**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policies, and interviews for 1 of 8 residents (Resident #35) reviewed for abuse, the facility failed to ensure a resident was treated in a dignified manner by nursing staff. The findings include: Resident #35 was admitted to the facility in September 2024 with diagnoses that included atrial fibrillation, congestive heart failure, and encephalopathy. The quarterly MDS dated [DATE] identified Resident #35 had intact cognition, mood interview identified the following symptoms and frequency: little interest or pleasure in doing things (half or more days), feeling down, depressed, hopeless (several days), trouble falling asleep or staying asleep (several days), feeling tired or having little energy (half or more days), poor appetite or overeating (several days), feeling bad about yourself (several days), trouble concentrating on things (several days), and moving or speaking slowly that other people could have noticed (half or more days). The care plan dated 2/26/25 identified Resident #35 exhibited or was at risk for distressed/fluctuating mood symptoms related to: sadness/depression caused by functional changes, etc.). Interventions included refocusing resident to something positive and allowing time to express feelings, providing empathy, encouragement, and reassurance. Interview with Resident #110 on 4/6/25 at 10:26 AM identified that around 4:00 AM, he/she had heard an agency nurse aide and Resident #35 arguing. Resident #110 indicated that he/she heard Resident #35 ask the nurse aide for her name, but did not hear a response. Resident #110 further indicated that he heard Resident #35 say you're hurting me and being rude, to which the nurse aide replied, it's my first time here and I'm not being rude. Interview with Resident #35 on 4/6/25 at 10:39 AM identified that an agency nurse (NA #18), whom he/she had never met before, entered his/her room around 4:00 AM, without a name badge, and when the resident asked her name, NA#18 responded, Pudding [NAME]. Resident #35 indicated that NA #18 had an attitude and was rude immediately upon entering the room, and NA #18 had told him/her, look, there are only 2 nurse aides here, you could have at least cleaned up your bed for me, referencing the resident's glasses and iPad that were laying on the bed. Resident #35 identified that he/she had asked NA #18 to leave his/her room, and NA #18 stated, why don't you like me, is it my voice or is it because I'm black? Resident #35 indicated that NA #18 then went to assist his/her roommate (Resident #8), and he/she could hear NA #18 making comments about him/her (Resident #35), and when NA #18 was finished providing care for Resident #8, NA #18 had seen him/her (Resident #35), crying and very nicely said, oh honey, why are you crying? Resident #35 indicated that he/she was confused as to why NA #18 was now acting nicely, and the resident reported the concerns to the night shift Nurse Supervisor. Interview with the 11:00 PM - 7:00 AM Nursing Supervisor (RN #12) on 4/6/25 at 10:55 AM identified that around 5:45 AM, Resident #35 had brought to her attention that NA #18 had an attitude while providing care and had made a racial comment. RN #12 indicated that Resident #35 asked NA #18 to leave and she left. RN #12 further indicated that Resident #35 required 2 staff members for care because the resident has made accusatory statements, but RN #12 indicated that NA #18 identified she did not ask another staff member to accompany her while providing care because they had been short staffed. The Psychiatric Evaluation and Consultation form dated 4/6/25 identified that Resident #35 was evaluated after making an allegation towards a nursing assistant. The resident rescinded the allegation and reported frustration with the nurse assistant because she was rude. There was no abuse reported. Interview with NA #17 on 4/8/25 at 12:50 PM identified that she was an agency nurse aide, and this was her first time working at the facility on 4/5/25 11:00 PM - 7:00 AM shift, and she was assigned to the west wing with NA #18. NA #17 denied witnessing any verbally abusive or disrespectful behavior from NA #18 towards Resident #35. NA #17 indicated that she assisted NA #18 to boost Resident #35 in bed. NA #17 indicated that Resident #35 reported that he/she had been crying because he/she had been in pain and was frustrated, and then Resident #35 asked both nurse aides to leave once they were done repositioning him/her in bed. Interview with NA #18 on 4/8/25 at 3:03 PM identified that she was an agency nurse aide and had worked at the facility on the 4/5/25 11:00PM - 7:00 AM shift, for the first time. NA #18 indicated that she was assigned to Resident #35, and that the resident began arguing with her, as soon as she walked into the room. NA #18 indicated that she told Resident #35 that the facility was short staffed and there were only 2 nurse aides on the floor, both from agencies. NA #18 indicated that she was not provided with a photo ID badge from her agency and could not recall if she told Resident #35 her name was Pudding [NAME] when the resident asked her name. NA #18 indicated that she did not ask Resident #35 why he/she did not clean up the bed before she came in, as cleaning up the resident's bed was her responsibility, and she always cleans up. NA #18 further indicated that she has a heavy voice and that she tried to explain that to Resident #35. NA #18 then asked Resident #35 if he/she was judging her because she was black, to which Resident #35 replied now you're pulling the race card. NA #18 indicated that Resident #35 was the only resident that took issue with her out of the 60 residents on that unit. NA #18 identified that when she spoke with RN #12, she identified that Resident #35 has made accusatory comments, in the past. Interview with Resident #35's roommate (Resident #8) on 4/9/25 at 11:30 AM identified that he/she had been sleeping but could not remember hearing any verbal abuse or rude behavior, during the early morning of 4/6/25. Interview with the DNS on 4/10/25 at 10:44 AM identified that it is the expectation that facility and agency staff treat residents with dignity and respect. The facility's Promoting/Maintaining Resident Dignity policy directs all staff members to be involved in providing care to residents to promote and maintain resident dignity and respect resident rights. The policy further directs staff members to speak respectfully to residents. The facility's Professionalism-Customer Service policy directs the facility to provide professional, courteous service to all customers. Every employee is accountable for conducting themselves in a professional manner at all times. The facility is the resident's home and will be regarded as such. Each resident will be treated with compassion and respect at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #9, 91 and 81) the facility failed to ensure the physician and resident representative were notified according to facility policy. For 1 of 5 residents (Resident #9) reviewed for medication administration, the facility failed to ensure the physician was notified when medications were not given per the physician order. For 1 of 3 residents (Resident #91) reviewed for pressure ulcer, the facility failed to ensure the physician and resident representative were notified when a new pressure ulcer was identified. For 1 of 5 residents (Resident #81) reviewed for unnecessary medications, the facility failed to notify the physician and resident representative with episodes of hypo and hyperglycemia, and when a medication was not administered. The findings include: 1. Resident #69 was admitted to the facility in February 2025 with diagnoses that included leg surgery, chronic kidney disease and dependent on dialysis, hypertension, and gastroparesis. A physician's order dated 2/13/25 directed to give Gabapentin 600 mg by mouth three times a day for phantom pain, Lactobacillus give 1 capsule by mouth one time a day for supplement, and Bumetanide 2 mg give 1 tablet two times a day for hypertension. The care plan dated 2/17/25 identified Resident #69 was at risk for impaired renal function and complications related to hemodialysis. Interventions included providing medications as ordered. The admission MDS dated [DATE] identified Resident #69 had intact cognition and required moderate assistance with toileting, dressing, and personal hygiene. Additionally, Resident #69 was on antibiotics, diuretics, opioids, and anticonvulsants. Review of the April 2025 MAR dated 4/6/25 at 11:48 PM identified Bumetanide 2 mg due to be administered twice daily for hypertension was not available. Medication observation with RN #4 on 4/7/25 at 9:17 AM indicated she had taken Resident #69's blood pressure earlier and it was 176/84. RN #4 prepared Resident #69's medications then identified she did not have the Gabapentin 600mg, Lactobacillus capsule, or the Bumetanide 2 mg available. RN #5 indicated that she had searched the medication cart and there was not any available and these medications were not in the emergency supply. An interview with RN #4 on 4/7/25 at 9:25 AM indicated that Resident #69 had not received the evening dose of Bumetanide 2 mg the day prior, and the Bumetanide 2 mg, the Lactobacillus Capsule, and Gabapentin 600 mg were not available. RN #4 indicated that the nurses were responsible for reordering medications before the resident ran out of a medication. RN #4 indicated that she would reorder the medications from the pharmacy. Review of the nurses' notes dated 4/6/25 to 4/7/25 failed to reflect the APRN or physician had been notified that the Bumetanide 2 mg, the Lactobacillus Capsule, and Gabapentin 600 mg were unavailable and had not been administered. Review of the MAR dated 4/7/25 at 9:28 AM identified RN #4 documented the scheduled 9:00 AM doses of Gabapentin 600 mg for phantom pain, Lactobacillus capsule for supplement, and Bumetanide 2mg's for hypertension were not available in facility and pharmacy was notified. Review of the MAR dated 4/7/25 identified Resident #69 did not receive the scheduled 1:00 PM dose of Gabapentin 600 mg. Interview with RN #5 (Regional corporate nurse) on 4/8/25 at 11:01 AM indicated that when a nurse does not have a medication available to give a resident per the physician order, he or she is responsible for notifying the pharmacy and the physician to see if there was an alternate medication(s) or could change the time of administration. Interview with APRN #1 on 4/8/25 at 11:18 AM indicated Resident #69 was on Bumetanide for fluid retention because of his/her diagnosis and if Bumetanide was not available nursing must notify her. APRN #1 indicated if Resident #69 misses a dose she would want to find out why and do an intervention and evaluate resident's blood pressures to see if it was elevated and if he/she has sustainable blood pressures with dialysis treatments. APRN #1 indicated that her expectation would be she must be notified if of any resident miss doses of medications. APRN #1 indicated that Resident #69 was on gabapentin for phantom pain due to the BKA. APRN #1 noted Resident #69 came into the facility on a low dose but because Resident #69 has complaints of pain the dose has been going up a couple of times, so it is important to give it and have it available, and the Lactobacillus is because nephrology ordered it from dialysis for the gastrointestinal system. APRN #1 indicated that she was not aware Resident #69 had missed the Bumetanide the evening of 4/6/25 or medications on 4/7/25 in the am or afternoon. APRN #1 indicated it was the nurse's responsibility to reorder the medications timely. APRN #1 indicated that the nurses were responsible for documenting who they notified and when if a resident had missed a scheduled medication. Interview with the DNS on 4/8/25 at 12:52 PM indicated that when a resident does not receive a dose of a scheduled medication the charge nurse is expected to notify the RN supervisor who must notify the APRN or physician and it needed get an order for an alternate medication or any other new orders from the provider and then write a nurses note with who the nurse spoke with and any recommendation or new orders from the provider. After clinical record review, the DNS indicated that from 4/6/to 4/8/24 she did not see the APRN, or physician were notified of the missed doses of medication. The DNS indicated that the Lactobacillus was house stock and if the nurse had asked the supervisor, she would have gotten it for RN #4. An interview with the DNS on 4/9/25 at 12:54 PM indicated her expectation was the nurses follow the physician orders and give the medications at the time they are scheduled within the hour before or hour after window. The DNS indicated the expectation was the nurses will reorder the medications when there are 6 doses left in the blister pack, so the resident does not run out of medications. Review of the facility Unavailable Medications Policy identified mediations may be unavailable for several reasons. Staff should take immediate action when it is known that the medication is unavailable. Notify the physician of inability to obtain medication upon notification or awareness that the medication is not available. Obtain alternate treatment orders and/or specific orders for monitoring residents while medication is on hold. If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. Review of the Medication Eror Policy identified the facility shall ensure medications will be administered according to the physician's orders. Medication that is administered not in accordance with the prescriber's order, for example a medication omission. 2. Resident #91 was admitted to the facility in July 2023 and a readmission to the facility on 1/30/25 with diagnoses that included fall with left femur fracture, and dementia. The quarterly MDS dated [DATE] identified Resident #91 had severely impaired cognition and required maximum assistance with perineal hygiene and dressing. Resident #91 was at risk for developing a pressure ulcer but did not have any pressure ulcers. The readmission nursing assessment dated [DATE] identified Resident #91's skin was intact except for periorbital bruising to the face status post fall. The assessment did not identify any open areas or pressure areas. The care plan dated 2/13/25 identified Resident #91 was at risk for skin breakdown related to decreased mobility and left hip surgical incision. Interventions included applying barrier cream after each incontinent episode, dietitian consultation as needed, and weekly skin checks by the licensed nurse. The weekly skin check assessment documented by RN #2 dated 2/15/25 identified Resident #91's left heel had a blister with slough measuring 6cm by 6cm intact. (first time noted wound) The weekly skin check assessment documented by LPN #1 dated 2/22/25 at 7:23 PM identified a previously identified wound to the left heel. (second time noted wound) The APRN note dated 2/24/25 at 1:04 PM identified she was notified by RN #1 and had seen Resident #91 for a deep tissue injury (DTI) to left heel today noted by nursing. Recommended Santyl topically with daily dressing change to facilitate until seen by wound provider later this week. Nursing to off load heels for Resident #91. The Change of Condition Evaluation documented by RN #1 dated 2/24/25 at 1:21 PM identified Resident #91 noted to have a new injury to his/her left heel. RN #1 noted this is the leg affected by his/her broken hip and surgical fixation. Left heel measurements were 2.5 cm by 1.4 cm by 0.1 cm. APRN in the facility and notified. Dressing order recommendation for Santyl and dry clean dressing in place and wound physician to evaluate. Resident representative was notified. A physician's order dated 2/24/25 directed to cleanse left heel wound with normal saline, pat dry, apply Santyl to wound bed, and cover with dry clean dressing daily on evening shift for 30 days starting on 2/25/25. The dietitian note dated 4/2/25 identified Resident #91 triggers for significant weight loss over 1 month and pressure ulcer to the left heel. Resident #91 remains at risk for malnutrition related to unplanned weight loss and need for mechanically altered diet and requires total assistance for feeding. Recommendations included Glucerna once a day in the evening to assist with stability and protein supplement to support wound healing in view of pressure injury to left heel. A physician's order dated 4/2/25 directed to start Glucerna 1.5 give 8 ounces once a day and Prostat AWC (Advance Wound Care) 30 ml's 2 times a day for at risk for malnutrition. Interview with LPN #1 on 4/7/25 at 8:55 AM indicated that she did the weekly skin assessment on 2/22/25 for Resident #91. LPN #1 indicated that she thought the left heel was already noted and not new, so she did not call for an RN assessment, or call the APRN or Resident #91's representative. Interview with RN #1 on 4/7/25 at 9:46 AM indicated she had not been informed that Resident #91 had a pressure ulcer on the left heel until she found it on 2/24/25 when auditing the weekly skin assessments. RN #1 indicated after clinical record review on 2/24/25 she noted that the left heel pressure ulcer started on 2/15/25 in a weekly body audit. RN #1 indicated that she immediately went to Resident #91 to assess the left heel, and the blister had opened and was an unstageable DTI that measured 2.5 cm by 1.4 cm by 0.1 cm. RN #1 indicated that the first complete RN assessment for the left heel pressure area was completed on 2/24/25, 9 days after first found. RN #1 indicated that there was no treatment in place for the left heel from 2/15/25 to 2/24/25. RN #1 indicated that on 2/24/25 when she identified the area, she notified the APRN and resident representative. RN # 1 indicated that on 2/15/25 when the left heel pressure ulcer was first identified there should have been a complete wound assessment by an RN that day and shift with notification to the APRN or physician to obtain a treatment order. Further, the resident representative should have been notified at that time. Interview with the DNS on 4/7/25 at 11:21 AM indicated Resident #91 had a left heel pressure ulcer noted on 2/24/25 by the wound nurse, RN #1, on 2/24/25. The DNS indicated that when a pressure ulcer is first identified the charge nurse notifies the RN supervisor to do the initial wound assessment including measurements, description of wound and wound bed, and the surrounding skin. The DNS indicated that she thought the left heel started on 2/24/25 and she was first notified about it on 2/24/25. The DNS indicated that after the surveyor inquiry she started an investigation into the left heel and noted the left heel was first identified on 2/15/25 during the weekly body check by RN #2. The DNS indicated that RN #2 should have notified the RN supervisor to come assess the new pressure ulcer and do the change of condition assessment, notify the ADNS or physician and get a treatment order put into place that day, and notify the resident representative. The DNS indicated that the APRN and resident representative were not notified until 2/24/25, 9 days after being first found. An interview with RN #2 on 4/7/25 at 11:11 AM indicated that she was the charge nurse on the unit and was responsible on 2/15/25 to do the weekly body assessment on Resident #91. RN #2 indicated that she had noted an intact 6 cm by 6 cm blister with yellow drainage inside the blister but the skin under the blister was not viable skin. RN #2 indicated that she assumed the DTI to the left heel was old. RN #2 indicated that if it was new she would have told the supervisor so she could have done a change in condition assessment, get a treatment order, and notify the APRN and resident representative. RN #2 indicated that because she thought it was old she did not notify the RN supervisor or the APRN, or resident representative. RN #2 indicated that if she had she would have documented it. Interview with the Dietitian on 4/9/25 at 11:35 AM identified the wound nurse was responsible for providing her with a weekly wound report for all wounds that would include new wounds and if wounds are getting worse. The Dietitian indicated that she did not receive any wound reports for the month of February 2025 and only 1 report in March 2025. The Dietitian indicated the wound report for the week of 3/7/25 did not have Resident #91 on it. The Dietitian indicated that she had reported several times to the DNS that she was not receiving the weekly wound reports. The Dietitian indicated that if a resident receives a new facility acquired pressure ulcer and she is notified she would have seen the resident within a week at the most. The Dietitian indicated she would assess the resident and make sure the resident is meeting nutritional needs and would recommend some type of protein supplement based on the stage of the wound. The Dietitian indicated that Resident #91 was seen on 2/9/25 and 2/19/25 and was noted with no pressure ulcers. The Dietitian noted on 2/28/25 Resident #91 was only seen for weights and she was not aware of any wounds. The Dietitian indicated that on 4/2/25 after Resident #91 was readmitted on [DATE] she went to do the nutritional evaluation and noted the documentation of the left heel pressure ulcer. The Dietitian indicated at that time she had recommended the protein supplement (Prostat Advanced Wound Care) and the order was put into place. The Dietitian indicated that if she was aware on 2/15/25 when someone had first found the left heel, she would have seen Resident #91 right away. The Dietitian indicated that it is the protocol for stage 3, stage 4, or unstageable to immediately start the protein supplement to promote wound healing. Interview and clinical record review with DNS on 4/10/25 at 8:00 AM identified that Resident #91 had a DTI to the left heel identified on 2/15/24 which was not reported to the APRN and resident representative until 2/24/25. Further, she did not see that the dietitian was notified in any notes until a dietitian evaluation on 4/2/25. Review of the Notification of Change Policy identified the purpose was to ensure the facility promptly informs the resident, the physician, and the resident's representative when there is a change requiring notification. Review of the Facility Responsibilities Policy identified the facility will immediately inform the resident, physician, and resident representative a significant change in the residents physical, mental, or psychosocial status. Also, a need to alter a treatment such as a new, discontinue or change in an existing treatment. Review of Pressure Injury Prevention and Management Policy identified the facility as committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to promote treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injures. The attending physician will be notified of the presence of a new pressure injury identification. A review will be performed on each pressure injury that develops in the facility. Review of the Nutritional Management Policy identified the facility promotes care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in his/her overall condition. A comprehensive nutritional assessment will be completed by the dietitian within 72 hours of admission, annually, and upon significant change in condition. Components of the assessment will include, but not limited to residents' general appearance, height, weight, cognitive, physical, and medical conditions, food and fluid intake, poor intake, weight loss, review of medications, and review of labs. 3. Resident # 81 was admitted to the facility in July 2023 with diagnoses that included COPD, diabetes with hyperglycemia, and dementia. The care plan dated 11/17/24 identified Resident #81 has a diagnosis of Insulin dependent diabetes and hyperglycemia. Interventions included monitoring signs and symptoms of hyper/hypoglycemia and report abnormal findings to the physician, assess and record blood glucose levels as ordered, and administer hypoglycemic medications as ordered. A physician's order dated 12/16/24 directed to inject Glucagon 1 mg (a medication used to treat low blood glucose) IM as needed for blood glucose less than 70 if Resident #81 was unable to swallow or was unresponsive, monitor vital signs and stay with the resident, notify the provider and recheck the blood glucose in 15 minutes, repeat protocol if less than 70 and document response in the progress notes. A physician's order dated 12/16/24 directed to administer Glucose oral gel 15 mg/32ml (a medication used to treat low blood glucose) one application by mouth as needed for blood glucose less than 70 if Resident #81 was asymptomatic or symptomatic but responsive with the ability to swallow. The order further directed to repeat the blood glucose level in 15 minutes, document the results, and if still below 70, notify the provider and administer a second dose of the glucose gel. A physician's order dated 12/19/24 directed for sliding scale Insulin Lispro (a short acting Insulin) to be administered with blood glucose checks 3 times daily (7:30 AM, 11:30 AM, 4:30 PM) before meals and administered for a blood glucose of: 150 - 200 = 2 units. 201 - 250 = 4 units. 251 - 300 = 6 units. 301 - 350 = 8 units. 351 -400 = 10 units. 401 - 450 = 12 units. 451+ = Call Provider for additional orders. The 5 day MDS dated [DATE] identified Resident #81 had intact cognition, was always incontinent of bowel and bladder and dependent on staff to assist with toileting, bathing, and dressing. An APRN note dated 12/28/24 at 11:58 AM identified that a telehealth visit was conducted with RN #7 due to Resident #81's blood glucose result of 480 on that date. The APRN note identified Resident #81 was asymptomatic and the treatment orders included a total of 14 units of Insulin Lispro, recheck blood glucose in one hour, if blood glucose was above 400 in 2 hours to contact telehealth APRN for further instructions, and notify a clinician of any change in condition. A nurse's note dated 12/28/24 at 12:03 PM by LPN #2 identified Resident #81's blood glucose was 480 and 12 units of Insulin Lispro were administered, the supervisor was notified, and the physician would be contacted. Review of the clinical record failed to identify any documentation that Resident #81's resident representative was notified related to Resident #81's hyperglycemic episode requiring treatment visit. A physician's order dated 1/31/25 directed for sliding scale Insulin Lispro (a short acting Insulin) to be administered with blood glucose checks 4 times daily (7:30 AM, 11:30 AM, 4:30 PM, and 9 PM) before meals, at bedtime, and administer for a blood glucose of: 150 - 200 = 2 units. 201 - 250 = 4 units. 251 - 300 = 6 units. 301 - 350 = 8 units. 351 -400 = 10 units. 401 - 450 = 12 units. 451+ = Call Provider for additional orders. The January 2025 MAR identified LPN #2 documented Resident #81 had a blood glucose of 459 on 1/31/25 at 4:30 PM and received a partial dose of Insulin Lispro. The MAR failed to identify the dose administered. Review of the clinical record failed to identify any additional documentation related to Resident #81's blood glucose of 459 on 1/31/25 including notification to the provider per the physician's order due to the blood glucose level above 450, or that Resident #81's resident representative was notified. The February 2025 MAR identified Resident #81 had a blood glucose of 63 on 2/13/25 at 7:30 AM. The MAR identified that the blood glucose parameters were out of range and no Insulin was administered. Review of the clinical record for 2/13/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The February 2025 MAR identified Resident #81 had a blood glucose of 50 obtained by LPN #2 on 2/17/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 2/17/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The February 2025 MAR identified Resident #81 had a blood glucose of 47 obtained by LPN #2 on 2/18/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 2/18/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The February 2025 MAR identified Resident #81 had a blood glucose of 51 obtained by LPN #2 on 2/22/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 2/22/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. A nurse's note dated 3/3/25 at 10:26 PM by LPN #1 identified that Resident #81 had a blood glucose of 54. The note identified glucose gel was administered. Review the clinical record for 3/3/25 failed to identify any additional documentation that the provider or Resident #81's resident representative was notified. A nurse's note dated 3/14/25 at 8:52 AM by RN #12 identified Resident #81 had a morning blood glucose of 45, that Resident #81 was given juice and breakfast, a repeat blood glucose 15 minutes later was 78, and that the APRN was notified. Further review of the clinical record failed to identify that Resident #81's resident representative was notified of the hypoglycemic episode. The March 2025 MAR identified Resident #81 had a blood glucose of 62 on 3/16/25 at 11:30 AM. Further review of the MAR identified that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/16/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The March 2025 MAR identified Resident #81 had a blood glucose of 68 obtained by LPN #2 on 3/17/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/17/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The March 2025 MAR identified Resident #81 had a blood glucose of 55 obtained by LPN #2 on 3/20/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/20/25 failed to identify any additional documentation including that the provider or Resident #81's representative were notified. A nurse's note dated 3/21/25 at 3:49 AM by RN #12 identified Resident #81 had a blood glucose of 53 at 3:00 AM. The note also identified that an IM Glucagon injection was given, and Resident #81 had a repeat blood glucose of 112 at 3:45 AM. Further review of the clinical record for 3/21/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified. A nurse's note dated 3/22/25 at 7:54 AM by RN #12 identified that at 3:30 AM, Resident #81 was observed to be alert but lethargic with skin warm to the touch but clammy. The note further identified Resident #81 had a blood glucose of 50 and was administered glucose gel, and a recheck 20 minutes later identified a blood glucose of 69. The note identified Resident #81 reported feeling better and was offered orange juice, and a repeat blood glucose was 112 after an hour. The note also identified Resident #81 received Insulin Glargine 52 units at bedtime and that Resident #81 had a blood glucose of 149 at 7:30 AM. Review of the clinical record for 3/22/25 failed to identify that the provider or Resident #81's resident representative were notified. The March 2025 MAR identified on 3/22/25 at 8:00 PM that 52 units of Insulin Glargine was held by LPN #3 due to Resident #81's blood glucose levels dropping to 50 overnight. The clinical record failed to identify that the provider was notified that Resident #81 did not receive his/her nightly dose of Insulin Glargine on 3/22/25 or that Resident #81's resident representative was notified of the medication hold due to hypoglycemia. Review of the clinical record and MAR for March 2025 identified on 3/23/25 at 1:30 AM, LPN #3 identified Resident #81 had a blood glucose level of 50 and was administered glucose gel. Review of the clinical record identified on 3/23/25 at 2:00 AM, LPN #3 documented Resident #81 had a blood glucose recheck of 63. A nurse's note dated 3/23/25 at 2:32 AM by LPN #3 identified Resident #81 was clammy, cold, and lethargic and glucose gel was administered. Review of the clinical record identified on 3/23/25 at 2:30 AM, RN #12 documented Resident #81 had a blood glucose of 112. Review of the clinical record for 3/23/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified of Resident #81's hypoglycemic episode. Review of the clinical record identified on 3/25/25 at 2:00 AM LPN #3 documented Resident #81 had a blood glucose of 45. Further review of the clinical record identified a recheck by LPN #3 done at 3:44 AM was 70. Review of the clinical record and March 2025 MAR for 3/25/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified of Resident #81's hypoglycemic episode. A nurse's note dated 3/26/25 at 1:20 AM by LPN #1 identified she was notified by a nurse aide that Resident #81 was profusely sweating. LPN #1 identified that Resident #81 had blood glucose check of 41, that emergency glucose was given immediately, and that a recheck would be done in a few minutes. The March 2025 MAR identified LPN #1 administered glucose gel on 3/26/25 at 1:20 AM. A nurse's note dated 3/26/25 at 1:45 AM by LPN #6 identified Resident #81 had a repeat blood glucose check of 54. Further review of the nurse's note identified LPN #1 documented a repeat blood glucose check of 131 at 2:14 AM. Review of the clinical record for 3/26/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified of Resident #81's hypoglycemic episode. The March 2025 MAR identified Resident #81 had a blood glucose of 67 obtained by LPN #2 on 3/31/25 at 11:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/31/25 failed to identify any documentation that Resident #81's resident representative was notified of Resident #81's hypoglycemic episode. Interview with APRN #1 on 4/8/25 at 11:52 AM identified that she was aware that Resident #81 had variable blood glucose levels but felt these were related to dietary noncompliance and a recent course of antibiotics. APRN #1 identified she could not remember if she was notified that if Resident #81 received IM Glucagon or of all the blood glucose levels under 70 since 2/13/25, but if the resident had a blood glucose above 450 or below 70, she would expect that the nurses would assess the resident to ensure he/she was not symptomatic and that she or the on call provider would be notified if the resident had symptoms. Interview with LPN #1 on 4/9/25 at 10:50 AM identified that she was assigned to Resident #81 on 3/3 and 3/26/25. LPN #1 identified that LPNs in the facility were not allowed to complete an assessment of the residents or contact the physician/APRN and resident representative regarding a change in condition, so that should have been completed by the RN. LPN #1 identified she was unsure who she reported Resident #81's hypoglycemic episodes to and she did not document the information in the clinical record. Interview with RN #12 on 4/9/25 at 11:56 AM identified that she was the nurse assigned to Resident #81 on 3/20/25 on the 11:00 PM - 7:00 AM shift and was the RN supervisor working with LPN #3 on 3/22/25 on the 11:00 PM - 7:00 AM shift. RN #12 identified on 3/21/25 at 3:00 AM a nurse aide notified her that Resident #81 was very lethargic, and she administered IM Glucagon which was the standard order for all diabetics in the facility for hypoglycemia. RN #12 identified she obtained vital signs on Resident #81 and completed a repeat blood glucose check at 3:45 AM and documented a progress note. RN #12 identified that on 3/23/25 Resident #81 had a similar hypoglycemic episode with LPN #3 overnight and required glucose gel and juice. RN #12 identified she did not notify the on-call provider or Resident #81's resident representative regarding Resident #81's hypoglycemic episodes on 3/21 or 3/23/25 and that she would have passed the information on in morning report to the day shift or told APRN #1 in person if she was in the facility at shift change. RN #12 identified that she did not feel that it was necessary to notify the on-call provider but was aware that the physician orders and facility protocol for hypoglycemia directed to contact the physician or APRN for a blood glucose less than 70 Interview with LPN #2 on 4/9/25 at 12:15 PM identified she could not remember any blood glucose issues for Resident #81 from 12/28/24, 1/31/25, 2/2025, or 3/2025. LPN #2 identified that unless she noticed a specific issue or it was listed in her tasks in the MAR or TAR, she did not document a note or assess Resident #81 related to blood glucose issues. LPN #2 identified any documentation would be in a progress note, and that she would notify the RN superviso[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for residents 4 of 8 residents (Resident #42, 88, 92 and 99,) reviewed for allegations of abuse, the facility failed to ensure the residents were free from abuse. The findings include: 1a. Resident #7 was admitted to the facility in August 2024 with diagnoses that included paranoid schizophrenia, borderline personality disorder, and diabetes. The care plan dated 11/7/24 identified Resident #7 exhibits or has the potential to exhibit physical behaviors related to psychiatric disorder and is combative with care. Interventions include postponing care/activity and allowing time to regain composure. The quarterly MDS dated [DATE] identified Resident #7 had intact cognition and was independent walking 150 feet. The physician's order dated 1/1/25 directed to monitor behavior for hitting and swatting every shift. Review of the change in condition evaluation form dated 1/15/25 identified Resident #7 was observed by nursing staff striking his/her roommate (Resident #88). Resident #7 indicated he/she asked Resident #88 to get off his/her bed and identified he/she only touched Resident #88's leg to get off the bed. The APRN and conservator of person were notified. Resident #7 is on 1:1 monitoring until psychiatric evaluation. b. Resident #88 was admitted to the facility in May 2023 with diagnoses that included wandering, dementia, psychotic disturbance, mood disturbance, and anxiety disorder. The care plan dated 11/9/24 identified Resident #88 was an elopement risk and wanderer related to impaired safety awareness and wanders aimlessly. Intervention included wanderguard to left wrist, distract resident from wandering by offering pleasant diversions, and structured activities. Further, the care plan identified Resident #88 had a behavior problem related to dementia and could be difficult to redirect when anxious. Interventions included intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation and take to an alternate location as needed. The care plan dated 11/26/24 identified Resident #88 had the potential to exhibit physical behaviors related to cognitive loss and dementia. Resident #88 exhibited physical aggression toward another resident without injury. Interventions included gently guiding the resident from the environment while speaking in a calm, measuring voice, divert resident by giving alternative objects or activities. The quarterly MDS dated [DATE] identified Resident #88 had severely impaired cognition and was independent with walking 150 feet. Additionally, Resident #88 had no physical or verbal behaviors directed at others and had exhibited no wandering behavior. (This is in conflict with the care plan that identified Resident #88 wanders aimlessly and exhibited physical aggression toward another resident). The physician's order dated 1/1/25 directed to monitor behavior for wandering and exit seeking at the end of each shift for anxiety, monitor behavior for nighttime restlessness every evening and night shift and monitor behavior for anxious and panic every shift. Review of the change in condition evaluation form dated 1/15/25 identified Resident #88 was struck by roommate (Resident #7). The APRN, police, and resident representative were notified. Resident #88 will be evaluated by psychiatric APRN. The reportable event form dated 1/15/25 at 4:15 PM identified staff overheard yelling coming from Resident #7 and Resident #88's room. Upon entering the room, Resident #7 was observed hitting Resident #88 on the left shoulder twice with an open hand. Resident #7 indicated that Resident #88 was lying in his/her bed and when she asked Resident #88 to move the resident became upset and began yelling. Resident #7 was placed on 1:1 supervision pending psychiatrist evaluation. Both residents were evaluated for injury with none found. The APRN, police, Administrator, and conservator of person, and resident representative were notified. Neither resident was injured in the incident. Resident #7 has been moved to a different hallway. Both residents were evaluated by psychiatrist services. Resident #88 was given a one-time dose of Ativan with positive effect. Both residents will continue to receive psychiatric services. A written statement by LPN #4 dated 1/15/25 identified at approximately 3:50 PM she heard loud yelling and arguing coming from Resident #7 and Resident #88 room. LPN #4 indicated she approached the room and witnessed Resident #7 hitting Resident #88 while Resident #88 was on the floor. LPN #4 indicated she ran and called for help. A written statement by LPN #5 dated 1/15/25 identified she was in the middle of medication pass when LPN #5 indicated she was informed by another nurse at 3:50 PM that there was a resident-to-resident altercation between Resident #7 and Resident #88. LPN #5 indicated the supervisor informed her that Resident #88 would be on every 15 minutes monitoring for the remainder of the evening, and Resident #7 would be relocated to the 400 wing. The social service note dated 1/15/25 at 4:42 PM identified SW #2 spoke with Resident #7's conservator of person regarding incident that occurred between his/her and roommate. A room change was initiated for Resident #7. SW #2 will follow up with Resident #7 and the resident has been added to the psychiatrist book to be seen. The nurse's note by RN #10 dated 1/15/25 at 5:23 PM identified it was reported to her from LPN #4 that Resident #7 was observed in a physical altercation with roommate (Resident #88) at 4:15 PM. Resident #7 indicated Resident #88 sat on his/her bed, and he/she moved Resident #88's leg off the bed and Resident #88 sat on the floor. Resident #7 denies striking roommate. Both residents were separated at the time of the incident. Resident #7 was cleared by the psychiatrist with no new orders. The nurse's note by RN #10 dated 1/15/25 at 5:27 PM identified it was reported to her from LPN #4 that Resident #88 was observed in a physical altercation with Resident #7 at 4:15 PM. Resident #88 has no recollection of the event and was calm, and cooperative. The summary report dated 1/22/25 at 3:45 PM identified Resident #88 began yelling at Resident #7. Staff responded to the yelling and witnessed Resident #7 slapping Resident #88 on the left shoulder twice with an open hand. Both residents were immediately separated and placed on 1:1 supervision pending on psychiatrist evaluation. Both residents were evaluated for injury with none found. Both residents were evaluated by the psychiatrist and cleared from 1:1 monitoring. Resident #88 was given a dose of Ativan with positive effect. Resident #7's room has been relocated to a different hallway. Both residents will continue to receive psychiatric services. Behaviors will continue to be monitored. Interview with RN #10 on 4/14/25 at 12:18 PM identified she does remember the resident-to-resident physical and verbal altercation due to it was so long ago. 2a. Resident #42 was admitted to the facility in September 2022, with diagnoses that included anxiety disorder, depressive disorder, and chronic kidney failure disease stage 4. The quarterly MDS dated [DATE] identified Resident #42 had intact cognition and required substantial/maximum assistance with personal hygiene. The care plan dated 11/25/24 identified Resident #42 has the potential to exhibit physical behaviors related to ineffective coping skills, (example poor anger management). Resident #42 was in a physical altercation with another resident without injury. Interventions include monitor for emotional distress as ordered. Review of the change in condition evaluation form dated 11/26/24 identified Resident #42 was involved in a resident-to-resident altercation. The APRN, police, and the resident representative were notified. Resident #42 was monitored for emotional distress every shift for 72 hours. b. Resident #88 was admitted to the facility in May 2023, with diagnoses that included wandering, dementia, psychotic disturbance, mood disturbance, and anxiety disorder. The quarterly MDS dated [DATE] identified Resident #88 had severely impaired cognition and was independent with walking 150 feet. Additionally, Resident #88 had no behaviors (physical or verbal) directed at others, and no wandering behavior. The care plan dated 10/16/24 identified Resident #88 was an elopement risk with wandering related to impaired safety awareness and wanders aimlessly. Intervention included wanderguard to left wrist, distracting resident from wandering by offering pleasant diversions, and structured activities. Additionally, Resident #88 had a behavioral problem related to dementia and could be difficult to redirect when anxious. Interventions included intervening as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation and take to an alternate location as needed. The physician's order dated 11/1/24 directed to monitor for wandering/exit seeking each shift for anxiety, monitor behavior for nighttime restlessness every evening and night shift and monitor behavior for anxiety and panic every shift. The reportable event form dated 11/26/24 at 8:00 PM identified Resident #88 wandered into Resident #42's room. When Resident #42 asked Resident #88 to leave and stop touching him/her belongings, Resident #88 struck Resident #42 on the arm. Staff responded to yelling from Resident #42's room. Resident #42 reported that Resident #88 had wandered into his/her room and sat in his/her wheelchair. Resident #42 reported he/she grabbed Resident #88's arm to stop and guide him/her out of the room, when Resident #88 struck him/her on the left arm. Both residents were immediately redirected away from each other and assessed for injuries. No injuries were found on either resident. Resident #88 was placed on 1:1 supervision pending psychiatric evaluation. Investigation initiated. The APRN, Administrator, police, and resident representatives were notified. The LCSW #1 progress note dated 11/26/24 at 8:00 PM - 8:16 PM identified she met with Resident #88 in response to screaming in the hallway of the 500 wing. Resident #88 was screaming help, help and attempting to push his/her way past a nursing staff who was blocking the doorway to Resident #42's room. LCSW #1 redirected Resident #88 to walk with her to the day room area and participated in a breathing activity and it was successful. LCSW #1 provided Resident #88 with a cheese and cracker snack as a distraction. Resident #88 continues to be increasingly confused and agitated. Resident #88 was observed to wander in and out of resident rooms. Resident #88's roommate indicated Resident #88 wanders in the night hours and moves things in the room. It was reported that Resident #88 wandered into Resident #42's room thinking that it was his/her room, attempted to get into Resident #42's roommates bed after redirection Resident #88 sat in Resident #42's wheelchair. Resident #42 touched Resident #88's arm to redirect the resident to leave and Resident #88 reacted and assaulted Resident #42. The LCSW #1 progress note dated 11/26/24 at 8:53 PM - 9:12 PM identified Resident #42 was assaulted by Resident #88 while he/she was in bed. LCSW #1 met with Resident #42 to offer supportive therapy and provide support after the incident. Resident #42 was presented as anxious with constricted affect, was alert and oriented and friendly. Resident #42 indicated Resident #88 wandered into his/her room and attempted to lay in the roommate's bed. Resident #42's roommate redirected Resident #88 to leave, however, Resident #88 sat in Resident #42's wheelchair. Resident #42 touched Resident #88's arm to redirect him/her from sitting in the wheelchair and to leave the room. Resident #88 was agitated, confused and hit Resident #42 in response to being touched. Resident #42 indicated he/she was not expecting to be assaulted, but it did not hurt and there was no physical injury. Resident #42 indicated that Resident #88 often wanders into his/her room and Resident #42 verbalized the fear that it will happen again, noting that Resident #88's room was directly across from his/her room. A written statement by RN #4 dated 11/26/24 identified she was notified by RN #10 that there was an unwitnessed resident to resident altercation between Resident #88 and Resident #42. Resident #88 wandered into Resident #42's room and began sitting in his/her wheelchair. Resident #42 was shocked, annoyed, and grabbed Resident #88's arm to try and remove him/her out of the room. Resident #88 hit Resident #42 multiple times on the left arm. Resident #42 screamed, and NA #8 came into the room. A written statement by NA #8 dated 11/26/24 at 8:15 PM identified she last check on Resident #88 at 7:45 PM who was sitting at the nurse's desk eating a snack. NA #8 indicated she did not witness the incident. NA #8 indicated she heard Resident #88 screaming in the hallway. NA #8 indicated Resident #88 was physically aggressive towards her because she was blocking Resident #42's room door to prevent him/her from entering the room again. The psychiatric APRN note dated 11/27/24 identified urgent telehealth visit with Resident #42 after Resident #88 came into his/her room and sat in his/her wheelchair and would not leave. Resident #42 indicated she recalled the incident and asked Resident #88 to leave. Resident #42 indicated he/she grabbed Resident #88's arm to get Resident #88 to leave and Resident #88 slapped him/her in the face. Both residents were screaming at each other and the nursing staff came in and separated them. The psychiatrist APRN note dated 11/27/24 identified urgent telehealth visit With Resident #88 after a resident-to-resident incident last evening. It was reported that Resident #88 went into Resident #42's room and sat in his/her wheelchair and refused to leave. Resident #42 attempted to get Resident #88 to leave, and Resident #88 allegedly slapped him/her in the face. This was not witnessed by staff. Review of the summary report dated 12/4/24 at 1:24 PM identified on 11/26/24 at 8:00 PM Resident #88 wandered into Resident #42's room and sat in his/her wheelchair. Resident #42 touched Resident #88 right arm and asked him/her to leave. Resident #88 started yelling at Resident #42 and lightly swatted his/her on the left arm with an open hand. Resident #42 indicated staff immediately responded to the yelling and redirected Resident #88 out of the room. Resident #88 was placed on 1:1 supervision pending psychiatric evaluation and both were assessed for injury with none found. Resident #88 remains on every 15 minutes checks. Resident #88 continues to receive psychiatric services, and psychoactive medication has been reviewed. A Velcro stop sign was ordered for Resident #42's room door. Interview with the DNS on 4/9/25 at 8:00 AM identified Resident #88 is alert, confused, ambulates independently, and has a history of wandering. The DNS indicated Resident #88 wandered into Resident #42 room and sat in his/her wheelchair. Resident #42 attempted to have Resident #88 leave the room when Resident #88 hit him/her on the arm. The DNS indicated the social service department has met with Resident #88 representative regarding searching for another facility with a dementia secure unit. The DNS indicated the facility is addressing Resident #88 wandering behavior with ongoing staff monitoring the resident throughout the day, and Resident #88 attending recreation activities of his/her choice. 3. Resident #92 was admitted to the facility in August 2023 with diagnoses that included dementia with behavioral disturbance, psychotic disturbance, mood disturbance, anxiety disorder, and cerebrovascular disease. The quarterly MDS dated [DATE] identified Resident #92 had severely impaired cognition and required setup or clean-up assistance with toileting hygiene. Additionally, Resident #92 had exhibited no physical or verbal behavior symptoms directed toward others. The care plan dated 3/19/25 identified Resident #92 requires assistance for ADL care related to dementia, decreased ability to perform ADL'S. Interventions included providing extensive assistance of 1 for bed mobility, toileting and hygiene. The care plan dated 3/19/25 identified Resident #92 was resistive to care related to dementia. Refusing care at times. Interventions included to give a clear explanation of all care activities prior to and as they occur during each contact. Further, Resident #92 had the potential to be physically aggressive related to dementia, and poor impulse control. Interventions included giving the resident as many choices as possible about care and activities. The physician's order dated 4/1/25 directed to monitor behavior for anxiety, resistive/combative with care, and emotional distress every shift. The reportable event form dated 4/8/25 at 12:00 PM identified Resident #92 was alert, oriented to self, pleasant, and cooperative. Resident #110, who resides across the hallway from Resident #92, reported to the social worker between 2:00 AM and 3:00 AM that he/she overheard NA #3 telling Resident #92 to shut up and be quiet. The care plan dated 4/8/25 identified Resident #92 was involved in an alleged verbal incident involving a staff member. Interventions included to monitor for emotional distress. The psychiatric APRN note dated 4/8/25 identified Resident #92 was seen for alleged negative interaction with staff member. Resident #92 was seen in bed, alert, smiling upon approach, calm, and cooperative. Resident #92 was unable to accurately state day, month, year. Resident #92 does not recall having a negative interaction with staff. A statement by LPN #1 dated 4/8/25 identified she worked on 4/7/25 on the 11:00 PM - 7:00 AM shift on the [NAME] wing. LPN #1 indicated RN #6 came over to the unit. LPN #1 indicated Resident #110 reported to her that NA #3 was in Resident #92's room and was aggressive with Resident #92 and told him/her to shut up. LPN #1 indicated she reported to RN #6 that Resident #110 reported to her that NA #3 was in Resident #92's room and was aggressive with Resident #92 and told him/her to shut up. A statement by NA #3 dated 4/8/25 at 5:01 PM identified she provided care to Resident #92 around 1:00 AM and 5:00 AM as she does every morning when she works. NA #3 indicated some mornings Resident #92 can be a bit loud talking to his/herself as he/she was on the morning of 4/8/25. NA #3 indicated she had to go to the resident room several times to reassure him/her that it was in the middle of the night, and he/she had to be quiet. NA #3 indicated she sat with Resident #92 and gave him/her a tuna sandwich and a drink. NA #3 indicated she put the television on animal planet with no volume, and Resident #92 eventually fell asleep. Interview with LPN #1 on 4/10/25 at 10:57 AM identified she worked on 4/7/25 on the 11:00 PM - 7:00 AM shift on the [NAME] wing. LPN #1 indicated she observed NA #3 had an attitude towards her during the shift. LPN #1 indicated NA #3 was yelling, screaming, cursing profanity, and argumentative. LPN #1 indicated NA #3 was very upset because the agency nurse aide left and went home, leaving the [NAME] wing with only with 2 nurse aides instead of 3 nurse aides. LPN #1 indicated she gave a written statement to the DNS regarding everything that happened on the shift with NA #3. LPN #1 indicated RN #6 was at the nurse's station while NA #3 was still yelling and talking inappropriately. LPN #1 indicated she reported to RN #6 that Resident #110 reported to her that NA #3 told Resident #92 to shut up and NA #3 yanked Resident #99's wheelchair and told Resident #99 to act like a damn man and that he/she was behaving like a child. LPN #1 indicated RN #6 stated that NA #3 and her (LPN #1) need to get along and she will address the issue with the DNS in the morning. LPN #1 indicated that was not the first time she has witnessed NA #3 yelling, using profanity, and being argumentative with agency nurse aides or other staff on the 11:00 PM - 7:00 AM shift on the [NAME] wing. Interview with Resident #110 on 4/10/25 at 9:55 AM identified he/she does not sleep throughout the night, so he/she ambulates up and down the hallway and watches television in the common area on the wing (which is across from the nurse's station). Resident #110 indicated on Monday night his/her bedroom door was open, and Resident #92's bedroom door was also open. Resident #110 indicated Resident #92 was talking out loud to his/herself which the resident does sometimes. Resident #110 indicated around 2:00 AM or 3:00 AM overheard NA #3 across the hallway in Resident #92's room yelling at Resident #92 to shut up and be quiet. Resident #110 indicated NA #3 said it four times to Resident #92. Resident #110 indicated he/she got up and stood in the doorway of his/her bedroom and listened. Resident #110 indicated afterward NA #3 left Resident #92's room. Resident #110 indicated a little while later he/she witnessed and heard NA #3 was yelling and arguing with LPN #1 in front of the nurse's station saying who is going to clean Resident #99 and the urine on the floor. Resident #110 indicated Resident #99 was sitting in the wheelchair at the nurse's station. Resident #110 indicated he/she reported to LPN #1 that he/she overheard NA #3 in Resident #92's room yelling at Resident #92 to shut up and be quiet. Resident #110 indicated he/she told SW #2 that morning that he/she overheard NA #3 in Resident #92's room yelling at Resident #92 to shut up and be quit, and NA #3 was yelling and arguing with LPN #1 in front of the nurse's station saying who is going to clean Resident #99 and the urine on the floor. Interview with the DNS on 4/10/25 at 12:00 PM identified she was made aware on 4/8/25 at 12:00 PM that Resident #110 had reported to SW #1 between 2:00 AM and 3:00 AM he/she overheard NA #3 telling Resident #92 to shut up and be quiet. The DNS indicated she reported the allegation of verbal abuse to the survey team immediately. The DNS indicated she placed NA #3 on administrative leave immediately. The DNS indicated RN #6, and LPN #1 did not inform her of the allegation by Resident #110. The DNS indicated she must investigate and see if LPN #1 had reported the allegation of staff to resident abuse to RN #6. DNS indicated RN #6 did not inform her that there was an argument between LPN #1 and NA #3 on the unit and residents were present. The DNS indicated that the expectation of the facility is that when there is an allegation of abuse the staff member is to be removed from the unit and sent home immediately. The DNS indicated NA #3 should have been removed from the unit and sent home until further notice. DNS indicated she is not aware if LPN #1 had reported to RN #6 about the alleged staff to resident abuse of Resident #99. DNS indicated RN #6 did not inform her that there was an argument between LPN #1 and NA #3 on the unit and residents were present. Review of the facility abuse, neglect, and exploitation policy identified facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical arm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 4. Resident #99 was admitted to the facility in January 2024 with diagnoses that included Parkinson's disease, dementia, mood disturbance, anxiety disorder, hallucinations, delusional disorders, psychotic disorder with delusions, depressive disorder, and wandering in disease. The quarterly MDS dated [DATE] identified Resident #99 was moderately cognitively impaired and required partial/moderate assistance with toileting hygiene. Additionally, Resident #99 had no behaviors of physical or verbal symptoms directed towards others, and no wandering. Further Resident #99 does not use a wheelchair. The care plan dated 2/26/25 identified Resident #99 is at risk for complications related to the use of psychotropic drugs: antipsychotic and antidepressant for agitation, restlessness, and sleeplessness. Interventions included monitor for continued need of medication as related to behavior and mood. Resident #99 exhibits or is at risk for distress/fluctuating mood symptoms related to sadness, depression caused by current medical diagnoses and functional decline. Interventions included refer to behavioral health specialists as needed. Resident #99 has bowel incontinence and mixed bladder incontinence related to confusion, impaired mobility, and Parkinson's disease. Interventions included to provide peri-care with each incontinent episode. The physician's order dated 4/1/25 directed to monitor behavior for agitation, resistive, excessive wandering, intrusive behavior, and sleeplessness every shift. A statement by LPN #1 dated 4/8/25 identified she worked 4/7/25 on the 11:00 PM - 7:00 AM shift and indicated Resident #99 was sitting at the nurse's station when she came arrived. LPN #1 indicated Resident #99 had a fall and hit his/her head and sustained a laceration at the beginning of the shift. LPN #1 indicated Resident #99 was restless and would not remain still. LPN #1 indicated NA #3 was getting very agitated and aggressive with Resident #99 because the resident was grabbing everything and pushing chairs and at some point Resident #99 was yelling out another resident's name and yelling help. LPN #1 indicated that is when she observed NA #3 turn around and pull/yank Resident #99's wheelchair and say to Resident #99 (act like a damn man you're behaving like a child). LPN #1 told NA #3 that Resident #99 has dementia and will not understand her and that was inappropriate. LPN #1 indicated at 5:00 AM she started her medication pass and heard Resident #99 saying that he/she needed to go to the bathroom. LPN #1 informed NA #3 of the resident's request, however, NA #3 walked by her and ignored her. LPN #1 indicated at some point she walked by Resident #99 and observed a puddle of urine on the floor. LPN #1 indicated she notified NA #3 and NA #4 that Resident #99 had urinated on the floor, and again she got no response from the nurse aides. LPN #1 indicated she placed a few towels on the floor and underneath Resident #99's wheelchair and the resident's feet to soak up the urine. LPN #1 indicated that is when NA #3 approached her and stated, (oh you couldn't pick the piss off the damn floor). Resident #99 was present and could hear this comment. LPN #1 indicated she told NA #3 that she was in the middle of a medication pass and that if she had taken Resident #99 to the bathroom when he/she asked, the resident would not have urinated on the floor. LPN #1 indicated NA #3 insisted that LPN #1 provide incontinent care to Resident #99 and clean the floor with the urine. LPN #1 indicated she told NA #3 that she was in the middle of medication pass and that she (NA #3) was assigned to the resident. LPN #1 indicated NA #3 began shouting, cursing, speaking inappropriately to her in the [NAME] wing hallway in front of the nurse's station with Resident #99 present. LPN #1 indicated she told NA #3 that she would be calling the RN supervisor. LPN #1 indicated she walked down to the 400 wing with NA #3 still screaming at her while NA #3 was pushing Resident #99 down the hallway to the 600 wing to go and provide incontinent care to the resident. LPN #1 identified she called RN #6 to report the incident with NA #3. LPN #1 indicated Resident #110 reported to her that NA #3 had been in Resident #92's room and was aggressive with Resident #92 and told the resident to shut up. LPN #1 indicated Resident #110 also reported that NA #3 was yelling and screaming being disrespectful to the nurse and he/she was going to report NA #3 to the DNS. Interview with NA #3 on 4/9/25 at 11:23 AM identified she worked 4/7/25 during the 11:00 PM - 7:00 AM shift and was not assigned to Resident #99. NA #3 indicated at the beginning of the shift there were 3 nurse aides, and one of the aides, the agency nurse aide, left and went home which NA #3 indicated is an on-going issue with the agency nurse aides. NA #3 indicated Resident #110 was ambulating on the wing and was in the common area watching television. NA #3 indicated she was upset and probably loud when Resident #99, who was at the nurse's station in a wheelchair, urinated on himself/herself and the floor. NA #3 indicated LPN #1 placed a towel down on the floor and left it there. NA #3 indicated there was only 2 nurse aides overseeing the 400, 500, and 600 wings answering call lights and providing care, and she expected LPN #1 to help. NA #3 indicated she and LPN #1 had words. Interview with RN #6 on 4/9/25 at 11:50 AM identified she worked on 4/7/25 during the 11:00 PM - 7:00 AM shift as the RN supervisor. RN #6 indicated LPN #1 called her to the [NAME] wing because NA #3 was being disrespectful towards her. RN #6 indicated LPN #1 reported Resident #99 had urinated on the floor and she placed a towel on the floor and NA #3 told her it was everyone's job to provide resident care. RN #6 indicated LPN #1 never informed her that NA #3 was getting very agitated and aggressive with Resident #99 and pulled/yanked Resident #99's wheelchair and said to Resident #99 (act like a damn man you're behaving like a child). Further, RN #6 identified LPN #1 did not report to her that Resident #110 reported NA #3 was verbally abusive to Resident #92. RN #6 indicated she told LPN #1 and NA #3 to work out their issues or take it to Human Resource in the morning. RN #6 indicated she educated LPN #1 not to discussed what took place between her and NA #3. The reportable event form dated 4/10/25 at 11:30 AM identified during another investigation, it was discovered that LPN #1 witnessed NA #3 allegedly yank Resident #99's wheelchair and told the resident to (act like a damn man, you're behaving like a child). LPN #1, and NA #3 remain on administrative leave pending an investigation. Resident #99 was evaluated by psychiatrist and social services. The APRN, Administrator, police, and the resident Power of Attorney were notified. A statement by NA #3 dated 4/10/25 at 11:29 AM identified that she denied the allegations. Interview with LPN #1 on 4/10/25 at 10:57 AM identified she worked 4/7/25 during the 11:00 PM - 7:00 AM shift and NA #3 had an attitude towards her during the shift. LPN #1 indicated NA #3 was yelling, screaming, cursing profanity, and argumentative. LPN #1 indicated NA #3 was very upset because the agency nurse aide left and went home leaving the [NAME] wing with only 2 nurse aides instead of three. LPN #1 indicated NA #3 had an attitude and was upset that Resident #99 was at the nurse's station for monitoring. LPN #1 indicated she observed NA #3 pull/yank Resident #99's wheelchair and said to the resident (act like a damn man and that he/she was acting like a child). LPN #1 indicated she gave a written statement to the DNS regarding everything that happened on the shift with NA #3. LPN #1 indicated RN #6 was at the nurse's station while NA #3 was still yelling and talking inappropriately. LPN #1 indicated she reported to RN #6 that Resident #110 reported to her that NA #3 told Resident #92 to shut up and NA #3 yanked Resident #99's wheelchair and told Resident #99 to (act like a damn man and that he/she was behaving like a child). LPN #1 indicated RN #6 stated that she and NA #3 need to get along and s[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 8 residents (Resident #69, 99 and 269) reviewed for abuse and misappropriation, the facility failed to immediately report the allegations of abuse and misappropriation to the Administrator and the State Agency according to established timeframes. The findings include: 1. Resident #69 was admitted to the facility in February 2025 with diagnoses that included chronic kidney disease, diabetes, and surgery of the left leg. A physician's order dated 2/13/25 directed Resident #69 may go on a leave of absence with medications and responsible party. The admission MDS dated [DATE] identified Resident #69 had intact cognition and required moderate assistance with toileting, lower body dressing, transfers, and personal hygiene. The care plan dated 2/20/25 identified Resident #69 is resistive to care. Interventions included providing consistent, trusted caregiver, and structured daily routine, when possible. The social worker note dated 4/3/25 at 12:38 PM indicated that she met with Resident #69 to discuss concerns related to money being missing from his/her wallet. Resident #69 states that he/she had $152 and now is missing $150. Resident #69 reported last seeing his/her wallet in his/her backpack, and now only $2 dollars were left. Resident #69 was unsure if he/she had dropped it in the reception area prior to going out for an appointment but he/she is adamant that it was in his/her backpack. The Missing Item Form dated 4/3/25 identified at approximately at 9:00 AM Resident #69 reported he/she was missing $150, and it was one $100 bill and a $50 dollar bill. Attached was a statement from SW #1 that indicated she had spoken with RN #11 who reported that Resident #69 had told her that $150 was missing from his/her wallet. RN #11 reported that the wallet was given to her by a staff member, and that she had returned it to Resident #69 who said there was money missing. The social worker note dated 4/7/25 at 9:12 AM identified this social worker met with the resident following the allegation of stolen money. This writer will continue to follow-up with Resident#69 and offer support as needed. Interview with the Administrator on 4/8/25 at 2:20 PM indicated that she was responsible to complete an investigation related to Resident #69's missing money, and that she did it as a grievance because SW #1 informed her that the money was missing, not that it was stolen. The Administrator indicated that she did not know when Resident #69 last had seen the money or where Resident #69 kept his/her wallet. The Administrator indicated that she does not know if the resident really had the money or not because he does not keep it in the facility's account. The Administrator indicated that Resident #69 could have dropped it in the lobby that day when going out for an appointment. The Administrator indicated that the wallet was found by Laundry #1, and he opened it to see who it belonged to and brought it to the supervisor RN #11. Reviewing the investigation and missing item form, the Administrator could not provide statements from the supervisor RN #11 or Laundry #1. The Administrator indicated that she does not know how Resident #69's wallet had gotten out of the backpack into the laundry. The Administrator indicated that she could not confirm or deny if Resident #69 had the $150 but she was not informed until yesterday that the money was stolen, she thought it was just missing. The Administrator indicated that if she was informed on 4/3/25 that the money had been stolen, she would have immediately reported it to the State Agency, called the police, the regional team, DSS, and the Medical Director. Interview with Resident #69 on 4/9/25 at 1:00 PM indicated that he/she did not know his/her wallet was gone until the nurse brought the wallet to him/her after returning from an appointment Thursday morning on 4/3/25 about 11:00 AM when the charge nurse was giving him/her the morning medications. Resident #69 indicated that when the nurse stated that someone found the wallet in the laundry, he/she opened the wallet and reported there was $150 missing. Resident #69 indicated that he/she cannot make sense of how his/her wallet was found in the laundry. Resident #69 indicated that someone here took my $150 because he/she knew exactly how much he/she had the evening before. Resident #69 indicated that his/her wallet had $152 in it the evening before and was in his/her backpack in the pocket where it is always kept. The interview with SW #2 on 4/9/25 at 1:05 PM indicated that the supervisor, RN #11, had informed her that Resident #69 was missing money, and she could not name or identify who given it to her. SW #2 indicated that the wallet was found in the laundry and Laundry #1 had given the wallet to RN #11. Interview with SW #2 on 4/10/25 at 7:45 AM indicated that she was informed by RN #11 at approximate 11:00 AM that Resident #69 had reported there was $150 missing from his/her wallet. SW #2 indicated she immediately went and informed the DNS that Resident #69 had reported there was $150 missing from his/her wallet and then went to see Resident #69. SW #2 indicated Resident #69 had informed her maybe the wallet had fallen in the lobby before going to the appointment the morning of 4/3/25, but he/she always keeps the wallet in the backpack, and the backpack in always with him/her. SW #2 indicated Resident #69 was missing a $100 dollar bill and a $50 dollar bill and in the wallet was left the two $1 bills. SW #2 indicated that Resident #69 was adamant that his/her wallet was kept in his/her backpack in a specific area. Interview with RN #11 on 4/10/25 at 8:46 AM indicated the morning of 4/3/25, a guy with shorts brought her a wallet found outside and placed it on the desk and stated the owner of wallet, so she kept the wallet on her table and brought the wallet to Resident #69 when he/she returned from an appointment. RN #11 indicated she gave Resident #11 the wallet in the hallway while the nurse was giving medications, and Resident #69 immediately opened the wallet and reported there was $150 in there and it was gone. RN #11 indicated that she told the DNS and was not told to write a statement. RN #11 indicated then she informed SW #2. RN #11 indicated that Resident #69 reported he/she was not aware the wallet was missing until she handed it to him/her. Review of the facility Abuse, Neglect, and Exploitation Policy identified it is the policy of the facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the residents' consent. The abuse prevention coordinator designee was responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state agency and other officials in accordance with the state law. Investigation of alleged abuse identified the staff responsible for the investigation identifying and interviewing all involved people, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation. Focusing the investigation on determining if abuse, neglect, and/or mistreatment has occurred, the extent, and cause. Providing complete and through documentation of the investigation. Reporting all alleged violations to the Administrator, state agency, adult protective services law enforcement within specified timeframes: immediately, but not later than 2 hours after the allegation is made and not later than 24 hours if the event that causes the allegation do not involve abuse and do not result in serious bodily injury. Review of the Compliance with Reporting Allegations of Abuse, Neglect, or exploitation Policy identified the facility will report all allegations of abuse, neglect, or exploitation or mistreatment and misappropriation of resident property are reported immediately to the Administrator of the facility and appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. 2. Resident #99 was admitted to the facility in January 2024 with diagnoses that included Parkinson's disease, dementia, mood disturbance, anxiety disorder, hallucinations, delusional disorders, psychotic disorder with delusions, depressive disorder, and wandering in disease. The quarterly MDS dated [DATE] identified Resident #99 was moderately cognitively impaired and required partial/moderate assistance with toileting hygiene. Additionally, Resident #99 had no behaviors of physical or verbal symptoms directed towards others, and no wandering. Further Resident #99 does not use a wheelchair. The care plan dated 2/26/25 identified Resident #99 is at risk for complications related to the use of psychotropic drugs: antipsychotic and antidepressant for agitation, restlessness, and sleeplessness. Interventions included monitor for continued need of medication as related to behavior and mood. Resident #99 exhibits or is at risk for distress/fluctuating mood symptoms related to sadness, depression caused by current medical diagnoses and functional decline. Interventions included refer to behavioral health specialists as needed. Resident #99 has bowel incontinence and mixed bladder incontinence related to confusion, impaired mobility, and Parkinson's disease. Interventions included to provide peri-care with each incontinent episode. The physician's order dated 4/1/25 directed to monitor behavior for agitation, resistive, excessive wandering, intrusive behavior, and sleeplessness every shift. A statement by LPN #1 dated 4/8/25 identified she worked 4/7/25 on the 11:00 PM - 7:00 AM shift and indicated Resident #99 was sitting at the nurse's station when she arrived. LPN #1 indicated Resident #99 had a fall and hit his/her head and sustained a laceration at the beginning of the shift. LPN #1 indicated Resident #99 was restless and would not remain still. LPN #1 indicated NA #3 was getting very agitated and aggressive with Resident #99 because the resident was grabbing everything and pushing chairs and at some point Resident #99 was yelling out another resident's name and yelling help. LPN #1 indicated that is when she observed NA #3 turn around and pull/yank Resident #99's wheelchair and say to Resident #99 (act like a damn man you're behaving like a child). LPN #1 told NA #3 that Resident #99 has dementia and will not understand her and that was inappropriate. LPN #1 indicated at 5:00 AM she started her medication pass and heard Resident #99 saying that he/she needed to go to the bathroom. LPN #1 informed NA #3 of the resident's request, however, NA #3 walked by her and ignored her. LPN #1 indicated at some point she walked by Resident #99 and observed a puddle of urine on the floor. LPN #1 indicated she notified NA #3 and NA #4 that Resident #99 had urinated on the floor, and again she got no response from the nurse aides. LPN #1 indicated she placed a few towels on the floor and underneath Resident #99's wheelchair and the resident's feet to soak up the urine. LPN #1 indicated that is when NA #3 approached her and stated, (oh you couldn't pick the piss off the damn floor). Resident #99 was present and could hear this comment. LPN #1 indicated she told NA #3 that she was in the middle of a medication pass and that if she had taken Resident #99 to the bathroom when he/she asked, the resident would not have urinated on the floor. LPN #1 indicated NA #3 insisted that LPN #1 provide incontinent care to Resident #99 and clean the floor with the urine. LPN #1 indicated she told NA #3 that she was in the middle of medication pass and that she (NA #3) was assigned to the resident. LPN #1 indicated NA #3 began shouting, cursing, speaking inappropriately to her in the [NAME] wing hallway in front of the nurse's station with Resident #99 present. LPN #1 indicated she told NA #3 that she would be calling the RN supervisor. LPN #1 indicated she walked down to the 400 wing with NA #3 still screaming at her while NA #3 was pushing Resident #99 down the hallway to the 600 wing to go and provide incontinent care to the resident. LPN #1 identified she called RN #6 to report the incident with NA #3. LPN #1 indicated Resident #110 reported to her that NA #3 had been in Resident #92's room and was aggressive with Resident #92 and told the resident to shut up. LPN #1 indicated Resident #110 also reported that NA #3 was yelling and screaming being disrespectful to the nurse and he/she was going to report NA #3 to the DNS. Interview with NA #3 on 4/9/25 at 11:23 AM identified she worked 4/7/25 during the 11:00 PM - 7:00 AM shift and was not assigned to Resident #99. NA #3 indicated at the beginning of the shift there were 3 nurse aides, and one of the aides, the agency nurse aide, left and went home which NA #3 indicated is an on-going issue with the agency nurse aides. NA #3 indicated Resident #110 was ambulating on the wing and was in the common area watching television. NA #3 indicated she was upset and probably loud when Resident #99, who was at the nurse's station in a wheelchair, urinated on himself/herself and the floor. NA #3 indicated LPN #1 placed a towel down on the floor and left it there. NA #3 indicated there was only 2 nurse aides overseeing the 400, 500, and 600 wings answering call lights and providing care, and she expected LPN #1 to help. NA #3 indicated she and LPN #1 had words. Interview with RN #6 on 4/9/25 at 11:50 AM identified she worked on 4/7/25 during the 11:00 PM - 7:00 AM shift as the RN supervisor. RN #6 indicated LPN #1 called her to the [NAME] wing because NA #3 was being disrespectful towards her. RN #6 indicated LPN #1 reported Resident #99 had urinated on the floor and she placed a towel on the floor and NA #3 told her it was everyone's job to provide resident care. RN #6 indicated LPN #1 never informed her that NA #3 was getting very agitated and aggressive with Resident #99 and pulled/yanked Resident #99's wheelchair and said to Resident #99 (act like a damn man you're behaving like a child). Further, RN #6 identified LPN #1 did not report to her that Resident #110 reported NA #3 was verbally abusive to Resident #92. RN #6 indicated she told LPN #1 and NA #3 to work out their issues or take it to Human Resource in the morning. RN #6 indicated she educated LPN #1 not to discussed what took place between her and NA #3. The reportable event form dated 4/10/25 at 11:30 AM identified during another investigation, it was discovered that LPN #1 witnessed NA #3 allegedly yank Resident #99's wheelchair and told the resident to (act like a damn man, you're behaving like a child). LPN #1, and NA #3 remain on administrative leave pending an investigation. Resident #99 was evaluated by psychiatrist and social services. The APRN, Administrator, police, and the resident Power of Attorney were notified. A statement by NA #3 dated 4/10/25 at 11:29 AM identified that she denied the allegations. Interview with LPN #1 on 4/10/25 at 10:57 AM identified she worked 4/7/25 during the 11:00 PM - 7:00 AM shift and NA #3 had an attitude towards her during the shift. LPN #1 indicated NA #3 was yelling, screaming, cursing profanity, and argumentative. LPN #1 indicated NA #3 was very upset because the agency nurse aide left and went home leaving the [NAME] wing with only 2 nurse aides instead of three. LPN #1 indicated NA #3 had an attitude and was upset that Resident #99 was at the nurse's station for monitoring. LPN #1 indicated she observed NA #3 pull/yank Resident #99's wheelchair and said to the resident (act like a damn man and that he/she was acting like a child). LPN #1 indicated she gave a written statement to the DNS regarding everything that happened on the shift with NA #3. LPN #1 indicated RN #6 was at the nurse's station while NA #3 was still yelling and talking inappropriately. LPN #1 indicated she reported to RN #6 that Resident #110 reported to her that NA #3 told Resident #92 to shut up and NA #3 yanked Resident #99's wheelchair and told Resident #99 to (act like a damn man and that he/she was behaving like a child). LPN #1 indicated RN #6 stated that she and NA #3 need to get along and she will address the issue with the DNS in the morning. LPN #1 indicated that was not the first time she has witnessed NA #3 yelling, using profanity, and being argumentative with agency nurse aides or other staff on the 11:00 PM - 7:00 AM shift on the [NAME] wing. Interview with Resident #110 on 4/10/25 at 9:55 AM identified he/she does not sleep throughout the night, so he/she ambulates up and down the hallway and the common areas on the unit. Resident #110 indicated on Monday night he/she overheard NA #3 yelling and arguing with LPN #1 at the nurse's station and the hallway. Resident #110 indicated Resident #99 was sitting in a wheelchair at the nurse's station and NA #3 continued yelling, arguing, and was disrespectful to LPN #1 about who was going to clean Resident #99 and clean the urine off the floor. Resident #110 indicated NA #3 she was yelling, very angry and had an attitude that night. Interview with the DNS on 4/10/25 at 12:22 PM identified she was not aware that NA #3 was witnessed to pull/yank Resident #99's wheelchair and say to the resident (act like a damn man you're acting like a child) because until surveyor inquiry, she had not read LPN #1's statement that was written on 4/8/25. The DNS indicated NA #3 was not removed from the facility after LPN #1 witnessed NA #3 pull/yank Resident #99's wheelchair and say to the resident (act like a damn man, you're acting like a child). The DNS indicated that the expectation of the facility is that when there is an allegation of abuse, the staff member is to be removed and sent home immediately. The DNS indicated NA #3 should have been removed from the unit and sent home until further notice. The DNS indicated she is not aware if LPN #1 had reported the incident to RN #6. The DNS indicated RN #6 did not inform her that there was an argument between LPN #1 and NA #3 on the unit and residents were present. Review of the facility abuse, neglect, and exploitation policy identified facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical arm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The facility abuse, neglect, and exploitation policy identified the facility will provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Mistreatment means inappropriate treatment or exploitation of a resident. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility will have written procedures that include reporting of all alleged violations to the Administrator, State Agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. 3. Resident #269 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease and dementia. The care plan dated 4/1/25 identified Resident #269 was at risk for decreased ability to perform ADLs in grooming, bathing, personal hygiene, transfers. Interventions included providing assist of 1 for transfers using a rolling walker. Additionally, Resident #269 it was important that he/she had the opportunity to engage in daily routines that are meaningful relative to his/her preference. Resident #269 expressed it was important for staff to know which of his/her personal belongings he/she prefers to take care of him/herself. The admission MDS dated [DATE] identified Resident #269 had moderately impaired cognition and was dependent on staff for toileting and dressing and required maximum assistance with bathing and personal hygiene. Additionally, the MDS did not identify any psychiatric or mood disorders. Residents' overall goal indicated from Resident #269 was to be discharged to the community. Interview with Resident #269 on 4/6/25 at 10:30 AM indicated that he/she had been robbed. Resident #269 was lying in bed with sheets covering him/her and his/her pocketbook was on the bed at his/her left side. Resident #269 indicated that when he/she went to bed, his/her pocketbook was at his/her left side and when he/she woke up this morning it was on the bedside chair to the right side of the bed. Resident #269 indicated that he/she asked the nurse aide this morning to get the pocketbook from the bedside chair in the corner of room and place it back on the bed next to him/her. Resident #269 indicated that she felt uneasy about it because he/she did not know how it got over to the bedside chair during the night, so he/she checked the pocket when he/she kept the money and found it was missing $80. Resident #269 indicated that since then this surveyor was the first person in the room to inform about being robbed during the night last night. Surveyor reported the allegation of Resident #269 being robbed $80 to the charge nurse, LPN #2, on 4/6/25 at 10:40 AM. LPN #2 stated she would inform the supervisor immediately and started walking down the hallway towards the nurse's station. The interview with RN #11 on 4/7/25 at 12:55 PM indicated that she was the day supervisor on Sunday 4/6/25 from 7:00 AM to 3:00 PM. RN #11 indicated that there was a lot going on yesterday but did not remember LPN #2 reporting to her anything about Resident #269 or that Resident #269 had stolen or missing money. RN #11 indicated that if LPN #2 had reported stolen money she would have immediately reported it to the DNS because it was a reportable event. A Reportable Event Form dated 4/7/25 at 2:00 PM identified resident reported to a visitor that he/she had been robbed and was missing money. Resident #269 reported he/she had been robbed. Resident #269 reported he/she usually keeps the purse in bed with him/her, but when he/he woke up the purse was in the chair and reported $80 missing. Interview with DNS on 4/7/25 at 2:22 PM indicated that she was not aware there was an allegation from Resident #269 of being robbed or stolen money on 4/6/25 of $80. Interviewed with LPN #2 with the DNS present on 4/7/25 at 2:30 PM indicated that she did recall being informed that Resident #269 had reported being robbed but could not recall how much it was if it was $40 or $80. LPN #2 indicated that she had immediately gone to RN #11 and informed her that Resident #269 was reporting money was taken, but RN #11 informed her she was busy with 3 admissions and would talk to Resident #269 later. LPN #2 indicated that she did not question Resident #269 regarding the money because she thought the RN supervisor would. Interview with the DNS on 4/7/25 at 2:45 PM indicated that she had not reported the allegation to the State Agency and would do so now and start an investigation. The social worker note dated 4/7/25 at 3:10 PM indicated it was a late entry for 4/6/25 at 3:08 PM as a follow up to Resident #269 reporting to charge nurse LPN #2 he/she noticed $40 cash missing from purse this morning. Resident #269 reported to this writer it was $80 he/she reported this morning. Resident #269 informed this writer that he/she knows he/she had it when admitted in his/her wallet. Resident #269 reports that he/she always leaves his/her purse in his/her bed next to him/her so he/she can access the tissues inside when he/she needs them. Resident #269 presents as alert and cooperative during this interview. The social worker note dated 4/7/25 at 3:27 PM identified as a late entry for 4/6/25 Resident #269 was alert and oriented times two and was lying in bed. Resident #269 reported he/she had $80 inside his/her wallet inside the purse that was always kept with him/her in the bed. Resident #269 had shown social worker the wallet that had some change. Interview with the DNS on 4/10/25 at 9:49 AM indicated her expectation with any allegation involving money or abuse that staff would immediately report the allegation to the RN supervisor who she would expect to notify her immediately. The DNS indicated that the allegation occurred on 4/6/25 in the morning and she was not notified until 4/7/25 in the afternoon. The DNS indicated that she was aware she only had 2 hours from the time of the initial allegation and her staff were aware. The DNS indicated that she would have expected to be notified immediately. The DNS stated she spoke with the resident representative who verified that Resident #269 had $38 or $39 in his/her pocketbook when he/she left the assisted living to go to the hospital then came to the facility. The DNS indicated that they looked in Resident #269's pocketbook and there was no money left. The DNS indicated that she does not believe Resident #269 had spent any money at the hospital and something happened between the assisted living when the resident had the money and the facility. The DNS indicated that she was still working on the investigation. Review of the Abuse, Neglect, and Exploitation Policy identified it is the policy of the facility to provide protection for health, welfare, and rights of each resident by developing and implementing in written policies that prohibit ad prevent abuse, neglect, and misappropriation of resident's property. Misappropriation of residents' property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the residents' consent. Reporting all alleged violations to the Administrator, state agency, and to all other required agencies within the specified timeframes would be immediately, but no later than 2 hours after the allegation is made. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state agency and other officials in accordance with state law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 8 residents (Resident # 99) reviewed for abuse, the facility failed to take immediate steps to prevent further abuse from occurring while the investigation was in progress. The findings include: Resident #99 was admitted to the facility in January 2024 with diagnoses that included Parkinson's disease, dementia, mood disturbance, anxiety disorder, hallucinations, delusional disorders, psychotic disorder with delusions, depressive disorder, and wandering in disease. The quarterly MDS dated [DATE] identified Resident #99 was moderately cognitively impaired and required partial/moderate assistance with toileting hygiene. Additionally, Resident #99 had no behaviors of physical or verbal symptoms directed towards others, and no wandering. Further Resident #99 does not use a wheelchair. The care plan dated 2/26/25 identified Resident #99 is at risk for complications related to the use of psychotropic drugs: antipsychotic and antidepressant for agitation, restlessness, and sleeplessness. Interventions included monitor for continued need of medication as related to behavior and mood. Resident #99 exhibits or is at risk for distress/fluctuating mood symptoms related to sadness, depression caused by current medical diagnoses and functional decline. Interventions included refer to behavioral health specialists as needed. Resident #99 has bowel incontinence and mixed bladder incontinence related to confusion, impaired mobility, and Parkinson's disease. Interventions included to provide peri-care with each incontinent episode. The physician's order dated 4/1/25 directed to monitor behavior for agitation, resistive, excessive wandering, intrusive behavior, and sleeplessness every shift. A statement by LPN #1 dated 4/8/25 identified she worked 4/7/25 on the 11:00 PM - 7:00 AM shift and indicated Resident #99 was sitting at the nurse's station when she arrived. LPN #1 indicated Resident #99 had a fall and hit his/her head and sustained a laceration at the beginning of the shift. LPN #1 indicated Resident #99 was restless and would not remain still. LPN #1 indicated NA #3 was getting very agitated and aggressive with Resident #99 because the resident was grabbing everything and pushing chairs and at some point, Resident #99 was yelling out another resident's name and yelling help. LPN #1 indicated that is when she observed NA #3 turn around and pull/yank Resident #99's wheelchair and say to Resident #99 (act like a damn man you're behaving like a child). LPN #1 told NA #3 that Resident #99 has dementia and will not understand her and that was inappropriate. LPN #1 indicated at 5:00 AM she started her medication pass and heard Resident #99 saying that he/she needed to go to the bathroom. LPN #1 informed NA #3 of the resident's request, however, NA #3 walked by her and ignored her. LPN #1 indicated at some point she walked by Resident #99 and observed a puddle of urine on the floor. LPN #1 indicated she notified NA #3 and NA #4 that Resident #99 had urinated on the floor, and again she got no response from the nurse aides. LPN #1 indicated she placed a few towels on the floor and underneath Resident #99's wheelchair and the resident's feet to soak up the urine. LPN #1 indicated that is when NA #3 approached her and stated, (oh you couldn't pick the piss off the damn floor). Resident #99 was present and could hear this comment. LPN #1 indicated she told NA #3 that she was in the middle of a medication pass and that if she had taken Resident #99 to the bathroom when he/she asked, the resident would not have urinated on the floor. LPN #1 indicated NA #3 insisted that LPN #1 provide incontinent care to Resident #99 and clean the floor with the urine. LPN #1 indicated she told NA #3 that she was in the middle of medication pass and that she (NA #3) was assigned to the resident. LPN #1 indicated NA #3 began shouting, cursing, speaking inappropriately to her in the [NAME] wing hallway in front of the nurse's station with Resident #99 present. LPN #1 indicated she told NA #3 that she would be calling the RN supervisor. LPN #1 indicated she walked down to the 400 wing with NA #3 still screaming at her while NA #3 was pushing Resident #99 down the hallway to the 600 wing to go and provide incontinent care to the resident. LPN #1 identified she called RN #6 to report the incident with NA #3. LPN #1 indicated Resident #110 reported to her that NA #3 had been in Resident #92's room and was aggressive with Resident #92 and told the resident to shut up. LPN #1 indicated Resident #110 also reported that NA #3 was yelling and screaming being disrespectful to the nurse, and he/she was going to report NA #3 to the DNS. Interview with NA #3 on 4/9/25 at 11:23 AM identified she worked 4/7/25 during the 11:00 PM - 7:00 AM shift and was not assigned to Resident #99. NA #3 indicated at the beginning of the shift there were 3 nurse aides, and one of the aides, the agency nurse aide, left and went home which NA #3 indicated is an on-going issue with the agency nurse aides. NA #3 indicated Resident #110 was ambulating on the wing and was in the common area watching television. NA #3 indicated she was upset and probably loud when Resident #99, who was at the nurse's station in a wheelchair, urinated on himself/herself and the floor. NA #3 indicated LPN #1 placed a towel down on the floor and left it there. NA #3 indicated there was only 2 nurse aides overseeing the 400, 500, and 600 wings answering call lights and providing care, and she expected LPN #1 to help. NA #3 indicated she and LPN #1 had words. Interview with RN #6 on 4/9/25 at 11:50 AM identified she worked on 4/7/25 during the 11:00 PM - 7:00 AM shift as the RN supervisor. RN #6 indicated LPN #1 called her to the [NAME] wing because NA #3 was being disrespectful towards her. RN #6 indicated LPN #1 reported Resident #99 had urinated on the floor and she placed a towel on the floor and NA #3 told her it was everyone's job to provide resident care. RN #6 indicated LPN #1 never informed her that NA #3 was getting very agitated and aggressive with Resident #99 and pulled/yanked Resident #99's wheelchair and said to Resident #99 (act like a damn man you're behaving like a child). Further, RN #6 identified LPN #1 did not report to her that Resident #110 reported NA #3 was verbally abusive to Resident #92. RN #6 indicated she told LPN #1 and NA #3 to work out their issues or take it to Human Resource in the morning. RN #6 indicated she educated LPN #1 not to discuss what took place between her and NA #3. The reportable event form dated 4/10/25 at 11:30 AM identified during another investigation, it was discovered that LPN #1 witnessed NA #3 allegedly yank Resident #99's wheelchair and told the resident to (act like a damn man, you're behaving like a child). LPN #1, and NA #3 remain on administrative leave pending an investigation. Resident #99 was evaluated by psychiatrist and social services. The APRN, Administrator, police, and the resident Power of Attorney were notified. A statement by NA #3 dated 4/10/25 at 11:29 AM identified that she denied the allegations. Interview with LPN #1 on 4/10/25 at 10:57 AM identified she worked 4/7/25 during the 11:00 PM - 7:00 AM shift and NA #3 had an attitude towards her during the shift. LPN #1 indicated NA #3 was yelling, screaming, cursing profanity, and argumentative. LPN #1 indicated NA #3 was very upset because the agency nurse aide left and went home leaving the [NAME] wing with only 2 nurse aides instead of three. LPN #1 indicated NA #3 had an attitude and was upset that Resident #99 was at the nurse's station for monitoring. LPN #1 indicated she observed NA #3 pull/yank Resident #99's wheelchair and said to the resident (act like a damn man and that he/she was acting like a child). LPN #1 indicated she gave a written statement to the DNS regarding everything that happened on the shift with NA #3. LPN #1 indicated RN #6 was at the nurse's station while NA #3 was still yelling and talking inappropriately. LPN #1 indicated she reported to RN #6 that Resident #110 reported to her that NA #3 told Resident #92 to shut up and NA #3 yanked Resident #99's wheelchair and told Resident #99 to (act like a damn man and that he/she was behaving like a child). LPN #1 indicated RN #6 stated that she and NA #3 need to get along and she will address the issue with the DNS in the morning. LPN #1 indicated that was not the first time she has witnessed NA #3 yelling, using profanity, and being argumentative with agency nurse aides or other staff on the 11:00 PM - 7:00 AM shift on the [NAME] wing. Interview with Resident #110 on 4/10/25 at 9:55 AM identified he/she does not sleep throughout the night, so he/she ambulates up and down the hallway and the common areas on the unit. Resident #110 indicated on Monday night he/she overheard NA #3 yelling and arguing with LPN #1 at the nurse's station and the hallway. Resident #110 indicated Resident #99 was sitting in a wheelchair at the nurse's station and NA #3 continued yelling, arguing, and was disrespectful to LPN #1 about who was going to clean Resident #99 and clean the urine off the floor. Resident #110 indicated NA #3 she was yelling, very angry and had an attitude that night. Interview with the DNS on 4/10/25 at 12:22 PM identified she was not aware that NA #3 was witnessed to pull/yank Resident #99's wheelchair and say to the resident (act like a damn man you're acting like a child) because until surveyor inquiry, she had not read LPN #1's statement that was written on 4/8/25. The DNS indicated NA #3 was not removed from the facility after LPN #1 witnessed NA #3 pull/yank Resident #99's wheelchair and say to the resident (act like a damn man, you're acting like a child). The DNS indicated that the expectation of the facility is that when there is an allegation of abuse, the staff member is to be removed off the unit and sent home immediately. The DNS indicated NA #3 should have been removed from the unit and sent home until further notice. The DNS indicated she is not aware if LPN #1 had reported the incident to RN #6. The DNS indicated RN #6 did not inform her that there was an argument between LPN #1 and NA #3 on the unit and residents were present. Review of the facility abuse, neglect, and exploitation policy identified facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical arm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The facility abuse, neglect, and exploitation policy identified the facility will provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Mistreatment means inappropriate treatment or exploitation of a resident. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility will have written procedures that include reporting of all alleged violations to the Administrator, State Agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 2 of 3 residents (Resident #38 and 65) reviewed for Pre-admission Screening and Record Review (PASARR), the facility failed to ensure a PASARR rescreen was completed upon admission to the facility for a resident with a long-standing history of a serious mental health diagnosis and after a new mental health diagnosis was identified. The findings include: 1. Resident 38 was admitted to the facility in July 2024 with diagnoses that included chronic obstructive pulmonary disease, tracheostomy, and body dysmorphic disorder. Review of a PASARR level 1 screen outcome dated 7/10/24, prior to admission to the facility, identified that Resident #38 had not received any mental health services in the past and did not have any legal intervention due to mental health symptoms or behaviors. The PASARR level 1 outcome determined a level II was not required due to no evidence of a PASARR condition related to an intellectual disability or serious behavioral health condition. Review of the clinical record identified that Resident #38 had court appointed Conservator of Person and Estate in place upon admission to the facility due to bipolar illness and executive deficits. A psychiatric APRN note dated 7/19/24 identified that Resident #38 was seen as a new referral to the facility. The note identified that Resident #38 had a history of delusional disorders, dysthymic disorder, and anxiety disorder. The note identified that Resident #38 had chronic psychiatric illness and required medication that included Abilify (an antipsychotic medication) 5 mg daily. The quarterly MDS dated [DATE] identified Resident #38 had intact cognition, was always continent of bowel and bladder, required moderate staff assistance with toileting, dressing, and set up assistance with bathing. The MDS also identified that Resident #38 required antipsychotics on a routine basis. The care plan dated 2/12/25 identified that Resident #38 was at risk for complications related to the use of antipsychotic and anxiolytic medications for history of depression, dysthymic disorder, and anxiety. Interventions included monitoring for the continued need for medication for behavior and mood, and monitoring for changes in mental status and function and reporting to the physician as indicated. Review of the clinical record failed to identify any documentation related to a PASARR re- screen being initiated or completed following Resident #38's admission to the facility. Interview with the Social Work Director (SW #1) on 4/7/25 at 12:00 PM identified that she was unaware that Resident #38 had a significant psychiatric history. SW #1 identified she was aware that Resident #38 had a Conservator of Person and Estate and had a history of depression and anxiety but was not aware that Resident #38 had a history of bipolar illness or executive deficits, or that Resident #38 had psychiatric treatment prior to admission to the facility. SW #1 identified while it was the responsibility of the social work department to initiate the PASARR re-screen, the psychiatric provider and facility staff did not notify her of the resident's previous psychiatric history. SW #1 identified that Resident #38 should have had a PASARR rescreen completed upon admission to the facility. The facility policy on Resident Assessment- Coordination with PASARR Program directed that the facility coordinated assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder or related condition received care and services in the most integrated setting appropriate to their needs. The policy further directed that any resident with a newly evident or possible serious mental disorder would be referred for a level II review. Examples included: a resident whose related condition was not previously identified through PASARR, and a resident who is behavioral, psychiatric, or mood related symptoms were related to the presence of a mental disorder where dementia was not the primary diagnosis. 2. Resident #65 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, dysthymic disorder, and post-traumatic stress disorder (PTSD). The quarterly MDS dated [DATE] identified Resident #65 had intact cognition, and the resident mood interview identified the following symptoms and frequency: little interest or pleasure in doing things (several days) and feeling down, depressed, or hopeless (several days). The care plan dated 3/27/25 identified Resident #65 was at risk for distressed/fluctuating mood symptoms related to diagnoses of dysthymic disorder, generalized anxiety disorder, and PTSD. Interventions included observing for signs and symptoms of a new psychiatric disorder or worsening symptoms of current psychiatric disorder and encouraging resident to seek staff support for distressed mood. The care plan further identified that Resident #65 used psychotropic medications related to depression and anxiety. Interventions included administering psychotropic medications as ordered by the physician and to monitor, document, and report any adverse reactions to the medications. The Notice of PASRR Level 1 Screen Outcome dated 5/31/22 indicated that a PASARR disability was not present because of the following reason: there is no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. No Level II required. Review of the clinical record identified Resident #65 was diagnosed with major depressive disorder on 7/28/23. Interview and clinical record review with the Director of Social Services (SW #1) on 4/07/25 at 10:41 AM identified that at the time Resident #65's major depressive disorder diagnoses was identified, she was not his/her social worker, so she was not aware that Resident #65 had a new mental health diagnosis with no PASARR rescreen submitted, but she would have expected the social worker to have submitted a new Level 1 PASARR upon the identification of a new mental health diagnosis. SW #1 indicated that she would submit another Level 1 PASARR for Resident #65, subsequent to surveyor inquiry. The facility's Resident Assessment-Coordination with PASARR Program policy directs the facility coordinate assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis), a resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR, and a resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay, or equally intensive treatment. The social services director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #77) reviewed for medication administration, the facility failed to ensure a medication was administered in accordance with the physician's orders. The findings include: Resident #77 was admitted to the facility in November 2024 with diagnoses that included fractures of the left lower leg and patella, anemia, and bipolar disorder. A completed physician's order dated 1/24/25 with an end date of 2/21/25 directed to administer Cefadroxil oral capsule (antibiotic), give 500mg by mouth twice daily for four weeks, for septic arthritis. The quarterly MDS dated [DATE] identified Resident #77 had intact cognition and was currently taking an antibiotic. The care plan dated 3/12/25 identified Resident #77 was at risk for impaired skin integrity due to immobility and presence of cam boot (orthopedic footwear used to immobilize the foot and ankle). Interventions included turning and repositioning 4 times per shift. A physician's order dated 4/3/25 directed to administer Cephalexin oral capsule (antibiotic), give 500mg by mouth four times daily for 14 days, for cellulitis. Medication administration observation of LPN #2 on 4/7/25 at 8:38 AM identified LPN #2 reviewed the orders for Resident #77's morning medication pass which included the administration of the following medications: Ascorbic acid tablet 500mg give 1 tablet by mouth once daily for supplement. Cephalexin oral capsule 500mg by mouth four times daily for 14 days, for cellulitis. Trazadone HCL 50mg give 1 tablet by mouth once daily for bipolar. LPN #2 was observed removing a 500mg capsule of Cefadroxil from Resident #77's bubble pack into a medication cup and returned the bubble pack into the medication cart, then removed Resident #77's Trazadone bubble pack from the medication cart, removed the medication from the package into the medication cup, and returned the package into the medication cart. Subsequent to surveyor inquiry because LPN #2 had removed the incorrect antibiotic and placed it into the cup to be administered, LPN #2 removed the Cefadroxil bubble pack from the medication cart, again, and reviewed the physician's orders, for a second time. LPN #2 went back into the medication cart and identified a bubble pack containing 500mg of Cephalexin for Resident #77. LPN #2 reviewed Resident #77's discontinued and completed medication orders and identified that Resident #77 was no longer taking Cefadroxil. LPN #2 indicated that this was not the usual unit where she was assigned, and she would have expected that a discontinued medication would have been removed from the medication cart. LPN #2 removed the 500mg capsule of Cefadroxil from the medication cup and replaced it with the 500mg Cephalexin capsule. Interview with the DNS on 4/7/25 at 8:55AM identified that she would expect the nurse to adhere to the 5 right of medication administration and to double check the accuracy of the medication and ensure it matches the physician's order. The DNS further indicated that discontinued medications should be removed from the medication cart. The facility's Medication Administration policy directed that medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with standards of practice. Ensure that the six rights of medication administration are followed: right resident, drug, dosage, route, time, and documentation. Review MAR to identify medication to be administered and compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route and time. Refer to drug reference material if unfamiliar with the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, and interviews for 4 residents (Resident #39, 69, 81, 268) the facility failed to provide care according to professional standards, facility policy and physician's orders. For 1 of 2 residents, Resident #39) reviewed for falls, the facility failed to ensure the functionality of a remote cardiac transmission device. For 1 resident (Resident #69) the facility failed to administer medications according to the physician's orders. For 1 of 5 residents (Resident #81) reviewed for unnecessary medications, the facility failed to follow the physician's orders and complete RN assessments when the resident had multiple episodes of hyperglycemia and hypoglycemia that required additional treatment. For 1 of 5 residents (Resident #268) reviewed for medication administration, the facility failed to ensure medications were administered per the physician's order. The findings include: 1. Resident #39 was admitted to the facility in January 2016 with diagnoses that included the presence of a cardiac pacemaker, paroxysmal atrial fibrillation, and tachycardia. A cardiology consultant study dated 11/8/24 identified Resident #39's routine pacemaker remote transmission was received. Battery voltage and impedance stable, battery longevity 11.8 months, normal pacemaker function, no arrythmias noted, and to continue routine monitoring. The ECG 12 lead tracing document dated 1/13/25 identified AV dual-paced rhythm, abnormal ECG when compared with ECG of 9/25/24, no significant change was found. A physician's order dated 1/16/25 directed for a pacer transmission on 2/8/25 at 8:00 AM with a specialty provider remote card device. The quarterly MDS dated [DATE] identified Resident #39 had intact cognition and was taking an antiplatelet medication. The care plan dated 3/12/25 identified Resident #39 had a pacemaker related to a heart block diagnosis. Interventions included checking the pacemaker per physician's order and documenting in the chart: heart rate, rhythm, and battery check. The care plan further identified Resident #39 was at risk for cardiovascular symptoms or complications related to heart block, hypertension, tachycardia, pacemaker, and receiving aspirin and antiplatelet medications. Interventions included pacer checks as ordered and ensure transmitter is plugged in daily. Resident #39's clinical record December 2024 through April 2025 failed to identify documentation that the cardiac transmitter had been monitored for functionality. Observation on 4/8/25 at 9:55 AM identified a transmitter on the bedside table, with no indicator that the machine had power. Resident #39 indicated that the machine at his/her bedside was a device the heart doctor had given him/her years ago, and it hadn't worked in over a month. Interview with LPN #11 on 4/8/25 at 10:00 AM identified that she was the nurse assigned to Resident #39, but she was an agency nurse and was not familiar with the resident and could not answer questions about Resident #39's cardiac device or the transmitter. Interview with RN #4 on 4/8/25 at 10:05 AM identified that Resident #39 had an internal pacemaker and the device on his/her bedside table was a transmitter for his/her pacemaker. Observation at that time with RN #4 identified that usually a light would illuminate on the front of the device to indicate that it was on, but no light was visible. RN #4 identified that she was unaware that the transmitter was off, and that she would expect the charge nurse to be checking the transmitter daily, to ensure it is on, and to notify the supervisor if the device was not on. Interview with RN #4 and Person #2 (representative from the cardiac transmitter company) on 4/8/25 at 10:11 AM identified that 12/17/24 was the last time there was a connection from Resident #39's transmitter device to the transmitter company. A follow-up interview with RN #4 on 4/8/25 at 11:45 AM identified that a replacement part for the transmitter was ordered and that she was able to schedule an appointment for Resident #39 with the cardiologist on 4/25/25, for an in-person device check. Interview with Person #1 (medical assistant from the cardiology practice) on 4/9/25 at 11:49 AM identified that remote transmissions from Resident #39's device were scheduled for every 3 months however the last transmission reading received from the resident's device was on 11/8/24, 5 months ago. Person #1 indicated that a remote transmission was scheduled for 2/8/25, which was not completed, and that she did not have documentation identifying that the facility or Resident #39's resident representative were alerted that the transmission was missed. Person #1 identified that the medical assistant (Person #4) that would have been responsible for notifying the facility was currently out of the office and not available for an interview. Person #1 further indicated that the facility had reached out to their office on 4/8/25, and Resident #39 was scheduled for an in-person device check on 4/25/25. Interview with the DNS on 4/10/25 at 10:35 AM identified that the manufacturer's manual for the transmitter identified that the device would beep if there was a failed transmission, and that she was not aware that the device had alerted the staff that the transmission had failed. The DNS further indicated that there were no concerns identified with the device during the 11/8/24 transmission, and it was functioning properly during Resident #39's January 2025 hospital admission. The DNS identified that the nursing staff should be checking the device to ensure it is on and further investigate why the device is not on if they discover it is not functioning and report it to the supervisor. Interview with the Cardiology APRN (APRN #4) on 04/10/25 at 11:45 AM identified that Resident #39 had remote transmissions scheduled every 3 months, as a supplement to annual office checks, to monitor the functionality and condition of his/her pacemaker. APRN #4 further identified that Resident #39's last transmission was due in February of 2025 but was not completed and the last transmission completed, in November of 2024, identified that the pacemaker looked good and had approximately 1 year of battery life remaining. APRN #4 indicated that the home monitor would also ping the device daily looking for alert conditions, such as if the battery needed elective replacement or if the automatic measurement parameters were detected. APRN #4 was unable to identify which measurement parameters had been programmed on Resident #39's device, but if he/she had an episode that met that alert criteria it would also ping the system. APRN #4 identified that it is the standard of care for the pacemaker to be evaluated in the office, annually, and by remote transmissions every 3 months, which the transmission device would have to be turned on in order for the transmission to occur. Although attempted, an interview with Person #4 was not obtained. The transmitter user's manual identified the device records and stores heart data. The transmitter will securely send information to the doctor or clinic on a routine basis, typically every three months. It also does a quick check of the device on a nightly basis and will send information only if an event (as defined by your doctor) is detected. The facility's Remote Cardiac Telemetry policy directs the facility staff to notify the ordering provider if the device becomes damaged or does not appear to be working. 2. Resident #69 was admitted to the facility in February 2025 with diagnoses that included leg surgery, chronic kidney disease and dependent on dialysis, hypertension, and gastroparesis. A physician's order dated 2/13/25 directed to give Gabapentin 600 mg by mouth three times a day for phantom pain, Lactobacillus give 1 capsule by mouth one time a day for supplement, and Bumetanide 2 mg give 1 tablet two times a day for hypertension. The care plan dated 2/17/25 identified Resident #69 was at risk for impaired renal function and complications related to hemodialysis. Interventions included providing medications as ordered. The admission MDS dated [DATE] identified Resident #69 had intact cognition and required moderate assistance with toileting, dressing, and personal hygiene. Additionally, Resident #69 was on antibiotics, diuretics, opioids, and anticonvulsants. Review of the April 2025 MAR dated 4/6/25 at 11:48 PM identified Bumetanide 2 mg due to be administered twice daily for hypertension was not available. Medication observation with RN #4 on 4/7/25 at 9:17 AM indicated she had taken Resident #69's blood pressure earlier and it was 176/84. RN #4 prepared Resident #69's medications then identified she did not have the Gabapentin 600mg, Lactobacillus capsule, or the Bumetanide 2 mg available. RN #5 indicated that she had searched the medication cart and there was not any available and these medications were not in the emergency supply. An interview with RN #4 on 4/7/25 at 9:25 AM indicated that Resident #69 had not received the evening dose of Bumetanide 2 mg the day prior, and the Bumetanide 2 mg, the Lactobacillus Capsule, and Gabapentin 600 mg were not available. RN #4 indicated that the nurses were responsible for reordering medications before the resident ran out of a medication. RN #4 indicated that she would reorder the medications from the pharmacy. Review of the nurses' notes dated 4/6/25 to 4/7/25 failed to reflect the APRN or physician had been notified that the Bumetanide 2 mg, the Lactobacillus Capsule, and Gabapentin 600 mg were unavailable and had not been administered. Review of the MAR dated 4/7/25 at 9:28 AM identified RN #4 documented the scheduled 9:00 AM doses of Gabapentin 600 mg for phantom pain, Lactobacillus capsule for supplement, and Bumetanide 2mg's for hypertension were not available in facility and pharmacy was notified. Review of the MAR dated 4/7/25 identified Resident #69 did not receive the scheduled 1:00 PM dose of Gabapentin 600 mg. Interview with RN #5 (Regional corporate nurse) on 4/8/25 at 11:01 AM indicated that when a nurse does not have a medication available to give a resident per the physician order, he or she is responsible for notifying the pharmacy and the physician to see if there was an alternate medication(s) or could change the time of administration. Interview with APRN #1 on 4/8/25 at 11:18 AM indicated Resident #69 was on Bumetanide for fluid retention because of his/her diagnosis and if Bumetanide was not available nursing must notify her. APRN #1 indicated if Resident #69 misses a dose she would want to find out why and do an intervention and evaluate resident's blood pressures to see if it was elevated and if he/she has sustainable blood pressures with dialysis treatments. APRN #1 indicated that her expectation would be she must be notified if of any resident miss doses of medications. APRN #1 indicated that Resident #69 was on gabapentin for phantom pain due to the BKA. APRN #1 noted Resident #69 came into the facility on a low dose but because Resident #69 has complaints of pain the dose has been going up a couple of times, so it is important to give it and have it available, and the Lactobacillus is because nephrology ordered it from dialysis for the gastrointestinal system. APRN #1 indicated that she was not aware Resident #69 had missed the Bumetanide the evening of 4/6/25 or medications on 4/7/25 in the am or afternoon. APRN #1 indicated it was the nurse's responsibility to reorder the medications timely. APRN #1 indicated that the nurses were responsible for documenting who they notified and when if a resident had missed a scheduled medication. Interview with the DNS on 4/8/25 at 12:52 PM indicated that when a resident does not receive a dose of a scheduled medication the charge nurse is expected to notify the RN supervisor who must notify the APRN or physician and it needed get an order for an alternate medication or any other new orders from the provider and then write a nurses note with who the nurse spoke with and any recommendation or new orders from the provider. After clinical record review, the DNS indicated that from 4/6/to 4/8/24 she did not see the APRN, or physician were notified of the missed doses of medication. The DNS indicated that the Lactobacillus was house stock and if the nurse had asked the supervisor, she would have gotten it for RN #4. An interview with the DNS on 4/9/25 at 12:54 PM indicated her expectation was the nurses follow the physician orders and give the medications at the time they are scheduled within the hour before or hour after window. The DNS indicated the expectation was the nurses will reorder the medications when there are 6 doses left in the blister pack, so the resident does not run out of medications. Review of the facility Unavailable Medications Policy identified mediations may be unavailable for several reasons. Staff should take immediate action when it is known that the medication is unavailable. Notify the physician of inability to obtain medication upon notification or awareness that the medication is not available. Obtain alternate treatment orders and/or specific orders for monitoring residents while medication is on hold. If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. Review of the Medication Eror Policy identified the facility shall ensure medications will be administered according to the physician's orders. Medication that is administered not in accordance with the prescriber's order, for example a medication omission. 3. Resident # 81 was admitted to the facility in July 2023 with diagnoses that included COPD, diabetes with hyperglycemia, and dementia. The care plan dated 11/17/24 identified Resident #81 has a diagnosis of Insulin dependent diabetes and hyperglycemia. Interventions included monitoring signs and symptoms of hyper/hypoglycemia and report abnormal findings to the physician, assess and record blood glucose levels as ordered, and administer hypoglycemic medications as ordered. A physician's order dated 12/16/24 directed to inject Glucagon 1 mg (a medication used to treat low blood glucose) IM as needed for blood glucose less than 70 if Resident #81 was unable to swallow or was unresponsive, monitor vital signs and stay with the resident, notify the provider and recheck the blood glucose in 15 minutes, repeat protocol if less than 70 and document response in the progress notes. A physician's order dated 12/16/24 directed to administer Glucose oral gel 15 mg/32ml (a medication used to treat low blood glucose) one application by mouth as needed for blood glucose less than 70 if Resident #81 was asymptomatic or symptomatic but responsive with the ability to swallow. The order further directed to repeat the blood glucose level in 15 minutes, document the results, and if still below 70, notify the provider and administer a second dose of the glucose gel. A physician's order dated 12/19/24 directed for sliding scale Insulin Lispro (a short acting Insulin) to be administered with blood glucose checks 3 times daily (7:30 AM, 11:30 AM, 4:30 PM) before meals and administered for a blood glucose of: 150 - 200 = 2 units. 201 - 250 = 4 units. 251 - 300 = 6 units. 301 - 350 = 8 units. 351 -400 = 10 units. 401 - 450 = 12 units. 451+ = Call Provider for additional orders. The 5 day MDS dated [DATE] identified Resident #81 had intact cognition, was always incontinent of bowel and bladder and dependent on staff to assist with toileting, bathing, and dressing. An APRN note dated 12/28/24 at 11:58 AM identified that a telehealth visit was conducted with RN #7 due to Resident #81's blood glucose result of 480 on that date. The APRN note identified Resident #81 was asymptomatic and the treatment orders included a total of 14 units of Insulin Lispro, recheck blood glucose in one hour, if blood glucose was above 400 in 2 hours to contact telehealth APRN for further instructions, and notify a clinician of any change in condition. A nurse's note dated 12/28/24 at 12:03 PM by LPN #2 identified Resident #81's blood glucose was 480 and 12 units of Insulin Lispro were administered, the supervisor was notified, and the physician would be contacted. Review of the clinical record failed to identify any documentation that Resident #81's resident representative was notified related to Resident #81's hyperglycemic episode requiring treatment visit. A physician's order dated 1/31/25 directed for sliding scale Insulin Lispro (a short acting Insulin) to be administered with blood glucose checks 4 times daily (7:30 AM, 11:30 AM, 4:30 PM, and 9 PM) before meals, at bedtime, and administer for a blood glucose of: 150 - 200 = 2 units. 201 - 250 = 4 units. 251 - 300 = 6 units. 301 - 350 = 8 units. 351 -400 = 10 units. 401 - 450 = 12 units. 451+ = Call Provider for additional orders. The January 2025 MAR identified LPN #2 documented Resident #81 had a blood glucose of 459 on 1/31/25 at 4:30 PM and received a partial dose of Insulin Lispro. The MAR failed to identify the dose administered. Review of the clinical record failed to identify any additional documentation related to Resident #81's blood glucose of 459 on 1/31/25 including notification to the provider per the physician's order due to the blood glucose level above 450, or that Resident #81's resident representative was notified. The February 2025 MAR identified Resident #81 had a blood glucose of 63 on 2/13/25 at 7:30 AM. The MAR identified that the blood glucose parameters were out of range and no Insulin was administered. Review of the clinical record for 2/13/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The February 2025 MAR identified Resident #81 had a blood glucose of 50 obtained by LPN #2 on 2/17/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 2/17/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The February 2025 MAR identified Resident #81 had a blood glucose of 47 obtained by LPN #2 on 2/18/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 2/18/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The February 2025 MAR identified Resident #81 had a blood glucose of 51 obtained by LPN #2 on 2/22/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 2/22/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. A nurse's note dated 3/3/25 at 10:26 PM by LPN #1 identified that Resident #81 had a blood glucose of 54. The note identified glucose gel was administered. Review the clinical record for 3/3/25 failed to identify any additional documentation that the provider or Resident #81's resident representative was notified. A nurse's note dated 3/14/25 at 8:52 AM by RN #12 identified Resident #81 had a morning blood glucose of 45, that Resident #81 was given juice and breakfast, a repeat blood glucose 15 minutes later was 78, and that the APRN was notified. Further review of the clinical record failed to identify that Resident #81's resident representative was notified of the hypoglycemic episode. The March 2025 MAR identified Resident #81 had a blood glucose of 62 on 3/16/25 at 11:30 AM. Further review of the MAR identified that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/16/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The March 2025 MAR identified Resident #81 had a blood glucose of 68 obtained by LPN #2 on 3/17/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/17/25 failed to identify any additional documentation including directions according to the physician's order dated 12/16/24 or that the provider or Resident #81's representative were notified. The March 2025 MAR identified Resident #81 had a blood glucose of 55 obtained by LPN #2 on 3/20/25 at 7:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/20/25 failed to identify any additional documentation including that the provider or Resident #81's representative were notified. A nurse's note dated 3/21/25 at 3:49 AM by RN #12 identified Resident #81 had a blood glucose of 53 at 3:00 AM. The note also identified that an IM Glucagon injection was given, and Resident #81 had a repeat blood glucose of 112 at 3:45 AM. Further review of the clinical record for 3/21/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified. A nurse's note dated 3/22/25 at 7:54 AM by RN #12 identified that at 3:30 AM, Resident #81 was observed to be alert but lethargic with skin warm to the touch but clammy. The note further identified Resident #81 had a blood glucose of 50 and was administered glucose gel, and a recheck 20 minutes later identified a blood glucose of 69. The note identified Resident #81 reported feeling better and was offered orange juice, and a repeat blood glucose was 112 after an hour. The note also identified Resident #81 received Insulin Glargine 52 units at bedtime and that Resident #81 had a blood glucose of 149 at 7:30 AM. Review of the clinical record for 3/22/25 failed to identify that the provider or Resident #81's resident representative were notified. The March 2025 MAR identified on 3/22/25 at 8:00 PM that 52 units of Insulin Glargine was held by LPN #3 due to Resident #81's blood glucose levels dropping to 50 overnight. The clinical record failed to identify that the provider was notified that Resident #81 did not receive his/her nightly dose of Insulin Glargine on 3/22/25 or that Resident #81's resident representative was notified of the medication hold due to hypoglycemia. Review of the clinical record and MAR for March 2025 identified on 3/23/25 at 1:30 AM, LPN #3 identified Resident #81 had a blood glucose level of 50 and was administered glucose gel. Review of the clinical record identified on 3/23/25 at 2:00 AM, LPN #3 documented Resident #81 had a blood glucose recheck of 63. A nurse's note dated 3/23/25 at 2:32 AM by LPN #3 identified Resident #81 was clammy, cold, and lethargic and glucose gel was administered. Review of the clinical record identified on 3/23/25 at 2:30 AM, RN #12 documented Resident #81 had a blood glucose of 112. Review of the clinical record for 3/23/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified of Resident #81's hypoglycemic episode. Review of the clinical record identified on 3/25/25 at 2:00 AM LPN #3 documented Resident #81 had a blood glucose of 45. Further review of the clinical record identified a recheck by LPN #3 done at 3:44 AM was 70. Review of the clinical record and March 2025 MAR for 3/25/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified of Resident #81's hypoglycemic episode. A nurse's note dated 3/26/25 at 1:20 AM by LPN #1 identified she was notified by a nurse aide that Resident #81 was profusely sweating. LPN #1 identified that Resident #81 had blood glucose check of 41, that emergency glucose was given immediately, and that a recheck would be done in a few minutes. The March 2025 MAR identified LPN #1 administered glucose gel on 3/26/25 at 1:20 AM. A nurse's note dated 3/26/25 at 1:45 AM by LPN #6 identified Resident #81 had a repeat blood glucose check of 54. Further review of the nurse's note identified LPN #1 documented a repeat blood glucose check of 131 at 2:14 AM. Review of the clinical record for 3/26/25 failed to identify any documentation that the provider or Resident #81's resident representative were notified of Resident #81's hypoglycemic episode. The March 2025 MAR identified Resident #81 had a blood glucose of 67 obtained by LPN #2 on 3/31/25 at 11:30 AM. Further review of the MAR identified LPN #2 documented that the blood glucose was within range and no Insulin was administered. Review of the clinical record for 3/31/25 failed to identify any documentation that Resident #81's resident representative was notified of Resident #81's hypoglycemic episode. Interview with APRN #1 on 4/8/25 at 11:52 AM identified that she was aware that Resident #81 had variable blood glucose levels but felt these were related to dietary noncompliance and a recent course of antibiotics. APRN #1 identified she could not remember if she was notified that if Resident #81 received IM Glucagon or of all the blood glucose levels under 70 since 2/13/25, but if the resident had a blood glucose above 450 or below 70, she would expect that the nurses would assess the resident to ensure he/she was not symptomatic and that she or the on call provider would be notified if the resident had symptoms. Interview with LPN #1 on 4/9/25 at 10:50 AM identified that she was assigned to Resident #81 on 3/3 and 3/26/25. LPN #1 identified that LPNs in the facility were not allowed to complete an assessment of the residents or contact the physician/APRN and resident representative regarding a change in condition, so that should have been completed by the RN. LPN #1 identified she was unsure who she reported Resident #81's hypoglycemic episodes to and she did not document the information in the clinical record. Interview with RN #12 on 4/9/25 at 11:56 AM identified that she was the nurse assigned to Resident #81 on 3/20/25 on the 11:00 PM - 7:00 AM shift and was the RN supervisor working with LPN #3 on 3/22/25 on the 11:00 PM - 7:00 AM shift. RN #12 identified on 3/21/25 at 3:00 AM a nurse aide notified her that Resident #81 was very lethargic, and she administered IM Glucagon which was the standard order for all diabetics in the facility for hypoglycemia. RN #12 identified she obtained vital signs on Resident #81 and completed a repeat blood glucose check at 3:45 AM and documented a progress note. RN #12 identified that on 3/23/25 Resident #81 had a similar hypoglycemic episode with LPN #3 overnight and required glucose gel and juice. RN #12 identified she did not notify the on-call provider or Resident #81's resident representative regarding Resident #81's hypoglycemic episodes on 3/21 or 3/23/25 and that she would have passed the information on in morning report to the day shift or told APRN #1 in person if she was in the facility at shift change. RN #12 identified that she did not feel that it was necessary to notify the on-call provider but was aware that the physician orders and facility protocol for hypoglycemia directed to contact the physician or APRN for a blood glucose less than 70 Interview with LPN #2 on 4/9/25 at 12:15 PM identified she could not remember any blood glucose issues for Resident #81 from 12/28/24, 1/31/25, 2/2025, or 3/2025. LPN #2 identified that unless she noticed a specific issue or it was listed in her tasks in the MAR or TAR, she did not document a note or assess Resident #81 related to blood glucose issues. LPN #2 identified any documentation would be in a progress note, and that she would notify the RN supervisor. LPN #2 identified LPNs in the facility were not allowed to contact the physician/APRN of any issues with a resident and only the RN supervisor was allowed to contact the provider. LPN #2 also identified that Resident #81 typically had high blood glucose levels due to his/her resident representative bringing in a [NAME] Donuts coffee in daily. Interview with RN #7 on 4/9/25 at 12:54 PM identified that she vaguely remembered Resident #81 having an episode of hyperglycemia on 12/28/24. RN #7 identified that LPN #2 notified her, she then contacted the telehealth APRN and assisted with the visit, and notified LPN #2, who was assigned to Resident #81, of the orders including the additional 2 units of Insulin and rechecks. RN #7 identified that she could not remember any additional information regarding LPN #2, the telehealth orders, or contacting Resident #81's resident representative. Interview with LPN #3 on 4/9/25 at 1:01 PM identified that she was present with RN #12 on 3/20/25 and was assigned to care for Resident #81 on 3/22/25 on the 11:00 PM - 7:00 AM shifts. LPN #3 identified that Resident #81 was very lethargic and not responsive during the 3/21/25 hypoglycemic episode and she went in to assist RN #12. LPN #3 identified it was very hectic and scary, but following the IM Glucagon administration, Resident #81 improved. LPN #3 identified that later in the shift, she reviewed Resident #81's Insulin orders and blood glucose levels and noted that Resident #81 had multiple episodes of hypoglycemia dating back to January or February 2025. LPN #3 identified she printed out all the blood glucose levels and provided them to RN #12 for review. LPN #3 identified she did not know if RN #12 notified the physician, APRN, or Resident #81's resident representative, and that LPNs in the facility had been instructed they were not supposed to contact the providers or assess any of the residents following a change of condition, and that this was only to be done by RNs in the facility. LPN #3 identified that on 3/22/25, she was assigned Resident #81 for the first time, and since she had been present for the hypoglycemic episode on 3/21/25, she decided to hold Resident #81's bedtime Insulin Glargine, but that Resident #81 still had a hypoglycemic episode very similar to the one on 3/21/25. LPN #3 identified that she did notify RN #6 or RN #12 related to holding Resident #81's Insulin but could not remember who. Interview with the DNS and RN #5 (Regional Resource Nurse) on 4/9/25 at 1:35 PM identified that provider notification for blood glucose levels depended on the resident's orders. The DNS identified that for Resident #81, she would expect the nurses to notify the provider for any blood glucose levels under 70 or over 450, and that the nurses would assess the resident for symptoms of hypo or hyperglycemia. The DNS identified that LPNs in the facility did have the authority to notify the provider but to notify the RN. The DNS further identified if an RN assessment of the resident was needed due to a change in condition, the LPNs had been instructed to not bypass the RN and that the RN should be notified that the resident had a change that required an RN assessment. The DNS further identified that provider notification usually took place in person with APRN #1 when she was in the building. The facility policy on Hypoglycemia directed that the purpose of the policy was to a standard care routine for management of episodes of hypoglycemia based on the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #91) reviewed for pressure ulcer, the facility failed to ensure appropriate care according to professional standards and facility policy when a new pressure ulcer was identified. The findings include: Resident #91 was admitted to the facility on [DATE] and readmission on [DATE] with diagnoses that included fall with left femur fracture, and dementia. The quarterly MDS dated [DATE] identified Resident #91 had severely impaired cognition, was always incontinent of bowel and bladder and required moderate assistance with rolling left to right and transfers chair/bed to chair transfers. Additionally, Resident #91 required maximum assistance with perineal hygiene and dressing. Resident #91 was at risk for developing a pressure ulcer but did not have any pressure ulcers. The readmission nursing assessment dated [DATE] identified Resident #91's skin was intact except for periorbital bruising to the face status post fall. The assessment did not identify any open areas or pressure areas. A physician's order dated 1/31/25 directed for skin prep to bilateral heels daily on evening shift for 14 days last day 2/12/25. The care plan dated 2/13/25 identified Resident #91 was at risk for skin breakdown related to decreased mobility and left hip surgical incision. Interventions included applying barrier cream after each incontinent episode, dietitian consultation as needed, and weekly skin checks by the licensed nurse. The weekly skin check assessment documented by RN #2 dated 2/15/25 identified Resident #91's left heel had a blister with slough measuring 6.0 cm by 6.0 cm intact. (first identified) The weekly skin check assessment documented by LPN #1 dated 2/22/25 at 7:23 PM identified a previously identified wound to the left heel. (second time identified) Interview with LPN #1 on 4/7/25 at 8:55 AM indicated that she did the weekly skin assessment on 2/22/25 for Resident #91. LPN #1 indicated that she thought the left heel was already noted and not new, so she did not call for an RN assessment. An interview with RN #2 on 4/7/25 at 11:11 AM indicated that she was the charge nurse on the unit and was responsible on 2/15/25 to do the weekly body assessment on Resident #91. RN #2 indicated that she had noted an intact 6 cm by 6 cm blister with yellow drainage inside the blister but the skin under the blister was not viable skin. RN #2 indicated that she assumed the DTI to the left heel was old. RN #2 indicated that if it was new she would have told the supervisor so she could have done a change in condition assessment, get a treatment order. RN #2 indicated that because she thought it was old she did not notify the RN supervisor to do the change of condition RN assessment. The APRN note dated 2/24/25 at 1:04 PM identified she was notified by RN #1 and had seen Resident #91 for a deep tissue injury (DTI) to left heel today noted by nursing. Recommended Santyl topically with daily dressing change to facilitate until seen by wound provider later this week. Nursing to off load heels for Resident #91. The Change of Condition Evaluation documented by RN #1 dated 2/24/25 at 1:21 PM identified Resident #91 noted to have a new injury to his/her left heel. RN #1 noted this is the leg affected by his/her broken hip and surgical fixation. Left heel unstageable DTI measuring 2.5 cm by 1.4 cm by 0.1cm. The Wound Integrity Report written by RN #1 dated 2/24/25 identified Resident #91 had a new unstageable DTI to the left heel measuring 2.5 cm by 1.4 cm by 0.1 cm with sloughy appearance in wound bed, moderate amount of serous drainage, macerated surrounding tissue, and wound had no odor. Review of the nurse's and dietitian notes dated 2/15/25 to 4/1/25 identified the dietitian did not evaluate the residents nutritional status in relation to the new pressure ulcer until 4/2/25 (49 days later). The dietitian note dated 4/2/25 identified Resident #91 triggers for significant weight loss times 1 month and pressure ulcer to the left heel, resident was at risk for malnutrition. Resident #91 remains at risk for malnutrition related to unplanned weight loss and need for mechanically altered diet and requires total assistance for feeding. Recommendations included Glucerna once day in the evening to assist with stability and protein supplements to support wound healing in view of pressure injury to left heel. Interview with the Dietitian on 4/9/25 at 11:35 AM identified the wound nurse was responsible to provide her with a weekly wound report for all wounds that would include new wounds and if wounds are getting worse. The Dietitian indicated that she did not receive any wound reports for the month of February 2025 and only 1 report in March 2025. The Dietitian indicated the wound report for the week of 3/7/25 did not include Resident #91. The Dietitian indicated that notified the DNS that she was not receiving the weekly wound reports. The Dietitian indicated that if a resident receives a new facility acquired pressure ulcer and she was notified she would have seen the resident within a week at the most. The Dietitian indicated she would assess the resident and make sure the resident is meeting nutritional needs and would recommend some type of protein supplement based on the stage of the wound. The Dietitian indicated that on 4/2/25 after Resident #91 was readmitted on [DATE] she went to do the nutritional evaluation and noted the documentation of the left heel pressure ulcer. The Dietitian indicated at that time she had recommended the protein supplement (Prostat Advanced Wound Care) and the order was put into place. The Dietitian indicated that if she was aware on 2/15/25 when someone had first found the left heel, she would have seen Resident #91. The Dietitian indicated that it is the protocol for stage 3, stage 4, or unstageable to immediately start the protein supplement to promote wound healing. Interview with RN #1 on 4/7/25 at 9:46 AM indicated that no one had informed her of Resident #91's left heel pressure ulcer and that she had found it when auditing the weekly skin assessments that are completed weekly. RN #1 indicated that on 2/24/25 she noted that the left heel started on 2/15/25 and when she assessed the heel the blister had opened and was unstageable and measured 2.5 cm by 1.4 cm by 0.1 cm. RN #1 indicated that the first complete RN assessment for the left heel pressure area was completed on 2/24/25 that was 9 days after first found. RN #1 indicated that the wound assessment would have included measurements of wound measuring it by length by width by depth, description of wound bed, any drainage noted, if resident had any pain, appearance, undermining, surrounding tissue, or any odor. RN #1 indicated that there was no treatment in place for the left heel from 2/15/25 to 2/24/25. RN #1 indicated that when the wound physician saw the left heel on 2/27/25 he staged it as an unstageable DTI. RN #1 indicated that on 2/15/25 when the left heel pressure ulcer was first identified there should have immediately been an RN change of condition assessment with a complete wound assessment, and the physician should have been notified. Interview with the DNS on 4/7/25 at 11:21 AM indicated Resident #91 had a left heel noted on 2/24/25 by the wound nurse RN #1 on 2/24/25. The DNS indicated that when a pressure ulcer is first identified the charge nurse notifies the RN supervisor to do the initial wound assessment including measurements, description of wound and wound bed, and the surrounding skin. The DNS indicated that she thought Resident #91's left heel started on 2/24/25 and she was first notified about it on 2/24/25. Review of Pressure Injury Prevention and Management Policy identified the facility as committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to promote treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injures. Pressure injury refers to localized damage to skin and/or underlying soft tissue usually over a bony prominence. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be documented with the stage of the pressure injury will be clearly identified. Evidence based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate, presence of pain, signs of infection, wound bed, wound edges, and surrounding tissue characteristics. The goals and preferences of the resident and/or resident representative will be included in the care plan. The RN unit manager or designee will review all relevant documentation regarding skin assessments, pressure injury risks, progression of wound healing, and compliance at least weekly, and document a summary of findings in the medical record. The attending physician will be notified of the presence of a new pressure injury identification. A review will be performed on each pressure injury that develops in the facility. Findings will be reported in the monthly QAA committee meetings. Review of the Nutritional Management Policy identified the facility promotes care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in his/her overall condition. A comprehensive nutritional assessment will be completed by the dietitian within 72 hours of admission, annually, and upon significant change in condition. Components of the assessment will include, but not limited to residents' general appearance, height, weight, cognitive, physical, and medical conditions, food and fluid intake, poor intake, weight loss, review of medications, and review of labs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, and interviews for 2 of 3 residents (Resident #22 and 65) reviewed for respiratory care, the facility failed to ensure the CPAP (continuous positive airway pressure) tubing, filter, and mask were changed in accordance with the manufacturer's recommendations. The findings include: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses that included sleep apnea, obesity, and chronic obstructive pulmonary disease (COPD). The annual MDS dated [DATE] identified Resident # 22 had intact cognition and required a non-invasive mechanical ventilator (CPAP or Bi-pap). The quarterly MDS dated [DATE] identified Resident #22 had intact cognition and required maximum assistance with toileting, bathing, and personal hygiene. and required a non-invasive mechanical ventilator (CPAP or Bi pap). The care plan dated 2/3/25 identified Resident #22 has altered respiratory status and difficulty breathing related to COPD and sleep apnea. Interventions included Resident #22 utilizes a CPAP machine at bedtime. A physician's order dated 2/12/25 (original date 11/3/24) directed a CPAP at bedtime and remove in the morning. Nurses are directed to change or clean intake filter and disposable supplies (i.e. tubing) per manufacturers guidelines every Sunday between 11:00 PM and 7:00 AM and or if soiled as needed. Additionally, clean CPAP reservoir weekly every Wednesday between 11:00 PM to 7:00 AM. Review of the MAR dated 3/1/25 to 3/31/25 identified that RN #8 had signed off as cleaning or changing the CPAP intake filter, tubing, and any disposable equipment on 3/2, 3/16, and 3/30/25. Observation on 4/6/25 at 8:00 AM identified a CPAP mask on the nightstand without the benefit of being bagged. Additionally, there wasn't a date on the mask or head gear and at the base of the heated tubing it was dated 7/31/24, over 8 months ago. Observation on 4/7/25 at 10:00 AM identified a CPAP mask on the nightstand without the benefit of being bagged. There was no date on the mask or headgear and the heated tubing was dated 7/31/24 to identify when it last changed. Interview with LPN #1 on 4/8/25 at 2:30 PM indicated that the 7:00 AM to 3:00 PM nurses do not touch the CPAP equipment or machine for Resident #22 and the night nurse or management were responsible to order the equipment and change the equipment but was she did not know when. Observation of Resident #22's CPAP equipment and machine, LPN #1 identified that the tubing at the base in black marker was dated 7/31/24 and she indicated that was the last time the tubing was changed then she opened the air filter chamber and indicated the filter should be white but it was the color grey but could not identify when the disposable air filter was last changed or when the water chamber was last cleaned. Interview with the DNS on 4/8/25 at 2:55 PM indicated that Respiratory Therapist #1 was responsible to maintain the CPAP or BIPAP machines and equipment. The DNS wasn't able to explain when the mask, tubing, and air filter were to be changed and indicated to speak with Respiratory Therapist #1 that comes to the facility once a week. Interview with Respiratory Therapist #1 on 4/8/25 at 3:04 PM indicated that she came to the facility to initially set up the BIPAP and CPAP machines and then the nursing facility's nurses were responsible to clean and change the disposable parts such as the mask, head gear, tubing, and air filter. Respiratory Therapist #1 indicated the mask, head gear and tubing must be changed every 3 months and the air filter at least every 6 months if non disposable and can be washed but recommends changing the air filter while changing the other equipment every 3 months. Respiratory Therapist #1 indicated that her company only set up Resident #22's machine on admission, but the nurses were responsible for the routine changes of equipment. Observation of Resident #22's equipment and machine, Respiratory Therapist #1 indicated that the mask was not bagged and should be bagged when not in use. Respiratory Therapist #1 identified the mask and tubing were last changed on 7/31/24 and the air filter was a disposable air filter appears a dark grey instead of white and based on appearance and the sticker was last changed on 9/10/24. Respiratory Therapist #1 indicated that she will discard all the equipment and the air filter and get new equipment. Interview with RN #8 on 4/9/25 at 10:34 AM indicated that she works the 11:00 PM to 7:00 AM shift and verified she had worked on 3/2, 3/16, and 3/30/25 on Resident #22's unit. RN #8 indicated that she did sign off as cleaning or changing the equipment for the CPAP, but she did not. RN #8 indicated that there was no CPAP disposable equipment available to change the equipment and she had informed the supervisors and that she never cleaned any equipment because Resident #22 was sleeping before 11:00 PM and slept through past 7:00 AM. RN #8 indicated that although the order says to clean equipment during the 11:00 PM to 7:00 AM shift, the residents are using the equipment. RN #8 indicated that she does not recall the last time she had changed or cleaned the residents' CPAP or BiPAP equipment. Interview with RN #9 (Regional Nurse) on 4/9/25 at 11:00 AM indicated that the orders for Resident #22's CPAP was too broad and was not specific enough for the nurses to clearly change the air filter every 2 weeks and sign off, and change the humidified tubing every 3 months, and change the head gear and mask every 3 months. RN# 9 indicated the tubing, mask, and water reservoir were to be washed and cleaned weekly but should not be scheduled on night shift but should be done during the day when it has time to completely dry before the resident needs it that evening. Although attempted, an interview with LPN #3 was not obtained. Review of the facility CPAP and BiPAP Cleaning Policy identified the facility will clean CPAP/BiPAP equipment in accordance with current CDC guidelines and manufacturer recommendations to prevent the occurrence or spread of infection. CPAP is continuous positive airway pressure. Replace equipment general guidelines are the face mask and tubing are to be changed every 3 months, the headgear and humidifier chamber to be changed every 6 months, and the disposable filter changed twice a month. Additionally, the nurse will document the use of the machine, residents' tolerance, skin integrity, respiratory or other changes and responses. The Manufacturer Guide for CPAP indicated cleaning the device and components according to the schedules shown in this guide to maintain the quality of the device and to prevent growth of germs that can adversely affect your health. Clean daily the humidifier tub and wipe it thoroughly with a clean disposable cloth. Allow it to dry out of direct sunlight. Refill them with distilled water only. Weekly wash the air tubing, humidifier tub and outlet connector in warm water using mild dishwashing liquid. Rinse each component thoroughly in water and allow to air dry. Change every month the mask cushions or nasal pillows and the disposable filter, every 3 months change the CPAP tubing, and every 6 months change the mask headgear and the humidifier water tub. 2. Resident #65 was admitted to the facility in November 2021 with diagnoses that included chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA). The quarterly MDS dated [DATE] identified Resident #65 had intact cognition, and received a special treatment, procedure, or program: a non-invasive mechanical ventilator, while a resident at the facility. The care plan dated 3/27/25 identified Resident #65 had the potential for altered respiratory status/difficulty breathing related to diagnosis of OSA and required CPAP. Interventions included monitoring for signs and symptoms of respiratory distress, encouraging sustained deep breathing, and respiratory consultations as ordered. Physician's orders dated 3/31/25 directed to administer CPAP_10CM pressure, apply at night and remove in the morning: full face mask humidification (if appropriate) heated or cool fill humidifier with sterile or distilled water. The physician's orders further directed to clean CPAP/BIPAP reservoir weekly, every Wednesday night shift and to change or clean intake filer and disposable supplies (tubing) per manufacturers guidelines, or if soiled and as needed every night shift, on Wednesday. Observation and interview with Resident #65 on 4/8/25 at 2:25 PM identified that no staff member had cleaned his/her CPAP in months. Resident #65's CPAP tubing was dated 7/31/24, over 8 months, and the mask, which was uncovered, was dated 7/31/24. Resident 65 indicated that 7/31/24 must be the last time anyone had cleaned or changed the CPAP equipment. Observation and interview with RN #1 on 4/8/25 at 2:45 PM identified the date 7/31/24 on Resident #65's CPAP mask and tubing would indicate the date the mask and tubing were last changed. RN #1 further indicated that the cleaning and changing of the CPAP tubing and mask were scheduled to be completed during the overnight shift, but RN #1 was unsure how the CPAP tubing and mask could be cleaned and have time to adequately dry during the night shift while the resident would be sleeping. RN #1 identified she would have to review the facility's policy. Interview with the Clinical Manager of the consulting respiratory therapy group (RT #1) on 4/8/25 at 2:50 PM identified that she would expect a weekly soaking of the CPAP tubing, the mask to be wiped daily with a cloth and the mask to be bagged when not in use. RT #1 further indicated that the CPAP tubing and face mask should be changed according to the facility policy and manufacturer's recommendations, which was typically every 3 months or if the pieces remain soiled after cleaning. Interview with RN #1 on 4/10/25 at 9:29 AM identified that the orders to change Resident #65's mask and tubing were broad and said per manufacturer's guidelines. RN #1 indicated that there was no system in place for CPAP masks and tubing to be changed every 3 months. RN #1 indicated that the last time Resident #65's CPAP tubing and mask were changed was on 7/31/24. RN #1 further indicated that the policy for CPAP equipment cleaning and changes was, currently, being revised. Interview with the DNS on 04/10/25 at 10:44 AM identified that Resident #65's CPAP tubing and mask were not changed in accordance with the manufacturer's recommendations. The DNS indicated that the physician's order directed the disposable equipment to be cleaned per the manufacturer's recommendations and did not give a timeframe. The DNS identified that the facility is revamping the policy. The facility's CPAP/BiPAP Cleaning policy directs the facility to clean the CPAP/BiPAP equipment in accordance with the current CDC guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection; respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections. The policy further directs the facility to clean the mask frame daily after use with a CPAP cleaning wipe or soap and water, dry well, and cover with plastic bag or completely enclosed in machine storage when not in use. Weekly cleaning activities include washing head gear/straps and tubing in warm, soapy water and air dry. The policy directs for equipment to be replaced routinely in accordance with the manufacturer recommendations; general guidelines: face mask and tubing-once every 3 months, headgear, non-disposable filters, and humidifier chamber-once every 6 months, and disposable filters-twice monthly. Replace equipment immediately when it is broken or malfunctions, or if visible soiling remains after cleaning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policies, and interviews for 1 of 5 residents (Resident #65) reviewed for unnecessary medications, the facility failed to ensure a medication for the treatment of a mental health diagnosis was administered per the physician's order. The findings include: Resident #65 was admitted to the facility in November 2021 with diagnoses that included anxiety disorder, dysthymic disorder, major depressive mood disorder (MDD), and post-traumatic stress disorder (PTSD). The quarterly MDS dated [DATE] identified Resident #65 had intact cognition, and the resident mood interview identified the following symptoms and frequency: little interest or pleasure in doing things (several days) and feeling down, depressed, or hopeless (several days). The care plan dated 3/27/25 identified Resident #65 was at risk for distressed/fluctuating mood symptoms related to diagnoses of dysthymic disorder, generalized anxiety disorder, and PTSD. Interventions included observing for signs and symptoms of a new psychiatric disorder or worsening symptoms of current psychiatric disorder and encouraging the resident to seek staff support for distressed mood. The care plan further identified that Resident #65 used psychotropic medications related to depression and anxiety. Interventions included administering psychotropic medications as ordered by the physician and to monitor, document, and report any adverse reactions to the medications. A physician's order dated 6/28/24 directed to administer Rexulti oral tablet 1mg, give 1 tablet by mouth at bedtime for depression. The March 2025 MAR identified Resident #65 did not receive Rexulti 1mg on 3/22/25 (medication not available), 3/23/25 (on order), or on 3/24/25. The nurse's note dated 3/23/25 at 10:12 PM identified the writer spoke with the on-call APRN who directed the administration of Clonazepam 1mg tablet by mouth, now. The Psychiatric Evaluation and Consultation dated 3/24/25 identified Resident #65 had a psychiatric history including MDD, anxiety, PTSD, and sleep terrors with current exacerbation of anxiety related to Rexulti not being properly refilled due to insurance/pharmacy mix-up. Resident #65 is currently taking Rexulti as an adjunct therapy for MDD and was requesting something for anxiety/depression in the meantime until the Rexulti is refilled. Options were discussed and settled on Trazadone. Resident #65 denied SI/HI/AVH and was happy at the end of the visit and pleased medications were being adjusted. Collaboration with the nursing supervisor, the DNS, and pharmacy staff resolved the situation and the pharmacy will send the Rexulti dose later this evening. Interview with Resident #65 on 4/6/25 at 9:55 AM identified that he/she did not receive Rexulti from 3/19/25 through 3/24/25 before bed as prescribed. Interview and review of Resident #65's Rexulti refill history with the Consulting Pharmacist (Pharmacist #2) on 4/9/25 at 9:24 AM failed to identify that a request from the facility to refill the Rexulti was completed from 3/19/25 through 3/23/25. Pharmacist #2 indicated that the facility had made a 7-day supply refill request on 3/11/25, which arrived at the facility on 3/12/25 at 2:00 AM and the next 7-day supply refill request was made on 3/24/25 at 12:42 PM, which arrived at the facility on 3/25/25 at 2:29 AM. Pharmacist #2 further indicated that in November of 2024, Resident #65's Rexulti refill quantity changed to a 7-day supply, and submitting a medication refill request should be completed 2 - 3 days prior to the medication running out, to allow time for delivery and ensure the medication does not run out. Interview with the DNS on 4/9/25 at 1:10 PM identified that Resident #65 had missed Rexulti doses from 3/22/25 through 3/24/25, 3 doses, because the facility did not have it. The DNS indicated that when APRN #3 notified her of the missing doses on 3/24/25, she called the pharmacy to address the issue. The DNS indicated that medication refill requests should be completed in a timely manner to ensure medications are available for their scheduled administration times. The facility's Pharmacy Services policy directs the pharmacist, in collaboration with the facility and medical director, should include within its services to strive to assure medications are requested, received, and administered in a timely manner. The facility's Medication Administration policy directs medications are to be administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #269) reviewed for unnecessary medications, the facility failed to conduct a gradual dose reduction of Risperidone upon admission when the clinical record failed to reflect a psychiatric diagnosis. The findings include: Resident #269 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease and dementia. Notice of PASRR Level 1 Screen Outcome dated 3/31/25 identified Resident #269 had no mental health diagnosis that was known or suspected. A physician's order dated 4/1/25 directed to give Risperidone (antipsychotic medication) 0.25mg by mouth 3 times a day. The psychiatric APRN #2 note dated 4/1/25 identified Resident #269 was seen and assessed today for initial evaluation and will continue Risperidone 0.25mg by mouth three times a day for a diagnosis of Bipolar (this diagnosis is in conflict with the hospital and facility clinical records). The care plan dated 4/1/25 identified Resident #269 was at risk for complications related to the use of psychotropic medications. Interventions included monitor for continued need for medication as related to mood and behavior and obtain psychiatric evaluation. The admission MDS dated [DATE] identified Resident #269 had moderately impaired cognition and was dependent on staff for toileting and dressing and required maximum assistance with bathing and personal hygiene. Additionally, the MDS did not identify any psychiatric or mood disorders. Residents' overall goal indicated from Resident #269 was to be discharged to the community. Interview with APRN #2 on 4/8/25 at 11:39 AM after clinical record review APRN #2 indicated that Resident #269 was admitted on [DATE] and Resident #269 was taking the medication Risperidone at the hospital before coming to this facility. APRN #2 indicated that she did not review the hospital discharge paperwork to confirm a psychiatric diagnosis for the antipsychotic medication she just saw the Risperidone was in the orders from the hospital. APRN #2 indicated that she did not verify or give Resident #269 the diagnosis of Bipolar but just continued the diagnosis and continued the antipsychotic medication without trying to discontinue the antipsychotic medication. Interview with APRN #1 on 4/8/25 at 1:01 PM indicated Resident #269 was admitted on Risperidone without a diagnosis, so she referred the resident to APRN #2. APRN #1 indicated that the psychiatric APRN, APRN #2, had documented on 4/1/25 that Resident #269 was on Risperidone for Bipolar disorder. APRN #2 indicated that if Resident #269 does not have the diagnosis of Bipolar her expectation would be that Resident #269 must be weaned off Risperidone. The interview with APRN #2 on 4/8/25 at 1:04 PM indicated that she could not speak to the surveyor and must leave the facility immediately. APRN #2 packed up her belongings and headed to the front lobby area/exit. APRN #2 refused to speak to the surveyor and identified she was told by her boss she must leave immediately and not speak to the surveyor. RN #5, who was present, indicated that he does not know why APRN #2 must leave and that he would call her boss. The interview with RN #5 on 4/8/25 at 1:30 PM indicated the psychiatric group was sending someone out to reevaluate Resident #269 today regarding the diagnosis of Bipolar disease and being on the antipsychotic medication Risperidone. After surveyor inquiry, the psychiatric APRN, APRN #5's note dated 4/8/25 indicated that prior to hospitalization Resident #269 was at an assisted living where Resident #269 had started Risperidone 0.25 mg 3 times a day for agitation. Chart reviewed for psychiatric diagnosis and psychotropic medications. Diagnosis of Bipolar disorder was erroneously added to Resident #269's record. There is no record of Bipolar disorder noted in hospital notes dated 3/30/25 nor on the PASARR. Resident #269 carries a diagnosis of Dementia without behavioral disturbances and is prescribed Donepezil. Resident #269 was prescribed Risperidone 0.25mg 3 times a day for agitation. APRN #5 indicated that she will trial a gradual dose reduction of Risperidone as diagnosis does not support its use. Plan is to decrease Risperidone 0.25mg to twice a day with plan to continue gradual dose reduction. After surveyor inquiry, a physician's order dated 4/9/25 directed to decrease the Risperidone 0.25mg by mouth 2 times a day. The interview with APRN #5 on 4/10/25 at 10:28 AM indicated after APRN #2 had left the facility unplanned, she came in to evaluate Resident #269 on 4/8/25 and she could not find a diagnosis of Bipolar for Resident #269 to justify the use of the medication Risperidone. APRN #5 indicated that Resident #269 should not have been on for Risperidone for Bipolar because Resident #269 does not have Bipolar. APRN #5 indicated that APRN #2 should have reviewed all the hospital discharge documentation to determine if Resident #269 had a diagnosis of Bipolar which he/she did not. APRN #5 indicated that since Resident #269 does not have a diagnosis of Bipolar and APRN #2 on her visit on 4/1/25 should have started a gradual dose reduction to get Resident #269 off the Risperidone. APRN #5 indicated that the expectation would be to do a gradual dose reduction when seen by APRN #2 on 4/1/25 because Resident #269 only had a diagnosis of Dementia and not Bipolar. Review of the Use of Psychotropic Medications Policy identified residents are not given psychotropic medications unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the residents, as demonstrated by monitoring and documentation of the resident's response to the medication. Resident and/or representatives shall be educated on the risks and benefits of psychotropic medications use, as well as alternative treatments/non-pharma logical interventions. Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, to discontinue these drugs. Use of psychotropic medications an evaluation shall be documented to determine that the resident's expressions or indications of distress are not due to a medical condition or problems that can be expected to improve or resolve as the underlying condition is treated, or the offending medications are discontinued. New admissions the facility shall identify the indication for use by pre-admission screening and other pre-admission data. The physician in collaboration with the consultant pharmacist shall re-evaluate the use of the medication and consider whether or not the medication can be reduced or discontinued upon admission or soon after admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, interviews, and review of facility policies for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident's treatment order was entered correctly to ensure timely initiation of the practitioner's directive. The findings included the following: Resident #1 had diagnoses which included lymphedema, atherosclerotic heart disease, and adjustment order with anxiety. Review of Resident #1's Care Plan dated 1/7/25 identified the resident was at risk for skin breakdown related to reduced mobility and has actual skin breakdown and bilateral lower extremity lymphedema with interventions that directed to ace wraps as ordered for lymphedema. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of thirteen (13) indicative of intact cognition. The MDS further identified Resident #1 was dependent with bathing and toileting hygiene, and required substantial assistance with personal hygiene. Review of the 1/7/25 Advanced Practice Registered Nurse (APRN) #1's note on 1/7/25 at 2:57 PM identified Resident #1 was seen for increased confusion and lower extremity edema. The note the instructed to elevate Resident #1's lower extremities while in bed and start ace wraps to the lower extremities with application at 6:00 AM and removal at 6:00 PM. Review of the Medication Administration Report (MAR) dated January 2025 identified an order to wrap lower legs with ace wraps at 6:00 AM and remove at 6:00 PM daily one time a day for edema was not initiated until 1/12/25, (five days following the APRN's instruction). Interview with the Director of Nursing Services (DNS) on 2/21/25 at 3:30 PM identified the order to wrap Resident #1's legs with ace wraps was entered into Resident #1's medical record on 1/7/25, however the order was entered incorrectly (as an ancillary order - without a schedule), which prevented the order from appearing on the MAR with a scheduled times. The DNS further identified the standard of practice was for the nursing supervisor to confirm new orders that were entered into the electronic medical record; however, he/she had failed to realize the treatment schedule was missing from the order until 1/11/25, which caused the delay in initiating the resident's treatment unit; 1/12/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, interviews, and review of facility policies for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure that a resident was not provided an allergen at meal time. The findings included the following: Resident #1 had diagnoses which included dysphagia, atherosclerotic heart disease, and adjustment order with anxiety. Review of Resident #1's Care Plan dated 1/6/25 identified a risk for allergic reaction related to known allergy to cephalexin, erythromycin, sulfa antibiotics, pineapple, and shellfish with interventions that directed to note allergy in Point Click Care (the resident's electronic medical record) and to notify the physician of any signs and symptoms of an allergic reaction. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of thirteen (13) indicative of intact cognition. The MDS further identified Resident #1 was dependent with bathing and toileting hygiene, and required substantial assistance with personal hygiene. Review of RN #1's nursing noted dated 1/13/25 at 6:28 PM identified Resident #1 was given pineapple for dinner and that he/she had an allergy to pineapple. RN #1 further indicated that at the time of this writing, the resident showed no signs of having an allergic reaction, had pulse oximetry (a device which reads oxygen levels in the blood) reading of 95%, was on two (2) liters of oxygen, had diminished lungs sounds throughout, was without rash and wheezing, an order for Benedryl 25 milligrams by mouth every six (6) hours as needed was in place, and he/she would continue to monitor the resident. Interview with the Food Services Director (FSD) on 2/21/25 at 1:58 PM identified he/she was aware of that pineapple was served to the resident with a known allergy to pineapple. The FSD further identified the facility had now instituted a color-coded meal ticket for residents with known allergies and/or special diets to avoid this situation from happening again and that staff was in-serviced on meal safety/checks as well. Interview with Dietary Aide #1 on 2/21/25 at 3:00 PM identified he/she had observed a bowl of pineapple pieces on Resident #1's dinner tray and had removed it because of the allergy, however, was distracted when another nurse's aide had requested a food item for another resident. Kitchen Aide #1 indicated he/she inadvertently rested the bowl of pineapple pieces back onto Resident #1's tray to assist the nurse's aide with his/her request and forgot to remove it prior to placing it onto the food cart for delivery. Interview with RN #1 on 2/21/25 at 2:30 PM identified Resident #1 did ingest what appeared to be a small amount of pineapple with his/her dinner on 1/13/25 and was informed by Person #1 that a rash would result when the resident would consume pineapple. RN #1 indicated he/she contacted dietary regarding the mistake, had taken Resident #1's vitals twice, twenty (20) minutes apart, which were non-concerning (within normal limits) on both occasions, did not observe any signs or symptoms of an allergic reaction/anaphylactic shock at all, and had educated Person #1 to monitor for shortness of breath, wheezing, and/or dizziness, and instituted fifteen (15) minute checks to ensure patient safety. Interview with NA #1 on 2/21/25 at 3:16 PM identified he/she failed to check the items on Resident #1's dinner tray with the meal ticket prior to giving it to the resident. NA #1 identified that she would normally check the residents food prior food prior to serving and notify the nurse if something was not correct. NA #1 further identified it was his/her responsibility to check the dinner tray and meal ticket prior to serving the resident. NA #1 indicated he/she didn't ensure the meal matched the meal ticket as he/she thought Person #1 (family member), who was with Resident #1 during dinner that day, would check the meal ticket with the resident. Review of dierary and nursing policies identified that the dietary staff must check the meal tickets for allergies while working the tray lines and checked prior to being served to the resident by nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #3) reviewed for abuse, the facility failed to ensure the clinical record was complete an accurate to include an incident that required social service follow up. The findings include: Resident #3's included dementia with behavioral disturbance, delirium, and major depression. The 5-day Minimum Data Set (MDS) dated [DATE] identified Resident #3 had no behaviors, was alert and oriented, and ambulated with supervision. The care plan dated 3/19/2023 identified a potential for verbal behaviors related to dementia. Interventions directed to evaluate the circumstances of verbal behaviors, provide psychiatric/behavioral health consultations, and social service visits to provide support. The psychiatric note dated 3/27/2023 identified asked to see Resident #3 for alleged inappropriate interaction with a male peer. The note indicated Social Services reported a male resident asked Resident #3 to show a body part. Resident #3 indicated he/she said no and had no anxiety or distress with support provided by psychiatry. Review of the clinical record failed to identify any further notes regarding the alleged interaction; no social service notes or any nursing notes were located regarding the incident. Interview and clinical record review with the Director of Social Services (DSS) on 8/22/2023 at 8:59 AM identified on 3/27/2023 while Resident #3 was walking past Resident #1's room, Resident #1 asked Resident #3 to show him/her a body part. Resident #3 said no and kept walking. The DSS identified she met with Resident #3 about the alleged incident; Resident #3 had said no and kept walking and was not upset. Further she indicated Resident #1 denied the incident occurred. Interview identified although DSS met with Resident #3 after the alleged incident and asked psychiatry to see Resident #3, DSS failed to write a progress note regarding the allegation. The DSS was unable to explain why she did not write a note and indicated she should have written a note. Interview with the DON on 8/22/2023 at 9:58 AM identified Social Services saw both Residents #1 and #3 after the allegation and should have written a note to identify the visits were provided. Review of facility Charting and Documentation Policy, dated 10/2019, directed in part, all services provided to the resident shall be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy, and interviews for 1 sampled resident (Resident #1), who was reviewed for abuse, the facility failed to ensure a resident was treated in a respectful and dignified manner. The findings include: Resident #1's diagnoses included unspecified dementia and aphasia (unable to formulate language) following a cerebral infarction (death of brain tissue following lack of oxygen). The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 1 had severe cognitive impairment and was independent with activities of daily living (ADL). The Resident Care Plan dated 4/18/23 identified Resident #1 expressed that it was important to engage in daily routines that were important to him/her and could demonstrate verbal behaviors related to cognitive loss with interventions that directed to monitor for perseverating behavior, remove from the environment while speaking in a calm, reassuring voice and allow time for expression of feelings, provide empathy, encouragement and reassurance. A Reportable Event dated 7/17/23 at 4:00PM identified Person #1, the responsible party, called the facility to report that a nurse verbally abused her mother on 7/11/23. Person #1 identified the nurse as being the one who was assigned to her mother on 7/11/23. The nurse was placed on administrative leave pending an investigation. The Reportable Event Summary dated 7/19/23 identified that abuse could not be substantiated, and that education was provided to LPN #1 on approach, sensitivity and de-escalation techniques. An interview with LPN #1 on 8/7/23 at 11:12AM identified she was the assigned nurse working on 7/11/23 for the 3:00PM to 11:00PM shift for Resident #1. LPN #1 stated that Resident #1 began banging on the nurse's station counter demanding his/ her medications and was swinging his/her towel at LPN #1 who moved, in order to avoid being hit by the towel, the resident also tried to bite her when attempting to give h/her medications. LPN #1 told Resident #1 that if s/he did not stop, she would be sent out. An interview and statement review with NA #1 on 8/7/23 at 12:57PM identified that Resident #1 was well known to her. NA #1 stated she was working on 7/11/23 during the 3:00PM to 11:00PM shift and sometime after 7:30PM, she observed Resident #1 come out of his/her room requesting medications. LPN #1 told Resident #1 s/he would need to wait as she needed to deal with an emergency. NA#1 thought that LPN #1's tone was harsh, authoritative and inappropriate. Resident #1 began to cry and sought out staff including NA #1 to make his/her needs known. NA #1 walked Resident #1 towards his/her room to console h/her. NA #1 then observed Resident #1 raise a towel s/he was carrying and shake the towel at LPN #1, it appeared out of frustration, but not in an attempt to hit LPN #1 also indicating the medication cart was between them. LPN #1 stated that she would call the police on Resident #1 if threatened her. NA #1 was upset by what she observed and wrote a statement on 7/12/23 and submitted several copies of the statement on 7/12/23 on the 7:00AM to 3:00PM shift to the Administrator, then met with the DNS and corporate nurse to discuss the details. An interview with the DNS on 8/7/23 at 2:15PM identified a grievance was submitted on behalf of Resident #1 after speaking with Person #1 who expressed concerns over the interaction between LPN #1 and Resident #1. LPN #1 was suspended and provided education on approach, sensitivity and de-escalation techniques and that Person #1 seemed satisfied with the outcome. An interview with the Administrator on 8/8/23 at 9:16AM identified LPN #1 was subsequently terminated on 8/7/23 in an unrelated incident. A review of the facility policy for Quality of Life- Dignity directed that all residents be treated with dignity and respect at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy, and interviews for 1 sampled resident, (Resident #2), who was reviewed for medication administration, the facility failed to ensure medication was administered in accordance with physician's orders. The findings include: Resident #2 had diagnoses that included streptococcal meningitis. The admission nursing assessment dated [DATE] identified Resident #2 was alert and oriented to person place time, situation and appropriate. A review of the admission clinical record identified Resident #2 was self-responsible. A physician's orders dated 7/18/23 directed ceftriaxone sodium injection solution (an antibiotic) reconstituted 2grams every 12 hours intravenously at 9:00 AM and 9:00 PM for a diagnosis of sepsis (a blood stream infection) through 8/7/23. (The medication was not ordered STAT (as soon as possible)). The Pharmacy receipt dated 7/19/23 identified ceftriaxone sodium injection solution reconstituted 2 grams was delivered to the facility at 2:21 AM. A Reportable Event dated 7/19/23 identified Resident #2 did not receive the 9:00 (PM) dose of ceftriaxone sodium injection solution. The physician assistant (PA) was notified, and the pharmacy was contacted indicating the medication was in route. The Resident Care Plan (RCP) dated 7/20/23 identified Resident #2 had an alteration in neurological status related to diagnosis of meningitis and a peripherally inserted central catheter (PICC) line would be used for delivery of intravenous antibiotics related to a diagnosis of sepsis with interventions directed to give medications as ordered, inspect site for signs of inflammation, phlebitis, or infiltration every shift. A Reportable Event dated 7/25/23 identified Resident #2 stated s/he did not receive the evening dose of antibiotic on 7/24/23. The PA was notified. The admission Minimum data set (MDS) assessment dated [DATE] identified Resident was without cognitive impairment, required two person assist with bed mobility, one with transfers and toileting. Review of the Medication Administration Record (MAR) dated 7/18/23 through 7/28/23 identified on 7/18/23 and 7/24/23 ceftriaxone sodium injection solution was not administered for the 9:00 PM dose to Resident #2. A Nurse's note dated 7/24/23 at 10:45 PM identified Resident #2's antibiotic was checked for the correct medication and the correct rate on the IV pump. A Nurse's note dated 7/25/23 at 3:44 PM identified Person #2, an emergency contact stated Resident #1 did not the prescribed antibiotic on the evening shift on 7/24/23. A grievance dated 7/28/23 identified Resident #2 reported not receiving his/her antibiotic on 7/24/23. The grievance response dated 7/29/23 identified medication was witnessed as having been administered on 7/24/23 at 9:00 PM and that Resident #2 was asleep. A subsequent response to the grievance dated 7/28/23 identified through an investigation it was confirmed the antibiotic was not given on 7/24/23. An interview with Resident #2 on 8/8/23 at 10:05 AM identified Resident #1 was not given antibiotic medications on 7/18/23 following admission. She reported not receiving the antibiotic the following morning to the Medical Director. The staff seemed to quickly acquire access to the medication which was subsequently administered. On 7/24/23 on the evening shift Resident #2 reported a male nurse, Licensed Practical Nurse, LPN #4 told Resident #2 he would be in at 9:00 PM to administer the antibiotic but never came. An interview with the Medical Director on 8/8/23 at 1:17 PM identified he did visit with Resident #2 on 7/19/23 and learned the evening dose of the prescribed medication was not administered. The Medical Director indicated that although medications ordered on admission may take some time for delivery, he would expect the medication to be administered once available ( the medication was delivered on 7.18/23 at 2:21 AM). An interview with RN #1 on 8/8/23 at 1:48 PM identified she was working on 7/18/23 as the Nursing Supervisor during the 3:00 PM to 11:00 PM shift and admitted Resident #2. RN #1, however, could not recall if the medications were ordered STAT (as soon as possible) for Resident #2, and was not aware there was an emergency medication cart for IV medications until after learning of missed doses. Although attempted interviews with LPN #4 were unsuccessful. An interview with the Director of Nursing, (DNS) on 8/8/23 at 2:11 PM identified that medications were to be ordered from the pharmacy once orders were received. If a medication was not available by the next scheduled dose, the medication should be removed from the emergency medication cart ( ceftriaxone sodium injection solution was available in the cart). The DNS indicated staff were subsequently provided education on the use of the emergency medication cart and ordering medications STAT after learning of missed doses of medication. The DNS indicated Resident did not receive the IV antibiotic on 7/18/23 and 7/24/23 at 9:00 PM as prescribed. A review of the facility policy for Pharmacy Services directs that the facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing and administration of all routine and emergency drugs to meet the needs of each resident(s). A review of the policy for Ordering admission Medications directs that if not available in house, medications are to be ordered STAT.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and interviews for 1 of 1 sampled resident (Resident #391) reviewed for constipation/diarrhea, the facility failed to ensure a baseline care plan was completed to address the resident's constipation. The findings include. Resident #391's diagnoses included polyneuropathy chronic pain syndrome, atrial fibrillation, deep vein thrombosis and Urinary Tract Infection (UTI). A physician's order dated 6/30/2023 at 8:50 PM directed to provide Senna (a stool softener) 8.6. Milligrams (MG) 2 tablets by mouth daily for constipation. A physician's order dated 6/30/23 at 8:57 PM directed to administer Macrobid (an antibiotic) 100 MG orally twice daily for UTI. A physician order dated 6/30/23 at 9:21 PM directed to provide Oxycodone Hydrochloride (a narcotic analgesic) 10 MG tablet one tablet by mouth every 8 hours as needed for pain. Physician orders dated 6/30/23 at 9:22 PM directed to provide Oxycontin 40 MG (narcotic analgesic) extended release every 12 hours one tablet twice daily for chronic pain. A physician's order dated 6/30/2023 at 9:30 PM directed to provide Glycolax powder (an osmotic laxative)17 grams by mouth once daily for constipation for 3 days. The care plan dated 7/1/2023 identified Resident # 391 required assistance for activities of daily living related in part to toileting. An intervention includes providing supervision with toileting. The care plan further indicated Resident #391 was at risk for alterations in comfort related to chronic pain and polyneuropathy. Interventions included utilizing the pain scale, advising the resident to request pain medication before pain becomes severe, to medicate resident as ordered for pain and monitor for effectiveness and side effects. A physician's note dated 7/4/2023 at 0:00 notes in part Resident #931 is highly anxious and changes subjects frequently and can be easily agitated. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #391 was cognitively intact and required extensive assistance of one person for toileting. A physicians note dated 7/7/2023 at 6:26:01 AM indicated a diagnosis of constipation with a new order for Movantik 25 Mg one tablet daily and indicated Resident #391 describes manually dis-impacting stool and indicated the constipation was likely due to medication induced since Resident # 931 has a long history of prescription narcotic medication use. A physician's order dated 7/7/2023 directed to provide Movantik 25 mg orally once daily for constipation. On 7/11/2023 at 1:45 PM interview with the MDS Coordinator Licensed Practical Nurse (LPN # 9) indicated she/he had looked at the bowel documentation from the nurse aides and the resident was admitted on [DATE] was noted with 2 bowel movements on 7/1/23 and another on 7/5/23. LPN #1 indicated s/he coded the MDS based on the Resident Assessment Instrument Manual guidelines for coding and constipation was not present. On 7/11/23 at 1:50 PM interview with RN MDS Director Registered Nurse (RN #10) indicated the MDS nurses look at the resident as a whole when reviewing medications, diagnosis treatment and in part, looks at the nurse's notes, hospital notes, assessments, and physician orders. MDS Director RN #10 further indicated that the baseline care plan on admission is started by the nurse completing the admission or the supervisor on duty then the next day, the MDS nurses check the care plan to be sure it is complete. On 7/11/2023 at 11:52 PM MDS nurse MDS Director RN #10 indicated s/he makes sure the baseline care plan addresses the medications, Activity of daily living, potential or actual skin breakdown, pain falls and bleeding risk. MDS Director RN #10 also indicated although Resident #391 was not constipated the resident was taking medications to prevent constipation from admission through the MDS lookback period and s/he was unaware of the physician progress note dated 7/7/2023. MDS Director RN#10 indicated that s/he would add a care plan related to preventing constipation. Subsequent to inquiry, on 7/11/2023 to address Resident #391 at risk for constipation related to narcotic use and decreased mobility. Interventions included: to follow the bowel protocol for bowel management, monitoring medications for side effects of constipation and to keep the physician informed of any concerns, and to document and report the signs and symptoms related to constipation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record and staff interviews for 1 of 2 residents reviewed for care planning (Resident # 40), the facility failed to revise the resident care plan related to the resident's pathological fracture. The finding included: Resident # 40's diagnoses included malignant neoplasm of bone and articular cartilage, fracture of coccyx, and pelvic and perineal pain. The 5-day MDS assessment dated [DATE] identified the resident cognition was intact, the resident required set up to limited assistance with ADL, always incontinent of stool, and utilized a Foley catheter. The nurse notes dated 6/16/23 at 4:06 PM indicated Resident #40 was transported to the hospital. The hospital Discharge summary dated [DATE] identified a pathologic coccygeal fracture. The Resident Care Plan dated 3/13/23 to 7/13/23 identified the risk for adverse reactions to cancer treatment related to chemotherapy, pain medication therapy related to Ewing's sarcoma, and risk for alterations in comfort related to chronic pain, neuropathic pain. Interventions directed to medicate as ordered for adverse reactions, administer analgesic medications as ordered by the physician, and to medicate resident as ordered for pain. However, review of the care plan failed to identify the resident's care plan was revised to address the resident's pathological fracture. Interview with Director of Nursing Services (DNS) on 7/13/23 at 1:00 PM identified she could not provide a revision to Resident #40's care plan regarding the 6/28/23 identification of a pathologic coccygeal fracture due to the resident's medical condition because the pain management care plan addressed the pathological fracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, facility documentation review, facility policy review, and interviews for one of three residents (Resident #50) reviewed for wound prevention and healing, the facility failed to follow the residents plan of care and the physician's orders to off load/float heels when the resident was identified with wounds on both heels and for one of three residents ( Resident # 5) at risk for pressure ulcer development, the facility failed to ensure the resident's air mattress was set according to the plan of care. The findings included: 1. Resident #50's diagnoses included diabetes, osteomyelitis, malnutrition, pressure ulcer, malignant neoplasm of lung, disc degeneration lumbar region and chronic pain syndrome. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #50 had intact cognition, was at risk of developing pressure ulcer/injury, had one or more unhealed pressure ulcers/injuries and required extensive assistance with bed mobility, transfer, locomotion, and personal hygiene. A physician's order dated 6/27/23 directed to encourage the resident to offload heels as tolerated in bed every shift for prevention. The Resident Care Plan dated 6/29/23 identified Resident #50 was at risk for skin breakdown related to decreased mobility and or has actual skin breakdown. Interventions directed to off load/float heels while in bed with pillows and to observe verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered. The Change in Condition Evaluation dated 7/5/23 at 8:00 AM identified Resident #50's right heel discoloration measuring 1 centimeter (cm) x 0.7 cm, non-blanchable intact skin. Further review identified left heel discoloration measuring 1 cm x 1 cm non-blanchable intact skin. Recommendations included to always apply skin prep daily and to off load heels when the resident is in bed. Skin Integrity Report dated 7/5/23 identified intact left heel, with no pain, measuring 1 cm x 1 cm with healthy surrounding tissues. Further review identified right heel with intact, measuring 1 cm x 0.7 cm, no drainage with healthy surrounding tissue. Observation with Nurse Aide (NA #2) on 7/5/23 at 12:23 PM identified Resident #50 was lying on his/her bed, legs uncovered and visible from the hallway. A thin flatbed pillow was positioned under the resident's knees without the benefit of providing pressure relief to both heels that were making visible indentation into the mattress. Resident #50 identified that both heels were sore and sometimes when his/her legs were digging into the mattress, his/her heels hurt so he/she tried to move them. The resident was observed trying to push the pillow down from under his/her calves with his/her reacher. Interview with NA #2 on 7/5/23 at 12:40 PM identified although Resident #50's Visual/Bedside [NAME] Report directed to off load/float heels while in bed with pillows, she was not aware that the resident's heels should be offloaded, nobody told me, and she had no time to review the [NAME], since she came to work at 8:00 AM and it was breakfast time. Interview and clinical record review with RN #2 on 7/5/23 at 1:48 PM identified Resident #50 previously had a scab on right heel which was indicated as healed on 5/9/23. RN #2 further identified that she assessed the resident's wounds and offloaded the resident's heels with pillow in the morning, but the resident pushed the pillow down so his/her heels were not offloaded. Review of the resident's care plan identified the resident was resistive to care related to lack of motivation but noncompliance with offloading heels was not documented and no alternatives were offered. RN #2 identified it was important for the resident's heels with diabetic wounds to be offloaded to reduce pressure and to promote healing. The wound consultant evaluation by Medical Doctor (MD #2) dated 7/6/23 identified Resident #50 with diabetic wound of the right heel measuring 1.2 cm x 1.4 cm with unmeasurable depth due to presence of dried fibrinous exudate (scab). Further review identified diabetic wound of the left heel partial thickness measuring 1.2 cm x 1.5 cm with unmeasurable depth due to presence of dried fibrinous exudate (scab). Recommendations included to elevate legs, float heels in bed off-load wound and reposition per facility protocol and to apply skin prep once daily for 30 days. Interview with wound consultant MD #2 on 7/6/23 at 11:42 AM identified Resident #50 was able to move his/her feet off the pillow. MD #2 further identified that it was important to offload the resident's heels to prevent skin injury and staff should assist as needed. Observation with LPN #4 on 7/7/23 at 6:09 AM identified the resident lying in bed with pillow partially under ankles and calves, feet partially off loaded with left heel resting on the mattress and right heels offloaded. LPN #4 immediately readjusted the pillow and stated heels should be floating. Observation with NA #3 on 7/7/23 at 1:20 PM identified Resident #50 heels resting on top of his/her pillow without the benefit of being offloaded. NA #3 identified she thought that the resident's wounds on both heels were healed. NA #3 further identified that the resident refused to have his/her heels offloaded and wanted to rest them on top of the pillow. NA #3 with resident's permission offloaded his/her heels with his/her pillow. Resident #50 stated at the same time I was not thinking about them not being elevated, I was only thinking about the pillow being under my feet. Interview with DNS on 7/7/23 at 2:30 PM identified Resident #50's heels should have been offloaded to promote healing and to prevent any further skin injury. The DNS further identified that she would replace the bed pillow with heel lift booties to offload the resident's heels, she will review the new intervention with the wound doctor MD #2 and will update the resident's care plan as required. Review of facility Complete Care Skin Integrity-Foot Care Policy directed in part, Interventions will be based on specific factors identified in the risk assessment, skin assessment, and assessment of any foot ulcers. Appropriate offloading or orthopedic devices, diabetic shoes, or pressure-relieving devices will be utilized. The policy further identified that interventions will be modified in a resident's plan of care as needed. Considerations for need modifications include resident non-compliance. 2. Resident # 5's diagnoses included, obstructive hypertrophic cardiomyopathy, pleural effusion, metabolic encephalopathy, severe protein-calorie malnutrition anxiety and stage 4 pressure ulcer on the sacrum. The readmission MDS assessment dated [DATE] identified the resident was severely cognitively impaired, required total dependence two persons assistance for bed mobility, transfers, and toileting. The assessment also noted the resident needed total dependence one person assist for personal hygiene, incontinent of bladder and bowel and noted one stage 4 pressure ulcer. The RCP for at risk for skin breakdown related to decrease mobility and has stage 4 sacrum Moisture -Associated Skin Damage (MASD) dated 6/21/23. Interventions included: to provide wound treatment as ordered, weekly wound assessment to include measurements and description of wound status, to observe skin condition daily during ADL care, turn and reposition and check skin every two hours as tolerated and to a pressure redistribution surface bed as per guideline: Low Air Loss (LAL) mattress. The Health Status note dated 6/21/23 at 11:46 AM identified Resident # 5 was seen by Wound MD and RN unit manager for weekly wound rounds 6/20/23. The sacrum stage 4 pressure wound measured 0.8 cm x 1.1 cm x 0.3 cm. Moderate serous drainage. 10% slough, 90% granulation tissue and note no change. Surgically debrided by wound doctor. Non pressure wound to sacrum MASD 1.4 cm x 1.3 cm x 0.1 cm. Light Serous drainage. 100 % (Dermis) with no change. Treatment orders in place. The resident tolerated dressing changes without distress. The physician's orders 4/24/23 to 7/13/23 directed Low airloss mattress to be setting 80-160 lbs Normal pressure alternating every shift and directed staff to check setting and function every shift. The Treatment Administration Record for July 2023 directed LAL to bed 80-160 lb. setting. Observation on 7/6/23 at 1:40 PM identified the resident lying in bed with air mattress set at 400. Observation on 7/12/23 at 3:25 PM with the RN # 2- (Supervisor) identified the resident lying in bed with air mattress set at 400. Interview with RN # 2 Supervisor on 7/12/23 at 4:15 PM identified the resident's air mattress should not be set at 400 and reviewed the physician's order for the air mattress to be set at 80 160 lbs. Subsequent to inquiry, RN # 2 change the setting of the air mattress to the physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #3) reviewed for falls, the facility failed to transfer the resident in a safe manner. The findings include: Resident #3's diagnoses included traumatic brain injury, spastic hemiplegia, contractures, convulsions, hypertension, osteoarthritis, and anxiety. The annual Minimum Data Set assessment dated [DATE] identified Resident # 3 had intact cognition and required extensive two-person physical assistance with transfer, dressing and toilet use. A physician's order dated 9/2/23 directed to directed transfer with Hoyer lift, assist of two to custom wheelchair with according to 24-hour positioning plan. The Resident Care Plan dated 9/21/22 identified the resident was at risk for decreased ability to perform activity of daily living. Interventions directed to use Hoyer lift (mechanical lift) for transfers with the assistance of two staff members. The Resident Care Plan further identified Resident #3 as at risk for falls related history of falls. Intervention directs the resident to wear seat belt in wheelchair for safety and positioning per resident's request. The resident care card as of 10/5/22 identified mechanical lift for transfers. The nurse's note dated 10/6/23 at 10:41 AM identified RN #3 was called to room after Resident #3 had a fall in the bathroom. The NA stated the resident did not want to use a gait belt and resident was lowered slowly to the floor. The resident did not hit her/his head, had a small bruise to lateral left thigh and reddened area to right upper arm. The resident was assessed by Physicians Assistant (PA) #1. The physician progress notes by PA #1 dated 10/6/22 identified Resident #3 was being transferred from bed to bathroom when the resident fell in the bathroom. The resident complained of left shoulder pain. Pain with palpitation and movement. Left arm with contractures and spastic hemiplegia. The resident was unable to stop herself/himself during fall, fell to the left side. X-ray of left shoulder was ordered. An X-ray of left shoulder dated 10/6/22 identified there was no demonstrated soft tissue abnormality. Lucent line seen involving the humeral head, suggestive of an acute fracture. The physician progress notes by PA #1 dated 10/7/23 identified original information stating that the resident was transferring and fell. However, after further evaluation and investigation, it is to be noted the resident was on the toilet. The resident then attempted to self-adjust herself/himself and slipped forward and off the toilet landing on her/his left side. Further review identified x-ray showed a less dense region of the left humeral neck/head, suspicious for acute nondisplaced fracture. Sling to arm for comfort as well as splinting purposes, continue current pain medications and repeat x-ray in approximately 2 weeks. An X-ray of left shoulder dated 11/11/22 identified osteoarthritis changes, the bones were osteoporotic, normal humeral head and normal visualized scapula. There was no demonstrated soft tissue abnormality. Interview and clinical record review with PA #1 on 7/11/23 at 10:00 AM identified the second progress note identified the resident attempted to self-adjust on toilet and slid forward as far as I remember. However, my first progress notes without any additional details identified the resident could not stand up by her/himself, s/he could manipulate her/himself off chair but not to stand up by her/himself. Interview with DNS #2 on 7/11/23 at 10:30 AM identified s/he remembers the incident but cannot recall who assisted the nurse aide with the resident's transfer to the bathroom. DNS # 2 further indicated s/he recalls the resident was a Hoyer lift and required the assistance of two for safety. A telephone interview with RN #3(previous supervisor) on 7/11/23 at 11:11 AM identified s/he thinks the nurse aide who transferred the resident at the time of the incident was an agency nurse aide who did not the check the resident's care card for transfer status. The nurse aide transferred the resident by herself and did not use a gait belt. The agency nurse aide also did not know the resident was Hoyer lift. The nurse aide told me she transferred the resident by herself, and the resident fell but did not get hurt. RN # 3 further indicated that she thinks s/he told the DNS about the incident. Interview with Resident #3 on 7/12/23 at 10:40 AM identified s/he tried to help as much as s/he could. The nurse aide transferred her/him by herself, used a wheelchair to transfer, no other staff member was in the room, the nurse aide stood me up in the bathroom, no lift, I fell, and I got hurt, I hurt my shoulder. Interview with Occupation Therapist Assistant (OTA) of Rehabilitation in the presence of the administrator on 7/12/23 at 10:50 AM identified Resident # 3 has been a Hoyer lift with 2 assists since 11/22/22. OTA also indicated that the resident while sitting on the toilet would require a staff member to stand in front of the resident. Interview with NA #6 on 7/12/23 at 11:43 AM identified she did not assist with transferring Resident # 3 on the toilet the day of the incident. A telephone interview with NA #4 on 7/12/23 at 2:03 PM identified she received a paper on how to care for Resident # 3 which indicated the resident was an assistant of 1. She also indicated she was not the resident's regular nurse aide but instead worked for an agency and this was her first-time taking care of the resident. NA # 4 indicated she could not recall if someone asked her about the resident's transfer status but if she had known Resident # 3 was a Hoyer lift, she would have obtained a second person to assist. NA # 4 indicated on the day of question she transferred Resident # 3 as an assist of 1 stand and pivot, the resident did not want me to use gait belt, I placed Resident # 3 from the wheelchair via stand and pivot onto the toilet and begin care. NA # 4 indicated when she stood Resident # 3 up by herself to clean the resident's bottom the resident grabbed the bar on the wall and began to fall. NA # 4 grabbed Resident # 3, so the resident would not hit her/his head. During the fall Resident # 3 hit her/his shoulder on the trash can, not sure where the trash can was placed at that time. NA # 4 indicated she was not informed until after the fall that Resident # 3 was a Hoyer lift with 2 assists. Interview with current DNS on 7/12/23 at 3:45 PM identified Hoyer lift are 2 persons assist for safety. Review of facility Falls and Fall Risk, Managing Policy directed in part, based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling by trying to minimize complications from falling. Further review identified the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy and interview for 1 of 2 sampled residents (Resident #389) reviewed for hydration, the facility failed to maintain fluid intake per physician's order. The findings included: Resident #389's diagnoses included chronic diastolic Congestive Heart Failure ( CHF), dyspnea, and hypertensive urgency. A physician's order dated 6/6/2023 directed to monitor a daily fluid restriction total of 1500ml per day. The admission Minimum Data Set assessment dated [DATE] identified Resident #389 as cognitively intact, requiring extensive assistance with toileting and personal hygiene and indicated independent with eating. The Resident's Care Plan dated 6/22/23, revised on 7/7/2023, identified the resident was at risk for dehydration as evidenced by fluid restriction/insufficient intake. An intervention directs to monitor intake and output per protocol. The nurse's note and certified nursing assistant's fluid intake/output documentation dated 6/13/23 through 7/11/23 identified twenty-three days of total fluid intake below the daily 1500ml fluid restriction and four days of total fluid intake above the daily 1500ml fluid restriction. Interview with Director of Nursing Services (DNS) on 7/13/23 at 1:10 PM identified her expectation is that staff follow the physician's order for monitoring daily fluid intake. The DNS also indicated the daily intake and output policy directs staff to ensure daily intake and output are recorded and maintained for residents who need it. The DNS was unable to explain why the physician's order was not followed. Review of the Intake and Output Policy notes daily Intake/Output record would be implemented by the physician or nurse practitioner physician's order and directed staff to record the resident's food and fluid intake within the designated shift periods.

Based on review of the facility Payroll Based Journal (PBJ) records, interview, and review of facility policy for 4 out of 4 quarters reviewed, the facility failed to maintain weekend staffing at a level that was above excessively low, and for 2 of 4 quarters, failed to ensure the facility did not receive a 1 star rating for staffing. The findings include: Review of the Payroll Based Journal records for the second, third, fourth and first fiscal quarters of 2022 identified that during the second quarter, (January 1 through March 31), the third quarter, (April 1 through June 30), the fourth quarter, (July 1 through September 30) and first quarter, (October 1 through December 31, 2022), the facility electronically reported excessively low weekend staffing. Additionally, during the third and fourth quarters, the facility had a 1 star rating for staffing. Interview with RN # 12 the corporate nurse on 7/13/23 at 1:40 PM identified that the facility did not actually have excessively low weekend staffing but, according to RN # 12, who had conducted extensive research into the PBJ system, the facility had failed to accurately report staffing into the PBJ system. Additionally, RN # 12 indicated that, according to RN # 5 there may have been a problem including agency staff in the facility reporting and that RN # 5 would be better able to explain the problem. Subsequent to surveyor inquiry, RN # 5 indicated that she would provide staffing records to negate the inaccurate recording of facility staffing but staffing records were no available. Review of the facility Nursing Services and Sufficient Staff policy dated 7/1/23 identified, in part, that the facility is responsible for submitting timely and accurate staffing data through the CMS Payroll Based Journal (PBJ) system. Review of the facility Payroll Based Journal policy dated 7/1/23 referencing the Centers for Medicare & Medicaid Services (CMS) electronic staffing data submission PBJ Long Term Care Facility Policy Manual (June 2022) directed, in part, that the facility would ensure that all staffing data entered in the Payroll Based Journal system was auditable and able to be verified through either payroll, invoices, and/or tied back to a contract. The he facility would utilize the current submission guidelines as described in the CMS Electronic Staffing Data Submission Payroll Based Journal Policy Manual. The Administrator, Human Resource Director and director of Nursing were responsible for verifying the accuracy of the staffing data that is submitted to CMS using various facility audit forms and/or payroll vendor reports. The Business Office Manage was responsible for verifying the accuracy of census data and collaborating the Minimum Data Set (MDS) Coordinator or any correction and reports were available through CASPER to assist with verification of data. Lastly, the Administrator was responsible for reviewing validation reports and ensuring that any needed corrections were made prior to the quarterly deadline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, policy review, and facility documentation, for 1 of 1 sampled resident (Resident #65), reviewed for respiratory care, and for 1 of 1 sampled resident, (Resident #439), reviewed for infection prevention, the facility failed to ensure that infection prevention practices were followed and for one of six units, the facility failed to ensure bed pans were properly labeled and stored according to facility policy. The findings included: 1. Resident #65's diagnoses included chronic obstructive pulmonary disease, heart failure, atrial fibrillation, diabetes mellitus, and dementia. An Annual MDS assessment dated [DATE] identified Resident #65 was alert and cognitively intact, and required total dependence of one for toilet use, personal hygiene, extensive assistance of two with bed mobility, extensive assistance of one with dressing, and independence with set-up for meals. A Resident Care Plan revised dated 4/3/23 identified the resident required oxygen therapy was at risk for poor oxygen absorption, and shortness of breath. Interventions included monitoring for respiratory distress, positioning for lung expansion and improved air exchange, monitoring for difficulty breathing, and anxiety, confusion, restlessness, shortness of breath at rest, cyanosis (bluish discoloration of skin), or somnolence (excess sleepiness) due to respiratory insufficiency. Observation and interview on 7/5/23 at 1:19 PM with NA #1, identified while the resident was lying in his/her bed, the resident's oxygen nasal cannula was on the floor next to his/her bed. NA #1 picked up the oxygen nasal cannula off the floor and was about to put the oxygen nasal cannula back on the resident. Subsequent to inquiry NA #1 stopped and did not apply the oxygen and indicated s/he needed to get the nurse. Observation and interview on 7/5/23 at 1:21 PM with LPN #1, identified NA #1 went out of the room to get the nurse who return with a new oxygen cannula. LPN #1 further indicated when oxygen equipment is found on the floor staff is responsible for obtaining a new oxygen cannula for resident. Interview with DNS on 7/5/23 at 1:35 PM indicated that she would expect the nurse aide to tell the nurse to change a resident's nasal cannula/tubing if the tubing is found on the floor. A Medication Administration Record dated 6/1/23 to 7/10/23 directed nursing to check every shift the resident's oxygen is infusing at 2 liters/minute via nasal cannula continuously. A Resident Care Card for the resident failed to include monitoring or reporting for respiratory care concerns or ensuring oxygen in place. 2. Resident #439's diagnoses included diabetes mellitus, fracture of the femur, and pain. A physician's order dated 7/1/23 directed staff to obtain blood glucose levels before meals and at bedtime. Observation on 7/10/23 at 11:39 AM identified LPN #1 checking Resident #439's glucose level with the glucometer. LPN #1 then used Microdot disinfectant wipes which had an expiration date of 2/2023. Interview with LPN #1 on 7/10/23 at 11:42 AM, indicated she had failed to check the expiration date because she was unaware the Microdot disinfectant wipes had expiration dates. LPN #1 further indicated had she known the Microdot wipes had an expiration date, she would have checked to ensure the wipes were within the expiration date and that checking for expiration dates was the responsibility of all licensed nurses. Subsequent to inquiry, LPN #1 identified she would obtain new wipes and properly disinfect the glucometer. Interview with RN # 12 Corporate Nurse, on 7/11/23 at 10:00 AM identified the facility had begun educating staff to ensure disinfecting products were within expiration dates prior to use. Review of the Cleaning and Disinfecting Non-Critical Resident care items, policy dated 1/2019 directed, in part, that reusable items (stethoscopes, durable medical equipment) were to be cleaned and disinfected or sterilized between residents according to manufacturer recommendations. 3. Observation and interview with RN #7 on 7/13/23 at 3:43 PM identified the following: 1. room [ROOM NUMBER]'s shared bathroom contained a bed pan that was in a plastic bag and tied to the grab bar on the right side of the toilet without a label. 2. room [ROOM NUMBER]'s shared bathroom contained a bed pan that was unlabeled, in a plastic bag and tied to the grab bar on the right side of the toilet. room [ROOM NUMBER]'s shared bathroom also contained a urinal that was unlabeled and uncovered, hanging from the grab bar. Interview with RN #7 on 7/13/23 at 3:43 PM identified the nursing staff was responsible for ensuring bed pans and urinals were cleaned, covered, and stored in the bedside table following use and indicated she could not explain why this was not done. Interview with DNS on 7/13/23 at 9:49 AM failed to identify the bed pan policy. Review of the cleaning of bedpans and urinals policy indicated to store bedpans and urinals in the resident's bedside cabinet or drawer after placing in a plastic bag.

Based on observations of the kitchen, facility documentation and interview, the facility failed to properly store food in sanitary conditions. The findings include: During the initial kitchen tour with the District Food Manager on 7/5/2023 beginning at 10:38 AM identified the following: The ice maker was noted to be filled with ice with outside scoop on wall in closed container. Further observation identified the inside of ice maker on the top right and left interior above the ready to be used ice with several dark black patches. Interview on 7/5/23 at 11:51 AM with District Food Manager identified the black patches as mold. She further indicated that the cleaning schedule is monthly and was last done in June 2023 and was not done correctly. Observation of facility documentation indicated that the ice maker was last cleaned on 6/27/23 and further identified the ice maker cleaning log was not signed off as cleaned in the month of May 2023. Manufacturer specifications for the Ice Maker's vendor notes interior of the bin is lined with antimicrobial-treated polyurethane, which helps slow down the growth of mold and slime, but it will not eliminate it altogether. Additionally, the manufacturer specifications identified the best way to keep these growths out of your ice bin is to disinfect and sanitize it regularly. Subsequent to inquiry, the District Manager indicated she plans to educate her staff to look at the top of the ice machines going forward to ensure cleanliness. The District Manager also indicated she would follow up to ensure the ice machine black patches area was cleaned.

Based on observations of the dietary tray line, and review of facility documentation and interview, the facility failed to provide food at an appetizing temperature and failed to indicate holding temperature of sweet potatoes. The findings included: 1a. Observation of the dietary tray line and a test tray with Food Service Director of the lunch meal on 7/11/23 began at 11:23 AM identified the last cart left the kitchen at 12:46 PM and arrived at 600's wing at 12:48 PM, serving began at 12:52 PM, and the last resident tray was served to Resident #32 at 1:04 PM. A review of the food test tray with the surveyor in the presence of the Food Service Director on 7/11/23 at 1:04 PM identified the following food temperatures surveyor/ Food Service Director: the main meal item (ham with a temperature (in degrees Fahrenheit) of 103.5/103.4, sweet potatoes at 117/116, creamed spinach at 117.7/116.6, and fruit cup at 63.8/63.3. Interview with the Food Service Director at time of the observation identified the food should be held at 135 or greater. b. Review of Facility documentation of Holding Temperatures prior to the tray line on 7/11/23 for the lunch meal indicated ham at 160 degrees, sweet potatoes log failed to indicate temperature for sweet potato temperature, creamed spinach at 154 degrees and fruit cup at 47 degrees Fahrenheit. Interview with Food Service Director on 7/13/23 at 11:33 AM identified that the Holding Temperature log for 7/11/23 staff failed to record the temperature of the sweet potatoes served on 7/11/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy and interviews for one of twenty-four residents (Resident #26), reviewed for Advance Directives, the facility failed to ensure physician's order was in place that honored the resident's health care instructions for Advanced Directives. The findings include: Resident #26 with diagnoses that included dementia without behavioral symptoms and hypertension. The physician's orders dated [DATE] directed that Resident # 26 was a Do Not Resuscitate (DNR). The admission 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was severely cognitively impaired requiring extensive assistance of 1 staff for bed mobility, transfer, and personal hygiene. A physician's progress note dated [DATE] at 12:40 P.M. identified that Resident # 26's code status was a DNR. Review of the facility's health care instructions (Advanced Directive form) dated [DATE] identified in the event of Cardiopulmonary Arrest, Resident # 26 was to have Cardiopulmonary Resuscitation (CPR) administered. A physician's progress note dated [DATE] at 3:51 P.M. identified that Resident # 26's code status as of [DATE] was DNR. The physician's progress note dated [DATE] at 3:51 P.M. identify during care planning that Resident # 26's medical status was reviewed with the conservator who identified the resident wishes was to be a Full Code. Physician's progress notes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] identified that Resident # 26's code status was a DNR. Physician's progress notes dated [DATE], [DATE] and [DATE] identified that Resident # 26 had an unknown code status. Physician's progress notes dated [DATE] identified that Resident # 26's code status was a DNR. A care plan dated [DATE] identified Resident # 26 had a DNR in place. The facility Cardiac and/or Respiratory Arrest policy directed, in part, if there was no visual identification of DNR status or no DNR order in the resident's medical record , certified staff would initiate CPR and if there was a DNR order, staff will not initiate CPR. Interview with Licensed Practical Nurse (LPN #2) on [DATE] at 12:40 P.M. identified that if Resident # 26 should have an emergency, she would first go to the computer to check Resident # 26's profile. Observation of Resident # 26's profile with LPN #2 identified that Resident # 26's code status was a DNR. LPN #2 stated that she would not initiate CPR if she determined that Resident # 26 did not have a pulse. Review of the medical record and interview with LPN #2 at 12:47 P.M. identified that Resident # 26 s Advance Directive form directed that Resident # 26 should have CPR administered. LPN #2 continued by stating that if she had encountered an emergency for Resident # 26, she would first respond based on the computer profile. She also indicated she would ask someone to check the resident's Advance Directives as a double check. However, LPN 2 did not believe that it was the facility's policy. LPN #2 identified it was the responsibility of the physician or physician extender to review the Advance Directive with each resident or the resident's decision maker and then write the order based on what was documented on the Advance Directive form. Interview with LPN #3 on [DATE] at 1:10 P.M. identified that if a resident had an emergency, she would go to her computer and pull up the clinical record profile as it would be the most up to date. She stated that she would follow what the resident's profile identified as the resident's code status. She further identified that the profile is generated by the physician's orders. Interview with the Director of Nursing Services (DNS) on [DATE] at 2:15P.M. identified that Resident # 26's Advance Directive form was completed by the facility Physician Assistant (PA) #1 on [DATE] who identified he was unsure how to enter the resident's Advanced Directive orders into the computer system. PA #1 further indicated that after the discussion and a review with Resident # 26's conservator, he had left the completed Advance Directive on the supervisor's desk. The DNS further identified PA#1 did not verbally communicate Resident # 26's code status change as per the facility routine. Resident # 26s Advanced Directive form was then filed in his/her chart and the physician's order remained unchanged. The DNS further identified that she was aware that the staff would check the resident's profile to initially to obtain direction for code status and that Resident # 26's physician's orders did not reflect the actual Advance Directive form completed by the PA#1 on [DATE]. Subsequent to the surveyor inquiry and observation, a physician's order dated [DATE] directed that Resident # 26's code status was a full code. Interview with DNS on [DATE] at 2:00 P.M. identified that after discussion with Resident # 26's conservator, Resident # 26's full code status was confirmed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy and interviews for the only sampled resident (Resident # 56) reviewed for notification of change, the facility failed to notify the conservator of an abnormal diagnostic result. The findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to unspecified occlusion or stenosis of basilar artery, cognitive communication deficit and tracheostomy status. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #56 had severely impaired cognition and required extensive assistance with personal hygiene. The Situation, Background, Assessment, Recommendation (SBAR) Summary note dated 4/29/21 at 2:04 P.M. identified Resident #56's respiratory assessment revealed abnormal lung sounds (rales, rhonchi, wheezing), nursing observations, and recommendations were: Chest x-ray (CXR). The Physician Assistant (PA#1) was notified with new orders to obtain a chest x-ray. Resident #56's conservator was notified of the new order. A nursing progress note dated 4/29/21 at 10:11 P.M. identified Resident #56's CXR was completed, the resident had no shortness of breath, and no secretions. Additionally, Resident #56 did not require humidification, a pulse oximetry was 97% (Normal Range 95-100 percent) on room air, and tracheostomy care was performed. Review of the CXR report dated 4/29/21 at 8:16 P.M. identified Resident #56 had mild cardiomegaly and mild Congestive Heart Failure (CHF) and no pneumonia was identified. The physician's progress note dated 4/30/21 at 1:01 P.M. identified Resident #56 was seen at the request of the nursing staff for a CXR that was positive for CHF. PA #1's note indicated that the plan was to start Resident #56 on Lasix (diuretic medication), to monitor potassium level, and obtain blood work on Tuesday 5/4/21. Additionally, respiratory therapy was involved in Resident #56's care and aware of the positive CXR. A review of the clinical record on 5/10/21 failed to reflect that the family/conservator was notified of Resident #56's positive CXR result on 4/29/21. Review of facility notification of change in condition policy identified the facility must immediately inform the resident/patient, consult with the patient's physician and notify, consistent with his/her authority, the patient's Health Care Decision Maker (HCDM), when there is a significant change in the patient's physical, mental or psychosocial status, that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications. A need to alter treatment significantly, that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment. Interview with LPN #4 on 5/10/21 at 11:02 A.M. identified she was not aware that the family had not been notified of the positive CXR. LPN #4 indicated that when a diagnostic result comes in, the result is given to PA #1. If the result is a CXR result the results would go to respiratory therapy and the nursing supervisor. LPN #4 also indicated that it is the responsibility of the nursing supervisor to notify the family/conservator of the diagnostic results. Interview with RN #1 on 5/10/21 at 12:01 P.M. identified that the nurse or nursing supervisor are responsible for notification to the family/conservator regarding diagnostic results. RN #1 indicated that PA #1 may also notify the family/conservator of a diagnostic result.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interviews for one of three residents (Resident #67) reviewed for choices and for the only sampled resident (Resident #70) reviewed for specialized treatment, the facility failed to ensure a comprehensive person centered care plan was developed for the residents. The findings included: 1.Resident #67's diagnoses included tremors, diabetes mellitus and Parkinson's disease. A physician's order dated 4/11/21 directed to administer Carbidopa-Levodopa (Sinemet) 25-100 milligrams (mg), give two tablets by mouth three times a day for Parkinson's disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was without cognitive impairment, required supervision with Activities of Daily Living (ADL) and was independent with eating. Interview with Resident #67 on 5/06/21 at 10:37 A.M. identified that within the last two to three weeks, she/he did not receive his/her Sinemet (Anti- Parkinsonian medication) for 36 hours and began shaking. A review of Resident # 67's care plan on 5/12/21 failed to reflect a care plan related to tremors or Parkinson's disease. Interview with the DNS on 5/12/21 at 1:00 P.M. identified that there was no care plan for Resident #67's tremors or diagnosis of Parkinson's disease, but a care plan should have been developed. 2. Resident #70 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD), anemia in chronic kidney disease. A physician's order dated 4/9/21 directed to transfer Resident #70 to a specialized treatment on Mondays, Wednesdays, and Fridays. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #70 had intact cognition and required supervision with personal hygiene. Review of the current Resident Care Plan (RCP) dated 4/15/21 failed to include a care plan related to Resident #70's need for the specialized treatment. Interview and review of the clinical record with RN #1 on 5/10/21 at 1:20 P.M. failed to reflect a care plan had been initiated to address Resident #70's need for the specialized treatment. RN #1 identified she was not aware Resident #70 did not have a care plan for specialized treatment. RN #1 indicated it is the responsibility of all facility nurses to initiate a care plan. Interview with the DNS on 5/11/21 at 10:20 A.M. identified she was not aware Resident #70 did not have a care plan for the specialized treatment. The DNS identified that it is the responsibility of all facility nursing staff to initiate care plans as needed. The DNS also indicated the MDS Coordinator reviews the resident's RCP during the quarterly and annual MDS assessments. The DNS indicated she will in-service/educate the licensed nurse on the implementation of RCPs. Subsequent to surveyor inquiry, a care plan for Resident # 70's specialized treatment was initiated. Review of the person-centered care plan policy identified the facility must develop and implement a baseline person-centered care plan within 48 hours of each resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and staff interview for one of five residents in the survey sample reviewed for unnecessary medications, (Resident #17), the facility failed to revise the resident care plan related to antipsychotic medication use. The findings include: Resident #17's diagnoses included vascular dementia with behavioral disturbance. A quarterly Minimum Data Set ( MDS) assessment dated [DATE] identified no cognitive problem, no mood or behavior problems, the resident had received antipsychotic medications for the last seven (7) days, and received antipsychotic medications on a routine basis. The Resident Care Plan (RCP) dated 3/01/21 identified Resident #17 was at risk for complications related to the use of antipsychotic medications. Interventions included: to utilize the smallest most effective dose without side effects, conduct Abnormal Involuntary Movement Scale (AIMS) assessments, behavioral monitoring, to monitor for mental status changes, and noted Gradual Dose Reduction (GDR) of the resident's antipsychotic medications. The physician's orders dated September 2020 through May 2021 failed to note any medication administration orders for antipsychotic medication to be administered to Resident #17. During an interview and review of Resident #17's clinical record with the Assistant Director of Nursing (ADNS) on 5/11/21 at 9:15 A.M. indicated that she could not identify or locate in the clinical record that any antipsychotic medication was ordered and or utilized by Resident #17. Interview and review of clinical record with the Director of Nursing (DNS) on 5/11/21 at 10:53 A.M. indicated resident's the care plan required revision related to antipsychotic medication use. The Facility Person-Centered care plan policy and procedure identified, in part, care plans will be reviewed and revised by the Interdisciplinary Team (IDT) after each assessment, including both the comprehensive and quarterly MDS review assessments. The policy also noted the care plan needs to reflect the response to care and the changing needs and goals of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record and interviews for one of three sampled residents (Resident #67) reviewed for choices, the facility failed to ensure a medication was available and administered per the physician's order. The findings include: Resident #67's diagnoses included tremors, diabetes mellitus and Parkinson's disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was without cognitive impairment, required supervision with Activities of Daily Living (ADL) and was independent with eating. A physician's order dated 4/11/21 directed to administer Carbidopa-Levodopa (Sinemet) 25-100 Milligrams (MG) Anti-Parkinson medication two tablets by mouth three times a day for Parkinson's disease. The April 2021 Medication Administration Record (MAR) identified the abbreviation NN (indicating to reference the nurse's notes). The abbreviation NN was used on the MAR instead of the licensed staff initials that would indicate Sinemet was administered to Resident #67 per the physician's order on 4/24/21 and 4/25/21 at 9:00 A.M., 1:00 P.M., and 5:00 P.M. The nurse's notes dated 4/24/21 at 11:31 A.M., 12:52 P.M. and 4:20 P.M. and the nurse's notes dated 4/25/21 at 11:44 A.M., 12:27 A.M. and 4:41 P.M. identified that Resident #67's Sinemet was not available. Physician Assistant (PA#1) note dated 4/26/21 identified that the facility nursing staff reported Resident #67 did not receive his/her Sinemet doses on Saturday and Sunday (4/24/21 and 4/25/21). Resident #67 reported that she/he was having diffuse muscle aches that were nonspecific and she/he denied overt weakness. Resident #67 reported that the pain was mainly to the forearms. Additionally, Resident #67 missed four to five doses of Sinemet and a STAT (for immediate delivery) order was called to the pharmacy. PA #1's note further indicated that he ordered Flexeril (muscle relaxant) 10 MG, three times a day for the next five days as needed, and that the plan of care was discussed with Resident #67's physician who agreed. Interview with Resident #67 on 5/06/21 at 10:37 A.M. identified that within the last two to three weeks, she/he did not receive Sinemet (Anti-Parkinson medication) for 36 hours and began shaking. Interview with the ADNS on 5/11/21 at 11:47 A.M. identified Resident #67 had missed doses of Sinemet and that the nurse failed to report the missed doses to the RN supervisor on 4/24/21. The ADNS stated that LPN #6 worked a double shift on 4/24/21 that included both the 7:00 A.M. to 3:00 P.M. shift and the 3:00 P.M. to 11:00 P.M. shift. The ADNS also indicated that Resident #67 had complained to LPN #7 on 4/26/21 (Monday) that she/he had not received his/her Sinemet doses over the weekend. LPN #7 informed the RN supervisor (RN #1) who then informed the DNS. Additionally, Resident #67's representative had called over the weekend and left a message on the DNS's voice mail regarding the missed doses. The ADNS stated that prior to running out of the medication, the facility protocol is to pull off the medication label sticker from the medication container and send it to the pharmacy to refill the medication prior to running out. The ADNS further indicated that if the medication was not available, LPN #6 should have notified the RN supervisor who could then order the medication STAT from the pharmacy. The ADNS identified that according to the facility policy, a Risk Management System (RMS) document should have been created to record the missed doses but she did not see one. The ADNS indicated that, according to the facility policy, a report, RMS, should have been initiated by LPN #7 when the missed doses were identified. Interview with LPN #6 on 5/12/21 at 11:48 A.M. identified that Resident #67's Sinemet was not available on 4/24/21 so she reordered the medication from the pharmacy when she became aware that the first dose of medication was not available. LPN #6 stated that the Sinemet did not come in for the 1:00 P.M. dose, and that medications that were ordered in the morning did not usually come in until later, around 3:00 P.M. on the same day. LPN #6 indicated that she had return to work the next day on 4/25/21 at 7:00 A.M. and she had been assigned to had been assigned to the three floors and noted Resident # 67's medication had not arrived from the previous day. LPN #6 indicated that she did not have time to call the pharmacy on 4/25/21 due to a staffing shortage and having to work three units. LPN #6 stated that when the RN supervisor arrived at 3:00 P.M., she requested that RN supervisor call the pharmacy to reorder the missing Sinemet. LPN #6 stated that at 4:00 P.M. or 5:00 P.M. she recognized that the RN supervisor was too busy to call the pharmacy and had not called the pharmacy to reorder the medication. LPN #6 stated that she called herself, but was too late as she received a message that the pharmacy had already closed at 4:00 or 5:00 P.M. LPN #6 identified that she could not recall if she had notified the RN supervisor on 4/24/21 and could not recall if she had communicated the information to the next shift (11:00 P.M. to 7:00 A.M). LPN #6 stated that she should have notified the RN Supervisor and PA #1 if he was in the building. Additionally, according to LPN #6, the facility did not have an emergency supply of Sinemet. LPN #6 identified that she had not received any corrective education regarding the missed doses. Interview with Pharmacy Representative #1 on 5/12/21 at 12:10 P.M. identified that the pharmacy had not received a request to refill Resident #67's Sinemet until Monday 4/26/21. Pharmacy Representative #1 indicated the pharmacy had not received a verbal or written request for the Sinemet on 4/24/21 and/or 4/25/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interview for one of five residents (Resident #30) reviewed for unnecessary medications, the facility failed to monitor recommended resident behaviors. The findings include: Resident #30's diagnoses included dementia with behavioral disturbances. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #30 had intact cognition, exhibited no behaviors and was independent or required supervisor with Activities of Daily Living (ADL). An Advanced Practice Registered Nurse (APRN) note dated 4/5/20 identified episodes of forgetfulness, depressive behaviors, anxiety and a recent readmission after a psychiatric hospitalization for combativeness. The note also indicated a low dose of Risperdal (an Antipsychotic medication) was initiated and that Trazodone (an Antidepressant medication) was replaced with Remeron (an Antidepressant medication). The APRN recommended to continue to monitor for behaviors of delusions and combativeness. The Resident Care Plan (RCP), last revised 4/6/21, identified the resident was resistive to care/combative related to mood/psychiatric disorder, and dementia. Interventions included: to evaluate the nature and circumstances of the resistive behavior and to observe for non-verbal signs of resistance. The physician's orders dated 5/2021 included Seroquel 0.25 MG (an Antipsychotic medication) every day for paranoia. Review of the Medication Administration Record (MAR) for 5/2021 included to monitor for agitation and mood changes. Interview and review of the clinical record with LPN #1 on 5/11/21 at 1:50 P.M. indicated LPN#1 was only aware of tracking Resident #30's behaviors for agitation and mood changes. LPN #1 indicated she was not aware of APRN #1's recommendation to monitor Resident #30's behaviors for delusions and combativeness. LPN #1 further indicated she was not aware that Seroquel was being prescribed for paranoia. Facility policy for Behavior Monitoring identified that facility staff should monitor the resident's behavior as per facility policy with the use of a behavioral chart or behavioral assessment record for residents receiving psychotropic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy and interviews for one of two sampled residents (Resident #30) reviewed for dental, the facility failed to ensure dental services were provided to replace the resident's lost dentures. The findings include: Resident #30 diagnoses included dementia with behavioral disturbances, congestive heart failure and depression. The Oral Health Evaluations dated 10/2/19 and 10/2/20 identified the resident had both natural teeth, dentures/partials and upper full denture. The annual Minimum Data Set (MDS) assessment dated [DATE] identified the resident had intact cognition, was independent or required supervisor with Activities of Daily Living (ADL), experienced no weight loss and had no oral/dental issues. The Resident Care Plan (RCP) initiated 10/2/19 and last revised 4/6/21 identified the resident exhibited or was at risk for oral health or dental care problems. Interventions included: to brush/clean dentures two times per day and as needed, to monitor the resident for discomfort of the mouth, broken or loose teeth and to obtain a dental referral as needed. Interview with Resident #30 on 5/5/21 at 1:40 P.M. indicated his/her denture was missing for a long time. Interview with LPN #1 on 5/11/21 at 1:15 P.M. indicated Resident #30 does not currently have dentures. LPN #1 also indicated she/he did not recall the resident having or wearing dentures since transferred to the current unit. LPN #1 indicated the resident has had multiple recent room changes. Interview with Unit Clerk #1 on 5/11/21 at 2:45 P.M. indicated that although Health Drive ( the facility dental vendor) has been back to the facility since November 2020 to do dental exams, Resident #30 does not have a signed consent to see Health-Drive for dental services and indicated the resident had not been seen. Unit Clerk #1 also indicated he was not aware the resident's dentures were missing, and if he had been made aware, he would have initiated the process for a Health-Drive consultation. Although requested, a facility policy was not provided.

Based on review of facility documentation, facility employee job description and interview, the facility failed to designate a specific individual (with the required training and qualification) to oversee the facility infection control program. The findings include: Interview with the DNS on 5/10/21 at 1:53 P.M. identified the facility does not have a dedicated Infection Preventionist Nurse. The DNS also indicated she oversees both the infection control program, and the DNS position. The DNS stated that she had been overseeing the infection control program since the Infection Preventionist Nurse resigned on 4/9/21. The DNS identified the facility had been without a dedicated Infection Preventionist Nurse since 4/9/21 (approximately one month) and indicated the facility did not have a second, qualified, Infection Preventionist Nurse as a backup employed for the facility. According to the DNS, the facility was in the process of hiring an Infection Preventionist Nurse. The DNS indicated she and the ADNS are in the process of going through the required infection Preventionist education and certification and indicated she had two hours of introductory training. Interview with the DNS on 5/12/21 at 1:00 P.M. identified that she had receive infection control training back in 1998 or 1999 but failed to complete the new requirements under the current regulations. The Nurse Practice Educator Job Description identified the Nurse Practice Educator functions as a practitioner, consultant, educator, and facilitator for all nursing staff focusing on the following area: Infection Control. Infection Control and Employee Health: The Nurse Practice Educator also provides oversight of the facility's Infection Control Program. The Nurse Practice Educator must be a graduate of an accredited school of nursing with current Registered Nurse licensure by the State Board of Nursing. The Nurse Practice Educator is required to have a minimum of three years full-time or equivalent nursing experience and a minimum of two years of nursing experience in long-term care nursing with one year in a management/administrative or supervisory capacity is preferred.