**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality of two of four sampled residents (Resident 3 and Resident 226) when: 1. Resident 3's suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) urinary bag (urine drainage bag to collect urine) was observed without a urinary catheter bag cover. 2. Resident 226 who was hard of hearing (HOH) and spoke a foreign language that the facility staffs could not understand, and the resident could not understand the common language in the facility was not accurately assessed and provided the proper means of communicating with the staffs and residents. These deficient practices violated the resident's rights to maintain privacy, enhanced self-esteem, self-worth, that resulted in Resident 226 expressed frustration, weeping, and stated she suffered a lot because of poor communication and her needs were not met. Findings: 1. During a review of Resident 3 ' s, admission Record (AR), dated 2/5/2025, indicated Resident 3 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including benign prostatic hyperplasia (a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), obstructive and reflux uropathy (obstructive uropathy happens when urine can't flow through the urinary tract, while reflux uropathy occurs when urine flows backward into the kidneys), and history of urinary tract infection. A review of Resident 3 ' s History and Physical Examination (H&P), dated 12/3/2024, indicated Resident 3 does not have the capacity to understand and make decisions. A review of Resident 3 ' s Minimum Data Set (MDS-a resident assessment tool) dated 12/3/2024, the MDS indicated Resident 3 ' s cognitive status (the mental process of thinking and understanding) was severely impaired. MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, toileting and personal hygiene, and required partial/moderate assistance (helper does less than half the effort) with bathing. A review of Resident 3 ' s facility document titled Order Summary Report (OSR), dated 2/1/2025, the document indicated Resident 3 had a suprapubic catheter attached to a drainage bag for obstructive and reflux uropathy. During a concurrent observation and interview on 2/5/2025 at 8:20 AM with certified nurse assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 in Resident 3 ' s room, Resident 3 was sitting on his wheelchair with the suprapubic catheter urinary bag was without a urinary catheter bag cover. CNA 1 stated, she did not know where the urinary bag cover was. LVN 1 stated, Resident 3's urinary bag should have a cover, because not having the cover violates the resident ' s rights for privacy and dignity. During an interview on 2/5/2025 at 2:25 PM with Director of Nurses (DON), DON stated, Resident 3 should have a cover for his urinary bag, not having it violates his rights for privacy and dignity. A review of the facility ' s policy and procedure (P&P) titled, Resident Rights, dated 3/2023, indicated; a) employees shall treat all residents with kindness, respect and dignity, b) federal and state laws guarantee certain basic rights to all residents which includes, dignified existence, be treated with respect and dignity, and privacy and confidentiality. A review of the facility ' s policy and procedure (P&P) titled, Dignity, dated 2/2021, indicated; demeaning practices and standards of care that compromise dignity is prohibited, staff are expected to promote dignity and assist residents to keep urinary catheter bags covered. 2. During a review of Resident 226 ' s admission Record indicated Resident 226 was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control, dementia (a progressive state of decline in mental abilities), Unspecified abnormalities of Gait and Mobility (changes to the way a person walks or moves due to injuries, medical conditions, or other reasons.) During a review of Resident 226 ' s Minimum Data Set (MDS - a resident assessment tool) dated 10/1/24, indicated Resident 226 was severely cognitively impaired (a condition that makes it very difficult for a person to think, learn, and remember). The MDS also indicated Resident 226 had moderate difficulty in hearing. During a concurrent observation and interview 2/5/2025 at 9:05 AM, Resident 226 was observed writing on a piece of paper in foreign language back and forth with Certified Nursing Assistant (CNA) 1. Resident 226 stated the communication has been difficult between her and staffs, because she has hard of hearing (HOH) and she and the staffs do not understand each other sometimes with her limited English. Resident 226 stated there were times that staffs who didn't understand her language walked out of the room and did not come back. Resident 226 stated she had never been offered communication board, audio or video materials in the language that she speaks. Resident 226 was observed expressing frustration, weeping, and stated she suffered a lot because of poor communication and her needs were not met. During an interview on 2/5/25 at 9:15 AM with CNA 1, CNA 1 stated Resident 226 has HOH, speaks limited language that the facility uses, CNA 1 stated she communicates to the resident in writing when she was called to help translate in the language that the residents speak. CNA1 also stated she had noticed Resident 226 expressed sadness and frustration when complaining to her about not understanding the staffs and not being understood by the staffs. During an interview on 2/5/25 at 9:35AM, with Licensed Vocational Nurse (LVN )4, LVN 4 stated she communicated with Resident 226 via phone translation (connect with a live interpreter via phone for real-time translation), and she was aware the Resident 226 had HOH, and has language communication barrier, sometimes staffs assist translation, LVN 4 stated there was no communication board available at bedside for Resident 226 to use, and stated she does not use phone translation due to Resident 226 had a HOH so the method was not very effective. During an interview on 2/6/25 at 11:00 AM with Registered Nurse (RN) 2, RN 2 stated he uses body language, to communicate with Resident 226. RN 2 stated there was no communication board available. RN 2 stated he couldn ' t always ensure if Resident 226 understood him, sometimes based on translator ' s feedback. During a review of Resident 226 ' s Licensed Nurses Notes, dated 1/9/25 throughout 2/4/25, no documented evidence that indicated a translator and/or communication board was provided to the resident in a foreign language that the resident speaks and understands. During an interview on 2/6/25 at 9:16 AM with Director of Nursing (DON), DON stated when a resident is admitted with communication-sensory or language barrier, admission nursing staff should identify the risk factors, residents ' needs, develop and implement a person-centered care plan. Failure to communicate effectively between staffs and residents will impair resident rights. The DON stated communication is important, staffs should have properly assessed Resident 226 ' s needs, developed and implemented comprehensive care plan, and used effective communication methods to ensure staffs understand her, and Resident 226 can relate to the staffs. It's totally not acceptable to have resident's rights compromised due to any barrier. During a review of the facility ' s policy and procedure titled Resident Rights dated 2/2021, indicated Federal and State laws guarantee certain basic rights to all residents in the facility. These include resident ' s right to: a. be treated with respect, kindness, and dignity. b. be supported by the facility in exercising his or her rights. During a review of the facility ' s policy and procedure titled Dignity dated 2/2021, indicated Each resident shall be care for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The facility culture supports dignity and respect for resident goals, choices, preferences, values, and beliefs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure on Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) by failing to ensure the Advance Directive was offered and explained and the signed AD was in the chart for two of four sampled residents (Residents 14 and 39). This deficient practice has the potential to omit the residents ' medical decisions if they become incapacitated (unable to make decision for self) leading to unnecessary or unwanted treatments due to lack of clear instructions regarding their end-of-life care. Findings: 1. A review of Resident 14's admission Record indicated that the facility admitted Resident 14 on 11/15/2024 with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and schizophrenia (a mental illness characterized by disturbances in thought). A review of Resident 14's Minimum Data Set (MDS - a resident assessment tool), dated 11/22/2024, indicated that Resident 14 ' s cognition (mental action or process of acquiring knowledge and understanding) was intact. A review of Resident 14's medical records showed that the resident did not have an Advance Directive in his chart or in the facility's Point Click Care database program (PCC, a cloud-based software platform that helps healthcare organizations manage care and services of the residents). A review of Resident 14's admission Assessment and Nurse ' s Notes, dated 11/15/2024, showed no indication that the facility offered an Advance Directive to Resident 14 during admission. 2. A review of Resident 39's admission Record indicated that the facility initially admitted Resident 39 on 9/4/2019 and readmitted the resident on 10/31/2024 with diagnoses that included pneumonia (an infection/inflammation in the lungs) and schizophrenia. A review of Resident 39's History and Physical evaluation, dated 10/31/2024, indicated that the resident did not have the capacity to understand and make decisions. A review of Resident 39's MDS dated [DATE], indicated that Resident 39's cognition was intact. A review of Resident 39's medical records showed that the resident did not have an Advance Directive or a Physician's Orders for Life-Sustaining Treatment (POLST, a portable, medical order form that documents a patient's preferences for end-of-life care) in his chart or in the facility's PCC database program. During an interview on 2/4/2025 at 3:10 PM, Licensed Vocational Nurse (LVN) 3 stated that the facility should place the Advance Directive and the POLST in the chart of the resident. LVN 3 stated that she does not know who is responsible in ensuring that these forms are in place. During an interview on 2/4/2025 at 3:37 PM, LVN 4 stated that the facility should offer the Advance Directive and the POLST to the resident on admission and have it signed accordingly. LVN 4 stated that without these records in place, the facility would not know the medical interventions the resident wanted during end-of-life situations. During an interview on 2/4/2025 at 3:51 PM, the medical records director (MRD) stated that it was his responsibility to ensure that the facility offered the resident an Advance Directive and a POLST during admission and have it filled out and signed accordingly before he uploads them to the PCC and puts them in the chart of the resident. The MRD stated that without these records in place, the staff would not know what end-of-life treatment the resident wanted during emergency situations. The MRD stated that he must have overlooked it. A review of the facility's undated policy titled, Advance Directives, version 2.0, revised in 9/2022, indicated that prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. If the resident or representative indicates that he or she has not established advance directives, the facility staff will help in establishing advance directives and the nursing staff will document in the medical record that assistance was offered and the resident ' s decision to accept or decline assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 226 ' s admission Record indicated Resident 226 was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control, dementia (a progressive state of decline in mental abilities), Unspecified abnormalities of Gait and Mobility (changes to the way a person walks or moves due to injuries, medical conditions, or other reasons.) During a review of Resident 226 ' s Minimum Data Set (MDS - a resident assessment tool) dated 10/1/24, indicated Resident 226 was severely cognitively impaired (a condition that makes it very difficult for a person to think, learn, and remember). The MDS also indicated Resident 226 had moderate difficulty in hearing. During a review of Resident's 226's Care Plan dated 1/10/25, indicated Resident 226 was at risk of having needs unmet related to difficulty in communication secondary to hard of hearing and spoke a foreign language. 1. Resident will be able to relate to others effectively daily until the next assessment. 2. Resident will have communication needs met by use appropriate interventions daily until the next assessment. During a concurrent observation and interview 2/5/2025 at 9:05 AM, Resident # 226 was observed writing on a piece of paper in foreign language back and forth with Certified Nursing Assistant (CNA) 1. Resident 226 stated the communication has been difficult between her and staffs, because she has hard of hearing (HOH) and she and the staffs do not understand each other sometimes with her limited English. Resident 226 stated there were times that staffs who didn't understand her language walked out of the room and did not come back. Resident 226 stated she had never been offered communication board, audio or video materials in the language that she speaks. Resident 226 was observed expressing frustration, weeping, and stated she suffered a lot because of poor communication and her needs were not met. During an interview on 2/5/25 at 9:15 AM with CNA 1, CNA 1 stated Resident 226 has HOH, speaks limited language that the facility uses, CNA 1 stated she communicates to the resident in writing when she was called to help translate in the language that the residents speak. CNA1 also stated she had noticed Resident 226 expressed sadness and frustration when complaining to her about not understanding the staffs and not being understood by the staffs. During an interview on 2/5/25 at 9:35AM, with Licensed Vocational Nurse (LVN )4, LVN 4 stated she communicated with Resident 226 via phone translation (connect with a live interpreter via phone for real-time translation), and she was aware the Resident 226 had HOH, and has language communication barrier, sometimes staffs assist translation, LVN 4 stated there was no communication board available at bedside for Resident 226 to use, and stated she does not use phone translation due to Resident 226 had a HOH so the method was not very effective. During an interview on 2/6/25 at 11:00 AM with Registered Nurse (RN) 2, RN 2 stated he uses body language, to communicate with Resident 226. RN 2 stated there was no communication board available. RN 2 stated he couldn ' t always ensure if Resident 226 understood him, sometimes based on translator ' s feedback. During a review of Resident 226 ' s Licensed Nurses Notes, dated 1/9/25 throughout 2/4/25, no documented evidence that indicated a translator and/or communication board was provided to the resident in a foreign language that the resident speaks and understands. During an interview on 2/6/25 at 9:16 AM with Director of Nursing (DON), DON stated when a resident is admitted with communication-sensory or language barrier, admission nursing staff should identify the risk factors, residents ' needs, develop and implement a person-centered care plan. Failure to communicate effectively between staffs and residents will impair resident rights. Communication is important, staffs should have properly assessed Resident 226 ' s needs, developed and implemented comprehensive care plan, and used effective communication methods to ensure staffs understand her, and Resident 226 can relate to the staffs. It's totally not acceptable to have resident's rights compromised due to any barrier. During a review of the facility ' s policy and procedure titled Care Plans, Comprehensive Person-Centered dated 3/2022, indicated The comprehensive, person-centered care plan: a. Includes measurable objectives and timeframes. b. Describe services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. c. Builds on the resident ' s strengths. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and relevant clinical decision making. Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident for two of two sampled residents (Resident 9 and 226) in accordance to the facility's policy and procedure and the resident's rights by [NAME] to ensure: 1. A plan of care was developed to address Resident 9 with behavior of physically aggression towards staffs and the residents and went to other resident's rooms and took their personal belongings. 2. A plan of care was developed to address Resident 226's concern of hard of hearing (HOH) and communication in a foreign language that the facility staffs could not understand, These deficient practices resulted for Resident 9 to have multiple incidents of aggressive behavior that potentially exposed other residents to physical and psychological harm. In addition Resident 226 had verbalized frustration and the potential not to receive the necessary care and services the resident needed especially in an event of emergency. Cross reference to F550 and F740 Findings: 1. A review of Resident 9's admission Record indicated that the facility initially admitted Resident 9 on 2/27/2012 and readmitted the resident on 1/14/2025 with diagnoses that included schizophrenia (a mental illness characterized by disturbances in thought). A review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, indicated that Resident 9's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated that Resident 9 required partial/moderate assistance (helper does less than half the effort of the task) from a person when performing most of her daily living activities. A review of Resident 9's Change of Condition (COC) assessment, dated 1/16/2025 and 1/28/2025, indicated that Resident 9 showed an aggressive behavior towards the staff and residents. The COC on 1/16/2025 indicated that Resident 9 was trying to attack the staff and residents and went to the room of other residents to take their personal belongings. The COC on 1/28/25 indicated that Resident 9 was again trying to strike out at the staff and residents. A review of Resident 9's medical records indicated that the facility did not create a care plan for Resident 9 ' s COC on 1/16/2025 when Resident 9 tried to attack the staff and residents and went to the rooms of other residents to take their personal belongings. A review of Resident 50's admission Record indicated that the facility initially admitted on [DATE] and readmitted the resident on 3/13/2025 with diagnoses that included schizophrenia. A review of Resident 50's MDS, dated [DATE], indicated that Resident 50's cognition was moderately intact. The MDS indicated that Resident 50 required partial/moderate assistance (helper does less than half the effort of the task) from a person when performing most of her daily living activities. During an interview with Resident 50 on 2/5/2025 at 10:50 AM, she stated that about three weeks ago, Resident 9 went to her room, took her pillow, and left. Resident 50 stated that on 2/4/2025, Resident 9 went back to her room, stood at the doorway, and refused to leave when she asked her to go back to her room. Resident 50 stated that she reported the incident to one of the licensed nurses. During an interview with licensed vocational nurse (LVN) 4 on 2/5/2025 at 1:51 PM, LVN 4 stated that she initiated a COC for Resident 9 on 1/16/2025 since Resident 9 became physically and verbally aggressive towards the staff and other residents; however, she stated that Resident 9 did not have physical contact with any resident. LVN 4 stated that Resident 9 also went to the rooms of other residents on the same day and took their personal belongings. During an interview with LVN 1 on 2/5/2025 at 1:58 PM, LVN 1 stated that she initiated a COC for Resident 9 on 1/28/2025 since Resident 9 became physically aggressive towards the staff and other residents; however, LVN 1 stated that Resident 9 did not have physical contact with any resident. During an interview and a record review of Resident 9's medical records with the director of nursing (DON) on 2/7/2025 at 7:50 AM, the DON stated that the facility did not conduct an interdisciplinary team (IDT, a group of professionals from different disciplines who work together collaboratively to achieve a common goal) meeting or created a care plan to address Resident 9's behavior on 1/16/2025. The DON stated that the facility should have conducted an IDT meeting and created a care plan for Resident 9 to ensure the safety of the residents, prevent harm, and promote dignity and privacy among the residents. A review of the facility's undated policy titled, Care Plans, Comprehensive Person-Centered, version 2.0, revised in 3/2022, indicated that the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, should develop and implement a comprehensive, person-centered care plan to meet the physical and psychosocial needs of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received proper assistive devices to maintain hearing abilities for one of 3 sampled residents (Resident 226) who was not assisted by the facility in arranging a referral for audiologist (a physician specialized in hearing loss) consult. This deficient practice resulted in a delay of services and Resident 226 not being able to hear adequately while communicating with staffs. Findings: During an observation on 2/4/25 at 8:33 AM, Resident 226 was observed alert, lying in bed, with a raised voice speaking to a laboratory staff, who also had to raise volume for Resident 226 to hear the resident. Resident 226 also pulled out pieces of paper and requested to communicate in writing. During an interview on 2/4/25 at 9:31 AM, Resident 226 stated she has hard of hearing (HOH), has no device, to assist her with the difficulty hearing whatever the staffs say to her. During a concurrent observation and interview on 2/5/25 at 9:15 AM with CNA 1, CNA 1 was observed writing on a paper to communicate with Resident 226, CNA 1 stated writing works better than speaking to Resident 226. CNA1 also stated aware that Resident 226 has HOH, speaks limited language formally used in the facility. CNA 1 stated she was often called by staffs to Resident 226 ' s room to help translate in a language that the resident speaks and understands. CNA 1 stated she often hear Resident 226 complained not understanding the staffs and not being understood. During an interview on 2/5/25 at 9:20 AM, LVN 5 stated she aware that Resident 226 was HOH, and has language barrier. LVN 5 stated sometimes she use body gestures to communicate with the resident but can ' t be sure if Resident 226 fully understood what she ' s trying to tell Resident 226. During a review of Resident 226's admission Record indicated Resident 226 was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Unspecified Dementia (a progressive state of decline in mental abilities), abnormalities of Gait and Mobility (changes to the way a person walks or moves due to injuries, medical conditions, or other reasons.) During a review of Resident 226's Minimum Data Set (MDS - a resident assessment tool) dated 10/1/24, indicated Resident 226 was severely cognitively impaired (a condition that makes it very difficult for a person to think, learn, and remember). The MDS also indicated Resident 226 had moderate difficulty in hearing. During a review of a physician order dated 1/9/25, indicated Resident 226 was referred to Audiology consult PRN (as needed) for hearing problems. During a concurrent interview and record review on 2/6/25 at 8:50 AM with Social Service Director (SSD). SSD stated spoke to Resident 226 and her responsible party upon admission. SSD stated Resident 226 did not have hearing disability, that ' s why ENT (Ear, Nose, Throat) doctor appointment arranged set up necessary. No staffs reported SSD re: hearing disability. During an interview on 2/6/25 at 9:16 AM with Director of Nursing (DON), DON stated when a resident is admitted with communication-sensory barrier, the SSD has to do the assessment, MDS also assess resident upon admission, and reassess if there's discrepancy in the assessments. Then SSD arrange audiology consult and make appointment for resident. Failure to report resident ' s needs for specialty consultation delay the care and services, and impaired resident rights. Communication is important, staffs should have properly assessed Resident 226 ' s needs and used effective communication methods to ensure resident can understand. It's totally not appropriate to have resident's care delayed due to any barrier. During a review of the facility's policy and procedure titled Accommodation of Needs Related to Communication Deficits revision date 3/2021, indicated Communication needs will be identified, and appropriate interventions will be developed in order to accommodate the needs of the residents. Communication needs will be assessed as follows: a. Psycho-Social Assessment form; Resident Identifying Date- Language Spoken b. Rehabilitation Screening- Mode of Expression, etc c. Communication Section on Social Service Progress Notes. During a review of the facility's policy and procedure titled Accommodation of Needs, revision dated 3/2021, indicated that facility ' s environment and staff behavior are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The resident ' s individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. Interact with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) received appropriate treatment and services to prevent urinary tract infection (UTI-when bacteria gets into your urine and travels up to your bladder), in accordance with the facility's policy and procedures (P&P) on Infection Prevention and Control Program. 1. On 2/4/2025, Resident 3 was observed while sitting on his wheelchair, Resident 3's suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) drainage bag (urine drainage bag to collect urine) was hanging on the wheelchair ' s left arm rest (positioned higher than Resident 3's bladder). 2. On 2/5/2025, Resident 3 was observed with the suprapubic catheter tubing wrapped around his left leg while sitting on his wheelchair. This deficient practice had the potential for Resident 3 to have recurrent urinary tract infection and negatively affect Resident 3's quality of life. Findings: During a review of Resident 3's, admission Record (AR), dated 2/5/2025, indicated Resident 3 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including benign prostatic hyperplasia (a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), obstructive and reflux uropathy (Obstructive uropathy happens when urine can't flow through the urinary tract, while reflux uropathy occurs when urine flows backward into the kidneys), and history of urinary tract infection (UTI). During a review of Resident 3's History and Physical Examination (H&P), dated 12/3/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool) dated 12/3/2024, the MDS indicated Resident 3's cognitive status (the mental process of thinking and understanding) was severely impaired. The MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, toileting and personal hygiene, and required partial/moderate assistance (helper does less than half the effort) with bathing. During a review of Resident 3's care plan (CP) for suprapubic catheter, at risk for complication from catheter use (i.e. recurrent urinary tract infection) initiated 12/27/2019, the CP indicated staff to maintain proper alignment of the suprapubic catheter to promote proper drainage. During a review of Resident 3's facility document titled NC-COC/Interact Assessment Form (SBAR), dated 9/14/2022, the document indicated Resident 3 had a UTI and was placed on antibiotic (medicines that fight bacterial infections) therapy. During a review of Resident 3's Order Summary Report (OSR), dated 2/1/2025, the OSR indicated, an order date of 11/30/2024 the use of suprapubic catheter attached to drainage bag for obstructive and reflux uropathy. During a concurrent observation and interview on 2/4/2025 at 10:15 AM with Registered Nurse (RN) 1 in the Dining Room, Resident 3 was sitting on his wheelchair, his suprapubic catheter drainage bag was hanging on the wheelchair's left armrest (positioned higher than Resident 3's bladder). RN 1 stated, the urinary drainage bag should not be hanging on the armrest, it should be under the wheelchair seat and must be positioned lower that Resident 3's bladder. RN 1 stated, the position of the urinary drainage bag could cause backflow of urine back to Resident 3's bladder and can cause UTI. During a concurrent observation and interview on 2/5/2025 at 8:20 AM with Licensed Vocational Nurse (LVN) 1, and Certified Nurse Assistant (CNA) 1 in Resident 3 ' s room, Resident 3 while sitting on his wheelchair, noted his suprapubic catheter tubing was wrapped around his left leg. CNA 1 did not have an answer to why the suprapubic catheter tubing was wrapped around Resident 3's left leg, LVN 1 stated, Resident 3's suprapubic catheter tubing wrapped around his leg is not appropriate, the urine will not flow freely and could cause backflow to Resident 3's bladder and had the potential to cause UTI. During an interview on 2/5/2025 at 2:05 PM with the Infection Preventionist (IP), the IP stated, the suprapubic catheter urinary bag should always be positioned below the resident's bladder. The IP stated the suprapubic catheter tubing should not be wrapped around residents' leg because these practices could cause back flow to Resident 3's bladder and had the potential to cause UTI. During an interview on 2/5/2025 at 2:25 PM with the Director of Nurses (DON), the DON stated, the suprapubic catheter urinary bag should not be hanging on Resident 3's wheelchair arm rest, it should always be positioned below Resident 3's bladder, and the tubing should not be wrapped around Resident 3's leg, otherwise it could cause backflow to Resident 3's bladder and cause UTI. During a review of the facility's P&P titled, Suprapubic Catheter Care, dated 10/2010, the P&P indicated; a)the purpose of the procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident ' s urinary tract, b) to review the resident ' s care plan to assess for any special needs of the resident and c) the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. During a review of the facility's P&P titled, Infection Prevention and Control Program revised 4/2023, the P&P indicated; a) the facility established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and b) important facets of infection prevention include instituting measures to avoid complications or dissemination (to spread or scatter).

Based on interview and record review, the facility failed to implement its policy and procedure on behavioral health services by failing to provide one of two sampled residents (Resident 9) a referal to psychiatrist (a physician specialized in mental and behavioral health) consultation evaluation for aggressive behavior towards the staff and residents to attain the resident's highest practicable physical, mental, and psychosocial well-being. This deficient practice had the potential to worsen the mental health symptoms of the resident, increase risk of relapse, decrease quality of life, and increase the likelihood of needing more intensive interventions like hospitalization in the future. Findings: A review of Resident 9's admission Record indicated that the facility initially admitted Resident 9 on 2/27/2012 and readmitted the resident on 1/14/2025 with diagnoses that included schizophrenia (a mental illness characterized by disturbances in thought and false belief of reality). A review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, indicated that Resident 9's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated that Resident 9 required partial/moderate assistance (helper does less than half the effort of the task) from a person when performing most of her daily living activities. A review of Resident 9's Change of Condition (COC) assessment, dated 1/16/2025 and 1/28/2025, indicated that Resident 9 showed an aggressive behavior towards the staff and residents. The COC dated 1/16/2025 indicated Resident 9 was trying to attack the staff and residents, went to a resident's room, and took the personal belongings of another resident. The COC on 1/28/2025 indicated that Resident 9 was again trying to strike out at the staff and residents. A review of Resident 9's medical records indicated that the facility created a care plan on 1/28/2025 to address Resident 9's aggressive behavior towards the staff and residents. The interventions in the care plan included a consultation with a psychiatrist to evaluate the resident 's behavior. During an interview with Licensed Vocational Nurse (LVN) 4 on 2/5/2025 at 1:51 PM, LVN 4 stated that she initiated a COC on 1/16/2025 since Resident 9 became physically and verbally aggressive towards the staff and other residents. During an interview with LVN 1 on 2/5/2025 at 1:58 PM, LVN 1 stated that she initiated a COC on 1/28/2025 since Resident 9 became physically aggressive towards the staff and other residents. During an interview and a record review of Resident 9's medical records with the Director of Nursing (DON) on 2/7/2025 at 7:50 AM, the DON stated that the facility created a care plan on 1/28/2025 to address the aggressive behavior of Resident 9 with an intervention to consult a psychiatrist to evaluate the resident. The DON stated that the facility overlooked that intervention and failed to refer Resident 9 to the psychiatrist. A review of the facility's undated policy titled, Behavioral Health Services, version 1.0, revised in 2/2019, indicated that the facility would provide residents with behavioral services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident in accordance with the comprehensive assessment and plan of care.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five (5) percent (%) during medication pass by committing four (4) medication errors on one of six sampled residents (Resident 15) during medication observation with 29 medication opportunity that resulted to a 13.79% medication error rate. This deficient practice had the potential to result in adverse reaction) undesired effect of a drug or other type of treatment) to the medications that could jeopardize the safety of the residents that could lead to serious harm, injury, or death. Findings: A review of Resident 15's admission Record indicated that the facility initially admitted Resident 15 on 4/3/2024 and readmitted the resident on 10/9/2024 with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and schizophrenia (a mental illness characterized by disturbances in thought). A review of Resident 15's Minimum Data Set (MDS - a resident assessment tool), dated 12/27/2024, indicated that Resident 15's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. A review of Resident 15's Order Summary Report, indicated that as of 2/1/2025, the physician ordered to administer the following medications to Resident 15: 1. Depakote Sprinkles Oral Capsule Delayed Release Sprinkle (used to treat seizure disorders and mental/mood conditions) 125 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount). Give one capsule by mouth two times a day. 2. Docusate Sodium (a stool softener to treat constipation) Oral Tablet 100 mg. Give one tablet by mouth one time a day. 3. Multivitamin-Minerals (a combination of vitamins and minerals to prevent nutrient deficiencies) Oral Tablet. Give one tablet by mouth one time a day. 4. Sodium Chloride (an electrolyte replenisher) Oral Tablet 1 gram (metric unit of measurement, used for medication dosage and/or amount). Give one tablet by mouth one time a day. During a medication administration observation on 2/6/2025 at 8:42 AM, LVN 3 prepared four (4) oral medications (Docusate Sodium tablet, Depakote Sprinkles capsule, Multivitamin-Minerals tablet, and Sodium Chloride tablet), crushed them, and mixed them in a single container with apple sauce. The surveyor interrupted LVN 3 before she was about to administer the medications to Resident 15. During a concurrent interview with LVN 3, she stated that she realized she was not supposed to mix the medications all together. LVN 3 stated that Resident 15 would not know what medication she would be taking if she crushes and mixes them. During an interview on 2/7/2025 at 1:46 PM, the director of nursing (DON) stated that ideally, the licensed nurse should administer crushed medications separately, unless the resident wants to take them all together in a single container. The DON stated that it is a matter of resident preference whether to administer crushed medications individually or separately. A review of the facility's undated policy titled, Administering Medications, version 2.1, revised in 4/2019, indicated that medications should be administered in a safe and timely manner. The policy did not have a specific instruction or procedure on how to properly administer crushed medications.

Based on observation, interview, and record review, the facility failed to implement its policy and procedure on how to properly and safely store medications and biologicals by failing to separately store Hydrogen Peroxide Topical Solution (an external [outside the body] medication with mild antiseptic used on the skin to prevent infection of minor cuts, scrapes, and burns) on the same shelf with oral (medications given by mouth) medications such as stool softeners and vitamins. This deficient practice had the potential to cause medication errors and expose residents to adverse reactions (an undesired harmful effect) that could lead to serious harm or death. Findings: During an inspection of the facility's East Wing medication storage room with licensed vocational nurse (LVN) 3 on 2/6/2025 at 10:05 AM, a bottle of Hydrogen Peroxide Topical Solution, an external (applied outside the body) medication used on the skin to prevent infection of minor cuts, scrapes, and burns, was observed on the same shelf where oral medications were kept. During a concurrent interview with LVN 3, LVN 3 stated that the facility should not store external medications on the same shelf where oral medications are kept to prevent medication errors. During an interview on 2/7/2025 at 1:56 PM, the director of nursing (DON) stated that the facility should keep oral medications and external medications separately to avoid medication errors. The DON stated that storing oral and external medications together increases the risk of misidentification and accidental ingestion of an external medication, especially if the containers look similar. The DON stated that he did not know who placed the external medication on the same shelf where oral medications were stored. A review of the facility's undated policy titled Medications Storage in the Facility, effective 4/2008, indicated that medications and biologicals should be stored safely, securely, and properly. The policy indicated that orally administered medications should be kept separate from externally used medications, such as suppositories, liquids, and lotions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a system in preventing, controlling infections and communicable diseases were in place, when one of two sampled residents (Resident 3) according to the facility's Infection Prevention and Control Program. Resident 3 who was on an enhance barrier precaution (EBP) (taking extra steps to prevent the spread of serious infections, like using gowns and gloves) due to a suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) was observed receiving high contact care (fixing Resident 3 ' s suprapubic catheter tubing and urine drainage bag) from Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1). LVN 1 and CNA 1 failed to use an isolation gown as part of their PPE (Personal Protective Equipment) and proceeded to the Nurses Station without performing hand hygiene (a way of cleaning the hands, which can prevent the spread of germs) after the care. These deficient practices had the potential to cause and/or spread of infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) in the facility. Findings: During a review of Resident 3's, admission Record (AR), dated 2/5/2025, indicated Resident 3 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including benign prostatic hyperplasia (a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), obstructive and reflux uropathy (Obstructive uropathy happens when urine can't flow through the urinary tract, while reflux uropathy occurs when urine flows backward into the kidneys), and history of urinary tract infection. During a review of Resident 3's History and Physical Examination (H&P), dated 12/3/2024, indicated Resident 3 does not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool) dated 12/3/2024, the MDS indicated Resident 3's cognitive status (the mental process of thinking and understanding) was severely impaired. MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, toileting and personal hygiene, and required partial/moderate assistance (helper does less than half the effort) with bathing. During a review of Resident 3's care plan (CP) for suprapubic catheter, at risk for complication from catheter use (i.e. recurrent urinary tract infection) revised 1/31/2025, the CP indicated intervention included Enhance Standard Precaution due to status post suprapubic catheter. During a review of Resident 3's care plan (CP) for Enhance Barrier Precaution due to suprapubic catheter use, revised 1/31/2025, the CP indicated interventions that included hand hygiene during any direct contact, and providing enhance standard precaution gloves, gowns, mask. During a review of Resident 3's Order Summary Report (OSR), dated 2/1/2025, the OSR indicated; a) an order date of 11/30/2024 the use of suprapubic catheter attached to drainage bag for obstructive and reflux uropathy, and b) an order date of 12/2/2024, Resident 3 was placed on Enhanced Barrier Precautions due to suprapubic catheter in place. During an observation on 2/5/2025 at 8:30 AM in Resident 3's room, Resident 3, who was on an Enhance Barrier Precaution, was receiving a high contact care (fixing Resident 3's suprapubic catheter tubing and urine drainage bag) from two nursing staff (CNA 1 and LVN 1), both nursing staff was not wearing a gown as part of their PPE, then both staff proceeded to the nurses station after the care without performing hand hygiene. During an interview on 2/5/2025 at 8:45 AM with CNA 1, CNA 1 did not have an answer to why she did not wear a gown as part of her PPE prior to taking care of Resident 3, and not performing hand hygiene after taking care of Resident 3. During an interview on 2/5/2025 at 8:50 AM with LVN 1, LVN 1 stated, she was aware that she was supposed to wear a gown as part of her PPE when she took care of Resident 3 who was on EBP, and she was also aware that she was supposed to perform hand hygiene after providing care to Resident 3, she just forgot. LVN 1 stated, not using PPE prior to taking care of Resident 3 and not performing hand hygiene after providing care to Resident 3 had the potential to spread virus and bacteria in the facility. During an interview on 2/5/2025 at 2:05 PM with Infection Preventionist (IP), IP stated, Resident 3 is on enhance barrier precaution because he has a suprapubic catheter, as per policy staff should use PPE's which includes wearing a gown prior to direct care to the resident and practice hand hygiene before and after direct care to Resident 3. IP stated, adhering to EBP policy is for the protection of Resident 3 and other residents and staff, not following the enhance barrier precaution had the potential to cause the spread of virus, bacteria and multi-drug-resistant organisms (MDROs) in the facility During an interview on 2/5/2025 at 2:25 PM with the Director of Nurses (DON), the DON stated, Resident 3 is on an enhance barrier precaution, which means when staff has high contact care with the resident the staff should wear PPE's which includes gloves and gown and perform hand hygiene before and after the care of Resident 3. DON stated, performing care with Residents 3's suprapubic catheter tubing and urine drainage bag are considered high contact care. DON stated, LVN 1 and CNA 1 should have been wearing a gown prior to Resident 3's care and should have performed hand hygiene after the care, these mistakes of the staff had the potential to cause the spread of virus, bacteria and MDROs in the facility. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions dated 6/5/2024, the P&P indicated; a) Enhance barrier precaution are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents, b) gloves and gown are applied prior to performing the high contact resident care activity, and c) example of high-contact resident care activities requiring the use of gowns and gloves for EBP included device care or use (urinary catheter). During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, revised 4/2023, the P&P indicated; a) the facility established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and b) important facets of infection prevention include instituting measures to avoid complications or dissemination (to spread or scatter).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 14's admission Record indicated that the facility admitted Resident 14 on [DATE] with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and schizophrenia (a mental illness characterized by disturbances in thought). A review of Resident 14's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], indicated that Resident 14's cognition (mental action or process of acquiring knowledge and understanding) was intact. A review of Resident 14's medical records indicated that the facility prepared a POLST on [DATE] but failed to obtain the signature of the resident before placing it in the resident's chart. During an interview on [DATE] at 3:37 PM, LVN 4 stated that the facility should offer the Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) and the POLST to the resident on admission and have it signed accordingly. LVN 4 stated that without these records in place, the facility would not know the medical interventions the resident wanted during end-of-life situations. During an interview on [DATE] at 3:51 PM, the medical records director (MRD) stated that it was his responsibility to ensure that the facility offered the resident an Advance Directive and a POLST during admission and to have it filled out and signed accordingly before he uploads those documents to the PCC and place them in the chart of the resident. The MRD stated that without these records in place, the staff would not know what end-of-life treatment the resident wanted during emergency situations. The MRD stated that he must have overlooked it. A review of the facility's policy and procedure (P&) titled, POLST dated 5/2024, indicated ; a) the facility follows the guidance attached Quick Reference Guide ON POLST IN NURSING HOME which indicates the POLST isn't valid unless it is signed by a (1) physician, nurse practitioner or physician assistant and (2) the resident, if resident lacks capacity, the resident's legally recognized healthcare decision maker, b) by signing POLST, which becomes a medical order, the physician, nurse practitioner, or physician assistant certifies that the order on the form are consistent with the resident medical condition and preferences, and c) when completed by the patient or legally recognized representative a physician, nurse practitioner or physician assistant the POLST becomes a medical order that should also be included in the patient's medical record. A review of the facility's policy titled, Charting and Documentation, Version 1.2, revised in 7/2017, indicated that documentation in the medical record should be complete and accurate. During a review of the facility's policy and procedure (P&P) titled Resident Rights, dated 3/2023, indicated, federal and state law guarantee certain basic rights to all residents of the facility, these rights included resident rights to: a) be informed about his rights and responsibilities, and b) be informed of his medical condition and of any changes in his condition. Based on observation, interview, and record review, the facility failed to ensure residents the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options for four of four sampled residents (Residents 37, 12, 69 and 14) by failing to: 1. Obtain an informed consent for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) medications for Resident 37, who was prescribed Quetiapine (medication used to treat a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) for schizophrenia, and Divalproex Sodium (medication used to treat mental/mood conditions) for mood disorder. 2. Ensure the residents, or the responsible party was informed about the Physician Orders for Life-Sustaining Treatment (POLST) for Resident 12, 69 and 14. This deficient practice had violated resident rights to be informed when choosing the type of care or treatment to receive, make decisions on alternative measures the resident or responsible party preferred, which can negatively affect Residents 37,12, 69, and 14's quality of life and/or delay in residents care that could ultimately result to adverse health outcomes. Findings: 1. During a review of the admission record indicated Resident 37 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities), psychotic disorder (affect the mind, where there has been some loss of contact with reality), and schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and actions). The admission record indicated Resident 37 had a family member that has power of attorney [POA] and is considered the resident's representative [RR] and emergency contact. A review of Resident 37's History and Physical Examination, dated [DATE], indicated Resident 37 did not have the capacity to understand and make decisions. During a review of Minimum Data Set (MDS - a resident assessment tool), dated [DATE], indicated Resident 37 required partial/moderate assistance (helper does less than half the effort) with eating, toileting, personal hygiene, and bathing. During a review of Resident 37 ' s facility document Order Summary Report (OSR), dated [DATE], the document indicated physician orders for: a) Quetiapine 100 mg (unit of weight) to give 1 tablet every 12 hours for schizophrenia ordered [DATE], and b) Divalproex Sodium 500 mg to give 1 tablet every 12 hours for mood disorder, ordered [DATE]. During a concurrent interview and record review, on [DATE], at 9:45 AM, with Registered Nurse (RN) 1, Resident 37's facility document titled Informed Consent for medications Quetiapine and Divalproex sodium, dated [DATE], was reviewed. The documents did not have the signature of the prescriber nor the signature of Resident 37 ' s RR or POA. RN 1 stated, Resident 37 ' s informed consents were not complete, it should have the signature of the prescriber within 24 hours of admission. RN 1 stated, it is important to have a complete informed consent for psychotropic medications to ensure the Resident or the responsible party are aware of the cause and effect of the medications and other alternatives available. During a concurrent interview and record review, on [DATE], at 9:55 AM, with RN 1, Resident 37's electronic health records (EHR) was reviewed from admission[DATE] until [DATE] was reviewed. The EHR did not have any documentation that informed consent for the psychotropic medications Quetiapine and Divalproex sodium was obtained by the prescriber. RN 1 stated, she could not see any documentation specifically stating informed consent for the psychotropic drugs was obtained by the prescriber. During an interview on [DATE] at 10:00 AM with MDS Nurse (MDSN) 1, MDSN 1 stated, the informed consent for psychotropic drugs is not complete without the prescriber ' s signature. MDSN 1 stated, it is important to have informed consent for psychotropic drugs to ensure the resident or the responsible party are aware of the pros (advantages) and cons (disadvantages) of the medication prior to making a decision, it is also for patient safety. During an interview on [DATE] at 10:20 AM with Director of Nurses (DON), the DON stated, Resident 37's informed consent for psychotropic medications Quetiapine and Divalproex sodium was not complete, it should have been signed by the prescriber as soon as possible within 24 hours. The DON stated, he did not have proof consent for psychotropic drugs was obtained by the prescriber from Resident 37 or responsible party. The DON stated, it is to ensure the informed consent was done and the medications was explained to Resident 37 and /or the responsible party about the pros and cons of the medications and other alternative treatments. During a review of the facility's policy and procedure (P&P) titled Informed Consent for Psychotropic Drug Use (undated), indicated: a) prior to prescribing a psychotropic medication, the licensed prescriber shall examine the resident and obtained informed consent either from the resident (if able) or the resident ' s representative, b) the license nurse shall verify written informed consent specifying the disclosure of material information for proper informed consent c) licensed nurse shall verify from the resident and/or legal representative whether the consent has been obtained for the use of psychotropic medication and will sign the form and document the person who gave consent and the date the consent was verified, and d) the licensed prescriber, Resident representative may sign the informed consent using remote technology, if possible and as soon as practicable. 2. A review of Resident 12's admission Record indicated the facility admitted Resident 12 on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder (symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), Chronic Obstructive Pulmonary Disease (COPD) (a common lung disease causing restricted airflow and breathing problems), and history of urinary tract infection. A review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], indicated that Resident 12's cognitive status (the mental process of thinking and understanding) was moderately impaired. The MDS Indicated Resident 12 required set up or clean-up assistance (helper sets up or clean up resident; resident completes activity. Helper assists only prior to or following the activity) with eating and bathing and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with toileting and personal hygiene. During a concurrent interview and record review, on[DATE], at 12:27 PM, with Registered Nurse (RN) 1, Resident 12 facility document titled Physician Orders for Life-Sustaining Treatment (POLST) dated [DATE] was reviewed. The POLST indicated DNR (It instructs providers not to do CPR (cardiopulmonary resuscitation) if a patient's breathing stops or if the patient's heart stops beating) status, but it was missing the responsible party ' s signature. RN 1 stated, the POLST is not valid because it is missing the responsible party ' s signature. RN 1 stated, Resident 12 POLST is used as a Physician Order by other medical professionals when Resident 12 goes to the hospital or incase of emergency, not having a valid POLST may delay the care of Resident 12. A review of Resident 69's admission Record indicated that the facility originally admitted Resident 69 on [DATE] and readmitted on [DATE] with diagnoses that included Dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities), coronary artery dissection (a condition that affects your heart), and diabetes (lifelong condition that causes a person's blood sugar level to become too high). A review of Resident 's MDS, dated [DATE], indicated that Resident 69's cognitive status (the mental process of thinking and understanding) was moderately impaired. The MDS Indicated Resident 69 required set up or clean-up assistance (helper sets up or clean up resident; resident completes activity, helper assists only prior to or following the activity) with eating, toileting, bathing and personal hygiene. During a concurrent interview and record review, on[DATE], at 12:30 PM, with Registered Nurse (RN) 1, Resident 69 facility document titled Physician Orders for Life-Sustaining Treatment (POLST) dated [DATE] was reviewed. The POLST indicated DNR status, but it was missing the responsible party's signature. RN 1 stated, the POLST is not valid because it is missing the responsible party's signature. RN 1 stated, Resident 69 POLST is used as a Physician Order by other medical professionals when Resident 69 goes to the hospital or in case of emergency, not having a valid POLST may delay the care of Resident 69. During an interview on [DATE] at 2:30 PM with Director of Nurses (DON) , DON stated, the POLST needs to have the signature of the Physician, the Resident or the responsible party to be considered valid. DON stated, the POLST are kept in the Resident physical chart to be used by medical professionals as a Physician Order during transfers to the hospitals and/or during emergency, not having a valid POLST may cause delayed of care.

Based on observation, interview, and record review, the facility failed to ensure one of the two refrigerators (located in the temporary food storage room at nearby facility) temperatures were monitored and documented before and between meal service activities for stable temperatures. This deficient practice placed the facility residents at risk for foodborne illness an (illness that comes from eating contaminated food) due to inconsistent refrigerator temperature monitoring and documentation. Findings: During a follow up kitchen tour on 2/6/25 at 12PM with the Dietary Service Supervisor (DSS) in the temporary food storage room located outside the kitchen, three (3) refrigerators and one (1) freezer were observed in this storage room. Each was observed with one thermometer inside. A Refrigerator and Freezer Temperature Log for February 2025 was observed hanging on the door. The log for 2/4/25 PM through 2/6/25 for Refrigerator 2 was blank. The log for Refrigerator 3 and Freezer was blank from 2/4/25 through 2/6/25. During an interview with on 2/6/25 at 12:10 PM, the DDS stated that the cooks for AM and PM shift are designated for checking all the temperature in the refrigerators and freezers and logs. DSS stated she was not sure if the cooks checked the logs, but the DDS should have not missed daily inspection of the logs. DSS also stated she was responsible for checking the logs and supervising the staffs for keep the log to ensure all the temperature in the refrigerators and freezers being monitored for safe food storage. During a review of the facility's policy and procedure titled, Refrigerators and Freezers dated 11/2022, indicated Monthly tracking sheets include time, refrigerator temperature, temperature of PHF/TCS food, initials, and action taken, The last column will be completed only if temperatures are not acceptable. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.

Based on interview and record review, the facility failed to assist one of two sampled resident ' s representative (Resident 49) in formulating an Advance Directives (AD-a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). This deficient practice had the potential to cause conflict with Resident 49's wishes regarding health care treatment especially in an event of emergency. Findings: During a review of Resident 49 ' s admission Record indicated the facility admitted Resident 49 on 8/26/23 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and hypertension (high blood pressure). During a review of Resident 49 ' s History and Physical (H&P), dated 8/28/23, indicated Resident 49 does not have the capacity to understand and make decisions. During a review of Resident 49 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/4/23, indicated Resident 49 had intact memory and cognition (ability to think and reasonably). The MDS indicated Resident 49 required supervision or touching assistance with eating, oral hygiene, toilet hygiene, chair/bed-to-chair transfer, lower body dressing and personal hygiene. During a concurrent interview and record review on 2/7/24 at 9:45 AM, with the Licensed Vocational Nurse (LVN) 1, Resident 49 ' s Advanced Directive Acknowledgement (ADA), dated 8/28/23, and Preferred Intensity of Care-Surrogate Decision Maker (PIC-SDM), dated 8/28/23, were reviewed. LVN 1 stated the ADA and PIC-SDM were the same form but named differently. LVN 1 stated Resident 49 ' s ADA was filled out but was not signed by the resident and/or Resident 49 ' s representative. LVN 1 stated she was not sure who filled out the form. LVN 1 stated Resident 49 ' s PIC-SDM was filled out with a Register Nurse (RN) ' s signature as the facility representative and physician ' s signature, but without the resident ' s /representative ' s signature. LVN 1 stated she was not sure what the ADA and PIC-SDM were exactly used for and the MDS nurse was the one responsible for informing to the residents and their responsible parties (RPs) and having it signed. During a concurrent interview and record review on 2/7/24 at 9:50 AM, with the MDS nurse, Resident 49 ' s ADA, dated 8/28/23, and PIC-SDM, dated 8/28/23, were reviewed. The MDS nurse stated ADA or the PIC-SDM should be signed by the resident or the RP if the resident was not able to make decision. The MDS nurse stated Resident 49 was not capable of making decision and the RP should sign the form. The MDS nurse stated the social worker was responsible to inform and have the resident or the RP to sign the form, so the staff would know if the resident had an AD or not in order to care for the resident as her and RP's wishes. During a concurrent interview and record review with the Social Services Designee (SSD). Resident 49 ' s ADA, dated 8/28/23, and the PIC-SDM, dated 8/28/23, were reviewed. The SSD stated the ADA and PIC-SDM were the same form with different title and the facility was currently using both forms. The SSD stated she was responsible to inform the residents and/or the resident ' s RPs about the ADA, and also responsible to request the residents and/or RP to sign the form. The SSD stated Resident 49 ' s ADA and PIC-SDM were not completed because there was no signature of the resident or the RP on the forms. The SSD stated Resident 49 was not capable of making decision, so her RP should had been informed and sign the form. The SSD stated she did not know why Resident 49 ' s ADA was filled out without the RP ' s signature which she probably overlooked it. The SSD stated it was important to inform the resident and her RP about their rights to formulate an Advance Directive, so the facility would know If the resident had an advance directive or not upon admission and provide treatments as the resident ' s wishes. During a review of the facility ' s policy and procedure (P&P) titled, Advance Directives, dated 9/22, the P&P indicated, the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment and prior to or upon admission of a resident, the social service director, or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Create a comprehensive care plan for the use of lorazepam (a medication used to treat mental illness) to treat behaviors of restlessness and aggression in one of five sampled residents (Resident 62). Create a comprehensive care plan for the use of lorazepam to treat behaviors of increased agitation, yelling, and screaming toward other and staff in accordance with the facility policy for one of five sampled residents (Resident 70). This deficient practice of failing to create comprehensive, resident-specific care plans related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) increased the risk that Resident 62 and 70 ' s use of psychotropic medications would not be periodically reevaluated as intended. This increased the risk that Residents 62 and 70 may have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medications possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Findings: 1. A review of Resident 62 ' s admission Record (a document containing a resident ' s demographic and diagnostic information), dated 2/8/24, indicated Resident 62 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including anxiety disorder (a mental condition characterized by intense, excessive, and persistent worry and fear about everyday situations) and major depressive disorder (MDD - a mental condition characterized by depressed mood, loss of appetite, trouble sleeping, and lack of interest in usually enjoyable activities.) A review of Resident 62 ' s History and Physical (H&P - a comprehensive physician ' s note assessing a resident ' s current medical status), dated 8/16/23, indicated Resident 62 did not have the capacity to understand and make decisions. A review of Resident 62 ' s Physician Order, dated 2/6/24 indicated, Resident 62 ' s attending physician prescribed the following psychotropic medications: Lorazepam 0.5 milligrams (mg – a unit of measure for mass) one tablet by mouth every eight hours as needed for anxiety disorder manifested by restlessness and aggression for 14 days. Lexapro (a medication used to treat MDD) 10 mg one tablet by mouth one time a day for MAJOR DEPRESSIVE DISORDER manifested by self-expression of sadness and helplessness. A review of Resident 62 ' s available comprehensive care plans, last reviewed 11/21/23, indicated there was no care plan regarding the use of lorazepam to treat target behaviors of restlessness and aggression. During an interview on 2/8/24 at 11:33 AM, with the Registered Nurse Supervisor (RNS), the RNS stated there is currently no care plan available for Resident 62 describing the use lorazepam as a targeted intervention for the behaviors of restlessness and aggression or goals of therapy defined. The RNS stated the facility failed to create the new care plan when the lorazepam was prescribed. The RNS stated creating care plans with therapeutic goals for psychotropic therapy and monitoring for behaviors and adverse effects related to psychotropic therapy is important to ensure the therapy is reevaluated periodically in an objective way. The RNS stated if monitoring of adverse effects and target behaviors is not done for psychotropic medications, Resident 62 may be on psychotropic medication for longer than necessary or at a higher dose than necessary which could cause a decline in her quality of life. A review of Resident 70's admission Record indicated Resident 70 was admitted on [DATE] with diagnoses that included anxiety disorder, dementia (a medical condition characterized by a decline in a resident ' s cognitive abilities impacting their ability to perform daily activities), and MDD. A review of Resident 70's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/25/24, indicated Resident 70 had impaired cognition (thought process and ability to reason or make decisions) for daily decision making. The MDS indicated Resident 70 required supervision or touching assistance (helper provides verbal cues, and/or touching, and/or steadying, and/or contact guard assistance as resident completes activity) with eating, oral hygiene and upper body dressing and personal hygiene. A review Resident 70 ' s H&P, dated 9/27/23, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 70's Physicians Orders, dated 10/25/23, indicated Resident 70 was prescribed lorazepam 0.5 mg one (1) tablet by mouth (PO) two (2) times a day for anxiety manifested by (m/b) increased agitation, yelling, and screaming toward other and staff. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 3 on 2/8/24 at 12:47 PM, LVN 3 stated Resident 70 did not have a care plan for the use of lorazepam. LVN 3 stated residents should have a care plan for lorazepam so staff would know how to take care of the resident while receiving lorazepam. LVN 3 stated the care plan is important because it indicated what problems to look out for, so licensed nurses could be on the same page regarding resident ' s care. During an interview with the Director of Nursing (DON) on 2/9/24 at 2:46 PM, the DON stated Resident 70, who received lorazepam, should have a care plan which included the diagnosis, risk, goals, and implementation. The DON stated the care plan should include monitoring signs and symptoms to look out for. The DON further stated the purpose of the care plan was to let the staff know what the interventions were, what to look for if the resident had a change in condition, and when to call the physician. A review of the facility ' s undated policy The Resident Care Plan indicated The resident care plan shall be implemented for each resident on admission and developed throughout the assessment process . The care plan generally includes identification of medical, nursing, and psychosocial needs . It is the responsibility of the licensed nurse to ensure that the plan of care is initiated and evaluated . the facility shall identify of medical, nursing, and psychosocial needs; goals states in measurable/observable terms; approaches (staff action) to meet the above goals; staff responsible for approaches; and re-assessment and change as needed to reflect current status. The policy further stated care plans are considered comprehensive in nature and should be reviewed in its entirely. Problems, goals, and approaches can be addressed in more than one or different areas of the plan care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise care plans for one of 35 sampled residents (Resident 51). This failure had the potential to affect Resident 51 ' s provision of care and services while residing in the facility. Findings: During a review of Resident 51 ' s admission Record, the facility admitted Resident 51 on 11/10/2023, with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility (ability to move), dementia (decline in mental ability severe enough to interfere with daily life), and cerebral infarction (brain damage due to a loss of oxygen to the area). During a review of Resident 51 ' s care plan for self-care deficit (difficulty performing self-care tasks like bathing, dressing, grooming), revised on 11/27/2023, the care plan interventions included for the facility to provide Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) program to ambulate (walk) using a front-wheeled walker (FWW, an assistive device with two front wheels used for stability when walking) or hand held assistance five days per week as tolerated. During a review of Resident 51 ' s Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 1/3/2024, the MDS indicated Resident 51 had severely impaired cognition (ability to think, understand, learn, and remember) and indicated Resident 51 required supervision or touching assistance (helper provides verbal cues and/or steadying and/or contact guard assistance as resident completes the activity) to transfer from lying in bed to sitting on the side of the bed, transfer from sit to stand, and transfer to and from the bed to a chair. The MDS also indicated Resident 51 required moderate assistance (helper does less than half of the effort) for walking 10 feet, walking 50 feet, and walking 150 feet. During a review of Resident 51 ' s Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 51 was modified independent (requires an assistive device or more time to perform the task) for bed mobility, modified independent for functional transfers, and supervised for walking 50 feet using a two-wheeled walker (FWW). The PT Discharge Reason indicated Resident 51 maximized functional potential and recommended for Resident 51 to participate in the facility ' s activity program. During a concurrent interview and record review on 2/9/2024 at 12:01 PM with the MDS Coordinator (MDS 2), MDS 2 stated Resident 51 ' s care plan for self-care deficit was reviewed on 1/5/2024. MDS 2 stated Resident 51 ' s intervention for RNA was inaccurate since Resident 51 was not receiving any RNA services. MDS 2 stated she should have checked if Resident 51 had physician ' s order for RNA services and then should have removed it from the care plan interventions. During a review of the facility ' s undated Policy and Procedure (P&P) titled, The Resident Care Plan, the P&P indicated the resident care plans should be reviewed in its entirety. The P&P also indicated the care plan generally included a reassessment and change as needed to reflect a resident ' s status.

Based on observation, interview, and record review, the facility failed to have more than one staff to provide Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) services out of 12 residents who were supposed to receive RNA services on 2/7/2024. RNA 1 was unable to provide RNA services to three (Resident 6, 24, and 61) of 12 residents on 2/7/2024, because RNA 1 was assigned to supervise multiple residents out in the facility ' s patio on 2/7/2024. On 2/8/2024, RNA 1 was assigned as a Certified Nurse Assistant assigned to perform resident care and was not able to provide RNA services to the 12 residents requiring RNA. On 2/9/2024, the facility failed to provide RNA services to the 12 residents requiring RNA because RNA 1 did not report to work. This failure had the potential for the residents with physician orders for RNA to experience a decline in range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move). Findings: During a review of the facility ' s Order Listing Report (report of specific physician orders), dated 2/6/2024, the Order Listing Report indicated nine residents had physician orders for RNA to provide assistance with ambulation (walking), sit to stand transfers, passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises, active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises, and/or application of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion). During an interview on 2/6/2024 at 9:23 AM with the Restorative Nursing Aide (RNA 1), RNA 1 stated RNA duties included assisting with meals, providing ROM exercises, assisting residents with ambulation and mobility, weighing residents weekly and monthly, and assisting the Certified Nursing Assistants (CNAs) with providing care. RNA 1 stated she worked from Monday to Friday. During an observation and interview on 2/7/2024 at 9:32 AM, RNA 1 was standing outside of the facility ' s [NAME] Wing watching multiple residents. RNA 1 stated she was unable to provide RNA services this morning since RNA 1 had to supervise residents on the outside patio of the facility ' s [NAME] Wing. During an interview on 2/7/2024 at 11:31 AM, RNA 1 stated she provided RNA services to two residents early in the morning, went outside to supervise residents in the [NAME] Wing, went on break, will assist residents with lunch, and then will provide RNA services after lunch. During an interview on 2/7/2024 at 1:47 PM, RNA 1 stated there were 12 residents with RNA tasks (assigned work). RNA 1 stated two residents were already seen for RNA services and 10 more needed to be seen. During an interview on 2/7/2024 at 2:46 PM, RNA 1 stated her workday was supposed to end at 2 PM. RNA 1 stated she was unable to provide RNA services to three of 12 residents because RNA 1 was at the [NAME] Wing until 10:30 AM. During a review of the Nursing Staff Assignment and Sign-In Sheet, dated 2/8/2024 for the 6:00 AM shift, the Nursing Staff Assignment indicated RNA 1 was assigned as a CNA for 10 residents. During an interview on 2/8/2024 at 11:26 AM, RNA 1 stated she was scheduled as a CNA. RNA 1 stated there was no other staff available to provide RNA services to the residents. During an interview on 2/8/2024 at 11:56 AM with the Director of Staff Development (DSD), the DSD stated RNA 1 was scheduled as a CNA today since one CNA (unknown) called off work today. The DSD stated the facility did not have another staff member available to provide RNA services. During a review of the Nursing Staff Assignment and Sign-In Sheet, dated 2/9/2024 for the 6 AM shift, RNA 1 did not sign in for the day. During an interview on 2/9/2024 at 1:15 PM, the DSD stated the facility did not provide RNA services today since RNA 1 did not report for work. During an interview on 2/9/2024 at 2:38 PM with the DSD and the Director of Nursing (DON), the DON stated RNA services were important to maintain the residents ' function including mobility, ROM, and activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility). The DON and DSD stated RNA 1 was the only RNA available to provide RNA services in the facility. The DSD stated the DSD could provide RNA services in RNA 1 ' s absence but did not perform any RNA services on 2/9/2024. During a review of the facility undated Policy and Procedure (P&P) titled, Restorative Nursing Program, the P&P indicated the DON, or designee, shall design a schedule for the facility ' s staff to ensure that residents receive appropriate restorative programs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure the physician responded to a recommendation from November 2023 to justify prolonged use of pantoprazole (a medication used to reduce stomach acid) in one of five sampled residents (Resident 62). This deficient practice of failing to ensure the physician evaluated and responded to medication irregularities (potential issues with a resident ' s medication regimen) identified by the faciliity ' s consultant pharmacist during the Medication Regimen Review (MRR – a monthly report from the consultant pharmacist identifying any medication irregularities in a resident ' s current medication regimen) increased the risk that Resident 62 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to medication therapy possibly leading to decline in mental or physical condition or psychosocial status. Findings: A review of Resident 62 ' s admission Record (a document containing a resident demographic and diagnostic information), dated 2/8/24, indicated she was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including Gastro-Esophageal Reflux Disease (GERD – a medical condition characterized by frequent heartburn.) A review of Resident 62 ' s History and Physical (a comprehensive physician ' s note assessing a resident ' s current medical status), dated 8/16/23, indicated Resident 62 did not have the capacity to understand and make decisions. A review of Resident 62 ' s Order Summary Report (a summary of all current physician orders), dated 1/29/23 indicated Resident 14 ' s attending physician prescribed pantoprazole 40 milligrams (mg – a unit of measurement for mass) to give one tablet by mouth two times a day for GERD 30 minutes before meals on 8/1/23. A review of the MRR report from November 2023 indicated the consultant pharmacist requested the attending physician to evaluate the continued use of pantoprazole for Resident 62 given potential risks of long-term therapy. Further review of the MRR report indicated there was no physician response to the facility ' s consultant pharmacist ' s concern. A review of Resident 62 ' s clinical record indicated there was no apparent physician response to the facility ' s consultant pharmacist ' s MRR request from November 2023. During an interview on 2/8/23 at 2:38 PM with the Registered Nurse Supervisor (RNS), the RNS stated she could not produce any evidence that the physician responded to the consultant pharmacist's recommendation to justify the prolonged use of pantoprazole for Resident 62. The RNS stated although she may have faxed the request initially to the physician, she could not provide any evidence of follow up or physician response. The RNS stated it is important for the pharmacist recommendations to be evaluated by the physician to ensure the resident does not suffer adverse effects related to drug therapy. The RNS stated because Resident 62's pharmacist recommendation regarding pantoprazole was not evaluated by the physician, it could have increased the risk of medical complications. A review of the facility ' s undated policy Medication Regimen Review (Monthly Report) indicated .Recommendations are acted upon and documented by the facility staff and/or the prescriber. If irregularities are found, the Director of Nursing and/or designated licensed nurse will follow up with the prescriber within 3 working days of the receipt of the Medication Regimen Review report. The Director of Nursing and/or designated licensed nurse will carry out the new order for the recommendation in the resident ' s clinical records if the prescriber concurs with the recommendations. The prescriber, the Director of Nursing or the designated licensed nurse will document the rationale if the recommendation is decline

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 70) was free of unnecessary medications. Resident 70 was ordered for psychotropic medications (medications that affect the mind and behavior) with an inadequate indication of use for Seroquel (a medication used to treat mental illness) to treat psychosis (a mental disorder characterized by a disconnection from reality) without adequate indication for use and the resident's manifestations of behavior of constant worrying was not monitored. This deficient practice had the potential to place Resident 70 at risk for unrecognized adverse reactions associated with the use of psychotropic drug. Findings: A review of Resident 70's admission Record indicated Resident 70 was admitted on [DATE] with diagnoses that included anxiety disorder (a mental condition characterized by intense, excessive, and persistent worry and fear about everyday situations), dementia (a medical condition characterized by a decline in a resident ' s cognitive abilities impacting their ability to perform daily activities), and major depressive disorder (MDD - a mental condition characterized by depressed mood, loss of appetite, trouble sleeping, and lack of interest in usually enjoyable activities.) A review of Resident 70 ' s History and Physical (H&P - a comprehensive physician ' s note assessing a resident ' s current medical status), dated 9/27/23, indicated Resident 70 did not have the capacity to understand and make decisions. A review of Resident 70's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/25/24, indicated Resident 70 had impaired cognition (thought process and ability to reason or make decisions) for daily decision making. Resident 70 required supervision or touching assistance (helper provides verbal cues, and/or touching, and/or steadying, and/or contact guard assistance as resident completes activity) with eating, oral hygiene and upper body dressing and personal hygiene. A review of Resident 70 ' s Physician Order, dated 10/25/23 indicated, Resident 70 ' s physician prescribed the following psychotropic medications: Resident 70 was ordered to give one (1) tablet Seroquel Oral 25 milligram (mg, unit of measurement of mass) by mouth two (2) times a day for psychosis manifest by (m/b) Constant worrying about medical condition cause stress. A record review of Resident 70's Medication Administration Record (MAR) from 2/1/24-2/29/24, the MAR indicated Resident 70 was scheduled to received Seroquel 25 mg at 9AM and 5PM. During an interview and record review, on 2/8/24 at 2:46 PM, a Director of Nursing (DON) stated that Resident 70 was ordered to receive Seroquel 25 mg one tablet PO (per oral or mouth) two times a day for psychosis m/b constant worrying about medical condition that cause stress. The DON stated that Constant worrying about medical condition causes stress was a general term and was not specific indication for use of Seroquel and the resident's manifestations of behavior was not monitored. A review of the facility's undated policy and procedure (P&P) titled, Psychotherapeutic Drug Review, indicated that the resident who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors by attempting to administer one dose of expired insulin (a medication used to treat high blood sugar) prior to surveyor intervention for one of nine residents observed for medication administration (Resident 483.) This deficient practice of failing to administer medications in accordance with professional standards of practice increased the risk that Resident 483 may have experienced medical complications from ineffective insulin possibly resulting in hospitalization. Cross-referenced F759 Findings: A review of Resident 483 ' s admission Record (a document containing a resident ' s demographic and diagnostic information, dated [DATE], indicated he was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a medical condition characterized by the body ' s inability to regulate blood sugar levels.) A review of Resident 483 ' s Order Summary Report (a summary of all currently active physician orders), dated [DATE], indicated on [DATE], Resident 483 ' s attending physician prescribed insulin aspart FlexPen (a pen device for injecting insulin under the skin) to inject subcutaneously (under the skin) before meals and at bedtime according to a sliding scale dosing regimen (dose is based on current blood sugar reading.) During a concurrent observation of medication administration and interview with the LVN 3 in the East Wing hallway on [DATE] at 11:37 AM, LVN 3 was observed preparing two units (unit of measurement of insulin dosage) of insulin aspart in a FlexPen device for Resident 483. The insulin FlexPen device was observed to be labeled with an open date of [DATE]. During the same observation and interview, on [DATE] at 11:37 AM, LVN 3 was observed attempting to provide Resident 483 ' s injection from the expired insulin pen and was stopped by the surveyor and asked to check the product ' s open date. LVN 3 stated she failed to check the open date on the insulin aspart prior to attempting to administer it to Resident 483. LVN 3 stated it is her responsibility to check expiration date or open date on every medication prior to administration. LVN 3 stated because Resident 483's insulin was open on [DATE], it is now expired as this insulin expires 28 days after opening and should be removed from the cart and discarded. LVN 3 stated expired insulin may be ineffective at controlling blood sugar and could be dangerous to administer to a resident. LVN 3 stated administering expired insulin may cause the resident to develop medical complications which could result in hospitalization. A review of the manufacturer ' s product labeling for insulin aspart FlexPen indicated it should be used or discarded within 28 days of opening or storage at room temperature. A review of the facility ' s policy Specific Medication Administration Procedures, dated [DATE], indicated .Check expiration date on package/container. When opening a multi-dose container, place a date on the container . A review of the facility ' s undated policy Med Pass indicated .Make sure that meds are administered according to: . right medications . a med error is a violation in the ' 5 rights ' , or in medication regulations, or in approved medication policy or current standards of practice .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: Ensure unopened insulin (a medication used to control high blood sugar) was stored in the refrigerator per the manufacturer ' s requirements affecting Resident 483 in one out of two medication carts (East Wing Medication Cart). Remove expired insulin (a medication used to treat high blood sugar) from the medication cart affecting Resident 483 in one out of two inspected medication carts (East Wing Medication Cart). These deficient practices of failing to store medications per the manufacturers ' requirements and remove expired medications from the medication carts increased the risk that Resident 483 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. Findings: A review of Resident 483 ' s admission Record (a document containing a resident ' s demographic and diagnostic information, dated 2/9/24, indicated he was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a medical condition characterized by the body ' s inability to regulate blood sugar levels.) A review of Resident 483 ' s Order Summary Report (a summary of all currently active physician orders), dated 2/9/24, indicated on 2/1/24, Resident 483 ' s attending physician prescribed insulin aspart FlexPen (a pen device for injecting insulin under the skin) to inject subcutaneously (under the skin) before meals and at bedtime according to a sliding scale dosing regimen (dose is based on current blood sugar reading) and insulin glargine (a medication used to treat high blood sugar) to inject 27 units subcutaneously at bedtime. During a concurrent observation of medication administration and interview with the Licensed Vocational Nurse (LVN) 3 in the East Wing hallway on 2/7/23 at 11:37 AM, LVN 3 was observed preparing two units (unit of measurement of insulin dosage) of insulin aspart in a FlexPen device for Resident 483. The insulin FlexPen device was observed to be labeled with an open date of 1/5/24. A review of the manufacturer ' s product labeling for insulin aspart FlexPen indicated the insulin should be used or discarded within 28 days of opening or storage at room temperature. During the same observation on 2/7/23 at 11:37 AM, LVN 3 was observed attempting to provide Resident 483 ' s injection from the expired insulin pen and was stopped by the surveyor and asked to check the product ' s open date. LVN 3 stated she failed to check the open date on the insulin aspart prior to attempting to administer it to Resident 483. LVN 3 stated it is her responsibility to check expiration date or open date on every medication prior to administration. LVN 3 stated because Resident 483's insulin was open on 1/5/24, it is now expired as this insulin expires 28 days after opening and should be removed from the cart and discarded. LVN 3 stated expired insulin may be ineffective at controlling blood sugar and could be dangerous to administer to a resident. LVN 3 stated administering expired insulin may cause the resident to develop medical complications which could result in hospitalization. During a concurrent observation and interview on 2/7/24 at 12:27 PM of East Wing Medication Cart with LVN 3, the following medications were found either expired, stored in a manner contrary to their respective manufacturer ' s requirements, or not labeled with an open date as required by their respective manufacturer ' s specifications: 1. One unopened insulin glargine pen was found stored in the cart at room temperature. According to the product labeling, unopened insulin glargine pens should be stored in the refrigerator. During the same concurrent observation and interview on 2/7/24 at 12:27 PM, LVN 3 stated the insulin glargine for Resident 483 is unopened and should be stored in the refrigerator. LVN 3 stated because it was not stored in the refrigerator and we cannot determine when it was stored at room temperature, it is uncertain on when it will now expire and is unsafe to administer to the resident. LVN 3 stated insulin that is not stored properly could be ineffective at controlling blood sugar which could cause Resident 483 medical complications possibly leading to hospitalization. A review of the facility ' s policy Storage of Medications, dated April 2008, indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer ' s recommendations of those of the supplier . Medications requiring refrigeration .are kept in a refrigerator with a thermometer to allow temperature monitoring . Outdated, contaminated, or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal .

Based on observation, interview, and record review, the facility failed to ensure one of one seated leg bicycles in the Rehabilitation Room was functioning properly, including during use for one of 13 residents (Resident 43) receiving Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) services. Findings: During a review of Resident 43 ' s admission Record, the facility admitted Resident 43 on 1/17/2024 with diagnoses including Parkinson ' s disease (brain disorder that causes unintended or uncontrollable movements and difficulty with balance and coordination), encephalopathy (disease that affects the brain, causing changes in its function), muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility (ability to move), and anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one ' s daily activities). During a review of Resident 43 ' s PT Evaluation and Plan of Treatment, dated 1/18/2024, the PT Evaluation indicated Resident 43 was referred to PT for new onset of decreased strength, decreased mobility, increased need for assistance from others, and reduced balance. The PT Plan of Treatment included therapeutic exercises (movement prescribed to correct impairments and restore muscle function), neuromuscular reeducation (technique used to restore movement patterns through repetitive motion to retrain the brain), gait (manner of walking) training, therapeutic activities [tasks that improve the ability to perform activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility], and wheelchair management training, five times per week for 30 days. During a concurrent observation and interview on 2/7/2024 at 11:47 AM in the facility ' s Rehabilitation Area of the Dining Room, Resident 43 was seated in a chair attached to a leg bicycle machine. Resident 43 ' s legs were performing a cycling motion but the monitor on the machine was turned off. The leg bicycle ' s monitor had an exposed backing with empty battery slots. The Physical Therapy Assistant 1 (PTA 1) stated the leg bicycle machine did not work since there was no batteries but had resistance. PTA 1 stated the rehabilitation area had a manual leg bicycle if the resident could not tolerate resistance. During an interview on 2/8/2024 at 12:24 PM with the Maintenance Supervisor (MS), the MS stated he does not inspect any of the equipment in the Rehabilitation Area of the Dining Room, including the leg bicycle machine. During an interview on 2/8/2024 at 12:39 PM with the Director of Rehabilitation (DOR) and PTA 1, the DOR stated the therapy staff were not using the leg bicycle machine ' s function. The DOR stated the leg bicycle machine was used as a manual leg bicycle. PTA 1 stated weights could be attached to a resident ' s leg if the resident required more resistance while using the leg bicycle machine. During a review of the facility ' s Policy and Procedure (P&P) titled, Maintenance Service, revised 12/2009, the P&P indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide call lights to call for assistance from 2/6/2024 to 2/9/2024 for five (Resident 15, 39, 68, 69, and 78) out of six residents who experienced a temporary room change due to ceiling leaks, in accordance with their care plans. This failure had the potential to prevent Resident 15, 39, 68, 69, and 78 from asking assistance especially during emergency situations, and not receiving necessary care and services, which could negatively affect the residents ' physical comfort and psychosocial well-being. Cross reference F921 Findings: 1. During a review of Resident 15 ' s admission Record, the facility admitted Resident 15 on 2/14/2022 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility (ability to move), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one ' s daily activities), and schizophrenia (mental disorder characterized by abnormal social behavior). During a review of Resident 15 ' s Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 11/19/2023, the MDS indicated Resident 15 had clear speech, expressed ideas and wants, clearly understood verbal content, and was moderately impaired for cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 15 required supervision or touching assistance (helper provides verbal cues and/or steadying and/or contact guard assistance as resident completes the activity) to transfer from lying in bed to sitting on the side of the bed, transfer from sit to stand, and transfer to and from a bed to a chair. During a review of Resident 15 ' s Fall Risk Assessment, dated 9/6/2023, the Fall Risk Assessment indicated Resident 15 was a high risk for falls. During a review of Resident 15 ' s care plan for fall risk, revised on 9/15/2023, the fall risk care plan intervention indicated to place the call light within easy reach. During an interview on 2/6/2024 at 4:05 PM with the Administrator (ADM), the ADM stated residents in rooms with a leaking ceiling were moved out of the rooms for a temporary room change. During a concurrent observation and interview on 2/7/2024 at 7:56 AM, Resident 15 was present in a different bedroom. Certified Nursing Assistant (CNA) 4 stated Resident 15 was moved from another bedroom. During a concurrent observation and interview on 2/8/2024 at 8:42 AM in Resident 15 ' s new bedroom, Resident 15 wore a hospital gown and an incontinence brief while lying perpendicularly on the bed. Resident 15 ' s back was lying flat on the bed while both of Resident 15 ' s legs hung over the edge of the bed with both feet approximately two inches away from the ground. Resident 15 was asked to press the call light for assistance from nursing. Resident 15 stated the bed did not have a call light. Resident 15 placed both feet on the floor and moved both hips back into the bed. The MDS Nurse (MDSN) arrived at Resident 15 ' s bedroom and was unable to locate a call light for Resident 15. The MDSN stated it was important for Resident 15 to have a call light to call for help. 2. During a review of Resident 39 ' s admission Record, the facility admitted Resident 39 on 11/1/2023 with diagnoses including muscle wasting and atrophy, abnormalities of gait and mobility, anxiety disorder, and fracture (break in the bone) of the left humerus (shoulder bone). During a review of Resident 39 ' s MDS, dated [DATE], the MDS indicated Resident 39 had clear speech, expressed ideas and wants, clearly understood verbal content, and was severely impaired for cognition. The MDS indicated Resident 39 required supervision or touching assistance to transfer from lying in bed to sitting on the side of the bed, transfer from sit to stand, and walking 150 feet. The MDS also indicated Resident 39 required supervision or touching assistance for upper body dressing and lower body dressing. During a review of Resident 39 ' s care plan for self-care deficit (difficulty performing self-care tasks like bathing, dressing, grooming), revised on 9/29/2023, the care plan indicated an intervention to place the call light within easy reach. During an interview on 2/6/2024 at 4:05 PM with the ADM, the ADM stated residents in rooms with a leaking ceiling were moved out of the rooms for a temporary room change. During a concurrent observation and interview on 2/8/2024 at 9:48 AM with the RNS in Resident 39 ' s new bedroom, Resident 39 was sleeping in bed. The RNS stated Resident 39 did not have a call light after Resident 39 was transferred from another room to the current room. 3. During a review of Resident 68 ' s admission Record, the facility admitted Resident 68 on 11/16/2023 with diagnoses including muscle wasting and atrophy, abnormalities of gait and mobility, encephalopathy (disease that affects the brain, causing changes in its function), and dementia (decline in mental ability severe enough to interfere with daily life). During a review of Resident 68 ' s MDS, dated [DATE], the MDS indicated Resident 68 was severely impaired for cognition and required supervision or touching assistance to transfer from lying in bed to sitting on the side of the bed, transfer from sit to stand, and walking 150 feet. During a review of Resident 68 ' s Fall Risk Assessment, dated 11/17/2023, the Fall Risk Assessment indicated Resident 68 was a high risk for falls. During a review of Resident 68 ' s care plan for fall risk, revised on 11/21/2023, the fall risk care plan intervention indicated to keep the call light within easy reach and encourage Resident 68 to use it for assistance. During an interview on 2/6/2024 at 4:05 PM with the ADM, the ADM stated residents in rooms with a leaking ceiling were moved out of the rooms for a temporary room change. During an observation on 2/7/2024 at 8:42 AM, Resident 68 pushed a wheelchair while walking and asked CNA 4 for the location of Resident 68 ' s bed. CNA 4 reminded Resident 68 that the bed was in another room. During a concurrent observation and interview on 2/8/2024 at 8:51 AM with the RNS in Resident 68 ' s new bedroom, Resident 68 was sleeping in bed. The RNS stated Resident 68 did not have a call light. 4. During a review of Resident 69 ' s admission Record, the facility admitted Resident 69 on 11/21/2023 with diagnoses including muscle wasting and atrophy, abnormalities of gait and mobility, and dementia. During a review of Resident 69 ' s MDS, dated [DATE], the MDS indicated Resident 69 had moderately impaired cognition and required supervision or touching assistance to transfer from lying in bed to sitting on the side of the bed, transfer from sit to stand, walking 150 feet. The MDS also indicated Resident 69 required supervision or touching assistance for upper body dressing and lower body dressing. During a review of Resident 69 ' s care plan for self-care deficit, revised on 10/17/2023, the care plan indicated an intervention to place the call light within easy reach. During an interview on 2/6/2024 at 4:05 PM with the ADM, the ADM stated residents in rooms with a leaking ceiling were moved out of the rooms for a temporary room change. During a concurrent observation and interview on 2/8/2024 at 9:56 AM with Resident 69 in the new bedroom, Resident 69 stated Resident 69 was moved from another room due to maintenance for a ceiling leak. Resident 69 stated he yelled for help since there was no call light available in the new room. Resident 69 stated feeling insecure about not having a call light to call for help. 5. During a review of Resident 78 ' s admission Record, the facility admitted Resident 78 on 9/26/2023 with diagnoses including muscle wasting and atrophy, abnormalities of gait and mobility, encephalopathy, and dementia. During a review of Resident 78 ' s MDS, dated [DATE], the MDS indicated Resident 69 had severely impaired cognition and required supervision or touching assistance to transfer from lying in bed to sitting on the side of the bed, transfer from sit to stand, and walking 150 feet. The MDS also indicated Resident 69 required supervision or touching assistance for upper body dressing and lower body dressing. During a review of Resident 78 ' s Fall Risk Assessment, dated 11/28/2023, the Fall Risk Assessment indicated Resident 78 was a high risk for falls. During a review of Resident 78 ' s care plan for self-care deficit, revised on 6/5/2023, indicated an intervention to place the call light within reach. Resident 78 ' s care plan for fall history, revised 11/27/2023, indicated to attach the call light to bed within access of the resident. During an interview on 2/6/2024 at 4:05 PM with the ADM, the ADM stated residents in rooms with a leaking ceiling were moved out of the rooms for a temporary room change. During a concurrent observation and interview on 2/8/2024 at 9:54 AM with RNS in Resident 78 ' s new bedroom. The RNS stated Resident 78 was moved from another room and did not have a call light made available in the new bedroom. During an interview on 2/8/2024 at 10 AM with the RNS, the RNS stated it was important for all residents (in general) in the facility to have a call light for safety to call for assistance. During a review of the facility ' s undated Policy and Procedure (P&P) titled, Accommodation of Needs, the P&P indicated Efforts will be made to individualize the resident ' s environment and adapt the resident ' s bedroom for resident care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain comfortable and safe room temperature levels between 71 to 81-degree Fahrenheit (° F, unit of measurement) in the resident's rooms as required by the Federal regulation for five out of 17 residents (Resident 40, 49, 12, 47, and 30). This deficient practice resulted in the resident's increased level of discomfort and the potential to result in loss of body heat that could negatively impact the resident's quality of life. Findings: 1. During a review of Resident 40's admission Record indicated the facility originally admitted Resident 40 on 6/2/2015 and readmitted her on 7/27/2020 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and hypertension (high blood pressure). During a review of Resident 40's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/11/2023, indicated Resident 40 had intact memory and cognition (ability to think and reasonably). The MDS indicated Resident 40 required supervision or touching assistance with eating, oral hygiene, toilet hygiene, chair/bed-to-chair transfer, lower body dressing and personal hygiene. During a concurrent observation and interview on 2/6/2024 at 10:14 AM, Resident 40 was, in the hallway, wearing a white shirt underneath, a brown woven pullover sweater, a dark gray zip up sweater, a scarf around her neck, a pair of hot pink pants, a pair of socks and a pair of open toe slipper. Resident 40 stated there was no hot air from the heater vent in her room and she felt cold. 2. During a review of Resident 12's admission Record indicated the facility originally admitted Resident 12 on 1/30/09 and readmitted her on 2/15/2023 with diagnoses that included schizophrenia and anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat). During a review of Resident 12's MDS, dated [DATE], indicated Resident 12 had intact memory and cognition. The MDS indicated Resident 12 required supervision or touching assistance with eating, oral hygiene, toilet hygiene, chair/bed-to-chair transfer, lower body dressing and personal hygiene. During an observation and interview on 2/6/2024 at 10:17 AM, Resident 12, in the hallway, Resident 12 stated she felt the cold in the facility when the rain started because of the lack of heat the facility. During a review of Resident 30's admission Record indicated the facility originally admitted Resident 30 on 7/28/2021 and readmitted her on 12/4/2023 with diagnoses that included schizophrenia and anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 30's MDS, dated [DATE], indicated Resident 30 had intact memory and cognition. The MDS indicated Resident required supervision and touching assistance with eating, oral hygiene, chair/bed-to-chair transfer, lower body dressing, personal hygiene, and walk 50 feet with two turns. During a concurrent observation and interview on 2/6/2024 at 10:25 AM, with Resident 30, Resident 30 was wearing a white sweater, a pair of black pants, and a pair of black shoes. In an interview Resident 30 stated it was extremely cold in the facility. 3. During a review of Resident 49's admission Record indicated the facility admitted Resident 49 on 8/26/2023 with diagnoses that included schizophrenia and hypertension. During a review of Resident 49's MDS, dated [DATE], indicated Resident 49 had intact memory and cognition. The MDS indicated Resident 49 required supervision or touching assistance with eating, oral hygiene, toilet hygiene, chair/bed-to-chair transfer, lower body dressing and personal hygiene. During a concurrent observation and interview on 2/6/2024 at 10:35 AM, with Resident 49, in the hallway, Resident 49 was wearing a red knitted hat, a black sweater, a black woven open shirt, and a green jacket, a pair of black pants and a pair of black sneakers. Resident 49 was scrunching up her shoulders and stated, she had been feeling cold in the facility for the last 2 days. 4. During a review of Resident 47's admission Record indicated the facility originally admitted Resident 47 on 9/4/2019 and readmitted her on 2/28/2023 with diagnoses that included schizophrenia and hypertension. During a review of Resident 47's MDS, dated [DATE], indicated Resident 47 had intact memory and cognition. The MDS indicated Resident 47 required setup or clean-up assistance with eating, chair/bed-to-chair transfer, and walk 150 feet, and supervision or touching assistance with oral hygiene, toilet hygiene, lower body dressing and personal hygiene. During a concurrent observation and interview on 2/6/2024 at 10:36 AM, with Resident 47, Resident 47 was wearing a gray knitted hat, a white pull over fleece long sleeves shirt, a burgundy knitted buttoned sweater, a pair of black pants, a pair of non-skidded socks, and a pair of shoes. Resident 47 stated she was feeling cold in the facility, and the room got cold when the rain stated couple days ago. During an observation on 2/6/2024 at 10:38 AM, in the hallway, the door to the west wing unit was open to the open-air patio. room [ROOM NUMBER], 3, 6, 7, 8, 9, 10's doors were open to the hallway. Outside was raining and the wind blew cold air through the hallway of the unit and into residents' rooms. During a concurrent observation and interview on 2/6/2024 at 10:40 AM, with the Maintenance Supervisor (MS), the MS checked the room temperature with an infrared thermometer (a tool to measure surface temperature of an object without any physical touch) and the results were: room [ROOM NUMBER]: 54.5° F; room [ROOM NUMBER] 64.9° F, room [ROOM NUMBER]: 61.5° F. The MS stated the room temperature was cold. During a concurrent observation and interview on 2/6/2024 at 10:44 AM, with the MS, the MS went into the medication room and a heater thermostat was mounted on the wall inside the medication room. The heater thermostat was off. The MS stated he did not know why the heater was off and for how long the heater had been off. The MS stated the staff might forgot to lock the door of the medication room and the residents went in and played with the thermostat. During an interview on 2/6/2024 at 11:11 AM, Licensed Vocational Nurse (LVN) 1 stated only the licensed nurses had the key to the medication room and they made sure the medication room was locked at all times to prevent residents from going to the room where the medication was stored. The LVN 1 stated she did not know the heater was off today. LVN 1 stated she did not touch the thermostat in the medication room and did not know anyone would turn it off. LVN 1 stated maybe a staff turned it off accidentally. LVN 1 stated the room temperature should be around 76° F to 80s° F. LVN 1 stated the room temperature at 50s and 60s ° F were too cold for the residents. During an interview with the Administrator on 2/6/24 at 11:53 AM,, the ADM stated he was aware that there had been complaints from the residents that the rooms were cold and no heat was coming into the residents room because the residents who behavioral issues messes up with the thermostat- During an interview on 2/6/2024 at 11:22 AM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated she noticed it was a little cooler than usual this morning. CNA 2 stated she did not know the heater was off today. CNA 2 stated thermostat control was inside the medication room that residents could not access because only licensed nurses could enter the medication room and control the thermostat. CNAs stated she did not have keys to the medication room and the medication room was always locked. During an interview on 2/7/2024 at 1:56 PM, with the MS, the MS stated the room temperature should be between 71-80° F. The MS stated some of rooms' temperature was out of range on 2/6/2024 because the heaters were off. The MS stated the room temperature should be within the range, otherwise, low temperature could cause discomfort for the residents and put the residents at risk for hypothermia. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised 2/2021, the P&P indicated The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics included: .comfortable and safe temperatures (71° F-81° F).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report allegations of abuse (intentional causing of harm or injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental suffering; includes verbal, sexual, physical, and mental abuse) to the facility ' s abuse coordinator between two residents (Resident 43 and Resident 51) out of a census of 81 residents on 2/8/2024 in accordance with the facility ' s policy on Abuse Allegation Reporting. This failure had the potential to under report alleged cases of abuse, which could lead to a failure to investigate alleged abuse in a timely manner. Findings: During a review of Resident 51 ' s admission Record, the facility admitted Resident 51 on 11/10/2023 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility (ability to move), dementia (decline in mental ability severe enough to interfere with daily life), and cerebral infarction (brain damage due to a loss of oxygen to the area). During a review of Resident 51 ' s Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 1/3/2024, the MDS indicated Resident 51 had severely impaired cognition (ability to think, understand, learn, and remember) and required partial/moderate assistance (helper does less than half of the effort) for eating, oral hygiene (ability to use suitable items to clean teeth), upper body dressing, and lower body dressing. During a review of Resident 43 ' s admission Record, the facility admitted Resident 43 on 1/17/2024 with diagnoses including Parkinson ' s disease (brain disorder that causes unintended or uncontrollable movements and difficulty with balance and coordination), encephalopathy (disease that affects the brain, causing changes in its function), muscle wasting and atrophy, abnormalities of gait and mobility, and anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one ' s daily activities). During a review of Resident 43 ' s MDS, dated [DATE], the MDS indicated Resident 43 had clear speech, expressed ideas and wants, clearly understood verbal contact, and had intact cognition. The MDS indicated Resident 43 required partial/moderate assistance for moving from lying in bed to sitting at the edge of the bed and substantial/maximum assistance (helper does more than half of the effort) for sit to stand and bed-to-chair transfers. The MDS also indicated Resident 43 required partial/moderate assistance for eating and dependent (helper does all the effort) for upper body dressing and lower body dressing. During an interview on 2/8/2024 at 11:56 AM with the Director of Staff Development (DSD), the DSD stated abuse in-services (education sessions) occur every month. The DSD stated the facility staff should report abuse allegations to the Administrator (ADM), who was the facility ' s abuse coordinator. During a concurrent observation and interview on 2/8/2024 at 2:53 PM with Resident 43 in the hallway in front of the Nursing Station, Resident 43 was sitting in a wheelchair with orange juice on the left side of Resident 43 ' s shirt and left pant leg. Resident 43 stated Resident 51, who is blind, threw orange juice at Resident 43. Resident 43 then stated Resident 43 threw orange juice back at Resident 51. Resident 43 stated the nurses got mad at Resident 43 and took Resident 51 ' s side. Nurses (unknown) were observed entering the room to attend to Resident 51. During an interview on 2/9/2024 at 7:31 AM, with the Administrator (ADM), the ADM stated that the facility staff did not report the incident that occurred between Resident 43 and Resident 51 from 2/8/2024. During an interview on 2/9/2024 at 7:40 AM in the bedroom, Resident 51 stated being blind and unable to recall the incident that happened with Resident 43 on 2/8/2024. During an interview on 2/9/2024 at 7:43 AM with the Registered Nurse Supervisor (RNS), the RNS stated Resident 51 and Resident 43 were roommates and splashed each other with orange juice the other day (2/8/2024). The RNS stated both residents ' clothes were changed on 2/8/2024, and the Director of Nursing (DON) was informed regarding the incident (2/8/2024). During an interview on 2/9/2024 at 7:46 AM with the DON, the DON stated the facility did not report the altercation that happened between Residents 43 and 51 to the DON on 2/8/2024. The DON stated he just found out about the resident-to-resident altercation this morning (2/9/2024) The DON stated the facility staff should have completed a body assessment of Resident 43 and Resident 51, reported it to the administrator, and implemented an intervention to move them to different rooms since they are roommates. During an interview on 2/9/2024 at 7:50 AM with the RNS and the DON, the RNS stated splashing each other with juice was a form of abuse between Resident 43 and Resident 51. The RNS stated it should have been reported to the abuse coordinator immediately after the incident. The DON stated the staff failed to report the incident between Resident 43 and Resident 51. During a review of the facility ' s Policy and Procedure (P&P) titled, Abuse Allegation Reporting, revised 12/7/2021, the P&P indicated all allegation of abuse will be reported immediately to the administrator/abuse coordinator. The P&P also indicated the Administrator/Abuse Coordinator will report all alleged violations to the State agency and Ombudsman within two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess range of motion [ROM, full movement potential of a joint (where two bones meet)] for two of six sampled residents (Resident 4 and 24) with limited ROM. 1. For Resident 24, the facility failed to include any assessment of Resident 24 ' s actual ROM in both arms and both legs for a quarterly Joint Mobility Screen (brief assessment of a resident's range of motion in both arms and both legs), dated 2/6/2024, which included a conclusion statement that indicated Resident 24 did not have any decline in ROM. This failure resulted in the inaccurate assessment and transmission of Resident 24 ' s Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool) assessment, dated 1/25/2024, for ROM limitations. 2. For Resident 4, the MDS, dated [DATE], indicated Resident 4 did not have any functional ROM limitations in both arms. The OT Evaluation, dated 5/29/2023, indicated Resident 4 had contractures in both arms and impaired ROM in both shoulders and both hands. This failure resulted in the inaccurate assessment of Resident 4 ' s ROM to the left and right arms which resulted to inaccurate assessment and transmission of Resident 4 ' s MDS assessment. Findings: a. During a review of Resident 24 ' s admission Record, the facility admitted Resident 24 on 10/18/2023 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility (ability to move), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one ' s daily activities), dysphagia (difficulty swallowing), and dementia (decline in mental ability severe enough to interfere with daily life). During a review of Resident 24 ' s Joint Mobility Screen – PT (Physical Therapy, profession aimed in the restoration, maintenance, and promotion of optimal physical function), dated 10/20/2023, the Joint Mobility Screen – PT indicated Resident 24 had minimal ROM loss (less than 25 percent [%] loss) in both hips, minimal ROM loss in the right knee, and moderate (26 to 50% loss) ROM loss in the left knee. During a review of Resident 24 ' s MDS, dated [DATE], the MDS indicated Resident 24 had severely impaired cognition (ability to think, understand, learn, and remember) and did not have any ROM limitations in both arms and both legs. During a review of Resident 24 ' s Joint Mobility Screen – Quarterly, dated 2/6/2024, the Joint Mobility Screen – Quarterly indicated a conclusion statement that Resident 24 had no deterioration (decline) in ROM. The Joint Mobility Screen – Quarterly did not include a measurement of Resident 24 ' s ROM at each joint (both arms and legs). During an observation on 2/6/2024 at 12:22 PM in the Dining Room, Resident 24 was sitting up in a wheelchair with the left knee bent more than the right knee. During a concurrent interview and record review on 2/7/2024 at 10:44 AM with the MDS Coordinator (MDS 2), MDS 2 stated she completed the quarterly Joint Mobility Screen for each resident. MDS 2 stated Resident 24 was observed turning without assistance in the bed which indicated to MDS 2 that Resident 24 did not have any ROM limitations in both legs. MDS 2 reviewed Resident 24 ' s Joint Mobility Screen – Quarterly, dated 2/6/2024, and stated the quarterly Joint Mobility Screen did not include an assessment of Resident 24 ' s ROM in both arms and both legs. MDS 2 stated the quarterly Joint Mobility Screen included a conclusion statement that Resident 24 did not have any decline in ROM. During an interview on 2/7/2024 at 10:37 AM with the Director of Rehabilitation (DOR), the DOR stated the therapy staff performed a Joint Mobility Screen upon a resident ' s admission, during any change of condition with ROM or mobility concerns, and annually. The DOR stated the Occupational Therapist [OT, professional aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)] assessed both arms and the PT assessed both legs. The DOR stated the Nursing Department (MDS Coordinator) would complete the quarterly Joint Mobility Screen for each resident. During an observation on 2/7/2024 at 12:21 PM in the hallway, Resident 24 was sitting up in a wheelchair with the right knee bent and the right foot positioned on the footrest. Resident 24 ' s left knee was bent more than the right knee, causing the left foot to be positioned on the ground under the wheelchair seat. Certified Nursing Assistant (CNA) 8 attempted to place Resident 24 ' s left foot on the wheelchair ' s footrest but the left foot returned to the position on the ground underneath the wheelchair. During a concurrent interview and record review on 2/9/2024 at 12:16 PM with MDS 2, MDS 2 stated Resident 24 could not walk but could move both legs. MDS 2 stated Resident 24 was observed tapping both legs and determined Resident 24 did not have any decline in ROM. MDS 2 reviewed Resident 24 ' s Joint Mobility Screen – PT, dated 10/20/2023 and the quarterly Joint Mobility Screen, dated 2/6/2024. MDS 2 stated the quarterly Joint Mobility Screen did not monitor Resident 24 ' s hip and knee ROM since observations were made during Resident 24 ' s care and not during actual ROM exercises. During a follow-up interview on 2/9/2024 at 2:27 PM with MDS 2, MDS 2 stated the therapists showed MDS 2 how to perform the assessment on both arms and legs for Resident 24. MDS 2 stated Resident 24 ' s MDS, dated [DATE], was inaccurate. 2. During a review of Resident 4 ' s admission Record, the facility admitted Resident 4 on 5/28/2023 with diagnosis including encephalopathy (disease that affects the brain, causing changes in its function), muscle wasting and atrophy, abnormalities of gait and mobility, anxiety disorder, dysphagia, and schizophrenia (mental disorder characterized by abnormal social behavior). During a review of Resident 4 ' s OT Evaluation and Plan of Treatment, dated 5/29/2023, the OT Evaluation indicated Resident 4 had contractures in both arms and impaired ROM in both shoulders and both hands. During a review of Resident 4 ' s MDS, dated [DATE], the MDS indicated Resident 4 did not have any functional ROM limitations in both arms. During an observation on 2/6/2024 at 9:08 AM in the bedroom, Resident 4 was sitting in a wheelchair fully dressed in a t-shirt, pants, and non-slip socks. Resident 4 ' s torso was bent forward and Resident 4 ' s neck was bent downward. Both of Resident 4 ' s hands were in a closed fist position. During a concurrent interview and record review on 2/9/2024 at 12:11 PM with MDS 2, MDS 2 stated Resident 4 ' s hands were positioned in a fist. MDS 2 reviewed Resident 4 ' s MDS assessment, dated 9/1/2023, and stated the MDS assessment was incorrect. MDS 2 stated accuracy of the MDS was important to ensure residents received treatment as a result of the assessment. During a review of the facility ' s undated Policy and Procedure (P&P) titled, Joint Mobility Assessment, the P&P indicated the facility would determine a resident ' s range of motion for all major joints and .implement plans of care to increase, maintain or reduce decline in joint mobility. The P&P indicated the mobility assessment form was used to reassess the overall joint mobility of each resident as needed and/or quarterly basis. During a review of the facility ' s P&P titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, the P&P indicated any person completing a portion of the MDS must sign and certify the accuracy of that portion of the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility for three (Resident 15, Resident 62, and Resident 24) of six sampled residents with positioning and mobility (ability to move) concerns. 1. For Resident 15 and 62, the facility failed to use a front-wheeled walker (FWW, an assistive device with two front wheels used for stability when walking) in accordance with the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) recommendations and physician orders. The facility also failed to specify the distance for Resident 15 and 62 to walk to maintain their mobility after discharge from PT services. 2. For Resident 24, the facility failed to apply splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to both knees in accordance with the PT recommendations and physician order from 2/6/2024 to 2/8/2024. These failures had the potential for Resident 15 and 62 to experience a decline in the ability to walk and for Resident 24 to experience a decline in ROM and the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness). Findings: 1. During a review of Resident 15 ' s admission Record, the facility admitted Resident 15 on 2/14/2022 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility, anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one ' s daily activities), and schizophrenia (mental disorder characterized by abnormal social behavior). During a review of Resident 15 ' s PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 15 walked 50 feet (unit of measure) with minimal assistance (less than 25 percent [%] physical assistance to perform the task). The PT Discharge Summary recommendations included a Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) program to assist Resident 15 to ambulate (walk) with a FWW or perform sit to stand with handheld assistance. During a review of Resident 15 ' s physician orders, dated 4/11/2023, the physician orders indicated for the RNA to ambulate Resident 15 using a FWW or perform sit to stand with the FWW or handheld assistance, five days a week as tolerated, starting on 4/12/2023. During a review of Resident 15 ' s Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 11/19/2023, the MDS indicated Resident 15 had clear speech, expressed ideas and wants, clearly understood verbal content, and was moderately impaired for cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 15 required supervision or touching assistance (helper provides verbal cues and/or steadying and/or contact guard assistance as resident completes the activity) to transfer from lying in bed to sitting on the side of the bed, transfer from sit to stand, upper body dressing, and lower body dressing. The MDS indicated Resident 15 did not have any ROM limitations in both arms and both legs. During an observation on 2/7/2024 at 1:58 PM in the hallway, Resident 15 was sitting in a wheelchair while Restorative Nursing Aide 1 (RNA 1) placed a gait belt (assistive device placed around a person ' s waist to assist with safe transferring between surfaces or while walking) around Resident 1 ' s waist. RNA 1 placed a pick-up walker (PUW, an assistive device with four rubber-tipped legs used for stability and requires a person to lift to move while walking) in front of Resident 15, who asked, What happened to the wheels? Resident 15 continued to state the PUW did not have any wheels. RNA 1 encouraged Resident 15 to stand and walk using the PUW. Resident 15 walked approximately five to seven feet using the PUW with RNA 1 physical assistance and then stated, I cannot do this .I ' m tired. Resident 15 sat back onto the wheelchair. During an interview on 2/7/2024 at 2:21 PM with RNA 1, RNA 1 stated she did not notice the walker did not have any wheels. During a concurrent interview and record review on 2/8/2024 at 1:01 PM with the Director of Rehabilitation (DOR), the DOR reviewed Resident 15 ' s PT Treatment Encounter Notes and PT Discharge Summary. The DOR stated the PT Discharge Summary indicated Resident 15 walked 50 feet with minimal assistance but fluctuated between 10 to 50 feet during PT Treatment sessions. The DOR stated the PT Discharge recommendations included an RNA program for ambulation using a FWW or sit to stand. The DOR stated Resident 15 should be walking with the RNA using a FWW since it was the device recommended to maintain Resident 15 ' s mobility after discharged from PT services. During the same concurrent interview and record review on 2/8/2024 at 1:01 PM, the DOR stated Resident 15 should not walk with a PUW, which required coordination to physically pick up the walker. The DOR also stated Resident 15 ' s physician order indicated two types of mobility – sit to stand transfers and ambulation. The DOR also stated Resident 15 ' s physician order for RNA did not indicate the distance for Resident 15 to walk with the RNA. The DOR stated ambulation maintained Resident 15 ' s mobility more than performing sit to stand transfers. The DOR also stated the physician ' s order for the RNA prevented the RNA from knowing how far Resident 15 walked when discharged from PT services and prevented the RNA from identifying whether Resident 15 had a decline in mobility. During a concurrent observation and interview on 2/8/2024 at 2:08 PM with the DOR, Resident 15 sat in a wheelchair with a gait belt around the waist. Physical Therapy Assistant (PTA) 1 placed a FWW in front of Resident 15 and assisted Resident 15 to perform sit to stand. Resident 15 then walked 50 feet in the facility ' s hallway with PTA ' s assistance. PTA stated Resident 15 walked 50 feet using the FWW with minimal assistance. 2. During a review of Resident 62 ' s admission Record, the facility admitted Resident 62 on 8/1/2023 with diagnoses including muscle wasting and atrophy, abnormalities of gait and mobility, dementia (decline in mental ability severe enough to interfere with daily life), cerebral infarction (brain damage due to a loss of oxygen to the area), and legal blindness. During a review of Resident 62 ' s PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 62 walked 30 feet with minimal assistance using a two-wheeled walker (FWW). The PT Discharge Summary recommendations included an RNA program to assist Resident 62 to ambulate using a FWW. During a review of Resident 62 ' s physician orders, dated 10/1/2023, the physician order indicated for the RNA to ambulate Resident 62 using a FWW, five days per week as tolerated, starting on 10/2/2023. During a review of Resident 62 ' s MDS, dated [DATE], the MDS indicated Resident 62 had clear speech, expressed ideas and wants, clearly understood verbal content, had impaired vision, and had severely impaired cognition. The MDS indicated Resident 62 required supervision or touching assistance for to move from lying in bed to sitting at the edge of bed and partial/moderate assistance (helper does less than half the effort) for sit to stand and transfers to and from a bed to a chair. During an observation on 2/7/2024 at 1:49 PM in the hallway, Resident 62 was sitting in the wheelchair and agreed to walk with RNA 1. RNA 1 placed a pick-up walker (PUW) in front of Resident 62 and assisted Resident 62 to stand. Resident 62 walked using the PUW while RNA 1 was positioned on Resident 62 ' s left side for assistance. Resident 62 walked approximately eight feet and then sat back down onto the wheelchair. RNA 1 stated Resident 62 was tired but usually walked 15 to 20 feet. During an interview on 2/7/2024 at 2:21 PM with RNA 1, RNA 1 stated she did not notice Resident 62 ' s walker did not have any wheels. During a concurrent interview and record review on 2/8/2024 at 1:53 PM with the DOR, the DOR reviewed Resident 62 ' s PT Discharge summary, dated [DATE]. The DOR stated the PT Discharge Summary indicated Resident 62 walked 30 feet with minimal assistance using a FWW and recommended an RNA program for ambulation using the FWW. The DOR stated Resident 62 should be walking with a FWW during RNA since it was the device recommended to maintain Resident 62 ' s mobility after discharged from PT services. The DOR also stated the physician order for RNA should also indicate the distance to maintain Resident 62 ' s mobility. During a concurrent observation and interview on 2/8/2024 at 2:17 PM in the hallway, Resident 62 was sitting in a wheelchair and stated she never used the PUW before yesterday. Resident 62 stated the PUW had rubber bottoms which could cause Resident 62 to trip. Resident 62 was agreeable to walk with RNA 1 using the FWW. RNA 1 placed the FWW in front of Resident 62 and assisted Resident 62 to stand. Resident 1 walked using the FWW while RNA 1 was positioned on Resident 62 ' s left side for assistance. Resident 62 walked approximately 50 feet using the FWW with RNA 1 ' s assistance. 3. During a review of Resident 24 ' s admission Record, the facility admitted Resident 24 on 10/18/2023 with diagnoses including muscle wasting and atrophy, abnormalities of gait and mobility, anxiety disorder, dysphagia (difficulty swallowing), and dementia. During a review of Resident 24 ' s Joint Mobility Screen – PT, dated 10/20/2023, the Joint Mobility Screen – PT indicated Resident 24 had minimal ROM loss (less than 25 percent [%] loss) in both hips, minimal ROM loss in the right knee, and moderate (26 to 50% loss) ROM loss in the left knee. During a review of Resident 24 ' s PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 24 tolerated splints on both knees for four hours. The PT Discharge Summary recommendations indicated for the RNA to perform passive range of motion (PROM, movement of joint through the ROM with no effort from the person) to both legs and apply knee splints on both legs. During an observation on 2/6/2024 at 12:22 PM in the Dining Room, Resident 24 was sitting up in a wheelchair with the left knee bent more than the right knee. Resident 24 was not wearing any knee splints. During an observation on 2/7/2024 at 12:21 PM in the hallway, Resident 24 was sitting in a wheelchair with the right knee bent and the right foot positioned on the footrest. Resident 24 ' s left knee was bent more than the right knee, causing the left foot to be positioned on the ground under the wheelchair seat. Certified Nursing Assistant (CNA) 8 attempted to place Resident 24 ' s left foot on the wheelchair ' s footrest but the left foot returned to the position on the ground underneath the wheelchair. Resident 24 was not wearing any knee splints. During an interview on 2/7/2024 at 2:46 PM with RNA 1, RNA 1 stated Resident 24 did not have both knee splints because they were sent to the laundry. During a follow-up interview on 2/8/2024 at 11:26 AM with RNA 1, RNA 1 stated Resident 24 ' s knee splints have been missing since 2/6/2024 and were last applied to Resident 24 ' s legs on 2/5/2024. RNA 1 stated the therapists were aware of Resident 24 ' s missing knee splints. During a concurrent interview and record review on 2/8/2024 at 2:42 PM with the DOR, the DOR reviewed Resident 24 ' s PT Discharge summary, dated [DATE]. The DOR stated the PT Discharge Summary recommendations included an RNA program to perform PROM to both legs and apply the knee splints. The DOR stated Resident 24 required both knee splints to maintain ROM in both knees. The DOR stated Resident 24 ' s missing knee splints were not reported by Nursing Department to the DOR. During a concurrent observation and interview on 2/8/2024 at 2:56 PM with the DOR in Resident 24 ' s room, the DOR was unable to locate Resident 24 ' s knee splints in the bed side table, cabinet, and locked closet. The DOR stated both the DOR and Physical Therapy Assistant (PTA) 1 were not notified Resident 24 ' s knee splints were missing. During a review of the facility ' s undated Policy and Procedure (P&P) titled, Restorative Nursing Program, the P&P indicated the Restorative Nursing Program ' s purpose was to maintain residents ' functional ability and to reduce further decline in function. The P&P indicated the RNA was to walk with residents requiring ambulatory assistance, as prescribed by [the] physician. During a review of the facility ' s undated P&P titled, Restorative Nursing Program, the P&P indicated the Restorative Nursing Program ' s purpose was to maintain residents ' functional ability and to reduce further decline in function.

Based on observation, interview, and record review, the facility failed to apply bed brakes and repair wheelchair brakes for one (Resident 15) of six sampled residents with positioning and mobility (ability to move) concerns. This failure had the potential to cause Resident 15, who was assessed as a high risk for fall, to fall from both the bed and the wheelchair, placing Resident 15 at increased risk for physical injury. Findings: During a review of Resident 15 ' s admission Record, the facility admitted Resident 15 on 2/14/2022 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility, anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one ' s daily activities), and schizophrenia (mental disorder characterized by abnormal social behavior). During a review of Resident 15 ' s Fall Risk Assessment, dated 9/6/2023, the Fall Risk Assessment indicated Resident 15 was at high risk for falls. During a review of Resident 15 ' s care plan for fall risk, revised on 9/15/2023, the fall risk care plan intervention indicated for staff to provide a safe environment. During a review of Resident 15 ' s Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 11/19/2023, the MDS indicated Resident 15 had clear speech, expressed ideas and wants, clearly understood verbal content, and was moderately impaired for cognition (ability to think, understand, learn, and remember). The MDS also indicated Resident 15 required supervision or touching assistance (helper provides verbal cues and/or steadying and/or contact guard assistance as resident completes the activity) to transfer from lying in bed to sitting on the side of the bed, and transfer from sit to stand. The MDS indicated Resident 15 did not have any functional range of motion [ROM, full movement potential of a joint (where two bones meet)] limitations in both arms and both legs. 1. During an observation on 2/7/2024 at 1:58 PM in the facility hallway, Resident 15 was sitting in a wheelchair and agreed to walk with Restorative Nursing Aide (RNA) 1. Resident 15 required RNA 1 ' s assistance to perform sit to stand transfers and to walk. Resident 15 became tired and RNA 1 assisted Resident 15 back to sitting in the wheelchair. Resident 15 ' s wheelchair moved backward as Resident 15 sat back down. During a concurrent observation and interview on 2/7/2024 at 2:25 PM with RNA 1 in the bedroom, RNA 1 applied both brakes on Resident 15 ' s wheelchair. Resident 15 ' s wheelchair wheels was observed moving with both brakes applied. RNA 1 stated Resident 15 ' s wheelchair brakes were important to prevent falls. Resident 15 stated the facility staff have never inspected Resident 15 ' s wheelchair brakes. During an observation on 2/8/2024 at 11:44 AM in the Dining Room, Resident 15 was sitting in the wheelchair. Activity Assistant (Activity) 2 applied both brakes on Resident 15 ' s wheelchair. Resident 15 wheelchair ' s wheels continued to move with both brakes applied. During an interview on 2/8/2024 at 11:45 AM with RNA 1 and Certified Nursing Assistant (CNA) 2, RNA 1 stated she forgot to report Resident 15 ' s wheelchair brakes were broken but brought another wheelchair for Resident 15 to use. RNA 1 stated the nursing staff was notified to transfer Resident 15 to the new wheelchair. CNA 2 stated she was not notified to transfer Resident 15 to the new wheelchair this morning. During an interview on 2/8/2024 at 12:24 PM with the Maintenance Supervisor (MS), MS stated Resident 15 ' s wheelchair was not reported and there was nothing reported in the facility ' s maintenance logbook regarding Resident 15 ' s wheelchair brakes. During a concurrent interview and record review on 2/8/2024 at 12:31 PM with Licensed Vocational Nurse (LVN) 3 and LVN 4, LVN 4 reviewed the facility ' s maintenance logbook which was blank. LVN 3 and LVN 4 were not aware Resident 15 ' s wheelchair brakes were not functioning. LVN 3 stated Resident 15 frequently moved and could fall without functioning wheelchair brakes. 2. During an observation on 2/8/2024 at 8:42 AM in the bedroom, Resident 15 ' s bed was positioned away from the wall. Resident 15 wore a hospital gown and an incontinence brief while lying perpendicularly on the bed. Resident 15 ' s back was lying flat on the bed while both of Resident 15 ' s legs hung over the edge of the bed with both feet approximately two inches away from the ground. Resident 15 placed both feet on the floor and moved both hips back into the bed. During a concurrent observation and interview on 2/8/2024 at 8:51 AM in the bedroom, Resident 15 continued to move and reposition himself in the bed. Resident 15 ' s bed moved diagonally while Resident 15 continued to reposition himself in the bed. The Registered Nurse Supervisor (RNS) arrived at Resident 15 ' s room and stated Resident 15 ' s bed was moving because the bed brakes were not applied. The RNS applied the bed brakes and stated Resident 15 could have fallen without the bed brakes applied. During a review of the facility ' s Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing, revised on 3/2023, the P&P indicated the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated fall risk factors included improperly maintained wheelchairs. During a review of the facility ' s undated P&P titled, Accident/Incident Prevention, the P&P indicated the facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control. The P&P also indicated the facility will repair equipment to prevent defective equipment such as wheelchairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) and target behaviors (behaviors related to a diagnoses of mental illness) of restlessness and aggression related to the use of lorazepam (a medication used to treat mental illness) between 2/6/24 and 2/8/24 in one of five sampled residents (Resident 62.) This deficient practice of failing to monitor for adverse effects and target behaviors increased the risk Resident 62 could have experienced adverse effects related to her psychotropic medication (medications that affect brain activities associated with mental processes and behavior) therapy possibly leading to impairment or decline in her mental or physical condition or functional or psychosocial status. Findings: A review of Resident 62 ' s admission Record (a document containing a resident ' s demographic and diagnostic information), dated 2/8/24, indicated Resident 62 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including anxiety disorder (a mental condition characterized by intense, excessive, and persistent worry and fear about everyday situations) and major depressive disorder (MDD - a mental condition characterized by depressed mood, loss of appetite, trouble sleeping, and lack of interest in usually enjoyable activities.) A review of Resident 62 ' s History and Physical (a comprehensive physician ' s note assessing a resident ' s current medical status), dated 8/16/23, indicated Resident 62 did not have the capacity to understand and make decisions. A review of Resident 62 ' s Physician Order, dated 2/6/24 indicated, Resident 62 ' s attending physician prescribed the following psychotropic medications: Lorazepam 0.5 milligrams (mg – a unit of measure for mass) one tablet by mouth every eight hours as needed for anxiety disorder manifested by restlessness and aggression for 14 days. Lexapro (a medication used to treat MDD) 10 mg one tablet by mouth one time a day for major depressive disorder manifested by self-expression of sadness and helplessness. A review of Resident 62 ' s February 2024 Medication Administration Record (MAR – a record of all medications administered, and all regular monitoring done for a resident) indicated there was no monitoring for adverse effects or target behaviors of restlessness and aggression related to the use of lorazepam between 2/6/24 and 2/8/24. During an interview on 2/8/24 at 11:33 AM, with the Registered Nurse Supervisor (RNS), the RNS stated she received the new order for Resident 62's lorazepam on 2/6/23. The RNS stated she entered the order into the computer system but failed to enter orders to monitor for the adverse effects and behaviors related to lorazepam. The RNS stated she had to enter the monitoring orders manually and probably forgot to enter them for this order. The RNS stated monitoring for behaviors and adverse effects related to psychotropic therapy is important to ensure the therapy is reevaluated periodically in an objective way. The RNS stated if monitoring of adverse effects and target behaviors is not done for psychotropic medications, Resident 62 may be on psychotropic medication for longer than necessary or at a higher dose than necessary which could cause a decline in her quality of life. A review of the facility ' s undated policy Psychotherapeutic Medications indicated .Data shall be collected on all episodes of this specific behavior for the physician to use in evaluating the effectiveness of the medication. Data shall also be provided for any and all adverse reactions to the medication. The data collected is to be made available to the physician in the consolidated manner on a monthly basis. Documentation on the MAR will include a tally of hash-marks for behavior not controlled through intervention with explanation on reverse MAR .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that medication error rate was less than five percent (%). Three medication errors out of 29 total opportunities contributed to an overall medication error rate of 10.34 % affecting two of nine residents observed for medication administration (Residents 11 and 483). The medication errors noted were as follows: Omitted or late administration of vitamin C (a vitamin supplement) 500 milligrams (mg - a unit of measure for mass) for Resident 11. Omitted or late administration of zinc sulfate (a vitamin supplement) 220 mg for Resident 11. Attempted administration of one dose of expired insulin aspart (a medication used to treat high blood sugar) prior to surveyor intervention for Resident 483. The deficient practice of failing to administer medications in accordance with the physician ' s orders and professional standards of practice increased the risk that Residents 11 and 483 may have experienced medical complications possibly resulting in hospitalization. Cross-referenced to F760 Findings: 1. During a concurrent observation of medication administration and interview with the Licensed Vocational Nurse (LVN 1) in the [NAME] Wing Nursing Station on [DATE] at 8:14 AM, LVN 1 was observed preparing the following medications for Resident 11: One tablet of divalproex DR (a medication used to treat mental illness) 500 mg One tablet of olanzapine (a medication used to treat mental illness) 5 mg One tablet of lorazepam (a medication used to treat mental illness) 1 mg One tablet of a multivitamin (a vitamin supplement) One tablet of sodium chloride (a supplement) 1 gram (gm - a unit of measure for mass) During the same interview, LVN 1 stated there were five total medications to administer for Resident 11 this morning. During an observation on [DATE] at 8:18 AM, in the [NAME] Wing Nursing Station, Resident 11 was observed taking the five medications listed above by mouth with milk. A review of Resident 11 ' s admission Record (a document containing a resident ' s demographic and diagnostic information) indicated he was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including anxiety disorder (a mental condition characterized by intense, excessive, and persistent worry and fear about everyday situations.) A review of Resident 11 ' s Order Summary Report (a summary of all currently active physician orders), dated [DATE], indicated Resident 11 was also scheduled to receive the following medications during the 8:00 AM medication pass: One tablet of vitamin C 500 mg One tablet of zinc sulfate 220 mg During an interview on [DATE] at 10:49 AM with LVN 1, LVN 1 stated she failed to administer the zinc sulfate and the vitamin C to Resident 11 earlier this morning. LVN 1 stated she was confused about the available strength of the zinc in her cart and did not think it was the correct one. LVN stated she failed to see that the Resident needed vitamin C and failed to offer it. LVN 1 stated she documented in the Medication Administration Record (MAR - a record of medications administered to a resident) that the zinc and vitamin C were refused by the resident. LVN 1 stated the missed medications were documented as refused in the MAR in error. LVN 1 stated neither medication was refused by the resident. LVN 1 stated failing to administer medications to a resident per the physician's order can lead to medical complications possibly resulting in hospitalization. 2. A review of Resident 483 ' s admission Record, dated [DATE], indicated he was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a medical condition characterized by the body ' s inability to regulate blood sugar levels.) A review of Resident 483 ' s Order Summary Report, dated [DATE], indicated on [DATE], Resident 483 ' s attending physician prescribed insulin aspart FlexPen (a pen device for injecting insulin under the skin) to inject subcutaneously (under the skin) before meals and at bedtime according to a sliding scale dosing regimen (dose is based on current blood sugar reading.) During a concurrent observation of medication administration and interview with LVN 3 in the East Wing hallway on [DATE] at 11:37 AM, LVN 3 was observed preparing two units of insulin aspart in a FlexPen device for Resident 483. The insulin FlexPen device was observed to be labeled with an open date of [DATE]. During a concurrent review of the manufacturer ' s product labeling for insulin aspart FlexPen on [DATE] at 11:37 AM, the label indicated it should be used or discarded within 28 days of opening or storage at room temperature. During the same observation, on [DATE] at 11:37 AM, LVN 3 was observed attempting to provide Resident 483 ' s injection from the expired insulin pen and was stopped by the surveyor and asked to check the product ' s open date. During the same interview, LVN 3 stated she failed to check the open date on the insulin aspart prior to attempting to administer it to Resident 483. LVN 3 stated it is her responsibility to check expiration date or open date on every medication prior to administration. LVN 3 stated because Resident 483's insulin was open on [DATE], it is now expired as this insulin expires 28 days after opening and should be removed from the cart and discarded. LVN 3 stated expired insulin may be ineffective at controlling blood sugar and could be dangerous to administer to a resident. LVN 3 stated administering expired insulin may cause the resident to develop medical complications which could result in hospitalization. A review of the facility ' s policy Specific Medication Administration Procedures, dated [DATE], indicated .Check expiration date on package/container. When opening a multi-dose container, place a date on the container . A review of the facility ' s undated policy Med Pass indicated .Make sure that meds are administered according to: . right medications . a med error is a violation in the ' 5 rights ' , or in medication regulations, or in approved medication policy or current standards of practice .

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance. Pureed sausage was served with sweet syrup, puree waffle was drenched with syrup and oatmeal had lumps. This deficient practice placed 6 of 92 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During an observation of trayline (a place for resident ' s tray assembly) breakfast service in Facility 2 ' s kitchen on 2/7/2024 at 7:19 AM, puree diet trays received puree waffle that was drenched with syrup and puree sausage links had syrup. A review of Facility 1 ' s menu titled Winter Menus, dated 2/7/2024, indicated Pureed diet included the following food: Orange juice 4 ounces (oz, a unit of measurement) Puree oatmeal ¾ cup (c., a unit of measurement) Puree sausage #24 scoop (1.35 oz) Puree waffle ½ c Margarine 1 teaspoon (tsp, unit of measurement) Syrup 1 oz Milk 1 c During a test tray (a sample tray to evaluate taste, appearance, and palatability of food) of puree diet (a diet with smooth pudding like consistency food) with Dietary Supervisor 1 (DS 1) and Registered Dietitian 1 (RD 1) on 2/7/2024 at 7:42 AM, the puree diet tray included puree waffles drenched and covered with thick brown syrup, puree sausage with thick brown syrup, and a cup of oatmeal. The puree oatmeal had lumps and oatmeal particles in it. During an interview with DS 1 and RD 1 on 2/7/2024 at 7:55 AM, DS 1 stated all the diets including regular, bite sized, and puree diets received the same oatmeal across all diets. DS 1 stated the oatmeal consistency should have been blended with added thickener sometimes and the consistency should have been thicker and should not form or gel. RD 1 stated the puree oatmeal texture was different from the oatmeal served to the test tray and the staff served the puree oatmeal to puree diets for breakfast. RD 1 stated oatmeal in a puree diet should have a puree texture however, she needed to refer to the diet manual on the exact definition of a puree diet. RD 1 stated puree oatmeal should not have oatmeal particles and the oatmeal that was served on puree diet was not the right texture. DS 1 stated puree diet was intended for residents with difficulty swallowing and chewing and that possible outcome for resident not getting the right texture and consistency was residents could aspirate. During an interview with DS 1 and RD 1 on 2/7/2024 at 8:13 AM, RD 1 stated staff over poured the sweet syrup in the puree sausage, and it should not be. RD 1 stated the tray presentation looked good to her and she would eat it except the puree sausage should not have syrup on it. During an interview with DS 1 on 2/7/2024 at 11:28 AM, DS 1 stated the puree tray for breakfast was too much syrup and ruined the tray presentation. DS 1 stated the menu for puree was not followed for breakfast service. DS 1 stated it was important to follow the menu and prepare the meals accurately because the residents might not eat the food causing possible weight loss to the residents. A record review of the facility ' s policies and procedures (P&P) titled Food Preparation, dated 1/12/2024, indicated Policy. Food is to be prepared in such a manner as to maximized flavor, appearance, and nutritional value. PROCEDURE: 1. All foods will be prepared by methods that preserve nutritive value, flavor, and appearance that meet individual needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide lunch at the facility ' s established mealtime on 2/6/2024 and served lunch to residents in the facility ' s East Wing at least 30 minutes late. This deficient practice caused three of 10 sampled residents (Resident 12, 62 and 68) for dining observation to feel hungry and agitated. Findings: 1. During a review of Resident 62 ' s admission Record, the facility admitted Resident 62 on 8/1/2023 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility (ability to move), dementia (decline in mental ability severe enough to interfere with daily life), cerebral infarction (brain damage due to a loss of oxygen to the area), and legal blindness. During a review of Resident 62 ' s Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 11/10/2023, the MDS indicated Resident 62 had severely impaired cognition (ability to think, understand, learn, and remember) and required supervision or touching assistance (helper provides verbal cues and/or steadying and/or contact guard assistance as resident completes the activity) for eating. 2. During a review of Resident 68 ' s admission Record, the facility admitted Resident 68 on 11/16/2023 with diagnoses including muscle wasting and atrophy, abnormalities of gait and mobility, dementia, and encephalopathy (disease that affects the brain, causing changes in its function). During a review of Resident 68 ' s MDS, dated [DATE], the MDS indicated Resident 68 was severely impaired for cognition and required supervision or touching assistance for eating. During a dining observation on 2/6/2023 at 12:22 PM in the facility ' s Dining Room, Resident 62 and Resident 68 were sitting in wheelchairs across a small table from each other. Resident 62 yelled at Resident 68 to shut up. During a concurrent observation and interview on 2/6/2023 at 12:30 PM in the facility ' s Dining Room, a cart containing food trays arrived at the Dining Room. Resident 62 and Resident 68 yelled and used foul language toward each other. Resident 68 stated, I ' m hungry. Resident 62 stated he did not know what time lunch was supposed to be served but stated it was slow today. Resident 62 stated, I ' m hungry. During an interview on 2/6/2024 at 2:40 PM with the Administrator (ADM), the ADM stated the facility ' s mealtimes included breakfast at 7:00 AM, lunch at 12:00 PM, and dinner at 5 PM. During an interview on 2/6/2024 at 4:25 PM with the Dietary Supervisor (DS), the DS stated lunch was supposed to be served at 12:00 PM. The DS stated lunch was late since the facility ' s kitchen was being remodeled and the food was being transported from another facility. The DS stated it was important for lunch to be served on time because the residents expect lunch to be served at 12 PM and could feel agitated if lunch was served late. 3. During a review of Resident 12's admission Record indicated the facility originally admitted Resident 12 on 1/30/2009 and readmitted her on 2/15/2023 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat). During a review of Resident 12's MDS, dated [DATE], indicated Resident 12 had intact memory and cognition (ability to think and reasonably). The MDS indicated Resident 12 required supervision or touching assistance with eating, oral hygiene, toilet hygiene, chair/bed-to-chair transfer, lower body dressing and personal hygiene. During an observation on 2/6/24 at 12:32 PM, a group of residents were sitting at the tables in the dining room waiting for the lunch meal cart that had not arrived. Seven residents were sitting on the chairs and seven residents (total 14 residents) were sitting in the anteroom of the dining room waiting to have lunch. Resident 12 was standing in the anteroom next to the window, facing the door of the dining room. Resident 12 with crossed her arms was staring at the dining room. During an observation on 2/6/24 at 12:40 PM Resident 12 walked and stood at the door of the dining room, looking into the dining room. Then, Resident 12 turned around and walked through the anteroom to the staircase adjacent to the anteroom, she returned to the anteroom and stared at the dining room. During an observation on 2/6/24 at 12:45 PM, lunch meal carts were delivered to the dining room. The staff started to put lunch plates on the tables for the first group of residents who had seated in the dining room. During an observation and interview on 2/6/24 at 12:47 PM, with Resident 12, Resident 12 was standing in the anteroom next to the entrance of the staircase. Resident 12 turned her head and staring at the door to the dining room. Resident 12 stated lunch was supposed to be here at 12 PM and I am starving. Resident 12 stated the long wait made her anxious. During an observation and interview on 2/6/24 at 1:05 PM, Resident 12 and the rest of the residents who were waiting for their meals outside the dining room went into the dining room when the meal tray arrived. During a review of the facility ' s Policy and Procedure (P&P) titled, Frequency of Meals, revised on 7/2017, the P&P indicated the facility ' s established lunch time was at 12:00 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately reflect the amount of time the facility provided Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) services on 2/7/2024 to three of six sampled residents (Resident 62, 15, and 26) with positioning and mobility (ability to move) concerns. This failure resulted in the inaccurate records for the provision of RNA services to Residents 62, 15, and 26. Findings: 1. During a review of Resident 62 ' s admission Record, the facility admitted Resident 62 on 8/1/2023 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility, dementia (decline in mental ability severe enough to interfere with daily life), cerebral infarction (brain damage due to a loss of oxygen to the area), and legal blindness. During a review of Resident 62 ' s physician orders, dated 10/1/2023, the physician orders indicated for the RNA to ambulate Resident 62 using a front wheeled walker (FWW, an assistive device with two front wheels used for stability when walking), five days per week as tolerated, starting on 10/2/2023. During a review of Resident 62 ' s MDS, dated [DATE], the MDS indicated Resident 62 had clear speech, expressed ideas and wants, clearly understood verbal content, had impaired vision, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 62 required supervision or touching assistance (helper provides verbal cues and/or steadying and/or contact guard assistance as resident completes the activity) to move from lying in bed to sitting at the edge of bed and partial/moderate assistance (helper does less than half the effort) for sit to stand and transfers to and from a bed to a chair. During an observation on 2/7/2024 at 1:49 PM in the hallway, Resident 62 was sitting in the wheelchair and agreed to walk with Restorative Nursing Aide (RNA) 1. RNA 1 placed a pick-up walker (PUW, an assistive device with four rubber-tipped legs used for stability and requires a person to lift to move while walking) in front of Resident 62 and assisted Resident 62 to stand. Resident 62 walked using the PUW while RNA 1 was positioned on Resident 62 ' s left side for assistance. Resident 62 walked approximately eight feet and then sat back down onto the wheelchair. Resident 62 ' s RNA session ended on 2/7/24 at 1:55 PM. RNA 1 spent six (6) minutes with Resident 62. During a review of Resident 62 ' s Documentation Survey Report (record of nursing assistant tasks) for 2/2024, the Documentation Survey Report for 2/7/2024 indicated 15 minutes were spent performing RNA services with Resident 62 instead of six (6) minutes. During a concurrent observation and review record on 2/8/2024 at 11:26 AM with RNA 1, RNA 1 reviewed the electronic documentation for RNA services provided on 2/7/2024. RNA 1 stated she did not spend 15 minutes with each resident but was told to document 15 minutes for each RNA session. During a concurrent interview and record review on 2/9/2024 at 2:38 PM with the Director of Nursing (DON) and the Director of Staff Development (DSD), the DON and DSD reviewed Resident 62 ' s Documentation Survey Report for 2/7/2024 and stated RNA 1 spent 15 minutes with Resident 62. The DON and DSD were informed of the observation with RNA 1 and Resident 62 on 2/7/2024 from 1:49 PM to 1:55 PM. The DON stated Resident 62 ' s Documentation Survey Report for RNA was inaccurate and RNA 1 should be documenting the actual time spent with Resident 62 on 2/7/2024. 2. During a review of Resident 15 ' s admission Record, the facility admitted Resident 15 on 2/14/2022 with diagnoses including muscle wasting and atrophy, abnormalities of gait and mobility, anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one ' s daily activities), and schizophrenia (mental disorder characterized by abnormal social behavior). During a review of Resident 15 ' s physician orders, dated 4/11/2023, the physician orders indicated for the RNA to ambulate Resident 15 using a FWW or perform sit to stand with the FWW or handheld assistance, five days a week as tolerated, starting on 4/12/2023. During a review of Resident 15 ' s MDS, dated [DATE], the MDS indicated Resident 15 had clear speech, expressed ideas and wants, clearly understood verbal content, and was moderately impaired for cognition. The MDS also indicated Resident 15 required supervision or touching assistance to transfer from lying in bed to sitting on the side of the bed, transfer from sit to stand, and for transfers to and from a bed to a chair. During an observation on 2/7/2024 at 1:58 PM in the facility ' s hallway, Resident 15 was sitting in a wheelchair while RNA 1 placed a gait belt (assistive device placed around a person ' s waist to assist with safe transferring between surfaces or while walking) around Resident 15 ' s waist. RNA 1 placed a PUW in front of Resident 15 who walked approximately five to seven feet using the PUW with RNA 1 physical assistance. Resident 15 sat back onto the wheelchair. Resident 15 ' s RNA session ended at 2:05 PM. RNA 1 spent seven (7) minutes with Resident 15. During a review of Resident 15 ' s Documentation Survey for 2/2024, the Documentation Survey Report for 2/7/2024 indicated 15 minutes were spent performing RNA services with Resident 15, instead of seven (7) minutes. During a concurrent observation and review record on 2/8/2024 at 11:26 AM with the RNA 1, RNA 1 reviewed the electronic documentation for RNA services provided yesterday (2/7/2024). RNA 1 stated she did not spend 15 minutes with each resident but was told to document 15 minutes for each RNA session. During a concurrent interview and record review on 2/9/2024 at 2:38 PM with the DON and the DSD, the DON and DSD reviewed Resident 15 ' s Documentation Survey Report for 2/7/2024 and stated RNA 1 spent 15 minutes with Resident 15. The DON and DSD were informed of the observation with RNA 1 and Resident 15 on 2/7/2024 from 1:58 PM to 2:05 PM. The DON stated Resident 15 ' s Documentation Survey Report was inaccurate and RNA 1 should be documenting the actual time spent with Resident 15 on 2/7/2024. 3. During a review of Resident 26 ' s admission Record, the facility admitted Resident 26 on 4/20/2023 with diagnoses including sepsis (body ' s extreme response to an infection which can be life-threatening), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), and anxiety disorder. During a review of Resident 26 ' s physician orders, dated 6/29/2023, the physician orders indicated for the RNA to ambulate Resident 26 using a FWW or perform sit to stand with the FWW or handheld assistance, five days a week as tolerated, starting on 6/30/2023. During a review of Resident 26 ' s MDS, dated [DATE], the MDS indicated Resident 26 had clear speech, expressed ideas and wants, clearly understood verbal content, and had moderately impaired cognition. The MDS indicated Resident 26 required substantial/maximal assistance (helper does more than half of the effort) for sit to stand transfers and partial/moderate assistance for transfers to and from a bed to a chair. During an observation on 2/7/2024 at 2:07 PM in the facility ' s hallway, Resident 26 was sitting in a wheelchair while RNA 1 placed a gait belt around Resident 26 ' s waist. RNA 1 placed a PUW in front of Resident 26 who performed five repetitions of sit to stand transfers from sitting in the wheelchair to standing using the PUW. Resident 26 ' s RNA session ended on 2/7/2024 at 2:10 PM. RNA 1 spent three (3) minutes with Resident 26. During a review of Resident 26 ' s Documentation Survey for 2/2024, the Documentation Survey Report for 2/7/2024 indicated 15 minutes were spent performing RNA services with Resident 26, instead of three (3) minutes. During a concurrent observation and review record on 2/8/2024 at 11:26 AM with the RNA 1, RNA 1 reviewed the electronic documentation for RNA services provided yesterday (2/7/2024). RNA 1 stated she did not spend 15 minutes with each resident but was told to document 15 minutes for each RNA session. During a concurrent interview and record review on 2/9/2024 at 2:38 PM with the DON and the DSD, the DON and DSD reviewed Resident 26 ' s Documentation Survey Report for 2/7/2024 and stated RNA 1 spent 15 minutes with Resident 26. The DON and DSD were informed of the observation with RNA 1 and Resident 26 on 2/7/2024 from 2:07 PM to 2:10 PM. The DON stated Resident 26 ' s Documentation Survey Report was inaccurate and RNA 1 should be documenting the actual time spent with Resident 26 on 2/7/2024. During a review of the facility ' s undated P&P titled, Restorative Nursing Documentation, the P&P indicated the RNA shall be responsible for documenting all daily treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure three of three sampled residents (Residents 24, 49, 68) were competent in understanding the terms of the facility ' s binding arbitration agreement (an agreement that allows parties to resolve disputes and lawsuits privately rather than going to the court). This failure had the potential for Resident 24, 49, 68 to not understand their rights for a binding arbitration agreement. Findings: During a review of Resident 24 ' s History and Physical (H&P), dated 10/20/2023, the H&P indicated Resident 24 does not have the capacity (the ability to make a rational decision based upon all relevant facts and considerations) to understand and make decisions. During a review of Resident 24 ' s Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 10/22/2023, the MDS indicated Resident 24 was admitted on [DATE] with the following diagnoses, but not limited to, major depressive disorder (mental health illness causes a persistent feeling of sadness and loss of interest and can interfere with your daily), anxiety disorder (ongoing anxiety that interferes with daily activities), and non-Alzheimer ' s dementia (loss of memory, language, and problem-solving that are severe enough to interfere with daily life). During a review of Resident 24 ' s Preferred Intensity of Care Surrogate Decision Maker, form dated 10/18/2023, the Preferred Intensity of Care Surrogate Decision Maker form indicated Resident 24 is not capable of making decisions and a sister-in-law was identified as the surrogate decision maker (a substitute health care decision-maker who consents to or refuses to medical treatments). During a review of Resident 24 ' s Resident-Facility Arbitration Agreement (RFAA) undated, the RFAA indicated Resident 24 signed the agreement indicating Resident 24 wanted to do the arbitration process. During a review of Resident 24 ' s Information regarding the Resident-Facility Based Agreement (a facility document with nine questions and answers about the arbitration agreement) dated 10/25/2023, the Information regarding the Resident-Facility Based Agreement indicated Resident 24 acknowledged she read and understood the information regarding the RFAA. During a review of Resident 49 ' s H&P, dated 8/28/2023, the H&P indicated Resident 49 does not have the capacity to understand and make decisions. During a review of Resident 49 ' s MDS dated [DATE], the MDS indicated Resident 49 was admitted on [DATE] with the following diagnoses, but not limited to, schizophrenia (a mental health illness that can affect your thoughts, moods and behavior), major depressive disorder, anxiety disorder, and hepatic encephalopathy (a decrease in brain function that occurs as a result of severe liver disease). During a review of Resident 49 ' s Preferred Intensity of Care Surrogate Decision Maker, dated 8/27/2023, indicated Resident 24 is not capable of making decisions and a surrogate decision maker was informed via phone on 2/7/2024. During a review of Resident 49 ' s RFAA dated 8/29/2023, the RFAA indicated Resident 49 signed the agreement indicating Resident 49 wanted to do the arbitration process. During a review of Resident 49 ' s Information regarding the Resident-Facility Based Agreement dated 8/29/2023, the Information regarding the Resident-Facility Based Agreement indicated Resident 49 acknowledged she read and understood the information regarding the RFAA. During a review of Resident 68 ' s H&P, dated 6/30/2023, the H&P did not indicate the patient has capacity to understand and make decisions. During a review of Resident 68 ' s MDS dated [DATE], the MDS indicated Resident 68 was admitted on [DATE] with the following diagnoses, but not limited to, anxiety, schizophrenia, non-Alzheimer ' s and dementia. During a review of Resident 68 ' s Preferred Intensity of Care Surrogate Decision Maker, dated 6/30/2023, the Preferred Intensity of Care Surrogate Decision Maker indicated Resident 68 is not capable of making decisions. During a review of Resident 68 ' s Initial Psychiatric Evaluation (IPE, an assessment of one ' s mood and thought process) dated 7/24/23, the IPE indicated Resident 68 had impaired insight and judgement (a person's ability to recognize a problem and understand its nature and severity). During a review of Resident 68 ' s RFAA dated 7/3/2023, the RFAA indicated Resident 68 signed the agreement indicating Resident 68 wanted to do the arbitration process. During a review of Resident 68 ' s Information regarding the Resident-Facility Based Agreement dated 7/3/2023, the Information regarding the Resident-Facility Based Agreement indicated Resident 68 acknowledged he read and understood the information regarding the RFAA. During an interview on 2/9/2024 at 9:35 AM, Resident 49 stated she had not signed an arbitration agreement for the facility. Resident 49 stated she did not know what an arbitration agreement was and asked for assistance with getting her mail and making a phone call to her sister. During an interview on 2/9/2024 at 9:50 AM with Administrative Consultant (AC) 1, she stated the facility did not have a policy or procedure for the arbitration agreement. During an interview on 2/9/2024 at 1:34 PM, the admission Facility Based Recruiter (AFBR) 1 stated he uses the resident ' s face sheet and if the resident is the Accounts Receivable Guarantor (A/R Guarantor, person ultimately responsible for the bills), that means the resident can understand and sign the agreement. During an interview on 2/9/2024 at 2:11 PM, the Social Service Director (SSD) 1 stated she uses the resident ' s H&P to determine if a resident has decision making capacity and can sign informed consents. SSD stated A/R guarantor refers to finances and means the resident is self-paid and is not used to determine resident ' s capacity. She also stated it is important to determine a resident ' s decision-making capacity to ensure their rights are not violated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement, monitor, and evaluate identified Quality Assurance and Performance Improvement Program (QAPI, a program that is focused on action plan to correct identified quality deficiencies (a deviation in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement) relating to building maintenance and safety. The facility failed to: 1. Documented evidence the QAPI program implemented a plan to maintain the kitchen in good working condition and ensure the safe renovation of the kitchen, including a plan for providing meals to residents while the kitchen is closed. 2. Document evidence that the QAPI program implemented a plan to ensure the maintenance of the buildings roofing were maintained to prevent leaks and protect residents from a hazardous situation. These deficient practices resulted in leaking of the roof into 3 facility rooms and a hallway resulting in eleven residents (Residents 12, 15, 20, 28, 30, 39, 42, 47, 63, 69 and 71) being displaced. The deficient practices also resulted closure of the kitchen and disruption of dietary services for all 82 residents that could result in food borne illnesses (an illness that comes from eating contaminated food). Cross Reference to F921, F812 Findings: 1. During an entrance conference and an interview on 2/6/2024 at 8:15 AM, the Director of Nursing (DON) stated the Facility 1's kitchen was closed for remodeling and residents' meals were being prepared in Facility 2's kitchen. A review of the facility's record titled, Maintenance Crew Work Order Form, dated 1/4/2024 indicated that the kitchen subfloor was completely rotten. During an interview on 2/6/24 11:50 AM, with the ADM, the ADM stated, there was an emergency to reinforce the subfloor of the kitchen, the [NAME] (a person in charge of a group of workers on a particular operation) who was hired by the facility assessed the kitchen floor between January 22- 25, 2024 and observed the kitchen subfloor underneath the tiles which was soft and needed to tear down the kitchen. The ADM stated, Facility 1 began to use the kitchen in Facility 2 on 1/29/2024, when the renovation started in the kitchen in Facility 1. The ADM stated the residents are currently serve with disposable utensils and plates during meals that comes from the kitchen in Facility 2. The ADM stated he did not inform or submit a proposal to renovate the kitchen to the State Agency or the Department of HCAI (Health Care Access Information- a state department that oversee safe constructions of hospital buildings) prior to tearing down the kitchen. The ADM stated he did not have a written plan or process on how Facility 1 will safely prepare food, store food items, deliver the food to the residents within an acceptable food temperature to prevent food borne illnesses and to ensure the meals are delivered timely. During a concurrent interview and record review of the facility's QAPI minutes 2/9/2024 at 4:12 PM, ADM stated dietary department should have been discussed if there was anything wrong with the kitchen. ADM stated that the QAPI minutes from 1/12/2024 did not have the kitchen safety issues listed. A review of the QAPI minutes did not indicate the plan to ensure safe food storage, preparation, distribution and other dietary services were going to be implemented to prevent food borne illness. During an interview on 2/09/2024 at 4:23 PM, ADM stated that the QAPI team met on the 1/12/2024. ADM stated that the Maintenance Supervisor (MS) mentioned there was a submitted a work order about the kitchen needing repairs because of a department of health inspection report that kitchen is need of repairs, including floor repairs which occurred during an inspection in December 2023. ADM stated it was not in the QAPI record. 2. During a review of the facility's untitled record used by the facility for maintenance work requests and reports, the report indicated that on 2/5/2024, Room C had a new leak by the door and by the window. The record also indicated that on 1/29/2024 there was a previous leak in Room C. During a review of the facility's untitled record used for maintenance requests and reports, the report indicated that on 2/5/2024 leaks were reported in Room D, and Room E and in the hallway adjacent to room E. During an observation on 2/6/2024 at 11:55 AM, trash cans were placed to collect water from leaking ceiling in Room D, E, and the light fixture in the hallway adjacent to Room E near the nursing station. Rooms D and E were observed occupied by residents. During the recertification survey eleven residents (Residents 12, 15, 20, 28, 30, 39, 42, 47, 63,69 and 71) who resides in Rooms C,D and E were displaced due to leaking ceiling in their rooms on 2/6/24. During an interview on 2/09/2024 at 4:04 PM, Administrator (ADM) stated that the QAPI team meets monthly and reviews each department to discuss problems and who was involved accomplish goal for the overall wellbeing of the facility. During an interview on 2/09/2024 at 4:15 PM, ADM stated that during QAPI meetings, the maintenance department discussed what projects are ongoing, as well areas that were posing a safety hazard to the residents and projects pending. ADM stated there was a review of the maintenance logs to review which issues were resolved and which were still pending. During a concurrent interview and record review of the facility's QAPI minutes, dated 1/12/2024 on 2/09/2024 at 4:30 PM, ADM stated that concerns regarding roofing issues came up in anticipation for the upcoming rainy season and supposed to be brought up. ADM stated he did not see record of the roofing concerns being brought to the attention of the QAPI team. A review of the Facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated 2/2020 indicated that, the facility shall develop implement, and maintain an ongoing, facility wide, data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The policy also indicated that the objectives of the QAPI program are to, provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators.

Based on observation and interview, the facility failed to disinfect shared equipments for four sampled residents (Resident 52, 57, 15, and 26) out of of 15 residents observed for medication administration and position and mobility (ability to move) concerns. 1. Two (Residents 52 and 57) of nine residents observed for medication administration, the facility failed to disinfect the blood pressure cuff (material placed around a person ' s arm and then inflated to measure blood pressure) before and after use. 2. Two of six residents (Resident 15 and 26) observed for positioning and mobility concerns, the facility failed to disinfect a vinyl (type of nonporous material) gait belt (assistive device placed around a person ' s waist to assist with safe transferring between surfaces or while walking) before and after resident use. These failures had the potential to spread of infection throughout the facility. Findings: 1. During an observation of medication administration with the Licensed Vocational Nurse (LVN) 1 in the [NAME] Wing Nursing Station on 2/7/23 at 8:18 AM, LVN 1 was observed taking Resident 52 ' s blood pressure prior to medication administration with a dark blue, velcro-style blood pressure cuff without first disinfecting it. After taking Resident 52 ' s blood pressure, LVN 1 was observed placing the blood pressure cuff in a basket on a shelf in the Nursing Station without disinfecting it. During a subsequent observation on 2/7/23 at 8:23 AM, LVN 1 was observed using the same blood pressure cuff used for Resident 52 to take Resident 57 ' s blood pressure prior to medication administration without first disinfecting the cuff. After taking Resident 57 ' s blood pressure, LVN 1 was observed placing the blood pressure cuff back into the basket on a shelf located in the Nursing Station without first disinfecting it. During an interview on 2/7/24 at 9:03 AM - re with LVN 1, LVN 1 stated she failed to disinfect the blood pressure cuff before or after taking blood pressure for Residents 52 and 57. LVN 1 stated it is important to disinfect the blood pressure cuff or any other shared medical equipment before and after each use to minimize the risk of transferring infectious organisms between residents. LVN 1 stated failing to disinfect the blood pressure cuff increased the risk that Residents 52 and 57 could have developed an infection which could lead to medical complications and a diminished quality of life. 2. During a review of Resident 15 ' s admission Record, the facility admitted Resident 15 on 2/14/2022, with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility, anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one ' s daily activities), and schizophrenia (mental disorder characterized by abnormal social behavior). During a review of Resident 26 ' s admission Record, the facility admitted Resident 26 on 4/20/2023, with diagnoses including sepsis (body ' s extreme response to an infection which can be life-threatening), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), and anxiety disorder. During an observation on 2/7/2024 at 1:58 PM, in the facility ' s hallway, Resident 15 was sitting in a wheelchair while Restorative Nursing Aide (RNA) 1 placed a vinyl gait belt around Resident 15 ' s waist and then placed a pick-up walker (PUW, an assistive device with four rubber-tipped legs used for stability and requires a person to lift to move while walking) in front of Resident 15. Resident 15 stood, and his shorts immediately fell from his waist. RNA 1 lifted Resident 15 ' s shorts up while standing and walking. Resident 15 sat back onto the wheelchair and RNA 1 removed the gait belt. RNA 1 disinfected the PUW but did not disinfect the gait belt. During a subsequent observation on 2/7/2024 at 2:07 PM, while still in the facility ' s hallway, Resident 26 was sitting in a wheelchair while RNA 1 placed the same vinyl gait belt used for Resident 15, around Resident 26 ' s waist. RNA 1 placed the PUW in front of Resident 26 who performed five repetitions of sit to stand transfers from sitting in the wheelchair to standing using the PUW. The RNA removed the gait belt from around Resident 26 ' s waist but did not disinfect the gait belt and the PUW. During an interview on 2/7/2024 at 2:21 PM, with RNA 1, RNA 1 stated the gait belt was not disinfected before and after use with Resident 15 and Resident 26. RNA 1 stated the gait belt should have been disinfected with disinfectant wipes to prevent the spread of infection. During an interview on 2/8/2024 at 11:51 AM, with the Infection Prevention Nurse (IP Nurse), the IP Nurse stated shared equipments were considered contaminated once it touched one resident. The IP Nurse stated the facility staff were supposed to disinfect equipment shared between multiple residents before and after use to prevent contamination between each resident. A review of the facility ' s policy Cleaning and Disinfection of Resident-Care Items and Equipment, last revised September 2022, indicated Resident-care equipment, including reusable items and durable medical equipment will be cleaned according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard . Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment) . Durable medical equipment (DME) is cleaned and disinfected before reuse by another resident .

Based on observations, interviews, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as staff were not following the manufacturer ' s guidelines when checking the concentration of the dish machine chlorine (a chemical used for disinfection) solution. This failure had a potential to result to potential cross-contamination (a transfer of bacteria from one object to another), ineffective dish machine, and unsanitized dishes that could lead to food borne illness (an illness caused by contaminated food and beverages) in 82 of 82 medically compromised residents who received food and ice from the kitchen. Findings: During an interview with the Diet Aide (DA) 1 on 2/8/2024 at 12:27 PM, DA 1 stated he washed trays and pitchers in a low temperature dish machine in Facililty 2 ' s kitchen. DA 1 stated he checked the dish machine temperatures for wash and rinse and the wash temperature should be at 140 degrees Fahrenheit (°F, unit of measurement) and rinse temperature should be at 135°F. DA 1 stated he also checked the chlorine concentration in the dish machine and the acceptable range for the chlorine concentration was 50 parts per million (ppm, unit of measurement) and above. During an observation of the DA 1 testing of the dish machine ' s chlorine concentration in the Facility 2 ' s kitchen, interview with DA 1 and review of the manufacturer ' s guidelines of the chlorine test strips on 2/8/2024 at 12:32 PM, DA 1 dipped and agitated the chlorine test strips three (3) times back and forth into the dish machine water during the sanitizing cycle then immediately compared it to the color chart. The Chlorine Test Paper manufacturer ' s instructions indicated: Expired 6/2024 Dip one test strip into solution without agitation. Blot dry. Compare immediately to color chart. Color chart indicates approximate strength of the solution as total available chlorine. High concentrations will bleach the strip white and thin blue line may separate wet from dry area. DA 1 stated he shook the test strips and did not blot the test strip dry when he tested the chlorine concentration. DA 1 stated it was important to follow manufacturer ' s guidelines for the test strips to ensure that the chlorine concentration was measured accurately. DA 1 stated if chlorine concentration testing was done incorrectly, chlorine might not kill bacteria from the dishes that they washed. During an interview with the Dietary Supervisor 1 (DS 1) on 2/8/2024 at 12:51 PM, DS 1 stated Facility 1 used the same low temperature dish machine as Facility 2, however she has not done any in-services to the staff on how to use the Facility 2 ' s low temperature dish machine. DS 1 stated the process of checking the chlorine concentration was as follows: Let the test strip touch the plate and as soon as the color changes remove the strip. Compare the test strip to the color chart. Ppm should be at 50-100. DS 1 stated it was important to check the dish machine chlorine concentration to make sure it was sanitizing the dishes. DS 1 stated it was also important to follow manufacturer ' s guidelines of the test strip to ensure that the concentration was checked accurately. A review of the facility ' s policy and procedure (P&P) titled Dishwashing Procedures-Dish machine dated 1/12/2024, indicated Low temperature dish machine temperature -120 - 135°F. Chlorine – 50 to 100 ppm. (14) Manufacturer ' s guidelines for the dish machine shall be posted. A review of the facility ' s job description titled Dietary Aide 1-AM Dishwasher, dated 2019, indicated Wash and Organize to include the following: PLEASE CHECK PPM & TEMP PRIOR TO WASHING AND LOG INFORMATION. A review of the facility ' s competency checklist titled Dietary Competency Checklist signed on 1/8/2024 by DA 1, indicated DA 1 was competent in dish machine temperature and PPM log maintenance. A review of the facility ' s in-service meeting minute titled Dietary In-Service Meeting Minutes dated 12/15/2023, indicated DA 1 ' s signature that he attended an in-service regarding dish machine logs and ppm concentrations. A review of Food Code 2017 indicated 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness. Verifying the adequacy of chlorine-based solutions can be accomplished on an on-going basis by confirming that the concentration, temperature, and pH of the sanitizing solutions comply with paragraphs 4-501.114 (A) using acceptable test methods and equipment. The manufacturer should provide methods (e.g. test strips, kits, etc.) to verify that the equipment consistently generates solution on-site at the necessary concentration to achieve sanitation. A review of Food Code 2017 indicated 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.

Based on observation, interview, and record review the facility failed to provide the correct texture for puree and soft mechanical diets when: a. Five (5) of 5 residents on soft mechanical diet did not receive ground sausage links and sausage was dry. b. Six (6) of 6 residents on puree diet received oatmeal that was not pureed in texture and consistency. This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing causing a decrease food intake resulting to weight loss. Findings: During an observation of tray line (assembly area for resident ' s food) breakfast service in Facility 2 ' s kitchen on 2/7/2024 at 7:22 AM, the oatmeal for puree diet had lumps, oatmeal residue and was not pureed in consistency. During a test tray (a sample tray to evaluate taste, appearance and palatability of food) of puree diet (a diet with smooth pudding like consistency food) with Dietary Supervisor 1 (DS 1) and Registered Dietitian 1 (RD 1) on 2/7/2024 at 7:42 AM, the puree diet tray included puree waffles covered with thick brown syrup, puree sausage with thick brown syrup, and a cup of oatmeal. The oatmeal had lumps and oatmeal particles in it. During a test tray of soft mechanical diet (tray consisting of soft chopped, and ground foods) with DS 1 and RD 1 on 2/7/2024 at 7:54 AM, the soft mechanical tray included one (1) inch (in., a unit of measurement) to two (2) inches chopped waffle with thick brown syrup on top, round cut dry sausage pieces and a cup of oatmeal. A review of the facility ' s menu titled Winter Menus, dated 2/7/2024, indicated Pureed diet included the following food: Orange juice 4 ounces (oz, a unit of measurement) Puree oatmeal ¾ cup (c., a unit of measurement) Puree sausage #24 scoop (1.35 oz) Puree waffle ½ c Margarine 1 teaspoon (tsp, unit of measurement) Syrup 1 oz Milk 1 c During an interview with DS 1 and RD 1 on 2/7/2024 at 7:55 AM, DS 1 stated all the diets including regular, bite sized, and puree diets received the same oatmeal across all diets. DS 1 stated the oatmeal consistency should have been blended with added thickener sometimes and the consistency should have been thicker and should not form or gel. RD 1 stated the puree oatmeal texture was different from the oatmeal served to the test tray and the staff served the puree oatmeal to puree diets for breakfast. RD 1 stated oatmeal in a puree diet should have a puree texture however, she needed to refer to the facility ' s diet manual on the exact definition of a puree diet. RD 1 stated puree oatmeal should not have oatmeal particles and the oatmeal that was served on puree diet was not the right texture. DS 1 stated puree diet was intended for residents with difficulty swallowing and chewing and that possible outcome for resident not getting the right texture and consistency was residents could aspirate. During a concurrent review of the facility ' s menus titled Winter Menus, dated 2/7/2024 and interview with DS 1 and RD 1 on 2/7/2024 at 7:56 AM, Mechanical soft diet included the following foods: Orange juice 4 oz Oatmeal ¾ c. Ground meat using #24 scoop, moist with broth. Chopped waffle 1 square 4-5 inches. Margarine 1 tsp. Syrup 1 oz Milk 1 c During the same interview, on 2/7/2024 at 7:55 AM, DS 1 stated the soft mechanical tray included a ½ an inch chopped waffles with the 1 oz waffle syrup. RD 1 stated the sausage was chopped and had no broth as it was added during cooking process. RD 1 stated the sausage served was not matching the menu spreadsheet indicating ground meat. DS 1 stated soft mechanical diet was for residents with difficulty chewing or swallowing and the possible outcome if residents did not get the correct consistency was resident could have difficulty chewing or swallowing food. A review of the facility ' s diet manual titled Regular Pureed Diet, dated 2020. Indicated DESCRIPTION: The Pureed Diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be a smooth and moist consistency and able to hold its shape. All foods are prepared in a food processor or blender, with the exception of foods which are normally in a soft and smooth state such as pudding, ice cream, applesauce, mashed potato, etc. Foods avoided included, lumpy cereal (oatmeal), dry cereal, unless pureed. A review of facility ' s recipe titled Pureed Hot Cereal, undated, indicated DIRECTIONS: (1) Prepare hot cereal using recipe. Measure out the total number of ¾ cup portions needed for puree diets. (2) Gradually add warm milk as needed. Be sure if cereal has raisins, fruit, or is lumpy that it is pureed smooth. (3) Puree should reach a consistency slightly soften than whipped topping. May add more liquid if needed to reach this consistency. A review of facility ' s diet manual, titled Regular Mechanical Soft Diet, dated 2020, indicated DESCRIPTION: The Mechanical Soft diet is designed for residents who experience chewing or swallowing limitations. Food avoided: Whole or chopped dry meat (chopped meat only allowed when ordered by Speech Therapist) Size of the meat should be specified in the diet order, such as less than ½ inches or less than 1). A review of the facility ' s recipe titled Breakfast Meat/Low Sodium Sausage, undated, indicated Mechanical soft: Grind meat- 1 oz= about #24 scoop. Serve moist-add broth as needed. A review of facilities ' Policies and Procedures (P&P) titled Menus, dated 1/12/2024, indicated Twenty-eight-day cycle are prepared by the dietitian and modifications of individual resident menus are made as necessary to comply with physician orders and/or residents ' preferences. PROCEDURE: (5) The menus will be prepared as written using standardized recipes. The Dietary Services Supervisor and cooks are trained and responsible for the preparation and service of therapeutic diets prescribed. A review of facilities ' P&P titled Food Preparation, dated 1/12/2024, indicated (2) All recipes in use shall be standardized and will be maintained in a file or book accessible to the dietary staff. Recipes used are consistent to what is on the menu. (3) Food will be cut, chopped, ground, or pureed to meet individual needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, functional, and sanitary condition to ensure safe and sanitary food preparation and storage practices in Facility 1 ' s kitchen by failing to: 1. Ensure Facility 1 ' s Kitchen was maintained to prevent the subfloor from being completely rotten, and tile from disrepair due to having an old rotten floor, the dishwasher left rusted, and the wooden entrance door frames throughout the kitchen worn out and deteriorating as reported by the local Health Department on 12/14/2023. As a result, Facility 1 was required to start construction renovation to their kitchen on 1/29/2024. The facility did not develop plan on how to maintain food safety for the residents during a construction of the kitchen to ensure the food products being transported from the facility were kept dry and covered to prevent contamination and stored in sanitary condition. 2. Ensure not to store dry food in the dry storage area or store perishable foods (foods that are likely to spoil, decay or become unsafe to consume if not kept in the refrigerator or freezer) are stored in the walk -in refrigerator during the kitchen renovation that was observed visible dust and debris on the shelves and floor and two (2) reach-in freezer and one (1) reach-in-refrigerator with dirt and dust debris on the shelves. 3. Ensure kitchen staff wear a hairnet in the kitchen to protect the food being prepared, preparation surfaces and clean equipment from contamination. 4. Ensure the Dietary Aide (DA) 1 did not touched the towel dispenser handle after handwashing then proceeded to assemble resident ' s trays for breakfast service. 5. Ensure [NAME] 2 did not wash, rinse, and sanitize the sheet pans and kitchen utensils after washing them in the three (3) compartment sink. 6. Ensure residents trays used for meal service were in good condition without cracks, chips, stains, and black dirt. 7. Ensure the food and serving food items, used, and served to the residents were not left outside the facility exposed to extreme weather and pest. 8. Start set up and provide a designated area for food storage in Facility 2 until 2/7/2024 (10 days after the construction was started) leaving the food supplies in Facility 1 during constructions. These failures resulted in the closure of the Facility 1 ' s kitchen needing the use of Facility 2 ' s kitchen which had the potential to result in cross contamination (a transfer of harmful bacteria from one object to another or one place to another) that could lead to foodborne illness (an illness caused by contaminated food and beverages) in 82 of 82 medically compromised residents who received food from Facility 1 ' s kitchen. On 2/6/2024 at 7:40 p.m., the State Agency (SA) called an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation in the presence of the Administrator, the Director of Nursing (DON), and Nursing Consultant. For the facility ' s failure to ensure that the facility ' s kitchen was maintained in sanitary and in good repair and working order to provide dietary services that included food storage, cooking, preparation, and distribution to residents and prepare and execute a plan on how residents food will be maintained, stored, and prepared in sanitary condition during the kitchen renovation, On 2/8/2024, at 5:20 PM, the ADM was notified that the immediacy was removed based on the onsite verification that IJ Removal Plan (a list of steps taken to correct the deficient practices) was implemented. The IJ was removed on 2/8/2024 at 5:20 PM, in the presence of the facility's ADM and DON, while the survey team was onsite at the facility. The Health Recertification Survey exited on 2/9/24. The acceptable IJ Removal Plan, dated 2/8/2024 included the following: a. On 2/6/2024, Administrator (ADM), (Director of Nursing) DON and Director of Staff Development (DSD) initiated notification to the Dietary Department and other staff of the findings stated in the IJ template dated 2/6/2024 regarding Dietary Care. During the in-services, the Administrator emphasized the importance to always keep foods clean and dry. b. On 2/6/2024, The Dietary Supervisor and the Maintenance Supervisor conducted an inspection on the meal tray delivery carts. All carts are in good condition with complete food coverage. c. On 2/6/2024 and 2/7/2024, Administrator notified the Dietary Department and other staff of the findings stated in the IJ template, dated 2/6/2024, regarding Dietary Care and food transportation. During the in-services, the Administrator emphasized the importance of always keeping foods clean and dry. d. On 2/7/2024 the Compliance Officer from the Department of HCAI (Health Care Access Information) made an ocular (visual) visit of the facility to tour the kitchen. Compliance Officer assessed that structural integrity of the kitchen is still safe. e. On 2/7/2024 structural engineer came to the facility kitchen to assess the scope of the projects in preparation for HCAI, CDPH (California Department of Public Health), and EH (Environmental Health) permit applications. f. On 2/7/2024 all dry foods and containers were transferred to the sister facility (Facility 2) for storage. remaining perishable foods and containers that did not fit at new designated storage were discarded. g. On 2/7/2024 the Administrator, DON, RD, and DSS observed food transportation and tray lines, and found no issues during dinner time. h. On 2/7/2024 the Administrator and the Maintenance Supervisor conducted an inspection of the kitchen to ensure that the kitchen is completely secured and off limits to residents and unauthorized personnel. i. On 2/8/2024, remaining perishable food items and containers left behind at employee only patio was also discarded. j. Facility 1 will be sharing the kitchen with adjacent sister Facility 2 for the foreseeable future to ensure timely competition of the kitchen project. k. Future delivery of food will be dropped off at adjacent Facility 2. l. Food will be stored in safe, clean, and well-ventilated designated area (temporarily converted conference room to storage room) with staff access only at San [NAME] Convalescent Center for easy and safe handling of food ingredients during food preparation. m. Designated work area, food preparation area, cooking area, and serving area at Facility 2 will be provided for Facility 1 staff. o. Dietary staff shall ensure that transportation carts are fully sealed, secured, and covered prior to transporting meals to the facility residents. p. The Dietary Supervisor and/or Designee will observe food transportation to ensure that resident food will be always kept clean and dry. q. The Administrator will report all current and future projects to HCAI, CDPH, and Environmental Health and all necessary agencies depending on the scope of each project. r. The Administrator and/or Maintenance Supervisor will check the kitchen to ensure that it remains secured until further notice or until the substantial compliance is achieved. s. The Administrator, Maintenance Supervisor, and/or Designee will track all projects, scope of work, and schedule to ensure timely and compliant completion. t. This will be ongoing, and the Administrator will report recapitulations of any findings to the monthly QAPI committee for review, follow-up, and resolution as indicated. Findings: 1. A review of the Retail Food Official Inspection Report, inspection date 12/14/2023, indicated, corrected action needed to store, prepare, and display or held food so that it is protected from contamination. The report indicated the facility failed to ensure the floors, walls, ceilings of the facility did not have durable smooth, non-absorbent, and washable surface, and were kept clean, in good repair and free of peeling paint. The Retail Food Official Inspection Report indicated for the facility needed to replace the damaged floor and base covering tiles in the kitchen, renovate and replace deteriorating wooden entrance door frames throughout the kitchen. A review of the Maintenance Crew Work Order Form, dated 1/14/2024, indicated Facility 1 had a crucial problem that needed repair in 2 to 14 days to upgrade the kitchen, door and frames need to be metal, walls need have a stainless steel, subfloor is completely rotten, and tile cannot be repaired with old floor, and the dishwasher was very old and rusted. During an entrance conference for the annual recertification survey with the DON on 2/6/2024 at 8AM, the DON stated in an interview on 2/6/2024 at 8AM, that the Facility 1 ' s kitchen was closed for remodeling and residents ' meals were being prepared in Facility 2 ' s kitchen (located next to Facility 1 ' s building) about five minutes ' walk from Facility 1. During an initial kitchen observation on 2/6/2024 at 8:05 AM, the Facility 1 ' s kitchen door was closed and no plastic covering around the kitchen area while reported to be under construction by the DON. During an observation of the refrigerator in Facility 1 ' s on 2/6/2024 at 8:33 AM, food items such as four (4) tubs of mayonnaise, one (1) plastic bin with potatoes, one (1) plastic bin with lemons, one (1) bag of celery, 3 boxes of eggs a bag of grapes and 15 gallons of milk etc., with a built-up ice on the vent of the refrigerator were observed. During an interview on 2/6/2024 at 8:40 AM, Facility 2 ' s Dietary Supervisor (DS) 2 stated the meals for Facility 1 ' s residents were being prepared and cooked in Facility 2 ' s kitchen by Facility 1 ' s kitchen staff. DS 2 also stated this has been going on for a few weeks due to Facility 1 ' s kitchen being closed for remodeling. During an interview on 2/6/2024 at 9:13 AM with DS 2 for Facility 2 stated Facility 1 began using Facility 2 ' s kitchen about 3 weeks ago. DS 2 stated Facility 1 bring their own ingredients, prepares, and cook meals in Facility 2 ' s kitchen. During an observation on 2/6/2024 at 9:50 AM, Facility 1 ' s kitchen was observed with bare walls, and floors. The walls had dark brown and black substance and with exposed plumbing pipes. During an interview on 2/6/2024 at 11:50 AM, with the ADM, the ADM stated, there was an emergency to reinforce the subfloor of the kitchen, the [NAME] (a person in charge of a group of workers on a particular operation) who was hired by the facility assessed the kitchen floor between 1/22/2024- 1/25/2024 and observed the kitchen subfloor underneath the tiles which was soft and needed to tear down the kitchen. The ADM stated, Facility 1 began to use the kitchen in Facility 2 on 1/29/2024, when the renovation started in the kitchen in Facility 1. The ADM stated the residents are currently serve with disposable utensils and plates during meals that comes from the kitchen in Facility 2. The ADM stated he did not inform or submit a proposal to renovate the kitchen to the State Agency or the Department of HCAI (prior to tearing down the kitchen. The ADM stated he did not have a written plan or process on how Facility 1 will safely prepare food, store food items, deliver the food to the residents within an acceptable food temperature to prevent food borne illnesses and to ensure the meals are delivered timely. During an interview on 2/6/2024 at 12:20 PM, the ADM stated, Facility 1 ' s kitchen had been closed for two weeks and the process of food preparation was to cook the food in Facility 2 ' s kitchen, do the tray line, review the meal ticket, put in metal cart and then wheel over to the nursing stations or the dining area where the trays are distributed and reviewed by nurses and CNAs. During an observation and concurrent interview on 2/6/2024 at 1:49 PM, in Facility 2 ' s kitchen, a metal cart with wheels were observed in front of food prep area. Another cart (Cart 2) was observed with two brown plastic bags with bread. The plastic bags were observed with water drops on the outside. During an interview with the Facility 1 ' s [NAME] (Cook) 1 stated all food for the residents in Facility 1, including refrigerated food and dry goods remained in Facility 1 during the kitchen construction. [NAME] 1 stated the kitchen staff in Facility 1 brings the food to Facility 2 every day. [NAME] 1 stated the bag of bread was wet on the outside because we bring the food on carts around the facility. During an interview on 2/6/2024 at 2:15 PM, the Facility 2 ' s Administrator (ADM 2) stated, Facility 2 had been sharing the kitchen with Facility 1 for food preparation and cooking for over 2 weeks. The ADM 2 stated, she was verbally informed by their corporate office that Facility 1 will need to share the kitchen with Facility 2 (sister facility). The ADM 2 stated Facility 1 officially started sharing the kitchen in Facility 2 from 1/21/2024 due to kitchen remodeling and the kitchen in Facility 1 could not be used. The ADM stated she was not informed how long Facility 1 ' s kitchen remodel will last. During an interview and record review of the facility ' s QAPI (Quality Assurance and Performance Improvement (QAPI) proactive approach to quality improvement to ensure services are meeting quality standards and assuring care reaches a certain level) Safety Plan, with the ADM on 2/9/2024 at 4:40 PM, the ADM stated there was no documented evidence that the QAPI Committee developed a plan or interventions to implement and monitor to ensure the residents were provided food safety during the kitchen renovation. 2. During an observation on 2/7/2024 at 8:35 AM outside the southside of Facility 1, two kitchen refrigerators and kitchen tables were in an enclosed area next to Facility 1 building. During an observation of Facility 1 ' s kitchen dry storage area on 2/7/2024 at 10:20 AM, the kitchen floor was under construction and the dry storage room floors and shelves were visibly dusty and dirty. The dry storage area contained the following food items: one (1) container of rice, 1 container of dehydrated (dried or water removed) potatoes, 1 container of Cheerios (a cereal brand), 1 container of raisin bran cereals, two (2) canned grapes, a container of single serve pepper packets, a container of single serve salt packets, 1 canned beets, 1 container of single served crackers, 1 canned corn, three (3) bottles of lemon juice, 1 pack buttermilk biscuit mix, 1 pack corn bread mix, 1 pack of white cake mix, three (3) bottles of pancake and waffle syrup, 30 boxes of sugar, four (4) cans tomato ketchup, 3 cans mashed potatoes, 2 cases of canned goods, and 4 bottles of prune juices while the kitchen was under construction. During an observation of Facility 1 ' s walk-in-refrigerator in the kitchen on 2/7/2024 at 10:24 AM, there were 1 container of celery, 1 container of lemon, 1 container of potatoes, 2 pieces (pcs) of watermelon, 4 tubs of mayonnaise, 1 box of pickle relish, 1 box of mustard, 1 box of sunflower butter, 3 tubs of non-fat assorted flavor of yogurts, one box of margarine, 1 container of red onions, 1 box of whipped butter and 1 box of cucumber in the walk-in-refrigerator while the kitchen was under construction. During a concurrent observation of the dry storage area in the kitchen and interview with the Dietary Supervisor (DS) 1 on 2/7/2024 at 10:29 AM, DS 1 stated they were still using the dry storage area and the walk-in refrigerator in Facility 1 for food storage that was being served for residents in Facility 1, however, they planned on transferring all the food to the kitchen in Facility 2 (a sister facility) storage. DS 1 stated they transported food that they needed from their facility (Facility 1) to Facility 2 ' s kitchen using a utility cart. During a concurrent observation of the Facility 1 ' s meat freezer near DS 1 ' s office and interview with the DS 1 on 2/7/2024 at 11:10 AM, bottom freezer shelves had a visual dirt and dust debris when touched. DS stated the last time the freezer and refrigerator were cleaned on Monday (2/5/2024), but the freezer was not cleaned due to the visible dirt debris. DS stated it was important to clean the freezer to avoid cross-contamination. During a concurrent observation of the Facility 1 ' s vegetable freezer and bread refrigerator near DS 1 ' s office and interview with the DS on 2/7/2024 at 11:12 AM, the freezer and bread refrigerator shelves had dust residues and dirt debris. DS stated the cleaning schedule for all the freezers and refrigerator was on Monday. DS stated the vegetable freezer and bread refrigerator needed to be cleaned to prevent cross-contamination of resident ' s food. A review of the facility ' s P&P titled Cleaning Schedule dated 1/12/202024, indicated All areas and equipment should be cleaned daily. A review of Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) Non-Food-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. During an interview with the DS 1 on 2/8/2024 at 1:27 PM, DS 1 stated that the front patio in front of the medical record office was a temporary area to put food from Facility 1 because the refrigerators in Facility 2 were being cleaned and the plan was to transport the food from the front patio to Facility 2 ' s food storage areas. DS 1 stated she does not know when the Facility staffs moved the food from the food storage area of Facility 1 into the front patio. DS 1 stated that the front patio was not a safe area to put up food even if it was for temporary use as food such as lemons, flour were out in the open and it was not safe due to cross-contamination. During an observation of the front patio in front of the medical record office on 2/8/2024 at 1:38 PM, the front patio area was not enclosed and secured. The following food items were inside the carton box on a table and cart that was and exposed to extreme weather such as heat, rain, and pest in the front patio: · one clear uncovered container full of brown potatoes · one uncovered container full of red potatoes · two (2) pcs. of watermelon · one clear container of sugar on tip of the table near a garbage can · one clear container full of lemons on top of the table near a garbage can · one clear container full of onions on top of the table near a garbage can One container of flour · one carton of simply thick easy mix · one full green container of pepper packets · condiments in an uncovered cart o one container of salt seasoning packets o one container of chopped onions o one container of salt seasoning packets o one container of lemon blend o one open box of iodized salt o one full clear container of equal sweetener packets near a trash can o one full clear container of sugar packets near a trash can o one open box of sugar free beverage crystals cranberry flavor · four boxes of orange concentrate on a wooden tray · five boxes of sugar · two bottles of lime juice · 14 assorted canned goods (kernel corn, potatoes, tomato, ketchup, enchiladas) · Three bags of dry cereals (1 cheerios, 2 raisin bran cereals) · 1 box of uncovered bananas. · Assorted paper and disposable products (hinged Styrofoam, Styrofoam bowl, Styrofoam small plates and two-ply dinner napkins). During a concurrent observation of the front patio in front of the medical record office and interview with Maintenance Supervisor (MS) on 2/8/2024 at 1:41 PM, MS stated the food in the front patio was moved on 2/7/202024 in the afternoon from their kitchen (Facility 1 ' s kitchen) and the plan was to transport these foods to the Facility 2 ' s kitchen, however, he was not sure and he needed to ask the Administrator. During an interview with the Administrator (ADM) on 2/8/2024 at 1:53 PM, ADM stated the food in the patio by the medical records area was for disposal and not for resident ' s consumption and was not moved to Facility 2 prior to renovation of the kitchen on 1/29/2024. During concurrent observation of Facility 2 ' s conference room and interview with Facility 1 ' s Registered Dietitian 1 (RD 1) on 2/8/2024 at 3:30 PM, food containers were on the floor, three refrigerators and storage shelves for food were in the conference room. RD 1 stated she was not sure when the staff started to work on the conference room as a food storage however, it was her first day working in the area. RD 1 stated all the foods (listed above) on the floor came from Facility 1 ' s kitchen ' s storage. During an interview with the DS on 2/8/2024 at 3:37 PM, DS stated the three refrigerators were brought in last night and today from the corporate office and the plan was to use the conference room as a food storage area for Facility 1 starting today 2/8/2024, moving forward. During an interview with the ADM on 2/9/2024 at 9:30 AM, ADM stated he submitted a work order for the kitchen construction on 1/4/2024 and the actual kitchen construction started on 1/29/2024. ADM stated the facility did not remove the food in the storage area on the day of the construction because Facility 2 had no space for the food and dietary supplies from Facility 1. ADM stated it was on 2/7/2024 when they started to set up a designated area for food storage. ADM stated the food from the dry storage and walk-in-refrigerator was not safe to use for the residents as it was exposed to the construction area and should had been removed prior to construction of the kitchen. ADM stated the food from the front patio by the medical records office was out overnight during the rain and it was for disposal and donation. ADM stated he notified the staff informally to get the food that they want from the front patio before disposal. ADM stated he designated the conference room at Facility 2 on 2/7/2024 as part of the IJ removal plan. ADM stated everything happened very fast and the storage of food was just executed this way. A review of the facility ' s Policy and Procedure (P&P) titled Sanitation and Infection Control, dated 1/12/2024, indicated, Food Service Employees will follow infection control policies to ensure the department operates under sanitary conditions at all times. A review of the facility ' s P&P titled Refrigerator/Freezer Storage, dated 1/12/2024, indicated (5) Fresh fruits and vegetables should be stored in designated bins in a designated area of refrigerator. (6) All items should be properly covered, dated, and labeled. A review of the facility ' s P&P titled Cleaning Schedule dated 1/12/2024, indicated All areas and equipment in the kitchen should be cleaned daily. A review of Food Code 2017 indicated 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) where is not exposed to splash, dust, or other contamination; and (3) At least 15 centimeter (cm) (6 inches) above the floor. A review of Food Code 2017 indicated 3-305.12 Food Storage, Prohibited Areas (I) Under other sources of contamination. 3. During a concurrent kitchen observation in Facility 2 and interview with DA 1 on 2/7/2023 at 5:20 AM, DA 1 was not wearing a hairnet while setting up resident ' s tray for breakfast service. DA 1 stated he forgot to wear a hairnet because it was cold, and he was wearing a beanie (a soft material used to cover the head) instead. During an interview with DA 1 on 2/7/2024 at 5:51 AM, DA 1 stated it was important to wear hairnet in the kitchen to restrain the hair from getting to the food that could contaminate the resident ' s food. A review of the facility ' s P&P titled Sanitation and Infection Control, dated 1/12/2024, indicated Food Service employees will follow infection control policies to ensure the department always operates under sanitary conditions. PERSONAL HYGIENE: (5) A hair net or head covering which completely covers all hair should be always worn. A review of Food Code 2017 indicated 2-402.11 Effectiveness. (A) except provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designated and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. 4. During an observation of DA 1 ' s handwashing in the Facility 2 ' s kitchen on 2/7/2024 on 5:48 AM, DA 1 touched the towel dispenser handle after washing his hands then prepared resident ' s tray for breakfast meal service. During a concurrent observation of DA 1 ' s handwashing demonstration and interview with DA 1 on 2/7/2024 at 5:55 AM, DA 1 scrubbed and washed his hands for 20 seconds (using a phone timer). DA 1 stated after washing his hands and before going back to work, he should not be touching the water faucet and the towel dispenser handle because it could be contaminated with dirt and could go to resident ' s food. DA 1 stated he was sorry he touched the handle of the towel dispenser earlier. A review of the facility ' s P&P attachments titled Handwashing, dated 1/12/2024, indicated, PROCEDURE: (5) Protect clean hands by turning faucets of with paper towels. A review of Food Code 2017 indicated. 2-301.12 To avoid decontaminating their hands or surrogate prosthetic devices, food employees may use disposable paper towel or similar clean barriers when touching surfaces such as manual operated faucet handles on a handwashing sink or the handle of a restroom door. 5. During an observation of the manual dishwashing of pans and kitchen utensils in the three (3) compartment sink (three separate sink compartments, one for each step of the ware wash procedure: wash, rinse and sanitize) in the Facility 2 ' s kitchen by [NAME] 2 on 2/7/2024 at 6:11 AM, the three-compartment sink had no water. [NAME] 2 washed and rinsed a stainless-steel whip and two (2) tray pans. [NAME] 2 placed the stainless-steel whip and two tray pans in the rack to dry without sanitizing them. During an interview of [NAME] 2 on 2/7/2024 at 6:20 AM, [NAME] 2 stated she used the three-compartment sink to wash the kitchenware and the water in each sink needed to be at a certain temperature. [NAME] 2 stated dishwashing procedure included washing with soap and water then sanitizer. [NAME] 2 stated she did not follow the process earlier because she did not know how the facility set their sink with sanitizer. [NAME] 2 stated the utensils and tray pans she washed earlier was not clean and sanitize. [NAME] 2 stated it was important to follow the dishwashing procedures so there would be no bacterial growth and residue on the dishes when the dishes were used for cooking and meal service for the residents. A review of the facility ' s P&P titled Manual Dish Washing-3 Compartment Sink, dated 1/12/2024, indicated PROCEDURES: (3) The first compartment will be labeled WASH. Fill with hot water of at least 110-120 degrees F. Use detergent in proper concentration per manufacturer ' s instruction. (4) The second compartment will be labeled RINSE. Thoroughly rinse dishes with clean hot water (110-120 degrees F). Change rinse water when it gets cloudy and dirty. (5) The third compartment will be labeled SANITIZE. Sanitize dishes using one of the following methods: (a) Immersion for at least 30 seconds in hot water temperature of at least 171 degrees F, or (b) Immersion for at least 30 seconds in solution containing 100 pm chlorine or (c) Immersion for at least 1 minute in solution containing 200 pm quaternary ammoniums (a sanitizing agent). (7) Wash temperature and sanitizing solution will be taken and recorded A review of Food Code 2017 indicated 4-301.12 Manual Ware washing, Sink Compartment Requirements (A) Except as specified in (C) of this section, a sink with at least 3 compartments shall be provided for manually washing, rinsing, and sanitizing equipment and utensils. A review of Food Code 2017 indicated 4-510.111 Mechanical Ware washing Equipment, Hot Water Sanitization Temperatures. If immersion (submerge) in hot water is used for sanitizing in a manual operation, the temperature of water shall be maintained at 77°C (171°F) or above. A review of Food Code 2017 indicated 4-501.116 Ware washing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. 6. During a Facility 2 kitchen observation of the resident ' s tray cart for Facility 1 on 2/7/2024 at 5:53 AM, resident ' s trays were chipped, cracked, and stained with black color. During a concurrent observation of the resident ' s tray and interview with the DS 1 on 2/8/2024 at 12:19 PM, there were 18 trays that had crack, chip, and black color stain. DS 1 stated she requested a quote for tray replacement, but she did not have a chance to show it to the ADM. DS1 stated it was important to have a chip-free, crack-free and stain-free trays for presentation purposes and it does not look professional. During an interview with the RD 1 on 2/8/2024 at 12:23 PM, RD 1 stated trays should not be chip as it should be whole hence it needed to be replaced for presentation purposes for the residents. During a review of the facility ' s quote to purchase trays, dated 11/17/2023 and interview with DS 1 on 2/8/2024 at 1:15 PM, DS 1 stated she did not order the trays after receiving the quote as the trays were so expensive and there were a lot of holidays and events that she did not get to order it yet. A review of the facility ' s P&P titled Food Preparation, dated 1/12/2024, indicated, (2) Tray set up to be (b) dishes, glasses, flatware are free of rust, chips, cracks. A review of Food Code 201 indicated 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. 7. During an interview with the DS 1 on 2/8/2024 at 1:27 PM, DS 1 stated that the front patio in front of the medical record office was a temporary area to put food in because the refrigerators in Facility 2 were being cleaned and the plan was to transport the food from the front patio to Facility 2 ' s food storage areas. DS 1 stated she does not know as to w[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe environment for 11 out of 81 residents (Residents 12, 15, 20, 28, 30, 39, 42, 47, 63, 69 and 71), who were assessed at being at risk for falling, staff and visitors by failing to: 1. Ensure that the facility's roof was free from cracks, holes and other damage that allowed water from rain to penetrate through and drip into the space between the roof and ceiling. 2. Ensure that the ceiling structure inside the building did not become damaged from rainwater leaking in through holes, cracks, and other damage to the roof. 3. Maintain the ceiling structure free from moisture, water damage, active leaking, and degradation due to rainwater penetrating through cracks, holes, or other damaged areas of the roof. 4. Provide documented evidence that the facility routinely performs scheduled maintenance service to all areas in the facility that included the roof inspections. These deficient practices resulted in an outburst of 5 water leaks throughout the facility on 2/5/2024 during a rainstorm resulting in Resident 12, 15, 20, 28, 30, 39, 42, 47, 63, 69 and 71 to be displaced (being forced to leave their home). In addition, these deficient practices had the potential to lead to resident injury from slipping and falling and endangering the lives of the remaining 70 of 81 residents remaining in the facility including the staffs and visitors, by placing them at risk for accidents, electrical shocks, electrical fires, collapsed ceiling and structural damage. subjecting the residents to possible serious injuries. On 2/6/2024 at 4:05 PM, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation for the facility's failure to ensure that the facility's roof was well maintained and in working order in order to provide a safe and comfortable environment for the residents in the presences of the Administrator. On 2/9/2024, at 2:05 PM, the facility submitted an acceptable IJ Removal Plan ([Plan of Action] a list of steps taken to correct the deficient practices). The IJ was removed on 2/9/2024 at 2:05 PM, in the presence of the facility's Administrator (ADM) and Director of Nursing (DON), while onsite at the facility, after the surveyor verified and confirmed the facility's approved IJ Removal Plan (a detailed plan to address the IJ findings) was fully implemented through observations, interviews, and record reviews, in a manner that eliminated the likelihood of endangering the lives of the remaining 70 of 81 residents remaining in the facility from electrical shocks, electrical fires, and possible serious structural damage and the 11 residents that were displaced could safely reoccupy their rooms. The acceptable IJ Removal Plan, dated 2/9/2024 included the following: 1. On 2/6/24, the staff immediately removed all residents from Room A, B, C, D, and E 2. On 2/6/24, the staff placed all residents Room A, B, C, D and E in different rooms that are in good condition and without any water leak. 3. On 2/6/24, the Director of Nursing (DON) and the Registered Nurse (RN) supervisor conducted assessments for all residents who previously resided in room A, B, C, D and E. They are all at their baseline condition, without any signs/symptoms of changes in condition. 4. The DON and Maintenance Supervisor (MS) & Housekeeping Supervisor (HS) placed an Authorized Personnel Only signage to the rooms that have water leak. 5. The DON and Maintenance & Housekeeping Supervisor placed a Caution Wet Cone in the hallway that have water leak. 6. On 2/6/24, the MS conducted a roof and electrical inspection with corporate contractor from corporate office compromised areas were marked and ceiling lighting fixture near leak was removed. Electrician informed the facility that no other electrical components were at risk for hazard. 7. On 2/6/24, the MS conducted a roof inspection virtually, with a contractor from the roofing company. The roofing company confirmed that they will came to the facility to repair the roof early in the morning of 2/7/24. 8. On 2/6/24, the ADM and Director of Staff Development (DSD) notified the staff of the findings stated in the IJ template (a report given to the facility regarding the deficient practices of the facility that required immediate action to be corrected) and in-services was provided to the staff regarding hazardous roof leaking and safety. During the in-service, the administrator instructed the staff to make rounds hourly, to check the environment and resident safety, and to notify Maintenance immediately of any signs of hazard. 9. On 2/6/24 the ADM and DON created a monitoring log for environment and resident safety. The staff will make rounds every hour and as needed to ensure compliance. 10. On 2/7/24 Compliance Officer of HCAI (Health Care Access Information-a department that monitors the safety of renovations and construction in the skilled nursing facilities) made an ocular (visual) visit of the facility to tour the kitchen site and leak sites. On 2/7/24 facility completed form [NAME] MANUAL Request for Excluded Work and submitted to HCAI for review. 11. On 2/7/24 the roofing company came to the facility to repatch areas affected by the rain on the previous day. Roofing company utilized a camera which uses infrared thermal imaging (a camera used to help detect water moisture or leaks to show visually the temperature emitted by objects and identifying insulation issues. By utilizing the tool, the roofing company was able to identify compromised areas and repair accordingly. a. Room C - damaged ceiling drywall removed currently allowing wood to completely dry prior to installing new dry wall (a construction material used to create walls and ceilings) and applying joint. b. Room D - ceiling had minor damage and required minor patching using joint compound (also known as drywall mud) c. Hallway in front of Room E - square drywall removed and replaced like for like and joint compound applied. 12. On 2/8/24 HCAI H Class A Hospital Inspector 1 and Class A Hospital Inspector 2 came to the facility for initial review of Rooms C, D, E, and E hallway. Inspectors confirmed revisit for 2/9/24 for final verification. 13. On 2/9/24 HCAI Class A Hospital Inspector 2 came to the facility to verify the framing integrity and covering items used to patch the ceiling were safe for resident quarters. Inspector verified upon completion of patching that Rooms C, D, E, and E hallway are safe for residents to return. 14. On 2/9/24, with the authorization of HCAI Class A Hospital Inspector 2 and CDPH, the facility proceeded to execute room change notifications for cohorted (group together) residents. Upon completion of room change notifications, residents were excited to be placed back to their original rooms. Room changes completed for Wing A- residents at 12:00PM and Wing-B residents at 1:45PM. 15. On 2/9/24 the MS checked all areas of the facility, including the patient rooms, activity rooms, storage rooms, offices, hallways, etc. There were no other areas of water leakage, other than for room D and C and the area leaking from the hallway ceiling in front of room E. 16. The ADM will repeat the in-service regarding roof leak and safety every month for 3 months or until the substantial compliance is achieved. 17. The Administrator and/or Maintenance Supervisor will schedule roof assessment quarterly x 6 months and then annually thereafter. 18. The Administrator will report all current and future projects to CDPH, and Environmental Health and all necessary agencies depending on the scope of each project. 19. The Administrator will report recapitulations of any findings to the monthly QAPI (Quality Assurance and Performance Improvement a proactive approach to quality improvement to ensure services are meeting quality standards and assuring care reaches a certain level) committee for review, follow-up, and resolution as indicated. Findings: 1. During a review of Resident 12's admission Record indicated the facility originally admitted the resident on 1/30/2009 and readmitted her on 2/15/2023 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations that can result in fast heart rate, rapid breathing, and sweating), and hypertension (high blood pressure). During a review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/4/2024, indicated the resident had intact memory and cognition (ability to think and reasonably). The MDS indicated the resident required supervision or touching assistance by facility staff with eating, oral hygiene, toilet hygiene, chair/bed-to-chair transfer, lower body dressing, personal hygiene, and could walk 150 feet distance. A review of Resident 12's History and Physical dated 2/17/2023, indicated the resident did not have capacity to make decisions. During a review of Resident 12's Care Plan, revised on 1/9/2024, indicted Resident 12 was at risk for falls/injury and the interventions including staff will provide a safe and clutter-free environment. During a review of Resident 12's Care Plan, revised on 1/9/2024, indicated the Resident 12 sometimes wanders around the facility and confused as to where she is going and what she is doing. To ensure resident safety, the interventions indicated the facility staff will provide clutter free an environment and non-slippery floors. During a review of Resident 12's Care Plan, revised on 1/9/2024, indicated Resident 12 was, at risk for falls/injury related to tremor (involuntary shaking movement and to ensure Resident 12's safety, the facility staff will provide clutter free an environment. A record review of Resident 12's Change of Condition Assessment Form dated 2/6/2024 indicated that at 11:30 AM, resident's room floor noted slightly wet due to roof leaking from the rain. 2, During a review of Resident 15's admission Record indicated the facility originally admitted the resident on 2/25/2011 and readmitted on [DATE] with diagnoses that included schizoaffective disorder (a disorder that affects a person's ability to think, feel, and behave clearly), abnormalities of gait and mobility and anxiety disorder. During a review of Resident 15's MDS, dated [DATE], indicated the resident had moderate levels of memory and cognition (ability to think and reasonably). The MDS indicated Resident 15 required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting. The MDS also indicated that the resident used a wheelchair and required supervision or touching assistance for wheeling the chair for more than 150 feet. A review of Resident 15's History and Physical, dated 2/6/2023, indicated the resident had the capacity to make decisions. During a review of Resident 15's Fall Risk Assessment, dated 9/6/2023, indicated Resident 15 was at a risk for fall. During a review of Resident 15's Care Plan, revised on 9/6/2023, indicted Resident 15 was at risk for falls/injury, and to ensure Resident 15's safety, the staff will provide a safe and clutter-free environment. During a review of Resident 15's Care Plan, revised on 9/6/2023, indicated Resident 15 was at at risk for spontaneous/pathological (when force or impact didn't cause the break to happen) /stress fracture related to osteoarthritis (occurs when flexible tissue at the ends of bones wears down). To ensure Resident 25's safety the facility staff will provide a safe and hazard free environment. 3. During a review of Resident 20's admission Record indicated the facility originally admitted the resident on 12/6/2013 and then readmitted on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations that can result in fast heart rate, rapid breathing, and sweating). During a review of Resident 20's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/8/2023, indicated the resident had severe cognition impairment and required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting and with walking 10 feet or more. A review of Resident 20's History and Physical dated 7/1/2023, indicated the resident does not have the capacity to make decisions. During a review of Resident 20's Fall Risk Assessment, dated 12/8/2023, indicated the resident was a risk for fall. During a review of Resident 20's Care Plan, revised on 12/14/2023, indicated Resident 20 was at risk for falls/injury, and to ensure Resident 20's safety, the facility staff will provide a safe and clutter-free environment. A review of Resident 20's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:30 AM, room floor noted slightly wet due to roof leaking from the rain. 4. During a review of Resident 39's admission Record indicated the facility originally admitted the resident on 10/30/2019 and then readmitted on [DATE] with diagnoses that included schizophrenia and anxiety disorder and abnormalities of gait and mobility. During a review of Resident 39's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/29/2023, indicated the resident had severe cognition impairment and required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting and with walking 10 feet or more. A review of Resident 39's History and Physical dated 11/11/2023, indicated the resident does not have the capacity to make decisions. During a review of Resident 39's Fall Risk Assessment, dated 11/2/2023, indicated the resident was a high risk for fall. During a review of Resident 39's Care Plan, revised on 12/20/2023, indicated the resident was at risk for falls/injury, and to ensure safety, the facility staff will provide a safe and clutter-free environment. A review of Resident 39's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:40 AM, room floor noted slightly wet due to roof leaking from the rain. During a review of Resident 42's admission Record indicated the facility admitted the resident on 12/5/2023 with diagnoses that included schizophrenia anxiety disorder and abnormalities of gait and mobility. 5. During a review of Resident 42's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/12/2023, indicated the resident had severe cognition impairment and required substantial assistance by facility staff with eating, personal hygiene, sit to lying position. The MDS record also indicated Resident 42 required substantial/maximal assistance (where staff does more than half the effort) for toileting, showering, dressing, and bed to chair transfer. A review of Resident 42's History and Physical dated 12/7/2023, indicated the resident did not have the capacity to make decisions. During a review of Resident 42's Fall Risk Assessment, dated 12/6/2023, indicated the resident was a high risk for fall. During a review of Resident 42's Care Plan, revised on 12/6/2023, indicated the resident was at risk for falls/injury, and to ensure safety the staff will provide a safe and clutter-free environment. During a review of Resident 42's Care Plan, revised on 12/6/2023, indicated the resident had a seizure disorder (sudden, uncontrolled burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of consciousness) with risk for falls/injury, and the interventions including provide safe environment . free of safety hazards. A review of Resident 42's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:40 AM, room floor noted slightly wet due to roof leaking from the rain. 6. During a review of Resident 47's admission Record indicated the facility originally admitted the resident on 9/4/2019 and readmitted her on 2/28/2023 with diagnoses that included schizophrenia, seizures and hypertension. During a review of Resident 47's MDS, dated [DATE], indicated the resident had intact memory and cognition. The MDS indicated Resident 47 required setup or clean-up assistance with eating, chair/bed-to-chair transfer, and walk 150 feet, and supervision or touching assistance with oral hygiene, toilet hygiene, lower body dressing and personal hygiene. A review of Resident 47's History and Physical dated 3/2/2023 indicated that Resident 47 did not have the capacity to make decisions. During a review of Resident 47's Fall Risk Assessment, dated 1/12/2024 indicated the resident was at risk for falls. During a review of Resident 47's Care Plan, revised on 1/12/2024, indicated Resident 47 was at risk for falls/injury, and to ensure safety the facility the staff will provide a safe and clutter-free environment. During a review of Resident 47's Care Plan, revised on 1/12/2024, indicated the resident was at risk for injury .because of seizure activity, and the interventions included to provide a safe environment; free of safety hazards. A review of Resident 47's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:30 AM, room floor noted slightly wet due to roof leaking from the rain. 7. During a review of Resident 63's admission Record indicated the facility admitted the resident on 3/17/2020 with diagnoses that included vascular dementia (condition causes cognitive difficulty with reasoning and judgment), emphysema (a lung condition that causes shortness of breath), and anemia (a blood disorder that can result in symptoms that include extreme tiredness, weakness, and shortness of breath). During a review of Resident 63's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/25/2023, indicated the resident required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting and with walking 10 feet or more. A review of Resident 63's History and Physical dated 7/18/2023, indicated the resident does not have the capacity to make decisions. During a review of Resident 63's Fall Risk Assessment, dated 1/3/2024, indicated the resident was a risk for fall. During a review of Resident 63's Care Plan, revised on 1/3/2024, indicated the resident was at risk for falls/injury, and the interventions including staff will provide a safe and clutter-free environment. A review of Resident 63's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:30 AM, room floor noted slightly wet due to roof leaking from the rain. 8. During a review of Resident 69's admission Record indicated the facility originally admitted the resident on 5/30/2023 and readmitted on [DATE] with diagnoses that included schizoaffective disorder abnormalities of gait and mobility and dementia. During a review of Resident 69's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/6/2023, indicated the resident had moderate levels of memory and cognition (ability to think and reasonably). The MDS indicated Resident 69 required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting, and walking 10 feet or more. During a review of Resident 69's Fall Risk Assessment, dated 11/24/2023, indicated the resident was a risk for fall. During a review of Resident 69's Care Plan, revised on 12/27/2023, indicated the resident was at risk for falls/injury related to generalized weakness, poor safety awareness, and the interventions including staff will provide a safe and clutter-free environment. During a review of Resident 69's Care Plan, revised on 12/27/2023, indicated the resident was at at risk for spontaneous/pathological/stress fracture related to osteoarthritis (occurs when flexible tissue at the ends of bones wears down), and the interventions including provide a safe and hazard free environment. 9. During a review of Resident 71's admission Record indicated the facility originally admitted the resident on 1/11/2022 and readmitted her on 2/20/2022 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and hypertension (high blood pressure). During a review of Resident 71's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/17/2024, indicated the resident had intact memory and cognition (ability to think and reason). The MDS indicated Resident 71 required setup or clean-up assistance with eating, oral hygiene, toilet hygiene, chair/bed-to-chair transfer, lower body dressing, personal hygiene, and was able to walk 150 feet distance. During a review of Resident 71's Fall Risk Assessment, dated 1/3/2024, indicated the resident was at risk for fall. During a review of Resident 71's Care Plan, revised on 1/17/2024, indicated Resident 71 was at risk for falls/injury and to provide safety the facility staff will provide a safe and clutter-free environment. 10. During a review of Resident 30's admission Record indicated the facility originally admitted the resident on 7/28/2021 and readmitted her on 12/04/2023 with diagnoses that included schizophrenia and anxiety. During a review of Resident 30's MDS, dated [DATE], indicated the resident had intact memory and cognition. The MDS indicated Resident required supervision and touching assistance with eating, oral hygiene, chair/bed-to-chair transfer, lower body dressing, personal hygiene, and was able to walk 50 feet distance with two turns. During a review of Resident 30's Fall Risk Assessment, dated 12/19/2024, indicated the resident was at risk for fall. During a review of Resident 30's Care Plan, revised on 12/15/2023, indicated the resident was at risk for falls/injury and the interventions including staff will provide a safe and clutter-free environment. 11. During a review of During a review of Resident 28's admission Record indicated the facility originally admitted the resident on 10/23/2013 and readmitted her on 12/20/2023 with diagnoses that included schizophrenia and anxiety. During a review of Resident 28's MDS, dated [DATE], indicated the resident had moderately impaired memory and cognitive impairment. The MDS indicated Resident required supervision and touching assistance with eating, and partial/moderate assistance with oral hygiene, toilet hygiene, chair/bed-to-chair transfer, lower body dressing, and was able to walk 10 feet distance. During a review of Resident 28's Fall Risk Assessment, dated 12/23/2024, indicated the resident was at risk for fall. During a review of Resident 28's Care Plan, revised on 12/15/2023, indicated Resident 30 was at risk for falls/injury and the interventions including staff will provide a safe and clutter-free environment. During a review of the facility's record titled, Task Order Proposal, dated 1/14/2024, indicated the following roof assessment: 1. Remove all existing roofing and fascia (a long wooden board behind the gutters on a house) board from the existing roof area. 2. Replace the water damaged roof sheathing (the wooden board that make uo the framing of the roof system) with new sheathing. 3. Furnish and install primed fascia board (a composite or wood that make the exterior house more attractive) and entire roof cave (part of the roof that collapse). 4. Apply completely new Title 24 (State of California Building Standard Code-) compliant- SA mineral surfaced roof system including new perimeter edge flashing, new counter flashing and all other components required for complete roof system. 5. Apply Karnak sealants (brand waterproof sealant coating for the roof) penetrations. During a review of the facility's untitled record used by the facility for maintenance work requests and reports, the report indicated on 2/5/2024, Room C had a new leak by the door and by the window. The record also indicated that on 1/29/2024 there was a previous leak in Room C. During a review of the facility's untitled record used for maintenance requests and reports, the report indicated that on 2/5/2024 leaks were reported in Room D, and Room E and in the hallway adjacent to room E. During an observation on 2/6/2024 at 11:55 AM, trash cans were placed to collect water from leaking ceiling in Room D, E, and the light fixture in the hallway adjacent to Room E near the nursing station. Room D was observed occupied by Resident 39 and 42 and Room E was observed occupied by Resident 15 and 69. During an observation on 2/6/2024 at 11:55 AM, Room A and Room B were connected to Room C. Residents in Room A and Room B must exit through Room C to exit building or to exit into building hallway. In a concurrent interview and observation, Licensed Vocational (LVN5) stated the two trashcans in the hallway in front of the East nursing station were placed there because the ceiling was leaking. LVN 5 stated the trash can positioning was not correct since a water drop fell on his head, which is not where the trash can was located. Water was observed inside trash can and on floor around trash cans. During an interview on 2/6/24 at 12PM, the ADM stated he informed the MS to observe all rooms with water leak from the ceiling, and there were no new water leaks observed in the residents. However, he stated he will continue to observe the other resident's rooms for leakage. During an interview on 2/6/2024 at 12:05 PM, Administrator (ADM) stated that some of the leaks were present last week and that a roofing company was at the facility last week and did some patching of the roof. When requested for the work completed last week, the ADM was unable to produce record of work done from the previous week. During an interview on 2/6/2024 at 12:08 PM, ADM stated that rooms A, B, C, D, E had all been evacuated and that the rooms had been sealed off with caution tape to prevent anyone from going into an area that are dangerous with the potential of falls. He further stated an electrician was coming to assess the safety of the water leaking through the ceiling light fixture. During an interview on 2/6/2024 at 12:14 PM, ADM stated that he gave the directive to the staff to evacuate the affected rooms. (The leaks were identified on 2/5/2024). ADM stated that extra measures needed to be put in place to protect the resident from potential electrical issues until the leaking light could be assessed. During a concurrent observation and interview on 2/6/2024 at 2:34 PM, with the Infection Preventionist (IP) Nurse, IPN stated Residents 28, 71, 63, 20, and 30 were sharing a room (Room A). At the end of the shared room, there were two doors opening to two adjacent rooms where Resident 12 and Resident 47 resided. Residents 12 and 47 had to walk through Resident 28, 71, 63, 20 and 30's shared room to exit from Room A door to reach the hallway. Room A's ceiling was observed with a linear crack (a single narrow crack) and white paint marked with water stain across the ceiling. While Resident 28 was lying on the bed, water was dripping from the ceiling to the floor on the left side of the resident's head of the bed. On the right side of Resident 28's head of the bed, there were two trash bins with plastic liners on the floor to collect the dripping water from the ceiling. Three spots on the ceiling had bulging dry wall and water dripping down to the floor. Resident 28 was lying on the bed while on the right side of Resident 28, water was observed dripping from the ceiling into the two trash bins with plastic liners on the floor. During an observation on 2/6/2024 at 2:35 PM, one green damp towel was spread on the floor under the two trash bins near the exit door. Another two leaking spots were on the right end of the liner white paint mark between Resident 63 and Resident 20's bed, where the water was dripping from the ceiling to the floor, over a pathway to an exit door to the patio outside of the building. These two leaking spots were approximately three inches in length each spot. Two trash bins with plastic liners were on the floor to collect the dripping water from the ceiling and two white wet towels were on the floor between Resident 63 and Resident 20's bed. One white wet towel was spread on the floor next to the right side of Resident 63's head of bed. The exit door to the patio was unlocked from the inside. The IP stated the staff put the trash bins to collect the water and used the towel to keep the floor dry. During a concurrent interview on 2/6/2024 at 2:35 PM, the IP stated the residents should not walk in the area where is wet because they might trip, fall and get injury. The IP stated the wet towel on floor could put residents at risk for tripping and falling too and they should be removed. During a concurrent observation and interview on 2/6/2024 at 2:36 PM, in the shared room, with Resident 71, Resident 71 was sitting on her bed. Resident 71 stated she saw the ceiling was leaking. Resident 71 stated one leaking spot was on her side of bed of the room, another leaking spot was on other side of the room where the exit door was. Resident 71 stated the leaks started when the rain started. Resident 71 stated she was not going to that side of the room. During a concurrent observation and interview on 2/6/2024 at 2:37 PM, in the shared room, with Resident 30, Resident 30 was standing and fixing her bed. Resident 30 stated she knew about the ceiling was leaking, and it started when it rained. Resident stated she used the exit door in the room to exit to the patio. During a concurrent observation and interview on 2/6/2024 at 2:43 PM, in the shared room, Resident 28 was lying on her bed and covered herself with blanket. Resident 28 stated when it rained, the leak started. Resident 28 stated the staff told her they were fixing it, but it was still leaking. During an interview on 2/6/2024 at 2:45 PM, with the housekeeping (HK), HK stated they knew about the leaks for two days now. During an interview on 2/6/2024 at 2:47 PM, with the IP nurse, when surveyor asked if the residents in the shared room were going to stay in the room when the ceiling was leaking, the IP did not respond to the question. During an interview on 2/8/2024 at 8 AM, Registered Nurse Supervisor (RNS) stated that water leaking on the floor created a fall hazard for the residents. During an interview on 2/8/2024 at 8:17 AM, ADM stated that there was supposed to be annual assessment of the facility for structural i[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) in accordance the facility's policy and procedure titled Procedure for Prevention of Resident abuse and mistreatment by failing to ensure: 1. Resident 2 with diagnosis of schizoaffective disorder (mental health condition characterized by hallucinations [false perceptions of sensory experiences] or delusions [a false belief or judgment about external reality]), manifested by believing other people are against him and causing outburst of anger was monitored and supervised to prevent Resident 2 from entering Resident 1's room who was watching TV and pounded on Resident 1's head without a staff to stop Resident 2 from entering Resident 1's room. 2. Resident 2's clinical history from the GACH (General Acute Care Hospital) records were reviewed prior to admission and when the resident was admitted to the facility to ensure Resident 2 was supervised and monitored for aggressive behavior towards others. 3. A base line care plan was developed to indicate interventions of how to manage Resident 2's behavior believing other people are against him and causing angry outburst. This deficient practice resulted in Resident 1 experienced physical abuse and verbalized feeling traumatized because of the incident that resulted in a transfer to the ER (Emergency Room) for headache, chest pain and a laceration (deep skin cut) to the left forehead which required sutures and stayed in the GACH for higher level of care for four days from 10/31/23 to 11/3/23. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses that included dementia (a brain disorder that causes gradual decline in memory and thought process). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 11/7/23, indicated Resident 1 had the ability to understand others and express own ideas and wants, that required partial assistance (helper does less than half the effort) to walk ten feet distance, transfer to and from a bed to a chair, and changing position from sitting to standing. A review of Resident 2's admission Record indicated Resident 2 was originally admitted on [DATE] with diagnoses that included traumatic brain injury (brain injury usually results from a violent blow or jolt to the head or body that affects the persons mood and behavior such as aggression, combativeness, or other unusual behavior) and schizoaffective disorder. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had the ability to understand others and express own ideas and wants. The MDS indicated Resident 2 was able to walk 150 feet distance without the need of an assistive device, and without impaired range of motion (limit to which a part of the body can be moved) on both upper and lower extremities. A review of Resident 2's History and Physical (H&P, a document that contains the physician's examination of a resident) from General Acute Care Hospital (GACH), dated 10/10/23, indicated Resident 2 was admitted in the psychiatric (a unit in the hospital that focus patients with mental and behavioral care) unit of the hospital due to aggressive behavior. A review of Resident 2's Nursing Home Visit, dated 10/30/23, indicated Resident 2's initial H&P upon admission to the facility with diagnoses included recent hospitalization due to aggressive behavior. A review of Resident 2's COC (Change of Condition/INTERACT ASSESSMENT FORM SBAR (Situation Background Assessment and Recommendation -a communication tool that allows health professionals to communicate clearly about the resident's condition) dated 10/31/23, at 3:35 AM, indicated that a staff saw Resident 2 pounding at Resident 1 because Resident 2 thought that Resident 1 was raping him for some reasons. A review of Resident 1's COC /INTERACT ASSESSMENT FORM SBAR dated 10/31/23, timed at 6:53 AM, indicated, on 10/31/23 at 3:30 AM, a CNA was calling for help in Resident 1's room when the CNA found Resident 2 pounding on Resident 1. A head-to-toe assessment was conducted and noted Resident 1 with left eyebrow abrasion measuring 3 cm (centimeter- a unit of measurement) x 0.5 cm with slight bleeding and right eyebrow abrasion measuring 0.5 cm x 0.5 cm and left forehead swelling. During a review of the GACH record, dated 10/31/23, timed at 12:33 PM, indicated Resident 1 was admitted to the ER (Emergency Room) due to headache, chest pain and laceration (deep cut) of the forehead measuring three centimeter in length, that required three sutures (stitches on the skin) and given Morphine Sulfate (MS- a medication given for severe pain). The GACH record indicated Resident 1 reported being assaulted by another resident at the nursing facility and was punched on the left side of the head in the middle of the night. During an interview on 12/4/23, at 3 PM with Resident 1's Family (FAM), FAM stated, she was informed by Resident 1 that on 10/31/23 at 3:30 AM, he was beaten up by another resident and was bleeding on his head with left side eye brown wound. The FAM also added, Resident 1 stated he was traumatized, could not stop shaking and had muscle spasm after the incident happened. During an observation conducted on 12/15/23 at 12:56 PM, Resident 1 and Resident 2's rooms had a shared/common restroom located between each of their rooms. During an interview on 12/15/23 at 1:30 PM with Registered Nurse Supervisor (RNS), RNS stated, RNS stated that she did not know Resident 2 was admitted to the facility with history of diagnosed schizophrenia disorder related to aggressive behaviors. The RNS stated, she did not read Resident 2's H&P and record from GACH. The RNS stated, she should have reviewed Resident 2's H&P, diagnoses, and orders to make sure the right care plan and care was developed and provided to Resident 2. The RNS stated residents with history of aggressive behaviors must be monitored closely upon admission to prevent potential accidents and abuse. During an interview on 12/15/23 at 2:20 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, she usually took care of new resident's admission, including Resident 2. LVN 2 added, she received a package which included Resident 2's H&P, diagnoses, progress notes, and the physician orders upon admission. LVN 2 stated, she created Resident 2's baseline care plan and would request further physician orders if needed. LVN 2 stated, a baseline care plan was very important because it helped the nursing staff to provide Resident 2 with the right care based on his diagnoses. During a concurrent interview and record review on 12/15/23 at 2:30 PM with LVN 2, Resident 2's medical record was reviewed. LVN 2 stated, per H&P, Resident 2 was admitted to the hospital prior to transferring to the facility with chief complaint of aggressive behavior. LVN 2 stated his history of aggressive behaviors should have been addressed in the baseline care plan with strict monitoring for the safety of staffs and other residents per protocol. LVN 2 added, without the baseline care plan for aggressive behavior, the staffs were not aware, and the resident was not properly monitored so there was a high risk for resident-to-resident abuse. LVN 2 stated, she must have overlooked Resident 2's H&P and did not thoroughly review Resident 2's admission package and records from GACH so that the physical abuse and incident between Resident 1 and Resident 2 could have been prevented. During an interview on 12/15/23 at 4:05 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated to keep the residents safe, CNA 1 stated all CNAs were responsible to visually monitor and document their assigned residents' whereabout every 2 hours. During an interview on 12/15/23 at 4:22 PM with CNA 3, CNA 3 stated, it was important to monitor the residents every 2 hours and document on time to make sure that residents are okay. During an interview with Director of Staff Development (DSD) on 12/15/23 at 4:45 PM, the DSD stated, LVNs and the RNS should be checking and reminding the CNAs to document on time for their tasks and residents' whereabout because conducting timely monitoring and documentation was important to keep track of the resident's whereabout and monitor the resident behavior to prevent physical abuse. During an interview on 12/15/23 at 5 PM with LVN 1, LVN 1 stated that she was not aware that Resident 2 had an angry outburst because she did not read Resident 2's H&P and she was not informed by the other staffs. LVN 1 stated, she should have reviewed all new residents' admission information before taking care of them. During an interview on 12/15/23 at 5:42 PM with the Director of Nurses (DON), DON stated, according to the facility's policy, residents in the facility are monitored every 2 hours by the CNAs. DON stated that monitoring was important in preventing acts of abuse. DON stated that monitoring was even more important on new residents with history of aggressive behavior. During an interview on 12/15/23 at 6 PM with the Director of Nurses (DON), DON stated, nursing staffs including the admitting nurse, RNS, LVN charge nurse were expected to review new resident's admitting package before taking care of them. DON stated, RNS and LVN charge nurse should know how to do the care plan. During an interview and concurrent record review on 12/15/23 at 6:00 PM with the DON, Resident 2's Documentation Survey Report for monitoring resident location every 2 hours was reviewed. The record indicated, there were missing entries in the CNA's monitoring log indicated that Resident 1 and Resident 2 were not monitored every two hours consistently on 10/30/23 at 4 PM, 6 PM, 8 PM, 10 PM, and on 10/31/23 at 12 AM, 2 AM, 4 AM. The DON stated that if there was no documentation, the facility staffs did not provide supervision to the residents at those times. DON stated that with enough supervision and proper monitoring, Resident 1's abuse on 10/31/23, at 3:35 AM could have been prevented. During an interview on 12/15/23 at 6:30 PM with the Administrator (ADM), the ADM stated, if the documentation was blank, it meant the facility staffs did not do their job. A review of the facility's policy titled, Procedure for Prevention of Resident abuse and mistreatment, revised 12/7/21, indicated the facility will provide a safe environment as free of injury to prevent resident to resident abuse by each resident admitted will be assessed for aggressive behavior or potential for striking out as being abusive to others (patient and staff), a plan of care will be implemented to address and prevent aggressive behaviors. A review of the facility's policy titled, Routine Resident Checks, revised July 2013, indicated that routine checks of residents are done to maintain resident safety and well-being. A review of the facility's policy and procedure titled, Prevention of Resident Abuse and Treatment, revised 12/7/21, indicated that monitoring of residents shall be the responsibility of, but not limited to, direct caregivers, Charge Nurses, Nursing Supervisors, and the interdisciplinary team. The policy and procedure also indicated that samples of residents with behavioral symptoms and manifestations that may lead to conflict or anger are residents with history of aggressive behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess and provide the necessary behavioral health care and services for one of three sampled residents (Resident 2) with diagnosis of schizoaffective disorder (a chronic and severe mental disorder that affects how a person thinks, feels, behaves and experience psychosis [behavioral symptoms that affect the mind, and loss of contact with reality]) manifested by history of increase agitation, aggressive behavior toward staff, and paranoid delusion (profound fear and loss of the ability to tell what's real and what's not real) believing other people are against him causing outburst of anger as indicated in the facility's policy and procedure by failing to: 1. The Licensed Vocational Nurse (LVN) did not appropriately assess and monitor Resident 2's aggressive behaviors. 2. Administer Ativan (medication used to relieved anxiety [fear of the unknown]) and Haldol (a medication used to control mood and behavior) as ordered by the physician for Resident 2 on 10/30/23 with history of angry outburst. 3.The Certified Nursing Assistants (CNA) did not consistently monitor Resident 2 for safety whereabouts every two hours as indicated in the facility's policy and procedure. 4. A care plan was not developed to address and provide interventions on how to manage the paranoid and delusional behavior of the Resident 2. 5. Review Resident 2's clinical records prior to the admission to the facility and when admitted to the facility on [DATE] was not reviewed by the facility to ensure Resident 2 was properly placed in the facility. As a result of this deficient practice, Resident 2 entered a room adjacent to him without supervision and pounded on Resident 1's head with a delusion thought that Resident 1 was raping him (13 hours after Resident 2 was admitted to the facility). Resident 1 reported feeling traumatized and sustained a laceration (deep skin cut) of the left forehead and was hospitalized for suture placement above the left eyebrow from being pounded in the head. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses that included polyneuropathy (a nerve damage that causes pain, decreased ability to move and feel because of nerve damage) and dementia (a brain disorder that causes gradual decline in memory and thought process). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 11/7/23, indicated Resident 1 had the ability to understand others and express own ideas and wants, that required partial assistance (helper does less than half the effort) to walk ten feet distance, transfer to and from a bed to a chair, and changing position from sitting to standing. A review of Resident 1's COC /INTERACT ASSESSMENT FORM SBAR dated 10/31/23, timed at 6:53 AM, indicated, on 10/31/23 at 3:30 AM, a CNA was calling for help in Resident 1's room when the CNA found Resident 2 pounding on Resident 1. A head-to-toe assessment was conducted and noted Resident 1 with left eyebrow abrasion measuring 3 cm (centimeter- a unit of measurement) x 0.5 cm with slight bleeding and right eyebrow abrasion measuring 0.5 cm x 0.5 cm and left forehead swelling. During a review of the GACH record, dated 10/31/23, timed at 12:33 PM, indicated Resident 1 was admitted to the ER (Emergency Room) due to headache, chest pain and laceration (deep cut) of the forehead measuring three centimeter in length, that required three sutures (stitches on the skin) and given Morphine Sulfate (MS- a medication given for severe pain). The GACH record indicated Resident 1 reported being assaulted by another resident at the nursing facility and was punched on the left side of the head in the middle of the night. During an interview on 12/4/23, at 3 PM with Resident 1's Family (FAM), FAM stated, she was informed by Resident 1 that on 10/31/23 at 3:30 AM, he was beaten up by another resident and was bleeding on his head with left side eye brown wound, which resulted in a 4-day hospital stay. The FAM also added, Resident 1 stated he was traumatized, could not stop shaking and had muscle spasm after the incident happened. A review of Resident 2's admission Record indicated Resident 2 was originally admitted on [DATE] with diagnoses that included traumatic brain injury (brain injury usually results from a violent blow or jolt to the head or body that affects the persons mood and behavior such as aggression, combativeness, or other unusual behavior) and schizoaffective disorder. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had the ability to understand others and express own ideas and wants. The MDS indicated Resident 2 was able to walk 150 feet distance without the need of an assistive device, and without impaired range of motion (limit to which a part of the body can be moved) on both upper and lower extremities. A review of Resident 2's History and Physical (H&P, a document that contains the physician's examination of a resident) from General Acute Care Hospital (GACH), dated 10/10/23, indicated Resident 2 was admitted in the psychiatric (a unit in the hospital that focus patients with mental and behavioral care) unit of the hospital due to aggressive behavior. A review of Resident 2's Nursing Home Visit, dated 10/30/23, indicated Resident 2's initial H&P upon admission to the facility with diagnoses included recent hospitalization due to aggressive behavior. A review of Resident 2's COC (Change of Condition/INTERACT ASSESSMENT FORM SBAR (Situation Background Assessment and Recommendation -a communication tool that allows health professionals to communicate clearly about the resident's condition) dated 10/31/23, at 3:35 AM, indicated that A staff saw Resident 2 pounding at Resident 1 because Resident 2 thought that Resident 1 was raping him for some reasons. A review of Resident 2's Order Summary report, dated 10/30/23, indicated the physician ordered to administer Haloperidol to Resident 2 for behavior problem related to paranoid delusion believing other people are against him causing outburst of anger, Haloperidol 5 mg (milligram, a unit of weight measurement) to be given by mouth three times a day for schizoaffective disorder. A review of Resident 2's Medication Administration Record, indicated the Haloperidol was ordered on 10/30/23 at 4PM. The MAR indicated Resident 2 was not administered Haldol on 10/30/23. The MAR indicated Haldol was first administered to Resident 2 on 10/31/23 at 8 AM, (five hours after Resident 2 pounded Resident 1 on the head on 10/31/23 at 3:30 AM). A review of Resident 2's Order Summary Report, on 10/30/23 the physician ordered to administer Ativan to Resident 2 for increase agitation, aggressive behavior toward staff, The record also indicated; Ativan 1 mg was ordered to give by month every 6 hours as needed. A review of Resident 2's MAR, indicated, Ativan was ordered on 10/30/23 at 4PM, The MAR indicated Resident 2 was not administered Ativan as needed on 10/30/23. A review of Resident 2's Order Summary Report, dated 10/30/23, indicated Resident 2 the physician's ordered the staff to monitor behavior every shift related to agitation, aggressive toward staffs, and delusion and document hashmarks of 0 (meaning. no agitation, no delusion episode) or 1 (meaning, agitation or delusion presented) with the start date of 10/30/23. A review of Resident 2's Medication Administration Record, dated 12/28/23, indicated, during 11 PM on 10/30/23 to 7 AM on 10/31/23, night shift Licensed Vocational Nurse (LVN) documented 0 (no agitation or aggressive behavior and no delusion presented), following the abusive event on 10/31/23 at 3:35 AM. During an observation conducted on 12/15/23 at 12:56 PM, Resident 1 and Resident 2's rooms had a shared/common restroom located between each of their rooms. During an interview on 12/15/23 at 1:30 PM with Registered Nurse Supervisor (RNS), RNS stated, RNS stated that she did not know Resident 2 was admitted to the facility with history of diagnosed schizophrenia disorder related to aggressive behaviors. The RNS stated, she did not read Resident 2's H&P because she was not the admitting nurse. The RNS stated, she should have reviewed Resident 2's H&P, diagnoses, and orders to make sure the right care be provided to Resident 2. The RNS stated residents with history of aggressive behaviors must be monitored closely upon admission to prevent potential accidents and abuse. During a concurrent interview and record review on 12/15/23 at 2:30 PM with LVN 2, Resident 2's medical record was reviewed. LVN 2 stated, per H&P, Resident 2 was admitted to the hospital prior to transferring to the facility with chief complaint of aggressive behavior. LVN 2 stated his history of aggressive behaviors should have been addressed in the baseline care plan with strict monitoring for the safety of staffs and other residents per protocol. LVN 2 added, without the baseline care plan for aggressive behavior, the staffs was not be aware, and the resident was not be properly monitored so there would be a high chance of resident-to-resident abuse. LVN 2 stated, she must have overlooked the H&P and added, it was very important to review Resident 2's admission package because the abuse and incident should have been prevented. During an interview on 12/15/23 at 4:05 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated that the facility's policy and procedure indicated to keep the residents safe, the CNA's will visually monitor the residents for safety every 2 hours. CNA 1 stated all CNAs were responsible to document their assigned residents' whereabout every 2 hours for safety. During an interview with Director of Staff Development (DSD) on 12/15/23 at 4:45 PM, the DSD stated, LVNs and the RNS should had been checking and reminding the CNAs to document on time for their tasks and residents' whereabout because conducting timely monitoring and documentation is important to keep track of residents and prevent accidents. During an interview on 12/15/23 at 5 PM with LVN 1, LVN 1 stated she was familiar with the altercation between Resident 1 and Resident 2. LVN 1 stated that she was not aware that Resident 2 had an aggressive behavior because she did not read Resident 2's H&P. LVN 1 stated, she should have reviewed all new residents' admission information before taking care of the resident. During an interview on 12/15/23 at 5:42 PM with the Director of Nurses (DON), DON stated, according to the facility's policy, residents in the facility are monitored every 2 hours by the CNAs. DON stated that monitoring the residents with aggressive behavior was important in preventing acts of abuse. DON stated that monitoring was even more important on new residents with history of aggressive behavior. During an interview on 12/15/23 at 6 PM with the Director of Nurses (DON), DON stated, nursing staffs including the admitting nurse, RNS, LVN charge nurse were expected to review new resident's admitting package before taking care of them. DON stated, RNS and LVN charge nurse should know how to do the care plan. During an interview and concurrent record review on 12/15/23 at 6:00 PM with the DON, Resident 2's Documentation Survey Report for monitoring resident location every 2 hours was reviewed. The record indicated, there were missing entries in the CNA's monitoring log indicated that Resident 1 and Resident 2 were not monitored every two hours consistently on 10/30/23 at 4 PM, 6 PM, 8 PM, 10 PM, and on 10/31/23 at 12 AM, 2 AM, 4 AM. DON stated that if there was no documentation, the facility staffs did not provide supervision to Resident 2 at those times. DON stated that with enough supervision and proper monitoring, Resident 1's incident of being pounded on the head by Resident 2 on 10/31/23, at 3:35 AM could have been prevented. During an interview on 12/15/23 at 6:30 PM with the Administrator (ADM), the ADM stated, if the documentation was blank, it meant the facility staffs did not do their job. A review of the facility's policy titled, Procedure for Prevention of Resident abuse and mistreatment, revised 12/7/21, indicated the facility will provide a safe environment as free of injury to prevent resident to resident abuse by each resident admitted will be assessed for aggressive behavior or potential for striking out as being abusive to others (patient and staff), a plan of care will be implemented to address and prevent aggressive behaviors. A review of the facility's policy titled, Procedure for Prevention of Resident abuse and mistreatment, revised 12/7/21, indicated facility shall institute procedures that allows identification, correction, and intervention in situations in which abuse, neglect of resident is more likely to occur. Areas of identification, correction, and intervention may include but not limited to, identification of residents with potential for behavior symptoms and manifestations that may lead to conflict or anger through comprehensive assessment, care planning, and monitoring. A review of the facility's policy titled, Procedure for Prevention of Resident abuse and mistreatment, revised 12/7/21, indicated facility shall ensure care planning for residents with needs and behaviors which might lead to conflict or neglect. Samples of residents with behavioral symptoms and manifestations that may lead to conflict or anger are Residents with history of aggressive behavior. Residents with possible needs and potential for behavioral symptoms and manifestations that may lead to conflict and anger, or neglect shall be identified through comprehensive assessments, initially upon a resident's admission and continuously thereafter. A review of the facility's policy titled, Routine Resident Checks, revised July 2013, indicated that routine checks of residents are done to maintain resident safety and well-being. A review of the facility's job description for CNA's, dated 1/27/22, indicated it is the responsibility of the CNA to make actual resident rounds, providing care, and monitoring. It also indicated that it is the responsibility of the CNA to record care as given. A review of the facility's policy and procedure titled, Prevention of Resident Abuse and Treatment, revised 12/7/21, indicated that monitoring of residents shall be the responsibility of, but not limited to, direct caregivers, Charge Nurses, Nursing Supervisors, and the interdisciplinary team. The policy and procedure also indicated that samples of residents with behavioral symptoms and manifestations that may lead to conflict or anger are residents with history of aggressive behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the attending physician and the resident's representative for one 1 of 3 sampled residents (Resident 1) who was not administered and refused to take Zyprexa (an antipsychotic [a medication used to stabilize mood and behavior for residents with severe mental health conditions]) for seven times in May 2023. As a result of this deficient practice on 6/7/23 Resident 1 was transferred to a General Acute Care Hospital (GACH) due to severe agitation, blocking entry to the room for two days, becoming violent when approached, hitting staffs, and paranoid (false belief or disconnection to reality, and was placed on 51/50 hold ( a 72 hold to monitor a resident in the hospital or controlled environment with behavior that post danger to him/herself and others). Findings: A review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included diabetes (a health condition that the body has excess sugar in the blood), psychosis (a mental disorder characterized by a disconnection from reality), and schizoaffective disorder (a mental health problem when the person experience psychosis and mood symptoms). A review of Resident 1's physician order, dated 2/14/2023, timed at 2:01 PM, indicated the psychiatrist (a physician specialized in treating behavioral and mental disorder) indicated to administer Zyprexa 5 milligrams (mg, unit of measure) 1 tablet by mouth at bedtime to Resident 1 for schizophrenia (a serious mental disorder in which people interpret reality abnormally) as manifested by episodes of loud verbal outburst to staff. A review of the physician's order, dated 6/7/23, timed at 11:59 AM, indicated to transfer Resident 1 to the hospital vis 51/50 hold for further evaluation. A review of the police report, dated 6/7/23, timed at 1:15 PM, indicated Resident 1 was placed on a 51/50 hold, due to severe agitation, blocking entry to the room for two days, becoming violent when approached, hitting staffs, refused to take medications and paranoid that staff was poisoning him. During an interview on 6/16/2023 at 12:45 PM, the Administrator (ADM) stated Resident 1 had an episode of behavior issue by attacking staff on 6/4/23. During an interview on 6/16/2023 at 1:34 PM, the Acting Director of Nursing (ADON) stated, Resident 1's psychiatrist ordered Resident 1 to be transferred to the GACH on 6/7/2023 due to behavior issues. A review of Resident 1's care plan, dated 2/15/23, indicated Resident 1 was non-compliant to treatment and refusing medication. The interventions included to include the significant other of the resident care to gain cooperation. The intervention did not include to notify the physician for Resident 1's refusal to take medications. During an interview on 6/16/23 at 2:30 PM, the ADON stated, Resident 1 had been refusing medications. The ADON stated Resident 1's refusal to take Zyprexa could result in escalated behaviors and decline in health condition. During an interview and concurrent record review on 6/16/2023 at 3:39 PM, Resident 1's electronic Medication Administration Record (eMAR) conducted with the ADON. The ADON stated according to the eMAR Resident 1 refused to take Zyprexa seven times in May 2023 and one time in June 2023. ADON stated Resident 1 refused to take Zyprexa on the following dates, 5/8/23, 5/9/23, 5/12/23, 5/14/23, 5/15/23, 5/16/23, and 5/17/23 and 6/5/23. The ADON stated, according to Resident 1's clinical records from 5/1/2023 through 6/7/2023 there were no evidence that the facility notified Resident 1's attending physician or significant other of Resident 1's refusal to take Zyprexa or w when the resident not administered Zyprexa. A review of the facility undated policy and procedures, titled Medication Refusal, indicated Medication refusal will be documented and attending physician will be notified. If the resident refuses the administration of medication, for three consecutive doses or days (if prescribed daily), the attending physician will be notified. The notification of attending physician, family member, concerned party and the physician's orders will be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to ensure medication administration were properly documented when given for one of three sampled residents (Resident 1). The facility staff did not document in the resident's electronic medication administration record (eMAR) that Resident 1 received Zyprexa (brand name for olanzapine, an antipsychotic medication that stabilize mood and behavior and to treat severe mental health conditions) on 5/18/2023, 5/19/2023, and 5/20/2023. In addition, Resident 1 had behavior of refusing to take medications for seven days in May 2023 and one day in June 2023. This deficient practice resulted in Resident 1's increased violent, aggressive behavior, and was a danger to self and other by hitting the staffs and blocking entry to the room for 2 days. Resident 1 was transferred to the hospital on 6/7/23 on 51/50 hold (a 72 hold to monitor a resident in the hospital or controlled environment with behavior that post danger to him/herself and others). Cross reference to F580 Findings: A review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnosis that included, unspecified psychosis (a mental disorder characterized by a disconnection from reality) and schizoaffective disorder (a mental health problem when the person experience psychosis and mood symptoms). A review of Resident 1's physician order, dated 2/14/2023 at 2:01 PM, indicated the psychiatrist ordered for the resident to receive Zyprexa 5 milligrams (mg, unit of measure) 1 tablet by mouth at bedtime for schizophrenia (a serious mental disorder in which people interpret reality abnormally) manifested by episodes of loud verbal outburst to staff. During an interview and concurrent review on 6/16/2023 at 2:02 PM with the acting Director of Nursing (ADON), the ADON confirmed the nurses did not document in the eMAR for May 2023 whether Resident 1 refused to take Zyprexa or if Zyprexa was omitted or not given during medication administration on the following dates: 5/18/2023, 5/19/2023, and 5/20/2023. The boxes in the eMAR, that indicated the dates and times Zyprexa should had been administered, were blank. The ADON confirmed the facility had no documented evidence that Zyprexa was administered, nor refused. ADON stated Resident 1 did not leave the facility in May 2023. During a concurrent review of Resident 1's licensed nurse notes in May 2023, the ADON confirmed there was no documentation regarding the reason Zyprexa was not administered. A review of the facility's policy and procedure, revised on July 2017, titled Charting and Documentation indicated, the following information should be documented in the resident medical record, the medications that was administered, the care-specific details, the date and time the procedure/treatment was provided and, how the resident tolerated the procedure or whether the resident refused the procedure/treatment.

Based on observation, interview, and record review, the facility failed to maintain a safe and functional environment by failing to ensure the latch bolt (a part of a lockset that allows the bolt to retract to prevent the door from swinging open) were in good working condition for two of 6 sampled residents (Residents 3 and 5). Resident 3 and 5's cabinets did not fully closed or remained closed inside the shared residents ' rooms to ensure the residents personal belongings were safely stored. This deficient practice had the potential to have Resident 3 and 5's belongings to be misplaced, or subjet to theft and loss. Findings: During an observation of Resident 5 ' s room on 5/16/23 at 11:45 AM, in the presence of the Director of Nurses (DON), the cabinet in the center of the shared room which belonged to Resident 5 was observed open. Upon closer inspection of the cabinet, the latch bolt used to maintain the cabinet closed was observed not working appropriately. The DON stated all cabinet locks must work for the residents to have a safe space to keep their personal belongings in the shared rooms. The DON stated it is all staff ' s responsibility to report if something in a resident ' s room is not working properly and it must be reported immediately once it is found. During an interview, on 5/16/23 at 11:46 AM, CNA 6 stated she had reported the problem to the Maintenance department the other day and wrote it in the maintenance log. CNA 6 stated when something is broken it should be reported immediately. During an observation of Resident 3 ' s Room on 5/16/23 at 11:59 AM., in the presence of the DON, the cabinet of Resident 3 was observed open. Upon closer inspection, the latch bolt used to maintain the cabinet closed was observed not in working condition. During an interview on 5/16/23 at 12:01 PM, w CNA 7 stated the problem to maintenance department over a week ago and wrote it in the maintenance log. A review of the facility ' s binder titled Daily Maintenance Log problem dated 3/8/23 to 5/16/23, did not indicate that the cabinets lock for Resident 3 and 5 ' s rooms had been reported to the Maintenance Department. A review of the facility ' s policy titled, Physical Environment Policy, indicated 1.Maintain all essential mechanical, electrical and patient care equipment in safe operation condition i.e scales, mechanical lifts, beds, bedrails, wheel locks, bed cranks, night stands, dresser, closets, overbed table, shower curtains, wheelchairs, gerichairs and call lights, and etc.

Based on observation, interview and record review the facility failed promote dignity and respect by ensuring the privacy curtains were long enough to cover the entire bed area for three of 3 sampled residents (Resident 5,6 and 8), when the staffs were performing hygiene care or when the residents request to have privacy. This deficient practice violated the resident's rights for privacy which resulted in in Resident 8 ' s feeling embarrassed and potentially cause other residents to experience psychosocial (mental, emotional, social, and spiritual effects) decline or feelings of intimidation. Findings: During an observation on 5/16/23 at 10:20 AM, Residents 8 ' s bedroom. The privacy curtain around Resident 8 ' s bed did not cover the entire bed, leaving the foot part of the bed exposed. In a concurrent interview, Resident 8 stated he has no privacy even with the privacy curtain drawn around the bed because it did not cover the entire are of the bed and It is embarrassing. Resident 8 explained he asked the staffs to change the curtain for some months now, but it was not changed. During and observation and interview on 5/16/23 at 10:11 A.M with CNA 5 stated, Resident ' s 8 ' s privacy curtain is not long enough to provide full privacy to Resident 8. CNA 5 stated she has informed charge nurse of issue but did not receive a response. During and observation on 5/16/23 at 10:40 AM of Resident 5 and 6 ' s rooms was observed with the curtain that did not cover the entire bed area to provide the resident privacy during activities of daily living such as hygiene care. Residents 5 and 6 was attempted to be interviewed but refused to be interviewed. During an interview on 5/16/23 at 11:17 AM, the Director of Nursing (DON) stated it was important for the facility to provide privacy to all residents. The DON stated she informed the Administrator (ADM) months ago that the privacy curtains around the resident ' s bed were not long enough to provide full privacy to the residents, but she did not receive a response from the ADM and the curtains were not changed. A review of the facility ' s policy titled, Dignity and Privacy, with no date , indicated, the facility will take into consideration maximum safety, dignity and privacy for residents at all times.

Based on observation, interview, and record review the facility failed to: 1. Ensure discharged Resident 9 and Resident 10 prescribed medication was removed from one of one inspected Treatment Cart (Treatment Cart 1) upon resident discharge. 2. Ensure the expired house supply medication were removed from one of one inspected Treatment Cart (Treatment Cart 1)on expiration dates indicated. 3. Ensure the label on the bottle of one prescribed medication were legible to identify the medication and the resident ' s name. These deficient practices of failing to store or label medications per the manufacturer ' s requirements or remove expired medications from the medication cart increased the risk that Residents 11, 53 and 69 could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death. Findings: During an inspection of Treatment Cart 1 and concurrent interview with Licensed Vocational Nurse (LVN) 1 on 5/16/2 at 10:48 AM, the following medications and house supplies were found either expired, stored in a manner contrary to their respective manufacturer ' s requirements, or not labeled with an open date as required by their respective manufacturer ' s specifications: 1. For Resident 9, who had been discharged from the facility on 4/11/23, an open tube of Ciclopirox cream 0.77% (a medication used to treat fungal skin infections, such as ringworm, athlete's foot) was found stored and kept in Treatment Cart 1. 2. For Resident 10, who had been discharged from the facility on 4/8/23, an open tube of Triamcinolone Acetonide (a medication used to treat certain skin diseases, allergies, and rheumatic disorders among others) 0.1% cream was found stored and kept in Treatment Cart 1. 3. An opened betadine (a solution used to help prevent infection in minor cuts, scrapes, and burns) bottle was observed with no open date stored and kept in Treatment Cart 1. 4. An opened anti-dandruff shampoo was observed with no open date and expiration date of 3/2022 stored and kept in Treatment Cart 1. 5. An opened Ammonium lactose (medication is used to treat dry, scaly skin conditions) 12% lotion was observed with no open date and unreadable resident name label stored and kept in Treatment Cart 1. LVN 1 stated the medications above were either stored improperly, expired, and unlabeled with the required open date. LVN 1 stated it was his responsibility to check the treatment cart for expired medications routinely, identify and remove medications that were present in the Treatment Cart for longer than they should be based on their expiration dates. LVN 1 stated as soon as a resident is discharged , the medications should be removed from the Treatment Cart and placed in the medication return bin. LVN 1 stated if a medication is expired and given to a resident, there is a chance it might not work as intended and could cause harm to the resident. A review of the facility ' s policy titled, Disposal of Medications and medication-related supplies, dated December 2018, indicated: When medications are expired, discontinued by a prescriber, a resident is transferred or discharged and does not take medications with him/her, or in the event of a resident ' s death, the medications are marked as discontinued, stored in a separate location and later destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to conduct and document a Facility Assessment (a facility wide assessment is a facility plan that define the process of strategizing, or directing, and making decisions on allocating its resources to enable each nursing home to thoroughly assess the needs of its resident population and the required resources to provide the care and services the residents need) to ensure the staffs have sufficient competencies (a measurable knowledge and skills) necessary to provide the care level and types of care needed for residents with GT (a tube inserted into the stomach to deliver fluids, medications and nutritional formula) and GT dislodgement (forced out of position) on a day-to-day operations and emergencies. For one of two sampled residents (Resident 1), had a newly inserted GT was dislodged and was reinserted by DON and was flushed with fluids by the LVN and the DON without confirmation that the GT was in the right position. The DON and the LVN did not have evidence of sufficient competency to perform such task. This deficient practice had resulted in Resident 1 not to recieve the emergency intervention needed to when the resident's GT was dislodgement and placed the resident at high risk for complications related to GT such as peritonitis (a life-threatening infection of the lining in the abdomen), and perforation (hole made by piercing or boring) in the peritoneal (lining of the abdominal cavity) and spillage of gastric [acidic fluid in the stomach] contents in the abdominal tissue). This deficient practice also had the potential for other residents with GT or GT dislodgement to be at risk for similar complications. Cross reference to F693 and F658 Findings: A review of Resident 1's Face Sheet (admission Record) indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted in the facility on 4/12/2023, with diagnoses that included aphasia (unable to speak), blindness, adult failure to thrive (characterized by unexplained weight loss, malnutrition and disability), with gastrostomy tube (a surgical procedure for inserting a tube through the abdomen wall and into the stomach) and chronic duodenal ulcer (a sore that forms in the lining of the duodenum, the first part of your small intestine). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 4/13/2023, indicated Resident 1 had severely impaired cognition (ability to think, understand and reason) with moderate difficulty of hearing and sometimes could express ideas and wants, and understand others. The MDS indicated Resident 1 was totally dependent with one person assistance on dressing, eating, toilet use and personal hygiene. A review of the Medication Administration Record (MAR) for April 2023, indicated, Resident 1 received 30 cc water flush before and after medication administration on 4/13/23 at 8 AM, 12 PM, 4 PM and 5 PM, a total of more than 240 cc of fluid and medications. During an interview with the Director of Nursing (DON) on 5/16/2023 at 10:04 AM, the DON stated, she inserted an indwelling catheter into Resident 1's GT stoma site, when the resident's GT was found dislodged on 4/13/23. The DON also stated she flushed the indwelling catheter at the stoma site with 50 ml (milliliter, a unit of measurement) of water without verifying if there was a physician's order to insert an indwelling catheter into the stoma site when the GT was dislodged and flush the tubing. During an interview with the Licensed Vocational Nurse (LVN) 1 on 5/16/2023 at 12:31 PM, LVN 1 validated the DON inserted an indwelling catheter when Resident 1's GT dislodged and that an X-ray (images or pictures inside of the body using) was not done to check the GT placement after she had inserted the catheter. LVN 1 explained, he contacted the specialized GT services the morning of 4/13/23 to have the resident's GT replaced after it had been dislodged, however the GT services were unable to see the resident until 4/14/23. During an interview with the Director of Staff Development (DSD) on 5/16/23 at 1:08 PM, DSD stated as a facility's practice, The DON and any licensed nurse can re-insert a GT. During an interview on 5/18/23 at 12:23 PM, the Administrator (ADM) stated upon review of the facility's Facility Assessment dated 4/7/23, indicated the Facility Assessment did not specifically indicate the necessary care and services for the residents with GT and GT dislodgement, or the competency and resources needed by the facility staffs to care for the residents with GT. The ADM stated, he will suggest to the QAPI (Quality Improvement Program Improvement- a program that determines the quality of care and life to be delivered to the residents) to add GT service to the Facility Assessment, and confirmed the facility not to accept residents with GT at this time until the staffs are provided training and competencies about GT and GT dislodgement. A review of the facility's policy and procedure, dated 1/2023, titled Facility Assessment, indicated the facility will conduct a facility assessment annually to determine and update the capacity of the facility to meet the needs of and competently care for the residents during the day to day operations and during an emergency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide appropriate and sufficient supervision to one of three sampled residents (Residents 6) ambulatory cognitively impaired (unable to understand and make decisions) residents in the East Wing Unit to reduce the risk of a known foreseeable accident hazards while working on upgrading the floor in the hallway. This deficient practice could potentially result to injuries to residents related to falls from uneven flooring. Findings: A review of Resident 6 ' s admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 6 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/8/22, indicated Resident 6 had severe impairment in cognitive skills (ability to make daily decisions) and needed supervision when walking in the corridor. During an observation on 12/6/22 at 11 AM, an incomplete gray flooring in the hallway was seen covering the original floor halfway down the hall of East Wing unit with uneven edges at the end. The hallway did not have anyone working on the unfinished flooring during the tour of the unit. Residents 6 was observed walking in the hallway of the east wing unit, no staff observed assisting or supervising while resident was walking on the uneven flooring in the hallway. During an interview on 12/6/22 at 12:15 PM, the DON stated the orange cone in the hallway was to act as a reminder to let the residents know there was a construction going on for their safety. The DON also stated there should be a caution tape across the area in addition to the orange cone. The DON stated the nurses were aware and told ahead of time to supervise residents walking along the hallway of East unit to make sure residents were safe. The DON stated, she did not know why the nurses did not supervisre Resident 6 while walking in the hallway on 12/6/22 at 11 AM. A review of the facility ' s Policy and Procedure titled, Accident Prevention, (undated), indicated, the facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control including provision of adequate supervision as indicated. The policy also stated that to provide an environment that is free from accident hazards, the facility will assess even and uneven surfaces, and proper placement of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat three of four sampled residents (Residents 3, 4, and 6) with respect by failing to ensure underwear ' s were supplied as requested. This deficient practice violated resident ' s rights to be treated with respect and has the potential to have negative psychosocial outcomes for the residents. Findings: A review of Resident 3 ' s admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 3 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/8/22, indicated Resident 3 had severe impairment in cognitive skills (ability to make daily decisions) and required supervision in dressing himself. A review of Resident 4 ' s admission Record indicated the resident was initially admitted on [DATE] and readmitted on [DATE] with a diagnosis of unspecified anxiety disorder (an intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 4 ' s MDS, dated [DATE], indicated Resident 4 had severe impairment in cognitive skills and required supervision in dressing himself. A review of Resident 6 ' s admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of unspecified schizophrenia. A review of Resident 6 ' s MDS, dated [DATE], indicated Resident 6 had severe impairment in cognitive skills and required supervision in dressing himself. During a concurrent observation and interview on 12/6/22 at 10:20 AM, Resident 3 stated he did not wear any underwear. Resident 3 stated he requested for an underwear a while back (unable to recall when and to who) but have not received any. Resident 3 ' s closet did not have any underwear to use. During an interview on 12/6/22 at 10:45 AM, Resident 4 stated he has been trying to get an underwear and asking from the facility staff for a year now. During an interview on 12/6/22 at 11:25 AM, Resident 6 stated she had an underwear, but it went missing (unable to recall when), and the facility did not replace them when she asked. During a concurrent interview and record review on 12/6/22 at 12:25 PM, Social Services Director (SSD) stated they have a log for resident ' s needs (personal items)and was usually in the nurse ' s station but were unable to provide a copy of filled out log documenting the needs of the residents. During an observation on 12/6/22 at 2:20 PM, Resident 3 told the SSD he wanted underwear and a pair of pants. During an interview on 12/6/22 at 2:34 PM, Administrator (ADM) stated he ordered a lot of clothes and underwear for residents but wanted to wait until Christmas to distribute them, so the residents have something to open. During an interview on 12/6/22 at 4:05 PM, the Director of Nursing (DON) stated underwear ' s should have been provided to the residents to keep their dignity and it is not acceptable for the residents to wait for them. During an interview on 12/15/22 at 9:54 AM, CNA 3 stated Resident 3 always asks for underwear, and it was not provided. A review of the facility ' s policy and procedure titled, Resident Rights, (undated), indicated, the facility shall treat each resident with consideration, respect, and full recognition of his/her dignity. A review of the facility ' s policy and procedure titled, Dignity and Privacy, (undated), indicated, the facility will always take into consideration maximum dignity of residents at all times. It also indicated, personal clothing and possessions provide a sense of security and when you violate patients ' rights, you also violate the LAW.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate resident needs for one of 38 sampled residents by failing to ; 1. Provide telephone access for Resident 44 in the [NAME] Side Men's Wing. 2. Ensure the light switch cord was within easy reach of Resident 44. These deficient practices had the potential for Resident 44 to not be able to achieve independent functioning and well-being in accordance with the resident's own needs and preferences. Findings: 1. A review of Resident 44's admission Record indicated the resident was admitted on [DATE], with diagnoses including muscle wasting and atrophy (occurs when muscles waste away as a result of lack of physical activity) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Resident 44's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 9/17/2021, indicated the resident had no cognitive ( ability to understand) impairment. The MDS indicated Resident 44 required supervision with bed mobility, transfers, walking and required limited assistance (staff provided guided maneuvering of limbs or other non-weight-bearing assistance) with dressing, toilet use, and personal hygiene. The MDS indicated the resident used a wheelchair for mobility and was not steady when moving on and off the toilet. During an observation on 11/2/21 at 11:44 am, Resident 44 was lying in bed. There was an overhead light on top of the bed, located on the head part of the bed. The overhead light had a cord that was 1.5 inches in length. Resident 44 stated he did not use the light because he could not reach the cord and it would be helpful to be able to use the light at night so he can see better. A review of the facility's undated Policy and Procedure titled Accommodation of Needs indicated there should be adaptations of the resident's bedroom and furniture that is reasonable for resident care needs. 2. During a concurrent observation and interview on 11/2/2021 at 11:46 am, Resident 44 stated he cannot use a phone in the facility. He states, the CNAs ( general) would tell him there's a specific time to use a phone. Resident 44 stated he asked a facility staff five days ago to use a phone and he was told he could not use the phone at that time. During an observation on 11/2/2021 at 12:21 pm, there were seven resident rooms and one staff room in the [NAME] Side Men's Wing. There was no phone inside the staff room and no phone throughout the [NAME] Side Men's Wing. A review of the facility's phone location indicated there was one public phone located in the East Wing (locked unit) and for the 3 buildings in the [NAME] Wing, the phone for the resident to use was in the nurse's station of the Women's Wing. During an observation of the Women's Wing on 11/5/2021 at 8:44 am, there were two telephones inside the nurse's station. One of the telephones did not have a cord long enough to reach the counter for residents to use. Another telephone had a cord that is not long enough to reach the counter where residents stand. In a concurrent interview, Licensed Vocational Nurse 7 (LVN 7) stated the [NAME] Wing did not have a payphone and there was no cordless phone that the residents in the [NAME] Wing can use. LVN 7 stated residents in the [NAME] Wing had to go to the nurse's station which was located in another building in order for residents to access the telephone. LVN 7 stated when residents had to make a phone call he could leave the nurse's station, but he could not leave the nurse's station when he was preparing and/or passing medications. A review of the facility's undated Policy and Procedure titled Accommodation of Needs indicated residents will receive services in the facility with reasonable accommodation of individual needs and preferences. A review of the facility's undated Policy and Procedure titled Resident Rights, Purpose and Policies indicated the facility shall provide accessible telephones to all residents for making or receiving calls. The telephones are located in areas which permit access by wheelchairs, provide seating for the person using the telephone, and provide privacy for the telephone conversation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility licensed nurse failed to report a resident's fall to the physician for one of six sampled residents ( Resident 10). This deficient practice had the potential for Resident 10 not to receive needed care and services in a timely manner after a fall and to prevent further falls. Findings: A review of Resident 10's admission Record indicated the resident was admitted on [DATE], with diagnoses including bipolar disorder (a mental health illness that causes extreme mood swings) and schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real). A review of Resident 10's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 8/10/2021, indicated the resident had no cognitive ( ability to understand) impairment, was able to express ideas and wants and able to understand others. The MDS indicated the resident required supervision with bed mobility, transfers, walking and eating and required limited assistance (staff provide guided maneuvering of limbs of other non-weight-bearing assistance) with dressing and toilet use. During an observation on 11/1/2021 at 1:26 pm inside Resident 10's room, the resident was lying on the floor with his left arm under him, the wheelchair was beside him and Licensed Vocational Nurse 2 (LVN 2) was inside the room. There was a left knee open wound on Resident 10. Certified Nursing Assistant 1 (CNA 1) came and assisted LVN 2 move the resident back to the wheelchair. During an interview on 11/1/2021 at 1:32 am, Resident 10 stated he came out of the restroom and fell out of the chair. Resident 10 stated he hit his left shoulder and his head on the floor. A review of Resident 10's Nurse's Notes did not indicate the resident's fall was documented and there was no documentation the physician was notified of the resident's fall incident. During an interview with LVN 2 on 11/3/2021 at 12:41 pm, she stated she called the doctor's office to notify the physician regarding Resident 10's fall but she could not remember the person she gave the report. During an interview with the Director of Nursing (DON) on 11/3/2021 at 1:16 pm, he stated if there was a fall incident, the charge nurse needed to notify the attending physician so the physician can be made aware and provide MD orders after the fall. During a telephone interview on 11/10/21 at 11:07, Resident 10's attending physician stated he was not notified of Resident 10's fall incident on 11/1/2021. A review of Resident 10's plan of care for Fall revised on 11/26/2020, indicated to notify the physician as needed. A review of the facility's List of Resident Rights dated December 1991, indicated the facility must immediately consult with the resident's physician when there is an accident involving the resident and has the potential for requiring physical intervention. A review of the facility's Policy and Procedure titled Documentation in the Medical Record indicated Documentation of Physician Notification shall be completed as follows; a. Date of notification b. Time of notification c. Name of person receiving notification d. Response of person receiving notification

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to thoroughly investigate Resident 10's fall episode on 11/1/2021. This deficient practice had the potential to put Resident 10 at risk for repeated falls, injury, and harm. Findings: A review of the admission Record indicated Resident 10 was admitted on [DATE], with diagnoses that included bipolar disorder (a mental health illness that causes extreme mood swings that include emotional highs [mania] and lows [depression], and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of the Minimum Data Set (MDS - an assessment and care planning tool), dated 8/10/21, indicated Resident 10 had no cognitive (mental action or process of acquiring knowledge and understanding) impairment, was able to express ideas and wants and was able to understand others. During a concurrent observation with Licensed Vocational Nurse 2 (LVN 2) on 11/1/2021 at 1:26 pm inside Resident 10's room, Resident 10 was lying on the floor sideways. The wheelchair was observed beside Resident 10. Resident 10 was observed to have sustained a left knee open wound. Certified Nursing Assistant 1 (CNA 1) came and assisted LVN 2 move Resident 10 back into the wheelchair. During a concurrent observation and interview on 11/1/2021 at 1:32 am, Resident 10 stated he came from the restroom and then in action he reached for the floor and stated, I fell out of the chair. Resident 10 stated he hit his left arm and his head on the floor when he fell. During a concurrent record review of Resident 10's clinical record and interview with LVN 2 on 11/3/2021 at 12:41 pm, LVN 2 confirmed that there was no documentation of Resident 10's fall incident dated 11/1/2021 on the change of condition report, nurses's notes, communication report to other staff and anywhere in the clinical record. During an interview on 11/3/2021 at 1:16 pm, the Director of Nursing (DON) stated if there was a fall incident, the Charge Nurse (CN) needed to inform the Registered Nurse Supervisor (RN Supervisor) and the DON. DON stated the RN Supervisor would conduct an assessment on the resident who had a fall. DON stated he needed to be informed of the Resident's fall so he could ensure processes would be followed after the fall. The DON stated the CN would need to fill up a change of condition (COC) report in order to , track fall episodes to prevent future falls. DON also stated the CN would need to notify the attending physician so he can be made aware and could provide MD orders after the fall. During an interview on 11/3/2021 at 1:28 pm, the RN Supervisor stated there was no fall reported for 11/2021. The RN Supervisor stated if a resident fall occurred, the CN assigned to the resident would need to document, complete a COC report and observe the resident for 72 hours. The RN Supervisor stated the CN would need to assess the resident for any injury and perform a neurocheck to ensure there was no head injury. RN Supervisor stated the CN should notify the RN supervisor or the DON and ask for advise if she did not know the process to follow after a fall incident. RN Supervisor stated the CN would also need to report Resident's fall incident to the doctor. The RN Supervisor stated LVN 2 who was assigned to Resident 10 did not inform him regarding Resident 10's fall incident on 11/1/2021. RN Supervisor stated Resident 10 should have been assessed for injuries from the fall. During an interview on 11/05/21 at 11:25 am, CNA 1 stated sometimes Resident 10 was unstable to walk and he would fall. CNA 1 stated, Sometimes when I walk with him, he would just fall to the floor. I was not the assigned CNA that day he fell but I saw him on the floor so I assisted the nurse to get him up from the floor. A review of the undated facility's Policy and Procedure (P&P) titled, Incidents/Accidents, indicated incidents/accidents will be reported to the charge nurse and documented on the accident/incident repost as soon as they occur. The charge nurse initiating the report will be responsible for the completeness and accuracy of the information contained in the report. The P&P indicated nursing assessment and documentation of incident on: 2. Nurse's Notes to include: a. Complete body check b. Documentation of resident's activities prior to incident c. M.D notified d. M.D orders carried out e. Family notified f. Vital signs taken with neurocheck on any head injury X72 hours 3. Care plan entry 4. Investigation incident/fall 5. Documentation of conclusion and steps taken to prevent recurrence completed within 5 days. 6. In-service as related to incident 7. Post Fall Assessment completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards for one of eight sampled residents (Resident 17) by failing to remove an unoccupied metal bed frame in Resident 17's room. This deficient practice had the potential to put Resident 17 at risk for falls, injury, and harm. Findings: A review of the admission Record indicated Resident 17 was readmitted to the facility on [DATE] with diagnoses which included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) and hypertension (increased blood pressure). A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 8/15/2021 indicated Resident 17 had clear speech, had the ability to understand others and make self understood. Resident 17 required supervision (oversight, encouragement or cueing) with set up help only for transfer, walking in room, walking in corridor and toilet use. During an observation in Resident 17's room and concurrent interview on 11/1/2021 at 9:55 am, Resident 17 was sitting on a chair, which was in between the foot board of his bed and the head board of an unoccupied metal bed frame (without a mattress). Resident 17's bed side table was infront of him with a cup of water on top of it. The head portion of the unoccupied metal bed frame was elevated and was higher than the head board, with the corners pointing outward. The space where Resident 17 sat was only enough for one chair. Resident 17 stated this was a three occupancy resident room. Resident 17 stated the unoccupied metal bed frame was in his room for awhile now. Resident 17 stated he did not know why this was stored inside the room because it was taking away a lot of space. Resident 17 stood up, pushed away his bed side table to get out of chair and walked around the room with unsteady steps while trying to hold on to support surface. During an interview on 11/1/2021 at 10:05 am, Maintenance Supervisor (MS) stated Resident 17's room should only have three beds since it was a three occupancy resident room. MS stated he did not know why the 4th bed frame was in this room. MS stated the facility should not put an extra bed in Resident 17's room. MS stated it was a dangerous environment for Resident 17 especiallyit was a metal bed frame with the corners pointing out. MS stated this was an accident hazard. MS stated if Resident 17 falls, he could injure himself by accidentally hit his head on corner of the metal bed frame. MS stated an extra bed in room took away living space from residents and limited their movement in the room. MS stated it was important to keep residents free from possible injury. A review of Resident 17's care plan, initiated 1/23/2019 indicated Resident 17 was at risk for falls/injury because of arthritis (inflammation of joints), behavioral problems, dementia (an overall term for diseases and conditions characterized by a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities). The care plan interventions included was for the staff to provide a safe and cluster-free environment. A review of the facility's undated policy and procedure titled, Accident Prevention Policy and Procedure, indicated this facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accident and/or falls, provision of adequate care plans with procedures to prevent accidents, provision of adequate supervision and provision of assistive devices as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Residents 108) with a urinary indwelling catheter (a tube inside that removes urine from the bladder to a collection bag) receive appropriate care by failing to keep the urinary indwelling catheter secured and anchored and keep the foley drainage bag below the bladder in accordance to facility policy, Resident 181's care plan and physician order. This deficient practice resulted to Resident 181's urinary catheter dislodgment and had the potential to result in catheter related complications such as urethral tear (injury to the urethra [tube-like organ that carries urine from the bladder out of the body] or to result in a delay of necessary care, treatment, and possible infection. Findings: A review of the admission Record indicated Resident 181 was readmitted to the facility on [DATE] with diagnoses of, but not limited to, urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder, ureters [tube that carries urine from the kidney to the urinary bladder], and urethra [canal from the bladder), retention of urine (difficulty urinating and completely emptying the bladder), and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). A review of the Minimum Data Set (MDS, a standardized assessment and screening tool), dated 9/16/2021, indicated Resident 181 had a short-term memory problem and impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. MDS indicated Resident 181 required supervision with transfers, walking in room, and locomotion off unit. MDS also indicated Resident 181 required limited assistance with dressing, toilet use, and personal hygiene. A review of Resident 181's Order Summary Report, dated 11/1/2021 indicated to secure Foley catheter tubing with anchor to minimize dislodging of catheter. During an observation on 11/1/2021 at 9:49 am, Resident 181 got out of bed on her own and walked in the hallway. Resident 181 pushed a pole with the enteral feeding (nutrition delivered directly to the stomach) pump attached to the pole. The Foley catheter tubing was wrapped around the pole where the enteral feeding was attached. Foley catheter tubing was not secured to Resident 181's leg. During a concurrent observation in Resident 181's room and interview on 11/1/21 at 10:15 am, Licensed Vocational Nurse 2 (LVN 2) stated Resident 181's foley catheter tubing was not secured to resident's leg and the plastic clip on the foley catheter was not clipped to anything. LVN 2 stated the foley catheter should have been secured to avoid being pulled out. During a concurrent observation in Resident 181's room with Certified Nurse Assistant (CNA) and Licensed Vocational Nurse (LVN) on 11/1/21 at 1:39 pm, Resident 181 was observed trying to pull the foley catheter out. Resident 181's foley catheter was observed not secured. During an interview on 11/2/21 at 10:50 am, MDSC stated Resident 181 must go to the hospital to have the Foley catheter re-inserted because she pulled the Foley catheter out. MDSC stated Resident 181 needed catheter re-inserted due to diagnosis of urinary retention. A review of Resident 181's Change of Condition (COC)/Interact Assessment Form (SBAR), dated 11/2/2021 indicated Resident 181 pulled out her Foley catheter, was bleeding, and complained of pain. Documentation also indicated Resident 181 would be transferred to the hospital for re-insertion of the Foley catheter During an observation on 11/3/21 at 6:53 am, Resident 181 was in her bed with the foley drainage bag hanging off the enteral feeding machine. Resident 181's foley drainage bag was above her waist level. During a concurrent observation and interview with LVN 2 on 11/3/21 at 8:37 am, Resident 181 was observed to have a leg device on her right leg. LVN 2 stated the device was to keep the foley catheter in place and prevent it from being pulled out. Resident 181's foley catheter tubing was observed not secured in the device. During an interview on 11/3/21 at 1:15 pm, Restorative Nurse Assistant (RNA) stated the foley drainage bag should be lower than her bladder, if not the urine could backflow and cause an infection. RNA stated the Foley catheter tubing should be attached to Resident 181's leg to prevent it from being pulled out. A review of Resident 181's Care Plan for Foley Catheter, initiated on 10/29/2021 and revised on 11/2/2021 indicated staff interventions were for the staff maintain proper alignment of the foley catheter to promote proper drainage. A review of Resident 181's Care Plan titled, Change of Condition, dated 11/2/2021, indicated staff interventions were for the nurse to provide standard nursing care, reassurance, alleviate pain or discomfort as needed and for a resident to be assessed by licensed nurse. A review of the facility's undated policy titled, Foley Catheter Maintenance, indicated staff interventions were to never elevate the drainage bag to or above the level of the bladder with the objective to prevent backflow.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to follow physician's order for G-tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding in accordance with professional standards of practice for one of five sampled residents (Resident 27.) This deficient practice had the potential for Resident 27 not to receive needed nutrition which could lead to malnutrition. Findings: A review of Resident 27's admission record indicated the resident was readmitted to the facility on [DATE] with diagnosis including dysphagia (difficulty swallowing), and Gastrostomy (the creation of an artificial external opening into the stomach for nutritional support or medication administration ). A review of Resident 27's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 9/1/2021 indicated the resident had unclear speech, usually understood others and made self understood. Resident 27 required total dependence (full staff performance every time) with one person physical assistance for transfer, eating and personal hygiene. A review of Resident 27's Order Summary Report for active orders as of 11/1/2021 indicated an order of enteral feeding, once a day of Jevita 1.5 CAL ( formula that provides complete, balanced nutrition for tube feeding) at 55 milliliters (ml- unit of measurement) per (each) hour for 8 hours via pump to provide 440 ml/660 kcal per day, to start from 6 PM to 2 AM. During an observation on 11/1/2021 at 12:30 pm, Resident 27 was sitting on a wheelchair in his room. One staff was feeding Resident 27. Resident 27 completed 100 percent (%) of his meal. During an observation on 11/3/2021 at 8:09 am, Resident 27 was lying in bed with G-Tube pump at bedside with Jevita 1.5 CAL bottle hanging on a pole and the pump was not running. In a concurrent interview, Licensed Vocational Nurse 2 (LVN 2) verified a total of 297 ml of Jevita 1.5 CAL was delivered to Resident 27. LVN 2 stated the daily feeding time to Resident 27 was scheduled from 6 PM to 2 AM to deliver 440 ml of Jevita 1.5 CAL as ordered. LVN 2 stated the licensed nurse from the previous shift should run the tube feeding for Resident 27 until 440 ml was delivered. LVN 2 stated Resident 27 did not receive then full amount of tube feeding of 440 ml of Jevita 1.5 CAL on 11/3/21. LVN 2 stated Resident 27 was at risk for weight loss and tube feeding was to provide the resident the necessary nutrition and hydration to promote physical and mental well being. A review of Resident 27's care plan revised 7/1/2021 indicated the resident is on G-tube feeding, was at risk for aspiration (accidental breathing in of food or fluid) dehydration (body loses too much water and other fluids) weight fluctuation, weight gain or weight loss. The care plan nursing interventions included to administer enteral feedings as ordered and to check feeding bag prior to end of shift to ensure adequacy and accuracy of volume. A review of the facility's Policy and Procedure titled Enteral Nutrition revised 2019, indicated, enteral nutrition will be provided to residents who are unable to meet their nutrition and hydration needs by oral administration, nursing will be responsible for tube feeding administration.

Based on observation, interview, and record review, the facility failed to post nursing staffing information on 11/4/2021. This deficient practice had the potential for residents, resident representative and facility staff to not be aware of the nursing staffing at the facility. Findings: During an observation on 11/4/2021 at 3:56 pm, the posted nursing staffing information inside the front office was dated 11/2/2021. The front office was accessible to facility staff and/or visitors but it was not accessible to residents. During an interview on 11/4/2021 at 4:33 pm, the Director of Nursing (DON) stated the nursing staffing information should be posted daily and must be posted inside the front lobby or the staff break room. During an observation of the staff break room on 11/4/21 at 4:34 pm with the DON, there was no nursing staffing information posted inside the room. During an interview on 11/4/2021 at 4:36 pm, the DON stated the purpose of posting the nursing staffing information was to inform the staff, the residents and visitors of the daily nursing staffing at the facility. The DON stated the nursing staffing information will provide information if there was enough staff to provide care to residents for a particular day. A review of the facility's undated Policy and Procedure titled Federal Posting, indicated the facility will post Nursing Staffing Data on a daily basis per shift which includes the facility name, current date, resident census and the total number of actual hours worked by the Registered Nurses, Licensed Vocational Nurse and Certified Aides.

Based on observation, interview, and record review, the facility staff failed to ensure a. Accurate and safe recording of controlled drugs, including the provision of routine and emergency medication and biologicals for one of two refrigerator emergency kits (e-kit) in the East Wing. b. The Floor Narcotic Release Log Stock was completed to ensure accurate accounting of controlled medications. These deficient practices had the potential for abuse and diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications. Findings: a. During an observation of the e-kit in the refrigerator in the East Wing nurses station on 11/2/2021 at 12:28 p.m. with MDS Coordinator/ Registered Nurse (MDSC/RN), the e-kit was opened with yellow tag attached and Ativan ( anti anxiety medication) two milligrams ( mg- unit of measurement) was missing. During a concurrent interview, MDSC/RN stated, the pink slip of the Order Form was not dated and was checked at 10:00 pm for Resident 59 for Ativan 2mg Intramuscular ( IM) injection. The MDSC/RN stated, after the doctor has confirmed the order, the licensed nurse will inform the pharmacy the e- kit will be opened. The MDSC/RN stated the pharmacy should send the new e-kit the following day to replace the opened e kit. On 11/2/2021, at 12:47 p.m., during a record review of Resident 59's clinical record and interview with MDS assistant/Licensed Vocational Nurse (MDSA/LVN), she stated she did not see any new order for Ativan 2 mg IM for Resident 59. MDSA/LVN stated there was no order for Ativan 2 mg IM for Resident 59 for October 2021. MDSSA/LVN stated there were no documentation in the nurse's progress notes indicating Resident 59 was given Ativan 2 mg IM. During an interview with the facility's Director of Nursing (DON) on 11/2/2021, at 1:48 p.m., he stated Ativan 2 mg IM should not be given without physician's order and once the E-kit was opened, the pharmacy should replace it right away within 24 hours, per policy. During an interview with the DON on 11/4/2021, at 8:43 a.m., he stated when the doctor ordered for emergency medication from the e-kit, the licensed nurse should inform the pharmacy the e-kit will be opened, remove the medication log in the e-kit and the Order Form should be dated, timed and indicated the resident's name and when the e-kit was opened. The DON stated when the e-kit is intact, a red tag is attached and when the e kit was opened, a yellow tag is attached. The DON stated, once the e-kit is opened, the pharmacy with replace the whole e-kit. b. During a record review of the Floor Narcotic Release Log with LVN 2 on 11/3/2021, at 12:03 p.m., the following days were blank with no on-coming nurse's signatures and no outgoing nurse's signatures for 9/27/2021, 9/28/2021,10/4/2021, 10/5/2021, 10/21/2021, 10/23/2021, 10/29/2021, 10/30/2021, 10/31/2021, 11/1/2021. In a concurrent interview, LVN 2 stated every shift needs to do a narcotic count. LVN 2 stated blank boxes indicated licensed staff did not do the narcotic count on that day. LVN 2 stated, narcotics count was needed to ensure accuracy of the ordered narcotics and if there was a discrepancy it can be reported to the DON immediately. A review of the facility's Policy and Procedure titled Medication Storage In the Facility dated August 2014, indicated for controlled medication storage at each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. Emergency Pharmacy Service and Emergency Kits, is available on a 24 hours basis. Emergency needs for medication are met by issuing the facility's approved emergency medication supply or by special order from the provider pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dignity and respect for three of 38 sampled residents (Residents 181, 8, and 40) by failing to: a. Ensure Resident 181's Foley catheter (a tube that is inserted into the bladder to drain the urine) drainage bag was covered. b. Ensure Certified Nursing Assistant 2 (CNA 2) and CNA3 did not stand over Residents 8 and 40 while assisting with meals. These deficient practices had the potential to affect the residents' self-esteem and self-worth. Findings: a. A review of Resident 181's admission Record indicated the resident was readmitted to the facility on [DATE] with a diagnoses including urinary tract infection (an infection in any part of the urinary system), retention of urine (difficulty urinating and completely emptying the bladder), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 181's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/16/21, indicated Resident 181 had short-term memory problem and her daily decision making was moderately impaired. The MDS indicated Resident 181 required supervision with transfers, walking in room, and locomotion off unit. The MDS indicated Resident 181 required limited assistance with dressing, toilet use, and personal hygiene. During an observation on 11/1/21 at 9:49 am, Resident 181 was walking in the hallway with foley catheter drainage bag (bag that collects urine) was not covered. During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2) on 11/1/21 at 10:15 am, she stated was responsible for Resident 181's care. LVN 2 went to inside Resident 181's room and confirmed Resident 181's foley catheter drainage bag was uncovered. LVN 2 stated the foley catheter drainage bag should be covered. During a concurrent interview and observation on 11/1/21 at 12:47 pm, Resident 181's Foley bag was not covered. When asked how it makes her feel that the Foley bag is uncovered, Resident 181 stated, I don't like it. During an observation on 11/3/21 at 8:13 am, Resident 181 was walking in the hallway with uncovered foley catheter drainage bag . A review Resident 181's Care Plan for Foley Catheter dated 11/2/21 indicated staff to treat resident with respect and dignity. A review of the facility's undated Policy and Procedure, titled Privacy: Maintenance of Dignity, indicated the facility will protect the dignity of residents that includes the provision of privacy. b. A review of Resident 8's admission Record indicated the resident was admitted on [DATE], with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 40's admission Record indicated the resident was admitted on [DATE], with diagnoses including dysphagia (difficulty swallowing) and bipolar disorder (a mental health illness that causes extreme mood swings). During an observation on 11/3/21 at 7:31 am, Certified Nursing Assistant 3 (CNA 3) assisted Resident 8 with breakfast and she was standing over Resident 8 who was in bed. During an observation on 11/3/21 at 7:44 am, Certified Nursing Assistant 2 (CNA 2) assisted Resident 40 with breakfast and she was standing over Resident 40 who was in bed. During an interview on 11/03/21 at 7:55 am, CNA 2 stated when assisting a resident to eat, she should be at eye level with the resident. CNA stated she could be at eye level with the resident by sitting down. CNA 2 stated being on eye level with the resident during meals convey respect. A review of the facility's undated document titled Resident Rights under Quality of Life indicated the facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1c. A review of Resident 6's admission Record indicated the resident was admitted to facility on 7/22/2020, and readmitted on [DATE], with diagnoses including paranoid schizophrenia (a type of schizophrenia (mental disorder) associated with feelings of being persecuted or plotted against) A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 8/8/2021 indicated the resident's cognitive ( ability to understand) skills for daily decision making was intact. The MDS indicated the resident required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 6 was re-admitted on [DATE] and received antipsychotic medication during the last 7 days or since admission/entry. A review of Resident 6's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 6 was not performed as ordered and medication administration was not done. Entries on MAR were blank for the following: - 10/2/2021 (night shift) for monitoring behavior related to schizophrenia, cognitive impairment, adverse side effects for parkinsonism, akathisia, tradive dyskinesia, potential side effects for the use of haloperidol/zyprexa, oxygen saturation monitoring, monitoring s/sx of Covid 19, pain assessment, monitoring BP every shift(night shift) and monitoring for orthostatic hypotension on evening shift every Friday - 10/3/2021 for administration of Protonix 40 mg for GERD at 6:00 am. During an interview on 11/03/2021 at 1:40 PM, MDS Assistant stated monitoring Resident 6 and medication administration were done. MDS Assistant stated if the MAR was blank, it does not indicate it was not done, but rather it was just not charted. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the medication was not given or that the resident was not monitored for that day, as ordered. DON stated the MAR should be completed . 1d. A review of Resident 9's admission Record indicated the resident was admitted to facility on 8/1/19 and readmitted on [DATE], with diagnoses including schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real). A review of Resident 9's Minimum Data Set, dated [DATE], indicated Resident 9's cognitive skills for daily decision making was intact. The MDS indicated Resident 9 required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 9 was re-admitted on [DATE] and received antipsychotic medication during the last 7 days or since admission/entry. A review of Resident 9's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 9 was not performed as ordered and medication administration was not done. Entries on MAR were blank for the following: - On 10/1/2021 and 10/2/2021 (night shift) for pain assessment, monitoring s/sx of Covid 19, monitoring for side effects of zyprexa, adverse side effects for tardive dyskinesia, parkinsonism, akathisia, monitoring behavior for schizophrenia and monitoring for cognitive impairment. - On 103/2021 for administration of famotidine 20 mg for GERD at 6:00 am. During an interview on 11/03/2021 at 1:40 PM, MDS Assistant stated monitoring Resident 9 and medication administration was done. MDS Assistant stated if the MAR was blank, it does not indicate it was not done, but rather it was just not charted. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the medication was not given or that the resident was not monitored for that day, as ordered. DON stated the MAR should be completed . 1e. A review of Resident 43's admission Record indicated the resident was admitted to facility on 9/9/2021 with diagnoses including type 2 diabetes mellitus (high blood sugar), muscle wasting and atrophy (a loss of muscle mass due to the muscle weakening and shrinking) and psychotic disorder (a condition that causes loss of reality). A review of Resident 43's Minimum Data Set, dated [DATE] indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated Resident 43 required supervision to extensive assistance from staff for activities of daily living. The MDS indicated Resident 43 received antipsychotic and hypnotic medications during the last 7 days or since admission/entry. A review of Resident 43's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 43 was not performed as ordered and medication administration was not done. Entries on MAR were blank for the following: - On 10/1/2021 and 10/2/2021 (night shift) for pain assessment, side effects for the use of depakote/zyprexa, monitor for adverse side effects akathisia/tardive dyskinesia, cognitive impairment, parkinsonism,psychosis, psychotic delusion. - On 10/2/2021 and 10/3/2021 for monitoring s/sx of Covid 19. - On 10/3/2021 ( morning shift) for monitoring for side effects for the use of depakote/zyprexa, monitoring for cognitive impairment and Parkinson, monitor behavior for psychosis. - On 10/3/2021 for administering Humulin 70/30 insulin 32 units subcutaneous injection related to diabetes. - On 10/4/2021, 10/5/2021, 10/6/2021 for administering Humalog injection per sliding scale for 11:30 am. During an interview on 11/03/2021 at 1:40 PM, MDS Assistant stated monitoring Resident 43 and medication administration was done. MDS Assistant stated if the MAR was blank, it does not indicate it was not done, but rather it was just not charted. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the medication was not given or that the resident was not monitored for that day, as ordered. DON stated the MAR should be completed . 1f. A review of Resident 66's admission Record indicated the resident was admitted to facility on 3/27/2014 and readmitted on [DATE], with diagnoses including paranoid schizophrenia. A review of Resident 66's Minimum Data Set, dated [DATE], indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated the resident required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 66 received antipsychotic medication during the last 7 days or since admission/entry. A review of Resident 66's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 66 was not performed as ordered and medication administration was not done. Entries on MAR were blank for the following: - On 10/29/2021 (day shift) for pain assessment, monitoring for side effects of the use of risperdal/depakote/seroquel, monitoring for tardive dyskinesia and monitoring for s/sx of Covid 19. During an interview on 11/3/2021 at 1:40 PM, MDS Assistant stated monitoring Resident 66 and medication administration was done. MDS Assistant stated if the MAR was blank, it does not indicate it was not done, but rather it was just not charted. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the medication was not given or that the resident was not monitored for that day. 2a. A review of Resident 43's admission Record indicated the resident was admitted to facility on 9/9/2021 with diagnoses including type 2 diabetes mellitus (high blood sugar), muscle wasting and atrophy (a loss of muscle mass due to the muscle weakening and shrinking) and psychotic disorder (a condition that causes loss of reality). A review of Resident 43's Minimum Data Set, dated [DATE] indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated Resident 43 required supervision to extensive assistance from staff for activities of daily living. The MDS indicated Resident 43 received antipsychotic and hypnotic medications during the last 7 days or since admission/entry. A review of Resident 43's Informed Consent for Zyprexa medication, dated 10/6/2021 indicated the ordering physician's signature was missing. The consent indicated the resident consented for medication and the facility's representative signature and date were documented. During an interview on 11/4/2021 at 3:55 p.m., DON stated the ordering physician had 14 days to sign the Informed Consent and that nurses should not continue giving the medication if there's no physician's signature. 2b. A review of Resident 66's admission Record indicated the resident was admitted to facility on 3/27/2014, and readmitted on [DATE], with diagnoses including paranoid schizophrenia. A review of Resident 66's Minimum Data Set, dated [DATE], indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated the resident required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 66 received antipsychotic medication during the last 7 days or since admission/entry. A review of Resident 66's Informed Consent for Seroquel, Risperdal and Depakote medications, all dated 2/25/2020 indicated the ordering physician's signature was missing. The Informed Consents were obtained through the phone and consent was given by the resident's mother. The consent indicated tthe facility's representative signature and date were documented. During an interview on 11/4/2021 at 3:55 p.m., DON stated the ordering physician had 14 days to sign the Informed Consent and that nurses should not continue giving the medication if there's no physician's signature. 2c. A review of Resident 81's admission Record indicated the resident was admitted to facility on 3/27/2020, and readmitted on [DATE], with diagnoses including dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and schizophrenia . A review of Resident 81's Minimum Data Set, dated [DATE], indicated the resident's cognitive skills for daily decision making was severely impaired and required limited assistance to total dependence from staff for activities of daily living. The MDS indicated Resident 81 did not receive any medication during the last 7 days. A review of Resident 81's Informed Consent for Olanzapine medication, dated 12/12/2021 indicated the ordering physician's signature was missing. The Informed Consent was obtained through the phone and consent was given by the daughter. The consent indicated the facility's representative signature and date were documented. During an interview on 11/4/2021 at 3:55 p.m., DON stated the ordering physician had 14 days to sign the Informed Consent and that nurses should not continue giving the medication if there's no physician's signature. A review of the facility's undated Policy and Procedure, titled Psychotropic Medications indicated all medications used within the facility are to be ordered by a physician and informed consent will be obtained from physician prior to administering psychotherapeutic drugs. Based on interview and record review, the facility failed to : 1. Ensure facility staff accurately complete the Medication Administration Record (MAR) for October 2021 for six of 38 sampled residents (Resident 6, 9, 43, 66, 67, and 68). 2. Obtain physician's signature for Informed Consent for medication for three of 38 sampled residents (Residents 43, 66 and 81). These deficient practices had the potential for staff not to provide needed care and services to the residents in accordance with professional standard of care. Cross Reference: F758 Findings: 1 a. A review of Resident 67's admission Record indicated the resident was admitted to facility on 8/9/2021 and readmitted on [DATE] with diagnoses including type II diabetes mellitus (high blood sugar), and epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time). A review of Resident 67's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 10/6/2021, indicated the resident's cognitive (ability to understand) skills for daily decision making was intact. The MDS indicated, Resident 67 required supervision to extensive assistance from staff for his activities of daily living. The MDS indicated Resident 67 was readmitted on [DATE] and received insulin injection medication during the last 7 days or since re-admission/entry. A review of Resident 67's Physician Orders for the month of November 2021, indicated the following: - Monitor symptoms and signs of COVID -19 - document temperature, respiratory rate, oxygen saturation every shift; the order was dated 10/12/2021. - Monitor symptoms and signs of COVID 19 - (1) cough (2) shortness of breath (3) fatigue (4) chills (5) muscle or body ache (6) sore throat (7) new loss of taste or smell (8) headache (9) congestion or runny nose (10) diarrhea (11) nausea or vomiting. Document: N for No, Y for Yes, (if Yes, indicate in the nurse's note and call medical doctor) every shift. The order was dated 10/12/2021. A review of Resident 67's Medication Administration Record for 10/1/2021 to 10/31/2021 with MDS assistant (MDSA) indicated on 10/12/2021, the morning shift staff did not document the monitoring of symptoms and signs of COVID-19 and document every shift, as ordered. During a concurrent interview on 11/3/2021 at 1:40 PM with the MDSA, confirmed the finding and stated staff did not chart and did not monitor symptoms and signs of COVID 19 as ordered. 1 b.A review of Resident 68's admission Record indicated the resident was admitted to facility on 10/1/2021 with diagnoses including type II diabetes mellitus (high blood sugar), and arteriosclerotic heart disease (thickening and hardening of the walls of the coronary arteries). A review of Resident 68's Minimum Data Set, dated [DATE] indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated Resident 68 required supervision to extensive assistance from staff for his activities of daily living. The MDS indicated Resident 68 received the following medications: insulin injection, antipsychotic, and antidepressant medications during the last 7 days or since admission/entry. A review of Resident 68's History and Physical dated 10/5/2021 indicated the resident was able to make decisions for activities of daily living. A review Resident 68's recapitulated Physician Orders for the month of November 2021 indicated the following: - Monitor behavior for major depressive disorder manifested by (m/b) self expression of sadness, and tally wish yashmaks 0=absence 1=presence every shift for the use of Duloxetine. - Monitor behavior for major depressive disorder m/b panicky feeling causing stress, and tally with hashmarks 0=absence 1=presence every shift for the use of Trazodone. - Monitor behavior for schizophrenia m/b extreme negative thoughts interfering with daily living and self care, and tally with hashmarks 0=absence 1= presence every shift for the use of Seroquel. - Monitor anticoagulation medication for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, bleeding in any orifices, abnormal labs. Document: N, if monitored and none observed. Document: Y if monitored and any of the above observed. - Notify medical doctor (MD) and document in nurses' progress notes every shift for aspirin. - Monitor adverse side effect (ASE) for cognitive impairment and tally with hashmarks 0=absence 1=presence every shift. - Monitor ASE for Parkinson syndrome (unchanging facial expression, drooling, tremors, rigidity) and tally with hashmarks 0=absence 1=presence every shift. - Monitor ASE for akathisia (motor restlessness, anxiety) and tally with hashmarks 0=absence 1=presence every shift. - Monitor ASE for tardive dyskinesia (involuntary movements of tongue, jaw, face and mouth) and tally with hashmarks 0=absence 1=presence every shift. - Monitor for potential side effects of anti depressant (Duloxetine) such as sedation, drowsiness, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, weight gain, weight loss, 0=absence 1=presence every shift. - Monitor for potential side effects of anti depressant (Trazadone) such as sedation, drowsiness, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, weight gain, weight loss, 0=absence 1=presence every shift. - Monitor for potential side effects of antipsychotic (Seroquel) such as sedation, drowsiness, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, shuffling gait, drooling, weight gain, photosensitivity. - Monitor for symptoms and signs of Covid-19 and document, temperature, respiratory rate, oxygen saturation every shift. Monitor symptoms and signs of Covid -19. 1-cough, 2-shortness of breath, 3-fatigue, 4-chills, 5-muscle or body ache, 6-sore throat, 7- new loss of taste or smell, 8-headache, 9-congestion or runny nose, 10-diarrhea, 11-nausea or vomiting. Document: N=no, Y=yes, (if Yes, indicate in the nurse's note and call medical doctor) every shift. - Pain assessment (0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10=very severe pain) every shift. - Aspirin 325 milligram (mg- unit of measurement) by mouth one time a day for pain. - Duloxetine capsule delayed release sprinkle 30 mg 1 capsule by mouth one time a day related to major depressive disorder, single episode, m/b self expression of sadness. - Lantus Solostar Solution Pen-injector (insulin Glargine) 100 unit/milliliter (U/ml) inject 20 units subcutaneously (SQ) every morning and at bedtime related to type II diabetes mellitus without complications, ordered 10/1/21, - Insulin Lispro solution inject per sliding scale, ordered 10/1/21. - Seroquel tablet 300 mg one tablet by mouth at bedtime related to schizophrenia m/b extreme negative thoughts interfering with daily living and self care. - Seroquel tablet 50 mg one tablet by mouth two times a day related to schizophrenia m/b extreme negative thoughts interfering with daily living and self care. - Trazodone 50 mg tablet one tablet by mouth at bedtime related to major depressive disorder, single episode, unspecified m/b panicky feeling causing stress. A review of Resident 68's Medication Administration Record for 10/1/2021 to 10/31/2021 with MDS assistant (MDSA) indicated on 10/1/2021 and 10/2/2021 the night shift staff did not document monitoring behavior for major depressive disorder, schizophrenia, cognitive impairment, parkinson syndrome, akathisia, tardive dyskinasia, side effect of antidepressant Duloxetine and Trazadone, and antipsychotic Seroquel, anticoagulation, signs and symptoms of Covid 19, and pain assessment. During a concurrent interview with MDSA on 11/3/2021 at 12:50 p.m., she confirmed the finding and stated staff did not document in the MAR as ordered. A review of the facility's undated Policy and Procedure titled Documentation in Medical Record indicated all pertinent information concerning the resident shall be documented in the resident's medical record. A review of the job description for Licensed Vocational Nurse (LVN) dated 8/23/11 included to monitor side effects of medications as indicated, provide pain medication interventions as ordered, including evaluation of interventions and provide resident teaching regarding medication as required. A review of the Job Description for Registered Nurse (RN) dated on 8/23/11, included establish and implement patient plans of care and document care provided appropriately, monitor condition changes and properly document and follow-up as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff on a 24-hour basis on 11/1/2021 and 11/3/2021 in accordance to the facility assessment. This deficient practice had the potential to delay the provision of care nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Findings: a. During an observation on 11/1/2021 from 8:29 am to 1:40 pm, there were four (4) Certified Nursing Assistants (CNAs) in the East Wing, one (1) Licensed Vocational Nurse (LVN) and 1 Registered Nurse Supervisor (RN Supervisor) assigned for both the East and [NAME] Wing. There were two CNAs in the [NAME] Wing and 1 LVN. During a review of the Facility Census on 11/1/2021, indicated there were 82 residents, 40 residents in the East Wing and 42 residents in the [NAME] Wing. During an observation and interview on 11/1/2021 at 8:29 am in the [NAME] Wing, CNA 10 stated there were two CNAs assigned in the [NAME] Wing but the other CNA was on break at that time. CNA 10 and Activity Staff 1 were observed watching the residents outside the patio. During an observation on 11/10/2021 at 9:48 am in the East Wing, Resident 79 asked for water from CNA 1. During a concurrent observation and interview on 11/1/2021 at 10:34 am in the East Wing, Resident 79 did not get water. CNA 1 stated she informed the Activities Staff to bring water. CNA 1 added they were short staffed today. CNA 1 would usually have six (6) to seven (7) CNAs assigned in the East Wing but there were only 4 CNAs today for the 6 am to 2pm shift. During a concurrent review of the Nursing Staffing Hours and the Census and Direct Service Hours Per Patient Day, dated 11/1/2021 and interview with the Director of Nursing (DON) on 11/4/2021 at 4pm, DON stated the total actual CNA hours was 1.54 hours and the Total Direct Care Hours (TDCH) was 184 hours. DON stated TDCH divided by the facility census of 82 residents calculated to an actual Direct Hours Per Patient Day (DHPPD) of 2.42 hours. During an interview on 11/5/2021 at 9:34 am, the DON stated if there was a call off and no other staff could work for the available spot, staffing resources (Nursing Registry unit) will be called. DON stated he did not look for staff because it was in the middle of the night. DON stated if the charge nurse could not get another staff to work the staff would have to work as a team. b. A review of the Nursing Staffing Assignment for 11/3/2021 indicated there were seven (7) CNAs for the 6am to 2 pm shift. A review of the posted CNA assignment in the East Wing for 11/3/2021 indicated there were five (5) CNAs on the floor. During an observation on 11/3/2021 from 6:23 am to 1:28 pm, there were 5 CNAs in the East Wing. During a review of the posted CNA assignment, dated 11/3/2021, the two CNAs (CNA 15 and CNA 16) included on the CNA assignment had a declaration submitted that they did not work on 11/3/2021. A review of the Nursing Staffing Assignment for 11/3/2021, indicated there were two Activity Assistants included in the calculation of DHPPD. During an observation on 11/3/2021 at 9:54 am, Activity Staff 2 was providing activities to 10 residents in the outside patio (East Wing). A review of the Census and Direct Care Service Hours Per Patient Day indicated that only direct caregivers with a nursing services assignment shall be included in the DHPPD. A review of the facility's Census and Direct Service Hours Per Patient Per Day, dated 11/3/2021, indicated CNA 15 and CNA 16 were included in the computation of CNA Direct Service Hours, the actual CNA DHPPD was 2.36 and the actual total DHPPD was 3.14 hours. During an interview with the DON on 11/5/2021 at 9:38 am, DON stated the reason why we need sufficient staff was to be able to provide sufficient care for all the residents. A review of the Facility assessment dated [DATE], indicated the facility needed NHPPD 2.4 hours for CNAs and total of 3.5 hours NHPPD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' behavior and side effects for the use of psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) for 5 of 38 sampled residents (Residents 6, 9, 43, 66 and 68) were monitored, as ordered. These deficient practices had the potential for inadequate monitoring for effectiveness, dose adjustments and adverse (harmful) consequences to the residents. Findings: 1. A review of Resident 68's admission Record indicated the resident was admitted to facility on 10/1/2021 with diagnoses including type II diabetes mellitus (high blood sugar), and arteriosclerotic heart disease (thickening and hardening of the walls of the coronary arteries). A review of Resident 68's Minimum Data Set, dated [DATE] indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated Resident 68 required supervision to extensive assistance from staff for his activities of daily living. The MDS indicated Resident 68 received the following medications: insulin injection, antipsychotic, and antidepressant medications during the last 7 days or since admission/entry. A review Resident 68's recapitulated Physician Orders for the month of November 2021 indicated the following: - Monitor behavior for major depressive disorder manifested by (m/b) self expression of sadness, and tally wish yashmaks 0=absence 1=presence every shift for the use of Duloxetine. - Monitor behavior for major depressive disorder m/b panicky feeling causing stress, and tally with hashmarks 0=absence 1=presence every shift for the use of trazodone. - Monitor behavior for schizophrenia m/b extreme negative thoughts interfering with daily living and self-care, and tally with hashmarks 0=absence 1= presence every shift for the use of Seroquel. - Monitor anticoagulation medication for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, bleeding in any orifices, abnormal labs. Document: N, if monitored and none observed. Document: Y if monitored and any of the above observed. - Notify medical doctor (MD) and document in nurses' progress notes every shift for aspirin. - Monitor adverse side effect (ASE) for cognitive impairment and tally with hashmarks 0=absence 1=presence every shift. - Monitor ASE for Parkinson syndrome (unchanging facial expression, drooling, tremors, rigidity) and tally with hashmarks 0=absence 1=presence every shift. - Monitor ASE for akathisia (motor restlessness, anxiety) and tally with hashmarks 0=absence 1=presence every shift. - Monitor ASE for tardive dyskinesia (involuntary movements of tongue, jaw, face and mouth) and tally with hashmarks 0=absence 1=presence every shift. - Monitor for potential side effects of anti-depressant (duloxetine) such as sedation, drowsiness, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, weight gain, weight loss, 0=absence 1=presence every shift. - Monitor for potential side effects of anti-depressant (trazadone) such as sedation, drowsiness, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, weight gain, weight loss, 0=absence 1=presence every shift. - Monitor for potential side effects of antipsychotic (seroquel) such as sedation, drowsiness, dry mouth, blurred vision, constipation, postural hypotension, urinary retention, shuffling gait, drooling, weight gain, photosensitivity. - Duloxetine capsule delayed release sprinkle 30 mg 1 capsule by mouth one time a day related to major depressive disorder, single episode, m/b self-expression of sadness. - Seroquel tablet 300 mg one tablet by mouth at bedtime related to schizophrenia m/b extreme negative thoughts interfering with daily living and self-care. - Seroquel tablet 50 mg one tablet by mouth two times a day related to schizophrenia m/b extreme negative thoughts interfering with daily living and self-care. - Trazodone 50 mg tablet one tablet by mouth at bedtime related to major depressive disorder, single episode, unspecified m/b panicky feeling causing stress. A review of Resident 68's Medication Administration Record for 10/1/2021 to 10/31/2021 with MDS assistant (MDSA) indicated on 10/1/2021 and 10/2/2021 the night shift staffs did not document monitoring of behavior for major depressive disorder, schizophrenia, cognitive impairment, Parkinson syndrome, akathisia, tardive dyskinesia, side effect of antidepressant duloxetine and trazadone, and antipsychotic seroquel. During a concurrent interview with MDSA on 11/3/2021 at 12:50 p.m., she confirmed the finding and stated staff did not document in the MAR as ordered on 10/1/2021 and 10/2/2021. 2. A review of Resident 6's admission Record indicated the resident was admitted to facility on 7/22/2020, and readmitted on [DATE], with diagnoses including paranoid schizophrenia (a type of schizophrenia (mental disorder) associated with feelings of being persecuted or plotted against) A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 8/8/2021 indicated the resident's cognitive (ability to understand) skills for daily decision making was intact. The MDS indicated the resident required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 6 was re-admitted on [DATE] and received antipsychotic medication during the last 7 days or since admission/entry. A review of Resident 6's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 6 was not performed as ordered. For 10/2/2021 night shift, monitoring behavior related to schizophrenia, cognitive impairment, adverse side effects for parkinsonism, akathisia, tardive dyskinesia, potential side effects for the use of haloperidol/zyprexa were not documented in the MAR. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the resident was not monitored for that day, as ordered. DON stated the MAR should be completed. 3. A review of Resident 9's admission Record indicated the resident was admitted to facility on 8/1/2019 and readmitted on [DATE], with diagnoses including schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real). A review of Resident 9's Minimum Data Set, dated [DATE], indicated Resident 9's cognitive skills for daily decision making was intact. The MDS indicated Resident 9 required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 9 was re-admitted on [DATE] and received antipsychotic medication during the last 7 days or since admission/entry. A review of Resident 9's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 9 was not performed as ordered. For 10/1/2021 and 10/2/2021 night shift, monitoring for side effects of zyprexa, adverse side effects for tardive dyskinesia, parkinsonism, akathisia, monitoring behavior for schizophrenia and monitoring for cognitive impairment was were not documented in the MAR. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the resident was not monitored for that day, as ordered. DON stated the MAR should be completed. 4. A review of Resident 43's admission Record indicated the resident was admitted to facility on 9/9/2021 with diagnoses including psychotic disorder (a condition that causes loss of reality). A review of Resident 43's Minimum Data Set, dated [DATE] indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated Resident 43 required supervision to extensive assistance from staff for activities of daily living. The MDS indicated Resident 43 received antipsychotic and hypnotic medications during the last 7 days or since admission/entry. A review of Resident 43's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 43 was not performed as ordered. Entries on MAR were blank for the following: - On 10/1/2021 and 10/2/2021 (night shift) side effects for the use of depakote /zyprexa, monitor for adverse side effects akathisia/tardive dyskinesia, cognitive impairment, parkinsonism, psychosis, and psychotic delusion were not done. - On 10/3/2021 (morning shift) for monitoring for side effects for the use of depakote/zyprexa, monitoring for cognitive impairment and Parkinson and monitoring behavior for psychosis were not done. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the resident was not monitored for that day, as ordered. DON stated the MAR should be completed. 5. A review of Resident 66's admission Record indicated the resident was admitted to facility on 3/27/2014 and readmitted on [DATE], with diagnoses including paranoid schizophrenia. A review of Resident 66's Minimum Data Set, dated [DATE], indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated the resident required supervision to limited assistance from staff for activities of daily living. The MDS indicated Resident 66 received antipsychotic medication during the last 7 days or since admission/entry. A review of Resident 66's Medication Administration Record (MAR) for 10/01/2021 to 10/31/2021 indicated monitoring of Resident 66 was not performed as ordered. For 10/29/2021 day shift, monitoring for side effects of the use of risperdal/depakote/seroquel and monitoring for tardive dyskinesia were not done. During an interview on 11/4/2021, at 3:15 p.m., the Director of Nursing (DON) stated when there was a blank entry on the MAR it means the resident was not monitored for that day as ordered. DON stated the MAR should be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: a. Ensure one expired vial of tuberculin (skin test to help diagnose tuberculosis [TB] infection) was not stored in the refrigerator to store medications for residents. This deficient practice had the potential for staff to use expired medication for the residents. b. Ensure one staff specimen of COVID-19 swab test was not stored in the refrigerator to store medication for residents. This improper storage practice had the potential to result in adverse consequences for the residents. Findings: a. During an observation of the medication storage refrigerator in the East Wing with Registered Nurse 1 (RN1) on [DATE] at 12:01 p.m., one vial of tuberculin had an open date of [DATE]. During a concurrent interview, RN1 stated the tuberculin vial was expired and should not be kept in the refrigerator and must be safely disposed. RN 1 stated, expired medication should be placed into the red plastic bag and should not be kept inside the refrigerator to store medications for residents During an interview with the Director of Nursing (DON) on [DATE], at 12:10 p.m., he stated the tuberculin vial must be removed from the refrigerator and disposed per policy. A review of the facility's Policy and Procedure, titled Guide for Special Handling of Medications revised [DATE], indicated Tubersol, Aplisol should be stored in the refrigerator and discarded 30 days after opening. A review of the facility's Policy and Procedure titled Skilled Nursing Pharmacy dated [DATE], indicated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. b. During an observation of the medication storage refrigerator in the East Wing with Registered Nurse 1 (RN1) on [DATE] at 12:01 p.m., one specimen of COVID 19 swab test dated [DATE] was inside the refrigerator. In a concurrent interview, RN 1 stated, the swab test belonged to a laundry personnel. RN 1 stated, the swab test was an old specimen and should not be in the resident's refrigerator to store medication. During an interview with the DON on [DATE], at 12:10 p.m., he stated the facility sends specimen to the laboratory timely and he doesn't know why the specimen was inside the refrigerator to store medications for residents. The DON stated the refrigerator was for resident only and staff specimen sample for Covid 19 swab test should not be stored in the refrigerator to store medication for residents. A review of the facility's undated Policy and Procedure titled Lab Specimen Collection indicated when physicians order laboratory tests, the specimens will be collected and placed in specimen refrigerator.

Based on observation, interview and record review, the facility failed to follow food sanitation and handling practices in accordance with professional standards for food service safety. The facility staff failed to label the date of one container with leftover tuna salad and one container with sliced ham. These deficient practices had the potential risk for food-borne illnesses (illness caused by eating or drinking contaminated food) to residents in the facility. Findings: During an observation of the facility's kitchen on 11/1/2021 at 8:25 am, one container of mixed tuna salad and one container of sliced ham were found inside one of the facility's refrigerator, without a date. In a concurrent interview, the facility's [NAME] 1 verified the findings and stated, the tuna salad was pre-mixed, ready to serve and the sliced ham was unused portion from the original package. [NAME] 1 stated he did not know when the tuna salad was mixed and when the sliced ham was opened. [NAME] 1 stated he did not know when and who placed the leftover tuna salad and sliced ham in the refrigerator. [NAME] 1 stated tuna salad containers should be labeled with the date prepared and the sliced ham container should be labeled with the date taken out from its original package. [NAME] 1 stated all leftover food should be labeled for infection control purposes and to prevent food-borne illness to residents. [NAME] 1 stated leftover food in the refrigerator without a date should be thrown away. During an interview on 11/1/2021 at 8:43 am, Dietary Supervisor (DS) stated, the kitchen staff should label food with the date it was opened or the date staff mixed the food before they put them inside the refrigerator. DS stated the purpose of labeling leftover food was to identify items for preparation time and when to discard the food for infection control and to prevent food-borne illness to residents. DS stated if spoiled food will be served to residents, they will get sick. A review of the facility's Policy and Procedure titled Left-over Food revised 2019, indicated, leftover food shall be refrigerated, dated, labeled and properly covered after meal service.

c. During an observation 11/3/2021 at 9:07 am, Certified Nursing Assistant 9 (CNA 9) just finished providing a shower to Resident 30, wheeled the resident out of the shower then went back inside to pick up dirty towels from the floor. CNA 9 did not disinfect the shower area and the shower chair after Resident 30's use. During an observation on 11/3/2021 at 9:09 am, CNA 2 assisted Resident 10 inside the shower room using the wheelchair, assisted him to sit on the shower chair and proceeded to provide shower to the resident. During an observation on 11/3/2021 at 9:22 am, CNA 2 completed assisting Resident 10 with shower and assisted the resident back to his room using the wheelchair. During an interview on 11/3/2021 at 9:34 am, CNA 2 stated she washed the shower area and the shower chair with water before and after using the shower area. CNA 2 stated she did not know what to use to disinfect the shower chair. A review of the Local Public Health Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities updated 10/1/2021, indicated environmental cleaning recommendations should be followed where applicable before and after patient care. This includes properly disinfecting shared equipment, e.g blood pressure cuffs and pulse oximeters before and after vital checks. Routine cleaning and disinfecting procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital grade disinfectant to frequently touched surfaces). Based on observation, interview, and record review, the facility failed to: a. Ensure staff properly wear Personal Protective Equipment. b. Complete the Visitor Screening For Covid-19 (Coronavirus disease 2019, is a respiratory illness that can spread from person to person) and Employee Screening For Covid-19, prior to entering the facility in October 2021. c. Disinfect the shower area and shower chair in between residents' use. These deficient practices had potential to spread infection to residents, staff, and visitors. Findings: a. During an observation on 11/4/2021 at 2:42 p.m. Restorative Nurse Assistant (RNA) was wearing a surgical mask below the nose. In a concurrent interview with the facility's Infection Preventionist Nurse (IPN), he stated, masks should be worn correctly and not worn below the nose, to provide protection. b. During a record review with IPN on 11/4/2021, at 2:42 p.m., The Visitor Screening For Covid-19 was not completed on 10/15/21 for one visitor, 10/19/21 for one visitor and on 10/24/21 for one visitor . There was no information on travel history, temperature upon entrance and exit, signs and symptoms (s/sx) related Covid-19, contact with confirmed Covid-19, education on Covid-19, visitor contact information, and visitor's signature. In a concurrent interview with IPN, he stated a staff is assigned in the front lobby to screen visitors. IPN cannot explain why there were no visitor screenings documented on 10/15/21, 10/19/21 and 10/24/21. The IPN stated screening for Covid-19 should be done and accurately documented. During a concurrent review of the Employee Screening Log for October 2021 indicated the screening was not completed for the following days: 10/1/2021, 10/4/2021, 10/9/2021, 10/10/2021, 10/23/2021, 10/24/2021, and 10/25/2021 - CNA 9 was not screened for s/s Covid-19 and contact with anyone with Covid-19. 10/23/2021- CNA 10 was not screened for s/sx of Covid-19 and contact with anyone with Covid-19. 10/19/2021- CNA 11 was not screened for s/sx of Covid-19 and contact with anyone with Covid-19. 10/1/2021, 10/2/2021, 10/8/2021, 10/9/2021, 10/16/2021 - LVN 4 was not screened for s/sx of Covid-19 and contact with anyone with Covid-19. 10/8/2021 and 10/12/2021 Rehabilitation Department 1 (Rehab D 1) was not screened for fever within 24 hours. 10/12/2021- CNA 12 was not screened for fever within 24 hours, for s/sx of Covid-19 and contact with anyone with Covid-19. 10/10/2021- LVN 5 did not sign the screening log. 10/10/2021- LVN 6 did not sign the screening log. 10/9/2021- Laundry Personnel 2 (LP 2) did not sign the screening log. 10/9/2021- Activities Assistant (AA) was not screened for contact with anyone with Covid-19. 10/2/2021 and 10/9/2021- CNA 13 was not screened for contact with anyone with Covid-19. 10/9/2021- CNA 1 was not screened for travel history, for s/sx of Covid-19 and contact with anyone with Covid-19. 10/5/2021- Dietary Aid (DA) was not screened for contact with anyone with Covid-19. 10/1/2021 and 10/4/2021- House Keeping1 (HK1)not screened for s/sx of Covid-19 and contact with anyone with Covid-19. 10/1/2021- RNA was not screened for s/sx of Covid-19 and contact with anyone with Covid-19. 10/1/2021 - CNA 14 not screened for s/sx of Covid-19 and contact with anyone with Covid-19. A review of the facility's Policy and Procedure, titled COVID-19 Visitations dated 9/7/2021, indicated the facility will actively screen and will restrict visitation by those who meet the following criteria: . Signs and symptom of Covid-19, such as fever or chills, cough, shortness of breath, sore throat, headache, muscle or body ache, fatigue, new loss of taste or smell, congestion, nausea or vomiting, and/or diarrhea. . In the last 14 days, has had contact with someone with a diagnosis of Covid-19, or under investigation for Covid-19, or are ill with respiratory illness. . Unvaccinated visitors returning from international trip are required to quarantine for 14 days. . Provide proof of vaccination (must be fully vaccinated) or testing results. This will be documented as part of the screening process. For those individuals that do not meet the above criteria, their entry may be restricted. The facility screens and documents every individual entering the facility (including staff) for Covid-19 symptoms. Proper screening includes temperature checks (Employee Screening Log/Visitors Screening Log).