**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility policy, and interviews for 1 of 10 sampled residents (Resident #19) reviewed for Activities of Daily Living (ADLs), the facility failed to identify and implement communication devices for effective communication. The findings include:Resident #19 ‘s diagnoses included hemiplegia (paralysis 1 side) and hemiparesis (weakness on 1 side) following a stroke, sensorineural (neurological) hearing loss on both sides.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was modified independence with cognitive skills and daily decision making, had inattention and disorganized thinking, highly impaired hearing and required assistance with eating, partial moderate assistance with dressing, personal hygiene, transfers, and was independent with bed mobility. Review of the Resident Care Plan dated 6/2/2025 failed to identify Resident #19 had a communication deficit related to highly impaired hearing loss (deafness). A. Observation and attempted interview on 7/15/2025 at 2:49 PM, identified Resident #19 was very hard of hearing and unable to communicate with the surveyor. Observation on 7/22/2025 at 11:46 AM identified Resident #19 was attempting to communicate with LPN #3 but was not understood. The Administrator was called to the resident's room to talk with him/her. Although the Administrator utilized a pen and paper and identified an issue with missing money in the amount of $400.00, he was unable to determine any further details. The Recreation Director was called to assist but was also unable to understand Resident #19. A fourth staff member, NA #2, a Spanish speaking staff interpreter was then utilized and identified that Resident #19 was waiting for $400.00 to be able to buy cigarettes and that his/her money had not been missing.Interview and record review with Director of Rehabilitation on 7/22/2025 at 1:20 PM identified that communication has been a problem for the resident and that cue cards and a communication board should have been utilized to assist with Resident #19's ability to communicate. B. Review of the Resident Care Plan dated 6/2/2025 failed to identify a communication deficit related to highly impaired hearing loss (deafness) or any interventions that would assist staff to communicate with Resident #19. A Speech Therapy Discharge summary dated [DATE] identified Resident #19's ability to communicate using yes/no responses with minimal initiation difficulty, with occasional cues in order to participate in vocational, avocational and social activities. Resident #19 needed intermittent cues from trained caregivers.A Physician Assistant (PA) note dated 3/27/2025 at 8:48 PM identified a sensorineural hearing loss bilaterally. A review of systems was noted to be limited to unobtainable due to hearing loss (deaf) and the use of Spanish sign language.A nurse's note dated 4/8/2025 at 7:49 PM identified that Resident #19 had a speech and hearing impairment.A nurse's note dated 4/21/2025 at 9:21 PM identified New [NAME] Police were in to see the resident but were unable to effectively communicate with Resident #19 as he/she was Spanish speaking and utilized American sign language.A nurse's note dated 5/6/2025 at 11:29 PM identified Resident #19 was nonverbal but communicated with sign language.A PA note dated 7/8/2025 at 10:30 AM identified as before, a history was limited due to expressive aphasia and possible language barrier. Resident #19 shook his/her head no to all questions asked.Interview and record review with the Director of Rehabilitation on 7/22/2025 at 1:20 PM identified that communication had been a problem for the resident and that cue cards and a communication board should have been utilized to assist with Resident #19's ability to communicate. Further, the Director of Rehabilitation identified that those interventions, or any other type of intervention should have been placed on the care plan or on the Nurse Aid (NA) care card (directive for NA as to how to provide care) to assist with communication.Interview and record review with RN #2 on 7/23/2025 at 11:52 AM identified that the facility had been without a Minimum Data Set (MDS) Coordinator since September 2024. RN #2 indicated that she had been overseeing the Resident Assessment Instrument (RAI) process, mostly remotely, and that a contract company had been assisting to complete the MDS assessments and subsequent creation and review and revision of RCPs. RN #2 identified no communication care plan was in place for Resident #19 but there should have been since he/she utilized sign language and was Spanish speaking. Additionally, the nurse who completed the MDS assessment would have been responsible to write a communication care plan, and RN #2 was unable to explain why a communication care plan had not been implemented. Subsequent to surveyor inquiry, RN #2 indicated that she would have to contact the contract company that had completed the MDS assessment.Review of the Activities of Daily Living (ADL), supporting policy dated 2018 directed, in part, appropriate care and services will be provided for residents who are unable to carry out ADL's independently, in accordance with the plan of care, including appropriate support and assistance with communication (speech, language and any functional communication systems).Review of the Comprehensive Care Plans policy dated 1/8/2024 directed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MD S assessment.Although requested, a facility policy for communication was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interviews for 2 of 3 sampled residents (Resident #48 and Resident #55) reviewed for advanced directives and for the only sampled resident (Resident #120) reviewed for death, the facility failed to ensure a choice for an advance directive was completed. The findings include: 1. Resident #48’s diagnosis included schizoaffective disorder, metabolic encephalopathy (brain dysfunction), and borderline intellectual functioning. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #48 had a Brief Interview of Mental status score of 15 indicating no cognitive impairment and was independent with Activities of Daily Living (ADL’s) The Resident Care Plan in effect for [DATE] failed to identify a care plan for an advanced directive. A physician’s orders in effect for [DATE] identified that Resident #55 was to be fully coded (receive Cardiopulmonary Resuscitation, CPR) in the event of his/her heart stopping. Interview and review of the clinical record with the Director of Nurses (DNS) on [DATE] at 12:05 PM failed to identify a signed consent from Resident #48’s conservator for an advanced directive choice and the physician order directed a full code. The DNS indicated that the advance directive consent should have been signed on admission and placed in the paper record or scanned to the Electronic Health Record. 2. Resident #55’s diagnosis included diabetes, legal blindness, anxiety, and bipolar disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #55 had a Brief Interview of Mental status score of 15 indicating no cognitive impairment, required set up assistance with eating, dependent on staff to transfer, and partial/moderate assistance with personal and oral hygiene. The Resident Care Plan in effect for [DATE] identified Resident #55 wanted a full code, CPR. Interventions included to respect the family and resident’s request regarding their choice for advanced directive. Interview and review of Resident #55’s clinical record on [DATE] at 11:23 AM with LPN #1 identified an unsigned Advanced Directive in the chart coded as Do Not Intubate, Do Not Resuscitate (DNI/DNR). LPN #1 indicated that a physician order could not be written in the clinical record until the advanced directive form had a choice from the resident or resident representative and was signed by the physician. LPN #1 indicated that she would make the Social Work Department aware that the conservator had not filled out the appropriate paperwork. The facility procedure was to have the advanced directive choice signed on the day of admission, but if the resident was unable to sign due to being conserved or confused, a nurse or social worker should have left a message with the conservator/family and scheduled a meeting to complete the paperwork. Some conservators have asked to have the information faxed, sometimes it was tricky to get family in if a resident was not conserved. Interview and review of the clinical record on [DATE] at 11:54 AM with the Director of Nursing Services (DNS) identified that there was no signed advanced directive or a physician order documented in Resident #55’s clinical record. The DNS indicated that social work had conducted an audit for the entire facility, and she thought any missing advanced directive documentation had been addressed. She identified that the social worker had written a note on [DATE] indicating a full code but was unable to identify where the social worker’s information came from. The DNS indicated that on admission the protocol was for the nurse to get the advanced directive form signed, when possible, but in the past the facility has had difficulty reaching conservators. Further, Resident #55 arrived in March so should have been part of the audit and should have had his/her advanced directive signed by now. Interview with Social Worker (SW) #3 on [DATE] at 11:40 AM identified that the SW’s work together, but he had not been informed that Resident #55’s advanced directive had not been signed. SW #3 indicated that a Resident Care Conference (RCC) was held last week, but the conservator did not attend and does not respond to calls, and the facility had called the court, but they did not respond. Interview with SW #1 on [DATE] identified that he had conducted a facility wide audit of advanced directive documentation but was unsure how Resident #48 was not listed as a resident included in the audit. He further indicated Resident #55 was a full code on the audit and a side note stated, “call conservator” and “nursing”. SW #1 was unable to provide documentation the conservator was notified but stated that he had left a message. Subsequent to surveyor inquiry, the conservator was contacted and signed an advance directive on [DATE] to attempt resuscitation, do not intubate for Resident #55. 3. Resident #120‘s diagnoses included cauda equina syndrome, chronic obstructive pulmonary disease, and morbid obesity. The admission Minimum Data Set assessment dated [DATE] identified Resident #120 was cognitively intact and required was dependent on staff for toileting hygiene, shower/bathing self, and transfers. The Resident Care Plan from [DATE] through [DATE] identified Resident #120 had an advance directive for Cardiopulmonary Resuscitation (CPR) meaning in the event of his/her heart stopping, they would be a full code (perform CPR). Interventions included that needs would be anticipated and met by staff and to respect the family and resident request regarding their choice for advanced directive. A social services note dated [DATE] at 12:39 identified that Resident #120’s 72-hour meeting was conducted and that Resident #120’s code status was a full code. A review of Resident #120’s clinical record identified that the resident’s advance directive had not been signed by the resident and/or a physician. An interview and document review with the Director of Admissions on [DATE] at 11:52 AM identified that for a newly admitted resident, an admission packet was provided and included paperwork for an advance directive choice. The admission nurse was responsible to ensure the advance directive was completed. The document would then be uploaded into the resident’s electronic health record and then the Social Services Department assisted with this process. An interview and review of the clinical record with Social Worker #3 on [DATE] at 12:11 PM identified that although the admitting nurse should ensure the advance directive was fully completed, the Social Services Department would review the admission packet at the resident's 72-hour post admission care conference meeting to ensure the advance directive documentation was properly completed. SW #3 indicated that Resident #120’s advance directive was missing the residents and physicians’ signature which was required to complete Resident #120’s advance directive choice. SW #3 was unable to indicate why the advance directive was not completed. Review of the residents’ rights regarding treatment and advance directives policy directed, in part, that on admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. Additionally, the facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advanced directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of the clinical record, staff interviews, and facility policy for 1 of 5 sampled resident (Resident #84) reviewed for unnecessary medications, the facility failed to notify the physician of an elevated blood sugar. The findings include: Resident #84's diagnosis included diabetes, schizophrenia, and chronic kidney disease. Review of Resident #84's Medication Administration Record (MAR) for 7/11/25 at 5:25 PM identified a blood sugar level of 331 (normal is 70 - 100). Physician's orders in effect from 7/1/25 through 7/24/25, directed to notify the physician if results of Resident #84's blood sugars were elevated. The order failed to include any blood sugar parameters, which would direct staff, when the physician should be notified. Review of clinical record, nursing notes and physician notes failed to identify that the physician was notified of Resident #84's elevated blood sugar level. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #84 had a Brief Interview of Mental Status score of 12 indicating moderate cognitive impairment, was independent with eating, dressing, bed mobility, and ambulation. Additionally, Resident #84 received insulin daily. The Resident Care Plan dated in effect for July 2025 identified Resident #84 had diabetes. Interventions directed staff to monitor/document for side effects and effectiveness and obtain a fasting serum blood sugar as ordered by doctor. Interview with LPN #8 on 7/24/25 at 11:23 AM, identified he could not recall if he was the nurse who took Resident #84's blood sugar level on 7/11/25, but stated if the results were initialed by him, then he must have taken the reading. LPN #8 further identified he knew Resident #84 well, and although he documented a blood sugar level of 331, he indicated he did not think the reading could have been that high. LPN #8 reported that if the provider was notified, the notification would have been documented in the resident's clinical record. Additionally, LPN #8 identified if the order and facility policy directed him to notify the physician of an elevated blood sugar level he should have done so but was unable to state why he did not notify the provider when Resident 84's blood sugar level (331) read higher than the normal range. During an interview with APRN #2 on 7/24/25 at 12:43 PM, she was unable to recall if she had been notified of Resident #84's elevated blood sugar. APRN #2 indicated that had she been notified, she would have directed facility staff to monitor Resident #84's blood sugar levels more frequently for trending purposes, and that no increased blood sugar monitoring had been directed following Resident #84's abnormal blood sugar Subsequent to surveyor's inquiry, APRN #2 directed monthly blood sugar monitoring for Resident #84. Review of the Notification of Change policy dated 1/18/24 directed, in part, that the physician is notified when there is a change that requires notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, documents, facility policy, and interviews for 1 of 8 residents (Resident #4) reviewed for abuse, the facility failed to ensure a resident was free from misappropriation of his/her bank card and use of the bank card. The findings include:Resident #4's diagnoses included mononeuropathy, type 2 diabetes, and chronic respiratory failure with hypoxia (low level of oxygen).A nurse's note dated 6/30/2025 at 2:22 PM by Licensed Practical Nurse (LPN) #7 identified that Resident #4 informed her that he/she went to the bank on 6/30/2025 with Person #3 (Resident #4's family member) and noticed his/her bank card was missing and money was missing from his/her bank account. The nurse's note further identified her supervisor, Registered Nurse (RN) #6, was made aware, the Police Department was called, and social services had started an investigation.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, required set-up assistance with personal hygiene, used a wheelchair for mobility, and was independent with chair/bed-to-chair transfers.The Resident Care Plan (RCP) in effect from 5/3/2025 through 7/22/2025 identified Resident #4 needed socialization and independent activities at his/her own leisure to support his/her independence. Interventions included participating in smoke breaks, providing independent leisure activity materials, and visits by the Recreation Department 2 to 3 times weekly.A nurse's note dated 6/30/2025 at 2:22 PM by Registered Nurse (RN) #6 identified that LPN #7 informed her that Resident #4 was missing his/her bank card. RN #6 spoke with Resident #4 and was informed he/she went to the bank on 6/30/2025 and noticed the bank card was missing. He/she identified a charge that was made on the account that was not made by him/her when reviewing the bank statement. The nurse's note further identified the Director of Nursing Services (DNS), and the Administrator were made aware of the incident.A social services note dated 6/30/2025 at 3:44 PM identified Resident #4 was offered talk therapy and assured that all facility protocols would be followed, including reporting to the police and the State Agency (SA).A psychiatric Advanced Practice Registered Nurse (APRN) note dated 7/2/2025 identified that Resident #4's mood was stable after the 6/30/2025 allegation of misappropriation of funds. The psychiatric APRN note further identified that the resident had not checked the location of the bank card in about a month.Interview on 7/16/2025 at 10:57 AM with Resident #4 identified his/her bank card was stolen from his/her room and around $25.00 was charged at a grocery store approximately 10 miles away from the facility. He/she stated a police report was filed but the facility had not returned the money that had been stolen.A bank statement for Resident #4 dated 6/25/2025 identified that bank account activity on 6/9/2025 had occurred at a grocery store approximately 10 miles away from the facility in the amount of $25.80. No other charges were made to his/her account for the dates 4/30/2025 through 6/25/2025.A signed police report dated 7/18/2025 identified the police were dispatched to the facility on 7/2/2025 at 11:40 AM. The report identified Resident #4 signed a sworn statement that he/she used the debit card on 5/5/2025 at the bank to directly withdraw $400.00. The report further identified he/she had neither left the facility nor used her card after 5/5/2025. The report indicated he/she would like to press charges against the individual who stole his/her bank card and used it to make a purchase at the grocery store. Interview on 7/21/2025 at 9:16 AM with Person #3 identified he/she took Resident #4 to the bank on 6/30/2025 when the resident discovered his/her bank card was missing and there was a charge at a grocery store approximately 10 miles away from the facility made by an unauthorized person. Person #3 further identified no one other than him/her takes Resident #4 out of the facility, he/she had not taken the resident out of the facility on any other date in June, and that he/she did not take or borrow Resident #4's bank card for any reason.Interview on 7/21/2025 at 1:55 PM with the DNS identified a complete investigation into the allegation of misappropriation of funds was not performed. The DNS indicated that she failed to review the facility video cameras for potential evidence, she failed to obtain a copy of Resident #4's bank statement, and she failed to obtain written statements from all staff who worked with Resident #4 during the time of the incident. The DNS identified that she had unsubstantiated the allegation of misappropriation of funds because she could not substantiate or unsubstantiate the event had actually occurred. She stated the rationale for marking the investigation as unsubstantiated was she did not want to be late filing her summary. The DNS indicated the only way someone would have access to Resident #4's bank card, if kept in his/her wallet, would be if it was stolen. Review of the facility's Abuse, Neglect, and Exploitation policy identified in part that the facility will complete an immediate investigation when a report of abuse occurs, provide complete and thorough documentation of the investigation, and respond immediately to protect the alleged victim. The policy further identified a report will be made to the SA immediately but no later than 2 hours after the allegation is made, and the Administrator will follow-up with the SA to report the results of the investigation within 5 working days of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the clinical record, review of documentation, and facility policy for 1 of 8 sampled residents (Resident #58) reviewed for abuse, the facility failed to revise the Resident Care Plan (RCP) to include allegations of abuse. The findings include:Resident #58's diagnoses included fracture of the left arm humerus, fracture of the left femur, displaced fracture of the right tibia, and acute pain due to trauma.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, did not experience episodes of delusions or verbal behavioral symptoms towards others, and was dependent for his/her personal hygiene and rolling left and right in bed.The Resident Care Plan (RCP) in effect from 5/15/2025 through 7/20/2025 failed to indicate Resident #58 had reported 2 allegations of mistreatment and failed to ensure the RCP had interventions that Resident #58 would be monitored for psychosocial well-being, or what interventions would be used to assist the resident in dealing with emotional distress. A. Review of a Reportable Event Form sent to the State Agency (SA) on 5/15/2025 identified Resident #58 reported a Nurse Aide (NA) was verbally inappropriate towards him/her, used profanities at him/her, and sat at his/her door the rest of the night after the incident and stared at him/her.Review of a Psychiatric Advanced Practice Registered Nurse (APRN) note dated 5/16/2025 identified Resident #58 was evaluated for an allegation of NA #9 being verbally abusive towards him/her, calling him/her a bitch, and tormenting the resident. The note further identified Resident #58 was found to be frustrated, with clear emotional distress, and that he/she indicated being mistreated and felt unsafe because he/she cannot defend his/herself due to a disability. The note indicated he/he was reporting disturbed sleep due to fear of what NA #9 might do while he/she was sleeping, and that other staff members have witnessed NA #9's mistreatment of him/her but no disciplinary action had been taken against NA #9 due to racial bias. The Psychiatric APRN note stated Resident #58's insight was intact and not delusional in nature.Review of the facility summary, identified the allegation was unsubstantiated because the resident changed her story during a police interview, stating he/she did not like the NA.B. Review of a Grievance form dated 7/1/2025 (written in response to an allegation that occurred on 6/28/2025) identified Resident #58 had reported to the facility that a staff member referred to him/her as the N-word. The Grievance form further identified that the facility made him/her aware that the incident was under investigation and the facility would adhere to the facility policy. The grievance form stated that the staff member was educated but continued to demonstrate an inability to adhere to policies, exhibited insubordination, and was non-compliant. Additionally, the staff member lacked adequate customer service skills, and, as a result, their employment was terminated. (later identified that NA #6 was not terminated as an employee but made a Do Not Return to the facility from the staffing agency). The Grievance form was signed by the facility's Administrator on 7/4/2025. Interview on 7/16/2025 at 10:03 AM with Resident #58 identified on 6/28/2025 Nurse Aide (NA) #6 called her a F***ing N-word and he/she reported feeling abused to a Social Worker (SW). Resident #58 further identified since the incident of verbal abuse he/she had difficulty sleeping due to being afraid of retaliation by other staff for reporting the abuse, and he/she was not sure what people will do these days.Review of nursing notes for June 2025 and July 2025 failed to identify any documentation in Resident #58's Electronic Medical Record (EMR) or in the paper chart, that there were allegations of verbal abuse that occurred on 5/15/25 and 6/28/2025. Review of physician notes for June 2025 and July 2025 failed to identify any documentation of Resident #58's allegation of verbal abuse that there were allegations of verbal abuse that occurred on 5/15/25 and 6/28/2025. An interview with the DNS on 7/21/2025 at 1:16 PM identified that she was aware of a history of staff to resident abuse for Resident #58 and that he/she was care-planned for accusatory behaviors. The DNS failed to identify that the 5/15/2025 incident of a staff member calling the resident a bitch nor the 6/28/25 incident of a staff member calling the resident a f***ing N-word were included in the RCP. She indicated she should have initiated an intervention that the resident has 2 people present during care due to accusatory behaviors. The DNS failed to identify why the resident should be care planned for accusatory behaviors as opposed to allegations of verbal abuse. Subsequent to surveyor inquiry, a revision to Resident #58's RCP dated 7/21/25 and effective 7/1/2025 identified that he/she was newly care-planned for a behavioral problem related to accusatory behaviors related to the resident reporting that a staff member called him/her a derogatory name. Interventions included encouraging him/her to express feelings appropriately and intervening as necessary to protect the rights and safety of others and remove him/her from the situation to take to an alternate location as needed. The interventions failed to include any intervention to protect the resident from future abuse, failed to include the 5/15/2025 Reportable Event of a staff member calling him/her a bitch, and failed to identify that the resident was present in his/her bed, in his/her own room, during both alleged incidents of staff to resident abuse.Review of the Comprehensive Care Plan policy dated 1/8/2024 directed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the clinical record, and facility policies for 1 of 5 sampled residents (Resident #1) reviewed for nutrition, the facility failed to provide treatment in accordance with standards of care for a resident with heart failure. The findings included: Resident #1's diagnoses included hypertensive heart disease with heart failure, diabetes mellitus, and hyperlipidemia.The Resident Care Plan (RCP) dated 6/23/25 identified Resident #1 had altered cardiovascular status related to hypertension and hyperlipidemia. Interventions included encouraging a low fat low/salt intake and obtain lab testing as needed.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired, independent for transfers and toileting, and required substantial/maximal assistance for lower body dressing. Additionally, the MDS identified Resident #1 had a weight gain of 5% or more in the last month or 10% or more in the last 6 months and was not a physician prescribed weight gain regimen.A review of Resident #1's weights identified a weight of 171 pounds (lbs.) on 6/10/25, a weight of 179 lbs. on 6/17/25, a weight of 182.2 lbs. on 7/1/25, and 188.6 on 7/7/25 indicating a significant weight gain of 10.29 % in 27 days.A review of the Nutrition/Dietary note dated 7/10/25 at 10:45 AM identified Resident #1 was triggered for a significant, undesirable, but anticipated weight change due to edema and diuretic (fluid reducing medication) therapy in place.Interview and record review with the supervisor, Registered Nurse (RN) #3 on 7/24/25 at 9:26 AM identified it was the facility policy to assess residents who had a diagnosis of heart failure for lung sounds, respiratory status, and pedal pulses daily, as well as notify the provider of a weight gain of 2.5 lbs. in one day or 5 lbs. in 1 week. Review of the clinical record with RN #3 identified he/she was receiving diuretic medication 3 times per week as well as being weighed monthly. RN #3 was unable to identify how the facility would be aware of Resident #1 gaining weight on a daily or weekly basis if the resident was only weighed monthly. Further, RN #3 was unable to provide documentation that any nursing assessments for heart failure had been conducted, unable to locate a physician order directing the dietary restrictions as indicated in the RCP, or physician orders directing staff to perform assessments for Resident #1's condition that would indicate signs and symptoms of heart failure.Interview and clinical review with APRN #1 on 7/24/25 at 10:15 AM identified that the facility policy to manage heart failure was to track the residents fluid intake and output for renal function, check laboratory values (BMP and CBC which indicate values related to heart failure) and have the individual seen by cardiology monthly. APRN #1 identified Resident #1 was not compliant with education on his/her fluid restriction, and staff was managing his/her heart failure by assessing if he/she had an altered mental status that deviated from his/her baseline as well as assessing for edema of his/her face and feet. Although APRN #1 indicated Resident #1 was on intake and output monitoring, a review of the clinical record failed to identify an order for a fluid restriction or intake and output monitoring, failed to identify an order for a no added salt diet per the RCP, and failed to identify an order to assess the resident for edema or daily weights. Additionally, APRN #1 identified an awareness of Resident #'1's weight gain, believed it was due to dietary intake, however, after reading the Registered Dietitian's note, indicated that Resident #1 would be evaluated today and daily weight monitoring and edema monitoring would be added to the plan of care. Subsequent to surveyor inquiry APRN #1 initiated a physician's order dated 7/26/25 for daily weights and to inform the provider of a weight gain of 2 lbs. or greater in 24 hours to be completed daily as well as orders for laboratory work (BMP) to be done the next day.Although requested a Heart Failure Policy was not provided.Although requested a Resident Assessment Policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, and staff interviews for 1 of 10 residents (Resident #99) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure fingernail care was provided to a dependent resident. The findings include: Resident #99 diagnoses included dementia, anxiety disorder, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #99 had a BIMS score of 13, indicating no cognitive impairment, and was dependent for showering/bathing and personal hygiene.The Resident Care Plan dated 5/6/2025 identified Resident #99 has an ADL self-care performance deficit related to deconditioning and multiple comorbidities. Interventions include that the resident requires assist of one for bathing.Physician's orders in effect for July 2025 directed staff to provide a shower every Thursday on the day shift and every Sunday on the evening shift. Observation and interview with Resident #99 on 7/15/2025 at 11:53AM identified that the length of his/her nails was not by choice and he/she would have preferred to have his/her fingernails cut. Observations on 7/16/2025 at 10:18 AM identified Resident #99's fingernails remained unchanged. A review of the Treatment Administration Record (TAR) dated 7/17/2025 for the day shift indicated Licensed Practical Nurse LPN #1 had signed off that Resident #99 had received his/her shower. Interview and observation with Licensed Practical Nurse (LPN) #2 on 7/17/25 at 3:31 PM identified that Resident #99's fingernails were long and with dark brown debris under the nails. LPN #2 indicated nail care should have been provided with the residents shower during the day and could not explain why the nail care had not been provided. Subsequent to survey inquiry, LPN #2 indicated fingernail care would be provided that evening. Review of the Activities of Daily Living (ADLs), policy directed, in part, residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 sampled residents (Resident #2) reviewed for medication administration, the facility failed to follow the physician's orders to obtain a blood sugar level and failed to administer insulin at the correct time and for 1 of 4 sampled residents (Resident #27) reviewed for pressure ulcers, the facility failed to follow a physician's order for wound care. The findings include: Resident #2 ‘s diagnoses included diabetes with ketoacidosis without coma, and long-term drug therapy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required set up assistance with eating, substantial maximum assistance with upper body dressing and personal hygiene, and was dependent for bed mobility. Additionally, Resident #2 received insulin injections for the previous 7 days. The Resident Care Plan dated 6/12/2025 identified diabetes mellitus. Interventions included diabetes medication as ordered. Monitor and document for side effects and effectiveness, monitor, document, and report as needed any signs or symptoms of hyper or hypoglycemia. Physician’s orders in effect for July 2025 directed to check Resident #2’s blood sugar and administer Lyumjev (insulin) 100 units/milliliter (ml) inject 10 units subcutaneously before meals related to type 2 diabetes. Hold the medication if a blood sugar level was less than 90 or less that 25% of a meal was consumed. An additional, separate order directed to provide Lyumjev injection solution 100 units/ml inject per sliding scale: if blood sugar was 150-200 give 2 units, 200-250 give 4 units, 251- 300 give 6 units, 301- 350 give 8 units, 351- 400 give 10 units, 401-459 give 12 units subcutaneously before meals related to type 2 diabetes. Inform the physician for a blood sugar less than 70 or greater than 300. During medication reconciliation on 7/17/2025 at 10:30 AM of Resident #2’s medication regimen, the Medication Administration Record (MAR) failed to indicate that the residents 8:00 AM blood sugar level had been obtained or that the Lyumjev injection had been given. An interview and review of the MAR with LPN #4 on 7/17/2025 at 10:42 AM identified that LPN #4 had not obtained a blood glucose level and had not provided Resident #2 with his/her insulin injection at 8:00 AM as directed. LPN #4 explained that the Assistant Director of Nursing (ADNS) relieved her from her previously assigned unit and reassigned her to Resident #2’s unit at approximately 8:30 AM. Although the supervisor, RN #4, had initially assumed responsibility for Resident #2’s unit he had not passed any medications or conducted any blood sugar testing. LPN #4 stated she knew she was out of compliance for administration, but that RN #4 should have started the medication administration and blood glucose testing prior to her arrival. Subsequent to surveyor inquiry, LPN #4 stated she would check Resident # 2’s blood sugar when it was due again at 12:00 PM. (A subsequent blood sugar test at 12:00 PM identified a result of 275 (normal 70-100 mg/dL.). Interview with the Director of Nursing Service (DNS) on 7/17/2025 at 12:00 PM identified she had not been made aware that Resident #2 had an omission error for checking Resident #2’s blood sugar level and subsequent insulin administration. An interview with Registered Nurse Supervisor (RN) #4 on 7/17/2025 at 12:28 PM identified that he assumed responsibility for Resident #2’s unit at 7:30 AM due to the originally scheduled nurse’s absence. RN #4 indicated that he had to leave the facility to obtain methadone for a resident because no other nurse, including the ADNS, DNS, or IP was available. RN #4 indicated that he informed both the ADNS and the Administrator that he needed help prior to leaving the facility. RN #4 indicated the shift-to-shift report as well as the MAR was available to any nurse who could have covered Resident #2’s unit in his absence. Subsequent to surveyor inquiry, on 7/22/2025 a Reportable Event document/Medication Error Report created by the DNS identified the missing blood sugar level and missed dose of insulin that had occurred on 7/17/2025. Review of the Medication Administration and Documentation policy directed, in part, medications are to be administered within a 2-hour time frame, i.e. 1 hour before or after the medication order time. Review of the Blood Glucose Monitoring policy dated 2023, directed, in part, the facility will perform blood glucose monitoring as per physician’s orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility policy, and interviews for 1 of 10 sampled residents (Resident #19) reviewed for Activities of Daily Living (ADLS), the facility failed to appropriately assess a contracture, failed to initiate splint use to prevent potential worsening of a contracture, failed to correctly code the Minimum Data Set (MDS) related to a contracture, and failed to include the contracture in the Resident Care Plan. The findings include: Resident #19's diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following a stroke, muscle weakness, and limitation of activities due to a disability.Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified modified independence with cognitive skills for daily decision making with inattention and disorganized thinking. Further Resident #19 required assistance with eating, partial moderate assistance with dressing, personal hygiene, and transfers. and was independent with bed mobility. The MDS was not coded to indicate a functional limitation in range of motion impairment on one side for the upper extremity.A. The Resident Care Plan (RCP) dated 6/2/2025 identified left sided weakness and difficulty walking. Interventions included providing the assistance of 1 person for transfers and ambulation via a large base quad cane and was independent with wheelchair mobility.Observations on 7/15/2025 at 2:48 PM, 7/16/2025 at 9:20 AM, and 7/16/2025 at 10:15 AM identified Resident #19 with a contracted left hand and wrist, but without the benefit of splint use.Review of the physician orders from 11/18/2024 through 7/16/2025 failed to include use of a splint or a diagnosis for a contracture.Review of the Occupational Therapy (OT) evaluation and plan of treatment documentation dated 11/18/2024 through 1/16/2025 identified Goal #3: Resident #19 would wear the least restrictive splinting/orthotic device 2 hours on 2 hours off without complaints of discomfort and skin irritation in order to maintain joint integrity and maintain joint mobility. There was a left upper extremity impairment with impairment of the shoulder, elbow/ forearm, wrist, and hand. Functional limitations were present due to contracted left fingers, left hand, and left wrist. Recommendations were for orthotics/splinting: it was recommended to further assess and order/fabricate a splint for the left hand in order to manage tone, maintain joint integrity, maintain joint mobility, and increase ability to perform self-care tasks. The OT evaluation failed to include contracture measurements. OT progress notes and OT treatment encounter notes dated 11/18/2024 through 12/10/2024 identified that the splint/orthotic Goal #3 was excluded but failed to identify a reason for the exclusion.An OT Discharge Summary which included dates of treatment from 11/18/2024 through 1/3/2025 failed to indicate why Goal #3: Resident # 19 would safely wear the least restrictive splinting/orthotic device 2 hours on/2 hours off without complaints of discomfort and skin irritation in order to maintain joint integrity and maintain joint mobility was discontinued on 1/3/2025 when Resident #19 was discharged from OT.An interview and record review with the Director of Rehabilitation on 7/22/2025 at 1:20 PM identified Resident #19 did not have a splint for his/her contractures but should have had one in order to prevent worsening of the contractures. The Rehabilitation Director was unable to find documentation that Resident #19's contractures/immobility had been measured (to indicate stability or worsening), or that the resident was unable to tolerate a splint. Although the Director of Rehabilitation indicated Resident #19 had documentation of working with OT, he/she had previously refused to work with OT. The Director of Rehabilitation was unable to provide documentation of any refusals, stating if the resident had refused, the refusals should have been documented in the notes. She indicated that the facility policy directed quarterly screens but was unable to identify why the screens dated 5/6/2025, 7/7/2025 failed to identify that Resident #19 had contractures or that rehabilitation had addressed or provided any splinting. Additionally, she was unable to indicate if a splint had been previously trialed for tolerance or if contracture measurements had been obtained, as there were no rehabilitation notes. Due to a lack of documentation, she could not identify if Resident #19's contractures had stabilized or worsened since being discharged from OT on 1/3/2025. Subsequent to surveyor inquiry, the Director of Rehabilitation indicated that she would request a screen for contracture/Range of Motion (ROM) management and place a referral for Resident #19's splinting needs. B. Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] was incorrectly coded failing to indicate a functional limitation in range of motion impairment on one side for the upper extremity that had been previously documented by OT.C. Review of the Resident Care Plan dated 11/18/2024 to 7/22/2025 failed to identify Resident #19 had a contracture of the left hand.In an interview and clinical record review with RN #2 on 7/23/2025 at 11:52 AM, she identified that the facility had been without a Minimum Data Set (MDS) Coordinator since September 2024. RN #2 indicated that she had been mostly overseeing the Resident Assessment process remotely and that a contract company had been assisting in completing the MDS assessments and Resident Care Plan. RN #2 indicted that the MDS assessment was incorrectly coded, failing to identify the left-hand contracture, and that the Resident Care Plan failed to reflect that Resident #19 had a left hand contracture. RN #2 indicated that the nurse completing the MDS was responsible for updates to the Resident Care Plan, and she was unable to explain why Resident #19 did not have an accurately coded MDS or a Resident Care Plan that included the resident's contracture. Subsequent to surveyor inquiry, RN #2 indicated that she would contact the contracted MDS company to inquire about Resident #19's missing data.Review of the Comprehensive Care Plan policy dated 1/8/2024 directed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.Although requested, facility policies for contractures and range of motion were not made available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy, and interviews for 1 of 5 sampled residents (Resident #9) reviewed for unnecessary medications, the facility failed to ensure a pharmacy recommendation for lab work was completed and failed to include interventions in the Resident Care Plan for the occurrence of behavioral issues, other than to use medications. The findings include:Resident #9's diagnoses included schizophrenia, paranoia, and HIV.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was moderately cognitively impaired and required substantial/maximal assistance with dressing and rolling in bed.A. The Resident Care Plan (RCP) dated 11/29/2024 identified a self-care performance deficit. Interventions included praise efforts, Physical Therapy/Occupation Therapy, and assist of 1 staff with ambulation.Physician's orders in effect from 11/1/2024 and 7/23/2025 directed to administer Dolutegravir lamivudine 50-300 milligrams (mg) 1 tablet by mouth in the morning for HIV.Review of the pharmacy recommendation dated 2/4/2025 requested laboratory work be drawn for the use of the antiretroviral (Dolutegravir) therapy, and then every 6 months thereafter. The physician signed in agreement to the recommendation on 2/7/2025 and a physician's order was written.Interview and review of the clinical record with the Assistant Director of Nursing (ADON) on 7/22/2025 at 11:30 AM identified that when Resident #9 had the physician ordered lab work scheduled to be drawn on 2/7/2025. The lab work was not drawn due to the resident being at an appointment. The ADON indicated that Resident #9's lab work had never been rescheduled to be drawn following the missed appointment. Further, the ADON stated that it was the responsibility of the Registered Nurse Supervisor to ensure the lab work was rescheduled once a lab draw day was missed. Although the ADON indicated that there was a system currently in place to ensure that all lab work had been completed, she was unable to find documentation of lab work oversite. The ADON indicated that going forward a new system would be in place to ensure all lab work was drawn.The facility did not have a policy for laboratory work.B. Review of the RCP dated 11/1/2024 through 7/23/2025 identified the use of an antipsychotic medication but failed to identify alternate interventions to treat behavioral symptoms should the resident experience behavioral issues.The physician's order dated 11/1/2024 through 7/23/2025 directed the use of Seroquel (an antipsychotic).Interview and review of the RCP with the Care Plan Coordinator on 7/23/2025 at 12:16 PM identified that the RCP should include interventions for alternatives to medication use per the requirement. Review of the undated facility Resident Care Plan policy identified that care plans would be modified with new or modified interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Personal Funds Account, facility documentation, facility policy, and interviews for 3 of 6 sampled resident (Residents #7, #104, and #114) reviewed for personal funds, the facility failed to honor same day requests for withdrawals of personal funds and failed to provide access to resident funds outside of the facility's posted banking hours. The findings include:1.Interview with Resident #7 on 7/16/2025 at 9:50 AM identified that he/she had a personal fund account with the facility but was unable to take out funds from the account on weekends. Resident # 7 ‘s diagnoses included quadriplegia, anxiety, and chronic pain.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #7 had moderate cognitive impairment. 2. Interview with Resident #104 on 7/22/2025 at 11:21AM identified he/she had a personal fund account with the facility and had been told he/she could not take out any money since June from the account.Resident # 104‘s diagnoses included anxiety, depression, and had a seizure disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #104 had a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #7 had no cognitive impairment.3. Interview with Resident #114 on 7/15/2025 at 11:10 AM identified that he/she had a personal fund account with the facility and was unable to take out funds from the account at night or on weekends. Resident #114 reported that the facility only allowed withdrawals during banking hours and that he/she could only take out $20.00 at a time because the facility was in transition. Resident #114 reported he/she received $75.00 per month that was placed in the personal fund account.Resident # 114 ‘s diagnoses included anxiety, Post Traumatic Stress Syndrome, and bipolar.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #114 had a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #114 had no cognitive impairment.Interview with the Business Office Manager and the Administrator on 7/23/2025 at 1:58 PM identified Residents # 7, #104, and #114 had personal fund accounts with the facility. The Business Office Manager indicated that residents were only allowed to take money out of their account during the posted banking hours which were Monday - Friday from 9:00 AM to 3:00 PM. She explained that residents did not have any access to their personal funds after 3:00 PM or on weekends. The facility also limited how much a resident could take out of their personal funds account as they had been going through a change in ownership. The Business Office Manager indicated the facility was having difficulty accessing the bank accounts. She reported the facility limited the amounts a resident could withdrawal based on the amount of money the facility had on-hand. She reported that although the maximum withdrawal amount was $75.00, if cash was unavailable, then a check would need to be generated, which would take about 24 hours and then the Administrator would need to cash the check in order for the residents to receive their funds. The Administrator identified the facility would need to implement a process that allowed a resident to withdraw funds at night and on the weekends.A Personal Funds policy was requested, but the facility stated they did not have a policy. Review of the Resident's Rights Policy directed, in part, that residents have the right to manage his or her financial affairs, this includes the right to know, in advance, what charges a facility may impose against a resident's funds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, facility policy, and interviews for 10/122 of sampled residents (Resident #2, #19, #39, #98, #99, #106, #107, #500, #501, #502) reviewed for personal funds, the facility failed notify residents when their accounts were within $200.00 of the Social Security Income (SSI) resource limit and failed to covey personal funds within 30-days of a resident's discharge from the facility. The findings include:Review of the facility's Trial Balance report and interview with the Business Office Manager and Administrator on [DATE] at 1:58 PM identified on [DATE] Residents #2, #19, #39, #98, #99, #106, #107 resided in the facility, were on Medicaid, and had account balances exceeding the SSI resource limits as follows:Resident #2 had an account balance of $1,620.65Resident #19 had an account balance of $1,799.39Resident #39 had an account balance of $2,125.10Resident #98 had an account balance of $2,234.64Resident #99 had an account balance of $1,611.98Resident #106 had an account balance of $2,127.64Resident #107 had an account balance of $2,042.28Further interview with the Business Office Manager and Administrator identified for Residents #500, #501, and #502 that although these residents had been discharged from the facility over 30 days prior, the facility had not distributed the Resident's personal fund balance from the facility account as follows:Resident #500 had been discharged on [DATE] and had an account balance of $150.00 (facility was 14 days late)Resident #501 had been discharged on [DATE] and had an account balance of $45.00 (facility was 73 days late)Resident #502 had been discharged on [DATE] and had an account balance of $2,301.80 (facility was 14 days late)Interview with the Administrator on [DATE] at 12:35 PM reported the facility standard when a resident approaches $1,600.00 in their personal funds account was to work with Social Services, Recreation, and the resident's family to purchase items for the resident in an effort to spend down on their account. He reported that while he was aware there was a backlog of Medicaid residents who have balances over the SSI limits, the Business Office Manager was working hard to rectify the accounts, and the facility now had a process in place to avoid this from happening in the future. The Administrator further indicated that he was not aware there were residents that were not deceased whose funds had not been returned to them within 30 days of discharge.Subsequent to the surveyor's inquiry, the facility processed a check request for the remaining balance in Resident #501 and Resident #502's personal funds account. A Personal Funds policy was requested, but the facility stated they did not have a policy. Review of the Resident's Rights Policy directed, in part, that residents have the right to manage his or her financial affairs, this includes the right to know, in advance, what charges a facility may impose against a resident's funds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 8 sampled residents (Resident #15, Resident #55, and Resident #58) reviewed for abuse, the facility failed to report or report timely, allegations of abuse. The findings include: 1. Resident #15's diagnoses included encephalopathy, cirrhosis of the liver and a personal history of a traumatic brain injury.Review of the facility Reportable Event (RE) form dated 7/16/25 at 10:00 AM identified Resident #15 reported a staff member placed his hands around his/her neck and used derogatory names towards the resident and his family. The RE indicated a state classification indicating abuse. The Advanced Practice Registered Nurse (APRN) was notified of the incident at 10:30 AM and the RE was signed and dated on 7/16/25 by the Director of Nursing (DNS).The annual Minimum Data Set (MDS) dated [DATE] identified Resident #15 was severely cognitively impaired and required partial/moderate assistance with bed mobility and was dependent with transfers and toileting. The Resident Care Plan (RCP) dated 7/16/25 identified Resident #15 had impaired cognitive function with the potential to be verbally aggressive related to ineffective coping skills and poor impulse control. Interventions included monitoring behaviors, providing emotional support, and giving positive feedback for good behavior. Review of RN #4's written statement dated 7/16/25 indicated that on 7/16/25 he was asked to speak to Resident #15 because the resident was refusing care. Attempts to interview RN #4 were unsuccessful. Interview and review of facility documentation with the DNS on 7/22/25 at 1:30 PM identified on 7/16/25 at 10:00 AM Resident #15 had reported an allegation of physical abuse, the RE form was completed on 7/16/25 and signed by her on 7/16/25 but she had not reported the event to the state agency until 7/17/25 at 6:00 PM (32 hours post allegation). The DNS indicated that it would have been her responsibility to report Resident #15's allegation to the SA timely, she had made a mistake because the reporting criteria required the allegation be reported to the state agency within 24 hours of facility notification, and she was unable to identify why the late reporting occurred. 2. Resident #55 ‘s diagnoses included legal blindness, type 2 diabetes, and bipolar disorder.Review of the Reportable Event form dated 7/17/2025 at 1:00 PM identified Resident #55 alleged that he/she was verbally and physically assaulted by RN #4 on 7/16/2025 at approximately 7:00 PM, the resident notified police, the APRN was notified by the facility, an investigation was initiated, and statements were pending. RN #4 was suspended while the investigation was in progress.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, required partial assistance with sit-to-lying positioning, was dependent on staff for sit-to-stand and chair to bed positioning changes, and walking 10 feet was not attempted.The Resident Care Plan (RCP) dated 6/18/2025 identified Resident #55 had a history of accusatory behavior. Interventions directed staff to approach Resident #55 with 2 staff members when providing Activities of Daily Living (ADL) care. A physician's order in effect from 7/1/25 through 7/24/2025 directed staff to approach Resident #55 with 2 staff members at all times every shift. Interview with Resident #55 on 7/17/2025 at 3:12 PM identified that he/she had returned to the facility with pizza the evening of 7/13/2025 and requested that it be refrigerated. On 7/16/2025, Resident #55 asked NA #9 to retrieve and heat the pizza, however, when NA #9 returned, she stated she did not find any pizza in the refrigerator. Resident #55 became upset and called RN #4 on the phone asking to be reimbursed for the missing pizza. RN #4 stated someone from social services would follow up with the resident the next day. Further, Resident #55 indicated that at approximately 6:00 PM RN #4 entered his/her room unexpectedly and alleged he began yelling profanities, including I am tired of your s***, you f****** p**** you little s*** and then he proceeded to spit in his/her face. Resident #55 indicated when he/she stated that he/she was going to call 911, RN #4 responded that he didn't care. Resident #55 called 911, began to speak with dispatch but dropped the cell phone. Resident #55 indicated that when he/she attempted to pick up the phone, RN #4 shoved him/her in the chest causing him/her to stumble and twist his/her left ankle. Resident #55 managed to retrieve the cell phone from the ground and informed the dispatcher, who was still on the call, that he/she had been assaulted by a staff member and was now hurt. At 7:00 PM the police had not arrived so Resident #55 placed another call to 911 and dispatch informed the resident the police were on their way. The police arrived at approximately 7:20 PM and a report was filed. Resident #55 further indicated that he/she was transported to the hospital secondary to chest and left foot pain. At the hospital Resident #55 identified he/she was diagnosed with a sprained left ankle, given a splint, and returned to the facility later that evening. Resident #55 went on to state that on 7/17/2025 (the next morning) he/she became upset upon hearing RN #4 being paged. Resident #55 indicated that he/she believed RN #4 would no longer be working at the facility due to the incident that happened the night before. Resident #55 stated that he/she requested to speak to the Administrator (did not recall who he/she asked) but was told the Administrator was busy. Resident #55 then contacted the facility ombudsman and his/her conservator.Interview with Social Worker #3 on 7/21/2025 at 12:44 PM identified that during his morning rounds on 7/17/202, Resident #55 seemed very upset. Resident #55 told Social Worker #3 that he/she was disturbed after hearing RN #4 paged and was confused as to why he was still in the building due to being physically assaulted by RN #4 the previous evening. Resident #55 told Social Worker #3 about the pizza incident and recounted that RN #4 went into the resident's room and just started yelling at him/her, spit in his/her face, and then physically assaulted him/her. Resident #55 also stated the police were called and that he/she needed to go to the hospital. Social Worker #3 immediately reported the allegations to his supervisor at approximately 9:15 AM on 7/17/2025, who then requested he write a statement and give the statement to the DNS and Administrator.Interview with RN #4 on 7/21/2025 at 1:07 PM, identified he first learned about the missing pizza when Resident #55 called him on the phone and reported the pizza had been thrown away. RN #4 offered to replace the pizza through the kitchen and stated that social services would follow up the next day. He felt the resident was agreeable to the plan. He then got a call from NA #9 indicating the resident was upset and she asked him to come up and speak with the resident. He was involved in another matter and could not go up stating he had already spoken with Resident #55. RN #4 stated NA #9 then reported Resident #55 was yelling and throwing things in his room. Although Resident #55 required a 2-person approach at all times, RN #4 indicated he went to the resident's room alone and stood at the resident's doorway. He reported Resident #55 was throwing things and yelling profanities. RN #4 asked Resident #55 to calm down. He stated the resident swore at him and then threatened to call 911. He took a few steps into the room to try to calm the resident, who then called 911, stating he/she had been assaulted by a staff member and was now hurt. RN #4 denied arguing or touching Resident #55. He reported that he left the room after he heard Resident #55 tell 911 that he was hurt and he returned to his office thinking let me go, this guy is accusing me of a serious allegation. About an hour later, an officer arrived, and RN #4 shared his account with the officer. The officer left to speak with Resident #55 and approximately five minutes later, RN #4 was informed by the LPN charge nurse that Resident #55 was being sent to the emergency room for chest and foot pain. RN #4 stated he then called the DNS to inform her that Resident #55 was going to the Emergency room, indicating he had told the DNS of the allegation of mistreatment, however, he later recanted this statement in a subsequent interview. RN #4 then resumed his duties, completed his 3:00 PM to 11:00 PM shift and returned to the building on 7/17/25 for the 7:00 AM to 3:00 PM shift. Interview with the DNS on 7/21/2025 at 4:35 PM, identified RN #4 contacted her on the evening of 7/16/2025. Although she could not remember the exact time, she indicated RN #4 informed her that Resident #55 had gone off on him and the resident had subsequently called the police. RN #4 told the DNS he had entered the resident's room, asked the resident to calm down, and left after the resident began yelling at him. The DNS reported RN #4 stated that Resident #55 had later complained of chest pain and foot pain and was sent to the hospital. The DNS stated RN #4 did not report that Resident #55 had alleged that he was the perpetrator and was accused of verbally and physically abusing Resident #55. The DNS said she only became aware of the full context the next morning when rounding on the unit and learning from Resident #55 that there had been a serious allegation of verbal and physical abuse involving RN #4. She stated she was aware that allegations of verbal or physical abuse needed to be reported within 2 hours. The DNS stated, had she known the nature of the accusation, she would have immediately reported it to the State Agency and suspended the supervisor per the facility policy, pending an investigation. 3. Resident #58's diagnoses included fracture of the left arm humerus, fracture of the left femur, displaced fracture of the right tibia, and acute pain due to trauma. A Grievance form dated 7/1/2025 (written in response to an allegation that occurred on 6/28/2025) identified Resident #58 had reported to the facility that a staff member referred to him/her as the N-word. The Grievance form further identified that the facility made him/her aware that the incident was under investigation and the facility would adhere to the facility policy. The grievance form stated that the staff member was educated but continued to demonstrate an inability to adhere to policies, exhibited insubordination, and was non-compliant. Additionally, the staff member lacked adequate customer service skills, and, as a result, their employment was terminated. (later identified that NA #6 was not terminated as an employee but made a Do Not Return to the facility from the staffing agency). The Grievance form was signed by the facility's Administrator on 7/4/2025. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, did not experience episodes of delusions or verbal behavioral symptoms towards others, and was dependent for his/her personal hygiene and rolling left and right in bed.The Resident Care Plan (RCP) in effect from 5/15/2025 through 7/20/2025 identified Resident #58 required assistance with activities of daily living and had a history of refusing care and medications. Interventions included encouraging the resident to participate in his/her care and praising all efforts at self-care. The RCP was not revised for the grievance dated 7/1/2025 that occurred on 6/28/2025. Interview on 7/16/2025 at 10:03 AM with Resident #58 identified on 6/28/2025 Nurse Aide (NA) #6 called her a F***ing N-word and he/she reported feeling abused to a Social Worker (SW). Resident #58 further identified since the incident of verbal abuse he/she had difficulty sleeping due to being afraid of retaliation by other staff for reporting the abuse, and he/she was not sure what people will do these days.Interview on 7/18/2025 at 10:23 AM with SW #3 identified that Resident #58 notified her during rounds that a Nurse Aide (NA) called him/her the N-word, that the racial slur made him/her feel uncomfortable, and he/she requested not to receive care from that NA going forward. SW #3 stated she notified her supervisor (SW #1) and the DNS of the allegation of abuse, and she was not involved with completing an investigation as the DNS and her supervisor (SW #1) were responsible for investigations. Interview on 7/18/2025 at 10:33 AM with the Director of Nursing Services (DNS) identified that she was made aware of the allegation of abuse by social services, that Resident #58 had reported he/she was called the N-word, and it was a team decision to place the NA #6 on a do not return list for future assignments. She stated that she did not conduct an investigation and believed that social work had completed an investigation. The DNS further identified that the incident of abuse was documented as a grievance and not reported to the State Agency (SA) per a directive from the facility Administrator. The DNS stated that the NA calling the resident the racial slur of the N-word constituted verbal abuse and that the incident should have been reported to the SA. An interview on 7/18/2025 at 11:15 AM with the Administrator identified that he was notified of the allegation of verbal abuse towards Resident #58 by SW #1. Further, he identified he signed the Grievance form and determined the incident was not reportable to the SA because he believed the use of the N-word was said in Resident #58's presence but was not said directly to him/her. The Administrator disagreed that a NA referring to a resident as a f***ing N-word in the presence of that resident was an allegation of verbal abuse. Review of the facility's Abuse, Neglect, and Exploitation policy identified, in part, that it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Further, the abuse policy directed that the facility will complete an immediate investigation when a report of abuse occurs, provide complete and thorough documentation of the investigation, and a report will be made to the SA immediately but no later than 2 hours after the allegation is made, and the Administrator will follow-up with the SA to report the results of the investigation within 5 working days of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 5 of 8 sampled residents (Resident #4, Resident #43, Resident #55, Resident #58, and Resident #59) reviewed for abuse, the facility failed to ensure complete, thorough, and timely investigations were conducted. The findings include:F610 Grandview merged Based on review of the clinical record, facility documentation, facility policy, and interviews for 5 of 8 sampled residents (Resident #4, Resident #43, Resident #55, Resident #58, and Resident #59) reviewed for abuse, the facility failed to ensure complete, thorough, and timely investigations were conducted. The findings include: 1. Resident #4's diagnoses included mononeuropathy, type 2 diabetes, and chronic respiratory failure with hypoxia (low level of oxygen). A nurse’s note dated 6/30/2025 at 2:22 PM by Registered Nurse (RN) #6 identified that LPN #7 informed her that Resident #4 was missing his/her bank card. RN #6 spoke with Resident #4 and was informed he/she went to the bank on 6/30/2025 and noticed the bank card was missing. He/she identified a charge that was made on the account that was not made by him/her when reviewing the bank statement. The nurse’s note further identified the Director of Nursing Services (DNS), and the Administrator were made aware of the incident. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, required set-up assistance with personal hygiene, used a wheelchair for locomotion, and was independent with chair/bed-to-chair transfers. The Resident Care Plan (RCP) in effect from 5/3/2025 through 7/22/2025 identified Resident #4 needed socialization and independent activities at his/her own leisure to support his/her independence. Interventions included participating in smoke breaks, providing independent leisure activity materials, and visits by the Recreation Department 2 to 3 times weekly. A nurse’s note dated 6/30/2025 at 2:22 PM by Licensed Practical Nurse (LPN) #7 identified that Resident #4 informed her that he/she went to the bank on 6/30/2025 with Person #3 (Resident #4’s family member) and noticed his/her bank card was missing and money was missing from his/her bank account. The nurse’s note further identified her supervisor, Registered Nurse (RN) #6, was made aware, the Police Department was called, and social services had started an investigation. A social services note dated 6/30/2025 at 3:44 PM identified Resident #4 was offered talk therapy and assured that all facility protocols would be followed, including reporting to the police and the State Agency (SA). A psychiatric Advanced Practice Registered Nurse (APRN) note dated 7/2/2025 identified that Resident #4’s mood was stable after the 6/30/2025 allegation of misappropriation of funds. The psychiatric APRN note further identified that the resident had not checked his/her wallet in about a month. Review of a Reportable Event summary form dated 7/8/2025 and investigation documentation identified the DNS unsubstantiated the allegation of abuse and that the Police Department was conducting their own investigation into the allegation of misappropriation of Resident #4’s personal funds. Review of the facility’s investigation documentation identified 6 staff members provided single sentence statements attesting they were not aware of Resident #4’s missing bank card. The facility failed to ensure the forms were complete and contained a supervisory staff signature (blank) indicating that supervisory staff discussed the provided written statement with the staff member as indicated on the form. The investigation failed to obtain statements from all staff members from different shifts who had access to the resident during the time in question, failed to include an interview with the resident’s roommate, and failed to conduct an interview with the resident, Resident #4, who had the bank card taken. Interview on 7/16/2025 at 10:57 AM with Resident #4 identified his/her bank card was stolen from his/her room and around $25.00 was charged at a grocery store approximately 10 miles away from the facility. He/she stated a police report was filed, and the facility had not reimbursed the money that had been stolen. After requesting and obtaining approval to review, the bank statement for Resident #4 dated 6/25/2025 identified that bank account activity on 6/9/2025 had occurred at a grocery store approximately 10 miles away from the facility in the amount of $25.80. No other charges were made to his/her account for the dates from 4/30/2025 through 6/25/2025. A signed police report dated 7/18/2025 identified the police were dispatched to the facility on 7/2/2025 at 11:40 AM. The report identified Resident #4 signed a sworn statement that he/she used the debit card on 5/5/2025 at the bank to directly withdraw $400.00. The report further identified that he/she had neither left the facility nor used his/her card after 5/5/2025 and that he/she would like to press charges against the individual who stole his/her bank card, making a charge to his/her account. Interview on 7/21/2025 at 9:16 AM with Person #3 identified he/she took Resident #4 to the bank on 6/30/2025 when the resident discovered his/her bank card was missing and found out there had been unauthorized use of Resident #4’s bank card. Person #3 further identified no one other than him/her takes Resident #4 out of the facility, he/she had not taken the resident out of the facility any date in June, and he/she did not take or borrow Resident #4’s bank card for any reason. Interview on 7/21/2025 at 1:55 PM with the DNS identified a complete investigation into the allegation of misappropriation of funds was not performed. The DNS indicated that she failed to review the facility video cameras for potential evidence, she failed to request/obtain a copy of Resident #4’s bank statement, and she failed to obtain written statements from all staff who worked with Resident #4 during the time of the incident. The DNS identified that she had unsubstantiated the allegation of misappropriation, and her rationale was due to time constraints. The DNS indicated the only way someone would have access to Resident #4’s bank card, if it was kept in his/her wallet, would be if it was stolen. 2. Resident #43's diagnoses included anxiety and depressive disorder. Interview with Resident #43 on 7/15/25 at 11:15AM identified that he/she had reported to Registered Nurse (RN) #1 that $10.00 was missing from the drawer in his/her room a few weeks ago. Resident #43 could not recall the date but stated it was on a weekend. Resident #43 indicated that RN #1 told her she would have to report the missing money to the police. Resident #43 stated he/she asked that RN #1 not to report the missing $10.00 to the police as he/she did not want anyone to get in trouble. Resident #43 identified he/she did not report the missing $10.00 to any other staff member. Furthermore, Resident #43 stated that her locked box was broken when the incident happened and he/she had placed the $10.00 under the locked box. Resident #43 indicated that the locked box was repaired by maintenance not too long after the incident. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #43 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment and was independent with activities of daily living. The Resident Care Plan dated 7/15/25 identified Resident #43 reported $10.00 missing, and interventions included to follow the facility policy for reports of missing items, educate the resident on the use of a locked box, and encourage the resident to utilize a locked box for safe keeping of personal items and money. Interview with the DNS on 7/15/25 at 12:15 PM identified that she was unaware Resident #43 was missing $10.00, and the missing money had not been reported to her. Subsequently, the DNS filed an Accident & Incident report with the State Agency for Resident #43's missing $10.00 and initiated an investigation. During an interview with RN #1 on 7/15/25 at 1:50 PM, she denied that Resident #43 reported missing $10.00 and if Resident #43 had reported the missing money she would have reported the occurrence and completed an Accident and Incident report. RN #1 indicated that she only worked on the weekends. Re-interview with Resident #43 on 7/17/25 at 12:00 PM confirmed that he/she had reported the missing $10.00 to RN #1 when he/she noticed the $10.00 was missing. Resident #43 stated that he/she had asked RN#1 not to report the missing money to the police. A review of nursing notes and social service notes for June and July 2025 failed to identify documentation that Resident #43 had reported the missing $10.00 to RN #1. An interview and review of the investigation for Resident #43's missing money with the DNS on 7/23/25 at 12:00 PM indicated that the DNS had completed her investigation. The DNS stated the only remaining issue was that the facility was going to reimburse Resident #43 for the missing $10.00. A review of statements with the DNS identified that the investigation lacked a statement from RN #1 or any other staff members that worked on Resident #43's unit. The only statement that was obtained was from Resident #43. The DNS indicated that statements from RN #1 and staff members who had worked on Resident #43's unit should have been obtained for the investigation and that the investigation was not thoroughly completed. Furthermore, the DNS indicated that it was her responsibility to ensure investigations were completed per the facility policy. 3. Resident #55 ‘s diagnoses included legal blindness, type 2 diabetes, and bipolar disorder. Review of the Reportable Event form dated 7/17/2025 at 1:00 PM identified Resident #55 alleged that he/she was verbally and physically assaulted by RN #4 on 7/16/2025 at approximately 7:00 PM, the resident notified police, the APRN was notified by the facility, an investigation was initiated, and statements were pending. RN #4 was suspended while the investigation was in progress. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, required partial assistance with sit-to-lying positioning, was dependent on staff for sit-to-stand and chair to bed positioning changes, and walking 10 feet was not attempted. The Resident Care Plan dated 6/18/2025 identified Resident #55 had a history of accusatory behavior. Interventions directed staff to approach Resident #55 with 2 staff members when delivering activities of daily living (ADL) care. Physician’s orders that were in effect from 7/1/2025 through 7/24/2025 directed staff to approach Resident #55 with 2 staff members at all times every shift. Review of the facility Accident and Investigation Report indicated that the facility was unable to substantiate the allegation following the completion of the investigation, but the documentation was incomplete as there was no statement from Resident #55 and 2 statements were written but lacked signatures as to who had completed the statements. Interview with Resident #55 on 7/17/2025 at 3:12 PM identified that he/she had returned to the facility with pizza the evening of 7/13/2025 and requested that it be refrigerated. On 7/16/2025, Resident #55 asked NA #9 to retrieve and heat the pizza, however, when NA #9 returned, she stated she did not find any pizza in the refrigerator. Resident #55 became upset and called RN #4 on the phone asking to be reimbursed for the missing pizza. Resident #55 indicated that RN #4 stated someone from social services would follow up with the resident the next day. Further, Resident #55 identified that at approximately 6:00 PM RN #4 entered his/her room unexpectedly and began yelling profanities, including “I am tired of your s***, you f****** p**** you little s***” and then according to Resident #55, RN #4 proceeded to spit in his/her face. Resident #55 indicated when he/she stated that he/she was going to call 911, RN #4 responded that he didn’t care. Resident #55 stated he/she called 911and began to speak with dispatch but dropped the cell phone. Resident #55 indicated that when he/she attempted to pick up the phone, RN #4 shoved him/her in the chest causing him/her to stumble and twist his/her left ankle. Resident #55 managed to retrieve the cell phone from the ground and informed the dispatcher, who was still on the call, that he/she had been assaulted by a staff member and was now hurt. At 7:00 PM the police had not arrived so Resident #55 placed another call to 911 and dispatch indicated the police were on their way. The police arrived at approximately 7:20 PM, and a report was filed. Resident #55 indicated that he/she was transported to the hospital secondary to chest and left foot pain. At the hospital Resident #55 identified he/she was diagnosed with a sprained left ankle, given a splint, and returned to the facility later that evening. Resident #55 went on to state that on 7/17/2025 (the next morning) he/she became upset upon hearing RN #4 being paged. Resident #55 indicated that he/she believed RN #4 would no longer be working at the facility due to the incident that happened the night before. Resident #55 stated that he/she requested to speak to the Administrator (did not recall who he/she asked) but was told the Administrator was busy and then Resident #55 indicated he/she contacted the facility ombudsman and his/her conservator. Review of the hospital Discharge summary dated [DATE] at 1:22 AM identified Resident #55’s was diagnosed with a sprained ankle, given an ankle splint air cast, and discharged back to the facility. Interview with Social Worker (SW) #3 on 7/21/2025 at 12:44 PM identified that during his morning rounds on 7/17/202, Resident #55 seemed very upset. Resident #55 told Social Worker #3 that he/she was disturbed after hearing RN #4 paged and was confused as to why he was still in the building due to being physically assaulted by RN #4 the previous evening. Resident #55 told SW #3 about the pizza incident and recounted that RN #4 went into the resident’s room and just started yelling at him/her, spit in his/her face, and then physically assaulted him/her. Resident #55 also stated the police were called and that he/she needed to go to the hospital. Social Worker #3 immediately reported the allegations to his supervisor around 9:15 AM on 7/17/2025 who then requested he write a statement and give the statement to the DNS and Administrator. Interview with RN #4 on 7/21/2025 at 1:07 PM, identified he first learned about the missing pizza when Resident #55 called him on the phone and reported the pizza had been thrown away. RN #4 offered to replace the pizza through the kitchen and stated that social services would follow up the next day. He felt the resident was agreeable to the plan. He next received a call from NA #9 indicating the resident was upset and she asked him to come up and speak with the resident. RN #4 indicated he was involved in another matter and could not go up stating he had already spoken with Resident #55. RN #4 stated NA #9 then reported Resident #55 was yelling and throwing things in his room. Although Resident #55 required a 2 person approach at all times, RN #4 indicated he went to the resident’s room alone and stood at the resident’s doorway. He reported Resident #55 was throwing things and yelling profanities. RN #4 asked Resident #55 to calm down. He stated the resident swore at him and then threatened to call 911. He took a few steps into the room to try to calm the resident, and then Resident #55 called 911, stating he/she had been assaulted by a staff member and was now hurt. RN #4 denied arguing or touching Resident #55. He reported that he left the room after he heard Resident #55 tell 911 that he was hurt and he returned to his office thinking to himself, let me go, this guy is accusing me of a serious allegation. About an hour later, an officer arrived, and RN #4 shared his account with the officer. The officer left to speak with Resident #55 and approximately five minutes later, RN #4 was informed by the LPN charge nurse that Resident #55 was being sent to the emergency room for chest and foot pain. RN #4 stated he then called the DNS to inform her that Resident #55 was going to the Emergency room, indicating he had told the DNS of the allegation of mistreatment. He later recanted he had told the DNS of the allegation in a subsequent interview. RN #4 then resumed his duties, completed his 3:00 PM to 11:00 PM shift and returned to the building on 7/17/2025 for the 7:00 AM to 3:00 PM shift. Interview with the DNS on 7/21/2025 at 4:35 PM, identified RN #4 contacted her on the evening of 7/16/2025. Although she could not remember the exact time, she indicated RN #4 informed her that Resident #55 had “gone off” on him and the resident had subsequently called the police. RN #4 told the DNS he had entered the resident’s room, asked the resident to calm down, and left after the resident began yelling at him. The DNS reported RN #4 stated that Resident #55 had later complained of chest pain and foot pain and was sent to the hospital. The DNS stated RN #4 did not report that Resident #55 had alleged that he (RN #4) was the perpetrator and was accused of verbally and physically abusing Resident #55. The DNS said she only became aware of the full context the next morning when rounding on the unit and learning from Resident #55 that there had been a serious allegation of verbal and physical abuse involving RN #4. She stated that once she became aware of the situation, the DNS reported the allegation to the State Agency and started an investigation. She stated she obtained statements from all those involved but was unable to produce the full investigation and did not substantiate the allegation of abuse. 4. Resident #58's diagnoses included fracture of the left arm humerus, fracture of the left femur, displaced fracture of the right tibia, and acute pain due to trauma. A Grievance form dated 7/1/2025 (written in response to an allegation that occurred on 6/28/2025) identified Resident #58 had reported to the facility that a staff member referred to him/her as the “N-word”. The Grievance form further identified that the facility made him/her aware that the incident was under investigation and the facility would adhere to the facility policy. The grievance form stated that “the staff member was educated but continued to demonstrate an inability to adhere to policies, exhibited insubordination, and was non-compliant. Additionally, the staff member lacked adequate customer service skills, and, as a result, their employment was terminated.” (later identified that NA #6 was not terminated as an employee but made a Do Not Return to the facility from the staffing agency). The Grievance form was signed by the facility’s Administrator on 7/4/2025. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, did not experience episodes of delusions or verbal behavioral symptoms towards others, and was dependent for his/her personal hygiene and rolling left and right in bed. The Resident Care Plan (RCP) in effect from 5/15/2025 through 7/20/2025 identified Resident #58 required assistance with activities of daily living and had a history of refusing care and medications. Interventions included encouraging the resident to participate in his/her care and praising all efforts at self-care. The RCP was not revised for the grievance dated 7/1/2025 that occurred on 6/28/2025. A. Interview on 7/16/2025 at 10:03 AM with Resident #58 identified on 6/28/2025 Nurse Aide (NA) #6 called him/her a “F***ing N-word” and he/she reported feeling abused to a Social Worker (SW). Resident #58 further identified since the incident of verbal abuse he/she had difficulty sleeping due to being afraid of retaliation by other staff for reporting the abuse, and he/she was “not sure what people will do these days”. Interview on 7/18/2025 at 10:23 AM with SW #3 identified that Resident #58 notified her during rounds that a Nurse Aide (NA) called him/her the “N-word”, that the racial slur made him/her feel uncomfortable, and he/she requested not to receive care from that NA going forward. SW #3 stated she notified her supervisor (SW #1) and the DNS of the allegation of abuse, and she was not involved with completing an investigation as the DNS and her supervisor (SW #1) were responsible for investigations. Interview on 7/18/2025 at 9:50 AM with Social Worker (SW) #1 identified that he was made aware through daily report that a staff member used the “N-word” to Resident #58 and SW #3 collected information on the incident. He stated that social services did not perform an investigation into the allegation nor was he a part of the investigation, as it was the Nursing Department’s responsibility to do so, but social services did perform wellness checks on Resident #58 as use of the “N-word” can cause pain and he wanted to be certain he/she was safe. SW #1 failed to document the details of the wellness check within the clinical record. SW #1 stated he did not report the incident of abuse to administration because they were already aware. Interview on 7/18/2025 at 10:33 AM with the Director of Nursing Services (DNS) identified that she was made aware of the allegation of abuse by social services, that Resident #58 had reported he/she was called the “N-word”, and it was a team decision to place the NA #6 on a do not return list for future assignments. She stated that she did not conduct an investigation and believed that social work had completed an investigation. The DNS further identified that the incident of abuse was documented as a grievance and not reported to the State Agency (SA) per a directive from the facility Administrator. The DNS stated that the NA calling the resident the racial slur of the “N-word” constituted verbal abuse and that the incident should have been reported to the SA. A second interview on 7/18/2025 at 10:46 AM with the DNS, SW #1, SW #3, and SW #4 identified that an investigation was not completed. SW #1 stated the reason an investigation was not completed was because the incident was labeled a Grievance and that nursing or administration would be responsible for investigating verbal abuse. The DNS stated the social workers should have investigated the occurrence as verbal abuse. The DNS, SW #1, SW #3, and SW #4 all stated they had received abuse training, that use of the racial slur “N-word” was a form of verbal abuse. An interview on 7/18/2025 at 11:15 AM with the Administrator identified that he was notified of the allegation of verbal abuse towards Resident #58 by SW #1. Further, he identified he signed the Grievance form and determined the incident was not reportable to the SA because he believed the use of the “N-word” was said in Resident #58’s presence but was not said directly to him/her. The Administrator disagreed that a NA referring to a resident as a “f***ing N-word” in the presence of that resident was an allegation of verbal abuse. B. According to punch in and punch out records: NA #6 punched in on 6/28/2025 at 3:00 PM and punched out on 6/28/2025 at 11:15 PM and was scheduled to work on Resident #58’s floor; punched in on 6/29/2025 at 3:00 PM and punched out on 6/29/2025 at 10:45 PM and was scheduled to work on Resident #58’s floor; punched in on 7/5/2025 at 3:00 PM and punched out on 7/5/2025 at 11:00 PM and was not scheduled to work on Resident #58’s floor; and punched in on 7/6/2025 at 3:00 PM and punched out on 7/6/2025 at 11:00 PM and was scheduled to work on Resident #58’s floor. The facility failed to protect Resident #58 from abuse on 3 out of 3 occasions after the allegation of verbal abuse was made. When NA #6 continued to work at the facility, the facility failed to protect Resident #58 from further abuse as NA #6 still had access to Resident #58. Interview on 7/22/2025 at 1:40 PM with the Nurse Scheduler identified that NA #6 was placed on the Do Not Rehire (DNR) list because she called Resident #58 the “N-word”. The Nurse Scheduler further identified it was either social services or the DNS who provided her with the reason for placing NA #6 on the DNR list. Interview on 7/22/2025 at 1:40 PM with Person #1 identified the facility told him/her that NA #6 had called a resident the “N-word”. He/she further identified that NA #6 continued to work at the facility after the incident even though Person #1 told her not to go back to the facility. Review of text messages dated 7/7/2025 at 11:54 AM between Person #1 (staffing agency) and NA #6 identified that NA #6 was asked to not return to the facility by Person #1 because an investigation into NA #6’s actions on 6/28/2025 had not been completed. NA #6 responded via text, that the DNS had told her she was off Resident #58’s assignment but the DNS had not told her not to come back to work. 5. Resident #59’s diagnoses included obstructive hydrocephalus, difficulty in walking and unspecified vision loss. A nurse note dated 6/17/25 at 6:22 PM identified Resident #59’s left eye was swollen, bruised, and dark purple. He/she was noted to be in pain and stated that he/she rolled over and hit his/her eye on the side of the bed the night before. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 was severely cognitively impaired, required supervision or touch assistance for walking 150 feet or more and was independent for transfers. The Resident Care Plan dated 6/27/25 identified Resident # 59 had an ADL self-care performance deficit related to altered mental status and hydrocephalus. Interventions included the assistance of 1 staff with the use of a standard single point cane. Review of the Accident and Incident Report dated 6/17/25 identified Resident #59 sustained a left periorbital bruise. His/her mental status was described as confused and forgetful, and physical status noted to be independent with transfers, ambulation, and eating. The summary conclusion report submitted to the State Agency (SA) by the Director of Nurses on 6/20/25 identified that upon investigation the origin of the left orbital bruise could not be determined (an injury of unknown origin). Additionally, upon interviewing the resident, he/she did not know how the left orbital bruise had occurred and that Resident #59 was a poor historian. Interview with Licensed Practical Nurse (LPN) #2 on 7/22/25 at 12:15 PM identified the facility policy directed the charge nurse or the supervisor to fill out an Accident and Incident Report upon discovery of an injury that was not witnessed. She stated that on 6/17/25 around 6:00 PM it was reported to her that Resident #59 had a dark blue, swollen bruise to his/her left eye. LPN #2 stated Resident #59 told her that he/she sustained the bruise from rolling over in bed, but the bruising was to her left inner eye so it could not have been caused by rolling over. Interview and clinical record review with the Director of Nurses (DNS) on 7/22/25 at 1:00 PM identified it was the facility policy that Accident and Incident reports were initiated by the charge nurse and supervisor, and if the occurrence was identified by the DNS to be a Reportable Event that needed to be submitted to the SA, this information was completed by the DNS. The DNS further indicated that the facility policy was to include a 72 hour look back investigation during the period prior to the event on the resident's unit that consisted of staff interviews for all staff who worked during that 72-hour period. A review of the Accident and Incident Report investigation dated 6/17/25 for Resident #59 identified the current investigation consisting of 4 employee statements that were all dated 6/17/25 were attached. The DNS could not identify if the attached interviews were the only ones obtained since “there were quite a few missing” and stated she would double-check the supervisor’s office. Additionally, the DNS identified that she was responsible for overseeing Accident and Incident form completion, and since it was an injury of unknown origin, investigation statements should have included all staff that worked on the unit for all shifts, dating back to 6/14/25. Interview and observation with Registered Nurse Supervisor (RN) #6 on 7/22/25 at 3:20 PM in the supervisor's office identified that although the DNS stated that 72-hour look back statements were kept in the supervisor’s office, RN #6 indicated that statements had never been kept in the supervisor’s office. RN #6 indicated that the Assistant Director of Nurses (ADNS) was responsible to keep track of and store investigation statements. RN #6 looked through the stacks of paper waiting to be filed but was unable to identify that any 72- hour look back statements for Resident #59 were located in the supervisor’s office. Interview and clinical record review with the ADNS on 7/22/25 at 3:30 PM identified she was responsible for the 72-hour look back statements, however, did not currently have any investigation statements for Resident #59 for the Accident and Incident report dated 6/17/25. The ADNS indicated that all the statements obtained had already been already attached (4 employee statements) to the current documentation, and that the statements did not include everyone that the facility policy directed a statement to be obtained from, as only 4 statements had been completed. Further, the ADNS indicated that she did not currently have any statements whatsoever in her office area. A review of the Abuse, Neglect and Exploitation policy dated 1/18/2024 directed, in part, that written procedures for investigations include to identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and any others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent, and cause: and providing complete and through documentation of the investigation, that an immediate investigation will take place when there is a suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. A report will be made to the SA immediately but no later than 2 hours after the allegation is made, and the Administrator will follow-up with the SA to report the results of the investigation within 5 working days of the incident. Additionally, the facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well as additional abuse, during and after the investigation. The Incidents and Accidents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, facility documentation, facility policy and interviews for 3 of 4 sampled residents (Resident #2, Resident #24, and Resident #45) reviewed for activities, the facility failed to ensure individualized activities were provided to bedbound residents, dependent residents, and failed to ensure activity calendars were revised to reflect actual activities provided. The findings include:1.Resident #2's diagnoses included chronic pain syndrome and pressure induced deep tissue damage of sacral region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment and was totally dependent on staff for bed mobility, washing, dressing, and did not transfer out of bed.The Resident Care Plan dated 6/9/25 identified that Resident #2 needed socialization and self-directed leisure pursuits to support feelings of fulfillment and empowerment. Interventions included assistance in transportation to activities, provide 1:1 visits that inform resident of current events, offers music, activity packet, and independent leisure activity material as needed.Interview and observation on 7/15/25 at 11:20 AM with Resident #2 identified he/she was lying in bed on his/her right side facing the cubicle curtain. without the benefit of any activities such as music, television, or other sensory stimulation. Resident #2 identified that he/she could not recall the last time someone from the Recreation Department came for a visit. Resident #2 stated that he/she was very particular and liked things a certain way, but activities provided in his/her room were limited.Observation on 7/17/25 at 10:00 AM identified Resident #2 lying in bed without the benefit of any activities such as music, television, or any other sensory stimulation. A review of Resident #2's recreation participation calendar identified all of the available facility recreation programs. For June 2025, out of 30 available days, Resident #2 received 1:1 visits 8 times, had 1 communion visit, and had 1 refusal of activity participation. From July 1 to July 22, 2025, out of 22 available days, 1:1 was provided 6 times with 1 communion visit, and 2 documented refusals.2. Resident #24's diagnoses included osteoarthritis and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 had a Brief Interview of Mental Status (BIMS) score of 7 indicating severe cognitive impairment and was totally dependent on staff for washing, dressing, and w/c mobility. The Resident Care Plan in effect for June and July 2025 identified Resident #24 had little or no activity involvement and their primary language was Albanian. Interventions included to encourage the resident's family to attend activities with Resident #24 to support participation.A review of Resident #24's recreation participation calendar identified all of the available facility recreation programs. For June 2025, out of 30 available days, Resident #2 received 1:1 visits 10 times, 5 family visits (3 of occurred on the same days as the 1:1) and attended the monthly birthday party. From July 1 to July 22, 2025, out of 22 available days, 1:1 was provided 4 times, 8 family visits (4 on the same days as the 1:1) and attended the July 4th picnic and the monthly birthday party.Observations on 7/15/25 at 10:00 AM and 2:00 PM and on 7/16/25 at 11:30 AM identified Resident #24 sitting in w/c by the nursing station with no activities provided.3. Resident #45's diagnoses included schizoaffective disorder and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment and required maximum assistance from staff for bed mobility, washing, dressing, and did not transfer out of bed.The Resident Care Plan dated 6/12/25 identified that Resident #45 preferred self-directed independent activities in the comfort of his/her room. Interventions included TV, listening to music, reading, writing and assistance with telephone and facetime/zoom calls.Interview and observation on 7/15/25 at 11:00 AM, identified Resident #45 in bed with the overbed table in place. He/she was noted to be using copy paper to write. Resident #45 indicated he/she was unable to get out of bed and that he/she had requested a notebook from recreation several times but had not yet received one. Resident #45 could not recall the last time a recreation representative had spent any time in his/room.Observations on 7/16/25 at 1:00 PM and 7/22/25 at 11:30 AM identified Resident #45 laying on his/her back in bed without the benefit of any activities such as music, television, or any other sensory stimulation. A review of Resident #45's recreation participation calendar identified all of the available facility recreation programs. For June 2025, out of 30 available days, Resident #45 received 1:1 visits 8 times and 1 communion visit. From July 1 to July 22, 2025, out of 22 available days, 1:1 was provided 7 times with 1 communion visit, and 1 documented refusal.None of the participation calendars signified what type of 1:1 activity occurred, or the amount of time spent with Resident #2, 24, or 45. 4. During a review of recreation programming with the Recreation Director on 7/24/25 at 9:00 AM, it was identified that the program calendar did not match the participation calendars. The Recreation Director indicated that during the months of April and May 2025, due to a lack of staff and being the only available recreation staff, she had to adjust the activities that were offered. Although she announced on the overhead paging system which activities would take place for that day, none of the activity calendars had been amended to reflect the correct activities offered. Review of the Activities Programming Policy, directed, in part, programs will be planned to include empowerment, maintenance and supportive activities. Supportive activities included sensory stimulation, 1:1 visits and pet therapy. Although requested, a facility policy for resident participation/documentation was not provided as the facility did not have a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 sampled residents (Resident #6) reviewed for accidents, the facility failed to update the Resident Care Plan with new interventions following falls and failed to complete neurological checks following a fall, for 1 of 4 sampled residents (Resident #27) reviewed for accidents, the facility failed to ensure a safe and effective system was in place during non-medical Leave of Absences (LOA), to account for residents in the event of an emergency, for 1 of 8 sampled residents (Resident #59) reviewed for abuse, the facility failed to follow a physician's order for an assist of 1 staff to keep a resident free from accidents/incidents and for 6 of 31 sampled residents (Resident #1, #31, #33, #85, #91, and #122) reviewed for the environment, the facility failed to maintain an accident free environment for resident with impaired cognition, due to a lack of water temperature monitoring from September 2024 to 7/18/2025. The findings include:1. Resident #6‘s diagnoses included dementia with severe agitation, unsteadiness on feet, and syncope and collapse. The admission Minimum Data Set, dated [DATE] identified Resident #6 had a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment, required set up assistance with eating, partial moderate assistance with dressing, personal hygiene, and was not assessed for bed mobility, transfer and ambulation. The Resident Care Plan (RCP) dated 1/21/2025 identified Resident #6 was at risk for falls related to gait and balance problems from psychoactive medication use and was unaware of his/her safety needs. Interventions included call bell within reach and encourage use for assistance as needed, prompt response to all requests for assistance, follow fall protocol, and Physical Therapy to evaluate and treat as ordered or as needed. The RCP failed to indicate the level of assistance required for ambulation. A physician’s order dated 1/21/2025 and in effect through May 2025 directed assistance of 1 for out of bed transfers using a rolling walker. Additionally, orders directed to administer quetiapine [an antipsychotic known to cause orthostatic hypotension (low blood pressure)] 25 mg 1 tablet at bedtime for agitation, quetiapine 50 mg give 1 tablet in the morning for agitation, and Mirtazapine 30 mg at bedtime for depression. Review of a Reportable Event dated 3/10/2025 at 7:00 AM identified Resident #6 was found on the bedroom floor. Resident #6 denied pain or injury, the fall was unwitnessed, and the fall protocol and assistance of 1 for activities of daily living for him/her was initiated. It was further identified that Resident #6 was lying in bed prior to fall and was unable to identify the cause of the fall, stating “I was just walking around. A nurse’s note dated 3/10/2025 at 7:12 AM identified Resident #6 was lying on the floor on his/her right side, dressed in a hospital gown, barefoot, had range of motion to all extremities, denied striking his/her head, and was assisted off the floor and back to bed by the charge nurse and the supervisor. Resident #6’s bed was in the lowest position, and he/she was reoriented to use call light for assistance. The Advanced Practice Registered Nurse (APRN) was notified and gave orders to notify the clinician of any changes in condition, monitor neurological checks per protocol, initiate fall precautions, and assess pain per protocol. Review of Resident #6’s fall risk assessment dated [DATE] identified a score of 80, indicating a high risk for falls. The Resident Care Plan revised on 3/10/2025 identified Resident #6 had an actual fall without injury due to poor balance and unsteady gait. Interventions included a Physical Therapy (PT) consult for strength and mobility. (The clinical record indicated Resident #6 was already receiving PT). A nurse’s note dated 4/2/2025 at 5:59 AM identified Resident #6 was found lying on the floor in a supine (facing up) position and had an unwitnessed fall. Resident #6 was assisted by 2 staff to get up off the floor and his/her blood pressure was noted to be low at 104/50 (normal 120/80). The APRN was notified and gave orders to assess pain, initiate fall precautions, and monitor neurological checks per protocol, notify the clinician of any changes in condition, and indicated there was no need to send Resident #6 to the hospital. A Reportable Event for the 4/2/2025 fall was requested from the facility but never provided. A Fall Risk assessment dated [DATE] at 9:31 AM identified a score of 90 indicating a high risk for falling. Although the Resident Care Plan had an entry dated 4/2/2025 indicating the resident fell, the facility failed to implement a new intervention to prevent future falls, for 7 days, until the RCP was updated on 4/9/2025 to keep the bed in the lowest position. Review of the Reportable Event and fall investigation dated 4/15/2025 at 4:45 AM identified Resident #6 was observed lying on the floor in a supine position and not aware he/she was on the floor. Resident #6’s mental status was at baseline (moderate cognitive impairment). Resident #6 was assessed and transferred back to bed, re-educated and reinforced to use the call bell for assistance. The fall investigation identified Resident #6 did not remember what happened, was forgetful, and staff continued to remind him/her what the call bell was used for and to keep the bed in the lowest position at all times (Repeat RCP interventions for call bell use and to keep the bed in low). An unsigned written statement by NA #9 signed and dated on 4/15/2025 by the supervisor identified Resident #6 was very restless all night, sat up and down in bed 15 times, and around 4:45 AM, tried to stand up on the left side of bed, lost his/her balance, and fell backwards onto the bed causing him/her to roll and gently slid off the right side of the bed. It was further identified that the fall was witnessed, the bed broke his/her fall, Resident #6 did not hit his/her head, and landed on their side. The Resident Care Plan revised on 4/15/2025 identified Resident #6 had a fall without injury due to poor balance, unsteady gait, and hypotension. The interventions included monitor, document, and report as needed for 72 hours for signs or symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture or agitation, neurological checks per protocol. The Resident Care Plan failed to include a new intervention to prevent future falls. A Reportable Event dated 5/20/2025 at 2:05 PM identified Resident #6 was lying on the floor in the dining room, his/her mental status was alert to self and place, he/she had a Brief Interview of Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment and required the assistance of 2 people with transfers and assist of 1 in the wheelchair. The APRN was notified and gave orders to hold his/her 5:00 PM dose of Carvedilol (a medication for high blood pressure) related to hypotension (low blood pressure), encourage fluids, transfer Resident #6 to bed and position him/her in the Trendelenburg position, (feet up, head down), perform skin and neurological assessments, perform pain and range of motion evaluations, and notify the family. A nurse’s note dated 5/20/2025 at 3:51 PM identified that at 2:50 PM Resident #6 was observed in a side lying position on the floor in the dining room. Upon assessment he/she denied pain, his/her skin was intact, he/she was able to follow simple commands, and had hand grasps that were strong and equal bilaterally. At the time of the fall Resident #6’s blood pressure was noted to be 74/54 (normal 120/80). The APRN was notified and gave orders to place Resident #6 in bed in the Trendelenburg position and to recheck blood pressure in 20 minutes (20-minute check of blood pressure was 84/61). Resident #6 denied pain or dizziness. New orders directed to hold Carvedilol 3.125 mg one dose only and encourage fluid intake, the conservator was notified. The fall investigation dated 5/20/25 identified Resident #6 was unable to describe the unwitnessed fall related to his/her cognitive impairment and had no skin issues or complaints of pain. The fall risk assessment dated [DATE] at 7:28 PM identified a fall risk score of 75 indicating a high fall risk. Although the Resident Care Plan was revised on 5/20/2025 and identified Resident #6 had an unwitnessed fall, the RCP failed to include a new intervention to prevent Resident #6 from future falls. Review of the clinical record failed to indicate neurological checks had routinely been performed other than 2 entries in the nursing notes, a partial assessment conducted on 5/20/2025 at 3:51 PM noted hand grasps and on 5/20/2025 at 9:23 PM, neurological checks were identified as intact without further information. Although neurological checks were requested no documentation was provided. Interview and record review with the Director of Nursing (DNS) on 7/23/25 at 2:56 PM identified Resident #6 had a subsequent fall on 5/22/2025 and that a new intervention for bilateral floor mats at the bedside was implemented as well as repeating the intervention to keep the bed in a low position. She further stated this was communicated to the staff through the Nurse Aid (NA) care card (directs resident care) and the nurse worksheet. Review of the NA care card and nurse worksheet failed to identify interventions for floor mats or for keeping the bed in low position. The DNS indicated that the Assistant Director of Nursing (ADNS) was responsible for the fall program. An interview on 7/24/2025 at 10:34 AM with RN #3 identified the timeframe to update a RCP should occur immediately, or if on a weekend, on the Monday following the weekend. Interview and record review with the ADNS on 7/23/2025 at 3:25 PM identified the fall that occurred on 3/10/2025 had a Resident Care Plan intervention to refer to Physical Therapy (PT) however Resident #6 was already working with PT. Review of the fall on 4/2/2025 identified a new intervention had been put in place (late) 7 days post fall and directed the bed be kept in the lowest position. Review of the 4/15/2025 and 5/20/2025 falls failed to identify any new fall prevention interventions had been put in place, and there was no further documentation (other than the 2 nurses notes) of neurological signs being completed for the 5/20/2025 fall. Although monitoring for pain and change of mental status were in place as an intervention for the fall on 4/15/2025, the ADNS indicated this would not prevent any future falls, and the ADNS added that following all falls, a new intervention should have been added to Resident #6’s Resident Care Plan. The ADNS indicated the facility protocol was to review falls during the morning meeting and the At-Risk meeting, however the NA care cards, and Resident Care Plans were not brought to or reviewed during these meetings. Further, the ADNS indicated that she and the supervisors were responsible to initiate a new intervention following each fall and resident assessment, however, she was unable to explain the lack of Resident Care Plan interventions for Resident #6. The ADNS was unable to provide neurological signs following Resident #6’s fall on 5/20/2025. The ADNS indicated that on 5/22/2025 Resident #6 was sent to the emergency room following a fall and abnormal vital sign reading (low blood pressure of 64/22 mmHg, and high pulse) which may have contributed to Resident #6’s fall. Review of the Fall Prevention policy dated 2023 directed, in part, the nurse will evaluate resident risk factors (for falls), and environmental hazards will be evaluated when developing the resident’s comprehensive plan of care. The plan of care will be revised as needed. When a resident experiences a fall the facility will assess the resident, complete a post fall assessment, complete an incident report, notify the physician and family, review the resident’s care plan and update as indicated, document all assessments and actions and obtain witness statements in the case of injury. Review of the Incidents and Accidents policy dated 2023 directed, in part, in the event of an unwitnessed fall or a blow to the head, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet. Abnormal findings will be reported to the practitioner. Although requested a Resident Assessment Policy was not provided. Review of the Documentation in the Medical Record Policy directed in part that each resident's medical record shall contain an actual representation of the actual experiences of the resident. Review of the Head Injury Policy directed in part to assess the resident following a suspected, known or verbalized head injury by completing a neurological evaluation and continue to do so for 72 hours. 2. Resident #27‘s diagnoses included paraplegia, chronic osteomyelitis, pressure ulcer of the left hip and bilateral feet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #27 had a Brief Interview of Mental Status (BIMS) score of 14, indicating no cognitive impairment. Resident # 27 required a wheelchair for mobility, was dependent for bathing and all transfers, required maximal assistance with toileting, dressing, personal care, and some assistance with bed mobility. The Resident Care Plan dated 5/25/2025 identified Resident #27 was non-compliant with his/her treatment plan. Interventions included educate on the importance of compliance with the plan of care. Interview with Resident #27 on 7/15/2025 at 1:57 PM identified he/she had leave of absence (LOA) privileges but could not independently leave the facility without being “badged out” by a nurse or staff member. Observation on 7/15/2025 at 3:30 PM identified Resident #27 was across and down the street in his/her wheelchair smoking a cigarette. Observation on 7/16/2025 at 8:28 AM identified Resident #27 was alone outside the facility between the upper and lower parking lots, sitting in his/her wheelchair. Observation on 7/17/2025 at 8:24 AM identified Resident #27 was in the lower parking lot, sitting in a wheelchair, smoking a cigarette, and was sitting next to another resident from the facility. Interview with LPN #7 on 7/22/2025, at 12:32 PM identified that Resident #27 regularly went outside of the facility to smoke. When she reviewed Resident #27’s chart, she could not locate a physician’s order for independent LOA. She stated residents should not leave the facility without an LOA order. LPN #7 indicated she did not check to see if Resident #27 had an order because she assumed he/she had one, as Resident #27 had left the facility frequently. She acknowledged it was her responsibility to verify the order before allowing a resident to exit (badge out) the facility and that she should have made sure Resident had a current LOA physician order. Interview with RN #8 on 7/22/2025, at 12:41 PM identified Resident #27 did not have a LOA order. He believed Resident #27 may have had an order in the past but thought the order may have been discontinued months ago when Resident 27’s was discharged to the hospital but must not have been reinstated when he/she returned. RN #8 stated a LOA requires a physician’s order. Further criteria for the LOA included, a resident must be alert, oriented, safe to have LOA privileges, and they must sign the LOA book before leaving the unit. LOA orders were maintained in the electronic medical record and reviewed every three months. He confirmed Resident #27 had not signed out of the facility using the unit sign out LOA book but indicated a second book was kept at the reception desk. Interview with Receptionist #1 on 7/22/2025, at 2:30 PM identified the facility kept one LOA book at the reception desk for residents who left the facility for non-medical reasons. She stated she had no knowledge of an LOA order for Resident #27, nor did she have access to this information in the electronic medical record, or a list of residents with LOA privileges. Receptionist #1 reviewed the July LOA log tracking sheet and found multiple entries that were illegible or missing identifying information, which prevented her from confirming which residents had left the building according to the listings. Interview with the Director of Recreation on 7/22/2025, at 2:40 PM in the presence of the Administrator identified residents who left the facility for non-medical reasons were required to have a physician’s order. She stated the order would provide guidelines such as the length of time a resident was permitted to be outside. The Director of Recreation reviewed the July 2025 LOA tracker log that was at the receptionist desk and acknowledged that the log lacked pertinent information such as legible time and date information, incomplete information, and there were 2 entries that had no name and only time and date had been completed. Additionally, there were no entries for Resident #27’s observed LOA dates and times. She indicated the system needed to be reviewed as the facility could not identify which residents had left or for how long. She stated that in the event of an emergency, the current system would not allow staff to determine who was off the premises or for what duration. Interview with the DNS on 7/22/2025, at 4:10 PM identified residents who left the facility for non-medical reasons were required to have a physician’s order. She stated she would have expected Resident #27 to have an LOA order in the chart and would have expected nursing staff to verify the order before allowing the resident to leave the facility. Subsequent to surveyor inquiry, staff obtained an LOA order for Resident #27. Review of the Therapeutic Leave policy dated 1/15/2024 directed, in part, the nurse to obtain an order from the practitioner specifying approval of a therapeutic leave. Also, the facility will document in the medical record the resident’s leave of absence. 3. Resident #59’s diagnoses included obstructive hydrocephalus, difficulty in walking, and unspecified vision loss. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 had a Brief Interview of Mental Status score of 2 indicating severe cognitive impairment, required supervision or touch assistance for walking 150 feet or more, and was independent for transfers. The Resident Care Plan in effect for June and July 2025 identified Resident #59 had an ADL self-care performance deficit related to altered mental status and hydrocephalus. Interventions included assistance from 1 staff member with the use of a standard single point cane. The physician’s order in effect for June and July 2025 directed for Resident #59 to be assisted by 1 staff member with no assistive device due to confusion and fall risk. Review of Resident #59’s Resident Care Card (nurse aid care provision) directed an independent transfer status and identified Resident #59 was a high risk for falls. The Fall Risk Evaluations dated 5/2/25 identified Resident #59 had a fall risk score of 65, indicating a high risk for falling. The Accident and Incident Report dated 6/17/25 identified Resident #59 sustained a left periorbital bruise classified as an injury of unknown origin. Resident #59’s mental status was confused/forgetful, and physical status was independent with transfers, ambulation (not reflective of the physician order), and eating. The intervention was to apply an ice pack for 15 to 20 minutes as needed for 3 days. The Accident and Incident Report dated 6/21/24 identified Resident #59 sustained bruising to her/his left shoulder and a bump to her/his head when he/she was witnessed walking independently into the corner of a door while ambulating without assistance from staff. Resident #59’s mental status was alert/confused, and physical status was assistance from 1 staff. The intervention was to send Resident # 59 to the hospital. The Accident and Incident Report dated 7/22/25 identified Resident #59 seated on the floor next to the elevator after an unwitnessed fall and was noted to have been independently ambulating. Resident #59’s mental status was confused/forgetful, and physical status was assistance from 1 staff member. The intervention was to send Resident #59 to the hospital. Observations on 7/15/25 at 11:25 AM, 7/17/25 at 3:43 PM, and 7/22/25 at 11:15 AM identified although staff were in the area, Resident #59 was ambulating independently on the unit without an assistive device or staff assistance. Interview with Nursing Assistant (NA) #4 on 7/23/25 at 12:48 PM identified she was the NA for Resident #59 and that he/she wandered throughout the unit frequently without staff assistance because he/she was independent for ambulation. Interview with Licensed Practical Nurse (LPN) #2 on 7/22/25 at 12:15 PM identified Resident #59 wandered independently throughout the day and would get tired as the day went on, resulting in accidents or incidents. LPN #2 added she was a strong advocate for Resident #59 to be moved to a secure unit due to the shorter length of the hallways. Interview and clinical record review with the Director of Rehab, Physical Therapist (PT) #1 on 7/23/25 at 10:11 AM identified Resident #59 was currently being seen by PT as of 7/10/25 with goals that included leg strengthening, balance and ambulation, and by Occupational Therapy (OT) as of 7/15/25. From 5/21/25 to 7/3/25 Resident #59 was seen by OT but was not referred to PT because he/she was noted to be independent, without an assistive device, for ambulation. Review of the physician’s orders in effect for June 2025 and July 2025 identified that Resident #59 currently had an order to be assisted by 1 staff member meaning that a staff member should be next to the resident when he/she was walking and transferring. PT # 1 stated that for optimal safety the physician’s order originally dated 11/5/24 and in place during the Resident #59’s 2 falls should have been followed. Review of the Fall Prevention Program Policy directed in part that each resident be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. High Risk protocols include a fall prevention indicator on the door, and interventions including but not limited to assistive devices, increased rounds, a sitter, medication regimen review, low bed, alternate call system, scheduled ambulation, family/caregiver education and therapy services referral. 4. The quarterly Minimum Data Set assessment identified Resident #1, #31, #33, #85, #91, and #122 had a Brief Interview for Mental Status (BIMS) score between 0 and 12, indicating Residents #1, #31, #33, #85, #91, and #122 were mildly to severely cognitively impaired but were independently mobile and could have accessed the resident sink areas with high hot water temperatures readings. Observation on 7/18/2025 at 10:30 AM identified hot water temperatures exceeded 120 degrees Fahrenheit (F) in 15 out of 27 rooms observed. Water temperatures ranged from 120.2-degrees F to 148.5 degrees F. Observation and Interview with the Director of Maintenance on 7/18/2025 at 12:10 PM identified a discrepancy during validation of hot water temperatures between the facility and state surveyors thermometers. The Director of Maintenance utilized an infrared thermometer (typically used to test ambient air temperatures) while the surveyor’s thermometer was a probe type thermometer. During temperature validation testing of the sink in the lower-level staff break room, the state surveyor’s calibrated probe read 132.4 degrees Fahrenheit (F) and the Director of Maintenance infrared thermometer recorded a temperature of 119 degrees F. The facility had failed to monitor water temperatures using a probe type thermometer and had instead relied on an infrared thermometer. Furthermore, the Director of Maintenance identified that the facility had not monitored hot water temperatures since September 2024. He stated that it was the responsibility of his Assistant Maintenance worker to ensure temperatures were routinely checked. Although this task had been delegated to his assistant, the Director of Maintenance indicated that, ultimately, he had the responsibility to ensure the temperatures had been properly monitored. He stated the facility had a daily temperature log, and per the facility protocol, daily temperatures should have been completed. Subsequent to Surveyor inquiry, the facility purchased appropriate temperature monitoring probes and completed a whole house water temperature assessment. The facility also made necessary repairs to the boiler system to mitigate the hot water temperature rising above 120 degrees F. Although a maintenance water monitoring policy was requested, the facility stated they did not have a policy.

Based on observation, clinical record review, facility documentation, facility policy, and interviews, the facility failed to administer its resources effectively and ensure timely and effective administrative oversight of staff and resident care to maintain the highest practicable physical, mental, and psychosocial well-being of residents. The findings include: The facility administration failed to: Ensure residents were provided with an environment free from verbal abuseEnsure residents were provided with an environment free from involuntary seclusion.Ensure the State Agency was notified, in a timely manner, of events needing to be reported according to the requirement. Ensure allegations of abuse were investigated timely and thoroughly and that staff accused of abuse were removed from the schedule timely. Ensure resident personal needs accounts were managed according to the requirements. Ensure individualized activities were provided to bedbound residents, dependent residents, and failed to ensure activity calendars were revised to reflect actual activities provided.Ensure physician's orders were followed.Ensure the environment was free from accidents due to high water temperatures.Ensure the facility maintained an adequate pest control environment. Please cross reference: F600, F603, F609, F610, F657, F659, F679, F689, and F925. Based on the deficiencies during the survey, actual harm occurred in the area of Freedom from Abuse, Neglect, and Exploitation. Review of the Administrator Job Description signed and dated by the Administrator on 2/24/25, identified that the major purpose of their position was to plan, organize, develop, direct, control and supervise the overall operations of the facility in accordance with applicable federal, state and local laws, regulations, standards and guidelines. Additionally, to direct all departments, delegate authority, responsibility and accountability to department head and supervisor as appropriate, submits Reportable Event reports to appropriate state agencies according to defined procedures, and protects the personal and property rights of all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, interviews, and review of facility documentation and policy for 5 of 15 residents (Residents #8, 57, 68, 108, & 114) reviewed for physical environment, the facility failed to ensure an effective pest control program was maintained to prevent rodents. The findings include:1. Resident #8's diagnoses included multiple sclerosis, type 2 diabetes, and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Mental Interview for Mental Status (BIMS) of 15 indicative of intact cognition. Interview with Resident #8 on 7/15/2025 at 12:45 PM identified he/she observed mice and ants on 7/14/2025 in his/her room. Further, Resident #8 stated he did not make anyone aware at the time because everyone knows. 2. Resident #57's with diagnoses included diabetes, post-traumatic stress disorder (PTSD), coronary artery disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 had a Brief Mental Interview for Mental Status (BIMS) of 15 indicative of intact cognition. Interview and observation with Resident #57 on 7/15/2025 at 6:59 PM identified that he/she had seen mice in the room the previous night. A mouse trap was noted to be in the room. 3. Resident #68's diagnosis included cerebrovascular accident (stroke), coronary artery disease, and hypertension. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #68 had a Brief Mental Interview for Mental Status (BIMS) of 15 indicative of intact cognition. Interview with Resident #68 on 7/16/2025 at 11:49 AM identified that mice come out of the radiator hole in the room and that the facility was aware. Further the resident noted that a mouse had just been present in the unit hallway. 4. Resident #108's diagnosis included diabetes, heart failure, kidney transplant failure, and dependence on hemolytic treatments. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #108 had a Brief Mental Interview for Mental Status (BIMS) of 14 indicative of intact cognition. Interview and observation with Resident #108 on 7/15/2025 at 7:30 PM identified that the resident observed mice in his room and a mouse trap was present. 5. Resident #114's diagnosis included spina bifida, neurogenic bladder, depression, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #114 had a Brief Mental Interview for Mental Status (BIMS) of 15 indicative of intact cognition. Interview with Resident #114 on 7/15/2025 at 11:10 AM identified he/she observed mice in the room every night. Interview and observation with Resident #114 on 7/16/2025 at 10:45 AM identified that mice were typically observed by the garbage can and under the radiator, but no one had come into the room to install traps. In the corner of Resident #114's room an area of numerous small, black granular pellets approximately the size of grains of rice was observed under the radiator between the wall and the dresser. Interview with Licensed Practical Nurse (LPN) #4 identified that mice are seen on day shift, but that it is mostly nights that they are a problem. Further, LPN #4 identified that although the facility has attempted to treat the issue, the mice continue to run around the floor. Interview with Person #3 on 7/17/2025 at 9:50 AM identified that pest control is provided weekly, but they have not been asked to do resident rooms. Further, Person #3 identified that three (3) mice were caught on the 2nd floor during the 7/17/2025 visit. Person #3 noted that the facility has been told about structural deficiencies since August 2024 however no repairs have been made. Person #3 noted that radiator pipes needed to be sealed so rodents could not enter and that the facility was instructed to keep the ambulance entrance dock area doors closed as a preventative measure, however he always observed the doors open. Further, Person #3 stated closing the dock doors was a behavioral change to prevent rodents, not a structural issue. Interview with Nurse Aide (NA) #10 On 7/15/2025 at 2:10 PM identified that on 7/4/2025 on the 3:00 PM to 11:00 PM shift she saw what she believed to be a rat jumping off a resident wheelchair. NA #10 stated he/she began to record the encounter with a cell phone. Further, NA #10 stated they notified another NA on the unit, whose name she did not know, but they brushed it off, stating that rodents were always there. NA #10 identified that he/she made the decision to leave the facility prior to the end of shift due to feeling uncomfortable with the physical environment. Review of the facility contracted pest management Service Inspection Reports dated 6/13/2025 through 7/10/2025 identified that pest control services were provided weekly and noted the presence of mice in the facility at each visit. The Service Inspection Report for 7/10/2025 included notation that on 8/29/2024 it was reported to the facility that an exterior emergency exit door was not rodent proof with a severity level of High and recommended adding or replacing the door sweep. The report noted that this concern was last reviewed with the facility on 5/29/2025. Additionally, the Service Inspection Report for 7/10/2025 included documentation that on 8/29/2024 the facility was notified that the kitchen had two areas that served as an entry point for rodents with a High severity level and recommended a seal gap and wall repair. The report noted these concerns were last reviewed with the facility on 7/10/2025. Review of the facility Pest Control Program directed, in part, that it is the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records and staff interviews for 1 of 4 residents (Resident # 68) reviewed for abuse, the facility failed to ensure staff interacted with residents in a dignified manner. The findings include: Resident #68 was admitted with diagnoses that included legal blindness, bipolar disorder, and impulse disorder. A Resident Care Plan (RCP) dated 10/5/2024 identified Resident #68 had the potential to be verbally aggressive, shouting at staff and exhibited anger easily due to poor impulse control and mental/emotional illness. Interventions included: Interventions before agitation escalate, engaging calmly in conversation, and if the resident's response was aggressive, staff were directed to walk calmly away and approach later. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #68 was cognitively intact and exhibited verbal behavioral symptoms directed toward others. An Accident and Incident report (A&I) dated 1/17/2025 indicated Resident #68 had been yelling at staff and the Social Work Assistant had become verbally disrespectful towards the resident. The A&I further indicated the presence of witnesses, the Human Resource Manager, and the Business Office Manager. However, a review of the clinical record failed to identify documentation of the staff-to-resident incident. On 2/6/2025 at 11:24 AM, an interview with the Human Resources Manager indicated Resident #68 was yelling at the Social Work Assistant, Human Resources Manager, and Business Office Manager regarding his/her lost iPad and air-pods (a type of headphone). The Human Resources Manager further indicated the Social Work Assistant had raised her voice when speaking to Resident #68 and that is when the resident indicated she/he wanted to leave, the Social Work Assistant said, Goodbye, have a good life. Additionally, the Human Resources Manager indicated the Social Work Assistant continued to attempt to talk to Resident # 68 despite the resident yelling at the Social Work Assistant to leave his/her room. On 2/6/2025 at 11:40 AM an interview with the Administrator identified the expectation of the Social Work Assistant in interacting with an agitated resident was to de-escalate the situation and believed the Social Work Assistant's behavior may have been her reaction to the resident's foul language. The Administrator further indicated the Social Work Assistant was terminated based on customer service-related issues. On 2/6/2025 at 11:55 AM an interview with the Business Office Manager identified the Social Work Assistant had raised her voice when speaking to Resident # 68 and told the resident to calm down. The Business Office Manager indicated that the Social Work Assistant did not yell but rather raised her voice to be heard over the residents yelling. The Business Office Manager indicated the Social Work Assistant did not use foul language or derogatory statements. The Business Office Manager further indicated Resident #68 yelled to the Social Work Assistant to get out of his/her life, to which the Social Work Assistant responded, Have a nice life. On 2/11/2025 at 11:14 AM an interview with The Social Work Assistant indicated Resident # 68 had been yelling that his/her iPad had been stolen and the Social Work Assistant tried informing the resident that it was not an iPad missing but his/her air-pods and that the social work was working on locating the missing item. The Social Work Assistant indicated she did not yell or use profanity towards Resident #68. The Social Work Assistant further denied treating Resident # 68 in an undignified way or saying to the resident to have a nice life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review and interviews for 1 of 2 residents reviewed for choices (Resident #27), the facility failed to honor the resident's choices regarding personal food. The findings include: Resident #27 was admitted on [DATE] with diagnoses that included a heart attack, diabetes mellitus, and stroke. A physician's order dated 12/27/2024 directed a consistent carbohydrate diet with regular texture and a thin consistency of liquids. The admission MDS assessment dated [DATE] identified Resident #27 was cognitively intact and independent with eating and that having snacks available between meals was somewhat important to the resident On 2/3/2024, an interview with Resident #27 indicated she/he kept personal snacks, noodles, and canned soups in his/her room because she/he did not like the facility's food. The personal food sometimes requires heating. However, Resident #27 indicated two weeks prior to the interview, staff were unwilling to heat up his/her food. Resident #27 further indicated staff indicated to her/him that heating up her/his food in the microwave was against facility policy. A review of nursing progress notes identified on 1/18/2025 (a Saturday), Resident #27 was requesting assistance to heat up soup. The nursing notes also indicated the staff explained to Resident # 27 that the facility protocol prohibited staff from heating food or beverages for safety reasons. Additional notes on the same day indicated that staff explained to Resident # 27 no one would be heating up soup for her/him until it was cleared by the administration on Monday 1/20/25. A nursing progress note dated 1/21/2025 (a Tuesday) indicated Resident #27 was upset about being unable to heat up soup in the microwave, and staff educated Resident # 27 on the importance of not being able to heat soup in the microwave. On 2/6/2025 at 1:43 PM during an interview with LPN #7 indicated staff were not allowed to heat up liquids, but she was not sure about soup. LPN #7 indicated that she was unsure how long the policy had been in place and indicated this policy could have been in place for a year or two. On 2/6/2025 at 1:57 PM, an interview with NA#5 indicated she had been told she was not allowed to heat up food for residents, either liquid or solid. NA#5 indicated she was made aware of this policy by another aide while on orientation but could not recall the name of the aide. On 2/10/2025 at 2:45 PM an interview with the Administrator identified she had spoken to Resident #27 on 1/24/2025 to address the resident's concerns and that the resident was allowed to have his/her food heated in the microwave. The Administrator indicated that the current policy for heating food was the policy in effect during Resident #27's complaint. The Administrator also indicated staff may have been verbally told by the previous administration that resident food should not be reheated. The Administrator further identified that a thermometer would be required when reheating food and that the nursing units either did not have thermometers or the device had gone missing. The Administrator ordered new thermometers on 1/26/2025. A review of the facility policy for Food Brought in from Outside Sources and Personal Food Storage given while onsite during survey notes food can be reheated in a microwave. The policy further indicated that food should be stirred during the reheating process and reheated to at least 165 degrees Fahrenheit for 15 seconds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interviews for 1 of 4 residents for (Resident # 86) reviewed for abuse, the facility failed to ensure the resident was free from physical abuse by (Resident#29). The findings include: 1.Resident #86 's diagnoses included unspecified dementia without behavioral disturbance, difficulty in walking and localized edema. The care plan dated 10/8/2024 identified mood problems related to schizophrenia, Major Depressive Disorder, anoxic brain damage, dementia. Interventions included: to administer medications as ordered, monitor/document for side effects and effectiveness and to have behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #86 was cognitively impaired and dependent on staff for transfers, bed mobility and lower body dressing. 2.Resident # 29's diagnoses included personal progressive neurological condition, cancer, schizophrenia. The MDS quarterly 10/24/24 identified the resident as cognitively intact, no behaviors exhibited and utilize the wheelchair manual / electrical. The nursing progress notes dated 1/08/25 at 1:00 PM noted in part Supervisor called to the unit regarding a resident altercation that resulted in this residents' feet getting run into and over by another resident. The nursing progress notes dated 1/08/25 at 10:47 identified Resident #29 was upset because he/she wanted to go to another unit and wanted to be pushed. The NA stated that she needed to finish what she was doing and then she could take him/her. Resident # 29 became angry calling the NA names, began to speak profanity and told her to get away from him/her if they were going to help them now. The note indicated that staff tried to explain to Resident #29 she (NA) would help him/her, but he/she needed to wait, and the NA is trying to tell him/her that there is another resident (Resident #86) behind him/her. Resident #29 started to speak profanity and stated I don't care who's behind me. He/she needs to move, or I will hit his/her. This resident (Resident # 29) proceeded to push back forcefully hitting Resident #86 by running over his/her feet. This writer tried to move Resident#29, but she/he kept swearing yelling and was not redirectable. The interview with LPN #6 on 2/5/25 2:05 PM indicated Resident #29 was aware that Resident #86 was behind her/him prior to moving his/her chair. LPN #6 recounted the note above, stating Resident # 29 was so agitated that he/she was unable to be redirected and stated he/she did not care that Resident #86 was behind him/her. The facility Abuse, Neglect and Exploitation in part indicated that ongoing assessment, care planning for appropriate interventions and revision of resident care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents for (Resident # 86) reviewed for abuse, the facility failed to implement interventions to prevent further physical abuse from Resident # 29. The findings include: 1.Resident #86 's diagnoses included unspecified dementia without behavioral disturbance, difficulty in walking and localized edema. he nursing progress notes dated 1/08/25 at 1:00 PM noted in part Supervisor called to the unit regarding a resident altercation that resulted in this residents' feet getting run into and over by another resident. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #86 was cognitively impaired and dependent on staff for transfers, bed mobility and lower body dressing. 2.Resident # 29's diagnoses included personal progressive neurological condition, cancer, schizophrenia. The MDS quarterly 10/24/24 identified the resident as cognitively intact, no behaviors exhibited and utilize the wheelchair manual / electrical. The nursing progress notes dated 1/08/25 at 10:47 AM identified Resident #29 was upset because he/she wanted to go to another unit and wanted to be pushed. The NA stated that she needed to finish what she was doing and then she could take him/her. Resident # 29 became angry calling the NA names, began to speak profanity and told her to get away from him/her if they were going to help them now. The note indicated that staff tried to explain to Resident #29 she (NA) would help him/her, but he/she needed to wait, and the NA is trying to tell him/her that there is another resident (Resident #86) behind him/her. Resident #29 started to speak profanity and stated I don't care who's behind me. He/she needs to move, or I will hit his/her. This resident (Resident # 29) proceeded to push back forcefully hitting Resident #86 by running over his/her feet. This writer tried to move Resident#29, but she/he kept swearing yelling and was not redirectable. The interview with LPN #6 on 2/5/25 2:05 PM indicated Resident #29 was aware that Resident #86 was behind her/him prior to moving his/her chair. LPN #6 recounted the note above, stating Resident # 29 was so agitated that he/she was unable to be redirected and stated he/she did not care that Resident #86 was behind him/her. LPN #6 also reported she does not recall if any interventions were put in place subsequent to the incident. Review of Resident #86 care plan was not updated with interventions on how to prevent any further abuse/ unintended altercations by Resident # 29. The facility Abuse, Neglect and Exploitation in part indicated that ongoing assessment, care planning for appropriate interventions and revision of resident care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, observations, facility policy and staff interviews for 2 of 4 residents for ( Residents (#17 and # 42) reviewed for pressure ulcers , the facility failed to ensure staff revised the resident's care plan to reflect the resident's need to offload heels from pressure and current pressure ulcer status. The findings included. 1.Resident #17's diagnosis included diabetes mellitus and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17's cognitive status was severely impaired, the resident was at risk for pressure ulcers and had one unstageable Deep Tissue Injury (DTI) and noted the resident was receiving pressure ulcer care. A physician's order dated 12/18/2024 directed to utilize an offloading boot to the left foot while in bed every shift for off-loading pressure to the left heel. Resident #17's care plan dated 1/15/2025 for resident at risk for exhibiting non-compliance with treatment. Interventions included: to allow the resident to make decisions regarding daily care, clothing and meals educate on importance of compliance with the plan of care and to consult with psychiatric services as needed and to reapproach later if refuses. Interview and record review with LPN # 3, the Infection Preventionist (IP) and wound nurse, identified she/he did not find an intervention in the care plan regarding off-loading Resident #17's heels and she/he would update the care plan. The facility policy labeled Care Plan Revisions Upon Change in Status indicated in part the care plan would be updated with the new or modified interventions. 2. Resident #42's diagnoses included paraplegia, pressure ulcer of right hip, and pressure ulcer of left hip. The Resident Care Plan with a revision date of 10/3/24 identified resident had an actual impairment to skin integrity of the right ischium and right hip stage 4 decubitus ulcer. Interventions included following the protocols for treatment of injury. The annual Minimum Data Set assessment dated [DATE] identified Resident #42 was cognitively intact and required moderate assistance for showering, upper body dressing and personal hygiene. A physician's order dated 2/1/25 directed to monitor skin weekly. The Weekly Skin Audit tool dated 2/1/25 indicated the resident had a right hip and right buttock pressure ulcer stage III. On 2/5/25 8:45 AM an observation of Resident # 42's wound care with LPN #8 identified the following : Upon rolling the resident onto his/her side identified a DTI on the right heel and a cream color fibrous area on the bottom of his/her foot in the plantar area. No drainage from either. Interview with LPN #8 identified that this was her/his first time doing wound care on this resident and indicated she/he was only told about the areas on the resident's left foot, not the right foot. Review of the Treatment Administration Record from 1/1/25 through 2/4/25, indicated off-loading boots were applied bilaterally while resident was asleep and in the wheelchair. Observation and interview on 2/5/25 with IP nurses at 10:50 AM who measured the wounds identified the right heel was a DTI measuring 2 Centimeter (CM) x 3 CM and the plantar was calloused and was 3 CM x 2.3CM. The IP indicaed they were unaware of those areas. The resident stated those areas have been there for some time and the nurses have been putting skin prep on them. The IP nurse stated the resident is non-compliant with off loading boots on the right foot. After surveyor inquiry, the IP nurse attached the right leg rest to the resident's wheelchair. The IP nurse further indicated there is no indication on the resident's care plan that Resident # 42 refuses to wear the off-loading boots. Observation on 2/3 through 2/5/2025 identified Resident # 42 had a left leg rest on the wheelchair, but did not have a right leg rest. Resident # 42 wore an off-loading boot on the left foot, however, did not wear one on his/her right foot. In an Interview with wound Advanced Registered Practice Nurse (APRN) on 2/5/25 at 11:00AM confirmed that she was there on Monday to evaluate the wounds and she did not notice anything on the resident's right foot. The APRN stated that in her opinion a DTI could develop within hours. Not sure about the calloused area. The APRN further indicated she would evaluate the wounds. Further she stated the resident is a paraplegic and is often non complaint with off-loading. Interview with NA # 3 on 2/5/25 at 11:30 AM identified the last time she/he provided care to Resident # 42 on 2/4/25 she/he did not notice on any area on the resident's right foot. NA # 3 also indicated that Resident # 42 only wears left offloading boot daily. In an interview with LPN#1 on 2/6/25 at 12:00 PM identified she regularly provides wound care to Resident # 42 and did not notice the areas on the right heel and right plantar areas. In an interview with the Medical Director on 2/5/25 at 12:05 PM identified a DTI could develop quickly, however a callous type of area would develop over time and with this resident it is probably due to him/her propelling with his/her right foot in the wheelchair. A progress note written by the Wound APRN on 2/5/25 at 2:41 PM after surveyor inquiry identified the resident had 2 new areas, both DTIs. The right plantar non blanching purple with cluster of 2 epithelial. The right plantar was due to foot pressure and the right heel was due to pressure. In an interview on 2/10/25 at 12:50 PM with the INC identified the care plans have not been regularly updated and may not be accurate. The INC further indicated that the MDS Coordinator and the DNS have only been at the facility for a short time therefore there has not been a consistent person supervising the care planning process. She stated that the care plans are being reviewed at the morning meeting to ensure they are accurate and up to date. Review of facility policy, Care Plan Revisions Upon Status Chage, undated and currently in effect, directed in part, the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.

Based on observation, facility policy, and staff interview for 1 of 4 residents reviewed for accidents (Residents #32), the facility failed to ensure safe smoking receptables were readily accessible for residents. The findings include: Observations on 2/10/2025 at 9:45 AM of the facility's supervised resident smoke break identified the following: The resident smoke break took place under a covered patio. Seven residents attended the smoking break, all sitting against the edges of the covered patio. There were three metal cigarette disposal receptacles also located at the edges of the covered patio not readily accessible to residents. There were also two staff members supervising the smoking session: a Smoking Monitor and NA #4. Resident #32 was observed smoking one cigarette, and after she/he had finished the cigarette, Resident # 32 was unable to dispose of the cigarette butt. Resident #32 handed the cigarette to the Smoking Monitor, who then disposed of the cigarette butt into a receptacle. An interview with NA#4 indicated residents would ask for assistance to extinguish cigarette buts and dispose of them in the cigarette disposal receptacles. An interview with the Smoking Monitor identified it was difficult to ensure all residents in the smoking session had readily access to the cigarette disposal receptacles because residents would congregate with each other depending on the type of cigarette they smoked. Both NA# 4 and the Smoking Monitor were unaware if the cigarette disposal receptacles were movable. The facility policy on smoking indicated that safety measures for the designated smoking area would include the provision of ashtrays made of noncombustible material and safe design, as well as accessible metal containers with self-closing covers into which ashtrays can be emptied.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, observations, facility policy and interviews for the only sampled resident (Resident #6) reviewed for Respiratory Care, the facility failed to follow physicians order related to oxygen liter flow rate. The findings include: Resident #6 's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Fibrosis and Type 2 diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was moderately cognitively impaired and required moderate assistance with personal hygiene and bed mobility and was independent with eating.The MDS also identified Resident #6 as receiving Oxygen Therapy. The care plan dated 12/20/24 identified Resident #6 is at risk for altered respiratory status/ difficult breathing related to sleep apnea. Interventions in part included: to administers medications as ordered, monitor for signs and symptoms of respiratory distress and shortness of breath. A physician's order dated (facility did not provide requested orders dates) directed nasal cannula to be at 1-4 liters and indicated the oxygen should be off in the morning. Observation on 2/3/25 at 11:37 AM identified Resident # 6's oxygen was set at 5liter (slightly above red line). Observation on 2/4/25 at 8:59 AM of nasal canula oxygen at 5L Interview with LPN #5 on 2/4/25 at 9:12 AM identified she was unsure why the oxygen was set at 5literes. She indicated all nurses are responsible for ensuring that physician's orders are administered correctly. LPN #5 identified that she had not completed her morning rounds therefore was unable to adjust sooner. After surveyors' inquiry, LPN #5 adjusted Resident's #6 oxygen setting to reflect physicians' order 1-4 liters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy and staff interviews for 1 of 5 residents ( Resident #17) reviewed for Medication Regimen Review, the facility failed to ensure target behaviors were being monitored while a resident was receiving psychoactive medications including an antipsychotic medication. The findings include: Resident #17 was readmitted to the facility on [DATE]. A physician's order dated 12/8/2024 directed to provide Rexulti (an antipsychotic medication) 2.0 Milligrams (MG) orally once a day for dementia. A physician's order dated 12/8/2024 directed to provide Trazadone 25 MG by mouth twice daily (an antidepressant). A pharmacist Drug Regimen Review completed on 12/9/2024 indicated the need to add behavioral monitoring with appropriate target behaviors for Resident #17 utilization of psychoactive medications. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #17 as severely cognitively impaired, the resident exhibited physical and verbal behavior towards others and behaviors not directed towards others 1-3 times per day. The MDS further indicated Resident #17 received an antipsychotic medication. The care plan dated 12/17/2025 indicated Resident #17 has a behavior of laying down on the floor, potential to be physically aggressive, hitting, spitting, slapping throwing items, banging the wall, and was at risk for wandering. Interventions included : redirection, bilateral floor mats for safety, provide physical and verbal cues to decrease anxiety, reorient to surroundings and to provide a wander guard A psychiatric visit note dated 12/20/2024 directed a visit to monito behavior and adjust plan of care as needed. A psychiatric visit note dated 1/7/2025 indicated Resident #17 no longer required an antipsychotic and the plan was gradual dose reduction (GDR) of the Rexulti with new physician's orders to decrease the Rexulti to 0.5 MG orally every AM. A psychiatric visit note dated 1/14/2025 directed to discontinue the Rexulti as a result of this visit. An interview and clinical record review on 2/11/2025 at 8:40 AM with RN #2 identified she/he could not find any physician's orders for monitoring target behaviors related to psychoactive medications and no documentation of target behaviors for 36 days while Resident #17 was on the antipsychotic. RN #2 indicated without an physician's order in place the monitoring of target behaviors will not display on the Medication Administration [NAME] to monitor and document the target behaviors. A policy regarding the use of antipsychotic medications and monitoring of target behaviors was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of facility documentation, review of facility policy and staff interviews for 1 of 3 residents (Resident #118) reviewed for Environment, the facility failed to ensure a functioning call bell system was in place at the time of admission. The findings include: Resident #118's diagnosis includes Alzheimer's disease. Resident #118 was admitted to the facility on [DATE]. The care plan dated [DATE] indicated Resident #118 had a self-care deficit. Interventions included: to encourage the use of the call bell for assistance. An Occupational Therapy Evaluation and Plan of Treatment dated [DATE] indicated Resident #118's upper extremity function and strength was within functional limits, was independent with eating and noted impaired safety awareness. The plan of treatment also noted impaired fine and gross motor coordination with goals of increasing Resident #118's independence with bathing dressing and toileting. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #118 as severely cognitively impaired, dependent for activities of daily living but able to eat independently with set up meals. An observation on [DATE] at 11:25 AM identified Resident #118 without a call bell and no cord coming from the call bell box on the wall. An interview and observation with the regular charge nurse on the unit (LPN #2) on [DATE] at 11:30 AM identified there was never a call bell because the facility did not finish the room before the resident's admission. LPN # 2 also indicated Resident #118 may not have used the call bell anyway but indicated she/he would provide Resident #118 with a manual handbell. After obtaining the manual hand bell for Resident #118, LPN #2 further identified she/he did not tell anyone Resident #118 had no call bell and no plan was put in place with her/his knowledge of the resident not having a call bell. An interview with the Maintenance Director with RN #5, the facility Independent Nurse Consultant present on [DATE] at 11:35 AM indicated there had to be a call bell and they were unaware of a problem. An interview and observation of Resident #118's room with the Maintenance Director on [DATE] at 11:50 AM identified no call bell cord or call buttons. The call bell system was a nonfunctioning call box on the wall, different than the roommate's box who's was functioning. The Maintenance Director indicated s/he would call an electrician to install a new call box. The Maintenance Director further indicated before admission, one of the maintenance workers would have gone to the room to check to see if the call bell system was functioning and indicates she/he was not sure who was assigned to check Resident #118's room prior to admission and would follow up. On [DATE] at 11:55 AM the Maintenance Director identified she/he was not able to locate the workers who were responsible for checking the call bell system on the day of admission for an interview. On [DATE] at 12:20 PM the Maintenance Director indicated the electrician would be at the facility during the week which was the company's earliest availability. An interview and facility document review with the Admissions Coordinator #1 indicated s/he was new to the facility and was not working for the facility when Resident #118 was admitted . S/he further indicated an admission checklist was part of the process since he/she started working for the facility and had no check list for Resident #118's admission in the admission office. The admission Coordinator #1 provided a sample list where each department is listed and is responsible for completing their section then passing the check list to the next department until completed, returning the form to Admissions Coordinator #1. A sample check list noted under the maintenance department heading to check the call bell for functioning. On [DATE] at 12;15 PM an interview with RN #5, the facility Independent Nurse Consultant indicated s/he was in the process of staff completing a call bell audit for the building to ensure all others were functioning. The facility policy labeled, Call Lights: Accessibility and Timely Response notes in part; the call bell system will be accessible to residents while in bed or other sleeping accommodations within the resident's room, staff will ensure the call bell is within reach of the resident and secured as needed. The policy indicated that staff would report problems with the call light or the call bell system immediately to the supervisor or Maintenance Director and staff will provide immediate or alternative solutions until the problem can be remedied.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy, and interviews for one of three sampled residents (Resident #101) reviewed for facility acquired pressure ulcers, the facility failed to ensure the physician was notified after the development of a pressure ulcer. The findings include: Resident #101 was admitted to the facility on [DATE] with diagnoses that included dementia, anemia, heart failure, thrombocytopenia, malignant neoplasm of the rectum, and presence of ileostomy. The physician's order dated 7/23/24 directed to complete skin monitoring and observation weekly. The skin assessment dated [DATE] identified Resident #101 had intact skin. The Braden scale assessment (used to predict risk for development of pressure ulcer/injury) dated 7/23/24 identified Resident #101 had a score of 16 which is indicative of the resident being at risk for the development of a pressure ulcer. The Resident Care Plan (RCP) dated 7/24/24 identified Resident #101 was at risk for the potential for skin breakdown related to decreased mobility, ileostomy, and incontinence. Care plan interventions included: follow facility protocol for treatment of injury, keep skin clean and dry, and staff to provide frequent incontinence care. The admission MDS assessment dated [DATE] identified Resident #101 had severe cognitive impairment, did not display behaviors, required extensive assistance with toileting, bed mobility, hygiene, dressing, and transfers. The assessment further identified Resident #101 was non-ambulatory, utilized a wheelchair for mobility, did not have range of motion deficits, was frequently incontinent of bladder and had an ileostomy in place for bowel function. It further noted the resident was at risk for the development of pressure ulcers, but did not currently have a pressure ulcer, and had a pressure reducing device to the bed. The assessment did not identify that the resident was on a turning and repositioning program or that the resident had a pressure reducing device to the wheelchair. The nurse's note dated 8/2/24 at 11:13 PM written by LPN #1 identified that the assigned nurse's aide and Resident #101's responsible party reported the resident had a small open wound to the coccyx, Resident #101 denied pain and/or discomfort, and the nursing supervisor was notified. Further review of the nurse's note failed to identify any further documentation about the wound such as a description, measurements, the presence or absence of an odor Review of the clinical record failed to identify that the wound to Resident #101's coccyx was assessed and/or that a treatment order was put in place. Review of the clinical record failed to identify that the weekly skin monitoring and observation for the week of 8/9/24 was completed as ordered by the physician. The nurse's note dated 8/16/24 at 4:32 PM written by LPN #2 (wound nurse) identified Resident #101 had two small open wounds to the coccyx. The first wound size was documented as 0.8 centimeters (cm) in length by 0.5 cm in width and 0.1 cm in depth and the second wound size was documented as 1.0 cm in length by 0.8 cm in width and 0.1 cm in depth. The APRN was updated, and new orders obtained that directed to cleanse the wound with normal saline followed by the application of Calcium Alginate and cover with a dry clean dressing. The wound bed was noted with 100 percent granulation (wound bed characteristics described as red and/or pink in color) and a scant amount of serosanguineous drainage was also noted. Resident #101 denied pain and/or discomfort during the treatment. The resident's responsible party was notified and updated. The physician's order dated 8/16/24 directed to apply pressure reducing air mattress to the bed and check function every shift per resident's weight and comfort. The revised RCP dated 8/16/24 identified Resident #101 had an unstageable pressure ulcer. Care plan interventions directed to check mattress for function every shift and mattress setting adjusted in accordance with patient weight, RN will assess wound and provide appropriate wound treatment per physician orders, and staff will provide frequent incontinent care ensuring bedding and skin remain dry. APRN #1's (wound specialist) initial wound progress note dated 8/19/24 at 7:58 AM identified Resident #101 had a new unstageable pressure ulcer and/or injury to the coccyx related to pressure. The wound size was documented as 0.5 cm in length by 1.5 cm in width and 0.2 cm in depth. The wound bed was covered with 100 percent slough (a yellow and/or white material dead cell that accumulates in the wound bed) and with moderate amount of serosanguineous drainage. The treatment plan directed to apply Santyl (chemical wound debridement) ointment followed by calcium alginate daily and as needed, to follow facility pressure ulcer prevention protocol, apply pressure redistribution mattress per facility protocol, wheelchair pressure redistribution cushion per facility protocol, offload pressure wound and reposition patient every two hours. The physician's order dated 8/19/24 directed to cleanse coccyx wound with normal saline, apply nickel thick layer of Santyl ointment followed by Calcium Alginate and cover with dry clean dressing. The weekly physician's wound progress note dated 8/26/24 at 4:35 PM identified Resident #101 continued with unstageable pressure injury to the coccyx. The wound bed remains with 100 percent slough and the wound size was documented as 0.8 cm in length by 0.5 cm in width and 0.2 cm in width and with small amount of serosanguineous drainage. The treatment plan was to continue to cleanse the wound with normal saline and apply Santyl ointment at the base of the wound and cover with dry clean dressing. The weekly APRN#1 wound progress note dated 9/2/24 at 8:06 AM identified the unstageable wound to the coccyx had worsened. The wound size was documented as 0.5 cm in length by 1.5 cm in width and 0.2 cm in depth and the wound bed remained at 100 percent slough with moderate amount of serosanguineous drainage noted. The treatment plan noted to apply Santyl ointment followed by Calcium Alginate and cover with dry clean dressing daily. The social services progress note dated 9/6/24 at 9:41 AM identified Resident #101 was discharged to the community with rehabilitation and nursing services. Interview with LPN #1 on 9/9/24 at 12:30 PM identified the NA reported Resident #101 had a new open wound to the coccyx on 8/2/24. She could not recall who the Na was that reported the wound to the coccyx. She identified that she visualized Resident #101's coccyx and noted an open wound to the coccyx. She did not measure the open coccyx wound, nor did she call the physician to obtain a treatment, but she immediately reported the open coccyx wound to the nursing supervisor. She further identified that she was an agency staff nurse, and it would be the nursing supervisor's responsibility to assess the coccyx wound, to call the physician and to obtain a treatment order. She further noted that she did not receive any further instruction from the nursing supervisor related to Resident #101 coccyx wound. Interview with RN #1 (nursing supervisor) on 9/9/24 at 1:30 PM identified that she could not remember whether there was a reported open wound to Resident #101's coccyx. She identified that she would document the wound assessment in the nursing progress notes and/or wound documentation, call the physician and obtain treatment orders, and update the wound nurse. Interview with LPN #2 (7-3 charge nurse) on 9/9/24 at 2:00 PM identified that the charge nurse is responsible for checking and documenting the resident skin weekly on their shower day. She identified that she signs off in the TAR (treatment administration record) to indicate that the skin check is completed and completes the weekly skin monitoring assessment under the evaluation. Additionally, LPN #2 could not verify whether she did a skin check for Resident #101 because there was no weekly skin monitoring assessment completed and she did not sign off in the TAR. She further noted that she would report to the nursing supervisor immediately when there is a new wound. Interview with LPN #3 (wound nurse) on 9/9/24 at 2:30 PM identified that she was responsible for monitoring the wounds weekly and also identified that the nursing supervisor or the DNS would assess the wound with her when there is a new onset of wound reported. On 8/16/24, she identified that the charge nurse on the unit reported that Resident #101 had open wound to the coccyx. She identified Resident #101 had 2 small open wound to the coccyx and she measured both wounds. When she referred Resident #101 to the APRN #1 (wound specialist) the following week, the 2 open wounds combine into one open wound to the coccyx. She was not made aware of Resident #101 open coccyx wound that was first noted on 8/2/24. She identified she would expect the physician to be notified, and a treatment to be initiated at the time of discovery to prevent the wound from worsening and the wound should be assessed weekly. Interview with APRN #1 (wound specialist) on 9/9/24 at 2:45 PM identified that her initial consultation with Resident #101 was on 8/19/24 during her wound rounds. She identified that Resident #101 had an unstageable wound to the coccyx because the wound bed was covered with 100% slough. She also noted that the cause of the wound to the coccyx was related to pressure because of the wound's location. She identified that Resident #101 was at risk for pressure injury because of his/her dementia, decreased mobility, and anemia. She was not made aware of the wound to the coccyx on 8/2/24 and it would be the facility's responsibility to let her know when there is a new onset of a wound that needed to be evaluated. She further noted on her wound consult dated 9/2/24 that Resident #101 pressure wound to the coccyx had worsened because the measurement of the wound became larger from the previous wound assessment and the wound bed continued to be covered with 100% slough. She further identified that a pressure ulcer/injury could worsen quickly without a timely assessment and appropriate treatments and interventions provided. Interview with the DNS on 9/10/24 at 11:20 AM identified that he would expect the nurse to assess the wound promptly and call the physician to obtain and implement the treatment immediately. He also was aware that any pressure wound and/or injury could worsen without immediate intervention and treatment. He identified that the weekly skin check needed to be documented under the evaluation of weekly skin monitoring and done weekly. He was not made aware that Resident #101 had a new open wound to the coccyx on 8/2/24. He further identified the coccyx wound should have been assessed by a nurse and documented in a nurse's note that included the wound measurement, description and/or pressure wound stage, call to the physician and obtain and implement treatment, and the wound should have been monitored weekly from the time it developed. The facility policy title Documentation of Wound Treatment and Assessment identified that the physician or APRN would be notified of new onset of wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility policy and interviews, for one of seven sampled residents (Resident #94) reviewed for accidents, the facility failed to ensure the care plan was comprehensive to reflect the resident's status of not having a call bell or other hanging items in his/her room. The findings include: Resident #94's diagnoses included Alzheimer's disease, visual hallucinations, anxiety disorder, and schizoaffective disorder. The significant change in status MDS assessment dated [DATE] identified Resident #94 had significantly impaired cognition, behaviors of inattention and disorganized thinking, utilized a walker and required supervision or touching assistance with position changes and ambulation. The care plan dated 7/15/24 identified Resident #94 refused care and had interventions that included: one on one social services support, supervision as needed. The care plan also identified Resident #94 was unaware of safety needs with interventions to be sure the call light is within reach and encourage to use it for assistance as needed, promptly respond to all requests for assistance. Observation on 9/9/24 at 10:11 AM identified Resident #94 wandering around his/her room. The resident's room contained a bed, a chair, a side table, and a walker. There was a bracket secured to the wall for a television, although there was not a television. The bedside curtain had been removed from the room. There was a call bell box on the wall with a plug to receive the call bell cord; however, there was not a call bell in the room. Interview with LPN #15 on 9/10/24 at 12:15 PM identified Resident #94 did not have a call bell in his/her room because it was a safety concern because Resident #94 pulled items off of the walls and tied items up with cords. LPN #15 indicated that information was passed on to her from another staff member, although she could not remember who, and that she was not aware if the doctor was aware. LPN#15 indicated that should be something that was included in the care plan, and that nursing was able to add to the care plan. Interview with LPN #2 on 9/13/24 at 8:53 AM identified Resident #94 did not have a call bell in the room, nor anything that plugged in or hung in the room. LPN #2 indicated Resident #94 had pulled wires out of the wall and wrapped items up. LPN #2 indicated the resident had pulled the television off of the wall and the curtains off of the track and that leaving items such as call bell wires in the room was a safety hazard. LPN #2 further identified that at one time the resident was given a hand bell instead of the call bell and that the resident hid it somewhere and it had yet to be found. Physician's orders active as of date 9/13/2024 identified Behavior Monitoring for delusions, hallucinations, hitting, paranoia, anxiety, agitation, confusion, and furniture moving. Observation on 9/13/24 at 8:35 AM identified Resident #94 wandering around the perimeter his/her room attempting to take the television bracket off of the wall. Interview with APRN #2 on 10/17/24 at 10:25 AM identified that the safety concern of Resident #94 having corded items should be represented in the care plan and possibly a doctor's order. Interview with the DNS and RN#6 on 9/16/24 at 3:10 PM identified that a safety issue or behavior should be identified in the care plan in order to direct proper care of the resident. Review of the facility policy for Comprehensive Care Plans identified the comprehensive care plan will be prepared by an interdisciplinary team, that included a nurse aide or a registered nurse with responsibility for the resident. The policy further indicated that the care plan would contain resident specific interventions that reflect the resident' needs. The facility failed to ensure the resident's care plan was revised to reflect the resident's behavior of pulling the call light out of the wall and pulling other items off of the wall. The care plan reflected the use of a call light when the resident did not have a call light in his/her room and when it was an accident hazard for him/her to have in his/her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility policy, and interviews for one of five sampled residents (Resident #2) reviewed for unnecessary medications, the facility failed to ensure the medication was administered in accordance with the physician's order and for one of three sampled residents (Resident #48) reviewed for possible misappropriation of medication, the facility failed to ensure a medication used to treat anxiety was administered as ordered. The findings include: 1. Resident #2 had diagnoses included dementia, type 2 diabetes mellitus, chronic kidney disease, and anemia. The quarterly MDS assessment dated [DATE] identified Resident #2 had moderate cognitive impairment and required extensive assistance with toileting, hygiene and dressing, was independent with transfers and ambulation and received insulin injections. The RCP dated 5/14/24 identified Resident #2 had diabetes mellitus. Care plan interventions directed to administered diabetic medications as ordered by the physician, monitor side effects and effectiveness, dietary consult for nutrition regimen and on-going monitoring, and monitor for signs and symptoms of hypoglycemia (low blood sugar) not limited to sweating, tremors, increased heart rate and confusion. The physician's order dated 5/20/24 directed to administer insulin Humalog (a fast-acting insulin) 8 units at 8:00 AM, 12:00 PM, and 4:30 PM every day. Special instruction to the medication included: hold when blood sugar was less than 110 and notify physician when blood sugar was less than 70. Review of the medication administration record (MAR) from 7/1/24 to 7/31/24 for Resident #2 identified the following: On 7/1/24 at 12:00 PM, Resident #2 blood sugar was documented as 103, and the MAR indicated that the Humalog insulin was administered. On 7/4/24 at 12:00 PM, Resident #2 blood sugar was documented as 92, and the MAR indicated that the Humalog insulin was administered. On 7/8/24 at 12:00 PM, Resident #2 blood sugar was documented as 106, and the MAR indicated that the Humalog insulin was administered. On 7/9/24 at 8:00 AM, Resident #2 blood sugar was documented as 103, and the MAR indicated that the Humalog insulin was administered. On 7/11/24 at 12:00 PM, Resident #2 blood sugar was documented as 94, and the MAR indicated that the Humalog insulin was administered. On 7/17/24 at 4:30 PM, Resident #2 blood sugar was documented as 108, and the MAR indicated that the Humalog insulin was administered. On 7/22/24 at 8:00 AM, Resident #2 blood sugar was documented as 107, and the MAR indicated that the Humalog insulin was administered. On 7/23/24 at 12:00 PM, Resident #2 blood sugar was documented as 78, and the MAR indicated that the Humalog insulin was administered. On 7/25/24 at 8:00 AM, Resident #2 blood sugar was documented as 98, and the MAR indicated that the Humalog insulin was administered. On 7/30/24 at 8:00 AM, Resident #2 blood sugar was documented as 90, and the MAR indicated that the Humalog insulin was administered. Resident #2 received Humalog insulin injection 10 out of 31 opportunities when his/her blood sugar was documented as less than 110. Interview and clinical record review of the MAR with the DNS on 9/10/24 at 11:10 AM identified that he expected all licensed nurses to follow the physician's order when administering medications. Review of the July 2024 MAR with the DNS indicated the Humalog insulin was administered on 7/1/24 at 12:00PM, 7/4/24 at 12:00PM, 7/8/24 at 12:00PM, 7/9/24 at 8:00AM, 7/11/24 at 12:00PM, 7/17/24 at 4:30PM, 7/22/24 at 8:00AM, 7/23/24 at 12:00PM, 7/25/24 at 8:00AM, and 7/30/24 at 8:00AM. He further identified that he would start an immediate education to all licensed nurses for medication administration. Interview with LPN #4 on 9/10/24 at 2:30 PM identified that she was aware of Resident #2's insulin administration parameters to not administer when his/her blood sugar was less than 110. She identified that she would not administer and documents in the MAR that Resident #2's insulin was held when his/her blood sugar was less than 110. She further identified that she was not sure why the MAR would indicate that the insulin injection was administered despite the blood sugar of less than 110. The Administration Procedure for all Medications policy identified that the medications would be administered in a safe and effective manner. The license nurse would obtain and record any vital signs or other monitoring parameters ordered by the physician as deemed necessary prior to medication administration. 2. Resident #48's diagnoses included displaced fracture of base of neck of right femur, unspecified fall, and generalized anxiety disorder. The significant change MDS assessment dated [DATE] identified Resident #48 had intact cognition and was independent with toileting, eating, dressing, and personal hygiene, and required set up clean up assistance with bathing and oral hygiene. Resident #48's care plan dated 8/2/24 identified the resident had anxiety and depression. Interventions directed to administer psychotropic medications as ordered and monitor for side-effects, allow resident to express their emotions/feelings, have resident evaluated and treated by psychiatric services. The physician's order dated 9/4/24 directed Clonazepam 1mg to be administered three times daily. Interview with Resident #48 on 9/16/24 at 1:45 PM identified he/she had not received his/her last few doses of Clonazepam (benzodiazepine) and was experiencing a lot of anxiety due to not getting it and identified that the nurse knew. LPN #14's note dated 9/15/24 at 11:06 PM identified Resident #48 complained that he/she could not sleep, Clonazepam medication was re-ordered from pharmacy and would arrive the following day. The on call APRN was contacted after no more Clonazepam was found in the Omni-cell, and an order was given for Lorazepam, no Lorazepam was found in the omni cell as well. APRN stated to give Melatonin to help patient sleep. When LPN #14 returned to patient room, patient was sleeping. Review of the Medication Administration Record (MAR) identified Resident #48 did not receive the 8pm dose on 9/15/24 and the 8am dose on 9/16/24 of the Clonazepam 1mg. Interview with LPN#5 on 9/16/24 at 1:54 PM identified that she had received in report that Clonazepam 1mg was not available but had been ordered the night before so it should arrive at some point that day. Review of pharmacy orders received identified the 9/4/24 order of Clonazepam was not received by the pharmacy. On 9/4/24 pharmacy received a discontinue order for Clonazepam 1mg tab- 1 tab by mouth once daily for anxiety with breakfast and once daily at bedtime (take with 0.25mg for a total dose of 1.25mg) and a discontinue order for Clonazepam 0.5mg 1 tablet by mouth once daily and 1 half tablet at bedtime (take with 1mg for a total dose of 1.25mg.) Interview with Pharmacy Tech #1 on 9/16/24 at 12:48 PM identified there was no order received by pharmacy for the Clonazepam 1mg TID ordered on 9/4/24. There were two orders pending in their system. There was a refill request on a Clonazepam 1mg twice daily with an original order date of 8/19/24 which was requested on 9/15/24 at 7:22 PM to be refilled which would have been after their delivery cut off so not able to be delivered until 9/16/24, and there was a new order from 9/15/24 with a short fill order of 6 pills of Clonazepam 1mg TID ordered scheduled to go out. It looked like the 9/15/24 7:22 PM order was pending possibly due to the fact the medication was not due to be re-ordered yet as they had it down to be administered only twice daily. Interview with Pharmacist #1 on 9/16/24 at 2:35 PM identified that if this medication was not administered to the resident as scheduled the resident could experience increased restlessness and anxiety. Interview with RN Supervisor #2 on 9/17/24 at 11:15 AM identified that she had received the order from MD#1 on 9/4/24 and thought it had been sent electronically to the pharmacy from MD#1 but did not realize schedule IV medications needed a separate form to be filled out and sent to the pharmacy signed by the physician. Interview with MD#1 on 9/17/24 at 11:30 AM identified that he was not aware of the missed medication but that the on-call may have been made aware. He thought the order on 9/4/24 had originally come from the psychiatric provider in which they sometimes send him the changes to be signed, but in review remembered that the order came from a risk management meeting in which it was brought to his attention that Resident #48 had multiple orders, and it was confusing to the nurses administering the medications, so the clarification was made. He assumed the Schedule IV form to pharmacy would be filled out by the RN Supervisor and did not fill one out himself. Interview with the DNS on 9/17/24 at 11:50 AM identified he was unaware how the pharmacy would not receive an order if it were in Point Click Care and that medication should be ordered when it is in the last week of the blister pack. The DND also identified the Omni-cell just had an inventory completed on it on 9/14/24 and a reorder of medication was being made to fill it. The previous ADNS who had left in early August was previously responsible for keeping it filled and he was unsure when an Audit of the contents was completed, and a refill last done. Review of the pharmacy policy titled Controlled Substance Prescriptions directed all new prescriptions for controlled medications to be transmitted via fax to the pharmacy by the prescriber or the prescriber's agent. Emergency/STAT orders not in Emergency supply are placed with the provider pharmacy and is scheduled to be given as soon as received. Review of the Electronic Interim Box directed inventory restock to be performed by an authorized pharmacy representative or by authorized nursing personnel. Authorized personnel will conduct an inspection and quality assurance check relating to drug storage, segregation, environmental control, labeling, device operation, inventory quality, security and system integrity at least monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for two of three residents (Resident #68 and #22) reviewed for accidents, the facility failed to ensure residents on 1:1 observation did not have possession of smoking paraphernalia. The findings include: A. Resident #68's diagnoses included end stage renal disease, psychoactive substance abuse, and major depressive disorder. Record review identified Resident #68 had a court appointed Conservator of Person (COP). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #68 was alert and oriented, required assistance for transfers and supervision for mobility with a wheelchair. The Resident Care Plan (RCP) dated 7/23/2024 identified Resident #68 as at risk for injury to self and others secondary to unsafe smoking practices and had stored smoking supplies on his/her person and/or in his/her room. Interventions directed to provide one-to-one (1:1) staff for supervision, assigned a companion to go on all (outpatient) dialysis outings to ensure no vapes are acquired, search room/belongings search as needed, review facility smoking policy, have resident re-sign smoking contract. Further the COP makes all purchases for Resident #68 (to avoid purchase of smoking supplies), and COP provided list of approved visitors. Record review identified the following: 1. On 8/17/2024 at 11:00 AM, Resident #68 was observed vaping in his/her room. The corrective action plan was to continue 1:1 observation and encourage Resident #68 to comply with facility rules. Smoking policy was re-signed by Resident #68. 2. On 8/22/2024 at 2:00 PM, staff observed Resident with two vape pens in his/her pocket. The corrective action plan was to continue on 1:1 observation, remind visitors to not bring smoking/vaping materials to Resident #68. 3. On 8/30/2024 at 3:30 PM, Resident #68 was observed receiving a vape pen from another resident. The corrective action plan identified Social Services (SS) spoke with Resident #68 regarding facility smoking and vaping polices (re-education). Resident #68 verbalized understanding and re-signed the smoking policy. 4. On 9/5/2024 at 9:15 AM, the NA providing 1:1 observation observed Resident #68 with a vape pen. The DON and Social Services responded to the room and observed a yellow vape pen on the seat of the wheelchair. The corrective action plan directed to continue to encourage Resident #68 to comply with the smoking policy of the facility and maintain 1:1 observation. 5. On 9/5/2024 at 1:45 PM, Resident #68 was observed with a vape pen by the staff providing 1:1 observation, and Resident #68 tucked the vape into his/her brief. The corrective action plan directed facility staff will continue to encourage Resident #68 to comply with the smoking policy and to maintain 1:1 observation. 6. On 9/7/2024 at 10:30 AM, Resident #68 was observed with a vape pen in his/her possession. The corrective action plan directed facility staff will continue to encourage Resident #68 to comply with the smoking policy and to maintain 1:1 observation. Interview with DON on 9/16/2024 at 2:40 PM identified Resident #68 was alert and oriented, was offered smoking cessation interventions but declined them, and was noncompliant with the smoking policy. The interview identified although Resident #68 was on 1:1 observation, the interview failed to identify how Resident #68 continued to obtain smoking paraphernalia while on 1:1 staff observation. B. Resident #22's diagnoses included chronic kidney disease stage 3, anxiety disorder, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 was alert and oriented, and was independent with transfers and wheelchair mobility. The Resident Care Plan (RCP) dated 7/12/2024 identified Resident #22 as at risk for injury to self and others secondary to unsafe smoking practices, shared smoking supplies (lighters, cigarettes, vapes, e-cigs) with other residents and stored smoking supplies on his/her person and/or in his/her room. Interventions directed provide smoking education, staff to be present when opening deliveries, and room/belongings search as needed. Record review identified the following: 1. On 8/25/2024 at 12:00 PM, Resident #22 was observed with a vape pen. The corrective action plan identified vape pen was removed, and immediate education was provided. Resident #22 stated he/she purchased the vape while out on his/her last LOA (leave of absence). Resident verbalized understanding facility smoking policy and re-signed the policy. 2. On 8/29/2024 at 1:00 PM, staff observed a vape pen on Resident #22's power chair and removed the pen. The corrective action plan identified Resident #22 was reminded that having vape pens were not permitted and Social Services (SS) follow up was provided. 3. On 8/29/2024 at 10:00 PM, staff discovered five (5) vape cartridges in Resident #22's room. The corrective action plan identified Resident #22 was re-educated on the smoking and vaping policy and re-signed the smoking. 4. On 9/9/2024 at 9:0 AM, while receiving ADL care, the NA observed two (2) vape pens in Resident #22's possession, and the pens were given to staff. The corrective action plan identified Resident #22 was re-educated regarding facility smoking policy, re-signed the smoking policy, and was placed on 1:1 observation. 5. On 9/10/2024 at 7:50 AM, while the NA observed two (2) vape pens in Resident #22's possession, and the pens were given to staff. The corrective action plan identified Resident #22 was provided with re-education, re-signed the smoking policy, and continued on 1:1 observation. Interview with DON on 9/16/2024 at 2:40 PM identified Resident #22 was alert and oriented, and noncompliant with the smoking policy. DON stated Resident #22 may have obtained the smoking paraphernalia from items ordered and delivered to the facility, or when out of the facility on an LOA. The interview identified although Resident #22 was placed on 1:1 observation on 9/9/2024, the interview failed to identify how Resident #22 continued to obtain smoking paraphernalia while on 1:1 staff observation. Review of the Smoking Policy identified under smoking rules, residents are not permitted to carry any smoking materials, such as: cigarettes, cigars, vapes, pipes, and lighting devices (matches, lighter). Anyone in violation of this rule will be reassessed, and re-educated. If non-compliance continues, the resident could receive an involuntary discharge notice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, review of facility policy, review of facility documentation, and interviews during a review of the Infection Control Program, the facility failed to have the appropriate signage posted for a resident on transmission-based precaution (TBP) and the facility failed to utilize personal protective equipment (PPE) when entering a transmission-based precaution resident's room. Resident #58's diagnoses included type 2 diabetes mellitus, anxiety and polyneuropathy. The annual MDS assessment dated [DATE] identified Resident #58 was cognitively intact, required limited assistance with toileting hygiene, personal hygiene, and dressing. The assessment further identified that the resident was ambulatory, utilized a walker and wheelchair. The physician's order dated 9/6/2024 directed contact precautions secondary to stool for Clostridium difficile (C. diff) ordered and pending every shift. The nurse's note dated 9/9/24 at 6:32 AM identified that Resident #58 remained on contact precautions for a possible C. diff. The nurse's note dated 9/10/24 2:45 PM identified that Resident #58 remained on contact precautions and awaiting to collect stool for C. diff secondary to loosen stool on 9/6/24. Intermittent observation of Resident #58's room door entrance on 9/9/24 failed to identify posted signage that identified the need for contact precautions which would have noted the need for everyone to clean hands before entering and leaving the room, providers and staff must also wear gloves and gown before room entry and discard gown before room exit. Further observation identified a bin that was placed on the outside of Resident #58's room containing gown, gloves, face shield, surgical mask and a bottle of hand sanitizer on the top of the bin and a white bin located inside the room, just before the door exit for PPE disposal. Observation on 9/10/24 at 12:10 PM failed to identify posted signage that identified the need for contact precautions which would have noted the need for everyone to clean hands before entering and leaving the room, providers and staff must also wear gloves and gown before room entry and discard gown before room exit. Further observation identified a bin that was placed on the outside of Resident # 58's room containing gown, gloves, face shield, surgical mask and 2 bottle of hand sanitizer on the top of the bin and a white bin located inside the room, just before the door exit for PPE disposal. Interview with the Charge Nurse (LPN #13), NA #3 and NA #4 on 9/10/24 at 12:15 PM identified that staff knew when a resident is on precautions based on the signage posted on the outside of the room, which notes the type of transmission-based precautions, the type of PPE to be worn and when to wear the PPE, along with a bin on the outside of the room containing the appropriate PPE supplies. The staff also identified that the facility had provided education on transmission-based precautions which included, the type of precautions and how to don ad doff PPE. Observation on 9/10/24 at 12:20 PM identified NA #4 entered Resident #58's room without the use of PPE and spoke with the resident regarding when to have a shower. Interview with NA #4 on 9/10/24 at 12:23 PM identified that she did not need to utilize PPE as she was not providing care to the resident. Observation on 9/10/24 at 12:30 PM identified NA #4 entering Resident #58's room with his/her lunch meal tray without the use of PPE. Observation on 9/10/24 at 12:45 PM identified NA #3 entering Resident #58's room without the use of PPE to remove the resident's lunch meal tray and place the tray inside of the food meal cart, then proceeded to pick-up the other meal trays from other resident's room. Interview and observation with LPN #13 on 9/10/24 at 1:20 PM identified that Resident #58's room entrance failed to have signage on the outside of the room identifying the type of transmission-based precaution and the appropriate PPE to be worn and when to wear the PPE for the staff to follow. She then identified that Resident #58 was on contact precautions, which was a part of the physician's orders, which required PPE to be worn upon entering the resident's room. LPN #13 identified that the signage needed to have had been posted on the outside of the room as it was the responsibility of the Infection Preventionist and the supervisor to place the signage on the outside of the room. In addition, as additional signs are kept at the nurses' station in the drawer, LPN #13 indicated that she had not been working for the past couple of days and shift-to-shift reports are not always thorough. She then notified the Infection Preventionist (LPN #3) about the lack of signage on Resident #58's room and on the unit. Interview with NA #3 on 9/10/24 at 1:20 PM identified he did not utilized PPE when he removed the tray from Resident #58's room as there weren't any signage outside of the room, however based on the cart on the outside of the room knew the resident was on some type of precaution. Interview with NA #4 on 9/10/24 at 1:20 PM identified she knew the resident was on an isolation precaution but failed to ask the type of transmission-based precaution to be followed. She indicated that she did not think that PPE was to be worn when entering the room, when asking a question or delivering the resident's meal tray. Observation with the Infection Preventionist (LPN #3) on 9/10/24 at 1:25 PM identified a bin containing gowns, masks, face shield, gloves, and 2 containers of the hand sanitizer on the top of the bin, a white bin was located inside the room, just before the door exit for PPE disposal and there was not a posted signage that would have had identified the need for contact precautions which would note the appropriate PPE to be worn and when to wear the PPE for the staff to follow. Interview with LPN #3 on 9/10/24 at 1:25 PM identified she had placed the contact precaution signage and the bin containing the PPE supplies outside of the room on 9/6/24, as the resident was experiencing loose stool. LPN #3 identified that the hand sanitizers should not have been placed on the cart as hand washing is required for a resident with or suspected of C. diff, as well as a signage should have been outside of the room. She identified that staff needed to wear PPE upon entering the room, wash hands with soap and water after exiting the room, and bleach wipes was required to clean any reusable equipment. Subsequent to surveyor's inquiry LPN #3 posted a contact precaution signage outside of the room on the wall, which noted the need for everyone to clean hands before entering and leaving the room, providers and staff must also wear gloves and gown before room entry and discard gown before room exit. Review of the Transmission-Based (Isolation) Precautions policy identified that contact precautions are intended to prevent the transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment, and PPE to be donned upon room entry and discarded before existing the room. The policy further identified that the nursing staff may place a resident on transmission-based precaution/isolation with suspected or confirmed infectious diarrhea, or symptoms consistent with a communicable disease by obtaining an order for transmission-based precautions /isolation that specifies the type of precaution, reason for the precautions. The policy further identified that a signage that included instructions for the use of specific PPE and the transmission-based precautions such as contact, droplet or airborne, would be placed in a conspicuous location outside the resident's room with PPE readily available near the entrance of the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility policy for eight of eight sampled residents observed for medication administration, the facility failed to ensure medications were administered on time and according to physician's orders. The findings include: A. Resident #13's diagnoses included Type II diabetes mellitus, nausea with vomiting, gastroesophageal reflux disease. Physician's orders for September 2024 identified the following orders: Flush G-tube with 30 cc water prior to medication administration, 10 cc water between each medication and 30 cc after medication administration every shift Glucerna 1.5-250 ml every 5 hours at 7 am, 12 pm Multi-vitamin tablet give 1 tablet via G-tube one time a day Ondansetron HCL oral solution 4mg/5ml give 10 ml via PEG tube every 8 hours as needed for nausea and/or, 5pm, and 10 pm. No feeds between 11 pm and 7 am. Total volume of 1000mls. Acetaminophen tablet 325mg Give 2 tablet via G-tube every 4 hours as needed for generalized pain. Not to exceed 3 gm in a 24-hour period. Aspirin 81 oral tablet chewable give 1 tablet via PEG tube in the morning for cardiac supplement. Banatrol plus oral packet give 1 unit via G-tube every 8 hours related to Nausea with vomiting. Carvedilol oral tablet 3.125 mg Give 1 tablet via PEG tube two times a day, Hold if sbp <100 and HR <60. Famotidine oral tablet 40 mg give 1 tablet via G-tube one time a day. Ipratropium-Albuterol Inhalation solution 0.5-2.5 3mg/3ml 1 vial inhale orally four times a day. Metoclopramide HCL oral tablet 5mg give 1 tablet via PEG tube four times a day. Multi-vitamin tablet give 1 tablet via G-tube one time a day. Ondansetron HCL oral solution 4mg/5ml give 10 ml via PEG tube every 8 hours as needed for nausea. Prosource oral liquid give 30 ml via G-tube one time a day. Observation of medication administration for Resident #13 on 9/10/24 at 10:12 AM identified the following medications were administered after the scheduled administration time and were placed in a medication packet and were crushed together and mixed with 30cc water for administration: 1. Aspirin 81 mg chewable 2. Metoclopramide HCL oral tablet 5 mg four times a day 3. Famotidine oral tablet 40 mg 4. Multivitamin tablet 5. Carvedilol 3.125 mg via PEG tube 2x daily 6. Acetaminophen 650 mg via G-tube Additional medications administered separately at 9/10/24 at 10:42 AM included: 7. Prosource oral liquid 30 mg via G-tube one time a day for supplement. 8. Banatrol plus oral packet give 1 unit via G-tube Q 8 hours related to nausea with vomiting. Additional medications observed at 9/10/24 at 10:48 AM included: 9. Ondansetron HCL oral solution 4mg/5ml (10ml) 10. Toujeo Solostar SQ 5 units QD left upper arm 11. Ipratropium albuterol via mask Interview with LPN #15 on 9/10/14 at 10:45 AM indicated that medication administration is usually finished by 10:30 AM. LPN#15 identified that she had other duties, including a bladder scan, from a newly admitted resident that took precedence this morning. LPN #5 also identified the G-tube administration takes a long time because Resident #13 gets nausea. LPN #15 indicated that crushing the medications together is normal practice. LPN#15 also indicated that she had other morning medications to administer. She indicated she had not notified anyone the administrations were late, nor did she identify to anyone that she needed assistance on the unit. B. Resident #15 was admitted to the facility on [DATE]. Diagnoses included Type II Diabetes Mellitus, Chronic Kidney disease, and other specified depressive episodes. The Physician's orders dated September 2024 identified the following medication orders: Apixaban oral tablet 5mg give 1 tablet by mouth two times a day Aspirin Oral tablet delayed release 81mg give 1 tablet by mouth one time a day Cyanocobalamin oral tablet 1000 mcg give 1 tablet by mouth in the morning for supplement Fish oil oral capsule 1000 mg give 2 capsule by mouth two times a day for supplement Gabapentin oral capsule 100 mg give 2 capsules by mouth two times a day Lasix oral tablet 20 mg give 1 tablet by mouth one time a day every Tue, Thu, Sat Lidocaine Pain relief 4% patch apply to right knee topically one time a day for pain and remove per schedule Metformin HCL oral tablet 500 mg give 1 tablet by mouth two times a day Propranolol HCL oral tablet give 30 mg by mouth two times a day Rexulti oral tablet 0.5mg give 0.5 mg by mouth one time a day Thiamine mononitrate oral tablet 100mg give 2 tablet by mouth one time a day Trazodone HCL oral tablet 50 mg give 1 tablet by mouth three times a day for anxiety/agitation Wellbutrin SR oral tablet extended release 12 hour 100mg give 1 tablet by mouth two times a day Observation of medication administration for Resident #15 on 9/10/24 at 11:02 AM identified the following medications administered outside of the medication administration time: 1. Aspirin 81 mg 2. Vitamin B12 1000mcg 3. Fish oil 1000mg 4. Bupropion hcl sr 100 mg BID 5. Eliquis 5mg tab BID 6. Furosemide 20 mg (T,TH,Sat) 7. Gabapentin 100 mg capsule (2) 8. Metformin 500mg BID 9. Lidocaine patch exp 3/15/2027 (dated and initialed) 10. Propanolol 10mg tabs (30mg BID) 11. Rexulti 0.5mg QD 12. Thiamine B-1 13. Trazodone 50 mg 1-tab TID Review of the medication administration audit report for 9/10/24 identified all morning medications were scheduled for 9:00 AM. All recorded administrations were between 11:03 AM and 11:11 AM. Trazodone 50mg was prescribed TID and was administered at 2:13 PM and 4:51 PM for the 2nd and 3rd doses. C. Resident #92 was admitted to the facility on [DATE]. Diagnoses included dysphagia, oropharyngeal phase, dementia, unspecified severity with other behavioral disturbance, anxiety disorder, unspecified. The Physician's orders dated September 2024 identified orders for the following medications: Lisinopril oral tablet 10 mg give 10 mg by mouth one time a day. Tramadol HCL oral tablet 50 mg give 0.5 tablet by mouth two times a day Zoloft oral tablet (sertraline) Give 50 mg by mouth in the morning Observation of medication administration for Resident #92 on 9/10/24 at 11:17 AM identified the following medications were all crushed together and mixed together with vanilla pudding: 1. Lisinopril 10mg every day 2. Sertraline 50 mg one time in the AM 3. Tramadol 50 mg 1/2 tablet BID The medication administration audit report for 9/10/2024 indicated the above medications were administered between 11:17 AM and 11:20 AM. D. Resident #51 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, anxiety disorder, and gastro-esophageal reflux disease without esophagitis. Physician's orders for Resident #51 dated September 2024 identified the resident was a regular diet and identified the following medications: Bictegravir-Emtricitab-Tenofov tablet 50-200-25 mg give one tablet by mouth one time a day Lipitor oral tablet 20 mg give one tablet by mouth one time a day Multivitamin adults tablet give 1 tablet by mouth in the morning for supplement Nuedexta Capsule 20-10 mg give 1 capsule by mouth two times a day Trazodone HCL tablet give 25 mg by mouth two times a day Observation of medication administration on 9/10/24 at 11:27 AM identified the following medications were crushed together, the capsule was opened, all mixed together with vanilla pudding and administered to Resident #51: 1. Atorvastatin 20 mg QD 2. Biktarvy 50/200/25 mg 3. Multivitamin 4. Nuedexta 20-10mg cap BID 5. Trazodone 50 mg BID The medication administration audit report for 9/10/24 identified the above mentioned medications were scheduled for 9:00 AM and were marked administered between 11:27 and 11:28 AM. Interview with LPN #15 on 9/10/24 at 11:32 AM identified that she was trained by the previous nurse that whatever the diet order was identified whether to crush the medications or not. LPN#15 indicated that she didn't think she needed an order to crush medications. LPN#15 indicated that Resident #51 was a pureed diet and that she believed crushing the medication is decided on their diet order. LPN #15 indicated that although she was oriented to the facility she didn't recall if crushing medications required an order. Interview with RN #2, nursing supervisor, on 9/10/24 at 11:41 identified there should be a set of batch orders that identify that the medications can be crushed. There is not a crushed order for Resident #51 nor Resident #92. E. Resident #91 was admitted to the facility on [DATE]. Diagnoses included dementia in other disease classified elsewhere unspecified severity with agitation dysphagia unspecified, anxiety disorder, and Alzheimer's disease. Physician's orders dated September 2024 identified Resident #91 was a regular diet mechanical soft texture, thin consistency and the following medications: Buspirone HCL oral tablet 10 mg give 2 tablets by mouth two times a day Lipitor oral tablet 20 mg give 1 tablet by mouth in the morning Multivitamin oral tablet give 1 tablet by mouth one time a day Trazodone HCL oral tablet give 25 mg by mouth two times a day Observation of medication administration for Resident #91 on 9/10/24 at 11:45 AM identified the following medications administered: 1. Atorvastatin 20 mg QAM 2. Buspirone 10 mg 2 tabs BID 3. Trazodone 50 mg 25 mg PO q 6 hrs. as needed 4. Daily vitamin QD The medication administration audit report for 9/10/24 identified the above listed medications were scheduled for 9:00 AM and were administered from 11:48 AM to 11:50 AM. F. Resident #94 was admitted to the facility on [DATE]. Diagnoses included dysphagia unspecified, delusional disorders, unspecified psychosis not due to a substance or known physiological condition, and dementia in other diseases moderate with other behavioral disturbance. Physician's orders dated September 2024 identified Resident #94 was on a 2-gram Sodium diet with mechanical soft texture, thin consistency and medications that included the following: Furosemide oral tablet 20 mg give 1 tablet by mouth one time a day every other day Trazodone HCL oral tablet 50 mg give 25 mg by mouth three times a day Observation of medication administration on 9/10/24 at 11:55 AM identified the following medications were administered to Resident #94: 1. Furosemide 20 mg qod 2. Trazodone 50 mg 1/2 tablet PO TID The medication administration audit report dated 9/10/24 identified the above listed medications for Resident #94 were scheduled to be administered at 9:00 AM and the administration time was 11:56 AM Interview with the DNS on 9/10/24 at 12:00 PM identified the facility expectation would be that the nurse has an hour on either side of the ordered time for administration. He indicated that sometimes medications are difficult to administer on time depending on what is going on. The DNS indicated the facility would fix the batch orders immediately to include crushing medications and include it for residents who would have medications crushed. Additionally, the DNS indicated the doctor, and the pharmacist were responsible for making sure the medications were able to be crushed. G. Resident #104 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia with psychotic disturbance, unspecified psychosis not due to a substance or known physiological condition, and anxiety disorder, unspecified. Physician's orders dated September 2024 identified Resident #104 had a regular diet, regular texture, thin consistency and orders that included the following medications: Amlodipine Besylate oral tablet 5 mg give 1 tablet by mouth one time a day Hydrochlorothiazide oral tablet 12.5 mg give 1 tablet by mouth one time a day Levothyroxine Sodium oral tablet 25 mcg give 1 tablet by mouth in the morning Risperdal oral tablet 1 mg give 1 mg by mouth in the morning Trazodone HCL oral tablet give 25 mg by mouth in the morning Observation of medication administration on 9/10/24 at 12:02 PM identified the following medications were administered to Resident #104 1. Amlodipine 5mg qd 2. Levothyroxine 25mcg QAM 3. Hydrochlorothiazide 12.5 mg 4. Trazodone 50 mg tab 25 mg 5. Risperidone 1 mg tab QAM The medication administration audit report for 9/10/24 identified the above listed medications were scheduled for administration at 9:00 AM and administration times from 12:01 PM to 12:03 PM. H. Resident #21 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, unspecified severity with other behavioral disturbance, schizoaffective disorder bipolar type, and other psychotic disorder not due to a substance or know physiological condition. Physician's orders dated September 2024 identified Resident #21 was ordered the following medications: Acetaminophen tablet 500mg give 500mg by mouth every 12 hours for pain Depakote oral tablet delayed release 250 mg give 1 tablet by mouth every 12 hrs Depakote oral tablet delayed release 500mg give 1 tablet by mouth every 12 hrs Gabapentin capsule 400 mg give 1 capsule by mouth two times a day Lopressor oral tablet give 25 mg by mouth in the morning Seroquel oral tablet give 12.5 mg by mouth in the morning Tradjenta tablet 5 mg give 1 tablet by mouth one time a day Trazodone HCL oral tablet 50 mg give 0.5 tablet by mouth in the morning Observation of medication administration on 9/10/24 at 12:07 PM identified the following medications were administered to Resident #21 1. Acetaminophen 500 mg 1 tab Q 12 hrs 2. Depakote 250 mg DR tab 1 tab Q 12 hours 3. Gabapentin 400mg cap BID 4. Divalproex 500mg DR tab Q12 hrs 5. Metoprolol tartrate 25 mg qam 6. Quetiapine 25mg 12.5 mg po qam 7. Tradjenta 5mg tab qd 8. Trazodone 50 mg tab 1/2-tab qam The medication administration audit report dated 9/10/24 identified that the above listed medications for Resident #21 were scheduled for administration at 9:00 AM and were marked administered between 12:07 PM and 12:12 PM. Interview with RN #6, (Independent Nurse Consultant) on 9/11/24 at 10:06 AM identified that the medications should be administered separately for a g-tube administration. Additionally, RN #6 indicated that in order to administer medications crushed, there needed to be a physician's order that directed a crushed administration. Interview with Pharmacist #2 on 9/13/24 at 12:19 PM identified that late administration could be a problem if the medication had multiple doses throughout the day. If the medication was administered three TID or three times a day the prescription doesn't list administration times but if the first administration was late, the nurse would adjust the next dose if needed. If the medication was every 12 hrs, the next dose would have to be at least 9 to 10 hours later, then this wouldn't pose a problem. In order to administer crushed medications Pharmacist #2 identified there should be a physician's order stating the medications would be administered in that manner. Additionally, Pharmacist #2 indicated the medications administered through the G-tube were okay to be crushed together regarding the efficacy of the medication, however, there should be an order for them to be crushed together as G-tube medications were usually administered separately. The provider should be notified of late medications and BID, TID, or QID medications should have the next administration times adjusted. Interview with the Medical Director on 9/17/24 at 11:45 AM identified there was clinically very little effect to taking medications at a later time than prescribed. TID medications should be delayed for the next doses because there was too short of a window if one was administered after 11 AM and then again at 1 PM. Typically, the nurse should adjust the time and notify the provider to adjust the time. The sedative drug should be spread out. Additionally, the Medical Director indicated he was not at the facility on 9/10/24 and didn't recall being notified of late medications. He also identified that another provider, such as the Psych APRN or the APRN could have been notified. Review of the facility Medication administration schedule identified the standard administration time for medications scheduled for once a day or daily will be administered at 9 am. Medications scheduled 2 times a day, BID, would be administered at 9 am and 5 pm. Medications scheduled 3 times a day, TID, would be administered at 9 am, 1 pm, and 5 pm. Medications scheduled 4 times a day, QID, would be administered 9am, 1 pm, 5 pm, and 9 pm. Medications scheduled every 12 hours, Q12H, would be administered at 9 am and 9 pm. Medications scheduled every 8 hours, Q8H would be administered at 6 am, 2 pm, and 10 am. Medications administered every 6 hours, Q6H would be administered 12 am, 6 pm, 12 am, and 6 pm. Medications administered every 4 hours, Q4H, would be administered 12 am, 4 pm, 8 am, 12 pm, 4 pm, and 8 pm. Medications scheduled to be administered at bedtime, HS, would be administered at 9 p. Medications administered with meals would be administered at 7:30 am, 11:30 am, and 5 pm. The facility policy for the administration procedures for all medications identified that prior to removing the medication from the cart, the staff administering the medication would check the MAR/TAR for the order and at a minimum, review the 5 rights at each of the steps of medication administration. The 5 rights of medication administration included the right patient, the right drug, the right time, the right dose, and the right route. The facility policy for Enteral tube medication administration identified the medication should be prepared one at a time, and tablets that must be crushed prior to administration via feeding tube must have a specific order related to crushing. Further preparation directions indicated each immediate-release tablet should be crushed one at a time, into a fine powder and dissolve in at least 15 ml (or prescribed amount) of warm purified or sterile water, and that each immediate release capsule one at a time and crush the contents into a fine powder and dissolve in a t least 15 ml (or prescribed amount) of warm purified or sterile water. The policy identified to administer each medication separately and flush the tubing between each medication.

Based on review of facility documentation, review of facility policy and interviews, the facility failed to ensure that controlled medications were safe guarded and periodically reconciled to ensure against diversion of medication. The findings include: Interview with the DNS on 9/12/24 at 1:40 PM identified the Controlled Substance Disposition Records (CSDR) come in duplicate form with the controlled medications. The CSDR yellow form is placed in a box in the supervisor's office, and after the medication is completed, the CSDR white forms, with the administration forms get paired with the yellow form and the medication is reconciled. The DNS indicated that job was part of the ADNS duties and, since the ADNS left over a month ago, no one had been assigned to complete the task of narcotic reconciliation. Interview with the DNS on 9/13/2024 at 12:40 PM identified the facility had not conducted a facility narcotic audit for an undisclosed amount of time. The DNS indicated that the ADNS who left in August of 2024 was responsible for maintaining the narcotic reconciliations, and no one had been assigned to complete the task since he left employment. The DNS further indicated that he was not able to find any paperwork to prove that audits were completed and was not able to provide the date of the last audit for 2024 nor 2023. The DNS described step by step what happened once the pharmacy delivered a controlled medication. He indicated the delivery person obtains a signature from the supervisor who checks the medication being delivered against the packing slip. The supervisor signs and dates the packing slip, and the facility receives a copy of the packing slip. The DNS further identified that until the current survey, it was not the facility's practice to maintain the packing slips. The Controlled Substance Disposition Records (CSDR) are a duplicate form. One is yellow and one is white. The yellow form goes to the nursing supervisor's office and is placed in a binder (post surveyor inquiry and established during survey) and the white copy goes to the units to the controlled medication binders on the medication carts for the nurses to sign out the controlled medications along with the controlled medication that matches the specified medication on the form (CSDR). Interview with RN#6 on 9/13/24 at 12:50 PM identified that she and the DNS did a house wide narcotic audit the previous night and identified the following CSDRs (yellow copies) that did not have a corresponding CSDR (white copy), nor a corresponding bubble pack of medication in the building: 1. Oxycodone IR 10 mg tablets, 30 delivered from the pharmacy on 3/28/24 2. Oxycodone IR 5 mg tablets, 30 delivered from the pharmacy on 4/16/24 3. Oxycodone IR 10 mg tablets, 30 delivered from the pharmacy on 4/25/24 4. Oxycodone IR 5 mg tablets, 30 delivered from the pharmacy on 5/7/24 5. Oxycodone IR 5 mg tablets, 30 delivered from the pharmacy on 5/25/24 6. Oxycontin ER 10 mg tablets, 28 delivered from the pharmacy on 5/29/24 7. Oxycodone IR 5 mg tablets, 30 delivered from the pharmacy on 6/11/24 8. Oxycodone IR 5 mg tablets, 30 delivered from the pharmacy on 7/11/24 9. Oxycodone IR 5 mg tablets, 30 delivered from the pharmacy on 7/25/24 10. Oxycodone IR 5mg tablets, 30 delivered from the pharmacy on 8/14/24 11. Tramadol 50 mg tablets, 30 delivered from the pharmacy on 3/18/2024 12. Lorazepam 0.5 mg tablets, 30 delivered from the pharmacy on 8/27/24 13. Oxycodone IR 10 mg tablets, 30 delivered from the pharmacy on 5/24/24 14. Oxycodone IR 10 mg tablets, 30 delivered from the pharmacy on 6/6/24 15. Oxycontin ER 10 mg tablets, 28 delivered from the pharmacy on 6/12/24, 16. Oxycodone IR 5 mg tablets, 30 delivered from the pharmacy on 6/12/24 17. Xtampza ER 13.5mg caps, 28 delivered from the pharmacy on 7/6/2024 18. Oxycodone IR 5 mg tablets, 30 delivered from the pharmacy on 7/17/24 19. Hydromorphone 2mg tablets, 30 delivered from the pharmacy on 6/14/24 20. Oxycodone IR 20mg tablets, 30 delivered from the pharmacy on 6/15/24 21. Oxycodone IR 30mg tablets, 30, delivered from the pharmacy on 6/15/24 22. Oxycodone-APAP 5-325 mg tablets, 30 delivered from the pharmacy on 11/29/23 23. Oxycodone IR 5 mg tablets, 30 delivered from the pharmacy on 3/14/24 24. Hydromorphone 2 mg tablets, 30 delivered from the pharmacy on 8/1/24 25. Hydromorphone 4 mg tablets, 30 delivered from the pharmacy on 7/6/24 26. Hydromorphone 4 mg tablets, 30 delivered from the pharmacy on 8/14/24 27. Lacosamide 200mg tablets, 30 delivered from the pharmacy on 7/4/24 28. Clonazepam 0.5 mg tablets, 15 delivered from the pharmacy on 5/22/24 29. Clonazepam 0.5 mg tablets, 30 delivered from the pharmacy on 6/14/24, 30. Oxycodone IR 10 mg tablets, 30 delivered from the pharmacy on 6/27/24 31. Morphine Sulfate IR 15 mg tablets, 28 delivered from the pharmacy on 7/17/24 32. Morphine Sulfate IR 15 mg tablets, 30 delivered from the pharmacy on 8/6/24 33. Oxycodone IR 10 mg tablets, 30 delivered from the pharmacy on 8/8/24, 34. Oxycodone IR 5mg tablets, 15 delivered from the pharmacy on 2/6/24 35. Zolpidem 10 mg tablets, 30 delivered from the pharmacy on 5/31/24 36. Tramadol 50 mg tablets, 30 delivered from the pharmacy on 6/21/24 37. Tramadol 50 mg tablets, 30 delivered from the pharmacy on 6/14/24 38. Hydromorphone 2 mg tablets, 30 delivered from the pharmacy on 6/28/24 39. Oxycodone IR 5 mg tablets, 12 delivered from the pharmacy on 9/6/24 40. Oxycodone-APAP 5-325 mg tablets, 10 delivered from the pharmacy on 5/4/24 41. Oxycodone-APAP 5-325 mg tablets, 30 delivered from the pharmacy on 6/11/24 42. Oxycodone-APAP 5-325 mg tablets, 30 delivered from the pharmacy on 6/25/24 43. Oxycodone-APAP 5-325 mg tablets, 30 delivered from the pharmacy on 6/7/24 44. Tramadol 50 mg tablets, 30 delivered from the pharmacy on 8/13/24 45. Oxycodone-APAP 5-325 mg tablets, 30 delivered from the pharmacy on 8/20/24 46. Lorazepam 0.5 mg tablets, 30 delivered from the pharmacy on 8/21/24 47. Oxycodone IR 5 mg tablets, 30 delivered from the pharmacy on 8/1/24 48. Oxycodone IR 5 mg tablets, 8 delivered from the pharmacy on 9/1/24 Interview on 9/16/24 at 12:22 PM with the former ADNS (employed 1/2023 through 8/7/24) identified he was responsible for investigating missing narcotics but could not recall an instance where the white CSDR and the bubble pack of medication were both reported missing. The ADNS identified that he was taught to conduct narcotic audits and had a binder to log them in but lost the binder and was not able to conduct the audits due to other duties. The ADNS could not recall when the last audit was completed. Additionally, he identified that he had witnessed destruction of narcotics with the DNS but did not recall specific dates. Interview with the DNS, Administrator, and RN#6 on 9/16/24 at 3:10 PM identified that a second in house narcotic audit was conducted that morning and additional medications were found missing bringing the total to 49 medications that were unaccounted for. The DNS indicated that he is uncertain where all of the narcotic medications could have gone and that he and RN#6 would continue to review the medication administration records (MAR) of the residents and that he thinks it could be possible that the white CSDR sheets could have been thrown out before they were reconciled. Interview with the Medical Director on 9/17/24 at 11:25 AM identified that narcotic disposition is a nursing procedure. When shown the CSDR sheets for the unaccounted-for controlled medications, the Medical Director denied being aware. The Medical Director indicated he would expect a thorough investigation. Additionally, he indicated he had never been informed that residents were not receiving their medications. The Handling of Controlled Substances policy indicated that any discrepancy in controlled drug counts should be reported to the Director of Nursing as soon as possible and the DNS will notify the administrator and the consultant pharmacist immediately and the Administrator and Pharmacist will consult concerning possible notification of police or other enforcement actions. Although requested, the facility did not provide a narcotic requisition/disposition/destruction/audit policy.

**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 three (3) residents, (Resident #95), reviewed for abuse, the facility failed to ensure a resident was free from abuse. The findings include: Resident #95 had diagnoses that included schizoaffective disorder, anxiety depression, paraplegia, restlessness, and agitation. The care plan dated 2/23/2024 identified Resident #95 had behavior problems related to traumatic brain injury with interventions that directed to praise any indication of progress or improvement in behavior, approach and speak in a calm manner, divert attention, and educate the resident on successful coping and interaction strategies. A physician's order dated 2/23/2024 directed to provide direct supervision from 7:00 A.M. to 11:00 P.M. to Resident #95 when at his/her doorway, when room door is open, or when Resident #1 is out of his/her room for safety. A significant change Minimum Data Set, dated [DATE] identified Resident #95 had moderately impaired cognition, was continent of bowel and bladder, and required supervision ADSL's. The nurse's note dated 3/7/2024 at 1:44 P.M. identified Resident #95 demonstrated agitation during lunch time and was redirected with a positive outcome. Resident #95 remained on 1:1 monitoring. A review of the Facility's Reportable Event form dated 3/8/2024 identified at 12:00 P.M. Resident #95 was yelling and swearing at NA #8 and NA #8 yelled back at Resident #95. According to a witness NA #8 raised his hand, told Resident #95 to shut up before he slapped Resident #95. NA #8 was immediately removed from the unit, instructed to write a statement, and sent home pending investigation. The APRN was notified, and the police were called. The facility's corrective action plan dated 3/13/2024 identified NA #8's employment was terminated due to non-compliance with the facility policy. A nurse's note dated 3/8/2024 at 6:01 P.M. identified status post an incident earlier today Resident #95 seems back to his/her baseline. Resident #95's behavior's were minimal. Interview with NA #2 on 4/9/2024 at 9:50 A.M. identified on 3/8/2024 around lunch time Resident #95 was in the hallway using profanities and made a racial slur. NA #2 identified she observed NA #8 react to Resident #95's profanities NA #8 with had a closed fist, aiming at Resident #95's face while trying to punch Resident #95. NA #2 identified NA #8 did not make any contact with Resident #95. Interview with NA #6 on 4/9/2024 at 10:05 A.M. identified on 3/8/2024 shortly after the start of his shift at 7:00 A.M. he was assigned to be the one-to-one monitor for Resident #95. NA #6 identified at approximately 12:00 P.M. Resident #95, a few other staff, and himself were standing next to the nurse's desk waiting for the lunch trays to arrive on the unit. NA #6 identified Resident #95 was being verbally disrespectful, and swearing loudly. NA #6 identified he witnessed NA #8 react to Resident #95's behavior by raising his hand to Resident #95, but NA #8 did not hit Resident #95. Interview with LPN #1 on 4/9/2024 at 10:20 A.M. identified on 3/8/2024 at 12:00 P.M. she and the nurse aides were at the desk waiting for the lunch trays. LPN #1 identified before she could intervene she seen NA #8 raise his hands up to Resident #95 telling Resident #95 to shut up before NA #8 slapped Resident #95. LPN #1 identified NA #4 was standing between Resident #95 and NA #8 which may have prevented NA #8 from hitting Resident #95. Interview with NA #4 on 3/22/2024 at 10:40 A.M. she identified on 3/8/2024 at 12:00 P.M. she identified NA #2, NA #6, NA #8, LPN #1, Resident #95, and she were in front of the nurse's desk in the hallway waiting for the lunch trays to arrive. NA #4 identified Resident #95 was swearing in the hallway. NA #4 identified she seen NA #8 raise his right hand while aiming at Resident #95, telling Resident #95 he was going to slap him/her. NA #4 identified she pulled NA #8 away from Resident #95 to prevent NA #8 from hitting Resident #95. Interview with the DNS on 4/9/2024 at 11:05 A.M. identified on 3/8/2024 at approximately 12:00 P.M. he was notified that there was an incident between NA #8 and Resident #95. The DNS identified per staff interviews and statements obtained Resident #95 had been swearing loudly and NA #8 reacted by telling Resident #95 to shut up while NA #8 raised his hands at Resident #95 but did not hit Resident #95. The DNS indicated NA #8 was immediately removed from the unit. The DNS identified NA #8 was interviewed, NA #8 denied that he raised his hands at Resident #95, and NA #8 was suspended on 3/8/2024 pending the outcome of the investigation. The DNS identified based on the investigation, staff interviews, and statements obtained NA #8 was terminated on 3/11/2024 for raising his hands at Resident #95. Interview with Resident #95 on 4/9/2024 at 12:00 P.M. Resident #95 identified while he/she was in the hallway sitting in his/her wheelchair NA #8 tried to hit him/her. Resident #95 identified another nurse aide stopped NA #8 from hitting him/her. Although attempts were made an interview with NA#8 was not obtained. Review of the facility abuse policy identified, in part, it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by implementing written policies and procedures that prohibit and prevent abuse. The facility has written procedures to assist staff in identifying the different types of abuse that includes staff to resident 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 three (3) residents reviewed for abuse, (Resident #5), the facility failed to ensure abuse was reported timely. The findings include: Resident #5 was admitted to the facility with diagnoses that included stroke, dementia and mood disorder. The quarterly MDS dated [DATE] identified Resident #5 had severely impaired cognition, had physical behavioral systems that occurred for one (1) to three (3) days a week, was incontinent of bladder and bowel and required assistance of one staff for ADL's. The care plan dated 10/23/23 identified Resident #5 had impaired social interaction due to dementia and mood disorder with interventions that included to provide assistance with ADL's as needed and that staff would provide positive feedback when Resident #5 would participate with ADL's. The care plan further identified Resident #5 had a diagnosis of dementia with interventions that included to cue, reorient and supervise as needed, keep Resident #5's routine consistent and to prevent just one thought, idea, question of command at a time. The psychiatric note dated 12/11/23 identified Resident #5 occasionally refused care, but it was not an ongoing problem and otherwise had been stable at his/her baseline. A nursing note dated 12/13/23 at 10:25 PM identified a Nurse Aide (NA) reported on 12/12/23 between 7:00 PM and 8:00 PM she witnessed the guiding of Resident #5's feet was a little rough when putting the resident to bed and Resident #5 kicked her and the NA slapped Resident #5's right forearm with an open hand. Review of the A & I dated 12/13/23 identified on 12/13/23 at 4:30 PM NA #3 reported on 12/12/23 between 7:00 PM and 8:00 PM while orienting on the floor with NA #4, she witnessed NA #4 hit Resident #5 on the hand/arm after Resident #5 kicked h/her. NA #4 was immediately removed from the floor and was terminated. Resident #5 had no recollection of the event. Review of NA #4's undated statement identified on 12/12/23 she was orienting NA #3 and they were putting Resident #5 to bed, Resident #5 kicked her and she pushed his/her foot away from her. Review of NA #4's timesheet identified NA #4 worked on 12/12/23 from 2:51 PM to 12/13/23 6:57 AM and 12/13/23 2:59 PM to 5:22 PM. Interview with NA #3 on 12/19/23 at 10:12 AM identified on 12/12/23 it was her first day orienting on the floor with another NA. She identified when NA #4 was caring for Resident #5 before bed NA #4 lifted Resident #5's legs and dropped them quickly onto the bed, Resident #5 then kicked NA #4 and NA #4 smacked Resident #5 with an open hand on his/her forearm. She further identified she was scared to tell anyone because it was her first day training on the floor. She however identified during orientation she was educated on reporting abuse as soon as witnessed. She identified she reported the event on 12/13/23 because the event stuck with her and she was previously in shock as to what she witnessed on 12/12/23. Although multiple attempts were made, an interview with NA #4 was not obtained. Interview with the DNS on 12/19/23 at 1:00 PM identified he was not aware of the incident that occurred on 12/12/23 until 12/13/23 at 4:30 PM . At that time NA #4 was removed from the floor and now no longer works in the facility. He identified NA #3 was a new NA but would still have expected her to report the incident immediately. He further identified NA #4 should have backed away and re-approached the resident when being combative. Review of the abuse investigation, protection and reporting process policy directed the facility will ensure all alleged violations are thoroughly investigated and appropriate corrective actions taken. Investigations shall be prompt and shall include information as is required to reasonably assess the nature of any alleged abuse or neglect.

**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 three (3) residents reviewed for behaviors, (Resident #2), the facility failed to clearly transcribe physician's orders resulting in the lack of administration of an as needed medication for behaviors. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included altered mental status, bipolar disorder and alcohol use. The admission assessment dated [DATE] identified Resident #5 was alert to person and required limited assistance with activities of daily living (ADL). The care plan dated 11/27/23 identified Resident #2 had a behavior problem and psychotic disturbances related to dementia associated with alcoholism with interventions that included to administer medications as ordered and to anticipate and meet Resident #2's needs. A physician's order dated 11/27/23 directed to administer Trazodone 50 mg at bedtime for bipolar disorder. A nursing note dated 11/30/23 at 2:39 PM identified she was called to the unit by staff and staff reported Resident #2 pushed Resident #3. Resident #2 was placed on one to one observation and was transported to the hospital. A subsequent nursing note dated 12/1/23 identified Resident #2 returned back to the facility at approximately 4:05 AM and hospital paperwork stated Resident #2 was not a danger to self or others at the time. The care plan dated 11/30/23 identified Resident #2 was a wanderer related to disorientation to place with interventions that included to distract Resident #2 from wandering, identify patterns of wandering, monitor location every 15 minutes and document wandering behavior and attempted diversional interventions in the behavioral log. An assessment completed by APRN #2 (Psychiatric APRN) dated 11/30/23 identified Resident #2 was alert, confused and staff reported continued wandering into other resident's rooms and sometimes got agitated with redirection. APRN #2 ordered Trazodone 50 mg (an anti-depressant/sedative medication) every 12 hours as needed (PRN) or 14 days for restlessness and anxiety. A physician's order dated 11/30/23 directed to administer Trazodone 50 mg every 12 hours as needed for restlessness/anxiety. Resident #2 had a nurse's note dated 12/1/23 that identified at approximately 4:05 AM the resident returned to the facility with a no harm letter. Nurse's note dated 12/3/23 and 12/4/23 identified that Resident #2 had a bowel movement on the floor of h/her room and the resident was sent to the emergency room on [DATE] for evaluation of behaviors. A nurses note on 12/11/23 at 3:00 PM identified that Resident #2 was re-admitted to the facility at 2:55 PM with a letter stating the resident was not a harm to self or others. A physician's order dated 12/11/23 directed to administer Trazodone 50 mg at bedtime related to bipolar disorder (may repeat one time as needed). Review of the hospital Discharge summary dated [DATE] identified Resident #2's medications included Trazodone 50 mg at bedtime time and Trazodone 50 mg at bedtime PRN may repeat one time PRN tablet. A physician's order dated 12/11/23 directed Trazodone 50 mg at bedtime related to bipolar disorder (may repeat one time as needed). A physician's order dated 12/11/23 directed Trazodone 50 mg every 24 hours as needed for bipolar (may repeat one time at bedtime). A nurse's note written by LPN #1 dated 12/14/23 at 6:38 AM identified during the shift Resident #2 wandered the hallways, dining room, in other resident's room, disturbed the peace of the unit and was redirected several times with some effect. It identified Resident #2 was observed in another resident's room naked and was redirected without issue. Resident #2 attempted to wander naked into the same room a second time and was redirected back to his/her room. Resident #2 appeared to lack understanding of personal space and boundaries. A nurse's note written by LPN #4 dated 12/14/23 at 2:57 PM identified Resident #2 was noted to be restless and pacing throughout the halls during the shift. Resident #2 needed redirection throughout the shift on keeping his/her clothes on, personal space/boundaries and inappropriate touch. Resident #2 was not redirected well. An assessment written by APRN #2 dated 12/14/23 identified Resident #2 continued behavior dysregulation while at the facility including disrobing and sexually inappropriate behaviors with frequent redirection. Resident #2 was sent to the hospital on [DATE] for combative behaviors at which time his/her Seroquel, Namenda and Cymbalta were discontinued. Staff reported Resident #2 was up all night and had some episodes going into other resident's rooms and PRN Trazodone was not used. APRN #2 encouraged PRN medication use as appropriate. An A & I dated 12/14/23 at 7:50 PM identified Resident #2 was seen pushing his/her roommate, (Resident #4), causing Resident #4 to fall to the floor. Resident #2 was placed on one to one supervision until the EMT's arrived and then transferred to the hospital. Resident #4 had complained of pain to the right wrist, X-rays were ordered and on 12/15/23 the result identified a fracture of the distal ulna and Resident #4 was transferred to the hospital with and returned with splint in place. Review of the MAR dated December 2023 identified Resident #2 had behaviors (hallucinations, delusions, striking out and hitting) on the night shift of 12/14/23. The MAR failed to identify that Trazodone 50 mg one tablet every 24 hours as needed was documented as administered on 12/14/23. Interview with LPN #1 on 12/18/23 at 1:50 PM identified she was Resident #2's nurse on 12/14/23 during the 11:00 PM - 7:00 AM shift. She identified Resident #2 would wander into anyone's room but was easy to redirect. She identified she did not give Resident #2's as needed Trazodone for his/her behaviors on 12/14/23 because it was too soon to give because Resident #2 had his/her scheduled Trazodone at 9:00 PM and the order identified every 24 hours. Interview with APRN #1, psychiatric practitioner, on 12/19/23 at 11:55 AM identified Trazodone would help with Resident #2's behaviors, and she would expect staff to at least try Trazodone. She identified she saw Resident #2 prior to the event on 12/14/23 with Resident #4. She further identified Resident #2 had a history of wandering and disrobing at night and told staff to try Trazodone as needed to see if it works. If Trazodone did not work, then she would have changed Resident #2's medications. Interview and record review with the DNS on 1/12/24 at 10:30 AM identified there was no specific policy on ho was needed orders should be written, however, Resident #2's Trazodone orders were written unclearly. He identified he assumed Resident #2 had a scheduled nighttime dose ordered and the PRN for use if the nighttime dose did not work or to help Resident #2's nighttime behaviors such as insomnia. He further identified he would not be able to identify how the order should have been written because he was not the one who wrote the order. He identified APRN #2 is a newer APRN and they are learning his transcription style. Interview with APRN #2, facility practitioner, on 1/12/24 at 11:30 AM identified Resident #2 came back from the hospital with the Trazodone orders. He identified on 12/11/23 Resident #2 was prescribed Trazodone 50 mg at bedtime and Trazodone 50 mg as needed at bedtime for bipolar if Resident #2 continued to have behaviors and/or difficulty sleeping. He further identified he was not aware of Resident #2's behaviors on 12/14/23 of disrobing numerous times in other residents' rooms and disturbing the peace of the unit and identified himself or the psychiatric practitioner should have been called for a PRN dose of if it was prior to the scheduled Trazodone order time (9:00 PM). He further identified Resident #2's Trazodone orders appeared confusing how they were written. He identified the PRN dose of Trazodone should not have indicated to repeat one time as needed, there should have been a time frame of how often the medication could be administered and for what symptoms the medication was to be administered for. According to the American Nurses Association (ANA), Standards of Practice, (2021), 4th edition, Chapter 21, Part 4, The time frame the medication can be given and symptom to be administered for should be included in the physician's as needed order. Review of the medication administration policy directed that the facility staff will provide safe and accurate medication administration to the residents. It identified that the nurse reviews each resident's medication administration record to determine which medications need to be administered at a given time.

**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 three (3) residents reviewed for behaviors, (Resident #2), the facility failed to provide as needed medications in accordance with physicians orders to address behaviors. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included altered mental status, bipolar disorder and alcohol use. The admission assessment dated [DATE] identified Resident #5 was alert to person and required limited assistance with activities of daily living (ADL). The care plan dated 11/27/23 identified Resident #2 had a behavior problem and psychotic disturbances related to dementia associated with alcoholism with interventions that included to administer medications as ordered and to anticipate and meet Resident #2's needs. A nursing note dated 11/30/23 at 2:39 PM identified she was called to the unit by staff and staff reported Resident #2 pushed Resident #3. Resident #2 was placed on 1 to 1 observation and was transported to the hospital. A subsequent nursing note dated 12/1/23 identified Resident #2 returned back to the facility at approximately 4:05 AM and hospital paperwork stated Resident #2 was not a danger to self or others at the time. The care plan dated 11/30/23 identified Resident #2 was a wanderer related to disorientation to place with interventions that included to distract Resident #2 from wandering, identify patterns of wandering, monitor location every 15 minutes and document wandering behavior and attempted diversional interventions in the behavioral log. A physician's order dated 11/30/23 directed every fifteen minute checks for wandering every shift. An assessment completed by APRN #2 (Psychiatric APRN) dated 11/30/23 identified Resident #2 was alert, confused and staff reported continued wandering into other resident's rooms and sometimes got agitated with redirection. APRN #2 ordered Trazodone 50 mg (an anti-depressant/sedative medication) every 12 hours as needed for 14 days for restlessness and anxiety. Resident #2 had a nurse's note dated 12/1/23 that identified at approximately 4:05 AM the resident returned to the facility with a no harm letter. Nurse's note dated 12/3/23 and 12/4/23 identified that Resident #2 had a bowel movement on the floor of h/her room and the resident was sent to the emergency room on [DATE] for evaluation of behaviors. A nurses note on 12/11/23 at 3:00 PM identified that Resident #2 was re-admitted to the facility at 2:55 PM with a letter stating the resident was not a harm to self or others. A physician's order dated 12/11/23 directed to administer Trazodone 50 mg at bedtime related to bipolar disorder (may repeat one time as needed). A physician's order dated 12/11/23 directed Trazodone 50 mg every 24 hours as needed for bipolar (may repeat one time at bedtime). A nurse's note written by LPN # 3 dated 12/13/23 at 10:37 PM identified Resident #2 was noted to be in another resident's room with clothing off, removed brief two times and replaced without issue. A nurse's note written by LPN #1 dated 12/14/23 at 6:38 AM identified during the shift Resident #2 wandered the hallways, dining room, in other resident's room, disturbed the peace of the unit and was redirected several times with some effect. It identified Resident #2 was observed in another resident's room naked and was redirected without issue. Resident #2 attempted to wander naked into the same room a second time and was redirected back to his/her room. Resident #2 appeared to lack understanding of personal space and boundaries. A nurse's note written by LPN #4 dated 12/14/23 at 2:57 PM identified Resident #2 was noted to be restless and pacing throughout the halls during the shift. Resident #2 needed redirection throughout the shift on keeping his/her clothes on, personal space/boundaries and inappropriate touch. Resident #2 was not redirected well. An A & I dated 12/14/23 at 7:50 PM identified Resident #2 was seen pushing his/her roommate, (Resident #4), causing Resident #4 to fall to the floor. Resident #2 was placed on one to one supervision until the EMT's arrived and then transferred to the hospital. Resident #4 had complained of pain to the right wrist, X-rays were ordered and on 12/15/23 the result identified a fracture of the distal ulna and Resident #4 was transferred to the hospital with and returned with splint in place. A nurse's note written by LPN #3 dated 12/14/23 at 8:28 PM identified at 7:50 PM Resident #2 was observed pushing another resident out of the room causing them to hit the floor. The resident's were immediately separated. Resident #2 was placed on 1:1 until transferred to hospital at 9:17 PM. An assessment written by APRN #2 dated 12/14/23 identified Resident #2 continued behavior dysregulation while at the facility including disrobing and sexually inappropriate behaviors with frequent redirection. Resident #2 was sent to the hospital on [DATE] for combative behaviors at which time his/her Seroquel, Namenda and Cymbalta were discontinued. Staff reported Resident #2 was up all night and had some episodes going into other resident's rooms and PRN Trazodone was not used. APRN #2 encouraged PRN medication use as appropriate. Review of the MAR dated December 2023 failed to identify Trazodone 50 mg one tablet every 24 hours as needed was documented as administered during the dates of 12/11/23 - 12/14/23. Interview with LPN #1 on 12/18/23 at 1:50 PM identified she was Resident #2's nurse on 12/14/23 during the 11:00 PM - 7:00 AM shift. She identified Resident #2 would wander into anyone's room but was easy to redirect. She identified she did not given Resident #2's as needed Trazodone for his/her behaviors on 12/14/23 because it was too soon to give because Resident #2 had his/her scheduled Trazodone at 9:00 PM and the order identified every 24 hours. Interview with LPN #3 on 12/18/23 at 12:50 PM identified she was Resident #2's nurse on 12/13/23 during the 3:00 PM - 11:00 PM shift. Resident #2 was pleasantly confused and would be redirected back to his/her room or lounge. She identified she did not need to give him/her PRN Trazodone as Resident #2 was his/her baseline behavior with no aggression. Interview with APRN #1, psychiatric practitioner, on 12/19/23 at 11:55 AM identified Trazodone would help with Resident #2's behaviors and she would expect staff to at least try Trazodone. She identified Resident #2 had a history of wandering and disrobing at night and told staff to tray Trazodone as needed to see if it works. If Trazodone did not work, then she would have changed Resident #2's medications. Interview and record review with the DNS on 12/19/23 at 11:30 AM identified Resident #2's scheduled order and as needed order for was not clearly written causing potential confusion for LPN#1. He further identified subsequent to surveyor inquiry, he would reach out to the nursing supervisor to clarify the order. Review of the resident to resident policy directed if a resident was observed/accused of abusing another resident the facility will consult psychiatric services as needed for assistance in assessing the resident, identify the causes and developing a care plan for intervention and management as necessary or as may be recommended by the attending or interdisciplinary care planning team.

**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 three (3) residents, (Resident #2), reviewed for behaviors, the facility failed to document every fifteen (15) minute checks in accordance with the plan of care and physician's orders. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included altered mental status, bipolar disorder and alcohol use. The admission assessment dated [DATE] identified Resident #5 was alert to person and required limited assistance with activities of daily living (ADL). The care plan dated 11/27/23 identified Resident #2 had a behavior problem and psychotic disturbances related to dementia associated with alcoholism. Interventions included to administer medications as ordered and to anticipate and meet Resident #2's needs. A nursing note dated 11/30/23 at 2:39 PM identified she was called to the unit by staff and staff reported Resident #2 pushed Resident #3. Resident #2 was placed on one to one observation and was transported to the hospital. A subsequent nursing note dated 12/1/23 identified Resident #2 returned back to the facility at approximately 4:05 AM and hospital paperwork stated Resident #2 was not a danger to self or others at the time. A subsequent care plan dated 11/30/23 identified Resident #2 was a wanderer related to disorientation to place with interventions that included to distract Resident #2 from wandering, identify patterns of wandering, monitor location every 15 minutes and document wandering behavior and attempted diversional interventions in the behavioral log. A physician's order dated 11/30/23 directed every fifteen minute checks for wandering every shift. A nursing note dated 12/1/23 at 1:44 PM and 12/14/23 at 7:19 AM identified 15 minute checks were in place. A nursing note written by LPN#3 dated 12/14/23 at 8:28 PM identified at 7:50 PM Resident #2 was observed pushing another resident out of the room causing them to hit the floor. The resident's were immediately separated. Resident #2 was placed on 1:1 until transferred to hospital at 9:17 PM. The accident and incident (A & I) form dated 12/14/23 identified Resident #2 was seen pushing his/her roommate causing the roommate to fall to the floor, Resident #2 was transferred to the hospital for evaluation. A nursing note written by LPN #1 dated 12/15/23 at 4:38 AM identified Resident #2 arrived back to the facility around 3:20 AM, and continued on every 15 minute checks. Review of Resident #2's close observation checklists since 11/30/23 identified that Resident #2 only had documented fifteen minute checklists completed for 12/4/23 1:15 AM to 10:45 AM and 12/15/23 3:15 AM to 12:45 PM (The resident was on every 15 minute checks 11/30/23 through 12/4/23 when the resident was discharged to the hospital and from re-admission on [DATE] through 12/14/23). Review of the November 2023 and December 2023 Medication Administration Record identified that the nurses were signing off that the resident was on every fifteen minute checks every shift. Interview with the DNS on 12/19/23 at 1:00 PM identified Resident #2 was ordered 15 minute checks on 11/30/23 due to wandering. Although the checks were completed by staff as ordered it would be best practice would be for the staff to document on the observation document every 15 minutes. He identified the nurses sign it off on the medication administration record and communicate that with the NA's. Interview with the Administrator on 12/18/23 at 11:00 AM identified there is no fifteen minute check or 1:1 monitoring policy. He identified the facility uses the close observation checklist to document observations Although requested, a policy on direct observation and fifteen minute checks was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of facility documentation and review of video/pictures provided to the surveyor for a resident's room on one of five units (Resident #371), the facility failed to ensure that the facility was free from pests and housekeeping practices were effective. The findings include: Resident #371's diagnoses included dementia, anxiety, and legal blindness. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #371 had severely impaired cognition, and required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Review of a video and pictures from Person #1 on 11/1/23 identified resident's closet on 9/30/23 at 12:41 PM with clothes items, pair of shoes, white hospital blanket and therapy supplies (foam leg abductor and green item with velcro) laying mixed-up in a pile on the bottom of the closet and some clothes hanging above. Further observation identified in-between those items laying on the bottom of the closet were multiple mice droppings. Interview and review of the above pictures with the Administrator on 11/1/23 at 5:00 PM identified this was not acceptable. The Administrator further stated the facility completed a Grievance/Concern Form on 9/30/23 identifying Person #1 arrived at the facility to gather Resident #371's belongings and found clothes in closet crumpled in corners, dirty and covered with mouse droppings. Closet and drawers dirty and unorganized. The Administrator further identified that the facility upgraded the frequency of pest control exterminator visits at that time. In addition, when the facility emptied and cleaned out a large storage area on the ground floor, staff noted some evidence of rodents, but no major sightings were identified. Maintenance and housekeeping audited other residents' rooms and starting immediately NA's will pack resident's belongings at discharge. Interview with the Director of Maintenance and Housekeeping on 11/2/23 at 3:35 PM identified she was not aware of mice problem in Resident #371's room until 9/30/23 grievance report. The facility contracts a pest control exterminator to provide service twice a month and if needed they will come more often. The Director of Maintenance and Housekeeping further identified that during cleaning of resident rooms housekeeping duty did not include cleaning inside resident's closets and nursing was responsible to organize and keep closets with resident's belongings clean, unless the resident was discharged . Interview with RN #3 on 11/5/23 at 11:20 AM identified on 9/30/23 together with Person #1 she observed Resident #371's drawers and closet containing the resident's clothes that were unorganized and appeared possibly soiled. Further observation identified mice droppings on the resident's clothes and white blanket at the bottom of the closet. RN #3 notified the DNS and the Administrator. Interview with LPN #7 on 11/5/23 at 2:15 pm identified that a couple of weeks ago she saw a mouse running by and residents had been coming to the nursing station and saying that mice was running around in their rooms, but since then LPN #7 did not see any mice and she never saw any mice droppings. LPN #7 further identified that although she did not document in a maintenance logbook, maintenance was notified of mice activity at the facility. Review of facility Cleaning and Disinfecting Resident's Rooms policy revised on 9/6/23 identified personnel should remain alert for evidence of rodent activity (droppings) and report such findings to the Environmental Services Director. Review of Facility Pest Control policy identified the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

**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 one (1) of three (3) Residents (Resident #1), reviewed for medication administration, the facility failed to ensure a physician's order was in place to hold Resident #1's medications. The findings include: Resident #1 was admitted with diagnoses that included central cord syndrome with resultant quadriplegia, contracture of the left and right upper arm, osteoarthritis, chronic pain, atrial fibrillation, and hypertension (HTN). A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact and required extensive assistance with one (1) staff for bed mobility, extensive assistance of two (2) staff for transfer and supervision with set up help only for eating. A Resident care plan (RCP) dated 5/2/2023 identified Resident #1 had HTN and altered neurological status and to administer medications as ordered. Physician's orders dated 8/27/2023 directed to administer Apixaban (prevents clotting of the blood) tablet 5 milligrams (mg) two (2) times a day, Gabapentin (nerve pain medication) three (3) capsules three (3) times a day, Claritin (allergy pill) 10 mg daily, and Famotidine (reduces stomach acid) 20 mg one (1) tablet daily. A facility reportable event form dated 8/28/2023 identified that Resident #1 took all his medications from 3:00 PM to 11:00PM (Metoprolol 50 mg, Baclofen tablet 10 mg and Gabapentin 300mg, dietary supplements and vitamins) and the prescribed 6:00 AM medications (Metoprolol 50 mg, and Gabapentin 300mg) at once. The 3:00 PM to 11:00PM medications had been left at Resident #1's bedside by the 3:00PM to 11:00 PM nurse (LPN #2). Interview with RN #1 (Unit manager) and review of Resident #1's medication administration record (MAR) on 9/13/2023 at 2:00 PM identified that LPN #3 notified her on 8/28/2023 that Resident #1 had told her that he/she had taken his/her evening medications and night medications at the same time earlier that morning. Resident #1 was alert and oriented and was displaying symptoms such as low blood pressure and some lethargy that led her to believe Resident #1's statement. RN #1 contacted the APRN and the physician who directed Resident #1 to be transferred to the hospital emergency department and to monitor Resident #1 every 15 minutes for 1 hour. Resident #1 refused the transfer, and the physician was updated. In review of Resident #1's MAR, she identified that LPN #3 had documented that she had held Resident #1's 8:00AM Gabapentin 300mg, give 3 capsules and the 9:00 AM doses of Apixaban 5 mg, Claritin 10 mg and Famotidine 20 mg as well as 9:00 AM scheduled dietary supplements and vitamins. RN #1 continued that she was unaware that LPN #3 had held medications and that a physician's order would have been required. Both MD #1 and APRN #1 did not direct to hold any of Resident #1's medications on 8/28/2023. Interview with LPN #3 on 9/19/20 at 11:38 AM identified that she was assigned to Resident #1 on 8/28/2023 when at approximately 8:00 AM a Nursing Assistant reported that Resident #1 was not feeling well. When she went to evaluate Resident #1, Resident #1 reported that he/she had taken the evening medications left at the bedside at around 5:00 AM and then took the 6:00 AM medications when the 11:00PM to 7:00 AM provided them at 6:00 AM stating he/she had overdosed. Resident #1 appeared lethargic with slow speech with BP 80/50, supervisor and APRN notified. She continued that she decided to hold Resident #1's 8:00AM and 9:00 AM medications as a nursing measure and she did not notify RN #1, APRN #1 or MD #1 that she had done so. Interview with Assistant Director of Nurses (ADNS) on 9/19/2023 at 1:00 PM identified that a physician's order was required to hold prescribed medications and that the physician should be notified if a nurse identified that based on a Resident's assessment, a need to hold medications would be necessary. The nurse should review each medication with the physician and the physician would determine if the medication should not be given. He was unaware that LPN #1 had held Resident #1's morning medications on 8/28/2023 and could not explain why LPN #1 would do so without a physician's order. The Director of Nurses (DON) was unavailable for interview during the survey. The facility's administration of medication policy dated July 2012, directs in part, that it should guide a safe and timely practice of administration of medications.

**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 one (1) of three (3) Residents (Resident #1) reviewed for medication administration, the facility failed to ensure the safe storage of a prescribed medication. The findings include: Resident #1 was admitted with diagnoses that included central cord syndrome with resultant quadriplegia, contracture of the left and right upper arm, osteoarthritis, chronic pain, atrial fibrillation, and hypertension (HTN). A medication self-administration evaluation completed 1/2/2022 identified that Resident #1 was not able to self-administer medications. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact and required extensive assistance with one (1) staff for bed mobility, extensive assistance of two (2) staff for transfer and supervision with set up help only for eating. A Resident care plan (RCP) dated 5/2/2023 identified Resident #1 had HTN and altered neurological status and to administer medications as ordered. Physician's order dated 8/27/2023 directed to administer Apixaban (prevents clotting of the blood) tablet 5 milligrams (mg) two (2) times a day, Baclofen (muscle relaxant the decreases muscle spasms) tablet 10 mg three (3) times a day, Gabapentin (nerve pain medication) three (3) capsules three (3) times a day and Metoprolol (decreases blood pressure) 50 mg two (2) times a day. Resident #1's August 2023's Medication Administration Record (MAR) identified the following: Apixaban 5 mg to be administered at 5:00 PM Baclofen tablet 10 mg to be administered at 6:00 PM Gabapentin 300 mg, give 3 capsules at 6:00 AM and 10:00 PM Metoprolol 50 mg to be administered at 6:00 AM and 6:00 PM A facility reportable event form dated 8/28/2023 identified that Resident #1 took all his medications from 3:00 PM to 11:00 PM and the prescribed 6:00 AM at once. The 3:00 PM to 11:00 PM medications were left at the bedside and Resident reports not feeling well, the residents Blood pressure (BP) 80/50, Heart Rate (HR) 77, Respirations 20 with oxygen saturation on room air at 97 %. The physician was notified and directed to transfer Resident #1 to the hospital emergency room and to monitor vital signs every 15 minutes for 1 hour. Resident #1 refused transfer, and the physician was notified. A facility statement by LPN #2 dated 8/29/2023 identified that between 9:30 PM and 10:00 PM on 8/28/2023, he entered Resident #1's room to provide evening medications. Resident #1 had been out on LOA until approximately 7:00 PM. He woke Resident #1 to provide his/her medications and asked if Resident #1 needed help to take them. Resident #1 responded no, and LPN #2 left the medications and water within reach and left Resident #1's room. Interview with RN #2 (Regional nurse) on 9/12/2023 at 10:30 AM identified that she assisted in the investigation, and it was determined that LPN #2 had left the 8/27/2023 evening medications at Resident #1's bedside. Resident #1 had taken the medications when he/she discovered them on the bedside table in the early morning on 8/28/2023 and also took his/her 8/28/2023 6:00 AM medications . She identified that LPN #2 thought it was appropriate to leave the medications for Resident #1's bedside. Interview with LPN #1 on 9/13/2023 at 9:06 AM identified that she was assigned to Resident #1 on the 11:00 PM to 7:00 PM shift on 8/27/2023 and had provided Resident #1 with his/her scheduled 6:00 AM Metoprolol 50 mg and Gabapentin 300 mg as per physician's order on 8/28/2023. Interview with RN #1 (Unit manager) and review of Resident #1's medication administration record (MAR) on 9/13/2023 at 2:00 PM identified that LPN #3 notified her on 8/28/2023 that Resident #1 had told her that he/she had taken his/her evening medications and night medications at the same time earlier that morning, Resident #1 could not recall how many pills were in the medication cup that was left at the bedside but reported that when he/she woke up at around 5:00 AM, he/she took them. When the night nurse (LPN #1) came in and provided the 6:00 AM medications, he/she just took them and did not say anything about just taking his/her evening medications (Metoprolol 50 mg, Baclofen tablet 10 mg and Gabapentin 300 mg, dietary supplements and vitamins were scheduled to given on the 3:00 PM to 11:00 PM shift). LPN #1 and LPN #2 had signed that they had administered the medications in the MAR as scheduled on 8/27/2023 and 8/28/203. Resident #1 was alert and oriented and was displaying symptoms such as low blood pressure and some lethargy that led RN #1 to believe Resident #1's report. RN#1 contacted the APRN #1 and MD #1 who directed to transfer Resident #1 to the hospital emergency department and to monitor Resident #1 every 15 minutes for 1 hour. Resident #1 refused the transfer, and she updated MD#1. Interview with LPN #3 on 9/19/20 at 11:38 AM identified that she was assigned to Resident #1 on 8/28/2023 when at approximately 8:00 AM when a Nursing Assistant reported that Resident #1 was not feeling well. When she went to evaluate Resident #1, Resident #1 reported that he/she had taken the evening medications left at the bedside at around 5:00 AM and then took the scheduled 6:00 AM medications when the 11:00 PM to 7:00 AM provided them that [NAME]. Resident #1 appeared lethargic with slow speech with BP 80/50 and she notified the Unit Manager (RN #1) and APRN #1. Interview with RN #2 on 9/19/2023 at 10:00 AM identified that subsequent to the investigation of Resident #1's 8/28/2023 incident, the facility provided education on medication management, medication administration and medication security and storage for all licensed staff. Random weekly medication pass audits were completed by 9/12/2023. Interview with Assistant Director of Nurses (ADNS) on 9/19/2023 at 1:00 PM identified that it was inappropriate for LPN #2 to leave Resident #1's 3:00 PM to 11:00 PM medications at the bedside and it was his expectation that LPN #2 would stay with the Resident until the medications were taken. He did not know why LPN #2 left the medications at the bedside, but LPN #2 was responsible to administer medications as per facility policy. Attempts to contact LPN#2 were unsuccessful. The Director of Nurses (DON) was unavailable for interview during the survey. The facility's self-administration of medication policy dated 2016, directs in part, identified that the Interdisciplinary Care team determines, with whether self-administration of medications is safe. The facility's administration of medication policy dated July 2012, directs in part, that a physician's order is needed for self-administration or medications that are kept at the bedside. And that all medications are administered by or under the direct supervision of licensed medical or nursing personnel. The facility's medication storage policy, dated 2/2009, directs in part, that all medications except the emergency drug kit, will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy. The facility failed to store and administer Resident #1's 8/27/2023 3:00 PM to 11:00 PM medications as per facility policy leading Resident #1 to take the 8/27/2023 3:00 PM to 11:00 PM medications and receive his/her 8/28/2023 6:00 AM medications within an hour's timeframe that included Gabapentin 300 mg,and Metoprolol 50 mg.