Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse when Resident 2 placed Resident 1's hand on her genital area without Resident 1's consent. This failure resulted in Resident 1 experiencing emotional distress. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in July 2024 with multiple diagnoses including wedge compression fracture of lumbar vertebra (fracture of the spinal column, lower back, caused by the front of the vertebra collapsing), dementia (a progressive state of decline in mental abilities), and metabolic encephalopathy (brain does not function properly due to an imbalance in the body's metabolism). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/20/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 0 out of 15 that indicated Resident 1 had severe cognitive impairment. A review of Resident 1's Care Plan indicated, .The resident has impaired cognitive function; impaired thought processes r/t [related to] dementia . initiated 7/24/24, indicated .Interventions .Keep the resident's routine consistent . A review of Resident 1's Progress Note, dated 8/5/24 at 1:30 p.m., indicated .It was reported that While [Resident 1] was seated in his wheelchair, in the hallway near [Resident 2], she took his hand and tried to place it in her genital area. Licensed Nurse [LN 1] observed the incident and responded immediately separating the 2. Writer took [Resident 1] to a private area to interview him regarding the incident. [Resident 1] has dementia a very poor short-term memory. I asked him how he was doing? He smiles and states good. I asked him if he remembered what had just happened? He smiles and looks a little confused. I asked him if anyone had touched him or made him feel uncomfortable? He smiles and states No. I asked him if he is being treated well here? He states yes. I asked him if he feels safe here? He states yes. [resident's name] was pleasant, polite and cooperative throughout our conversation and he continued to smile and was friendly. He did not exhibit any signs or symptoms of anxiety or distress right after the incident . A review of Resident 1's Progress Note, dated 8/5/24 at 2:45 p.m., indicated .Resident was observed @ 1315 [at 1:15 p.m.] in the hallway having his hand grabbed by [Resident 2] and she placed it on her genitalia area. Nurse immediately separated residents. Resident was tearful, nurse asked if resident was ok to which he replies, why wouldn't I be. Resident has dementia and not oriented to situation . A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in April 2019 with multiple diagnoses including dementia, cerebral infarction (stroke-loss of blood flow to a part of the brain), heart failure (a heart disorder which causes the heart to not pump blood efficiently), and diabetes (a disorder characterized by difficulty in blood sugar control). A review of Resident 2's MDS, Cognitive Patterns, dated 7/8/24, indicated Resident 2 had a BIMS score of 8 out of 15 that indicated Resident 2 had moderate cognitive impairment. A review of Resident 2's Care Plan .Behavior, Alteration In Inappropriate Sexual Touching of another resident . initiated 8/5/24, indicated .Interventions .Assess the resident's behavior for any causative or triggering factors .Do not seat the resident within reach of or in close proximity of another opposite sex resident during any activity or meal .Maintain awareness of the resident's location at all times .Observe the negatively affected resident for any S/SX [signs or symptoms] of being injured or emotionally negatively affected by the offending resident's actions or behaviors .Take action immediately .to prevent the resident from inappropriately touching the personal private parts of another resident, or other sexually oriented actions or behaviors .Take actions as needed to protect the helpless resident from inappropriate touching by another resident . A review of Resident 2's Progress Note, dated 8/5/24 at 1:30 p.m., indicated .It was reported by [LN1] that while [Resident 2] was seated in the hallway near t[Resident1], she took his hand and placed it near her genital area. [LN 1] separated the 2 immediately. Writer went to interview [Resident 2] regarding the incident. When I approached her she was visiting with her [Family Member] on the patio. I asked her if I could talk with her? She states What do you want to talk about? SEX!? I asked her if she would like to talk about anything? She states no. I asked her how she was feeling? She states okay. I asked her if she remembered her interaction with [Resident 1] in the hallway? She states no. I asked her if she feels safe here? She states yes. I asked her if everyone treats her well? She states yes. I reminded her that it is important to respect the personal space of others request their consent before touching and inappropriate touches aren't allowed. She was polite and respectful during our talk. She did not seem to remember or have any distress or anxiety related to the occurrence . A review of Resident 2's Progress Note, dated 8/5/24 at 3:30 p.m., indicated . Resident was observed [ at 1:15 p.m.] in the hallway grabbing another resident's [Resident 1] and placed it on her genitalia area. Nurse immediately separated residents. Resident was informed that that was inappropriate and not okay, to which she replied oh whatever. Resident has dementia and intermittently confused . A review of the facility's Incident Investigation Report, report date 8/5/24, incident date 8/5/24, indicated .What happened? .Resident [Resident 1] was seated in the hallway near nursing station 2. Resident [Resident 2] was next to him (both in wheelchairs). Resident 2 took [Resident1]'s hand and tried to place it in her own private areas .What caused the incident? .Resident with dementia inappropriate behavior .List corrective actions to be taken? .Staff reminded & updated regarding potential for residents with dementia to behave inappropriately .Care plans to monitor residents closely & redirect from inappropriate behavior . During an interview on 2/12/25 at 12:11 p.m. with Director of Staff Development (DSD), the DSD stated she was acting as LN 1 on 8/5/24. The DSD stated Resident 1 and Resident 2 were sitting in the hallway near the nurse's station when Resident 2 grabbed Resident 1's hand and tried to place it on her genital area. The DSD stated Resident 1 resisted and had tears in his eyes. The DSD stated Resident 1 was difficult to understand, mumbled his words, but mentioned his wife. The DSD stated residents were separated and she called Resident 1's wife. The DSD stated 72 hour monitoring for emotional distress for Resident 1 and behaviors for Resident 2 was initiated. During an interview on 2/12/14 at 12:19 with the Social Services Director (SSD), the SSD stated she interviewed Resident 1 and Resident 2 but neither recalled the incident. The SSD stated that nurses should chart monitoring for 72 hours after incident. During a concurrent interview and record review on 2/12/25 at 3:00 p.m. with the Director of Nursing (DON), the DON acknowledged that nursing staff did not document monitoring for emotional distress for Resident 1 or for behaviors for Resident 2 for 72 hours after incident. The DON stated it was the expectation that nurses monitor and chart in the progress notes for 72 hours after incident. The DON also acknowledged that Resident 1 did not have a care plan created for this incident, and it should have been created by nursing at the time of the incident. The DON stated that facility uses traveling nurses frequently and procedures may not have been followed. A review of the facility's Policy and Procedure (P&P) titled Abuse Prevention Program, revised 8/2006, indicated .Our residents have the right to be free from abuse .Our facility is committed to protecting our residents from abuse by anyone including .other residents . A review of the facility's P&P titled Abuse Investigations, revised 4/14, indicated .All reports of resident abuse .shall be thoroughly and promptly investigated by facility management . A review of the facility's P&P titled Charting and Documentation, revised 8/2008, .All services provided to the resident, or any changes in the resident's medical or mental condition shall be documented in the resident's medical record .All observations .must be documented in the resident's clinical record .All incidents, accidents, or changes in the resident's condition must be recorded . A review of the facility's P&P titled Care Plans-Comprehensive, revised 9/10, indicated .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Department a written report of the results of an abuse investigation within 5 working days of an incident that involved an abuse allegation of inappropriate touching for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential to delay the Department's investigation of abuse allegations which may have led to continued abuse. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in July 2024 with multiple diagnoses including wedge compression fracture of lumbar vertebra (fracture of the spinal column, lower back, caused by the front of the vertebra collapsing), dementia (a progressive state of decline in mental abilities), and metabolic encephalopathy (brain does not function properly due to an imbalance in the body's metabolism). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/20/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 0 out of 15 that indicated Resident 1 had severe cognitive impairment. A review of Resident 1's Progress Note, dated 8/5/24 at 1:30 p.m., indicated .It was reported that While [Resident 1] was seated in his wheelchair, in the hallway near [Resident 2], she took his hand and tried to place it in her genital area. Licensed Nurse [LN 1] observed the incident and responded immediately separating the 2. Writer took [Resident 1] to a private area to interview him regarding the incident. [Resident 1] has dementia a very poor short-term memory. I asked him how he was doing? He smiles and states good. I asked him if he remembered what had just happened? He smiles and looks a little confused. I asked him if anyone had touched him or made him feel uncomfortable? He smiles and states No. I asked him if he is being treated well here? He states yes. I asked him if he feels safe here? He states yes. Writer called [Resident 1]]'s wife to notify her of the occurrence and an . [a report of Suspected Adult/Elder Abuse] was documented and forwarded to CDPH [California Department of Public Health-The Department], The Ombudsman's office [an advocate for residents in nursing homes] and FBPD [Fort [NAME] Police Department]. Staff will monitor the residents and keep them separated . A review of Resident 1's Progress Note, dated 8/5/24 at 2:45 p.m., indicated .Resident was observed @ 1315 [at 1:15 p.m.] in the hallway having his hand grabbed by [Resident 2] and she placed it on her genitalia area. Nurse immediately separated residents. Resident was tearful, nurse asked if resident was ok to which he replies, why wouldn't I be. Resident has dementia and not oriented to situation. Notified SSD [Social Services Director], DON [Director of Nursing], Administrator and RP [Responsible Party] . A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in April 2019 with multiple diagnoses including dementia, cerebral infarction (stroke-loss of blood flow to a part of the brain), heart failure (a heart disorder which causes the heart to not pump blood efficiently), and diabetes (a disorder characterized by difficulty in blood sugar control). A review of Resident 2's MDS, Cognitive Patterns, dated 7/8/24, indicated Resident 2 had a BIMS score of 8 out of 15 that indicated Resident 2 was moderately cognitively impaired. A review of Resident 2's Care Plan .Behavior, Alteration In Inappropriate Sexual Touching of another resident . initiated 8/5/24, indicated .Interventions .Assess the resident's behavior for any causative or triggering factors .Do not seat the resident within reach of or in close proximity of another opposite sex resident during any activity or meal .Maintain awareness of the resident's location at all times .Observe the negatively affected resident for any S/SX [signs or symptoms] of being injured or emotionally negatively affected by the offending resident's actions or behaviors .Take action immediately .to prevent the resident from inappropriately touching the personal private parts of another resident, or other sexually oriented actions or behaviors .Take actions as needed to protect the helpless resident from inappropriate touching by another resident . A review of Resident 2's Progress Note, dated 8/5/24 at 1:30 p.m., indicated .It was reported by [Licensed Nurse 1] that while [Resident 2] was seated in the hallway near [Resident1], she took his hand and placed it near her genital area. [LN 1] separated the 2 immediately. Writer went to interview [Resident 2] regarding the incident. When I approached her she was visiting with her [Family Member] on the patio. I asked her if I could talk with her? She states What do you want to talk about? SEX!? I asked her if she would like to talk about anything? She states no. I asked her how she was feeling? She states okay. I asked her if she remembered her interaction with [Resident 1] in the hallway? She states no. I asked her if she feels safe here? She states yes. I asked her if everyone treats her well? She states yes. I reminded her that it is important to respect the personal space of others request their consent before touching and inappropriate touches aren't allowed. She was polite and respectful during our talk. She did not seem to remember or have any distress or anxiety related to the occurrence . A review of Resident 2's Progress Note, dated 8/5/24 at 3:30 p.m., indicated . Resident was observed [at 1:15 p.m.] in the hallway grabbing another resident's [Resident 1] and placed it on her genitalia area. Nurse immediately separated residents. Resident was informed that that was inappropriate and not okay, to which she replied oh whatever. Resident has dementia and intermittently confused. Notified SSD [Social Services Director], DON [Director of Nursing], Administrator and RP . A review of Resident 2's Progress Note, dated 8/5/24 at 5:24 p.m. indicated . [report name] regarding this incident was documented and faxed to CDPH . A review of the facility's Incident Investigation Report, report date 8/5/24, incident date 8/5/24, indicated .What happened? .Resident [Resident 1] was seated in the hallway near nursing station 2. Resident [Resident 2] was next to him (both in wheelchairs). Resident 2 took [Resident1]'s hand and tried to place it in her own private areas .What caused the incident? .Resident with dementia inappropriate behavior .List corrective actions to be taken? .Staff reminded & updated regarding potential for residents with dementia to behave inappropriately .reporting requirements. Care plans to monitor residents closely & redirect from inappropriate behavior . During an interview on 2/12/25 at 12:11 p.m. with Director of Staff Development (DSD), the DSD stated she was acting as LN 1 on 8/5/24. The DSD stated Resident 1 and Resident 2 were sitting in the hallway near the nurse's station when Resident 2 grabbed Resident 1's hand and tried to place it on her genital area. The DSD stated Resident 1 resisted and had tears in his eyes. The DSD stated Resident 1 was difficult to understand, mumbled his words, and mentioned his wife. The DSD stated residents were separated and she called Resident 1's wife. The DSD stated 72 hour monitoring for emotional distress for Resident 1 and behaviors for Resident 2 was initiated. The DSD stated she referred the incident to the SSD to follow up. During an interview on 2/12/14 at 12:19 p.m. with the SSD, the SSD stated she interviewed Resident 1 and Resident 2 but neither recalled the incident. The SSD stated she completed the Incident Investigation Report. The SSD stated she did not send the investigation report to the Department because, at the time of the incident, she was not aware that the report needed to be sent to the Department within 5 working days of the incident. The DSD stated she was not aware of the regulation because she was new to the position, but now she knows to send the report. A review of the facility's Policy and Procedure (P&P) titled Abuse Investigations, revised 4/14, indicated .All reports of resident abuse .Shall be thoroughly investigated by facility management .The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency .within five (5) working days of the reported incident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from abuse when Resident 1 hit with her fist Resident 2's thigh while they were seated close to each other. This failure caused pain and potential mental anguish to Resident 2. Findings: A review of Resident 1's medical records indicated the following: - The Quarterly Minimum Data Set (MDS - federally mandated clinical assessment) dated 9/23/24 indicated Resident 1 had severe memory issues. - The MDS further indicated Resident 1 had delusions (misconceptions or beliefs that are firmly held, contrary to reality) and exhibited verbal behavior symptoms directed towards others such as threatening, screaming, and cursing at others; - Resident 1's order summary report for 12/2024 indicated she was receiving Quetiapine Fumarate (an antipsychotic - medications used to treat several kinds of mental health conditions to regulate your mood, behaviors and thoughts) 50 milligram (mg, unit of measure) tablet in the afternoon and 25 mg in the morning for severe dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), with agitation. - Resident 1's care plan dated 8/1/24 indicated verbally abusive behaviors directed towards roommates, confused residents, and aggressive behaviors involving striking out at others, interfering with other resident's activities, etc. - Resident 1's care plan Interventions included: assist the resident from the confused resident's presence if the resident becomes abusive at the confused resident in a public environment or area; attempt to redirect the resident away from others if the resident is behaving aggressively or overly assertive manners or behaviors - be aware that the resident may not be easily redirected; do not locate or assist the resident to a location that enables the resident to be able to reach another resident by striking out when stimulated by the other resident. A review of Resident 2's medical records indicated the following: - The Quarterly MDS dated [DATE] indicated Resident 2 had minimal hearing difficulty, cognition severely impaired, difficulty focusing attention, easily distracted, difficulty keeping track of what was said, exhibits disorganized thinking manifested by incoherent, rambling and unclear or illogical flow of ideas. - Resident 2's face sheet (one-page summary of important information about a patient, includes patient identification, allergies, insurance status, or other pertinent information like diagnosis on admission) indicated she was admitted with multiple diagnoses which inlcuded unspecified dementia without behavior disturbance. During an interview on 12/23/24, at 11:39 AM, Unlicensed Staff A stated, on the day of incident residents including Resident 1 and Resident 2 were out in the hallway seated in their wheelchairs near each other across the nurses' station. Unlicensed Staff A stated, Resident 1 said something to Resident 2, then Resident 1 said: what, are you not gonna answer me? Resident 1 then hit with her balled fist Resident 2 on the thigh area and Resident 2 said, Ouch! Unlicensed Staff A told Resident 1: you could not be hitting others, as she took her back to her room. A review of the facility's policy titled: Preventing resident abuse taken from the Operational policy and procedure manual for long-term care 2021 Med Pass, Inc., revised 12/2013, indicated, the facility's goal was to achieve and maintain an abuse-free environment and assess residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavior issues.

Based on interview and record review, the facility failed to report an alleged resident abuse immediately when Resident 1 allegedly hit Resident 2 who was sitting near and opposite her. This failure reduced the faciltiy's potential to ensure resident safety. Findings: A review of facility Transmission Verification report sent 11/11/24 at 4:52 p.m. and received by the Department on 11/12/24 at 8:00 a.m., indicated an allegation of suspected dependent adult/elder abuse had been made related to a resident-to-resident altercation between Resident 1 and Resident 2. A review of the Report of Suspected Dependent Adult/Elder Abuse (documenting a report of abuse or neglect of an elder or dependent adult) between Resident 1 and Resident 2, indicated the incident happened on 11/10/24, at 4:18 p.m. During a review of record and concurrent interview on 12/23/24 at 11:45 a.m., the facility's abuse prevention policy did not indicate a timeframe for reporting suspected abuse incidents. The DON stated they follow the flowchart of Mandated Reporter (attached in facility documents) posted on his workstation. The DON was not familiar with the reporting requirement timeline for alleged abuse incident after he was informed by the Department that alleged incidents of abuse were reported not later than 2 hours after the allegation is made. A review of the facility's policy titled: Reporting abuse to State Agencies and other entities/individual, indicated, all suspected violations . of abuse will be immediately reported to appropriate state agencies . as maybe required by law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate the Level II Preadmission Screening (PASARR) after a positive result for Level I PASARR) for one (1) of eight (8) residents, Resident 17. This failure resulted in a delay of MD's evaluation for mental illness and a delay of care and services needed for Resident 17. Findings: Level II PASARR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in a nursing home for long term care. A record review of Resident 17 titled admission record indicated she was initially admitted to the facility on [DATE] with mental illness (MI). A record review of Resident 17's evaluation titled Level I PASARR dated 08/10/21 was positive indicated a Level II PASARR mental health evaluation from Department of Health Services was required. A review of the regulatory health and safety code § 483.20(e)(1) Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. A review of the regulatory health and safety code § 483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Mental Disorder (MD) For purposes of this section, the term mental disorder is the equivalent of mental illness used in the definition of serious mental illness in 42 CFR. A review of regulatory health and safety codes §483.102(b)(1), which states: An individual is considered to have a serious mental illness (MI) if the individual meets the following requirements on diagnosis, level of impairment and duration of illness: (i) Diagnosis. The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised in 1987. This mental disorder is- (A) A schizophrenic, mood, paranoid, panic, or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure for one out of six sampled residents (Resident 12): 1.was using his continuous positive airway pressure (CPAP, a breathing therapy device that delivers air to a mask worn over the nose) every night at bedtime and staff was assisting him on putting on his CPAP mask. 2.staff obtained a physician order for the setting of his CPAP machine. 3.staff put on a no smoking signage in his room since he was using a CPAP. These failures could lead to daytime Fatigue (lack of energy), high Blood Pressure, low oxygen levels, increased Blood Sugar, elevated heart rate, headaches, and mood changes. Findings: A review of Resident 12's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Essential Hypertension (HTN, high blood pressure) and Muscle Weakness. His Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 2/25/24 indicated Resident 12 needed up to maximum assistance when performing his ADL. Resident 12 was dependent on staff with lower body dressing and when putting on or taking off his shoes. His Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score dated 2/23/24 score was 14 indicating intact cognition. During a concurrent observation and interview on 5/20/24 at 2:54 p.m., a CPAP machine was noted on Resident 12's bedside table on his left side. Resident 12 stated he had not used his CPAP regularly for months now because staff would not assist him in wearing his CPAP mask. Resident 12 stated he had difficulty wearing the CPAP mask by himself due to the location of his CPAP and because of some issue with his hand strength and dexterity when putting on the mask. Resident stated staff would often not help putting on his CPAP mask and would often say, you can do it yourself. Resident 12 stated there was also the plan for a room transfer so that he could have an easier access to his CPAP, but it had not happened yet. Resident 12 stated he wished he could wear his CPAP every night. There was not a no smoking sign noted in his room. Resident 12 stated there was not a no smoking sign posted in his room for as long as he could remember. During an interview on 5/23/24 at 9:00 a.m., the Director of Nursing (DON) verified Resident 12 had a CPAP. The DON stated he was not aware Resident 12 was not using his CPAP every night. The DON stated nurses should have assisted him in using his CPAP every night. The DON stated the way his CPAP was situated in his room made it difficult for Resident 12 to put on his CPAP so the plan was to change room where Resident 12 could have an easier access to his CPAP. The DON stated since the room change had not happened yet, it was important for staff to assist him on using his CPAP every night. The DON was unable to provide explanation on why the room change had not happened yet. When asked what the risks could be if Resident 12 was not using his CPAP regularly, the DON stated it was a risk for fatigue, low oxygenation level and mood changes. During an interview on 5/23/24 at 11:06 a.m., Licensed Staff D stated it was important to ensure there was a physician order that indicates the proper setting of Resident 12's CPAP machine. Licensed Staff D stated staff should always help Resident 12 put on his CPAP if he requested it no matter what his capabilities were. Licensed Staff D stated Resident 12 not using his CPAP every night meant the physician order was not followed. Licensed Staff D stated not using the CPAP regularly could affect Resident 12's quality of life, he'll feel tired, and could affect his sleep and breathing could be affected as well. During an interview on 5/23/24 at 12:20 p.m., the IP stated staff should ensure there was a physician order regarding the proper setting of Resident 12's CPAP machine. The IP stated it was important to ensure Resident 12 was using his CPAP machine every night. The IP stated if Resident 12 requested for help in putting on his CPAP mask, staff should not ignore his request. The IP stated Resident 12 not using his CPAP every night was a safety risk and could lead to less oxygenation which was a big problem. During a concurrent interview and CPAP physician order dated 4/2/24 record review on 5/23/24 at 2:37 p.m., the DON verified Resident 12 had an order for the CPAP but was missing important components such as setting for oxygen concentration and flow. The DON stated it was important to ensure the setting for Resident 12's CPAP was appropriate to ensure he was getting the amount of oxygen he needed throughout the night for his safety and comfort. During a concurrent observation and interview on 5/23/24 at 5:20 p.m., Licensed Staff D verified there was not no smoking sign posted in Resident 12's room although he was using CPAP. Licensed Staff D stated there should be a no smoking sign posted in his room. Licensed Staff D stated it was important to have this signage in his room to prevent risk of accidents and fire. During an interview on 5/23/24 at 5:24 p.m., the IP stated residents using CPAP should have a no smoking signage posted in their room. The IP stated the no smoking signage could decrease the risks for fire and accidents. A review of the physician order for CPAP dated 4/2/24 did not include the mode and the proper setting for his CPAP machine. A review of the facility's policy and procedure (P&P) titled CPAP/BiPAP Support, revised 3/2015, the P&P indicated to review the physician's order to determine the oxygen concentration and flow .review and follow manufacturer's instruction for CPAP machine set up and oxygen delivery .a no smoking sign for the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure for one out of six sampled residents (Resident 1) 1.in gaining access to hearing services by obtaining an audiologist (a specialist in the treatment of hearing disorders) referral. 2. making an appointment to see an audiologist. 3 .Resident 1's hearing aids (HA, a small electronic devices that amplify sound, help improve hearing and speech comprehension in people with hearing loss) were checked for functionality. These failures led to Resident 1's having difficulty in hearing spoken words. These failures put Resident 1 at risk for miscommunication, frustration and difficulty understanding spoken words. Findings: A review of Resident 1's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. Her diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Type 2 Diabetes Mellitus (DM, disease caused by a problem in the way the body regulates and uses sugar as a fuel) and Muscle Weakness. Her Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 3/15/2024, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 14 indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 1's functional status indicated she needed set up to moderate assistance when performing his Activities of Daily Living (ADL, activities related to personal care which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During a concurrent observation and interview on 5/21/24 at 9:58 a.m., Resident 1 was noted to be hard of hearing. Resident 1 stated she was hard of hearing on both ears with her left ear being worse than the right ear. Resident 1 stated she had not been seen by the audiologist and nobody offered it. She stated she had requested to see an audiologist, but she had not seen one up to this day. Resident 1 stated her HA was not working properly. She stated as far as she knew, staff just did not attempt to look into why her HA was not functioning properly and staff did not attempt to put her HA again. During a concurrent observation and interview on 5/22/24 at 9:15 a.m., Resident 1 was not wearing a HA. Resident 1 stated she would like to see an audiologist and would like wear HA again. During a concurrent observation and interview on 5/23/24 at 8:50 a.m., Resident 1 was not wearing a HA. Resident 1 stated she would very much like to see an audiologist and would like to wear HA again. During an interview on 5/23/24 at 10:03 a.m., the Director of Nursing (DON) stated he was not sure if Resident 1 had been seen by the audiologist. The DON stated Resident 1 need to see an audiologist. The DON verified Resident 1 was hard of hearing (HOH, feeling like speech and other sounds are quiet or muffled, having trouble hearing other people). During an interview on 5/23/24 at 10:40 a.m., the Social Services Director (SSD)/ Medical Records Director (MRD) verified Resident 1 was HOH. The SSD/ MRD stated Resident 1 had not seen an audiologist as far as she could remember. The SSD/MRD stated as far as Resident 1's HOH was concerned; she does not have anything actively pursuing at this time. The SSD/MRD stated the facility had no protocol on how to address issues when resident was HOH. The SSD/MRD stated in hindsight, Resident 1 could have benefitted if she was referred and seen by an audiologist or be fitted with a functioning HA. The SSD/MRD stated not hearing properly could lead to misunderstanding and not being able to get their concerns addressed. During an interview on 5/23/24 at 11:58 a.m., the Activity Director (AD) stated Resident 1 was HOH and should have seen the audiologist to see if anything could help with her hearing. The AD stated difficulty of hearing was a safety risk and would put Resident 1 at risk for miscommunication, not understanding instructions and frustration. During an interview on 5/23/24 at 12:03 p.m., Licensed Staff D verified Resident 1 was HOH and should have seen an audiologist to see if she needed a new HA and to address difficulty of hearing. Licensed Staff D stated residents with difficulty hearing was at risk for miscommunication and frustration. Licensed Staff D stated this was also a dignity issue. During an interview on 5/23/24 at 12:20 p.m., the Infection Preventionist (IP) stated residents who were HOH needs to be seen by the audiologist and be fitted for HA if needed. The IP stated HOH could put residents at risk for miscommunication, residents getting upset, angry and frustrated. During an interview on 5/23/24 2:22 p.m., the DON stated residents' who were HOH should be offered an audiologist referral. The DON stated that in Resident 1's case, the facility had assumed this was discussed between family and the Administrator. When asked if an audiologist referral was offered to Resident 1, the DON stated not to his knowledge. When asked what the risks could be if a resident was HOH, the DON stated it would be a risk for miscommunication and could lead to resident's frustration. During an interview on 5/24/24 at 9:49 a.m., Licensed Staff E stated residents who were HOH were at risk for anger, frustration, refusal of care, miscommunication, and poor care outcome. Licensed Staff E stated Resident 1 was HOH, so the facility would need to notify the physician and request for referral to see what could be done to improve Resident 1's hearing. During a concurrent observation and interview on 5/24/24 at 11:09 a.m., Resident 1 was not wearing a HA. Resident 1 stated nobody had talked to her about getting an audiologist referral and HA although she had mentioned this request to several staff. Resident 1 stated she needed the referral, and the Administrator knew about these requests. A request for the facility's P&P for residents with HOH was requested but was not provided. A review of the facility's policy and procedure (P&P) titled Activities of Daily Living (ADL), Supporting, revised 3/2018, the P&P indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADL's.

Based on interviews and record reviews, the facility failed to ensure that one out of four sampled residents, Resident 23, received Range of Motion (ROM- means the extent or limit to which a part of the body can be moved around a joint or a fixed point; the totality of movement a joint is capable of doing. Range of motion of a joint is gauged during passive ROM (assisted) PROM or active ROM (independent) AROM) exercises as ordered by her physician and according to her comprehensive care plan. This failure had the potential to result in the development of new contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) or worsening of contractures to her left and right ankles that could affect her health and well-being. Findings: A review of Resident 23's admission Record, dated 5/23/24, indicated that her principal diagnosis was Multiple Sclerosis (a chronic degenerative, often episodic disease of the central nervous system marked by patchy destruction of the myelin that surrounds and insulates nerve fibers, usually appearing in young adulthood and manifested by one or more mild to severe neural and muscular impairments, as spastic weakness in one or more limbs, local sensory losses, bladder dysfunction, or visual disturbances). Resident 23's other diagnoses included contractures to left and right ankles, and paraplegia (Paraplegia is a term used to describe the inability to voluntarily move the lower parts of the body. The areas of impaired mobility usually include the toes, feet, legs, and may or may not include the abdomen). A review of Resident 23's MDS, (Minimum Data Set) Section G, Cognitive Patterns, dated 4/9/24, indicated that her BIMS, (Brief Interview for Mental Status) score was 15, meaning she did not have any cognitive (Cognitive means relating to the mental process involved in knowing, learning, and understanding things) impairment. A review of Resident 23's Order Summary Report, active orders as of 5/23/24, indicated that she had an order written by her physician on 11/27/23, which states, RNA (Restorative Nursing Assistant): PROM with bilateral (both) UE (upper extremities), 2-3 times per week or as tolerated. A review of Resident 23's Care Plan, for Multiple Sclerosis, initiated on 1/6/21, indicated the goal, Resident 23 will remain free of complications or discomfort related Multiple Sclerosis through the review date. One of the interventions for this care plan initiated on 1/6/21, indicated, Range of motion (Active or Passive) with AM/PM care daily. During an interview on 5/23/24, at 10:43 a.m., with Unlicensed Staff H, he stated that the person who did RNA left a long time ago. During an interview on 5/23/24, at 11:05 a.m., with Licensed Staff D, she stated that the RNA was the person doing the ROM exercises with the residents. Licensed Staff D stated that facility did not have an RNA for about two months now due to the staff's medical leave of absence. During an interview on 5/23/24, at 11:30 a.m., with Resident 23, she stated nobody has been doing ROM exercises with her, not the former RNA, nor the CNAs (Certified Nursing Assistants). Resident 23 stated that the CNAs would not know how to do the ROM exercises, nor would they have the time to do it. Resident 23 stated that she needed some ROM exercises on her left leg. During an interview on 5/24/24, at 9:12 a.m., with the Director of Nursing (DON), he stated that the facility did not have the services of an RNA but could not recall for how long. A review of a facility document titled, Restorative Nursing Program, dated 5/28/13, the document indicated on the introduction, Restorative Nursing program is a service provided by the facility generally under nursing, to ensure maintenance of patient's optimum level of function. The patients on this program are encouraged or assisted to achieve and maintain their highest level of self-care and independence. These services must be performed daily. The Restorative Program has four components: 1. Gait /ambulation 2. ROM 3. ADLs (Activities of Daily Living) 4. Feeding The program may also involve occasional wound care patients.

Based on interview and record review, the facility failed to identify three instances of abuse, when: 1) One unlicensed staff member withheld food for one resident (unidentified resident) due to the resident's behavior; 2) Staff neglected to change briefs soiled with urine and feces, resulting in skin breakdown (no specific resident was identified) and staff verbally abused a resident (Resident 19), who was one out of one sampled resident. These failures to identify abusive behavior from a staff member toward residents created an environment where residents' rights were violated, and the residents were fearful to report any abusive behaviors from the staff for fear of retaliation. Findings: During a telephone interview on 2/8/24 at 8:35 a.m., a Complainant indicated there were bad things going on between a staff person and the residents, but specifically something happened around 1/25/24, and it was bad. The Complainant indicated the resident involved wanted anonymity and no names were identified. The Complainant indicated, since the Administrator started working at the building in 2022, the residents and staff would not discuss concerns or issues. The Complainant indicated the residents were fearful the building would close if any complaints or issues were brought up to the Administrator. The Complainant indicated the staff turnover had been high since 2022, and the residents did not feel safe with the staff, and the staff would not advocate for them since the staff seem scared of the Administrator. During an interview on 2/15/24 at 11:40 am., in Resident 87's room, Resident 87 was asked if he had been aware of any staff incidents with the residents. Resident 87 indicated things that do not affect him, he would leave alone. Resident 87 was asked if he heard anything since his room was so close to the nurses' station, and he responded with the same message and then abruptly changed the subject to how his hair had turned white overnight. A review of Resident 87's, Annual Assessment, MDS (Minimum Data Set, a clinical assessment process which provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 2/4/24, indicated Resident 87 had a BIMS (Brief Interview of Mental Status) score of 15, indicating zero cognitive impairment. During an interview on 2/15/24 at 11:51 a.m., with Unlicensed Staff A, Unlicensed Staff A indicated she had overheard Unlicensed Staff C yelling at Resident 19 in Resident 19's room. Unlicensed Staff A indicated the words were not distinguishable and could not explain what was said but the tone was hostile and angry. During an interview on 2/15/24 at 12:10 p.m., with Director of Staff Development (DSD), the DSD indicated a licensed staff member (Licensed Staff B) had requested the DSD's presence in meeting with Administrator regarding the behavior of Unlicensed Staff C. The DSD indicated the meeting with the Administrator, the DSD and Licensed Staff B had taken place, and the topic centered around Unlicensed Staff C was not being respectful to the volunteer religious group who had visited the facility during Unlicensed Staff C's shift. Unlicensed Staff C was described by the DSD as being unprofessional to the group of visitors, in the entrance part of the facility and not around the residents. The DSD indicated the behavior of Unlicensed Staff C did not involve other residents and she was not aware of any other incidents with Unlicensed Staff and other residents. During an interview on 2/15/24 at 12:41 p.m with Director of Nursing (DON), the DON indicated, if there were any abuse issues at the facility, he would notify the Administrator who would then report to the Department and other entities. The DON indicated there were no issues with staff altercations and residents. During an interview on 12/15/24 at 1:02 p.m., with Licensed Staff B, Licensed Staff B indicated there had been an issue with Unlicensed Staff C and Resident 19, where Resident 19 requested Unlicensed Staff C to not be her caregiver for the day (2/4/24) because Unlicensed Staff C had yelled at Resident 19. Licensed Staff B indicated Unlicensed Staff C had stated to another resident (unidentified, could not remember name), Is this what I am going to be dealing with this all day? Licensed Staff B indicated Unlicensed Staff C's anxiety was too high, and Unlicensed Staff C was continuing to yell and agitating the other residents. Licensed Staff B indicated Unlicensed Staff C was crying at the nurses' station, later she was observed sitting on the floor in the break room, acting strange, and Licensed Staff B thought Unlicensed Staff C could not finish her shift but was not considered safe to drive home either. Unlicensed Staff C was encouraged to sleep in the car until she was able to drive home safely. Licensed Staff B indicated this was not the first incident, as there had been others and there was a meeting with the DSD and the Administrator regarding the behavior of Unlicensed Staff C, with regards to residents and co-workers. Licensed Staff B indicated, on other instances, Unlicensed Staff C was yelling at residents and making them feel bad and uncomfortable. Licensed Staff B indicated the Administrator was aware of the behavior issues with Unlicensed Staff C. Licensed Staff B indicated she was not aware of the employment status of Unlicensed Staff C and thought maybe the Administrator might have terminated her. During an interview on 2/15/24 at 2:45 p.m., with the Social Services Assistant (SSA), the SSA indicated she was aware of the incident (2/4/24) regarding the behavior of Unlicensed Staff C as she was at the facility the day of the incident. The SSA indicated there were no direct observations of Unlicensed Staff C providing resident care because Unlicensed Staff C was in her car asleep. The SSA indicated Unlicensed Staff C had to stay in the car and sleep the rest of the shift due to her behavior. The SSA indicated, if there were instances of abuse with staff and residents, the Administrator would be notified and report any instance of abuse. The SSA indicated she did not think Unlicensed Staff C was abusive toward the residents and had not been aware of any other instances about Unlicensed Staff C's previous behavior. During a concurrent interview and record review on 3/13/24 at 11 a.m., with the Administrator, Unlicensed Staff C's, Untitled Disciplinary Document, dated 1/21/24, was reviewed. The Administrator confirmed the narrative of the document was written by Licensed Staff B who indicated in the document that Unlicensed Staff C would not change residents' briefs, and due to being left soiled for a period of time, the skin had changed color, creating a pink line. Unlicensed Staff C was indicated to refuse changing a resident's (unidentified resident in document) soiled brief of urine and feces because it had been done, and Unlicensed Staff C would not be able to control when residents would soil their briefs or not. Licensed Staff B indicated in the document, that Unlicensed Staff C repeatedly left the residents in her care soiled so when the next shift made rounds (checking on residents visually to see if they required assistance or care) on those residents, they were soaking wet with urine and feces. Licensed Staff B indicated this had been reported to the DON, the DSD and the Administrator without any improvement from Unlicensed Staff C. The Administrator indicated the document reviewed was correct and indicated, leaving a resident soiled and refusing to change a resident was not considered neglect or mental anguish. The Administrator indicated the allegation was investigated, and when Unlicensed Staff C was questioned about the allegation, Unlicensed Staff C denied residents were left soiled for the oncoming shift. The Administrator indicated Licensed Staff B was reputable in reporting the issues, but the results of the investigation indicated no abuse had taken place, and there was no abuse taking place. A review of, Untitled Disciplinary Document, dated 1/22/24, with the Administrator and found to be accurate, indicated Licensed Staff B observed Unlicensed Staff C to be away from residents and found to be asleep for one and one-half hours. The same document noted another dated incident on 12/27/23, where Licensed Staff B indicated Unlicensed Staff C was observed missing during the shift and was found sleeping in her car, and when staff knocked on the window, Unlicensed Staff C would not wake up and did not return to resident care for approximately two and one-half hours. The same document included another incident, dated 1/20/24, where Licensed Staff B indicated during the lunch time meal, Unlicensed Staff C was observed by Licensed Staff B to remove the lunch tray, stating, He can't eat my food, if he acting like that towards me. The Administrator indicated the incident was not considered disciplinary abuse or mental anguish for the resident. The Administrator indicated Unlicensed Staff C was asked about the incident and denied the incident occurred. The Administrator indicated the result of the investigation indicated the incident was not considered abuse. A review of, Untitled Disciplinary Document, dated 2/6/24, was reviewed with Administrator, which indicated Unlicensed Staff C was observed at work, with mental confusion, slurred speech and could not keep her balance and walk appropriately. Unlicensed Staff C was indicated to be yelling at residents and co-workers which was described as dangerous to residents. Licensed Staff B indicted the DON was at the facility during the incident. The document, dated 2/6/24, indicated Unlicensed Staff C was recommended for termination by the DON and Administrator. The Administrator indicated Unlicensed Staff C had reported to work under the, influence, and the Administrator did not agree that having a staff member caring for residents under the, influence or with the described behavior by Licensed Staff B, could be considered abusive to the residents. The Administrator indicated all four instances (12/27/23, 1/21/24, 1/22/24 and 2/6/24) were investigated and found not to be an issue of abuse, but more of a personnel matter, which was why Unlicensed Staff C was terminated from the facility. Resident 19 was unable to be interviewed as the medical record indicated he had been transferred to the hospital on 2/15/24, and wanted to be transferred to another facility rather than returning to the facility. During a review of the facility's policy titled, Reporting Abuse to Facility Management Policy, dated 11/30/17 indicated, it is the responsibility of our employee, facility consultants, Attending Physicians, family members, visitors etc. to promptly report any incident or suspected incident of neglect .Our facility does not condone resident abuse by anyone, including staff members, physicians, consultants .Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents .or within their hearing distance .Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness .All personnel, residents, family members, visitors, etc. are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff. Employees .must immediately report any suspected abuse or incidents of abuse to the Administrator . In the absence of the Administrator such reports may be made to the director of Nursing or Charge Nurse .any Individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, Director of Nursing Services, or charge Nurse.

Based on interview and record the facility failed to identify and report three instances of abuse when the Administrator had documented disciplinary actions (1/21/24, 1/22/24 and 2/6/24) for one unlicensed staff (Unlicensed Staff C) and did not notify the Department. These failures to report abusive behavior from unlicensed staff towards residents created an environment where residents' rights were violated, and the residents were fearful to report any negative behaviors from staff due to retaliation. Findings: During a telephone interview on 2/8/24 at 8:35 a.m., with a Complainant, the Complainant indicated there were bad things going on between a staff person and the residents, but specifically something happened around 1/25/24, and it was bad. The Complainant indicated the resident involved wanted anonymity and no names were identified. The Complainant indicated, since Administrator started working at the building in 2022, the residents and staff would not discuss concerns or issues. The Complainant indicated the residents were fearful the building would close if any complaints or issues were brought up to the Administrator. The Complainant indicated staff turnover had been high since 2022, and the residents did not feel safe with the staff, and the staff would not advocate for them since the staff seemed scared of the Administrator. During an interview on 2/15/24 at 11:40 am., in Resident 87's room, Resident 87 was asked if he had been aware of any staff incidents with the residents. Resident 87 indicated things that do not affect him, he would leave alone. Resident 87 was asked if he heard anything since his room was so close to the nurses' station, and he responded with the same message and then abruptly changed the subject to how his hair had turned white overnight. A review of Resident 87's, Annual Assessment, MDS (Minimum Data Set, a clinical assessment process which provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 2/4/24, indicated Resident 87 had a BIMS (Brief Interview of Mental Status) score of 15, indicating zero cognitive impairment. During an interview on 2/15/24 at 11:51 a.m., with Unlicensed Staff A, Unlicensed Staff A indicated she had overheard Unlicensed Staff C yelling at Resident 19 in Resident 19's room. Unlicensed Staff A indicated the words were not distinguishable and could not explain what was said but the tone was hostile and angry. During an interview on 2/15/24 at 12:10 p.m., with Director of Staff Development (DSD), the DSD indicated a licensed staff member (Licensed Staff B) had requested the DSD's presence in meeting with Administrator regarding the behavior of Unlicensed Staff C. The DSD indicated the meeting with the Administrator, the DSD and Licensed Staff B had taken place, and the topic centered around Unlicensed Staff C was not being respectful to the volunteer religious group who had visited the facility during Unlicensed Staff C's shift. Unlicensed Staff C was described by the DSD as being unprofessional to the group of visitors, in the entrance part of the facility and not around the residents. The DSD indicated the behavior of Unlicensed Staff C did not involve other residents and she was not aware of any other incidents with Unlicensed Staff and other residents. During an interview on 2/15/24 at 12:41 p.m with Director of Nursing (DON), the DON indicated, if there were any abuse issues at the facility, he would notify the Administrator who would then report to the Department and other entities. The DON indicated there were no issues with staff altercations and residents. During an interview on 12/15/24 at 1:02 p.m., with Licensed Staff B, Licensed Staff B indicated there had been an issue with Unlicensed Staff C and Resident 19, where Resident 19 requested Unlicensed Staff C to not be her caregiver for the day (2/4/24) because Unlicensed Staff C had yelled at Resident 19. Licensed Staff B indicated Unlicensed Staff C had stated to another resident (unidentified, could not remember name), Is this what I am going to be dealing with this all day? Licensed Staff B indicated Unlicensed Staff C's anxiety was too high, and Unlicensed Staff C was continuing to yell and agitating the other residents. Licensed Staff B indicated Unlicensed Staff C was crying at the nurses' station, later she was observed sitting on the floor in the break room, acting strange, and Licensed Staff B thought Unlicensed Staff C could not finish her shift but was not considered safe to drive home either. Unlicensed Staff C was encouraged to sleep in the car until she was able to drive home safely. Licensed Staff B indicated this was not the first incident, as there had been others and there was a meeting with the DSD and the Administrator regarding the behavior of Unlicensed Staff C, with regards to residents and co-workers. Licensed Staff B indicated, on other instances, Unlicensed Staff C was yelling at residents and making them feel bad and uncomfortable. Licensed Staff B indicated the Administrator was aware of the behavior issues with Unlicensed Staff C. Licensed Staff B indicated she was not aware of the employment status of Unlicensed Staff C and thought maybe the Administrator might have terminated her. During an interview on 2/15/24 at 2:45 p.m., with the Social Services Assistant (SSA), the SSA indicated she was aware of the incident (2/4/24) regarding the behavior of Unlicensed Staff C as she was at the facility the day of the incident. The SSA indicated there were no direct observations of Unlicensed Staff C providing resident care because Unlicensed Staff C was in her car asleep. The SSA indicated Unlicensed Staff C had to stay in the car and sleep the rest of the shift due to her behavior. The SSA indicated, if there were instances of abuse with staff and residents, the Administrator would be notified and report any instance of abuse. The SSA indicated she did not think Unlicensed Staff C was abusive toward the residents and had not been aware of any other instances about Unlicensed Staff C's previous behavior. During a concurrent interview and record review on 3/13/24 at 11 a.m., with the Administrator, Unlicensed Staff C's, Untitled Disciplinary Document, dated 1/21/24, was reviewed. The Administrator confirmed the narrative of the document was written by Licensed Staff B who indicated in the document that Unlicensed Staff C would not change residents' briefs, and due to being left soiled for a period of time, the skin had changed color, creating a pink line. Unlicensed Staff C was indicated to refuse changing a resident's (unidentified resident in document) soiled brief of urine and feces because it had been done, and Unlicensed Staff C would not be able to control when residents would soil their briefs or not. Licensed Staff B indicated in the document, that Unlicensed Staff C repeatedly left the residents in her care soiled so when the next shift made rounds (checking on residents visually to see if they required assistance or care) on those residents, they were soaking wet with urine and feces. Licensed Staff B indicated this had been reported to the DON, the DSD and the Administrator without any improvement from Unlicensed Staff C. The Administrator indicated the document reviewed was correct and indicated, leaving a resident soiled and refusing to change a resident was not considered neglect or mental anguish. The Administrator indicated the allegation was investigated, and when Unlicensed Staff C was questioned about the allegation, Unlicensed Staff C denied residents were left soiled for the oncoming shift. The Administrator indicated Licensed Staff B was reputable in reporting the issues, but the results of the investigation indicated no abuse had taken place, and there was no abuse taking place. A review of, Untitled Disciplinary Document, dated 1/22/24, with the Administrator and found to be accurate, indicated Licensed Staff B observed Unlicensed Staff C to be away from residents and found to be asleep for one and one-half hours. The same document noted another dated incident on 12/27/23, where Licensed Staff B indicated Unlicensed Staff C was observed missing during the shift and was found sleeping in her car, and when staff knocked on the window, Unlicensed Staff C would not wake up and did not return to resident care for approximately two and one-half hours. The same document included another incident, dated 1/20/24, where Licensed Staff B indicated during the lunch time meal, Unlicensed Staff C was observed by Licensed Staff B to remove the lunch tray, stating, He can't eat my food, if he acting like that towards me. The Administrator indicated the incident was not considered disciplinary abuse or mental anguish for the resident. The Administrator indicated Unlicensed Staff C was asked about the incident and denied the incident occurred. The Administrator indicated the result of the investigation indicated the incident was not considered abuse. A review of, Untitled Disciplinary Document, dated 2/6/24, was reviewed with Administrator, which indicated Unlicensed Staff C was observed at work, with mental confusion, slurred speech and could not keep her balance and walk appropriately. Unlicensed Staff C was indicated to be yelling at residents and co-workers which was described as dangerous to residents. Licensed Staff B indicted the DON was at the facility during the incident. The document, dated 2/6/24, indicated Unlicensed Staff C was recommended for termination by the DON and Administrator. The Administrator indicated Unlicensed Staff C had reported to work under the, influence, and the Administrator did not agree that having a staff member caring for residents under the, influence or with the described behavior by Licensed Staff B, could be considered abusive to the residents. The Administrator indicated all four instances (12/27/23, 1/21/24, 1/22/24 and 2/6/24) were investigated and found not to be an issue of abuse, but more of a personnel matter, which was why Unlicensed Staff C was terminated from the facility. Resident 19 was unable to be interviewed as the medical record indicated he had been transferred to the hospital on 2/15/24, and wanted to be transferred to another facility rather than returning to the facility. During a review of the facility's policy titled, Reporting Abuse to Facility Management Policy, dated 11/30/17 indicated, it is the responsibility of our employee, facility consultants, Attending Physicians, family members, visitors etc. to promptly report any incident or suspected incident of neglect .Our facility does not condone resident abuse by anyone, including staff members, physicians, consultants .Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents .or within their hearing distance .Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services .Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness .All personnel, residents, family members, visitors, etc. are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff. Employees .must immediately report any suspected abuse or incidents of abuse to the Administrator . In the absence of the Administrator such reports may be made to the director of Nursing or Charge Nurse .any Individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, Director of Nursing Services, or charge Nurse .6. Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect or any other criminal offense shall immediately report, or cause a report to be made of the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. A SOC 341 Form will be filled out and faxed to the appropriate agencies as listed on the TLC Mandated Reporter flow chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send a copy of Notice of Discharge or Transfer to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a public advocate (official) is an official who is charged with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of rights) for four Resident's: Residents 85, was discharged to home, and Residents 86, 87 and 88 were transferred to acute facilities. These failures had the potential for Residents (Resident 85, 86, 87 and 88) were not being provided an advocate who could inform them of their rights and options before being discharge to home or transferred to an acute care facility out of 36 sampled residents. Findings: During a concurrent interview and record review on [DATE] at 2:21 p.m., with Social Services Assistant (SSA), SSA reviewed, a resident who had been discharged and when reviewing the electronic medical record, the progress note did not indicate the resident had been discharged or where the resident had been discharged to. SSA, indicated off the top of her head that the particular resident had been transferred to another facility. SSA indicated if a discharge has been indicated to be a Facility Initiated Discharge (a transfer or discharge which the resident objects to or did not originate), those discharges require a form to be sent to the Ombudsman. SSA indicated she was confused about the form and exactly which discharges require the form. SSA indicated Administrator instructed her to send the form on those discharged the facility initiated not the ones where the resident wants to go home. During a concurrent interview and record review on [DATE] at 11:00 a.m., with Administrator, reviewed, Admission/Discharge to/From Report, dated [DATE] indicated 40 residents who were had been discharged , transferred, or died at the facility. Administrator was driving and unable to review the document, so each resident was reviewed. Resident 88 was reviewed and indicated to be admitted to the facility on [DATE] and had been discharged on [DATE] after a form indicating Resident 88 no longer qualified for Medicare services. Administrator indicated Resident 88 was considered a Resident Initiated Discharge and thus did not need to be reported to the Ombudsman office. Administrator indicated Resident 88 had been at the facility for months and date of Notice of Medicare Non-Coverage (NOMNC) (form which indicates a date a resident no longer has Medicare coverage and will have to pay for services to remain at the facility) dated [DATE], signed by Resident 88 on [DATE] and the actual discharge date of [DATE] was not considered a Facility Initiated Discharge. Administrator indicated Resident 88 wanted to go home and the NOMNC form just happened to correspond around the same time. Administrator indicated the NOMNC form had to be sent to Resident 88 because she no longer qualified for skilled care. Administrator indicated all of the discharges which occurred from the facility were always resident initiated. Resident 86's transfer to a higher level of care was revied with Administrator. Administrator indicated Resident 86 was transferred out of the facility to a higher level of care on [DATE] and returned on [DATE]. Administrator indicated the Ombudsman office was not notified and could not explain why. Administrator indicated many times a resident will be transferred to a higher level of care emergently only to come back to the facility the same day. Administrator agreed in the situation of Resident 86, that was not the case and the Ombudsman office should have been notified. Resident 87's transfer was reviewed with Administrator. Administrator indicated Resident 87 had been transferred out of the facility to a higher level of care on [DATE] due to vomiting but was discharged on [DATE]. Administrator indicated the Ombudsman office was not notified and was not sure if Resident 87 was discharged from the hospital or from the facility. Resident 88's transfer to a higher level of care was reviewed with Administrator and Resident 88 was transferred out of the facility to a higher level of care on [DATE] and did not return to the facility until [DATE]. Resident 88 was indicated to have had surgery but it was emergent (not scheduled or planned in advance). Administrator agreed the Ombudsman office should have been notified of this transfer as well. Administrator indicated the weekend discharges and especially the residents transferring to a higher level of care would be hard to be compliant with regulation since there would be limited staff on the weekend to take care of the paperwork. Administrator was asked why the facility submitted a policy with an outdated Federal referenced tag and Administrator indicated there was a more current policy. A review of the facility's policy and procedure titled, Transfer and Discharge Notice, dated 7/05, indicated Reference F 177, did not indicate notifying the Ombudsman office. A review of the facility's policy and procedure titled, Transfer of Discharge Notice, dated 2001, indicated The resident and representatives are notified in writing of the following information: The name, address and telephone number of the Office of the State Long-term Care Ombudsman; .A copy of the notice is sent to the Office of State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident or representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure: 1. basic care plans (BCP, a plan that promotes continuity of care and communication among nursing home staff to increase resident safety) were completed timely for one out of four sampled residents (Resident 6). 2. the Interdisciplinary Team (IDT, a group of dedicated healthcare professionals who work together to provide you with the care you need) reviewed the physician's order and implement the BCP to meet the residents immediate care needs, initial goals, physician's orders, dietary orders, therapy services, social services and Preadmission Screening and Resident Review (PASRR, Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) recommendations if applicable for four out of four sampled residents (Residents 6, 12, 27 and 31). 3. residents or their representative were provided a summary of the BCP for four out of four sampled residents (Residents 6, 12, 27 and 31). These failures had the potential to put residents' safety at risk and for residents to not receive the quality care that they need. A review of Resident 6's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Parkinsonism (a term used to describe the collection of signs and movement symptoms associated with several conditions), Feeding Difficulties (behavioral conditions characterized by severe and persistent disturbance in eating behaviors) and Muscle Weakness. His Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 2/27/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 3 indicating severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 6's functional status indicated he was dependent on staff assistance during eating. A review of Resident 12's face sheet indicated he was initially admitted to the facility on [DATE]. His diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Essential Hypertension (HTN, high blood pressure) and Muscle Weakness. His BIMS dated 2/23/24 score was 14 indicating intact cognition. His MDS, dated [DATE] indicated Resident 12 needed up to maximum assistance when performing his ADL. Resident 12 was dependent on staff with lower body dressing and when putting on or taking off his shoes. A review of Resident 27's face sheet indicated his admission date was 2/3/24. Resident 27's diagnoses included Muscle Weakness, Dysphagia (difficulty swallowing) and HTN. His BIMS dated 5/9/24 indicated severe cognitive impairment. His MDS dated [DATE] functional status indicated he was dependent on staff for provision of care. A review of Resident 31's face sheet indicated her admission date was 12/20/23. Her diagnoses included HTN, HLP, and Muscle Weakness. Her MDS dated [DATE] functional status indicated she was dependent on staff with some of her ADLs. Her BIMS dated 5/5/24 score was 11 indicating moderately impaired cognition. During a concurrent interview and BCP records review on 5/22/24 at 9:03 a.m., the Director of Staff Development (DSD) stated the Director of Nursing (DON) should not be the only person present in baseline care planning and stated the IDT, the resident or the responsible party should be involved in Baseline care planning as well. The DSD stated she was not sure if the resident or the RP should receive a copy of the BCP summary. The DSD verified the following information: A. Resident 12's BCP, undated on when it was completed, was not completed by the collaborating efforts of the IDT and the only signature present on Residents 12 BCP was that of the DON. The BCP did not indicate whether the resident or the responsible party (RP, a person who is able to act on behalf of the resident) was involved in developing the BCP. There was also no indication a summary of the BCP was provided to the resident or the RP. B. Resident 31's BCP, undated on when it was completed, was not completed by the collaborating efforts of the IDT and the only signature present on Residents 31's BCP was that of the DON. The BCP did not indicate whether the resident or the RP was involved in developing the BCP. There was also no indication a summary of the BCP was provided to the resident or the RP. C. Resident 6's BCP dated 11/8/22 was completed late on 11/14/22. Resident 6's BCP was not completed by the collaborating efforts of the IDT. Resident 6's BCP did not indicate whether the resident or the RP was involved in developing the BCP. There was also no indication a summary of the BCP was provided to the resident or the RP. Resident 6's BCP was missing information on initial goals and physician's orders. D. Resident 27's BCP, undated on when it was completed, was not completed by the collaborating efforts of the IDT and the only signature present on Residents 27's BCP was that of the DON. The BCP did not indicate whether the resident or the RP was involved in developing the BCP. There was also no indication a summary of the BCP was provided to the resident or the RP. During an interview on 5/22/24 at 9:15 a.m., the Infection Preventionist (IP) stated she was not aware of the time frame for completing a BCP but thought it was supposed to be completed within 72 hours of admission. The IP stated BCP was important for residents' safety and to provide appropriate care. The IP stated baseline care planning involved different department heads and the resident, or the RP should be involved in developing the BCP. When asked if the BCP summary should be provided to the resident or the RP, the IP stated yes. During an interview on 5/23/24 at 2:37 p.m., the DON stated he was the only one who completed the BCP and not the IDT for Residents 12, 27 and 31. The DON also stated the resident, or the responsible party was not involved in developing the BCP for Residents 6, 12, 27 and 31 and the resident or the RP was not provided a copy of the BCP summary for Residents 6, 12, 27 and 31. During an interview on 5/23/24 at 10:46 a.m., the Social Services Director/ Medical Record Director (SSD/MRD) stated the IDT should be completing the BCP along with resident and RP because they could provide invaluable input. The SSD/MRD stated a copy of the BCP summary should be given to the resident and the RP. The SSD/MRD stated it was important the resident and RP be part of BCP to focus on the care that they need to receive at this facility. The SSD/MRD stated not involving the resident or the RP in baseline care planning could put the resident at risk for not receiving the safe care that they need which could result to decreased quality of care and decreased quality of life. A review of the facility's policy and procedure (P&P) titled Care Plans-Baseline, revised 12/2016, the P&P indicated a baseline plan of ca shall be developed within 48 hours of admission . the Interdisciplinary team reviewed the physician's order and implement BCP to meet the residents immediate care needs including but not limited to initial goals, physician's orders, dietary orders, therapy services, social services and PASRR recommendations if applicable .residents or their representative was provided a summary of the BCP

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure oral care was provided regularly and per plan of care for one out of six sampled residents (Resident 31). This failure led to Resident 31 having a thick whitish, yellowish tinged material on her tongue and could put Resident 31 at risk for dental caries, bad breath and infections. Findings: A review of Resident 31's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. Her diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Essential Hypertension (HTN, high blood pressure) and Failure to Thrive (FTT, a decline in older adults that manifests as a downward spiral of health and ability). Her Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 3/25/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 11 indicating moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 31's functional status indicated she was dependent on staff when performing oral hygiene. During a concurrent observation and interview on 5/20/24 at 4:17 p.m., Resident 31 was noted with buildup of whitish yellowish tinged material on her tongue. Resident 31 could not recall on when was the last time staff had provided oral care for her. During a concurrent observation and interview on 5/21/24 at 1:00 p.m., Resident 31 was still noted with whitish yellowish tinged material on her tongue. Resident 31 could not recall whether staff had provided her oral care. During an interview on 5/21/24 at 1:03 p.m., the Director of Staff Development (DSD) verified Resident 31 had a thick whitish yellowish tinged material on her tongue. The DSD stated this was not acceptable and would have staff provide her oral care now. During an interview on 5/22/24 at 8:25 a.m., the DSD stated staff should provide oral care to the residents at least every shift and as needed. The DSD stated if there were no documentation that an oral care was done, then it meant oral care was not provided for the residents. The DSD stated if oral care was not provided after every meals, then residents would be at risk for tooth decay, tooth aches, pain and mouth infection. During an interview on 5/22/24 at 8:41 a.m., Licensed Staff D stated residents should be offered oral care after every meal per facility policy. Licensed Staff D stated if residents were not provided regular oral care, it could lead to infection, tooth decay, bad breath, loss of appetite, Pneumonia (PNA, an infection of one or both of the lungs caused by bacteria, viruses, fungi, or chemical irritants), and stomach problems. Licensed Staff D stated if the point of care documentation did not indicate they provided oral care, it meant an oral care was not provided. During an interview on 5/22/24 at 8:56 a.m., Unlicensed Staff F stated staff should provide oral care to residents after every meal. Unlicensed Staff F stated if there was no documentation that an oral care was provided, then it meant the oral care was not provided. Unlicensed Staff F stated not providing oral care after every meal could put Resident 31 at risk for tooth decay, yeast infection (oral thrush, a mouth infection caused by a yeast fungus) and bad breath. During an interview on 5/22/24 at 9:15 a.m., the Infection Preventionist (IP) stated staff should provide oral care to the residents after every meal. The IP stated if not documented, it meant oral care was not provided. The IP stated not providing an oral care could lead to tooth decay, bad breath, and infection. During a concurrent observation and interview on 5/22/24 at 10:55 a.m., Resident 31 still had whitish yellowish tinged material on her tongue. Resident 31 stated staff did not provide her oral care after breakfast. Resident 31's son verified Resident 31 still had whitish yellowish tinged material on her tongue. During an interview on 5/22/24 at 4:35 p.m., Licensed Staff G stated oral care should be provided to the residents after every meal. Licensed Staff G stated if not documented, it meant the oral care was not provided. Licensed Staff G stated not providing oral care consistently after every meal could lead to cavities, periodontal disease (gum disease, is a serious gum infection that damages the soft tissue around teeth), PNA and infection. A review of Resident 31's point of care (POC, the process of documenting clinical information while interacting with and delivering care to patients) documentation on oral care from 5/1/24 up to 5/21/24 indicated staff were not providing oral care after breakfast. During a concurrent interview and record review of Resident 31's POC documentation on oral care on 5/23/24 at 9:00 a.m., the DON stated staff should perform oral care to resident 31 every shift. The DON verified based on POC documentation, staff were not providing oral care to Resident 31 in the morning, after breakfast. The DON stated not performing oral care to residents every shift or after every meal could lead to bad breath, cavities and infection. A review of the facility's policy and procedure (P&P) titled Activities of Daily Living (ADL), Supporting, revised 3/2018, the P&P indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADL's .appropriate care and services will be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (oral care).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a significant weight change was reported to the physician and the Registered Dietician (RD) for one out of six sampled residents (Resident 6), when: 1.Resident 6 lost 12.8 pounds (#, a measure of weight) or 7.6 percent (%, a relative value indicating hundredth parts of any quantity) between 4/2023 and 5/2023. 2.Resident 6 gained 17.8# or 11.5 % between 5/2023 and 8/2023. These significant weight changes, if not reported to the physician and RD, could put Resident 6 at risk for increased mortality and subsequent occurrence of adverse health outcomes. A review of Resident 6's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Parkinsonism (a term used to describe the collection of signs and movement symptoms associated with several conditions), Feeding Difficulties (behavioral conditions characterized by severe and persistent disturbance in eating behaviors) and Muscle Weakness. His Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 2/27/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 3 indicating severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 6's functional status indicated he was dependent on staff assistance during eating. A review of Resident 6's weight log indicated that on 5/10/2023, Resident 6 weighed 155.2# and on 4/27/2023, Resident 6 weighed 168.0# indicating a 12.8# or 7.6 % weight loss in 1 month. Further review of Resident 6's weight log indicated that on 9/6/2023, Resident 6 weighed 173.0# and on 5/10/2023, Resident 6 weighed 155.2# indicating a weight gain of 17.8# or 11.5% significant weight gain in 4 months. During a concurrent interview and weight log record review on 5/22/24 at 2:55 p.m., the DON stated the weight log information was incorrect, however, there was no documentation to indicate Resident 6 was re-weighed to obtain accurate weight for Resident 6. The DON verified there was no indication the physician was notified of Resident 6's significant weight changes when Resident 6 on 5/10/23 weighed 155.2# and on 4/27/2023, Resident 6 weighed 168.0# indicating a 12.8# or 7.6 % weight loss in 1 month or when Resident 6's weight log indicated that on 9/6/2023, Resident 6 weighed 173.0# and on 5/10/2023, Resident 6 weighed 155.2# indicating a weight gain of 17.8# or 11.5% significant weight gain in 4 months. The DON stated the physician was not notified right away when resident had a significant weight loss when on 5/10/23, Resident 6 weighed 155.2# and on 4/27/2023, Resident 6 weighed 168.0# indicating a 12.8# or 7.6 % weight loss in 1 month. The RD was also not notified when Resident 6 weighed 173.0# on 9/6/23 and 5/10/2023, weighed 155.2# indicating a weight gain of 17.8# or 11.5% in 4 months. The DON stated not reporting significant weight changes to the physician and RD would put Residents 6 health and safety at risk. During an interview on 5/22/24 at 4:11p.m., the Administrator stated a weight variance of 5# should have been reported to the physician and the RD as soon as possible. The Administrator stated it was important to report significant weight variance to the physician and RD to find out what was going on with the resident and to implement plan that would address resident significant weight changes. During an interview on 5/22/24 at 4:35 p.m., Licensed Staff G stated a weight gain of 17.8 # from 5/2023 to 9/2023 should be reported to the physician and the RD, and a weight loss of 12.8# from 5/2023 to 4/2023 should be reported to the MD and RD as well. Licensed Staff G stated if these significant weight variances was not reported to the physician and the RD, it could lead to malnutrition, further weight loss or weight gain and was a health risk for Resident 6. Licensed Staff G stated significant weight changes should be reported to the physician and the RD so the facility knew what was causing the significant weight changes and the physician and the RD could address the cause of the significant weight changess. During an interview on 5/22/24 at 4:45 p.m., the Administrator stated there was a note from the RD on 5/24/23 which indicated Resident 6 should be re-weighed as the weight taken on 5/10/24 was incorrect. When asked how they knew the weight taken on 5/10/23 was incorrect, the Administrator was silent. The Administrator stated Resident 6 was not reweighed immediately after obtaining an alleged erroneous weight on 5/10/24. The Administrator was not able to find documentation the physician was notified of Resident 6's significant weight changes. The Administrator was not able to find documentation the RD was notified of Resident 6's significant weight gain. During an interview on 5/23/24 at 12:03 p.m., Licensed Staff D stated significant weight loss and weight gain should be reported to the physician and RD. Licensed Staff D stated if significant weight changes were not reported to the physician, it could lead to misdiagnosis, malnutrition, impaired nutrition, and continued weight loss or weight gain. Licensed Staff D stated significant weight changes could affect residents' safety and quality of life. During an interview on 5/23/24 at 12:11 p.m., the Infection Preventionist (IP) stated significant weight gain or weight loss needed to be reported to the physician and RD immediately. The IP stated if significant weight changes were not reported to the physician and the RD immediately, it could result in heart attack, continued weight loss or weight gain, misdiagnosis, inadequate treatment, and malnutrition. During an interview on 5/24/24 at 9:36 a.m., Licensed Staff E stated significant weight changes should be reported to the physician and RD as soon as possible. Licensed Staff E stated a resident weight was a fundamental indicator of good health. Licensed Staff E stated Resident 6's significant weight changes should be reported to the physician and the RD as soon as possible because these significant weight changes were not a normal path of health and the physician need to assess Resident 6 further. Licensed Staff E stated if the physician or the RD was not aware and did not check on Resident 6's significant weight changes, Resident's 6 health could be compromised and it could become a health hazard. A review of the facility's policy and procedure (P&P) titled Weight Assessment and Intervention revised 9/2008, the P&P indicated any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation .the dietician will review the unit weight record by the 15th of the month to follow individual weight trends over time .a weight loss of 5% in 1 month is significant, greater than 5% was severe, a weight loss of 7.5% in 3 months was significant, greater than 7.5% was severe, and weight loss of 10% in 6 months was significant, greater than 10% was severe .care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include physician, the nursing staff, the dietician .the dietician will discussed undesired weight gain with the resident and or the family

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure they were adequately staffed when: A.six out of six sampled residents (Residents 12, 13, 20, 24, 27 and 31) complained the facility was short staffed. B. for the month of 4/2024, the total direct care service hours patient per day (DHPPD, staffing requirement ) was not met for 24 out of 30 days on these dates: 4/1/24, 4/4/24, 4/6/24, 4/7/24, 4/9/24, 4/10/24, 4/11/24, 4/12/24, 4/13/24, 4/14/24, 4/16/24, 4/17/24, 4/118/24, 4/19/24, 4/20/24, 4/21/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, 4/27/24, 4/28/24, 4/29/24, 4/30/24 and the Certified Nursing Assistant (CNA) PPD was not met for 28 out of 30 days on these dates: 4/1/24, 4/2/24, 4/3/24, 4/4/24, 4/4/24, 4/5/24, 4/6/24, 4/7/24, 4/8/24, 4/10/24, 4/11/24, 4/12/24, 4/14/24, 4/15/24, 4/16/24, 4/17/24, 4/18/24, 4/19/24, 4/20/24, 4/21/24, 4/22/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, 4/27/24, 4/28/24, 4/29/24, 4/30/24. C. for the month of 5/2024, the total DHPPD was not met on 6 out of 20 days on these dates: 5/3/24, 5/4/24, 5/5/24, 5/6/24, 5/12/24, 5/18/24 and CNA PPD was not met on 6 out of 20 days on these dates: 5/4/24, 5/5/24, 5/11/24, 5/12/24, 5/17/24, 5/18/24. This failure resulted in residents feeling frustrated and scared nobody could get to them in time if there was a medical emergency. This failure could also put the residents at risk for late provision of care, care not being rendered at all, and increased incidents of falls or accidents. Findings: A review of Resident 12's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Essential Hypertension (HTN, high blood pressure) and Muscle Weakness. His Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) dated 2/23/24 score was 14 indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). His Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 2/25/24 indicated Resident 12 needed up to maximum assistance when performing his Activities of Daily Living (ADL, activities related to personal care which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 12 was dependent on staff with lower body dressing and when putting on or taking off his shoes. A review of Resident 13's face sheet indicated she was readmitted to the facility on [DATE]. Her diagnoses included Stroke (occur when blood flow to the brain is blocked or there is sudden bleeding in the brain) HTN, and HLP. Her MDS dated [DATE] functional status indicated she needed up to maximal assistance when performing her ADLs and her BIMS score was 13 indicating intact cognition. A review of Resident 20's face sheet indicated his admission date was 3/1/24. His diagnoses included Muscle Weakness, Compartment Syndrome (a painful condition that occurs when pressure within the muscles builds to dangerous levels) and Seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain. His MDS dated [DATE] functional status indicated he needed up to maximal assistance when performing his ADLs and was dependent on staff when putting on or taking off his shoes. His BIMS score dated 3/3/24 was 3 indicating intact cognition indicating severely impaired cognition. A review of Resident 24's MDS dated [DATE] indicated his diagnoses included Quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down) Cerebral Palsy (CP, a group of movement disorders that can cause problems with posture, manner of walking (gait), muscle tone, and coordination) and Neurogenic Bladder (lack bladder control due to a brain, spinal cord or nerve problem). His MDS dated [DATE] functional status indicated he needed up to maximal assistance when performing his ADLs but was dependent on staff during toileting, lower body dressing, showering and putting on/off his shoes. His BIMS dated 4/11/24 score was 15 indicating intact cognition. A review of Resident 27's face sheet indicated his admission date was 2/3/24. Resident 27's diagnoses included Muscle Weakness, Dysphagia (difficulty swallowing) and HTN. His BIMS dated 5/9/24 indicated severe cognitive impairment. His MDS dated [DATE] functional status indicated he was dependent on staff for provision of care. A review of Resident 31's face sheet indicated her admission date was 12/20/23. Her diagnoses included HTN, HLP, and Muscle Weakness. Her MDS dated [DATE] functional status indicated she was dependent on staff with some of her ADLs. Her BIMS dated 5/5/24 score was 11 indicating moderately impaired cognition. During an interview on 5/20/24 at 2:54 p.m., Resident 12 stated the facility was short staffed and staff took forever to answer call light. Resident 12 stated staff does not really like it if he asked for help all the time. Resident 12 stated some staff would answer call light after an hour and only after multiple calls. Resident 12 stated sometimes he goes to the nursing station to call staff but even then, he could not find any staff around. Resident 12 stated he wished there were more staff to care for the residents at the facility. Resident 12 stated he felt scared and frustrated. Resident 12 stated nobody comes right away when he needed help. Resident 12 stated staff do not answer call light timely, and he had to wait a long time before staff answers his call light. During an interview on 5/20/24 at 3:35 p.m., Resident 20 stated he does not think there was enough staff at the facility. During an interview on 05/20/24 at 3:37 p.m., Resident 24 stated he hoped the facility staffing improves. Resident 24 stated the facility staffing was bad. Resident 24 stated the Director of Nursing (DON) was often working on the floor because there were no other staff to work on a shift. During an interview on 5/20/24 at 3:44 p.m., when asked if he felt the facility was short staffed, Resident 27 responded yes. Resident 27 stated the facility should have more staff. Resident 27 stated he felt scared nobody would come right away when he needed help. When asked if he had to wait a long time before staff answered his call light, he stated yes. During an interview on 5/20/24 at 4:17 p.m., Resident 31 stated the facility was short staffed. Resident 31 stated staff does not come right away if she needed help. During an interview on 5/20/24 at 4:31 p.m., Resident 13 stated the facility was sort staffed. Resident 13 stated staff took a while to answer call lights. Resident 13 stated she had to wait for 30 minutes before staff answered her call light. Resident 13 stated she feel scared no one could come to her in time if there's an emergency. Resident 13 stated when she asked staff why it took them awhile to answer her call light, staff would respond they were short staffed, somebody called off and they had a lot of patients to take care of. During an interview on 5/21/24 at 11:15 a.m., Licensed Staff D stated the facility could benefit from more staffing. Licensed Staff D stated the facility was short staffed sometimes and could use more staff on some days. Licensed Staff D stated short staffing could lead to late provision of care, increased incidence of fall and long wait times for staff to answer call light. During an interview on 5/22/24 at 8:17 am., the Director of Staff Development (DSD) stated short staffing could lead to increased incidents of falls, late provision of care, care not being provided at all and late response to call light. DSD stated insufficient staffing could put residents' safety at risk. During an interview on 5/22/24 qat 8:56 a.m., Unlicensed Staff F stated the facility was short staffed. Unlicensed Staff F stated she had 10 residents to care for this morning. Due to short staffing, Unlicensed Staff F stated sometimes, she was unable to complete her task in an 8-hour period, but she tries her best. Unlicensed Staff F stated it will serve residents' best interest if the facility was not short staffed. Unlicensed Staff F stated short staffing was a safety risk and could result in falls, late provision of care and late response to call light. During an interview on 5/22/24 at 9:15 a.m., the Infection Preventionist (IP) stated short staffing was a safety risk for the residents. The IP stated short staffing could lead to increased incidents of fall, late answering of call lights, increased accidents and late provision of care. During an interview on 5/22/24 at 9:20 a.m., Unlicensed Staff H stated the facility was short staffed. Licensed Staff H stated it would be good for residents if the facility was adequately staffed. Unlicensed Staff H stated short staffing could lead to late provision of care or care not being rendered at all. Unlicensed Staff H stated short staffing put residents' safety at risk. During an interview on 5/22/24 at 4:35 p.m., Licensed Staff G stated the facility was short staffed. Licensed Staff G stated short staffing could lead to decreased quality of care and could put residents' safety at risk for accidents and falls. During an interview on 5/23/24 at 9:00 a.m., when asked if he was aware the facility was not meeting the minimum requirement for DHPPD, the Director of Nursing (DON) stated I'm sure. The DON stated not meeting the DHPPD meant the facility was short staffed and could put residents at risk for falls and delayed care. During an interview on 5/23/24 at 10:11 a.m., the Administrator Assistant (AA) stated she was aware they were not meeting the DHPPD and the CNA PPD hours. The AA stated this could mean there were not enough hours for staff to provide direct care to the residents. The AA stated not meeting the DHPPD could result in decreased quality of care and delayed care. A review of Census and DHPPD for all direct care staff and CNAs for the month of 4/2024 indicated: 4/1/24 Actual DHPPD not met 3.39, Actual CNA PPD not met 2.32 4/2/24 Actual CNA PPD not met 2.34. 4/3/24 Actual CNA PPD not met 2.36. 4/4/24 Actual DHPPD not met 3.43, Actual CNA PPD not met 2.33. 4/5/24 Actual CNA PPD not met 2.33. 4/6/24 Actual DHPPD not met 3.44, Actual CNA PPD not met 2.09. 4/7/24 Actual DHPPD not met 3.20, Actual CNA PPD not met 1.84. 4/8/24 Actual CNA PPD not met 2.05. 4/9/24 Actual DHPPD not met 3.45. 4/10/24 Actual DHPPD not met 3.33, Actual CNA PPD not met 2.29. 4/11/24 Actual DHPPD not met 3.45, Actual CNA PPD not met 2.24. 4/12/24 Actual DHPPD not met 3.40, Actual CNA PPD not met 2.30. 4/13/24 Actual DHPPD not met 3.42, 4/14/24 Actual DHPPD not met 3.22, Actual CNA PPD not met 1.96. 4/15/24 Actual CNA PPD not met 2.0. 4/16/24 Actual DHPPD not met 3.29, Actual CNA PPD not met 2.3. 4/17/24 Actual DHPPD not met 3.46, Actual CNA PPD not met 2.25. 4/18/24 Actual DHPPD not met 3.45, Actual CNA PPD not met 2.17. 4/19/24 Actual DHPPD not met 3.48, Actual CNA PPD not met 2.25. 4/20/24 Actual DHPPD not met 3.37, Actual CNA PPD not met 2.13. 4/21/24 Actual DHPPD not met 3.23, Actual CNA PPD not met 1.98. 4/22/24 Actual CNA PPD not met 2.18. 4/23/24 Actual DHPPD not met 3.25 Actual CNA PPD not met 2.11. 4/24/24 Actual CNA PPD not met 2.22. 4/25/24 Actual DHPPD not met 3.35, Actual CNA PPD not met 2.17. 4/26/24 Actual DHPPD not met 3.35, Actual CNA PPD not met 2.24. 4/27/24 Actual DHPPD not met 3.37, Actual CNA PPD not met 2.13. 4/28/24 Actual DHPPD not met 3.24, Actual CNA PPD not met 1.99. 4/29/24 Actual DHPPD not met 3.46, Actual CNA PPD not met 2.19. 4/30/24 Actual DHPPD not met 3.21, Actual CNA PPD not met 2.04. For the month of April, the total DHPPD was not met for 24 out of 30 days on these dates 4/1/24, 4/4/24, 4/6/24, 4/7/24, 4/9/24, 4/10/24, 4/11/24, 4/12/24, 4/13/24, 4/14/24, 4/16/24, 4/17/24, 4/118/24, 4/19/24, 4/20/24, 4/21/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, 4/27/24, 4/28/24, 4/29/24, 4/30/24. For the month of 4/2024, the CNA PPD was not met for 28 out of 30 days on these dates: 4/1/24, 4/2/24, 4/3/24, 4/4/24, 4/4/24, 4/5/24, 4/6/24, 4/7/24, 4/8/24, 4/10/24, 4/11/24, 4/12/24, 4/14/24, 4/15/24, 4/16/24, 4/17/24, 4/18/24, 4/19/24, 4/20/24, 4/21/24, 4/22/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, 4/27/24, 4/28/24, 4/29/24, 4/30/24. A review of Census and DHPPD for all direct care staff and the CNAs for the month of 5/2024 indicated: 5/3/24 Actual DHPPD not met 3.47, 5/4/24 Actual DHPPD not met 3.4, Actual CNA PPD not met 2.10. 5/5/24 Actual DHPPD not met 3.47, Actual CNA PPD not met 2.16. 5/6/24 Actual DHPPD not met 3.47, 5/11/24 Actual CNA PPD not met 2.35. 5/12/24 Actual DHPPD not met 3.47, Actual CNA PPD not met 2.16. 5/17/24 Actual CNA PPD not met 2.39. 5/18/24 Actual DHPPD not met 3.4. Actual CNA PPD not met 2.10. The total DHPPD not met on 6 out of 20 days on these dates: 5/3/24, 5/4/24, 5/5/24, 5/6/24, 5/12/24, 5/18/24. The CNA PPD was not met on 6 out of 20 days on these dates: 5/4/24, 5/5/24, 5/11/24, 5/12/24, 5/17/24, and 5/18/24. A review of the facility's policy and procedure (P&P) titled Facility Policy Regarding Emergency Staffing Situations , undated, the P&P indicated this P&P will be implemented, effective immediately to ensure appropriate nursing staff to care for their residents .follow AFL DHPPD requirement 3.5/2.4.

Based on interviews and record reviews, the facility failed to ensure staff have the specific competencies and skill sets necessary to care for residents' needs when: 1.staff did not know what a Baseline Care Plan (BCP, should be developed within 24 hours of admission and contain the minimum health care information necessary to care for the residents) was, and its completion time frame. 2. staff did not know what a Trauma Informed Care (TIC, an approach care that acknowledges the complete picture of a resident's life situation, past and present, to provide effective health care services with a healing orientation and prevent retraumatization) was. These failures could put residents at risk for unsafe, inadequate, and ineffective care. During an interview on 5/22/24 at 8:25 a.m., the Director of Staff Development (DSD) stated she was not aware of what BCP was and stated she did not know the timeframe for completing a BCP. However, the DSD stated if a care plan (CP, a form that summarizes a person's health conditions and current treatments for their care) was not completed timely it could lead to residents' not receiving the care they need. The DSD stated it was a safety risk and could compromise residents' health and safety. The DSD stated she was not aware of what a TIC was and had not provided staff any in service about TIC. During an interview on 5/22/24 at 8:41 a.m., Licensed Staff D stated she was not aware of what a BCP was and its time frame for completion. Licensed Staff D stated care plan was important to ensure residents were being provided with the care they need, and staff were providing care to the residents safely. Licensed Staff D stated she did not know what TIC was and had not received in service on how to care for residents with trauma. During an interview on 5/22/24 at 8:56 a.m., Unlicensed Staff F stated she did not know what TIC was and had not received an in service on how to care for residents with trauma. Unlicensed Staff F stated she would like to receive in service about TIC so she could provide safe and effective care to residents who experienced trauma. During an interview on 5/22/24 at 9:15 a.m., the Infection Preventionist (IP) stated she was not aware of the time frame for completing a BCP but thought it was supposed to be completed within 72 hours of admission. The IP stated BCP was important for residents' safety and to provide appropriate care. The IP stated she was not aware of what TIC was. During an interview on 5/22/24 at 10:40 a.m., the Activity Director (AD) stated she did not know what TIC was and had not receive an in service about TIC. The AD stated she was not aware on how to safely and effectively care for residents who had traumatic experiences in life, but she'll do her best. During an interview on 5/22/24 at 10:41 a.m. Housekeeping I stated she did not know what TIC was and had not received in service on how to properly respond to residents' negative behavior. Housekeeping I stated she did not know what TIC was. During an interview on 5/22/24 at 10:42 a.m., Unlicensed Staff H stated he did not know what TIC was and had not received an in service about TIC and how to provide safe care for resident that had traumatic experiences in life. During an interview on 5/22/24 at 4:35 p.m., Licensed Staff G stated she was not aware of what BCP was and its completion time frame. Licensed Staff G stated she was not aware of what TIC was and had not received in service on how to properly and safely care for residents who had traumatic experiences in life. During an interview on 5/24/24 at 9:56 a.m., Licensed Staff E stated she had not received in service about TIC. Licensed Staff E stated she would like to know more about TIC because trauma had long impact, it affects residents' health and was a safety issue. Licensed Staff E stated it was important to know about TIC to prevent retraumatization, to increase staff ability to safely care for residents who had traumatic experiences in life, to manage their behavior safely and effectively. Licensed Staff E stated trauma had long impact, it affects health and the health delivery system. A review of the facility's Registered Nurse Competency Checklist and Certified Nursing Competency Checklist indicated BCP and TIC was not included in this checklist. A review of the DSD Mandatory Topics in services did not include BCP and TIC.

Based on observations, interviews and record reviews, the facility failed to ensure: 1. staffing information was posted in a prominent place readily accessible to residents and visitors, when the nursing staffing information was kept in a binder behind the counter at the nursing station 2. staffing information was accurate and current. 3. staffing information was complete and was not missing information when the nursing home patient per day (NHPPD, the actual nursing hours performed by direct caregivers per patient day) was left blank. These failures resulted in the nurse staffing information being inaccessible to residents and visitors at any given time and the facility not meeting the NHPPD staffing requirement (cross reference F725). Findings: During an observation on 5/20/24 at 4:00 p.m., there was no visible staffing information posted in the building or at the nursing station. During a concurrent observation, interview, and staffing information, dated 5/21/24, record review on 5/21/24 at 11:15 a.m., Licensed Staff D verified there was no visible staffing information posted in the building or at the nursing station because this information was kept in a binder behind the counter at the nursing station. When asked if the staffing information in the binder behind the counter at the nursing station was accessible to residents and visitors, Licensed Staff A stated no. Licensed Staff D verified the staffing form did not have information on NHPPD and was not signed by the Director of Nursing (DON) or the designee. During a concurrent observation, interview, and staffing information dated 5/21/24 and 5/22/24 review on 5/22/24 at 8:17 a.m., the Director of Staff Development (DSD) verified there was no visible staffing information posted in the building or at the nursing station because this information was kept in a binder behind the counter at the nursing station. The DSD stated the staffing information was not readily accessible if the staffing information was kept in a binder behind the counter at the nursing station.The DSD stated she did not know what NHPPD meant. The DSD verified the staffing form dated 5/21/24 and 5/22/24 did not have information on the NHPPD and were not signed by the DON or designee. The DSD stated that it would be good if the NHPPD was computed daily to ensure the facility was following the regulation and there were sufficient staff to care for the residents at the facility. During an interview on 5/22/24 at 8:41a.m., Licensed Staff D stated the NHPPD calculation was not being done daily. Licensed Staff D stated she did not have an idea of whether the daily NHPPD was being met. Licensed Staff D stated it was important the NHPPD was computed daily to ensure the facility was following the regulation and there were sufficient staff to care for the residents at the facility. Licensed Staff D stated the staffing information should be posted in a visible and accessible area. During an interview on 5/22/24 at 10:00 a.m., the Administrator Assistant (AA) stated she does not fill out the NHPPD portion of the staffing form daily. The AA stated she only filled out the NHPPD information on the staffing form every 2 weeks during pay period. The AA stated she kept the staffing information in a binder behind the counter at the nursing station. When asked if keeping the staffing information in a binder behind the counter at the nursing station made it readily accessible to the residents or the visitors, the AA stated no. The AA stated she always did it this way. During an observation on 5/23/24 at 8:35 a.m., there was still no visible posting of staffing and NHPPD information in the building or at the nursing station. During an interview on 5/23/24 at 9:00 a.m., the Director of Nursing (DON) stated he had no idea the staffing information should be posted so it was readily accessible to residents and visitors. When asked if keeping the staffing information in the binder behind the nursing station counter made it readily accessible to residents and visitors, the DON stated no. The DON verified he also does not sign off on any of the NHPPD staffing information and was not aware the Administrator Assistant was only calculating the NHPPD every 2 weeks. During an interview on 5/23/24 at 10:11a.m., the AA stated she was not aware the NHPPD information should be posted. The AA verified the staffing information was kept in a binder behind the nursing station counter. When asked if this location seemed accessible, she did not respond. During an observation on 5/23/24 at 10:54 a.m., the staffing information was still not posted in a visible area in the building or at the nursing station. The facility policy and procedure for nurse staffing posting was requested but was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure for one out of eight sampled residents (Resident 12): 1. all his medications were secured in a locked storage area with limited access to authorized personnel consistent with state or federal requirements and professional standards of practice. This failure resulted in unsecured and unsafe storage of all the medications of Resident 12 which was a huge safety risk not only to Resident 12 but also to the other residents at the facility. 2. the facility followed their procedures for ensuring his safety when he was self-administering his medications. This failure put Resident 12 at risk for accessing and ingesting medications that could cause clinically significant adverse consequences, worsening of his symptoms which could also result to serious harm or death. Findings: A review of Resident 12's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Essential Hypertension (HTN, high blood pressure) and Muscle Weakness. His Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 2/25/24 indicated Resident 12 needed up to maximum assistance when performing his ADL. Resident 12 was dependent on staff with lower body dressing and when putting on or taking off his shoes. His Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score dated 2/23/24 score was 14 indicating intact cognition. During a concurrent observation and interview on 5/20/24 at 3:12 p.m., it was noted Resident 12 had over the counter (OTC, drugs you can buy without a prescription) topical medications such as antifungal powders and topical pain medication on the shelf on the left side wall of Resident 12's room. It was also noted on Resident 12's bed, a yellow, red, blue and purple colored large medication pill box. Resident 12 stated he had these OTC medications in his room for months. Resident 12 stated the nurses, and the Director of Nursing (DON) were aware he was keeping these OTC medications in his room. Resident 12 stated he was not sure if there was a physician order for him to keep his OTC medications. Resident 12 stated he was not sure if the physician had an order for his OTC medications as well. Resident 12 stated nobody from the facility had assessed if it was appropriate for him to self-administer his OTC medications or if it was safe to keep his OTC medications in his room. During an observation on 5/21/24 at 11:57 a.m. Resident 12 still had OTC topicals kept in his room by the shelf on the left side of the wall. Resident 12's yellow, red, blue and purple colored large medication pill box was on his bed. During an interview on 5/23/24 at 9:00 a.m., the Director of Nursing stated Resident 12 should not keep any OTC medications in his room. The DON stated the facility did not notify the physician Resident 12 was keeping OTC medications in his room. The DON verified there was no self-administration assessment completed for Resident 12. The DON stated Resident 12 was not allowed to self-administer medications and store medications in his room for safety purposes. During an interview on 5/23/24 at 11:06 a.m., Licensed Staff D stated Resident 12 was not supposed to have medication stored in his rooms unless there was an assessment indicating he was safe to store his medications in his room and there was a physician's order indicating Resident 12 was safe to store his medications in his room. Licensed Staff D also stated Resident 12 should not self-administer medications unless a self-administration assessment had been completed which indicated Resident 12 was safe to self-administer his medications and the physician had ordered that Resident 12 was safe to self-administer his medications. Licensed Staff D stated keeping a medication in Resident 12's room without a proper assessment was a safety risk because they would not know if Resident 12 was taking these medications safely, if Resident 12 could take his medications safely, if Resident 12 knew his medications and what symptoms to report to the nurses. Licensed Staff D also stated it was a safety risk because staff would not be able to monitor for drug-to-drug interactions and side effects. Licensed Staff 12 stated another concern was if a confused resident grabbed Resident 12's medication and ingested it, Licensed Staff D stated this resident could be allergic to it and could suffer adverse effect from the medication. During an interview on 5/23/24 at 12:11 p.m., the Infection Preventionist (IP) stated Resident 12 was not supposed to have medication stored in his room unless there was an assessment and physicians order indicating Resident 12 was safe to store medications in his room. The IP stated Resident 12 was not allowed to self-administer medications unless a self-administration of medications was completed indicating it was safe for him to self-administer medication and a physician order indicating he was safe to self-administer his medications. The IP stated Resident 12 self-administering and storing his OTC medications in his room without a proper assessment and physician order was a safety risk which could result to medication errors, not knowing what side effects to monitor and other confused residents could grab the medications which they could be allergic to and on worst scenario, they could die from. During an interview on 5/24/24 at 9:42 a.m., Licensed Staff E stated she was aware Resident 12 had been bringing in OTC medications from home, was storing his OTC medication in his room and was self-administering his OTC medications. Licensed Staff E stated she was aware there was no assessment completed to indicate Resident 12 was safe to self-administer medication and was safe to store his OTC medications in his room. Licensed Staff E also stated she was aware there was no physician order indicating Resident 12 may self-administer medications and may store his medications in his room. Licensed Staff E stated these were safety issues not only for Resident 12, but also to other residents who might access his medications, ingest it and die from it in extreme cases. A review of the facility's policy and procedure (P&P) titled Self-Administration of Medications revised 12/2013, the P&P indicated .in addition to general evaluation of decision making capacity, the staff and the practitioner will perform a more specific skill assessment including but not limited to ability to read and understand medications labels, comprehension of the purpose and proper dosage and administration time for his or her medications, ability to recognize risks and major adverse consequences of his or her medications .self-administered medications must be stored in a safe and secure place, which is not accessible. Based on observation, interview and record review, the facility failed to ensure that all controlled discontinued medication were stored securely and only authorized Licensed staff such as the Director of Nursing (DON) had the key to the storage. The individual medication packets were not labeled according to the Doctor's order when: a) Discontinued controlled medications were not properly secured. Missing discontinued control medications such as narcotics were identified. Unauthorized Licensed Staff Nurse had a direct access to the locked storage for discontinued medication. b) Inaccurate labeling of the individual medications from the Pharmacy dispensed apparatus. The label did not indicate the route, and durations ordered by the Doctor. This failure had the potential for drug diversions by Licensed Nurse and medication administration error. Findings: (a) During a concurrent observation and interview on 5/22/24 at 12:39 pm, the DON stated that he destroyed all discontinued controlled medications (Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) with the Pharmacist consultant once a month during the Medication Regimen Review (MRR). The DON showed the container where he stored all discontinued controlled medications before destroying in the presence of the pharmacist. The black tin can box container was in the unused portion of the building with double lock. The black tin can box was locked with key but not securely vaulted on the counter. During a review of the discontinued controlled medications on 5/22/24, a bubble pack medication called Hydroco/APAP 5-325MG (Norco) was submitted with six (6) tablets on the reconciliation sheet. The actual number of Norco in the bubbled pack was five (5) tablets. This bubble pack was missing one tablet of Norco. Another bubble pack for oxycodone tablet (Percocet) indicated that medications to be given ½ tablet. In the reconciliation sheet did not indicate when the Percocet was given ½ tablet or whole. The reconciliation sheet did not indicate any wasted medication. Another individually wrapped Percocet counted as six (6) and in the reconciliation sheet, indicated there were eight (8) tablets was submitted to be destroyed. This individual wrapped Percocet was missing two tablets. During an interview on 5/23/24 at 3:56 p.m. with the Pharmacist, she said that she had noted that missing narcotic in January 2024 during the destructions of other medications. The Pharmacist stated that during the medication destruction on January 2024, she informed the DON that there were some missing tablets of controlled medications. The Pharmacist stated that the DON would investigate for the missing controlled medications. During an interview on 05/23/24 at 04:02 p.m., the Administrator (ADM) stated that she was not aware of any missing controlled medications. The ADM stated that she just learned now when this surveyor informed her. The ADM stated that the DON did not tell her about the missing controlled medications. During an interview on 05/23/24 at 04:12 p.m. the DON, stated that he knew about the missing controlled medications and said that he spoke to the Licensed Nurse J (LN) and had her signed the reconciliation sheets the amount she submitted. The DON stated that he could not remember the reason for missing controlled medications. During a telephone interview on 05/23/24 04:15 p.m. LN J (Licensed Nurse who placed the discontinued controlled medication in the box) stated that she was the charge nurse for the night shift with two Certified Nursing Assistant. LN J stated that when there was a discontinued controlled medication, she would get the DON's key in the office and put the discontinued medication in the black tin box. LN J stated that she would go to the black tin box alone since there was no other Licensed Nurse available. When asked LN J if that was her job duty to put the controlled medications away, LN J stated No. LN J stated that she was helping and that she bought that black tin box container for the facility. LN J stated that when she brought the bubbled pack of Norco it had eight (8) tablets, not six (6). LN J stated that she was not aware of what happened to the missing controlled medications. (b) During a concurrent interview and record review on 05/22/24 3:15 p.m., of the medication administration record (MAR), Doctor's order and medication label in individual packet came from an apparatus that prints out the medication label. The medication label did not have the same order written as ordered by the doctor. The medication did not reflect the route and duration. Pharmacist Manager stated that the labeling on individual medicine packet did not require a direction of route and duration. The Pharmacist Manager did not provide a Policy & Procedure of the Medication labeling.

Based on observations and interviews, the facility failed to provide residents with food that was palatable (Palatability may influence food choice as it is proportional to the pleasure someone experiences when eating a particular food. It depends on the sensory properties of the food such as taste, smell, texture, sound, and sight). This failure had the potential to result in nutritional problems if the residents declined to eat the food served by the facility. Findings: During an interview on 5/20/24, at 2:54 p.m., with Resident 12, he stated the food was bad and canned vegetable food that was being served were mushy. He stated the food served had no taste, sometimes served cold. He stated sometimes he did not eat the food provided by the facility. During an interview on 5/20/24, at 3:44 p.m., with Resident 27, he stated the food was not great but did not elaborate what his concerns were with the food served by the facility. During an interview on 5/20/24, time not specified, with Resident 7, she stated she was not getting fresh food. She stated food served was mostly frozen, and pasta dishes. During an interview on 5/20/24, at 3:13 pm., with Resident 18, she stated food served by the facility can be better but did not elaborate on her concerns. During an observation of food preparation on 5/22/24, at 11:45 a.m., at the facility kitchen with the facility RD (Registered Dietitian) and DM (Dietary Manager), it was observed that the main entrée was an oven BBQ (Barbecued) beef roast cut into 2 to 3 oz. (ounces) portions, and sides of sauteed zucchini and carrots, and mashed sweet potatoes. After the last food tray was assembled by the dietary staff, a test tray was requested from the RD and the DM. After the last food tray was delivered to a resident by a facility staff and a surveyor, the test tray was served to two surveyors at the facility's conference room. The surveyors found that the zucchini was mushy, and the barbecued beef was very tough in texture. During an interview on 5/22/24, at 4 p.m., with Resident 23, she stated that meat served for lunch was so tough. She stated the texture was like eating leather, and it was so terrible. She stated she could not even cut the meat into small pieces because it was tough to cut into. She stated she only ate the mashed sweet potatoes and the vegetables. During an interview on 5/22/24, at 4:10 p.m., with Resident 7, she stated her meat for lunch was very hard to chew. During an interview on 5/22/24, at 4:20 p.m., with Resident 19, she stated the meat she had during lunch was tough.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.A review of Resident 6's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Parkinsonism (a term used to describe the collection of signs and movement symptoms associated with several conditions), Feeding Difficulties (behavioral conditions characterized by severe and persistent disturbance in eating behaviors) and Muscle Weakness.His Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 2/27/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 3 indicating severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 6's functional status indicated he was dependent on staff assistance during eating. A review of Resident 24's MDS dated [DATE] indicated his diagnoses included Quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down) Cerebral Palsy (CP, a group of movement disorders that can cause problems with posture, manner of walking (gait), muscle tone, and coordination) and Neurogenic Bladder (lack bladder control due to a brain, spinal cord or nerve problem). His MDS dated [DATE] functional status indicated he needed moderate assistance with personal hygiene. His BIMS dated 4/11/24 score was 15 indicating intact cognition. A review of Resident 27's face sheet indicated his admission date was 2/3/24. Resident 27's diagnoses included Muscle Weakness, Dysphagia (difficulty swallowing) and HTN. His BIMS dated 5/9/24 indicated severe cognitive impairment. His MDS dated [DATE] functional status indicated he was dependent on staff for provision of care. During an observation on 5/21/24 at 12:20 p.m., no HH was offered by Unlicensed Staff F to Resident 27 prior to him eating his lunch. During an observation on 5/21/24 at 12:27 p.m. Unlicensed Staff H shook Resident 6's hand. No HH performed by Unlicensed Staff H prior to assisting Resident 6 with his lunch. Resident 6 was not offered HH by Unlicensed Staff H prior to eating his lunch. During an interview on 5/21/24 at 12:33 p.m., Resident 24 stated staff were not consistent in performing HH and did not consistently offer HH to residents before and after meals. Resident 24 stated he was not offered HH before his lunch. During an interview on 5/22/24 at 8:25 a.m., the Director of Staff Development (DSD) stated staff should perform HH before assisting residents with their meals. The DSD stated residents should be offered HH before and after meals per the facility's HH policy. The DSD stated staff were not performing HH before assisting residents with their meals or if staff were not offering HH to residents before and after meals, then the facility was not in compliance. The DSD stated HH was important to ensure there was no cross contamination and for infection control purposes. The DSD stated if residents did not have HH before and after meals, it could lead to residents getting sick with diarrhea or vomiting. During an interview on 5/22/24 at 8:56 a.m., Unlicensed Staff F stated residents should be offered or provided with HH before and after meals, so they do not get sick such as diarrhea. During an interview on 5/22/24 at 4:35 p.m., Licensed Staff G stated residents should be offered or assisted with HH before and after meals for infection control purposes, to prevent cross contamination and to prevent spread of bacteria. Licensed Staff G stated if HH was not offered to the residents before and after meals, residents could be at risk for COVID and GI illnesses like C diff and diarrhea. During an interview on 5/22/24 at 4:45 p.m., the IP stated staff should offer or assist residents with HH before and after meals per facility policy to prevent infection and cross contamination. The IP stated if the HH was not done before and after meals, the facility policy was not followed. The IP stated HH was important before and after meals to prevent residents from contracting GI illnesses. The facility's policy and procedure for HH was requested but was not provided. 3. A review of Resident 12's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Essential Hypertension (HTN, high blood pressure) and Muscle Weakness. His Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 2/25/24 indicated Resident 12 needed up to maximum assistance when performing his ADL. Resident 12 was dependent on staff with lower body dressing and when putting on or taking off his shoes. His Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score dated 2/23/24 score was 14 indicating intact cognition. A review of Resident 20's face sheet indicated his admission date was 3/1/24. His diagnoses included Muscle Weakness, Compartment Syndrome (a painful condition that occurs when pressure within the muscles builds to dangerous levels) and Seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain. His MDS dated [DATE] functional status indicated he needed up to maximal assistance when performing his ADLs and was dependent on staff when putting on or taking off his shoes. His BIMS score dated 3/3/24 was 3 indicating intact cognition indicating severely impaired cognition. During a concurrent observation and interview on 5/20/24 at 3:12 p.m., Resident 12 had two urinals, filled with about one fourth (1/4, one of four equal parts) of yellow tinged liquid hung on his walker. Resident 12 stated the yellow tinged liquid was his urine. During a concurrent observation and interview on 5/22/24 at 12:54 p.m., Resident 20's urinal which was filled about ¼ of yellow tinged liquid was kept at his bedside table. Resident 20 stated the yellow tinged liquid in his urinal was his urine. During an interview on 5/23/24 at 10:53 a.m., Unlicensed Staff H stated it was not appropriate to leave a urinal with urine on residents' bedside or hung at the resident's walker for dignity and infection control. During an interview on 05/23/24 at 10:58 a.m., Unlicensed Staff F stated it was not acceptable to hung urinal with urine on the resident's walker or at the bedside table for dignity and infection control purposes. During an interview on 5/23/24 at 11:02 a.m., the Director of Staff Development (DSD) stated it was not acceptable to hang a urinal on residents' walker and at the bedside table for safety purposes due to risk for spillage which could result in falls and accidents. The DSD stated it was not acceptable to hang a urinal on residents' walker and at the bedside table because it affects residents' dignity and for infection control purpose. During an interview on 5/23/24 at 11:06 a.m., Licensed staff D stated it was not appropriate to leave a urinal with urine at residents' bedside or hung on the residents' walker. Licensed Staff D stated it affects residents' dignity and was a big infection control issue. During an interview on 5/23/24 at 11:58 a.m., the Activity Director (AD) stated it was not appropriate to keep a residents' urinal with urine at his bedside table or and hung on the walker. The AD stated it was an infection control issue and a dignity issue. The AD stated residents should have a dignified existence. During an interview on 5/23/24 at 12:20 p.m., the Infection Preventionist (IP) stated it was not appropriate to leave a urinal with urine on residents' bedside table or hung on the walker. The IP stated it affects resident's dignity and was a big infection control issue. During an interview on 5/23/24 at 2:22 p.m., the Director of Nursing (DON) stated it was not acceptable to keep a urinal with urine at residents' bedside or hung on the walker. The DON stated this was a dignity issue and a big infection control issue. There was no care plan (CP, a form that summarizes a person's health conditions and current treatments for their care) to indicate Resident 6 was requesting to keep his urinal at his bedside table or Resident 12 requesting to keep his urinal hung on his walker. A review of the facility's policy and procedure (P&P) titled Bedpan/Urinal, Offering/Removing, revised 2/2018, the P&P indicated if the resident prefers to keep a urinal at his bedside, check it frequently, empty and clean as necessary .note on resident's care plan his request to keep his urinal at his bedside. Based on observations, interviews, and record reviews, the facility failed to ensure that: 1. clean linens were transported from the laundry room to the clean storage areas of the facility by methods that promoted cleanliness and protection from dust and soil, when the linen cart used for the transport was not covered. 2. staff perform hand hygiene (HH, a term used to cover both hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers (an alcohol-containing preparation (liquid, gel or foam) designed for application to the hands to inactivate microorganisms and/or temporarily suppress their growth) was being done by staff prior to assisting residents with their meal and staff were offering to the residents HH before and after meals for three out of three sampled residents (Residents 6, 24, and 27) 3. urinals (a vessel for receiving urine) with collection of urine were not hung on resident's walker for one out of two sampled residents (Resident 12), and was not left at his bedside table for one out of two sampled residents (Resident 20). These failures had the potential to result in: 1. contamination of the clean linens and could spread infectious pathogens (Pathogens are microorganisms that have the potential to cause infectious diseases. Viruses, bacteria, protozoans and fungi are all potential pathogens. A pathogen is simply defined as an organism that has the potential to cause infectious diseases in its host) to the residents of the facility. 2. transfer of bacteria and virus resulting to residents getting sick with COVID ( a mild to severe respiratory illness that is caused by a coronavirus), GI illnesses (any illness linked to the gastrointestinal system-a collective term referring to the stomach, the small and large intestine), Clostridium Difficile infection (C Diff, a germ that causes diarrhea and colitis (inflammation of the colon) which can be life-threatening), Vomiting (the involuntary, forceful expulsion of the contents of one's stomach through the mouth or nose), and Diarrhea (loose, watery stools three or more times a day). 3. overflow of urine with possible infectious pathogens that could spill on the bedside table or on the floors of different hallways of the facility. Findings: 1. During an observation on 5/23/24, at 2:35 p.m., at a facility hallway, Unlicensed Staff I was observed transporting clean bed linens and clean towels using a laundry cart that had no covers, leaving the clean laundry exposed to dust and soil. During an interview on 5/23/24, at 2:37 p.m., with Unlicensed Staff I, she stated she knew that she had to transport the clean bed linens and towels using a laundry cart that had covers but did not in this instance. A picture of this uncovered cart with clean laundry was taken in the presence of Unlicensed Staff I. During an interview on 5/23/24, at 2:39 p.m., with the facility's IP (Infection Preventionist) nurse, she stated that it was her expectation that clean linens transported from the laundry room to the clean storage rooms in the hallways needed to be covered. During an interview on 5/23/24, at 2:48 p.m., with the Administrator, she stated that Unlicensed Staff I informed her that she just forgot to use the covered clean linen transport cart. A review of a CDC (Centers for Disease Control and Prevention) guidelines on Appendix D- Linen and Laundry Management, dated March 19, 2024, under Best Practices for Handling Clean Linen, indicated, Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens, or other soiled items.

Based upon interview and record review the facility failed to have a dedicated full time Director of Nursing. This failure had the potential to put residents at risk for a multi-faceted role of Director of nursing, charge nurse and MDS (Minimum Data Set, a clinical assessment of the resident's functional capabilities and helps staff identify health problems) coordinator whereby the residents were not given the appropriate oversight by a dedicated Director of Nursing. Findings: During an interview on 2/15/24 at 11:05 a.m., Director of Nursing (DON) indicated he was currently the DON, MDS coordinator and floor nurse who administers medications among other duties. During an interview on 2/15/24 at 12:10 p.m., with Director of Staff Development (DSD), DSD indicated DON worked the medication cart passing medication or administering medications to residents every day, (Monday to Friday) DSD indicated the days she would come to work, she would pass medications for DON so he may focus on other duties. DSD indicated if there were issues with the licensed and unlicensed staff then the DON would handle it and then notify the administrator. During an interview on 2/15/24 at 4:11 p.m., DON indicted he was fulfilling the role as DON until Administrator was able to find someone to employ into the role. DON indicated he had been the MDS coordinator for a number of years and would fulfill the DON role when the DON role had been vacated. DON indicated the role of DON had been vacant since 2022 and he had been fulfilling the role ever since. DON indicated there had been no interviews or observable indication that the DON position was attempted to being actively filled. DON indicated he would be expected to pass or administer medications Monday through Friday on half of the residents within the facility, handle all pharmacy related tasks, like ensuring medications were ordered, received and doses changes for medications were reviewed and updated in the medical record. DON indicated part of the DON role was to ensure the pharmacist recommendations and physician follow up occurred especially with regard to gradual dose reduction of certain medications for residents. DON indicated this was very time consuming along with handling the admissions and discharging of residents at the facility. DON indicated there were additional pharmacy type issues he was expected to handle at the facility for all of the residents which made being able to function as a full time DON impossible. A review of Resident 19's MDS record, Quarterly Assessment Review dated, 1/31/22, 4/25/22, 10/24/22, 1/24/23, 4/26/23, 10/25/23 and 1/25/24 was completed and documented by DON. During a review of Resident 16's, MDS record, Quarterly Assessment Review, dated 3/23/22, 6/23/22, 12/22/22, 3/24/23, 6/24/23, 9/22/23 and 12/23/23 was completed and documented by DON. During a review of Resident 84's, MDS record, Quarterly Assessment Review, dated 3/22/22, 6/22/22, 9/22/22, 3/23/23, 6/23/23 and 9/23/23, was completed and documented by DON. During a review of Resident 84's, MDS record, Annual Assessment, dated 2/9/24 was completed and signed by DON. During a review of Resident 18's MDS record, Quarterly Assessment Review, dated 6/7/22, 9/7/22, 12/8/22, 6/8/23, 9/8/23 and 12/9/23, was completed and documented by DON. A review of Resident 19's, Medication Administration Record, dated 11/23, indicated DON administered medications to Resident 19 on 21 days (11/1/23, 11/2/23, 11/3/23, 11/6/23, 11/7/23, 11/8/23, 11/9/23, 11/10/23, 11/13/23, 11/14/23, 11/15/23, 11/16/23, 11/17/23, 11/20/23, 11/21/23, 11/22/23, 11/23/23, 11/24/23, 11/27/23, 11/28/23 and 11/29/23 out of a total of 31 days. A review of Resident 16's, Medication Administration Record, dated 11/23, indicated DON administered medications to Resident 16 on 21 days (11/1/23, 11/2/23, 11/3/23, 11/6/23, 11/7/23, 11/8/23, 11/9/23, 11/10/23, 11/13/23, 11/14/23, 11/15/23, 11/16/23, 11/17/23, 11/20/23, 11/21/23, 11/22/23, 11/23/23, 11/24/23, 11/27/23, 11/28/23 and 11/29/23 out a total of 31 days. A review of Resident 84's, Medication Administration Record, dated 11/23, indicated DON administered medications to Resident 84 on 21 days (11/1/23, 11/2/23, 11/3/23, 11/6/23, 11/7/23, 11/8/23, 11/9/23, 11/10/23, 11/13/23, 11/14/23, 11/15/23, 11/16/23, 11/17/23, 11/20/23, 11/21/23, 11/22/23, 11/23/23, 11/24/23, 11/27/23, 11/28/23 and 11/29/23 out of a total of 31 days. During a review of Resident 18's, Medication Administration Record, dated 11/23, indicated DON administered medications to Resident 18 on 20 days (11/1/23, 11/2/23, 11/3/23, 11/6/23, 11/7/23, 11/8/23, 11/9/23, 11/10/23, 11/13/23, 11/14/23, 11/15/23, 11/16/23, 11/20/23, 11/21/23, 11/22/23, 11/24/23, 11/27/23, 11/28/23 and 11/29/23 out of a total of 31 days. During a review of Resident 18's, Medication Administration Record, dated 12/23, indicated DON administered medications to Resident 18 on 18 days, (12/1/23, 12/4/23, 12/5/23, 12/7/23, 12/8/23, 12/11/23, 12/12/23, 12/15/23, 12/18/23, 12/19/23, 12/20/23, 12/21/23, 12/22/23, 12/25/23, 12/26/23, 12/27/23, 12/28/24 and 12/29/24) out of a total of 31 days. During a review of Resident 19's, Medication Administration Record, dated 12/23, indicated DON administered medications to Resident 19 on 18 days, (12/1/23, 12/4/23, 12/5/23, 12/7/23, 12/8/23, 12/11/23, 12/12/23, 12/15/23, 12/18/23, 12/19/23, 12/20/23, 12/21/23, 12/22/23, 12/25/23, 12/26/23, 12/27/23, 12/28/24 and 12/29/24) out of a total of 31 days. During a review of Resident 16's, Medication Administration Record, dated 12/23, indicated DON administered medications to Resident 16 on 18 days, (12/1/23, 12/4/23, 12/5/23, 12/7/23, 12/8/23, 12/11/23, 12/12/23, 12/15/23, 12/18/23, 12/19/23, 12/20/23, 12/21/23, 12/22/23, 12/25/23, 12/26/23, 12/27/23, 12/28/24 and 12/29/24) out of a total of 31 days. During a review of Resident 18's, Medication Administration Record, dated 12/23, indicated DON administered medications to Resident 18 on 18 days, (12/1/23, 12/4/23, 12/5/23, 12/7/23, 12/8/23, 12/11/23, 12/12/23, 12/15/23, 12/18/23, 12/19/23, 12/20/23, 12/21/23, 12/22/23, 12/25/23, 12/26/23, 12/27/23, 12/28/24 and 12/29/24) out of a total of 31 days. During a review of Resident 19's, Medication Administration Record, dated 1/24, indicated DON administered medications to Resident 19 on 16 days (1/2/24, 1/4/24, 1/5/24, 1/9/24, 1/10/24, 1/11/24, 1/12/24, 1/15/24, 1/16/24, 1/17/24, 1/18/24, 1/19/24, 1/23/24, 1/24/24, 1/25/24 and 1/29/24 out of a total of 31 days. Requested policy on Director of Nursing job description and the facility did not provide one.

Based on interviews and record reviews, the facility failed to ensure they were electronically submitting Payroll Based Journal (PBJ, a system that facilitate the submission of staffing information) data as required every quarter when the Certification and Survey Provider Enhanced Reporting system (CASPER, an assortment of real-time data that allows skilled nursing facilities (SNFs) the opportunity to pinpoint areas where changes in care and operations are necessary to improve performance) report indicated there was no information for the first quarter (Q1 1/2024 up to 3/2024). Findings: During an interview on 5/22/24 at 10:00 a.m., the Administrator Assistant (AA) stated she did not know how to submit report for PBJ. The AA stated another staff from their sister facility submits the facility's PBJ information to Centers for Medicare and Medicaid Services (CMS, works in partnership with the entire health care community to improve quality, equity and outcomes in the health care system). During an interview on 5/22/24 at 3:04 p.m., the Administrator stated PBJ staffing information should be reported quarterly. The Administrator was unable to provide PBJ information was submitted for the first quarter. The Administrator stated the facility did not have a policy for PBJ reporting. During an interview on 5/23/24 at 9:40 a.m., the Director of Nursing (DON) stated she did not know anything about PBJ and had no idea about PBJ reporting. During an interview on 5/23/24 at 10:11 a.m., the AA stated she assumed PBJ reporting was important to monitor the facility's nursing hours. The AA did not respond when asked what could happen if the nursing hours was not reported to CMS timely. The facility did not have policy and procedure for PBJ reporting.

Based on interview and facility document review, the facility's Quality Assurance and Performance Improvement Program (QAPI, a data driven and proactive approach to quality improvement. It combines two approaches - Quality Assurance (QA) and Performance Improvement (PI). QA is a process used to ensure services are meeting quality standards and assuring care reaches a certain level.) failed to identify quality deficiencies as evidenced by: 1) One sampled resident (Resident 12) self-administered and stored his medications in his room. 2) lack of management oversight that resulted in missing narcotics. There was no investigation or report made to the appropriate agencies until one of the surveyors discovered this deficient practice. 3) lack of protocol and facility's effort to monitor residents and obtain referral and treatment for residents (Resident 1) that were hard of hearing. 4. lack of facility's monitoring and tracking residents that were in need of oral care. 5. lack of monitoring to ensure DHPPD meet the minimum hours required for direct care staffing. 6. lack of Restorative Nursing Assistant (RNA) program for over 2 months. 7. lack of monitoring and tracking of residents (Resident 6) significant weight fluctuations and lack of management oversight on ensuring weight taken were accurate. 8. there were no in services provided for staff regarding baseline care planning (BCP, contain the minimum health care information necessary to care for the residents) and Trauma Informed Care (TIC, an approach care that acknowledges the complete picture of a resident's life situation, past and present, in order to provide effective health care services with a healing orientation and prevent retraumatization). 9) lack of interdisciplinary team's collaboration on ensuring BCP were done thoroughly, completely and timely by the team including the resident or the responsible party (RP, a person who is able to act on behalf of the resident) for Residents 6, 12, 27 and 31. 10A) lack of oversight to ensure residents were offered hand hygiene before and after meals and lack of protocol on where residents should keep their own urinal. 10B) lack of management oversight to ensure there was an effective infection control practice when residents urinal with urine was left at his bedside (Resident 20) or was hung on his walker (Resident 12). The failure to identify these quality deficiencies prevented the QAPI committee from addressing issues and developing corrective plans of actions to mitigate these areas of concern. During an interview on 5/24/24 at 11:18 a.m., the Administrator stated the following issues above were not discussed in QAPI. Findings: 1) During an interview on 5/23/24 at 9:00 a.m., the Director of Nursing stated Resident 12 should not keep any OTC medications in his room. The DON stated the facility did not notify the physician Resident 12 was keeping OTC medications in his room. The DON verified there was no self-administration assessment completed for Resident 12. The DON stated Resident 12 was not allowed to self-administer medications and store medications in his room for safety purposes. 2) During an interview on 5/23 24, the Administrator stated although the DON was aware of the missing narcotics, this deficient practice was not reported to her. There was no investigation done to find out what happened to the missing narcotics and this was not reported to the appropriate agencies as well. 3) During an interview on 5/23/24 at 10:40 a.m., the Social Services Director (SSD)/ Medical Records Director (MRD) verified Resident 1 was HOH. The SSD/ MRD stated Resident 1 had not seen an audiologist as far as she could remember. The SSD/MRD stated as far as Resident 1's HOH was concerned; she does not have anything actively pursuing at this time. The SSD/MRD stated the facility had no protocol on how to address issues when resident was HOH. The SSD/MRD stated in hindsight, Resident 1 could have benefitted if she was referred and seen by an audiologist or be fitted with a functioning HA. The SSD/MRD stated not hearing properly could lead to misunderstanding and not being able to get their concerns addressed. During an interview on 5/23/24 2:22 p.m., the DON stated residents' who were HOH will be offered an audiologist referral. The DON stated that in Resident 1's case, the facility had assumed this was discussed between family and the Administrator. When asked if an audiologist referral was offered to Resident 1, the DON stated not to his knowledge. When asked what the risks could be if a resident was HOH, the DON stated it would be a risk for miscommunication and could lead to resident's frustration. 4) During an interview on 5/21/24 at 1:03 p.m., the Director of Staff Development (DSD) verified Resident 31 had a thick whitish yellowish tinged material on her tongue. The DSD stated this was not acceptable and would have staff provide her oral care now. During an interview on 5/22/24 at 8:25 a.m., the DSD stated staff should provide oral care to the residents at least every shift and as needed. The DSD stated if there were no documentation that an oral care was done, then it meant oral care was not provided for the residents. The DSD stated if oral care was not provided after every meals then residents would be at risk for tooth decay, tooth aches, pain and mouth infection. 5) for the month of 4/2024, the total direct care service hours patient per day (DHPPD, staffing requirement ) was not met for 24 out of 30 days on these dates: 4/1/24, 4/4/24, 4/6/24, 4/7/24, 4/9/24, 4/10/24, 4/11/24, 4/12/24, 4/13/24, 4/14/24, 4/16/24, 4/17/24, 4/118/24, 4/19/24, 4/20/24, 4/21/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, 4/27/24, 4/28/24, 4/29/24, 4/30/24 and the Certified Nursing Assistant (CNA) PPD was not met for 28 out of 30 days on these dates: 4/1/24, 4/2/24, 4/3/24, 4/4/24, 4/4/24, 4/5/24, 4/6/24, 4/7/24, 4/8/24, 4/10/24, 4/11/24, 4/12/24, 4/14/24, 4/15/24, 4/16/24, 4/17/24, 4/18/24, 4/19/24, 4/20/24, 4/21/24, 4/22/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, 4/27/24, 4/28/24, 4/29/24, 4/30/24. -for the month of 5/2024, the total DHPPD was not met on 6 out of 20 days on these dates: 5/3/24, 5/4/24, 5/5/24, 5/6/24, 5/12/24, 5/18/24 and CNA PPD was not met on 6 out of 20 days on these dates: 5/4/24, 5/5/24, 5/11/24, 5/12/24, 5/17/24, 5/18/24. During an interview on 5/23/24 at 9:00 a.m., when asked if he was aware the facility was not meeting the minimum requirement for DHPPD, the Director of Nursing (DON) stated I'm sure. The DON stated not meeting the DHPPD meant the facility was short staffed and could put residents at risk for falls and delayed care. 6) During an interview on 5/24/24, at 9:12 a.m., with the Director of Nursing (DON), he stated that the facility did not have the services on an RNA but could not recall for how long. 7) Resident 6 weighed 168.0# indicating a 12.8# or 7.6 % weight loss in 1 month. Further review of Resident 6's weight log indicated that on 9/6/2023, Resident 6 weighed 173.0# and on 5/10/2023, Resident 6 weighed 155.2# indicating a weight gain of 17.8# or 11.5% significant weight gain in 4 months. During an interview on 5/22/24 at 4:11p.m., the Administrator stated a weight variance of 5# should have been reported to the physician and the RD as soon as possible. The Administrator stated it was important to report significant weight variance to the physician and RD to find out what was going on with the resident and to implement plan that would address resident significant weight changes. During an interview on 5/22/24 at 4:45 p.m., the Administrator stated there was a note from RD on 5/24/23 which indicated Resident 6 should be reweighed as the weight taken on 5/10/24 was incorrect. When asked how they knew the weight taken on 5/10/23 was incorrect, the Administrator was silent. The Administrator stated Resident 6 was not reweighed immediately after obtaining an alleged erroneous weight on 5/10/24. The Administrator was not able to find documentation the physician was notified of Resident 6's significant weight changes. The Administrator was not able to find documentation the RD was notified of Resident 6's significant weight gain. 8) During an interview on 5/22/24 at 8:25 a.m., the Director of Staff Development (DSD) stated she was not aware of what BCP was and stated she did not know the timeframe for completing a BCP. However, The DSD stated if a care plan (CP, a form that summarizes a person's health conditions and current treatments for their care) was not completed timely it could lead to residents' not receiving the care they need. The DSD stated it was a safety risk and could compromise residents' health and safety. The DSD stated she was not aware of what a TIC was and had not provided staff any in service about TIC. 9) During an interview on 5/23/24 at 2:37 p.m., the DON stated he was the only one completing the BCP and not the IDT for Residents 12, 27 and 31. The DON also stated the resident, or the responsible party was not involved in developing the BCP for Residents 6, 12, 27 and 31 and the resident or the RP was not provided a copy of the BCP summary for Residents 6, 12, 27 and 31. 10A) During an interview on 5/22/24 at 8:25 a.m., the Director of Staff Development (DSD) stated staff should perform HH before assisting residents with their meals. The DSD stated residents should be offered HH before and after meals per the facility's HH policy. The DSD stated staff were not performing HH before assisting residents with their meals or if staff were not offering HH to residents before and after meals, then the facility was not in compliance. The DSD stated HH was important to ensure there was no cross contamination and for infection control purposes. The DSD stated if residents did not have HH before and after meals, it could lead to residents getting sick with diarrhea or vomiting. 10B) During an interview on 5/23/24 at 12:20 p.m., the Infection Preventionist (IP) stated it was not appropriate to leave a urinal with urine on residents' bedside table or hung on the walker. The IP stated it affects resident's dignity and was a big infection control issue. A review of facility's policy and procedure (P&P) titled Quality Assurance and Performance Improvement (QAPI) Committee, dated 7/2016, the P&P indicated, The primary goals of the QAPI committee were to establish, maintain and oversee facility systems and processes to support the delivery of quality care and services .to promote the consistent use of facility systems and process during provision of care and services .help identify actual and potential negative outcomes relative to resident care and resolve them appropriately .

Based on observation, interviews, and record reviews, the facility failed to employ a Certified Dietary Manager with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, when there was no designated full time Director of Food and Nutrition Services onsite, as required, when the facility's Registered Dietitian was not employed on a full-time basis. This failure had the potential to result in food borne illnesses when no oversight was provided to the dietary staff during food preparation and could affect the health and safety of all residents of the facility. Findings: During a concurrent observation and interview on 9/14/23, at 2:15 p.m., with Dietary Staff A, the dietary manager was not in the facility. Dietary Staff A stated Dietary Staff B was the dietary manager, and if there were issues in the kitchen, he would contact her by phone. During an interview on 9/14/23, at 2:40 p.m., with CNA C (Certified Nursing Assistant C), she stated she had not seen this dietary manager (Dietary Staff B) in the building. CNA C stated, This is what the facility does, put out names from their other facility and make it seem like they actually work here. During an interview on 9/14/23, at 3:25 p.m., with Dietary Staff B, she stated she was a full-time employee of another facility but she was not a full-time employee at this facility. Dietary Staff B stated the last time she was at this facility was from 7/14/23-7/15/23. During an interview on 9/14/23, at 3:35 p.m., with the facility's RD (Registered Dietitian) consultant. She stated the facility's former dietary manager left the second week of July 2023. The RD consultant stated she was not a full-time dietitian of this facility. A review of a resident's (Resident 1's) MDS (Minimum Data Set- is part of the federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) Section C (Cognitive Patterns), dated 7/21/23, indicated Resident 1's BIMS (Brief Interview for Mental Status) score was 15 (0-7= suggests severe cognitive impairment, 8-12, suggests moderate cognitive impairment, 13-15= suggests cognitively intact, no impairment). During an interview on 12/1/23, at 10:28 a.m., with Resident 1, he stated he had concerns about the food because it did not look appetizing and was not served hot. Resident 1 stated he would end up refusing to eat the food. Resident 1 stated he had not spoken to the dietitian or the dietary manager for a while now. Resident 1 stated the last time he spoke to the former dietary manager was some time ago, and the former dietary manager quit his job. A review of a resident's (Resident 2's) MDS Section C, dated 7/13/23, indicated, Resident 2's BIMS score was 15, cognitively intact. During an interview on 12/1/23, at 10:50 p.m., with Resident 2, she stated she had concerns about the food here. Resident 1 stated that one time she cut into a piece of chicken, and it was not fully cooked. Resident 2 stated that sometimes the food here looked horrible. Resident 2 stated the last dietary manager quit a long time ago and she had not seen or talked to his replacement. During a follow-up interview on 12/4/23, at 1:55 p.m., with the facility's part-time RD, she stated the facility was still looking to hire a full-time Certified Dietary Manager. The RD stated that after the former dietary manager left the second week of July 2023, there had not been a staff to fill this position. The RD stated Dietary Manager B was not a full-time employee at this facility. During an interview on 12/5/23, at 9:27 p.m., with CNA D, she stated she called to the attention of the kitchen because she was assisting a resident (Resident 3) with her meal and the kitchen kept on giving meat products to Resident 3 when she was a vegetarian. CNA D stated Resident 1 had complained about his food. During an interview on 12/6/23, at 1:05 p.m., with the Administrator, she stated Dietary Staff B worked off-site and went to the facility every two weeks. The Administrator stated she was actively trying to hire a Certified Dietary Manager for this facility. A review of the facility's job description for the, Certified Dietary Manager, position, dated October 2020, indicated, The primary purpose of this position is to plan, organize, develop, and direct the operations of the food and nutrition services department in accordance with current federal, state, and local standards, guidelines and regulations, and as directed by the Administrator. The duties and responsibilities included: 1. Assist the Infection Preventionist in identifying, evaluating, and classifying routine and job-related food and nutrition services functions to ensure that tasks involving potential exposure to blood/body fluids are properly identified and recorded. 2. Assist in developing and maintaining written job descriptions and performance evaluations for each level of personnel. 3. Assist in developing methods for determining quality and quantity of food served. 4. Communicate with families and residents as necessary. 5. Visit residents periodically to evaluate the quality of meals served, likes and dislikes, etc. 6. Make daily rounds to assure that personnel are performing required duties and to assure that the appropriate procedures are being rendered to meet the needs of the facility. 7. Assist is establishing a production line, etc., to assure that meals are prepared on time.

Based on interviews and record reviews, the facility failed to implement its policies and procedures on abuse investigation and reporting and ensure that an allegation of abuse and mistreatment of one of three sampled residents, Resident 1, was reported to the appropriate agencies and within the mandated timeframes by a covered individual (owner, operator, employee, manager, agent, or contractor of the facility). This failure had the potential to result in further abuse and mistreatment of Resident 1, or other residents of the facility that could negatively affect their health and well-being. Findings: During an interview on 1/10/23, at 3:15 p.m., with Certified Nursing Assistant C (CNA C), she stated she worked the afternoon shift of 12/24/22. CNA C stated that at around 2:30 p.m., Resident 1 was calling for help and Licensed Nurse A shut the door of his room because Resident 1 had an infection. CNA C stated that at 3 p.m., she heard Resident 1 screaming for help, like someone was being murdered. CNA C stated that Licensed Nurse A slammed the door of Resident 1's room without asking him what he needed. CNA C stated that at around 3:10 p.m., Licensed Nurse A responded to Resident 1's calls for help and he was having a panic attack and his O2 (oxygen) at 85% (A normal level of oxygen is usually 95% or higher). During an interview on 1/10/23, at 3:25 p.m., with CNA D, she stated at around 2 p.m., while Licensed Nurse E and Licensed Nurse A were doing the change of shift report, Resident 1 started to scream in distress. CNA D stated that Resident 1 liked to keep his door open because he was claustrophobic (a person with extreme fear or irrational fear of confined spaces). CNA D stated that she and other aides would like to check on Resident 1, but Licensed Nurse A kept them from doing it. CNA D stated that Licensed Nurse E did not restrict the morning CNA'S from going into Resident 1's room and left the room door open. CNA D stated she left the facility at 3 p.m., and Resident 1 was still screaming inside the room while the door was shut. During an interview on 3/13/23, at 3:35 p.m., with Licensed Nurse A, she stated she could not remember if Licensed Nurse E told her what precaution (e.g. Contact Precaution- Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission; Droplet Precaution- Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking; Airborne Precaution- Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking) Resident 1 should be on. Licensed Nurse A stated that she informed Resident 1 that she would close his door for now. Licensed Nurse A stated after she received report that Resident 1 was on contact precaution and not on droplet or airborne precaution, she opened Resident 1's door. Licensed Nurse A stated that Resident 1 was screaming at her because she closed his door. Licensed Nurse A stated that staff were hearing Resident 1 screaming in his room to have the door opened after she closed it. Licensed Nurse A stated that at 6:30 p.m., Resident 1's oxygen level dropped to 80%. Licensed Nurse A stated that Resident 1 declined to be transferred to the hospital but later agreed and was transferred. During an interview on 3/13/23, at 4:05 p.m., with the Administrator/Owner, she stated she investigated the incident regarding Licensed Nurse A and Resident 1. She stated Licensed Nurse A was not placed on suspension because there was no incident. The Administrator stated Licensed Nurse A opened the door after the change of shift when she confirmed that the isolation precaution was just contact and not droplet precaution. During an interview on 3/14/23, at 1:16 p.m., with Management Staff B, he stated he was on his way back to the kitchen when he passed by Resident 1's room and the door to his room was open. Management Staff B stated that he saw Resident 1 raised his hand to get his attention. Management Staff B stated that he peeked into Resident 1's room and observed that he was in a bad shape, health wise. Management Staff B stated that Resident 1 had a mask for his oxygen, which Resident 1 removed temporarily, and told him he needed CNA D. Management Staff B stated he talked to Licensed Nurse E informing her that Resident 1 was looking for CNA D. Management Staff B stated that Licensed Nurse E told him that CNA D will not be able to go to Resident 1's room at that time because she was in the Red Zone (isolated area for Covid positive residents). Management Staff B stated that another nurse, Licensed Nurse A held his arm and guided him towards the room of Resident 1. Management Staff B stated Licensed Nurse A told him, This is how to take care of that, and said bye to Resident 1, while Licensed Nurse A closed Resident 1's door abruptly. Management Staff B stated he reported the incident to the Management Staff F because Licensed Nurse A's conduct surprised him, because it lacked respect to Resident 1 and Licensed Nurse A did not ask Resident 1 what he needed. During a follow-up interview on 3/17/23, at 2:34 p.m., with CNA D, she stated she informed Licensed Nurse A that Resident 1's door did not need to be closed because he was on contact precaution only. CNA D stated that Licensed Nurse A closed the door of Resident 1 before getting the shift report from Licensed Nurse E. During an interview on 6/2/23, at 12:30 p.m., with the Director of Nursing (DON), he stated that he was not at the facility when the incident between Licensed Staff A and Resident 1 happened. The DON stated he learned about the incident from CNA D. The DON stated that Management Staff B was aware of what had happened. The DON stated that he was not a part of the staff that investigated the incident. The DON stated that the facility did not have a single person who acted as the abuse coordinator, but all suspected abuse would be reported to the Administrator. The DON stated that the Administrator at that time was the owner of the facility. During an interview with Licensed Nurse E on 6/2/23, at 3 p.m., she stated she was the AM (morning) nurse on 12/24/22. Licensed Nurse E stated she remembered giving shift report to Licensed Nurse A and she mentioned to Licensed Nurse A that Resident 1 had an infection that was contagious. Licensed Nurse E stated that Licensed Nurse A went to Resident 1's room and closed the door. Licensed Nurse E stated that she informed Licensed Nurse A that Resident 1's room did not need to be closed. Licensed Nurse E stated that during her morning shift on 12/24/22, Resident 1's room door remained open. Licensed Nurse E stated she continued to give report to Licensed Nurse A after Licensed Nurse A closed Resident 1's door. Licensed Nurse E stated that she left the facility at around 3 p.m. Licensed Staff E stated when she passed by Resident 1's room on her way out of the facility, she heard Resident 1 calling for help while his door was closed. Licensed Nurse E stated that there was another resident, Resident 2, who was across the hallway who looked perplexed as he was hearing the calls for help from Resident 1. During an interview on 6/2/23, at 3:35 p.m., with Resident 2, he stated that he remembered Resident 1 calling for help. Resident 2 stated he could not see if the door to Resident 1's room was closed, but he could definitely hear him calling out for help. Resident 2 stated that Resident 1 did not usually call for help. Resident 2 stated he was not sure how long Resident 1 was calling for help before somebody came to help him. During an interview on 6/2/23, at 4:24 p.m., with Management Staff F, she stated Management Staff B reported the incident to her on 12/26/22. Management Staff F stated she informed Management Staff B that his report should be in writing. Management Staff F stated that Management Staff B gave his account of the incident on 12/26/22. Management Staff F stated that she reported the incident to the administrator via phone call and it was investigated by the Administrator. Management Staff F stated it was not reported to the Ombudsman or to the State. A review of a facility document titled, Staff Complaint/Grievance Form, dated 12/26/22, indicated that a complaint/grievance was communicated by Management Staff B and Licensed Nurse I, concerning another staff, Licensed Nurse A. The document indicated that Management Staff B was concerned that Licensed Nurse A did not provide enough attention to address Resident 1's needs, by closing the door. The document indicated Licensed Nurse I complained that Licensed Nurse A ignored Resident 1's needs, did not pay enough attention to assess Resident 1, and caused his death. The document indicated that the department affected by the complaint/grievance was the Nursing department. During a follow-up interview on 6/5/23, at 2:55 p.m., with the Administrator, she stated that she did not report the complaint allegations of Management Staff B and Licensed Nurse I to the Ombudsman or the State because Licensed Staff A was justified in closing the door of Resident 1 because of infection precaution. The Administrator stated that the allegation of Licensed Staff I regarding Licensed Staff A not providing enough attention to assess Resident 1 and caused his death was absurd because Licensed Staff I was not even on duty that day and her complaint was hearsay. The Administrator stated that she and Management Staff F investigated the complaints. When the Administrator was asked why the DON was not involved in the investigation because on the complaint/grievance form, the department affected by the complaint/grievance was the Nursing department, she stated the DON was involved with the investigation. When the Administrator was asked why Licensed Staff A was not placed on suspension pending the investigation, she stated because Resident 1 was transferred to the hospital and had passed away. A review of a facility document titled, Abuse Investigation and Reporting Policy, dated 11/30/17, indicated, All reports of resident abuse, neglect, exploitation, misrepresentation of resident property, mistreatment, and/or injuries of unknown source (abuse) shall be promptly reported to the local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Under Procedure: Role of the Administrator: The P&P indicated: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. Under Reporting, the P&P indicated: 1. All mandated reporters (covered Individuals), are required by law to report incidents of known or suspected abuse in two ways: 1) by telephone immediately or as soon as practically possible, to the local ombudsman or local law enforcement agency and CDPH (California Department of Public Health), and 2) by written report, Department of Social Services Form (SOC Form 341), Report of Suspected Dependent Adult/Elder Abuse sent within two (2) working days to CDPH. 12. Administrator shall report all incidents of alleged abuse or suspected abuse to CDPH within 24 hours and the results of the investigation to DHS (Department of Health Services) withing 5 working days of the incident, and if alleged violation is verified, appropriate action must be taken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that the rights of six out of six sampled residents (Resident 1, 2, 3, 4, 5, and 6) to receive written notices, including the reason for change, before a resident's room or roommate at the facility was changed, were exercised by the residents. This failure had the potential to result in a negative psychosocial (describing the intersection and interaction of social, cultural, and environmental influences on the mind and behavior) and physical outcomes if the residents were not provided the opportunity to see the new location, meet the new roommate, and ask questions about the move that may affect their health and safety. Findings: During a review of Resident 1's Minimum Data Set (MDS) assessments dated 11/21/22, it indicated Resident 1 had a mild cognitive impairment. During an interview on 12/5/22, at 11:45 a.m., with Resident 1, she stated she was transferred to three different rooms in 10 days. She stated it was the Management Staff A who was making the room changes. Resident 1 stated she never received any written notice about the room changes. Resident 1 stated that she and her roommate, Resident 2, were transferred together to different rooms. During a re review of Resident 2's MDS assessments, dated 10/13/22, it indicated that Resident 2 had a severe cognitive impairment. During an interview on 12/5/22, at 1:35 p.m., with Resident 2's representative, she stated that she was not informed about Resident 2's room changes. Resident 2's representative stated that she recently visited Resident 2 and was surprised to see her in a different room. Resident 2's representative stated that she, (Resident 2), and her roommate, (Resident 1), had been moved three times. During an interview on 12/5/22, at 2:25 p.m., with Management Staff A, she stated that there had been six residents who recently had their room changed and copies of their room change notifications were provided to this surveyor. Management Staff A stated that she had not furnished copies of the room change notifications to the residents or their representatives. During an interview on 12/5/22, at 2:30 p.m., with the facility Administrator, she stated that residents were given verbal notification of the room changes. Facility documents titled, Room Change Notification, for the six sampled residents indicated that the room changes for the six residents occurred as follows: Resident 1: Room changed from room [ROOM NUMBER] to room [ROOM NUMBER]A on 10/27/22. Resident 2: Room changed from room [ROOM NUMBER] to room [ROOM NUMBER] on 10/27/22. Resident 3: Room changed from room [ROOM NUMBER]C to room [ROOM NUMBER]C on 10/25/22. Resident 4: Room changed from room [ROOM NUMBER]A to room [ROOM NUMBER]A on 10/18/22. Resident 5: Room changed from room [ROOM NUMBER] to room [ROOM NUMBER]C on 10/18/22. Resident 6: Room changed from room [ROOM NUMBER] to room [ROOM NUMBER] on 10/15/22. The documents indicated, Resident/Resp. (Responsible) Party must be notified verbally and in writing prior to move. A facility policy and procedure (P&P) titled, Room Change/Room Assignment, dated November 2010, the P&P indicated, Prior to changing a room or roommate assignment all parties involved in the change/assignment (e. g. residents and their representatives (sponsor) will be given a one day advance notice of such change. Based on interviews and record reviews, the facility failed to ensure that the rights of six out of six sampled residents (Resident 1, 2, 3, 4, 5, and 6) to receive written notices, including the reason for change, before a resident's room or roommate at the facility was changed, were exercised by the residents. This failure had the potential to result in a negative psychosocial (describing the intersection and interaction of social, cultural, and environmental influences on the mind and behavior) and physical outcomes if the residents were not provided the opportunity to see the new location, meet the new roommate, and ask questions about the move that may affect their health and safety. Findings: During a review of Resident 1's Minimum Data Set (MDS) assessments dated 11/21/22, it indicated Resident 1 had a mild cognitive impairment. During an interview on 12/5/22, at 11:45 a.m., with Resident 1, she stated she was transferred to three different rooms in 10 days. She stated it was the Management Staff A who was making the room changes. Resident 1 stated she never received any written notice about the room changes. Resident 1 stated that she and her roommate, Resident 2, were transferred together to different rooms. During a review of Resident 2's MDS assessments, dated 10/13/22, it indicated that Resident 2 had a severe cognitive impairment. During an interview on 12/5/22, at 1:35 p.m., with Resident 2's representative, she stated that she was not informed about Resident 2's room changes. Resident 2's representative stated that she recently visited Resident 2 and was surprised to see her in a different room. Resident 2's representative stated that she, (Resident 2), and her roommate, (Resident 1), had been moved three times. During an interview on 12/5/22, at 2:25 p.m., with Management Staff A, she stated that there had been six residents who recently had their room changed and copies of their room change notifications were provided to this surveyor. Management Staff A stated that she had not furnished copies of the room change notifications to the residents or their representatives. During an interview on 12/5/22, at 2:30 p.m., with the facility Administrator, she stated that residents were given verbal notification of the room changes. During a review of a facility document titled, Room Change Notification, for the six sampled residents, the documents indicated the room changes for the six residents occurred as follows: Resident 1: Room changed from room [ROOM NUMBER] to room [ROOM NUMBER]A on 10/27/22. Resident 2: Room changed from room [ROOM NUMBER] to room [ROOM NUMBER] on 10/27/22. Resident 3: Room changed from room [ROOM NUMBER]C to room [ROOM NUMBER]C on 10/25/22. Resident 4: Room changed from room [ROOM NUMBER]A to room [ROOM NUMBER]A on 10/18/22. Resident 5: Room changed from room [ROOM NUMBER] to room [ROOM NUMBER]C on 10/18/22. Resident 6: Room changed from room [ROOM NUMBER] to room [ROOM NUMBER] on 10/15/22. The document indicated, Resident/Resp. (Responsible) Party must be notified verbally and in writing prior to move. During a review of a facility policy and procedure (P&P) titled, Room Change/Room Assignment, dated November 2010, the P&P indicated, Prior to changing a room or roommate assignment all parties involved in the change/assignment (e. g. residents and their representatives (sponsor) will be given a one day advance notice of such change.

Based on interviews and record reviews, the facility failed to provide sufficient qualified nursing staff available at all times to provide nursing services to meet the resident's needs safely and in a manner that promotes each resident's rights and physical well-being when: 1. Nine (9) residents, (Resident 1, 2, 3, 4, 5, 6, 7, 8, and 9) did not get their scheduled showers on 8/24/22. 2. Resident 10 eloped from the facility on 8/24/22, at 9:56 a.m., and was discovered missing just before lunch. 3. Resident 11 had to wait 30 minutes after she had activated her call light before her soiled depends (adult diapers used for incontinence) was changed because only one Certified Nursing Assistant (CNA) was assigned to do patient care for the residents during the morning shift of 8/24/22. These failures had the potential to result in: 1. Nine residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, and 9) having skin irritations and rashes when dirt, perspiration, sebum (an oily secretion of the sebaceous glands), some bacteria, and slough off dead skin cells were not removed from their skin through showering/bathing and could lead to skin infections. 2. Harm to Resident 10 when he eloped out of the facility and was by himself for five (5) hours and thirty-four minutes (9:56 am- 3:30 p.m.) and got himself intoxicated from drinking whiskey while out of the facility. 3. Skin irritations or rashes to Resident 11's perineal area (relating to the perineum, (the area extending from the anus to the vulva in the female and to the scrotum in the male) that was exposed to urine and feces. Findings: 1. During a review or a facility document titled, Daily Nursing Assignment Sheet, dated 8/24/22, Wednesday, the AM shift and PM shift assignment sheets indicated that no showers were given to residents that were scheduled to have showers on Wednesdays. During a review of a facility document titled, Station Two Shower Schedule, it indicated that Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9 were scheduled to have their showers on Wednesdays. During an interview on 9/8/22, at 1:15 p.m., with CNA A, he stated he started his shift on 8/24/22, at 6:30 a.m. He stated he was the only CNA for the whole building. CNA A stated he was not able to do his scheduled showers that day because it was too busy. During a review of a facility document titled, Daily Census, dated 8/24/22, it indicated on this day, a Wednesday, there were thirty-four (34) residents in the facility. During an interview on 9/8/22, at 3:02 p.m., with Resident 6, she stated she got a shower two days ago and the one before that was 1 month ago. Resident 6 stated that the facility was short staffed. Resident 6 stated that staff did not have time to perform patient care. 2. During a review of Resident 10's Nurses Notes, dated 8/24/22, at 10 a.m., authored by Licensed Staff B, the note indicated, Gave resident (Resident 10) meds (medications) this AM at breakfast. Just before lunch noted resident (Resident 10) wasn't in T.V. room or bed, ambulates most of the day. Notified all staff and management, per camera, resident (Resident 10) eloped facility at 0956 (9:56 a.m.) .Sheriff dept (department) contacted, staff out searching in vehicles and on foot .At approx (approximately) 1530 (3:30 p.m.) he (Resident 10) was located at a pharmacy by staff member. This nurse (Licensed Staff B) went to location and talked him into returning to facility. Noted resident (Resident 10) was intoxicated .Placed resident (Resident 10) in bed, skin check completed, no issues noted . During an interview on 9/8/22, at 1:15 p.m., with CNA A, he stated he was so busy that day (8/24/22) and he just noticed people were trying to look for a resident (Resident 10) who had left the building. CNA A stated on 8/24/22, he went home at 3 p.m., and Resident 10 was not yet found. During an interview on 9/8/22, at 2:05 p.m., with Licensed Staff B, she stated she was the charge nurse on 8/24/22, when Resident 10 eloped from the facility. Licensed Staff B stated she discovered Resident 10 missing at around lunch time. Licensed Staff B stated that Resident 10 was intoxicated when he was found and on the site were 2 police officers. During a review of Resident 10's Care Plan, initiated on 8/25/22, authored by Licensed Staff C, the care plan indicated, The resident (Resident 10) is an elopement risk. Resident (Resident 10) walked out of the facility yesterday (8/24/22) unattended. 3. During an interview on 9/8/22, at 1:15 p.m., with CNA A, he stated he was a little scared to work on 8/24/22, because the facility was short on staff. CNA A stated it was only him and Licensed Staff B for the AM shift. During a review of a facility document titled, Daily Nursing Assignment Sheet, dated 8/24/22, for the AM shift, the document indicated, the charge nurse was Licensed Staff B and under Nursing Assistants, it indicated CNA A only one, meaning he was the only CNA assigned to work for the AM shift schedule. During an interview on 9/8/22, at 2:45 p.m., with Resident 11, she stated on 8/24/22, CNA A was by himself and had to be helped by Licensed Staff B in providing care to residents. Resident 11 stated she activated her call light but had to wait for about 30 minutes before CNA A came and changed her depends. Resident 11 stated it was uncomfortable having to wait for that long to be changed while soiled with urine an feces.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a safe discharge plan for one of one sampled residents (Resident 26) when 1) the facility did not discuss Resident 26's facility-initiated discharge plan with the resident's daughter or obtained the daughter's agreement to care for Resident 26, and 2) the facility-initiated discharge plan to discharge Resident 26 to a location that was not determined by the choice or the best interests of Resident 26. This failure resulted in Resident 26 feeling very upset and had to go through an appeal process. Findings: The intake information sheet dated 4/28/22 indicated that the Department (the California Department of Public Health) received an anonymous complaint on 4/28/22 regarding a involuntarily discharge of a resident. The complaint information included that the resident had gone through an appeal process with the Office of Administrative Hearing and Appeals. The resident was granted to be remained in the facility due to the facility did not provide the resident with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. The complaint information also included that the facility did not obtain the daughter's agreement to allow her mother to reside with her in another state. During a review of Resident 26's admission Record, dated 3/15/18, indicated she had been admitted to the facility on [DATE] originally and had been readmitted to the facility on [DATE] with a history of right artificial knee replacement and difficulty walking. During a concurrent interview and record review on 4/28/22 at 2:00 p.m., with the Social Services Director (SSD), Resident 26's Facility-Initiated Discharge Notice, dated 3/1/22 was reviewed with the SSD. The SSD stated Resident 26's daughter would provide care to Resident 26 in her home. The SSD stated Resident 26 was no longer eligible for covered skilled nursing services and neither Resident 26 nor her family were able to pay privately to remain at the facility. During a review of Resident 26's Social Services Progress Notes, dating from 2/2/22 to 3/29/22 indicated there were no documented encounters where Resident 26's daughter had agreed to provide care and housing for Resident 26. The SSD could not explain how Resident 26's daughter was indicated to be agreeable to providing housing and care to Resident 26. The SSD stated, there was nothing else to be done and did not know what to do since Resident 26 was unable to pay for her stay at the facility and other measures for housing and care were not available. During an interview on 4/28/22 at 4:11 p.m., with Resident 26, she stated she was very upset when she received a paper from the SSD and the paper indicated Resident 26 would be living with her daughter out of state. Resident 26 stated both of her daughters did not have the space nor the time to care for her and she did not want to be a burden to her daughters. Resident 26 stated, she felt comfortable and safe living at the facility. During a review of the facility's policy and procedure titled, Transfer or Discharge Notice, dated 2016, the P&P indicated, 3. The resident and/or representative (sponsor) will be notified in writing of the following information: .c. The location to which the resident is being transferred or discharged ; .10. At the time of notification, the facility will provide each resident and responsible party with the following information: a. The plan for the transfer and adequate relocation of resident. B. The date by which the transfer/relocation of the resident will be completed; and c. Assurances that the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services, and location. 11: In determining the transfer location for a resident, the decision to transfer to a particular location will be determined by the needs, choices and best interests of that resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an observation on 5/17/22, at 9:30 a.m., in the hallway, Resident 23 was in his wheelchair. Resident 23 propelled himself by pushing with one foot. Resident 23 propelled himself via wheelchair back and forth from the nurse station to the facility entrance. Resident 23 continued to go back and forth until the lunch meal was served at 12:30 p.m During a review of the clinical record for Resident 23, the Physician Orders, dated 2/15/22, indicated Resident 23 had an order for the Restorative Nursing Assistant (RNA) program. The order indicated Resident 23 would ambulate with a hemi walker (a small, one-handed walker that is intended to be used by persons that have one-half of their body weakened) 2 times a week. During a review of the clinical record for Resident 23, the Restorative Nursing Program Activity Record, dated 2/22, indicated Resident 23 was participating in the RNA program. The record indicated Resident 23 received 3 out of 4 session opportunities. The record indicated 1 session was not carried out due to the equipment not being available. During a review of the clinical record for Resident 23, the Restorative Nursing Program Activity Record, dated 3/22, indicated Resident 23 was participating in the RNA program. The record indicated Resident 23 received 8 out of 10 session opportunities. The record did not provide documentation to show a rationale for the 2 missed sessions. During a review of the clinical record for Resident 23, the Restorative Nursing Program Activity Record, dated 4/22, indicated Resident 23 was participating in the RNA program until the sessions were stopped. The record indicated Resident 23 received 4 out of 8 session opportunities. There was no documentation to indicate why the physician's order was no longer carried out. During an interview with Licensed Nurse Z (LN Z), on 5/20/22, at 1:03 p.m., she stated Resident 23 looked so sad. LN Z stated the facility had paused the RNA program so Resident 23 was not getting to walk. LN Z stated over time he will lose function. LN Z stated Resident 23 asked Unlicensed Staff Y (UNLS Y, who was a RNA) for a walking session, but UNLS Y had to refuse because she was assigned to work on the floor providing direct care. Based on observation, interview and record review, the facility failed to ensure residents received the necessary care and services to ensure resident's abilities to perform Activities of Daily Living did not decline when Restorative Nursing Assistant (RNA) services (RNAs perform range of motion exercises and strengthening exercises) were not provided as ordered for four Residents (Resident 4, Resident 84, Resident 28 and Resident 23). This failure had the potential to result in decline of resident's Activities of Daily Living (ADL)(The ability to be able to eat, wash, shower, brush teeth, walk, transfer to a toilet or wheelchair independently or with minimal assistance.), and contractures (A condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: 1. During an observation and interview on 5/17/22, at 8:34 a.m., Resident 4 was observed seated in his wheelchair at his bedside. He stated he had not had and Physical Therapy (PT) or RNA services for 6 months or longer. He stated the facility had a lot of problems and one day the PT just stopped. Resident 4 stated he was informed he was not getting any PT or exercises (RNA services) because the facility had money problems. He stated a year ago he had PT and was walking, but he is not walking now. Resident 4 stated he was worried about the care he was receiving at the facility, and Was scared he was to never going to be able to get better. A review of a document titled admission RECORD, for Resident 4, indicated he was admitted [DATE], with Diagnoses that included Chronic Obstructive Pulmonary Disease, (A type of progressive lung disease that cases airflow blockage and breathing related problems.), Obesity, Muscle Weakness and Lack of Coordination. A review of Resident 4's Minimum Data Set (MDS) (A health screening and assessment toll used for all Residents) indicated a Brief Interview for Mental Status (BIMS) score of 15 (BIMS is an assessment used to get a quick snapshot of how well you a resident is functioning cognitively at the moment. Residents with a BIMS score of 8-12 considered to be mildly impaired. Residents were considered cognitively intact if they were able to complete the BIMS and scored between 13 and 15). Review of a facility document for Resident 4, titled RESTORATIVE NURSING PROGRAM ACTIVITY RECORD, dated March 2022, indicated he received RNA services once a week on 2/2/22 and 2/8/22. The document indicated for April, Resident 4 had 10 minutes of RNA therapy on 4/4/22 and had no other RNA services documented for April or May. 2. During a lunch observation on 5/16/22, at 1:10 p.m., Resident 84 was observed to eat her lunch with her fingers. No staff were observed to assist her. A review of a document titled admission RECORD, for Resident 84, indicated she was admitted [DATE], with Diagnoses that included Multiple Sclerosis (A degenerative disease of the brain and spinal cord that disrupts the signals from the brain to the body that results in paralysis.). Diagnoses with onset date of 7/16/21 indicated Contracture , Right Wrist, Left Wrist, Left Hand, Muscle Weakness, Abnormal Posture. Review of a facility document for Resident 84, titled FAX TRANSMITTAL SHEET, dated 12/22/21, indicated To Dr. [NAME] . RNA program for PROM (Passive Range of Motion) to U.E.'s (Upper Extremities), and L.E's, (Lower Extremities) x 5 (5 times) 3 months, 2 x's a week .Renewed 3/22/22. Review of a Physician's Order document titled Order Summery Report, dated 2/27/22, indicated a doctor's order for RNA program: PROM for UE's & LE's 2 X / wk X 3 months one time a day every Tue, Thur for RNA program. Review of a document titled RESTORATIVE NURSING PROGRAM ACTIVITY RECORD, dated 2/22 indicated Resident 84 received RNA services once a week on 3/1/22 and 3/7/22. On 4/3/22, the document indicated Resident 84 had 10 minutes of RNA therapy, and no other RNA services documented for the month of April or May. 3. During an interview on 5/19/22, at 12:35 p.m., Resident 28 stated the facility was really short of staff. He stated they moved the RNA to CNA duties, and he has noticed he was stiffer and was worried about losing his strength. A review of Document titled admission RECORD, for Resident 28, indicated he was admitted [DATE], with Diagnoses that included Quadriplegia (A condition paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso.), Cerebral Palsy (A group of movement disorders that include poor coordination and muscle control.), Muscle Weakness. A review of Resident 28's MDS indicated a BIMS score of 15. Review of a facility document for Resident 28, titled FAX TRANSMITTAL SHEET, dated 1/26/22, indicated To Dr. [NAME] . Continue RNA program for PROM to LE's, 2 x's a week, x 3 months. Renew April 26, 2022. Review of a Physicians Order document titled Order Summary Report, dated 3/30/22, indicated RNA Program: PROM to LE's 2 X / wk X 3 month one time a day every Tue, Thur for RNA program. Review of a document titled RESTORATIVE NURSING PROGRAM ACTIVITY RECORD, dated 3/22 indicated Resident 28 received RNA services once a week on 3/3/22 and 3/8/22. On 4/1/22, the document indicated Resident 28 had 15 minutes of RNA therapy, and no other RNA services document for the month of April or May. During an interview on 5/18/22, at 1 p.m., Unlicensed Staff K and Unlicensed Staff L stated their duties included checking the residents every two hours and repositioning them. They stated they did not assist residents with exercise. They stated the risk to residents if they do not get repositioned was sores or contractures (A condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). During a phone interview on 5/19/22, at 8:49 a.m., the Director of Physical Therapy stated she started in April 2022. She stated she was aware the facility used to have an RNA but not now. She stated the RNA had been reassigned to work as a Certified Nursing Assistant (CNA). She stated there were no RNA services being performed in the facility. Director of Physical Therapy stated seven Residents who were supposed to have RNA services were not receiving it. She stated the risk to residents when they do not receive RNA services was decline in walking, potential contractures, inability to function independently for feeding themselves. She stated she was unaware the facility had 21 residents with diagnosed contractures and six residents had developed them after admission. She stated residents could have developed contractures from lack of exercise and positioning and lack of an RNA and staffing may have contributed to that. During a phone interview on 5/19/22, at 9:59 a.m., the Medical Director stated the facility used to have full time PT and Occupational Therapy (OT), but the facility ran out of money. He stated about 6 months ago, the facility prioritized nursing care and PT was not a priority. Medical Director stated Rehabilitation services was essential, but lack of staffing was an issue. He stated during COVID there were no resident admissions and so there was no work for PT. He stated the RNA was pulled to do CNA duties around 3 months ago. Medical Director stated two times a week for PT or RNA was sub-optimal, but it was better than nothing. He stated if someone has a risk of decline I would order Rehabilitation services 3 times a week. He stated if someone not receiving PT services or Rehabilitation services physical decline would have been inevitable. During an interview on 5/19/22, at 10:53 a.m., Licensed Nurse P stated there was no RNA anymore. Licensed Nurse P stated RNA was currently doing CNA work only. Licensed Nurse P stated finding staffing was so difficult that a decision was made to use RNA as a CNA for direct resident care. Licensed Nurse P stated the lack of staffing increased the workload and walking residents or exercising was not done, which would contribute to contractures or decline in Activities of Daily Living (ADL)(Being able to eat, wash, shower, brush teeth, transfer to a toilet or wheelchair independently or with minimal assistance). A review of a facility Policy and Procedure (P&P) titled Restorative Nursing Services, revised July 2017, indicated Residents will receive restorative nursing care as needed to help promote optimal safety and independence. A review of a facility document titled Restorative Nursing Program, dated 5/28/13, indicated Restorative Nursing Program is a service provided by the facility generally under nursing, to ensure maintenance of patient's optimum level of function.These services must be performed daily.Restorative Nurse's Aide Is responsible for administering the restorative program on a daily basis and will assure that each patient is treated according to the therapist guidelines.Program Structure 1. Frequency of treatment: daily, 7 x/wk., QD(every Day). 2. Conducted by RNA on a one-to-one basis .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure enough staff to meet the needs of residents, when Restorative Nursing Assistant (RNA) services were discontinued and used RNA staff as a Certified Nursing Assistant (CNA). This failure had the potential to result in resident falls, skin breakdown, and residents decline of resident's Activities of Daily Living (ADL)(The ability to be able to eat, wash, shower, brush teeth, walk, transfer to a toilet or wheelchair independently or with minimal assistance.), and contractures (A condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: (Reference F676) 1. During an observation on 5/16/22, at 11:05 a.m., the white board in Nurse Station 1 indicated Licensed Nurse P, Unlicensed Staff Q, Unlicensed Staff R, and Unlicensed Staff S on duty. During an interview on 5/16/22, at 12:36 p.m., Resident 4 stated staffing was really short. He stated the short staffing had resulted in less therapy for him. He stated he had gotten much weaker after he did not have therapy. He stated when he was admitted , he could stand but now he cannot. Resident 4 stated there are only 2 CNAs scheduled during the day. During an observation on 5/16/22, at 12:35 p.m., Resident 4 was observed seated in his wheelchair at his bedside eating lunch. At 3:46 p.m. he was observed seated in his wheelchair at his bedside. At 4:15 p.m., he was observed seated in his wheelchair at his bedside. During an observation and interview on 5/17/22, at 8:34 a.m., Resident 4 was observed seated in his wheelchair at his bedside. He stated he had not had and Physical Therapy (PT) or RNA services for 6 months or longer. He stated the facility had a lot of problems and one day the PT just stopped. Resident 4 stated he was informed he was not getting any PT or RNA exercises because the facility had money problems. He stated a year ago he was walking, but he is not walking now. Resident 4 stated he was worried about the care he was receiving at the facility, and Was scared he was to never going to be able to get better. A review of a document titled admission RECORD, for Resident 4, indicated he was admitted [DATE], with Diagnoses that included Chronic Obstructive Pulmonary Disease, (A type of progressive lung disease that cases airflow blockage and breathing related problems.), Obesity, Muscle Weakness and Lack of Coordination. A review of Resident 4's Minimum Data Set (MDS) (A health screening and assessment toll used for all Residents) indicated a Brief Interview for Mental Status (BIMS) score of 15 (BIMS is an assessment used to get a quick snapshot of how well you a resident is functioning cognitively at the moment. Residents with a BIMS score of 8-12considered to be mildly impaired. Residents were considered cognitively intact if they were able to complete the BIMS and scored between 13 and 15). Review of a facility document for Resident 4, titled RESTORATIVE NURSING PROGRAM ACTIVITY RECORD, dated March 2022, indicated he received RNA services once a week on 2/2/22 and 2/8/22. The document indicated for April, Resident 4 had10 minutes of RNA therapy on 4/4/22 and had no other RNA services documented for April or May. 2. During an interview on 5/16/22 at 1:16 p.m., Resident 17 stated staffing could be pretty short. 3. During a lunch observation on 5/16/22, at 1:10 p.m., Resident 84 was observed to eat her lunch with her fingers. No staff were observed to assist her. A review of a document titled admission RECORD, for Resident 84, indicated she was admitted [DATE], with Diagnoses that included Multiple Sclerosis (A degenerative disease of the brain and spinal cord that disrupts the signals from the brain to the body that results in paralysis.). Diagnoses with onset date of 7/16/21 indicated Contracture , Right Wrist, Left Wrist, Left Hand, Muscle Weakness, Abnormal Posture. Review of a facility document for Resident 84, titled FAX TRANSMITTAL SHEET, dated 12/22/21, indicated To Dr. [NAME] . RNA program for PROM (Passive Range of Motion) to U.E.'s (Upper Extremities), and L.E's, (Lower Extremities) x 5 (5 times) 3 months, 2 x's a week .Renewed 3/22/22. Review of a Physician's Order document titled Order Summery Report, dated 2/27/22, indicated a doctor's order for RNA program: PROM for UE's & LE's 2 X / wk X 3 months one time a day every Tue, Thur for RNA program. Review of a document titled RESTORATIVE NURSING PROGRAM ACTIVITY RECORD, dated 2/22 indicated Resident 84 received RNA services once a week on 3/1/22 and 3/7/22. On 4/3/22, the document indicated Resident 84 had 10 minutes of RNA therapy, and no other RNA services documented for the month of April or May. 4. During an interview with Resident 28, on 5/19/22 at 12:35 p.m., he stated there was a shortage of staff that resulted in the facility taking away the RNA program. A review of Document titled admission RECORD, for Resident 28, indicated he was admitted [DATE], with Diagnoses that included Quadriplegia (A condition paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso.), Cerebral Palsy (A group of movement disorders that include poor coordination and muscle control.), Muscle Weakness. A review of Resident 28's MDS indicated a BMS score of 15. Review of a facility document for Resident 28, titled FAX TRANSMITTAL SHEET, dated 1/26/22, indicated To Dr. [NAME] . Continue RNA program for PROM to LE's, 2 x's a week, x 3 months. Renew April 26, 2022. Review of a Physicians Order document titled Order Summary Report, dated 3/30/22, indicated RNA Program: PROM to LE's 2 X / wk X 3 month one time a day every Tue, Thur for RNA program. Review of a document titled RESTORATIVE NURSING PROGRAM ACTIVITY RECORD, dated 3/22 indicated Resident 28 received RNA services once a week on 3/3/22 and 3/8/22. On 4/1/22, the document indicated Resident 28 had 15 minutes of RNA therapy, and no other RNA services document for the month of April or May. During an interview on 5/17/22, at 4:32 p.m., the Administrator stated staffing was very hard to provide in this area, and to fill the empty nursing shifts, the Minimum Data Set Nurse (MDS) (A health status screening and assessment tool used for all Residents.), and the IP Nurse were pulled off their assignments to provide direct patient care. The Administrator was asked to explain the nursing schedule. She stated MDS nurse did the schedule and calculations, and had the documents, but he worked the Night shift last night and would not be available until 5/18/22. During an interview on 5/18/22, at 1 p.m., Unlicensed Staff K and Unlicensed Staff L stated their duties included checking the residents every two hours and repositioning them. They stated the risk to residents if they were not repositioned, the resident could develop skin breakdown or contractures (A condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Unlicensed Staff K and Unlicensed Staff L stated they turned all the residents, unless they declined, and then they told the nurse. During an interview with Unlicensed Staff Q on 5/18/22 at 4:02 p.m., she stated usually there are three CNA's during the day. She stated today she was working 2:30p.m. to 11 p.m., but she usually worked day shift. During a phone interview on 5/19/22, at 8:16 a.m., Director of Physical Therapy stated the facility used to have a Restorative Nursing Assistant (RNA) program, but not right now. She stated the residents were not receiving RNA services because the trained RNA had to work as a Certified Nursing Assistant. She stated the Physical Therapy was short staffed and she had to use the Occupational Therapist to complete assessments. She stated she could not screen all the residents. She stated the risk of not having RNA services was Resident decline as exhibited by development of contractures, muscle weakness, atrophy, lack of positioning, lack of exercise. She stated the shortage of all staff contributed to risk of Resident decline. During a phone interview on 5/19/22 at 9:59 a.m., the Medical Director stated they used to have full time PT and OT, but because of COVID and hiring Travelers, the facility ran out of money. He stated the facility prioritized nursing care over PT and used the RNA as a CNA to provide direct patient care. He stated the facility lost PT department about 6 months ago. He stated if residents did not receive PT or RNA services, there was a risk of residents experiencing physical decline would be inevitable. Medical Director stated he was not sure when a change took place but there used to be two nurses everyday and now there is frequently only one licensed nurse. He stated having only one licensed nurse means they have less time to do assessments, spend time with residents, doing just the basic stuff. During an interview and record review with MDS on 5/19/22, at 10:45 a.m., he stated he was responsible for scheduling staff. He stated the facility prioritized resident care. MDS stated staff worked overtime, double shifts, and split shifts to provide nursing coverage. He stated he tried to schedule two licensed nurses on days, two licensed nurses on evening shift and one nurse on night shift. During an interview on 5/19/22 at 10:53 a.m., Licensed Nurse P stated usually there were two licensed nurses and four unlicensed staff scheduled for days. Licensed Nurse P stated he worked double shifts and split shifts (Work 6 hours and go home, to return later and work another shift) pretty regularly. He stated he worked a lot of overtime, like 20 hours a week. Licensed Nurse P stated the RNA services were discontinued so that the RNA could work as a CNA. Licensed Nurse P stated the high workload, and the short staffing has a potential for residents to develop contractures without the exercise and stated I worry the hours we put in are not sustainable. If the facility cannot recruit staff I am worried about being able to meet the needs of residents. He stated Things get prioritized and Range of Motion falls off the list of things to do. A review of a facility Policy and Procedure (P&P) titled Restorative Nursing Services, revised July 2017, indicated Residents will receive restorative nursing care as needed to help promote optimal safety and independence. A review of a facility document titled Restorative Nursing Program, dated 5/28/13, indicated Restorative Nursing Program is a service provided by the facility generally under nursing, to ensure maintenance of patient's optimum level of function.These services must be performed daily.Restorative Nurse's Aide Is responsible for administering the restorative program on a daily basis and will assure that each patient is treated according to the therapist guidelines.Program Structure 1. Frequency of treatment: daily, 7x/wk., QD(every Day). 2. Conducted by RNA on a one-to-one basis . A review of a document titled CENSUS and DIRECT CARE SERVICE HOURSE PER PATIENT DAY(DHPPD), dated 5/1/22 - 5/16/22 indicated out of 15 days: Two-day shifts had only one licensed nurse scheduled when there was supposed to be two licensed nurses. Three evening shifts had only one licensed nurse schedule where there was supposed to be two licensed nurses. Eight evening shifts had only 12 hours of licensed nursing scheduled where there was supposed to be 16 hours. Coverage was provided four times by having licensed nurses work double shifts. A request to review the Policy and Procedure for the staffing matrix for the facility. The Policy and Procedure was not provided before the end of survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure menus were followed when; 1. 3 out of 3 recipes were not followed for the lunch meal served on 5/19/22, 2. All Residents were given 2 slices from a 5 inch personal pizza rather than 2 slices from a twelve inch pizza for the dinner meal served on 5/16/22, 3. The wheat roll was omitted from the lunch meal served on 5/16/22, a substitution was not offered, 4. 1 resident on a pureed diet (Resident 8) received the wrong dessert item for 1 lunch meal served on 5/19/22. These failures resulted in altered nutritional content of the menu and put vulnerable residents at risk for imbalanced nutrition, weight loss and worsening of medical conditions. Findings: 1a. During a review of the facility document titled, Good For Your Health Menus, dated 5/16/22-5/23/22, the menu indicated what was expected for lunch on 5/19/22. The menu indicated Szechuan pork, fried rice, stir fry vegetables, confetti coleslaw, and tapioca pudding would be served. During an observation and concurrent record review, on 5/19/22, at 10:55 a.m., Dietary G used granulated garlic to season the stir fry vegetables. A review of the recipe titled, Stir Fry Vegetables, [undated], indicated powdered garlic would be used. During an interview, on 5/19/22, at 12:15 p.m., With the DM (dietary manager), she confirmed there was a difference between garlic powder and granulated garlic. The DM stated the texture was different. The DM stated the change in ingredients could alter the taste and or the texture of the dish. 1b. During an observation and concurrent record review, on 5/19/22, at 9:25 a.m., Dietary G opened a 3-ring binder that contained recipes for all items listed on the menu. Dietary G started preparing the fried rice. Dietary G poured 2 quarts plus 2 cups of water into a large metal tray that she placed over 2 burners on the range. During an observation and concurrent record review, on 5/19/22, at 9:35 a.m., Dietary G added brown rice to the boiling water. Dietary G stirred the mixture and left the tray on the range. The recipe indicated mix the rice and boiling water then cover tightly and bake at 350 degrees for 45-55 minutes. During an observation and concurrent record review, on 5/19/22, at 10:55 a.m., Dietary G mixed the egg, vegetables, and soy sauce into the brown rice. The recipe indicated the rice would be added to the vegetables and pan fired in oil. During an observation, on 5/19/22, at 11:45 a.m., Dietary G scooped fried rice into a blender. Dietary G added approximately 4 ounces of the reconstituted chicken broth to the blender. Dietary G blended the mixture for approximately 1 1/2 minutes. During an interview and concurrent record review, on 5/19/22, at 12:15 p.m., with the DM, she reviewed the recipe titled, Fried Rice, [undated]. The recipe indicated for residents with a pureed diet the rice could be pureed with milk as needed. The DM was unable to show documentation that indicated chicken broth was an acceptable liquid to puree the rice with. The DM asked Dietary G how she pureed the rice and Dietary G stated with chicken broth. During an interview and concurrent record review, on 5/19/22, at 12:23 p.m., with the DM and Dietary G, they reviewed the recipe titled, Fried Rice, [undated]. The recipe indicated the rice would be baked and then added to an oiled pan and sauteed with all other ingredients. Dietary G confirmed the rice was boiled, not baked. Dietary G confirmed the other ingredients were cooked and added to the rice in a serving dish, the rice did not get sauteed as per the recipe. Dietary G was asked what product was used when the recipe called for lite soy sauce. Dietary G pulled a large container of dark liquid. The label on the container indicated the liquid was Tamari Soy Sauce. The DM stated the product used was not the same as the lite soy sauce the recipe called for. 1c. During an observation and concurrent record review, on 5/19/22, at 10 a.m., Dietary G reviewed the recipe for Szechuan Pork and stated she was going to make the sauce. Dietary G poured ½ cup plus 1 tablespoon of tamari soy sauce into a measuring cup. A review of the recipe indicated the use of lite soy sauce. Dietary G used a chicken base to make a chicken broth and then used 1 and ½ cups of the broth. A review of the recipe indicated low sodium chicken broth. Dietary G used 1 jar of hoisin sauce, the label indicated it was 7 ounces. A review of the recipe indicated 1 and ½ cups or 12 ounces of hoisin sauce. Dietary G added the other ingredients listed into a pot and put the pot on the range. The Recipe called for 1 and ½ quarts of water which was omitted. The recipe indicated after the pork was fully cooked the excess fat needed to be drained. Dietary G did not drain any fat off the pork. During an observation and concurrent record review, on 5/19/22, at 10:53 a.m., Dietary G added the previously omitted water to the pork and then added the sauce to the pork/water mixture. The pork was left on the range at a full boil in the liquid from 10:53 a.m. until 11:15 a.m. At 11:15 am the pork was moved into the oven. The pork was transferred from the oven to the steam tray at 11:45 a.m. During an observation of [NAME] line, on 5/19/22, at 12:05 p.m., the Szechuan pork tray had liquid that covered 2/3 of the pork. The liquid was thin and ran all over the plate when the scoop of pork was plated. During an interview and concurrent record review, on 5/19/22, at 12:23 p.m., with the DM and Dietary G, they reviewed the recipe titled, Szechuan Pork, [undated]. The recipe indicated the sauce would be made with lite soy sauce. Dietary G was asked what product was used when the recipe called for lite soy sauce. Dietary G pulled a large container of dark liquid. The label on the container indicated the liquid was Tamari Soy Sauce. The DM stated the product used was not the same as the lite soy sauce the recipe called for. Dietary G was asked what product was used when the recipe called for low sodium chicken broth. Dietary G pulled a tub of Chicken Base from the refrigerator and stated the base was mixed with water to make the broth. The DM reviewed the tub and stated the product used was not the same as the low sodium chicken broth listed on the recipe. Dietary G was asked if they found Hoisin sauce as indicated by the recipe and Dietary G provided 1 empty 14 tablespoon jar of hoisin sauce. Dietary G confirmed only 14 tablespoons were used instead of the 24 tablespoons the recipe called for. Dietary G stated that was all the facility had. During an interview and concurrent record review, on 5/19/22, at 12:30 p.m., with the DM and Dietary G, they stated the Registered Dietician (RD) was not made aware or consulted for any of the changes to the recipe or cooking technique. A review of the document titled, Substitution Log, dated [DATE], showed no indication the changes had been documented. The DM reviewed the log and confirmed none of the changes that had been made throughout the week were documented for the RD to review. During an interview on 5/19/22, at 12:45 p.m., with the DM, she stated the changes made to the recipe would change the nutritional composition of the meal. The DM stated the meal had a lot more sodium. During a review of the nutritional labels for the ingredients used and the ingredients listed in the recipes a comparison of the sodium content was reviewed. The lunch meal on 5/19/22 would have had 308 milligrams (mgs) of sodium (a mineral that is important for maintaining normal fluid balance in the body, diets higher in sodium are associated with an increased risk of developing high blood pressure, which is a major cause of stroke and heart disease) per regular serving if it was prepared as indicated in the recipes. The lunch meal on 5/19/22 had 442 mgs of sodium per regular serving. The lunch meal had 133 mg, equal to 43 percent more sodium than intended. During a review of a recipe titled, The Best Szechuan Sauce, dated 5/25/2019, indicated Szechuan Sauce was a thick and bold Chinese condiment that had savory heat and a tangy bit of sweetness. The recipe indicated the sauce was highly viscose. The recipe indicated the thickness of the sauce was similar to a very thick BBQ sauce. 2. During an observation and interview on 5/17/22 at 8:56 a.m., Resident 4 stated for dinner on 5/16/22, they served two small pieces of pizza smaller that his computer mouse. He stated it was cold and tasted terrible. Resident 4 stated he asked for a substitution of a grilled cheese sandwich, and they brought him another slice of cold pizza. He stated the green salad was put through a blender and was flaky in texture. He stated it was very unappetizing. Resident 4 state he and his roommate wanted to order a takeout pizza because they could not eat their dinner. During an interview with the DM, on 5/17/22, at 11:13 a.m., she stated the facility's food supplier was not providing the food ordered. The DM stated there was many items that were out of stock. The DM stated some of the items would be substituted for a different item the supplier had. The DM stated sometimes there was just a lack of food products. During an interview and concurrent record review, with the DM and Dietary G, on 5/17/22, at 11:23 a.m., Dietary G stated the facility received 5-inch personal size cheese pizzas form the supplier. The DM reviewed the Spring Cycle Menu document titled, Cooks Spreadsheet, [undated], and stated the menu indicated a regular serving would be 2 slices from a 12-inch combination pizza that had been cut into 16 slices. The DM stated the RD had not been consulted to determine nutritional equivalency. Dietary G stated she thought they had about 15 pizzas for 35 residents. Dietary G confirmed they cut the personal pizza into slices and gave each resident 2 pieces. 3. During an observation, on 5/16/22, 12:25 p.m., in Resident 2's room, Resident 2's lunch tray was served. There was no wheat roll on her tray. The meal ticket card on Resident 2's tray indicated the meal would include a wheat roll. During an observation, on 5/16/22, 12:26 p.m., in Resident 6's room, Resident 6's lunch tray was served. There was no wheat roll on her tray. The meal ticket card on Resident 6's tray indicated the meal would include a wheat roll. During an interview with Unlicensed Staff K (UN K), on 5/16/22, at 12:40 p.m., UN K stated none of the trays had wheat rolls on them. During an interview and concurrent record review, on 5/17/22, at 11:40 a.m., with the DM, she reviewed the Spring Cycle Menus Cooks Spreadsheet, dated Week 3 Monday. The menu indicated the lunch meal was roast turkey with [NAME] sauce, parsley and herb penne pasta, green beans with garlic, a wheat roll, and an apple crisp. The DM stated she did not know there was a missing item from the lunch meal. The DM stated there was no communication to herself or the Registered Dietician (RD) from staff that indicated a missing item from the lunch meal. During an interview with Dietary H, on 5/17/22, at 11:50 a.m., she stated she remembered making the rolls. Dietary H stated she did not plate the lunch meal on 5/16/22. Dietary H stated the rolls were prepared but not included on the trays, they were missed. 4. During an interview and concurrent record review, on 5/19/22, at 12:25 p.m., with the DM, she reviewed the Spring Cycle Menus Cooks Spreadsheet, dated Week 3 Thursday. The spreadsheet indicated residents on the pureed therapeutic diet would get P-cherry instead of tapioca pudding. The DM stated she did not know what P-cherry was. Dietary J stated she pureed the tapioca pudding for the lunch meal. During a review of the facility policy and procedure titled, Food Preparation, dated 2018, the policy indicated the facility will use approved recipes, standardized to meet the resident census. The policy indicated recipes were specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide.

Based on observation, interview, and record review, the facility failed to follow the physician prescribed therapeutic diets when: 1. Mechanical Soft (MS) texture was not followed during the 5/19/22 lunch meal, which increased the risk for choking for residents with chewing or swallowing difficulty; 2. High protein diets were not followed, which had the potential for worsening nutritional status of residents that needed protein dense meals. Failure to follow physician ordered diets had the potential to compromise the medical status for all 23 residents with a therapeutic diet. Findings: 1. During an observation, on 5/19/22, at 12:10 p.m., in the kitchen, Dietary G removed 8-10 scoopfuls of pork and put them into a food processor. Dietary G pulsed the food processor 4 short pulses and 2 long pulses. During a concurrent interview and record review, on 5/19/22, at 12:25 p.m., with the DM and Dietary G, Dietary G stated the pork in the food processor was used for residents on a mechanical soft diet. Dietary G stated the small, chopped up pork pieces were appropriate for residents on a mechanical soft therapeutic diet. The DM stated she agreed with Dietary G. The DM reviewed the Szechuan Pork recipe, the special diets section indicated, Dysphagia/ Mechanical Soft: grind pork and make recipe. The DM reviewed a document titled, Spring Cycle Menus Cooks Spreadsheet, dated Week 3 Thursday, the spreadsheet indicated mechanical soft and dysphagia mechanical were two different therapeutic diet options. The spreadsheet indicated, make recipe but grind pork for both options. Dietary G stated she did not use ground pork to make any lunch items. 2. During an interview with the DM, on 5/17/22, at 12:10 p.m., she stated she was not sure if the supplement shakes in stock were considered high protein. During a review of the resident meal tray cards, dated 5/16/22, 6 cards indicated the meal included a high protein shake. During an interview, on 5/17/22, 4:35 p.m., with Licensed Nurse W (LN W), she stated Resident 13 was given a high protein shake every meal. LN W stated the shake was served in a glass with a lid. LN W stated the shake was a doctor's order on Resident 13's Medication Administration Record (MAR). LN W stated she documented the percentage consumed on Resident 13's MAR. When asked how the nurse knew the supplement was high protein, LN W stated she assumed it was, since it was listed on the card as a high protein shake. During an interview with the Registered Dietician (RD), on 5/20/22, at 10:30 a.m., she stated she heard the survey team was asking about the high protein shake supplements. The RD did not answer when asked if the shakes the facility had in stock were considered high protein. The RD stated she audited the resident's electronic medical records on 5/19/22. The RD stated she changed all the supplement orders from high protein shake to house supplement. When asked what were the nutritional parameters for house supplements, the RD stated it did not matter. The RD stated the facility could use any brand supplement, whatever was available at the time. The RD stated she could write or change any and all diet orders, including supplement orders, per her scope of practice. During a review of the facility policy and procedure titled, Purchasing Food And Supplies, dated 2018, the policy indicated supplies shall be appropriate to meet the requirements of the menu and therapeutic diets ordered.

Based on interview and record review, the facility failed to ensure an active and engaged Quality Assurance and Performance Improvement committee. This failure had the potential to not proactively identify resident care issues and develop a sustainable plan to address the concerns. Findings: During an interview and record review, with the Administrator, on 5/20/22 at 12:31 p.m., she stated she had started as the Administrator in April 2022, and had met once with the Quality Assurance Performance Assurance Committee. She could not provide a Quality Assurance Performance Improvement Plan, approved by the QAPI Committee or Governing board for 2022. She stated she had prioritized to work on Dietary Remodeling Issues and Staffing. The Administrator stated she had not fully developed the QAPI process at this time. A review of the QAPI minutes indicated the committee met in April, but had not fully developed any Performance Improvement Projects to address Falls Prevention, Staffing shortages, Suspension of the Restorative Nursing Assistant program, Pharmacy Recommendations, or Dietary Issues. A review of the QAPI binder indicated a QAPI Committee had met in April 2022. The minutes of the meeting were reviewed and did not indicate a facility specific plan, identify any resident care issues or have any QAPI Policies and procedures.

Based on observation, interview, and record review, the facility failed to ensure the Registered Dietician (RD) provided comprehensive oversight of the dietary services. Failure to ensure comprehensive oversight by the RD might have resulted in: 1. menus were not followed. Refer to F 803; 2. facility did not follow physician prescribed therapeutic diets. Refer to F 808; and 3. the facility did not store and prepare food in accordance with professional standard. Refer to F 812. This failure also had the potential for systematic failures of nutrition service and impaired quality of life for all 35 residents in the facility and had the potential to cause widespread food-borne illness in a vulnerable population with complex medical conditions. Findings: During multiple observations, interviews, and record reviews, from 5/16/22 - 5/20/22, at various times through out the day, nutritional services were provided in a manor that did not meet the 2017 Food Code standards. During an interview with the RD, on 5/20/22, at 10:16 a.m., the RD stated she had been contracted to provide RD services to the facility since 2019. The Rd stated she worked in the facility 1 day a month. The RD stated the facility census was really low, residents were stable, and she did not think the facility was taking admissions. The RD stated she was onsite in April. The RD stated during her monthly visit she would perform a kitchen inspection which included inspection of the physical environment, inspection of food storage, observation of meal preparation, meal portioning and serving. The RD stated results of the inspection were communicated to the facility via a document titled, Sanitation and Food Safety Checklist. The RD stated she also reviewed all new admission residents and participated in weight change meetings. and all new admission assessments. The RD stated a summary of tasks performed was communicated to the facility via documents titled, Consultant Dietitian Report. The RD stated she completed both forms for the month of April. The RD was aware the facility had no documentation to indicate an April visit was completed. During a review of the facility document titled, Sanitation and Food Safety Checklist, dated 3/21/22, the form indicated the RD assessed the equipment which included the ovens and ice machine. The RD indicated equipment was Very Clean - Sparkling! Great Job. The RD indicated all carts and racks were clean and in good repair. The RD indicated soiled rags were stored in labeled covered containers. The RD indicated logs were maintained for the dishwasher and QUAT sanitizer. The RD indicated recipes were followed, spreadsheets were followed, and all food items were received met professional standards. During a review of the facility document titled, Consultant Dietitian Report, dated 3/21/22, the document indicated the RD observed meal service. The document indicated the RD's evaluation of meal service was Great Job. During an interview with the RD, on 5/20/22, at 10:20 a.m., the RD stated her professional opinion was that the facility's kitchen staff's job performance was exceptional. The RD stated she was, hard pressed to find anything wrong. The RD stated she had not observed staff failing to follow the recipe or cooking methods. The Rd was unaware the facility had many out-of-stock items that required substitution. The RD stated the need for nutritional equivalency of substituted items was not brought to her attention. During an interview with the RD, on 5/20/22, at 10:30 a.m.,, the RD confirmed part of the inspection included food storage. The RD Stated she always looked at food storage. The RD stated she had no concerns in the dry storage area. When asked if she had identified expired food or food without an expiration date in the dry storage the RD stated No. When asked if she had identified items opened and put back into storage the RD stated You tell me. When asked if she had identified a concern that the facility's eggs were not pasteurized, the RD stated she never noticed that. The RD stated she thought she reviewed the kitchen log binder, but she could not recall. The RD stated she identified a concern when the cooks were not documenting food temperatures prior to serving. The RD had not identified a concern with the QUAT log or the dishwashing log. During an interview with the RD, on 5/20/22, at 10:40 a.m.,, the RD stated she had not audited the meal tray cards in comparison to the diet order or to the meal served. The RD stated she had not checked the menu against the food the facility had on hand. The RD stated the facility was supposed to order from the list provided so it should be done. When asked what did she consider her responsibility in regards to oversight of the nutritional services department, the RD stated my effectiveness is only as good as the effectiveness of the dietary manager. The RD refused to elaborate further. During an interview with the administrator, on 5/20/22, at 11:22 a.m., she stated the Dietary manager (DM) and Registered Dietician (RD) managed the dietary department for the facility. The administrator stated she expected the RD to provide services and oversight to maintain the facility in compliance with all the difference regulatory bodies that provided oversight for food services. The administrator stated food safety, sanitization, and resident diets needed to be in compliance. The administrator stated the expectation was for the RD to accurately assess the dietary department for compliance. When asked if failing to identify the ice machine noncompliance for 7 months, or the use of unpasteurized eggs, or the active storage of expired food met the facility expectation; the administrator stated the RD should have identified those concerns. The administrator stated the RD was expected to complete all new admission nutritional assessments. When asked if she thought 3 weeks was an acceptable timeframe to wait for the initial assessment, the administrator stated it should be done right away. The administrator stated 3 weeks was unacceptable. During a review of the facility job description titled, dietician, dated 2003, the document indicated the purpose of the position was to plan, organize, develop and direct the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility. The document indicated the RD was to assure that quality nutritional services were being provided on a daily basis and that the food services department was maintained in a clean, safe, and sanitary manner. The Duties and Responsibilities section indicated the RD would assume the administrative authority, responsibility and accountability of directing the Food Services Department. The section indicated the RD would visit residents periodically to evaluate the quality of meals served, likes and dislikes, mealtimes, bedtime snacks, and food substitutions. The section indicated the RD would review therapeutic and regular diet plans and menus to assure they are in compliance with the physician's orders. The Staff Development section indicated the RD would develop and participate in the planning, conducting, and scheduling of timely in-service training classes that provided instructions on how to do the job, to ensure a well-educated food services department. The section indicated the RD would develop, implement, and maintain an effective orientation program that oriented the new employee to the department, its policies and procedures, and to his/her job duties. The policy further indicated the RD would ensure that food service personnel attended annual/mandatory training programs. The Miscellaneous section indicated the RD would make weekly inspections of all food service functions to assure that quality control measures were continually maintained.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when: 1. eggs were purchased for resident consumption that were not pasteurized, 2. food was stored past the facility's use by date, 3. food was stored in open packaging, 4. fruits and vegetables stored for use had mold spots, had turned brown, and had gotten soft and squishy, 5. food containers were removed from their external packaging and stored without documentation to show the products expiration date, 6. prepared food was stored and ready for use past the facility's policy, 7. food preparation areas were not cleaned or sanitized between uses, 8. staff did not perform hand hygiene after removing their gloves, 9. the solution used to sanitize kitchen surfaces was not at an acceptable concentration per the manufacturer's guidelines 79 times out of 79 opportunities, 10. the internal components of the ice machine were not drained, cleaned, and sanitized as needed or according to the manufacturer's specifications, 11. the dishwashing machines manufacturer's instructions to ensure clean sanitized dishes were not followed, 12. Fans, vents, drains, oven knobs, and the stationary can opener were visibly soiled with large amounts of build-up and debris on them. These failures had the potential to result in a food-borne illness outbreak amongst a population of vulnerable residents with complex medical conditions. Findings: 1. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:11 p.m., in the refrigerator, there were 2 full cases of eggs and one open tray of eggs. There was no indication on the open eggs that the product had been pasteurized. Dietary H pulled out 1 case of eggs and read the labels. Dietary H was unable to find any indication that the eggs had been pasteurized. Dietary H stated they cooked with eggs, as well as made eggs in many different ways almost every breakfast. During a concurrent observation and interview, on 5/17/22, at 10:57 a.m., with DM, in the kitchen, the DM inspected an egg. The DM stated usually pasteurized eggs had a marking on the shell. The DM stated the eggs in the refrigerator did not have any markings on them. The DM inspected the cardboard box the eggs were delivered in. The DM was unable to locate any label to indicate the eggs were pasteurized. The DM stated if the eggs were not pasteurized, they would not suitable for use in the facility. 2. During an initial kitchen tour with Dietary H, on 5/16/22, at 12 p.m., in the dry storage room, on the back shelf was a box of powdered drink mix and a pouch of powdered instant pudding mix. The powdered drink mix had a delivery date of 1/2021. The pouch of powdered instant pudding mix had a delivery date of 7/2/21. Dietary H stated the facility followed a universal food storage guideline and pointed to a paper pinned to the wall. Dietary H looked at the powders then reviewed the guideline and stated the pudding mix should be stored for only 6 months. During a concurrent observation and interview, on 5/17/22, at 10:50 a.m., with DM, in the dry storage room, she stated she was aware there was expired pudding and pink lemonade mix in the storage area. The DM looked at an open case of canned meat and stated the product had gone past the facility's universal storage guideline date. 3. During an initial kitchen tour with Dietary H, on 5/16/22, at 12 p.m., in the dry storage room, there was an open box of carrot cake mix. Dietary H opened the box and stated the plastic bag was left open. Dietary H stated open food items should be tied or in some way closed for storage. During an initial kitchen tour with Dietary H, on 5/16/22, at 12 p.m., in the freezer, there was a cardboard box labeled beef patties. The cardboard box had the tape removed which indicated it had been previously opened. Inside the cardboard box was a plastic bag filled with frozen beef patties. The bag had an opening than spanned the width of the bag. Dietary H stated the plastic should have been tied or in some way sealed. Dietary H stated the bag could be tied or the patties could be transferred to a resalable plastic storage bag During a concurrent observation and interview, on 5/17/22, at 10:50 a.m., with DM, in the dry storage room, an open box of carrot cake mix was stored on the back shelf. Inside the box was an open plastic bag of carrot cake mix. The DM looked into the box and stated the plastic bag should be tied or sealed. The DM stated storing the mix in an open bag increased the risk for contamination. During a concurrent observation and interview, on 5/17/22, at 10:56 a.m., with DM, in the kitchen, she opened the freezer. In the freezer there was a cardboard box labeled beef patties. The cardboard box had the tape removed which indicated it had been previously opened. Inside the cardboard box was a plastic bag filled with frozen beef patties. The bag had an opening than spanned the width of the bag. The DM stated the patties should not be stored with the packaging open. The DM stated the expectation was to close or seal all items in storage. During a concurrent observation and interview, on 5/19/22, at 8:50 a.m., with DM, in the kitchen, she opened the freezer. Inside the freezer was an open cardboard box that contained an open plastic bag full of bacon. The DM stated the plastic bag should be tied or sealed prior to putting the box back into the freezer. The DM stated the bacon was at risk for contamination or freezer burn (a condition that occurs when frozen food has been damaged by dehydration and oxidation due to air reaching the food). The DM took plastic storage bags that had a resalable opening from a drawer and asked staff to portion the bacon into the bags and store them sealed. 4. During an initial kitchen tour with Dietary H, on 5/16/22, at 12 p.m., in the dry storage room, there were three bunches of bananas on a shelf. The bananas were black on approximately 80% of their peel. Dietary H stated, we have what we have and explained if they threw out the bananas, they wouldn't have any fresh fruit. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:11 p.m., in the refrigerator, there was a clear plastic bin that contained carrots tomatoes and cucumbers. The tomatoes had multiple small black fuzzy spots on their skin. Dietary H looked at the bin and stated the tomatoes needed to be thrown out. Dietary H pulled the bin out of the refrigerator and placed it on a countertop. Dietary H removed the tomatoes from the bin. During the adjustment 1 cucumber had a wrinkled texture at both ends that spanned approximately 2 inches inwards. Dietary H touched the cucumber and it squished. Upon further inspection almost every cucumber had some length of wrinkled squishy part. Dietary H stated they must have gone bad. Dietary H called out to Dietary E and asked E to sort through the vegetables and remove the bad ones. During a concurrent observation and interview, on 5/17/22, at 11 a.m., with DM, in the kitchen, she stated vegetables should not be stored or used if they had signs or mold or had gone bad in any way. 5. During an initial kitchen tour with Dietary H, on 5/16/22, at 12 p.m., in the dry storage room, there were multiple large cans of sauces, boxes of fruit juice concentrates, and cartons of thickened water all with no expiration date labeled on the packaging. Dietary H looked for an indication of the expiration date on each item. Dietary H stated she thought the date was printed on the cardboard box the items were delivered in. Dietary H pulled out a cardboard box with a label that indicated 1 case of fruit juice concentrate. On the cardboard there was a stamped expiration date of 3/2024. When asked how staff would know if a food item was not expired if it was not stored in the outer cardboard Dietary H stated they referred to the universal storage guideline. When asked what would happen if the product delivered expired sooner than the storage time indicated on the universal guideline Dietary H stated she did not know. During a concurrent observation and interview, on 5/17/22, at 10:50 a.m., with DM, in the dry storage room, she looked at the [brand] cans and cartons for the manufacturer's expiration date. The DM stated she could not find and expiration date. The DM stated the date was stamped onto the cardboard boxes the products were delivered in. The DM confirmed it was the facility's practice to remove the products from the outer cardboard packaging. The DM stated she knew the products were not expired because they used a first in last out stocking plan and did not stockpile products. The DM stated the facility used a universal storage guideline. When asked what would happen if the supplier provided a product that was due to expire sooner than the universal guide indicated the item could be stored, the DM stated the product would be expired. The DM stated she would have no way of knowing the product was expired. 6. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:10 p.m., in the refrigerator, there was a tray of sandwiches dated 5/12/22. Dietary H stated the sandwiches were made in the kitchen for resident snacks and per resident request. Dietary H stated the facility policy indicated sandwiches could be stored for 72 hours. Dietary H looked at the date on the sandwiches and stated they should be thrown out. Dietary H stated she did not know whether any residents had received sandwiches outside of the 72-hour window. During a concurrent observation and interview, on 5/17/22, at 10:56 a.m., with DM, in the kitchen, she stated she thought sandwiches prepared by staff would not be stored longer than 1 day. The DM stated the staff would refer to the universal storage guideline. The DM stated she expected staff to throw out any food items not used within acceptable storage time. 7. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:15 p.m., in the room used to wash dishes, Dietary H was asked how the staff cleaned and disinfected the kitchen. Dietary H removed a spray bottle from a closet and stated she sprayed the product on a surface and then wiped it dry with a towel. During a review of the spray bottle label, the how to use section, indicated the product was used to sanitize hard, non-porous food contact surfaces. The label indicated surfaces must be pre-cleaned with the same product prior to sanitizing. The label indicated no rinse was required prior to sanitizing. The label indicated to sanitize, spray the product 6-8 inches away from the hard, non-porous surface. The label indicated the surface needed to remain wet for not less than 1 minute. The label indicated the surface should be allowed to air dry. During a concurrent observation and interview, on 5/17/22, at 11:07 a.m., with DM, in the dishwashing room, the DM stated red and green buckets were used to clean and sanitize the kitchen. The DM stated the green bucket was filled with soap and water and the red bucket was a QUAT (Ammonium quaternary compounds are potent disinfectant chemicals that can often effectively kill germs on surfaces that have not been fully washed and rinsed) sanitizer from an auto pump machine. The DM was unable to locate where the filled, in use buckets were located. The DM was not aware of any cleaning and sanitizing sprays used in the kitchen. During an observation, on 5/19/22, at 9:45 a.m., in the kitchen, dietary G added approximately 4 ounces of soap to a green 6 quart plastic bucket. Dietary G filled the bucket with water. Dietary G used a white towel and the soap solution from the green bucket to wipe the counter workspace that was used to cut carrots and onions for the fried rice. Dietary G put the used towel into the green bucket and then walked away. No sanitizing solution was used on the workspace. During an observation, on 5/19/22, at 9:50 a.m., in the kitchen, Dietary V was chopping raw pork cubes into smaller pieces. Dietary V finished chopping the pork and placed the large metal tray of pork onto 2 burners on the range. Dietary G walked a crossed the kitchen and showed Dietary V the green bucket. Dietary V used the towel from the green bucket and wiped down the workspace. Dietary V put the towel back into the green bucket and walked away. No sanitizing solution was used on the workspace. During a concurrent observation and interview, on 5/19/22, at 9:50 a.m., with DM, in the kitchen, the DM stated towels should be used once and then put aside to be laundered. The DM stated the staff should be cleaning and then using QUAT sanitizer on all workspaces between tasks. The DM removed the rag from the bucket. The DM was unable to locate a receptacle for used towels. The DM asked Dietary G what was in the green bucket and confirmed it was water and soap. The DM was unable to locate where any QUAT solution had been prepared and used after each task. The DM had no answer when asked how the staff had been cleaning and sanitizing all day long if the buckets were not in use. During an observation, on 5/19/22, at 11 a.m., in the kitchen, Dietary J finished pouring drinks for lunch meal. Dietary J switched tasks to portioning and serving tapioca pudding. Dietary J did not wash or sanitize the workstation prior to switching tasks. During an observation and concurrent record review, on 5/19/22, at 11:30 a.m., Dietary E chopped lettuce, then tomatoes, then carrots, without cleaning and sanitizing the workstation. Dietary E used the same knife for all three tasks without cleaning and sanitizing to prevent cross contamination. 8. During an observation, on 5/19/22, at 9:31 a.m., Dietary H removed a pair of gloves and put on a new pair. No hand hygiene observed before putting on the clean gloves. 9. During a concurrent interview and record review, on 5/17/22, at 11:20 a.m., with DM, the log binder was reviewed. The facility document titled, Quaternary Ammonium Log, dated 5/22, indicated the expectation was for staff to test the concentration and document it in the log 5 times a day. The log indicated proper concentration would be between 150-200 ppm. The log indicated the concentration was 700 ppm for 79 tests out of 79 opportunities. The DM stated she did not know the QUAT had a known concentration of 700. The DM did not know what test kit the staff was testing with. 10. During an interview with MS (maintenance supervisor), on 5/17/22, 3 p.m., he stated he cleaned and wiped down the outside of the ice machine daily. The MS stated that had a contracted company that serviced the ice machine every 6 months. The MS provided documentation that showed daily external cleaning. The MS provided documentation that indicated a company had completed quarterly impatience on 7/29/2021. During a review of the ice machine's manual chapter 4 titled, Maintenance, [undated], indicated the machine required a Remedial Cleaning Procedure to be completed at least monthly or as indicated by the electronic menu indicator. During an interview with the Maintenance Supervisor (MS), on 5/19/22, at 12:05 p.m., he stated the menu on the ice machine was never set-up. MS confirmed the ice machine could provide monthly alert reminders to clean the interior components of the machine and complete monthly descaling. MS stated at the time on instillation he was not aware of the menu and its functions. MS confirmed the manufacturer's instructions included a cleaning and descaling at least monthly, if not sooner based on ice consumption. MS stated he had placed a call to a repair company and that a technician would be out within the hour to perform a cleaning and descaling procedure. MS stated the technician would also set up the menu on the ice machine. During an interview on 5/19/22, at 4:20 p.m., with the ice machine technician, he stated the ice machine had shown signs of buildup. The technician confirmed the menu had not been activated when the machine was installed. 11. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:15 p.m., in the room used to wash dishes, Dietary V was washing dishes. The gauge on the dishwasher indicated a temperature of 110 degrees during both the wash and rinse cycles. Dietary H stated the machine was a high temperature dishwasher. The sink on the dirty side of the dishwasher had a large garbage disposal attached to the drain. Dietary V stated the garbage disposal was not working. The wall that separated the dishwashing room and the kitchen had a 3 compartment sink. The wall had plastic wrapped around each side of it. Dietary H stated the sink was not in use. Dietary H stated there was a leak and the wall had been partially demolished and needed to be replaced. During a concurrent observation and interview, on 5/17/22, at 11:10 a.m., with DM, in the dishwashing room, the DM stated the dishwasher was a low temperature machine that used chemicals to sanitize. The DM stated the water needed to reach 120 degrees during the wash cycle. The DM stated the water needed to reach 120 degrees during the rinse cycle. The DM stated the sanitizer needed to have a concentration of 50 or more to be effective. The DM stated the expectation was that staff tested the sanitizer and recorded the concentration in the log binder. During a concurrent observation and interview, on 5/17/22, at 11:13 a.m., with DM, in the dishwashing room, a load of dishes was put into the dishwasher. The gauge at the bottom of the machine reached 118 degrees during the wash cycle. The gauge at the bottom of the machine reached 118 degrees during the rinse cycle. The DM stated the machine needed to warm up. The DM took a small piece of paper out of a plastic tube and dipped it into the water after the cycle was complete. The paper changed to different shades of purple to indicate the sanitizer concentration. The plastic tube had a label that indicated the paper expired 6/1/21. The DM looked at a second tube and stated that one expired 4/1/22. The DM stated she would need to call the MS and get papers that were not expired. The DM stated the expired papers might not give an accurate concentration level. During a concurrent interview and record review, on 5/17/22, at 11:20 a.m., with DM, the log binder was reviewed. The facility document titled, Dish Machine Temperature Log, dated 5/22, indicated the expectation was the wash cycle temperature, the rinse cycle temperature and the sanitizer concentration were documented 3 times a day. The log indicated the wash cycle was 120 degrees for 46 cycles out of 46 opportunities. The log indicated the rinse cycle was 125 degrees for 46 cycles out of 46 opportunities. The log indicated the sanitizer concentration had been recorded 0 out of 46 opportunities. The DM stated she did not know the log was incomplete. During an interview with MS, on 5/17/22, 11:35 a.m., he stated the facility contracted a company to maintain the dishwasher. The MS stated the company services the machine monthly. The MS stated the machine should be at temperature without warming up because it was piped directly from the hot water tank. The MS stated he would call the company to assess the temperature and provide more strips. During an interview with the dishwasher technician, on 5/17/22, 12:05 p.m., he stated the dishwasher was set to wash at 120 degrees, rinse at 122 degrees and have a 90 ppm concentration of sanitizer. The technician stated if the temperature was not reached the dishes would need to be rewashed. The technician stated the sanitizer could get highly concentrated if there was something blocking the water intake. The technician stated a common blockage was seen when a plastic lid to a cup was accidentally left on a dish and then blocked the water intake. The technician confirmed the dishwasher was not reaching temperature during both the wash and rinse cycles. During an interview with the administrator, on 5/17/22, at 12:37 p.m., she stated she was aware there was an issue with the dishwashing machine. The administrator stated the technician inspected the machine and determined the gauge was broken. The administrator stated a thermometer was used to verify the water was above 138 degrees for both the wash and rinse cycles. The administrator could not determine when the gauge was broken or how the staff was able to get exactly 120 and 125 degrees on a gauge that was stuck and would not go above 118 degrees. 12. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:15 p.m., the ovens and range were approximately 90% covered in black sticky buildup. On the front of the oven there were knobs to control burner temperatures. In the open space around each knob there was black sticky buildup, crumbs of various colors and sized and fluffy dust material filling approximately 80% of each space. When asked who cleaned the ovens and range, Dietary H stated she did not know. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:15 p.m., the room used to wash dishes had debris and buildup on almost every surface. The two ceiling fans and one exhaust vent were caked in gray fuzzy dust that crumbed and fell to the surface below with gentle touch. Dietary H observed the dust and stated the maintenance department cleaned the equipment. The dishwasher drain had large particles of food and bits of wrappers covering approximately 50% of the drain screen. The metal back splash, and metal tables on the dirty and clean sides of the dishwasher had splattered off white spots and food debris in the corners. In the center of the room was a metal 3-tiered cart. Each tier had metal rods a crossed the width of the cart approximately 3 inches apart. The cart had rust covering almost every lateral surface and some vertical surfaces. Dietary H grabbed the cart and stated it was the rack used to air dry the plastic covers that go over resident meal plates. Dietary H confirmed the rusty cart was in use in its current state. When asked if the rust ever transferred to the plastic Dietary H stated they had to be careful because when the rust got wet it would drip onto the covers below. During a concurrent observation and interview, on 5/17/22, at 11:05 a.m., with DM, in the dishwashing room, the DM stated the Maintenance Supervisor (MS) and his department were responsible for cleaning the equipment and both rooms. During an interview with MS, on 5/17/22, 11:35 a.m., he stated the facility was out of dishwasher sanitizer test strips. The MS confirmed he was responsible for cleaning and maintaining the kitchen and dish washing rooms. The MS stated the vents, fans and all aspects of the rooms were cleaned weekly. The MS was unable to provide documentation to show a log or cleaning schedule. The MS could not explain how the level of buildup on the vents, fans, and oven had accumulated in 1 week. According to a review of the USDA Food Code, 2017, the standard of practice was to ensure dietetic services areas and equipment were clean to site and touch. During a review of the facility policy and procedure titled, Sanitation, dated 2018, the policy indicated the facility would have a cleaning schedule in which each cleaning task is assigned to an employee by name or job title. The policy indicated all counters shelves and equipment would be kept clean, free from corrosions and maintained and in good repair. The policy indicated ice that was used in connection with food.or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner. The policy indicated after each use chopping boards would be thoroughly cleaned and sanitized. The policy indicated no use of cleaning products or sanitizer in the food preparation or food storage areas that in any way that could result in contamination of exposed food items. That included spraying or pouring cleaning products near food items, during preparation, or while cooking. During a review of the facility policy and procedure titled, Quaternary Ammonium Log Policy, dated 2018, indicated the concentration of the ammonium in the quaternary sanitizer would be tested to ensure the effectiveness of the solution. The policy indicated the concentration would be tested at least every shift or when the solution was cloudy. The policy indicated the solution would be replaced when the reading was below 200 ppm. The policy indicated a high concentration may be potentially hazardous and may be a chemical contaminate of food.

Based on observation and interview, the facility failed to provide privacy during care for one Resident (R) 53 of three residents observed during the administration of insulin. The Director of Nurses (DON) verified that 12 residents, residing in the facility, received insulin injections. This failure had the potential to violate Resident 53's rights to privacy and confidentiality in all areas of care; and the potential to affect all residents who received personal care in the facility. Findings: Review of the quarterly, Minimum Data Set (MDS) assessment dated 08/25/19, documented Resident 53 had a, Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. The assessment also included an active diagnosis of diabetes mellitus type two. On 09/19/19 at 8:30 AM, Licensed Vocational Nurse (LVN) 38 administered insulin to R53. R53 was sitting in his wheelchair, in the hallway outside his room. The LVN asked R53 if he wanted the insulin administered into his abdomen, and he stated he did. She lifted R 53's gown, exposing his bare skin to anyone who might have walked by in the hallway and administered the injection into his abdomen. On 09/19/19 at 8:38 AM, the LVN was asked if she had provided privacy during the administration of the insulin. She stated, No, not this time. On 09/20/19 at 9:10 AM, the Director of Nursing stated the facility did not have a policy and procedure regarding full visual privacy during the provision of care. When asked if she would expect her staff to provide privacy for an insulin injection in a resident's abdomen, she stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents, who received a Pre-admission Screening and Resident Review (PASARR) Level I, and were later identified with a newly-diagnosed serious mental disorder, were referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination. This failure affected one of two sampled residents (R)52, reviewed for PASARRs, and had the potential to result in inappropriate placement and/or a failure to provide necessary mental health care and services. Findings: Interview, on 09/21/19 at 10:31 AM, with the Administrator, revealed the facility did not have a policy related to PASARR. Review of R52's, Face Sheet, dated 08/19/19, and located in R52's electronic medical record (EMR), revealed R52 was readmitted to the facility on [DATE], with diagnoses which included major depressive disorder and anxiety disorder. Continued review of R 52's face sheet revealed on 01/27/18, R52 was diagnosed with bipolar disorder. Review of R52's, Preadmission Screening and Resident Review (PASRR) Level I Screening Document, dated 11/13/15, revealed for, Section III-Mental Illness (MI) Screen, the only diagnoses selected was, Depression. Continued review of R52's screening revealed the diagnosis of, bipolar was not selected; and also revealed the, PASRR was a positive screening, and R52 was appropriately referred for a Level II screening. Interview, on 09/19/19 at 3:45 PM, with the Social Service Director (SSD) revealed she was responsible for completing the Level I PASARR. Continued interview revealed, if the Level I was positive, she would make the referral for a Level II PASARR. The SSD confirmed R52 received a new mental health diagnosis of bipolar disorder in January of 2018. The SSD further stated she did not know until yesterday (when she was questioned by the surveyor) that a new Level I needed to be completed. Continued interview revealed she completed a new Level I this day and it resulted as a, positive screening, so she referred it for a Level II review. Interview, on 09/21/19 at 10:01 AM, with the Director of Nursing (DON), revealed it was her expectation the SSD would have completed a new Level I PASARR screening once R52 received the new mental illness diagnosis. Continued interview revealed the relevance of a new Level I screening was to identify serious mental illness, and establish if the resident qualified for a Level II referral and to ensure the residents received the mental health services they were assessed for. Interview, on 09/21/19 at 10:30 AM, with the Administrator, revealed it was his expectation nursing staff would have let the SSD know a resident had received a new mental health diagnosis, and then the SSD would have reacted and completed a new Level I. Continued interview revealed it was important that a new Level I screening was completed, and it could potentially prompt a referral for a Level II and subsequent mental health care. Subsequent interview, on 09/21/19 at 10:53 AM, with the DON revealed, prior to the surveyor identifying the PASARR concern, it was not her expectation the nursing staff would have communicated a new diagnosed mental illness to the SSD; however, that was the process now.

Based on record review and interview, the facility failed to ensure a discharge plan of care was completed for one Resident (R) 67, reviewed for discharge home from the facility. This failure had the potential to affect any current or future residents admitted , with the intention of discharging back to the community. Findings: Review of R67's 5-day admission, Minimum Data Set (MDS), assessment, dated 05/23/19, revealed an admission date of 05/16/19, with medical diagnoses of chronic obstructive pulmonary disease (COPD), cardiomegaly (enlarged heart), generalized muscle weakness, debility, and other fracture. Review of R67's hard (paper) chart and electronic medical record, showed no care plan regarding R67's anticipated discharge. R67's care plan addressed the following focus care areas: -Abnormal bleeding related to anticoagulant use; -Alteration in gas exchange related to COPD; -Psychosocial well being related to skilled nursing placement and decline in independence; -Alteration in cardiac function related to diagnosis atrial fibrillation; -Alteration in activities of daily living function related to weakness, shortness of breath and pain; -At risk for falls related to weakness; -Potential for pain related to lumbar compression fracture; and, -Activities: Resident has need for altered activity due to muscle weakness. In an interview on 09/21/19 at 11:10 AM, the Social Services designee stated she was in charge of discharge care plans and confirmed, The discharge care plan was not done. Review of the facility policy, Care Plans - Comprehensive Person-Centered, revised December 2016, showed: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident The comprehensive, person-centered care plan will: -Include measurable objectives and timeframe's; -Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . -Include the resident's stated goals upon admission and desired outcomes; -Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire .

Based on observations, record reviews, and interviews, the facility failed to ensure dependent residents received required assistance for Activities of Daily Living (ADLs). This affected one Resident (R12) of three sampled residents reviewed for assistance with ADLs. The facility Census and Conditions of Residents, dated 09/17/19, documented 62 residents, residing in the facility, required assistance with, or were dependent upon, staff for ADLs. This failure had the potential to result in unmet resident needs and a lack of services for the residents to maintain good nutrition, grooming, and personal hygiene. Findings: Per the current physician's orders for R12, dated 09/2019, R12 was admitted to the facility in 2013. His diagnoses included rheumatoid arthritis, swan-neck deformity of right and left fingers, and major depressive disorder. The quarterly, Minimum Data Set, with an, Assessment Reference Date, of 06/25/19, documented R12 had a, Brief Interview for Mental Status, score of 15, which indicated he had no cognitive impairment. The assessment documented R12 had not rejected care, required limited assistance with personal hygiene, and required extensive assistance with bathing. The care plan, most recently reviewed/revised 06/30/19, documented R12's problems included impaired mobility, which limited his ADL participation due to limited range of motion in extremities, due to contractures from rheumatoid arthritis. One intervention noted was to provide assistance to R12, as needed, for the performance and completion of ADL tasks. On 09/17/19 at 12:07 PM, R12's fingernails were observed to have a significant amount of black debris under them. R12's fingers of both hands were observed to be deformed; some fingers were unable to be bent. When asked if he needed assistance with fingernail care, R12 stated, the person who usually cleaned his nails, was on leave. A review of the, Nurses' Notes, from 06/25/19 to present, were reviewed. There was no documentation R12 had refused care. The, Weekly Nursing Summary, dated 08/14/19, 08/28/19, 09/04/19 and 09/18/19, were reviewed. There was no documentation R12 had interfered with, or refused, care. The facility's, ADL Flow Record, did not address the provision of nail care. On 09/18/19 at 3:28 PM, Certified Nurse Aide (CNA)55 was interviewed. He stated he cleaned residents' fingernails weekly. When asked if he documented nail care, he stated, No. When told R12's nails all had a significant amount of a black substance under them, CNA55 stated R12 used the bathroom by himself. On 09/18/19 at 3:43 PM, R12 stated he had been given a shower by CNA55, either on 09/11/19 or on 09/14/19. He stated CNA55 had not cleaned his fingernails during the shower. He stated he would allow someone to clean his fingernails if they offered to do so. On 09/18/19 at 3:44 PM, the Director of Nursing (DON) was interviewed. When asked if it was the facility's policy that nails could only be cleaned in the bathing area, she stated it was not. When asked if the R12's nails should have been cleaned prior to this day, the DON stated, Yes. The facility's, Activities of Daily Living (ADLs), Supporting, policy/procedure, revised 03/2018, documented: 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to ensure an as-needed (PRN) anti-anxiety medication was time limited in duration, for three of five residents reviewed, for unnecessary medications (Residents: R52, R64 and R49). Record reviews revealed Ativan (medication used to treat anxiety) PRN, was ordered for these three residents; however, the physicians failed to indicate the duration of use (psychotropic medications ordered on an as-needed basis require a 14-day stop date). Additionally, the facility failed to ensure non-pharmacological interventions were attempted and documented, prior to the administration of psychoactive medications for one of the five Residents (R49) reviewed for unnecessary medications. The facility's failures had the potential to result in unnecessary medication administration for any of the 65 residents residing in the facility at the time of the survey. Findings: Review of the facility's policy titled, Medication Therapy, revised April 2007, revealed each resident's medication regimen should include only those medication necessary to treat existing conditions, and all medication orders would be supported by appropriate care processes and practices. Continued review of the policy revealed, upon or shortly after admission and periodically thereafter, the staff and practitioner (assisted by the Consultant Pharmacist) would review an individual's current medication regimen to identify whether the frequency of administration and duration of use were appropriate. 1. Review of R52's, admission Record, dated 8/19/19, located in R52's Electronic Medical Record (EMR), revealed R52 was admitted to the facility on [DATE], with diagnoses which included anxiety disorder. Review R52's, Physician Order, dated 07/24/19, revealed an order for Ativan tablet, 1 mg by mouth every 8 hours as needed for anxiety/panic attacks. Continued review of the order revealed no duration as to when the medication would be discontinued or re-evaluated. Review of R52's, Consultation Report, dated 08/20/19, completed by the facility's Consultant Pharmacist, revealed the pharmacist comment: R52 has a PRN order for Ativan (Lorazepam), and CMS (Centers For Medicare And Medicaid) regulations require a stop order. Continued review of the consultation report revealed the pharmacist recommendation: Would you want to authorize the order to be x3 more months? Further review of the consultation report revealed under, Physician's Response: a check mark was beside, I accept the recommendation(s) above, please implement as written, and the consultation report was signed by R52's physician, who was also the facility's Medical Director. There was no clinical rationale to support the continued use of the medication, x3 months. Interview, on 09/18/19 at 3:09 PM, with the facility's Medical Director and R52's Attending Physician, revealed he did not know it needed to be written in the original order for 14 days. The interview revealed he signed the pharmacy recommendation for a three-month continued use, and when he signed it, that became an order. When asked if he put a clinical rational on the pharmacy recommendation that became an order, he stated, It does ask for rational, but he meant for it to be used for initial use of anxiety attacks, and his clinical rational was, continue. Further interview with the Medical Director revealed he would not have expected the facility to have shown a stop date on the order; he would have expected the responsibility be on the Consulting Pharmacist to catch it prior to the end of the three months. 2. Review of R64's, admission Record, dated, 9/21/19, located in R64's Electronic Medical Record (EMR), revealed R64 was admitted to the facility on [DATE], with diagnoses which included anxiety disorder. Review R64's, Physician Order, dated 04/28/19, revealed an order for Lorazepam tablet 0.5 mg. Continued review of the order revealed the Lorazepam was ordered 0.25 mg by mouth every 24 hours, as needed, for anxiety related to anxiety disorder. The order revealed no duration as to when the medication would be discontinued or re-evaluated. Review of R64's, Consultation Report, dated 05/21/19, completed by the facility's Consultant Pharmacist, revealed the pharmacist comment: R64 has a PRN order for Ativan (Lorazepam), and CMS regulations require a stop order when used beyond 14 days. Continued review of the consultation report revealed the pharmacist recommendation: Would you want to authorize the order to be x90 more days? The Consultant Pharmacist's, Rationale for Recommendation: CMS requires that PRN order for non-antipsychotic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rational for the extended time period and the duration for the PRN order. Further review of the consultation report revealed no evidence the physician responded to the pharmacy recommendation. Review of R64's, Consultation Report, dated 06/26/19, completed by the facility's Consultant Pharmacist, revealed the pharmacist comment: R64 has a PRN order for Ativan (Lorazepam), and CMS regulations require a stop order when used beyond 14 days. Continued review of the consultation report revealed the pharmacist recommendation: Would you want to authorize the order to be x90 more days? Further review of the consultation report revealed no evidence the physician responded to the pharmacy recommendation. Review of R64's, Consultation Report, dated 07/23/19, completed by the facility's Consultant Pharmacist, revealed the pharmacist comment: R64 has a PRN order for Ativan (Lorazepam), and CMS regulations require a stop order. Continued review of the consultation report revealed the pharmacist recommendation: Would you want to authorize the order to be x90 more days? Further review of the consultation report revealed no evidence the physician responded to the pharmacy recommendation. Review of R64's, Consultation Report, dated 08/20/19, completed by the facility's Consultant Pharmacist, revealed the pharmacist comment: R64 has a PRN order for Ativan (Lorazepam), and CMS regulations require a stop order. Continued review of the consultation report revealed the pharmacist recommendation: Would you want to authorize the order to be x90 more days? Further review of the consultation report revealed on 08/27/19, R64's physician circled the pharmacist recommendation of continuing the order x90 more days and initialed where he circled and signed and dated the recommendation; however, there was no documented clinical rational to support continuing the PRN anti-anxiety medication. Interview, on 09/18/19 at 3:23 PM, with the Medical Director, revealed he was just finding out about CMS's expectation to limit the first PRN prescription to 14 days, so he could not expect R64's Attending Physician (who wrote the order for the Ativan) to know the limited duration. On 09/20/19 at 5:23 PM, telephone interview with R64's attending physician was attempted. There was no voicemail to leave a message for a return call. Interview, on 09/20/19 at 4:09 PM, with the Director of Nursing (DON), revealed it was her expectation if the physicians were going to extend the PRN order for anti-anxiety medications past 14 days, the physicians would have given a rational why they were going to extend it. Continued interview revealed she would have expected the physician to respond to the Consultant Pharmacist's recommendations in a timely manner. The DON stated she would not have expected the physician to write the PRN order with a stop date; however, she would expect the physician to indicate a duration on the order. Interview, on 09/21/19 at 10:34 AM, with the Administrator, revealed it was his expectation for PRN anti-anxiety medications, nursing would have checked the order, and if it did not have a duration, nursing should have contacted the doctor. 3. Review of R49's Annual, Minimum Data Set (MDS), assessment, dated 11/17/18, revealed an admission date of 11/13/18, with medical diagnoses that included generalized muscle weakness, dorsalgia (upper back pain), aortic valve disorder, panic disorder, and chronic pain. Review of R49's EMR, Orders, tab revealed the physician had prescribed Lorazepam (brand name Ativan; an anti-anxiety medication) 0.5 milligrams (mg) one tablet every 6 hours, as needed, for agitation related to panic disorder, not to exceed 2 mg per day. A review of the August PRN medication administration record (MAR) showed R49 received Ativan on 8/10/19, for anxiety; the result was, helpful, but no non-pharmacological interventions were noted as having been attempted prior to medication administration, as required. R49 received Ativan on 08/22/19, for increased anxiety; the result was, helpful, however, no non-pharmacological interventions were documented. R49 received Ativan on 08/26/19, for increased agitation, noted to be, effective, however, no non-pharmacological interventions were documented. A review of the July PRN MAR showed R49: 07/28/19, received Ativan for increased anxiety - noted, eff (effective); no non-pharmacological interventions documented; 07/26/19, Ativan for signs/symptoms (s/sx) of anxiety; noted, helps, no non-pharmacological interventions documented; 07/25/19, Ativan for s/sx of anxiety; noted, helps, no non-pharmacological interventions documented; 07/20/19, Ativan for complaints of anxiety; noted, helps, no non-pharmacological interventions documented; 07/19/19, Ativan for increased anxiety; noted, helps, no non-pharmacological interventions documented; 07/19/19 (second dose for the 24-hour period), Ativan for increased anxiety; noted, helps, no non-pharmacological interventions documented; and, 07/05/19, Ativan for anxiety; noted, helps, no non-pharmacological interventions were documented. Review R49's hard chart July and August 2019, Interdisciplinary Progress Notes, did not show any non-pharmacological interventions, most of the PRN doses had no Nurses' Progress Notes at all. In an interview on 09/19/19 at 4:14 PM, the Director of Nursing (DON) stated, Non-pharmacological interventions for PRN psychoactive medications are being done, but not documented. Like, I will have him in my office for coffee and cookies - but I don't document it. In an interview on 09/20/19 at 9 AM, the Administrator stated the facility did not have a policy regarding non-pharmacological interventions for psychoactive PRN medications. In an interview on 09/20/19 at 9:45 AM, regard non-pharmacological interventions before administering psychoactive medications, Licensed Vocational Nurse (LVN)38 stated, Oh, I try other things like redirection or toileting, but I don't chart them.

Based on observation and interview, the facility failed to ensure the wheelchairs for two of seven Resident's (R57 and R62) had armrests which were not in a state of disrepair, potentially resulting in an alteration in the residents' skin integrity; additionally, the broken surfaces presented a potential source of contamination due to having un-cleanable surfaces that could harbor bacteria. This failure had the potential to affect any of the 65 residents who used a wheelchair while in the facility. Findings: Observation of R57's wheelchair on 09/18/19 at 9:19 AM, showed the wheelchair's vinyl armrest was torn or worn off on a large section of the right armrest, and the vinyl on both armrests was cracked and no longer a smooth and cleanable surface. Observation of R62's wheelchair on 09/20/19 at 2:38 PM, showed the wheelchair's vinyl armrest was cracked and peeling. On 09/21/19 at 9:04 AM, the Administrator was shown R57's and R62's wheelchair armrests. Upon observation of R62's wheelchair, the Administrator confirmed the armrests had cracked, peeling vinyl that needed replacing. Upon observation of R57's wheelchair armrest with a large area of vinyl missing, the Administrator stated, it [armrest] should have been changed out a while ago. The Administrator confirmed the armrests needed replacing, and stated he did not believe his, maintenance supervisor had a PM [preventative maintenance] program for the wheelchairs yet. The Administrator was asked about a facility maintenance policy, and at 11:35 AM, the Administrator stated he was unable to find a policy regarding wheelchair maintenance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and interviews, the facility failed to ensure its abuse policy was implemented; and failed to report and thoroughly investigate two of four allegations of abuse, which affected four Residents(R): R37, R41, R59 and R216, of seven sampled residents involved in the abuse allegations. Failure to report allegations of abuse, within federally mandated timelines, had the potential to result in a failure to provide adequate protections from abuse, for the health, welfare and rights of each of the 65 residents at the time of the survey. Findings: The facility's abuse policy and procedure, effective 11/30/17, documented the following: All reports of resident abuse.shall be promptly reported to local state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Administrator shall report all incidents of alleged abuse or suspected abuse to.DPH within 5 working days of the incident. An alleged violation of abuse.will be reported immediately, but no later than: .Two (2) hours if the alleged violation involves abuse. Roll [sic] of the Investigator.Interview the person(s) reporting the incident; Interview any witnesses to the incident; interview the resident (as medically appropriate) . 1. Per his, admission Record, R41 had been admitted to the facility on [DATE], with diagnoses which included alcohol abuse and Wernicke's encephalopathy. The admission, Minimum Data Set, with an, Assessment Reference Date (ARD) of 02/10/19, documented R41 had a, Brief Interview for Mental Status, of 00, which indicated he had severe cognitive impairment. A, Nurse's Progress note, dated 03/04/19 at 11 PM, for R41, documented: Pt [patient] was involved in an altercation [with] other resident. [No] injuries. Pt moved to another room [and] will be under frequent supervision.Language barrier remains as well as dementia state. 2. Per his, admission Record, R37 was admitted to the facility on [DATE], with diagnoses which included unspecified dementia without behavioral disturbance. The admission, MDS, with an, ARD of 02/05/19, documented R37 had a, BIMS, of 15, which indicated he was cognitively intact. A Nurse's Progress note, dated 03/04/19 at 11 PM, for R37, documented: This pt [patient] was involved in an altercation toward another pt. No injuries. Pt under frequent supervision to prevent any further incidences [with] any other pts. He is very protective toward his perceived territory [and] his agitation will markedly [increase] if he feels his territory is being violated. An investigation, dated 03/12/19, provided by the Administrator, of the altercation between R37 and R41, was reviewed. It documented: On March 4th at approximately [8:15 PM R37] was sitting hallway and [R41] passed close by and started to verbally assault [R37]. He got close to [R37] who then reached out to grab him. Residents were immediately separated and [R41] was moved to a room on the opposite station. Both residents have some degree of dementia. Follow up with both residents has resulted in no negative psychosocial problems. The investigation report documented there had been no further incidents involving either resident or with any other resident or staff. The report documented both residents continued to be monitored. The investigation revealed another version of the incident as follows: Abuser [R41] was intimidating victim [R37]. Angry at victim for sitting in hallway close to Abuser's room. In spite of multiple attempts to de-escalate, Abuser continued to verbally assault victim and finally laid hand on the Abuser, who has been moved. The investigation listed Certified Nurse Aide (CNA) 40 as a person believed to have knowledge of the abuse. There was no documentation in the abuse packet which indicated, R37, R41, CNA40, or any other staff, who were working the evening of the incident, had been interviewed regarding the incident. The investigation revealed the incident occurred on 03/04/19 at 8:15 PM, and was reported to the Department on 03/05/19. The final report was faxed to the Department on 03/12/19. On 09/21/19 at 10:15 AM, the Administrator was asked if the incident had been reported to the Department within two hours. He stated, No. He stated he had no additional documentation pertaining to the investigation of the incident. The Administrator was asked if a thorough investigation occurred, which would include interviews with the staff who were working the evening the incident, the person who reported the incident, any witnesses to the incident and the residents involved, had been completed and documented. He stated, No, because I don't have the witness statement. The administrator stated the results of the investigation had not been sent to the Department within five working days. The Administrator said the facility's abuse policy had not been followed by: Not sending an initial report about the incident to the Department within two hours (federally-mandated reporting timeline); failed to complete/document a thorough investigation; and failed to send the results of the investigation to the Department within five working days (federally-mandated reporting timeline). 2. Per her physician's orders, R59 was admitted to the facility on [DATE], with diagnoses which included unspecified alcohol use with alcohol-induced persisting dementia and unspecified dementia with behavioral disturbance. The quarterly, MDS, with an, ARD, of 06/05/19, documented R59 had a, BIMS of 09, which indicated she had moderate cognitive impairment. Per Physician's Orders, R216 was admitted to the facility on [DATE], with diagnoses which bipolar disorder, currently in remission and unspecified dementia without behavioral disturbance. The quarterly, MDS, with an ARD of 04/25/19, documented R216 had a, BIMS of 15, which indicated he had no cognitive impairment. A Nurse's Note, dated 06/30/19, for R216, documented: Pt was looking [at] books sitting in his [wheelchair] while holding the TV remote control [at] Station 2 entrance. Apparently, another resident attempted to grab the remote [and] hit this resident [with] a book on the back of his head. [No] injuries noted. An investigation report, dated 07/08/19, provided by the Administrator, documented: On June 30th at approximately [4:30 PM, R216] was sitting in the Station 2 foyer next to the book table attempting to choose a book, when [R59] picked up a book and hit him on the head for no apparent reason and attempted to grab the TV remote from him. This was witnessed by a staff member who immediately separated them and directed [R59] back to her room. [R216] was assessed by the licensed staff and had no visible injuries. SSD [Social Services Director] assessed resident for emotional distress with none noted. [R59] has some degree of dementia. The report documented there had been no further incidents involving either resident or with any other resident or staff; and both residents continued to be monitored. A fax transmission verification report documented the initial report had been transmitted to the Department on 07/01/19 at 12:40 PM. There was no documentation which indicated R59, R216, the staff member who witnessed the incident, or any other staff member or resident, had been interviewed regarding the incident. On 09/21/19 at 10:20 AM, the Administrator was interviewed. When asked if he had reported the alleged abuse to the Department within two hours, he stated, No. He stated he had no additional documentation regarding the incident. When asked if a thorough investigation, including interviews with the witnesses, the person who completed the initial report, either resident or any other residents or staff, had been completed and documented, he stated, No. When asked if the facility's abuse policy and procedure had been implemented to report the alleged abuse to the Department within two hours and to complete and document a thorough investigation, as required, the Administrator stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and interviews, the facility failed to ensure two of four allegations of abuse were reported to the Department within the two hour and/or five-day federally-mandated reporting time line, as required. This affected four Residents (R): R37, R41, R59 and R216, of seven sampled residents involved in the abuse allegations; and had the potential to result in a failure to provide adequate protections from abuse for the health, welfare and rights of each of the 65 residents residing in the facility, at the time of the survey. Findings: The facility's abuse policy and procedure, effective 11/30/17, documented the following: All reports of resident abuse.shall be promptly reported to local state and federal agencies [as defined by current regulations] and thoroughly investigated by facility management. Administrator shall report all incidents of alleged abuse or suspected abuse to.DPH within 5 working days of the incident. An alleged violation of abuse.will be reported immediately, but no later than: .Two (2) hours if the alleged violation involves abuse. 1. Per his, admission Record, R41 had been admitted to the facility on [DATE], with diagnoses which included alcohol abuse and Wernicke's encephalopathy. The admission, Minimum Data Set, with an, Assessment Reference Date (ARD) of 02/10/19, documented R41 had a, Brief Interview for Mental Status, of 00, which indicated he had severe cognitive impairment. A Nurse's Progress Note, dated 03/04/19 at 11 PM, for R41, documented: Pt [patient] was involved in an altercation [with] other resident. [No] injuries. Pt moved to another room [and] will be under frequent supervision.Language barrier remains as well as dementia state. 2. Per his, admission Record, R37 had been admitted to the facility on [DATE], with diagnoses which included unspecified dementia without behavioral disturbance. The admission, MDS, with an, ARD of 02/05/19, documented R37 had a, BIMS, of 15, which indicated he was cognitively intact. A Nurse's Progress Note, dated 03/04/19 at 11:00 PM, for R37, documented: This pt [patient] was involved in an altercation toward another pt. No injuries. Pt under frequent supervision to prevent any further incidences [with] any other pts. He is very protective toward his perceived territory [and] his agitation will markedly [increase] if he feels his territory is being violated. An investigation, dated 03/12/19, provided by the Administrator, of the altercation between R37 and R41, was reviewed. It documented: On March 4th at approximately [8:15 PM, R37] was sitting hallway and [R41] passed close by and started to verbally assault [R37]. He got close to [R37] who then reached out to grab him. Residents were immediately separated and [R41] was moved to a room on the opposite station. Both residents have some degree of dementia. Follow up with both residents has revealed no negative psychosocial problems/outcomes. The investigation report documented there had been no further incidents involving either resident or with any other resident or staff. The report documented both residents continued to be monitored. The investigation listed Certified Nurse Aide (CNA)40 as a person believed to have knowledge of the abuse. The investigation revealed the incident had occurred on 03/04/19 at 8:15 PM and was reported to the Department on 03/05/19. The final report was faxed to the Department on 03/12/19. On 09/21/19 at 10:15 AM, the Administrator was asked if the incident had been reported to the Department within two hours. He stated, No. The Administrator also stated the results of the investigation had not been sent to the Department within five working days, as required. 3. Per her Physician's Orders, R59 was admitted to the facility on [DATE], with diagnoses which included unspecified alcohol use with alcohol-induced persisting dementia and unspecified dementia with behavioral disturbance. The quarterly, MDS, with an, ARD, of 06/05/19, documented R59 had a, BIMS, of 09, which indicated she had moderate cognitive impairment. Per the Physician's Orders, R216 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder, currently in remission, and unspecified dementia without behavioral disturbance. The quarterly, MDS, with an ARD of 04/25/19, documented R216 had a, BIMS, of 15, which indicated he had no cognitive impairment. A Nurse's Note, dated 06/30/19, for R216, documented: Pt was looking [at] books sitting in his [wheelchair] while holding the TV remote control [at] Station 2 entrance. Apparently, another resident attempted to grab the remote [and] hit this resident [with] a book on the back of his head. [No] injuries noted. An investigation report, dated 07/08/19, provided by the Administrator, documented: On June 30th at approximately [4:30 PM, R216] was sitting in the Station 2 foyer next to the book table attempting to choose a book, when [R59] picked up a book and hit him on the head for no apparent reason and attempted to grab the TV remote from him. This was witnessed by a staff member who immediately separated them and directed [R59] back to her room. [R216] was assessed by the licensed staff and had no visible injuries. SSD [Social Services Director] assessed resident for emotional distress with none noted. [R59] has some degree of dementia. The report documented there had been no further incidents involving either resident or with any other resident or staff. It documented both residents continued to be monitored. A fax transmission verification report documented the initial report had been transmitted to the Department on 07/01/19 at 12:40 PM. On 09/21/19 at 10:20 AM, the Administrator was interviewed. When asked if he had reported the alleged abuse to the state within two hours, as required, he stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy reviews and interviews, the facility failed to thoroughly investigate, document and report, three of four allegations of abuse. This failure affected six sampled Residents (R): R37, R41, R59, R216, R49 and R51) involved in the abuse allegations. Additionally, the facility's failure had the potential to result in inadequate protections from abuse for the health, welfare and rights of each of the 65 residents residing in the facility at the time of the survey. Findings: 1. a.) Per his, admission Record, R41 was admitted to the facility on [DATE], with diagnoses which included alcohol abuse and Wernicke's encephalopathy. The admission, Minimum Data Set (MDS),assessment with an, Assessment Reference Date (ARD) of 02/10/19, documented R41 had a, Brief Interview for Mental Status, of 00, which indicated he had severe cognitive impairment. A Nurse's Progress Note, dated 03/04/19 at 11 PM, for R41, documented: Pt [patient] was involved in an altercation [with] other resident. [No] injuries. Pt moved to another room [and] will be under frequent supervision. Language barrier remains as well as dementia state. b.) Per his, admission Record, R37 was admitted to the facility on [DATE], with diagnoses which included unspecified dementia without behavioral disturbance. The admission, MDS, with an, ARD of 02/05/19, documented R37 had a, BIMS of 15, which indicated he was cognitively intact. A Nurse's Progress Note, dated 03/04/19 at 11 PM, for R37, documented: This pt [patient] was involved in an altercation toward another pt. No injuries. Pt under frequent supervision to prevent any further incidences [with] any other pts. He is very protective toward his perceived territory [and] his agitation will markedly [increase] if he feels his territory is being violated. An investigation, dated 03/12/19, provided by the Administrator, regarding an altercation between R37 and R41, was reviewed. It documented: On March 4th at approximately [8:15 PM, R37] was sitting hallway and [R41] passed close by and started to verbally assault [R37]. He got close to [R37] who then reach out to grab him. Residents were immediately separated and [R41] was moved to a room on the opposite station. Both residents have some degree of dementia. Follow up with both residents has not resulted in any negative psychosocial problems. The investigation report documented there had been no further incidents involving either resident or with any other resident or staff. The report documented both residents continued to be monitored. The investigation listed Certified Nurse Aide (CNA) 40 as a person believed to have knowledge of the abuse. There was no documentation in the abuse investigation which indicated, R37, R41, CNA40, or any other staff who were working the evening of the incident, had been interviewed regarding the incident. The investigation revealed the incident occurred on 03/04/19 at 8:15 PM, and was reported to the Department on 03/05/19. The final report was faxed to the Department on 03/12/19. On 09/21/19 at 10:15 AM, the Administrator stated there was no additional documentation pertaining to the investigation of the incident. The Administrator was asked if a thorough investigation, which would include interviews with the staff who were working the evening the incident occurred, the person who reported the incident, any witnesses to the incident and the residents involved, had been completed and documented. He stated, No, because I don't have the witness statement. 2. a.) Per her physician's orders, R59 was admitted to the facility on [DATE], with diagnoses which included unspecified alcohol use with alcohol-induced persisting dementia and unspecified dementia with behavioral disturbance. The quarterly, MDS, with an, ARD of 06/05/19, documented R59 had a, BIMS of 09, which indicated she had moderate cognitive impairment. b.) Per the physician's orders, R216 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder, currently in remission, and unspecified dementia without behavioral disturbance. The quarterly, MDS, with an ARD of 04/25/19, documented R216 had a, BIMS of 15, which indicated he had no cognitive impairment. A Nurse's Note, dated 06/30/19, for R216, documented: Pt was looking [at] books sitting in his [wheelchair] while holding the TV remote control [at] Station 2 entrance. Apparently, another resident attempted to grab the remote [and] hit this resident [with] a book on the back of his head. [No] injuries noted. An investigation report, dated 07/08/19, provided by the Administrator, documented: On June 30th at approximately [4:30 PM, R216] was sitting in the Station 2 foyer next to the book table attempting to choose a book, when [R59] picked up a book and hit him on the head for no apparent reason and attempted to grab the TV remote from him. This was witnessed by a staff member who immediately separated them and directed [R59] back to her room. [R216] was assessed by the licensed staff and had no visible injuries. SSD [Social Services Director] assessed resident for emotional distress with none noted. [R59] has some degree of dementia. The report documented there had been no further incidents involving either resident or with any other resident or staff. It documented both residents continued to be monitored. There was no documentation which indicated R59, R216, the staff member who witnessed the incident, or any other staff member or resident, had been interviewed regarding the incident. On 09/21/19 at 10:20 AM, the Administrator was interviewed. He stated he had no additional documentation regarding the incident. When asked if a thorough investigation, including interviews with the witness, the person who completed the initial report, either resident or any other residents or staff, had been completed and documented, he stated, No. 3. Review of a report to the State of California on 04/24/19, regarding Resident (R) 49 running over R57's foot with a wheelchair on 4/23/19, and bumping into R57's knee on 04/24/19, was submitted to the Department on 04/24/19. In an interview on 09/18/19 at 2:30 PM, a request was made to the Administrator to review the investigation related to this report. The Administrator provided a file and fax confirmation report. In an interview on 09/19/19 at 9:12 AM, the Administrator was made aware there was no 5-day report found in the file when it was reviewed. The Administrator stated, I can't believe I didn't do a 5 day [investigation] on this incident! I checked all the other files, and they had the five days [investigations] but I missed this one. A review of the facility policy, Resident-to-Resident Altercations Policy, effective 11/30/17, revealed: Purpose: All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. Procedure: . If two residents are involved in an altercation, staff will: -Separate the residents, and institute measures to calm the situation; -Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; -Notify each resident's representative and Attending Physician of the incident; . -Complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; . -Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy Review of the facility, Abuse Investigation and Reporting Policy, effective 11/30/17, showed: Reporting .5. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, review of facility policy and review of a, User Instruction Manual, the facility failed to ensure adequate infection control standards of practice were implemented; and failed to follow manufacturer's recommended cleaning instructions for equipment cleaning and maintenance to prevent the spread of infections. Poor infection control standards of practice had the potential to spread infections from one resident to another for all 12 of the residents who received blood glucose monitoring at the time of the survey. Findings: Multiple medication administration observations were conducted throughout the survey. These observations revealed the facility staff failed to: a. Clean the glucose meter with an EPA (Environmental Protection Agency)-registered disinfectant, as recommended in the, User Instruction Manual (specific to the glucometer used by the facility), for one Resident (R9) of three residents observed receiving a fingerstick blood sugar (FSBS) testing; and, b. Use appropriate infection control and hand hygiene procedures while obtaining FSBSs to prevent cross-contamination for one Resident (R20) of three residents observed receiving blood glucose monitoring. In an interview on 09/19/19 at 9:35 AM, the Director of Nursing (DON) stated 12 residents in the facility had a physician's order for a FSBS. 1. The undated, Face Sheet, for R9 documented he had been admitted to the facility on [DATE], with diagnoses which included diabetes mellitus. R9's current physician's orders documented he was to have a FSBS with meals. On 09/19/19 at 8:18 AM, Licensed Vocational Nurse (LVN) 38 was observed as she performed blood glucose monitoring on R9. Upon completing the FSBS, LVN38 placed the glucose meter in a plastic container and set the container on top of the medication cart. She proceeded to administer R9's insulin. Without disinfecting the meter, LVN38 returned it to a drawer in the medication cart and moved the medication cart down the hall. On 09/19/19 at 8:35 AM, after she had administered oral medications to two residents, LVN38 was asked what the facility's policy was for disinfecting the glucose meter. She stated she cleaned the glucose meter with an alcohol pad prior to using it. She stated she cleaned the meter between residents throughout the shift with an alcohol pad. She stated she used a Sani Cloth, first thing in the morning, when she cleaned the medication cart. LVN38 stated she, generally didn't use a Sani Cloth between residents. She again stated she used just an alcohol pad to clean the glucometer between residents. On 09/19/19 at 9:35 AM, the DON stated there were 12 residents who had a physician's order for a FSBS. She stated seven of the 12 residents resided on the Station 2 hall where R9 resided and LVN38 was working. She further stated one of the residents on the Station 2 hall, who received FSBSs, had a history of receiving treatment for Hepatitis C. This resident had completed the treatments/medication on 09/04/19, and would not be re-tested for Hepatitis C for six months from the last dose. When asked about the facility's policy for disinfection of a glucose meter, the DON reviewed the glucose meter. User Instruction Manual. and the facility's. Blood Sampling - Capillary (Finger Stick), policy and procedure, revised 09/2014. After her review, the DON stated the meter should be cleaned with an EPA-registered disinfectant between residents. When asked if an alcohol pad was appropriate to use for disinfection of a glucose meter between residents, the DON stated, It has to be an EPA-registered disinfectant. When asked if LVN38 had followed the facility's policy and procedure for cleaning the glucose meter, the DON stated, No. On 09/19/19 at 10:44 AM, LVN85, an agency nurse who was working her second shift at the facility, was interviewed regarding cleaning a glucometer. She stated she cleaned the glucose meter with alcohol pads after use and before putting the meter back into the medication cart drawer. She stated she had performed FSBS for residents during the previous shift she had worked at the facility and had cleaned the glucose meter with alcohol pads then. LVN85 stated she had received no orientation in the facility. She further stated she used either Sani Cloths and alcohol pads interchangeably, since they disinfect the same way. On 09/19/19 at 12:47 PM, LVN85 was observed as she performed a FSBS for R9. Following the FSBS, LVN85 used an alcohol pad to clean the glucometer. She stated she was the last one who used the meter prior to finger stick and used alcohol to clean it, so she knew it was clean. On 09/19/19 at 12:51 PM, LVN85 was informed she should speak to the DON prior to completing anymore blood glucose checks. 09/19/19 at 12:57 PM, the DON was informed the survey team had serious concerns regarding inadequate disinfecting of the glucose meters between resident testing. The observations of the use alcohol pads, only, failed to provide adequate disinfecting of the machines, per the manufacturer's guidelines (available on the medication carts); and interviews with the facility staff confirmed this was standard operating procedure for glucometer use in the facility. The glucose meter's, User Instruction Manual, documented: Cleaning [and] Disinfecting Guidelines Cleaning and disinfecting can be completed by using a commercially available EPA registered disinfectant detergent or germicide wipe. The facility's, Blood Sampling - Capillary (Finger Sticks), policy and procedure, revised 09/2014, documented: .Equipment and Supplies.Approved EPA registered disinfectant for cleaning of sampling device.Steps in the Procedure.Following the manufacturers' instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. 2. On 09/19/19 at 8:01 PM, LVN87 was observed as she prepared supplies to perform a FSBS for R20. LVN87 donned gloves at the medication cart, picked up the supplies (glucose meter, lancet, and cotton balls in a plastic medication cup), took them into R20's room and set them down onto the over-bed table. The over-bed table had not been cleaned. LVN87 realized she had forgotten to get an alcohol pad, removed her gloves and set them on the unclean over-bed table next to the other supplies. She then left the room, went to the medication cart, used her keys to unlock the cart, opened the drawer, removed an alcohol pad, closed the drawer, locked the cart and re-entered R20's room. LVN87 donned the same gloves she had left on the unclean over-bed table and administered R20's insulin. On 09/19/19 at 8:11 PM, LVN87 was interviewed. When asked if the facility's policy required clean supplies to be placed on a clean barrier, she stated, Absolutely. When asked if she had set the FSBS supplies onto a clean over-bed table, she stated she had not. The observations of LVN87 leaving R20's room to get an alcohol pad was reviewed with her. When asked if she should have washed her hands and donned clean gloves after she left the room to get the alcohol pad and prior to administering the insulin, LVN87 stated, Yes, I should have. On 09/19/19 at 9:35 AM, the above observations were reviewed with the DON. When asked if LVN87 had used appropriate infection control standards of practice to prevent cross-contamination, the DON stated, No. The facility's, Blood Sampling - Capillary (Finger Sticks), policy and procedure, revised 09/2014, documented: .Steps in the Procedure.Place blood glucose monitoring device on clean field. On 09/20/19 at 9:07 AM, the above observations were reviewed with the DON. When asked if she would expect staff to set clean FSBS supplies on a clean barrier, she stated, Yes. When asked if she would expect staff to use good hand hygiene and clean gloves, she stated, Yes.