Staff #85 said that she helps when the CNAs are in a bind and answers call lights. The LPN said that for their hallway, 6 out of 26 residents are 2-person assists and 4 are Hoyer-lift transfer. Due to this, depending on the team and management it can be tough. On a good day it is doable, on a bad day it can be really tough. An interview with the Director of Nursing (DON/staff #90) was conducted on April 9, 2025 at 11:19 p.m. The DON stated that to ensure sufficient staffing the facility has an assessment protocol that they follow. However, staff #90 noted that unfortunately healthcare staffing is an issue everywhere. The DON admitted that people have voiced concerns about staffing. These are from both residents and burned out staff. Staff #90 stated that sufficient staffing is important since low staffing burn out staff and this can increase to falls, and longer call wait times. The DON denied that staffing impacts care or services provided at the facility. However, she conceded that it can impact timing and documentation. Staff #90 commented that low staffing impacts documentation since they provide the care but sometimes it is not reflecting on documentation, an example being with shower sheets. The main issue is with documentation. Review of the Facility Assessment indicated the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. The assessment noted that the facility is licensed to provide care for 112 residents with the average census ranging from 60-75 residents. The Staffing Plan portion of the assessment revealed the following: - Licensed Nurses: at least one RN (Registered Nurse) per 24-hour period - Direct Care staff: up to 6 CNAs for days and evening shift and up to 4 CNAs for NOC (night) shift

Based on resident and staff interviews, facility documentation and policy review, the facility failed to ensure ensure staffing information submitted was accurate. The deficient practice could result in residents receiving inadequate care due to potential lack of staffing. Findings include: The PBJ (Payroll-Based Journal) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing for all four quarters in 2024 and, the 1st quarter of 2025. Per the report, submitted weekedng staffing data was excessively low. The facility assessment reviewed on February 4, 2025 revealed that the facility was licensed to provide care for 112 residents, had an average daily census of 60-75 with 20-30+ of this census being short term stays, and, had an average number of admission and discharges of 25-35 per month Staffing plan included the following: -full time Director of Nursing (DON); -At least 1 registered nurse (RN) per 24 hour period; -Up to 6 certified nursing assistant (CNAs) for the AM shift (6:00 a.m. to 2:00 p.m.); -Up to 6 CNAs for evening shift (2:00 p.m. to 10:00 p.m.); and -Up to 4 CNAs for the NOC (night) shift (10:00 p.m. to 6:00 a.m.) The facility's staffing schedule were documented as follows: -3 shifts for nurses and CNAs for the rehab and long term care unit: AM shift (6:00 a.m. to 2:00 p.m.); evening shift (2:00 p.m. to 10:00 p.m.) and NOC shift (10:00 p.m. to 6:00 a.m.); and, -2 shifts for nurses and CNAs for the behavior unit: AM shift (6:00 a.m. to 6:00 p.m.) and PM shift (6:00 p.m. to 6:00 a.m.) The rehab and the long term care (LTC-also known as the east unit) were divided into front, middle and back. During resident interviews conducted during the initial pool on April 6, 2025, there were multiple with an alert and oriented residents who reported having to wait a long time before receiving assistance they needed. One male resident reported that he had to wait for up to an hour a couple of times a week before he receives help; and, there was no specific day or time of day that the issue was more prevalent. A female resident reported that she had to wait for 30-45 minutes for assistance; and that, staff were supposed to change her at 5:00 a.m. this morning but the staff were not able to. She stated that she ended up being wet all over including her bed sheets. Another female resident reported that she had to wait an hour to get the assistance she needed; and that's the reason why she requested for a bedside commode so she would not soil or wet herself. A female resident also reported that the facility was short-staffed during weekends. An observation of room tray delivery for the rehab unit, middle was conducted on April 6, 2025 at 12:00 p.m. The food cart containing the room tray meals arrived in the hallway at 12:10 p.m. There were two nurses and one CNA in the rehab unit and they were delivering the meal trays for the rehab unit front section. There were no staff delivering the meal trays for the resident rooms located in the rehab middle hall. At 12:27 p.m., a female staff took the food cart from the rehab middle hall, wheeled it to rehab back hall and started delivering the meal trays for residents in that hall. At 12:36 p.m., the same female staff took the food cart from the rehab back hall, wheeled the cart back to rehab middle hall and started delivering the meal trays into the resident rooms in rehab middle unit (approximately 26 minutes after the food cart was first delivered to rehab middle hall). During a family interview conducted on April 6, 2025 at 1: 33 p.m., the family member stated he had observed that there was really low staffing on the weekend and this resulted in delay in provision of care to his family who was a resident at the facility. In an interview with the licensed practical nurse (LPN/staff #68) conducted on April 8, 2025 at 10:35 a.m., she stated that staffing/staffing ratios were based on the facility census; and, staffing/staffing ratios were the same for weekdays and the weekends. She stated that the typical staffing ratios were as follows: -Day and Evening shift in Rehab and East unit: One nurse for each cart in the rehab and east unit (total of 4); and, 2-3 CNAs each in the rehab and east unit (total of 4-6); -Day shift in the Behavior unit: One nurse and one CNA; and, -Night shift in Rehab, East and Behavior unit: One nurse for each unit (total of 3) and one CNA for each unit (total of 3). An interview with a CNA (staff #70) conducted on April 8, 2025 at 1:39 p.m. the CNA stated that the facility had shortage of staff; and that, regular staffing pattern includes usually 2 CNAs in the rehab, 2 CNAs in the east unit and 1 CNA in the BU (behavior unit) during day shift. He said at night, there was 1 CNA in the rehab unit, 1 CNA in the east unit and 1 CNA in the BU. He stated that this was the normal staffing ratio even in the weekend. He said that staff help each other so if one unit was short of a CNA, the unit that was not busy usually will help. During an interview with another LPN (staff #73) conducted on April 8, 2025 at 3:35 p.m., the LPN stated that on the avarage, there was 1 nurse on each cart in the rehab unit, east (LTC) unit and BU on both the day and night shift. She stated that there were at least 3 CNAs for the day shift in the rehab and LTC unit; and, 1 CNA in BU. She stated that the night shift, there is 2 CNAs in the rehab and LTC unit and 1 CNA in BU. She stated that this was the same staffing ratio for the weekends. The LPN stated that residents had complained of not having enough staff; and that, staff were not fast enough to come and assist when residents press the call light on. She stated that this staffing ratio had always been the same. She said that sometimes she has residents that were a 2-person assist or needed more time to assist them, so probably could use more staff. In a phone interview with a staffing coordinator (staff #93) conducted on April 9, 2025 at 10:40 a.m., she stated that the facility had instances during the winter months when they had low staffing which mean that there were not enough CNA to work on the rehab/east unit. She stated that full staff meant there was 3 CNAs for the rehab/east unit; and that, not enough staffing meant that there were less than 3 CNAs on shift for the rehab/east unit. She said that the BU always had a full staff meaning there was always one CNA in the unit for both shifts. In a later interview with the staffing coordinator (staff #93) conducted on April 9, 2025 at 10:53 a.m., she stated that she was not involved with the staffing data submission to CMS. She said that the facility's corporate office was in-charge or involved with this. the facility had adequate staff to provide care to the residents. During an interview with the administrator conducted on April 9, 2025 at 11:27 a.m., she stated that the data that was submitted to CMS for the quarterly PBJ staffing report is directly taken from the data n their payroll software. She said that the payroll software have the data on who actually worked and the actual hours worked by staff for a specific date and time. She stated that she was working with their corporate to figure out why the facility was triggering for excessively low staffing on weekends because she believed that the facility had adequate staffing on the weekend. An interview with the Vice-President (VP) of Clinical Operations (staff #59) conducted on April 9, 2025 at 12:00 a.m., she stated that she does not know why the facility triggerred for excessively low weekend staffing. She stated that when the data was submitted there was no notice or any report that the facility received to let them know that excessive low staffing triggered. She said that the PBJ Final Validation Reports received by the facility after each submission did not indicate any errors in the data submitted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and review of policies, the facility failed to ensure one resident (#4), was free from significant medication errors, related to the resident receiving the wrong dosage of Parkinson's disease medication. The deficient practice could result in complications and adverse medication side effects. Findings include: Resident #500 was admitted to the facility for respite care on June 18, 2024 with diagnoses that included Parkinson's disease, anxiety disorder, and depression. Review of the order summary revealed a prescription for Carbidopa-Levodopa tablet 25-100MG (milligrams) with an order date of June 17, 2024 which indicated to give 1 tablet by mouth four times a day for Parkinson's Disease. Additionally, the Hospice Admitting Orders dated June 17, 2024 indicated an order for Carbidopa-Levodopa 25-100mg QID (four times a day) for Parkinson's disease. A care plan identifying that the resident is on hospice, initiated June 18, 2024 included an intervention that directed to medicate as ordered to ensure comfort. A progress note dated June 19, 2024 documented that the resident was found kneeling on the floor by his bed. During assessment, a small skin scrape on the left forearm was noted. Review of the Medication Administration Record dated June 2024 revealed the following orders that were current from June 18-21, 2024: -Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG (milligram), give 1 tablet by mouth one time a day for Parkinson's disease. -Carbidopa-Levodopa Tablet 25-100 MG (milligram), give 1 tablet by mouth four times a day for Parkinson's disease. -Carbidopa-Levodopa Tablet 25-100 MG (milligram), give 1 tablet by mouth as needed for Parkinson's disease qdaily. Review of nursing notes for June 2024 revealed that medications administered: - June 18: Carbidopa-Levodopa Tablet 25-100 MG, 1 tablet by mouth. - June 18: Carbidopa-Levodopa Tablet 25-100 MG, 1 tablet by mouth - effective. - June 19: Carbidopa-Levodopa Tablet 25-100 MG, 1 tablet by mouth, resident stated he felt like needed another. - June 20: Carbidopa-Levodopa Tablet 25-100 MG. 1 tablet by mouth, per patient's request for tremors and pain. - June 20: Carbidopa-Levodopa Tablet 25-100 MG, 1 tablet by mouth - effective. - June 21: Carbidopa-Levodopa Tablet 25-100 MG, 1 tablet by mouth. - June 21: Carbidopa-Levodopa Tablet 25-100 MG, 1 tablet - effective. Further review of the resident's progress notes revealed a nursing note dated June 21, 2024 which documented that the resident is at the facility for respite care. The note indicated that per discharge orders from hospice, resident was to get 1 tablet of Sinemet (Carbidopa/Levodopa). The note stated that the resident's family informed the facility staff that the resident's prescribed order is two tablets every four hours instead of 1 tablet. The note documented that the nursing staff called hospice and a hospice nurse came in and did a medication reconciliation to correct the order. Another progress note dated June 21, 2024 documented that the facility received a verbal order from hospice to give 2 Carva Dopa 25-100 QID. The note indicated that the original order from hospice was for 1 tablet QID. The note also stated that a copy of hospice orders and facility orders were given to the resident's family as requested and that the DON (Director of Nursing) was aware. In another progress note also dated June 21, 2024, the note stated that Updated order for cab/levo ER 50-200 mg to 2 tablets QID and PRN (as needed) Q4hrs per verbal order from hospice. The note stated that family is aware of change. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident is cognitively intact. A review of the list of self-reports and investigations in the last 90-days revealed that the facility reports did not include the issue with medication administration pertaining to resident #500. Review of the incident/accident log covering the last 90-days revealed that the medication administration issue pertaining to resident #500 was not included. The review of the grievance log revealed that a grievance was filed by resident #500's wife regarding customer service concerns. The resolution provided by the facility was marked as staff education. A telephonic interview with the hospice Area Executive of Clinical Operations (staff #27) was conducted on July 22, 2024 at 11:53 a.m. According to staff #27 resident #500 was admitted to the facility for respite care from June 18-22, 2024. The resident discharged back to home on June 23, 2024. She noted that any questions regarding medications of respite residents is clarified with hospice. A hospice nurse comes into the facility to ensure everything is good to go. In addition, the facility's nurse can call hospice to clarify any questions. The Area Exec of Clinical Operations said that on June 21, 2024 the family raised concerns regarding resident #500's regarding the medication Carbidopa-Levodopa. The issue was that the resident received low dosage of Carbidopa-Levodopa. The resident complained that he received 1 tablet QID instead of 2 tablets QID. Staff #27 admitted that there was a transcription error made by their hospice nurse. The order that was written on an order sheet was transcribed incorrectly. However, the order sent via fax and the medication bottles had the correct order. The transcription error was corrected the same day. Staff #27 indicated that she would have the Director of Clinical Services call the surveyor/investigator to provide more info regarding the incident when she returns on Wednesday. During an interview with a Licensed Practical Nurse (LPN/staff #18) conducted on July 23, 2024 at 8:07 a.m., staff #18 that the process for transcribing orders for residents coming in for respite is that when they come in, the orders is given to the facility mostly by fax. Medical Records then puts it in the system for the staff to see and it will then be reflected on the MAR (Medication Administration Record). The LPN said that they believe it is the DON or the Unit Manager that is responsible for verifying that the medications are accurately transcribed. For respite residents, hospice is contacted to clarify any questions with an order. Staff #18 stated that the impact of an inaccurately transcribed medication depends on the medication but it can have some serious side effects. The LPN noted that she had a resident on respite that had an issue with one of his medications and the medication was Sinemet (Carbidopa-Levodopa). Staff #18 stated that during Medication Pass, the resident questioned only being given 1 tablet for Carbidopa-Levodopa. The resident said that he gets 2 tablets. The LPN checked the MAR (Medication Administration Record) and it said 1 tablet so the resident was informed and resident stated that it was wrong and that he takes 2 tablets. The resident wanted to call his wife, and the wife verified that he takes 2 tablets. Staff #18 then called hospice and they noted that it was 2 tablets. However, the received orders from hospice stated 1 tablet. Another hospice nurse also indicated that the resident gets 2 tablets. A hospice nurse then came in to do medication reconciliation. The LPN said that the discrepancy was not identified until the resident brought it up which was a few days after he was admitted . Staff #18 noted that the order received from hospice was a handwritten order. It was the only order that was seen and indicated 1 tablet. An interview with a Licensed Practical Nurse (LPN/staff #9) was conducted on July 23, 2024 at 8:43 a.m. Staff #9 stated that the process for transcribing orders for residents coming in for respite care is that the facility staff puts in the prescription as ordered. The LPN stated that depending on what the prescription is, if it is new, it is normally received via fax. The fax is received by Medical Records and nurses are responsible for checking that it is the same as what is on the admission. Staff #9 stated that nurses are responsible for verifying that the medications are accurately transcribed. The LPN noted that if there is a question regarding an order, specifically if there is conflicting information regarding a medication, the doctor has to be contacted to clarify the order. Staff #9 said that sometimes you do not see that there is a discrepancy since they have to go by the information that was sent to them. The LPN noted that for hospice, especially for respite residents, the order is normally handed to the facility staff and informed that the resident is in for respite care. Staff #9 stated that it is less predictable since there is another nurse (from hospice) that had originally taken the order from the physician so the facility staff normally just turns around and puts in the order and the facility clears the prescription as such. The LPN noted that the facility staff is basically confirming another nurse's work, and the facility do not actually know what the doctor actually said/ordered. Staff #9 said that for respite residents, their medications are normally sent in typically in medicine bottles from home. Therefore, the resident/resident's family bring the medications and hands it to the facility. The LPN noted that they are familiar with resident #500. Staff #9 said that resident #500's orders were both faxed and some were handed to the nurse, which they were given since the nurse was on the floor. The LPN indicated that some faxed orders were never received. Staff #9 said that some of resident #500's medications were brought with him from hospice and some were brought by the family. The LPN noted that the medications from home were in bottles and some they got from hospice. Staff #9 stated that the medications from home's label/instructions were different from the order. However, the LPN noted that if a nurse looks at the bottle, they should check and verify with the MAR (Medication Administration Record) to compare that the information matches. If the information does not match, the nurse should get clarification. However, staff #9 indicated that some nurses think that if you have an updated info (newer date) on the order you can follow it even if the label on the medications has a different instruction. The LPN stated that nurses should get verification if there is discrepancy or conflicting order/direction regarding the administration of the medication before providing it to the resident. Staff #9 reiterated that it can be a cluster not dealing with the prescribing doctor directly. The LPN said that any medication should not be given if it is not correct. Staff #9 stated that for Carbidopa, wrongly given, it could cause the resident to have seizures and a lot of things the could have been dangerous. The LPN said that they believed resident #500 had an issue with his medications - there might have been a discrepancy that had to be brought to the attention of hospice. Staff #9 stated that in the case of resident #500 whose medications dosage were different from the transcribed/faxed medication list, clarification with hospice should have been done since that is where the orders originated from. The LPN noted that they were not sure how the discrepancy was caught-believed that family said something. Not sure if it could have been caught sooner. It took that long since it was the family that identified the discrepancy. Staff #9 said that their expectation is that the nurse verify/compare the information on the MAR with the medication's information prior to administering the medication. The LPN said that the wrong dosage could have been prevented/caught sooner by the nurse if they noticed that the info on the bottles/medications were not the same as the info on the MAR. The mismatched info should have triggered a need to clarify the order. Staff #9 said that there is no inventory or medications if it comes from hospice or the family. The LPN noted that it is a problem since they cannot verify if the mediations they are receiving from the family is what it is supposed to be and whether the doctor agrees. Staff #9 said that it is hard to say what the impact of the wrong dosage was on the resident since resident #500 was behavioral from square1. During head to toe exam, he was upset to be in the facility. He was having movements that Parkinson's patients have, he was fidgety, and uncomfortable-it made it hard to define his baseline or if it was medication related. The LPN said that the Carbidopa-Levodopa being administered according to physician's orders is important because it is for the resident's Parkinson's disease. A telephonic interview was conducted with a Registered Nurse (RN/staff #45) on July 23, 2024 at 9:38 a.m. Staff #45 stated that the front office normally have the arrangements with hospice so that medications can be inputted in the system but sometimes they get a copy of the medication list from hospice. The RN said that they cross reference orders for what is put in the computer. The nurse verifies that the medications were accurately transcribed. If there are questions, contact the doctor; if the resident is in hospice then contact hospice. Staff #45 said that hospice is responsible for medications and it either comes from the resident's home or hospice supplies the medication. The RN stated that respite residents' medications are normally in bottles but sometimes they come in blister packs. Either way, the medication has the info of what it is and what the dosage is. Staff #45 said that you compare the info on the meds versus the info on the MAR (Medication Administration Record). If the info is not the same, then you cannot use it or you have to get clarification to change the order. During the telephonic interview with the hospice Associate Medical Director (AMD/staff #36) conducted on July 23, 2024 at 10:10 a.m., staff #36 stated that it is very important for patients with Parkinson's disease to receive Carbidopa-Levodopa as ordered. The AMD said that once they have a patient on a certain dose, they can start to withdraw, so you cannot just stop it abruptly since it will cause the patient to have agitation. Staff #36 said that they have to make sure that patients are at the recommended dose to manage their symptoms. The AMD stated that if a patient do not receive the medication as ordered, specifically, at the right dosage, they can have confusion and issues with rigidity of muscles. Staff #36 said you do not want to stop it or only reduce dose when it was assessed based on symptoms since you do not want side effects related to withdrawal. The AMD said that her expectation of nursing staff with regards to administration of medication is that they follow the orders given, have an updated medication list, and notify provider if there are issues. Staff #36 stated that they are familiar with resident #500. The AMD said that resident #500 is a gentleman, who in mid-March received a primary diagnosis of Parkinson's disease and was sent to the facility in June for respite care. He is on Carbidopa-Levodopa as treatment for Parkinson's disease. Staff #36 noted that a hospice nurse filled out a handwritten medication list and instead of 2 tablets QID, he received 1 table for a period of about June 19 until the family noticed and notified the facility on June 21. Hospice was notified and corrected the error. The AMD acknowledged that hospice provided the list and that it was a hospice error that the medication list was written wrong based on records. Staff #36 noted that medications are brought from home or if it was picked up from pharmacy, those medications would still have the right name and dosage of the medications. It would have been noticed if the administering nurse double checked the actual medications and label against the orders. The AMD said the mismatched info should have triggered a clarification for that medication order. Staff #36 said that based on report, on the June 21, the facility's nursing staff called hospice and they did a medication reconciliation that day. The AMD noted that resident #500 had a fall with a minor injury which was a scape on his right forearm while he was at the facility. However, it is unsure whether the fall was due to low dose of Carbidopa-Levodopa. Additionally, the resident had confusion but they are unsure whether it was related to low dose of Carbidopa-Levodopa. Staff #36 stated that the low dose could have contributed to what was going on with him (fall, confusion, agitation). If they are withdrawing, he was getting less than before and it can cause agitation, and behaviors, irritability, and it can present. The AMD said that at the time of resident #500's admission, Parkinson's disease, anxiety, and depression were his diagnoses. Staff #36 stated that the resident's medication was effective in controlling and try to keep him at the dose. An interview with the Director of Nursing (DON/staff #63) was conducted on July 23, 2024 at 11:30 a.m. Staff #63 stated that her expectation with regards to administering medications especially if medications are from hospice/resident's home is that staff check the order and use the current order that is on the paper. The DON said that staff should look at the info on the medication package but she expects that her staff follow the medication order on paper and follow the most recent order given. Staff #63 said that if the info on the medication label is different from the order, then they should call hospice to verify. The DON said that it is important to verify medication is right essentially because it goes back to medication rights-right dose and right medication. If the same medication, they can still use the same bottle but go off the current order. However, you still want to clarify which info is correct if it is in conflict. Staff #63 noted that with regards to resident #500, the issue could have been prevented or caught earlier by hospice. She said it was hospice that gave the order incorrectly. The DON noted that the resident was getting 1 tablet instead of 2. The resident was having behaviors. The facility called hospice and they did a whole new medication reconciliation but never caught the transcription error until the facility was giving the medication and it was brought up. Staff #63 acknowledged that medications are labeled with the name of the medication and the dosage regardless of whether the mediation is in a blister pack or bottle. The DON said that staff should read the label when administering medication. Staff #63 also acknowledged that yes, the nurse could have caught the discrepancy sooner. The DON said that if they read the label and noticed that the info on the label and order was different. However, as nurses when new order comes thru, if what was sent was the wrong info it is not something they would recognize. Staff #63 said that if the info on the medication container is not matching the order then it should have triggered that there should have been a time out to verify what the actual order was. The DON said the nurse checks medication and dosage and compare it to MAR/TAR (Medication Administration Record/Treatment Administration Record) prior to administering medications. Staff #63 noted that it is important that the resident received the right dosage of Carbidopa-Levodopa. The DON said that as far as impact of the wrong dosage it is fair to say there was some-anxiety and impulsivity. However, from the medical side, staff #63 said in hospice, medications are for comfort and not necessarily work anymore. They mask but the treat the progression. During the exit conference conducted on July 23, 2024 at approximately 12:09 p.m., the [NAME] President of Clinical Operations (VP of Clinical Ops/staff #72) stated that it is not best practice to verify the label of the medication to compare it to the MAR (Medication Administration Record) when administering medication. Staff #72 said that it is not what happens in the real world. When asked is her staff is supposed to verify the medication to compare it to the MAR prior to giving the medication, she said all they have to do is follow the physician's orders and that is what her staff did. A telephonic interview was conducted with the hospice Director of Clinical Services (staff 54) on July 24, 2024 at 10:35 a.m. The Director of Clinical Services said that resident #500's wife called on July 21, 2024 to report that the resident was getting the wrong medication and that the facility will not listen. Staff #54 said that an order for medication reconciliation was done. The Director of Clinical Services stated that there was a discrepancy in the handwritten order originally given to the facility. However, a printed order was also sent to the facility. Staff #54 stated that her expectation is that administering nurse compare the medication label to the medication sheet to ensure that the right medication/dosage is given. The Director of Clinical Services indicated that the facility giving the resident the wrong dosage upset the resident's family. Staff #54 said that if the staff administering the medication looked at the info on the medication and compared it against the medication sheet, the error could have been caught sooner. The Director of Clinical Services said that resident #500's wife reported that the resident fell because he was not getting the right dose. Staff #54 said that resident's behaviors possibly related to not getting the right dose but that the resident already had issues with falling. Review of the facility policy titled F027-Medications: Administering Oral Medications with an effective date of January 1, 2024, indicated that the purpose of this procedure is to provide guidelines for the safe administration of oral medications. The section Steps in the Procedure directed to Check the label on the medication and confirm the medication name and dose with the MAR. Additionally, it reiterated to Check the medication dose. Re-check to confirm the proper dose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based off of clinical record review, staff interviews, observation of current practice, and review of the facility's policies, the facility failed to ensure residents #3, #4, and #5, were free from abuse from other residents. The deficient practice could result in residents experiencing emotional and mental trauma from the abuse. Related to resident #5 Resident #5 was admitted to the facility on [DATE] with diagnoses that included Dementia, a history of strokes, and stage 3 Kidney disease. A review of a Quarterly MDS, dated [DATE] revealed resident #5 had a BIMS assessment completed. Resident #5 scored a 08 which indicated they were mildly cognitively impaired. A review of the care plan reveals it was revised on January 16, 2023 to include behavior issues as an area of focus. The care plan goals included that resident #5 would not harm themselves or others. The care plan interventions included administering medications as ordered, allowing the resident to make their own decisions about their care, anticipating and meeting their needs, remove the resident from the situation if an issue occurs, provide the resident an opportunity to make choices, and refer to a psychiatrist for consult as ordered. A review of resident #5's progress notes in the Electronic Health Record (EHR), reveals an entry dated August 25, 2023 at 9:08 AM. The note reveals resident #5 was not in a good mood as evidenced by them calling other people names and telling others to leave them alone. A second progress note, dated August 26, 2023 at 3:56 PM, reveals that a Licensed Practical Nurse (LPN) contacted the Director of Nursing (DON) to inform them that resident #5 was hit by another resident (resident #3). The progress note also indicates that a skin assessment was completed and there were no injuries. Review of additional Progress Notes show that alert charting was done to monitor the resident for the next two days after the incident. Further review of resident #5's EHR reveals that a psychiatric consult was provided on August 21, 2023 and it was recommended that resident #5 continue with their medication regimen at that time, do LABs to rule out other contributing medical conditions, and to follow up with their primary care physician. Related to resident #3: Resident #3 was admitted to the facility on [DATE] with diagnoses that included Dementia, Diabetes, and Chronic Obstructive Pulmonary Disease (COPD). Resident #3 was discharged from the facility on January 17, 2024. A review of the 14-day Minimum Data Set (MDS), dated [DATE] revealed resident #3 had a Brief Interview for Mental Status (BIMS) assessment completed. Resident #3 scored 03 which indicated they were severely cognitively impaired. A review of the care plan reveals it was revised on August 26, 2023 to include behavior issues as an area of focus. The care plan goals included that resident #3 will be able to effectively cope with his behaviors. The care plan interventions stated to administer medications as ordered ., monitor/document for side effects and effectiveness ., if issues arise, remove from situation ., intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed ., and to refer to psychiatric provider for consultation as ordered. A review of resident #3's Progress Notes reveals an entry dated August 24, 2023 that indicated the resident had a room change, was attempting to elope, was confused, and had a hard time finding their new room. The note also indicates that staff reoriented resident #3 to their new room throughout the shift. A second Progress Note entry, dated August 25, 2023, indicated resident #3 was awake most of the night. A review of a Behavior Note entry, dated August 26, 2023, noted that staff heard resident #3 yelling loudly in the hallway. The note indicated that staff observed resident #3 swinging arms toward resident 2 (resident #5) and making contact to back of resident 2 head, as these two resident's yelling obscenities at each other. The note also indicated that staff separated the two residents and skin assessments were conducted with no injuries noted. The note reveals that resident #3 refused to allow staff to check their vitals after the incident. Additional review of resident #3's Progress Notes revealed an Alert Charting note dated September 8, 2023 at 1:08 AM. The note indicated that on September 7, 2023 at 8:30 PM resident #3 was hit in their chest by resident #4. Resident #4 told staff that resident #3 would not leave them alone. The note indicates that there were no marks on resident #3's chest. There were no other notes in Resident #3's Progress Notes related to the September 7th incident. A review of the facility's records indicate that resident #3 was involved in three incidents from August through September 2023. Related to resident #4: Resident #4 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Insomnia, and Major Depressive Disorder. A review of a Quarterly MDS, dated [DATE], revealed resident #4 had a BIMS assessment completed. Resident #4 scored a 07 which indicated they were severely cognitively impaired. A review of the care plan reveals it was revised on September 7, 2023 to include behavior issues as an area of focus. The care plan goals included that resident #4 will demonstrate effective coping of their behaviors. The care plan interventions included administering medications, anticipating the resident's needs, teaching the resident coping skills, encourage the to express their feelings, provide positive interactions, identify triggers of the behaviors, and to remove the resident from the situation if an issue occurs. A review of resident #4's Progress Notes revealed a note dated September 8, 2023 at 1:05 AM. The note indicated that on September 7, 2023 at 8:30 PM the staff heard resident #4 yell at another resident (resident #3) to get away. The note also indicates that staff observed resident #4 hit resident #3 in the chest. The note indicated that resident #3 told staff that resident #4 was bothering them and wouldn't leave them alone. Further review of the Progress Notes indicates that resident #4 was monitored for the next two days and no behaviors were noted. A phone call was placed to staff #4, a LPN, on May 21, 2024 at 10:40 AM to conduct an interview. It was noted in resident #5's chart that staff #4 witnessed the altercation between resident #5 and resident #3. A voicemail was left requesting staff to call the investigator back. There was no callback prior to the end of the investigation. A phone call was placed to staff #6, a LPN, on May 21, 2024 at 10:54 AM to conduct an interview. A voicemail was unable to be left as the voicemail inbox was full. An interview was conducted on May 21, 2024 with a Certified Nursing Assistant (CNA/Staff #2). Staff #2 indicated that the facility provides training to staff throughout the year related to abuse. Staff # 2 indicated that when there is a resident-to-resident abuse, they have been trained to redirect the residents and provide 1:1 staffing to monitor. Staff #2 indicated that they typically care for approximately 11 residents during their shift. An interview was conducted on May 21, 2024 at 8:32 AM with staff #3 (CNA). Staff indicated they care for around 15 residents during a shift. When asked how the facility ensures residents are safe from other residents, staff #3 indicated that they monitor their behaviors. They know who are prone to altercatins and will monitor those residents more closely. Staff also indicate that they are aware of specific residents that do not get along with other residents and will monitor those situations as well. An interview was conduced with the Director of Nursing (DON/Staff #1) on May 21, 2024. Staff #1 indicated that all residents were care planned for their behaviors and the facility had the appropriate interventions in place. They indicated that the facility was taking all of the appropriate measures to ensure the safety of the residents. A review of the facility's policy, titled Resident Rights/Dignity: Abuse and Neglect - Clinical Protocol indicates that it was last reviewed on January 1, 2024. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure there was sufficient staffing to provide quality resident care. The deficient practice could result in residents' care needs not being met. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included a fracture of the left femur, Chronic Obstructive Pulmonary Disease (COPD), and Anxiety disorder. The 5-day Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS also indicated resident #1 needed partial/moderate staff assistance for moving from a laying in the bed position to sitting on the side of the bed position. It also indicated that the ability to get on and off the toilet was not assessed due to a medical condition or safety concern. The facility's staff schedule was reviewed for Thursday, May 2, 2024 and Friday, May 3, 2024. Thursday May 2, 2024 had the following staff: Day shift -4 Certified Nursing Assistants (CNA) -1 Certified Medical Assistant (CMA) - 2 Licensed Practical Nurses (LPN) Night shift -1 CNA -1 Registered Nurse (RN) Friday May 3, 2024 had the following staff: Day shift -2 CNAs -1 CMA -2 LPN Night shift -2 CNAs -1 LPN -1 RN Review of the facility assessment, dated March 21, 2024, reveals that the facility had determined it needed 3 - 4 CNAs working the night shift in order to meet resident needs. A call was placed to a RN (Staff #5) on May 21, 2024 at 8:02 AM. This staff worked the night shift on May 2nd . A voicemail was left and was not returned prior to the conclusion of the investigation. A call was placed, two times, to a CNA (Staff #7) on May 21, 2024 at 8:05 AM. Both times the call did not go through. This staff worked the night shift on May 2nd. An interview was conducted on May 20, 2024 with the Director of Nursing (DON/Staff #1) at 2:40 PM. Staff #1 stated that a second CNA had been scheduled to work the night shift on May 2, 2024 but had called off. Staff #1 indicated that they had ended up working that shift so there was a total of three staff members working the night shift on May 2nd. Staff #1 stated that resident #1 was upset that night because between the three of them that were working, they were not able to be as attentive as the resident wanted. Staff #1 also indicated that resident #1 did not make any complaints about the care she received that night until the next day. Staff stated that resident #1 had told them that staff #5 had been rough with them because they had moved the resident too quickly. The resident then complained of hip pain and was sent to the hospital immediately. The resident never returned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#1) was administered pain medications as ordered. The deficient practice resulted in a resident experiencing unnecessary pain. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included a fracture of the left femur, Chronic Obstructive Pulmonary Disease (COPD), and Anxiety disorder. The 5-day Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of the physician's orders dated April 26, 2024 included Hydrocodone-Acetaminophen (an analgesic opioid) Oral 5-325 milligram (mg) tablet every 4 hours as needed for pain 6-10. A second order was revealed for Acetaminophen 325 mg two tablets every 4 hours as needed for pain 1-5. Review of resident #1's care plan, initiated April 26, 2024, revealed the resident was at risk for pain. Interventions included to administer analgesia medications as ordered. A review of the April 2024 Medication Administration Record (MAR) indicates on April 26 and April 27 resident #1 had pain rated at an 8 and was administered Acetaminophen 325mg. Review of the clinical record reveals no evidence of the resident's pain levels in the progress notes for April 26, 2024. Review of the clinical record reveals a progress note dated April 27, 2024 at 12:49 PM. The note indicated that Hydrocodone-Acetaminophen 5-325mg was administered. There are no notes documenting the pain level. This note does not match what was documented on the MAR for April 27, 2024. A call was placed to a Registered Nurse (RN/Staff #5) on May 21, 2024 at 8:02 AM who was the staff who administered pain medications outside of the established parameters. A voicemail was left and was not returned prior to the conclusion of the investigation. An interview was conducted with the Director of Nursing (DON/Staff #1) on May 20, 2024 at 2:40 PM. Staff #1 indicated that resident #1 was a late admit on Friday, April 26, 2024. Staff #1 indicated that the staff working the floor did not have access to a new medication supply cart called Subix which is stored in the Medication room. Because of this, staff were not able to access the Hydrocodone-Acetaminophen at the time the resident requested it. Staff #1 stated they came into the facility on April 27, 2024 to assist staff with access to Subix. Staff #1 stated that they started using Subix on May 1st and some staff were having troubles accessing it. Surveyor reminded staff #1 that the medication concern in question took place on April 26 and April 27, 2024 which was before the switch took place. Staff #1 was not able to explain why medication parameters were not followed and why staff #5 did not have access to the medication supply cart. When asked what their expectation was related to administering pain medications, Staff #1 indicated that staff are to follow the pain scale and administer pain medications according to the resident's pain level according to physician's orders. Staff #1 stated that they have a flyer at each nurses' station that outlines the steps nurses are to take if medications are not available. When asked what would be the risks associated with not following physician's orders related to pain medications, Staff #1 stated that the resident's pain is not targeted and relief is not provided. Staff #1 acknowledged that resident #1 did have their pain treated appropriately that night (April 26 and April 27). A review of the facility policy titled, Pain Management: Administering Pain Medications, revealed the facility will administer pain medications as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, staff and resident interviews and policy review, the facility failed to ensure that one resident (#1) was treated with dignity and respect, and that two residents (#1, #3) were provided privacy during showers. -Regarding Resident #1 Resident #1 was admitted on [DATE] with diagnoses that included right femur fracture, protein calorie malnutrition, depression, reduced mobility, abnormalities of gait and mobility, history of falling, unsteadiness on feet. Review of the care plan revealed the following areas of focus: -Requires assistance with Activities of Daily Living (ADL), initiated September 15, 2022. -ADL self-care performance deficit related to activity intolerance, impaired balance, limited mobility, initiated September 29, 2022. Interventions included cares and pairs with all ADLs, requires skin inspection during routine cares and per bath schedule. -At risk for falls, initiated November 9, 2022. An intervention dated May 10, 2023 revealed that the resident was educated on needs of supervision during showers. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment also revealed the resident required supervision and set up for toilet use and hygiene. Review of the clinical record revealed no evidence of a progress note related to the shower altercation with resident #2. Review of the clinical record revealed no evidence of a progress note related to the resident's behavior in the courtyard after the altercation with resident #2. -Privacy An interview was conducted with Resident #1 on August 25, 2023 at 8:54 AM. The resident stated that she thinks her psychiatrist made a complaint regarding a shower occurrence on August 19, 2023. She stated that on August 19, 2023 at 10:30 AM she was in the shower, and that she heard the entry code entered into the shower room door. She stated that she called out occupied twice, but the person kept coming into the shower room. She also stated that she then grabbed a towel/blanket, opened the shower curtain and saw Resident #2 entering the shower room. She stated that she told him she was using the shower and asked him to leave, and he stated that he needed to use the restroom. She stated that she then called out and a CNA came into the shower room and removed Resident #2. Resident #1 stated that she did not feel safe in the shower, and she took another bath sheet from the rack, wrapped it around her, and left the shower room. She also stated that as she was exiting the shower room Resident #2 was still at the shower room door. Resident #1 further stated that as she was exiting the shower room there were 2 CNAs sitting at the nursing station and a nurse (Staff #37), as she passed by them she told them she was going to her room to dry, so no man would walk in on her. The resident stated that she talked to the night nurse (staff #35) about what had occurred, and he said that the CNAs are supposed to stay with a person when they are in the shower. The resident further stated that later on Saturday the day that it occurred, she told the CNAs that she wanted to have a shower when Resident #2 was not awake, either at night or on the rehabilitation side. Resident #1 stated that CNAs stayed with her in the shower at first because she needed assistance, but not now. She also stated that she can use the call light if she needs assistance, but it is not within easy reach. She stated that she would have to get out of the shower and walk across the room to use the call light. Resident #1 also stated that on Sunday, August 20, 2023, RN (staff #37) came to her and told her that it must have been upsetting to have someone walk in on her in the shower. She also stated that at 8:30 -9:00 PM on Sunday (he was working a double shift) that staff #37 came into her room and stated that he did not know when he was going to be back and that he would miss her, now that they were now on the same page. The resident stated that when the incident occurred she was angry, that Resident #2 came in after she said the shower room was occupied, and that no one acknowledged her feelings, that she did not feel heard. -Dignity/Respect Resident #1 further stated that as she passed the nursing station, she heard nurse #37 state that he wished he could watch girls shower and not get in trouble, and something along the line that Resident #2 is living the dream, way to go George. She also stated that after the nurse made those comments the CNAs present all laughed. Resident #1 stated that a CNA said that there is no reason for her to be upset that resident #2 did not know that she was in the shower. The resident stated that resident #2 did know that she was in the shower, because she called out twice, and she told him to leave. She also stated that Resident #2 has walked in on her before this and that she told staff each time that it occurred and that she was upset. Resident #1 stated that she was most upset when staff #37 made the comments, and when a CNA told her that there was no reason to be upset because Resident #2 did not know any better. The resident stated that when staff were laughing at her she was hurt and felt betrayed, and that anger went to furious. She further stated that she felt like no one cared. -Regarding Resident #3 -Privacy Resident #3 was admitted on [DATE] with diagnoses that included Alzheimer's disease, dementia, and anxiety disorder. Review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 7, which indicated severe impairment. The assessment also revealed that bathing supervision was required. Review of August 1 through August 25, 2023 CNA Bathing Task revealed that supervision with bathing was provided. However, there was no supervision observed in or around the shower room on August 25, 2023 at 9:34 AM when the resident was in the shower room. An observation was conducted on August 25, 2023 at 9:34 AM of the Skilled Nursing shower room. The signage outside of the shower room revealed open. The door to the shower room had a key pad on the door above the handle. The door was observed to be unlocked. As the door was pushed open a resident was observed to be in the shower room, dressed, with wet hair, who stated that she had just completed a shower and was leaving. No CNA was observed to be in the room with the resident, or outside of the shower room supervising for anyone entering the shower room while the resident was inside. An interview was immediately conducted with Resident #3 on August 25, 2023, who stated that staff will tell her when she needs to take a shower. She stated that she does not have a CNA go in the shower room with her. She stated that it has happened that other residents have walked in on another resident in the shower room, but not her. She stated that CNAs will open the shower door for the residents to use the shower. Resident #3 also stated that there are some residents that know what the code is but she does not know who. An interview was conducted on August 25, 2023 at 10:51 AM with a Certified Nursing Assistant (CNA/staff #36), who state that if a resident is full assist they will stay in the shower room while the resident is showering. She also stated that if a resident is more independent showering they will leave the resident alone in the shower room, but will check in on them to see if the resident is ok. She stated that she was aware that Resident #1 had been showering when another resident walked in on her. She further stated that the resident would not have been able to enter the shower room if a CNA had been in the hall monitoring resident #1's shower. She stated that when she arrived, staff had already removed resident #2 from the shower room. The CNA stated that resident #1 was very angry, and stated that she was going to her room to dry off, where no one else can walk in on her. She further stated that as resident #1 walked by a nurse (Registered Nurse (RN)/staff #37), he was laughing, and the resident stated you think it was funny, but it wasn't. The CNA also stated that she heard the nurse (RN/staff #37) make a comment and other staff were also laughing. She stated the RN (staff #37) said that he wished he could watch girls shower and not get in trouble, and something along the line that Resident #2 was living the dream, wat to go. She also stated that the facility policy regarding verbal abuse would include laughing at a resident. The CNA stated that she should have reported this incident to management when it occurred. She further stated that the facility policy regarding privacy, is to ensure that residents are provided privacy and are being protected. An interview was conducted on August 25, 2023 at 11:13 AM with a CNA (staff #38), who stated that thy are required to stay in the shower room when residents are showering, that they have to stay with the resident at all times. She stated that Resident #1 does not want any staff to stay in the shower room, but they are supposed to check on her every 2-3 minutes to see if she is ok. She stated that she saw they occurrence where a resident walked in on Resident #1 while she was in the shower. She stated that she heard Resident #1 yelling from the shower room, telling Resident #2 not to come in. She stated that when Resident #1 was showering, the shower room door is locked, and she is not sure how Resident #2 was able to open the door. She further stated that Resident #1 covered herself with a blanket and left the shower room, stating she was going to get dressed in her room where she had privacy. The CNA stated that nurse #37 mad a comment that got resident #1 upset. She further stated that nurse #37 was laughing and making fun of what happened and stated way to go. The CNA stated that when resident #1 heard this comment she became even more upset, and later in the courtyard the resident was observed to be hitting herself. She stated that dietary staff told her that the resident was in the courtyard hitting herself, and she tried to calm the resident, but the resident would not let her get close. She stated that the resident does have behaviors that she will hit/harm herself if she is afraid. She further stated that the occurrence in the shower could have caused this behavior. The CNA stated that the resident's privacy and rights had not been respected, and laughing at the resident and making comments could be considered verbal abuse. She also stated that she should have reported the incident to management but did not. An interview was conducted on August 25, 2023 at 12:14 PM with a RN (staff #35), who stated that showers are to be supervised by CNAs. He stated that patients that are able to shower independently still need supervision while in the shower room, that staff should not walk away. He further stated that whoever is in charge of a resident (in the shower) staff should be in the area to make sure no one goes in during their shower. During the day the shower room is locked. He also stated that privacy is part of resident rights, and that one resident walking into the shower room while another resident is showering would be a privacy issue. He stated that this is where CNA supervision is so important. He stated that later that day when he came on shift the resident told him what had happened to her in the shower room earlier that day. He also stated that the resident was frustrated with how staff had handled the situation. He stated that the occurrence in the shower room had invaded the resident's privacy. The RN stated that the occurrence should have been documented in progress notes. He also stated that the resident would be at risk for self-harming behavior if she would be upset about something, and that if this occurred it should also be documented in progress notes and the provider should have been notified. The RN stated that any behaviors should be documented in the clinical record. An interview was conducted on August 25, 2023 at 1:25 PM with a Licensed Practical Nurse (LPN/staff #39), who stated that staff are expected to stay in the shower room when a resident is in the shower, and the door should be locked. She stated that a resident should not be able to walk in the shower room when another resident is showering. She also stated that this would be considered a privacy breach, and if staff were laughing and making comments, it would not be acceptable and would be a resident rights issue. She also stated that if a resident to resident incident occurs it should be documented in the clinical record. She further stated that staff should discuss the resident's concerns, notify administration, comfort the resident with one on one discussion. The LPN also stated that if the resident would exhibit self-harm behaviors after a resident to resident occurrence it should be documented in the clinical record, and the provider, Director of Nursing (DON) and responsible party should be notified. An interview was conducted on August 25, 2023 at 1:27 PM with a (LPN/Staff #39), who stated that resident #3 should not be left in the shower alone. An interview was conducted on August 25, 2023 at approximately 1:45 PM with the DON (staff #40), who stated that the expectation for shower supervision with independent residents would be for staff to knock on the shower room door to make sure that the resident is ok. She stated that she would not expect the shower door to be locked when a resident is in the shower, that the supervising CNA should be outside the door, readily available. She stated that a resident walking in on another resident in the shower room would not meet the facility shower policy. She further stated that the resident has the right to privacy during a shower. She also stated that the care plan should include the resident's dependence for showers. The DON stated that when a resident is upset regarding privacy issues during a shower, she expected to be notified, and for staff to console, reassure and support the resident. She stated that she had reviewed the facility records and did not see any documentation regarding the shower incident, and was not aware until this morning. She stated that she would have expected the occurrence to be documented in the clinical record, including any behaviors the resident may have exhibited after the incident and to have been notified. The DON also stated that it would be considered harassment if staff were laughing at the resident and making rude comments after the shower incident. She further stated that there was no evidence in the clinical record of the resident's self-harm behavior after the shower incident. Review of a facility policy titled, Resident Rights, revealed that employees should treat all residents with kindness, respect, and dignity, privacy and confidentiality. Review of a facility policy titled, Behavioral Assessment, Intervention and Monitoring, revealed that the nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior and cognition. Including any precipitation or relevant factors or environmental triggers. Review of the facility policy titled, Bathing and Showers, included to stay with the resident throughout the bath, never leave the resident unattended in the tub or shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical documentation, staff interviews, and facility policy and procedures, the facility failed to ensure that one resident (#11) did not receive unnecessary pain medication. The census was 57. The deficient practice could result in residents being overmedicated. Findings include: Resident #11 was admitted on [DATE] with diagnoses of Alzheimer's Disease, scoliosis, acute kidney failure, and displaced intertrochanteric fracture of the right femur. A care plan dated September 11, 2022 included that the resident was at risk for pain related to a medical condition. Interventions included to evaluate for and adequately respond to any sign or complaint of pain. Review of the Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 7 indicating the resident has a severe cognitive impairment. The care plan dated January 16, 2023 revealed the resident use opioid/and or analgesic related to pain. Interventions included to evaluate the effectiveness of pain interventions as needed, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. The current Order Summary Report revealed the following orders: -Acetaminophen (analgesic) tablet give 650 mg (milligrams) by mouth every 6 hours as needed for pain 1-5; and, -Oxycodone (narcotic opioid) 5 mg tablet by mouth every 6 hours as needed for pain 6-10. These medications were transcribed onto the MAR (medication administration record) for February and March 2023. The MAR for February and March 2023 revealed that oxycodone was administered on: -February 14 with a pain level of 0; -February 23 with a pain level of 5; -February 27 with a pain level of 5; -March 2 at a pain level of 5; -March 6 at a pain level of 5; -March 9 at a pain level of 4; -March 10 at a pain level of 4; and, -March 15 at a pain level of 4. There was no evidence found in the clinical record of any reason why oxycodone was administered outside of the ordered parameter; and that, the physician was notified. An interview was conducted on March 22, 2023 at 10:31 a.m. with a registered nurse (RN/staff #74) who stated that a pain medication prescribed as needed (PRN) needs a pain scale; and that, pain level is documented on the MAR when the medication is administered. The RN said that an hour after administration, she would document on the MAR if the pain medication was effective or not. The RN stated that there was a risk of developing constipation, sedation and addiction when pain medication was given outside of the ordered parameters. She stated that she would contact the physician if she was going to give a medication outside of the parameters and would document it in the progress notes. During the interview, a review of the clinical record was conducted with the RN who stated there was a physician order for acetaminophen as needed for pain 1-5 and oxycodone HCI oral tablet 5 mg for pain 6-10 for resident #11. However, the RN stated that the MAR documented that oxycodone was administered at a pain level of 4 and 5, which was outside the ordered pain scale parameters. The RN also stated that oxycodone was given for a pain level of 4 to resident #11 on March 15; however, she could not find any documentation why it was given and that the physician was notified. Further, the RN stated that these were medication errors and she would have to notify the physician and the Director of Nursing. On March 22, 2022 at 10:40 a.m., the Director of Nursing (DON/staff #36) joined the interview and stated that there was a risk of overmedicating or under medicating a resident when administering pain medications outside of parameters; and, she would contact the physician to report the errors. The facility's policy, Administering Pain Medication, revised October 2010 states that the purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. Residents are not at risk for addiction to narcotic analgesics if used as prescribed for moderate to severe pain. Conduct a pain assessment as indicated. The initial assessment is comprehensive and should follow the facility pain assessment procedure. Administer pain medications as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, policy and procedures the facility failed to ensure services met professional standards by failing to provide bowel care for one resident receiving opioid therapy (resident #47). This deficient practice could result in residents having complications from constipation including fecal impaction, bowel obstruction or death. Findings include: Resident #47 was readmitted to the facility on [DATE] with diagnoses of morbid obesity, bilateral primary osteoarthritis of knee and need for assistance with personal care. A physician order dated December 18, 2022 Senna S (stool softener) 8.6-50 mg give 1 tablet by mouth two times a day for constipation and to hold medication for loose stool. The care plan dated March 10, 2023 revealed the resident was at risk for pain and takes opioid/non-opioid/and or analgesic related to general discomfort secondary to a sacrum wound. The goal was that the resident will not have an interruption in normal activities due to pain through the review date. Interventions included to administer medications as ordered, anticipate resident's need for pain relief and respond as soon as possible to any complaint of pain, evaluate the effectiveness of pain interventions as needed. Review of the physician order with a start date of March 10, 2023 included pain evaluation every shift and to implement routine bowel care 3 step program if no BM (bowel movement) in 3 days. Review of the admission minimum data set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The assessment also included that the resident was always incontinent with his bowel. A physician order dated March 17, 2023 included for hydrocodone-acetaminophen (narcotic opioid) 5-325 mg (milligrams) give 1 tablet by mouth two times a day for prior to wound care and prn (as needed). Review of the MAR (medication administration record) for March 2023 included that the hydrocodone-acetaminophen was administered twice daily as ordered beginning on March 17, 2023. Review of the clinical record revealed that the resident did not have a bowel movement on March 17, 18, 19 and 20, 2023. Despite a physician order that routine bowel care 3 step bowel care program may start after three days with no bowel movement, no bowel care program was implemented for resident. An interview conducted with a certified nurse assistant (CNA/staff #24) on March 21, 2023 at 2:21 p.m. The CNA stated bowel movements are charted in the electronic record and includes whether the resident is continent or incontinent and whether the resident had a bowel movement. She stated that CNAs were required to notify the nurse if a resident does not have a bowel movement within 3 days; and that, if a resident independently toilets the CNA will ask the resident about their bowel movements. During an interview with a licensed practical nurse (LPN/staff #103) on March 22, 2023 at 11:51 a.m., the LPN stated that residents taking opioid medication were monitored for adverse effects such as nausea, drowsiness, confusion, pain or constipation. She stated that bowel movements are documented in the electronic record; and that, a red bell will pop up on the electronic clinical record which alerts nurses about abnormal vital signs or too many days since last bowel movement. The LPN stated that the doctor is notified about constipation on a case by case basis according to a resident's norm; but, the facility's policy was to inform the physician if the resident shows signs/symptoms of constipation or bowel obstruction. The LPN said that she did not know if a bowel program was put in place for residents at this facility; but, she had seen bowel programs at other facilities she worked at. She stated that a physician order was required for any bowel program. A review of the clinical record was conducted with the LPN during the interview. The LPN stated that the clinical record revealed resident #47 had no bowel movements from March 17 through March 20, 2023; and that, there was order dated March 10, 2023 that the facility may implement routine bowel care 3 step program if the resident had no BM in 3 days. The LPN further stated that the resident did not have a standing laxative order; and that, the nurse should have administered some form of laxative to the resident. Further, the LPN stated that if a resident does not have a bowel movement the risk includes bowel obstructions, bowel perforations and even death.; and that, it was very serious and painful for the resident. During an interview with the assistant director of nursing (ADON/Staff # 21) on March 03, 2023 at 9:42 a.m., the ADON stated that the nursing staff monitors residents for side effects related to medications such as constipation; and that, the nurses were expected to document the side effects. The ADON also said that the nurse and the CNAs monitor the resident's bowel movements; and, the facility has a standing order that bowel care can be implemented after the CNAs chart and notify the nurse about lack of bowel movements. The ADON said that once the nurse is notified, the facility can get a PRN or scheduled bowel medication for the resident. The ADON said that physicians are notified after 3 days of no bowel movement; however, the ADON said that she was not sure if a bowel program was put into place for a resident on opioids. The ADON also said that the facility was working on getting standardized orders; and, the NP is in the facility frequently and was also available after hours for concerns. Further, the ADON stated that a bowel protocol required a physician order; and, a resident having no bowel movement could result in fecal impaction, bowel perforation and it could be lethal. An interview was conducted with director of nursing (DON/staff #32) on March 23, 2023 at 10:00 a.m. The DON stated it was her expectation that nurses know how to manage a resident with constipation; and that, both the CNAs and nurses monitor the bowel movements. The DON said that if it has been 3 days without a bowel movement the CNA would notify the nurse who would then notify the provider. The DON was not able to explain what the 3-step routine bowel care standing order was; but said that the facility calls the provider to receive orders and would continue to call for different medications until bowel movements occur. The facility policy on Bowel (lower gastrointestinal tract) disorders-clinical protocol revised September 2017, revealed that as part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. Examples of lower gastrointestinal tract conditions and symptoms include alteration in bowel movements, pain with defecation and residents taking antidiarrheal medications or medications related to bowel motility. In addition, the nurse shall assess and document/report the following: abdominal assessment, presence of fecal impaction, signs of dehydration, onset, duration, frequency, severity of signs and symptoms, all current medications and all active diagnoses. The staff and physician will identify risk factors related to bowel dysfunction for example severe anxiety disorder, recent antibiotic use, or taking medications that are used to treat, or that may cause or contribute to gastrointestinal erosion, bleeding, diarrhea, dysmotility, etc. The physician will identify and order pertinent cause-specific and symptomatic interventions, for example institute a regimen to prevent constipation. The staff and physician will monitor the individual's response to interventions and overall progress. The physician will adjust interventions based on identification of causes, resident responses to treatment and other relevant factors. Upon requesting a facility-initiated bowel protocol, it was revealed that no such policy exists.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, policy and procedures review, the facility failed to ensure that medications were properly secured for one resident (resident #2). The deficient practice could result in the inappropriate use of medications by residents. Findings include: Resident #2 was admitted on [DATE] with diagnoses of quadriplegia, stage IV pressure ulcer of sacral region, need for assistance with personal care and muscle weakness (generalized). The care plan dated December 24, 2022 did not mention the resident was assessed to be able to do self-administration of medication. Review of the minimum data set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of 15 indicating the resident was cognitively intact. The assessment included the resident required extensive assistance with two-person physical assist with bed mobility and transfers; and required extensive assistance with one-person physical assist with eating. A physician order dated March 13, 2023 included for wound care to the right knee: cleanse with normal saline, pat dry, cover with oil emulsion, cover with kerlix, secure with tape 3 times a week and as needed. Another physician order dated March 15, 2023 included for triamcinolone acetonide (topical ointment) External Cream 0.1 % for itchy, dry, scaly skin dated March 15, 2023. A review of the clinical record revealed no documentation of any self-administration assessment completed for the resident. During an observation conducted on March 20, 2023 at 11:32 a.m. , the resident was inside her room and there was 454 gram sized container of Triamcinolone Acetonide External Cream 0.1% and 100 ml (milliliter) bottle of normal saline was found on resident's bedside table. On March 20, 2023 at 11:57 a.m., an observation was conducted with a licensed practical nurse (LPN/staff #88) who picked up container of Triamcinolone 0.1% cream from the bedside table and read the label aloud. The LPN stated that the medication was to be applied to back of neck, scalp topically one time a day for itchy, dry, scaly skin. In an interview conducted immediately following the observation, the LPN said that resident #2 does not self-apply medication; and that, the LPN was not aware of the policy of self-administration of medication as she was an agency nurse. Resident #2 who was present in the room during the interview then said that, she was too weak to apply the cream. In another observation conducte on March 20, 2023 at 1:00 p.m. it revealed that the medicated cream (triamcinolone 0.1%) and normal saline bottle were still found on bedside table. An interview was conducted on March 20, 2023 at 1:04 p.m. with registered nurse (RN/staff#55) who stated that the facility have a self-administration policy; but, the resident had to be assessed first and see if they were capable of performing the task themselves. The RN said that the resident must demonstrate they can administer it appropriately and understand timing between doses; and that, an order must also be present. The RN further stated that the determination that the resident can self-administer medications would be documented in the clinical record. A review of the clinical record was conducted with the RN during the interview. The RN stated that resident #2 was completely paralyzed in all 4 extremities, completely dependent, and could not administer medications at all. An interview with the director of nursing (DON/staff #36) was conducted on March 23, 2023 at 1:20 p.m. The DON stated that the facility has a policy for self-administration of medication. The DON said that an assessment must be performed to be sure the resident was safe to administer and there also needs to be an order from the physician. The DON stated that the resident does not self-administer medications because he is a quadriplegic. The DON also said that residents are permitted to self-administer and the medications would be stored in a locked box or drawer. If a resident is not permitted to self-administer medications, the medications would be stored in the nurses locked cart or locked medication room. The DON said that there would be a risk to other residents if medications are stored at bedside rather than being locked up because if a resident were to walk into another resident's room they could be exposed to medications they are not prescribed. Review of the self-administration of medications policy, revised December 2016 revealed that as part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. If the team determines a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications. The policy also states that self-administered medications must be stored in a safe and secure place which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication car or in the medication room. Nursing will transfer the unopened medication to the resident when the residents requests them. Staff shall identify and give to the charge nurse any medications found at bedside that are not authorized for self-administration for return to the family or responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical documentation, staff interviews, and facility policy and procedures, the facility failed to implement non-pharmacological interventions for continued use of psychotropic medication for two residents (#6 and #11). The census was 57. The deficient practice could result in resident receiving unnecessary psychotropic medications. Findings include: -Resident #6 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, major depressive disorder, Parkinson's Disease and schizoaffective disorder, bipolar type. A care plan initiated on January 27, 2020 revealed that resident use antipsychotic medication related to a bipolar diagnosis. Interventions included to give medication as per the physician's order, and to report the ineffectiveness of the medication to the physician at any point in the assessment phase. The care plan did not include non-pharmacological interventiosn for the use of antipsychotic medication. Review of the Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. Active diagnoses included depression, bipolar disorder, and schizophrenia. The clinical record revealed the resident was prescribed with Seroquel (antipsychotic) for bipolar disorder on November 19, 2022. It also included that Seroquel continued to be prescribed and transcribed onto the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from November 2022 through March 2023. Review of the for February 1 through and March 23, 2023 revealed that Seroquel was administered as ordered; and that, the resident was monitored for anti-psychotic side effects and target symptoms/behavior tracking such as episodes of tearfulness every shift. However, there was no evidence found in the clinical record that non-pharmacological interventions related to the use of the antipsychotic was developed and implemented. -Resident #11 was admitted on [DATE] with diagnoses of Alzheimer's Disease, anxiety disorder, depression, and schizoaffective disorder. The care plan dated September 25, 2022 revealed the resident was an antidepressant and antipsychotic medications. Interventions included to administer medications as ordered and to monitor/document side effects and effectiveness. The care plan did not include non-pharmacological interventions for the use of the antidepressant and antipsychotic medications. The Minimum Data Set (MDS) dated [DATE] included a BIMS score of 7 indicating the resident had severe cognitive impairment. The current Order Summary Report revealed orders for Olanzapine (antipsychotic) for schizoaffective disorder as evidenced by mood swings; and, Venlafaxine (antidepressant) for depression as evidenced by sad mood. These medications were transcribed onto the TAR from September 2022 through March 2023. Review of the MAR and TAR for February and March 2023 revealed that Olanzapine and Venlafaxine were administered as ordered; and that, the resident was monitored to side effects, target behaviors such as mood swings and sad mood. However, the clinical record revealed no evidence that non-pharmacological interventions related to the use of an antidepressant and antipsychotic was developed and implemented. An interview with the Care Coordinator (staff #39) and the MDS Director (staff #81) was conducted on March 23, 2023 at 8:51 a.m. Staff #39 stated that he completes the MDS and then completes the care plan; and that, use of high-risk medications, such as antipsychotics, antidepressants, and anti-anxiety would be included on the care plan and must include 2 to 3 interventions. Staff #39 stated that the purpose of the care plan was to basically give an insight for staff to understand what care was needed. During the interview, a review of the clinical record for residents #11 and #61 was conducted with staff #39 stated that the care plans for these two residents (#11 and #61) did not include non-pharmacological interventions. The MDS director (staff #81) stated that the most important thing to do was to monitor the side effects of the medications; but she was not aware of needing non-pharmacological interventions. Staff #81 further stated that if there was a physician order for non-pharmacological interventions related to the use of medications, then it would be included in the resident's care plan. The facility's policy, Psychotropic Medication Use, revised December 2018 states that for enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are not sufficiently relieved by non-pharmacological interventions. The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews and policy review, the facility failed to ensure pressure ulcers were consistently assessed, monitored, documented and treated for one (#21) of three sampled residents. The deficient practice could result in wound not being treated appropriately, delayed wound healing or worsening of the pressure ulcer. Findings include: Resident #21 was admitted on [DATE] with diagnoses of peripheral vascular disease, diabetes mellitus type 2, and acute kidney failure; and had a history of amputation of left toes related to gangrene infection. The resident was discharged to the hospital on November 5, 2022. The care plan dated March 15, 2022 included resident had a potential impairment to skin integrity related to impaired mobility. Interventions included to keep the skin clean and dry, use lotion on dry skin and good nutrition and hydration to promote healthier skin. The admission MDS (Minimum Data Set) assessment dated [DATE] included the resident was at risk for pressure ulcer; and that, the resident had no unhealed pressure ulcer. An encounter note dated March 25, 2022 included skin was warm and dry. Plan was for wound care team to follow and assess, document and make recommendations and to continue medical treatment. A late entry wound note dated April 11, 2022 revealed the resident had deep tissue injury to the right and left heels. Per the documentation, treatments were initiated. A care plan dated April 11, 2022 included resident had a potential for pressure ulcer development related to decreased mobility; and that, the resident had an actual DTI (deep tissue injury) to the right and left heels. Interventions included to administer medications as ordered; assess/record/monitor wound healing weekly and as necessary; measure length, width and depth and to assess/document status of wound perimeter, wound bed and healing progress; weekly assessments; and, follow facility policies/protocols for the prevention/treatment of skin breakdown. Another alert charting note dated April 13. 2022 revealed resident was non-compliant with heel boots A physician note dated May 6, 2022 included that resident had three deep tissue injuries with an onset date of April 11, 2022. However, the location of the injuries were not noted. The pressure ulcer documentation dated May 11, 2022 revealed unstageable pressure ulcer to the right lateral foot, right medial foot and right heel. The documentation did not include pressure wound to the left heel. A system note dated May 21, 2022 revealed resident was alert and oriented x 4 and skin integrity was better. The note did not indicate include identification, location, assessment or status of the wounds. The system note dated June 17, 2022 included the resident was alert and oriented, able to make needs known; and that, wound care to the right heel was complete and was healing well. The documentation did not include assessment and/or status of the wound to the left heel. A pressure ulcer documentation dated June 27, 2022 revealed unstageable pressure ulcer to the right lateral foot and right heel. The documentation did not include pressure wound to the left heel. Succeeding wound provider notes dated June 16, 24 and 29, 2022 included diagnoses of unstageable pressure ulcers for the right heel and other site; and a deep tissue damage to the left heel. However, the wound assessment was conducted for the pressure ulcer to the right right heel. The note did not mention assessment and/or status of the previously identified pressure ulcer wounds to the left heel. The wound provider note dated July 19, 2022 included diagnoses of stage 3 pressure ulcer to the right heel, unstageable pressure ulcer to other site and deep tissue damage to the left heel. However, only the wound to the right heel was documented as assessed. The documentation did not include assessment and/or status of the previously identified wound to left heel. The clinical record revealed documentation that the resident had pressure ulcer/injuries to the left heel; however, there was no evidence that the wound to the left heel was consistently assessed and monitored. The wound provider note dated August 10, 2022 revealed the location of the wounds were the right lateral foot and right heel. Diagnoses included stage 3 pressure ulcer to the right heel and unstageable pressured ulcer to other site and deep tissue damage to the left heel. However, documentation, assessment and plan was only for the wound to the right heel. Succeeding wound provider notes documented assessment and plan for the right heel only; and none for the left heel. Succeeding documentation in the clinical record revealed no clear indication that the pressure ulcer to the left heel was assessed and monitored. A physician order dated September 28, 2022 included an order to apply skin prep to the left heel two times a day for wound care; and had a stop date of October 24, 2022. This order was transcribed onto the Treatment Administration Record (TAR) for September 2022 and was documented administered as ordered. A physician note dated October 6, 2022 revealed that the reviewed problems included three separate entries of deep tissue injuries with onset date of April 11, 2022. However, the location of the injuries were not noted. An encounter note dated October 17, 2022 revealed the resident complained of heel ulcers. Per the note, the resident was being seen by the wound care team on a daily basis. Diagnoses included stage 3 pressure ulcer to the right and left heel. It also included that resident was diabetic with bilateral heel ulcers, probably stage 2-3 and had eschar that needed debridement. However, the wound care provider note dated October 19, 2022 included an unstageable pressure injury to the right heel; and, deep tissue injury to the left heel that received an outcome of resolved. Further review of the note revealed diagnoses of pressure induced deep tissue damage of sacral region and unstageable pressure ulcer of other site. However, the note did not include assessment of the sacral region and did not indicate the location of the other unstageable pressure ulcer. Despite documentation that the resident had deep tissue injury to the sacral region, there was no evidence found in the clinical record that the wound was assessed and treatment was initiated. A physician order dated October 23, 2022 revealed an order to apply skin prep to the left heel twice daily. A physician order dated October 26, 2022 included orders an order to cleanse the right heel with dakin's solution, pat dry, apply skin prep to peri wound area, apply nickel thick layer of Santyl to wound bed, place calcium alginate over Santyl and cover with a dry protective dressing two times a day; and, to not use foam dressing. These orders were transcribed onto the TAR for October 2022. A review of the TAR for October 2022 revealed that on the following dates, treatments were not administered as ordered: -Left heel: October 1, 2, 4, 5, 6, 20, 27 and 28; and, -Right heel: October 27 and 28, 2022 The clinical record revealed no documentation that treatment to the right and left heels was provided on the dates not marked in the TAR. There was also no documentation of any reason why treatments were not provided; and that, the physician was notified. An interview was conducted with a licensed practical nurse (LPN/staff #151) on December 8, 2022 at approximately 10:15 a.m. Staff #151 stated all physician orders must be followed; and that, that if a treatment is provided, it must be documented on the TAR. He stated that if a resident refuses the treatment, it must also be documented on the TAR or in the nursing notes. Further, staff #151 stated that if the treatment was not documented, it was not done. During an interview conducted with the DON (staff #219) on December 8, 2022 at approximately 12:45 p.m., the DON stated that all nurses are to administer treatments as ordered by the physician; and, the nurses are to document that treatment was provided or resident refusal in the clinical record. A review of the clinical record was conducted with the DON during the interview and the DON stated that wound treatments to the right and left heel for resident #21 for October 27, 2022 and October 28, 2022 were not documented as administered. The facility's policy/procedure regarding wound care revealed that it is their policy that a resident with a wound receive care to promote healing; and, nursing staff shall administer treatment per the physician's order. The policy also included all wound treatments should be documented in the resident's clinical record at the time they are administered, any problems or complaints made by the resident, and if the resident refused treatment and why.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to provide evidence that the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) was issued to one resident (#156). The sample size was 3 residents. The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #156 was admitted to the facility on [DATE] with diagnoses that included heart failure, anemia, hypertension, renal insufficiency, and diabetes mellitus. Review of the Notice of Medicare Non-Coverage (NOMNC) form revealed that the resident's last covered day under Medicare Part A was September 20, 2021. The form was signed by the resident on September 17, 2021. The clinical record included that the resident remained in the facility after September 20, 2021 until the resident's discharge on [DATE]. Review of the clinical record revealed no evidence that the SNFABN had been completed. The form was requested from the facility on February 8, 2022 and the facility documented that the form could not be located. An interview was conducted on February 8, 2022 at 1:55 PM with the Social Services Director (staff #65), who stated that once a resident is near discharge, she will explain the NOMNC and SNFABN forms to the resident and/or the representative. She said the forms are usually done at the same time and that the SNFABN explains the cost of the services if the resident decides to stay in the facility after the Medicare Part A last skilled day. She said that once the form is reviewed with the resident and/or representative, a signature would be obtained and the form would be scanned into the clinical record. She said the original copy would be kept in a notebook for 6 months. She stated that it would not be following the facility policy if the form was not completed and signed by the resident and/or representative. She reviewed the resident's clinical record and stated that an SNFABN form was not in the medical record and that she would not have documented that the SNFABN was completed in any other area of the record. An interview was conducted on February 9, 2022 at 1:00 PM with the Director of Nursing (DON/staff #17) who stated that the SNFABN form is completed by social services. The DON stated that the form should be completed when a resident is discharged from a Medicare Part A stay and remains in the facility after that date. She stated that the form would be reviewed with the resident or resident representative, a signature would be obtained, and the completed form would be scanned into the clinical record. The DON further stated that she reviewed the resident's clinical record and the SNFABN form was not found which did not meet the facility expectation. Review of the facility's Medicare denial notices revealed that the facility is to maintain compliance with issuance of Medicare beneficiary notices per Center for Medicare & Medicaid (CMS) guidelines. The policy noted that if a resident comes off of Medicare Part A and continues to reside in the facility under another payer source, the facility is to issue the SNFABN at the same time as the NOMNC. The policy noted that the form is to be signed and dated by the resident/representative and will be uploaded into the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and facility policy, the facility failed to ensure weights were completed as ordered and blood pressure medication was administered as ordered for one resident (#6). The sample was 17 residents. The deficient practice could result in residents not receiving medications or being weighed as ordered by the physician. Findings include: Resident (#6) was admitted to the facility on [DATE] with diagnoses that included low back pain, bed confinement, obesity, congestive heart failure, need for assistance with personal care, other reduced mobility, hypertensive heart disease with heart failure, and dementia without behavioral disturbance. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. -Regarding the resident's weights: Review of the physician's orders dated November 24, 2021, revealed to weigh the resident per the facility's protocol. The resident's weight was documented as 174.2 pounds via wheelchair on November 24, 2021. Review of a care plan initiated on November 24, 2021, revealed a risk for nutritional problems related to heart failure, hypertension and major depression with interventions including to provide weights as ordered. The resident was not weighed again until January 21, 2022. The weight was documented as 154.4 pounds via mechanical lift. The weight was flagged as a weight loss of 10.22% in two months. The resident was interviewed on February 9, 2022 at 8:12 AM. She stated that she has had a gastric bypass and was not concerned that she had lost weight. An interview was conducted on February 9, 2022 at 10:19 AM with a Registered Nurse (RN/staff #34) who stated the facility process for weighing residents includes daily weights for the first 3 days after admission, then every week for 4 weeks, then monthly after that. She also stated that if a resident is losing weight or had a diagnosis of heart failure and was collecting fluids, the resident would need to be weighed more often. She further stated that she would follow physician orders. She reviewed the physician's orders which stated weigh per protocol. The RN stated that the facility protocol for weighing residents includes weekly weights. She also reviewed the medical record and stated that weights had been documented twice since admission, on November 24, 2021 and January 21, 2022. She further stated that the resident was not weighed per facility protocol, and that it did not follow physician's orders. The RN stated that the risk of not completing weekly weights, would be that weight loss is not monitored. She also stated according that the resident's diagnoses of congestive heart failure it would be important to monitor weight. An interview was conducted on February 9, 2022 at 11:04 AM with the Director of Nursing (DON/staff #17) who stated that the facility protocol for weights is for daily weights the first 3 days after admission, then once a week for four weeks, then monthly. She reviewed the physician's orders and stated it was written for weights per facility protocol. She reviewed the documented weights and stated that the resident had not been weighed according to facility protocol, or the physician's order. She also stated that the resident had a weight loss of 20 pounds between November 2021 and January 2022. The facility weight assessment and intervention policy, revised September 2008, revealed that the nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. -Regarding the resident's blood pressure medication: Review of the February 2022 recapitulation of physician's orders revealed an order for diltiazem (a blood pressure medication) tablet 30 milligrams (mg) 0.5 tablet by mouth three times a day for hypertension, hold for Systolic Blood Pressure (SBP) <100 or Heart Rate (HR) <60 beats per minute. The Medication Administration Records (MAR) for November 2021 through February 2022 revealed the diltiazem was administered outside of the physician ordered SBP on 10 occasions. Also, from January 5 through January 27, the medication was documented as administered each day for three shifts a day, but there was no documentation of the resident's blood pressure results. Review of the clinical record revealed no documentation as to why the medication was not administered as ordered or that the physician had been notified. The clinical record also revealed no evidence the resident refused the medications. An interview was conducted on February 9, 2022 at 10:19 AM with an RN (staff #34), who stated that the facility process is to follow physician's orders as written, including those with parameters. She stated if the resident's blood pressure is outside of parameters, the medication would be held, and the physician would be notified. She further stated that the physician notification would be documented in the skilled nursing progress notes. An interview was conducted on February 9, 2022 at 11:04 AM with the DON (staff #17), who stated that the facility expectation is to follow physician's orders as written, including all parameters. She also stated that if a blood pressure or HR is outside of parameters, the medication would be held and the provider notified. She further stated that nursing should document physician notification in the progress notes. A second interview with the DON (staff #17) was conducted on February 9, 2022 at 1:00 PM. She reviewed the February 2022 MAR and stated that diltiazem was administered outside of ordered parameters. She also stated according to documentation on the MAR January 5 through January 27, 2022, diltiazem had been administered, but no SBP had been documented. The DON reviewed the December 4 through December 8, 2021 MAR and stated that diltiazem had been documented as administered on those dates, but the SBP was outside of parameters on seven occasions. She also reviewed the MAR dated November 28 and 30, 2021 and stated that diltiazem had been administered outside of parameters on both days. She reviewed the progress notes November 2021 through February 2022, and stated that she did not see any documentation that the physician had been notified regarding the resident's SBP. She further stated that this was not following physician's orders, and the medication had been administered outside of the parameters. She further stated the risk of diltiazem being administered outside of parameters could causes the resident to go into cardiac arrest. Review of the facility's medication administration policy, revised December 2012, revealed that medications shall be administered in a safe and timely manner and as prescribed. The policy included that medications must be administered in accordance with the orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedures, the facility failed to administer pain medication as prescribed for one resident (#38). The sample size was 3 residents. The deficient practice could result in residents receiving more pain medications than they require. Findings include: Resident (#38) was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis, pressure ulcer of right ankle, and major depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) with a score of 4 indicating severe cognitive impairment. The assessment included that the resident had received both scheduled and as needed pain medications in the past 5 days and that pain has made it hard for the resident to sleep at night. Review of the resident's pain care plan revealed that the resident had pain related to depression and wounds. Interventions included to provide pain medications as per physician's orders and to give oxycodone (an opioid) half an hour before treatments or care. The January 2022 recapitulation of physician's orders revealed the following orders for pain medication: -Percocet (oxycodone and acetaminophen) tablet 5-325 milligrams (mg), one tablet by mouth every four hours as needed for pain of 1-5 on a scale of 1-10. -Percocet tablet 5-325 mg, two tablets by mouth every four hours as needed for pain 6-10 on a scale of 1-10. Review of the Medication Administration Record (MAR) for January 2022 revealed that two tablets of Percocet was administered three times for a pain level of 5 despite the order showing to give the medication for pain levels of 6-10. On February 10, 2022 at 12:45 p.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #63), who stated that if a pain medication is given as needed, it should be given within the pain scale parameters on the physician's order. She said that if a pain medication is administered outside of the ordered parameters, the resident will be getting more medication than is required. She reviewed the order for the two tablets of Percocet and said that the medication was given out of parameters for a pain level of 5 on 3 occasions in January 2022. On February 10, 2022 at 1:01 p.m., an interview was conducted with the Director of Nursing (DON/staff #17), who stated that if a pain medication is prescribed on an as needed basis, it should include a pain scale. She reviewed the resident's January 2022 MAR and said that the two tablets of Percocet was given for a pain level less than 6. She said that there is a risk of oversedating the resident if the pain medication is given outside of the ordered parameters. The facility's medication administration policy, revised December 2012, revealed that medications shall be administered in a safe and timely manner and as prescribed. The policy noted that the individual administering the medication must check the label three times to verify that the medication is going to the right resident, is the right medication, includes the right dosage, is being administered at the right time, and is going to be administered using the right method (route) before giving the medication.

Based on an observation, facility documentation, staff interviews, and facility policy, the facility failed to ensure that one staff member's (staff #74) COVID-19 test was adequately completed and accurately documented. The facility census was 65 residents. The deficient practice could result in the spread of COVID-19. Findings include: An observation was conducted of staff COVID-19 testing on February 10, 2022 at 9:30 a.m. The Director of Nursing (DON/staff #17) had established a testing area by putting a blue chuck pad on a table. She placed a box of gloves in the upper left hand corner of the table just above the chuck. She then opened two rapid COVID-19 test cards and placed them on the chuck. At 9:35 a.m., she took a swab and tested staff #74. She put the swab into the test card and left it on the chuck. At 9:38 a.m., she used the same procedure and tested staff #40, again leaving the swab in the test card on the chuck. At approximately 9:45 a.m., she stated that the chuck on the table had been contaminated by the box of gloves that was in the upper left corner of the table because it had touched the upper left corner of the chuck when she pulled out a clean pair of gloves. She then threw the chuck and the test cards for staff #74 and #40 in the trash and said that she needed to start over. Between 9:51 and 10:03 a.m., the DON retested staff #40, tested and retested staff #71, tested staff #101, and tested staff #66. She did not retest staff #74. Review of facility testing documentation for February 10, 2022 revealed that it was documented that staff #74 had tested negative for COVID-19. An interview was conducted on February 10, 2022 at 11:09 a.m. with the DON (staff #17) and the Assistant Director of Nursing (ADON/staff #14). The DON stated that due to the global pandemic, it is important to monitor, control, isolate, and document COVID-19 test results accurately. She said the person doing the test is responsible for ensuring the test results are accurate. She said the test results for staff #74 were thrown away because she felt the test may be contaminated and so the staff member would need to be retested. She also stated that the documentation for the test results for February 10, 2022 was accurate. She reviewed the testing documentation and acknowledged that the documentation showed that staff #74 had tested negative and the documentation was inaccurate. She said she knew staff #74 had to be retested, and that is why she put the letter, R, next to his name. Upon further review of the testing documentation, she observed that there was not a letter R next to staff #74's name and stated that she would need to look at the current process. The facility's COVID-19 infection control policy, dated 2020, revealed that routine and outbreak testing will be conducted according to Center for Medicare & Medicaid Services (CMS) and Center for Disease Control (CDC) guidance. The policy noted that the facility will record the administration of employee testing as currently required and established for their records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, interviews, and policy review, the facility failed to provide three residents (#32, #34 and #154) and/or their representatives with a summary of their baseline care plans. The sample was 17 residents. The deficient practice could result in residents not being aware of their plan of care. Findings include: -Resident #32 was admitted to the facility on [DATE] with diagnoses that included frostbite of right toes and fingers and left toes and fingers, homelessness, and need for assistance with personal care. Review of the resident's care plan, initiated on January 7, 2022, included focus areas for impaired skin integrity related to frostbite of bilateral feet and finger tips, Activities of Daily Living (ADL) self care performance deficit, and pain related to frostbite diagnosis, Goals and interventions to address these areas were included. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. Review of the clinical record revealed there was no documentation that the resident and/or the resident's representative was provided a written summary of the baseline care plan. An interview was conducted on February 7, 2022 at 10:02 AM with the resident who stated that he was not sure if anyone has been in to tell him about treatments or medical care during his stay at the facility. The resident further stated he was waiting to hear if he was getting his toes amputated. -Resident #34 was admitted to the facility on [DATE] with diagnoses that included cellulitis of right lower limb, paraplegia, anxiety disorder, and need of assistance with personal care. Review of the resident's care plan, initiated on January 9, 2022, included focus areas for impaired mobility related to ADL self-care performance, difficulty breathing, bladder and bowel incontinence, anemia, and pain. Goals and interventions to address these areas were included. Review of the admission MDS assessment dated [DATE], documented a BIMS score of 13, which indicated intact cognition. Review of the clinical record revealed there was no documentation that the resident and/or the resident's representative was provided a written summary of the baseline care plan. -Resident #154 was admitted to the facility on [DATE] with diagnoses that included sepsis, cellulitis of right and left lower limb, urinary tract infection, lymphedema, need for assistance with personal care, and COVID-19. Review of the resident's care plan, initiated on January 30, 2022, included focus areas for altered respiratory status, deep vein thrombosis, incontinence, hypertension, impaired cognition, oxygen therapy and potential impairment to skin integrity. Goals and interventions to address these areas were included. Review of the admission MDS assessment dated [DATE], documented the BIMS score as 12, which indicated moderately impaired cognition. Review of the clinical record revealed there was no documentation that the resident and/or the resident's representative was provided a written summary of the baseline care plan. An interview was conducted on February 9, 2022 at 10:19 AM with a Registered Nurse (RN/staff # 34), who stated that the baseline care plan summary should be completed the day of admission. An interview was conducted on February 9, 2022 at 11:04 AM with the Director of Nursing (DON/staff #17) who stated that the initial care plan is completed on admission by the admitting nurse. The DON further stated that there should be a 48-hour care plan that is printed, reviewed with the resident or their representative, that should be signed and then scanned into the clinical record. She also stated that according to the facility policy this should be completed for all new admissions. She reviewed the clinical records for residents #32 and #154 and stated that she did not see the baseline care plan summary in the clinical records. An interview was conducted with the DON (staff #17), and Assistant Director of Nursing (ADON/staff #14) on February 10, 2022 at 12:46 PM. They stated that nursing should be completing the 48 hour baseline care plan summary. The ADON also stated that when nursing completes the summary it is signed by the resident and/or resident representative then scanned into the clinical record. She stated that she realizes that this is an issue and that the summary needs to be completed. The DON then reviewed the medical record for resident #34 and stated that she did not see the baseline care plan summary completed for this resident, and this did not meet the facility expectations. Review of the facility's baseline care plan policy, revised December 2016, revealed that a baseline care plan to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. The policy included that the resident and their representative will be provided a summary of the baseline care plan.

Based on facility documentation, staff interviews, and manufacturer's instructions, the facility failed to ensure that quality control solution testing was consistently completed on multi-use glucometers. The census was 65 residents. The deficient practice could result in glucometers that do not function properly and therefore provide inaccurate glucose level results. Findings include: Review of facility documentation revealed a glucose equipment quality check record which included sections for staff to document the glucometer number, the date the solutions were opened, discard date, lot number and range, date, time, the control range, if the glucometer passed or failed, action taken for reading outside control range, an area for a nurse signature, and comments. Further review of the records revealed that two glucometers (#1 and #2) on the rehabilitation unit were missing several control checks from October 2021 through February 7, 2022. Glucometer #1 and glucometer #2 were both missing over 10 days of control checks. An interview was conducted with a Registered Nurse (RN/staff #34) on February 7, 2022 at 9:20 AM, who stated that it is the facility policy that nursing completes the glucometer controls nightly and documents the results on the glucometer logs for each glucometer. She also stated that the glucometer logs are kept on the medication carts. She reviewed the logs for glucometer #1 and #2 on the rehabilitation unit and stated stated that there was no documentation that the control testing had been completed on multiple days in October 2021 through February 7, 2022. An interview was conducted on February 9, 2022 at 11:04 AM with the Director of Nursing (DON/staff #17) who stated that her expectation and the facility policy is that blood glucose controls should be completed daily on the night shift and documented on the control logs. The DON reviewed the glucometer control logs for glucometer #1 and #2 from the rehabilitation unit and said that there were several days between October 2021 through February 7, 2022 where the controls had not been documented. She stated that this did not meet the facility expectation. She said that the risk of the glucometer controls not being completed and documented daily could result in faulty readings, and if the glucometer is not accurate a nurse may administer more or less insulin than needed. The facility's daily task list for nursing revealed that night shift is responsible for checking parameters of glucometers daily after midnight. Review of the manufacturer's instructions for the glucometer control solutions included that the control solution may be used to check the performance of the glucometer. The instructions included that the test results obtained should fall within the control solution range printed on the vial of test strips being used. The manufacturer's instructions included to perform the control solution testing when using the meter for the first time, using a new bottle of test strips, to make sure the test strips and the meter are working together properly, and when the blood glucose test results do not reflect how the resident feels.

Based on observations, staff interviews, and facility policy, the facility failed to label and date food items in the nourishment rooms. The resident census was 65 residents. The deficient practice could result in food spoilage and foodborne illness. Findings include: An observation of a nourishment room on the rehabilitation unit on 2/8/2022 at 1:00 p.m. revealed that two open gallons of milk in the refrigerator did not include an open date. They had a use by date of 2/9/2022. In the nourishment room cabinets, a clear container containing a white grainy powder did not include a label or a date. An observation of a nourishment room on the Special Care Unit (SCU) was conducted on 2/8/2022 at 1:15 PM. In one of the cabinets, a clear container containing a white grainy powder did not include a label or a date. An interview was conducted with the Assistant Director of Nursing (ADON/staff #14) on 2/8/2022 at 1:30 PM. She stated that the container with the white substance was thickener used to thicken beverages. When asked how she knew it was thickener, she said she just knew because she has been a nurse for a long time. She said she would discard the thickener. During an interview with the Director of Nursing (DON/staff #17) on 2/8/22 at 1:45 PM, she said that the unlabelled milk should have been labeled with an open date. She also said the thickener should have been labeled. She said that everything should be labeled and dated. She said that this is important because without a label, staff won't know what is in the container or how long it has been there. An interview was conducted with the kitchen manager (staff #35) on 2/8/22 at 2:36 PM. She said that the dietary department stocked the nourishment refrigerators. She said that she normally has individual milk cartons, but the supplier was out of these, so that is why they were using the gallon sized milk in the nourishment fridges. She acknowledged that they were not labeled. The facility's food storage and data marking policy, dated 2018, revealed that plastic containers with tight fitting lids must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. The policy included that all containers must be legible and accurately labeled if products are not easily identifiable and an open date is recommended. The procedure included that food may be dated as it is placed on the shelves.