**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, interviews, and facility documentation for one (1) of three (3) residents (Resident #3) reviewed for pain management, the facility failed to ensure that the physician was notified when the resident's prescribed pain medication was unavailable and an alternate pain medication that was administered was ineffective. Resident #3 had diagnoses of acute osteomyelitis of the left ankle and foot. Review of Resident #3's Care Plan dated 11/1/24 identified the resident was on pain medication therapy with interventions directed to administer analgesic medications as ordered by the physician, and to monitor and document the side effects and effectiveness. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of seven (7) indicative of severe cognitive impairment. The MDS further identified Resident #3 was independent with Activities of Daily Living. A physician's order dated 12/6/24 directed acetaminophen 325 milligram tablets, two (2) tablets by mouth every six (6) hours as needed for pain. A physician's order dated 12/9/24 directed Oxycodone APAP, 5-325 milligrams by mouth, one (1) tablet every six (6) hours as needed (PRN) for moderate pain and two (2) tablets every six (6) hours as needed (PRN) for severe pain (a narcotic pain reliever). Review of Resident #3's Controlled Substance Disposition Record identified one (1) tablet of Oxycodone 5-325 milligrams was administered on 12/15/24 at 9:00 AM, which left zero (0) available for future administrations. Review of Resident #3's Medication Administration Record (MAR) for December 2024 identified Resident #3's pain level had ranged from five (5) to ten (10) (on a scale from one (1) to ten (10), (one (1) being the least amount of pain and ten (10) being the most pain). Review of the Resident #3's Medication Administration Record (MAR) dated 12/16/24 identified a pain level of nine (9) and 650 milligrams of acetaminophen was administered at 11:39 AM by LPN #1 ( location of pain not identified) . Review of LPN #1's nursing note dated 12/16/24 at 12:32 PM identified Resident #3 reported a pain level of eight (8) and that the acetaminophen was ineffective at relieving his/her pain. Review of the Controlled Substance Disposition Record identified Resident #3 received his/her next dose of Oxycodone 5-325 milligrams on 12/16/24 at 5:35 PM, thirty-two (32) hours and thirty-five (35) minutes after his last dose. Interview with LPN #1 on 2/18/25 at 1:51 PM identified that he/she did not inform the supervisor that Resident #3 was out of his/her Oxycodone 5-325 milligram pain medication on 12/16/24 and that the back-up emergency supply of Oxycodone 5-325 milligram was also not available on 12/16/24. LPN #1 further indicated at 2:40 PM on 2/16/25 that the charge nurse was aware that there was no Oxycodone available and the pain was unrelieved by acetaminophen. (although he/she was unable to identify who that was) further, the practioner was not contacted to request an alternate pain medication to help relieve the resident's pain. Interview with RN #1 (Nurse Supervisor on 7:00 AM to 3:00 PM shift on 12/16/24) on 2/19/25 at 11:41 AM identified that h/she was not informed that Resident #3 had reported the acetaminophen was ineffective in relieving his/her pain or that Resident #3 reported a pain level of eight (8) following administration of acetaminophen on 12/16/24. RN #1 further identified that he/she did not recall being informed the resident was out of his/her Oxycodone 5-325 milligram medication, if he/she had been informed he/she would have informed the provider of the resident's pain, and that the resident was out of his/her Oxycodone 5-325 milligram medication, checked the availability of the medication in the emergency box/PIXUS (dispenses emergency medication), and inquired about an alternative that could have been given in the meantime until the Oxycodone came in from the pharmacy. Interview with the Assistant Director of Nurses (ADNS) on 2/19/25 at 11:48 AM identified that he/she was not notified Resident #3 was still in pain after being administered 650 milligrams of Acetaminophen on 12/16/24. Interview with the Medical Director on 2/19/25 at 2:10 PM identified he/she would expect the facility to notify him/her or the provider of the resident's unresolved pain and inquire about an alternative medication that could be offered. The Medical Director indicated he/she would have given the resident a one-time dose of an alternate medication to relieve his/her pain and would expect a call back if the resident's pain persisted. Interview with the DON on 2/19/25 at 12:02 PM identified when Resident #3's pain was not relieved following the administration of pain medication, the nurse supervisor should have been notified, and provider informed of the resident's unrelieved pain. The DON further indicated he/she would have reviewed Resident #3's orders for an alternate medication that could have provided pain relief. Review of the change in condition policy identified that a change in condition is a significant clinical development that requires assessment and intervention. The RN supervisor will do an assessment and report findings to the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policies, and interviews for one (1) of two (2) sampled residents (Resident #1) who were reviewed for an allegation of resident to resident abuse, the facility failed to ensure Resident #1 was free from physical abuse. The findings include: 1. Resident #1's diagnoses included bipolar disorder and anxiety. The Resident Care Plan (RCP) dated 1/3/25 identified Resident #1 had behavioral problems. Interventions directed to administer medications as ordered, monitor and document for side effects and effectiveness, anticipate and meet the resident's needs, and provide opportunities for positive interaction. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #1 was alert and oriented to date, time and place and ambulated independently with a cane. 2. Resident #2's diagnoses included anxiety, adjustment disorder, and depression. The quarterly MDS dated [DATE] identified Resident #2 had a BIMS score of 11 indicating Resident #2 had some memory recall deficits, was independent with transfers and utilized a motorized wheelchair. The RCP dated 1/16/25 identified Resident #2 had a mood problem related to anxiety, insomnia and depression. Interventions directed to administer medications as ordered, monitor and document for side effects and effectiveness, behavioral health consults as needed, and monitor, record and report to physician if the resident was at risk for harming others, had increased anger, labile mood or agitation. The nurse's note dated 2/4/25 at 1:46 PM identified Resident #1 was observed sitting on his/her buttocks on the floor and a large laceration was noted to the right side of the forehead. The note identified Emergency Medical Services (EMS) was called and Resident #1 was transferred to the Emergency Department (ED) for treatment. The nurse's note dated 2/4/25 at 7:36 PM identified Resident #1 returned from the hospital and seven (7) sutures were noted to the right lateral aspect of the head. The nurse's note dated 2/4/25 at 2:03 PM identified Resident #2 was involved in a resident-to-resident altercation with Resident #1. The note identified witnesses reported Resident #2 hit Resident #1 in the forehead with a cane. The note identified Resident #2 was sent to the ED for evaluation and treatment to ensure no further harm would be done. The nurse's note dated 2/5/25 at 2:40 AM identified Resident #2 returned from the hospital at 12:15 AM with a no harm letter. The facility's investigational summary report dated 2/7/25 at 12:00 PM identified Resident #1 and Resident #2 had a verbal altercation in the dining room. Resident #2 then drove his/her motorized wheelchair towards Resident #1 causing Resident #1 to stumble and fall. Resident #2 then picked up Resident #1's cane, struck Resident #1 in the head and Resident #1 sustained a laceration to the right side of the forehead. Interview with the Social Worker (SW) #1 on 2/20/25 at 11:47 AM identified she arrived on the unit while the altercation in the dining room was occurring. SW #1 explained that Resident #2 reported to her that he/she had sugar packets on the table and Resident #2 told Resident #1 not to touch the condiments, but Resident #1 did touch the sugar. Resident #2 reported to her that it was then he/she wheeled towards Resident #1 in his/her motorized wheelchair causing Resident #1 to fall to the ground. Resident #2 identified while on the floor Resident #1 attempted to swing his/her cane at Resident #2 who then grabbed the cane and struck Resident #1 with it. Interview with the Physical Therapy Assistant (PTA) #1, on 2/20/25 at 12:03 PM identified at the time of the incident, he was in the hallway on the unit and observed Resident #1 on the ground in the dining room swinging his/her cane at Resident #2. PTA #1 indicated Resident #2 grabbed the cane from Resident #1 and hit Resident #1 on the head. PTA #1 identified he then took the cane away from Resident #2. Interview with the Certified Occupational Therapy Assistant (COTA) #1 on 2/20/25 at 1:23 PM identified on 2/4/25 she observed Resident #1 being a bit irritated while in the dining room. COTA #1 identified she heard a tussle, and when she turned around she saw Resident #2 going towards Resident #1 with his/her motorized wheelchair, bump into Resident #1 and Resident #1 fell to the floor. COTA #1 indicated Resident #2 continued to move towards Resident #1, and she observed what appeared to be Resident #1 attempting to get Resident #2 to stop by using his/her cane. COTA #1 identified at that time, Resident #2 grabbed the cane from Resident #1 and began to hit Resident #1. COTA #1 indicated she called for help and attempted to redirect the residents away from each other. Interview with the Director of Nursing (DON) on 2/20/25 at 2:01 PM identified on 2/4/25, she responded to the unit when she heard the page overhead and arrived at the dining room. The DON identified both residents were separated, the provider was notified, police were called, and an investigation was immediately initiated. The DON identified the facility policy on abuse is that all residents are to be free from abuse of any type from anybody. Review of the facility policy titled Abuse, last reviewed 3/20/24, directed, in part, abuse, neglect, exploitation, and/or mistreatment of residents is prohibited. The policy further directed, in part, residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies service the residents, family members or legal guardians, friends or other individuals. Review of the facility policy titled Nursing Facility Residents' [NAME] of Rights directed, in part, each resident has the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, interviews, and review of facility policy and documentation for two (2) of three (3) residents (Resident #4, and #5) reviewed for medication administration, the facility failed to administer resident's medications in accordance with facility policy. The findings included: 1. Resident #5 had diagnoses that included schizoaffective disorder, major depressive disorder, and Crohn's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition. The MDS further identified Resident #5 was independent with oral, toileting and personal hygiene. Review of Resident #5's Care Plan dated 12/18/24 identified an alteration in gastro-intestinal status related to Crohn's, use of antidepressant medication related to depression, chronic pain and arthritis, and for staff to be alert for the efficacy of his/her pain medication with interventions that directed to administer medications as ordered by the physician and to monitor for side effects and effectiveness. Review of the physician's orders dated 2/1/25 and the Medication Administration Record dated 2/19/25 identified the following medication orders: -Hydroxyzine (Antihistamine), 25 milligram tablet, three (3) tablets to be given twice daily at 8:00 AM and 5:00 PM. -Omega-3 Acid (Supplement), 1 gram capsule, twice daily at 8:00 AM and 5:00 PM. -GuaFENesin (Expectorant), 400 milligram tablet, twice daily at 8:00 AM and 5:00 PM. -Morphine Sulfate Extended Release (Narcotic Pain Reliever), 15 milligram tablet, twice daily at 9:00 AM and 9:00 PM. -Furosemide (Diuretic), 40 milligram tablet daily at 9:00 AM. -Loratadine (Antihistamine), 10 milligram tablet daily at 9:00 AM. -Multivitamin Tablet (Supplement), one (1) daily at 9:00 AM. -Senna with Docusate (Laxative), 8.6-50 milligram tablet, two tablets twice daily at 9:00 AM and 5:00 PM. -Lisinopril (Antihypertensive), 20 milligram tablet, one tablet daily at 9:00 AM. -Gabapentin (Anticonvulsant), 400 milligram tablet three (3) times daily at 9:00 AM, 1:00 PM, and 5:00 PM. -Potassium Chloride (Supplement), 10 milliequivalent tablet, daily at 9:00 AM. -Metoprolol Succinate (Antihypertensive), 100 milligram Extended Release tablet daily at 9:00 AM. -Sertraline (Antidepressant), 100 milligram tablet, two tablets daily at 9:00 AM. -Metamucil Powder (Laxative), one serving daily at 9:00 AM. Review of the time the aforementioned medications were administered was recorded as 10:53 AM and 11:17 AM, one (1) hour and fifty-three (53) minutes and two (2) hours and seventeen (17) minutes after their scheduled administration times. 2. Resident #4 had diagnoses that included metabolic encephalopathy, diffuse traumatic brain injury, and adjustment disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition. The MDS further identified Resident #4 was dependent with toileting hygiene, bathing, dressing, and mobility. Review of Resident #4's Care Plan dated 1/6/25 identified a nutritional problem or potential nutritional problems related to diabetes mellitus, hypertension, congestive heart failure, dysphagia/shortness of breath, and obesity with interventions that directed to administer medications as ordered and provide and serve supplements as ordered. Observation of LPN #1 on 2/19/25 at 10:20 AM identified he/she was administering morning medications. Review of the Physician's orders dated 2/1/25 and the Medication Administration Record dated 2/19/25 identified the following medication orders: -Prosource Protein Liquid (Supplement), 30 milliliters to be administered daily at 8:00 AM -Prednisone (Anti-Inflammatory), 2.5 milligram tablet to be administered daily at 9:00 AM -Eliquis (Anticoagulant), 5 milligram tablet, to be administered twice daily at 9:00 AM and 9:00 PM. -Incruse Ellipta Inhalation Aerosol Powder (Bronchodilator), 62.2 micrograms to be given daily at 9:00 AM. -Suboxone Sublingual Film (Substance Addiction), 12-3 milligrams to be administered daily at 9:00 AM. -Ferrous Sulfate (Supplement), 325 milligrams to be administered daily at 9:00 AM. -Ascorbic Acid Tablet (Supplement) 250 milligrams to be administered daily at 9:00 AM. -Allopurinol Tablet (Uric Acid Depletion), 100 milligrams daily to be administered daily at 9:00 AM. -Metoprolol Tartrate Oral Tablet (Antihypertensive), 25 milligrams given twice daily at 9:00 AM and 6:00 PM. Review of the time the medications were administered was recorded in the electronic medical record system as administered at 11:29 AM and 11:30 AM, two (2) and one-half (1/2) to three (3) and one-half (1/2) hours past their scheduled times. Interview with LPN #1 on 2/19/25 at 1:55 PM identified he/she did not communicate to the supervisor that he/she was running late in administering medication because he/she was running late was due to a heavy resident assignment (thirty (30) to thirty-one (31) residents) with multiple medications to administer. LPN #1 further identified that the late medication administrations is not something new and that the facility was aware that this was happening. Interview with RN #1 on 2/19/25 at 2:00 PM identified he/she was not aware that resident's medications were being administered late and had he/she known, he/she would have discussed the issue with the Director of Nursing Services (DNS) to resolve the issue so that medications were administered timely. Interview with the DNS on 2/19/25 at 4:00 PM identified resident medications could be administered up to one (1) hour before and one (1) hour after the scheduled time and that staff should notify the nursing supervisor that medications were being administered late in order for the issue to be attended to and resolved. Review of the Medication Administration policy directed medications were to be administered within sixty (60) minutes of the scheduled administration time and that unless otherwise specified by a prescriber, routine medications were administered according to the established medication administration schedule for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, interviews, and facility documentation for one (1) of three (3) residents (Resident #3) reviewed for pain management, the facility failed to ensure medications were available to and treat a resident's unrelieved pain. The findings included: Resident #3 had diagnoses of acute osteomyelitis of the left ankle and foot. Review of Resident #3's Care Plan dated 11/1/24 identified the resident was on pain medication therapy with interventions directed to administer analgesic medications as ordered by the physician, and to monitor and document the side effects and effectiveness. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of seven (7) indicative of severe cognitive impairment. The MDS further identified Resident #3 was independent with Activities of Daily Living. A physician's order dated 12/6/24 directed acetaminophen 325 milligram tablets, two (2) tablets by mouth every six (6) hours as needed for pain. A physician's order dated 12/9/24 directed Oxycodone - APAP, 5-325 milligrams by mouth, one (1) tablet every six (6) hours as needed (PRN) for moderate pain and two (2) tablets every six (6) hours as needed (PRN) for severe pain (a narcotic pain reliever). Review of Resident #3's Controlled Substance Disposition Record identified one (1) tablet of Oxycodone 5-325 milligrams was administered on 12/15/24 at 9:00 AM, which left zero (0) available for future administrations. Interview with RN #2 on 2/19/25 at 12:35 PM identified he/she had approached Resident #3 in the hallway during second shift (3:00 PM to 11:00 PM) on 12/15/24 as the resident had appeared frustrated. RN #2 identified that Resident #3 had informed him/her that the facility had run out of h/her Oxycodone 5-325 milligrams pain medication. RN#1 identified the facility was also out of the emergency supply of Oxycodone 5-325 milligrams so she contacted the APRN to request a prescription be sent to the pharmacy. A Nurse's note written by (RN) #2 dated 12/15/24 at 7:32 PM identified the facility was out of Resident #3's PRN (as needed) Oxycodone 5-325 milligram medication, a call was made to the on-call Advanced Practice Registered Nurse (APRN) who informed a script would be called into the pharmacy, a substitute medication was requested until the resident's pain medication was delivered, however, APRN stated the medication should be in the facility sometime today, and to continue to offer Tylenol to the resident. Review of Resident #3's Medication Administration Record (MAR) for December 2024 identified Resident #3's pain level had ranged from five (5) to ten (10) (on a scale from one (1) to ten (10), one (1) being the least amount of pain and ten (10) being the most pain). Review of the Resident #3's Medication Administration Record (MAR) dated 12/16/24 identified a pain level of nine (9) and the administration of 650 milligrams of acetaminophen at 11:39 AM by LPN #1. Review of LPN #1's nursing note dated 12/16/24 at 12:32 PM identified Resident #3 reported a pain level of eight (8) and that the tylenol was ineffective at relieving his/her pain. Review of the Controlled Substance Disposition Record identified Resident #3 received his/her next dose of Oxycodone 5-325 milligrams on 12/16/24 at 5:35 PM, thirty-two (32) hours and thirty-five (35) minutes after his last dose. Interview with LPN #1 on 2/18/25 at 1:51 PM identified that he/she did not inform the supervisor that Resident #3 was out of his/her Oxycodone 5-325 milligram pain medication on 12/16/24 and that the back-up emergency supply of Oxycodone 5-325 milligram was also not available on 12/16/24. LPN #1 further indicated at 2:40 PM on 2/16/25 that the charge nurse was aware that there was no Oxycodone available and the pain was unrelieved by tylenol. (although he/she was unable to identify who that was) further, the APRN was not contacted to request an alternate pain medication to help relieve the resident's pain. Interview with RN #1 (Nurse Supervisor on 7:00 AM to 3:00 PM shift on 12/16/24) on 2/19/25 at 11:41 AM identified that h/she was not informed that Resident #3 had reported the acetaminophen was ineffective in relieving his/her pain or that Resident #3 reported a pain level of eight (8) following administration of acetaminophen on 12/16/24. RN #1 further indicated he/she did not recall being informed the resident was out of his/her Oxycodone 5-325 milligram medication, if he/she had been informed he/she would have informed the provider of the resident's pain, and that the resident was out of his/her Oxycodone 5-325 milligram medication, checked the availability of the medication in the emergency box/PIXUS, and inquired abot an alternative that could have been given in the meantime unitl the Oxycodone came in from the pharmacy. Interview with the Assistant Director of Nurses (ADNS) on 2/19/25 at 11:48 AM identified that he/she was not notified Resident #3 was still in pain after being administered 650 milligrams of Acetaminophen on 12/16/24. Interview with the DON on 2/19/25 at 12:02 PM identified when Resident #3's pain was not relieved following the administration of pain medication, the nurse supervisor should have been notified, and provider informed of the resident's unrelieved pain. The DON further indicated he/she would have reviewed Resident #3's orders for an alternate medication that could have provided pain relief. Interview with the Clinical Service Manager (CSM) of the On-Call Nurse Practitioner Service) on 2/20/25 at 12:03 PM identified a call was received on 12/15/24 at 5:34 PM from the facility requesting a new script for Oxycodone 5-325 milligrams be placed for Resident #3 as the resident had run out of his prescription and the facility did not have any of the medication on hand. The CSM further indicated the caller had inquired about substituting the Oxycodone 5-325 mg with Tramadol and indicated the facility was giving the resident Acetaminophen, 650 milligrams, for his/her pain in between administration of his/her Oxycodone. RN #1 did not indicate the resident was experiencing any pain during the call and that APRN #1 did not direct the facility to use Acetaminophen for the resident's pain in the meantime. An order for eight (8) tablets of Oxycodone 5-325 milligrams was electronically submitted to the pharmacy immediately following the call, however was not placed as a stat order (to be filled and delivered immediately). The CSM identifed that no additional calls were received into the on-call service following the prescription refill request through to 8:00 AM the following day (12/16/24) for Resident #3. Interview with the Medical Director on 2/19/25 at 2:10 PM identified he/she would expect the facility to notify him/her or the provider of the resident's unresolved pain and inquire about an alternative medication that could be offered. The Medical Director indicated he/she would have given the resident a one-time dose of an alternate medication to relieve his/her pain and would expect a call back if the resident's pain persisted. Review of the Pain Management policy directed pain strategies to include as applicable, pharmacologic, and non-pharmacologic interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (2) of two (2) residents (Resident #1 and #2) reviewed for resident-to-resident abuse, the facility failed to ensure residents were free from physical and verbal abuse. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included fibromyalgia and mood disorder. A psychiatric note dated 10/14/24 identified Resident #1 was tolerating his/her medications well and maintaining a stable mood. The quarterly MDS dated [DATE] identified Resident #1 had a BIMS of fifteen (15) indicative of intact cognition, no physical behavioral symptoms and verbal behavior symptoms that occurred one to three days out of a seven-day period. A physician's order dated November 2024 directed independent mobility with a power wheelchair. The care plan dated 10/23/24 identified on 5/0/24 Resident #1 yelled at others, called others names and tended to threaten others when upset with interventions that included to have Resident #1 see the psychiatric team for therapy and medication management, offer 1:1 visits by the social workers so that Resident #1 could express concerns/issues about others, facility- contracted behavioral health services available as needed and to keep Resident #1 separated from residents if bothered by their presence. A psychotherapy note dated 11/5/24 identified one of Resident #1's treatment goals was to decrease conflict dynamics and reduce his/her conflicts with peers and others. Resident #1 expressed difficulty in managing intense emotions during stressful situations, which sometimes lead to conflict dynamics with others. Resident #1 had no current conflict with others reported by Resident #1 or staff. Resident #1 continued to implement coping strategies discussed in previous sessions, including deep breathing and mindfulness techniques. Resident #1 was assessed to be at no harm to self or others. A nursing note written by RN #1 dated 11/6/24 at 11:41 AM identified she was notified by the supervisor of an alleged resident to resident altercation in the first floor dining room. Resident #2 was sitting at a table coloring when Resident #1 approached the table yelling at Resident #2 that he/she was not allowed to sit at that table ever again. Resident #2 started to gather his/her things to leave when Resident #1 punched Resident #2 on the left side of his/her face. Resident #2 placed Resident #1 in a head lock to prevent him/her from further punches to his/her face. The residents were immediately separated and placed on 1:1. Psychiatry evaluated both residents, discontinued 1:1 and initiated every 15-minute checks. A psychiatry note dated 11/6/24 at 11:59 PM identified Resident #1 was seen for a peer-to-peer altercation. Resident #2 recalled the events, affirmed feeling safe. He recommended every 15-minute checks. Resident #1's care plan was updated on 11/6/24 with the intervention that Resident #1 was re-educated to not have physical altercations with other staff or residents and to notify staff of any issues. 2. Resident #2 was admitted to the facility with diagnoses that included fracture of the sternum, Tourette's disorder and attention deficit disorder (ADD). The nursing admission assessment dated [DATE] identified Resident #2 was alert and oriented, had no behaviors and ambulated with a manual wheelchair. The five-day MDS dated [DATE] identified Resident #2 had a BIMS of fifteen (15) indicative of intact cognition and had no behavioral symptoms. A physician's order dated November 2024 directed ambulation with assistance of one. The care plan dated 11/5/24 identified Resident #2 had a mood problem related to obsessive compulsive disorder (OCD), ADD, and Tourette's disorder. Interventions included to administer medications as ordered, assist Resident #2 to identify strengths and positive coping skills and behavioral consults as needed. A nurse's note dated 11/6/24 at 11:50 AM written by RN #identified she was notified by the supervisor of an alleged resident to resident altercation on the first-floor dining room. Resident #2 was sitting at a table coloring when Resident #1 approached the table yelling at Resident #2 that he/she was not allowed to sit at that table ever again. Resident #2 started to gather his/her things to leave when Resident #1 punched Resident #2 on the left side of his/her face. Resident #2 placed Resident #1 in a head lock to prevent him/her from further punches to his/her face. The residents were immediately separated and placed on 1:1. Psychiatry evaluated both residents, discontinued 1:1 and initiated every 15-minute checks. Resident #2 was provided a room change. A nurse's note dated 11/6/24 at 6:49 PM identified Resident #2 verbalized he/she would not be able to sleep tonight. The room change was completed, in-house APRN was notified and ordered Trazodone 25 mg at bedtime for five days for sleep. A Psychiatric note dated 11/6/24 at 11:59 PM identified Resident #2 was seen for a peer-to-peer altercation. Resident #2 recalled the events and affirmed feeling safe. He recommended every 15-minute checks. Resident #2's care plan was updated on 11/6/24 with the intervention that Resident #2's room was changed to a different wing to avoid interactions with Resident #1. a. Review of the accident and incident form dated 11/6/24 identified Resident #2 was punched by Resident #1 in the head in the dining room. The residents were placed on 1:1, evaluated by psychiatry and then placed on every 15-minute checks. Resident #2's room was changed. The summary identified the allegation was substantiated related to the fact that the statements from the witnesses were consistent. Review pf RN #2's statement dated 11/6/24 identified RN #2 heard noise in the dining room and rushed over. He identified Resident #1 and Resident #2 were observed fighting and Resident #2 had Resident #1 in a headlock. The residents were immediately separated. Resident #2 reported he/she was sitting at the table when Resident #1 approached him/her and asked him/her to leave. Resident #2 stated he/she was leaving but Resident #1 told Resident #2 he/she could not use the table anymore and punched Resident #2. Resident #1 stated he/she had to protect him/herself by putting Resident #1 in a headlock. Upon assessment, Resident #2 had no injuries. Interview with Resident #2 on 11/26/24 at 2:10 PM identified he/she was able to recall the event that occurred on 11/6/24. Resident #2 identified he/she was in the dining room working on a craft when Resident #1 rolled up in his/her wheelchair and stated that was his/her table. Resident #2 started to pack up his/her belongings and leave the table when Resident #1 then ran into Resident #2 with his/her wheelchair at full force and punched Resident #2 three times. Resident #2 stated he/she put Resident #1 in a head lock to stop Resident #1 from punching him/her. Resident #2 identified Resident #1 stated I will kill you. Interview with LPN #1 on 11/26/24 at 2:35 PM identified he was assigned Resident #1 and Resident #2's unit on 11/6/24. He identified Resident #1's behavior that day was calm, friendly and did not identify any concerns. He identified he last saw Resident #1 in the common room in his/her power wheelchair and Resident #2 in the common room sitting at the table where Resident #1 usually sat around 11:20 AM. He identified he was passing through the common room at that time. He identified he was in the supervisor's office when he heard yelling and went to the common room where Resident #1 and Resident #2 were already separated. Interview with NA #1 on 11/26/24 at 2:40 PM (identified on the staffing for 11/6/24 as working in Resident #1 and Resident #2's unit) identified on 11/6/24 she heard he/she's hitting in the common room and ran over. Resident #2 was at a table gathering his/her supplies and Resident #1 was yelling at Resident #2 close to the table. Interview with the DNS and Administrator on 11/26/24 at 3:00 PM identified that the facility has no tolerance for abuse. He identified subsequent to the event; recreation was notified to ensure when Resident #2 comes to the common room after activities to clear a spot for Resident #2 and continue education on handling his/her emotions. He identified this is the first event where Resident #2 was territorial about his/her table in the common area. Attempts to interview RN #1 were unsuccessful. Review of the abuse policy directed that abuse, exploitation and/or mistreatment of residents is prohibited. It further directed residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #2) reviewed for resident-to-resident abuse, the facility failed to complete and document 1:1 and every fifteen minute (Q 15) checks subsequent to a resident-to-resident abuse event per facility policy. The findings include: physical altercations with other staff or residents and to notify staff of any issues. 2. Resident #2 had diagnoses that included fracture of the sternum, Tourette's disorder and attention deficit disorder (ADD). The nursing admission assessment dated [DATE] identified Resident #2 was alert and oriented, had no behaviors and ambulated with a manual wheelchair. The five-day MDS dated [DATE] identified Resident #2 had a BIMS of fifteen (15) indicative of intact cognition and had no behavioral symptoms. A physician's order dated November 2024 directed ambulation with assistance of one. The care plan dated 11/5/24 identified Resident #2 had a mood problem related to obsessive compulsive disorder (OCD), ADD, and Tourette's disorder. Interventions included to administer medications as ordered, assist Resident #2 to identify strengths and positive coping skills and behavioral consults as needed. A nurse's note dated 11/6/24 at 11:50 AM written by RN #identified she was notified by the supervisor of an alleged resident to resident altercation on the first-floor dining room. Resident #2 was sitting at a table coloring when Resident #1 approached the table yelling at Resident #2 that he/she was not allowed to sit at that table ever again. Resident #2 started to gather his/her things to leave when Resident #1 punched Resident #2 on the left side of his/her face. Resident #2 placed Resident #1 in a head lock to prevent him/her from further punches to his/her face. The residents were immediately separated and placed on 1:1. Psychiatry evaluated both residents, discontinued 1:1 and initiated every 15-minute checks. Resident #2 was provided a room change. A nurse's note dated 11/6/24 at 6:49 PM identified Resident #2 verbalized he/she would not be able to sleep tonight. The room change was completed, in-house APRN was notified and ordered Trazodone 25 mg at bedtime for five days for sleep. A Psychiatric note dated 11/6/24 at 11:59 PM identified Resident #2 was seen for a peer-to-peer altercation. Resident #2 recalled the events and affirmed feeling safe. He recommended every 15-minute checks. Resident #2's care plan was updated on 11/6/24 with the intervention that Resident #2's room was changed to a different wing to avoid interactions with Resident #1. Review of the accident and incident form dated 11/6/24 identified Resident #2 was punched by Resident #1 in the head in the dining room. The residents were placed on 1:1, evaluated by psychiatry and then placed on every 15-minute checks. Resident #2's room was changed. The summary identified the allegation was substantiated related to the fact that the statements from the witnesses were consistent. Interview with the DNS and Administrator on 11/26/24 at 3:00 PM identified he could not locate Resident #2's 1:1 or Q15 minute monitoring flowsheet for 11/6/24. He identified he would expect staff to document in a nursing note or the 1:1 or Q15 minute monitoring flowsheet when a patient is on increased monitoring. He further identified that he was not aware of when Resident #2 was taken off of fifteen-minute checks. He identified the process for taking a patient off Q15 checks is usually based on psychiatry feedback, discussion during morning rounds and/or during behavior rounds every Monday. Review of the close observation policy identified that residents are placed on close observation when the physician, nursing supervisor or the interdisciplinary team deem it necessary to ensure their safety or the safety of others. The policy directed that if an observation level is ordered by a physician, PA or APRN, it must be entered into the physician order sheets in the clinical record and must be discontinued by a physician, PA or APRN order. It directed the initiation of checks must be documented in an appropriate location in the clinical record. Documentation of staff monitoring of any resident on observation should be entered on either a Q15 or Q30 minute flowsheet. Documentation of 1:1 monitoring should be entered on a Q15 minute flowsheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #317) reviewed for ADL's the facility failed to feed the resident in a dignified manner and according to facility policy. The findings include: Resident #317 was admitted to the facility on [DATE] with diagnoses that included dementia, dysphagia, and abnormalities of gait and mobility. A Nutritional assessment dated [DATE] identified Resident #317 was total dependence with eating. The care plan dated 10/21/24 identified concerns with eating and nutrition related to dementia. Interventions included Resident #317 be provided an assist of one with eating, and to provide, and serve diet as ordered, as well as to monitor intake and record every meal. The admission MDS dated [DATE] identified Resident #317 had severely impaired cognition and was edentulous with no natural teeth or tooth fragments. Observation on 11/3/24 at 8:20 AM identified Resident #317 was seated on his/her bed which was in a low position, and being fed by NA #10, who was standing. The Residents head level with NA #10's mid chest. There was no observed dialogue between Resident #317 and NA #10. NA #10 identified at that time, it was up to him to sit or stand while feeding. Resident #317 was silent during the meal and continued to open his/her mouth as the spoon was presented. Interview with RN #10 on 11/3/24 at 8:25AM identified nurse aides have been trained to be seated while feeding. Interview with the DNS on 11/5/24 at 3:27 PM identified the nurse aides have received training on feeding residents, and NA #10, knows that he should be seated while feeding. The policy for Feeding (Dependent Feeding) identified that the employee is to give the resident their complete attention, and sit to be at eye level with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policies, and interviews for 1 of 2 residents (Resident #103) reviewed for advance directives, the facility failed to accurately document the resident's life support choices. The findings include: The Inter-Agency Referral Report dated 9/27/24 identified Resident #103 had a Full Code status during his/her hospital admission (full code directs the medical team to take all possible measures to save the residents' life in the event of a medical emergency). Resident #103 was admitted to the facility on [DATE] with diagnoses that included hypertension, COPD, endocarditis, and heart valve disorders. The Advance Directive/Code Status Consent signed and dated 9/27/24 identified Resident #103 requested the following advance directive: DNR (Do Not Resuscitate). The MD Order/Progress Note dated 10/1/24 identified that advance directives had been reviewed with the resident and/or resident representative, in the event of a cardiac/respiratory arrest, the resident's DNR wishes would be honored. The admission MDS dated [DATE] identified Resident #103 had intact cognition. The Care Conference signature sheet dated 10/17/24 identified Resident #103 was a full code but failed to identify Resident #103's signature. The November 2024 Physician's Orders identified Resident #103 was a full code. Interview and review of the clinical record with the DNS on 11/4/24 at 11:00 AM identified that Resident #103 was admitted to the facility from the hospital with a status of full code. The advance directive form that was signed by the resident and dated 9/27/24 identified the residents wish was a DNR status. The DNS indicated that he would have expected that the change from full code to DNR would have been updated, by the nurse confirming Resident #103's advance directive/code status and reflected in the physician's orders. The facility's Advance Directive-Decision-Making policy directs upon admission, the facility's designee will ask whether the resident has completed any other advance directive documents and review and place any documents received in the medical record, the resident and authorized decision maker will be provided with this advanced directive decision making policy and the code status policy and will be given the opportunity, but not required to submit any additional advance directive documents for inclusion in the medical record. The facility will review and make part of the medical record any advance directive documents presented to it at admission or any time after admission. The policy further directs a physician or other health care provider shall record in the resident's medical record any oral communication concerning any aspect of the resident's health care, including the withholding or withdrawal of life support systems, made by the resident directly to the physician or other health care provider or the resident's health care representative, legal guardian, conservator and next-of-kin. The Physician's Orders-Transcription policy directs physician orders will be transcribed by a licensed nurse and followed through in a manner consistent with quality standard of care practices; routine orders are reviewed on the Physician's order sheet and transcribed onto appropriate worksheets and signed off by the licensed nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #111 was admitted to the facility on [DATE] with diagnoses that included dementia, nicotine dependence, and aphonia. A physician's order dated 7/31/24 directed Resident #111 may have supervised smoking per facility policy. Review of Resident #111's census sheet identified he/she was placed on the secured dementia unit upon admission on [DATE] Review of the clinical record identified legal documentation that directed Person #1 as Resident #111's conservator of person. Review of the clinical record identified a CAN DO LIST dated 8/2024 for Resident #111. The list identified Resident #111 had moderately severe cognitive decline and did not anticipate safety hazards. The admission MDS dated [DATE] identified Resident #111 had severely impaired cognition, was always continent of bowel and bladder, required set up with showering, and was independent with toileting, dressing, and eating. The MDS also identified Resident #111 had current tobacco use. The care plan dated 8/9/24 identified Resident #111 enjoyed smoking. Interventions included to observe Resident #111 for any signs/symptoms of unsafe smoking and to complete smoking evaluations per facility policy. A smoking agreement dated 8/10/24 identified verbal consent was obtained from Person #1 (Resident #111's resident representative) on that date related to Resident #111 being able to have supervised smoking at the facility. Review of the agreement signatures identified an illegible staff member and Security Guard #3. A smoking evaluation completed on 8/10/24 by Security Guard #3 identified Resident #111 had an understanding of the facility smoking policy, safety issues, and the importance of the smoking rules and regulations. A nurse's note dated 8/21/24 at 3:38 PM identified Person #1 was notified that Resident #111 was caught smoking and vaping in his/her room. The note further identified that Resident #111 was informed of the smoking policy and that smoking in his/her room was a fire hazard. A nurse's note dated 9/4/24 at 11:36 AM identified that laundry staff alerted nursing of a strong odor of cigarette smoke when delivering clothing items to Resident #111's room. The note further identified that upon nursing staff entering the room and identifying the odor, Resident #111 initially denied but subsequently turned over a half a pack of cigarettes along with a lighter. Review of the clinical record failed, including the reportable event form dated 9/4/24 failed to identify any additional documentation related to the 9/4/24 smoking incident including that Person #1 was contacted or notified of this incident. A 9/5/24 psychiatric note identified Resident #111 was seen after smoking in his/her room and that Resident #111 normally smoked cigarettes on his/her assigned smoke break. The note identified Resident 111 was very forgetful, pleasantly confused, and forgot that he/she could not smoke in his/her room. A 9/17/24 nurse's note identified a lighter was found in Resident #111's room behind his/her television and removed from the room. Review of the clinical record including the reportable event form dated 9/17/24 failed to identify that Person #1 was contacted or notified of when the lighter was found and removed from the resident's room. Interview with Person #1 on 11/5/24 at 2:06 PM identified that he/she became Resident #111 conservator following issues with cognitive decline. Person #1 identified that Resident #111 had multiple incidents related to cognition, including forgetting about cooking items on a stove top that resulted in a house fire. Person #1 identified that the facility staff were making sure to check Resident #111 for smoking materials regularly following 8/21/24 smoking incident and that Resident #111 regularly left the faciity on leave of absence with family members and friends. Person #1 identified that because of these checks, Resident #111 had not had any other smoking related incidents the facility. Person #1 identified the facility staff had only notified him of one incident related to smoking on 8/21/24. Person #1 also identified he primarily communicated with SW #1 (Director of Social Work). The facility policy on change of condition directed that a change of condition was a significant clinical development that required assessment and intervention. The policy further directed that the resident representative would be notified. 3. Resident #4 was admitted to the facility in June 2024 with diagnoses that included diabetes, anxiety disorder, major depressive disorder, and history of traumatic brain injury. The physician's orders dated 8/2024 directed to perform a skin check on shower days however, the order failed to reflect the scheduled shower day. The unit shower schedule form identified Resident #4's shower days were Wednesday on the 3:00 PM - 11:00 PM shift. Review of the August 2024 TAR identified skin checks to be done on shower day, Wednesday during the 3:00 PM - 11:00 PM shift, and reflected Resident #4 refused his/her shower on 8/7/24 and on 8/14/24. Resident #4 was hospitalized on [DATE] and 8/28/24. Review of the nurse aide flowsheet dated 8/1/24 - 8/31/24 identified Resident #4 refused his/her shower on 8/7, and 8/14/24. Review of the nurse's note dated 8/1/24 through 8/19/24 failed to reflect Resident #4 refused the shower on his/her scheduled day Wednesday 8/7, and 8/14/24 during the 3:00 PM - 11:00 PM shift. The physician's orders dated 9/2024 directed to perform a skin check on shower days, the order failed to reflect the schedule shower day. The quarterly MDS dated [DATE] identified Resident #4 had severely impaired cognition and required setup or clean-up assistance with shower. Review of the nurse aide flowsheets dated 9/1/24 - 9/30/24 identified Resident #4 refused his/her shower on 9/4/24, was provided a shower on 9/11/24, was independent with the shower on 9/18/24, and 9/25/24 was blank. Review of the nurse's note dated 9/4/24 at 6:44 PM identified Resident #4 refused the shower and bed bath. The nurse's notes failed to reflect Resident #4 was provided or refused a shower on 9/11/24, 9/18/24 or 9/25/24 during the 3:00 PM - 11:00 PM shift. The care plan dated 9/23/24 identified Resident #4 had an Activity Daily Living (ADL's) self-care performance deficit related to disease process traumatic brain injury, and deafness. Interventions included to provide assistance with bathing/showering. Review of the nurse aide flowsheet dated 10/1/24 - 10/31/24 identified Resident #4 refused his/her shower on 10/2, 10/9, 10/16, 10/23, and 10/30/24. Review of the nurse's note dated 10/2/24 at 2:33 PM identified Resident #4 requested to take a shower. Resident #4 was informed his/her shower was tonight on the 3:00 PM - 11:00 PM shift and Resident #4 agreed. The nurse's note failed to reflect documentation that Resident #4 had been provided a shower on the 3:00 PM - 11:00 PM shift. Review of the nurse's note dated 10/3/24 through 10/23/24 failed to reflect documentation that Resident #4 had been provided a shower on his/her scheduled day Wednesday 10/9, 10/16, and 10/23/24 during the 3:00 PM - 11:00 PM shift. Review of the nurse's note dated 10/30/24 at 9:24 PM identified Resident #4 was alert and verbal. Resident #4 refused his/her shower. Staff made several attempts, and he/she continued to refuse. Resident #4 indicated he/she wanted the shower in the morning. Review of the nurse's note dated 10/31/24 at 2:07 PM identified Resident #4 was asked, verbally and written out on paper. When would he/she like to take a shower today? Resident #4 indicated he/she did not want to take a shower today and would like a shower tomorrow morning. Resident #4 was asked again by a different nurse aide, and he/she refused the shower today. Resident #4 was educated on importance of regular bathing and skin checks. The care plan dated 11/1/24 identified Resident #4 has a behavior problem related to refusal of showers. Interventions included to provide opportunity for positive interaction. The nurse aide care card dated 11/4/24 identified Resident #4 shower day is on Wednesdays on the 3:00 PM - 11:00 PM shift. Interview and review of the clinical record with the ADNS on 11/5/24 at 10:30 AM identified she was aware that Resident #4 had been refusing his/her showers. The ADNS indicated the staff has been making multiple attempts to encourage Resident #4 to take a shower, but the resident continues to refuse. The ADNS indicated the licensed nurses should have documented every Wednesday on the 3:00 PM - 11:00 PM shift when Resident #4 had refused his/her shower. Interview and review of the clinical record with the Interim DNS on 11/6/24 at 6:30 AM identified he was not aware that Resident #4 had not been receiving showers. The Interim DNS indicated that Resident #4 refuses care and shower per the clinical record. The Interim DNS indicated the licensed nurses should have documented every Wednesday on the 3:00 PM - 11:00 PM shift when Resident #4 had refused the shower. The Interim DNS indicated that all nursing staff will be in-service regarding showers and documentation. Interview with the NA #10 on 11/7/24 at 12:31 PM identified she was aware that Resident #4 has not been receiving his/her schedule showers. NA #10 indicated Resident #4 refuses care and showers all the time. NA #10 indicated she reports to the charge nurse on duty when Resident #4 refuses his/her shower. NA #10 indicated she does document the resident refusal on the nurse aide flowsheet. Interview with the NA #13 on 11/7/24 at 12:45 PM identified she was aware that Resident #4 has not been receiving his/her schedule showers. NA #13 indicated Resident #4 shower day is on Wednesday on the 3:00 PM - 11:00 PM shift. NA #13 indicated Resident #4 refuses shower all the time. NA #13 indicated she reports to the charge nurse when Resident #4 refuses his/her shower. NA #13 indicated she does document the resident refusal on the nurse aide flowsheet. Interview with the NA #12 on 11/7/24 at 1:02 PM identified she was aware that Resident #4 has not been receiving his/her schedule showers. NA #12 indicated Resident #4 shower day is on Wednesday on the 3:00 PM - 11:00 PM shift. NA #12 indicated Resident #4 refuses showers or bed bath all the time. NA #12 indicated she reports to the charge nurse when Resident #4 refuses his/her shower. NA #12 indicated she does document the resident refusal on the nurse aide flowsheet. Interview with the LPN #10 on 11/7/24 at 1:44 PM identified she was aware that Resident #4 had been refusing his/her schedule showers. LPN #10 indicated she and the nurse aides has been making multiple attempts to encourage Resident #4 to take a shower, but the resident continues to refuse. LPN #10 indicated she always notified the RN supervisor when the Resident #4 refuses his/her shower. LPN #10 indicated she is aware that she does not document Resident #4 refusal of his/her schedule showers. LPN #10 indicated going forward she will attempt to document Resident #4 refusal of shower. Review of the clinical record failed to reflect that the physician or resident representative had been made aware of the residents continued refusal of showers. Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #76) reviewed for unnecessary medications, the facility failed to notify the physician or APRN of a change in condition and for 1 resident (Resident #111) reviewed for accidents, the facility failed to ensure that the resident representative was notified when the resident was found smoking in his/her room and was found with smoking materials in his/her room, and for 1 of 3 residents, (Resident #4) reviewed for ADL's, the facility failed to ensure the physician and resident representative were made aware when the resident continued to refuse showers. The findings include: 1. Resident #76 was admitted to the facility in July 2024 with diagnoses that included congestive heart failure, seizures, diabetes, and hypertension. The admission MDS dated [DATE] identified Resident #76 had intact cognition and required touching assistance by staff for ambulation in room and corridor. The care plan dated 8/8/24 identified Resident #76 was at risk for falls. Interventions included to record and report any concerns or changes in condition to the attending physician. A physician's order dated 10/22/24 directed to transfer the resident with assist of 2 staff person. A nurse's note written by LPN #1 on 11/4/2024 at 10:10 PM indicated that Resident #76 was observed with increased tremors and weakness to extremities which was reported to the supervisor. A notation was placed in the APRN communication book for evaluation. Interview with Resident #76 on 11/5/24 at 9:00 AM indicated last night he/she was ambulating to the bathroom with a staff member when he/she became so shaky, weak and was having tremors that he/she could not get off the toilet. Resident #76 indicated that it took 2 staff to assist him/her from the bathroom back to bed. Review of the clinical record 11/4/24 to 11/6/24 failed to reflect the APRN or physician was notified that Resident #76 was observed with increased tremors and weakness, could not get off the toilet and required assist of 2 to get back to bed from the bathroom on 11/4/24. Interview with the ADNS on 11/6/24 at 8:54 AM indicated that if there was a change in condition the LPN must notify the RN supervisor, the RN Supervisor must do an assessment of the resident and contact the physician or APRN at that time. The ADNS indicated that the LPN or the RN Supervisor cannot put change of condition information in the APRN communication book. The ADNS indicated that she had worked on 11/4, 11/5, and today from 7:00 AM to 3:00 PM and was not aware that Resident #76 became shaky, weak and was having tremors and could not get off the toilet on 11/4/24. Further, it was not discussed during supervisor daily report from shift to shift. After review of the clinical record, the ADNS indicated that the provider was not notified. Interview with RN #6 with ADNS present on 11/6/24 at 9:04 AM indicated that she had worked on 11/4/24 from 3:00 PM to 11:00 PM as the RN supervisor. RN #6 indicated that she was called by LPN #1 to see Resident #76. RN #6 indicated that LPN #1 had reported to her that Resident #76 while ambulating to the bathroom became shaky, had fine tremors, and was weak. RN #6 indicted that she gave the directive for LPN #1 to place the change of condition in the APRN communication book and she would pass the information to the 11:00 PM to 7:00 AM supervisor. RN #6 indicated that on 11/5/24 about 10:00 PM she looked in the APRN communication book and had seen that APRN #1 indicated that Resident #76 was not her resident and was not going to see Resident #76 on 11/5/24. RN #6 indicated that she then wrote on a sticky note for APRN #2 so see Resident #76 but did not know or had confirmed that APRN #2 was coming into the facility on [DATE]. RN #6 indicated that she did not call a provider because she did not feel it was an emergency she just felt that Resident #76 may just need labs, so she left it in the APRN communication book. Interview with the ADNS on 11/6/24 at 9:14 AM indicated that her expectation was that RN #6 would have called via the phone the APRN on call at that time on 11/4/24, not just write it in the communication book or leave a sticky in the supervisor office. The ADNS indicated that the RN #6 should have called the APRN and then by the APRN directive could have left a note in the communication book. Interview with APRN #1 on 11/6/24 at 11:00 AM indicated that when there is a change of condition with a resident her expectation was there would be an RN assessment and documentation of the assessment, and then call the APRN on duty to give all the information to. Interview with the DNS on 11/6/24 at 10:27 AM indicated that when a resident has a change of condition the LPN must notify the RN supervisor. The DNS Indicated that the RN supervisor must perform an assessment and document the assessment in the progress notes and updated the provider via the phone and not just place it in the communication book. Although attempted, an interview with MD #1 was not obtained. Review of the Change of Condition Policy identified it is the policy to notify the physician when the resident's condition or status changes unexpectedly. This will ensure that the physician will be kept informed of changes in an appropriate and timely manner. A change of condition is a significant symptom(s) or development, which requires assessment and intervention. If a resident is evaluated by a charge nurse to have a change in condition, the charge nurse will notify the RN Supervisor on duty. The RN Supervisor will do a follow up assessment and to ensure that the assessment is documented and reported to the physician. All assessment findings and relevant information should be compiled prior to calling the physician to ensure accurate information. The physician will be contacted to report findings. The nurse will obtain new orders as warranted from the physician. The resident will be notified. The nurse will document in the nurse's notes regarding assessments, findings, changes, physician notification, and resident and/or representative notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #76 was admitted to the facility in July 2024 with diagnoses that included congestive heart failure (CHF), peripheral vascular disease, and hypertension. Review of the nurse's notes dated 7/10/24 to 11/6/24 failed to reflect Resident #76 had refused to take a shower or was offered a shower. The admission MDS dated [DATE] identified Resident #76 had intact cognition. Additionally, Resident #76 indicated that it was very important to him/her to choose between a tub bath, shower, bed bath, or sponge bath. Resident #76 needed touching assistance for showering/bathing with washing, rinsing, and drying self. The care plan dated 8/8/24 identified Resident #76 would be able to speak openly to the social worker any feelings or coping impairments. Interventions included to record and report any concerns or condition changes to the physician and the interdisciplinary team as needed. The care plan did not identify Resident #76's preferences for showers. The nurse's aides flow sheets for September 2024 identified shower documentation as follows. 9/7/24, was blank. 9/14/24, was blank. 9/21/24, NA #5 documented NA. 9/28/24, supervision was provided. The nurse's aides flow sheets for October 2024 identified shower documentation as follows. 10/5/24, moderate assistance from NA #3 (who in an interview indicated that she gave the resident a bed bath not a shower). 10/12/24, independent for a shower. 10/19/24, was blank. 10/26/24, partial assistance. The nurse's aides flow sheets for November 2024 identified shower documentation as follows. 11/2/24, independent, by NA #4, who in an interview indicated that she did not see Resident #76 in the shower room. Interview with Resident #76 on 11/3/24 at 8:41 AM indicated that he/she has only had 1 shower since admission to the facility in July 2024 and wants at least one shower a week. Resident #76 indicated that the nurse's aides have given him/her a bed bath, but he/she has told the staff he/she really prefers and wants a shower. Resident #76 indicated that he/she asks the nurse's aides almost daily for a shower and the nurse's aides reply they don't have time or tomorrow and never give him/her a shower. Resident #76 indicated that he/she has told the charge nurses and SW #1, but nothing has changed. Resident #76 indicated that he/she has tried many times to talk with SW#1, but she tells Resident #76 she will go to his/her room later that day and never shows up. The unit shower schedule at first floor desk identified Resident #76's room and bed assigned was scheduled for a shower on Saturdays 7:00 AM to 3:00 PM shift. Interview with SW #1 on 11/4/24 at 9:53 AM indicated that Resident #76 had come to her office twice last week and she did inform Resident #76 she would see him later each day but did not see Resident #76 because she was busy with other residents. SW #1 indicated before 10/3/24 Resident #76 had gone to her office and had complained about not getting any showers, so SW #1 contacted the DNS at that time and Resident #76 received a shower on that day. SW #1 indicated that she did not document that Resident #76 was upset that he/she had not received a shower since admission and was only getting a bed bath. SW #1 indicated that Resident #76 indicated that he/she only wanted showers not a bed bath and that she had notified the prior DNS. SW #1 indicated that right after that she had gone out on leave and had just returned about a week ago and had not had time to speak to Resident #76 regarding showers. SW #1 indicated that resident #76 prefers to speak with her. Interview with NA #3 on 11/4/24 at 2:22 PM indicated that she works full time on the unit and sometimes has Resident #76 on Saturdays (shower day). NA #3 indicated that she does not recall giving Resident #76 a shower, only a bed bath. NA #3 indicated that Resident #76 would need assistance to go to the shower and receive a shower. NA #3 indicated that Resident #76's unit works short with only 2 nurse aides and that sometimes it is just too much to get everything done. NA #3 indicated that it is quicker to give a bed bath compared to a shower. NA #3 indicated that she does not recall if Resident #76 had informed her that he/she prefers a shower. After review of the nurse aide flow sheets, NA #3 indicated that she had signed off on 9/19 9/27, 9/30, 10/2, 10/5, 10/9, 10/11, and 10/14/24 that she had given Resident #76 a shower but she has never given Resident #76 a shower, and she documented incorrectly at times putting a number 1 indicating Resident #76 was totally dependent on staff for a bed bath or a shower and other times a 6 that Resident #76 was totally independent taking his/her own shower. NA #3 indicated that she was not sure how to answer that question on the computer but does know she has not given Resident #76 a shower and has only given bed baths because they were quicker. NA #3 indicated that her documentation was not accurate. NA #3 indicated that since Resident #76 was admitted in July 2024 she has not given Resident #76 a shower or brought him to the shower room. Interview with NA #5 on 11/5/24 at 9:09 AM indicated that she had documented on 9/10, 9/11, 9/21, 9/22 9/24, 10/27, and 10/29/24 NA every day and that meant not applicable. NA #5 indicated that she has not given Resident #76 a shower. Interview with NA #4 on 11/5/24 at 9:52 AM indicated that Resident #76 can take his/her own shower independently. NA #4 indicated when she was assigned to Resident #76, she gives Resident #76 a washcloth and towel and it was up to Resident #76 if he/she took a shower or washed up at the sink. NA #4 indicated that she has not seen Resident #76 going into or coming out of the shower room. NA #4 indicated that she documented a number 6 on 10/21, 10/22, 10/24, 10/25, 10/31, 11/2, and 11/3/24, because she believed Resident #76 was independent with his/her own showers. NA #6 indicated that a number 6 means the resident was independent with taking showers. NA #4 indicated that she had never seen Resident #76 take him/herself into or out of the shower room down the hallway and could not verify that Resident #76 had received a shower. NA #4 indicated that she has never physically given Resident #76 a shower. NA #4 indicated that this unit is very busy with only 2 nurse aides, and she does not know if Resident #76 either washed him/herself or took a shower. Interview with the DNS on 11/5/24 at 2:02 PM indicated that all residents are scheduled at least weekly for showers and could ask for more often as the resident wanted another shower. The DNS indicated that Resident #76 required extensive assistance of one staff person for transfers was at risk for falls and has had falls at the facility. The DNS indicated that the nurse aides just started with this new electronic medical record in September 2024 and may need reeducation on how to document. The DNS indicated that the care plan would reflect residents' preference for showers or bed baths and would reflect if resident was refusing showers. The DNS indicated that Resident #76 could not give him/herself a shower and that Resident #76 was not to be left alone in the shower room. Interview with PTA #1 on 11/5/24 at 2:08 PM indicated Resident #76 required assist of 1 staff person for ambulation and transfers. PTA #1 indicated that Resident #76 could ambulate with a rolling walker and assistance of 1 staff person to the shower room, but not by him/herself. PTA #1 indicated that Resident #76 would have to have a staff person stay in the shower room with him/her for assistance and safety. PTA #1 indicated that Resident #76 definitely could not take a shower or be alone in the shower room by him/herself. Review of the Personal Care Policy identified showers and/or baths and shampoos are scheduled at least weekly and more often as needed. Document according to the facility guidelines. 3. Resident #116 was admitted to the facility in August 2024 with diagnoses that included syncopal fall related to alcohol abuse, subdural hematoma, and cervical spine fracture. The nursing admission assessment completed on 8/16/24 identified Resident #116 was alert and oriented, had a history of 2 or more falls in the last 3 months, was a high risk for falls, and required the assistance of 1 staff member with toileting and dressing, and 2 staff members for transfers. Review of the clinical record failed to identify a care plan related to Resident #116's recent history or risks of falls. A reportable event form dated 8/24/24 at 3:15 AM identified Resident #116 had an unwitnessed fall. The report identified Resident #116 reported attempting to retrieve a blanket, loosing balance and falling. The report also identified Resident #116 reported bumping his/her head during the fall. The report identified that the physician was notified and that neurological checks would be initiated per facility policy and would have monitoring every shift for 72 hours. Review of the clinical record failed to identify any neurological checks or shift monitoring documentation completed after 5:00 AM on 8/26/24, approximately 50 hours after Resident #116's fall. Interview with MD #1 (Medical Director) on 11/5/24 at 3:12 PM identified that the nursing staff should have completed 72 hours of neurological monitoring and shift assessments on Resident #116 following the unwitnessed fall with a reported head strike on 8/24/24. MD #1 identified with Resident #116 history of falls and recent diagnosis of a subdural hematoma, he would have expected that the nursing staff would have adhered to the facility policy and completed the full 72 hours of monitoring to ensure Resident #116 did not have any new injury or worsening of his/her previous head injury. The facility policy on the fall management program directed that if a resident had an unwitnessed fall or if a head injury was suspected, neurological signs would be monitored, and that the resident would be monitored for 72 hours after the fall and any concerns identified would be documented. The facility policy on neurological checks directed that residents with a suspected head injury would have neurological signs monitored and recorded for 72 hours per policy unless otherwise ordered by a physician and would be performed as follows: Every 15 minutes for one hour (4x). Every 30 minutes for one hour (2x). Every hour for 4 hours (4x). Every 2 hours for 10 hours (5x). Every 4 hours for 16 hours (4x). Every 8 hours for 40 hours (5x). The policy further directed that the neurological check documentation should include blood pressure, pulse, respirations, hand grasp, level of consciousness, pupil reactivity to light, and any additional comments or findings. Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #102, 76) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the residents were provided a weekly shower on scheduled shower days. The findings include: 1. Resident #102 was admitted to the facility in April 2024 with diagnoses that included severe morbid obesity, paraplegia, and spinal cord compression. The unit shower schedule form identified Resident #102's shower days were Friday on the 7:00 AM - 3:00 PM shift. Review of the nurse's notes and nurse aide flowsheet dated 7/1/24 - 7/31/24 failed to reflect documentation that Resident #102 had been provided a shower on his/her scheduled day Friday 7/5, 7/12, 7/19, and 7/26/24 during the 7:00 AM - 3:00 PM shift. Review of the nurse's notes and nurse aide flowsheet dated 8/1/24 - 8/31/24 failed to reflect documentation that Resident #102 had been provided a shower on his/her scheduled day Friday 8/2, 8/9, 8/16, 8/23 and 8/30/24 during the 7:00 AM - 3:00 PM shift. Review of the nurse's notes and nurse aide flowsheet dated 9/1/24 - 9/30/24 failed to reflect documentation that Resident #102 had been provided a shower on his/her scheduled day Friday 9/6, 9/13, 9/20, and 9/27/24 during the 7:00 AM - 3:00 PM shift. The quarterly MDS dated [DATE] identified Resident #102 had intact cognition and required total assistance with shower/bath. Review of the nurse's notes and nurse aide flowsheet dated 10/1/24 - 10/31/24 failed to reflect documentation that Resident #102 had been provided a shower on his/her scheduled day Friday 10/4, 10/11, 10/18, and 10/25/24 during the 7:00 AM - 3:00 PM shift. The care plan dated 10/30/24 identified Resident #102 has an activity of daily living self-care performance deficit related to paraplegia. Interventions include to provide bathing/showering: Check nail length, trim, and clean on bath day and as necessary. Report any changes to the nurse Interview with Resident #102 on 11/3/24 at 9:42 AM identified he/she has not had a shower since June 2024. Resident #102 indicated the nurse aides told him/her that the facility does not have a shower that fit him/her. Resident #102 indicated his/her shower day is on Friday on 7:00 AM - 3:00 PM shift. Resident #102 indicated he/she would like to take a shower. Resident #102 indicated the nurse aides has been providing him/her with a bed bath on Fridays on the 7:00 AM - 3:00 PM shift but that is not the same as taking a shower. The nurse aide care card dated 11/5/24 identified Resident #102's shower day is on Fridays on the 7:00 AM - 3:00 PM shift. Interview with NA #6 on 11/5/24 at 9:38 AM identified she was aware that Resident #102 not has not been receiving his/her showers on Friday on the 7:00 AM - 3:00 PM shift. NA #6 indicated the old bariatric shower chair was not safe for Resident #102 to take a shower. NA #6 indicated the previous DNS was aware of the bariatric shower chair was not safe. NA #6 indicated a new bariatric shower chair was purchased sometime in June 2024. NA #6 indicated the new bariatric shower chair was too wide and did not fit through the shower room door. NA #6 indicated once Resident #102 was placed in the new bariatric shower chair, the bariatric shower chair did not fit through the shower room door even when attempted to push the bariatric shower chair through the door sideway. NA #6 indicated the nurse aides did notifiy the previous DNS and physical therapy that the bariatric shower chair did not fit through the shower room door. NA #6 indicated the previous DNS was aware of the issue. NA #6 indicated on Fridays she would provide Resident #102 with a complete bed bath and also washed his/her hair. Interview with NA #7 on 11/5/24 at 11:10 AM identified she was aware of Resident #102 not receiving his/her showers. NA #7 indicated the last time she had given Resident #102 a shower was sometime in May 2024 or the beginning of June 2024. NA #7 indicated the old bariatric shower chair was no longer safe to give Resident #102 a shower. NA #7 indicated she notified the previous DNS and physical therapy. NA #7 indicated the old bariatric shower chair was removed off the unit. NA #7 indicated the facility purchased a new bariatric shower chair in June 2024. NA #7 indicated the bariatric shower chair was too wide and did not fit through the shower room door. NA #7 indicated once Resident #102 was placed into the bariatric shower chair, the bariatric shower chair did not fit through the shower room door even when the staff tried to push the bariatric shower chair side way. NA #7 indicated when she is assigned to Resident #102 on a Friday, she would provide Resident #102 with complete bed bath and shampooed the resident's hair. NA #7 indicated the previous DNS was aware that the new bariatric shower chair did not fit through the door. Interview with NA #8 on 11/5/24 at 11:20 AM identified she was aware of Resident #102 has not been receiving his/her showers. NA #8 indicated she did not used the old bariatric shower chair to give Resident #102 a shower because the bariatric shower chair was not safe. NA #8 indicated she always provided Resident #102 with a complete bed bath and washed his/her hair on Fridays. NA #8 indicated the previous DNS was aware that the new bariatric shower chair did not fit through the door. Interview with the Administrator on 11/5/24 at 11:30 AM identified she was not aware that Resident #102 had not been receiving showers since June 2024, over 4 months. The Administrator indicated the facility will look into purchasing a different bariatric shower chair that is safe and can fit through the shower room door. Interview with the ADNS on 11/5/24 at 11:45 AM identified she was not aware that Resident #102 had not been receiving showers. The ADNS indicated the previous DNS during the summer was addressing the issue with the bariatric shower chair. Subsequent to surveyor inquiry, a new bariatric shower chair was acquired, and Resident #102 was provided a shower. Review of the facility personal care policy identified the facility nursing personnel will offer AM and PM care to all residents. Showers and/or baths and shampoos are scheduled at least weekly and more often as needed. Report any changes to the nurse. Document according to facility guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #63 was admitted to the facility on [DATE] with diagnoses that included dementia, bipolar disorder, and depression. The care plan dated 9/3/24 identified Resident #63 was at risk for falls related to deconditioning, gait/balance problems, medication side effects, and left AKA (above the knee amputation). Interventions included to anticipate the needs of the resident. The care plan identified that Resident #63 was using psychotropic medications related to bipolar disorder. Interventions included monitoring and reporting any adverse reactions of psychotropic medications: unsteady gait, rigid muscles, and frequent falls. The care plan further identified that Resident #63 was using antidepressant medications related to depression. Interventions included monitoring and reporting any adverse reactions to antidepressant therapy: decline in ADL ability, balance problems, falls, dizziness, and vertigo. The admission MDS dated [DATE] identified Resident #63 had intact cognition and was independent with sitting to standing, chair/bed-to-chair transfers, and toilet transfers. A physician's order dated 9/5/24 directed to complete orthostatic blood pressure monitoring weekly, times 4 weeks. The September 2024 MAR, Weights and Vital Signs Summary and nurse's notes failed to identify orthostatic blood pressure monitoring was completed during the weeks of 9/5/24, 9/12/24, 9/19/24, or 9/26/24. Interview with the DNS on 11/06/24 at 10:15 AM identified that he would expect orthostatic blood pressures to be completed, per the physician's order, by the floor nurse and documented in the resident's clinical record. The facility's Vital Signs-Blood Pressure-Orthostatic policy directs that orthostatic blood pressures are taken by licensed staff when ordered by a physician and/or when orthostatic changes are suspected. 6. Resident #103 was admitted to the facility on [DATE] with diagnoses that included endocarditis and heart valve disorders, hypertension, post-traumatic stress disorder (PTSD), and anxiety. A physician's order dated 9/27/24 directed to complete orthostatic blood pressure monitoring weekly times 4 weeks. The admission MDS dated [DATE] identified Resident #103 had intact cognition and required partial/moderate assistance with chair/bed-to-chair transfers, toilet transfers, and walking 10 feet. The care plan dated 10/17/24 identified Resident #103 had altered cardiovascular status related to endocarditis, was on intravenous (IV) antibiotics, and was followed by Cardiology and Infectious Disease. Interventions included monitoring vital signs, as ordered, and notifying the physician of significant abnormalities. The care plan further identified that Resident #103 had depression related to the admission. Interventions included administering medications as ordered and to monitor and document for side effects and effectiveness. The September and October 2024 MAR, Weights and Vital Signs Summary and nurse's notes failed to identify orthostatic blood pressure monitoring was completed during the weeks of 9/27/24, 10/4/24, 10/11/24, or 10/18/24. Interview with the DNS on 11/06/24 at 10:15 AM identified that he would expect orthostatic blood pressures to be completed, per the physician's order, by the floor nurse and documented in the resident's clinical record. The facility's Vital Signs-Blood Pressure-Orthostatic policy directs that orthostatic blood pressures are taken by licensed staff when ordered by a physician and/or when orthostatic changes are suspected. 7. Resident #7 was admitted to the facility on [DATE] with diagnoses that included hepatic encephalopathy, type 2 diabetes mellitus, and abnormalities of gait and mobility. The quarterly MDS dated [DATE] identified Resident #7 had intact cognition and was independent walking 150 feet. The care plan dated 7/6/24 identified Resident #7 did not want to have any falls with serious injuries. Interventions included observing for signs and symptoms of decreased balance, leaning, dizziness, or fatigue, encourage Resident #7 to take Lactulose, per the physician's order, and monitor labs (ammonia levels) per the physician's order. The nurse's note dated 8/10/24 at 6:49 AM identified that Resident #7 was noted to be sitting on the floor near the outside bathroom wall. Resident #7 indicated that he/she was trying to get the TV remote and slid out of the wheelchair, denied hitting his/her head, was alert and oriented to person, place, and time, denies injury, and denies pain or discomfort from the fall. Resident #7 was found sitting upright and was assisted back to the wheelchair, range of motion to all extremities, neurological checks within normal limits (wnl), vital signs stable, on-call APRN notified, will continue to monitor neurological status and vital signs per facility protocol. Review of Resident #7's clinical record dated 8/10/24 through 8/12/24 failed to identify documentation that neurological monitoring was completed. The reportable event form documentation following Resident #7's 8/10/24 fall failed to identify documentation that neurological monitoring was completed. Subsequent to surveyor inquiry, Resident #7's Neurological Check Sheet dated 8/10/24 was provided. The Neurological Check Sheet identified missing neurological assessments on 8/12/24 at 4:05 AM and 8/12/24 at 12:05 PM. The Neurological Check Sheet further identified a discrepancy in the timeline between the facility's policy and the documentation form. The Neurological Check Sheet outlined documentation for 62 hours only, not 72 hours, per the facility policy. The nurse's note dated 10/24/24 at 11:45 PM identified that Resident #7 appears to have slid out of his/her bed and was unable to state what happened, see status post fall evaluation, left message for conservator of person and APRN was notified, will continue neurologic checks and vital signs, per the facility protocol, denies pain or discomfort. Review of Resident #7's clinical record dated 10/24/24 through 10/27/24 failed to identify documentation that neurological monitoring was completed. The reportable event form documentation following Resident #7's 10/24/24 fall failed to identify neurological monitoring was completed. Subsequent to surveyor inquiry, Resident #7's Neurological Check Sheet dated 10/24/24 through 8/27 (August 27) was provided. The Neurological Check Sheet identified missing neurological assessments for an undated 1:30 AM assessment, undated 5:30 AM assessment, undated 9:30 PM assessment, and an 8/27 (August 27) untimed assessment. The Neurological Check Sheet further identified a discrepancy in the timeline between the facility's policy and the documentation form. The Neurological Check Sheet outlined required neurological assessment documentation for 62 hours only, not 72 hours, per the facility policy. Interview with LPN #12 on 11/6/24 at 6:59 AM identified that neurological assessments are expected to be completed on residents for 72 hours following an unwitnessed fall, by the charge nurse or the nursing supervisor. Interview with RN #12 on 11/6/24 at 7:02 AM identified that neurological assessments were to be completed in accordance with the facility policy and body assessments were to be completed every shift, for 3 consecutive days or longer if there is a clinical reason to continue monitoring. RN #12 further identified that following a fall the RN Supervisor always completes the first assessment, and the charge nurse will continue to monitor the resident with the oversight from the RN Supervisor. Interview with the DNS on 11/06/24 at 10:07 AM identified that he would expect the neurological monitoring to be completed by the nurse per the facility policy and the documentation sheet should reflect the facility's policy, which is 72 hours of neurological monitoring, following an unwitnessed fall. The Fall Management Program policy directs that in the event of an unwitnessed fall or when a head injury is suspected, to monitor neurological signs per physician orders (refer to Neurological Assessment policy). The facility's Neurological Checks policy directs that residents with a suspected head injury will have neurological signs monitored and recorded for 72, unless otherwise ordered by the physician. Neurological checks are performed as follows, unless otherwise ordered by a physician: Every 15 minutes for 1 hour (4 times). Every 30 minutes for 1 hour (2 times). Every 1 hour for 4 hours (4 times). Every 2 hours for 10 hours (5 times). Every 4 hours for 16 hours (4 times). Every 8 hours for 40 hours (5 times). 8. Resident #59 was admitted to the facility on [DATE] with diagnoses that included dementia, PTSD, and a traumatic brain injury. The quarterly MDS dated [DATE] identified Resident #59 had moderately impaired cognition, had no presence of the following behavioral symptoms: physical behavioral symptoms directed toward others, verbal behavioral symptoms, or other behavioral symptoms not directed toward others, and was independent with walking 150 feet or similar space. The care plan dated 8/24/23 identified Resident #59 would identify to the facility social work staff that he/she felt safe from risk of physical harm or mental anguish while receiving care in the facility. Interventions included offering 1:1 social worker visits to discuss conflict resolution techniques and having staff accompany Resident #59 when going to the second floor. The nurse's note dated 9/12/23 at 12:57 PM identified the nurse was called to the resident dining room by staff. On arrival Resident #59 was observed lying on his/her back with another resident (Resident #73) standing over him/her using profound language. The nurse separated both residents immediately and placed Resident #59 on a 1:1 for safety. Resident #59 identified that he/she was hit in the face by another resident during an argument that transpired between the two residents which contributed to Resident #59 falling. Resident #59 had a small abrasion to the back of his/her head; Resident #59 was alert and oriented, at baseline, no complaints of dizziness or headache, bilateral upper and lower extremities symmetrical, positive range of motion. Local police were called to facility, APRN notified, no new orders, continue facility protocol. Resident #59 was seen by the Psychiatric provider, who ordered the discontinuation of the 1:1 supervision, based on his assessment. The APRN note dated 9/15/23 at 1:24 PM identified that Resident #59 was seen status post an altercation earlier in the week; Resident #59's history of present illness identified that he/she walked past another resident, said excuse me, and the other resident pulled his/her shirt, punched him/her in the face, and he/she fell backwards hitting his/her head on the floor. Per staff there were witnesses who added the two parties were yelling at each other prior to the physical altercation and confirmed Resident #59 was punched and fell. On exam, Resident #59 denied headaches, light sensitivity, dizziness, nausea/vomiting, or changes in vision; he/she denied facial pain or tenderness. The APRN note further identified the plan of care for Resident #59 was to continue to monitor vital signs and neurological assessments per the fall protocol, monitor for signs and symptoms of concussion, pain, etc; resident is capable of reporting changes to nursing staff. Review of Resident #59's clinical record failed to identify documentation that neurological assessments were completed, per the facility's fall protocol after the incident on 9/12/23 at 12:57 PM. The state agency Request for Documents Sheet dated 11/5/24 at 2:28 PM identified a request for Resident #59's neurological monitoring documentation, q 15-minute checks documentation, and 1:1 monitoring documentation which were identified by the facility as not found. Interview with the DNS on 11/6/24 at 10:00 AM identified that he had been serving as the interim DNS for 2 days, and he would not be able to speak to the specifics of the incident. The DNS further identified that he would have expected that the neurological checks would have been completed, following Resident #59's fall, and he believed that the neurological checks were completed but the issue may be around the filing of the documents. The DNS indicated that documents should still be accessible one year following the incident. The Neurological Checks policy directs that residents with a suspected head injury will have neurological signs monitored and recorded for 72 hours per policy unless otherwise ordered by a physician. 4. Resident #116 was admitted to the facility in August 2024 with diagnoses that included syncopal fall related to alcohol abuse, subdural hematoma, and cervical spine fracture. The nursing admission assessment completed on 8/16/24 identified Resident #116 was alert and oriented, had a history of 2 or more falls in the last 3 months, was a high risk for falls, and required the assistance of 1 staff member with toileting and dressing, and 2 staff members for transfers. Review of the clinical record failed to identify a care plan related to Resident #116's recent history or risks of falls. A reportable event form dated 8/24/24 at 3:15 AM identified Resident #116 had an unwitnessed fall. The report identified Resident #116 reported attempting to retrieve a blanket, loosing balance and falling. The report also identified Resident #116 reported bumping his/her head during the fall. The report identified that the physician was notified and that neurological checks would be initiated per facility policy and would have monitoring every shift for 72 hours. Review of the clinical record failed to identify any neurological checks or shift monitoring documentation completed after 5:00 AM on 8/26/24, approximately 50 hours after Resident #116's fall. Interview with MD #1 (Medical Director) on 11/5/24 at 3:12 PM identified that the nursing staff should have completed 72 hours of neurological monitoring and shift assessments on Resident #116 following the unwitnessed fall with a reported head strike on 8/24/24. MD #1 identified with Resident #116 history of falls and recent diagnosis of a subdural hematoma, he would have expected that the nursing staff would have adhered to the facility policy and completed the full 72 hours of monitoring to ensure Resident #116 did not have any new injury or worsening of his/her previous head injury. The facility policy on the fall management program directed that if a resident had an unwitnessed fall or if a head injury was suspected, neurological signs would be monitored, and that the resident would be monitored for 72 hours after the fall and any concerns identified would be documented. The facility policy on neurological checks directed that residents with a suspected head injury would have neurological signs monitored and recorded for 72 hours per policy unless otherwise ordered by a physician and would be performed as follows: Every 15 minutes for one hour (4x). Every 30 minutes for one hour (2x). Every hour for 4 hours (4x). Every 2 hours for 10 hours (5x). Every 4 hours for 16 hours (4x). Every 8 hours for 40 hours (5x). The policy further directed that the neurological check documentation should include blood pressure, pulse, respirations, hand grasp, level of consciousness, pupil reactivity to light, and any additional comments or findings. Based on review of the clinical record, facility documentation, facility policy, and interviews for 7 residents (Residents #76, 81, 116, 63, 103, 7 and 59) the facility failed to provide care in accordance with professional standards of practice, and physician's orders. For 1 of 5 residents (Resident #76) reviewed for unnecessary medications, the facility failed to document an RN assessment when the resident exhibited a change in condition and failed to obtain weights according to facility policy and physician order. For (Resident #81) reviewed for nutrition, the facility failed to monitor the resident's fluid intake and output and weights per the physician's orders. For 1 resident (Resident #116) reviewed as a closed record for discharge, the facility failed to ensure that neurological checks and post fall assessments were completed when the resident sustained an unwitnessed fall with a reported head strike. For 1 of 5 residents (Resident #63) reviewed for unnecessary medications and for 1 resident (Resident #103) reviewed for pain management, the facility failed to ensure orthostatic blood pressure monitoring was completed per the physician's order. For 1 resident (Resident #7) reviewed for falls, the facility failed to ensure neurological assessments were completed following 2 unwitnessed falls, per the facility policy. For 1 of 4 residents (Resident #59) reviewed for resident-to-resident abuse, the facility failed to ensure neurological assessments were completed and documented, per facility policy. The findings include: 1. Resident #76 was admitted to the facility in July 2024 with diagnoses that included congestive heart failure, seizures, diabetes, and hypertension. The admission MDS dated [DATE] identified Resident #76 had intact cognition, and needed touching assistance by staff for ambulation in room and corridor. The care plan dated 8/8/24 identified Resident #76 was at risk for falls. Interventions included to record and report any concerns or changes in condition to the attending physician. A physician's order dated 10/22/24 directed to transfer with assist of 2 staff person. A nurse's note written by LPN #1 on 11/4/24 at 10:10 PM indicated that Resident #76 was observed with increased tremors and weakness to the extremities which was reported to the supervisor and a notation was placed in the APRN communication book for evaluation. Review of the clinical record dated 11/4/24 to 11/6/24 failed to reflect that an RN assessment had been done when Resident #76 was observed with increased tremors and weakness to the extremities on 11/4/24 at 10:10 PM. Interview with Resident #76 on 11/5/24 at 9:00 AM indicated last night he/she was walking to the bathroom with a staff member when he/she became so shaky and weak and was having tremors that he/she could not get off the toilet. Resident #76 indicated that it took 2 staff to assist walking him/her back to bed. Interview with the ADNS on 11/6/24 at 8:54 AM indicated that if there was a change in condition the LPN must notify the RN supervisor. The ADNS indicated that the RN must do an assessment of the resident and document the assessment under progress notes. The ADNS indicated that she had worked on 11/4, 11/5, and today for the 7:00 AM to 3:00 PM shift and was not aware that Resident #76 was observed with increased tremors and weakness to the extremities on 11/4/24 and it was not given during supervisor daily report from shift to shift. After review of the clinical record, the ADNS indicated that there was no RN assessment documented including a set of vital signs, a blood sugar or a neurological assessment. Interview with RN #6 with ADNS present on 11/6/24 at 9:04 AM indicated that she had worked on 11/4/24 from 3:00 PM to 11:00 PM as the RN supervisor. RN #6 indicated that she was called by LPN #1 to see Resident #76. RN #6 indicated that she had seen Resident #76 and had him/her squeeze her hands and she had asked what had happened. RN #6 indicated that LPN #1 had reported to her that while ambulating Resident #76 to the bathroom the resident became shaky, had fine tremors, and was weak. RN #6 indicted that she gave the directive for LPN #1 to place that information in the APRN communication book and she had passed the information to the 11:00 PM to 7:00 AM supervisor. RN #6 indicated that she did not write a progress note because she was busy with admissions. RN #6 indicated that on 11/5/24 about 10:00 PM she looked in the APRN communication book and had seen that APRN #1 indicated that Resident #76 was not her resident and was not going to see Resident #76 on 11/5/24. RN #6 indicated that she then wrote on a sticky note for APRN #2 so see Resident #76 but did not know or could verify if APRN #2 was coming into the facility on [DATE]. RN #6 indicated that when there is a change of condition, the expectation was for her to do the RN assessment and document the assessment. Interview with the ADNS on 11/6/24 at 9:14 AM indicated RN #6 should have done and documented an RN assessment of Resident #76's condition. Interview with APRN #1 on 11/6/24 at 11:00 AM indicated that when there is a change of condition with a resident her expectation was there would be an RN assessment and documentation of the assessment and then a report the to the APRN on duty. Interview with the DNS on 11/6/24 at 10:27 AM indicated that when a resident has a change of condition the LPN must notify the RN supervisor. The DNS Indicated that the RN supervisor must perform an assessment and document the assessment in the progress notes. Although attempted, an interview with MD #1 was not obtained. Review of the Change of Condition Policy identified it is the policy to notify the physician when the resident's condition or status changes unexpectedly. This will ensure that the physician will be kept informed of changes in an appropriate and timely manner. A change of condition is a significant symptom(s) or development, which requires assessment and intervention. If a resident is evaluated by a charge nurse to have a change in condition, the charge nurse will notify the RN Supervisor on duty. The RN Supervisor will do a follow up assessment and to ensure that the assessment is documented and reported to the physician. All assessment findings and relevant information should be compiled prior to calling the physician to ensure accurate information. The physician will be contacted to report findings. The nurse will obtain new orders as warranted from the physician. The resident will be notified. The nurse will document in the nurse's notes regarding assessments, findings, changes, physician notification, and resident and/or representative notification. 2. Resident #76 was admitted to the facility in July 2024 with diagnoses that included congestive heart failure (CHF), peripheral vascular disease, and hypertension. The hospital Discharge summary dated [DATE] identified Resident #76 was hospitalized for fluid overload on examination and was started on Lasix 80 mg intravenously. Discharge medication changes identified Resident #76 was to start taking Torsemide 40 mg daily and continue Spironolactone 25 mg daily with breakfast. Discharge weight was 190 lbs. Additionally, the discharge summary identified and directed that daily weight monitoring was crucial for heart failure patients. Record daily weights and call physician if weight gain of 2 - 3 lbs. in a day or a gain of 5 lbs. in a week. The care plan dated 7/10/24 identified Resident #76 had a nutritional problem related to chronic heart failure and history of edema and fluid retention. Interventions included to weigh resident at the same time of day and record. Additionally, weigh resident as ordered by the physician. The physician's admission orders dated 7/10/24 directed to weigh Resident #76 daily per CHF guidelines. If weight is 2 lbs. over in 24 hours or over by 5 lbs. in a week notify the physician. Additionally, give Spironolactone 25mg (diuretic) daily for fluid retention (edema) and Torsemide 40 mg (diuretic) daily. Review of the Weight Summary dated 7/10/24 to 11/6/24 identified the following. 7/10/24, weight 191.2 lbs. 8/8/24, weight 177.5 lbs. 8/12/24, weight 177.5 lbs. 8/19/24, weight 185.0 lbs. 9/2/24, weight 193.4 lbs. 9/4/24, weight 187.4 lbs. 9/6/24, weight 193.4 lbs. 9/9/24, weight 187.4 lbs. 10/18/24, weight 152.0 lbs. Although the July 2024 TAR identified to obtain a daily weight: if over 2 lbs. in 24 hours or over 5 lbs. in a week notify the physician, there were no signatures to indicate the weights had been obtained. The admission MDS dated [DATE] identified Resident #76 had intact cognition. The physician's readmission orders dated 8/8/24 directed to weigh Resident #76 daily per CHF guidelines. If weight is 2 lbs. over in 24 hours or over by 5 lbs. in a week notify the physician. Additionally, give Torsemide 40 mg (diuretic) daily. The physician's orders dated October and November 2024 directed to weigh Resident #76 daily per CHF guidelines. If weight is 2 lbs. over in 24 hours or over by 5 lbs. in a week notify the physician. Additionally, give Torsemide 40 mg daily and Spironolactone 12.5 mg daily. Review of the August, September, October, and November 2024 TAR's failed to reflect the readmission orders of 8/8/24 to weigh Resident #76 daily. A physician order dated 8/28/24 directed to decrease Spironolactone to 12.5 mg daily. Interview with NA #3 on 11/4/24 at 2:22 PM indicated that she works full time on the unit and sometimes has Resident #76. NA #3 indicated that she is not aware that Resident #76 required daily weights. Interview with Resident #76 on 11/5/24 at 9:27 AM indicated that the staff do not ask to weigh him/her daily. Resident #76 indicated that he/she has not refused to be weighted while at the facility and would have no problem to get weighted as needed. Interview with the DNS on 11/5/24 at 2:02 PM indicated that it was his expectation that the nursing staff would follow the physician's orders for daily and weekly weights and document the weights in the electronic medical record. The DNS indicated that the facility does not have a CHF program, protocol, or policy. Interview with the Dietitian on 11/5/24 at 3:12 PM indicated that Resident #76's weight on 10/18/24 appeared as a significant weight loss so she had requested a reweight to be done. The Dietitian indicated that she still has not received a reweight or the November weight for Resident #76. The Dietitian indicated that the reweight should be obtained within a couple of days and the November monthly weights by the 10th of each month. The Dietitian indicated that she has requested a reweight to the charge nurse and the ADNS on 10/18/24 and has not received the reweight yet. Interview with the ADNS on 11/6/24 at 8:15 AM indicated that she was responsible to oversee that all weekly weights and monthly weights were completed. The ADNS indicated that weekly weights were to be done on Mondays no later than Tuesdays because the dietitian comes in on Tuesdays and a reweight needs to be done by Wednesday. The ADNS indicated that the monthly weights were to be done by the 5th of the month. The ADNS indicated that a reweight was to be done by the next day. The ADNS indicated that the nurse aides were responsible to get the weights, and the charge nurse was responsible to document the weight in residents electronic clinical record or on the paper TAR. The ADNS indicated that Resident #76 had an admission weight of 191.2 lbs. on 7/10/24. After clinical record review, the ADNS indicated that there was a physician order since admission on [DATE] and readmission 8/8/24 for Resident #76 to have daily weights with parameters. The ADNS indicated that she did not see any documentation that the daily weights were being done. The ADNS indicated that she did not see any documentation that Resident #76 had refused to be weighted since admission. Interview with the DNS on 11/6/24 at 10:27 AM indicated that weights were to be obtained on day of admission and then follow the physician orders which include weekly times 4 weeks then monthly, unless the physician directs otherwise. The DNS indicated that if the physician orders daily weights he would expect that the nursing staff to weigh the resident daily at the same time every day and if the weight was outside of the parameters that the supervisor would notify the provider. Review of the Weight Policy identified weights will be obtained for all residents on admission. The frequency of weights will be determined by the interdisciplinary team post admission based on resident's individual needs. 3. Resident #81 was admitted to the facility in May 2024 with diagnoses that included congestive heart failure (CHF) and stroke. a. A physician order dated 5/29/24 directed to administer Torsemide 40 mg (diuretic) daily. Additionally, per CHF guidelines Resident #81 requires a fluid restriction of 1500 ml to 2000 ml per day. A physician's order dated 6/5/24 directed qn 1800 ml per day fluid restriction. The quarterly MDS dated [DATE] identified Resident #81 had intact cognition. The care plan dated 7/28/24 identified Resident #81 had a stroke. Interventions included to monitor for swelling and edema in the extremities, participate in cardiac rehab program, and encourage adequate fluid intake. Weigh resident as ordered by the physician. Review of the August, September, and October 2024 MAR's and TAR's failed to reflect documentation of fluid intake or fluid output. Review of the August, September, and October 2024 intake and output records identified many shifts and days were not completed and lacked any 24-hour total intake/output. A physician order dated 10/22/24 directed to discontinue the fluid restriction. Interview with the ADNS on 11/4/24 at 7:20 AM indicated the intake and output records were to be completed every shift by the nurse aides and the charge nurses. The ADNS indicated that the 11:00 PM to 7:00 AM charge nurse or supervisor was responsible to add up the 3 shifts for a total to see if a resident went over the fluid restriction. The ADNS indicated that the supervisors should be checking to make sure the charge nurses are completing the 24-hour totals. The ADNS indicated that if the resident had gone over his/her fluid restriction the APRN or physician must be notified. After clinical record review, the ADNS indicated that during August, September, and October 2024 until 10/22/24 no 24-hour totals had been completed. Interview with the DNS on 11/6/24 at 10:16 AM indicated that Resident #81 was on an 1800 ml per day fluid restriction. The DNS indicated that his expectation was the nurse aides and nurses would document every shift what the resident drinks as the intake amount and the supervisor was responsible to do the 24 hour totals every day. The DNS indicated that if Resident #81 had gone over the 1800 ml fluid restriction the supervisor would notify the APRN or physician and document the notification. Interview with APRN #1 on 11/6/24 at 10:30 AM indicated the nurses were expected to follow the physician's orders for a fluid restriction. APRN #1 indicated that the nursing staff must document every shift what a resident drinks during their shift. APRN #1 indicated that if a resident goes over the fluid restriction nursing must notify the APRN or the physician and document it. b. A physician order dated 5/29/24 directed to administer Torsemide 40 mg (diuretic) daily. Additionally, Resident #81 was on daily weights per CHF guidelines: if weight gain over 2 lbs. in 24 hours or 5 lbs. in a week notify the physician. Review of the weight summary dated 5/29/24 to 6/14/24, 16 days, identified that weights were obtained on 5/29/24 (223.0 lbs.) and 6/3/24 (223.0 lbs.). A physician order dated 6/15/24 directed to discontinue daily weights and start weekly weights. Review of the weight summary dated 6/15/24 to 7/4/24 identified the following. 6/17/24 Resident #81 weighed 215.4 lbs. 6/24/24 Resident #81 weighed 213.8 lbs. 7/15/24 Resident #81 weighed 215.6 lbs. 8/1/24 Resident #81 weighed 214.0 lbs.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility documentation, facility policy, and interview for 3 of 7 residents (Residents #20, 13 and 111) reviewed for accidents, the facility failed to implement interventions and/or assistive devices to ensure the residents safety and a safe environment. For 1 of 2 residents (Resident #20) the facility failed to ensure the resident consistently utilized the smoking apron while smoking, for 1 resident (Resident #13) the facility failed to ensure a fan being used in the resident room had its cover in place, and for 1 of 7 residents (Resident #111) the facility failed to ensure the resident was reassessed and interventions implemented after multiple smoking policy violations to ensure the safety of the residents in the facility. The findings include: 1. Resident #20 was admitted to the facility in April 2022 with diagnoses that included generalized muscle weakness, traumatic brain injury and Schizophrenia. The annual MDS dated [DATE] identified Resident #20 had intact cognition but had verbal behavioral symptoms directed towards others such as threatening, screaming, and cursing at others. Additionally, Resident #20 had other behavioral symptoms not directed towards others such as physical hitting or scratching self, pacing, and throwing or smearing food or bodily waste. These behaviors significantly interfere with residents' participation in activities or social interactions and significant disrupt care or living environment. Resident #20 needs assistance with personal hygiene. Resident #20 uses tobacco. The care plan dated 5/22/24 and 7/23/24 identified Resident #20 was a smoker. Interventions included for the resident to wear a smoking apron while smoking and staff to observe clothing and skin for signs of cigarette burns. The Smoking Agreement dated 7/30/24, signed by Resident #20, identified the resident who smokes will be evaluated for smoking safely by a member of the interdisciplinary team at the time of admission or when a resident has a change in condition. If necessary, a smoking apron or other individualized intervention may be required as part of residents personalized plan of care for smoking. Smoking Evaluation dated 7/31/24, signed by Security Guard #3, identified Resident #20 was appropriate for supervised smoking without individualized interventions. Review of the physician's monthly orders dated October 2024 directed to have supervised smoking per facility policy. The care plan dated 11/1/24 identified Resident #20 was a smoker. Interventions included for the resident to wear a smoking apron while smoking and staff to observe clothing and skin for signs of cigarette burns. Observations outside during supervised smoking on 11/4/24 at 10:10 AM identified a second group of residents (7 residents) came outside with Security Guard #1 and NA #3. Resident #20 was given a cigarette by Security Guard #1 and the security guard lit the cigarette. Resident #20 was observed dropping ashes onto his/her black jacket. Security Guard #1 walked over to Resident #20 and brushed the ashes off Resident #20's jacket with his hand. At 10:12 AM Security Guard #1 went back over to Resident #20 and brushed off ashes from his/her jacket again and asked Resident #20 if he/she was done smoking. Security Guard #1 had Resident #20 place the cigarette but in a paint can. Resident #20 did not have the benefit of a smoking apron during this smoke break. Interview with Security Guard #1 on 11/4/24 at 10:20 AM indicated that Resident #20 wore a smoking apron a while ago but has not worn one in at least a month. Security Guard #1 indicated that when he started working at the facility, he was informed by the prior security guard that trained him that it was at his discretion if he felt a resident needed to wear a smoking apron or not. Security Guard #1 indicated there was not a list of residents that needed to wear a smoking apron for safety. Security Guard #1 indicated he did not need to inform anyone because it was at his discretion whether to put smoking aprons on residents. Security Guard #1 indicated he was not trained to do an evaluation of residents that smoke but to use his judgement. Observation outside during the supervised smoking on 11/5/24 at 10:12 AM identified Resident #20 seated in a wheelchair wearing a t-shirt and sweatpants was provided a cigarette from Security Guard #1, but the cigarette was not immediately lit. At 10:14 AM the Security Guard #1 lit the cigarette. After almost half the cigarette was smoked, NA #2 put the smoking apron on Resident #20. Resident #20 was dropping cigarette ashes onto the smoking apron. Interview with Security Guard #1 on 11/5/24 at 10:20 AM indicated that he put the smoking apron on Resident #20 today as a precaution and that no one had told him to put the apron on Resident #20 it was at his discretion to put the apron on residents. Security Guard #1 indicated that until Resident #20 can show him that he/she will not drop ashes on him/herself he will put the apron on Resident #20. Security Guard #1 indicated that in about 5 days he will consider taking off the apron on Resident #20 and see how Resident #20 does. Security Guard #1 indicated there was not a list on the smoking cart to identify which residents were to wear a smoking apron. Security Guard #1 indicated he did not tell anyone in management, the social worker, or the nursing supervisor that Resident #20 was dropping ashes on him/herself yesterday because he had made the decision to put the apron on Resident #20. Security Guard #1 indicated when he started about 2 months ago Resident #20 was wearing a smoking apron then but about a month ago, he decided to stop using the smoking apron on Resident #20 because he felt Resident #20 was safe to smoke without one. Security Guard #1 indicated he did not do a smoking assessment or ask nursing, as he made the decision, and it was at his discretion to stop using the smoking apron on Resident #20 a month ago. Security Guard #1 indicated after yesterday 10:00 AM smoke break when Resident #20 had multiple times dropped ashes on his/her jacket he decided for the afternoon smoke break to put the smoking apron on Resident #20 for the next 5 days and then will redetermine if it is necessary. Interview with Staff Development Nurse (LPN #2) on 11/5/24 at 12:10 PM indicated that she was responsible for staff education and competencies. LPN #2 indicated that all employees have general orientation at the corporate office and maintenance does fire safety at the facility. LPN #2 indicated that she has not done any education or competencies with the nurse aides or security guards regarding the resident smoking policy or their responsibilities during the resident smoking breaks in the last 2 and a half years she has been in this position. Interview with the Administrator on 11/5/24 at 12:11 PM indicated that she was responsible to oversee the security guards. The Administrator indicated that Security Guard #2 was the security guard at a sister facility and assists with the training for all new security guards. Interview with Security Guard #2 on 11/5/24 at 12:30 PM indicated he is responsible for doing smoke breaks and he had verbally told Security Guard #1 how to do the resident's smoking breaks 3 times a day. Security Guard #2 indicated that there should be a list of residents that need to wear a smoking apron on the cart. Security Guard #2 indicated that the security guards can determine or judge if the resident is a safe smoker or not a safe smoker. Security Guard #2 indicated that the security guards can judge if a resident was not safe and then should notify the nursing supervisor or a social worker. Security Guard #2 indicated that nursing or social worker would have to observe Resident #20 dropping ashes on him/herself and document it in the resident's clinical record. Security Guard #2 indicated that if a security guard felt a resident does not need a smoking apron anymore then the security guard must notify the management team and wait for further instructions. Security Guard #2 indicated that if Resident #20 was dropping ashes on him/herself then the security must notify the nursing supervisor or social worker, and they will take it from there. Security Guard #2 indicated that since the security guard is the one out there and if he felt someone was not safe, he could put a smoking apron on someone for that smoke break and then notify the management team, but he cannot remove the smoking aprons if they were required per nursing or social services. Security Guard #2 indicated that the security guards do not have access to the electronic medical record to view or update the care plans. Security Guard #2 indicated that the security guard cannot determine to put the smoking apron on and then in 5 days take it off if he feels resident is safe, that comes from nursing or social services. Security Guard #2 indicated that he verbally educated Security Guard #1 to do smoking at this facility but there wasn't any written education facility specific, nor did he do any competences of security guard #1. Interview with the Administrator on 11/5/24 at 1:00 PM indicated that she wrote Security Guard #1's 30-day evaluation but did not sign it based on a discussion with Security Guard #1 and not by observing him do the smoking break. The Administrator indicated that she did not observe a smoke break while Security Guard #1 was doing it, but when questioning Security Guard #1 he acknowledged he was not making sure all cigarette butts were picked up. The Administrator indicated that the security guards do the smoking evaluations to determine if residents need smoking aprons or not. The Administrator indicated the prior security guard, Security Guard #3, did the smoking evaluation dated 7/31/24 and nursing does the care plans. Interview with the MDS Coordinator (LPN #7) on 11/5/24 at 1:50 PM indicated the nurses must do the assessment/evaluation for a resident that smokes on admission and a change of condition and update the care plan. Interview with the DNS on 11/5/24 at 1:51 PM indicated the smoking assessment was to be done on admission, readmission, and a change in condition. The DNS indicated that a nurse must ask their resident the questions and observe the resident smoking safely to sign the smoking evaluation or assessment form. The DNS indicated that a security guard or nurse's aide can observe that a resident may need the smoking apron, but a nurse must do the assessment, that is why it is part of the nursing admission assessments. After review of the clinical record, the DNS indicated the care plan in both electronic medical records indicated that Resident #20 should have been wearing the smoking apron at every smoke break. Interview with the MD #1 on 11/5/24 at 12 :00 PM indicated his expectation was since smoking was part of the physician orders that a nurse must do the smoking assessment and would have to do an observation to complete the assessment. Review of the Facility Smokers List, undated, identified a security guard and a nurse's aide must be present at all times during resident's smoke break. Review of the Resident Smoking Policy identified smoking evaluations should be done upon admission, readmission, and a significant change in a resident's status. During the supervised observation it will be determined if the resident requires adaptive equipment and or individualized intervention. Smoking care plans with appropriate interventions will be developed, reviewed, quarterly as part of the care plan review process and updated to reflect the resident's current status. 2. Resident #13 was admitted to the facility in August 2023 with diagnoses that included end stage renal disease with hemodialysis, congestive heart failure, and major depression. The annual MDS dated [DATE] identified Resident #13 had intact cognition and was independent with personal hygiene, transfers, and ambulation. Resident #13 was not on oxygen, a bi-pap, or a c-pap. Physician's orders dated October and November 2024 directed Resident #13 required a transfer with assist of 1 and could ambulate independently with a rolling walker. Additionally, Resident #13 was to use oxygen at 2 liters per minute continuously. Observation on 11/3/24 at 10:30 AM in a semiprivate room identified that Resident #13 had a pedestal fan at the foot of the bed that did not have a front cover on the front which exposed the blades. The fan was running on high at the time and Resident #13 was laying in the bed. Resident #13's roommate was in bed with a walker at the bedside. Observation and interview with NA #4 on 11/3/24 at 10:40 AM indicated that she had picked up the breakfast trays in this room, but did not notice the fan. NA #4 indicated that the nurse aides just bring in the food and drinks and then pick up the trays because the 2 residents in the room do not need assistance. NA #4 indicated that she has not noticed the fan without the cover exposing the blades. Interview with Resident #67 and NA #4 translating on 11/3/24 at 10:41 AM indicated that the fan has not had a cover in months, that Resident #13 removed it. Interview with the DNS and RN #5 on 11/3/24 at 10:45 AM indicated that the fan should not be running without the cover over the blades for safety. The DNS indicated that he would remove it immediately and noted that the fan was last inspected on 7-10 and 2 initials, but DNS was not able to state what year the 7-10 was from and whose initials were on the fan. Interview with Housekeeper #1 on 11/3/24 at 10:55 AM indicated that he was the full-time housekeeper for Resident #13's room. Housekeeper #1 indicated that he does recall seeing the cover off the fan before and he would put it back on but does not recall if he had seen it on or off yesterday and today. Housekeeper #1 indicated that he had already cleaned that room this morning and did not notice if the fan had a cover. Housekeeper #1 indicated that there have been many times that he has found the front cover of the fan on the floor or under the bed and he just puts it back on. Housekeeper #1 indicated that he did not inform anyone because he fixed it. Interview with NA #3 on 11/3/24 at 11:00 AM indicated that she works full time on the unit with Resident #13 and his/her roommate and they take care of themselves, and she and the other nurse aides just pick up their dirty linens and bring in their food and drinks for meals. NA #3 indicated that she had not noticed there was not a cover on the fan, but it had probably not been there since those 2 residents had moved to this unit a couple of months ago. Interview with RN #5 on 11/3/24 at 11:43 AM indicated staff would have put a notation of the fan without the cover in the maintenance book at the nursing station. RN #5 indicated that Resident #13 was provided a new fan, and a house wide audit was done, and no other residents have fans without covers. Interview with the DNS on 11/6/24 at 10:23 AM his expectation was that all fans have a cover so a resident would not get hurt if touched it. The DNS indicated that when staff see the fan without a cover, they should first unplug the fan and then notify maintenance. The DNS indicated that maintenance should put something on the cover so the resident cannot remove it. The DNS indicated the audit was done immediately after Resident #13's was found and there were no other fans in the facility missing covers. The DNS indicated that Resident #13 received a replacement fan that had a secure front cover that easily could not be pulled off. Interview with Regional Maintenance Director on 11/6/24 at 10:52 AM indicated that the first thing is to unplug the fan, call maintenance, and removed the fan from the area for the safety of resident so the resident cannot touch it. Regional Maintenance Director indicated that if Resident #13 was repeatedly removing the cover he would have zip tied it closed. Regional Maintenance Director indicated that the facility is in transition from the maintenance log at the nurse's station which had no current sheets in it and the new process of a web-based work order system from any phone or computer message. Regional Maintenance Director indicated that there was nothing regarding Resident #13's fan in either system for the last 3 months. Interview with Regional Maintenance Director and the DNS on 11/6/24 at 11:00 AM indicated that here was not a policy related to resident safety or use of fans in resident rooms. 3. Resident #111 was admitted to the facility in July 2024 with diagnoses that included dementia, nicotine dependence, and aphonia. A physician's order dated 7/31/24 directed Resident #111 may have supervised smoking per facility policy. Review of the clinical record identified legal documentation that directed Person #1 as Resident #111's conservator of person. Review of the clinical record identified a CAN DO LIST dated 8/2024 for Resident #111. The list identified Resident #111 had moderately severe cognitive decline and did not anticipate safety hazards. The admission MDS dated [DATE] identified Resident #111 had severely impaired cognition, was always continent of bowel and bladder, required set up with showering, and was independent with toileting, dressing, and eating. The MDS also identified Resident #111 had current tobacco use. The care plan dated 8/9/24 identified Resident #111 enjoyed smoking. Interventions included to observe Resident #111 for any signs/symptoms of unsafe smoking and to complete smoking evaluations per facility policy. A smoking agreement dated 8/10/24 identified verbal consent was obtained from Person #1 (Resident #111's resident representative) on that date giving permission for Resident #111 to smoke. Security Guard #3 and a staff member (illegible signature) signed the agreement. A smoking evaluation completed on 8/10/24 by Security Guard #3 identified Resident #111 had an understanding of the facility smoking policy, safety issues, and the importance of the smoking rules and regulations. A nurse's note dated 8/21/24 at 3:38 PM identified Person #1 was notified that Resident #111 was caught smoking and vaping in his/her room. The note further identified that Resident #111 was informed of the smoking policy and that smoking in his/her room was a fire hazard. Review of the clinical record failed to identify any additional documentation related to the 8/21/24 smoking incident for Resident #111 including any additional smoking evaluations or assessments completed by nursing staff or revisions to Resident #111's care plan related to smoking inside the facility. Review of the facility A&I reports failed to identify any documentation or investigation related to Resident #111 smoking and vaping in the facility on 8/21/24. A nurse's note dated 9/4/24 at 11:36 AM identified that laundry staff alerted nursing of a strong odor of cigarette smoke when delivering clothing items to Resident #111's room. The note further identified that upon nursing staff entering the room and identifying the odor, Resident #111 initially denied but subsequently turned over a half a pack of cigarettes along with a lighter. Review of the clinical record failed to identify any additional documentation related to the 9/4/24 smoking incident for Resident #111 including any additional smoking evaluations or assessments completed by nursing staff or revisions to Resident #111's care plan related to smoking inside the facility. Review of the facility A&I reports failed to identify any documentation or investigation related to Resident #111 smoking inside the facility on 9/4/24 and failed to identify that Person #1 was contacted or notified regarding this incident. A 9/5/24 psychiatric note identified Resident #111 was seen after smoking in his/her room and that Resident #111 normally smoked cigarettes on his/her assigned smoke break. The note identified Resident #111 was very forgetful, pleasantly confused, and forgot that he/she could not smoke in his/her room. A 9/17/24 nurse's note identified a lighter was located in Resident #111's room behind his/her television and removed from the room. Review of the clinical record failed to identify any additional documentation related to the 9/17/24 lighter located behind the television in Resident #111 including any additional smoking evaluations or assessments completed by nursing staff or revisions to Resident #111's care plan. Review of the facility A&I reports failed to identify any documentation or investigation related to the lighter being found in the resident's room or that Person #1 was contacted or notified regarding this incident. Interview with Person #1 on 11/5/24 at 2:06 PM identified that he/she became Resident #111 conservator following issues with cognitive decline. Person #1 identified that Resident #111 had multiple incidents related to cognition, including forgetting about cooking items on a stove top that resulted in a house fire. Person #1 identified that the facility staff were making sure to check Resident #111 for smoking materials regularly following the 8/21/24 smoking incident and that Resident #111 regularly left the faciity on leave of absence with family members and friends. Person #1 identified that because of these checks, Resident #111 had not had any other smoking related incidents the facility. Person #1 identified the facility staff had only notified him/her of one incident related to smoking on 8/21/24, and also identified that Resident #111 resided on a dementia unit and the facility had notified him/her on admission that the dementia unit had extra staff due to the needs of the residents on the unit, however the unit was not secured, which was why Resident #111 was able to go on leave of absences from the facility. Interview with MD #1 on 11/5/24 at 3:10 PM identified that it was the responsibility of the floor nurse caring for a resident or the RN supervisor to complete the smoking evaluations for residents of the facility. Interview with the DNS on 11/6/24 at 9:45 AM identified that there were no A&I documents related to the smoking incidents for Resident #111, and that the incidents were investigated, and education was provided to the resident in the moment but the facility did not document this information. The DNS identified he would have expected the nursing staff to notify Person #1 regarding the incidents on 9/4/24 and 9/17/24, and that the smoking evaluation should have been completed by the admission nurse as part of the admission assessment. The DNS also identified that while the facility may have provided Resident #111 additional education related to smoking materials in his/her room, he would not expect Resident #111 to comprehend the information well due to Resident #111's severely impaired cognition. The facility smoking agreement directed that residents who smoke would be evaluated for smoking safety by a member of the interdisciplinary team at the time of admission or when a resident experienced a significant change of condition. The agreement also directed that if a resident was suspected of having any hazardous material in their room (i.e. lighter, matches) that the staff would provide education on safety. The facility policy on care plans directed members of the interdisciplinary team included representatives from nursing (charge nurse and nurse aide with responsibility for the resident), MDS coordinator, social services, behavioral health, dietary, rehabilitation, activities, the resident, resident representative, and any other staff in disciplines as requested by the resident. The facility policy on resident smoking directed that smoking evaluations would be done on admission, readmission, and after a significant change in resident status. The policy also directed that smoking care plans with appropriate interventions would be developed, reviewed quarterly as part of the care plan review process, and would be updated to reflect the resident's current status. The policy further directed that environmental safety included no smoking in the facility, no unsafe behavior related to smoking, and in the event of policy infringement, each individual resident's needs/capabilities would be considered to determine the most appropriate revision to the resident's plan of care/course of action. The facility policy on Reportable Events-Reporting accidents and incidents; investigations directed that a reportable event was an event that was clinically unusual or inconsistent with the policies and practices of the facility. The policy further directed that a reportable event form would be completed at the time of identification of the incident, an investigation would be initiated within 24 hours of the identification of the event, would be concluded within 72 hours, and investigation findings and conclusions would be documented and submitted to the facility Medical Director for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interview for the 1 resident (Resident #7) reviewed for falls, the facility failed to ensure the resident's medication orders were correctly transcribed and administered resulting in a significant medication error. The findings include: Resident #7 was admitted to the facility in March 2023 with diagnoses that included hepatic encephalopathy, hepatic failure, and type 2 diabetes mellitus. The care plan dated 7/6/24 identified Resident #7 was at risk for falls due to comorbidities. Interventions included observing for signs and symptoms of decreased balance, leaning, dizziness, or fatigue. The care plan further identified Resident #7 may chose not to accept certain things that were recommended for his/her wellbeing including, treatments, medications, appointments/consultations, therapy, and personal care. Interventions included education and encouragement on the benefits and risks of not accepting services based on personal choices including, taking prescribed medications, attending appointments, and being seen by in-house providers and if care or services were not accepted by Resident #7, reapproach at a later time. The quarterly MDS dated [DATE] identified Resident #7 had intact cognition, was independent with a motorized wheelchair, and had sustained 2 or more falls since the prior assessment. A nurse's note dated 9/16/24 at 3:12 PM identified Resident #7 continued with blisters to the right hand, and reported this may be a result of wearing jewelry on his/her hand, resident was encouraged to remove jewelry from both hands. Resident #7 had orders for skin prep which was applied and he/she was refusing medications especially the Lactulose. Resident #7 was educated and took his/her medications, resident was lethargic, pupils were dilated, and abdomen was distended. APRN was notified and orders to check ammonia level and apply Hydrocortisone cream 1%, three times daily, as needed for itching, were obtained. A physician's order dated 9/17/24 directed to obtain the following labs, ammonia, complete blood count (CBC), comprehensive metabolic panel (CMP), erythrocyte sedimentation rate (ESR), prothrombin time/international normalized ratio test (PT/INR), and rheumatoid factor. The Laboratory and Pathology Services report dated 9/17/24 identified Resident #7's ammonia result was high at 179 umol/L (normal range 0 - 31umol/L). A physician's telephone order dated 9/18/24 (transcribed by RN #2) directed to administer Lactulose 60ml by mouth 6 times daily for 3 days, then decrease to 60ml once daily (qd) and repeat ammonia level on 9/20/24. The Laboratory and Pathology Services report dated 9/20/24 identified Resident #7's ammonia result was 33 umol/L(normal range 0 - 31umol/L). The September 2024 MAR identified on 9/19, 9/20, and 9/21/24, Resident #7 was administered Lactulose 60ml by mouth, 6 times daily and on 9/22/24 through 9/30/24, Resident #7 was administered Lactulose 60ml by mouth, once daily. The October 2024 MAR identified on 10/1/24 through 10/15/24 Resident #7 was administered Lactulose 60ml by mouth, once daily. The nurse's note dated 10/15/24 at 4:36 AM identified Resident #7 was laying on the floor at 1:45 AM, increased lethargy, weakness and altered mental status noted, color pale, skin warm and pale. Resident #7 was responsive by opening and closing his/her eyes and responsive only to yes/no questions. Resident #7 was unable to remain in an upright seated position, no apparent head injury noted.v EMS/911 was called for transfer to the ER for evaluation. Resident #7 was transferred to the ER via stretcher and attendants. The hospital Discharge summary dated [DATE] identified Resident #7's reason for visit was acute encephalopathy and the resident was admitted with altered mental status and confusion. Resident #7 was initially admitted to the intensive care unit (ICU) due to abnormal blood pressures and high ammonia levels and was found to have a urinary tract infection (UTI). Resident #7 had a negative head and abdominal CT scan. Due to Resident #7's liver cirrhosis the Spironolactone was held and would be discontinued. Due to Resident #7's high ammonia levels, lactulose will be continued, and the UTI was treated with antibiotics. Due to improvement in symptoms, Resident #7 was downgraded to a medicine floor, and due to resolve of the altered mental status and no longer being confused, he/she was deemed safe and stable for discharge on [DATE]. The discharge summary further identified Resident #7's ammonia level on 10/15/24 was 74 umol/L and home medications and new prescriptions included Lactulose 90ml by mouth, four times daily. The October/November 2024 MAR identified 10/17/24 through 11/4/24, 18 days, Resident #7 was administered Lactulose 60ml by mouth, once daily. Interview and clinical record review with APRN #1 on 11/04/24 at 9:52 AM identified that Resident #7 had chronic liver disease and cirrhosis, and he/she would often refuse Lactulose and had a history of high ammonia levels. APRN #1 identified that she was unaware that Resident #7 had been receiving Lactulose once daily, since 9/22/24, and that there must have been a transcription error from the hospital, as she did not recall initiating a once daily order for Lactulose. APRN #1 further identified that she would expect Resident #7 would be receiving Lactulose four times daily (QID) due to his/her chronic liver cirrhosis, and that she usually checks medication order changes, but she could not identify what happened in this situation. APRN #1 indicated that missed doses of Lactulose would decrease the amount of bowel movements the resident would pass and could lead to increased lethargy and confusion, however she did not think this was the case for Resident #7 because she had not observed any alterations in his/her mental status and had been more alert and active in recent days. APRN #1 indicated that refusing Lactulose had been an on-going issue for Resident #7, but recently he/she had been compliant, per her conversations with the nursing staff. Subsequent to surveyor inquiry, a physician's order dated 11/4/24 directed to administer Lactulose 60ml by mouth, four times daily. Interview with LPN #1on 11/4/24 at 12:23 PM identified that elevated ammonia levels were not uncommon for Resident #7 due to his/her end stage liver disease. LPN #1 indicated that Resident #7's Lactulose order was frequently changing and that most times Resident #7's order would be three times daily or four times daily. LPN #1 identified that she confirmed that she was correctly reading the order, to administer Lactulose 60ml by mouth daily, with the evening RN Supervisor (RN #6), before transcribing it, because she had never seen Resident #7's Lactulose ordered for once daily, in the past. LPN #1 indicated that RN #6 was not the nurse that took the telephone order directing to administer Lactulose 60ml by mouth 6 times daily for 3 days, then decrease to 60ml daily (qd) and repeat ammonia level on 9/20/24, it was the day RN Supervisor (RN # 2) who took the telephone order (and RN #2 was no longer employed at the facility). Although attempted, an interview with RN #2 was not obtained. Although attempted, an interview with RN #6 was not obtained. Interview with the Medical Director (MD #1) on 11/05/24 at 3:03 PM identified Resident #7's baseline ammonia level runs high, and he/she has not always been compliant with the treatment. MD #1 identified that he did not know why Resident #7's Lactulose dose was decreased, but with Resident #7's end-stage cirrhosis Lactulose would need to be administered a minimum of three times daily to combat chronic encephalopathy; and a once daily dose could lead to an increased ammonia level, which could lead to the altered mental status. Interview with the DNS on 11/06/24 at 10:10 AM identified that he was not the DNS at the time of this incident, and he would have to have another conversation with APRN #1, to better identify what happened with Lactulose dosing; it was unclear at this point and the facility had not yet identified where the communication gap occurred. The DNS further identified that this situation was not something that he had seen happen, in any other instances at the facility. The DNS indicated that he would have to have another conversation with APRN #1 before he could identify if a subtherapeutic dose of Lactulose could have resulted in Resident #7's hospitalization. The facility's Telephone and Verbal Orders policy directs for paper systems: a. The nurse shall place the telephone or verbal order in the residence chart in such a manner to indicate the date and time of the order, and the nurse responsible for taking the order. b. All telephone and verbal orders shall be flagged in the Physician's order book. These orders shall be reviewed and signed by the attending physician, covering physician, licensed physician extender, or medical director. c. The nurse shall telephone the pharmacy indicating that a telephone order has been received. The facility's Physician Orders-Transcription policy directs orders will be transcribed by a licensed nurse and followed through in a manner consistent with quality standard of care practices. Telephone orders: 1. Only a licensed nurse may accept a telephone order from the Physician. 2. Record the order exactly as the physician dictates it onto the Physician Order Sheet. 3. Repeat the order back to the physician for verbal confirmation 4. Sign the order The facility's Medication Errors policy directs for the facility to establish a procedure for monitoring and keeping a record of any errors which may be observed in the medication system in this facility, whether they occur through the source of supply comma or in the ordering or administration of medications. The procedure: 1. The Director of Nursing and/or supervisory personnel will instruct licensed nursing personnel to enter any problems or errors they notice in the medication system at this facility. Licensed personnel will further be instructed to take appropriate action to have errors corrected and to enter that information in the medication incident/error report form. 2. Serious errors should be brought to the attention of the nursing supervisor and/or the attending Physician immediately. In the case of a medication error, the Physician and the Pharmacist must be notified immediately. 3. Any adverse effect to a resident resulting from a medication incident/error requires immediate notification of the attending physician and the pharmacist. 4. Medication errors will be reviewed at the quarterly pharmacy services committee meeting. The committee may direct that further follow up action be taken.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #49, 78, and 94) the facility failed to ensure that the resident or resident representative were provided education on the benefits and potential side effects of the influenza vaccine before receiving the vaccine. The findings include: During an infection control program review, conducted as part of an annual recertification survey, review of facility documentation was completed on 11/4/24 at 10:30 AM related to influenza education, consents, and vaccination administration for the 2024 flu vaccinations. Review of the facility vaccination documentation and clinical records identified Resident #78 and 94 received the influenza vaccination on 10/15/24. The documentation also identified Resident #49 received the influenza vaccination on 10/18/24. Review of the clinical record and facility documentation failed to identify that education related to the influenza vaccine including benefits, risks associated with, or potential side effects associated with the influenza vaccine were provided to or reviewed with Resident #78, Resident #49, Resident #94 or their resident representatives prior to administration of the influenza vaccination by LPN #2 (Infection Control Nurse) Interview with LPN #2 and RN #8 (Regional Director of Infection Control) on 11/5/24 at 9:20 AM identified that LPN #2 administered the influenza vaccinations for Residents #49, 79 and 94. LPN #2 identified she provided the residents of the facility with vaccine information statement (VIS) from the CDC related to the vaccine upon administration of the vaccinations but did not document any education provided to the residents, including providing the residents the VIS sheets, in the residents' clinical record. RN #8 identified that he thought providing the VIS to each resident was sufficient and was not aware that vaccination education that was provided to the residents should be documented in the clinical record. The facility policy on Resident Influenza Immunizations directed that the resident or the resident's legal representative would be educated about the risks and benefits of the influenza vaccine on an annual basis, would be provided with a copy of the current vaccine information statement (VIS), and that the education provided would be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, job descriptions, and interviews, for 2 of 4 units, the facility failed to ensure the environment was maintained in good repair and in a homelike manner and for 1 resident, (Resident #95) the facility failed to ensure a homelike environment. The findings include: Observation on 11/5/24 at 8:35 AM through 11:00 AM, and on 11/5/24 at 11:49 AM with the Regional Maintenance Director and the Administrator identified the following: a. Damaged, chipped, stains and/or marred bedroom walls on A wing in rooms 102, 103, 105, 106, 109, 110, 114, 115, 116, and 117. B wing in rooms [ROOM NUMBER]. b. Damaged, chipped, stains and/or marred bedroom radiators on A wing in rooms [ROOM NUMBER]. B wing in room [ROOM NUMBER]. c. Damaged, chipped and/or marred bathroom radiators on A wing in rooms [ROOM NUMBER], 107, and 108. B wing in room [ROOM NUMBER]. d. Damaged, bent, and/or missing window blind in bedroom on A wing in room [ROOM NUMBER]. e. Damaged, broken, and/or missing nightstand, closet, and dresser drawer knobs on A wing in rooms 101, 102, 110, 111, and 119. B wing in room [ROOM NUMBER]. f. Damaged, broken, and/or missing nightstand, dresser drawer and/or door on A wing in room [ROOM NUMBER]. B wing in room [ROOM NUMBER], and 137. g. Damaged, bent, and/or missing window blind in bedroom on A wing in room [ROOM NUMBER]. h. Damaged, cracked, and/or stained ceiling in the bathroom on A wing in rooms 102, 105, 112, 117, and 118. B wing in rooms 122, 123, 124, 125, 126, 128, 129, 131, 132, 133,134, 135, 136, 137, and 138. i. Damaged, broken, and/or peeling nightstand, closet, and dresser drawer on A wing in rooms 102, 105, 110, and 119. B wing in room [ROOM NUMBER]. j. Damaged and/or missing bathroom wall tile on wing in room [ROOM NUMBER]. k. Damaged, broken, and/or cracked floor tile in bedroom and/or bathroom on A wing in rooms 102, 105, 109, 112, 114, and 116. B wing in rooms 121, 122, 124, 127, 136, and 137. l. Damaged, loose, and/or off-wall bedroom sink on A wing in rooms 105, 108, 115, and 117. B wing in room [ROOM NUMBER]. m. Damaged, broken, missing, peeling and/or dirty cove base in the bedroom on A wing in rooms [ROOM NUMBER]. B wing in room [ROOM NUMBER]. n. Damaged, dirty, dusty, and/or black stains on window air conditioner on A wing in room [ROOM NUMBER]. Interview on 11/5/24 at 11:54 AM with the Regional Maintenance Director identified he was not aware of the issues. The Regional Maintenance Director indicated that maintenance of the facility is ongoing. The Regional Maintenance Director indicated that the facility is going through the process of changing the maintenance log onto a computer system log. The Regional Maintenance Director indicated that the staff are responsible for calling the maintenance department with any maintenance problems/issue that require repair and if there is an emergency or safety related concern, the staff members are responsible for calling maintenance department immediately. The Regional Maintenance Director indicated he will have a meeting with the Administrator, Interim DNS, Infection Preventionist, housekeeping department and the maintenance department. Interview on 11/5/24 at 11:56 AM with the Administrator identified she was not aware of the issues. The Administrator indicated it is the responsibility of the maintenance department to oversee the repairs of the facility. The Administrator indicated that she will in-service the maintenance department. Interview on 11/5/24 at 12:24 PM with the Interim DNS identified he was not aware of the issues. The Interim DNS indicated he will have an in-service with the maintenance department, and the Infection Preventionist. Review of the maintenance director job description identified the primary purpose of position is to direct and conduct physical plant maintenance and grounds upkeep at a designated facility and oversee these functions at other facilities/building. Such maintenance includes building improvements, grounds, utilities, and mechanical/electrical systems. Review of the maintenance assistance job description identified the purpose of this position is to maintain the facility grounds, and building in a safe and efficient manner. This position will also repair faulty and broken equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #97 and 59) reviewed for resident to resident altercations, for Resident #97, the facility failed to protect Resident #97 from physical abuse by Resident #217 and 71 who had a history of resident to resident altercations, and for Resident #59 the facility failed to protect Resident #59 from physical abuse by Resident #73. The findings include: 1. Resident #97 was admitted to the facility in August 2023 with diagnoses that included adjustment disorder with mixed disturbance of emotions and conduct, anxiety disorder, mood disorder and depressed mood. The physician's orders dated 11/2023 directed to administer Trazadone (antidepressant medication) 50mg tablet give half tablet (25mg) tablet twice a day for insomnia, agitation, and anxiety. The care plan dated 11/2/23 identified Resident #97 was involved in an altercation with Resident #7. Interventions included ensure Resident #97 adhere to the no contact boundary with Resident #7. The behavior/intervention monthly flow record dated 11/1/2023 - 11/30/23 directed to monitor behavior of agitation and anxiety every shift day, evening, and night. The behavior/intervention monthly flow record identified Resident #97 had one episode of behavior of agitation and anxiety on (11/5/23 during the 7:00 AM - 3:00 PM shift) for the month of November 2023. The quarterly MDS dated [DATE] identified Resident #97 had intact cognition and required total dependence with personal hygiene. Additionally, Resident #97 had exhibited physical and verbal behavioral symptoms directed toward others (e.g. hitting, kicking, pushing, screaming and cursing at others). The reportable event form dated 11/27/23 at 10:45 AM identified Resident #97 alleges that Resident #217 came into his/her room after they had a verbal argument and hit him/her in the face. Both residents were immediately separated, and Resident #217 was placed on 1:1 monitoring. The left side of Resident #97's face was swollen and red. Resident #97 was alert, oriented and able to make his/her needs known. The APRN was notified and assessed Resident #97. The psychiatrist was notified and assessed both residents. Resident #217 was seen by the psychiatrist and was transferred to the hospital for further psychiatric evaluation. The Administrator and the police were notified, and an investigation was initiated. The neurological check sheet dated 11/27/23 at 10:45 AM identified Resident #97 was on neurological monitoring. The APRN note dated 11/27/23 identified Resident #97 was evaluated for left jaw swelling and pain. Resident #97 was hit on the left jaw by Resident #217. Resident #97 complained of pain in the trauma area and ringing in the left ear. Resident #97 indicated Tylenol was not effective and was requesting stronger medication. The APRN ordered to monitor left mandible swelling, and report worsening symptoms to the physician. Cool compress with wash cloth. Apply to left mandible swelling for 10 minutes each time 4 times daily as needed for pain. Check vital signs every shift time 3 days. Tramadol (pain medication) 50mg tablet every 8 hours as needed for 3 days. The psychiatrist note dated 11/27/23 identified Resident #97 had a resident to resident altercation. Resident #97 was not currently a danger to self or others. Resident #97 was pleasant, engaging and in a fair mood. Resident #97 indicated Resident #217 came to his/her room after a verbal altercation and hit him/her on the left side of face causing swelling and pain. Resident #97 indicated he/she would not feel safe until Resident #217 was moved to another floor or transferred to another facility. Resident #97 endorsed feeling distress about the incident but denies suicidal/hallucination ideation. Recommend continuing current medications and monitor mood/sleep. No new orders. A written statement by the Security Specialist dated 11/27/23 at 1:15 PM identified Resident #217 thought Resident #97 was cutting the smoking line and addressed him/her. The Security Specialist indicated this resulted in a verbal altercation between Resident #97 and Resident #217. The Security Specialist indicated both residents were calling each other derogatory names. The Security Specialist indicated both residents were immediately separated and not allowed to smoke at the same time. The nurse's note dated 11/27/23 at 4:00 PM by the ADNS (RN supervisor for the 7:00 AM - 3:00 PM shift) identified she was notified to assess Resident #97 after an altercation with Resident #217. Resident #97 indicated he/she had an argument that started in the smoking line and Resident #97 alleged Resident #217 punched him/her on the left side of the face. An RN assessment was performed, and Resident #97 left side of face was swollen, red, and tender to touch. Neurological checks were initiated. Resident #97 also complained of left ear ringing. Resident #97 indicated he/she would like to press charges against Resident #217. The police department was called and came to the facility and interviewed Resident #97. The APRN, and psychiatrist APRN was notified. The care plan dated 11/27/23 identified Resident #97 had alleged that he/she was struck in the face by a peer. Interventions included to encourage Resident #97 to maintain a no contact boundary with Resident #217. The summary report dated 12/1/23 at 5:39 PM identified this was an unwitnessed incident that occurred on 11/27/23 which started as a verbal altercation during smoke break. The verbal altercation was immediately broken up by the Security Specialist. However, after returning to their unit Resident #217 alleges that Resident #97 continued to call him/her derogatory name. Resident #217 indicated this angered him/her, so he/she went into Resident #97's room and punched him/her in the face. Resident #217 agreed to a room and unit change. Resident #217 was seen by the facility psychiatrist and Resident #217 indicated feeling anxious about the altercation and was having auditory hallucination and hearing impairment. Resident #217 was transferred to the hospital for further psychiatrist evaluation due to safety concerns. Resident #217 returned from the hospital with a letter of no harm. The facility continued Resident #217 on 1:1 supervision. The medication dose was adjusted, and labs ordered. Resident #217 was followed by facility psychiatrist and denied hallucinations, suicidal ideation, and hearing impairment. Resident #217 has agreed to maintain a no contact boundary with Resident #97. Resident #217 smokes in a group separate from Resident #97. The 1:1 was discontinued. The psychiatrist and social workers continue to follow and support residents. Interview and review of the clinical record with the ADNS on 11/5/24 at 2:00 PM identified she was the supervisor on 11/27/23 on the 7:00 AM - 3:00 PM shift. The ADNS indicated she was called to the unit to assessed Resident #97. The ADNS indicated an RN assessment was completed, and Resident #97 observed with the left side of face swollen, red, and painful to touch and neurological checks were initiated. The ADNS indicated Resident #97 indicated Resident #217 hit him/her in the face. The ADNS indicated both residents were seen by the APRN, and the psychiatrist APRN. The ADNS indicated Resident #217 was placed on 1:1 until transferred to the hospital. Both resident care plans were revised. Resident #217 was moved to another unit and room upon return from the hospital. 2. Resident #97 was admitted to the facility in August 2023 with diagnoses that included adjustment disorder with mixed disturbance of emotions and conduct, anxiety disorder, mood disorder and depressed mood. The care plan dated 2/20/24 identified Resident #97 was observed hitting another resident in the stomach. Intervention included Resident #97 had agreed to no contact boundary with other resident. The physician's orders dated 5/2024 directed to administer Trazadone (antidepressant medication) 50mg tablet give half tablet (25mg) tablet twice a day for insomnia, agitation, and anxiety. The quarterly MDS dated [DATE] identified Resident #97 had intact cognition and required total dependence with personal hygiene. Additionally, Resident #97 had no behaviors of physical or verbal directed toward others. The reportable event form dated 5/2/24 at 3:15 PM identified Resident #71 was observed by Resident #7 to have punched Resident #97. Resident #97 was in Resident #7's room when Resident #71 asked him/her to leave. Resident #97 refused to leave Resident #7 room. Resident #97 proceeded to knock over a cup of milk which splashed onto Resident #71. Resident #71 then punched Resident #97 on the left side of face. Resident #97 informed the nurse on the unit of the alleged incident. Resident #97's skin was intact, slight swelling and discoloration noted to left side of face. Both residents were placed on 1:1 monitoring. The police, Administrator, physician, and the resident representatives were notified. An investigation was initiated, an RN assessment was completed, and neurological checks initiated. The nurse's note dated 5/2/24 at 10:03 PM by the ADNS (RN supervisor) identified at 3:15 PM she was called to unit due to a resident to resident altercation. Resident #97 reported that he/she was in Resident #71's room and Resident #71 asked to Resident #97 to leave his/her room but Resident #97 refused. Resident #97 identified that Resident #71 punched him/her on the left side of the face twice and punched him/her once in the center of the chest. Resident #97 indicated he/she immediately went to the nurse's station and told the charge nurse of the altercation. Resident #97 reported pain to the left side of face. Subsequently there was swelling and a bruise forming to the left side of face by the cheek bone. No discoloration or swelling to mid chest. Resident #97 denies feeling shortness of breath. Lungs sound clear. Both residents were immediately placed on 1:1 monitoring. Resident #97 is responsible for self. Psychiatric APRN had a telehealth call with Resident #97 and discontinued 1:1 monitoring. Every 15 minute checks were initiated. No contact boundary with Resident #71. Social workers to follow up. The nurse's note dated 5/2/24 at 10:38 PM identified Resident #97 was currently on every 15 minute checks. Resident #97 was to have no contact with Resident #71. Resident #97 left side of face slightly bruised with redness. Resident #97 complained of pain with Tylenol given with some positive effect. Resident #97 remained in the room with no issues. A written statement by Resident #97 undated at 3:15 PM identified Resident #97 went into Resident #71's room for candy. Resident #97 indicated he/she was trying to turn the wheelchair to leave, and Resident #71 stood up and punched him/her on the left side of face and twice and in the center of the chest. Resident #97 indicated he/she left the room and notified the staff. Resident #97 identified it's not over, I want to retaliate and stab Resident #71 but promised he/she would not retaliate. A written statement by Resident #71 (with no date) at 3:15 PM identified Resident #71 indicated Resident #97 came into Resident #7 room without knocking. Resident #71 indicated he/she asked Resident #97 to leave. Resident #97 indicated Resident #7 said I can come to the room. Resident #7 indicated no I didn't. Resident #71 indicated Resident #97 then took a cup of milk off Resident #7 table and threw it toward them and tried to punch Resident #71 but missed. Resident #71 indicated he/she then punched Resident #97 on the left side of face and that is when Resident #97 left the room. Resident #71 indicated he/she will not retaliate. The care plan dated 5/2/24 identified Resident #97 had got into an altercation with another resident and was punched in the face by Resident #71. The care plan failed to reflect documentation of interventions. The psychiatrist note dated 5/3/24 identified met with Resident #97 due to a recent resident to resident altercation. Resident #97 was pleasant and appropriately processed the events by his/her recall. Reviewed with Resident #97 conflict de-escalation skills and conflict prevention skills. Resident #97 was not assessed to be a harm to self or other at this time. The note failed to address Resident #97's statement regarding the desire to retaliate and stab Resident #71. The summary report dated 5/7/24 at 1:31 PM identified both residents were placed on 1:1 monitoring. Both residents were seen by the psychiatrist and 1:1 were discontinued. Both residents were placed on monitoring every 15 minutes for 48 hours. Both residents are being followed by the psychiatrist. Resident #71's medication regimen was completed. Both residents were offered a room change and declined. Both residents were placed on a no contact boundaries. Both resident care plans updated. Review of the facility abuse policy identified abuse, neglect, exploitation, and/or mistreatment of residents or misappropriation of resident property is prohibited. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. 3. Resident #59 was admitted to the facility on [DATE] with diagnoses that included dementia, PTSD, and a traumatic brain injury. The quarterly MDS dated [DATE] identified Resident #59 had moderately impaired cognition, had no presence of the following behavioral symptoms: physical behavioral symptoms directed toward others, verbal behavioral symptoms, or other behavioral symptoms not directed toward others, and was independent with walking 150 feet or similar space. The care plan dated 8/24/23 identified Resident #59 would identify to the facility social work staff that he/she felt safe from risk of physical harm or mental anguish while receiving care in the facility. Interventions included offering 1:1 social worker visits to discuss conflict resolution techniques and having staff accompany Resident #59 when going to the second floor. The nurse's note dated 9/12/24 at 12:57 PM identified the nurse was called to the resident dining room by staff. On arrival Resident #59 was observed lying on his/her back with another resident (Resident #73) standing over him/her using profound language. The nurse separated both residents immediately and placed Resident #59 on a 1:1 for safety. Resident #59 identified that he/she was hit in the face by another resident during an argument that transpired between the two residents which contributed to Resident #59 falling. Resident #59 had a small abrasion to the back of his/her head; Resident #59 was alert and oriented, at baseline, no complaints of dizziness or headache, bilateral upper and lower extremities symmetrical, positive range of motion. Local police were called to facility, APRN notified, no new orders, continue facility protocol. The Reportable Event Form dated 9/12/23 identified that Resident #59, the alleged victim, asked Resident #73, the alleged perpetrator who had diagnoses that included intermittent explosive behavior and anxiety, to move out of the way, so he/she could pass by; Resident #73 accused Resident #59 of stepping on his/her foot and a verbal argument ensued. Resident #73 indicated that he/she pushed Resident #59, causing him/her to fall backwards. The report further identified that the facility staff entered the dining room and saw Resident #73 standing over Resident #59 and immediately separated the residents; Resident #59 was placed on 1:1 for safety until both residents could be seen by the Psychiatric Provider. The APRN note dated 9/15/24 at 1:24 PM identified that Resident #59 was seen status post an altercation earlier in the week; Resident #59 stated that he/she walked past another resident, said excuse me, and the other resident pulled his/her shirt, punched him/her in the face, and he/she fell backwards hitting his/her head on the floor. Per staff there were witnesses who added the two parties were yelling at each other prior to the physical altercation and confirmed Resident #59 was punched and fell. On exam, Resident #59 denies headaches, light sensitivity, dizziness, nausea/vomiting, or changes in vision; he/she denied facial pain or tenderness. The nurse's noted dated 9/18/23 at 11:00 PM identified Resident #59 had complained of tinnitus. The nurse's note dated 9/20/23 at 1:54 PM identified that Resident #59 had new orders for an Ear, Nose, and Throat (ENT) referral & audiology with an outside provider. The ENT office visit notes dated 10/25/23 identified Resident #59's subjective history of the present illness included complaints of a right ear clogging sensation; he/she received a punch on his/her right ear about 2 months ago and started losing his/her hearing after that. Resident #59 reported hearing ringing sounds in the right ear that started after the trauma, reports feeling dizzy sometimes but denied ear pain or discharge. Resident #59's physical examination identified normal exterior ears, clear external auditory canal, normal tympanic membranes, intact and mobile on Pneumatoscopy (an examination that allows determination of the mobility of the tympanic membrane), and no middle ear mass. The report further identified that Resident #59 had diagnoses that included hearing loss to the right ear, with an unspecified hearing loss type, tinnitus of the right ear, dizziness, and giddiness; an ambulatory referral to Audiology was made. Interview with Resident #59 on 11/3/24 at 9:15 AM identified that approximately one year ago, Resident #73 had been threatening him/her, and while in the dining room after trying to walk by Resident #73, Resident #73 struck Resident #59 on the side of his/her face, threw him/her to the ground, and punched him/her in the ear, resulting in a blown-out ear drum. Resident #59 indicated that he/she was separated from Resident #73. Resident #59 identified that he has had no additional altercations with Resident #73, they reside on different units, and he/she stays away from Resident #73 but indicated that sometimes Resident #73 will follow him/her around. Interview with the DNS on 11/6/24 at 10:00 AM identified that he had been serving as the interim DNS for 2 days, and he could not speak to the specifics of the incident or investigation. The DNS indicated that a portion of the facility's population have psychosocial issues, and some residents have compromised coping skills with a limited ability for conflict resolutions; unfortunately, there may be times when individuals revert to their prior coping mechanisms. The DNS further indicated that sometimes incidents escalate in a matter of a seconds; the temper of an individual can escalate with no time for the staff to intervene despite interventions being implemented. The DNS identified that the facility handles their resident populations as best they can; they educate residents and staff frequently, update resident care plans and implement interventions, but they may not always be able to intervene timely. The facility's Abuse policy directs that residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interview for 4 of 4 residents (Resident #43, 84, 89, and 111) who reside on a locked dementia unit, the facility failed to provide the method of opening doors independently to the residents who voluntarily reside on the unit and do not meet the criteria for the unit, failed to educate the social worker on required assessments according to the Greater Hartford Memory Care Center Program guidelines, failed to complete initial and ongoing assessments of the residents according to the Greater Hartford Memory Care Center Program guidelines, and failed to ensure the clinical record included documentation according to 483.12(a)(1) to ensure the residents were free from involuntary seclusion. The findings include: 1. According to §483.12(a)(1) Each resident has the right to be free from involuntary seclusion. Involuntary seclusion includes, but is not limited to, the following: A resident placed in a secured area of the facility but does not meet the criteria for the unit and is not provided with access codes or other information for independent egress. A resident who chooses to live in the secured/locked unit and does not meet the criteria for placement, must have access to the method of opening doors independently. Staff should be aware of which residents have access to opening doors and monitor their use of the access to ensure other residents' safety. According to the Greater Hartford Memory Care Center Program guidelines, initial and periodic reviews of the residents continued stay in the program by the facilities interdisciplinary treatment planning team will be conducted for the resident, which will be updated and revised as needed on a quarterly basis, and concurrent with the resident's care plan. (Appendix C). Facility social worker will administer an Ability to Meet Minimal Basic Needs assessment (Appendix D) upon admission and on a quarterly basis. Resident #43 was admitted to the facility in December 2023 with diagnosis that included depression and bipolar disorder. The quarterly MDS dated [DATE] identified Resident #43 had intact cognition. Review of the clinical record identified Resident #43 was moved to the secured locked dementia unit on 7/23/24. A social worker progress note dated 7/23/24 identified Resident #43 had a room change today, will follow up with the resident for 72 hours. Resident #43 signed consent for locked unit and is free to come down as he/she pleases although it's a locked unit. Social worker will keep supporting the resident. Review of the dementia unit evaluation tool (Appendix C) dated 11/4/24, done for the first time subsequent to surveyor inquiry identified the following. Quarterly evaluation. The resident does not present a risk to self or others, resident/resident representative choose to reside in the secured unit while not meeting program criteria. Resident's choice to go to unit, resident does not meet criteria but wishes to continue residing on the program unit. Two illegible signatures noted at bottom. Review of the clinical record failed to reflect documentation regarding a discussion with the resident/representative regarding the move to the secure locked dementia unit or a care plan with ongoing assessments regarding the resident residing on the locked dementia unit including how the resident will be provided independent egress from the unit. Further, the clinical record lacked the Ability to Meet Minimal Basic Needs assessment (Appendix D) upon the residents move to the locked unit or the next quarter. Interview with the Charge Nurse, LPN #11, on 11/4/24 at 11:15 AM identified that no residents are allowed to know the code to independently leave the locked dementia unit. Interview with the Director of Social Services, (SW #1) on 11/4/24 at 12:15 PM who was observed reviewing and toggling between the 2 Electronic Medical Records (EMR) (as the facility is in a transition from one electronic health system to another) identified there was no initial or quarterly dementia unit evaluation (Appendix C) done when Resident #43 was moved to the locked dementia unit on 7/23/24. Further, an initial care plan that addressed Resident #43's placement on the locked dementia unit or ongoing documentation of the review and revision of the care plan related to the resident's placement on the unit was not found. SW #1 also indicated that residents' who do not meet the criteria for the locked dementia unit but are on the unit by choice are not given the code to leave the unit independently. The residents need to be let out by staff. Additionally, there were no follow up social service notes after the resident was placed on the locked dementia unit on 7/23/24 and SW #1 identified she had never seen the Ability to Meet Minimal Basic Needs assessment (Appendix D) prior to today. The VP of Clinical Services and the Director of Specialty Programming were also in the room and in attendance during the interview reviewing both facility Electronic Medical Records (EMR) looking for the information requested Although according to §483.12(a)(1) a resident who chooses to live in a secured/locked unit and does not meet the criteria for placement, must have access to the method of opening doors independently, review of the Greater Hartford Memory Care Center Program Consent to Voluntarily Reside on a Secure Unit identified the exits to the unit are alarmed and secured, requiring staff intervention to permit egress. Your placement on this unit is by your choice. If your residency on any secured unit is by your choice AND you do not meet the criteria of the program, you are to be provided as needed egress from the unit. 2. According to §483.12(a)(1) Each resident has the right to be free from involuntary seclusion. Involuntary seclusion includes, but is not limited to, the following: A resident placed in a secured area of the facility but does not meet the criteria for the unit and is not provided with access codes or other information for independent egress. Further, it is expected that each resident's record would include the following. Documentation of the clinical criteria met for placement in the secured/locked area by the resident's physician along with information provided by members of the interdisciplinary team. Documentation that reflects the resident/representative's involvement in the decision for placement in the secured/locked area. Documentation that reflects whether placement in the secured/locked area is the least restrictive approach that is reasonable to protect the resident and assure his/her health and safety. Documentation by the interdisciplinary team of the impact and/or reaction of the resident, if any, regarding placement on the unit. Ongoing documentation of the review and revision of the resident's care plan as necessary, including whether he/she continues to meet the criteria for remaining in the secured/locked area, and if the interventions continue to meet the needs of the resident. Review of the Greater Hartford Memory Care Center Program Guidelines directed initial and periodic reviews of the residents continued stay in the program by the facilities interdisciplinary treatment planning team will be conducted for the resident, which will be updated and revised as needed on a quarterly basis, and concurrent with the resident's care plan. (Appendix C). Facility social worker will administer an Ability to Meet Minimal Basic Needs assessment (Appendix D) upon admission and on a quarterly basis. Resident #84 was admitted in May 2023 to the secure locked dementia unit with diagnosis that included anxiety, schizoaffective disorder bipolar type, and vascular dementia. The quarterly MDS dated [DATE] identified Resident #84 had short and long term memory problems and severely impaired cognition. Review of the care plan dated 11/4/24, done subsequent to surveyor inquiry identified the following: I meet the criteria, and I and/or my responsible party have given consent to voluntarily live on a unit that is secure to protect myself or another resident from leaving the unit. The goal identified the resident will seek permission or assistance when I want to leave the unit. Assess me for the reason I may need to be on a unit that is secured. I acknowledge that I have voluntarily chosen to live on this unit. If I feel these circumstances do not apply to me, I will discuss with my social worker or nursing supervisor in order for a safe and effective means of providing me with access with access or egress at my discretion can be arranged. Review of the clinical record failed to reflect an initial or periodic review of the residents continued stay in the program (Appendix C), or the Ability to Meet Minimal Basic Needs assessment (Appendix D) had been done. Interview with the Director of Social Services, (SW #1) on 11/4/24 at 12:15 PM who was observed reviewing and toggling between the 2 Electronic Medical Records (EMR) identified that an initial assessment, including whether the resident met the criteria for admission to the unit (Appendix C), or the Ability to Meet Minimal Basic Needs assessment (Appendix D) had not been done. SW #1 identified she had never seen Appendix D prior to today. The VP of Clinical Services and the Director of Specialty Programming were also in the room and in attendance during the interview and were reviewing both facility Electronic Medical Records (EMR) looking for the information requested and could not find the requested information. The facility failed to ensure the clinical record reflected documentation of the clinical criteria met for placement, documentation that reflected the resident/representative's involvement in the decision for placement, documentation that reflected the placement is the least restrictive approach, documentation of the impact and/or reaction of the resident and ongoing documentation of the review and revision of the resident's care plan, including whether he/she continues to meet the criteria, and if the interventions continue to meet the needs of the resident. 3. According to §483.12(a)(1) Each resident has the right to be free from involuntary seclusion. Involuntary seclusion includes, but is not limited to, the following: A resident placed in a secured area of the facility but does not meet the criteria for the unit and is not provided with access codes or other information for independent egress. Further, it is expected that each resident's record would include the following. Documentation of the clinical criteria met for placement in the secured/locked area by the resident's physician along with information provided by members of the interdisciplinary team. Documentation that reflects the resident/representative's involvement in the decision for placement in the secured/locked area. Documentation that reflects whether placement in the secured/locked area is the least restrictive approach that is reasonable to protect the resident and assure his/her health and safety. Documentation by the interdisciplinary team of the impact and/or reaction of the resident, if any, regarding placement on the unit. Ongoing documentation of the review and revision of the resident's care plan as necessary, including whether he/she continues to meet the criteria for remaining in the secured/locked area, and if the interventions continue to meet the needs of the resident. Review of the Greater Hartford Memory Care Center Program Guidelines Assessment directed initial and periodic reviews of the residents continued stay in the program by the facilities interdisciplinary treatment planning team will be conducted for the resident, which will be updated and revised as needed on a quarterly basis, and concurrent with the resident's care plan. (Appendix C). Facility social worker will administer an Ability to Meet Minimal Basic Needs assessment (Appendix D) upon admission and on a quarterly basis. Resident #89 was admitted in July 2024 to the secure locked dementia unit with diagnosis that included dementia. The admission MDS dated [DATE] identified Resident #89 had moderately impaired cognition. Review of the clinical record failed to reflect a quarterly/periodic review of the residents continued stay in the program (Appendix C), or an initial or quarterly Ability to Meet Minimal Basic Needs assessment (Appendix D) had been done. Interview with the Director of Social Services, (SW #1) on 11/4/24 at 12:15 PM who was observed reviewing and toggling between the 2 Electronic Medical Records (EMR) identified that the quarterly assessment, including whether the resident met the criteria for admission to the unit (Appendix C), and the initial or quarterly Ability to Meet Minimal Basic Needs assessment (Appendix D) had not been done. SW #1 identified she had never seen Appendix D prior to today. The VP of Clinical Services and the Director of Specialty Programming were also in the room and in attendance during the interview and were reviewing both facility Electronic Medical Records (EMR) looking for the information requested and could not find the requested information. The facility failed to ensure the clinical record reflected quarterly documentation of the clinical criteria met for placement, documentation that reflects the resident/representative's involvement in the decision for placement, documentation that reflects the placement is the least restrictive approach, documentation of the impact and/or reaction of the resident and ongoing documentation of the review and revision of the resident's care plan, including whether he/she continues to meet the criteria, and if the interventions continue to meet the needs of the resident. 4. According to §483.12(a)(1) Each resident has the right to be free from involuntary seclusion. Involuntary seclusion includes, but is not limited to, the following: A resident placed in a secured area of the facility but does not meet the criteria for the unit and is not provided with access codes or other information for independent egress. A resident who chooses to live in the secured/locked unit and does not meet the criteria for placement, must have access to the method of opening doors independently. Staff should be aware of which residents have access to opening doors and monitor their use of the access to ensure other residents' safety. Resident #111 was admitted in July 2024 to the secure locked dementia unit with diagnosis that included alcohol abuse, opioid use disorder and acute toxic encephalopathy. A progress note dated 7/31/24 identified Resident #111 was admitted to the facility subsequent to a hospitalization for a fentanyl overdose. The baseline care plan dated 7/31/24 identified Resident #111 had a diagnosis of substance use disorder and had a conservator. The care plan dated 8/2/24 identified I live on a unit which is locked to protect myself or another resident from leaving the area. I will not attempt to leave the unit without permission and/or assistance through my next review. Assess me for the reason I may need to be on a locked unit. If I choose to leave the unit, ensure I am not a wanderer and have permission to leave the unit. If I do not meet the criteria of the program I will be provided egress from the unit through my next review. If I feel these circumstances don't apply to me, I will discuss this with my social worker or nursing supervisor in order for a safe and effective means of providing me with access or egress at my discretion can be arranged. I acknowledge I have chosen to voluntarily reside on this unit. Review of the Greater Hartford Memory Care Center Program Consent to Voluntarily Reside on a Secure Unit identified the exits to the unit are alarmed and secured, requiring staff intervention to permit egress. Your placement on this unit is by your choice. If your residency on any secured unit is by your choice AND you do not meet the criteria of the program, you are to be provided as needed egress from the unit. I have read and understand the above information, and consent to reside in a secured dementia program under these circumstances. I attest that I have been made aware of the purpose and nature of this unit and understand that I have chosen to voluntarily reside on this unit. The name of the resident representative was printed on the form (as COP), the form was dated 8/10/24, the staff witness signature was illegible, and there was a notation of verbal consent obtained. The quarterly MDS dated [DATE] identified Resident #111 had moderately impaired cognition. A dementia unit evaluation tool (Appendix C) was done on 11/4/24, for the first time subsequent to surveyor inquiry. Review of the clinical record failed to reflect documentation regarding a discussion with the resident/representative regarding the move to the secure locked dementia unit or a care plan with ongoing assessments regarding the resident residing on the locked dementia unit. Interview with the Charge Nurse, LPN #11, on 11/4/24 at 11:15 AM identified that no residents are allowed to know the code to independently leave the locked dementia unit. Interview with the Director of Social Services, (SW #1) on 11/4/24 at 12:15 PM who was observed reviewing and toggling between the 2 Electronic Medical Records identified that residents who do not meet the criteria for the locked dementia unit but are on the unit by choice are not given the code to leave the unit independently. The residents need to be let out by staff. The VP of Clinical Services and the Director of Specialty Programming were also in the room and in attendance during the interview and were reviewing both facility Electronic Medical Records (EMR) looking for the information requested. Interview with Person #1 on 11/5/24 at 2:06 PM identified that staff reported Resident #111 resided on a dementia unit and that the dementia unit had extra staff due to the needs of the residents on the unit, however Person #1 identified he/she was not aware that the unit was locked, which was why Resident #111 was able to go on leave of absences from the facility. Although according to §483.12(a)(1) a resident who chooses to live in a secured/locked unit and does not meet the criteria for placement, must have access to the method of opening doors independently, review of the Greater Hartford Memory Care Center Program Consent to Voluntarily Reside on a Secure Unit identified the exits to the unit are alarmed and secured, requiring staff intervention to permit egress. Your placement on this unit is by your choice. If your residency on any secured unit is by your choice AND you do not meet the criteria of the program, you are to be provided as needed egress from the unit. Although review of the Greater Hartford Memory Care Center Program Guidelines, Assessment, directed initial and periodic reviews of the residents continued stay in the program be conducted which will be updated and revised as needed on a quarterly basis, (Appendix C), and the social worker will administer an Ability to Meet Minimal Basic Needs assessment (Appendix D) upon admission and on a quarterly basis, Appendix C was not done initially, and according to an interview with SW #1, she had never seen, knew about, or completed the required Ability to Meet Minimal Basic Needs (Appendix D) assessment. Interview with the Director of Recreation on 11/4/24 at 12:24 PM identified she leads the recreation department and is not aware of the Greater Hartford Memory Care Center Program or any of its requirements. The Director of Recreation indicated she started at the facility 3 weeks ago. Interview with the Director of Specialty Programing on 11/4/24 at 1:00 PM identified she oversees the Greater Hartford Memory Care Center Program Coordinators in each care center and indicated the Director of Recreation is the designated Greater Hartford Memory Care Center Program Coordinator here in this building. The Director of Specialty Programing identified that the Greater Hartford Memory Care Center Program is a brand name of the facility memory care guidelines and is not a separate entity. The Director of Specialty Programing identified the previous Director of Recreation held the title of Greater Hartford Memory Care Center Program Coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, facility policy, and interview the facility failed to ensure the nourishment refrigerator was clean and sanitary, and food items were labeled and dated, and discarded timely, and failed to ensure food transport carts were clean and sanitary prior to placing meals on carts. The findings include: 1. Observation of the first-floor nourishment refrigerator with RN #5 on 11/3/24 at 8:15 AM identified the following. Freezer items: a. 4 half gallon water pitchers full by weight but unable to open, not dated or labeled b. Freezer had a grocery bag with partial eaten sherbert cup and fudge pops not labeled or dated c. Freezer friendly ice cream half empty not labeled or dated. d. 3 ice cream sandwiches that appeared to have thawed and refrozen not dated or labeled e. Freezer snickers bar partially eaten not labeled or dated. Refrigerator: a. A package of [NAME] dean sausages expired on 5/8/24. b. 15 kitchen prepared cups of pudding dated as prepared on 11/7/24 and expire on 11/12/24. c. Rotted watermelon with odor dated 10/30/24 not labeled and expired. d. Half apple pie best by date 10/25/24 not labeled and expired. e. A tossed salad that appeared wilted store dated 10/26/24 without a label f. A store-bought baked potato cooked dated 10/26/24 without a label. g. A store-bought container of asparagus cooked dated 10/26/24 without a label. h. 2 pitchers of juice not labeled or dated. i. A half-gallon of whole milk half gone with expiration date 10/21/24. Observation on 11/3/24 at 8:55 AM of the freezer identified large black frozen substance, and there was orange and brown spots in the refrigerator. Interview with RN #5 on 11/3/24 at 9:00 AM indicated that dietary was responsible to keep refrigerator and freezer clean and discard any food or drink items not labeled or dated and if not discarded within 3 days. RN #5 indicated that she would discard all food and drinks and have someone come and clean the refrigerator and freezer. Interview with the Director of Dietary on 11/3/24 at 10:30 AM indicated that dietary was responsible to clean the refrigerator and maintenance had to defrost and clean the freezers. The Director of Dietary indicated that the dietary aides were responsible to discard and food after 3 days and if any items were not labeled and dated. 2. Observation with the Director of Dietary in the first-floor dining room on 11/4/24 at 1:05 PM the cook was preparing plates of food from the steam table and handing to the dietary aide that placed the freshly made plates of food on a 3-shelf cart with wheels. The cart was soiled with stains and caked on filth in the wheels and sides of the cart. DA #1 placed 6 plates of food on the second shelf and another 6 plates of food on the top shelf. The DA #1 then took another cart that was soiled with white dried drippings and proceeded to place 6 plates of food from the cook onto the second shelf and 6 plates of food on the top shelf. The DA #1 proceeded to get the third cart which was soiled and proceeded to place 6 plates of food on the center shelf and 6 plates of food on the top shelf. DA #1 proceeded to get the fourth cart which was soiled and proceeded to place 6 plates of food on the center shelf and 6 plates of food on the top shelf. Interview with the Director of Dietary on 11/4/24 at 1:15 PM identified that the four 3 shelf carts were dirty, and the dietary staff were responsible to keep the carts clean. The Director of Dietary indicated that right after lunch she would make sure all the carts would be washed down and cleaned. Interview with DA #1 on 11/4/24 at 1:18 PM indicated that she had wiped down with a wet cloth this morning 2 of the carts but the other 2 carts were brought down from the second-floor dining room (where there is active covid-19) after lunch was served up there first. DA #1 indicated that she assumed the carts were clean and was just trying to get lunch served. Review of the Food Guide Policy posted on the front of the refrigerator identified that prepared foods brought in were good for 3 days, pudding was good for 7 days after opening, milk was good for 3 days after opening or manufacturers date, open ice cream for 4 weeks, frozen foods for 3 months from time placed in freezer, and a tossed salad for 1 day. Notice on front of refrigerator indicated for all nursing staff to make sure all items are labeled with resident's name and date to avoid items from being thrown away. This refrigerator is not for staff food or drinks. Please use the refrigerator in the staff break room. All food will be thrown away if no name and date is on the item when bought. Fridge/freezer will be checked daily by dietary. There is a guide dietary uses to follow with dates of how long we can keep food and drinks in the refrigerator and freezer. Review of the Dietary Cleaning Policy identified it was the responsibility of the dietary department to maintain all areas of the facility's kitchen and related areas in a clean and sanitary manner. Review of the Family and Visitor Provided Food Policy identified information provided is to provide for the safety and sanitary handling, storage, and consumption of food brought in by families and visitors. The nurse or designee with place the residents name and date on any food item prior to placing it in the refrigerator for storage. Nursing, dietary, and housekeeping staff are responsible to discard food outside the expiration dates, show signs of spoilage, or foods received more than 3 days prior to maintain sanitary conditions and resident safety. It is the facility's discretion to discard resident food if observed or evidence of being spoiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interview for 3 residents (Resident #64, 79, and 368) reviewed for transmission based precautions (TBP), the facility failed to ensure that facility staff implemented infection control measures for 2 residents (Resident #64 and 79) who required transmission-based precautions due to active respiratory infections, and for 1 resident (Resident #368), the facility failed to ensure that transmission based precautions were implemented for a resident with an active infection related to a multi drug resistant organism (MDRO). The findings include: 1. Resident #64 was admitted to the facility in March 2023 with diagnoses that included COPD, viral infection, and hepatic encephalopathy. The care plan dated 6/26/24 identified Resident #64 had a history of viral infection. Interventions included monitoring for signs of active infection including elevated temperature, cough and shortness of breath. The quarterly MDS dated [DATE] identified Resident #64 had severely impaired cognition, was always incontinent of bowel and bladder and required maximum staff assistance with toileting, dressing, and bathing. A nurse's note dated 10/30/24 at 4:42 PM identified Resident #64 tested + for Covid 19. The physician's orders dated 10/30/24 directed Resident #64 be placed on droplet/contact precautions for Covid infection/isolation, Resident #64 was to remain in his/her room, and all services were to be brought in to Resident #64's room including rehab services and dining. A physician's order dated 11/1/24 directed Resident #64 was to isolate for 14 days for diagnosis of Covid 19 and stay in room. 2. Resident #79 was admitted to the facility on [DATE] with diagnoses that included dementia, COPD, and diabetes. The care plan dated 7/8/24 identified Resident #79 had a history of dementia. Interventions included to use a slow calm approach and explanation. The quarterly MDS dated [DATE] identified Resident #79 had severely impaired cognition, was frequently incontinent of bowel and bladder and was dependent on staff to assist with toileting, dressing, and bathing. A nurse's note dated 10/30/24 at 4:33 PM identified Resident #79 tested + for Covid 19. The physician's orders dated 10/30/24 directed Resident #79 be placed on droplet/contact precautions for Covid infection/isolation, Resident #79 was to remain in his/her room, and all services were to be brought in to Resident #69's room including rehab services and dining. A physician's order dated 11/1/24 directed Resident #79 was to isolate for 14 days for diagnosis of Covid and stay in room. Upon entrance to the facility on [DATE] as part of an annual recertification survey, the survey team was notified by the facility staff that 2 residents were currently on TBP, both due to positive Covid 19 results. Observations on 11/3/24 at 9:00 AM identified Resident #64 and Resident #79 in the unit dining room, seated in a communal dining space, unmasked, along with approximately 22 other residents, also unmasked. Observations of signage on Resident #64 and #79's door entryways on 11/3/24 at 9:10 AM identified PPE carts and 2 TBP signs for Droplet Precautions and Contact Precautions, which directed that in addition to standard precautions, only essential personnel should enter, everyone must (including visitors, doctors, and staff) clean hands when entering and leaving room, wear mask (fit tested n-95 or higher required when performing aerosol-generating procedures), wear eye protection (face shield or goggles), gown and gloves at the door and keep door closed. Interview with LPN #6 on 11/4/24 at 8:20 AM identified that the facility staff had given up on trying to ensure TBP were maintained for Resident #64 and Resident #79. LPN #6 reported that both residents had a history of combative and resistive behaviors, and due to this, the staff did not attempt to prevent the residents from leaving isolation, dining with other residents, or masking while out in common areas. Observation on 11/4/24 at 8:25 AM identified Resident #64 sleeping in his/her room with the door open. Resident #79 was observed walking in the unit hallway, unmasked, until 8:32 AM, when Resident #79 returned to his/her room. At 8:33 AM, Resident #64 began to walk in the unit hallway unmasked. At 8:37 AM, a female staff member, with a standard mask and no eye protection, was observed walking Resident #64 from the hallway to the unit dining room and assisting him/her to a seat at a table with 7 other residents, all unmasked. The residents directly to either side of Resident #79 were approximately 18 inches away, and the resident seated across the table from Resident #79 was approximately 2 feet away. During this observation, a total of 26 other residents were located in the dining area, all unmasked. Additionally, a large steam table was located approximately 10 feet from Resident #79, along with 4 facility dietary staff plating meals. An additional 4 facility staff were also observed assisting residents with meals and set up. No facility staff were observed wearing any additional PPE outside of a paper mask. Multiple residents were heard coughing during this observation. Observation on 11/4/24 at 9:48 AM identified Resident #79 seated at a table with LPN #6. During this observation, a large industrial wall mounted air conditioning (AC) unit was observed to be blowing a large force of air directly at the back of LPN #6 and directly to Resident #79's face, who was positioned approximately 6 feet from the unit. During this observation, LPN #6 was observed with a standard face mask and no eye protection. Additionally, a total of 18 other residents were seating in the dining area. Observation also identified that the force of the air from the AC unit could be felt by this surveyor approximately 12 feet from the unit. The observation was discontinued at 10:05 AM, at which time Resident #79 remained in the same seat in front of the AC unit. Interview on 11/4/24 at 11:24 AM with LPN # 2 (Infection Control/Staff Development Nurse), RN #6 (Regional Coordinator of Education and Infection Control) and RN #8 (Regional Director of Infection Control) included review of the observations of Resident #64 and #79 on 11/3/24 and 11/4/24 as well as the lack of PPE use by facility staff including gloves, gown, N-95 mask, and face protection. LPN #2 and RN #6 identified that facility staff has been educated to offer continuous redirection to both residents, and identified they were not aware that Residents #64 and #79 were walking the unit ad lib or that the orders related contact and droplet precautions not being adhered to. Interview on 11/4/24 at 12:25 PM with the DNS identified he spoke with facility staff on 11/3/24 in the afternoon about source control for Resident #64 and 79. The DNS identified he was aware that there were issues related to maintaining contact/droplet precautions but identified the residents had cognitive and behavior issues and the staff were having difficulty instituting source control (masking/isolation) for the residents. Upon review of this surveyor's observations on 11/3/24, and the 11/4/24 observations of Resident #79 seated directly in front of a large AC unit blowing air directly towards Resident #79 and throughout the dining room with 18 other residents present without PPE in place, the DNS identified I guess we could try masking again. The DNS was unable to identify if there were any potential risks to other residents in the common areas with a large industrial AC unit running blowing forced air directly at a resident with newly diagnosed Covid 19 infection. Subsequent to surveyor inquiry, LPN #2 and RN #8 identified on 11/5/24 at 8:00 AM that they had been in contact with MD #1 regarding this surveyor's observations and begun testing all residents on the unit and that Resident #88 had a positive Covid 19 test on 11/4/24. RN #8 provided in-service education identifying he reviewed Covid 19 isolation precautions, redirections, and dining for Covid 19 positive residents with facility staff on 11/4/24. LPN #2 also provided PPE audit observations for 11/4/24 and 11/5/24. Interview with MD #1 (Medical Director) on 11/5/24 at 3:12 PM identified that Resident #64 and #79 should not have been dining in the communal dining area with other residents following their positive Covid 19 diagnoses on 10/30/24 or directly in front of a running industrial AC unit and indicated Covid 19 is not as bad as it was before but we still have to follow CDC guidelines. MD #1 identified that for any residents newly diagnosed with Covid, the resident should be placed on isolation, contact tracing should be done per CDC guidelines, the resident should be monitored with vital signs and symptoms, and all staff interacting with the resident should be donning and doffing appropriate PPE. The facility policy on strategies to reduce the risk of spread of Covid 19 or other influenza like respiratory illnesses directed strategies during identified outbreaks included wearing appropriate PPE when caring for Covid 19 infected residents and/or entering a Covid 19 isolation room (gown/gloves/eye protection/N-95 mask). The facility policy on droplet precautions directed these precautions should be used when a resident with a known or suspected infection with a microorganism transmitted by droplets generated by coughing, sneezing, talking, etc. PPE for droplet precautions should include a gown, mask, gloves and eye protection, and that an N-95 respirator was recommended when caring for a resident with active Covid 19. The policy also directed that a surgical mask must be applied to the resident if the resident was being transported outside of their room. The facility policy on contact precautions directed that a resident's individual clinical situation (active signs and symptoms of infection or colonization) would determine if contact precautions were necessary. The policy also directed that a private room would be preferred and contact precautions should include donning gloves and a gown when entering the resident's room, removing gloves and gown prior to exiting the room, performing hand hygiene and using dedicated or disposable equipment for a resident on contact precautions when possible. 3. Resident #368 was admitted to the facility in October 2024 with diagnoses that included MRSA bacteremia, viral infection and sepsis. Review of hospital discharge documentation dated 10/14/24 identified Resident #368 had a positive blood culture for MRSA on 9/23/24. The documentation also identified Resident #368 had a PICC line placed on 10/2/24. The nursing admission assessment dated [DATE] identified Resident #368 had intact cognition, was continent of bladder, required a walker for ambulation, and had a PICC line in place at the upper right arm. Review of Resident #368's care plan failed to identify any interventions in place related to MRSA, the viral infection, PICC line use, or transmission-based precautions. Upon entrance to the facility on [DATE] as part of an annual recertification survey, the survey team was notified by the facility staff that 2 residents (Resident #64 and #79) were currently on TBP that included contact and droplet precautions due to positive Covid 19 results. Additionally, the survey team was notified Resident #67 had been transported to the hospital on [DATE]. Review of a facility provided Enhanced Barrier Precautions (EBP) list, provided to the survey team on 11/4/24, identified Resident #368 required EBP due to a PICC line in place. Interview with LPN #2 (Infection Control/Staff Development Nurse), RN #6 (Regional Coordinator of Education and Infection Control) and RN # 8 (Regional Director of Infection Control) on 11/4/24 at 10:30 AM identified that 3 residents of the facility required TBP. LPN #2 identified that Resident #368 required Contact Precautions for newly diagnosed MRSA bacteremia. Observation with LPN #2 and RN # 8 on 11/4/24 at 12 PM identified that Resident #368 did not have any signage or PPE located outside of his/her room identifying the need for contact precautions or EBP. Additionally, the identification outside the room noted Resident #67 also resided in the room. LPN #2 identified that she had placed a contact precaution sign and PPE cart in front of Resident #368's room upon admission, and the sign as well as the PPE cart were in place as of 10/30/24. LPN #2 identified that without any signage posted, staff and visitors would not immediately know Resident #368 required contact precautions or EBP. LPN #2 also identified that while Resident #67's name was on the door, Resident #368 had been in the room alone since 10/14/24. Review of facility documentation identified Resident #67 had been in the same room since admission to the facility on 9/30/24 until transfer to the hospital on [DATE]. Resident #67 had no history of MRSA. Review of Resident #368's census sheet identified he/she was placed with Resident #67 in the same room on 10/14/24. Resident #368 and Resident #67 shared the same room from 10/14/24 -11/2/24. Interview with MD #1 (Medical Director) on 11/5/24 at 3:12 PM identified Resident #368 should have had a private room with no roommate if possible, or with a roommate who had a history of MRSA. MD #1 identified that Resident #368 had newly diagnosed MRSA, and it would not be appropriate to cohort Resident #67 and Resident #368 together due to the risk of MRSA transmission, and Resident #368 should have been maintained on contact precautions due to his/her MRSA diagnosis. The facility policy on transmission-based precautions directed that these precautions may be implemented by the physician, DNS, ADNS, Professional Development coordinator, or the nursing supervisor. The facility policy on contact precautions directed that a resident's individual clinical situation (active signs and symptoms of infection or colonization) would determine if contact precautions were necessary. The policy also directed that a private room would be preferred and contact precautions should include donning gloves and a gown when entering the resident's room, removing gloves and gown prior to exiting the room, performing hand hygiene and using dedicated or disposable equipment for a resident on contact precautions when possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy, and interviews for one (1) of four (4) residents reviewed for abuse, the facility failed to ensure that the resident was free from verbal abuse. The findings include: Resident #13 was admitted with diagnoses that included difficulty in walking, reduced blood flow to limbs, anxiety, and depression. A quarterly MDS assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and required extensive assistance for Activities of Daily Living (ADL's).A Resident care plan (RCP) dated 10/02/2023 identified Resident #13 was at risk for skin breakdown due to overall health and needed assistance with activities of daily living (ADLs) with intervention sthat directed to explain what you are going to do before giving care and to encourage or assist the resident with repositioning changes as appropriate. A facility accident and investigation report dated 11/19/2023 at 1:00 PM identified an incident of staff to resident abuse without injury. RN #3 (the nursing supervisor) alleged she overheard loud noises coming from the hallway on B wing. As she went to investigate, she observed NA #4 coming out of Resident #13's room using profanity directed towards Resident #13, RN #3 told NA#4 not to use profanity when talking to a resident. NA#4 identified Resident #13 had refused care and attempted to hit her with his/her reacher and she was upset. NA #4 was taken off the floor and schedule pending investigation. Interview with RN #3 on 12/13/2023 at 4:10 PM identified on 11/19/2023 at approximately 1:00 PM she heard NA#4 loudly saying to Resident #13 that she didn't care, it's your f------ a--- that stinks. NA #4 continued with the profane comments as she walked from Resident #13's room to the nurse's station. RN #3 asked what happened and NA #4 responded that Resident #13 had refused care and was inappropriate. RN #3 immediately re-educated NA #4 that Residents had a right to refuse care and the use of profanity when addressing a resident was inappropriate. RN #3 then sent NA #4 home pending investigation. RN #3 attempted to interview Resident # 13, however the resident refused to answer any questions. Interview with NA # 4 on 12/14/2023 at 9:50 AM identified that she was assigned Resident #13 on 11/19/2023 and had offered to provide care to Resident #13 earlier in the shift and he/she had refused. She returned to check him/her at around 1:00 PM and Resident #13 became combative. As she left the room, she used profanity telling the Resident that it was his f------ a--- that was dirty. NA #4 stated that she had become frustrated as she felt it reflected how she provided care if a resident was not cared for on her shift. She made the comment using foul language as she was leaving the room, not directing to the Resident. RN #3 overheard her and re-educated her immediately that use of profanity when talking about a resident was not appropriate and that residents can refuse care and then sent her home. She was also re-educated on Abuse and Resident's rights before returning to work at the facility. Interview with the DON on 12/14/2023 at 9:52 AM identified that NA #4 should not have used profanity when exiting Resident #13's room. She concluded that NA#4 had expressed the profane comments loudly, as it was loud enough for the supervisor to hear at the nurse's station. She continued that NA #4's use of profanity was not intentional and was a reaction to Resident #4's interaction with her when he/she refused care and became combative threatening to hit NA #4 with their reacher. She interviewed Resident #13, and he/she did not comment about NA #4. Review of facility Abuse Policy, dated 1/23/2018, directed in part, verbal abuse means the use of oral, written, or gestured language that included disparaging and derogatory terms to residents within their hearing distance, to describe residents regardless of their age, ability to comprehend or disability. The Policy further directed that resident had the right be free from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of four (4) residents, (Resident #10), reviewed for abuse, the facility failed to follow the plan of care for one to one supervised smoking, leading to a resident-to-resident incident of verbal abuse. The findings include: 1. Resident #10 had diagnoses that included borderline personality disorder, traumatic brain injury, paranoid schizophrenia. A MDS dated [DATE] identified that the resident was alert and oriented and is independent for all activities of daily living (ADLs), transfers, and mobility using a wheelchair. A resident care plan (RCP) dated 9/6/2023 identified that Resident #10 will smoke safely, feel safe from physical harm or mental anguish and refrain from verbal threats and racial slurs with interventions that included Resident #10 would only smoke while supervised with one to one monitoring at designated times and areas, and if known that he/she were bothered by the presence of someone, please help to keep separated. 2. Resident #12 had diagnoses that included dysphagia, depression, and psychiatric illness. A MDS dated [DATE] identified that Resident #12 was alert and oriented and was independent for transfer, ADLs and mobility with a walker or wheelchair. A resident care plan (RCP) dated 10/16/2023 identified that Resident #12 will be redirected with minimal verbal cues when exhibiting socially inappropriate behavior and will smoke safely with interventions that directed to use a calm gentle approach to redirect to a quiet environment, assist with problem solving, and to smoke while supervised in designated areas. A nursing progress note dated 11/23/2023 at 12:48 AM identified that at approximately 6:00 PM on 11/22/23, Resident #12 identified that Resident #10 had verbally threatened her/him while on her/his way outside to smoke break. Resident #10 attempted to initiate verbal communication with her/him, and Resident #12 told Resident #10 not to talk to her/him. The residents exchanged verbal insults resulting in Resident #10 threatening to cut off Resident #12's head. Resident #12 reported not feeling safe and fearing for their life. Notifications were completed as per facility policy and Resident #12 pressed charges against Resident #10. Resident #10 was placed on one to one supervision. A facility accident and incident report dated 11/22/2023 identified a resident-to-resident abuse without injury. This event occurred at 6:00 PM when Resident #12 refused to interact with Resident #10. Resident #10 made threatening remarks to Resident #12 and called Resident #12 derogatory names. Security Specialist was present and separated residents immediately. Resident #10 was placed on one to one supervision. Interview with the Security Specialist on 12/14/2023 at 11:00 AM identified that he was assigned to monitor the smoke break on 11/22/2023 and when he came in to bring out the Residents to smoke, he observed Resident #10 and Resident #12 arguing. He immediately separated them, and then Resident #12 went back upstairs. SW #1 had come out of her office and notified the supervisor, placing Resident #10 on a 1 to 1 supervision. The security specialist identified that he was unaware that Resident #10 was a one to one supervision for smoke breaks and had he known he would have monitored Resident # 10 as they started to go outside to smoke. Interview with the DON on 12/14/2023 at 11:05 AM identified that Resident #10 was placed on one to one supervised smoke breaks after a similar issue had occurred in the summer. The person monitoring smoke break should monitor Resident #10 to redirect any socially inappropriate behaviors during smoke break. Residents line up and congregate in the hallway by the social workers office as they wait to go outside. She would anticipate that if the Security Specialist was assigned to smoke break, he would be aware that Resident #10 needed one to one supervision. She expected all staff to follow a Resident's plan of care. Resident #10 was started on separate smoke breaks after the incident on 11/22/2023 where he/she smokes 15 minutes before any other residents and does not line up to go outside. The Care Plan policy, dated 11/16/2023, directed in part, that each resident will have a comprehensive person-centered plan of care and that residents have the right to receive services in the care plan. The care plan contains residents' goals, strengths, preferences, identified problems, measurable realistic goals, and the interventions to be utilized to reach the goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for four (4) of nine (9) residents, (Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for resident rights, the facility failed to allow residents to exercise their rights for room searches, food preferences, and leave of absences. The findings include: 1. Resident #4 was admitted to the facility on with diagnoses that included post-traumatic stress disorder, schizoaffective disorder, bipolar disorder, and anxiety. The annual quarterly MDS dated [DATE] identified Resident #4 had intact cognition and was independent with ADL's. The care plan dated 6/27/2023 identified Resident #4 enjoyed smoking with interventions directed that the smoking policy and agreement will be reviewed with me per facility policy. A Resident Room Search Worksheet dated 7/7/2023 at 1:20 P.M. identified that the reason for the room search was due to a concern that Resident #4 was selling cigarettes. No items or contraband were found. Resident #4 was not present during the room search. The Resident present during room search box was checked no, and further identified that the resident was offered to stay for the search and declined. An interview with Resident #4 on 12/11/2023 at 9:25 A.M. he/she identified over the summer while he/she was in the bathroom, SW#2 and Security Guard #1 requested to conduct a room search. Resident #4 indicated he/she requested that the SW #2 and Security Guard #1 come back at a later time, and they agreed. Resident #4 identified he/she then went to attend the facility's cook out and upon return to his/her room SW#2 and Security Guard #1 were in Resident #4's room finishing up the room search. Resident #4 identified he/she was not reapproached and asked if he/she gave permission for the room search to be done and was not asked if he/she wanted to be present during the room search. An interview with SW #2 on 12/11/2023 at 2:45 P.M. identified that she is directed by the Administrator to conduct room searches. SW #2 indicated she does not obtain consent from the resident prior to conducting the room search. SW #2 identified over the summer she and Security Guard #1 were directed to search Resident #4's room for contraband with a focus on cigarettes. SW #2 indicated there was not any contraband or cigarettes found in Resident #4's room. SW #2 identified she did not ask Resident #4 for permission to search his/her room nor did she ask Resident #4 if he/she would like to be present for the room search. SW#2 identified Resident #4 was not present when the room search was conducted. An interview with Security Guard #1 on 12/12/2023 at 3:12 P.M. he indicated he could not recall if Resident #4 was present when he conducted the room search. An interview with the Administrator on 12/12/2023 at 1:00 P.M. he identified when Resident #4's room search was conducted Resident #4 should have been present during the room search. Review of the facility's Room Searches policy identified room searches should be conducted with no less than 2 staff members present and resident's whose rooms are to be searched do not have to be present if there is reasonable cause to suspect risk to resident safety 2. a) Resident #5 had diagnoses that included adjustment disorder with mixed anxiety and depression and alcohol dependence. The care plan dated 9/27/2023 identified Resident #5 will pursue interests of his/her choice with interventions that directed to discuss any changes in my participation level with the interdisciplinary team. The quarterly MDS dated [DATE] identified Resident #5 had intact cognition and was independent with ADL's. b) Resident #4 was admitted to the facility with diagnoses that included post-traumatic stress disorder, schizoaffective disorder, bipolar disorder, and anxiety. The annual quarterly MDS dated [DATE] identified Resident #4 had intact cognition and was independent with ADL's. Observations on 12/11/2023 at 9:15 A.M. on the resident care units identified signage was posted in the hallways that read in part: Here is a list of restaurants (4) residents are allowed to order from, the form further identified that no orders may be placed after 7:00 P.M., and NO DOOR DASH OR UBER EATS. Interview with Resident #5 on 12/11/2023 at 11:35 A.M. identified that the facility had restricted residents ability to order from any restaurant of their choice. Resident #5 identified the facility had created a list of restaurants that the residents are permitted to order from and will not allow any ordering of food after 8:00 P.M. Interview with Resident #4 on 12/11/23 at 12:45 PM identified that he/she found out about the list of restaurants that he/she can order food from only after he/she ordered food from a restaurant paid for it, and the food was sent back to the restaurant by the facility. An interview with the ADNS and RN #1 (Regional Nurse) on 12/11/2023 at 2:25 P.M. identified residents were given some time to come up with a list of restaurants they would like to order from. The lists were reviewed by management and the approved list of restaurants the residents are allowed to order from was then posted on the units. The restrictions remained that the residents could not order from door dash or uber eats, because the specific restaurants that were selected had the food coming directly from the restaurant which would decrease the likelihood of illegal substances entering the building. 3. a) Resident #6 was admitted to the facility with diagnoses that include alcohol dependence with withdrawal and anxiety. The quarterly MDS dated [DATE] identified Resident #6 had intact cognition and was independent with ADL's. The care plan dated 11/9/2023 identified Resident #6 will pursue interests of his/her choice through the next review. The Social worker assessment and interview dated 11/13/2023 identified Resident #6 capacity to meet minimal basic needs in the community, was not an exit seeking risk, and has a current history of alcohol use. The nurse note dated 11/25/2023 at 7:44 P.M. identified Resident #6 returned from a Leave of Absence (LOA) and appeared intoxicated, h/her breath smelled of alcohol, with slurred speech, slow to respond, lack of coordination, reddened dilated eyes, and unfocused. Resident #6 was aggressive towards staff. Resident #6 refused to go to the hospital. The Behavioral Rounds form dated 11/27/2023 noted Resident #6 is denied any LOA's after he/she come back intoxicated, impaired, and denied to be searched when he/she arrived back to the facility. The social worker note dated 11/29/2023 at 4:07 P.M. identified SW#1 was notified by the Administrator that Resident #6 leave of absences were to be denied until further notice due to Resident #6 coming back from LOA intoxicated. SW #1 identified on 11/25/2023 Resident #6 came back to the building, unaccompanied, refused to have his/her bags searched, Resident #6 became belligerent and caused a scene. Resident #6 was then notified by the Administrator that his/her LOA's/Travel Passes were being denied until further notice. SW #1 indicated the front desk staff were notified that Resident #6 was not allowed out of the building with the exception being for any medical appointments. A review of Resident #6's Travel Pass Request Form dated 11/28/2023 identified the travel pass request was for travel on 12/2/2023. Resident #6 indicated he/she would leave at 12:00 P.M. and return to the facility at 6:30 P.M. The Travel Pass Request was denied due to use of alcohol on his/her prior LOA, and coming back impaired. The social worker note dated 12/1/2023 at 3:26 P.M. identified Resident #6 came to the social services office to obtain information regarding his LOA status. SW #1 informed Resident #6 that his/her LOA's are denied by management and medical director due to the incident that occurred on 11/25/2023. SW #1 spoke with Resident #6 regarding the concerns of his/her alcohol issue on 11/25/2023 providing education on options of AA meetings and Recovery Groups therapy. Resident #6 adamantly declined stating I don't drink and denied every coming back from LOA intoxicated. An interview with Resident #6 on 12/12/2023 at 8:55 A.M. he/she indicated he/she has always been able to go out on LOA independently until recently. Resident #6 identified on 10/26/2023 the Administrator made it so no one could go out on an LOA alone due to drug overdoses at the facility. Resident #6 identified it was not communicated to the residents and he/she found out when he/she was ready to go out on an independent LOA. Resident #6 indicated he/she fought the Administrator and was able to get two LOA passes in November. Resident #6 indicated his/her Travel Pass Request for 12/2/2023 was denied and he/she has not been able to go out on any LOA's since. Resident #6 identified this was because on his/her LOA on 11/25/2023 he/she was accused of being. Resident #6 identified he/she was visiting his/her children on 11/25/2023 was not intoxicated, did not drink any alcohol, and did not refuse to have his/her bags searched. Resident #6 indicated his/her speech was a bit off due his/her back tooth falling out on the morning of 11/25/2023 prior to his/her LOA. Resident #6 indicated he/she feels like it is a prison at the facility. An interview with SW #1 on 12/12/2023 at 11:00 A.M. she indicated Resident #6 was able to go out on independent LOA's until his/her last LOA. SW #1 identified on 11/25/2023 Resident #6 came back to the facility from an LOA intoxicated, belligerent, and refused a search of his/her bags. SW #1 identified generally, if a resident comes back from an LOA and is intoxicated, they are not denied further LOA's they are only denied if they are belligerent and refuse to have bags searched. b) Further interview with Resident #5 on 12/12/23 at 9:35 AM identified he/she was able to go out on independent leave of absences until the facility took away his/her independent LOA privileges. Resident #5 indicated he/she likes to go outside and walk the perimeter of the facility's grounds. Resident #5 identified the last time he/she attempted to go outside he/she was stopped by the guard at the desk and told he/she was not allowed outside alone. Resident #5 identified all residents must be supervised by staff when going outside on the facility's grounds. Although Resident #5 has been offered to outside with staff during fresh air activity, h/she has not. Interview with the Recreation Assistant #1 on 12/12/2023 at 10:30 A.M. she identified the facility does have a Fresh Air activity for residents to go outside with recreation staff. Recreation Assistant #1 indicated the Fresh Air activity usually takes place from 1:30 P.M. to 2:15 P.M. and any resident is allowed to go outside at that time with the recreation department at that time. Recreation Assistant #1 identified there are weather restrictions on the Fresh Air activity during the winter if the temperature is below 60 degrees, they do not take residents outside and during the summer months if it is too hot or humid the residents are not taken outside. An interview with DNS, Administrator, RN #1 (Regional Nurse), RN #2 (Regional Nurse) on 12/12/2023 at 1:00 P.M. noted the facility only allows two residents to go LOA unsupervised, all other residents residing in the facility require supervised LOA's with a responsible party, and residents may go outside but only when supervised by a staff member. The Administrator identified that the physician does not write orders in advance for leaves of absences in advance and all residents are required to obtain a travel pass to leave the facility. Review of the facility's Authorized Leave of Absences policy identified the facility will exercise appropriate measures for a resident to participate in an authorized leave of absence. Review of the facility's Fresh Air Break Education identified a major clinical program offered is the provision of sub-acute care to patients who a have medical condition brought on by Substance Use Disorder and the facility has to be vigilant in ensuring that drugs and other illicit substances do not enter the building. The following procedure that must be followed during Fresh Air Breaks: security must be present and it will be the primary responsibility of Security to ensure no visitors arrive and go directly to a resident who is on supervised visits. According to Appendix PP §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

**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 (1) of three (3) residents reviewed for abuse, (Resident #20), the facility failed to ensure the resident was free from abuse. The findings include: Resident # 20's diagnoses included quadriplegia, adult antisocial behavior, neurogenic bowel, neuromuscular dysfunction of bladder, opioid abuse, cocaine abuse, adjustment disorder with depressed mood, anxiety, post-traumatic stress disorder and schizophrenia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #20 had a Brief Interview for Mental Status (BIMS) score of thirteen (13) of fifteen (15), indicative of no cognitive impairment, and required extensive assistance with dressing, toileting, and personal hygiene. The Resident Care Plan (RCP) dated 1/4/23 identified incontinence of bowel and bladder with interventions that directed to check skin during incontinent care for signs of redness, maceration, or irritation, offer help to the bathroom as needed, provide an adult brief, and provide incontinent care as needed. A facility reportable event form dated 1/17/23 at 6:00 PM identified it was reported by Ultrasound (US) Tech #1 that she witnessed Nurse Aide (NA) #8 hit Resident #20 on the back. The form further identified a body audit was done on Resident #20, as well as a head-to-toe assessment, with no injury noted. An investigation was started, the Advanced Practice Registered Nurse (APRN), family, police department were notified. A resident interview form dated 1/17/23 at 6:00 PM identified Resident #20 stated the NA hit me in my ribs, however the resident had no complaints of pain. A nurse's note dated 1/17/23 at 9:00 PM written by Registered Nurse (RN) #5 identified she was called to the unit at approximately 6:00 PM after a staff to resident altercation was reported, US Tech #1 reported that she witnessed NA #8 hit Resident #20 on his back. The note further identified Resident #20 was interviewed and stated the NA hit me in my ribs, the police were called, the APRN and family were notified and Resident #20 did not want to press charges, however, did not want NA #8 to provide care to him/her any longer and the DNS was updated and NA #8 was removed from the resident area immediately pending an investigation. An employee statement/interview form dated 1/20/23 at 2:08 PM with NA#8 identified when asked if she hit Resident #20, NA #8 stated out of reflex, the bowel movement got all over my arm and I reacted with oh my God, yuck, I honestly don't know, all I know is at that moment, I reacted with wiping my arm off, I know I didn't hit him period, Resident #20 said it but, I honestly don't know if I hit him. Interview with RN #5 on 1/17/23 at 9:26 AM identified RN #5 was called to the unit by the nurse and NA #8 and when RN #5 went to the unit it was reported to her that Resident #20 alleged NA #8 hit him on the back, and US Tech #1 was there as a witness. RN #5 identified US Tech #1 reported to her that she observed NA #8 hit Resident #20 on the back. Additionally, RN #5 identified she then went to assess Resident #20 who reported to RN #5 NA #8 hit him/her in the ribs but had no complaints of pain. RN #5 further identified NA #8 was sent home pending an investigation, the DNS, APRN and Police were notified of incident. Interview with US Tech #1 on 1/17/23 at 9:56 AM identified she was performing a scan on Resident #20 when it was identified Resident #20 had a large bowel movement (BM). US Tech #1 identified she requested assistance from NA #8, who gathered supplies and came into provide care to Resident #20. US Tech #1 further identified while NA #8 was turning Resident #20 to continue to provide incontinent care, Resident #20 had to pass gas and some liquid stool came out and landed on NA #8. US Tech #1 identified at that time NA #8 raised her arm up and punched Resident #20 on the back to which Resident #20 stated why are you punching me. Additionally, US Tech #1 identified that she did see NA #8 punch Resident #20. US Tech #1 identified she then reported the incident to the facility supervisor. Interview with the Administrator and the Chief Clinical Officer (CCO) on 2/2/23 at 12:25 PM identified an investigation which consisted of interview with Resident #20, staff involved, and the US Tech and they were asked to provide statements. The administrator identified the results of the facility investigation was inconclusive based on the conflicting statements from NA #8, US Tech #1, and Resident #20, but that NA #8 was terminated because this was a negative encounter with a resident. Although multiple attempts were made to contact NA #8, all attempts were unsuccessful. Review of the facility policy titled Abuse, dated 1/23/18 directed, in part, abuse of a resident is prohibited and residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers and staff of other agencies serving the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for three (1) of seven (7) sampled residents (Resident #1), who was reviewed for baseline care plans the facility failed to develop a baseline care to address a substance abuse disorder timely. The findings include: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses included psychoactive substance abuse and opioid dependance. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had no cognitive impairment and was independent with activities of daily living. A visitor risk/belonging search assessment dated [DATE] identified that upon admission the resident had drug paraphernalia in h/her possession. A nurse's note dated 12/14/22 at 4:13 PM identified that the Director of Nurses went to see Resident #1 and assess, and talk about reports of active drug use in the facility around 3:45 PM. Upon entering the room Resident #1 was noted to be swaying, pupils were pinpoint, and speech was slurred. Resident #1 refused vital signs taken or have Narcan administered, other staff responded to the room and 911 was called and arrived in the facility at 4:00 PM with 3 EMT's and 2 police officers. The Police searched Resident #1 person and room and found bags of drugs which according to police were Fentanyl, several needles, a lighter, a tourniquet, Suboxone strips, a knife, and a normal saline flush. Resident #1 admitted to the police using actively. Resident #1 was transported to the hospital at 4:15 PM. Review of the baseline care plan dated 11/19/22 failed to identify that the resident's substance abuse disorder was addressed. Further review identified that the resident had a care plan meeting on 12/7/22 and a care plan for suboxone use was completed, however, the resident did not have a care plan for substance abuse disorder completed unitl the resident was found impaired and in possession of drug paraphernalia on 12/14/22. Interview with the DON on 1/13/23 at 10:25 AM identified there was no baseline care plan developed for Resident #1 upon admission and it was the responsibility of the admitting nurse to initiate a baseline care plan upon admission and she was unsure as to why the baseline care plan was not initiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy, police reports and interviews for two (2) of seven (7) sampled residents who were reviewed for a change in condition, (Resident #1 and #3), the facility failed to investigate incidents of drug overdoses, and for Resident #5 who received a medication to treat opioid dependence/addiction, the facility failed to accurately transcribe the frequency of a medication resulting in a medication error. The findings include: 1. Resident #1's diagnoses included psychoactive substance abuse and opioid dependence. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had no cognitive impairment and was independent with Activities of Daily Living (ADL's). A nurse's note dated [DATE] at 4:13 PM identified the DON went to see Resident #1 and assess/talk about reports of active drug use in facility around 3:45 PM. Upon entering the room Resident #1 was noted to be swaying, pupils were pinpoint and speech was slurred. Resident #1 refused to have vital signs taken or have Narcan administered. The DON stayed with Resident #1 and called staff to the room. staff responded and was told to call 911. 911 arrived to the facility at 4:00 PM with 3 EMT's and 2 police officers. The police searched Resident #1's person, room, and found bags of drugs which according to police were Fentanyl, several needles, a lighter, a tourniquet, Suboxone strips, a knife, and a normal saline flush. Resident #1 admitted to the police using actively. Resident #1 was transferred to the hospital. The Resident Care Plan dated [DATE] identified it was suspected Resident #1 was under the influence of illicit drugs and actively using while at the facility. Interventions directed to call 911 and administer Narcan if Resident #1 was impaired. A nurse's note dated [DATE] at 9:36 PM identified nursing supervisor was made aware by a charge nurse that someone claimed Resident #1 was high. Resident #1 was erratic, very talkative then very weepy. Room search was conducted with Resident #1 consent and found what appeared to be drug paraphernalia in Resident #1's pocketbook. Resident #1 was placed on one-to-one observation and 911 was called. The nurse's note dated [DATE] at 4:20 PM identified Resident #1 was found on the floor, no apparent injuries were noted. Resident #1 was semiconscious when name called. Narcan was administered twice, 911 was called and resident #1 was send to the hospital. The nurse's note dated [DATE] at 1:22 PM identified Resident #1 was observed by the floor nurse and NA this morning with behavior suspicious of being under the influence of an unknown substance. On assessment Resident #1 was found to be lying in bed, asleep with shallow respirations 7-8 per minute. Resident #1 was easily arousable with calling his/her name, but notably drowsy with slow, slurred speech. Vital signs stable on assessment. Every fifteen (15) minutes checks continued, and Resident #1 woke up to eat breakfast and was able to carry a conversation. DON was notified and Narcan on hand if required. The nurse's note dated [DATE] at 7:11 AM identified an audible breathing was heard from the hallway. Resident #1 was unable to stand by self, the resident's respiratory rate was 3-4 breaths per minute, pinpoint pupils were noted, and Resident #1 kept drifting off to sleep. Resident #1's pulse was 99 and oxygen saturation 88% on room air. Narcan was administered once, 911 was called and Resident #1 was sent to the hospital at 3:45 AM. 2. Resident #3's diagnoses included pelvis fracture and substance abuse. A care plan dated [DATE] identified Resident #3 used Methadone due to history of a substance disorder, Resident #3 took Methadone to prevent cravings and withdrawal symptoms with interventions that directed to provide Resident #3 with Methadone as directed, individual and group substance abuse counseling as indicated. The admission MDS assessment dated [DATE] identified Resident #3 had no cognitive impairment, required extensive assistance with transfer, locomotion on unit, locomotion off unit and used a wheelchair as a mobility device. A nurse's note dated [DATE] at 10:06 PM identified a charge nurse received a report that Resident #3 had received 4 bags of an unknown drug and had ingested 3 of the 4 bags. Resident #3 allegedly showed another resident the remaining bag. Resident #3 was approached regarding what was being reported and Resident #3 adamantly denied occurrence. Upon assessment Resident #3 was observed to be in an agitated/irritated mood, hyper-verbal with pressured speech, paranoid delusional and pupillary function was Nystagmus. Resident #3 refused vital signs, 911 and police was called, and Resident #3 was transferred to the hospital for further evaluation. The nurse's note dated [DATE] at 11:57 AM identified an update from the hospital was received and Resident #3 tested positive for Fentanyl and admitted to using in facility. The care plan dated [DATE] identified Resident #3 had tested positive for Fentanyl use and admitted to using Fentanyl in the facility. Interventions directed to offer Resident #3 social work and psychiatric support as needed, conduct room searches as needed, obtain urine toxicology test as ordered by physician, and administer Methadone per order. The Police Case/Incident Report dated [DATE] identified on [DATE] at approximately 8:34 PM police officer was dispatched for a report of possible overdose. Upon arrival Resident #3 had possibly used a narcotic provided to Resident #3 by a guest. On [DATE] police responded to this facility for a similar incident with Resident #3 and at that time it was also believed Resident #3 had used a narcotic and had become violent and erratic. Police officer asked the staff as to how Resident #3 possibly obtained the narcotics. The staff stated that they were alerted by a resident that another resident had provided them. Police officer identified it did not appear the facility was making any attempt to resolve this matter within the facility. Review of the clinical records and facility documentation failed to provide documentation investigations were conducted after drug use/overdoses were identified to determine how the illicit substances entered the facility. Interview with the Administrator and the DON on [DATE] at 4:00 PM identified there were no Facility Reported Incidents forms or investigations completed for Resident #1 and Resident #3 when the resident overdosed because the residents were admitted with substance abuse disorder, and it would not be an unusual occurrence for the residents to overdose since they had the diagnosis of substance abuse disorder. Review of the Reportable Events-Reporting Allegations and Incidents Policy directed it was the policy of this facility to report all allegations and events for which reports were required under state and federal laws. An event that was clinically unusual or inconsistent with the policies and practices of the facility. Further the policy directed to report under the Public Health Code an event which had caused or resulted in a resident's death or present an immediate danger of death or serious harm. 3. Resident #5's diagnoses included right acetabulum fracture and history of substance abuse. A quarterly MDS dated [DATE] identified that the resident had intact cognition and was independent with ADL's. A psychiatric note dated [DATE] identified Resident #5 was seen due to Fentanyl overdose over the weekend. Resident #5 was found unresponsive in his/her room, CPR was started and Resident #5 was transferred to the hospital. Resident #5 with long history of substance abuse but was not on Methadone or Suboxone. Counseling was provided and Resident #5 agreed to start Suboxone. Recommend starting Suboxone 2-0.5 milligram one film sublingual daily. A physician's order dated [DATE] directed Suboxone 2-0.5 milligram one film sublingual daily. A Facility Reported Incident dated [DATE] at 2:30 PM identified Resident #5's Suboxone order for 2-0.5 milligram one film sublingual daily was transcribed for three times a day in error. Resident #5 with no signs or symptoms of distress, usual baseline mentation. APRN was notified and order was corrected. Review of the Medication Administration Record (MAR) and Control Substance Disposition Record for [DATE] identified Suboxone was administered three (3) times a day on 11/11 and [DATE] resulting in Resident #5 receiving 4 extra doses of Suboxone in two (2) days. Interview with the Director of Nurses on [DATE]at 1:55 PM identified Suboxone order was a transcription error, and the resident received the medication three times daily on 1/11 and [DATE] instead of one time daily in accordance with the physician's orders. The error was corrected and Resident #5 had no ill effects from receiving four (4) extra doses of Suboxone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation and interviews for one (1) of seven (7) sampled resident who were reviewed for change in condition, the facility failed to consistently document one to one or every fifteen (15) minute monitoring flowsheet form Resident #5's behavior, mood, and location while on every fifteen (15) minute monitoring. The findings include: Resident #5's diagnoses included right acetabulum fracture and history of substance abuse. A quarterly Minimum Data Set (MDS) dated [DATE] identified that the resident had intact cognition and was independent with ADL's. A nurse's note dated [DATE] at 11:59 PM identified at 8:20 PM Resident #5 was found to lying on bed unresponsive to verbal and tactile stimuli, a sternal rub was performed without effect. Resident #5 had no pulse, no respirations, eyes were rolled back, the skin was pale and diaphoretic, CPR was initiated, and 911 called. The resident was administered Narcan without effect, a second dose of Narcan administered with positive effect. Resident #5 began to gurgle, positive pulse and respirations were noted, and CPR stopped due to positive pulse and respirations. Resident #5 become alert, responsive, vomited twice, and was then transported to the hospital for evaluation. A nurse's note dated [DATE] at 8:05 AM identified Resident #5 returned from the hospital at 7:20 AM with a diagnosis of overdose. Every fifteen (15) minute monitoring was put into place. Review of the one to one or every fifteen (15) minute monitoring form for [DATE] failed to provide documentation Resident #5 was consistently monitored on 12/25, 12/26 and 12/29 while on every 15-minute monitoring. Interview with Medical Records #1 on [DATE] at 2:40 PM identified she could not locate every fifteen (15) minute monitoring forms for 12/25, 12/26 and 12/29 in Resident #5's record. Interview with the Director of Nurses on [DATE] at 3:00 PM identified the Medical Record #1 could not locate every fifteen (15) minute monitoring forms for 12/25, 12/26 and 12/29 in Resident #5's record. The DON indicated it was responsibility of the Medical Records to organize, ensure the overflow documentation was complete and in Resident #5 record. Review of the Close Observation policy directed documentation of staff monitoring of any residents on primary levels on observation should be entered on either an every fifteen (15) minute or every thirty (30) minute flowsheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #76) reviewed for injury of unknown origin, the facility failed to submit the outcome of an investigation in a timely manner. The findings include: Resident #76 was admitted on [DATE] with diagnoses that included dementia, aphasia and dysphagia. The quarterly MDS dated [DATE] identified Resident #76 had moderately impaired cognition, was independent with bed mobility and walking, required limited assistance with transfers personal care. The care plan dated 11/26/21 identified Resident #76 was at risk for falls due to dementia and may need assistance with ADL's. Interventions included to allow the resident to do as much of ADL's as able and remind him/her to ask for assistance when weak or unsteady. A reportable event form dated 11/27/21 at 7:30 AM identified Resident #76 was noted with right hand edema (knuckles and inside of right hand), with no known injury. An assessment was completed, the medical and resident representative were notified. An x-ray dated 11/27/21 identified a metacarpal (finger bone of the hand) fracture. An orthopedic consult dated 12/2/21 identified right hand swelling, non-tender on palpation. The x-ray indicates sub-acute, chronic small metacarpal fracture at the base. Recommendations included a compression glove for swelling. The reportable event summary dated 12/7/21, 7 working days after the injury was identified, indicated an x ray noted sub-acute chronic small metacarpal base fractur and osteoporosis, there was no bruising or signs of trauma and the original fracture may have been indicative of a pathological fracture. An orthopedic consultation dated 12/2/21 also noted subacute chronic fracture. A compression glove was put in place for swelling. An interview on 4/14/22 at 1:41 PM with RN #2 identified she was covering as the DNS when the incident occurred and likely was untimely with the investigation findings as she was focused on ensuing the investigation was thoroughly completed. The facility policy for reportable events directs reporting allegations and incidents of unknown origin to be concluded within 5 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #76) reviewed for injury of unknown origin, the facility failed to submit the outcome of an investigation in a timely manner. The findings include: Resident #76 was admitted on [DATE] with diagnoses that included dementia, aphasia and dysphagia. The quarterly MDS dated [DATE] identified Resident #76 had moderately impaired cognition, was independent with bed mobility and walking, required limited assistance with transfers personal care. The care plan dated 11/26/21 identified Resident #76 was at risk for falls due to dementia and may need assistance with ADL's. Interventions included to allow the resident to do as much of ADL's as able and remind him/her to ask for assistance when weak or unsteady. A reportable event form dated 11/27/21 at 7:30 AM identified Resident #76 was noted with right hand edema (knuckles and inside of right hand), with no known injury. An assessment was completed, the medical and resident representative were notified. An x-ray dated 11/27/21 identified a metacarpal (finger bone of the hand) fracture. An orthopedic consult dated 12/2/21 identified right hand swelling, non-tender on palpation. The x-ray indicates sub-acute, chronic small metacarpal fracture at the base. Recommendations included a compression glove for swelling. The reportable event summary dated 12/7/21, 7 working days after the injury was identified, indicated an x ray noted sub-acute chronic small metacarpal base fractur and osteoporosis, there was no bruising or signs of trauma and the original fracture may have been indicative of a pathological fracture. An orthopedic consultation dated 12/2/21 also noted subacute chronic fracture. A compression glove was put in place for swelling. An interview on 4/14/22 at 1:41 PM with RN #2 identified she was covering as the DNS when the incident occurred and likely was untimely with the investigation findings as she was focused on ensuing the investigation was thoroughly completed. The facility policy for reportable events directs reporting allegations and incidents of unknown origin to be concluded within 5 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #90) reviewed for smoking, the facility failed to ensure the care plan was revised to include individualized interventions and measures to restore smoking privileges following a safety violation according to policy. The findings include: Resident #90 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. The quarterly MDS dated [DATE] identified Resident #90 had intact cognition and was independent with supervision for personal care. The care plan dated 7/2/21 identified Resident #90 enjoyed smoking with interventions that included observation for signs of unsafe smoking, smoking while supervised at designated times and review of the facility smoking agreement per policy. A nurse ' s note dated 8/25/21 at 6:55AM identified Resident #90 was observed coming out of the bathroom at 5:30 AM and staff noted smoke in the bathroom. Staff asked the resident if he/she was smoking and the resident denied smoking. A room search was conducted, and the resident refused to open one lock in his/her room, as the resident walked towards the nursing station, cigarettes fell out of his/her pants. The resident was placed on every 15-minute checks for close observation. Resident #90 indicated a family member provided the cigarettes. Subsequently, the family was called and notified of the incident. A social worker progress note dated 8/25/21 identified Resident #90 was caught smoking cigarettes in his/her room and upon a room search, no other smoking paraphernalia was found. Resident #90 became upset and agitated at the nurse's station after a pack of cigarettes fell out of his/her pants. Social worker re-educated the resident on the smoking policy and the policy for storing cigarettes. The social worker discussed the safety concerns of smoking in the room and the consequences of doing so. The care plan dated 8/25/21 was revised to include non-compliance with smoking policy. Interventions included to observe for unsafe smoking, educate as to the dangers of unsafe smoking, and conduct room and person searches as ordered. A social work progress note dated 3/17/22 identified the interdisciplinary team met and discussed Resident #90's request on 3/15/22 to reinstate smoking privileges. A new smoking assessment was completed upon approval. A review of the nurse ' s notes and social worker notes and social work post MDS review dated 8/26/21 through 3/17/22, 7 over 6 months, failed to reflect ongoing smoking violations or the status of Resident #90's smoking suspension. Interview with the Administrator and Corporate Behavior Specialist on 4/14/22 at 12:42 PM identified when a smoking violation occurs, the resident is re-educated on the smoking rules and the smoking policy is provided to all residents on admission. Violations include interventions on the violation (safety vs. harm to self or others). Lifting restrictions is subjective and determined by the behavior team who meets regularly. Resident #90's smoking privileges were reinstated in March 2022 at his/her request as he/she had previously expressed an interest in quitting and a social work progress note should have detailed this information. Interview with Resident #90 on 4/14/22 at 2:45 PM identified his/her smoking privileges were suspended in August of 2021 following an accusation of smoking in his/her room when smoke was observed in the bathroom for which Resident #90 denied. Resident #90 indicated he/she made subsequent requests to resume smoking privileges following the incident but was denied by nursing staff (of which he/she was unable to name) who told the resident he/she would never be able to smoke in the facility again. Resident #90 saw no use in continuing to ask beyond that and did not discuss the concern with the social worker. Resident #90 denied stating he/she wanted to quit smoking but recalled having a recent conversation with the social worker (SW #2), in March 2022 who had inquired about smoking. Resident #90 told SW #1 that it had been so long since he/she had been able to smoke previously, but if able, would like to have smoking privileges resumed which were done so in March 2022. Interview with SW #2 on 4/18/22 at 9:59 AM identified the residents smoking violations and the return of privileges was reviewed by the interdisciplinary team to determine the return of privileges. SW #2 indicated in March 2022 Resident #90 requested to resume smoking privileges. SW #1 indicated that between August 2021 and March 2022, she could not recall if there were any discussions related to Resident #90 ' s smoking privileges. Further, during that timeframe, SW #2 was unable to provide any written documentation on the status of Resident #90's smoking suspension, any individualized interventions implemented for Resident #90 in order to have smoking privileges reinstated, documentation Resident #90 wishes to quit smoking or the supports offered. Interview with PA #1 on 4/18/22 at 10:55 AM identified he provided psychiatric services for Resident #90 at least monthly and more often if needed. PA #1 indicated he was not aware smoking privileges had been suspended for Resident #90, the resident had never expressed increased anxiety, and had not requested smoking cessation products. A subsequent interview and smoking policy review with the Administrator and [NAME] President of Operations on 4/19/22 at 9:00 AM identified violations outlined in the Resident Smoking Rules where smoking in resident rooms was considered a Level 3, strictly forbidden and, may result in progressive measures to ensure resident safety ranging from re-education up to revocation of smoking privileges. The Smoking Agreement detailed implementation of interventions once a violation occurred which may include, temporary termination of smoking privileges, modification of the smoking schedule, offering of smoking cessation materials, smoking cessation classes, written agreements between the resident and team that reinforced compliance, and psychiatric assessments for mental status changes. Smoking infractions were to be documented on a tracking sheet with remedies applied per episode and progressive corrected action. The Administrator and [NAME] President of Operations were unable to provide written documentation of any individualized interventions put in place for Resident #90 that included temporary suspension of smoking privileges as a result of the violation, the offering of smoking cessation products, the offering of smoking cessation classes, written agreement between the resident and team that reinforced compliance, modification of smoking schedule or that a tracking worksheet was utilized indicating the implementation of such measures according to policy and documented progress toward reinstatement of privileges for no further violations. Additionally, these components were not included as part of Resident #90's individualized care plan. The facility policy for resident smoking further directs care plans to be developed with appropriate interventions and updated to reflect the resident's current status. Although a policy for resident care plans was requested, none was provided. The facility failed to ensure the care plan was revised to include measures to restore smoking privileges according to the policy following a safety violation for a resident who smokes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and review of clinical records and and interviews for one of three residents (Resident #79), reviewed for dining observations, the facility failed to ensure adequate supervision during mealtimes to ensure a dignified dining experience and/or for one of five residents (Resident #90) reviewed for mistreatment/ dignity, the facility failed to ensure the resident received care in a respectful / dignified manner that enhanced the resident's quality of life. The findings included: 1. Resident #79's diagnoses included dementia, confusion secondary to dementia with depressed mood, hypertension and hypothyroidism. A quarterly Minimum Data Set ( MDS) assessment dated [DATE] identified the resident as severely impaired for cognitive status and requiring supervision and/or cueing and/or set up help from staff for eating/ no unknown weight loss and/or weight gain, and indicated the resident received a mechanically altered and/or therapeutic diet as a nutritional approach. The Resident Care Plan (RCP) updated on 7/13/19 identified at risk for alteration in nutrition as a problem. Interventions included : to provide diet as ordered, provide fortified foods, provide supplements as order, provide foods resident enjoys as available, provide snack per protocol, observe diet tolerance and address problem when needed , to provide the resident with set up assistance at meal time and to report concerns to the dietitian. On 8/26/19 during the time frame of 12:32 P.M. through 12:54 P.M. on the second floor in the main dining room, during dining observations of the lunch meal identified Resident # 79 confused taking bites of food, spitting the food out in a napkin and utilizing his/her left hand as though it were a piece of bread and spreading rice on the palm of his/her left hand. Although there were staff members in the dining room, passing out meals, beverages and feeding other residents, no redirection and/or supervision and/or guidance was offered to the resident. When Resident # 79 completed his/her meal he/she left the dining room and proceeded back to the second floor E wing unit. 8/27/19 at 1:45 P.M. an interview with Person #2 indicated that although he/she had was satisfied with the resident's overall care, Person # 2 was aware the resident had the tendency to play with his/her food and/or if the resident is served something he/she doesn't like, Resident # 79 will not eat the food. Person # 2 indicated that although he/she cannot always be present he/she does try to come and visit during lunch to assist Resident #79 eat and wonders what happen when she/he is not present to provide the assistance On 8/29/19 12:30 P.M. through 8/29/19 12:51 P.M. identified Resident #79 observed sitting in the dining room at a table with two other residents utilizing a clothing protector to cover his/her upper body. Resident #79 was identified with a butter knife cutting up spaghetti repeated with portions of it sliding off his/her lunch plate onto the table and/or the floor and/or onto the resident's lap. Although the resident was observed taking small bites of the spaghetti while utilizing a fork, the resident was further noted spitting food out of his/her mouth onto the floor to the right. Resident # 79 dropped his/her butter knife at which time staff picked up the butter knife and did not replace the utensil. The resident was further observed taking off his/her clothing protector and wrapping in a ball (type manner) and placing it onto his/her lap. Resident#79 once again was observed playing with strains of spaghetti in his/her hand and spitting it on the floor. On 8/29/18 at 12:51 P.M. the unit charge nurse Licensed Practical Nurse (LPN#8) for the 2-E wing assigned to provide care to Resident #79 was asked by surveyor to accompany him/her to observe Resident #79 during the lunch meal. Occupational Therapist ( OT#2) who was also on the unit was present for the observation. Upon further observation of Resident #79 by both LPN#8 and OT #2 identified Resident # 79 with globs of spaghetti and chewed up mixed vegetables on the thigh area of his/her sweat pants and a balled-up clothing protector on the table beside his/her plate and/or on the floor to the right. OT #2 was observed adjusting the resident in his/her chair to bring the resident closer to the table after adjusting the resident's clothing and clothing protector. An interview with OT#2 at the time of the observation identified Resident #79 required assistance with his/her meals and suggested a screening to see what could be done to assist the resident with his/her meals or functional level. 2. Resident #90's diagnoses included sepsis due to endocarditis, an infection of the heart's inner lining, usually involving the heart valves. The admission Minimum Data Set assessment dated [DATE] identified Resident #90 had no short and/or long term memory problems, was independent and/or required limited one (1) person assistance with activities of daily living, and was receiving intravenous medications. The resident grievance report dated 7/8/19 identified Resident #90 reported he/she was unhappy with the care and services provided to him/her by one of the charge nurses, Licensed Practical Nurse (LPN) #2. Resident #90 reported the nurse did not prep the intravenous access site with the alcohol prep pad properly and LPN #2 became frustrated speaking in a loud tone when the resident questioned her about the technique. The report indicated Resident #90 commented LPN #2 was unpleasant at times, does not know what she was doing and/or how to perform her job and the incident occurred 7/7/19. The grievance report identified when Resident #90 was approached on 7/16/19 to discuss the findings and actions taken, Resident #90 proceeded to hand the Administrator, Director of Nursing, and the Director of Social Services seven (7) pages of handwritten notes indicating that he/she had been verbally abused by LPN #2. Subsequent to the meeting a Reportable Event Form was completed, an investigation was immediately initiated and LPN #2 was removed from the schedule pending the investigation. The Reportable Event Form dated 7/16/19 identified although Resident #90 stated a staff member was verbally abusive to him/her, the resident was unable to give an exact date when the incident had occurred. The facility's investigation summary identified that Resident #90 originally handed in a grievance on 7/8/19 regarding a customer service concern involving LPN #2 on how she cleaned the intravenous access site, LPN #2 did receive, on the day the grievance had taken place (7/6/19) immediate education by the Nursing Supervisor, both verbally and by the way of demonstration, on how to appropriately clean an intravenous access site. The summary indicated on 7/16/19 Resident #90 met with the Administrator, Director of Nursing, and the Director of Social Services and identified that he/she felt he/she had been mistreated by LPN #2 on 7/6/19. At the conclusion of the investigation due to inconsistencies with interviews and written statements, the facility was unable to substantiate an allegation of mistreatment. Resident #90 had been followed up by the psychiatrist and social services to ensure no ill effects, LPN #2 had been provided education and LPN #2 would not provide care to Resident #90 per the resident's request. Review of LPN #2's performance evaluation dated 7/26/19 identified areas of needing improvement were customer service and to work on how the residents perceived her. Interview with Resident #90 on 8/27/19 at 10:00 AM identified he/she felt that LPN #2 did not clean the intravenous access site correctly prior to connecting the intravenous tubing to the port site. Resident #90 stated when he/she asked LPN #2 to clean the port site properly, LPN #2 started getting upset, getting temper in her voice and raised her voice towards him/her. Resident #90 stated that was when he/she become upset with LPN #2 and stated he/she would file a complaint against LPN #2. Interview with the 3-11PM Nursing Supervisor, Registered Nurse (RN) #3, on 8/28/19 at 12:35 PM identified LPN #2 reported to her that Resident #90 accused her of not cleaning the intravenous port site properly. RN #3 stated although Resident #90 identified LPN #2 was rude, Resident #90 would not give more specifics and stated that he/she wanted to file a grievance. RN #3 stated that she provided Resident #90 with a grievance form to fill out and referred Resident #90 to social services because they handle the resident grievances. RN #3 identified that she spoke with LPN #2 regarding her tone of voice and how it was perceived by others. Interview with the Director of Social Services on 8/28/19 at 12:44 PM identified Resident #90 came to her and made a complaint regarding LPN #2's care that she provided and the tone of LPN #2's voice. The Director of Social Services offered to fill out the complaint for Resident #90 so the investigation could be initiated and also provided a grievance form for Resident #90 to fill out. The Director of Social Services identified that when she, the Director of Nursing and the Administrator went to talk to Resident #90, Resident #90 submitted a grievance with a lot more allegations and at that point the allegation was reported to the Department of Public Health. The Director of Social Services identified interviews with other residents on the unit were conducted to determine whether other residents had any complaints regarding LPN #2. The Director of Social Services identified there were a couple of residents who were unhappy with LPN #2, that LPN #2 was unpleasant, and complained about LPN #2's tone of voice. The Director of Social Services identified Resident #90 had no ill effects from the incident. Interview and clinical record review with the Director of Nursing (DON) on 8/28/19 at 3:15 PM identified that LPN #2 had been removed from the schedule after Resident #90's allegation of mistreatment was reported. The DON stated that LPN #2 came across to Resident #90 and other residents as being rude. The DON identified that she spoke to LPN #2 in the past regarding customer service issues. Interview with LPN #2 on 8/28/19 at 3:30 PM identified that Resident #90 did not voice any concerns to her and she find out about Resident #90's allegation when she was called into the DON's office. Review of the customer service in-service indicated that tone of voice and non-verbal communication was important, to keep tone of voice calm, speak politely and make eye contact. Review of the employee code of conduct directed to show respect, dignity and empathy for all residents regardless of their race, gender, age, nationality, language, religion, sexual orientation, physical traits, or any other personal characteristics. To not harass others or use any words or actions that were disrespectful or potentially harmful. To act professionally and not use profanity, vulgarity, yelling or other inappropriate language or gesture when communicating with others. Review of the Resident's [NAME] of Rights directed that residents had the right to be treated with consideration, respect and full recognition of their dignity and individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation and staff interview of one of three sampled residents (Resident # 254) who required assistance with ADL, the facility failed to ensure the resident's call bell was within reach to accommodate the resident's need for assistance with toileting. The finding include: Resident # 254's diagnoses included Peripheral Vascular Disease PVD, hypertension , anxiety, depression and Traumatic Brain Injury (TBI), history of falls and Non-Alzheimer's Dementia. A review of the Resident Council Minutes for March 29, 2019 identified one resident stated he/she had to wait for 90 minutes before a Nurse Aide (NA) came in his/her room and indicated many calls bells are not in reach. The RCP dated 6/4/19 for I have dementia, anxiety and TBI and require assistance of one person with all my self-care tasks including toileting. Interventions included: to encourage me to use the call bell for assistance and to assist me with the urinal to minimize spills even thou I think I can do it myself. The annual MDS assessment dated [DATE] identified the resident's was moderately cognitively impaired and memory problems, required extensive assistance one person physical assistance with transfers and personal hygiene, limited assistance with one person physical assistance with toileting. The annual assessment also noted impairment of lower extremity and utilization of a manual or electrical wheelchair. Observation on 8/26/19 during pool selection at 11:05 A.M. identified Resident # 254 out of bed in the wheelchair in his/her wheelchair with the resident's call bell on left side of the bed without in reach of the resident. Further observation on 8/26/19 at 11:05 A.M. identified the call bell tied to the left side rail, curtain pulled, the roommate night table and bed noted minimum space for Resident # 254 to obtain the call bell. Further observation on 8/26/19 at 11:05 A.M. identified Resident # 254 attempting to self-toilet in the bathroom. Surveyor immediately notified LPN # 2 of the resident's call bell out of reach and the resident's attempt to self-transfer to the bathroom. Observation with Licensed Practical Nurse #2 and Administrator # 2 on 8/26/19 at 11:10 A.M. identified the surveyor having difficulty accessing the call bell on the left side of the side rail and secondary to limited space the resident's roommate night table, curtain and bed. Interview with LPN # 2 on 8/26/19 at 11:05 A.M. identified the resident's call bell should be in reach and indicated the resident had weakness on one side of the body and require assistance to go the bathroom. Subsequent to inquiry, LPN #2 moved the resident's call bell to the right side of the bed and updated the care plan on 8/26/19 to indicated please make sure my call bell is within reach on my right side.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #112) reviewed for personal property, the facility failed to follow the lost clothing and/or personal possession policy. The findings include: Resident #112's diagnoses included weakness, anxiety and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #112 was without cognitive impairment. An interview with Resident #112 on 8/26/19 at 11:55 AM noted several different items of lost clothing that were never found, he/she had his/her name on the items and indicated nobody cared that the items were missing. Review of the grievance log identified although missing personal property for other residents, nothing was identified as missing for Resident #112. Re-interview with Resident #112 on 8/29/19 at 11:30 A.M. identified that he/she was missing a University of Connnecticut (Un [NAME]) jacket and some other items that had his/her name written on the clothing. Resident #112 identified that he/she had reported the missing items to the Director of Housekeeping. Interview with the Director of Housekeeping on 08/29/19 at 12:12 PM identified Resident #112 had reported to him/her that he/she had lost a UConn jacket that had jean material sleeves and a dark center and some dresses months ago. The Director of Housekeeping identified that the process for lost clothing is that the facility will search for the missing items in the unlabeled clothes bin, if the items are not found, the entire facility is searched, and indicated if the items are still not found, social services is notified. The Director of Housekeeping identified that he/she had instructed Resident #112 to fill out a grievance form and then call social services for follow up. The Director of Housekeeping identified that he/she was not sure if Resident #112's memory was intact. The Director of Housekeeping further identified that he/she had asked the personal laundry staff if he/she had seen Resident's 112's clothing and that the personal laundry staff identified that he/she had never seen the items. The Director of Housekeeping was unable to identify how a missing item that had not gone down to be laundered was identified. Interview with the Personal Laundry Aide #1 on 8/29/19 at 12:15 PM identified that he/she had been told that Resident #112 had a missing UConn jacket and other stuff, that all of Resident #112's items were labeled and that he/she had never seen the missing items come to laundry. Interview and review of facility policy with the Administrator and RN #6 on 8/29/19 at 12:41 PM identified the Director of Housekeeping should have notified the Director of Social Work and should have not expected Resident #112 to independently write out a grievance and notify the Director of Social Work of the missing items. The Administrator and RN #6 identified that the facility policy for Resident Grievances identified that if laundry was not found within 14 days that a grievance form should have been generated. Subsequent to surveyor inquiry, the Administrator identified that he/she would have the Director of Social Work complete a grievance form for Resident #112.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, review of facility documentation and interviews and review of facility policy, the facility failed to check the performance of glucometers per the manufacturer recommendations and/or per facility policy and/or for one sampled resident ( Resident # 12) who required a pain medication, the facility failed to administer the medication in accordance to physician's orders and /or for one of three residents observed for medication administration (Resident #38), the facility failed to ensure standards of practice were met related to ensuring medications were reordered in a timely manner to ensure availability. The findings included: 1. A review of the facility infection control practices for glucometer monitoring, reviews of facility documentation on 8/26/19 and 8/27/19 identified that the licensed staff failed to consistency document the results of the quality assurance control test for glucometer test monitoring in accordance to professional standard of practice. Interview on 8/28/19 at 7:12 AM with LPN #9 identified when he/she opens a new bottle of glucose test strips, he/she will run the quality assurance control test. LPN #9 further identified he/she does not document the results of the quality assurance control test because nobody ever told him/her that he/ she had to and indicated he/she knew that the night shift document the quality assurance control test results every night. Interview on 8/28/19 at 7:20 A.M. with LPN #10 identified when he/she opens a new bottle of glucose test strips, he/she will run the quality assurance control test. LPN #10 further identified he/she only documents the quality assurance control test results if she/he performs the tests when he/she is at the nurse's station. A review of the C wing glucometer quality assurance logs with LPN #11 on 8/28/19 at 7:23 A.M. identified the quality assurance control test had not been completed on the C wing glucometers since 2018. Interview with LPN #11 identified he/she was responsible for performing the quality assurance control the previous night but had not done so because he/she was too busy. LPN #11 also indicated he/she did not notify the supervisor that he/she was too busy to perform quality assurance control test. LPN #11 further identified he/she could not recall the last time he/she had run a quality assurance control test. Interview on 8/28/19 at 7:54 A.M. with LPN #5 identified he/she performs but does not document the quality assurance control test when he/she opens a new bottle of glucose test strips. Interview on 8/28/19 at 8:12 A.M. with LPN #12 identified a quality assurance control test should be run on every glucometer daily and whenever a new bottle of glucose test strips is opened. Subsequent to surveyor inquiry, the facility initiated education of the staff that included when and how to perform and document the quality assurance control test on the glucometers. A review of the facility's capillary blood glucose monitoring policy identified a quality control check should be performed daily or more often per manufacturer's guidelines. Results of the quality control check should be documented on the blood glucose meter quality control record. The DNS or designee will monitor results/compliance. 2. Resident # 12's diagnoses included respiratory failure, opioid dependence in remission, anxiety, Post-Traumatic Stress Disease (PTSD) and pneumonia. The admission MDS assessment dated [DATE] identified the resident's cognition and memory were intact, required limited assistance with personal hygiene and noted the utilization of anti-depressant medication. The physician's orders dated 7/26/19 directed Suboxone 8-2 MG sl film bid. A review of the Reportable Event dated 8/21/19 identified Resident # 12 was scheduled to receive Suboxine 8-2 mg sl flim daily and instead received ( 2) of the 8-2 MG sl films on 8/29/19. Additionally, the RE noted the resident suffered no discomfort/injury /distress and the resident was assessed by an RN and staff was directed to monitor the resident's vital signs every shift for 24 hours. Interview with the ADNS on 8/29/19 at 1:10 P.M. identified she/he was on duty the day on 8/21/19 when she/he received a call that the narcotic count was incorrect. The ADNS on 8/29/19 further indicated after investigating the incorrect narcotic count she/he discovered that Resident # 12's Suboxone 8-2 MG sl film was mixed with another resident's medication which was the cause of the medication error. The ADNS also indicated she /he reported the medication error per facility practice. 3. Resident #38 was admitted [DATE]. The resident's diagnoses included dementia and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #38 had severe cognitive impairment, required supervision for walking in the room, and received an antidepressant medication. The care plan dated 6/13/19 identified psychotropic drug use for anxiety and dementia, with intervention to report any target behaviors noted. A physician's order dated 6/26/19 directed to administer Trazodone (Desyrel) 50 Milligram (MG) by mouth twice daily at 9:00 A.M. and 5:00 P.M. for agitation. Observation and interview with LPN #5 on 8/27/19 at 8:45A.M. identified Resident #38's Trazodone 50 MG, could not be located in the medication cart. LPN #5 notified the RN Supervisor (RN #7). LPN #5 then identified that he/she called the pharmacy and reported to RN #7 that the pharmacy said it was not reordered and would send the medication today. Subsequent to LPN #5 calling the pharmacy, he/she reported the Trazodone 50 MG was not located in the medication cart to RN #7 who identified that the medication was not available in the emergency medication supply. LPN #5 identified that the medication should have been re-ordered several days ago, and last evening's nurse should have ensured that the medication was available when using the last tablet. LPN #5 was unable to explain why the evening nurse did not order the medication. Interview with RN #7 on 8/27/19 at 10:25 A.M. identified Trazodone was in the emergency medication supply, but he/she did not recognize the medication as Trazodone because it was listed under the brand name of Deseryl. RN #7 identified the second shift nurse (LPN # 6) should have ensured the medication was available. Interview with LPN #6 on 8/28/19 at 3:32 P.M. identified he/she did administer the last dose of Trazodone and looked for more in the bottom drawer but there was none. LPN #6 identified that he/she did not call the pharmacy on the night shift because he/she saw the sticker was off the blister pack, so he/she believed the medication had been re-ordered. LPN #6 further indicated that it was his/her responsibility and in the future he/she would call the pharmacy to make sure the medication was ordered. Interview with Pharmacist #1 on 8/29/19 at 12:40 P.M. identified that the pharmacy had sent a 30 day supply (60 tablets) on 8/4/19 and on 8/27/19 received a faxed refill request at 9:39 A.M. A nurse then called for a back-up dose for one day and this was dispatched to the facility from the local pharmacy at 12:00 P.M. on 8/27/19. Pharmacist #1 identified that on 8/28/19 another 30 day supply (60 tablets), was delivered and this was an early refill of the medication and Resident #38's supply should have lasted longer. The Pharmacy Procedure for reordering medication refills identified refills are written on a medication reorder form/ordered by peeling the reorder tabs from the prescription label and placing it in the appropriate area on the order form. The procedure further identified the refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, interviews, review of facility documentation and review of facility policy for one of five residents reviewed for Abuse (Resident #9) the facility failed to perform every 15 minute monitoring checks after an allegation of mistreatment. The findings include: Resident #9's diagnoses included diabetes, heart failure, and depression. The Resident care Plan (RCP) dated 2/20/19 identified another resident of the facility alleged Resident #9 kissed a female resident while performing an inappropriate act. Interventions included to place Resident #9 on close observation and the community awareness program. A physician's order dated 2/20/19 directed a nursing intervention to provide every 15 minute monitoring checks and to place Resident #9 on community awareness. A psychiatric APRN note dated 2/22/19 identified the APRN met with Resident #9 to discuss an allegation of inappropriate behavior with another resident. The admission minimum data set (MDS) assessment dated [DATE] identified Resident #9 had no cognitive impairment and needed set up help for personal hygiene. A physician's order dated 3/13/19 directed a nursing intervention to discontinue every 15 minute monitoring checks and to change the monitoring checks to every 30 minutes. A nursing progress note dated 3/22/19 identified Resident #9 was observed in another resident's room involved in an inappropriate behavior. The RCP dated 3/22/19 identified a staff member observed Resident #9 leaned over a resident who was laying on a bed. Resident # 9's head appeared to be positioned at the other resident's pelvic area. An APRN note dated 3/23/19 identified he/she was asked to examine Resident #9 on 3/22/19 after a social worker reported that Resident #9 appeared to be leaning over the bed of another resident with his/her face in the other resident's pelvic area. A review of the clinical record failed to identify any documentation that every 15 minute and/or every 30 minute checks were completed for Resident # 9 from 2/22/19 through 3/22/19 as directed in the physician orders in accordance to the plan of care. Interview with RN #6 on 8/29/19 at 8:45 AM identified if residents are on every 15 minute and/or every 30 minute checks a flowsheet should be completed to reflect the checks were done. The facility has been unable to locate any every 15 minute and/or every 30 minute monitoring flowsheet checks for Resident # 9 from 2/22/19 through 3/22/19. A review of the facility's close observation policy identified documentation of staff monitoring of any resident on primary levels of observation should be entered on either every 15 minute or every 30 minute flowsheets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of the clinical record and review of facility documentation, for one of eleven Residents reviewed for dining (Resident # 80), the facility failed to ensure proper positioning for dining. The findings include: Resident #80 was admitted on [DATE]. The resident's diagnoses included dysphagia and dementia. The quarterly MDS assessment dated [DATE] identified Resident #80 had moderate cognitive impairment, was totally dependent for eating, and had a weight loss of 5% or more in the last month or loss of 10% or more in the last six months, and was not on a physician-prescribed weight loss-regimen. The care plan dated 7/15/19 identified a risk for an alteration in nutrition related to dementia, behaviors and poor vision with interventions that included to provide assistance as needed for mealtimes. A physician's order dated 8/1/19 directed pureed diet with thin liquids, supervision during all meals. Dining observation on 8/26/19 at 12:36 PM identified Resident #80 with eyes closed, top of head leaning back resting on the wheelchair head rest, chin elevated. NA #3 was observed attempting to feed Resident #80 with his/her head in this position. When asked by the surveyor if the Resident was safe to eat with his/her head positioned tilted way back, NA #3 was observed placing her/his hand in the back of the Resident's head to prevent the resident's head from leaning back on the headrest. The surveyor asked if a therapy staff was present to evaluate the resident's positioning. Observation and interview with OT #2 on 8/26/19 at 12:45 .PM identified that the Resident # 80's headrest needed to be adjusted for proper positioning. Interview with RN #6 on 8/26/18 at 12:50 P.M. identified that, subsequent to surveyor inquiry, the resident's food would be covered and the Resident # 80 would be brought out of the dining room and the resident's headrest would be adjusted. On 8/26/19 at 12:53 P.M. Resident #80 was returned to the dining room with headrest adjusted and NA #3 resumed feeding the resident. Interview with RN #6 on 8/29/19 at 2:30 P.M. identified there is no facility policy specific to positioning for dining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, interviews, review of facility documentation for one sampled resident ( Resident #12), the facility failed to follow a physician's order for medication administration and/or for one of two residents reviewed for Behaviors (R#126), the facility failed ensure staff monitor the resident for specific target behaviors in accordance to the plan of care and/ or for one of two residents reviewed for impaired skin integrity and medication administration (Resident #205), the facility failed to ensure that dressing changes were administered and/or administered in accordance with physician orders, and/or that medications were administered in accordance with physician's orders. The findings included: 1. Resident # 12's diagnoses included respiratory failure, opioid dependence in remission, anxiety, Post-Traumatic Stress Disease (PTSD) and pneumonia. The admission MDS assessment dated [DATE] identified the resident's cognition and memory were intact, required limited assistance with personal hygiene and noted the utilization of anti-depressant medication. The physician's orders dated 7/26/19 directed Suboxone 8-2 MG sl film bid. A review of the Reportable Event dated 8/21/19 identified Resident # 12 was scheduled to receive Suboxine 8-2 mg sl flim daily and instead received ( 2) of the 8-2 MG sl films on 8/29/19. Additionally, the RE noted the resident suffered no discomfort/injury /distress and the resident was assessed by an RN and staff was directed to monitor the resident's vital signs every shift for 24 hours. Interview with the ADNS on 8/29/19 at 1:10 P.M. identified she/he was on duty the day on 8/21/19 when she/he received a call that the narcotic count was incorrect. The ADNS on 8/29/19 further indicated after investigating the incorrect narcotic count she/he discovered that Resident # 12's Suboxone 8-2 MG sl film was mixed with another resident's medication which was the cause of the medication error. The ADNS also indicated she /he reported the medication error per facility practice. 2. Resident #126's diagnoses included severe major depression, dementia with delusions and depression and anxiety disorder. A quarterly MDS assessment dated [DATE] identified the resident as severely impaired for cognitive status, mildly depressed as a mood severity, without behaviors, requiring limited, extensive and total assistance from staff for activities of daily living and receiving antidepressant medications for the last seven days. The RCP updated on 5/16/19 identified sometimes resident chooses not to accept treatments/medications/appointments as the problem. Intervention directed if I choose not to accept any treatment, appointment or care, please approach resident at a later time. The psychiatric note dated 6/27/19 identified in part, Resident #126 was seen for pulling hair and spitting on the floor. Medications included Namenda 10 mg twice daily and Trazodone 25 mg twice daily. No target behaviors listed. Impression and plan: Resident with increased spitting behavior and pulling hair, Zoloft 50mg daily, Trazodone 25 mg twice daily discontinued, Ativan 0.25mg twice daily. Resident not considered a danger to self and/or others at this time. The psychiatric note for Resident #126 dated 7/25/19 identified the resident was seen for constantly spitting. Current medications at the time included Zoloft 50 mg daily and Ativan 0.25 mg twice daily. No target behavior listed. Resident not considered a danger to self and/or others at this time. Impression and plan: Resident continues spitting on the floor. Ativan with no effect. Depakote sprinkles 250mg twice daily, VPA in 3 weeks and discontinue Ativan. The physician's orders dated 7/26/19 directed to discontinue Depakote Sprinkles 250mg twice daily and directed Depakote Sprinkles 125mg twice daily with Valporic levels to be drawn in three weeks. Review of the TAR for August 2019 identified Valporic acid levels on 8/8/19 and 8/23/19 laboratory blood work were not drawn. The nurse's notes dated 8/23/19 at 6:20 A.M. noted patient alert/verbal responsive confused, denies pain refused laboratory blood work as ordered for VPA level, redirected several times, due to confusion, unable to obtain blood work by laboratory technician. Observation of Resident #126 on 08/26/19 at 10:47 A.M. identified the resident sitting in his/her wheelchair across from the nurse's desk talking about residents who were either walking by and/or wheeling themselves in their wheelchairs throughout the unit. Although staff frequently approached the resident concerning his/her behavior, Resident #126 was not easily redirected, but did eventually quieted down. Review of Behavior/Intervention monthly flow sheet for the months of March 2019 through August 28, 2019 for all three shifts, identified in part, that although the facility were monitoring Resident#126 for diagnoses of delusion, depression and/or mood, documentation failed to reflect specific target behaviors associated with the utilization of the resident's psychoactive medications and/or diagnoses were identified. On 8/29/19 at 5:20 PM. an interview and review of the clinical record with RN#6 (the facility's Regional Nurse) in the presence of the DNS and the survey team indicated PA#1 should be documenting Resident#126's target behaviors. 3 . Resident #205 was admitted to the facility on [DATE] with a diagnosis of septic arthritis to the left shoulder and right wrist and hypertension. An admission assessment dated [DATE] identified that the resident was alert and oriented, required extensive assistance with activities of daily living, and the resident's right hand was swollen with a 0.5 centimeter open area noted, and a surgical site with 3 sutures in place to the left shoulder with dressings placed over both areas. Review of care plan dated 2/6/19 identified that the resident had a surgical site to the right wrist and left shoulder with interventions that included to administer treatments as ordered. a) Review of a hospital Discharge summary dated [DATE] identified that the resident was admitted for septic arthritis of the left shoulder and right wrist, a joint aspiration and culture grew group c strep, and the resident was started on intravenous antibiotics. The discharge summary report instructed to bandage the right wrist and left shoulder, and to continue the Ceftriaxone 2 grams intravenously daily for 38 days. Review of the admission physician's orders dated 2/6/19 failed to identify a physician's order for dressing change to the right wrist and/or left shoulder. Review of the Treatment Administration Record (TAR) for February 2019 identified to cleanse the right wrist and left shoulder with normal saline and cover with a dry dressing once a day, the treatment was signed off as completed on 2/6/19. The TAR failed to identify a dressing change was completed on 2/7/19. Review of a wound care progress note dated 2/8/19 identified that the left shoulder surgical incision measure 1 cm in length, and 1 cm in width, and the surgical incision on the right hand measured 1 cm in length, and 1 cm in width, both areas noted with drainage, the physician was notified and orders were obtained to apply silver alginate to the areas twice a day. Review of the physician's orders dated 2/8/19 directed to cleanse the right wrist and left shoulder with normal saline and apply calcium alginate with sliver followed by a clean dry dressing. Review of the TAR for 2/8/19 failed to identify that the treatment had been done twice a day, as an arrow was drawn on the TAR to indicate the treatment to be started on 2/9/19. Interview with Registered Nurse (RN) #7 on 8/30/19 at 11:00 AM identified that she had done the admission orders on 2/6/19, had obtained the physicians order for the dressing, and had placed in on the TAR, but may have not placed it in the physicians orders. Interview and review of the February 2019 TAR with Licensed Practical Nurse (LPN) #12 (the facility wound nurse) on 8/30/19 at 12:30 PM identified that the dressing was changed on 2/6/19 by RN #7, but then the dressing was marked as discontinued on 2/6/19 and an order for the dressing change was not entered onto the TAR until 2/8/19, and not documented as completed until 2/9/19. LPN #12 identified that there was documentation on the TAR that the dressing was changed on 2/7/19, but there was no order at that time, so it was unclear what dressing was administered. She further identified that when she evaluated the wound on 2/8/19 she noted that the TAR lacked documentation of a treatment and/or in the physicians orders for a treatment, she contacted the surgeon for recommendations, wrote the order for the calcium alginate on 2/8/19, and completed the dressing change on that day but did not document on the TAR that she had completed the treatment. LPN #12 further identified that the treatment was not completed on 2/8/19 on the 3:00 PM to 11:00 PM shift as ordered by the physician. b) Review of the a nurse's note dated 2/10/19 identified that the resident was sent to the hospital for increased swelling in the left shoulder and decreased range of motion in the left shoulder. The hospital Discharge summary dated [DATE] identified that the resident was admitted to the hospital on [DATE] for further treatment of the septic right wrist and left shoulder, the left shoulder and right wrist were washed out for the septic joint, with discharge instructions to have wet to dry dressings to the right wrist, and a sterile bandage to the left shoulder. Review of a wound assessment dated [DATE] identified that the right wrist has one suture and measured 1.0 cm in length by 1.0 cm in width with 100% epithelial tissue, the left shoulder had 2 sutures and measured 1.0 cm by 1.0 cm. Review of physician's re-admission orders dated 2/13/19 failed to reflect the dressing change orders for the right wrist and left shoulder. Review of February 2019 TAR's failed to identify that the wet to dry dressing to the right wrist and the sterile bandage to the left shoulder were transcribed. The TAR identified that the treatment administered from 2/13-2/18/19 was for normal saline rinse followed by calcium alginate with silver followed by a clean dry dressing to both areas. Interview with LPN #12 on 8/30/19 at 12:30 PM identified that on 2/18/19 the resident had approached her and was concerned about his/her dressing changes, she looked at the hospital Discharge summary dated [DATE] and the TAR and noted that the treatment for recommended on the admission on [DATE] was not transcribed onto the physicians orders and/or the TAR, but identified that the previous treatment that was ordered on 2/6/19 was completed from 2/13-2/17/19. The wound nurse further identified that the incorrect treatment was administered to the resident on 2/13, 2/14, 2/15, 2/16, 2/17 and 2/18/19. LPN #12 stated that she called the physician and the order was changed to reflect the dressing on the discharge summary. Interview with the Director of Nurses on 8/30/19 at 3:10 PM identified that the admitting nurse should ensure that treatments to the surgical areas are in place upon admission, and wound care should be provided in accordance with physician's orders. Interview with the wound care physician (MD#2) on 8/30/19 at 1:45 PM identified that although she would expect the wound care to be done as the discharge summary identified, the wound care that was provided to the resident from 2/13 to 2/18/19 would not have had any impact on the wound. Interview with the Director of Nurses on 8/30/19 at 3:10 PM identified that the admitting nurse should ensure that treatments to the surgical areas are in place upon admission, and wound care should be provided in accordance with physician's orders. Review of the transcription policy identified that all orders will be accurately transcribed and executed in a timely manner to ensure accurate administration of physician's orders. c) Review of the admission nursing assessment identified that the resident was admitted at 2:00 PM on 2/6/19. Review of the admission physicians orders dated 2/6/19 directed to administer isosorbide mononitrate 60 milligrams (mg) by mouth daily, cholecalciferol (Vitamin D3) 1000 units by mouth daily, and Ceftriaxone 2 grams intravenously (IV) daily for 6 weeks. Review of a facility IV order sheet for the ceftriaxone 2 gram IV dated 2/6/19 at 9:00 PM identified that the medication was required on 2/6/19, as soon as possible. There was a handwritten notation at the top of the form that read STAT!!! A nurses note dated 2/7/19 at 6:45 AM identified that the IV medication was to be started when the pharmacy delivers the medication. Review of the Medication Administration Record (MAR) for February 2019 identified that the isosorbide mononitrate 60 mg was not administered on 2/7/19 with the first dose documented as administered on 2/8/19. The cholecalciferol was not administered on 2/7, 2/8, 2/9, and 2/10/19 (the resident was hospitalized 2/10-2/13/19). The Ceftriaxone 2 gr IV was not administered on the day of admission [DATE]), with the first dose administered on 2/7/19. Review of the February 2019 MAR with LPN #12 on 8/30/19 at 12:45 PM identified that the isosorbide mononitrate was not given on 2/7/19 because whoever had written the order on the MAR mistakenly had drawn a line for the medication to be administered on 2/8/19 instead of 2/7/18. The cholecalciferol was entered onto the MAR on 2/6/19 but was not signed off as administered until 2/14/19 (when the resident returned from the hospital), and although R #204 should have received the cholecalciferol on the dates listed, LPN #12 was unable to identify why the cholecalciferol was not administered until 2/14/19. LPN #12 further identfied that the Cholecaliferol is a house stock medication, and is readily available for administration. Interview with RN #7 on 8/30/19 at 3:00 PM identified that she was the nursing supervisor on 2/6/19 when the resident was admitted to the facility, and had filled out the IV order sheet and faxed it to the pharmacy, she further identified that if the form was timed at 9:00 PM, that was the time the form was faxed to the pharmacy. She stated that she was unsure why she documented that the medication was needed on 2/6/19, as soon as possible. She further identified that she was unable to recall if she had received information in the hospital report if the resident had received the medication at the hospital on 2/6/19, the day of admission to the facility. RN#7 stated that if she knows if she needs a medication stat she must call the pharmacy, but was unsure if she had called for the IV medication on 2/6/19. Interview with the facility's consulting pharmacist on 8/30/19 at 1:45 PM identified that if a medication is needed stat, the facility must call the pharmacy and delivery will usually happen within 2 to 3 hours. The pharmacist stated that the facility did not call in the medication order on 2/6/19, and the pharmacy did not receive the fax from the facility until 2/7/19 at 6:18 AM, the medication was delivered to the facility at 8:20 AM on 2/7/19. Interview with the physician (MD #3) on 8/30/19 at 2:10 PM identified that it would be the expectation that the facility inquire with the hospital on the day of admission if the resident had received the medication at the hospital prior to admission to the facility, and further stated that if the resident arrived at 2:00 PM on 2/6/19 the facility should administered the IV medication. Interview with the Director of Nurses (DON) on 8/30/19 at 3:05 PM identified that there was no documentation available to verify if the resident received the IV antibiotic at the hospital on 2/6/19 prior to admission, but her expectation would be for the admitting nurse to verify this information on admission, she further identified that there is no policy in place for medication ordering, but if a medication is needed stat it should be called into the pharmacy. In addition, the DON stated the cholecalciferol and isosorbide mononitrate should have been administered in accordance with physician's orders. Review of the medication transcription policy identified that prescriber medication orders will be accurately transcribed and executed in a timely manner to ensure accurate administration of all physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, interviews and review of facility policy, for one of two residents reviewed for Pressure Ulcers (Resident #102), the facility failed to ensure consistent wound monitoring/assessment and/or failed to notify the physician when there was a change in the resident's skin condition. The findings include: Resident #102 was admitted on [DATE]. The resident's diagnoses included cerebral infarction, diabetes and vascular dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #102 had moderate cognitive impairment, was totally dependent on one staff for bed mobility and transfers, and had no pressure injuries. The care plan dated 12/31/18 identified alteration in skin integrity. Interventions included to obtain wound consultation as indicated and to record/report any concerns or changes to the physician. A physician's order dated 11/29/18 directed skin prep to bilateral heels twice a day, booties to offload heels when in bed and in wheelchair. Interview and record review with LPN #12 on 8/28/19 at 12:53 P.M. identified that he/she was first aware of the recurrence of a left heel pressure wound on 2/26/19 and that prior, the resident had a left heel pressure wound that had healed in November 2018. Review of facility documentation failed to identify wound assessments for the left heel were completed between 11/14/18 and 2/26/19, as LPN #12 was not aware of any left heel skin issue between those dates. A left heel stage 2 pressure wound was reported to LPN #12 on 2/26/19. Upon review of January and February 2019 nurse's notes, LPN #12 identified documentation of the presence of a left heel pressure injury in both January and February 2019, prior to the 2/26/19 initial wound assessment. Interview and record review with LPN #12 on 8/28/19 at 3:05 PM identified that the notes identifying the pressure injury prior to 2/26/19 were written by LPN #4. LPN #12 further identified that he/she was not notified prior to 2/26/19, but should have been. LPN #12 was unable to identify why he/she was not notified. LPN #12 further identified that weekly wound data collection/ assessments were not completed and the record did not reflect notification to the physician of the development of the pressure wound prior to 2/26/19. LPN #12 identified it is a nursing responsibility per policy to monitor wounds and conduct assessments. Interview and record review with LPN #4 on 8/28/19 at 3:26 PM identified that the nurse's note dated 1/22/19 identified the left heel continued to have an area of discoloration measuring 0.5 centimeters (cm) x 0.4 cm and that there was no drainage or odor. The nurse's note dated 2/11/19 identified the left heel area appeared to be larger with no drainage. The nurese's note dated 2/17/19 identified a left heel, deep tissue injury (DTI) appeared to be spreading. LPN #4 identified that she/he usually notify the RN supervisor for any changes, or the wound nurse, LPN #12, and did notify an RN on the days that the changes were noted, but could not recall who was notified and/or did not know that he/she could and/or should document who was notified. Interview with the DNS on 8/29/19 at 3:25 P.M. identified that the DNS would look for any progress notes and/or documentation related to this note and provide if found. The facility policy for wound documentation identified that the facility will document notification of the physician, resident and /or responsible party at the onset of a new wound or the deterioration of an existing wound. The policy further identified that the facility will perform weekly wound assessments and document findings on each area until healed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #52) reviewed during dining, the facility failed to .provide adaptive dining equipment. The findings include: Resident #52's diagnoses included bi-polar disorder. The Quarterly MDS assessment dated [DATE] identified that the resident required extensive assistance with eating. The NA care card directed the use of a lipped plate. Observations on 8/28/19 at 5:45 PM identified Resident #52 eating a fruit platter with cottage cheese on a flat plate without the benefit of a lipped/scoop plate. Resident #52 was noted to have spilled approximately 1/4 of the cottage cheese onto the table. Interview and observation with NA #5 on 8/28/19 at 5:45 PM identified that Resident #52 required a scoop plate on his/her meal ticket but that he/she had not been provided with a scoop plate. NA #5 identified that, although he/she had not delivered the meal to Resident #54, he/she should have been provided with the scoop plate. NA #5 identified that Resident #52's scoop plate was on a table next to the steam table in the dining room, and that whoever took the ticket to the cook should have brought the scoop plate to the cook to provide the meal to Resident #52. An interview and review of facility policy with the Food Service Supervisor (FSS) on 8/29/19 at 11:02 AM identified that the Dietary Department is responsible for bringing up the necessary adaptive equipment, and they will read the ticket. If a NA grabs the ticket, he/she gets the plate for the resident and tells the cook which diet to serve.