**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 #1) reviewed for accidents, the facility failed to ensure a safe Hoyer lift (mechanical lift) transfer for a resident, due to environmental constraints that impeded stabilization of the Hoyer lift's legs, resulting in the resident being struck in the head by the Hoyer lift arm. The findings include: Resident #1's diagnoses included atrial fibrillation (irregular heart rate), neuropathy (nerve damage causing weakness, numbness and pain), right hand contracture, muscle wasting and atrophy (decreasing in size) and adjustment disorder (excessive reaction to stress that causes negative thoughts, emotions and behavioral changes). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required substantial assistance with bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 3/3/25 identified Resident #1 bumped his/her forehead on the Hoyer lift arm. Interventions included providing three (3) staff to assist with mechanical lift transfers as needed. A nurse's note dated 3/3/25 at 7:30 AM identified that RN #1 was paged to Resident 1's room for reports that Resident #1 bumped his/her forehead on the Hoyer lift arm. The note identified that Resident #1 was alert and oriented, reported discomfort to the area which later resolved, denied a headache or dizziness and neurological vital signs were within normal limits. The note identified that a bump with redness was noted, the Advanced Practice Registered Nurse (APRN) was notified and a new order was obtained to ice the area every two (2) hours as needed for 24 hours. The facility Accident & Investigation (A & I) report dated 3/3/25 at 7:30 AM identified that Resident #1 bumped his/her head on the arm of the Hoyer lift during a transfer in his/her room and sustained a bump to his/her mid forehead and bruising to both eyes The report identified that the APRN was notified and new orders were obtained to apply ice to the area as needed for 24-hours and to hold Eliquis (blood thinner medication) for three (3) days. The report identified that NA #2 and NA #3 witnessed the incident, performed a reenactment with RN #1 (day shift supervisor), and Hoyer lift transfer reeducation was provided at that time. An APRN note dated 3/3/25 at 9:30 AM identified that Resident #1 was evaluated for a head contusion after an incident that morning during a Hoyer lift transfer where he/she hit their forehead, between the eyes, into the Hoyer lift, and staff reports of a small hematoma. The note identified that upon evaluation, Resident #1 was aware of the bump, was icing his/her forehead, reported having a mild headache and was administered tramadol with good effect. Resident #1 was noted to have worsening ecchymosis (discoloration of the skin caused by blood leaking from broken blood vessels into the surrounding tissue) around the eyes but denied dizziness, nausea, vomiting or chest pain and remained alert and oriented to person, place and time. The note identified that Resident #1 had no signs and symptoms of neurological changes and that they would continue ice as ordered and hold Eliquis for the next 48-hours. The note indicated that if Resident #1 presented with significant mental status changes, he/she would be sent to the Emergency Department (ED) for a possible CAT scan (x-rays that are used to create detailed cross-sectional images of the body) or evaluation. A physician's order dated 3/3/25 directed to apply ice to forehead 20-minutes on and 20-minutes off every two (2) hours as needed for one (1) day. A physician's order dated 3/3/25 directed to hold Apixaban (Eliquis) 2.5 milligram (mg) oral tablet twice daily from 3/3/25 to 3/5/25. Review of nurse's notes from 3/3/25 through 3/4/25 identified no notable neurological changes or complaints. A nurse's note dated 3/5/25 at 11:14 AM identified Resident #1 was assessed after reporting a headache with ten (10) out of 10 pain (severe). The note identified Resident #1 denied dizziness or double vision and neurological checks were within normal limits. The APRN was notified, and a new order was obtained to transfer Resident #1 to the ED for evaluation. The hospital Discharge summary dated [DATE] identified Resident #1 was admitted to the hospital from [DATE] through 3/7/25 with worsening tachycardia (faster than normal heart rate) which was likely due to headache and recent head injury and further identified that a head CT scan was completed, and a brain bleed was not seen on imaging. Interview with LPN #1 (day shift charge nurse on 3/3/25) on 3/26/25 at 10:38 AM identified that NA #2 and NA #3 reported when they pulled Resident #1 back with the Hoyer lift pad to position him/her over the shower chair, the Hoyer lift tilted sideways and struck Resident #1 on the forehead. LPN #1 identified Resident #1 initially said he/she was fine and he/she appeared to be at baseline, so NA #2 and NA #3 showered Resident #1 per his/her request. LPN #1 identified that, after the shower, visible bruising was noted to his/her forehead that spread to both eyes. LPN #1 identified that the APRN assessed Resident #1 shortly after and gave an order to apply ice to the area. Interview with RN #1 on 3/26/25 at 11:21 AM identified that Resident #1, NA #2 and NA #3 reported that when Resident #1 was turned in the Hoyer lift to be positioned to sit in the shower chair, the Hoyer lift started to tip sideways, and the arm of the lift struck Resident #1 on the forehead. RN #1 identified that Resident #1 initially complained of pain from the impact, had a bump and redness above the bridge of his/her nose, and she requested the APRN evaluate Resident #1 right away. Interview with NA #2 on 3/26/25 at 11:28 AM identified that on 3/3/25, NA #3 and herself placed the Hoyer pad under Resident #1, attached the pad to the hooks of the Hoyer pad, covered Resident #1 with a blanket and lifted Resident #1 into the air. She identified that due to space constraints, the large shower chair was positioned in the doorway because it did not fit next to the bed with the Hoyer lift. NA #2 identified that NA #3 pushed Resident #1 from his/her window bed in the Hoyer lift, past Resident #2 (roommate) to the shower chair positioned between Resident #2 and the doorway of the room. NA #2 identified that she was inside the room behind the back of the shower chair and NA #3 was controlling the Hoyer lift and then she (NA #2) pushed the shower chair in between the Hoyer lift legs, locked the shower chair, and NA #3 began to lower Resident #1. She reported that she pulled the Hoyer lift pad slightly from behind to position Resident #1 over the shower chair and as she did that, the Hoyer lift tipped to its side and struck Resident #1 on the forehead. NA #2 identified the incident happened fast, and although she was unable to fully see if the Hoyer lift legs were completely opened, due to where she was positioned behind Resident #1, she indicated she was able to push the shower chair forward between the Hoyer lift legs so she assumed the Hoyer lift legs were completely open for stabilization. NA #2 identified that she never worked with NA #3 prior to the 3/3/25 incident but reported that she had given Resident #1 numerous showers in the past and had never had an issue with the Hoyer lift tipping before. Additionally, she identified that they used the regular Hoyer lift (not bariatric) to transfer Resident #1. Interview with the DNS on 3/26/25 at 11:41 AM identified that although she was unable to determine how or why the Hoyer lift tipped and struck Resident #1 on the forehead, she reported that if the staff operated the lift correctly, it should not have tipped. Further, she identified that when NA #2 and NA #3 redemonstrated the transfer with Resident #1, they demonstrated it correctly with no issues. Observation on Resident #1's unit on 3/26/25 at 11:45 AM identified one Hoyer lift in the shower room. Review of the manufacturer's guidelines for the Hoyer lift provided by the Administrator identified a weight capacity of up to 500 pounds. Review of the clinical record identified Resident #1's weight was 228 pounds on 3/3/25. Observation and interview with Resident #1 on 3/26/25 at 11:49 AM identified dark discoloration under both eyes. Resident #1 identified that on 3/3/25, the NA's hooked him/her up to the Hoyer lift and pushed him/her to the shower chair, by the door, and when they went to lower him/her, the Hoyer lift tipped and struck him/her in the head. Resident #1 identified his/her head hurt but he/she still wanted to be showered. Resident #1 identified he/she has had intermittent headaches since the incident. Interview with NA #3 on 3/26/25 identified that he was employed by an agency and had never met Resident #1 prior to the 3/3/25 incident. He identified that NA #2 was present during Resident #1's Hoyer lift transfer and indicated he pushed Resident #1, in the Hoyer lift, to where the shower chair was positioned by the doorway, because there was not enough space on Resident #1's side of the room to fit both the Hoyer lift and shower chair. He identified that Resident #2's (roommate) bed side table was in the way and when he asked Resident #2 to move it, Resident #2 barked at him and told him not to touch his/her stuff. NA #3 identified that although the space was tight and the bedside table was too close to the area they were transferring Resident #1 in, he opened the Hoyer lift legs as much as he could. NA #3 identified he was facing the room door and the Hoyer lift leg, on his right side, was against the long wall opposite the bathroom door. NA #3 indicated the position of the Hoyer lift prevented the Hoyer lift legs from opening completely. He identified that as they started to lower Resident #1 onto the shower chair, the Hoyer lift started to tip and Resident #1's forehead swung into the arm of the Hoyer lift. NA #3 identified they were able to keep the Hoyer lift from completely falling over, as it fell against the long wall and he used the emergency release on the Hoyer lift to slowly lower Resident #1 into the shower chair. NA #3 identified the battery on the Hoyer lift was charged but he used the emergency release to enable more control and get the Hoyer lift back on both legs. He identified that the Hoyer lift tipped over due to not having enough space to open the Hoyer lift legs. Re-interview with NA #2 on 3/26/25 at 12:41 PM identified that it is difficult to transfer Resident #1 onto the shower chair due to performing the transfer partially on Resident #2's side of the room. She reported that she could not recall exactly what was in the way at the time of Resident #1's transfer, but identified that Resident #2 does not want his/her stuff touched. Re-interview with the DNS on 3/26/25 at 2:08 PM identified that she was unaware that staff were having difficulty maneuvering both the Hoyer lift and the large shower chair in Resident #1's room and that they were having to push Resident #1 in the Hoyer lift to the area between Resident #2 and the doorway to the room. She identified that the staff should not have transferred Resident #1 with the Hoyer lift if the environment was not clear of hazards and if there was not enough space to open the Hoyer lift legs completely. Review of the Mechanical Lift policy dated 01/2023 directed, in part, that the base legs of the lift will be locked in the maximum open position. The base legs must be always locked for stability and resident safety when lifting and transferring a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation review, facility policy review, and interviews for one of three residents (Resident #4) who were reviewed for an allegation of abuse, the facility failed to report an allegation of abuse to the Director of Nursing or Administrator and State Agency within two (2) hours after the incident occurred. The findings include: Resident #4's diagnoses included Alzheimer's disease, vascular dementia, hemiplegia and hemiparesis following cerebral infarction, post traumatic stress disorder, and anxiety disorder. The Resident Care Plan (RCP) dated 8/19/24 identified Resident #4 has the potential to be verbally abusive by making accusatory statements regarding care. Interventions include psychiatric/psychogeriatric consults as indicated. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Provide positive feedback for good behavior and emphasize positive aspects of compliance. The significant change in condition Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had some difficulty making decisions regarding tasks of daily life, required was extensive assistance of two (2) with bed mobility, toilet use, and transfers, and exhibited physical behaviors towards others. The Facility Reported Incident and Summary Form identified on 9/20/24 at 11:40 AM Resident #4 reported to the Recreation Assistant that he/she was afraid of was a afraid of a nurse aide, Nurse Aide (NA) #3, and alleged that NA #3 hit him/her. The report indicated NA #3 was immediately removed from the floor, the local town police were called, NA #3 was placed on administrator leave pending the investigation, psych and social services followed up with Resident #4. Review of a written statement by NA #3 on 9/20/24 identified today at breakfast time, NA #3 saw Resident #4 lying down in bed with his/her breakfast tray on the bedside table. NA #3 asked NA #4 (who was already in Resident #4's room assisting the roommate) to help assist with a boost. As NA #3 walked into the room, Resident #4 became aggressive and calling NA #3 curse words and belittling her intelligence, including to stating, you hurt me. NA #3 indicated she wasn't even at the bedside yet prior to the abuse allegation. NA #3 and NA #4 continued with care and provided the boost for Resident #4, as Resident #4 continued to attempt to punch and hit NA #3. NA #3 identified once Resident #4 was appropriately positioned and settled, she immediately reported the allegation of abuse to the charge nurse, Licensed Practical Nurse (LPN) #3 but was brushed off. Later in the shift, NA #3 asked Resident #4 if he/she would like to get washed up for the day, to which he/she replied, I'm ready when you are. NA #3 asked NA #5 to help assist with bathing, and during care, Resident #4 became agitated again and threw the washcloth over NA #3's head and punched and hit NA #3. NA #3 and #5 were able to redirect Resident #4 enough to place a new brief and Hoyer pad underneath him/her, during the Hoyer transfer, Resident #4 began to shout, help me x 4, which NA #3 expected LPN #3 to come by and see the commotion, since the allegations and behaviors were reported earlier, but LPN #3 did not come by. Once the transfer was complete, NA #3 once again reported the allegations and behaviors to LPN #3, but she did not get any response or reaction from LPN #3. NA #3 continued with the shift and documented all behaviors. Review of the written statement by NA #4 on 9/20/24 identified she was Resident #4's room assisting the roommate, when NA #3 requested assistance with a boost for Resident #4. Prior to starting care and during care, Resident #4 yelled at NA #3, and then stated, you hurt me, once finished with care, NA #4 reported the allegation to LPN #3. Interview with NA #3 on 10/10/24 at 10:35 AM identified on 9/20/24, Resident #4 was agitated at breakfast time, which NA #3 asked NA #4 for assistance during care. NA #3 explained before starting care, Resident #4 was alleging I was hurting him/her and once care was provided both she and NA #4 reported the allegation and behaviors to LPN #3 between 8:00-8:30 AM. NA #3 identified LPN #3 did not question and pursue anything further at that time, and NA #3 continued with the day. NA #3 indicated later in the shift, she and NA #5 assisted Resident #4 out of bed with a Hoyer lift transfer, and during this process, Resident #4 once again alleged NA #3 was hurting him/her and she again reported the incident to LPN #3 at approximately 9:30-10:00 AM, which there was no response too. NA #3 identified at approximately 12:30 PM, she was taken off the floor pending an investigation. Interview with NA #5 on 10/10/24 at 10:50 AM identified herself and NA #3 were assisting Resident #4 with a Hoyer lift transfer and during the transfer, Resident #4 was alleging that NA #3 was hurting him/her, and once finished she reported the abuse concerns to LPN #3. NA #5 believes LPN #3 reported the allegations to the Nursing Supervisor afterwards. Interview and review of the facility reported incident investigation with the Director of Nursing (DON) on 10/10/24 at 11:30 AM identified the allegation of abuse was reported timely upon notification by the Recreation Assistant. The DON identified the Assistant Director of Nursing (ADON) performed the investigation and she did not review the written statement by NA #3 and after reviewing the written statements, she verified the allegation of abuse should have reported immediately by either NA #3 or LPN #3 at the first occurrence/allegation to the Nursing Supervisor. The DON identified allegations of abuse are to be reported to the State Agency within two (2) hours. Although attempted, interview with LPN #3 and NA #4 was not able to be obtained. Review of the CMS (Centers for Medicare/Medicaid Services) Interpretive Guidelines for abuse identified alleged violations of abuse or if there is resulting serious bodily injury, the facility must report the allegation immediately, but no later than two (2) hours after the allegation is made. For alleged violations of neglect, exploitation, misappropriation of resident property, or mistreatment that do not result in serious bodily injury, the facility must report the allegation no later than 24 hours. Review of the Abuse, Neglect, and Exploitation Policy dated 02/2023 identified 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. Under Reporting/Response, identified the facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies (e.g., law enforcement when applicable) within the specified timeframes. 1a. Immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who required staff supervision during meals due to dysphagia (difficulty with swallowing) and non-compliant with following the plan of care, the facility failed to ensure the resident's safety when the nurse aide left the resident unsupervised in the room and failed to inform the nurse that the resident refused meal supervision. The findings include: Resident #2's diagnoses included dysphagia, aphasia, traumatic brain injury, and right sided hemiplegia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had some difficulty in new situations, required staff supervision with eating and was dependent with all other daily living skills and was on a mechanically altered diet. The Resident Care Plan dated 9/12/24 identified Resident #2 had dysphagia, was at risk for aspiration, and often refused to be supervised during meals. Interventions directed a regular, mechanical soft diet ground texture with thin liquids, aspiration precautions, continuous supervision with eating, small bowls for meals, cue resident to eat at a slow rate, provide a teaspoon only, inform resident of risks of non-compliance with supervision, provide education on dietary restrictions, and notify nursing staff if resident refuses supervision. Review of the August 2024 physician orders identified an order initiated on 11/29/23 that directed Resident #2 be on a regular mechanical soft ground texture, thin liquid diet with aspiration precautions, continual supervision with eating, and meals in small bowls, to provide a teaspoon utensil only, no soup spoon and may have regular consistency chips, hard cookies, or peanut butter crackers. The nurse's note dated 9/23/24 at 7:31 PM identified the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #2 was in the hallway and heard a cough with a high pitch sound. The note indicated when LPN #2 entered Resident #2's room she noted the Resident #2's eyes were watery and Resident #2 was performing the universal choking sign. The note identified LPN #2 yelled for a nurse aide to call for assistance and began performing the Heimlich maneuver while encouraging the resident to cough. The nurse's note dated 9/23/24 at 7:44 PM identified the Assistant Director of Nursing (ADON) was called to the unit at 6:15 PM and when she entered Resident #2's room LPN #2 was performing the Heimlich maneuver, Resident #2 remained alert, and although no food visibly passed with the Heimlich, Resident #2's airway cleared. The Advanced Practice Registered Nurse (APRN) note dated 9/23/24 identified Resident #2 was seen due to active choking and upon arrival nursing staff was performing the Heimlich maneuver, Resident #2 was able to drink a glass of water and resumed normal breathing and did not appear to be in acute distress and swallowed the food. The note indicated Resident #2 had a history of noncompliance with getting out of bed to eat meals and supervision during meals. The note identified a chest x-ray was not taken due to the lungs sounds being normal, and staff to monitor vital signs, oxygen levels and lung sounds over the next twenty-four (24) to seventy-two (72) hours. The nurse aide care card identified Resident #2 required supervision when eating. The Speech Language Pathologist (SLP) note dated 9/24/24 identified the SLP recommended Resident #2's diet be downgraded to a pureed diet due to Resident #2 being at risk for aspiration and frequent refusals to allow staff to supervise during meals. A written statement dated 9/23/24 by the 3-11PM nurse aide, Nurse Aide (NA) #2, that was assigned to Resident #2 identified when she went in to Resident #2's room to assist Resident #2, Resident #2 pointed to the door for her to leave the room. NA #2 indicated she positioned Resident #2 in the bed in an upright position to eat dinner prior to leaving the room. NA #2 identified she did not inform the charge nurse that Resident #2 refused to be supervised while eating. An interview with the Assistant Director of Nursing (ADON) on 10/15/24 at 12:09 PM identified if a resident that required supervision for eating refused supervision, it was the responsibility of the nurse aide to inform the nurse so the nurse could speak with the resident, and the nurse would then follow proper protocol if the resident continued to refuse and notify the MD. The ADON identified NA #2 did not follow physician's order to notify the nurse that Resident #2 refused meal supervision on 9/23/24. An interview with LPN #2 on 10/15/24 at 1:20 PM identified she was working on 9/23/24 and heard the resident coughing while she was in the hallway passing medications. LPN #2 indicated she noted Resident #2 using the universal sign for choking, called for assistance and began the Heimlich maneuver. LPN #2 identified when the Nursing Supervisor arrived, and she took over doing the Heimlich and Resident #2 returned to baseline. LPN #2 identified she was not informed by NA #2 that Resident #2 refused to be supervised during the dinner meal and the nurse aides are responsible to inform the nurse if Resident #2 refused care and then the nurse would follow protocol and speak to Resident #2. Review of the facility policy Feeding the Resident identified the steps involved in feeding a dependent resident The policy did not address steps to take if a resident refused assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for mistreatment, the facility failed to ensure resident was treated with respect. The findings include: Resident #1's diagnoses included Alzheimer's and left sided hemiparesis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had moderate cognitive impairment and was dependent for toileting, ADLs, transfers, and independent with manual wheelchair use. The Resident Care Plan (RCP) dated 6/24/2024 identified Resident #1 required assistance with ADLs. Interventions directed encourage independent mobility in wheelchair, assist if needed and give the resident sufficient time to accomplish each task. Review of nurse aide care card directed dependent with wheelchair use. Review of Facility Reportable Event Form dated 7/3/2024 at 2:30 PM identified the hairdresser reported a NA pushing Resident #1 quickly down the hallway, and Resident #1 wanted the NA to slow down. The NA pushed Resident #1's wheelchair into the resident's room and Resident #1's hand got stuck between wheelchair wheel and door frame. Redness was noted to the left hand, and a new order was obtained for an x-ray. Review of facility indicated summary (titled Final Report) dated 7/8/2024, identified when NA #1 was pushing Resident #1 quickly in his/her wheelchair, the NA turned into Resident #1's room and Resident #1's hand hit the doorframe causing the resident to call out. The summary identified the x-ray was negative. Facility investigation identified although Resident #1 had requested NA #1 to slow down, NA #1 continued to push the wheelchair quickly. Interview and facility documentation review on 7/22/2024 at 11:04 AM with NA #1 identified that on 7/3/2024 around 2:30 PM, Resident #1 was in his/her wheelchair in the middle of the hallway when the laundry staff was trying to get by. NA #1 stated Resident #1 was trying to wheel him/herself down the hallway and then just completely stopped. NA #1 indicated that she and another NA asked Resident #1 to move his/her chair, but he/she did not, and NA #1 then pushed the resident at a regular speed as she would push any other resident and Resident #1 did not ask her to slow down. NA #1 stated she assumed Resident #1's hand got caught between the wheelchair and doorframe when Resident #1 said ow and Resident #1 stated he/she was o-[NAME]. Interview, clinical record review, and facility documentation review with the DNS on 7/22/2024 at 1:18 PM identified NA #1 should have slowed down when Resident #1 requested and should have been careful going through the doorway to prevent hitting his/her hand. Review of facility Residents' [NAME] of Rights directed in part, you (resident) have the right to be treated with consideration, respect and full recognition of your dignity and individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review of policy and interviews for 1 of 8 residents (Resident # 49) reviewed for Advanced Directive, the facility failed to provide evidence of the resident's complete and signed DNR wishes / code status form and failed to ensure a physician signed the resident's code status. The findings include: Resident #49's diagnoses included: dementia, neurological disease, and dysphagia (difficulty with swallowing). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as severely cognitively impaired, dependent for bathing, dressing, personal hygiene and toilet use, substantial/maximal assist of one with sit to lying and lying to sit on side of bed, eating and receiving a special service program. A physician's order dated [DATE] directed code status full code and remained an active order. A physician's order dated [DATE] directed code status Do Not Resuscitate (DNR), Do Not Intubate (DNI), Do Not Hospitalize (DNH), no laboratory bloodwork, no feeding tube. A Social Worker's (SW) progress note dated [DATE] indicated a significant change in condition and noted the resident was now receiving specialized care services. A Resident Care Plan (RCP) [DATE] revised on [DATE] indicated Resident #49 had an advanced directive. Interventions included do not administer Cardiopulmonary Resuscitation (CPR). On [DATE] at 12:29 PM review of clinical record and observation with Licensed Practical Nurse (LPN # 1), identified Resident #49 has been on specialized care services since [DATE], and the resident's facility hard chart copy record did not contain resident or resident representatives advanced directive wishes for code status. Interview with resident's representative on [DATE] at 12:31 PM identified Resident #49's code status was DNR (Do Not Resuscitate). On [DATE] at 12:33 PM interview and record review with Registered Nurse (RN #11) identified Resident #49's facility clinical record and the specialized services providers' communication book did not contain a copy of the Advanced Directives Declaration Code Status, Advanced Directives Declaration of Health Care Wishes, or verification of Do Not Resuscitate (DNR) order. RN #11 was able to provide forms from the specialized services provider. However, all 3 forms were signed by the responsible party but not signed by a physician. On [DATE] at 2:00 PM RN #11 provided a signed copy of the specialized services providers' Advanced Directives Declaration form, indicating code status and the Verification of DNR Order but was unable to provide the facility's completed and signed DNR wishes/code status form. Interview on [DATE] at 11:00 AM with the Director of Nursing Services (DNS) identified the specialized services provider recommendations are communicated at times verbally by stopping by the supervisor's office, and the special services' meeting minutes. She further indicated that supervisors put in minutes after the meeting and communicate with the facility's provider. Review of facility policy annually reviewed [DATE] titled Withholding and Withdrawal of Life Sustaining Treatment notes the policy of this facility is to provide, to the fullest extent possible, for each resident's physical, emotional, and social wellbeing in a safe and secure environment. This includes the provision of life sustaining medical treatment available in the long-term care setting. We respect the rights of the capable resident who is in a terminal condition to refuse life sustaining treatment including artificially supplied nutrition and hydration. It is also the policy of this facility to honor a resident's advance directives where the resident is incapacitated and unable to make sure determinations. This applies to withholding and withdrawal of life sustaining treatment only where a terminal condition and/or a permanent state of unconsciousness exists, as defined by the law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy, facility documentation and interviews for 1 of 4 residents ( Resident # 134) reviewed for Abuse, the facility failed to ensure the resident was free from physical abuse. The findings include : Resident #134's diagnoses included depressive episodes and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #134 was cognitively intact and was independent with transfer and ambulation. A nursing progress note dated 10/22/2023 at 12:48 PM by the RN supervisor indicated the resident had sustained a hematoma below the right eye with slight redness to the sclera and inner canthus bumping it on the bathroom door on the 11-7 AM shift, denied headache or dizziness ice compress applied Advanced Practice Registered Nurse (APRN) and family updated by the charge nurse. A physician's order dated 10/22/23, no time, with end date of 10/23/2023 at 11:59 PM directed to apply ice compress to hematoma below eye for 10 minutes every shift. A nursing progress note dated 10/22/2023 at 3:45 PM indicated in part while administering medication on the 7-3 PM shift, the nurse noticed Resident #134 had bruising and redness to the right eye and bleeding to the sclera. When Resident #134 was asked how the injury happened, the resident reported s/he had awoken around 5-6 AM to go to the bathroom and hit her/himself in the face with the door by accident as it was dark. The supervisor, family and medical provider were notified. A Nursing Post Event Progress Note dated 10/26/2023 at 10:17 PM indicated at 7:45 PM a family member of Resident #134 visited resident and reported to the RN supervisor Resident #134 indicated being punched in the face by roommate ( Resident # 85 ) due to loud music at 5:00 AM on 10/22/2023 and denied hitting face on the door as previously reported on 10/22/2023 sustaining a hematoma below the right eye. The note further indicated the residents were immediately separated the APRN was notified along with the responsible party. The state agency report dated 10/26/2023 indicated first knowing of incident at 8:00 PM. A report was received by the state agency at 8:43 PM which indicated this was an isolated incident, a room change was completed, psychiatric services, medical and social work were to follow up with both residents involved (Resident #134 and roommate (Resident # 85 .) The care plan dated 10/27/2023 identified Resident #134 had a resident-to-resident altercation with roommate ( Resident # ) initially indicating he/she had walked into a door sustaining the facial injury not wanting to get the roommate ( Resident # 85 ) in trouble. Interventions included to encourage to express feelings of worry, fear and anxiety as needed to the social worker, charge nurse and other caregivers, to provide support and reassurance as needed, to provide psychiatric services and social services for support and reassurance as needed and the roommate (Resident # 85) ( was transferred to an alternate wing/room. A care plan progress note dated 10/27/203 at 9:28 AM written by SW#2 indicated visiting Resident #134 regarding the incident of being struck on 10/22/2023 by the roommate ( Resident # 85). The note further indicated the roommate (Resident # 85) admitted not only hitting Resident #134 on 10/22/2023 but had hit Resident #134 in the past as well. Interview and clinical record review with SW #2 on 1/5/2023 at 2:08 PM identified s/he thought he/she had reported the verbalization of the past occurrence of hitting roommate (prior to the reported incident of 10/22/2023) to the DNS or during morning report. SW # 2 indicated 10/27/2023 9:28 AM was the first time SW#2 became aware of the prior abuse toward Resident #134(13.5 hours after the 10/22/2023 abuse incident was reported to the state agency). SW#2 further indicated his/her responsibility when becoming aware of alleged abuse is to report immediately to the DNS or administrator. Interview and record review (Resident #134 and Resident 85 # ) with the DNS on 1/8/2023 at 8:58 AM indicated not being aware of SW#2's notes on 10/27/2023 indicating the roommate ( Resident # 85) admitted striking Resident #134 in the past but hit harder this time. A review of psychiatric and psychiatric social worker notes prior to and after the known incident date of 10/22/2023 identified no indication psychiatric services staff were aware of Resident #134 having been abused even though providing psychiatric services after the abusive incident was part of the facility plan related to the reported incident. An interview and record review on 1/8/2023 at 10:26 AM with SW#3 identified the facility practice of communication for residents to be seen by psychiatric services is to place the resident in name in the psychiatric binder. SW # 3 also indicated facility can sometimes use verbal communication when psychiatric services is needed. SW#3 indicated the visit note dated 10/24/2023 indicated Resident #134 was staying out of the room more often, verbalizing wanting to be on own but was making the best of the circumstances. This visit was 2 days after the abuse occurred and 2 days prior to the facility becoming aware that an abusive event occurred on 10/22/2023. SW #3 visited Resident #134 on 11/7/2023 identified s/he was not aware of the abusive incident that occurred on 10/22/2023 so no counseling regarding the incident occurred. SW#3 did indicate the incident was not written in the psychiatric binder and no verbal report from staff was provided to him/her. SW#3 indicated if a resident was cognitively intact, they would remember the incident so there would be a need to increase visits to check mood, make sure the resident feels safe, determine if there was no trauma after the incident and once the resident was stable routine visit could be scheduled. Interview and record review on 1/8/2023 at 10:36 AM with Medical Doctor (MD #2) indicated a victim of abuse would be interviewed to be sure they felt safe in the current environment and their mood would be assessed. After review of psychiatric services notes from 10/22/2023 through 11/7/2023 identified MD #2's visit note on 11/6/2023 did not mention any changes in mood but if MD #3 was made aware of the abusive incident he/she would have asked more probing questions of the resident. Interview with APRN #3 on 1/8/2023 at 11:01 AM indicated when s/he visited Resident #134 on 11/2/2023 s/he was not aware of the abusive incident that occurred on 10/22/2023. APRN #3 indicated he/she would have visited more frequently to attain the resident's reaction and adaptation to the incident. Interview, clinical record review and facility document review with APRN #1, the current psychiatric APRN 1/8/24 at 1:15 PM for the facility, indicated no entries were made for Resident #134 into the psychiatric communication book that would have alerted psychiatric services staff of the need to visit Resident #134. APRN #1 further indicated if he/she was aware of the abusive incident he/she would have seen and evaluated the resident for mood, behavior and adjustment and seen him/her again during that week, continued with visits particular due to the circumstance, until the resident was stable then resumed the resident's usual schedule. APRN #1 further indicated he/she had visited Resident #134 this day and the resident indicated feeling safe in his/her current environment. An interview and record review with APRN #2 (the previous facility Psychiatric APRN) on 1/9/2023 at 11:58 AM indicated he/she was not made aware of Resident #134's abusive incident prior to his/her 11/15/2023 visit to Resident #134 after checking the psychiatric communication binder and talking with the nursing supervisor prior to visiting the residents. Although APRN #2 had made visits to the aggressor ( Resident # 85) in the incident he/she indicated the identity of the victim would not be known to SW#2 unless the facility specifically asked Psychiatric services to see the victim. The facility failed to ensure that Resident # 134 was free from physical abuse

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, review of facility policy and interviews for 1 of 4 residents reviewed for abuse, the facility failed to ensure staff reported and investigated an allegation of abuse and timely. The findings included. Resident #134's diagnoses included depressive episodes and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #134 was cognitively intact and was independent with transfer and ambulation. A nursing progress note dated 10/22/2023 at 12:48 PM by the RN supervisor indicated the resident had sustained a hematoma below the right eye with slight redness to the sclera and inner canthus bumping it on the bathroom door on the 11-7 AM shift, denied headache or dizziness ice compress applied Advanced Practice Registered Nurse (APRN) and family updated by the charge nurse. A physician's order dated 10/22/23, no time, with end date of 10/23/2023 at 11:59 PM directed to apply ice compress to hematoma below eye for 10 minutes every shift. A nursing progress note dated 10/22/2023 at 3:45 PM indicated in part while administering medication on the 7-3 PM shift, the nurse noticed Resident #134 had bruising and redness to the right eye and bleeding to the sclera. When Resident #134 was asked how the injury happened, the resident reported s/he had awoken around 5-6 AM to go to the bathroom and hit her/himself in the face with the door by accident as it was dark. The supervisor, family and medical provider were notified. A Nursing Post Event Progress Note dated 10/26/2023 at 10:17 PM indicated at 7:45 PM a family member of Resident #134 visited resident and reported to the RN supervisor Resident #134 indicated being punched in the face by roommate (Resident # 85 ) due to loud music at 5:00 AM on 10/22/2023 and denied hitting face on the door as previously reported on 10/22/2023 sustaining a hematoma below the right eye. The note further indicated the residents were immediately separated the APRN was notified along with the responsible party. The state agency report dated 10/26/2023 indicated first knowing of incident at 8:00 PM. A report was received by the state agency at 8:43 PM which indicated this was an isolated incident, a room change was completed, psychiatric services, medical and social work were to follow up with both residents involved (Resident #134 and roommate (Resident # 85.) The care plan dated 10/27/2023 identified Resident #134 had a resident-to-resident altercation with roommate ( Resident # 85 ) initially indicating he/she had walked into a door sustaining the facial injury not wanting to get the roommate ( Resident # 85 ) in trouble. Interventions included to encourage to express feelings of worry, fear and anxiety as needed to the social worker, charge nurse and other caregivers, to provide support and reassurance as needed, to provide psychiatric services and social services for support and reassurance as needed and the roommate (Resident # 85) (was transferred to an alternate wing/room. A care plan progress note dated 10/27/203 at 9:28 AM written by SW#2 indicated visiting Resident #134 regarding the incident of being struck on 10/22/2023 by the roommate ( Resident # 85). The note further indicated the roommate (Resident # 85) admitted not only hitting Resident #134 on 10/22/2023 but had hit Resident #134 in the past as well. Interview and clinical record review with SW #2 on 1/5/2023 at 2:08 PM identified s/he thought he/she had reported the verbalization of the past occurrence of hitting roommate (prior to the reported incident of 10/22/2023) to the DNS or during morning report. SW # 2 indicated 10/27/2023 9:28 AM was the first time SW#2 became aware of the prior abuse toward Resident #134 (13.5 hours after the 10/22/2023 abuse incident was reported to the state agency). SW#2 further indicated his/her responsibility when becoming aware of alleged abuse is to report immediately to the DNS or administrator. An interview and record review with the DNS on 1/8/2023 at 8:58 AM indicated he/she was unaware of Resident #58's statement to SW#2 about striking Resident # 134 in the past and would start an investigation. Interview with the DNS on 1/09/24 at 10:37 AM indicated the investigation was initiated continues in progress and the state agency was notified. The state agency report indicated receiving the report on 1/8/23 at 11:06 AM with first knowledge of the incident on 1/8/2023 at 8:00 AM (3 hours 6 minutes after the DNS first knowing of the incident). The Report to the state agency indicated neither party could remember the exact date of the prior occurrence and did not report the incident to staff. The facility policy labeled Abuse Prohibition Policy dated 1/3/2024 notes it is the responsibility of the facility to ensure each resident has the right to be free from abuse mistreatment neglect, exploitation, and misappropriation of personal property. The policy indicated in part all staff are trained regarding abuse, how to report incidents of potential or suspected abuse and to whom they can report concerns without fear of reprisal or retaliation. The policy further indicated alleged abuse would be immediately reported to the state agency but no later than 2 hours after the allegation is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record and interviews for 1 of 5 residents reviewed for accidents (Resident # 32), the facility failed to complete a significant change in condition for a resident with a decline in status. The findings include. Resident #32's diagnosis included unspecified fracture of the right tibia, other fractures of the upper and lower end of the right fibula, dementia, bipolar disorder, hemiparesis, and hemiplegia affecting the right side. The discharge Minimum Data Set (MDS) dated [DATE] indicated Resident #32 had short and long-term memory problems and had no functional limitation in upper and lower extremities. The MDS further indicated Resident #32 required set up and clean up for eating, supervision for oral hygiene, toileting, upper and lower body dressing, putting on and taking off footwear and assistance to perform personal hygiene. The MDS also indicated Resident #32 was independent in rolling left and right in bed and sit to stand and stand to sit but required supervision with touch assistance for sit to lying, lying to sitting, bed to chair and chair to bed and transfer on and off the toilet. Resident #32 utilized a wheelchair when out of bed. Resident #32's care plan dated 11/16/2023 for activity of daily living deficit due to cognition and resistance to care. Interventions included, in part, providing Resident #32 with the assistance of one person for ADL, set up for all meals and assist of one person for transfer. A physical therapy evaluation and plan of treatment completed on 11/23/2023 identified a referral was made after the resident's recent hospitalization for behavioral disturbances and frequent falls while sitting in the wheelchair and with transferring. The therapy evaluation indicated Resident #32 required moderate assistance of one person for bed mobility, transfer, and wheelchair mobility. The evaluation further indicated Resident #32 's prior level of function was independent with bed mobility, stand by assistance of one person with transfers and independent with wheelchair mobility. The goal set for physical therapy included to have stable upright posture while sitting in wheelchair and noted resident would have more difficulty maneuvering the wheelchair independently as opposed to the prior level of function of self-propelling in wheelchair. The transfer goal included transferring with moderate assistance of one person with occasional verbal cues for safety as opposed to prior level of function of stand by assistance of one person. The occupational therapy evaluation dated 11/23/2023 indicated in part Resident #32's prior level of function for hygiene/grooming included stand by assistance, moderate assistance of one person for toileting, assist of one person for upper and lower body dressing and transfers and was independent for wheelchair mobility. The nursing admission/readmission assessment dated [DATE] at 6:45 PM indicated admitting diagnosis of right tibial fracture and popliteal thrombus of the right lower leg. The assessment further indicated Resident #32 had no upper body impairment, noted impairment on one side of the lower extremities and indicated the resident was non weight bearing. The physician's orders dated 12/4/2023 directed to provide the assistance of 2 persons to complete activities of daily living, non-weight bearing of right lower extremity every shift and to provide treatment to the right lower extremity external fixation devise( in place to treat the fractures) by cleansing the pin sites with normal saline, removing any debris, wipe with iodine, cover with xeroform, split gauze, and wrap with a kerlix wrap every day. A physician order dated 12/5/2023 directed to feed Resident #32 at all meals. An interview and record review on 1/9/2023 at 9:14 AM with RN # 5 the regional MDS Coordinator indicated Resident #32 would have benefited from the completion of a change in condition MDS due to changes in functional status. RN# 5 indicated identification of Resident #32's decline in functional status was overlooked by the MDS staff due to staffing changes in the MDS department at the time. Subsequent to inquiry, RN # 5 scheduled a Significant change MDS pending completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation and interview for 1 of 6 residents (Resident # 114) the facility failed to submit a level 2 preadmission screening and resident review (PASRR) with a newly identified psychiatric diagnosis. The finding include: Resident #114's diagnoses included dementia, anxiety, and delusional disorder. The quarterly MDS assessment dated [DATE] indicated Resident #114 was severely cognitively impaired and needed extensive assistance of 1 person for dressing, toilet use, and personal hygiene. The MDS further indicated Resident #114 had active psychiatric diagnoses of anxiety disorder and psychiatric disorder. The psychiatric resident log dated 11/2/23 identified Resident #114 as having a 1st visit with Supportive Care Psychiatric services and to add schizophrenia to the residents diagnoses. The psychiatric note dated 11/17/23 indicated Resident #114 had a newly added diagnosis of schizophrenia. The quarterly MDS assessment dated [DATE] indicated Resident #114 was severely cognitively impaired and needed extensive assistance of 1 person for dressing, toilet use, and personal hygiene. The MDS further indicated that Resident #114 had active psychiatric diagnoses of anxiety disorder, psychotic disorder, and Schizophrenia. Interview with Social Services worker #1 on 1/4/23 at 10:30 AM indicated that a level 2 PASRR should have been performed on Resident #114 when a new psychiatric diagnosis is found. Social Work #1 further indicated that she was not aware of the newly psychiatric diagnosis until this interview secondary to a lack of communication between interdisciplinary departments

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy and interviews for 2 of 10 sampled residents (Residents # 69 and 134) reviewed for Accidents, the facility failed to develop and implement comprehensive person-centered care plan for smoking. The findings included: 1.Resident #69's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), asthma, depression, Cerebral Vascular Accident (CVA) and tobacco use. The annual Minimum Data Set assessment dated [DATE] identified Resident #69 as cognitively intact and a current tobacco user. The Smoking Evaluation and Safely Screen dated 7/17/23 identified Resident #69 as a current smoker. The Resident Care Plan dated 11/3/2023 failed to identify a comprehensive person-centered Resident #69 for smoking. 2. Resident #134 ' s diagnoses included COPD, depression, and heart failure. The annual Minimum Data Set assessment dated [DATE] identified Resident #134 as moderately cognitively impaired and a current tobacco user. Review of the Smoking Evaluation and Safety screen dated 7/25/23 indicated Resident #134 was a current smoker. The Resident Care Plan dated 10/27/23 failed to identify a comprehensive person-centered care plan for smoking. Interview with Director of Nurses (DNS) on 1/9/24 at 9:40AM identified Resident #69 and Resident #134 were not care planned for smoking. The MDS Coordinator is responsible for developing care plans and she could not explain why this was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of policy and staff interviews for 1 of 7 residents (Resident # 57), who required assistance with medication administration, the facility failed to meet professional standards of practice when administering a pain medication and 1 of 1 sampled resident who utilized Narcan, the failed to ensure that the Registered Nurse stayed with resident after the first dose of Narcan administration per facility practice. The findings included: Resident #57's diagnoses included pain in left shoulder, other low back pain, and unspecified displaced fracture of third cervical vertebra. A physician's order dated 10/7/23 directed administration of Dilaudid oral tablet, 4 Milligrams (MG), by mouth every 4 hours as needed for severe pain and not to exceed three doses in twenty-four hours. The annual Minimum Data Set assessment dated [DATE] identified Resident #69 was cognitively intact, independent with activities of daily living, and on a scheduled pain medication regimen. a. A review of the Controlled Substance Disposition Record and Medication Administration Record (MAR) identified Resident #57 was administered one 4mg dose of Dilaudid on 1/6/24 at 11:45AM and one 4mg dose on 1/6/24 at 6:38PM. However, MAR for January 2024 failed to identify both doses were administered on 1/6/24. Interview with the Director of Nursing Services on 1/10/24 at 2:08 PM identified nurses are responsible for administering Resident #57's medication, following physician's orders, and documenting the medication administration in both the MAR and Controlled Substance Disposition Record (for narcotics). A telephone interview and review of the Controlled Substance Disposition Record and MAR with Licensed Practical Nurse (LPN #2) at 2:24PM on 1/10/24 identified Resident #57 was administered one 4mg dose on 1/6/24 at 11:45AM and one 4mg dose on 1/6/24 at 6:38 PM. However, the Controlled Substance Disposition Record and MAR failed to identify both doses were administered. LPN #2 identified s/he gave both doses of the Dilaudid 4mg dose to Resident #57 at the times written on the Controlled Substance Disposition Record and watched him/her take both doses orally but forgot to sign them off on the MAR. LPN#2 indicated s/he was responsible for signing off medications following administration. LPN # 2 also indicated the policy was to follow the physician's order and sign that medications were administered in both the MAR and Controlled Substance Disposition Record. b. Resident #57's diagnoses included pain in left shoulder, other low back pain, and unspecified displaced fracture of third cervical vertebra. A physician's order dated 10/7/23 directed administration of Dilaudid oral tablet, 4 Milligrams (MG), by mouth every 4 hours as needed for severe pain and not to exceed three doses in twenty-four hours. Review of RN #9 nursing notes dated 1/7/24 at 12:57 PM noted was called to the floor by the charge nurse to assess Resident # 57 who was disoriented to time this morning which was outside of resident's baseline mentation of alert and oriented times four, redirected and verbalized correct time. Continued with forgetfulness, nodded off during conversation, presented with pinpoint pupils and was pale with a respiratory rate of 10 breaths per minute, blood pressure of 170/82, heart rate of 78, and an oxygen level of 91% (Normal Range 95-100 percent) via nasal cannula and indicated Narcan was administered at 11:50 AM. A physician's order was obtained at 11:50 AM directed to administer Narcan nasal liquid 4 MG/0.1 ML one application in nostril one time only for suspected opioid depression until 1/7/24 11:59 PM. Interview with RN #9 on 1/11/24 at 1:36 PM identified LPN #7 had administered the first dose of Narcan on 1/7/24 at 11:50 AM under RN #9's supervision, however RN #9 left LPN #7 with Resident #57 as s/he was called to another emergency. Upon arriving to the other emergency involving Resident #85, RN #9 indicated another RN and LPN were present in the room. The LPN present requested that RN #9 not leave, however RN #9 did leave the room and asked the DNS to go to Resident #85's room. RN # 9 then returned to Resident #57's room. Interview with LPN # 7 on 1/11/24 at 2:30 PM identified the time between the first dose of Narcan administration on 1/7/24 at 11:50 AM and RN # 9's return to the room was between 10 and 12 minutes when the resident's condition began to worsen. Upon returning to Resident #57's room on 1/7/24, RN #9 reassessed the resident and found his/her condition had worsened: his/her respiratory rate had improved from 10 breaths per minute to 14 breaths per minute, but the resident continued with pinpoint pupils, pallor, became diaphoretic, had slurred speech, weakness, swaying movements throughout his/her body, and noted some jerking movements. RN #9 further indicated Resident # 57's breathing remained shallow therefore she administered a second dose of Narcan at 12:07 PM. Interview with the Director of Nurses on 1/25/24 at 12:30 PM indicated she bumped into RN #9 in the stairwell on 1/7/24 while in route to Resident #85's room. Review of the Emergency Nasal Narcan Administration Policy revised on 1/2/24 directed staff to wait 2 to 3 minutes following administration. If there's no response or the resident/patient is slow to respond, repeat 4mg/0.1 ml in other nostril and to stay with the resident/patient and continue to attempt to arouse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, facility policy and interviews for 2 of 2 sampled residents (Resident #s 102 and 119) reviewed for Respiratory Care, the facility failed to ensure the resident oxygen was administered as directed by the physician. The findings included: 1. Resident #102's diagnoses included anxiety disorder, pulmonary embolism, and essential hypertension. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #102 as moderately cognitively impaired, required moderate assistance with toileting, dressing and performing personal hygiene and received oxygen therapy during residency. The Resident Care Plan dated 10/20/23 identified Resident #102 had respiratory disease related to asthma and a history of anxiety. Interventions directed to encourage the resident to report difficulty breathing and administer anti-anxiety medications per order. A physician's order dated 8/16/23 directed to administer oxygen via nasal cannula at 2 liters per minute and to check pulse oximetry. Observation with LPN #2 on 1/2/24 at 1:18PM identified Resident #102's oxygen setting at 3 liters per minute. LPN #2 indicated Resident #102's oxygen order was for 2 liters per minute. 2. Resident #119's diagnoses included chronic obstructive pulmonary disease, dementia, and anxiety. The quarterly Minimum Date Set assessment dated [DATE] identified Resident #119 as cognitively impaired and required supervision with eating, oral and toileting hygiene. The Resident Care Plan dated 11/28/23 identified a diagnosis of chronic obstructive pulmonary disease. Interventions directed to administer oxygen and monitor effectiveness by checking saturation as/if indicated. A physician's order dated 9/14/23 directed to administer oxygen via nasal cannula at 2-3 liters/minute and to check pulse oximetry every shift. Observation with LPN #2 on 1/2/24 at 1:21 PM identified Resident #119's oxygen setting at 5.5 liters per minute. LPN #2 indicated Resident #119's oxygen order was for 2-3 liters per minute. LPN #2 also indicated the facility policy directs staff to follow the physician's order, and that she did not check the Residents #102 and 119 oxygen level on this shift. Interview with the Director of Nurses (DNS) on 1/4/24 at 9:30 AM identified the facility policy is to follow physician orders for oxygenation. The DNS further indicated it was the nurse's responsibility to follow the physician's orders for oxygenation via nasal cannula and that the pulse oximetry should be monitored per physician's order. Review of the revised Oxygen Administration Nasal Cannula policy dated 1/2/24 directed to deliver low flow oxygen per physician's order via nasal cannula.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation review of policy and interviews for 1 of 1 resident reviewed for specialized treatment (Resident #58), the facility failed to ensure the resident intake and output were consistently monitored and the residents pre and post weight were monitored on the resident's communication log. The findings included: Resident #58's diagnoses included end stage renal disease and dependence on specialized treatment center. The annual Minimum Data Set assessment dated [DATE] identified Resident #58 as cognitively intact, required set-up assistance with meals, and was always incontinent of urine and bowel. The Resident Care Plan dated 11/14/23 identified the resident required specialized treatment had End Stage Renal Disease and was at risk for weight fluctuations related to the treatment. Interventions directed to encourage fluids, daily weights and monitoring of fluid intake and output. a. A physician's order dated 7/20/22 directed intake and output monitoring each shift. Review of Resident #58's total intake and output records from 9/24/23 through 1/8/24 identified missing daily intake and output records and/or incomplete intake recordings from 9/24/23 through 1/8/24. Interview with the DNS on 1/4/23 at 3:49 PM identified each shift was responsible to complete and document the totals of the resident intake and out per the physician's order and the nurse aides are responsibility for documenting daily intake amounts. Interview with RN #7, first shift Nurse Supervisor, on 1/8/24 at 8:22AM indicated intake and output is recorded on the daily intake and output record sheet by the unit nurse aides and is ultimately managed by the charge nurse who receives the data, adds on the fluids given during medication administration, and documents intake totals each shift. RN #7 further indicated he/she was unaware Resident # 58's intake and output records sheets had not been completed. Interview with LPN #6, charge nurse, on 1/8/24 at 4:05 PM indicated intake and output records are dated and the charge nurses are responsible for completing the total intake per shift. LPN #6 identified the intake and output flow sheets were only completed up to 12/18/23, with some days missing documentation, and most of the daily recordings since 9/24/23 were incomplete. Furthermore, LPN #6 identified the physician's order directed 1000cc to 1620cc of fluid daily and as fluid intake was not monitored each shift, he/she was unable to determine if the resident had met her/his daily fluid goals. LPN #6 indicated he/she was unaware of the intake and output policy and referred to the DNS on 1/8/24 at 4:26 PM to obtain the policy. Review of the Intake and Monitoring Policy revised on 1/2/24 directed to document intake and output each shift and to be total daily by the 3:00PM - 11:00PM nurse and the twenty-four-hour totals are entered into the Medication Administration Record. b. A physician's order dated 5/30/23 directed to enter pre and post specialized treatment weight into the electronic medical record from the specialized treatment communication sheet twice daily every Monday, Wednesday, and Friday. Review of the Electronic Medical Record's weights and vitals summary identified several missed weight entries from October 2023 and December 2023 on the resident's specialized treatment days. Interview with the DNS on 1/4/24 at 3:49 PM identified that pre and post specialized treatment weights should be documented in the electronic medical record and per physician orders/The DNS also indicated the policy directs weights will be obtained from the specialized center and monitored per physician order. Interview with RN #8 on 1/8/24 at 12:30 PM identified the charge nurse checks the vitals and weights on the communication sheet sent from the specialized treatment unit. RN #8 further indicated the communication sheet was not always completed by the specialized unit, and that the nurse supervisor or charge nurse was responsible for calling the unit to obtain the post weight and vital signs. Additionally, the resident's vital signs were checked upon return to the unit from the specialized center, however obtaining the resident's weight was not part of the protocol. Interview with LPN #6 on 1/8/24 at 4:05 PM identified the specialized treatment center did not consistently complete the communication log sheet and the charge nurse or supervisor of the unit should have called the specialized center to obtain the resident's pre and post weights. LPN #6 further indicated the facility would sometimes follow-up with the center regarding the resident's post weight or would weigh the resident once they returned to the facility. LPN #6 was unaware of the facility's policy regarding pre and post specialized treatment weight documentation. Review of the Specialized treatment policy revised on 1/2/24 directed pre and post weights would be obtained from the center and weights would be monitored per physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews for 1 of 1 resident reviewed for medication administration of Narcan (Resident #57), the facility failed to ensure the licensed was educated and trained prior to administering the medication. The findings include: Resident #57's diagnoses included pain in left shoulder, other low back pain, and unspecified displaced fracture of third cervical vertebra. A physician's order dated 10/7/23 directed administration of Dilaudid oral tablet, 4 Milligrams (MG), by mouth every 4 hours as needed for severe pain and not to exceed three doses in twenty-four hours. The annual Minimum Data Set assessment dated [DATE] identified Resident #69 was cognitively intact, independent with activities of daily living, and on a scheduled pain medication regimen. Review of RN #9 nursing notes dated 1/7/24 at 12:57 PM noted was called to the floor by the charge nurse to assess Resident # 57 who was disoriented to time this morning which was outside of resident's baseline mentation of alert and oriented times four, redirected and verbalized correct time. Continued with forgetfulness, nodded off during conversation, presented with pinpoint pupils and was pale with a respiratory rate of 10 breaths per minute, blood pressure of 170/82, heart rate of 78, and an oxygen level of 91% (Normal Range 95-100 percent) via nasal cannula and indicated Narcan was administered at 11:50 AM. A physician's order was obtained at 11:50 AM directed to administer Narcan nasal liquid 4 MG/0.1 ML one application in nostril one time only for suspected opioid depression until 1/7/24 11:59 PM. Interview with RN #9 on 1/11/24 at 1:36 PM identified LPN #7 had administered the first dose of Narcan on 1/7/24 at 11:50 AM under RN #9's supervision, however RN #9 left LPN #7 with Resident #57 as s/he was called to another emergency. Upon arriving at the other emergency involving Resident #85, RN #9 indicated another RN and LPN were present in the room. The LPN present requested that RN #9 not leave, however RN #9 did leave the room and asked the DNS to go to Resident #85's room. RN # 9 then returned to Resident #57's room. Interview with LPN #7 on 1/11/24 at 2:20 PM indicated, prior to administration of Resident # 57 Narcan on 1/7/24, s/he had received training on how to administer Narcan to residents. Following review of the box instructions with RN #9 and with verbal instruction from RN #9, LPN #7 administered Resident #57 the first dose of Narcan with RN supervision. Interview with the Director of Nursing Services on 1/24/24 at 10:38 AM identified staff had been trained on suspected overdose on 1/8/24 but failed to identify staff receiving education on how to administer Narcan 4mg/0.1ml. Review of the Emergency Nasal Narcan Administration Policy revised on 1/2/24 directed staff to wait 2 to 3 minutes following administration. If there's no response or the resident/patient is slow to respond, repeat 4mg/0.1 ml in other nostril and to stay with the resident/patient and continue to attempt to arouse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy, facility documentation and interviews for 1 of 4 residents ( Resident # 134) reviewed for Abuse, the facility failed to ensure psychiatric services were provided to a resident specifically related to trauma after an abusive incident . The findings included. Resident #134's diagnosis included depressive episodes and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #134 was cognitively intact and was independent with transfer and ambulation. A nursing progress note dated 10/22/2023 at 12:48 PM by the RN supervisor indicated the resident had sustained a hematoma below the right eye with slight redness to the sclera and inner canthus bumping it on the bathroom door on the 11-7 AM shift, denied headache or dizziness ice compress applied Advanced Practice Registered Nurse (APRN) and family updated by the charge nurse. A physician's order dated 10/22/23, no time, with end date of 10/23/2023 at 11:59 PM directed to apply ice compress to hematoma below eye for 10 minutes every shift. A nursing progress note dated 10/22/2023 at 3:45 PM indicated in part while administering medication on the 7-3 PM shift, the nurse noticed Resident #134 had bruising and redness to the right eye and bleeding to the sclera. When Resident #134 was asked how the injury happened, the resident reported s/he had awoken around 5-6 AM to go to the bathroom and hit her/himself in the face with the door by accident as it was dark. The supervisor, family and medical provider were notified. A Nursing Post Event Progress Note dated 10/26/2023 at 10:17 PM indicated at 7:45 PM a family member of Resident #134 visited resident and reported to the RN supervisor Resident #134 indicated being punched in the face by roommate due to loud music at 5:00 AM on 10/22/2023 and denied hitting face on the door as previously reported on 10/22/2023 sustaining a hematoma below the right eye. The note further indicated the residents were immediately separated the APRN was notified along with the responsible party. The state agency report dated 10/26/2023 indicated first knowing of incident at 8:00 PM. A report was received by the state agency at 8:43 PM which indicated this was an isolated incident, a room change was completed, psychiatric services, medical and social work were to follow up with both residents involved (Resident #134 and roommate (Resident # .) The care plan dated 10/27/2023 identified Resident #134 had a resident-to-resident altercation with roommate ( Resident # ) initially indicating he/she had walked into a door sustaining the facial injury not wanting to get the roommate ( Resident # ) in trouble. Interventions included to encourage to express feelings of worry, fear and anxiety as needed to the social worker, charge nurse and other caregivers, to provide support and reassurance as needed, to provide psychiatric services and social services for support and reassurance as needed and the roommate (Resident # ( was transferred to an alternate wing/room. How did the facility monitor the roommate ( Resident # on the alternate wing to protect other residents A care plan progress note dated 10/27/203 at 9:28 AM written by SW#2 indicated visiting Resident #134 regarding the incident of being struck on 10/22/2023 by the roommate ( Resident # ). The note further indicated the roommate admitted not only hitting Resident #134 on 10/22/2023 but had hit Resident #134 in the past as well. Interview and clinical record review with SW #2 on 1/5/2023 at 2:08 PM identified s/he thought he/she had reported the verbalization of the past occurrence of hitting roommate (prior to the reported incident of 10/22/2023) to the DNS or during morning report. SW # 2 indicated 10/27/2023 9:28 AM was the first time SW#2 became aware of the prior abuse toward Resident #134(13.5 hours after the 10/22/2023 abuse incident was reported to the state agency). SW#2 further indicated his/her responsibility when becoming aware of alleged abuse is to report immediately to the DNS or administrator. Interview and record review (Resident #134 and roommate Resident # ) with the DNS on 1/8/2023 at 8:58 AM indicated not being aware of SW#2's notes on 10/27/2023 indicating the roommate admitted striking Resident #134 in the past but hit harder this time. A review of psychiatric and psychiatric social worker notes prior to and after the known incident date of 10/22/2023 identified no indication psychiatric services staff were aware of Resident #134 having been abused even though providing psychiatric services after the abusive incident was part of the facility plan related to the reported incident. An interview and record review on 1/8/2023 at 10:26 AM with SW#3 identified the facility practice of communication for residents to be seen by psychiatric services is to place the resident in name in the psychiatric binder. SW # 3 also indicated facility can sometimes use verbal communication when psychiatric services is needed. SW#3 indicated the visit note dated 10/24/2023 indicated Resident #134 was staying out of the room more often, verbalizing wanting to be on own but was making the best of the circumstances. This visit was 2 days after the abuse occurred and 2 days prior to the facility becoming aware that an abusive event occurred on 10/22/2023. SW #3 visited Resident #134 on 11/7/2023 identified s/he was not aware of the abusive incident that occurred on 10/22/2023 so no counseling regarding the incident occurred. SW#3 did indicate the incident was not written in the psychiatric binder and no verbal report from staff was provided to him/her. SW#3 indicated if a resident was cognitively intact, they would remember the incident so there would be a need to increase visits to check mood, make sure the resident feels safe, determine if there was no trauma after the incident and once the resident was stable routine visit could be scheduled. Interview and record review on 1/8/2023 at 10:36 AM with Medical Doctor (MD #2) indicated a victim of abuse would be interviewed to be sure they felt safe in the current environment and their mood would be assessed. After review of psychiatric services notes from 10/22/2023 through 11/7/2023 identified MD #2's visit note on 11/6/2023 did not mention any changes in mood but if MD #3 was made aware of the abusive incident he/she would have asked more probing questions of the resident. Interview with APRN #3 on 1/8/2023 at 11:01 AM indicated when s/he visited Resident #134 on 11/2/2023 s/he was not aware of the abusive incident that occurred on 11/22/2023. APRN #3 indicated he/she would have visited more frequently to attain the resident's reaction and adaptation to the incident. Interview, clinical record review and facility document review with APRN #1 on 1/8/24 at 1:15 PM the current psychiatric APRN for the facility, indicated no entries were made for Resident #134 into the psychiatric communication book that would have alerted psychiatric services staff of the need to visit Resident #134. APRN #1 further indicated if he/she was aware of the abusive incident he/she would have seen and evaluated the resident for mood, behavior and adjustment and seen him/her again during that week, continued with visits particular to the circumstance until stable then resumed the resident's usual schedule. APRN #1 further indicated he/she had visited Resident #134 this day who indicated feeling safe in his/her current environment. An interview and record review with APRN #2(the previous facility Psychiatric APRN) on 1/9/2023 at 11:58 AM indicated he/she was not made aware of Resident #134's abusive incident prior to his/her 11/15/2023 visit to Resident #134 and further indicated checking the psychiatric communication binder and talking with the nursing supervisor prior to visiting the residents. Although APRN #2 had made visits to the aggressor in the incident he/she indicated the identity of the victim would not be known to SW#2 unless the facility specifically asked Psychiatric services to see the victim. The facility failed to provide psychiatric services to Resident #134, the victim of an abusive event, as indicated in part of the facility plan.

Based on observation and staff interview for 1 of 4 medication carts, the facility failed to ensure resident safety by ensuring a medication cart was locked on the secure memory care unit. The findings include: Observations on 1/2/24 at 11:18 AM on the second floor, secure memory care unit, noted the medication cart located near the nurses' station, was unlocked and unattended while residents were noted to be sitting in the hall area near the medication cart and another resident was wandering the floor who had a diagnosis of dementia and unspecified psychosis. Interview with charge nurse, LPN #1 indicated the medication cart on a memory care unit should have been locked, she also indicated she thought it had swung closed and proceeded to immediately lock the medication cart. Review of facility policy, annual review 1/02/24 titled Medication Storage Room/Medication Cart Policy notes the facility provides pharmaceutical services that are conducted in accordance with ethical and professional standards of practice and that meet applicable Federal, State and Local Laws, rules, and regulations. Medications are stored primarily in a locked medication cart which is accessible only to licensed nursing personnel. The medication cart is to be locked at all times when not in use by the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy and interviews for 1 of 3 residents (Resident #45) who required assistance with ADL, the facility failed to ensure the resident's call light was accessible to resident while in bed. The findings include: Resident #45's diagnoses included: dementia, diabetes mellitus, depression, and dysphagia (difficulty with swallowing). The quarterly MDS assessment dated [DATE] identified the resident as severely cognitively impaired, extensive assistance of two for bed mobility, dependent for bathing, personal hygiene and toilet use, substantial/maximal assist of one with sit to lying and lying to sit on side of bed, partial/moderate assist with upper/lower dressing, mechanically altered diet and required supervision and set up help for meals. A Resident Care Plan dated 12/26/23, indicated Resident #45 required extensive assistance needed for activities of daily living (ADLs) and the resident has an ADL deficit related to cognitive loss/dementia limited to extensive assist. Interventions included assist of one for ADLs and keep call bell and needed items within reach. On 1/02/24 at 11:50 AM observation identified Resident #45 appearing to be uncomfortable, sitting with the head of the bed in a partially upright position, leaning to his/her left side. The resident was also attempting to shift his/her pillow and upper body, when asked if he/she was comfortable Resident # 45 responded no. Further observation of the resident identified Resident # 45's call light button on floor in the resident's room, curled up on the floor, against head of bed wall and below where the call light was connected to the call system. On 1/2/24 at 11:52 AM upon surveyor inquiry, NA #1 and NA #2 boosted the resident into a more comfortable position. Observation and interview with NA #1 identified Resident #45 was on her assignment and she regularly provides care to Resident # 45. She further indicated the call light was in the resident's reach when she had entered the room for breakfast. On 1/2/24 at 11:54 AM observation and interview with LPN #1 indicated Resident #45's call light should be in reach, in her/his hand. The NA then placed a call light in the residents' reach. Review of facility policy annually review dated 1/2/24 titled Call Light, Use of indicates that all resident/patients will have a call light or alternative communication device within his/her reach when unattended. The policy directs when providing care to residents/patients be sure the position of the call light is convenient for the resident and directs staff to tell/show the resident/patient where the call light is located.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observation, facility documentation, review of facility policy and interviews for 1 of 2 sampled residents ( Resident # 5) reviewed for skin condition non-pressure, the facility failed to consistently conduct weekly wound assessment per facility policy and for 1 of 3 residents (Residents #45) reviewed for dining, the facility failed to ensure a physician's order for supervision and staff assistance during meals and for 3 of 10 residents ( Residents # 69, # 106 and # 120) reviewed for smoking, the facility failed to conduct smoking evaluation and safety per policy and for 1 of 7 sampled residents ( Resident # 57), the facility failed to administer the resident's medications as directed by the physician. The findings included: 1. Resident #5's diagnoses included Peripheral Vascular Disease (PVD), chronic venous hypertension with ulcer of left lower extremity, and non-pressure chronic ulcer of other part of left foot with unspecified severity. A physician's order dated 3/7/23 directed to rinse wounds with normal saline, apply triad paste to intact skin around wounds, apply gauze dampened with anasept gel, cover with optilock, followed by ABD pads, wrap with kerlix, and wrap with ace wraps every 24 hours as needed for if soiled. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 as cognitively intact and was independent in ambulating ten and fifty feet with two turns and changing positions. The MDS assessment dated [DATE] identified the resident's cognition and memory were intact and noted venous and arterial ulcers. The Resident Care Plan dated 10/29/23 identified a chronic venous ulcer to the left lower leg and left third toe. Interventions directed to treatments as ordered and weekly evaluation by wound advanced practice registered nurse as ordered. A review of Resident# 5 Wound Assessment Sheets dated 9/2023 through 12/8/23 failed to reflect that staff consistently conducted weekly wound assessment per facility policy. In an interview and clinical record review with Director of Nurses (DNS) on 1/8/24 at 1:30PM identified the clinical record failed to reflect non-pressure wound evaluations were not performed for Resident #5 from 9/29/23 through 10/27/23, from 11/3/23 through 11/7/23, and 11/20/23 through 12/8/23. The DNS further indicated wound evaluations were not completed weekly per facility policy secondary to the facility did not have an infection control nurse until 10/30/23. The DNS also indicated and nurse that came in to support the facility with wound evaluations did not capture the missing wound assessment above for Resident # 5. Review of the Non-Pressure Wound Assessment policy dated 1/3/24 directed venous wounds, arterial wounds or diabetic ulcers would be assessed on a weekly basis. 2. Resident #45's diagnoses included: dementia, diabetes mellitus, depression, and dysphagia (difficulty with swallowing). A Speech Language Pathologist (SLP) Evaluation note dated 10/31/23 indicated a recommendation to continue with the mechanical soft diet, thin liquids, patient/resident was found to have mucosal infection, unable to wear dentures, due possibly to oral infection, appeared to be at baseline swallow function. Additionally, the SLP recommended self-feeding and swallowing with set-up with verbal and/or tactile cues, and no further consults indicated. An Occupational Therapy (OT) Evaluation note dated 10/31/23 indicated functional skills assessment of supervised self-feeding, impressions indicated that due to documented physical impairments and associated functional deficits, risk factors for this resident included increased agitation, increased dependency on caregivers. An OT Evaluation note dated 11/9/23 functional assessment indicated self-feeding with supervision and OT evaluation visit only, no further consults indicated. A Nurse Aide Care Card dated 12/6/23 indicated continual supervision with intake by mouth, cue to eat at slow rate, small bites, and sips. A physician's order dated 12/7/23 directed supervision with all meals. The quarterly MDS assessment dated [DATE] identified the resident as severely cognitively impaired, mechanically altered diet and required supervision and set up help for meals. A Nutrition Evaluation dated 12/15/23 indicated small portions for meals, aspiration precautions, continual supervision with po (by mouth) intake. Resident Care Plan dated 12/26/23 indicated resident at nutritional risk related to dementia and dysphagia and at risk for aspiration related to diet. Interventions included Mechanical Soft (Dental) Ground texture, Thin (Regular) Liquids consistency, small portions for meals, aspiration precautions, continual supervision with by mouth, cue for slow rate, small bites/sips. Upright positioning 90 degrees during po (by mouth) intake and 30 minutes post, oral care 2-3 times a day. Observation on 1/2/24 at 12:38 PM noted Resident #45 was behind a curtain (not within eyesight), eating lunch in bed nearest to window, alone, roommate was not present, and his/her meal ticket dated 1/2/24 indicated diet of mechanical soft, ground food, with an Alert of Aspiration Precaution and Supervision. Additionally, Resident #45's call bell system was not within his/her reach and was located near the wall on the floor. On 1/2/24 at 12:43 PM observation, review of facility documentation and interview with LPN #1 identified Resident # 45's curtain was closed, not visible from the hallway and the resident was eating his/her lunch alone, and the resident's meal ticket indicated aspiration precautions and supervision. On 1/2/24 at 12:44 PM interview with SLP indicated that she was not sure where the order for aspiration precautions and supervision originated, and she would speak with her rehabilitation manager. On 1/2/24 at 2:53 PM interview with Rehabilitation Director indicated the SLP was not specifically looking at function when she last evaluated Resident #45 on 10/31/23 and OT evaluation on 12/7/23 left the resident's status as supervision for cueing and dignity to encourage the resident to utilize utensils rather than her/his hands. On 1/3/24 at 11:26 AM interview with SLP indicated the resident was now on a mechanical soft diet and if he/she was sitting upright, the resident no longer needed supervision with meals from a safety standpoint. She further indicated that she felt that residents' current meal needs set-up, required cueing to sit up, and reminded to go slow and take time to eat. Interview on 1/9/24 at 11:56 AM with DNS indicated she was not sure if the facility had a policy on supervision with meals and that she would investigate, however, DNS did not provide a policy on supervision with meals. Review of facility policy, annual review date of 1/2/24 titled Aspiration Precautions indicated that Aspiration Precautions will be utilized to reduce the risk of aspiration of food or liquid into the resident's lungs. The procedure indicates the resident must be assessed by Speech Language Pathologist (SLP) for the Aspiration Precautions to be discontinued, develop a care plan with the feeding strategies per speech therapy recommendation, and include on care plan as warranted. Subsequent to inquiry, an APRN's order dated 1/3/24 directed to discontinue supervision all meals order. 3. Resident # 69's diagnoses included COPD, major depressive disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #69 as cognitively intact and a current tobacco user. The Resident Care Plan dated 11/3/2023 failed to identify Resident #69 as a smoker. The Smoking Evaluation and Safely Screen dated 7/17/23 identified Resident #69 as a current smoker. However, review of Resident # 69's Smoking Evaluation and Safety Screens failed to reflect the fourth quarter for October through December 2023 had been completed by the facility. 4. Resident # 106's diagnoses included dementia and generalized muscle weakness. Review of Resident #106's Smoking Evaluation and Safety Screen dated 7/25/23 identified he/she was a current smoker. The Resident Care Plan dated 9/30/23 identified Resident #106 had a smoking history and is choosing to smoke at this time. However, review of Resident # 106's Smoking Evaluation and Safety Screens failed to reflect the fourth quarter for October through December 2023 had been completed by the facility. 5. Resident #120's diagnoses included Alzheimer's disease, dementia, and nicotine dependence. The annual Minimum Data Set assessment dated [DATE] identified Resident #120 as a current tobacco user. The Resident Care Plan dated 7/17/23 identified Resident #120 had a smoking history, smoking safety screen completed, resident wishes to smoke and can safely smoke cigarette with supervision. However, review of Resident # 120's Smoking Evaluation and Safety Screens failed to reflect the fourth quarter for October through December 2023 had been completed by the facility. Interview with the DNS on 1/3/23 at 12:26PM identified Safety Screens are to be completed quarterly for all smokers and the charge nurses were responsible for completing the screens. The DNS also was unable to provide evidence as to why the assessments for Residents # 69, 106 and 120 were not completed. After inquiry, Smoking Evaluations and Safety Screens were completed for Residents # 69, 106, and 120 on 1/4/24. Review of the Smoking Policy revised on 1/2/24 directed residents who smoke will be evaluated for their ability to smoke upon admission, quarterly, and as directed by any significant change in condition to ensure that they continue to be capable of smoking and use smoking materials without presenting a danger to themselves or others. 6. Resident #57's diagnoses included pain in left shoulder, other low back pain, and unspecified displaced fracture of third cervical vertebra. A physician's order dated 10/7/23 directed administration of Dilaudid oral tablet, 4 Milligrams (MG), by mouth every 4 hours as needed for severe pain and not to exceed three doses in twenty-four hours. The annual Minimum Data Set assessment dated [DATE] identified Resident #69 was cognitively intact, independent with activities of daily living, and on a scheduled pain medication regimen. a. A review of the Controlled Substance Disposition Record and Medication Administration Record (MAR) identified Resident #57 was administered one 4mg dose of Dilaudid on 1/6/24 at 11:45AM and one 4mg dose on 1/6/24 at 6:38PM. However, MAR for January 2024 failed to identify both doses were administered on 1/6/24. Interview with the Director of Nursing Services on 1/10/24 at 2:08 PM identified nurses are responsible for administering Resident #57's medication, following physician's orders, and documenting the medication administration in both the MAR and Controlled Substance Disposition Record (for narcotics). A telephone interview and review of the Controlled Substance Disposition Record and MAR with Licensed Practical Nurse (LPN #2) at 2:24PM on 1/10/24 identified Resident #57 was administered one 4mg dose on 1/6/24 at 11:45AM and one 4mg dose on 1/6/24 at 6:38 PM. However, the Controlled Substance Disposition Record and MAR failed to identify both doses were administered. LPN #2 identified s/he gave both doses of the Dilaudid 4mg dose to Resident #57 at the times written on the Controlled Substance Disposition Record and watched him/her take both doses orally but forgot to sign them off on the MAR. LPN#2 indicated s/he was responsible for signing off medications following administration. LPN # 2 also indicated the policy was to follow the physician's order and sign that medications were administered in both the MAR and Controlled Substance Disposition Record. b. Review of the MAR for December 2023 identified Resident # 57 received four doses of 4mg dose of Dilaudid on 12/3/23. Review of clinical records and interview with the Director of Nursing (DNS) on 1/24/24 at 10:37AM identified Resident #57 was administered four doses of Dilaudid 4mg on 12/3/23. The DNS indicated the facility policy directs staff to follow physician's orders and the resident was scheduled to receive Dilaudid 4mg by mouth every 4 hours as needed and not to exceed three doses in twenty-four hours. The DNS further indicated she would investigate why the error occurred. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, facility documentation, review, facility policy and interviews for 1 of 3 residents (Resident #30) review for self-administration of medications, the facility failed to provide an environment free of potential accident hazards when a syringe and prescribed medications were left unattended in the resident's room and for 2 of 7 residents ( Resident # 57 and Resident # 134) reviewed for smoking, the facility failed assess the resident's smoking compliance timely and failed to provide supervision during smoking per policy to ensure a hazard free environment . The findings included: 1. Resident #30's diagnoses included diabetes mellitus, heart disease, mood disorder and post-traumatic stress disorder. The Self Administration of Medication form dated 10/2/23 identified Resident #30 would like to maintain personal dignity and independence and self-administer insulin within the facility safety guidelines. The form further identified the resident can safely self-medicate and should be allowed to exercise this right. The admission Minimum Data Set assessment dated [DATE] identified Resident #30 had intact cognition, was independent with transfers and in picking up small objects. The Resident Care Plan (RCP) dated 10/13/23 identified Resident #30 with behavior problems. Interventions directed to introduce self to the resident and explain what you are going to do. Use a calm, gentle approach, work slowly and ask the resident cooperation with task. The RCP lacked a care plan related to self-administration of medications or storage of medications in the resident's room. a. A physician's order dated 12/19/23 directed Lispro insulin 20 units subcutaneously with meals for hyperglycemia. Current physician orders lacked an order for Resident #30 to self-administer medications, or to keep insulin/syringes in her/his room. Review of electronic Medication Administration Record (e-MAR) dated 1/4/24 identified at 11:44 AM Resident #30 received insulin Lispro 20 units subcutaneously to abdomen. Observations with RN #2 on 1/4/24 at 1:12 PM identified Resident #30 sitting in a recliner next to a nightstand by the entrance into her/his room. There was an unlabeled insulin syringe on the edge of the nightstand. The resident's roommate was resting in bed by the window and had two visitors walking around the room. RN #2 identified that insulin syringes should not have been left in Resident #30's room and she was not sure if the syringe was empty or contained medication. Interview with LPN #4 on 1/4/24 at 1:14 PM identified she gave Resident #30 a syringe with Lispro insulin, watched the resident self-administer then she walked away to assist the resident's roommate, forgot to pick up the used syringe after the resident put it on her/his nightstand and left the resident's room. LPN #4 further identified that the used syringe should have been disposed in a sharp container right away after use. LPN #4 immediately placed the syringe into the sharp disposal container with tight fitting lid and labeled to warn of hazardous waste inside that was mounted on the wall in the resident's bathroom. Review of facility Storage of Sharps Policy revised on 1/2/24 directed to maintain an avoidable accident-free environment, all sharps, (scissors, razors, lancets, needles, etc.) are stored and secured in designated areas at all times when not in use. When using a sharps object, maintain supervision of the item at all times before placing it back into its designated locked storage container. b. A physician's order dated 11/30/23 directed Ketoconazole external shampoo 2%, apply to scalp topically every Wednesday for dandruff, leave on 5 minutes and rinse off. Review of electronic e-MAR identified on 1/3/24 during 7:00 AM to 3:00 PM shift the resident had Ketoconazole shampoo applied to scalp and rinsed (2 days prior to observation). Observation on 1/5/24 at 11:48 AM identified Resident #30 sitting in a recliner next to a nightstand by the entrance into her/his room. There was an unattended plastic bottle, approximately 50 % full, labeled Ketoconazole 2% shampoo with directions and the residents name on the nightstand. Interview with LPN #4 on 1/5/24 at 11:49 AM identified she was unsure why Resident #30 had the prescribed shampoo in her/his room since she/he had a shower and shampoo a few days ago. A further interview identified the shampoo should not have been left in the resident's room as it was considered a medication. Interview with Resident #30 on 1/5/23 at 12:10 PM identified she/he had been using the shampoo as a body wash and she/he had been applying it to her/his fungal skin rash. Interview with RN #2 on 1/5/24 at 12:59 PM identified Ketoconazole 2% shampoo should not be left at the resident's bedside unless there was a physician order. Review of the resident's clinical record identified the physician orders lacked an order for Resident #30 to self-administer medications, or to keep Ketoconazole shampoo in her/his room. Review of facility Medication Storage Room/Medication Cart policy revised on 1/2/24 identified medications are stored primary in a locked mobile medication cart which is accessible only to licensed nursing personnel. Storage for other medications will be limited to a locked medication room. The medication cart is to be kept locked at all time when not in use by the nurse. The medication cart is to be locked when stored in the medication room or some other location. 2. Resident #57's diagnoses included chronic obstructive pulmonary disease, congestive heart failure, and anxiety disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #57 as cognitively intact, independent with activities of daily living and a current tobacco user. The Smoking Evaluation and Safely Screen dated 7/17/23 identified Resident #57 as a current smoker. The Resident Care Plan dated 11/3/2023 identified respiratory disease related to obstructive sleep apnea, active smoker, and oxygen dependency. Interventions directed to provide oxygen as ordered, encourage the resident to pace activities to prevent episodes of dyspnea and fatigue, and to instruct the resident concerning the facility's policy on smoking. Interview with the Director of Nurses (DNS) on 1/3/23 identified Smoking Evaluation and Safety Screen are performed and completed for all residents who smoke quarterly. The facility failed to provide completed Smoking Evaluation and Safety Screens for Resident #57 in both July 2023 through September 2023. Review of the Smoking Policy revised on 1/2/24 directed residents who smoke would be evaluated for their ability to smoke upon admission, quarterly, and as directed by any significant change in condition to ensure that the resident continue to be capable of smoking and use smoking materials without presenting a danger to themselves or others. b. Observation on 1/4/24 at 1:48 PM identified Resident #57 seated next to a smoking tower, smoking, with his/her nasal cannula placed on his/her face but not connected. Resident #57 had disconnected his/her oxygen tank and left the tank in the facility. Interview with the Facility Administrator on 1/4/24 at 3:20PM identified nasal cannulas were to be stored in a plastic bag and maintained in the facility during smoking breaks. The Administrator also indicated the residents should not be wearing nasal cannula during their cigarette breaks and are expected to follow policy for oxygen and smoking. Interview with Nurse Aide (NA #3) on 1/4/24 at 3:40 PM identified he/she was unaware residents were not to wear nasal cannula's during their smoking breaks or that the nasal cannula should be placed in a plastic bag during smoking breaks. Review of the Smoking Policy revised on 1/2/24 directed residents will not be allowed to take their oxygen tubing to the supervised smoking areas during scheduled smoking times and the nasal cannula will be stored in a plastic bag and maintained off the floor. 3. Resident #134's diagnoses included chronic obstructive pulmonary disease, congestive heart failure, and other specified depressive episodes. The annual Minimum Data Set assessment dated [DATE] identified Resident #134 as moderately cognitively impaired and a current tobacco user. The Resident Care Plan dated 10/27/23 identified the resident required assistance and supervision, noted a diagnosis of chronic obstructive pulmonary disease, and taking maintenance antidepressants. Interventions directed to gather, provide, set-up all materials, supplies, and equipment needed, monitor for dyspnea, rapid/shallow respirations, shortness of breath, and to provide support, reassurance, and encourage verbalization of thoughts and feelings and supportive listening. Observation on 1/4/24 at 1:35 PM identified Resident #134, seated next to an ashtray tower, smoking a cigarette during his/her supervised smoking break. At 1:38 PM, surveyor observed NA # 3 leaving the smoking area, with his/her back turned not within eyesight of the residents smoking, to open the door for another smoker, Resident #130. Interview with NA #3 on 1/4/24 at 2:17 PM identified he/she left Resident #134 to open the door for an additional resident to have their smoking break. NA#3 indicated residents cannot be left at any time or unsupervised at any time during their smoking break. NA # 3 indicated when he/she went to let an additional resident out of the building, he/she took his/her eyes off Resident #134 while smoking a cigarette. NA #3 further indicated it was policy to continually monitor residents while on smoking breaks to avoid a serious accident from occurring. Interview with the Facility Administrator and Director of Nurses on 1/4/24 at 3:47 PM indicated smokers should not be left unsupervised or unattended during their smoking breaks, even for a short period of time as it places the resident in an unsafe situation potentially at risk of harm. Review of the Smoking Policy revised on 1/2/24 directed smoking will take place under the supervision of a staff member.

Based on observation of the nourishment refrigerator and snack area on the memory care unit and interviews, the facility failed to date and label and remove expired food items. The findings include. An observation and interview with NA #3 on 1/4/23 at 12:39 PM with NA#3 who led the surveyor to the nourishment room on the memory care unit which he/she unlocked with keys on his/her person, identified a refrigerator on the right side of the room with and up to date temperature log on the refrigerator door. On top of the refrigerator was a plastic bin labeled snacks had 2 open containers which NA#3 indicated family members brought into the facility and further indicated it was nice to have something to give the residents if they were hungry. The opened container of cookies had no dates when opened and no expiration date. The container of gluten free muffins had 2 muffins remaining and the container had a manufacturer date of expiration of 12/24/2023. Interview and observation with the Director of Dietary on 1/4/2023 at 1:15 PM indicated the dietary department only services 3 nourishment room refrigerators one on the ground floor, one of the first and one on the second floor. The Dietary Director further indicated the temperature monitoring logs are maintained by housekeeping staff, the dietary department delivers food and drink to the refrigerators and cabinets on the three units, label items and discard items that are past the 3-day limit of opened items. On 1/4/2023 at 1:20 PM interview and observation with LPN #1 charge nurse on the memory care unit indicated the unit did not have a nourishment refrigerator but when shown where it was opening the door with a key kept on his/her person. LPN#1 further indicated s/he would call for the memory care Recreation/Coordinator to assist. On 1/4/2023 interview and observation at 1:25 PM with the Memory Care Coordinator and the Dietary Manager in attendance indicated the unit has a refrigerator that is used by staff. The refrigerator items included a small glass container with a sealed foil cover no indication of contents but stamped with best by November 2023, a bottle of ensure with an expiration dated of 12/1/2019, and 2 containers of a supplement labeled med pass unopened on regular and one sugar free that were not expired. The Memory Care Director indicated the further items, pitcher of juice in the refrigerator and carton of individual ice cream cups in the freezer are used for the residents during activities. One carton of a store brand strawberry ice cream with no expiration dated was noted in the freezer which the Memory care coordinator indicated a second shift staff member who is a nurse aide and recreation assistant brought the ice cream in to have something to give to residents in the evening. The draws in the snack area identified 2 packets of beverage thickener with expiration dates of 9/18/2022 and 2 packets with expiration dates of 11/22/23 in a basket along with non-expired thickener packets. The dietary manger indicated the dietary department does not supply items to this room, items come up on a cart for use during dining and the carts go back to dietary. The expired foods were gathered by the dietary manger and the Memory Care Coordinator to be discard. The DNS arrived at the unit at 1:30 PM was updated and shown the findings and indicated he/she first became aware of the refrigerator earlier that morning. The DNS indicated all the food items will be removed and discarded, and the refrigerator removed from the room. The facility policy dated 1/3/2024 indicated residents have the right to have food brought in by family members or other visitors and indicated the food must be handled in a way to ensure the safety of the resident. The policy further indicated all foods brought in that are manufactured and do not require refrigeration may be kept in the resident's room inside an appropriate container provided by the resident and or resident representative. Although a policy was requested of the Dietary Manager regarding labeling and storage of foods in and out of the refrigerator, no policy was found . However, the policy did indicated standard practice is to label foods with an expiration of 3 days once opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, review of facility documentation, review of policy and interviews for 2 residents ( Residents # 7 and# 10), the facility failed to store urinals, bath basins and bed pans in a sanitary way and in accordance to the facility policy and for 2 of 5 residents (Resident #83 and Resident #111), the facility failed to ensure the residents were protected against infection by ensuring Transmission Based Precautions were implemented. and for 1 of 2 sampled residents ( Resident # 126) reviewed for pressure ulcer, the facility failed to ensure staff perform hand-hygiene to prevent of the spread of infection. The findings included: 1. Resident #7's diagnoses included repeated falls, muscle weakness, and bilateral osteoarthritis of the knees (Osteoarthritis is a long-term degenerative joint condition in which the tissues and parts of the joints gradually deteriorate, causing pain and stiff joints). The quarterly MDS assessment dated [DATE] identified Resident #7 was cognitively intact and was dependent with assistance of 2 person for toileting and hygiene and was independent with set up with eating. The physician order dated 12/12/23 directed Resident #7 to be placed on enhanced barrier precautions every shift related to having a history of Extended-spectrum beta-lactamases (ESBLs), which are enzymes or chemicals produced by germs and bacteria. The physician order dated 12/24/23 directed Resident #7 be placed on droplet precautions every shift related to testing positive for Covid-19. The Resident care plan dated 12/26/23 identified Resident #7 was incontinent of bowel and/or bladder. Interventions included assisting with incontinence care approximately every 2 hours and as needed. The care plan also identified Resident #7 had an increased susceptibility for infections related to a history of ESBL with the goal to reduce the risk of transmission of infection. 2. Resident #10's diagnoses included urinary retention, neuromuscular dysfunction of bladder. The physician orders dated 7/14/23 directed Resident #10 be placed on enhanced barrier precautions every shift related to having a suprapubic catheter. The quarterly MDS assessment dated [DATE] identified Resident #10 was alert and moderately cognitively impaired and required total dependence with assistance of 2 for toilet use, personal hygiene, and was independent with set-up for meals. The RCP dated 11/14/23 identified Resident #10 had a suprapubic catheter (SPC) secondary to neurogenic bladder, placing the resident at risk for infection. Interventions included assessing for urinary tract infection, providing catheter care every shift and as needed and monitoring output for odor, color, consistency, amount, blood, and sediment. Observation on 1/2/24 at 11:47 AM in shared bathroom for room Resident # 7 and Resident # 10 contained the following: a) 1 pink bath basin with one gray bedpan inside, which was on the floor and to the right of the toilet, both unbagged and unlabeled. b) 1 pink bedpan behind the toilet, lodged in the metal rail and in front of 2 opened toilet paper rolls and 1 unopened toilet paper roll, unbagged and unlabeled. c) 1 clear plastic graduated cylinder sitting on top of opened white cloths, unlabeled and unbagged, resting on top of the back of the toilet. Observation and interview on 1/2/24 at 2:12 PM with LPN #3 in shared bathroom by Resident # 7 and # 10 identified the bathroom contained. a) 1 pink bath basin with one gray bedpan inside, which was on the floor and to the right of the toilet, both unbagged and unlabeled. b) 1 pink bedpan behind the toilet, lodged in the metal rail and in front of 2 opened toilet paper rolls and 1 unopened toilet paper roll, unbagged and unlabeled. c) 1 clear plastic graduated cylinder sitting on top of opened white cloths, unlabeled and unbagged, resting on top of the back of the toilet. LPN #3 indicated that she could not identify if the items in the bathroom were clean or dirty and she would expect the bedpans to be labeled, cleaned, and bagged, and not left in the shared bathroom. Interview with the Infection Control Nurse on 1/3/24 at 11:07 AM indicated the storage of bedpans, urinals and bath basins included cleaning, drying, and storing these items in a bag in the resident's bedside table according to facility policy. She further indicated she would not expect to see these items in a shared bathroom between residents. Interview on 1/5/24 at 1:20 PM with the Director of Nursing (DNS) indicated bedpans and urinals should be labeled with resident's room number, date and be placed in a bag and placed in the bottom drawer of each resident's bedside table. The DNS indicated nursing staff and nurse aides' responsibility include labeling and storing of bedpans per facility policy. The DNS included she could not explain why this did not occur. Policy review for the use of bedpans/ urinals indicated that each urinal and bedpan should be dry, covered, and returned to the residents/patient's bedside stand bagged. 3. Resident #83's diagnoses included nervous system disease, paraplegia, heart failure, diabetes, and dementia. The quarterly MDS assessment dated [DATE] identified the resident moderately cognitively impaired, dependent for bathing, rolling side to side, transfers, toilet use, and set-up/clean up assistance with meals. A Resident Care Plan dated 12/28/23, indicated Resident #83 at risk due to impaired cognition, forgetful, at times confusion, delusional though processes, difficulty seeing, and required assistance with bathing, dressing, grooming, hygiene, requires extensive assist due to limitation with extremities and hand tremors. Interventions included total lift to custom wheelchair, gather, provide, set-up all materials, supplies, equipment as needed. 4. Resident #111's diagnoses included: dementia, cerebral infarction (stroke), and dysphagia (difficulty swallowing). A Resident Care Plan dated 12/6/23, indicated Resident #111 at risk due to pneumonia and cognitive loss/dementia, required extensive assistance with bathing and dressing. Interventions included antibiotics as ordered, encouraging fluids, and monitoring for signs and symptoms of pneumonia, and providing verbal cues, prompts, redirection, and hand-over-hand assistance as needed. The admission MDS assessment dated [DATE] identified the resident as severely cognitively impaired, dependent for bathing, dressing, personal hygiene, eating, transfers varied from dependent to partial/moderate assistance, and bed mobility with supervision or touching assistance. An APRN's progress note dated 12/19/23 indicated Resident #111 an airborne transmission-based illness with pneumonia. An APRN's progress note dated 12/26/23 indicated APRN visited Resident #111 to review chest x-ray results and follow up on positive test of an airborne transmission-based illness. A nurse's progress note dated 12/25/23 identified Resident #111 had vomited and tested positive for airborne transmission-based illness. Review of facility documentation, an in-service dated 12/5/23 on 1/1/24, titled Infection Control indicated that the following content was provided to staff: During a COVID outbreak, ensure that nursing staff is updated on any respiratory symptoms related to COVID, hand hygiene must be practiced by all employees as it is the most important way to prevent the spread, masking is required in all patient care areas. Staff that do not follow these protocols can face disciplinary action. A Nurse's Progress Note dated 1/01/24, and 1/04/24 indicated Resident #83 was tested due to an airborne transmission-based illness exposure and was negative. On 1/02/24 at 12:31 PM surveyor observation of Resident #83 and Resident #111 identified the residents lying in bed, with the room door open, Resident #111 was coughing while Resident #83 was eating, with the privacy curtain located between the residents' beds in an open position. Interview and observation on 1/02/24 at 12:57 PM with LPN #5, identified Resident #111 was positive for an airborne transmission-based illness and his/her roommate, Resident #83 tested negative at the time. She further indicated the facility handles positive and negatively tested individuals by keeping them together and testing the residents, she additionally indicated there were no rooms available to move the resident to, therefore they were co-horted. Lastly, when the surveyor indicated to LPN #5, Resident #83 and Resident #111 were in their beds with the curtain opened between the residents while Resident #111 was observed coughing at the time Resident #111 was eating. Upon observation of residents and residents' room with LPN #5, she indicated that the curtain should be kept closed between positive and negative tested residents. On 1/3/24 the DNS provided a copy of a corporate memo from the Director of Infection Prevention dated 12/28/23 indicated that if a COVID positive resident is identified, that resident remained on isolation for 10 days, residents with exposures were not required to be on isolation unless they become symptomatic or test positive during post exposure testing, positive residents should be placed in a single room or be co-horted with another positive resident. Attempts should be made to separate a positive resident from a negative roommate, but if bed unavailability prevents this, the two can remain together with the curtain drawn with daily testing of the negative roommate and that COVID units are no longer a requirement. On 1/3/24 at 11:15 AM interview and facility documentation review with RN #1, Infection Control Nurse identified the facility manages co-horting of positive and negative residents, as guided by regional infection control as follows to have positive tested residents in 10 days of isolation, if exposure to a positive individual exposed resident then tested on days 1, 3, 5 or if any symptoms, if someone is positive then they are given a private room, if not available facility co-horts a positive and negative resident that were already roommates. She further indicated that the facility did not have bed availability to move and cohort as admissions would be arriving. Lastly, she confirmed that curtains are supposed to remain closed as per memo from regional infection control. Review of facility policy annual review dated 01/02/24 titled Emergency COVID-19 Pandemic Co-horting Residents to Prevent the Spread of COVID-19. The goal of co-horting is to minimize interaction of infectious individuals from non-infected individuals as much as possible. Every interaction is a risk because it is how the COVID-19 virus spreads. The procedure directs that co-horting plans must follow both the state and federal regulations. 5. Resident #126's diagnoses included Crohn's Disease, gastrointestinal hemorrhage, and diabetes mellitus, type 2. A physician's order dated for October 2023 directed to apply a protective foam dressing to left buttock every Monday, Wednesday, and Friday on the day shift. The annual Minimum Data Set assessment dated [DATE] identified Resident #126 was cognitively intact and was dependent with toilet hygiene, showering, and chair to bed transfer. The Resident Care Plan dated 10/5/23 identified Resident #126 is at risk for pressure injury and skin breakdown related to bowel incontinence, mobility, and nutrition. Interventions directed to offer turning and positioning every two hours, treatments as ordered, and weekly skin inspections. Observation of Resident #126's wound care and interview with RN #1 1/9/24 at 9:25 AM identified RN#1 setting up her work area on a clean work surface, removing the dressing from Resident #126's sacral area with gloved hands, then failing to remove her gloves and perform hand hygiene prior to cleaning the wound. RN#1 indicated she should have changed her gloves and performed hand hygiene after removing the resident's dressing as policy directs but forgot to as she was nervous being watched. Interview with the Director of Nursing on 1/9/24 at 9:35 AM indicated policy directs to changing gloves following the removal of a dressing during wound care and to perform hand hygiene following glove removal. Review of the Hand Hygiene policy revised on 1/2/24 directed to use alcohol hand sanitizer before placing on, after removing gloves, and after contact with the resident's skin.

Based on observations, review of facility documentation and interviews, the facility failed to ensure the kitchen ice machine was cleaned and sanitized regularly, the kitchen floor was free of a thick buildup of grease surrounding the grease trap, surrounding pipes were cleaned and failed to properly repaired hole in the dishwashing sink to ensure equipment was maintained in safe operating condition. The findings included. 1. Observation and interview with the Dietary Manager and Dietary Assistant #1 on 1/4/2023 at 9:30 AM identified the ice machine cover when opened the device was noted with a buildup of a dark substance along the top edge which makes the ice cubes. Dietary Assistant (DA #1) wiped the area with a paper towel which removed the dark substance. The Dietary Director indicated the maintenance of the ice machine included yearly maintenance and nightly wipe down of the inside of the ice machine by dietary staff. No logs or assignments for this task being completed by the dietary staff were provided. 2. Further observation in the kitchen on 1/4/2023 at 9:30 AM identified a thick buildup of grease on the floor surrounding the grease trap located under the dishwasher counter and the pipes leading to the area. DA #1 indicated staff tries to keep up with cleaning and have a log of regular cleaning or who was responsible to clean it. Observation of the dishwashing sink identified a slow water leak onto the floor from a crack in the corner of the steel sink half up the sink's outer right corner. The Dietary Manger indicated the sink was filled too high (past the crack, sink was ½ full of water), so the water was leaking through the crack onto the floor. Dietary Assistant #1 lowered the water level in response to the noted water leak. 3. During an interview and observation with the Dietary Director, Maintenance Director, and the Regional Maintenance Director on 1/4/2023 at 10:05 AM, the Maintenance Director indicated he had previously applied a material to seal the crack in the sink from the outside of the sink as the only other alternative was to have the whole sink system removed and sent out to be welded. The Maintenance Director also indicated the area needed to be sealed again and further indicated he/she would remove the current seal and reseal it to prevent the sink from leaking. The Director of Maintenance indicated he/she would find documentation regarding the cleaning of the ice machine. On 1/5/2023 at 9:00 AM documents were provided labeled Water Management Plan Ice Machine in Kitchen was a monthly inspection completed by facility staff and at a minimum, every 6 months the ice machine should be internally cleaned for bacterial build up with the ice and removed from the bin and the bin thoroughly cleaned. Interview and facility document review with the Regional Maintenance Manager noted a document dated 5/31/2023 indicating service of the ice machine, providing cleaning, sanitation, and inspection with filter cartridge replacement (512 days ago) was overdue for service and indicated the reason it was not completed in December 2023 was that the service personnel were ill and indicated an upcoming appointment is scheduled.

Based on observations, interviews, and review of facility documentation for 2 of 5 nursing units (with a total census of 68 residents affected), the facility failed to maintain safe/comfortable environmental temperatures, which are defined as a range of 71 to 81 degress Fahrenheit. The findings include: Observations on 7/18/23 at 2:45 PM identified resident room temperatures on the first floor reading 84-86 degrees Fahrenheit and on the second floor 89-91 degrees Fahrenheit. Interview with the Administrator on 7/18/23 at 2:45 PM identified on 7/13/23 the facility encountered a malfunction of the cooling system at which time a contractor was notified. The contractor was onsite on 7/13/23 and identified a problem with the 15 ton, rooftop, air conditioning unit for the affected areas. A replacement part was ordered and was anticipated to be delivered within 7-14 days. The facility installed 10 portable air conditioning units for both the first and second floors, however, the units were ducted incorrectly and ineffective in lowering temperatures for the affected floors on the resident units. The facility failed to supply a temperature log for the time period of 7/13/23 through 7/18/23. The Administrator failed to provide evidence of additional cooling interventions that were implemented to maintain safe and comfortable temperatures in the resident rooms and common areas when it was determined that the 10 portable air conditioning units were ineffective. Subsequent to surveyor inquiry, the facility contacted a rental company and a 25 ton trailer mounted air conditioning unit was delivered and installed to provide cooling for the second floor. On 7/19/23 additional duct work from the rental unit to the building was installed to provide cooling to the first floor (where temperatures remained high) as well as the second floor.

Based on observations, interview, and review of facility documentation, the Administrator failed to ensure a safe and comfortable resident environment for 2 of 5 nursing units. The findings include: Observations on 7/18/23 at 2:45 PM identified resident room temperatures on the first floor reading 84-86 degrees Fahrenheit, and temperatures on the second floor reading 89-91 degrees Fahrenheit. Interview with the Administrator on 7/18/23 at 2:45 PM identified on 7/13/23 the facility encountered a malfunction of the cooling system for the first and second floors, at which time a contractor was notified. The contractor was onsite on 7/13/23 and identified a problem with the 15 ton, roof top, air conditioning unit for the affected resident areas. A replacement part was ordered and was anticipated to be delivered within 7-14 days. The facility installed 10 portable air conditioning units for both the first and second floors, however, the units were ducted incorrectly and were ineffective in lowering temperatures for the affected resident nursing units. The Administrator indicated he was unaware there was a requirement to notify the state agency of the elevated temperatures on resident units. Although the Administrator identified excessive temperatures on the first and second floors, he failed to direct facility maintenance staff to routinely monitor temperatures in resident rooms and common areas. The Administrator failed to provide evidence that additional cooling interventions were implemented to maintain safe and comfortable temperatures for residents in their rooms or in common areas when the 10 portable air conditioning units were ineffective. Additionally, the Administrator failed to direct nursing staff to provide hydration stations to prevent resident dehydration, and failed to direct enhanced resident monitoring and assessment for resident changes in condition related to excessive heat. Subsequent to surveyor inquiry, the facility contacted a rental company and a 25 ton trailer mounted air conditioning unit was delivered and installed to provide cooling for the second floor. On 7/19/23, after determining that the 25 ton trailer unit failed to provide adequate cooling to the first floor, additional duct work from the rental unit was installed to provide cooling to the first floor (temperature remained high) as well as the second floor. Please refer to F584

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation review and interviews for one of two residents (Resident #144) reviewed for advanced directives, the facility failed to complete advanced directive in a timely manner. The findings include: Resident #144 was admitted during [DATE] with diagnoses that included hypertension, Parkinson's disease, and cognitive communication deficit. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #144 had mild cognitive impairment and required extensive assistance with activities of daily living. The Resident Care Plan dated [DATE] identified that resident had an established advanced directive and that Resident #144's wishes were to have CPR. Interventions directed to review the code status with Resident #144 or his/her responsible party quarterly. Review of the clinical record identified Resident #1 had a family member designated as his/her responsible party (Responsible Party #1). A physician's order dated [DATE] directed that Resident #144 code status was a Full code/CPR Interview with Resident #144's Responsible Party #1 on [DATE] at 11:45 AM identified that he/she was present with Resident #144 upon admission and visits almost daily. He/she indicated that no staff had mentioned or discussed Resident #144's advance directive with him/her. Responsible Party #1 indicated that they were waiting to complete the directive because there had been a change in Resident #144's wishes and Resident #144 did not wish to receive CPR. In an interview and clinical record review with the DON on [DATE] at 11:26 AM, the DON was unable to provide documentation that Resident #144 or his/her responsible Party #1 had designated advanced directives. She indicated that the clinical record failed to reflect documentation of Resident #144's advanced directive wishes. She reported that the nurse assigned to the admission process was responsible to ensure the advance directive consent was in place. She explained that the expectation was that the advance directive consent be completed within 24 hours of admission. Subsequent to surveyor's inquiry on [DATE], Resident #144's advanced directives were signed/completed, and MD orders were obtained that directed Resident #144's advance directives was Do Not Resuscitate (DNR) status (no CPR). Review of the advanced directive policy directed in part, that prior to or upon admission the director of admissions or designee will discuss with the resident and/responsible party whether or not they have executed any form of advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility policy review and interviews for one sampled resident (Resident #51) observed unsupervised with medications at the bedside, the facility failed to ensure licensed staff remained with the resident during medication administration and the facility failed to ensure medications were secure and inaccessible to unauthorized staff/residents. The findings include: Resident #51's diagnoses include dementia, hypertension, neuropathy, atrial fibrillation, and mood disorder. The quarterly MDS dated [DATE] identified Resident #51 had intact cognition and required limited assistance with ADLs. The Resident Care Plan (RCP) dated 8/26/2021 identified a diagnosis of dementia with long- and short-term memory deficits. Interventions directed assist Resident #51 in orienting to setting and routine. Observation on 9/14/2021 at 9:13 AM, identified Resident #51 was sitting at the edge of the bed in front of a tray table containing breakfast and a cup of medications. Further observation identified LPN #6 was three doors (three rooms) down the hall at a medication cart preparing medications for other residents. Interview with LPN #6 at the time identified that LPN #6 left the medications on the tray table because Resident #51 was going to be getting up and was going to take the medications. LPN #6 further indicated that medications are not be left with a resident unsupervised and the nurse must witness the resident taking medications. When LPN #6 and the surveyor walked back to Resident #51's room, the medication cup was empty. Interview with Recreation Therapist #1, who was with the resident at the time, indicated the therapist observed Resident #51 take the medications. LPN #6 identified the following list of medications were in the medication cup left unattended with Resident #51: Metoprolol Tartrate 12.5 milligrams (mg), Keppra 2-500 mg tablets, Aspirin 81 mg, Zoloft 50 mg, Ticagrelor 90 mg, Gabapentin 100 mg and Depakote 500 mg. LPN #6 indicated that she should not have left the medications with Resident #51, and she should have supervised Resident #51 taking the medications. Review of the Medication Administration Record identified all of the medications were signed off on 9/14/2021 at 8:47 AM, (approximately 26 minutes before the medications were observed Resident #51's tray table.) Review of the Oral Medication Administration Policy dated June 2015, directed in part, to stay with the resident/patient until he/she has swallowed the medication.

Based on observations, facility's documentation review and interviews for kitchen maintenance, the facility failed to ensure food items were labeled and dated in accordance with facility policy, and the facility failed to ensure foods were discarded timely when spoiled. The findings include: Observations on 9/13/2021 at 10 AM with the Director of Dietary (DD), two trays of buttered bread were observed in the refrigerator without any date to identify when they were placed in the refrigerator. Observation of the food storage room identified five (5) plastic bags containing bread rolls on the shelf. the rolls were observed to be covered with a gray colored matter and no expiration date was noted on the outside of the bags. Subsequent to surveyor inquiry, the DD discarded the bags of rolls. During an interview with the DD on 9/13/2021 at 10:20 AM the DD indicated the rolls may have been covered with mold because they were delivered frozen and the facility stored bread thawed, and they should have been discarded. She further identified that food items in the refrigerator should be labeled with a date to identify when the food was prepped (bread buttered) and the rolls should have had an expiration date. Review of the facility's undated Food Policy directed in part, that all food items should be labeled and dated to allow for rotation of supplies. The Policy further directed that all items stored in the refrigerator will be covered and labeled with the contents and the date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation and interviews for one sampled (Resident #85) who was reviewed for the misappropriation of personal property, the facility failed to ensure the resident's medication was not utilized for another individual. The findings include: Resident #85's diagnoses included venous insufficiency chronic peripheral, bilateral lower extremity lymphedema, and chronic pain syndrome. A physician's order dated 7/26/18 directed Cyclobenzaprine HCL 10 milligrams daily at bedtime for muscle spasms. The annual Minimum Data Set assessment dated [DATE] identified Resident #85 had no short and/or long term memory deficits, was independent with making decisions regarding tasks of daily life, and required supervision or limited one (1) person assistance with activities of daily life. The resident care plan dated 7/25/18 identified the resident was at risk for pain related to nerve pain in the legs and feet and muscle tightness in the hands. Interventions directed to administer the pain medication and muscle relievers as ordered and observe the effectiveness, and monitor symptoms of increased pain and report. The Reportable Event Form dated 8/17/18 at 4:00 PM identified the misappropriation of resident property. The report identified that the Director of Nursing was notified by the pharmacy Resident #85's medication Flexeril (Cyclobenzaprine) was being re-ordered to soon indicating a total of nine (9) tablets unaccounted for. Upon investigation that included multiple staff interviews, it was noted a charge nurse borrowed medication from Resident #85 on two (2) occasions for what was thought to be given to another resident. The report identified the employee involved in the incident was removed from the schedule pending the outcome of the investigation. In a statement the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, identified she had cluster migraines that came and went and the Flexeril helps to stop the spasms. LPN #1 identified she had a migraine the previous week and the night before the missing medication was noted. Interview with the Director of Nursing (DON) on 5/14/19 at 11:43 AM identified a 3-11PM charge nurse approached and informed her that another charge nurse, LPN #1, asked to borrow Flexeril and the pharmacy re-order form indicated it was too early to re-order the medication. The DON stated she conducted an audit of the facility and found that only one (1) resident, Resident #85, received the Flexeril. The DON identified LPN #1 was assigned to a different unit than Resident #85, however, LPN #1 knew the resident was on Flexeril because she had worked on the resident's unit in the past. The DON stated in an interview with herself, the Administrator and Human Resource, LPN #1 admitted to the misappropriation of personal property on two (2) occasions. Subsequent to the incident, LPN #1 resigned her employment. Review of the Abuse Prohibition policy identified the Misappropriation of Resident Property was the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #349) who had difficulty with swallowing and was being treated by speech therapy, the facility failed to ensure the resident care plan was reviewed and/or revised with the speech therapy strategy recommendations. The findings include: Resident #349's diagnoses included diabetes mellitus, Parkinson's disease, dementia, hypoxia, and a history of aspiration pneumonia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #349 had short and long term memory deficits, did not make decisions regarding tasks of daily life, and was totally dependent on one (1) person with eating. The resident care plan from 7/28/18 through 8/15/18 identified the resident had an ineffective breathing pattern and swallowing issues. Interventions directed puree diet with increased moistures and honey thick liquids as ordered, aspiration precautions, total assist with feeding, slow small bites and sips and alternate liquids and solids, speech therapy to evaluate and treat as indicated, and head of the bed elevated for meals and out of bed for other meals. The speech therapy evaluation and plan of treatment dated 7/28/18 identified Resident #349 was re-evaluated status post re-admission from the hospital. The evaluation identified the resident had delayed coughing and burping, inattention to bolus, difficulty and inability to open the oral cavity, and decreased safety awareness. The strategies to facilitate safety and efficiency were rate modification, alternation of liquids and solids, bolus size modifications, upright posture during meals and for greater than thirty (30) minutes after meals, one bite at a time, and watch for swallowing, allow thirty (30) to forty (40) seconds between bites, check the oral cavity for clearance, frequent liquid washes and small bites, and towel to prop head for optimal seating. Review of the resident care plan and resident care cad failed to reflect documentation of all the strategy recommendations by speech therapy. Interview with the Director of Nursing (DON) on 5/14/19 at 9:29 AM identified the speech therapy recommendation should be documented in the care plan and resident care card. Interview with the speech therapist on 5/4/19 at 10:30 AM identified the staff on the unit are in-serviced regarding the strategies, she would get as many staff as possible and the staff will sign when they have attended. The speech therapist indicated that she will update the care plans and was not sure why all the strategies were not included. The therapy department was unable to locate documentation, sign in sheets, of those staff members who had been in-serviced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #7) reviewed for nutrition, the facility failed to implement interventions according to the dietary assessments and physician's orders. The findings include: Resident #7's diagnoses included dementia, depression, diabetes, lymphedema, hypertension, anemia and failure to thrive. The quarterly MDS dated [DATE] identified that Resident #7 had intact cognition, required extensive assistance with bed mobility and transfers, supervision with eating, and weighed 155 lbs. The care plan dated 2/27/19 identified Resident #7 was at nutritional risk. Interventions included to provide supplement as ordered. A dietician note dated 4/12/19 identified that between March and April 2019, Resident #7 had a weight loss of 15.6 lbs. The dietitian suggested to add fortified cereal in the morning and fortified juice twice a day. A physician's order dated 4/13/19 directed to provide a regular consistency diet with thin liquids, fortified juice twice a day, and fortified cereal in the morning. A weight and vital summary sheet dated 4/20/19 identified Resident #7 weighed 125.3 lbs., (additional weight loss of 6.1 lbs.) A medical nutrition therapy assessment dated [DATE] identified Resident #7 weighed 125.3 lbs., the resident had further undesirable weight loss identified, had variable intake, often poor. APRN noted the above weight loss and anorexia, and Remeron was increased. The resident will start house shakes and will continue fortified supplements as ordered. A medical nutrition therapy assessment dated [DATE] identified Resident #7 weighed 126.7 lbs., the resident had significant weight loss, variable meal intake and was taking supplements. A provider monthly progress evaluation dated 5/11/19 identified that Resident #7 weighed 126.7 lbs. on 5/4/19 and had a weight loss. Assessment and plan identified that Metformin and antihypertensive medications were discontinued, directed to observe closely for more weight loss and continue supplements. Interview and review of facility documentation with the Director of Dietary on 5/15/19 at 8:50 AM identified that Resident #7's meal tickets were not updated and the resident had not received fortified cereal every morning or fortified juice twice a day as recommended by the dietician on 4/12/19 and ordered by the physician on 4/13/19, (for over 1 month). The Dietary Director identified that subsequent to inquiry, fortified cereal and fortified juice were started on 5/14/19 (31 days after the initial recommendation). The Dietary Director also indicated she could not explain why the physician's orders were not implemented. The Dietary Director further identified that the dietary communication system will be revised and staff will be provided education. Interview and review of the resident's clinical record and meal slips with Registered Diet Technician #1 on 5/15/19 at 10:00 AM identified that although the dietitian recommended and the physician ordered fortified cereal and fortified juice for the resident to boost, maintain and/or prevent further weight loss, staff did not provide the supplements. Diet Technician #1 further identified that when she assessed the resident on 4/24/19 due to significant weight loss, she thought that the resident was receiving fortified supplements as ordered by the physician. Interview with MD #1 on 5/15/19 at 1:40 PM identified that he expected the facility to follow the orders for supplements as suggested by the dietitian and ordered. MD #1 further stated that together with medication dose adjustments and implemented supplements the resident appetite and weight should improve. Review of the facility's policy food first-nutrition directed to assess all residents and identified those residents at risk for weight loss and provide appropriate interventions according to the physical and mental abilities and his/her wishes. The policy further directed supplements, when recommended by dietician and ordered by the physician are documented by the licensure nurse on the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility documentation and interviews, the facility failed to maintain resident rooms and/or furniture in good repair. The findings include: Intermittent observations on 5/13/19, 5/14/19, 5/15/19, and 5/16/19 identified the following: a. Damaged, chipped and/or peeling paint on wall in room [ROOM NUMBER]. b. Damaged, peeling and/or worn veneer on nightstand in room [ROOM NUMBER], 215 and 225. c. Damaged, marred and/or chipped wood on dresser in room [ROOM NUMBER]. Interview with LPN #7 on 5/14/19 at 1:38 PM identified she was not aware of the damaged furniture in the resident rooms. LPN #7 indicated when bedroom furniture is damaged and/or need of repair the staff is to fill out the maintenance log located at the nurse's desk. Interview with Housekeeper #1 on 5/14/19 at 1:57 PM identified she is a float housekeeper and was unaware of damaged nightstand in room [ROOM NUMBER]. Housekeeper #1 indicated when furniture in room is in need of repair she will fill out the maintenance log at the nurse's desk. Interview with the DNS on 5/15/19 at 6:52 AM identified she was not aware of the damaged furniture in the resident rooms and indicated that her expectation is when damaged furniture is noticed it would be reported to the maintenance department by a written entry in the maintenance log located on each unit. The DNS indicated if it is a safety issue, maintenance is to be called immediately. Review of the environmental rounds forms failed to reflect the damaged furniture and/or wall. Review of the maintenance log repair request form dated 1/12/19 through 5/13/19 failed to identify any requests for furniture repair. Interview with the Physical Plant Director on 5/16/19 at 11:24 AM identified he was not aware of damaged furniture in rooms and indicated when repairs are needed, staff is to fill out the maintenance log, and RN #2 will send him the result of environmental rounds if there are any issues. Interview with the Infection Control Nurse, (RN #2) on 5/16/19 at 11:38 AM identified she was not aware of the damaged furniture in the rooms. RN #2 indicated when she does environmental rounds a copy of the report is given to the Physical Plant Director. Review of the policy for environmental rounds identified it is the policy of this facility that the infection preventionist or his/her designee, charge nurses or supervisors, complete unit rounds on a regular basis, but at least quarterly. Review of housekeeping standards of cleanliness and repair identified in good repair standard: attention to regularly scheduled preventive maintenance and/or routine remedial maintenance procedures maintain components in good-repair. Review of the Director of Physical Plant job descriptions identified the primary purpose of your position is to plan, organize, develop and direct the overall operation of the maintenance department in accordance with current federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator/Assistant administrator or Director of Environmental Services to assure that our facility is maintained in a safe and comfortable manner. Review of the facility physical environment policy identified the facility provides a functional, sanitary, and comfortable environment for residents, personnel, and public.