**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 abuse, the facility failed to ensure a resident was treated in a respectful and dignified manner. The findings include: Resident #1 had diagnoses that included anxiety, tobacco use, and moderate dementia with psychotic disturbance. The quarterly MDS dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicative of intact cognition, without the presence of behaviors, continent of bowel and bladder, independent with ADLs and ambulation. The care plan dated 12/10/24 identified Resident #1 is a current smoker with interventions that directed cigarettes and/or lighting material to be given by nursing at the designated times. The physician's orders dated 12/19/24 directed Resident #1 is permitted to smoke during designated smoking times only. Review of the facility's reportable event form dated 1/17/25 at 7:35 P.M. identified NA #1, LPN #2, LPN #3, NA #1, and NA #4 reported that when Resident #1 approached the nurse's station to ask LPN #1 a question LPN #1 in a raised voice used inappropriate language towards Resident #1. The facility's reportable event identified Resident #1 had no apparent injuries, no signs or symptoms of distress, and emotional support was provided. LPN #1 was sent home and suspended pending investigation. A nurse's note dated 1/17/25 at 11:17 P.M. written by RN #1 identified she was notified when Resident #1 approached the nurse station to ask when they were taking the residents out to smoke staff observed LPN #1 responding to Resident #1 using inappropriate language in a raised voice. RN #1 indicated Resident #1 walked away and went to h/her room. RN #1 indicated emotional support to Resident #1, Resident #1 was asked if h/she felt safe, and Resident #1 stated h/she feels safe at this time. RN #1 identified she notified the DNS, MD, and the police. RN #1 indicated she left a message for psych and Resident #1's POA. The facility's summary dated 1/23/25 identified LPN #1 had recently completed abuse training education which included prevention on 1/13/25. Social services interviewed other residents that residents on the floor and no other concerns or incidents were identified. After a thorough investigation including staff and resident interviews, the facility concluded that LPN #1 did speak to Resident #1 in an inappropriate manner which included a raised voice and LPN #1 used the word damn. LPN #1 was placed on leave pending the outcome of the investigation and LPN #1's employment has since been terminated. Interview with Resident #1 on 2/7/25 at 11:00 A.M. identified on 1/17/25 at approximately 7:15 P.M. when h/she asked LPN #1 when smoke break was LPN #1 with a raised voice stated It is none of my business I don't give a damn I am not taking you out it's not my job. Resident #1 identified when LPN #1 raised her voice h/she started walking away and went in h/her room. Resident #1 identified h/she did not feel embarrassed, humiliated, threatened and h/she felt safe. Resident #1 identified following the incident on 1/17/25 LPN #1 was sent home, and Resident #1 never saw LPN #1 again. Interview with LPN #3 on 2/7/24 at 11:15 A.M. identified on 1/17/25 at approximately 7:15 P.M. when she was at the nurse's cart in the west hallway, she heard LPN #1 yelling from the nurse's station It is not my damn job LPN #3 identified she walked over to the nurse's station observed LPN #1 standing at the nurse's station and Resident #1 was walking into h/her room. LPN #1 indicated Resident #1 replied 'I am okay I feel safe.' LPN #3 asked Resident #1 what happened Resident #1 reported h/she wasn't getting anywhere with LPN #1 so h/she was going back to h/her room. LPN #3 identified she notified the DNS and RN #1, and LPN #1 was sent home. Interview with NA #1 on 2/7/25 at 12:10 P.M. identified on 1/17/25 at approximately 7:15 P.M. she heard LPN #1 yelling speaking loudly to Resident #1 Go ask the nurse aides they have the answers it's not my damn job. NA #1 identified Resident #1 reported he had just asked LPN #1 to call downstairs to find out if his buddy was going to go on smoke break and Resident #1 said h/she was okay. Interview with the DNS on 2/7/25 at 1:30 P.M. identified on 1/17/25 at approximately 7:30 P.M. LPN #3 and RN #1 notified him that Resident #1 went to the nurse's station to ask LPN #1 who was taking them out for smoke break and LPN #1 raised her voice and used profanity towards Resident #1. The DNS identified he directed RN #1 to remove send LPN #1 home pending who was suspended pending outcome of the investigation. The DNS indicated an investigation was conducted that included interviews with staff and residents on LPN #1's assignment, staff statements were obtained, and an interview with Resident #1 was completed. The DNS identified based on the investigation on 1/17/25 when Resident #1 asked LPN #1 who was taking them out for smoke break LPN #1 said It is not my damn job it's none of my business I am not taking you out. The DNS identified LPN #1 was terminated because she did not treat Resident #1 in a respectful and dignified manner. The DNS identified his expectations are staff always treat all residents with respect and dignity. Review of the facility policy for Resident Rights directed residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of facility policy and procedures and staff interview for 1 out of 3 sampled residents (Residents # 21) who required assistance with care, the facility failed to ensure that signs were not posted in resident's rooms that contained personal and confidential information regarding the resident's plan of care and treatment regimen within eyesight of public view. The findings include: Resident # 21's diagnoses included cerebral infraction with hemiplegia and hemiparesis, dysphagia, heart failure and osteoarthritis. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 21 had severe cognitive impairment and required extensive assistance with bed mobility, dressing, eating and personal hygiene. The Resident Care Plan (RCP ) dated 6/22/23 identified Resident #21 with Activity of Daily Living (ADL) deficit. Interventions directed to encourage self-performance, praise all attempts, allow sufficient time for task completion, and assist as needed. Observations on 8/17/23 at 11:14 AM and 8/18/23 at 2:34 PM identified signs posted above Resident #21 bed that contained information regarding the residents out of bed to adaptive wheelchair scheduled time and directions for no blood pressure and no blood draw on left hand. The posted signs also noted directions to the staff to place the resident's teeth in because the resident communicated better with them in and directions to place items on the residents left side due to the resident not being able to use her/his right side. Interview and clinical record review with the Director of Nursing Services (DNS) on 8/18/23 at 2:56 PM identified that personal care instructions posted on the wall above the head of bed should be facing the wall or be placed inside the resident's closet. The DNS further identified the signs with Resident # 21's personal information will be removed immediately. Interview with Person #1 on 8/21/23 at 6:25 PM identified signs posted above Resident #21's head of bed containing information about the resident's care and needs have been there for months. Person #1 further identified the facility did not speak to him/her regarding posted signs and he/she thought the facility placed the signs to help staff to remember how to care for the resident. Although requested, a facility policy regarding access to health information and/or privacy practices were not provided. Review of Residents' [NAME] of Rights given onsite identified the resident has the right to privacy in accommodations, in receiving personal and medical care and treatment, in visits and in meetings with family and resident groups. However, the facility was not required to provide the resident with a private room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation, facility policy and staff interviews for 1 of 2 sampled residents (Resident #11) who was reviewed for Accidents/Falls, the facility failed to follow physician's orders and for 1 sampled resident (Resident #473) receiving antiviral medication to treat COVID-19, the facility failed to ensure that verbal medication order was transcribed to a written order in the resident's clinical record per facility policy and to meet professional standards. The findings included: 1. Resident #11's diagnoses included dementia, history of falling, unsteadiness on feet, and muscle weakness. A physician's order dated 4/1/2023 directed to check for placement of pressure alarm and function of bathroom alarm at shift changes every shift. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #11 was severely cognitively impaired and required extensive assistance with bed mobility, transfers, and toilet use. The Resident Care Plan dated 8/16/23 identified an ADL deficit related to impaired cognition, noncompliance, and decreased mobility, and risk of falls secondary to cognitive impairment, shuffled gait, and noncompliance with safety measures. Interventions directed to apply an alarm at bathroom the door and directed the nurses to check placement and function of pressure and bathroom alarm at shift changes and to clip the resident's alarm to lower part of bedframe and not side rail. An interview and clinical record review with the DNS on 8/23/23 at 12:30 PM identified a physician's order for nurses to check for placement of the pressure alarm and function of the bathroom alarm at shift changes each shift. However, the DNS indicated the order was erroneously entered on 4/1/23. The staff failed to transmit the physician's order to the Treatment Administration Record (TAR) therefore daily checks each shift was not completed from 4/1/23 to 5/15/23. Review of the physician's orders - transcription policy directed to carefully transcribe orders as written to Medication Administration Record (MAR) and/(TAR). 2. Resident #473's diagnoses included COVID-19, atrial fibrillation, congestive heart failure, chronic ischemic heart disease, chronic kidney disease, diabetes mellitus, and hypertension. The admission assessment dated [DATE] identified Resident #473 was alert and oriented to person, place, and time, and required assistance with transfer, bed mobility and ambulation. The nurse's note dated 8/16/23 identified Resident #473's COVID-19 swab results were positive. The Resident Care Plan dated 8/16/23 identified Resident #473 had actual COVID-19 infection. Interventions directed to provide transmission-based precautions as ordered and directed a follow up with the Medical Doctor (MD) / Advanced Practice Registered Nurse (APRN) as indicated. A physician's order dated 8/16/23 directed to administer Paxlovid (antiviral medications to treat COVID-19) 150/100 oral tablet therapy pack 10 x 150 mg and 10 x 100 mg (Nirmatrelvir-Ritonavir) to give 2 tablets by mouth two times a day for 10 administrations. Further review identified physician's orders which directed to decrease Apixaban (anticoagulant medications) 5 mg one tablet by mouth two times a day to 0.5 tablet and to hold Atorvastatin (to treat high cholesterol and triglyceride) from 8/16/23 to 8/26/23. The Reportable Even Form dated 8/17/23 identified on 8/16/23 at 9:00 PM Resident #473 was given morning dose and evening dose (two doses equal to 200 mg) of Ritonavir 100 mg instead evening dose of Nirmatrelvir 150 mg and Ritonavir 100 mg. The nurse's note dated 8/17/23 identified during morning medication pass Licensed Practical Nurse (LPN #4) and APRN #1 noted the resident received wrong dose of Paxlovid on 8/16/23 during evening shift. The APRN immediately assessed the resident. The APRN #1's note dated 8/17/23 identified Resident #473 was started on renal dose of Paxlovid, but due to medication administration error last night, the resident received two doses of Ritonavir, and none of Nirmatrelvir. The resident was washing up in the bathroom and reported feeling better. Further review of the APRN's #1 note identified Paxlovid would be held that morning (8/17/23) and resumed that night, and Apixaban will be also held that morning (8/17/23). Review of physician's orders identified order for Paxlovid with added note on 8/17/23 directing staff to note dosage on package, 2 tablets labeled morning dose and 2 tablets labeled evening dose. A physician's order dated 8/17/23 directed to discontinue Paxlovid and on 8/18/23 the physician's order directed to administer Molnupiravir (antiviral medications to treat COVID-19) oral capsule 200 mg by mouth two times a day for 10 administrations. Interview with APRN #1 on 8/22/23 at 10:34 AM identified Ritonavir and Nirmatrelvir (Paxlovid) were prescribed to treat COVID-19 and were ordered to be given together to enhance effectiveness. Paxlovid may cause overdose of other medications that otherwise would not happen, that is why he ordered to decrease Apixaban doses and to hold Atorvastatin medication. The resident's order included renal dose of Paxlovid which was a lower dose and administering double dose of Ritonavir might cause overdose of other medications and/or other concerns. APRN #1 further identified he would have expected to be called to clarify any questions regarding medication orders prior to medication administration to prevent medication errors. APRN #1 identified that after assessing the resident and reviewing the clinical record he felt that it was not safe to resume Paxlovid and ordered Molnupiravil to be administered instead to ensure prevention of drug interactions. Further interview with APRN #1 identified on 8/17/23 when he went to LPN #4 to verify if Paxlovid was started the day before, they both realized there was a medication error and APRN #1 gave a verbal order to hold morning dose of Paxlovid at that time. It was a significant medication error, and he was concerned about the possible effect of overdose on the resident. He was trying to determine what was the safest way to continue the resident's treatment for COVID-19 and forgot to write the order in the resident's clinical record. LPN #4 already carried out the order and held the morning dose of Paxlovid as she was directed. Interview with LPN #4 on 8/23/23 at 10:31 AM identified APRN #1 usually writes orders in the resident's clinical record himself. LPN #4 further identified that she implemented the verbal order to hold the morning dose of Paxlovid and continued to give other residents their morning medications and did not check if the verbal order was written on 8/17/23. Interview with DNS on 8/23/23 at 11:25 AM identified expectations were for nurses when taking verbal orders from APRN or MD to enter the orders into electronic resident's clinical record in facility computer system. The RN supervisors would monitor and ensure that orders were entered by the APRN or MD and not just written in the progress notes. Further interview with the DNS identified medication orders or change in medication orders must have a written physicians order to avoid any possible miscommunication and/or medications error. APRN #1 gave a verbal order to hold Paxlovid and nurse followed that order, but no order was written. Review of facility Verbal/Telephone Orders policy ---- directed in part to reduce errors associated with misinterpreted verbal or telephone communications of medication orders or test results verbal orders and test results will be immediately written down by the recipient, read back by the recipient, and confirmed or corrected by the prescriber. The order must be written before it is read back. The policy further directed recipients of verbal orders to sign, date, time, and note the order at the time it is written on the order sheet or documented in the computer system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation and staff interviews for 1 sampled resident (Resident #473) receiving antiviral medication to treat COVID-19, the facility failed to administer medications as ordered by the physician. The findings include: Resident #473's diagnoses included COVID-19, atrial fibrillation, congestive heart failure, chronic ischemic heart disease, chronic kidney disease, diabetes mellitus, and hypertension. The admission assessment dated [DATE] identified Resident #473 was alert and oriented to person, place, and time, and required assistance with transfer, bed mobility and ambulation. The nurse's note dated 8/16/23 identified Resident #473's COVID-19 swab results were positive. The Resident Care Plan dated 8/16/23 identified Resident #473 had actual COVID-19 infection. Interventions directed to provide transmission-based precautions as ordered and directed a follow up with the Medical Doctor (MD) / Advanced Practice Registered Nurse (APRN) as indicated. A physician's order dated 8/16/23 directed to administer Paxlovid (antiviral medications to treat COVID-19) 150/100 oral tablet therapy pack 10 x 150 mg and 10 x 100 mg (Nirmatrelvir-Ritonavir) to give 2 tablets by mouth two times a day for 10 administrations. Further review identified physician's orders which directed to decrease Apixaban (anticoagulant medications) 5 mg one tablet by mouth two times a day to 0.5 tablet and to hold Atorvastatin (to treat high cholesterol and triglyceride) from 8/16/23 to 8/26/23. The Reportable Even Form dated 8/17/23 identified on 8/16/23 at 9:00 PM Resident #473 was given morning dose and evening dose (two doses equal to 200 mg) of Ritonavir 100 mg instead evening dose of Nirmatrelvir 150 mg and Ritonavir 100 mg. The nurse's note dated 8/17/23 identified during morning medication pass Licensed Practical Nurse (LPN #4) and APRN #1 noted the resident received wrong dose of Paxlovid on 8/16/23 during evening shift. The APRN immediately assessed the resident. The APRN #1's note dated 8/17/23 identified Resident #473 was started on renal dose of Paxlovid, but due to medication administration error last night, the resident received two doses of Ritonavir, and none of Nirmatrelvir. The resident was washing up in the bathroom and reported feeling better. Further review of the APRN's #1 note identified Paxlovid would be held that morning (8/17/23) and resumed that night, and Apixaban will be also held that morning (8/17/23). Review of physician's orders identified order for Paxlovid with added note on 8/17/23 directing staff to note dosage on package, 2 tablets labeled morning dose and 2 tablets labeled evening dose. A physician's order dated 8/17/23 directed to discontinue Paxlovid and on 8/18/23 the physician's order directed to administer Molnupiravir (antiviral medications to treat COVID-19) oral capsule 200 mg by mouth two times a day for 10 administrations. A review of Resident # 473's clinical record and facility documentation with DNS on 8/21/23 at 3:15 PM identified during the investigation of the medication administration error Registered Nurse (RN #2) identified that although she questioned the order and was confused regarding the medication order, packaging, and dose to be administered, she failed to call the physician and/or the pharmacy to clarify the order. RN #2 failed to follow the physician's order when she took two tablets of Ritonavir 100 mg from the blister pack that included one out of two tablets (Nirmatrelvir-Ritonavir) from morning dose and one out of two tablets (Nirmatrelvir-Ritonavir) from evening dose and administered to the resident. Following the medication error administration, on 8/17/23 the DNS added a clarification note to the Paxlovid medication order directing staff to note dosage on package, 2 tablets (Nirmatrelvir-Ritonavir) labeled morning dose and 2 tablets (Nirmatrelvir-Ritonavir) labeled evening dose. DNS further indicated to prevent future medication errors, the facility started performance improvement plan which included staff in services and weekly audits. Attempts to interview RN #2 during the survey were unsuccessful. Interview with APRN #1 on 8/22/23 at 10:34 AM identified Ritonavir and Nirmatrelvir (Paxlovid) were prescribed to treat COVID-19 and were ordered to be given together to enhance effectiveness. Paxlovid may cause overdose of other medications that otherwise would not happen, that is why he ordered to decrease Apixaban doses and to hold Atorvastatin medication. The resident's order included renal dose of Paxlovid which was a lower dose and administering double dose of Ritonavir might cause overdose of other medications and/or other concerns. APRN #1 further identified he would have expected to be called to clarify any questions regarding medication orders prior to medication administration to prevent medication errors. APRN #1 identified that after assessing the resident and reviewing the clinical record he felt that it was not safe to resume Paxlovid and ordered Molnupiravil to be administered instead to ensure prevention of drug interactions. Interview with Pharmacist #2 on 8/23/23 at 11:10 AM identified that for Paxlovid to be effective to treat COVID-19, both tablets Ritonavir and Nirmatrelvir must be administered. Further interview identified that if a resident had decreased kidney function and in error higher dose than ordered of Ritonavir was administered, the resident's kidney function should be monitored. Review of facility Medication Administration and Documentation Policy directed in part, licensed nurse assures the 5 rights: compares the medication name, strength, route and dosage schedule on the medication administration record against the prescription label. Always checks three times prior to administration of medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, facility documentation, facility policy and interviews for 1 of 7 sampled residents (Resident #624) reviewed for accidents and education regarding water temperature monitoring in resident rooms, and for 1 of 3 residents reviewed for smoking (Resident #37), the facility failed to ensure a portable oxygen delivery device was secured to the adaptive equipment used for ambulation to prevent an accident with a injury, failed to ensure staff was educated regarding acceptable water temperature levels in resident rooms and how to proceed if temperatures were out of normal range, failed ensure a smoking receptacle was within reach and failed to attempt to provide assistance with re-applying a smoking apron during a smoking session. The findings included: 1. Resident #624's diagnoses included malignant neoplasm of the lung, chronic obstructive pulmonary disease, and dementia. The admission Minimum Data Set assessment dated [DATE] identified Resident #624 had some short- and long-term memory recall deficits and required supervision when ambulating with the assist of a walker or wheelchair while in the corridor. The Resident Care Plan dated 7/21/22 identified Resident #624 had an activity of daily living deficit related to cognitive loss and a potential for alteration in respiratory status related to chronic obstructive pulmonary disease and malignant neoplasm. Interventions directed to provide assistance and cueing to maximize current level of function and provide oxygen as ordered. The nurse's note dated 10/16/22 at 12:30 PM identified Resident #624 knocked over the oxygen tank while transferring and the tank landed on Resident #624's left foot. The note indicated Resident #624 stated the foot hurts a little, the skin was intact with no visible bruising or discoloration, Resident #624 denied pain while weight bearing, range of motion to the left foot within normal limits, vital signs were stable, and the physician and responsible party were made aware. The nurse's note dated 10/17/22 at 10:59 AM identified Resident #624 continued with complaints of discomfort to the left foot during the shift, the Advanced Practice Registered Nurse, APRN #1, evaluated Resident #624 and ordered an x-ray of the left foot. The note indicated the x-ray results identified an acute fracture, APRN #1 was updated, an open toed postop rigid soled shoe was ordered with no need to see orthopedics and a call was placed to the responsible party who was updated. An x-ray dated 10/17/22 identified an acute appearing fracture of the first distal phalanx (toe) of the left foot. The Facility Reported Incident form dated 10/17/22 at 12:30 PM identified the portable oxygen tank fell and landed on Resident #624's left great toe resulting in a fracture. The report indicated the oxygen tank was placed on the seat of the walker while the nurse was trying to put the nasal cannula on Resident #624. The facility Reported Event Summary dated 10/21/22 identified Resident #624 walked out of his/her room without oxygen on, the charge nurse ran in Resident #624's room to grab the portable (oxygen) tank, placed it on the seat of the walker and applied the nasal cannula. Resident #624 then moved his/her walker and the tank fell on the left foot. The summary noted initially there were no complaints of pain, the following day Resident #624 was seen by APRN #1 after complaints of foot pain and an x-ray was ordered which revealed a first digit phalanx fracture. The summary identified Resident #624 was given an opened toed shoe for the left foot, was pain free and has had no change in ambulation status, the care plan was updated to include ensuring the oxygen tank was secured on the walker before placing the nasal cannula on Resident #624. An interview with the Director of Nursing (DON) on 8/22/23 at 11:21 AM identified he was the assigned Nursing Supervisor working the 3:00-11 PM shift on 10/16/22. The DON indicated he assessed Resident #624 after it was reported by the charge nurse the portable oxygen tank had dropped on Resident #624's foot while attempting to connect the nasal cannula. The DON identified it would have been his expectation that the portable oxygen tank be secured first before applying oxygen. An interview with the 3-11 PM charge nurse, Licensed Practical Nurse (LPN) #9, on 8/22/23 at 12:08 PM identified the portable oxygen tank was usually clipped to Resident #624's walker when in use. LPN #9 identified she was attempting to set up Resident #624's oxygen tubing and placed the tank on the seat of the walker without first securing it to the walker, Resident #624 was standing beside the walker when the tank slipped and fell onto Resident #624's foot. LPN #9 indicated she should have secured the portable oxygen tank to the walker prior to attempting to connect the tubing. An interview with Person #3, Operations Manager for the Oxygen vendor contracted with the facility identified the portable oxygen tank should be secured so it did not fall over. Although a facility policy for securing portable oxygen and manufactures guidelines was requested for the use of portable oxygen, none was provided. 2. On 8/17/2023 at 12:00 PM water temperatures were identified to be elevated above 120 degrees Fahrenheit (F.) in residents' rooms. The elevated water temperatures above 120 F were reported to Building Fire and Safety (BFSI) who worked with the facility Maintenance Director to conduct an audit of all resident rooms. The mixing valve was adjusted immediately, and the water temperatures came down to normal limits. (Below 120 degrees F.) The Maintenance Director indicated the temperatures would be monitored overnight. On 8/18/2023 at 11:15 AM a review of facility documentation of water temperature logs and interview with the Maintenance Director identified elevated water temperatures (highest 128.3 degrees F.) overnight in all the rooms at 1:00 AM and back to normal (below 120 degrees F.) at the 4:00 AM temperature check. Review of the facility water temperature log identified no instructions given to the staff on what expected normal water temperature ranges or instructions of what to do if the temperatures were not within normal range. The Maintenance Director indicated that s/he gave the nursing supervisor RN #6, the thermometers, and the log to complete but s/he provided no instructions how to proceed if the water temperature were found out of range. The Maintenance Director indicated that s/he would revise the log today to include guidelines and instructions on how to proceed if temperatures were found to be out of normal range including who to contact. 8/18/2023 at 2:40 PM a telephone call was placed to RN #6 without success. On 8/21/2023 at 10:00 AM a review of the revised facility temperature logs used for 8/19, 8/20, and 8/21/2023 and interview with the Administrator, indicated the Maintenance Director and himself were notified of the elevated temperatures that occurred overnight on 8/20/23 and 8/21/2023 and the Maintenance Director came into the facility both days and on 8/20/2023 staff was in serviced regarding the use of hot and cold water when providing care. Staff were also directed to accompany confused residents to and from the bathrooms and at 7:30 PM. The Administrator further indicated s/he called the management company requesting someone come out to service the mixing valve due to a sustained hot water level on the unit. The vendor onsite rebuilt the mixing valve and indicated s/he would be replacing it momentarily. The Administrator further indicated that the water temperatures would continue to be monitored twice daily for 3 days. 8/21/2023 2:40 PM an interview with RN #6 Indicated she was given a sheet of paper from the Maintenance Director who adjusted the paper to add room numbers and times. RN#6 further indicated s/he was working a double shift 3:00 PM until 7:00 AM and was asked to take the temperatures of the water in the resident bathrooms at the times indicated on the log, write the findings on the sheet and in the morning and to place the completed sheet into the Maintenance Directors mailbox. RN #6 indicated that on 8/18/2023 she was not provided instruction on what temperatures to expect or who to call but on 8/19/2023 she was provided a new form and received in-servicing on water temperature range on the new form and if it was out of range, then s/he was instructed to take a picture of the thermometer and text the Administrator and the Maintenance Director. RN #6 indicated each supervisor was to teach the next supervisor coming on the shift how to follow the procedure and further indicated that on 8/20/23 there were elevated temperatures, and the Maintenance Director came in. RN #6 also indicated that staff were instructed to provide supervision to the residents who needed to use the bathrooms and that since staff completed 15-minute checks they were able to anticipate needs of residents therefore no attempts were made by residents to go into the bathrooms independent. 3. Resident #37 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes, dementia and chronic obstructive pulmonary disease., The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was cognitively intact and required set up assistance only for bed mobility, transfers, dressing, eating and personal hygiene. The MDS further identified Resident #37 was a tobacco user. A Resident Care Plan dated 8/21/23 identified Resident #37 had a smoking history. Interventions included to instruct Resident #37 on the facilities smoking policy, education of resident of the importance of using the smoking apron during smoking sessions, ensure the safety of the resident during smoking, assist resident as necessary to ensure maximum safety. A Smoking Evaluation completed on 7/19/23 identified Resident #37 required the use of a smoking apron for safety during a smoking session. a. Observation of the smoking session on 8/22/23 at 1:04 PM identified 3 residents (Resident #10, Resident #31 and Resident #37) attended the smoking session along with the Recreation Director. The Recreation Director was observed to apply a smoking apron on Resident #37 but failed to secure the apron around Resident #37's back of the neck. The Recreation Director supplied a cigarette to Resident #37 and lit the cigarette for him/her. Resident #37 requested a second cigarette at 1:15 PM, and was noted that the smoking apron was only covering his/her pelvis and right leg, the upper chest and left leg were exposed. Further observation on 8/22/23 at 1:28 PM noted Resident #37's smoking apron had shifted down further. Resident #37 self removed the smoking apron while continuing to smoke 3 more puffs of the cigarette at 1:29 PM, without intervention or assistance to re-apply the apron from the Recreation Director. b. Resident #37 was noted to flick the ashes of the lit cigarette into the air numerous times related to not having a smoking receptacle within his/her reach. Resident #31 and Resident #10 both had smoking receptacles within their reach. When Resident #37 was finished with his/her first cigarette, the Recreation Director had to push one of the two smoking receptacles closer to Resident #37 because it was out of reach. Resident #37 continued to flick the second cigarette in the air not using the smoking receptacle which had been pushed away from Resident #37 by the Recreation Director and pushed closer to Resident #31. The Recreation Director again moved the smoking receptacle closer to Resident #37 to dispose of his/her cigarette. Interview with the Recreation Director on 8/22/23 at 1:45 PM identified the smoking apron was not placed correctly on Resident #37 as there was a clip with a quick release that was to be worn around the resident's neck that she did not secure. The Recreation Director further stated that Resident #37 does not want to wear the smoking apron and did not think of securing/fastening the apron or re-adjusting the apron once it fell to Resident #37's pelvis. The Recreation Director further identified the facility only had 2 smoking receptacles and needed 3 but did not notify anyone. Interview with RN #1 on 8/23/23 at 10:25 AM identified Resident #37 required a smoking apron because he/she flicks ashes on his/her clothing. Interview with RN #5 on 8/23/23 at 11:00 AM identified that she had performed the smoking evaluation on Resident #37, and she implemented the smoking apron, stating the smoking apron was used for safety reasons and that Resident #37 was not using the smoking receptacle as advised. Review of the facility Smoking Policy directed residents who smoke will be evaluated for their ability to smoke safely upon admission/quarterly and as indicated 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 of others. The need for assistive device and/or safety devices will be identified and noted in the residents individualized care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and interviews for 1 of 6 sampled residents (Resident #49) reviewed for nutrition, the facility failed to obtain weekly weights as ordered by the physician. The findings include: Resident # 49's diagnosis included unspecified dementia, depressive episodes and feeding difficulties. A review of Resident # 49's weight record identified on 2/1/23 the resident weighed 128 pounds. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #49 as severely cognitively impaired and required extensive assistance of two staff members for transfer. A physician's order dated 3/24/2023 directed to obtain weekly weights every Tuesday until 4/18/2023. The care plan dated 4/6/2023 indicated Resident #49 required a therapeutic diet, had poor oral intake and weight loss. The interventions included in part to monitor the resident's weight as needed. A physician's order dated 4/20/2023 directed to obtain weekly weights every Wednesday until 5/17/2023. Interview and review of the clinical record with the DNS on 8/22/2023 at 10:32 AM indicated s/he could not provide evidence of Resident # 49's weekly weight documented for 5/17/2023. The DNS indicated the clinical record noted the next weight completed was on 6/1/2023(15 days later). The DNS further indicated there was an order for a weekly weight which should have been done. The DNS also identified it was the responsibility of the charge nurse, supervisor, and the DNS to ensure physician orders are followed for weekly weights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #13) reviewed for respiratory therapy, the facility failed to ensure that portable oxygen tanks contained oxygen. The findings include: Resident #13 was admitted to the facility with diagnoses that included dependence on supplemental oxygen, chronic obstructive pulmonary disease, cardiomegaly, and anxiety. A physician's order dated 6/24/20 to present directed supplemental oxygen via nasal cannula at 2 Liters per minute. A physician's order dated 6/24/20 to present directed that pulse oximetry be checked every shift to maintain oxygen saturation greater than or equal to 92%. A physician's order dated 12/8/22 to present directed that the oxygen and tank be checked every shift and to check oxygen saturation one time a day while awake. The annual MDS assessment dated [DATE] identified Resident #13 had moderately impaired cognition and required extensive assistance with dressing and personal hygiene. Additionally, Resident #13 was receiving oxygen therapy at the facility. The Resident Care Plan dated May 2023 identified Resident #13 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Interventions included to administer oxygen and to monitor effectiveness by checking saturation as/if indicated. Observation on 8/17/23 at 10:48 AM and on 8/18/23 at 9:30 AM identified an oxygen nasal cannula attached to Resident #13 via nasal prongs and the other end of the oxygen nasal cannula was attached to a portable oxygen tank which was stored in the back pocket of Resident #13's wheelchair. On both dates the oxygen gauge indicated that there was zero oxygen in the portable tank. Interview with Resident #13 on 8/17/23 at 10:50 AM indicated he/she used oxygen at all times. Resident #13 indicated that when he/she was out of bed, he/she used the portable oxygen tank. Resident #13 indicated the nurses or Nurse Aides (NAs) check the oxygen level in the portable tank. Observation and interview with LPN #5 on 8/17/23 at 10:58 AM indicated Resident #13 had a physician order for oxygen at 2 liters via nasal cannula at all times. LPN #5 indicated Resident #13 did use oxygen at all times. LPN #5 observed Resident #13's portable oxygen tank and indicated that the tank was empty. LPN #5 indicated that it was the responsibility of NAs to check the level of oxygen in the portable oxygen tank. LPN #5 filled Resident #13's portable oxygen tank and checked the resident's oxygen saturation after the portable oxygen tank was filled and the oxygen saturation level was 98%. Observation and interview with LPN #6 on 8/18/23 at 10:19 AM indicated Resident #13 was on oxygen at 2 liters via nasal cannula at all times. LPN #6 indicated Resident #13 does use oxygen. LPN #6 observed Resident #13's portable oxygen tank and indicated that the tank was empty. LPN #6 checked the nasal cannula to see if there was any oxygen flowing through the nasal cannula by placing the nasal cannula nose prongs in a glass of which resulted in bubbling of the water indicating positive oxygen flow. LPN #6 also checked Resident #13's oxygen saturation which was 98%. LPN #6 filled the portable oxygen tank because the gauge indicated the tank was empty. Interview with the DNS on 8/22/23 at 12:10 PM indicated the portable oxygen tanks are filled by NAs that work overnight. Additionally, the DNS identified that NAs that work days are also competent to fill portable oxygen tanks. The DNS indicated that nurses and NAs are responsible for checking the oxygen level in portable tanks but that there was not a place to chart when the oxygen level was checked. Review of the facility Nasal Cannula Oxygen Policy identified that when oxygen via nasal cannula is placed on a resident the oxygen liter flow is set to the prescriber liters flow per minute and that verification is made that oxygen is flowing through tips of the nasal cannula.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and interview for 1 of 5 residents (Resident #32) observed during the dining initial screening, the facility failed to provide the resident with an assistive device for beverage as prescribed. The findings included: Resident #32 diagnoses included dementia, dysphagia, and lack of coordination. A physician's order dated 6/9/22 directed a two handled mug with spout lid. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #32 as severely cognitively impaired and required limited assistance with eating. Resident #32's care plan dated 8/10/22 identified an activity of daily living deficit related to generalized weakness, risk of dehydration related to cognitive deficit, and a potential for impaired nutrition status due to dysphagia/aspiration risk. Interventions included providing a 2 handled mug with spout lid, offering small amounts of fluid frequently, and maintaining aspiration precautions for all solid/beverage intakes. Observation and interview with Nurse Aide #2 on 8/17/23 at 12:35 identified Resident #32's meal ticket included a two handled mug with spout lid, however Resident #32's beverage was dispensed in a handle free tumbler. Interview with NA #2 also indicated Resident #32 was given a handle free tumbler in error and should have been set-up with the proper assistive beverage device. Interview with the Director of Nursing on 8/23/23 at 12:35 PM indicated the kitchen is responsible for providing adaptive devices to the resident and nurse aides are responsible for bringing the adaptive device to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation and staff interview for 1 of 1 sampled resident (Resident #58) reviewed for end of life, the facility failed to ensure the medical record was complete. The findings include: Resident #58's diagnoses included: Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Protein Calorie Malnutrition. The Resident Care Plans dated 2/2/23 and 10/4/22 had a terminal prognosis with a potential significant decline in all areas including comfort. Interventions included to assess, assist with coping strategies, respect of wishes, expression of feelings, listening with compassion, calm, quiet environment, monitor closely for signs of pain, goal of maximum comfort, providing privacy during visits, and working cooperatively with special services team. A quarterly MDS assessment dated [DATE], identified Resident #58 as alert and severely cognitively impaired, required extensive assistance of two for bed mobility, dressing, transfers, toilet use, personal hygiene, and supervision with set-up for eating. A review of facility documentation on 8/22/23 at 11:37 AM identified the medical record failed to provide documented evidence of the following: a. The facility/special services communication binder contained the Visit Documentation Log for special services visits for Resident #58 which identified sign in for monthly social worker visit on 8/16/23, nurse visits 6/6, 6/13, 6/20, 6/27, 7/2, 7/19, 7/25, 8/1, 8/7, 8/15, and 8/20/23. b. The communication binder (part of the medical record) failed to contain the updated every two-week Interdisciplinary Team (IDT) note from 6/1 through 8/10/23, and the Plan of Care (POC) (the special services orders) dated 6/4/23 through 8/2/23, and 8/2/23 through 10/1/23. c. Additionally, the communication binder failed to contain the Certificate/Recertification of Terminal Illness (CTI) dated from 8/3/23 through 10/1/23. Interview and review of the facility documentation with DNS on 8/22/23 at 11:52AM identified the facility/special services facility communication binder contained the last special services IDT note dated 5/18/23, POC (the special services orders) dated 4/5/23 through 6/3/23 and the CTI dated 4/5/23 through 6/3/23. The DNS identified that he would have to get the missing documentation from the special services nurse. Subsequent to inquiry on 8/23/23 at 10:32 AM the DNS provided (IDT) notes from 6/15 through 8/10/23, POC (the special services orders) dated 6/4/23 to 8/2/23, and 8/2/23 to 10/1/23, and the (CTI) dated from 8/3/23 through 10/1/23. Interview with DNS on 8/23/23 at 12:24 PM indicated the facility did not have a hospice policy and indicated that the facility had a Hospice Services Agreement.

Based on a review of the facility Quality Assurance and Performance Improvement (QAPI), review of facility documentation, facility policy and interviews, the facility failed to maintain an effective QAPI program that met at least quarterly, develop, and implement appropriate plans of action to correct identified quality deficiencies. The findings include: a. On 8/23/23 at 1:50 PM a review of the facility Quality Assurance and Performance Improvement (QAPI) program and an interview with the Administrator identified although no QAPI signature sheets for meeting attendance could be found for topics of resident appointments mentioned. The agency staff was not reporting off duty in April 2021 in a Medical Staff meeting. July and August 2021 Medical staff meetings addressed topics of vaccines, abuse, and verbal altercations. The Administrator also indicated weight loss and skin issues along with falls were discussed but could not provide an attendance record. The Administrator further indicated that no signature sheets for QAPI attendance or action plans could be found for the year 2021. b. The Administrator further indicated in the interview on 8/23/23 for the year of 2022 medical staff meeting topics included pressure ulcers, late reporting of assessments, weights and water pitcher were discussed However no signature sheets and no action plans could be found. The Administrator further indicated quality measures should be reviewed monthly, but staffing was an issue, and the Administrator and other staff were working on staffing the facility. The Administrator further indicated the facility had Administrators come and go during this time and that he/she was filling in temporarily and since started on July 17, 2023, and had a medical staff/ QAPI meeting on at time. Although, the Administrator indicated on July 17, 2023, meeting the topic of falls with a graph projecting the fall trends and a timeline were reviewed, no action plan has yet been put into place. An attendance sheet for the July 17 2023 meeting was provided with the appropriate staff members in attendance. Interview with the Administrator on 8/23/23 at 1:50 PM identified the topic of Abuse had not been reviewed as a concern in QAPI since 2020 and the facility Reportable Incidents have had numerous reports of resident-to-resident altercations and allegations of abuse. Although the Administrator indicated the delay in initiating an action plan for the falls was due to a vacation and upper management vacancies in the facility, a new administrator will start next week, the new DNS (Director of Nursing Services) is orienting and a new ADNS (Assistant Director of Nursing Services) will start on 8/24/23. The Administrator indicated that he/she plans to work with the upcoming new administrator and will put a structured process in place to formalize the QAPI program. The facility policy labeled Quality Assurance and Performance Improvement, dated 2/2/2023 indicated in part it is the facility policy to develop, implement and maintain an effective, comprehensive data driven QAPI program that focuses on the outcomes of care and quality of life of the residents.

Based on a review of the facility Quality Assurance and Performance Improvement (QAPI), review of facility documentation and interviews, the facility failed to maintain an effective QAPI program that met at least quarterly, develop, and implement appropriate plans of action to correct identified quality deficiencies and obtain feedback from staff and residents. The findings include: The Administrator further indicated in an interview on 8/23/23 for the year of 2022 medical staff meeting topics included pressure ulcers, late reporting of assessments, weights and water pitcher were discussed However no signature sheets and no action plans could be found. The Administrator further indicated quality measures should be reviewed monthly, but staffing was an issue, and the Administrator and other staff were working on staffing the facility. The Administrator further indicated the facility had Administrators come and go during this time and that he/she was filling in temporarily and since started on July 17, 2023, and had a medical staff/ QAPI meeting on at time. Although, the Administrator indicated on July 17, 2023, meeting the topic of falls with a graph projecting the fall trends and a timeline were reviewed, no action plan has yet been put into place. An attendance sheet for the July 17 2023 meeting was provided with the appropriate staff members in attendance. Interview with the Administrator on 8/23/23 at 1:50 PM identified the topic of Abuse had not been reviewed as a concern in QAPI since 2020 and the facility Reportable Incidents have had numerous reports of resident-to-resident altercations and allegations of abuse. Although the Administrator indicated the delay in initiating an action plan for the falls was due to a vacation and upper management vacancies in the facility, a new administrator will start next week, the new DNS (Director of Nursing Services) is orienting and a new ADNS (Assistant Director of Nursing Services) will start on 8/24/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility Infection Control Program, observations, facility policy and interviews, the facility failed to ensure face masks were properly worn during a COVID-19 outbreak. The findings included: 1. An observation on 8/21/23 at 12:20 PM identified Nurse Aide (NA) #7 preparing to serve lunch to a resident in room [ROOM NUMBER]/219 with his/her face mask only covering his/her chin to upper lip area. NA #7 indicated he/she was required to wear a mask during COVID-19 outbreak, policy directed to apply mask to cover the nose to under the chin area. NA # 7 further indicated s/he did not realize his/her nostrils were uncovered. b. Observation on 8/21/23 at 12:21 PM identified Social Worker #1 at the elevator with his/her mask only covering his/her chin to upper lip area. SW #1 indicated a mask is required when there is a COVID-19 outbreak or when a resident was sick, policy directed to apply mask to cover the nose to under the chin area, and the reason her nose was not covered was because his/her mask slid down off her nose. c. Observation on 8/21/23 at 12:24 PM identified (NA) #2 in front of room [ROOM NUMBER] with his/her mask only covering his/her chin to upper lip area. NA #2 indicated policy directed to wear a mask when there were COVID-19 cases in the facility, to apply the mask to cover his/her nose and mouth. NA # 2 further indicated he/she did not realize his/her mask was sliding off her nose. d. Observation on 8/21/23 at 12:26 PM identified (NA) #8 in front of room [ROOM NUMBER] with his/her mask only covering his/her chin to upper lip area. NA #8 indicated he/she was directed to wear a mask throughout the whole building due to the COVID-19 outbreak, policy directed to cover the nose, mouth and chin areas, and his/her nose was not covered because the mask was not applied properly. e. Observation on 8/21/23 at 12:40 PM identified Dietary Aide #2, while walking by the dining area on the lower level of the building, with his/her face mask only covering his/her chin to upper lip area. Dietary Aide #2 indicated face mask were to be worn covering the nose to bottom of chin area, policy specifies nose to bottom of chin mask coverage, and indicated he/she will pull the mask down due to difficulty breathing/asthma. f. Observation on 8/21/23 at 1:02 PM identified Dietary Aide #3 at the elevator on the first floor with his/her mask around his/her chin. Dietary Aide #3 indicated masks are always worn when out on the floor and in contact with residents diagnosed with COVID-19 in the building. Dietary Aide # 3 further indicated the mask was pulled down away from her face due to him/her having difficulty breathing. g. Observation of Nurse Aide (NA) #5 on 8/23/23 at 9:10 AM identified that NA #5 was not wearing a face mask at the Second Floor Unit Desk. Interview NA #5 at that time indicated that she was aware that face masks had to be worn in all patient care areas including at the Unit Desk. An interview on 8/23/23 at 11:15 AM with the DNS indicated that staff were expected to wear a face mask in all areas where residents can go to during a Covid Outbreak. Additionally, the DNS indicated that staff must be wearing surgical face masks in all areas except employee break rooms. Review of the Infection Control policy identified that the facility follows Centers for Disease Control (CDC), Centers for Medicare and Medicaid (CMS) and the respective State Department of Health guidance on infection control related to Covid 19. Interview with RN #8 on 8/21/23 at 12:36 PM identified N95 masks and personal protective equipment were required to be worn when caring for COVID-19 positive residents, otherwise staff were required to wear standard blue masks to cover the bridge of the nose to below the chin. Interview with Director of Nursing Services on 8/21/23 at 12:45 PM identified staff were required to wear face masks which covered chin, mouth, and nose due to the COVID-19 outbreak. She also indicated staff are required to wear an N95 mask and personal protective equipment when in a room with a COVID-19 positive resident. Facility policy directs that all staff will be required to wear a surgical mask while in the building during Covid-19 outbreak.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, facility documentation, facility policy and interviews for 2 of 2 sampled residents (Residents #11 and # 28) who were reviewed for accidents, the facility failed to ensure bedrails were securely attached to the resident's bed. The findings included: 1. Resident #11's diagnoses included dementia, history of falling, unsteadiness on feet, and muscle weakness. A physician's order dated 3/30/23 directed a quarter side rail to both sides of bed for mobility and transfers. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #11 was severely cognitively impaired and required extensive assistance with bed mobility, transfers, and toilet use. The Resident Care Plan dated 8/16/23 identified an activities of daily living deficit related to impaired cognition, noncompliance, and decreased mobility, and risk of falls secondary to cognitive impairment, shuffled gait, and noncompliance with safety measures. Interventions directed to provide assistance and/or cueing to maximize current level of function, to instruct the resident to ask for assistance prior to attempting to transfer or ambulate as needed. 2. Resident #28's diagnoses included dementia, repeated falls, unsteadiness on feet, and muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #28 as severely cognitively impaired and required extensive assistance with bed mobility, transfers, walking, and toilet use. The Resident Care Plan dated 8/15/23 identified a risk for frequent falls secondary to cognitive impairment, device used with ambulation, history of non-compliance with assist for mobility and an activities of daily living deficit related to cognitive loss/dementia. Interventions directed to provide assistance and/or cueing to maximize current level of function, floor mats/perimeter mats, and use of bed and chair alarm at all times. Interview and observation with RN# 7 on 8/23/23 at 11:58 AM identified a loose bed rail on the Resident #11's right side when in the bed and both sides of Resident # 28's bed. RN #7 identified s/he could not identify how long the bed rails were loose and what the policy was for maintenance checks. Interview with the DNS on 8/23/23 at 12:30 PM identified only quarter bedrails were used for positioning and mobility, and maintenance request /repairs were noted in the maintenance book located at the nurse's station. Interview with the Director of Maintenance (DOM) at 12:51 PM on 8/23/23 identified bedrails were checked annually unless problems were noted, at which point a work order would be entered into the maintenance book located at the nurse's station. The DOM indicated the maintenance book would be checked multiple times per day, however review of the maintenance book located at the nurse's station failed to identify an entry for loose bedrails for Resident #11 and Resident #28. On 8/23/23 a review of the facility bedrails safety check for residents identified bed rails was last check/completed on 12/7/22.

Based on observations of the noon meal, clinical record review, review of facility policy and staff interviews, the facility failed to ensure food was served in a manner that contained nutritive value, flavor and was not burned and for (Resident #34), the facility failed to ensure ice cream was not served in a softened form. The findings included: 1. During the noon meal a lunch test tray was ordered from the kitchen on 8/21/23 which consisted of breaded chicken with a side of potatoes and mixed vegetables. The meal served was warm, the chicken and potatoes were flavorful, however the vegetables were overcooked with some of the broccoli and green bean pieces burned. Interview with the Director of Dietary Services (DDS) on 8/22/23 at 11:55 AM indicated the steamer which was used to cook vegetables has been broken for five to six months, forcing staff to cook vegetables in the oven with some water in a pan. The DDS further indicated quality of the food served has diminished due to the alternate cooking method used. A lunch test tray was obtained from the steam table on 8/22/23 at 12:20 PM consisting of meatloaf, green beans, and potato croquettes. The temperature of each item was measured after leaving the warmer and steam table and identified the following: meatloaf temperature of 164.8 degrees, green bean temperature of 133.7 degrees and potato croquette temperature at 121.0 degrees. Interview with the Director of Dietary Services (DDS) on 8/22/234 at 12:23 PM identified all food served from the steam table should be held at 140 degrees and that the chaffing dishes would remain warmer if left covered, until ready to serve. The DDS also identified the convection oven and stove shut off in the middle of the cooking process and that one of four stove burners and two ovens were broken. The DDS indicated the appliances were too old to repair and that corporate had approved the purchase of new appliances to replace the broken appliances, but facility have not received the funds yet. Although requested, the facility failed to provide a policy related to food quality. 2. Interview with Resident #34 on 8/18/23 at 10:57 AM identified ice cream on the meal tray arrived melted on several occasions. On 8/21/23 at 11:45 AM, a test tray was conducted which included scalloped potatoes, fried chicken legs, vegetables, and ice cream. The ice cream arrived in the original disposable packaging and had been delivered on top of the warm meal. Upon opening the ice cream cup, it was noted that the inner portion was frozen, and the outer edges were melted. On 8/22/23 at 12:00 PM, an interview with Dietary Aide (DA) #1 indicated ice cream was brought from the kitchen on a tray and then placed in a refrigerator located in the dining room. The ice cream was then removed from the refrigerator and placed with resident meals on a cart for delivery to resident rooms. Upon further inquiry, DA #1 indicated that the refrigerator that was used was only a refrigerator and not a freezer. At 12:10 PM, Resident #34's meal was delivered to the room, and the ice cream cup was noted to be on top of the warm food and soft. On 8/22/23 at 12:30 PM, an interview with the Director of Dietary indicated that ice cream was delivered after the meals in a prior process but that this process had been changed at the start of the COVID-19 pandemic. Additionally, the Director of Dietary indicated that ice was previously placed on top of the ice cream, but the kitchen's ice machine had been broken for two weeks before the current survey.

Based on observations, facility policy, facility documentation, and interviews, the facility failed to contain food items appropriately in the dry storage room, to discard expired foods, to maintain their three-day emergency supply per menu and to complete daily temperature log sheets. The findings included: 1 a. During a tour of the kitchen with the Dietary Manager on 8/21/23 from 10:00 AM to 11:30 AM identified the following: .The small dry storage room located in the kitchen contained an expired jar of Admiration Maraschino Cherries (8/19/23), a container of Kikkoman Teriyaki Marinade and Sauce and a container of Kikkoman Less Sodium Soy Sauce that were opened and not refrigerated, expired vanilla pudding packets (5/16/23), expired chocolate pudding packets (5/17/23), expired butterscotch pudding and pie filling packets (11/24/21), expired gelatin dessert packets (6/3/21) and expired red assorted gelatin packets (6/3/21), an undated bag of cornflake cereal, an opened, undated, and open bag of croutons, a dented can of Northeast red and green pepper strips, and an opened bag of Par Excellence Whole Grain [NAME] #25. b. Further observation on 8/21/23 identified the refrigerator contained expired diet Jell-O (8/18/23), pre-sliced salami, ham, and bologna (8/21/23), an expired gallon of Ken's Buttermilk Ranch dressing (7/5/23), and an expired gallon of 1% Hood Milk (8/17/23). c. Observation on 8/21/23 of the facility Three-Day Emergency Food supply identified a damaged can of pears, supply of spinach (1 case), two expired cases of instant oatmeal, and a supply of soup and applesauce (a 3-day supply of each) which was not adequate for Three Day Emergency Food supply. Interview with the Dietary Manager on 8/22/2023 at 11:00 AM identified that all refrigerated, individual serving food items should be discarded 3 days after the preparation date, expired foods should be discarded by the expiration date listed on the container and foods requiring refrigeration after opening should be refrigerated. The Dietary Manager further identified all dry storage items should be discarded by date listed on the container, all undated, unopened dry storage items should be dated or discarded, opened dry storage food items should be contained and dated, and the Three-Day Emergency Food supply should be maintained and on premises. 2. A review of daily refrigerator temperature log sheets (staff, dietary, resident and resident/dietary) identified 27 missing entries from June 2023 and 3 for July 2023. Review of the daily temperature log sheets (including food temperatures, refrigerator temperatures, dishwasher temperatures and chemical ware washing Ph levels) for June 2023 identified several days of missed dish machine temperature entries, several days of missed Ph log entries for manual ware washing, three days of missing breakfast temperature entries, six days of missing lunch temperature entries, 4 days of missing dinner temperature entries and three days of missing daily temperature log sheets for (June 19, June 21 and June 22, 2023). Review of July 2023 daily temperature log sheets (including food temperatures, refrigerator temperatures, dishwasher temperatures and chemical ware washing Ph levels) identified several days of missed dish machine temperature entries, several days of missed Ph log entries for manual ware washing, 1 missed day of breakfast temperature entries, three days of missing lunch temperature entries, five days of missing dinner temperature entries, and five days of missing daily temperature log sheets for (July 24, July 26, July 28, July 30 and July 31 2023). The August 2023 daily temperature log sheets (including food temperatures, refrigerator temperatures, dishwasher temperatures and chemical ware washing Ph levels) identified eight missed Ph log entries for manual ware washing, one dish machine temperature entry, and nine days of missing daily temperature log sheets (August 4, August 14 through August 21, 2023). Interview with the Dietary Manager on 8/17/23 at 1:23 PM identified several days of missed entries on the daily temperature log sheets. Although, the Dietary Manager indicated kitchen staff were in-service on 7/24/23 regarding the missed temperature log entries and re-educated on the process and expectation, thirteen days of missed temperature log sheets were not completed. The Dietary Manager indicated the cooks were responsible for completing the daily temperature log sheets and the policy directed the temperature log sheets to be completed daily. Review of the Logging Food Temperature policy directed food temperatures would be taken with a monitoring device for each item and every consistency and that temperatures would be recorded on the temperature monitoring log sheet. Review of the Manual Ware Washing policy directed to log the Ph level of chemical sanitizer used onto the daily temperature log sheet. Review of the Food policy directed to monitor refrigeration temperatures regularly, to maintain logs of all refrigeration temperatures, and random testing of food temperatures would be done regularly, and logs would be maintained of all food temperatures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for two of two sampled residents (Residents #1 and #3) who were reviewed for an allegation of abuse, the facility failed to ensure the residents were free from verbal abuse. The findings include: 1. Resident #1's diagnoses included dementia and psychotic disorder with delusions. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had some short- and long-term memory recall deficits and required two (2) person assistance with turning and repositioning when in bed and getting in and out of the bed and chair. The Resident Care Plan dated 5/16/23 identified Resident #1 had impaired cognition related to vascular dementia/behavioral disturbances. Interventions directed to use simple, direct communication and assist the resident to eat and drink if needed. The Facility Reported Incident report dated 6/19/23 at 4:00 PM identified a nurse aide, Nurse Aide (NA) #2, reported overhearing another nurse aide, NA #1, telling a story about a verbal altercation with Resident #1 where NA #1 told Resident #1 to get his/her own F_ _king drink. The report identified NA #1 was placed on administrative leave during the investigation and abuse in-servicing initiated. The investigation identified that Resident #1 did not hear what NA #1 had said and had no recollection of the event. A statement dated 6/19/23 written by NA #2 identified on 6/16/23 NA #1 told her about a recent occasion when Resident #1 was ringing the call light all night and NA #1 finally ignored Resident #1. The statement indicated NA #1 later opened Resident #1's fridge and when Resident #1 asked why, NA #1 responded by saying, Get your own F_ _king drink. F_ _k you. NA #1 verbalized she was at her breaking point. A statement dated 6/19/23 written by NA #1 identified she admitted stating to Resident #1 get your own F_ _king drink after feeling overworked. Interview with the Director of Nursing (DON) on 7/11/23 at 12:19 PM identified NA #1 admitted to making the statement to Resident #1 and was subsequently terminated on 6/20/23 for violation of conduct. Attempts to interview Resident #1 were unsuccessful. Attempts to interview NA #1 were unsuccessful. Attempts to interview NA #2 were unsuccessful. 2. Resident #3's diagnoses that included schizoaffective disorder and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had some short- and long-term memory recall deficits, required one (1) person assistance with turning and repositioning when in bed and getting in and out of the bed and chair and was independent with ambulating using a walker. The Resident Care Plan dated 5/25/23 identified Resident #3 had episodes of anxiety. Interventions directed to provide a quiet environment and offer support and reassurance to the resident and family. The Facility Reported Incident report dated 6/19/23 at 4:00 PM identified a nurse aide, Nurse Aide (NA) #2, reported overhearing another nurse aide, NA #1, describe a verbal altercation with Resident #3. The report indicated NA #1 called Resident #3 a vulgar name in response to Resident #3 calling the nurse aide a name. The report identified NA #1 was placed on administrative leave during the investigation and abuse in-servicing initiated. A statement dated 6/19/23 written by NA #2 identified on 6/16/23 NA #1 told her on one (1) occasion she told Resident #3 to go back to his/her room, Resident #3 then called NA #1 a bitch and NA #1 responded by calling Resident #3 a c_ _cksucker. The investigation identified NA #1 called Resident #3 a c_ _cksucker after Resident #3 called NA #1 a bitch. A statement dated 6/19/23 written by NA #1 identified she admitted to calling Resident #3 a name after Resident #3 called her a bitch and other names. NA #1 indicated she felt overworked and was upset after Resident #3 called her name, so she called Resident #3 a name. Interview with the DON on 7/11/23 at 12:19 PM identified NA #1admitted to calling Resident #3 a name and was subsequently terminated on 6/20/23. A review of the facility policy for Abuse directed protection of resident rights from abuse including verbal abuse defined as oral, written, or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or within hearing distance regardless of age, ability to comprehend or disability. Attempts to interview Resident #3 were unsuccessful. Attempts to interview NA #1 were unsuccessful. Attempts to interview NA #2 were unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for two of two sampled residents (Residents #1 and #3) who were reviewed for an allegation of abuse, the facility failed to implement policies for immediate reporting of suspected verbal mistreatment. The findings include: 1. Resident #1's diagnoses included dementia and psychotic disorder with delusions. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had some short- and long-term memory recall deficits and required two (2) person assistance with turning and repositioning when in bed and getting in and out of the bed and chair. The Resident Care Plan dated 5/16/23 identified Resident #1 had impaired cognition related to vascular dementia/behavioral disturbances. Interventions directed to use simple, direct communication and assist the resident to eat and drink if needed. The Facility Reported Incident report dated 6/19/23 at 4:00 PM identified a nurse aide, Nurse Aide (NA) #2, reported overhearing another nurse aide, NA #1, telling a story about a verbal altercation with Resident #1 where NA #1 told Resident #1 to get his own F_ _king drink. The report identified NA #1 was placed on administrative leave during the investigation and abuse in-servicing initiated. A statement dated 6/19/23 written by NA #2 identified on 6/16/23 NA #1 told her about a recent occasion when Resident #1 was ringing the call light all night and NA #1 finally ignored Resident #1. The statement indicated NA #1 later opened Resident #1's fridge and when Resident #1 asked why, NA #1 responded by saying, Get your own F_ _king drink. F_ _k you. NA #1 verbalized she was at her breaking point. Interview with the Director of Nursing (DON) on 7/11/23 at 12:19 PM identified he was made aware of the allegation of verbal mistreatment on 6/19/23 by NA #2 who reported the incident that occurred three (3) days earlier on 6/16/23. The DON indicated he would expect that staff with any knowledge of suspected abuse report the information immediately. Attempts to interview NA #1 were unsuccessful. Attempts to interview NA #2 were unsuccessful. 2. Resident #3's diagnoses that included schizoaffective disorder and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had some short- and long-term memory recall deficits, required one (1) person assistance with turning and repositioning when in bed and getting in and out of the bed and chair and was independent with ambulating using a walker. The Resident Care Plan dated 5/25/23 identified Resident #3 had episodes of anxiety. Interventions directed to provide a quiet environment and offer support and reassurance to the resident and family. The Facility Reported Incident report dated 6/19/23 at 4:00 PM identified a nurse aide, Nurse Aide (NA) #2, reported overhearing another nurse aide, NA #1, describe a verbal altercation with Resident #3. The report indicated NA #1 called Resident #3 a vulgar name in response to Resident #3 calling the nurse aide a name. The report identified NA #1 was placed on administrative leave during the investigation and abuse in-servicing initiated. A statement dated 6/19/23 written by NA #2 identified on 6/16/23 NA #1 told her on one (1) occasion she told Resident #3 to go back to his/her room, Resident #3 then called NA #1 a bitch and NA #1 responded by calling Resident #3 a c_ _cksucker. A statement dated 6/19/23 written by NA #3 identified on 6/16/23, she was at the nurse's station and overheard NA #1 telling a story to the staff, about a verbal argument with a resident. NA #3 indicated she did not think anything of the situation because NA #1 was always kidding. An interview with NA #3 on 7/11/23 at 12:01 PM identified on 6/16/23 she was at the nurse's station with other staff that included NA #2. NA #3 indicated she overheard NA #1 talking about an incident where Resident #3 was verbally abusive to her and she in turn was verbally abusive to Resident #3 in response. NA #3 identified said she did not think anything of the incident as she thought NA #1was joking. An interview with the Director of Nursing (DON) on 7/11/23 at 12:19 PM identified he was made aware of the allegation of verbal mistreatment on 6/19/23 by NA #2 who reported the incident that occurred three (3) days earlier on 6/16/23. The DON indicated he would expect that staff with any knowledge of suspected abuse report the incident immediately. A review of the facility policy for Abuse directed staff were to respond immediately following an allegation of abuse to protect the resident and integrity of investigation. Attempts to interview NA #1 were unsuccessful. Attempts to interview NA #2 were unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, facility policy and interviews for 1 of 1 residents (Resident #37) reviewed for mistreatment, the facility failed to ensure Resident #37 was free from abuse. The findings include: Resident #37's diagnoses included dementia without behavioral disturbances, depression, difficulty walking, muscle weakness and osteoarthritis. A Resident Care Plan (RCP) dated 11/24/20 identified a problem with impaired cognition due to dementia with interventions to identify self, speak slowly/clearly and explain all procedures. A Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #37 was severely cognitively impaired, requiring extensive assistance of 2 staff for bed mobility and toilet use, and assistance of 1 staff for personal hygiene. A RCP dated 12/30/20 identified Resident #37 had behavior and mood patterns of sadness, apathy, anxious and negative statements due to dementia. Interventions included to allow time for expression and to listen attentively. A RCP dated 2/6/21 identified that Resident #37 had a potential for emotional distress/ bruising related to an allegation of being hit on the arm. Interventions included 1 to 1 visits with social work, observe for periods of anxiety and to psych evaluation as needed. A nurse's note dated 2/6/21 at 7:05 PM identified that a Dietary Aide (DA #1) had witnessed a Nurse Aide (NA #1) approach Resident #37 who was tearing apart his/her incontinent brief, rip the incontinent brief out of Resident #37's hand, strike Resident #37 on the arm/hand telling the resident to cut your sh_t, keep your diaper on, you know better. The nurse's note continued by identifying that per the DA #1, Resident #37 was crying and responded to the NA #1, No I didn't know any better, but you could have been nicer and not so mean. The nurse's note further identified Resident #37 was assessed, facility notifications were completed, and Resident #37 reported to not recall the event. A nurse's note dated 2/6/21 at 7:27 PM identified that the event had occurred earlier on the shift at 5:45 PM. A facility Grievance /Complaint Report dated 2/6/21 identified that a Dietary staff (DA #1) member witnessed a NA (NA #1) take Resident #37's brief from underneath him/her, strike Resident #37 on the arm and the tell Resident #37 to cut the sh_t. A facility interview dated 2/6/21 with NA #1 identified that Resident #37 kept climbing out of bed and it was the second brief he/she had torn off by him/herself. NA #1 continued by stating that she grabbed the brief out of Resident #37's hands and told her to cut the crap stating that she did not hit Resident #37 with the brief. NA #1 further stated that Resident #37 reached out to grab her with soiled hands and that she had quickly pushed Resident #37's hand down as to not get dirty, took the brief, put it back on Resident #37 and left. A Psychiatric note dated 2/11/21 identified that Resident #37 was confused and irritable, requiring effortful redirection, recommending supportive engagement with monitoring of mood and engagement. Interview with the Director of Nurses (DNS) on 7/6/21 at 1:00 PM identified that NA #1 stated she had made a derogatory remark while interacting with Resident #37 and had interacted with Resident #37 in an inappropriate manor. The DNS continued by saying that DA #1 stated that Resident #37 started to cry when the interaction occurred but Resident #37 could not recall the incident when later interviewed. The DNS continued by stating that crying was not an unusual behavior for Resident #37 and that reenacting the event led her to conclude that NA #1 did not strike the resident. The DNS continued by stating that NA #1 was re-educated on abuse, dignity, customer service and dealing with difficult behaviors. The facility then established an audit program to monitor staff. Interview with Person #1 on 7/9/21 at 1:15 PM identified that he/she was very involved in Resident #37's care and recalled that he/she was informed of the incident on 2/6/21. He/she continued by saying he/she could recall that Resident #37 had said something about someone not being nice or mean after the event. Resident #37 was unavailable for interview. Interview with DA #1 on 7/12/21 at 1:52 PM identified that she was passing drinks for dinner when she witnessed NA #1 enter Resident #37's room. Resident #37 appeared to have his/her incontinent brief in his/her hand and was pushing it towards NA #1. DA #1 indicated she observed NA #1 approach Resident #37, grabbed the brief out of the R resident's hand stating to the resident that she had told the resident not to pull off the brief and to stop doing that sh_t while taking the brief, swinging it and hitting Resident #37. Resident #37 started to cry. DA #1 continued by stating that when NA #1 had the diaper in her hand she seemed upset, very agitated, and frustrated with Resident #37. NA #1 did not respond to multiple attempts to contact her. The facility policy on Resident's bill of rights in part directs that residents have the right to be treated with consideration, respect and full recognition of their dignity and individuality. The facility failed to ensure Resident #37 was free from abusive treatment from NA #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews for one of three residents reviewed for Nutrition (Resident # 40), the facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed in a timely when the resident had a weight loss.The findings include: Resident # 40's diagnoses included dysphagia, acute kidney failure, muscle weakness and altered mental status. A review of the resident's admission assessment dated [DATE] identified the resident was 5 feet and 1 inch. The admission MDS assessment dated [DATE], completed by RN #3, identified the resident had severe cognitive impairment, required extensive assistance of two staff for bed mobility, required extensive assistance of one staff for eating, noted the resident's height as 61 inches tall [erroneous], weight 196 pounds, had not had weight loss or gain of 5% or more in the past month or 10% or more in the last 6 months and indicated Resident # 40 did not have any pressure ulcers. The nurse's notes dated 6/3/21 identified the resident had a seven-pound weight loss, dietician, physician, and resident representative were notified. The nursing pressure ulcer evaluations dated 6/3/21 identified a stage 2 pressure ulcer to left buttock, 3.0 Centimeters (CM) x 1.0 CM X 0 CM, and an unstageable pressure ulcer to coccyx, 0.5 CM x .5 CM. The care plan meeting form dated 6/10/21 identified the resident's weight was 186.9 pounds. The care plan dated 6/10/21 identified a potential for impaired nutritional status, intervention include to monitor the resident's weight. A review of the resident's weight documentation identified weights: 5/23/21 199.9 pounds, 5/26/20- 196.4 pounds, 6/1/21 186.0 pounds, 6/2/21 189.9 pounds, 6/8/21 186.8 pounds, 6/29/2 195.6 pounds (struck out on 7/2/21), 6/30/21- 154.4 pounds (struck out on 7/1/21), 7/1/21 168.2 pounds (struck out on 7/9/21), 7/3/2 166.3 pounds (struck out on 7/9/21), 7/11/2 163.5 pounds. A review of the resident's clinical record on 7/13/21 failed to reflect the facility conducted a significant change MDS assessment for the resident's weight loss and the development of the pressure ulcer. Interview with the DNS and the MDS Coordinator on 7/13/21 at 12:37 P.M. identified the resident should have had a significant change in weight MDS assessment and indicated the assessment was not done due to error. On 7/14/21 at 9:45 A.M. the DNS indicated Resident # 40 was re-measured and a height of 5 feet 9 inches was noted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of facility documentation, facility policy review, and interviews for one of three residents, (Resident #11), reviewed for Accidents, the facility failed to ensure the plan of care was implemented after a skin tear. The findings include: Resident #11's diagnoses included dementia without behavioral disturbances, protein calorie malnutrition, chronic congestive heart failure, anemia, anxiety, depression, dysphasia, psychotic disorders with hallucinations. The annual Minimum Data Set (MDS) quarterly assessment dated [DATE] identified the resident was severely cognitively impaired and indicated the resident required extensive assistance of two people for bed mobility and transfers. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #11 had a Brief Interview for Mental Status (BIMS) score of 4 out of fifteen, indicative of severe cognitive impairment and indicated the resident required extensive assistance with Activities of Daily Living (ADL). The Accident and Incident Report dated 3/13/21 at 8:00 P.M. indicted the resident hit his/her leg on leg rest causing a skin tear to the left lower leg. The intervention was for Physical Therapy (PT) PT/ Occupational Therapist (OT) to evaluate the leg rests. The Resident Care Plan (RCP) dated 4/20/21 identified a skin tear to right and left shins. Interventions directed to have physical and occupational evaluation for leg rests for use and Resident #11 to wear Derma-Savers in place to bilateral lower extremities when in wheelchair. Additionally, prior to the 3/13/21 incident the intervention to have padding to wheel chair foot pedals was in place The Accident and Incident Report dated 3/13/21 at 8:00 P.M. indicted the resident hit his/her leg on leg rest causing a skin tear to the left lower leg. The intervention was for Physical Therapy (PT) PT/ Occupational Therapist (OT) to evaluate the leg rests. The nurse's note dated 3/13/2021 at 9:04 P.M. identified this writer was informed that during care a Nurse Aide (NA) observed Resident # 11 with superficial skin tear, the resident was observed to hit his/her left leg on the left leg rest, prior to being transfer with assistance of one staff. A superficial skin tear exhibiting frank red blood was observed, exposing a pink wound bed with bright red capillary blood in small amounts over wound area. The skin was peeled but was noted still intact, Supervisor made aware, family/physician notified. Treatment order received by the physician. Pain evaluation was performed, with no complaints of pain. New treatment performed on resident without any difficulty. All safety measures in place. The Accident and Incident Report dated 4/4/21 at 3:00 P.M. identified Resident #11 hit his/her leg on leg rest. The intervention directed the resident to wear derma care (a type of padded Geri-Sleeves for her/ his upper and lower leg) to the Bilateral Lower Extremity (BLE) when in wheelchair. The nurse's note dated 4/4/21 at 3:13 P.M. identified the writer was called to assess the resident's compliant of pain in the right leg. Upon assessment, blood was seen on the compression stockings. Upon removal, a skin tear was noted which measured 4 Centimeter (CM) x 2 CM seen on the right shin. Resident # 11 had his/her leg dangling off of the foot pedals in an attempt to get out of the chair. Steri strips were placed followed by a dry clean dressing. The responsible party and Medical Doctor (MD) were notified. Resident #11 was unable to determine the cause of skin tear. Observations on 7/12/21 at 11:00 A.M. and 7/13/21 at 10:00 A.M. and 12:30 P.M. identified Resident #11 was out of the bed in the wheelchair without the benefit of the bilateral leg rests being padded and the bilateral padded derma cares. Interview with the Director of Nursing Services (DNS) on 7/13/21 at 1:00 P.M. indicated Resident #11 sometimes does not like to wear the derma savers at times and indicated the resident was non-compliant with wearing the derma savers. The DNS also indicated if the resident refuses to wear the derma savers there would be a nurse's note. Interview with NA # 4 on 7/13/21 at 1:45 P.M. identified he/she had worked with Resident #11 since the beginning of June 2021 and she was not aware of the resident needing to wear the tan padded derma care sleeves covering for both legs. NA #4 also indicated she had not seen any of the padded tan derma saver leg sleeves in Resident #11's room. NA #4 indicated she provided A.M. care to Resident #11 and did not apply the derma sleeves on the resident. NA #4 further indicated she did not notice the derma savers on the resident's care card. Interview with Person #1 and Person #2 on 7/13/21 indicated they visit Resident #11 between 2-3 times a weeks and had not seen the tan derma savers to the bilateral legs except for once in May 2021. Person #1 and Person #2 indicated they had not seen the leg rest on the left side padded in a while. The Nursing Assistant Care Card dated 7/13/21 indicated Resident #11 was an assist of one for transfers with a rolling walker, on 8/20/20 an intervention was added to apply padding to the wheelchair foot pedals, and on 4/4/21another intervention was add to apply derma savers when out of bed. After surveyor inquiry the Resident Care Plan (RCP) dated 7/13/21 identified at times resident prefers not to wear ted hose and derma savers. The nurse's notes dated 4/4/21 through 7/14/21 were reviewed and failed to indicate Resident #11 refused to wear the Derma-saver sleeves to bilateral legs. 7/14/21 10:19 A.M. the Rehabilitation Director indicated he/she was not able to find the original screen in the medical record on 7/13/21, but in the morning on 7/14/21 was able to provide a copy, he/ she stated he/she had a copy in his/her office. The Rehabilitation Director indicated when he/she did the screen on 3/16/21 he/she placed padding on both sides of both leg rests completely covering the metal from the knee area to the foot pedal. Observation on 7/14/21 at 10:00 A.M. identified Resident #11 sitting in the wheelchair in hallway with the bilateral leg rest with new padding covering all the metal from the knee area to the foot pedals. Resident #11 was not wearing the derma savers to bilateral lower extremities. Interview, clinical record review, and facility documentation review with the Director of Nursing Services (DNS) on 7/14/21 at 11:35 A.M. identified she/he was unable to provide documentation to reflect that Resident #11 refusal to wear the Derma Saver bilateral leg sleeves. The DNS indicated the intervention from the 4/4/21 to right lower extremity was for the resident to wear the derma-saver leg sleeves to bilateral lower extremities and the intervention was placed on the care plan and the nursing assistants care card. The DNS also indicated it was the nursing assistant's responsibility to apply the derma-sleeves on before resident get out of the bed and removed when the resident go to bed. The DNS indicated the nurse or the DNS will pick the size of the derma savers for the nursing assistants for Resident #11 by looking at the resident's legs and making sure they are not too big. The DNS further indicated if Resident #11 refuses to wear the protective derma sleeves then the nursing assistant should report the refusal to the charge nurse and the charge nurse would be expected to write a nursing note regarding the refusal. The Comprehensive Care Plan Policy dated 11/2017 identified care plans are developed recognizing each resident as an individual, the facility identifies and meet the resident's needs in a resident-centered environment. Care plans are oriented towards preventing avoidable decline in clinical and functional levels, maintaining a specific level of functioning, and reflect the resident preferences and right to refuse treatment. Care plans are a combination of evaluations conducted by professional and other disciplines, and acute/chronic events, behaviors and /or illness. Although requested, a facility policy for the use of Derma-Savers for extremities or use of skin prevention equipment was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy and interviews for one of three residents reviewed for Nutrition, (Resident # 40), the facility failed to ensure the resident's weight was monitored per facility policy and failed to ensure dietician recommendations were addressed or communicated in timely to ensure no further weight loss. The findings include: Resident # 40's diagnoses included dysphagia, acute kidney failure, muscle weakness and altered mental status. The admission MDS assessment dated [DATE], completed by RN #3, identified the resident had severe cognitive impairment, required extensive assistance of two staff for bed mobility, required extensive assistance of one staff for eating, noted the resident's height as 61 inches tall [erroneous], weight 196 pounds, had not had weight loss or gain of 5% or more in the past month or 10% or more in the last 6 months, and indicated Resident # 40 did not have any pressure ulcers. The nursing pressure ulcer evaluations dated 6/3/21 identified a stage 2 pressure ulcer to left buttock, 3.0 Centimeters (CM) x 1.0 CM X 0 CM, and an unstageable pressure ulcer to coccyx, 0.5 CM x .5 CM. The nurse's notes dated 6/3/21 identified the resident had a seven-pound weight loss, dietician, physician, and resident representative were notified. The physician's order dated 6/4/21 directed Prosource 30 ml twice a day for dietary supplement. The care plan meeting form dated 6/10/21 identified the resident's weight was 186.9 pounds. The care plan dated 6/10/21 identified a potential for impaired nutritional status, interventions included to monitor weight the resident. A review of the resident's weight documentation identified weights: 5/23/21 199.9 pounds, 5/26/20- 196.4 pounds, 6/1/21 186.0 pounds, 6/2/21 189.9 pounds, 6/8/21 186.8 pounds, 6/29/2 195.6 pounds (struck out on 7/2/21), 6/30/21- 154.4 pounds (struck out on 7/1/21), 7/1/21 168.2 pounds (struck out on 7/9/21), 7/3/2 166.3 pounds (struck out on 7/9/21), 7/11/2 163.5 pounds. Interview and record review with the Director of Nursing Services ( DNS) and RN #2 on 7/14/21 at 9:35 A.M. identified the resident's weight was not monitored per policy, the nursing staff was responsible for ensuring weights are conducted per policy, the facility policy is to have weights weekly x 4 after a significant weight loss, and to have re-weight for any change of 5 pounds or more if the resident weighed over 100 pounds. The DNS also identified he/she was on vacation for two weeks in June 2021 and had assigned monitoring of weekly weights to RN #2. RN #2 identified that he/she was new to the facility and had not followed up regarding weekly weights as requested by the DNS. Interview with the Registered Dietician (RD) on 7/14/21 at 10:51 A.M. identified she/he notified the nursing staff through the facility's communication board on 6/24/21 to give the resident 180 cc house supplement three time a day in addition to the supplement Resident #40 was receiving twice day supplements during medication pass. The RD also indicated she/he believed that these intervention had taken place per her/his request. RD also indicated she/he did not order daily weights because it is a nursing responsibility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of facility policies and procedures and interviews for one of three residents (R #472) reviewed for food, the facility failed to ensure a dietician assessment was completed for a new admission. The findings include: R #472's diagnoses included GI bleed and hypothyroidism. The nursing admission assessment dated [DATE] identified that R #472 was alert and was independent with meals. Review of the physician's order dated 8/25/18 directed a regular diet, regular texture consistency. Review of the physician's order dated 8/25/18 directed to discontinue the regular diet, regular texture consistency, and to provide a regular diet, mechanical soft ground texture diet. The Resident Care Plan (RCP) dated 8/27/18 identified a ground soft diet with interventions directed to allow adequate time to consume meals, provide selective menu as able, provide snacks as desired in compliance with diet, and update food preferences as needed. Review of the clinical record identified that although R #472 was discharged to the hospital on 9/2/18 and readmitted on [DATE], and then discharged from the facility on 9/10/18, the review failed to identify a dietary assessment was completed, any dietary visits were provided, and/or that R #472 was seen by a dietician during his/her stay. Further review identified that R #472 was present in the facility for a total of sixteen (16) days; seven (7) days in August, and nine (9) days in September. Review of the clinical record, review of facility documentation and interview with the DON on 3/24/19 at 1:40 PM identified that R #472 was never seen by the dietician during his/her stay at the facility and should have been seen. Interview with the DON on 3/27/19 at 1:13 PM identified that the facility had no dietician available to see residents between 7/19/18 and 9/17/18. Further interview with the DON indicated that the dietician had left employment at the facility, and while waiting for a new dietician to start, the facility was unable to provide a dietician to cover resident assessments. Review of the facility Food First-Nutrition Policy directed in part, to assess all residents and the resident will be assessed by a Registered Dietitian or a registered Diet Technician within 7 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of facility policies and procedures, and interviews for one of three residents (R #473) reviewed for transportation, the facility failed to provide transportation to a scheduled appointment, and/or failed to provide assistance with a car transfer for a dependent resident. The findings include: R #473's diagnoses included Lupus, muscle weakness, and rheumatoid arthritis. The admission MDS assessment dated [DATE] identified that R #473 was confused, unable to repeat words, unable to identify the correct day, month or year, required extensive assistance of two for transfers, and used a wheelchair for mobility. The Resident Care Plan (RCP) dated 11/29/18 identified R #473 required assistance with transfers with interventions directed to use a mechanical (Hoyer) lift with two assist for transfers. Review of NA care card identified R #473 required assist of two staff with Hoyer lift device for transfers. Review of the nurse's note dated 12/10/18 at 1:11 PM identified the DON was called to R #473's room and observed the resident lying on his/her left side in front of the wheelchair, positive range of motion of all limbs, no bruising or swelling, denied any head pain or discomfort and the family was notified. Review of the nurse's note dated 12/10/18 at 9:43 PM identified R #473's responsible party (RP) was informed. R #473 had no apparent injury and denied pain, a RP requested a CT scan of the head. The physician was notified and an order was obtained for the CT scan. The RP was notified of the new order and informed the CT scan could be done on 12/10/18 only through the emergency room, and the RP responded that he/she would agree to have the CT scan done on 12/11/18. Review of the physician's order dated 12/10/18 directed to obtain CT scan of the head, non-contrast. Review of the social service note dated 12/11/18 at 2:09 PM identified the RP requested discharge to home on [DATE] with homecare services/equipment put into place by the Social Worker. Review of the nurse's note dated 12/11/18 at 5 PM identified that education was provided to the RP and R #473 was discharged to home at 5 PM via family transport. Review of facility discharge papers dated 12/11/18 identified R #473 was non-ambulatory and required a Hoyer lift for transfers. Review of the social service note dated 12/12/18 at 9:37 AM identified that he/she spoke with the RP and was informed he/she would take R #473 to have the CT scan done and then return for the discharge paperwork, however the RP did not return on 12/11/18 as planned. Further review indicated that all services were in place for discharge: supplies, hospital bed, wheelchair and Hoyer lift. SW called the RP and was told that R #473 had pain in his/her left arm and suspected a fracture. Interview with the Director of Rehab on 3/26/19 at 12:03 PM identified at the time of discharge, R #473 required two staff and a Hoyer lift for transfers, no car transfers or family education for transfers had been attempted by rehab prior to discharge. Interview, clinical record review, and facility documentation review with RN #2 on 3/26/19 at 12:30 PM identified on 12/11/18 she witnessed R #473's RP and a visitor transfer R #473 without the assistance of any staff member from the wheelchair into a car by standing R #473 and turning him/her into the car seat. Interview, clinical record review, and facility documentation review with the DON on 3/27/19 at 10 AM identified on 12/11/18 when R #473 was discharged from the facility, R #473 required a Hoyer lift and two staff assistance for transfers, and the CT scan was to be completed on 12/11/18 was booked by the facility. Further interview with the DON identified that transportation companies were not willing to transport residents the short distance to the hospital, and stated that the facility had a wheelchair van to transport residents to appointments. The DON indicated that the facility van was in use at the time R #473 left the facility, and that no staff assisted with R #473's transfer into the car. The DON further stated that although the facility had a transport van, staff were aware the RP did not want to wait for the van to return and was going to transfer R #473 into the car. The DON indicated that the facility could have facilitated the transfer or had the resident discharged AMA. Interview with the Scheduler on 3/27/19 at 12:35 PM identified the CT scan was scheduled by the facility, and it was completed at 4:18 PM. Further interview identified that the facility transport van was used by recreation on 12/11/18 and did not return to the facility until 3:50 PM. Interview with DON on 3/27/29 at 10AM identified that there was no facility policy for surveyor review, however the expectation was that transportation would have been provided by the facility transport van.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of facility policy for 1 of 2 sampled residents (Resident #60) reviewed for nutrition, the facility failed to provide the appropriate consistency mealtray. The findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses that included multiple fractures, intracerebral hemorrhage, difficulty swallowing, gastro-esophageal reflux disease (GERD), and diabetes. The admission Minimum Data Set assessment dated [DATE] identified Resident # 60 had no cognitive impairment and required supervision when eating. A physician order dated 3/18/19 directed to implement aspiration precautions. A physician order dated 3/19/19 directed to provide a mechanical soft ground texture diet. The Resident Care Plan (RCP) dated 3/20/19 identified Resident #60 was at risk for aspiration. Interventions included to follow feeding guidelines as indicated, to cue Resident #60 to take small bites, small sips, to allow adequate time for swallowing and to provide an evaluation by the Speech Language Pathologist (SLP) with treatment as ordered. A SLP progress note dated 3/22/19 identified Resident #60 continued to be at risk for aspiration. 1. Observation on 3/24/19 at 12:00 PM identified Resident #60 eating lunch alone in his/her bedroom seated in a bedside chair. The tray of food in front of Resident #60 included chopped meat, mashed potatoes and whole brussel sprouts. Resident #60's meal ticket identified Resident #60's vegetables should be chopped and/or cut into small pieces. Interview and observation on 3/24/19 at 12:02 PM with NA #1 identified Resident # 60's brussel sprouts should have been cut into small pieces. Subsequent to surveyor inquiry, NA # 1 attempted to cut the brussel sprouts into small pieces however was unsuccessful because NA # 1 identified the brussel sprouts were too firm to be cut. When NA #1 was unable to cut the brussel sprouts and he/she removed the tray of food from the room. Interview on 3/24/19 at 12:07 PM with the Administrator identified he had delivered the lunch tray to Resident #60 on 3/24/19. The Administrator identified that although he read the meal ticket, he did not see the instructions on Resident #60's meal ticket to chop the vegetables into small pieces. The Administrator further identified he was unable to explain the reason he did not see the instructions to cut the vegetables into small pieces. A nursing progress note dated 3/24/19 at 1:00 PM identified RN #3 was called to assess Resident #60 because Resident #60 had consumed the wrong diet consistency. Resident #60 identified he/she had consumed two brussel sprouts that were not chopped. Resident #60's diet order directs the vegetables to be chopped. At the time of the assessment Resident #60's lungs were clear, no cough or shortness of breath were noted and the physician and family were notified. Interview with the Dietary Director (DD) on 3/24/19 at 2:00 PM identified if a resident's meal ticket directs that the resident receive chopped vegetables it would be the responsibility of the dietary server to chop the vegetables before the vegetables leave the kitchen. The DD further identified, when the dietary server was asked the reason that the brussel sprouts were not chopped, the dietary server identified he/she felt brussel sprouts were small enough and did not need to be chopped. Further interview with the DD identified he/she would have expected the brussel sprouts to have been cut in half and/or chopped prior to leaving the kitchen.

Based on review of facility documentation, interviews and review of facility policy for 3 of 3 Nurse Aides reviewed for sufficient and competent nurse staffing (NA #2, NA #3, and NA #8), the facility failed to complete a performance review every twelve months. The findings include: A review of the NA #2's personnel file identified he/she was hired as a NA for the facility in August of 2016. Further review of NA #2's personnel file failed to identify any annual performance evaluations. A review of NA #3's personnel file identified he/she was hired as a NA by the facility in November of 2016. Further review of NA #3's personnel file failed to identify any annual performance evaluations. A review of NA #8's personnel file identified he/she was hired as a NA by the facility in July of 2002. Further review of NA # 8's filed identified the last annual performance evaluation for NA #8 was 4/7/15. Interview with the DNS on 3/26/19 at 2:30 PM identified it was her responsibility to complete a yearly performance evaluation for NA. The DNS identified she was aware that NAs and nurses are required to have yearly performance evaluations and that she was behind in completing them. The DNS could not provide an explanation as to the reason yearly performance evaluations were not completed for NA #2, NA #3, and NA #8. A review of facility's employee performance appraisals policy identified department heads and supervisors will complete performance appraisals upon the following occasions: 1. By the end of the first six months of employment. 2. Prior to the anniversary date of employment. 3. Six months after the employee is transferred or promoted to a new job 4. Whenever appropriate, i.e. each time the employee performs exceptionally poor or well.