**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident, who was newly admitted to the facility, from a psychiatric facility, was supervised, and monitored to prevent one out of three sampled residents (Resident 1) from eloping (leaving a secured institution without notice or permission) from the facility. Resident 1 was last seen in the facility on 10/4/2024 at approximately 8:30 p.m., on the facility ' s patio, smoking. Resident 1 was noted missing on 10/4/2024 at approximately 9 p.m., and found at his family ' s residence, 22 miles away on 10/5/2024 at 5:30 a.m. This deficient practice resulted in Resident 1 eloping from the facility on 10/4/2024 at approximately 9 p.m. and missing for over eight hours. This deficient practice had the potential for Resident 1 ' s whereabouts to continue to be unknown, for Resident 1 to be exposed to excessive drops in temperature, motor vehicle accidents, hunger, dehydration, and death. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and anxiety disorder (a mental illness causing persistent fear and/or worry). During a review of Resident 1 ' s History and Physical (H/P), dated 9/23/2024, the H/P indicated, Resident 1 did not have the capacity to make medical decisions. During a review of Resident 1 ' s Minimum Data Set [(MDS), a standardized assessment and screening tool], dated 9/29/2024, The MDS indicated, Resident 1 was admitted from a psychiatric facility. The MDS indicated Resident 1 was able to understand and be understood by others, with moderate cognitive impairment (ability to register and recall information). The MDS indicated Resident 1 had no functional limitations in range of motion ([ROM] the direction a joint can move to its full potential). During a review of Resident 1 ' s Nurse Progress Note, dated 10/4/2024, the Nurse Progress Note indicated Resident 1 was noted missing after a head count was conducted. During a review of Resident 1 ' s Nurse Progress Note, dated 10/5/2024 and timed at 7:50 a.m., the Nurse Progress Note indicated Resident 1 arrived at his family ' s house (located approximately 22 miles away from the facility location) at 5:30 a.m., (eight hours and 30 minutes after Resident 1 was found missing from the facility). During an interview on 10/8/2024 at 4:28 p.m., Registered Nurse 1 (RN 1) stated on 10/4/2024 at approximately 9 p.m., she was notified by a staff person (identity unknown), that Resident 1 could not be located during the headcount. RN 1 stated Resident 1 was last seen on the patio during the smoke break at approximately 8 p.m. to 8:30 p.m. RN 1 stated she did not know how Resident 1 eloped from the facility. During a telephone interview on 10/9/2024 at 9 a.m., Resident 1 ' s Responsible Party (RP) stated Resident 1 arrived at her residence on 10/5/2024 at approximately 5:30 a.m., on foot, he appeared weak and incoherent (not able to express themselves clearly). The RP stated she called the facility and spoke with RN 2, who instructed her to take Resident 1 to a General Acute Care Hospital (GACH) for evaluation and treatment. During an interview on 10/10/2024 at 10:42 a.m., the Activity Assistant (AA 1) stated on 10/4/2024 at approximately 8:30 p.m., he saw Resident 1 on the patio during the smoke break after he gave Resident 1 a cigarette. AA 1 stated he was the only staff person on the patio during that time with about 20 residents and he did not see Resident 1 because he (AA 1) was attending to other residents who were waiting to receive and have their cigarettes lit. AA 1 stated it was not sufficient for one staff person to monitor all the residents during smoke breaks. AA 1 stated once Resident 1 received his cigarette he walked behind him (AA 1) and he (AA 1) lost sight of Resident 1, and he did not know how Resident 1 eloped from the facility but thought he might have climbed over a gate on the smoking patio. During an interview on 10/10/2024, at 2:18 p.m., with the DON, the ADM, the Maintenance Supervisor (MS), and the Director of Staff development (DSD), the DON stated it was important for all residents on the patio to be supervised to ensure the residents were safe and secure. The DON, ADM and DSD stated they felt one person monitoring residents on the patio during the smoke break was sufficient to provide adequate supervision to the residents. The DSD stated CNA 1 and a security guard were assigned to make rounds throughout the facility. The DSD stated the nursing staff who work inside the facility were able to see the residents who were on the patio through the windows that overlooked the patio and they had never had a problem with this system. The DSD stated if additional staff were designated to supervise the patio, it would decrease the amount of staff available to attend to the residents who remained inside the facility. The DON, DSD and the ADM stated they did not know where Resident 1 went after being seen on the patio at approximately 8:30 p.m. The ADM and DON stated they did not know how Resident 1 was able to elope from the facility. During an interview on 10/10/2024 at 3:42 p.m., CNA 1 stated on 10/4/2024 she made rounds and conducted a head count every 30 minutes to ensure all residents were accounted for. CNA 1 stated the last time she saw Resident 1 was at approximately 7:45 p.m. before the 8 p.m., smoke break, and at approximately 8:55 p.m., she inspected Resident 1 ' s room and could not locate him. CNA 1 stated she was assigned to monitor the area near Nursing Station 1, not the patio area and viewing the residents on the patio from inside the building through the windows that overlooked the patio did not provide adequate supervision for the residents because the patio has blind spots and at night, it was dark. During a review of the facility ' s Patio Monitoring Log, dated 10/4/2024, the Patio Monitoring Log indicated at 8 p.m. to 8:30 p.m., one staff person member was assigned on the patio and from 8:30 p.m. to 9 p.m., the Patio Monitoring Log had no designated staff person assigned to the patio. During a review of the facility ' s Follow Up Investigation Report, dated 10/10/2024, the Follow Up Investigation Report indicated Resident 1 possibly scaled the fence and left the facility between 8:45 p.m. to 9 p.m., after the final smoke break. During a review of the facility ' s Policy and Procedure (P&P) titled, Safety and Supervision of Residents, dated 5/2015, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated resident supervision is a core component of the systems approach to safety, the type and frequency of the supervision may vary among residents and over time for the same resident. During a review of the facility ' s, Facility Assessment (a review of a nursing home's resources and capabilities to care for residents), dated 7/21/2024, the Facility Assessment indicated the facility maintains adequate staffing necessary to ensure shift to shift coverage was provided for all needs and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two residents (Resident 61), who was diagnosed with post-traumatic stress disorder (PTSD - mental health condition that can develop after someone experiences a deeply distressing or disturbing event), received trauma informed care (a model that aims to provide effective mental health services by taking into account a person's past experiences with trauma). This deficient practice had the potential to result in resident 61's re-traumatization and can be detrimental for the resident's psychosocial status. Findings: During a review of Resident 61's admission Record, the record indicated Resident 61 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (mental health disorder that can cause people to lose touch with reality), major depressive disorder (mental health condition characterized by persistent sadness or loss of interest in activities), anxiety disorder (mental health condition that causes people to experience excessive, persistent, and uncontrollable worry), and PTSD. During a review of Resident 61's Minimum data Set (MDS), a federally mandated assessment tool, dated 9/19/2024, the MDS indicated Resident 61's cognition (ability to make decisions of daily living) was intact, and Resident 61 needed moderate assistance (helper does less than half the effort) with activities of daily living (ADL), tasks related to personal care. During a review of Resident 61's Brief Trauma Questionnaire and Life Events Checklist, dated 9/13/2024, the list indicated Resident 61 experienced five traumatizing events. Resident 61 experienced a fire, transportation accident, physical assault, sexual assault, and other unwanted or uncomfortable sexual experiences. During an interview on 10/1/2024 at 2:52 p.m., with the Social Services Director (SSD), the SSD stated Resident 61 was assessed for trauma the resident experienced or witnessed by using the Brief Trauma Questionnaire and Life Events Checklist. The SSD stated the care plan and interventions to address the trauma was developed by the nursing staff. During an interview and review on 10/2/2024 at 1:50 p.m. with the Assistant Director of Nursing (ADON), Resident 61's care plans and social services notes were reviewed and there were no trauma informed care plans for Resident 61. The ADON reviewed Resident 61's medical records and stated there was no documented evidence of the identification of triggers that can cause re-traumatization, and there were no personalized trigger specific interventions addressing Resident 61's PTSD. The ADON stated moving forward they would develop and implement a care plan for Resident 61. During an interview with the Director of Nursing (DON) on 10/3/2024 at 12:00 p.m., the DON stated the nurses need to develop individualized trauma informed care for residents who suffered PTSD, so the nurses know exactly how to take care of the resident. During a review of the facility's policy and procedure (P&P) titled, Trauma Informed Care, revised 2/2018, the P&P indicated residents who are trauma survivors will receive culturally competent, trauma informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re traumatization of the resident. The facility will provide nursing and related services to assure resident safety and attain or maintain the highest well-being of each resident, as determined by resident assessments and individualized plans of care and considering the number, acuity, and diagnoses of the resident population. Based on the comprehensive assessment the resident will receive the appropriate treatment and services to correct the assessed problem to attain the highest level of well-being (as linked to the history of PTSD). treatment and services to correct the assessed problem to attain the highest level of well-being (as linked to the history of PTSD).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow up and ensure one of eight sampled residents (Resident 7) received follow up dental care recommended by the dentist. This deficient practice had the potential to cause further decline in Resident 7's teeth and dental pain. Findings: During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), generalized anxiety disorder (a mental health condition that causes people to experience excessive, uncontrollable, and irrational worry about everyday things), and depression (a mental state that can affect a person's thoughts, feelings, behavior, and sense of well-being). During a review of Resident 7's Oral/Dental care plan dated 4/7/2024, the care plan indicated Resident 7 needed supervision for oral care. Goals for Resident 7 included Resident 7 would not complain of dental pain related to poor teeth condition with interventions that included dental consult and follow-up as needed and to follow up with dental treatment as needed. During a review of Resident 7's Dental Notes dated 5/29/2024, Resident 7 required dental crowns (a type of dental restoration that completely caps or encircles a tooth) on his two top front teeth (number 8 and number 9 teeth). Resident 7 denied treatment on this day (5/9/2024) but was willing to try a different day. During a review of Resident 7's Dental Notes dated 6/12/2024, Resident 7 refused to be seen that day but Resident 7 agreed to try a different day. There were no further Dental Notes or follow ups for dental care in Resident 7's chart after 6/12/2024. During a review of Resident 7's Resident Care Conference Review form dated 9/10/2024, the form indicated Resident 7 was last seen by the dentist on 6/12/2024. During a review of Resident 7's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/10/2024, the MDS indicated Resident 1 was cognitively intact (the person was able to think, learn, and remember clearly, and to carry out daily activities effectively). During an observation on 9/30/2024 at 2:59 p.m., Resident 7's two top front teeth were broken. During an interview on 10/1/2024 at 2:50 p.m., Resident 7 stated the dentist came to see him three times and took x-rays (imaging creates pictures of the inside of your body) to fix his broken teeth but he never came back to do the crowns. Resident 7 stated he would feel better about himself if his teeth were fixed. During an interview on 10/3/2024 at 11:01 a.m., the social services director (SSD) stated the last time Resident 7 was seen by the dentist was 6/12/2024. The SSD stated the dentist came to the facility as needed or every two months if there wasn't an immediate need. The SSD reviewed her ancillary notes and there were no attempts from the dentist to follow up with Resident 7 since he declined being seen by the dentist on 6/12/2024. The SSD stated she did not have it written down in her notes that Resident 7 was pending dental crowns. The SSD stated Resident 7 had cracked front teeth when she talks to him. During an interview on 10/3/2024 at 11:19 a.m., Resident 7 stated he did not remember declining dental treatment and hopes the dentist comes back soon to do the work because it would help him feel better about himself. During an interview on 10/3/2024 at 11:49 a.m., the director of nursing (DON) stated it was important to track ancillary services (supportive or diagnostic services beyond primary healthcare) and ensure the residents received follow up ancillary care because the facility needed to ensure the residents were getting the care and treatments they needed. The DON stated if a resident refused ancillary treatment, it should have been in the progress notes and the facility should have done an interdisciplinary care plan meeting to ensure they follow up with the resident regarding the treatment. The DON stated it was important to follow up with the resident to reevaluate how the resident was feeling because one day they may decline the treatment, but they may agree the next day or next week and then they could call the dentist to come back and do the work when the resident was up for it. The DON stated the potential outcome of not getting recommended dental treatment done was not good (the DON, did not specify what not good was). During a review of the facility's policy titled Social Services Department- Dental, Optometry, and Audiology Evaluations, undated, indicated dental evaluations were scheduled on annual basis and/ or as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to serve a snack that was prepared as prescribed by the physician for one of two sampled residents (Resident 33). This deficient practice had the potential to cause the resident to choke on their food. Findings: During a review of Resident 33's admission Record, dated 9/22/2024, the admission Record indicated Resident 33 was initially admitted to the facility on [DATE] with diagnoses including Dysphagia (difficulty swallowing). During a review of Resident 33's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/19/2024, the MDS indicated Resident 33 was cognitively (ability to make decisions of daily living) intact and able to recall recent events During a review of Resident 33's physician orders, dated 9/13/2024, the order sheet indicated Resident 33 was prescribed a pureed (consisting of foods that are ground, pressed, or strained until they have a smooth, soft consistency, similar to pudding) texture regular diet. During a review of Resident 33's s Speech Language Pathologist (SLP- a licensed professional who diagnoses and treats speech, language, communication, cognitive, and swallowing disorders in people of all age) Evaluation and Plan of Treatment, dated 9/16/2024, the evaluation indicated the SLP recommends Solids = Puree Consistencies for Resident 33. During an observation on 10/2/2024 at 10:14 a.m., Certified Nurse Assistant 3 (CNA 3) was observed passing snacks that included soft baked chocolate chip cookies and lemon cookies and juice on a cart. During a concurrent observation and interview on 10/2/2024 at 10:28 a.m., with Resident 33, Resident 33 was observed sitting up with one empty cookie wrapper. one cookie still in its packaging, and a cup of juice. Resident 33 stated they had just eaten one cookie and planning to eat the second cookie on the table. There were no other items observed on the table. During an interview on 10/2/2024 at 10:29 a.m., with CNA 3, CNA 3 was unable to state which residents were on pureed diets. and will find out. During an interview on 10/2/2024 at 10:39 a.m., with CNA 3, CNA 3 stated that she found out that Resident 33 was on a pureed diet and they can have yogurt and pudding that comes from the kitchen. CNA 3 stated they gave Resident 33 a yogurt. During a concurrent interview and record review on 10/2/2024 at 2:50 p.m., with Licensed Vocational Nurse 1 (LVN 1), the document titled, Situation-Background-Assessment-Recommendation (SBAR-document that indicates resident's change of condition) dated 10/2/2024 was reviewed. LVN 3 stated Resident 33 was being monitored for aspiration((food or liquid accidentally entering the lungs) because Resident 33 ate a cookie earlier. During an interview on 10/2/2024 at 3:21 p.m., with the SLP, the SLP stated appropriate snacks for a resident on a pureed diet included pudding, applesauce, or pureed fruits. The SLP stated Resident 33's diet recommendation is pureed and cookies are not an appropriate snack for a resident on a pureed diet. During an interview on 10/3/2024 at 11:49 a.m., with the Director of Nursing (DON), the DON stated it is important for staff to follow physician orders. The DON stated if a resident who is prescribed a pureed diet is provided a cookie as a snack, the resident is at risk for aspirating or choking. During a review of the facility's Charge Nurse job description (undated), the job description indicated general duties and responsibilities include, Perform treatments-administer medications, and/or implement other nursing interventions as indicated by the resident care plan r as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure to document the visual monitoring for behaviors, every 15 minutes for one of one resident's (Resident 113)'s medical records. The deficient practice indicated an inaccurate account of care and services received by Resident 113, and the inability of the facility to recognize and act on trends of Resident 113's behaviors. Findings: During a review of Resident 113's admission Record, the record indicated Resident 113 was admitted to the facility on [DATE] with diagnoses including schizophrenia (mental health disorder that can cause people to lose touch with reality), depressive episodes (feelings of sadness, tearfulness, emptiness, or hopelessness), and generalized anxiety disorder (mental health condition that causes people to experience excessive, persistent, and uncontrollable worry). During a review of Resident 113's Minimum data Set (MDS), a federally mandated assessment tool, dated 10/1/2024, the MDS indicated Resident 113's cognition (ability to make decisions of daily living) was moderately impaired, and Resident 113 needed supervision (helper provides verbal cues and touching assistance as resident completes activity) with eating, oral hygiene, dressing, and personal hygiene, and moderate assistance (helper does less than half the effort) with showering and toileting hygiene. During a review of Resident 113's care plan titled, Activities of Daily Living Self Care Deficit, dated 9/25/2024, the care plan goal indicated Resident 113 needed assistance with bed mobility, transfer, walking, dressing, eating, toilet use, personal hygiene, and bathing. The care plan intervention indicated to visually check resident frequently. During an observation and interview on 9/30/2024 at 10:12 a.m., with Certified Nurse Assistant (CNA) 1, at the hallway adjacent to Resident 113's room, CNA 1 was noted to be watching Resident 113 and just sitting in the hallway. CNA 1 stated he was closely monitoring Resident 113 to make sure Resident 113 does not wander in other residents' rooms and take things. CNA 1 stated he visually monitors Resident 113 at least every 15 minutes. CNA 1 stated every 15-minute visual check for behaviors was not documented anywhere in Resident 113's chart. During an observation and interview on 9/30/2024 at 10:52 a.m., with CNA 2, at the hallway adjacent to Resident 113's room, CNA 2 was noted standing in front of Resident 113's room looking at Resident 113. CNA 2 stated she was closely monitoring Resident 113 and making sure she can see Resident 113 continuously. CNA 2 stated they do not document that they were monitoring the resident continuously in the chart. During an interview and record review on 10/1/2024 at 12:05p.m., with the Assistant Director of Nursing (ADON), Resident 113's progress notes, care plans, and medical records were reviewed and there was no documented evidence of the staff closely monitoring and visually checking Resident 113 every 15 minutes. The ADON stated the facility staff closely monitors new admissions to ensure the resident was safe and was acclimated to the environment. The ADON stated it was an intervention in the care plan to visually check resident frequently, but it was not documented anywhere that the CNA's were providing the service. During an interview and record review with the Director of Nursing (DON) on 10/3/2024 at 12:00 p.m., the facility's policy and procedure (P&P) titled, Documentation Principles, revised 2/2018, was reviewed. The DON read a portion the P&P and stated it was the policy of the facility that clinical records shall be current and kept in detail consistent with good medical and professional practice based on care provided to each resident. The DON stated CNA documentation should be accurate. During a review of the facility's policy and procedure (P&P) titled, Documentation Principles, revised 2/2018, the P&P indicated clinical records shall be current and kept in detail consistent with good medical and professional practice based on care provided to each resident. Entries must be accurate, timely, objective, specific, concise, legible, clear, and descriptive. During a review of the facility's P&P titled, Certified Nurse Assistant Documentation, revised 10/2015, the P&P indicated certified nurse assistants document per shift, accurately and consistently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: a. Ensure one of four sampled residents (Resident 116)'s narcotic (drug that affects mood or behavior) was documented in the narcotic record when it was administered on 9/11/2024 at 5 pm. b. Ensure one of three sampled resident's (Resident 53)'s home medications were documented when facility staff received it. These deficient practices had the potential to result in medication errors and drug diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of narcotics. Findings: a. During a review of Resident 116's admission Record, the record indicated Resident 116 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental health disorder that affects the mood and behavior), depressive episodes (feeling sad, irritable, and empty), and generalized anxiety disorder (a mental health condition that causes people to experience excessive, persistent, and uncontrollable worry). During a review of Resident 116's Minimum data Set (MDS), a federally mandated assessment tool, dated 7/10/2024, the MDS indicated Resident 116's cognition (ability to make decisions of daily living) was intact, and Resident 116 was independent with all activities of daily living (ADL - tasks related to personal care). During a review of Resident 116's Physician's Order Summary Report, the order summary indicated, starting on 7/23/2024, Ativan (Lorazepam - medication used to treat anxiety) 0.5 milligrams by mouth every six hours as needed for anxiety manifested by panic attack (brief episode of intense anxiety, which causes the physical sensations of fear). During a concurrent observation, interview and record review on 9/30/2024 at 1:55 p.m., at the station 1 medication room, with the Assistant Director of Nursing (ADON), Resident 116's Antibiotic or Controlled Drug Record for Lorazepam 0.5 milligram was reviewed, and the record indicated the last dose was administered on 9/11/2024 at 7:45 a.m. and there should be 18 tablets left in the bubble pack (a card that packages doses of medication within small, clear, plastic bubbles). The ADON counted the Lorazepam and noted 17 tablets in the bubble pack. The ADON stated there was a discrepancy with the count and narcotic record because we are missing one 0.5 milligram tablet of lorazepam. During a concurrent interview and record review on 9/30/2024 at 3:00 p.m. with the ADON, Resident 116's Medication Administration Record (MAR) for 9/2024 was reviewed and the MAR indicated Ativan (Lorazepam) 0.5 milligrams was last administered on 9/11/2024 at 5:00 p.m. The ADON stated the nurse should have recorded the last dose on Resident 116's Narcotic Record for Lorazepam so the nurses know when the resident received it. b. During a review of Resident 53's admission Record, the record indicated Resident 53 was initially admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, depressive episodes, and generalized anxiety disorder. During a review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53's cognition was intact, and Resident 53 needed partial assistance (helper does less than half the effort) with ADLs. During a concurrent observation and interview on 9/30/2024 at 2:18 p.m., at the station 1 medication room, with the ADON, Resident 53's sealed, unopened, opaque plastic bag with unidentified medications were noted. The ADON stated we don't know what medications were in the bag because the bag was never opened and there was no home medication list with the medications. The ADON stated there should have been a medication list, so we know what medications Resident 53 was taking. During an interview with the Director of Nursing (DON) on 10/3/2024 at 12:00 p.m., the DON stated the Narcotic record needs to be accurate because we always need to know the disposition of narcotics. The DON stated inventory of all belongings including home medications were important so residents can leave with their personal belongings. During a review of the facility's policy and procedure (P&P), titled, Preparation and General Guidelines, IIA5: Controlled Medications, effective date 8/2014, the P&P indicated medications included in the Drug Enforcement Administration classification as controlled substances were subject to record keeping in the facility in accordance with federal, state, and applicable laws and regulations. When controlled medications were administered the licensed nurse administering the medication immediately enters the information on the accountability record and the MAR: 1. Date and time of administration 2. Amount administered 3. Signature of nurse administering the dose on the accountability record at the same time the medication is removed from the supply. During a review of the facility's P&P titled, Medication Storage in the Facility, ID3: Controlled Medication Storage, effective 8/2014, the P&P indicated at each shift change a physical inventory of all controlled medications, including the emergency supply, is conducted by two licensed nurses and it is documented on the Controlled Medication Accountability Record. Any discrepancy and controlled substance medication counts is reported to the DON immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. During a review of the facility's P&P titled, Medication Ordering and Receiving from Pharmacy, IC 120: Medications brought to the facility by a resident or Family Member, effective 8/2014, the P&P indicated a licensed nurse: a. Receives medication delivered to the facility and documents delivery of the medication on the appropriate form. b. Verifies medications received and directions for use with the original medication order.

Based on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions for 63 of 63 residents by not: 1. Labeling perishable food items (two open pasta bags) with open date. 2.Thawing diced beef according to facility policy. These deficient practices had the potential to cause food-borne illnesses. Findings: During a concurrent observation and interview on 9/30/2024 at 8:45 a.m., with the Dietary Supervisor (DS) in the dry storage room, two bags of dried pasta (one macaroni and one farfalle) were previously opened without an open date. The DS stated the bags did not have an open date. During an observation on 10/1/2024 at 11:45 a.m., in the kitchen meal prep sink, three bags of meat were sitting in a tray of still (not running) water. The sink faucet was off. During a concurrent observation and interview on 10/1/2024 at 12:13 p.m., with [NAME] 1, [NAME] 1 turned on the sink faucet. [NAME] 1 stated the bagged meat was diced beef for tomorrow's lunch. [NAME] 1 stated the water was running over the diced meat earlier, but does not know when the water was turned off. [NAME] 1 stated thawing meat should be placed under continuous running water and reach a goal of under 40 degrees Fahrenheit (a unit of measure of temperature) in two hours. During an observation on 10/1/2024 at 12:18 p.m., [NAME] 1 removed the thawing meat tray from under the running water, did not take the temperature, covered and labeled the tray, and placed the tray in the refrigerator. During an interview on 10/1/2024 at 12:20 p.m., with the DS, the DS stated when defrosting under running water, the process includes thawing the meat under running water with a goal of below 70 degrees Fahrenheit in two hours. The DS stated if food is not thawed properly, there is a risk for residents to contract a food borne illness. During an interview on 10/3/2024 at 11:26 a.m., with the DS, the DS if there is unlabeled opened food, the staff would not know when it was opened and when the food will expire. The DS stated the quality of food such as the texture would be compromised. During a review of the facility's policy and procedure (P&P), titled Labeling and Dating of Foods, dated 2020, The P&P indicated Newly opened food items will need to be closed and labeled with an open date . During a review of the facility's policy and procedure (P&P), titled Storage of Food and Supplies, dated 2020, The P&P indicated Dry food items which have been opened, such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc., will be tightly closed, labeled and dated. During a review of the facility's policy and procedure (P&P), titled Food Preparation, dated 2018, The P&P indicated Thawing meat properly can be done in these four ways: 3. Submerge under running, potable water at a temperature of 70?F or lower, with a pressure sufficient to flush away loose particles. a. The food product cannot remain in the temperature danger zone (41degrees Farenheit to 140 degrees Farenheit) for more than four hours, which includes the time the food is thawed. Use immediately.

Based on interview and record review the facility failed to provide privacy for one of 15 sampled residents (Resident 38) by discussing care and treatment of Resident 38 at the nurse's station in the presence of staff and other residents. This deficient practice had the potential to result in embarrassment and reveal private information for Resident 38. Findings: During a review of Resident 38's Face Sheet, the Face Sheet indicated, Resident 38 had diagnoses of but not limited to malignant (spreads fast) neoplasm (a type of abnormal and excessive growth of tissue) of the mouth, major depressive disorder (a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of pleasure in normally enjoyable activities), muscle wasting (a condition where muscles lose mass and strength) and atrophy (decrease in size or wasting away of a body part or tissue). During a review of Resident 38's History and Physical (H&P), dated 2/14/2023, the H&P indicated, Resident 38 had the mental capacity to understand and make decisions. During a review of Resident 38's Minimum Data Set (MDS) a standardized assessment and care planning tool, dated 8/21/2023, the MDS indicated, Resident 38 was able to understand and had the ability to express ideas and wants. The MDS indicated Resident 38 required supervision for bed mobility, transferring, walking, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. During an interview on 10/3/2023 at 11:57 am, with Resident 38, Resident 38 stated he went to the nurses' station because he wanted to speak with his doctor about receiving an alternative medication. Resident 38 stated he had to explain his issues about the alternative medication at the nurses' station in front of staff and residents. Resident 38 stated, he knows the facility has a room where doctors can speak to residents privately. During an interview on 10/4/2023 at 9:00 am with Resident 38, Resident 38 stated when speaking to the doctor, the doctor talks to him about his care in front of the nurses' station where other staff and residents could hear the conversation. During an interview on 10/5/2023 at 2:26 pm with Licensed Vocational Nurse (LVN 1), LVN 1 stated she saw Resident 38 at the nurses' station speaking with doctors while nurses were at the station charting. LVN 1 stated that speaking with the doctor at the nurses' station does not maintain privacy for Resident 38. LVN 1 stated the facility does have a room where residents and doctors can go to speak privately. During an interview on 10/6/2023 at 2:26 pm with the Director of Nursing (DON), the DON stated she had noticed Resident 38 at the nurses' station speaking to the doctor, discussing medications. The DON stated nurses are working at the nurses' station when residents are speaking with the doctors. The DON stated if doctors are talking about resident care there should not be anybody there, it is a Health Insurance Portability Accountability Act, (HIPPA a law designed to provide privacy standards to protect patient's medical records and other health information) violation. The DON stated the facility has a room that doctors can use to speak to residents privately. During a review of the facility's policy and procedure (P&P) titled, Resident Right's to Dignity and Privacy, revised 9/2017, the P&P indicated, Communication such as shift reports shall be conducted outside of the hearing range of residents and the public.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to initiate a person-centered care plan for one of three sampled residents (Resident 41) for missing teeth. This deficient practice had the potential for Resident 41 to not be monitored for adverse outcomes of missing teeth such as choking due to trying to swallow unchewed food. Findings: During a review of Resident 41's admission record, the admission record indicated Resident 41 was admitted to the facility on [DATE] with diagnoses including dysphagia (swallowing difficulties) and functional dyspepsia (recurring symptoms of an upset stomach that have no obvious cause). During a review of Resident 41's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/5/2023, the MDS indicated Resident 41 had the ability to makes self-understood and was able to understand others. During a review of Resident 41's Oral/ Dental Care plan (CP) initiated on 5/31/2023 and last revised on 9/2023, the CP indicated Resident 41 had a potential for the inability to do oral care because of behaviors. The CP goals for Resident 41 were his mouth and teeth would be clean daily as manifested by no visible debris in mouth and interventions that included diet as ordered, encouraging resident to report difficulty in chewing food and staff monitoring for signs and symptoms of chewing difficulty. The CP did not indicate Resident 41 was missing teeth, had the potential for choking and did not have goals related to no choking episodes. During a review of Resident 41's admission Nutritional Assessment (ANA) dated 6/2/2023, Resident 41 was edentulous (without teeth). During an observation on 10/3/2023 12:24 p.m., Resident 41 was eating his lunch and had no teeth. Resident 41 was eating a regular consistency (food that requires teeth and jaw strength to chew) diet. During an interview and concurrent record review on 10/5/2023 at 2:20 p.m., licensed vocational nurse (LVN) 3 confirmed Resident 41 did not have a CP that indicated he did not have any teeth or was a choking risk. LVN 3 stated it was important to have accurate information in the CPs so the facility can implement appropriate interventions and the residents can receive appropriate care. During an interview on 10/5/2023 at 3:31 p.m., the director of nursing (DON) stated if a resident had missing teeth, it needed to be care planned. The DON stated the CPs are important because it details the individualized care for each resident, and it is the communication between nurses as to what care the residents need. During a review of the facility's policy and procedure (P/P) titled Comprehensive Care Planning dated 1/2017, the P/P indicated the plan of care is driven not only by identified resident issues and/ or conditions but also by the resident's unique characteristics, strengths and needs, goals, life history and preferences and discharge planning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure two of 15 sampled residents (Resident 38 and Resident 53) optometrist (a healthcare professional who provides vision care) recommendations to arrange for Resident 38's new glasses, to be adjusted (to improve his sight) and to obtain new glasses for Resident 53 were followed. This failure resulted in a diminished quality of life for Resident 38 not being able to read fine print, and Resident 53 not having new glasses to maintain vision. Findings: a. During a review of Resident 38's Face Sheet, the Face Sheet indicated, Resident 38 had diagnoses of but not limited to malignant (spreads fast) neoplasm (a type of abnormal and excessive growth of tissue) of the mouth, major depressive disorder (a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of pleasure in normally enjoyable activities), muscle wasting (a condition where muscles lose mass and strength) and atrophy (decrease in size or wasting away of a body part or tissue). During a review of Resident 38's History and Physical (H&P), dated 2/14/2023, the H&P indicated, Resident 38 had the mental capacity to understand and make decisions. During a review of Resident 38's Minimum Data Set (MDS) a standardized assessment and care planning tool, dated 8/21/2023, the MDS indicated, Resident 38 was able to understand and had the ability to express ideas and wants. The MDS indicated Resident 38 required supervision for bed mobility, transferring, walking, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. During an interview on 10/3/2023 at 11:57 am with Resident 38, Resident 38 stated it had been four months since the optometrist had given him a prescription for glasses that do not work. Resident 38 stated he talked to the nurses at the facility several time and about two months ago was told he would get a new pair of glasses and has not heard anything about the glasses since. Resident 38 stated it is hard for him to read fine print. During an interview on 10/5/2023 at 10:22 am with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 38 was admitted to the facility with glasses and the Social Services is responsible for getting residents glasses, calling the optometrist or ophthalmologist (eye doctor) and make vision appointments and transportation to the appointments. During a concurrent interview and record review on 10/5/2023 at 2:15 pm with the Director of Social Services (DSS), Resident 38's Ophthalmology Consultation report, dated 7/2/2023 was reviewed. The Ophthalmology Consultation report indicated, a recommendation to obtain an appointment to adjust Resident 38's new glasses. The DSS stated residents will have problems seeing if ophthalmology recommendations for them, are not carried out. b. During a review of Resident 53's Face Sheet, the Face Sheet indicated, Resident 53 was admitted to the facility on [DATE] with diagnoses including but not limited to benign (not harmful) prostatic (prostate [a gland of the male reproductive system] enlargement) hyperplasia (abnormal enalrgment), kidney disease (a gradual loss of kidney function), and bradycardia (an abnormally slow heart rate). During a review of Resident 53's H&P, dated 5/24/2023, the H&P indicated, Resident 53 had the mental capacity to understand and make decisions. During a review of resident 53's Optometric Consultation report dated 8/16/2023, the report indicated a recommendation for new reading glasses. During a review of Resident 53's Minimum Data Set (MDS) a standardized assessment and care planning tool, dated 8/28/2023, the MDS indicated, Resident 53 used glasses. The MDS indicated, Resident 53 was able to understand and had make himself understood. The MDS indicated, Resident 53 required limited assistance with bed mobility, transferring, walking, locomotion on and off the unit, dressing, toilet use, and hygiene. During an interview on 10/6/2023 at 10:41 am with the DSS, the DSS stated she was not able to find proof that any of the residents with recommendations for new glasses, had received them. The DSS stated she did not follow up on any recommendations from ophthalmology and missed the recommendation because her system to track residents with recommendations does not work and will follow up on the recommendations now. The DSS stated negative outcomes for residents with ophthalmology recommendation that are not being followed would be problems with activities of daily living and not being able to see. During an interview on 10/6/2023 at 2:34pm with the Director of Nursing (DON), the DON stated the negative outcome for a resident whose recommendation by the eye doctor are not followed is not being able to see properly. During a review of the facility's policy and procedure (P&P) titled, Social Service Department, undated, the P&P indicated, Social Services staff will coordinate Dental, Optometry, and Audiology evaluations for Residents. Social Services will maintain a system to monitor the Dental, Optometry, and Audiology evaluations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor and reassess pain level on one of five sampled residents (Resident 9) in accordance with the standard practice of care. This deficient practice resulted in facility staff not reassessing Resident 9's pain level in a timely manner and placing Resident 9 at risk for unnecessary pain. Findings: During a review of Resident 9's admission Record (AR), the AR indicated the resident was admitted on [DATE] to the facility with diagnoses that included diabetes (high blood sugar), chronic pain syndrome (pain that lasts for over three months and can interfere with daily activities), and hypertension (high blood pressure). During a review of Resident 9's Minimum Data Set (MDS) standardized assessment and screening tool dated 9/11/2023, the MDS indicated the resident had intact cognition (thought process) and required one-person physical assist with bed mobility, transfer, dressing, and toilet use. The MDS indicated the resident had pain occasionally during the assessment. During an interview on 10/3/2023, at 12:15 p.m. with Resident 9, Resident 9 stated he was still having backpain despite receiving Tramadol ( narcotic pain medicine). Resident 9 stated Tramadol was not affording relief for his backpain. He stated his back pain is 4/10 and that he had told the nurses about his backpain not being relieved by Tramadol. During a review of Resident 9's Physician Order (PO) dated 9/5/2023, the PO indicated an order of Tramadol 50 milligrams([mgs.] unit of measurement) give one tablet by mouth every 6 hours as needed for severe pain 7-10 pain scale (numerical rating of pain with 0 being no pain and 10 being the worst pain possible). During a review of Resident 9's PO dated 9/5/2023, the PO indicated an order of Acetaminophen (a medication used to relieve mild pain) tablet 500 mgs. give one tablet every 6 hours as needed for mild pain, pain scale of 1-3 and Acetaminophen 325 mgs. 2 tablets by mouth every 6 hours as needed for moderate pain scale of 4 to 6. During a review of Resident 9's Medication Administration Audit Report dated 10/3/2023, the report indicated pain was assessed at 9:38 p.m., Tramadol 50 mgs. by mouth was administered at 10:00 p.m., for a pain level of 8 (severe pain) and was reassessed at 11:36 p.m. During a concurrent interview and record review on 10/5/2023, at 11:51 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated and verified Resident 9 had received Tramadol at 10:00 p.m. and was reassessed an hour and 36 minutes after administration of Tramadol. LVN 2 stated Resident 9 was always complaining of pain and the licensed nurse should have reassessed Resident 9's pain level within 30 minutes to an hour of administering it, to make sure the medicine was effective enough. During an interview on 10/5/2023, at 1:59 p.m., with RN Supervisor (RNS) 1, RNS 1 stated pain reassessment should be performed within an hour after administration of Tramadol to ensure accuracy of assessment and efficacy of intervention. During a review of Resident 9's Care Plan(CP) dated 9/5/2023, the CP indicated Resident 9 had chronic pain syndrome related to his back pain. The CP's goals indicated Resident 9's pain will be relieved within 30 minutes after pain medication is given. The CP's interventions included to assess intensity of pain using pain scale of 1 to 10, instruct resident to report any pain as soon as it begins, to reassess resident's pain after 30 - 45 minutes and notify physician for possible need for increased pain medication as needed. During a review of facility's policy and procedure (P/P) titled, Pain Management Protocol, revised 10/2017, the P/P indicated an ongoing evaluation of the status of resident's pain is vital and monitoring should include assessment of the effectiveness of pain medication with routine and medication administered as needed (PRN) medicines approximately 30 minutes after administration. The P/P indicated when pain is identified, pain rating should always be included in the documentation and in every prn medication administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary social services for five of 15 sampled residents (Resident 38, Resident 40, Resident 42, Resident 47, Resident 53) by : a. not following up on an ophthalmology consultation recommendation to adjust new glasses for Resident 38. b. not following up on a dental recommendation for a full mouth x-ray and dentures for Resident 40. c. not ensuring Resident 42 was initially assessed and received individualized intervention to meet his mental and psychosocial needs. d. not following up on dental recommendations for a full mouth x-ray for Resident 47. e. not following up on an optometrist consultation for new reading glasses for Resident 53. This failure resulted in a delay of care and services. Findings: a. During a review of Resident 38's Face Sheet, the Face Sheet indicated, Resident 38 had diagnoses of but not limited to malignant (spreads fast) neoplasm (a type of abnormal and excessive growth of tissue) of the mouth, major depressive disorder (a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of pleasure in normally enjoyable activities), muscle wasting (a condition where muscles lose mass and strength) and atrophy (decrease in size or wasting away of a body part or tissue). During a review of Resident 38's History and Physical (H&P), dated 2/14/2023, the H&P indicated, Resident 38 had the mental capacity to understand and make decisions. During a review of Resident 38's Minimum Data Set (MDS) a standardized assessment and care planning tool, dated 8/21/2023, the MDS indicated, Resident 38 was able to understand and had the ability to express ideas and wants. The MDS indicated Resident 38 required supervision for bed mobility, transferring, walking, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. During a review of Resident 38's Ophthalmology Consultation report dated 7/2/2023, the report indicated a recommendation for a referral to adjust his new glasses. b. During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40 was admitted on [DATE] with diagnoses of but not limited to osteoarthritis (a type of degenerative joint disease that results from breakdown of joint and underlying bone), anemia (a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of blood cells), dementia (a decline in cognitive abilities that impacts a person's ability to perform every day activities), muscle wasting and atrophy. During a review of Resident 40's H&P dated 4/27/2023, the H&P indicated Resident 40 did not have the mental capacity to make decisions. During a review of Resident 40's MDS dated [DATE], the MDS indicated Resident 40 usually understands and comprehends most conversations. The MDS indicated Resident 40 required limited assistance with bed mobility, transferring, walking, locomotion on and off the unit, dressing, toilet use, personal hygiene, and needed supervision while eating. During a review of Resident 40's dentist report from Elite Mobile Dental. dated 5/23/2023, the report indicated Resident 40 was recommended to have a full mouth x-ray. The report also indicated Resident 40 was interested in receiving dentures. c. During a review of Resident 42's Face Sheet, the Face Sheet indicated Resident 42 was admitted on [DATE] with diagnoses that included but not limited to post-traumatic stress disorder ( [PTSD] a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), hemiplegia (muscle weakness or partial paralysis on one part of the body), alcohol abuse (excessive use of alcohol that can be harmful to health and interferes with daily life) and paranoid schizophrenia (a serious mental disorder in which a person interprets reality abnormally). During a review of Resident 42's MDS dated [DATE], the MDS indicated Resident 42's cognition was intact and required one-person physical assist with bed mobility, transfer, dressing, toilet use and personal hygiene. During a concurrent interview and record review on 10/5/2023, at 2:48 p.m. with Director of Social Services (DSS), DSS stated the initial assessment for Resident 42 was incomplete and should have been completed within seven days from admission. Record Review of Resident 42's medical record indicated Social Services Progress Notes, Social Services Initial Assessment, and room visit logs were not found on resident's chart and was verified with SSD. SSD stated sometimes things get missed that was why she did not document what services she had provided for the resident. During a subsequent interview on 10/5/2023, at 3:51 p.m. with DSS, DSS stated she provided services to the residents by talking and assuring them they are safe, allowing them to verbalize any feelings, make referrals as needed and identify any residents' concerns. DSS stated she did room visits to Resident 42 but did not document nor a create a room visit log. During an interview on 10/6/2023, at 3:03 p.m. with Director of Nursing (DON), DON stated when a resident is admitted from General Acute Care Hospital (GACH) whatever diagnosis the GACH had identified and assessed like PTSD, the facility continues the care and services for that diagnosis in the facility. DON stated DSS is responsible for providing therapeutic communication and psychosocial (pertaining to social factor effects on a resident's feelings and behavior) support to all residents. DON stated DSS should have documented her assessments and visits when providing services to Resident 42. During a review of Resident 42's Brief Trauma Questionnaire and Life Events Checklist completed and dated 10/5/2023, the questionnaire indicated Resident 42 was admitted on [DATE] and suffered from PTSD related to getting beaten up in a boarding care, car accident and molestation (getting touch or attacked in a sexual way). d. During a review of Resident 47's Face Sheet, the Face Sheet indicated Resident 47 was originally admitted to the facility on [DATE] with diagnoses of but not limited to diabetes (high blood sugar levels), asthma (an inflammatory disease of the airways of the lungs), heart failure (impairment of the heart's blood pumping function) and muscle wasting and atrophy. During a review of Resident 47's H&P dated 8/30/2023, the H&P indicated Resident 47 had the mental capacity to make decisions. During a review of Resident 47's MDS dated [DATE], the MDS indicated Resident 47 had the ability to understand and express ideas and wants. During a review of Resident 47's dentist report from Elite Mobile Dental dated 7/15/2023, the report indicated Resident 47 was recommended to have a full mouth x-ray. During an interview on 10/5/2023 at 3:42 pm with the DSS, the DSS stated pain is one of the negative outcomes for a resident whose does not receive dental services they need. e. During a review of Resident 53's Face Sheet, the Face Sheet indicated, Resident 53 was admitted to the facility on [DATE] with diagnoses including but not limited to benign (not harmful) prostatic (prostate [a gland of the male reproductive system] enlargement) hyperplasia (abnormal enalrgment), kidney disease (a gradual loss of kidney function), and bradycardia (an abnormally slow heart rate). During a review of Resident 53's H&P, dated 5/24/2023, the H&P indicated, Resident 53 had the mental capacity to understand and make decisions. During a review of resident 53's Optometric Consultation report dated 8/16/2023, the report indicated a recommendation for new reading glasses. During a review of Resident 53's MDS dated [DATE], the MDS indicated, Resident 53 used glasses. The MDS indicated, Resident 53 was able to understand and had make himself understood. The MDS indicated, Resident 53 required limited assistance with bed mobility, transferring, walking, locomotion on and off the unit, dressing, toilet use, and hygiene. (please add the interview that it was not carried out) During a review of facility's Job Description of Director of Social Services indicated DSS would develop preliminary and comprehensive assessments of the social service needs of each resident and would assure that the social service progress notes are informative and descriptive of the services provided and of the resident's response to the service. During an interview on 10/6/2023 at 10:41 am with the DSS, the DSS stated she was not able to find proof that any of the residents with recommendations for new glasses received them. The DSS stated she did not follow up on any recommendations from the dentist or ophthalmology and missed the recommendation because her system to track residents with recommendations does not work and will follow up on the recommendations now. The DSS stated negative outcomes for residents with ophthalmology recommendation that are not being followed would be problem with activities of daily living and not being able to see and for residents with dentist recommendation not being followed could be a loss of weight. During an interview on 10/6/2023 at 2:34pm with the Director of Nursing (DON), the DON stated the negative outcome for a resident whose recommendation by the eye doctor are not followed is not being able to see properly and a potential risk for residents that do not have their dental recommendations followed up on are not being able to eat properly and loss of weight. During a review of the facility's policy and procedure titled, Social Service Department, undated, the P&P indicated, Social Services staff will coordinate Dental, Optometry, and Audiology evaluations for Residents. Social Services will maintain a system to monitor the Dental, Optometry, and Audiology evaluations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide routine dental service for three of 15 residents (Resident 40, Resident 47, and Resident 53). This failure resulted in Resident 40 and Resident 47 not receiving a recommended full mouth x-ray and Resident 53 not receiving new dentures. Findings: a. During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40 was admitted on [DATE] with diagnoses of but not limited to osteoarthritis (a type of degenerative joint disease that results from breakdown of joint and underlying bone), anemia (a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of blood cells), dementia (a decline in cognitive abilities that impacts a person's ability to perform every day activities), muscle wasting and atrophy. During a review of Resident 40's H&P dated 4/27/2023, the H&P indicated Resident 40 did not have the mental capacity to make decisions. During a review of Resident 40's Minimum Data Set (MDS) a standardized assessment and care planning tool dated 8/1/2023, the MDS indicated Resident 40 usually understands and comprehends most conversations. The MDS indicated Resident 40 required limited assistance with bed mobility, transferring, walking, locomotion on and off the unit, dressing, toilet use, personal hygiene, and needed supervision while eating. During a review of Resident 40's dentist report from Elite Mobile Dental dated 5/23/2023, the report indicated Resident 40 was recommended to have a full mouth x-ray. The report also indicated Resident 40 was interested in receiving dentures. During an interview on 10/3/2023 at 2:20 pm with Resident 40, Resident 40 stated he spoke with the DSS about an appointment to see the dentist and has not been seen yet. Resident 40 stated its hard for him to eat and painful. Resident 40 stated he feels sad, depressed, and angry about not being able to see the dentist. b. During a review of Resident 47's Face Sheet, the Face Sheet indicated Resident 47 was originally admitted to the facility on [DATE] with diagnoses of but not limited to diabetes (high blood sugar levels), asthma (an inflammatory disease of the airways of the lungs), heart failure (impairment of the heart's blood pumping function) and muscle wasting and atrophy. During a review of Resident 47's H&P dated 8/30/2023, the H&P indicated Resident 47 had the mental capacity to make decisions. During a review of Resident 47's MDS dated [DATE], the MDS indicated Resident 47 had the ability to understand and express ideas and wants. During a review of Resident 47's dentist report from Elite Mobile Dental dated 7/15/2023, the report indicated Resident 47 was recommended to have a full mouth x-ray. During an interview on 10/3/2023 at 9:59 am with Resident 47, Resident 47 stated she told the DSS she needed to see the dentist months ago because her teeth hurt all the time. Resident 47 stated the dentist came once and told her she has cavities but never came back to follow up with her. Resident 47 opened her mouth and showed she had multiple teeth that were black or missing. During a review of Resident 47's Physician Orders dated 8/28/2023, the Physician Orders indicated Resident 47 had a dental consult and follow up as needed. c. During a review of Resident 53's Face Sheet, the Face Sheet indicated, Resident 53 was admitted to the facility on [DATE] with diagnoses including but not limited to benign (not harmful) prostatic (prostate [a gland of the male reproductive system] hyperplasia (abnormal enalrgment), kidney disease (a gradual loss of kidney function), and bradycardia (an abnormally slow heart rate). During a review of Resident 53's H&P, dated 5/24/2023, the H&P indicated, Resident 53 had the mental capacity to understand and make decisions. During a review of Resident 53's Minimum Data Set (MDS) a standardized assessment and care planning tool, dated 8/28/2023, the MDS indicated, Resident 53 used glasses. The MDS indicated, Resident 53 was able to understand and had make himself understood. The MDS indicated, Resident 53 required limited assistance with bed mobility, transferring, walking, locomotion on and off the unit, dressing, toilet use, and hygiene. During a review of Resident 53's dentist report from Elite Mobile Dental dated 7/15/2023, the report indicated Resident 53's front upper dentures were old and worn out and had recommendation for new dentures. During a review of Resident 53's Physician Orders dated 5/23/2023, the Physician Orders indicated Resident 53 had a dental consultation and follow up as needed. During an interview on 10/5/2023 at 3:42 pm with the DSS, the DSS stated pain is one of the outcomes for a resident who does not receive dental services they need. During an interview on 10/6/2023 at 2:34 pm with the Director of Nursing (DON), the DON indicated one of the potential risks for residents that do not have their dental recommendations followed up on are not being able to eat properly and loss of weight. During a review of the facility's policy and procedure (P&P) titled, Dental Services, date revised on 1/2027, the P&P indicated, The facility will provide or obtain routine and emergency dental services to meet the need of each resident.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a specialized tool due to its small size) that could cause food borne illness (food poisoning: illness due to consuming spoiled food) for residents in the facility by not: a. ensuring Strawberry ready care shakes (nutritional shake that gets delivered frozen) were dated, when placed in the refrigerator to thaw (once thawed, shelf life is less than 14 days) b. ensuring a salad and bowl of lettuce was labeled and dated in the refrigerator. c.ensuring a bowl of tuna salad, a container of cornflakes, and a tupperware of peaches were not expired. c.ensuring the ice machine was maintained in a clean and sanitary way These deficient practices had the potential to affect residents of the facility and result in pathogen (germ) exposure, and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During an observation on 10/3/2023 at 10:48 a.m., with the dietary supervisor (DS), the dry storage area contained a container of corn flakes with a use by date of 9/28/2023. The DS removed the corn flakes from the shelf for disposal. During an observation and concurrent interview on 10/3/2023 at 10:54 a.m., with the DS, refrigerator one (1) contained strawberry Ready Care shakes without a date of when they were moved from the freezer to the refrigerator to thaw. The DS stated there was not a date on the Ready Care shakes for when they were brought to the refrigerator to thaw. During an observation on 10/3/2023 at 10:58 a.m., with the DS, refrigerator 2 contained a salad (chicken, egg, lettuce, shredded cheese, and shredded carrots) and lettuce that were not dated. Refrigerator 2 also contained, a bowl of tuna and a Tupperware of peaches dated 10/2/2023 (expired 1 day prior to the observation). The DS removed the tuna and peaches from refrigerator 2 for disposal. During an interview on 10/5/2023 at 2:46 p.m., the DS stated the potential outcome for having undated and expired food items in the kitchen was food borne illness, and need to ensure expired items are not served to their high-risk residents. During an interview on 10/5/2023 at 3:24 p.m., dietary assistant (DA 1) stated it was the job of all kitchen staff to ensure there was no expired or undated food in the kitchen. During an observation and concurrent interview on 10/5/2023 at 10:02 a.m., with the maintenance supervisor (MS), the MS opened the ice machine door and there were brown crusty areas that were chipping on the metal frame of the ice machine. The MS stated the brown crusty areas were rust and he should have requested to have the ice machine replaced since it could contaminate the ice served to the residents. During an interview on 10/5/2023 at 3:39 p.m., the MS stated there was rust on the ice machine and when he cleaned it in September 2023, he saw the rust. The MS stated he did not inform the administrator (admin) or the DS but the outside company that comes and services the ice machine monthly was aware. The MS stated they were going to replace the top portion of the ice machine, but it was not done yet. The MS state the importance of not having any rust on the ice machine was resident safety. During a review of the facility's policy and procedure (P/P) titled Ice Machine Cleaning Procedures dated 2020, the P/P indicated information regarding the operation, cleaning and care of the ice machine was to be obtained in the owner's manual. During a review of the facility's P/P titled Storage of Food and Supplies dated 2020, the policy indicated food was to be stored properly and in a safe manner. The P/P indicated no food will be kept longer than the expiration date on the product. The P/P indicated individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated. The P/P indicated supplemental shakes which are taken from the frozen state and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator.

Based on observation, interview and record review the facility failed to observe infection control measures by failing to ensure the dryer was running at the proper temperature. This deficient practice had the potential to place residents at risk for infection. Findings: During observations on 10/3/2023, at 3:50 pm, on 10/5/2023, at 8:16 am and at 9:00 am, the dryer temperature was reading between 124 to 128 degrees Fahrenheit ([F] scale of measuring temperature), loud and rattling noise was heard at the back of one of the dryers during the drying cycle. During an interview on 10/3/2023, at 8:16 a.m. with Laundry Aide (LA1), LA 1 stated the temperature of the dryer should be 160 degrees F to 180 degrees F to kill bacteria on the linens and clothes. During an interview on 10/3/2023, at 8:34 a.m. with Maintenance Supervisor (MS), MS stated the temperature of the dryer should be maintained between 160 to 180 degrees F to kill the bacteria and prevent spread of infection among residents. MS stated a laundry technician came to check and fixed both dryers last 9/20/2023 because the dryers were not warm enough to dry the clothes. During a telephone interview on 10/5/2023, at 9:05 a.m. with Laundry Technician (LT), LT stated the temperature of the dryer should be maintained to 180 degrees F when drying resident's clothes and linens. LT stated the dryer was checked last September 2023 because the dryers were not drying the clothes enough. LT stated there was a noise coming from the motor of one of the dryers. During an interview on 10/6/2023, at 3:03 p.m. with Director of Nursing (DON), DON stated the temperature of the dryer should be maintained at 180 degrees F when drying clothes and linens of residents in order for the germs to be killed. During a review of facility's policy and procedure (P/P) titled Laundry Department- Post in Laundry, P/P Manual and Use for Training revised 8/2016, the P/P indicated the dryers run for approximately 45 minutes and the temperatures are set up to 180 degrees F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an incident of verbal and physical abuse to the Department of Public Health (DPH), the Ombudsman and the Police within 2 hours. This deficient practice resulted in physical and verbal abuse going recognized by staff and had the potential to impede the Department's investigation and allow physical and verbal abuse to continue. Findings: During a review of Resident 72's admission Record (Face Sheet), the Face Sheet indicated Resident 72 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems), hypertension ([HTN] high blood pressure) and type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar as fuel). Resident 72 left the facility against medical advice (AMA) on 10/14/2022. During a review of Resident 122's admission Record (Face Sheet), the Face Sheet indicated Resident 122 was admitted to the facility on [DATE], with a diagnosis of paranoid schizophrenia (a severe mental health condition that can involve delusions and paranoia [suspicion or mistrust]). During a review of Resident 122's Minimum Data Set (MDS) a standardized assessment and care screening tool, dated 10/7/2022, the MDS indicated Resident 122 was able to make independent decisions that were consistent and reasonable. During an interview on 10/13/2022 at 10:30 a.m., with Resident 72, Resident 72 stated he had a problem with his previous roommate (Resident 122). Resident 72 stated Resident 122 called him names, called him a sex offender, made a gun gesture towards him, and punched him in his shoulder. Resident 72 stated he did not feel safe and felt his life was threatened. During an interview and record review on 10/13/2022 at 10: 35 a.m., the Registered Nurse Supervisor (RNS) stated Residents 72 and Resident 122 were incompatible as roommates. The RNS stated on the day Resident 72 was admitted to the facility (10/10/2022) he was moved from room [ROOM NUMBER] to room [ROOM NUMBER], the rooms were next to each other. Resident 72's clinical record indicated there was no documentation of a physical and/or verbal altercation between Resident 72 and Resident 122 nor was there any documentation indicating Resident 72's room was changed or why it was changed. During an interview on 10/13/2022 at 10:55 a.m., with Resident 122, Resident 122 stated he had a roommate (Resident 72) who was admitted (10/10/2022) to his room (room [ROOM NUMBER]) and was moved to another room the same day (10/10/2022). Resident 122 stated he did not hit Resident 72 but admitted to cursing at him. During a concurrent interview and record review on 10/13/2022 at 11:55 a.m., with the Social Services Director (SSD), the SSD stated she was aware of the incident between Resident 72 and Resident 122. The SSD stated Resident 122 was using foul language and she stated the roommates were incompatible, so a room change was initiated. A review of Resident 72's clinical record indicated there was no documentation of social services notes, interdisciplinary notes or physician order for a room change related to a physical and/or verbal altercation between Resident 72 and Resident 122 or that Resident 72's room was changed because the residents were incompatible with a description of what incompatible meant. During an interview on 10/14/2022 at 7:55 a.m., with Resident 122, Resident 122 stated he cursed out (10/10/2022) Resident 72 and the administrator (ADM) asked him questions about the incident on 10/13/2022. Resident 122 stated staff never questioned him about the incident until yesterday (10/13/2022). During a concurrent interview and record review on 10/14/2022 at 10:35 a.m., with the RNS, the RNS stated she failed to report the incident to the abuse coordinator (ADM), Ombudsman or police because she determined the incident was not abuse. During an interview on 10/13/2022 at 2:02 p.m., and a subsequent interview on 10/14/2022 at 12:27 p.m., with the ADM, the ADM stated he understood the regulation regarding abuse reporting was within 24 hours, he was not aware of the requirement of reporting within two hours and the issues with identification of abuse in the facility. The ADM stated if we do not report abuse timely, abuse can happen again and could affect residents. During a review of the facility's policy and procedure (P/P) titled Abuse Reporting and Prevention revised 2/2022, the P/P indicated the purpose of the policy is to ensure that resident rights are protected by providing a method of investigation and reporting of alleged violations involving mistreatment, neglect, abuse including injuries of unknown sources, unusual occurrences, and unauthorized use of resident property. A resident-to-resident altercation should be reviewed as a potential situation of abuse. When either or both residents have a cognitive impairment or mental disorder it does not automatically mean that an abuse did not occur. If during the investigation, it is determined that the resident's actions were willful or deliberate then abuse has occurred. Verbal abuse -use of written, oral, or gestured language that willfully used derogatory or disparaging terms regardless of their age, ability to comprehend, or disability. Abuse reporting of all alleged violations immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' Notice of Transfer/Discharge was sent to the Office of the State Long-Term Care Ombudsman (public advocate) for one of two sampled residents (Resident 43) by: 1. Failing to send a copy of the Transfer/Discharge notice to the Office of the State Long-Term Care Ombudsman in a timely manner. 2. Failing to retain a copy of the notice that was sent to the Ombudsman in Resident 43's medical record. This deficient practice had the potential for Resident 43 to be inappropriately discharged without access to an advocate. Findings: During a review of Resident 43's admission Record (Face Sheet), the Face Sheet indicated Resident 43 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease ([COPD] a chronic lung disease that blocks the airway), hypoxia (lack of oxygen supply to tissues), dyspepsia (digestion impairment), dementia (loss of memory), schizoaffective disorder (a combined disorder that causes hallucinations and mood swings), anxiety (extreme worry), and atrial fibrillation ([AFIB] irregular heartbeat). During a review of Resident 43's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 8/18/2022, the MDS indicated Resident 43's cognitive (ability to think, understand, and make daily decisions) skills for daily decision-making were severely impaired. The MDS indicated Resident 43 required limited assistance to complete his activities of daily living ([ADL] task such as eating, bathing, dressing, grooming and toileting). During a review of Resident 43's Transfer/Discharge Notice dated 10/2/2022, the Transfer/Discharge Notice indicated, Resident 43 was transferred to a general acute care hospital (GACH) on 10/1/2022 due to a COPD exacerbation (an increase in severity of the problem illness or bad situation) that occurred on 9/28/2022 which led to Resident 43's respiratory distress. During a review of Resident 43's Notice of Transfer/Discharge documentation, the Transfer/Discharge documentation indicated it was faxed on 10/3/2022, however the document did not indicate to whom or where it was faxed. At the bottom of the document, there was a section to indicate whether a copy of the notice was sent to the Ombudsman, but the box was not checked off nor was there a date stating a copy was sent. During a review of Resident 43's clinical record there was no documentation to indicate the Notice of Transfer/Discharge for Resident 43 was sent to the Ombudsman. During an interview on 10/13/2022 at 2:53 p.m., with the Social Services Director (SSD), the SSD stated there was a specific binder where faxed documents were kept. The SSD stated she had an assistant who resigned around the time Resident 43 was transferred to the GACH (10/1/2022), who maintained the documents in the binder, however, the whereabouts of the binder was unknown. During an interview on 10/14/2022 at 9:19 a.m., and a subsequent interview on the same day at 9:59 a.m., with the SSD, the SSD stated she does not have the initial copy of the transfer/discharge for Resident 43 that was sent to the Ombudsman on 10/1/2022. The SSD stated she spoke to the Ombudsman on 10/14/2022 regarding the situation and was instructed by the Ombudsman to fax Resident 43's notice of transfer/discharge document on that same day (10/14/2022). The SSD stated the notice of transfer/discharge documents were usually faxed to the Ombudsman the day following the resident's transfer and if the document could not be found, it was not sent. During a review of the facility's undated policy and procedure (P&P) titled, Discharge Planning, the P&P indicated, information needed for discharge planning includes availability of support system and community resources necessary to meet the Resident's needs. During a review of the facility's policy and procedure (P/P) titled, Discharge Process, dated 10/2017, the P/P indicated before the facility transfers or discharges a resident, the facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. The notice that must be provided and a copy sent to the Office of the State Long-Term Care Ombudsman and documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled resident's (Resident 29) Level II Preadmission Screening and Resident Review ([PASRR] a tool used to screen for mental illness and intellectual disability) was followed up to determine the facility's ability to provide recommended services. This deficient practice placed Resident 29 at risk of not receiving appropriate care and services. Findings: During a review of Resident 29's admission Record (face sheet), the face sheet indicated Resident 29 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder (a combined disorder that causes hallucinations and mood), generalized anxiety (extreme worry), depressive episodes, extrapyramidal (uncontrollable movements) movement disorders. During a review of Resident 29's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 7/25/2022, the MDS indicated Resident 29 was able to make independent decisions that were reasonable and consistent. The MDS indicated Resident 29 was conserved due to Resident 29's history of mental disorders. During a review of Resident 29's PASRR dated 11/2/2021, the PASRR indicated Resident 29 was positive for suspected mental issues and a Level II Mental Health Evaluation was required. During a review of a document from the Department of Health Care Services (DHCS), dated 3/1/2022, the document indicated the Level II evaluation was unable to be completed/not scheduled due to Resident 29 being isolated as a health or safety precaution. During an interview on 10/14/2022 at 10:40 a.m., with the Social Services Director (SSD), the SSD stated if the Business Office Manager (BOM) was not present in the office, the SSD covers the BOM duties and handles the PASRR. The SSD stated the Level I evaluations are conducted upon admission and the Department of Health comes to the facility to assess the residents, but due to the pandemic, the assessments were done over the phone and the PASRR II evaluation had been delayed. The SSD stated if the resident was unable to be assessed, the nurse or Social Services (SS) would update the Department of Health on the residents' status. During an interview on 10/14/2022 at 12:38 p.m. with the Administrator (ADM), the ADM stated the SSD was the one who follows up on the PASRRs and stated the case workers had not been at the facility for a long time to complete in person assessments on the residents. The ADM stated there was no documentation indicating an attempt was made to follow up on Resident 29's incomplete Level II PASRR screening. During an interview on 10/14/2022 at 1:07 p.m., with the SSD, the SSD stated the ADM and the BOM had access to the PASRR system and her (the SSD) job was to call the individual who handles the Level II PASSR. The SSD stated she did not have access to the PASSR system. The SSD stated the notice for Resident 29's Level II PASRR was received in March and a follow up should have been done. The SSD stated there was no documentation indicating the SSD called to follow up on the PASRR assessment. A review of the facility's policy and procedure (P&P) titled, PASRR (Preadmission Screening Resident Review), dated 3/2019, the P&P indicated, if the result of the Level 1 screening is positive due to a diagnosed or suspected mental illness, the Level 1 Screening will automatically be sent to the DHCS contractor for a Level II prescreening call for assessment of recommended services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Metformin (a medication used to control blood sugar [b/s] levels in the body) was administered with food for one of five sampled residents (Resident 72). This deficient practice had the potential to cause Resident 72 stomach irritation. Findings: During a review of Resident 72's Face Sheet (FS), the FS indicated Resident 72 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus (elevated b/s levels in the blood). During a review of Resident 72' s physician's order dated 10/10/2022, the physician's order indicated to administer Glucophage 500 milligrams ([mg] a unit of measurement) BID (twice a day) with meals. During an observation on 10/13/2022 at 8:58 a.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 administered Metformin 500 mg to Resident 72. There was no food/meal or food tray observed a Resident 72's bedside. During an interview on 10/13/2022 at 9 a.m. with LVN 5, LVN 5 stated breakfast is served between 7 a.m., and 7:30 a.m., and LVN 5 acknowledged Resident 72 was administered Metformin without any food. LVN 5 stated Metformin should be administered with a meal to minimize the effects on the resident's b/s level and to minimize possible stomach irritation. During an interview on 10/14/2022 at 2:32 p.m., with the Director of Nursing (DON), the DON stated breakfast is served between 7:30 a.m., and 8 a.m., and medications like Metformin should be given immediately after breakfast. The DON stated if Metformin is not given with a meal/food, it can cause irritation to the stomach. During a review of the facility's policy and procedure (P/P) titled Medication Administration-General Guidelines dated 10/2017, the P/P indicated medications should be administered according to written orders of the attending physician. During a review of the facility's job description for a Charge Nurse, the job description indicated the Charge Nurse should administer medications as ordered by the physician.

Based on observation and interview, the facility failed to ensure nurse staffing information was posted and placed in a visible and prominent location. This deficient practice resulted in the total number of nursing staff and the actual hours worked by the nursing staff unavailable and/or inaccessible to residents and visitors. Findings: During a tour of the facility on 10/12/2022 at 11:17 a.m., nurse staffing information was not seen including at or near the front office. During an interview with Receptionist 2 and a concurrent interview with Registered Nurse 1 (RN 1) on 10/12/2022 at 11:17 a.m., Receptionist 2 stated she could not find the nurse staffing information posted anywhere in the front office. RN 1 stated she had not seen the nurse staffing information posted at the nursing station. RN 1 stated the Director of Staffing Development (DSD) is responsible for posting the information. During an interview on 10/12/2022 at 11:30 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated the DSD only posts the nursing assignments at the station, not the nurse staffing information. During an observation and concurrent interview with Receptionist 1 on 10/13/2022 at 11 a.m., the nurse staffing information was noted on a clipboard which was lying flat on the front office's countertop. Receptionist 1 stated administrative staff are the ones who usually use the front office and residents' mainly come to the front office if they are waiting on a food delivery. During an interview on 10/13/2022 at 11:20 a.m., with the Director of Business Development (DBD), the DBD stated the front office is closed during the week after 4:30 p.m., and on weekends. During an interview on 10/14/2022 at 11:39 a.m., with the Director of Staff Development (DSD), the DSD stated he posts the daily nursing assignments at each nursing station but not the nurse staffing information. The DSD stated the front office is not open after 4:30 p.m., on weekdays and is closed on weekends which makes the nurse staffing information inaccessible to residents and visitors. The DSD stated it is important to post the nurse staffing information so residents and visitors can have a projection of the number of staff who are working daily. During a review of the facility's policy and procedure (P/P) titled, Staffing Nurse Information, dated 1/2017, the P/P indicated the facility must post the following information daily at the beginning of each shift: The facility name The facility current date The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed Vocational Nurses, Certified Nursing Assistants Resident Census The posted information will be clear and in a readable format The posted information will be in a prominent place readily accessible to resident and visitors

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow up with discharge planning for 1 of 2 residents, Resident 28. This failure had the potential to delay Resident 28 from planning future events and impede continuity of care. Findings: During a review of Resident 28's admission Record (AR), the AR indicated Resident 28 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder (a serious mental disorder in which people interpret reality abnormally), gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting the mouth and stomach), and hyperlipidemia (abnormally high levels of unhealthy fats in the blood). During a review of Resident 28's Minimum Data Set (MDS- a standardized care planning and assessment tool) dated 7/13/2022, the MDS indicated Resident 28 had clear speech, the ability to express ideas and wants, and clear comprehension (understanding). The MDS further indicated Resident 28 required limited assistance with dressing, toilet use, and personal hygiene. During an initial tour interview on 10/11/2022 at 10:17 a.m., Resident 28 stated he had been a resident in the facility for 17 months and the medical doctor and staff were aware, he wanted to discharge home. Resident 28 further stated he was able to cook and clean and take care of himself. During a follow-up interview on 10/13/2022 at 2 p.m., Resident 28 stated the social service worker wanted to discharge him to a board and care (a type of assisted living facility that offers personal assistance with basic daily tasks). Resident 28 stated he did not want to live in a Board and Care center, because he did not want to become institutionalized (a person that gradually stops thinking and acting independently due to being taken care of for a long time, in facilities such as Board and Care). During a concurrent interview and record review, on 10/13/2022 at 2:15 p.m., with the social service director (SSD) of the Social Service notes dated 8/23/2022, the notes indicated the SSD was assisting Resident 28 with the assisted living waiver program to discharge Resident 28 to a lower level of care. Referral was made to a home health agency and the SSD to follow up. The SSD stated she had failed to follow up and Resident 28 may feel that facility staff do not care about his discharge wishes. During a review of Resident 28's care plan titled Discharge Planning, dated 4/14/2021, the care plan indicated Resident 28 expected to discharge to the community. The care plan goals indicated Resident 28 would be assisted with discharge planning when feasible and would discharge to the appropriate facility in a timely manner in accordance with his needs and desires. Interventions included social services to follow up with local agencies, Interdisciplinary Team (a care team designed to support the health and well-being of residents in a person- center manner) will meet with resident or responsible party for goal setting, and resident or family will be referred to local placement agencies for further assistance. During a review of the facility's policy and procedure titled Social Services Department-Discharge Planning, no date, indicated discharge planning and evaluation will be provided by the Social Services staff for each resident. Discharge planning involves the resident, family or responsible party and others involved in the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Follow physician's order for one of five sampled residents (Resident 72) who had Metformin (a medication that helps regulate blood sugar absorption, prescribed for diabetes mellitus [disease where the body is unable to regulate and process blood sugar levels ) ordered to be given with meals. This deficient practice had the potential for harm to Resident 72 by placing the resident at risk for side effects of taking Metformin on an empty stomach such as diarrhea, gas bloating and upset stomach. 2. Complete the controlled medication inventory log for station 2 medication cart. This deficient practice had the potential for loss of accountability, and drug loss, diversion, or theft. Findings 1. During an observation on 10/13/22 at 8:58 am with Licensed Vocational Nurse (LVN) 4, LVN administered Metformin 500 mg one tablet by mouth to Resident 72 with no meal at bedside. During a review of Resident 72's Face Sheet (FS), the FS indicated Resident 72 was admitted on [DATE] with the diagnosis of diabetes mellitus. During a review of Resident 72' s physician order dated 10/10/22, the physician order indicated Glucophage (generic name for Metformin) 500 mg tab po BID (twice a day) with meals. During a review of Resident 72's History and Physical (H&P) dated 10/11/22, the H&P indicated Resident 72 has the capacity to understand and make decisions. During an interview on 10/13/22 at 9:00 am with LVN 4, LVN 4 stated that breakfast was served between 7-7:30 am. LVN 4 agreed the Metformin was administered with no meal. LVN 4 acknowledged that Metformin should be administered with a meal to minimize the effects on the resident's blood sugar level and to minimize the irritation on the stomach. During an interview on 10/14/22 at 2:32 pm with Director of Nursing (DON), the DON confirmed that breakfast was served between 730-8 am and medications like Metformin, should be given immediately after breakfast. According to the DON, if the medication was not given with a meal, it can upset the resident's stomachs. During a review of the facility's policy and procedure (p/p) titled Medication Administration-General Guidelines with an effective date of October 2017, the P/P indicated medications should be administered according to written orders of the attending physician. 2. During review of Controlled Drug Inventory log of Station 2; on 10/12/22, at 03:30 pm., 10/07/22 (7 am-3 pm), 10/08/22 (7 am-3 pm), 10/09/22 (7 am-3 pm), and 10/09/22 (11 pm-7am) were blank (not documented). During an interview, on 10/12/2022, at 3:40 pm., Licensed Vocational Nurse (LVN) 1 stated, he saw Controlled Drug Inventory Log on listed dates were not documented. LVN 1 stated that if I did not document it, it means it did not happen, or it was not done. LVN 1 stated, if incoming and outgoing charge nurses did not check the inventory each shift, medications might not be up to date, and nurses possibly did not recognize expired medications which could negatively affect resident care. During an interview, on 10/12/2022, at 3:50 pm., Registered Nurse (RN) 1 stated, at the beginning of each shift, incoming and outgoing nurses should count the controlled drugs and sign on the Controlled Drug Inventory Log before endorsing (handing over) a key to the med carts from one nurse to another. RN 1 stated, nurses should also check and sign on the log for the Emergency kit to monitor if any medications were expired or needed to be replaced from the pharmacy. During an interview, on 10/13/2022, at 3:05 pm., Director of Nurse (DON) confirmed the Controlled Drug Inventory Log of Station 2 on listed dates were not documented. DON stated, she doubts that the nurses did not count controlled drugs on those dates. DON stated, they just might forget to sign on the log. DON stated, even though nurses did not document and did not sign on Controlled Drug Inventory log, it will not affect any potential outcome on resident care. DON stated, it is just signature. A review of the facility's policies and procedures, titled, Medication Storage in The Facility, effective date August 2014, indicated, At each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurse and is documented on the controlled medication accountability record. A review of the facility's policies and procedures, titled, Charge Nurse Job Description, indicated, General Duties and Responsibilities included maintain inventory of supplies and/or medications to meet the needs of the resident.

Based on observations, interview, and record review, the facility failed to ensure that thermometer readings were monitored and recorded in a temperature log for the central supply cabinet to assure a safe temperature range for medication storage. This deficient practice had the potential for harm to the residents due to the potential loss of strength of the drugs, and the potential for the residents to receive ineffective drug dosages. Findings: During an observation on 10/13/22 at 2:00 pm of the central supply medication storage cabinet, the thermometer was on the corner on the fourth shelf of the cabinet. During an interview on 10/13/22 at 2:00 pm with Central Supply staff (CS), the CS stated he was not monitoring or recording the temperature for the cabinet. CS also stated the medications sit on the shelf for about 10 days. The CS stated that it was important to monitor and record the temperature of the cabinet to ensure the strength and integrity of the medication. During an interview on 10/14/22 at 2:32 pm with the Director of Nursing, the DON stated the medication storage cabinet's temperature should be monitored to ensure the medication strength was intact and the resident received an effective dose of the medication. During a review of the facility's policy and procedure (P/P) titled Medication Storage in the facility effective date of April 2008, the P/P indicated the medication storage area should be free of extreme temperatures and storage conditions are monitored on a routine basis.

Based on observation, interview and record review, the facility failed to: 1.label and date 3 of 5 open condiment containers 2.Clean can opener 3.Clean all sinks for several days. These failures had the potential to cause foodborne illnesses, spread bacteria and cause food spoilage. Findings: During a concurrent observation and interview on 10/11/2022 at 8:50 a.m. with the dietary supervisor (DS) in the kitchen, refrigerator 2 was contained one gallon jar of pickles ¾ full, one gallon jar of mustard ¼ full and one quart container of lemon blend juice ¾ full that was opened and not label indicating the date opened. The DS stated failure to date the condiments may cause spoiled and expired condiments to be served to facility residents. During a concurrent observation and interview on 10/11/2022 at 9:07 a.m., the Dietary Department Cleaning Schedule and checklist was not documented for cleaning of the can opener and all sinks on 9/27, 9/28/, 9/29, 10/5, 10/6, and 10/7/2022. The DS stated the kitchen staff were responsible for the cleaning of all sinks and the can opener, and documenting daily. During a review of the facility's policy and procedure titled Shelves, Counters and Other Surfaces Including Hand Washing Sinks dated 2018, indicated to wash surface with a warm detergent solution following manufacturers instructions. Use a brush when necessary. Rinse with clear water using a clean sponge or cloth. Wipe dry with a clean cloth. Spray with sanitizer. Read sanitizer directions to learn how long surface is to remain wet. Use enough sanitizer to meet the time. Do not rinse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to identify facility and resident care issues, develop and implement appropriate plans of action: 1. To ensure QAA/QAPI committee systemically implemented and evaluated measures to maintain infection control practices, mitigation plan policies and procedures. These deficient practices have the potential to increase the risk of transmitting the Coronavirus (Covid-19; a highly contagious infection, caused by a virus that can easily spread from person to person) to residents, staff and the community. 2. To ensure QAA/AQPI committee implemented the facility's policy and procedure to report an incident of verbal and physical abuse within 2 hours, between 2 of 2 residents (Resident 72 and Resident 122) to the Department of Public Health, Ombudsman and Police and document a change of condition, care plan and monitor resident's behaviors for 72 hours after the abuse incident. These failures had the potential to cause more physical harm and injuries to residents, impede the Departments investigation, and neglect the well-being and rights of all residents. Findings 1)During a concurrent observation and interview on 10/12/2022 at 3:10 p.m., with LVN 4, in the of yellow zone area, there was no visible yellow zone signage indicating yellow zone, observed. LVN 4 stated the signs above the door with the yellow outline indicated the yellow zone signage. LVN 4 stated if any ancillary (a person whose work provides necessary support to the primary activities of an organization, institution, or industry) staff arrived, such as Medical Doctors, paramedics, and volunteers, staff gave a verbal report upon arrival so they could put on the appropriate protective gear for the yellow zone. During an interview on 10/12/2022, at 3:35 p.m., with the Infection Preventionist (ICP), the ICP confirmed there were no prominent signs informing of entrance to the yellow zone. During an interview on 10/13/2022 at 8:40 a.m., with the housekeeper (HK). The HP stated she cleaned the shower room at 1 p.m., and the janitor took over after her shift ended. During a concurrent observation and interview on 10/13/2022 at 09:02 a.m., with the Janitor in station 2's shower room. The Clean Shower Log Station 2 was observed with no documentation of cleaning on October 9th and 10th at 6 a.m. and 1 p.m., and no cleaning at 7 p.m., from October 1 through October 12, 2022. The janitor stated housekeeping staff cleaned and disinfected the shower room at noon. The janitor further stated he cleaned the shower room but did not document cleaning of the shower room. During a concurrent interview and record review on 10/13/2022 at 9:10 a.m. with the HK. The HK acknowledged a failure to clean the shower rooms consistently may cause an outbreak of Covid-19. During an observation on 10/14/2022, at 12:35 p.m., in the facility entryway, while Receptionist (RECEPT 1) was screening one of the surveyors, RECEPT 1 was observed removing a pen from a right hoodie pocket. RECEPT 1 was observed using the pen, then handed the same pen over to the surveyor to sign the Covid-19 entry screening form. RECEPT 1 was observed cleaning the pen with hand sanitizer after use, then RECEPT 1 was observed putting the pen back into the right hoodie pocket. During an interview with the RECEPT 1 on 10/14/2022, at 12:49 p.m., RECEPT 1 stated I usually disinfect used pens with hand sanitizer after each use and keep them in a black case. I keep the black case in my hoodie pocket. I also keep clean pens in my hoodie pocket. RECEPT 1 stated, the facility did not have clean and dirty pen holder on the Covid-19 screening table. During an interview with Infection Control Preventionist (ICP) on 10/14/2022, at 12:58 p.m., the ICP stated, we use this wipe called Clorox Bleach Germicidal wipe to disinfect each equipment including pens. If we do not disinfect equipment correctly, the item will be considered contaminated. 2. During an interview on 10/13/2022 at 10:30 a.m., with Resident 72 in his room, Resident 72 stated he had a problem with his previous roommate, and he told staff and staff did a room change. Resident 72 stated the roommate was calling him names, calling him a sex offender and made a gun gesture and punched his shoulder. Resident 72 further stated he felt threatened for his life and safety. During a concurrent interview and record review on 10/13/2022 at 10: 35 a.m., with the registered nurse supervisor (RNS), the RNS stated Residents 72 and 122 were incompatible roommates on the day of admission and Resident 72 was moved from room [ROOM NUMBER] to room [ROOM NUMBER], the next door. Resident 72's medical chart/records were reviewed and there was no documentation of the verbal/physical abuse incident and room change or incompatibility with roommate. During an interview on 10/13/2022 at 10:55 a.m., with Resident 122, Resident 122 stated he had a roommate that was moved out the same day of admission. Resident 122 stated he did not physically hit Resident 72 and admitted to verbally abusing (cursing) him. During a concurrent interview and record review on 10/13/2022 at 11:55 a.m. with the Social Service Director (SSD), the SSD stated she was aware of the incident between Resident 72 and Resident 122. Resident 122 was using foul language, the room mates were incompatible, and a room change was initiated. A record review of Resident 72's chart indicated no documentation of social services notes, interdisciplinary notes or physician order for a room change related to roommate incompatibility During an interview on 10/14/2022 at 07:55 a.m., with Resident 122. Resident 122 states he verbally cursed out Resident 72 and the administrator asked him questions about the abuse incident yesterday (10/13/2022). Resident 122 further stated staff never questioned him about the abuse incident before yesterday, 10/13/2022. During an interview on 10/14/2022 at 9:35 a.m. with the Social Service Director, SSD stated Resident 72 signed out against medical advice (AMA) after talking with the police regarding the abuse incident. The SSD stated that failure to recognize abuse may leave the resident feeling ignored. During a concurrent interview and record review on 10/14/2022 at 10:35 a.m. with the RNS, RNS stated she discussed the abuse incident with Resident 72 after our interview yesterday. RNS further stated she failed to document the incident of abuse because she had determined the incident was not considered abuse and was not reported to the abuse coordinator/Administrator, Ombudsman, or police. The abuse incident should have been documented on an incident report. Nursing progress notes were not documented regarding the abuse incident nor was monitoring for 72 hours or care plan with nursing interventions. The RNS stated the incident was not determined to be abuse but roommate incompatibility and that was not documented. During a review of the facility's policy and procedure (P/P) titled Abuse Reporting and Prevention revised dated 02/2022, the P/P indicated the purpose of the policy is to ensure that resident rights are protected by providing a method of investigation and reporting of alleged violations involving mistreatment, neglect, abuse including injuries of unknown sources, unusual occurrences, and unauthorized use of resident property. A resident-to-resident altercation should be reviewed as a potential situation of abuse. When either or both residents have a cognitive impairment or mental disorder it does not automatically mean that an abuse did not occur. If during the investigation, it is determined that the resident's actions were willful or deliberate then abuse has occurred. Verbal abuse -use of written, oral, or gestured language that willfully used derogatory or disparaging terms regardless of their age, ability to comprehend, or disability. Abuse reporting of all alleged violations immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. During an interview on 10/14/2022 at 12:27 p.m., with the Administrator (ADMIN), the ADMIN stated that QAPI's current focus was on increasing COVID vaccinations booster numbers among staff and residents. According to the ADMIN, he was not aware of the problems with infection control practices related to the yellow zone signage and the lack of cleaning of the shower after yellow zone residents use. In addition, the ADMIN stated he understood the time frame for reporting an allegation of abuse was 24 hours, he was not aware of the requirement of reporting within 2 hours and the issues with identification of abuse in the facility. During a review of the facility's policy and procedure (P/P) titled Quality Assurance Performance Improvement Plan & Committee (QAPI) indicated the QAPI committee identifies and addresses specific care and quality issues and implements an action plan to resolve these issues. The P/P further indicates that all systems that affect resident and family satisfaction, quality of care and services provided, and all areas that affect the quality of life for residents and employee will be addressed.

Based on observation, interview, and record review, the facility failed to implement infection control practices and their mitigation plan policies and procedures by failing to: 1) Use adequate visible signage to indicate a yellow zone (separate area for residents who are symptomatic but unconfirmed or may have been exposed to Covid-19 [a highly contagious virus] break area, bathroom and hallway. 2) Clean and disinfect a shared shower room of yellow and green zone (area for residents that have not been exposed to and do not have Covid-19) residents after yellow zone residents showered in the shared shower rooms for several days. 3) Clean and disinfect equipment appropriately after screening (filling out a questionnaire for possible signs and symptoms of Covid-19 or exposure to Covid-19) staff/visitors These deficient practices have the potential to increase the risk of transmitting the Covid-19 to residents, staff, and the community. Findings: 1)During a concurrent observation and interview on 10/12/2022 at 3:10 p.m., with LVN 4, in the of yellow zone area, there was no visible yellow zone signage indicating yellow zone, observed. LVN 4 stated the signs above the door with the yellow outline indicated the yellow zone signage. LVN 4 stated if any ancillary (a person whose work provides necessary support to the primary activities of an organization, institution, or industry) staff arrived, such as Medical Doctors, paramedics, and volunteers, staff gave a verbal report upon arrival so they could put on the appropriate protective gear for the yellow zone. During an interview on 10/12/2022, at 3:35 p.m., with the Infection Preventionist (ICP), the ICP confirmed there were no prominent signs informing of entrance to the yellow zone. 2)During an interview on 10/13/2022 at 8:40 a.m., with the housekeeper (HK). The HP stated she cleaned the shower room at 1 p.m., and the janitor took over after her shift ended. During a concurrent observation and interview on 10/13/2022 at 09:02 a.m., with the Janitor in station 2's shower room. The Clean Shower Log Station 2 was observed with no documentation of cleaning on October 9th and 10th at 6 a.m. and 1 p.m., and no cleaning at 7 p.m., from October 1 through October 12, 2022. The janitor stated housekeeping staff cleaned and disinfected the shower room at noon. The janitor further stated he cleaned the shower room but did not document cleaning of the shower room. During a concurrent interview and record review on 10/13/2022 at 9:10 a.m. with the HK. The HK acknowledged a failure to clean the shower rooms consistently may cause an outbreak of Covid-19. 3)During an observation on 10/14/2022, at 12:35 p.m., in the facility entryway, while Receptionist (RECEPT 1) was screening one of the surveyors, RECEPT 1 was observed removing a pen from a right hoodie pocket. RECEPT 1 was observed using the pen, then handed the same pen over to the surveyor to sign the Covid-19 entry screening form. RECEPT 1 was observed cleaning the pen with hand sanitizer after use, then RECEPT 1 was observed putting the pen back into the right hoodie pocket. During an interview with the RECEPT 1 on 10/14/2022, at 12:49 p.m., RECEPT 1 stated I usually disinfect used pens with hand sanitizer after each use and keep them in a black case. I keep the black case in my hoodie pocket. I also keep clean pens in my hoodie pocket. RECEPT 1 stated, the facility did not have clean and dirty pen holder on the Covid-19 screening table. A review of manufacture for the 75% alcohol hand sanitizer on the Covid-19 screening table, indicated hand sanitizer uses for hand sanitizer to help decrease bacteria on the skin when water, soap and towel are not available recommended for repeat use. During an interview with Infection Control Preventionist (ICP) on 10/14/22, at 12:58 p.m., the ICP stated, we use this wipe called Clorox Bleach Germicidal wipe to disinfect each equipment including pens. If we do not disinfect equipment correctly, the item will be considered contaminated. 1)During a review of the facility's Corona Virus Disease 2019 (Covid-19) Mitigation Plan, dated May 2020, indicated yellow space designated to be used and occupied by non Covid-19 new admission and re-admitted residents, asymptomatic residents that were potentially exposed to a positive roommate, symptomatic residents that were potentially exposed to a positive roommate or staff and symptomatic resident were not exposed to Covid-19 but signs and symptoms are highly suggestive of Covid-19. 2)During a review of the facilities policies and procedures titled Housekeeping/Maintenance, revised dated 07/2019, indicated it is the policy of the facility to provide effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Frequent cleaning of the building's interior will aid in physically removing some of the micro-organisms which might cause these hazards. The housekeeping supervisor will implement effective systems of environmental sanitation, including a regular cleaning schedule for all areas. 3)During a review of the facility policy and procedures titled Infection Control Durable Medical Equipment (DME), dated 10/11, indicated it is the policy of the facility to properly and routinely sanitize DME. Bleach wipes or germicidal wipes will be used for DME after each use.