**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #12 and Resident 105) reviewed for choices, the facility failed to ensure that hand soap was not provided as a body/hair wash, per the residents' preferences. The findings include: 1. Resident #12 was admitted to the facility in February 2023 with diagnoses that included paraplegia, morbid obesity, and irritant contact dermatitis due to friction or contact with body fluids. The quarterly MDS dated [DATE] identified Resident #12 had intact cognition, was dependent for bathing, toileting and personal hygiene, and was always incontinent of bowel and bladder.Interview with Resident #12 on 7/27/25 at 8:40 AM identified that the nurse aides use hand soap pink soap and a paper towel (disposable cloth) for bathing, hair washing, and incontinent care. Resident #12 indicated that he/she could no longer use the pink soap provided by the facility because his/her skin became too dry and combing his/her hair hurt following a wash with the pink soap. Resident #12 further indicated that he/she had told multiple staff members about his/her concerns with the pink soap, but the concerns were not addressed. Subsequently a family member has been purchasing hair and body wash products for the nurse aides to use for his/her bathing and incontinent care. 2. Resident #105 was admitted to the facility in August 2024 with diagnoses that included rash and non-specific skin eruption, protein-calorie malnutrition, and enterocolitis due to clostridium difficile. The quarterly MDS dated [DATE] identified Resident #105 had intact cognition and was independent with toileting and personal hygiene. Interview with Resident #105 on 7/27/25 at 9:00 AM identified that the pink soap used in the bathroom for hand washing was the same pink soap that was provided for showers and hair washing. Resident #105 indicated that the pink soap dried out his/her skin, and that he/she would only use water to wash his/her hair because the pink soap tore up his/her hair. Resident #105 identified that for a short (unspecified) time, a body and hair combination wash was provided, but the facility had since returned to the pink soap with a stack of disposable towels for bathing and hair washing. Observation and interview with Housekeeper #1 on 7/29/25 at 7:11 AM identified that he had used the bottle labeled Hand Soap Pink Perfect Mild Lotion Hand Cleaner to stock the entire house: including bathrooms, resident rooms, and shower rooms.Interview with NA #7 and NA #8 on 7/29/25 at 9:15 AM identified that earlier this year the body and hair wash used to bath residents was taken away, and they were informed that the pink soap, stocked in the bathrooms for handwashing, would be used for body and hair washing. NA #7 and NA #8 indicated that residents had complained that it was drying their skin and clumping their hair. NA #7 and NA #8 identified that they had notified the Director of Housekeeping that the pink soap was not working out, and she had indicated that she was told by corporate that was what the facility uses. Interview with Housekeeper #2 on 7/29/25 at 12:10 PM identified that she had been filling all of the shower rooms and bathrooms from the bottle labeled Hand Soap Pink Perfect Mild Lotion Hand Cleaner, for the last few months. Interview with NA #4 on 7/29/25 at 12:13 PM identified that she had been using the pink soap to clean and bathe residents, since May or June of this year.Review of the Product History document dated 7/29/25 identified that 23 gallons of Hand Soap- Pink were purchased between the dates of 4/15/25 through 7/26/25, and 4 gallons of Shampoo and Body Wash had been purchased in the last 2 years, on 6/20/25 and 6/30/25. Interview with the Director of Housekeeping on 7/30/25 at 4:16 PM, hire date 12/10/24, identified that the facility was already using the pink soap when she was first hired, and that the staff had complained to her that they were experiencing dry skin from using the product; it was not communicated to her that the residents were complaining of dry skin due to the pink soap. The Director of Housekeeping indicated that, in response to the staff's feedback, she ordered shampoo and body wash in June of 2025, but the staff had not provided feedback if the shampoo and body wash was an improvement or not, so when it ran out, they resumed using the supply of pink soap. The Director of Housekeeping further indicated that the residents' concerns about the pink soap were not brought to her attention by staff or during any of the resident council meetings that she had attended, but she would circle back to residents and staff for feedback and order whatever they like.Interview with the Administrator on 7/31/25 at 10:35 AM identified that during the 6/6/25 resident council meeting it was brought up that some of the residents did not like the pink soap and liked the shampoo and body wash better. The feedback was discussed with corporate, and he was told that the pink soap was meant to be a full body wash. The Administrator indicated that he was not aware that the soap referred to as pink soap was a hand soap. The Resident Rights policy directs that residents have the right to receive quality care and services with reasonable accommodation of individual needs and preferences, except when the health or safety of others would be endangered by such accommodation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 6 residents (Resident #43, 65, 99 and 116) reviewed for abuse, the facility failed to protect Resident #43, 65, 99 and 115 from physical abuse by Resident #123, who had a history of resident-to-resident altercations, and injured Resident #99. The findings include:1a. Resident #65 was admitted to the facility in May 2019 with diagnoses that included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, schizophrenia, and obesity.The quarterly MDS dated [DATE] identified Resident #65 had intact cognition and required supervision with transfer, and locomotion on/off unit. Additionally, Resident #65 had no physical and verbal behaviors directed toward others. The care plan dated 3/9/23 identified Resident #65 had diagnoses of dementia and was at risk for impaired decision making. Interventions included to administer medications as ordered. Encourage to attend preferred recreational activities.The physician's order dated 5/1/23 directed Resident #65 was independent with bed mobility, transfer, and ambulation. No assistive device was needed.The nurse's note dated 5/9/23 at 4:57 PM identified RN #5 was called to the front desk. Receptionist #1 reported she observed Resident #65 chasing Resident #123 and grabbed Resident #123 by his/her shirt. Resident #65 said to Resident #123 do not put your hands on me again. Both residents were immediately separated by Receptionist #1. The investigation identified Resident #123 asked Resident #65 at the cafe area for a cigarette and Resident #65 reply no. Resident #123 then kicked Resident #65 on the right leg which led to the chase. RN assessment provided with no redness, no swelling to the right leg. The care plan dated 5/9/23 identified Resident #65 had a resident-to-resident altercation. Resident #65 was kicked by another resident on the right leg and Resident #65 chased the resident and grabbed him/her by the shirt. Interventions included to provide psychiatry and social worker support. Educate and encourage to approach staff and report any incidents for prompt interventionThe psychiatric evaluation and consultation form dated 5/9/23 identified the psychiatric APRN, APRN #2 was asked to evaluate Resident #65 who was alleged to have had an altercation with Resident #123. Resident #65 reported Resident #123 kicked him/her on the leg because he/she had refused to give him/her a cigarette. Resident #65 reported he/she did not hit or kick Resident #123. Resident #65 was placed on 1:1 monitor until evaluated by psychiatrist. Resident #65 was encouraged to talk to the nursing staff if there are issues with another resident. No adjustment of resident medications at this time. Considering Resident #65 was not a danger to himself or other at that time, Resident #65 was cleared. Discontinue 1:1 monitoring. Continue with current psychiatric medication as ordered.The social service note dated 5/9/23 at 4:18 PM identified SW #4 checked with Resident #65 regarding the incident that occurred. Resident #65 reported no issues or complaints.b. Resident #123 was admitted to the facility in July 2020 with diagnoses that included major depressive disorder, anxiety disorder, schizophrenia, paranoid personality disorder, and psychosis. The annual MDS dated [DATE] identified Resident #123 had moderately impaired cognition and required supervision with transfer and locomotion off on/off unit. Additionally, Resident #123 had no physical and verbal behaviors directed toward others. The care plan dated 4/20/23 identified Resident #123 was in a physical altercation with another resident. Interventions included psychiatric services as needed. Encourage the resident to seek out the staff when having difficulty with other residents.The physician's order dated 5/1/23 directed Resident #123 was independent with bed mobility, transfer, and ambulation. No assistive device was needed.A reportable event form dated 5/9/23 at 10:48 AM identified Resident #65 was kicked by Resident #123. Both residents were separated immediately. Resident #65 was placed on 1:1 monitoring. Resident #65 was evaluated by psychiatrist and cleared. The social service note dated 5/9/23 at 2:00 PM identified SW #4 checked with Resident #123 post resident to resident altercation. Resident #123 indicated he/she vehemently pursued Resident #65 because he/she refused to offer him/her a cigarette. Educated interventions of self-control and mood management are ineffective because of diminutive duration, as evidence of Resident #123 inability to preserve focus or maintain presence for an extended period. The nurse's note dated 5/9/23 at 4:37 PM identified RN #5 after the resident to resident altercation Resident #123 was placed on 1:1 monitoring immediately. Resident #123 refused assessment and was not cooperative with further questioning and stated to leave him/her alone he/she was ok. Resident #123 pending PEC (physician's emergency certificate) and to be sent to a facility in AM. The psychiatric evaluation and consultation form dated 5/9/23 identified Resident #123 was with increasing psychosis and assaultive behavior as well as non-adherence to medications. Transfer to inpatient geropsychiatric hospital once a bed is available. Resident #123 has a history of gradual dose reduction failure. At this time Resident #123 is considered a danger to self and others. The care plan dated 5/9/23 identified Resident #123 had acute agitation. Interventions included safeguarding the safety of the resident, or other residents, and others in the area. Help the resident manage their emotions by asking and offering a drink. A verbal statement by Resident #65 written by the previous Administrator #1 with no date and time. Resident #65 indicated Resident #123 asked him/her for a cigarette and he/she told Resident #123 no. Resident #65 indicated Resident #123 kicked him/her and ran and he/she chased Resident 123.A verbal statement by Resident #123 written by the previous Administrator #1 with no date and time. Resident #123 indicated he/she asked Resident #65 for a cigarette and Resident #65 said no. Resident #123 indicated that it was not nice, so I kicked him/her. Resident #123 indicated Resident #65 ran after me and grabbed my shirt.A written statement by Receptionist #1 dated 5/9/23 at 10:39 AM identified she witnessed Resident #123 running towards her saying he's/she's coming. Resident #65 ran after Resident #123 and asked him/her was he/she crazy and told him/her never to put his/her hands on him/her again. Receptionist #1 indicated she intervened and separated both residents and called the supervisor.A written statement by NA #4 dated 5/9/23 at 10:39 AM identified she was walking to the kitchen and heard Receptionist #1 saying no to Resident #65. NA #4 indicated she ran to the front desk area and saw Resident #65 grabbing Resident #123 shirt. The summary form dated 5/16/23 identified RN assessment performed to Resident #65 and resident did not sustain any bruising or skin tear as a result of the incident. Resident #65 did not hit Resident #123. Resident #65 was evaluated by psychiatrist and cleared. Resident #123 was placed on 1:1 monitoring. Both resident care plans had been updated. The summary form dated 5/17/23 identified Resident #123 remained on 1:1 monitoring after the incident until transferred to hospital on 5/10/23.The nurse's note dated 5/26/23 at 8:35 PM identified Resident #123 was readmitted to the facility at 1:30 PM with diagnoses of schizoaffective disorder, aggressive behavior of adult. Resident #123 was noted to have multiple medication adjustments. The APRN and the conservator updated of readmission. Will continue to monitor.Although attempted, an interview with the previous Administrator, (Administrator #1), previous DNS (DNS #1), RN #5, NA #4, and Receptionist #1 was not obtained. Review of the facility abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation policy identified the policy of the facility is to ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation. Physical abuse: the intentional infliction of physical pain, bodily harm, or physical coercion. 2a. Resident #99 was admitted to the facility in June 2021 with diagnoses that included takotsubo syndrome, schizoaffective disorder, anxiety disorder, borderline personality disorder, and obesity. The quarterly MDS dated [DATE] identified Resident #99 had intact cognition and required supervision with transfer and locomotion on/off unit. Additionally, Resident #65 had no physical and verbal behaviors directed toward others. The physician's order dated 9/1/23 directed independent bed mobility, transfers, and ambulation using rollator walker.The nurse's note dated 9/28/23 at 4:30 PM by the ADNS identified she heard a loud sound coming from a resident room. The ADNS observed Resident #99 on the floor with Resident #123 who was hitting Resident #99 on the head. The ADNS immediately separated both residents, provided first aid to Resident #99, and an RN assessment performed. Resident #99 was placed on 1:1 monitoring and sent to the hospital for further evaluation. The hospital documentations dated 9/28/23 identified Resident #99 presented for evaluation after an assault at a nursing facility. Resident #99 fell backwards and struck the back of head, no loss of consciousness. Resident #99 had mild pain to the back of head. Resident #99 had a small laceration with hematoma to the left back of head. The laceration was small and does not require sutures or staples for closure. The laceration was cleansed and closed with Steri-Strips. CT scan of head negative. Resident #99 was discharged back to the nursing facilityThe APRN note dated 9/29/23 at 9:18 AM identified Resident #99 was seen for a follow up hospital visit with diagnoses of laceration of scalp. The CT scan of the head was negative. Resident #99 was doing well this morning and denied headache. b. Resident #123 was admitted to the facility in July 2020 with diagnoses that included major depressive disorder, anxiety disorder, schizophrenia, paranoid personality disorder, and psychosis. The care plan dated 5/9/23 identified Resident #123 had kicked another resident on the leg. Interventions included the resident was educated and encouraged not to hit any peers or staff members, safeguarding the safety of the resident, or other residents, and others in the area. Help the resident manage their emotions by asking and offering a drink. The quarterly MDS dated [DATE] identified Resident #123 had severely impaired cognition and was independent with transfer and locomotion off/on unit. Additionally, Resident #123 had exhibited physical and verbal behaviors toward others. The summary form dated 10/1/23 identified Resident #123 was diagnosed with urinary tract infection and exacerbation of schizophrenia. Resident #123 was treated for urinary tract infection. Resident #99 has a stop sign at his/her room door. Both residents received support from the facility psychiatrist team and social service department. Both resident care plans were updated.Although attempted, an interview with the previous Administrator (Administrator #1), and previous DNS (DNS #1) were not obtained. Review of the facility abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation policy identified the policy of the facility is to ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation. Physical abuse: the intentional infliction of physical pain, bodily harm, or physical coercion. 3a. Resident #116 was admitted to the facility in October 2023 with diagnoses that included schizoaffective disorder, bipolar disorder, and congestive heart failure. The annual MDS dated [DATE] identified Resident #116 had intact cognition and required supervision or touching assistance with bed mobility, transfer and walking 10 feet. Additionally, Resident #116 had no physical and verbal behaviors directed toward others. The nurse's note dated 1/10/24 at 7:03 PM by RN #3 identified at 4:00 PM she was informed by the Director of Recreation that Resident #116 was hit by Resident #123 during smoking break. Both residents were separated immediately and placed on 1:1 monitoring. Resident #116 indicated he/she asked Resident #123 to move, and Resident #123 hit him/her on the mouth. RN assessment performed no redness or swollen noted to mouth. Resident #116 refused to be transferred to the hospital and indicated he/she was ok. Resident #116 is responsible for self. The APRN and the police were notified. The psychiatrist APRN was notified and cleared resident off monitoring. The care plan dated 1/10/24 identified Resident #116 was involved in a resident-to-resident altercation. Interventions included keeping the resident at a designated chair away from the other resident during smoking break. Offer psychiatrist and social services support.b. Resident #123 was admitted to the facility in July 2020 with diagnoses that included major depressive disorder, anxiety disorder, schizophrenia, paranoid personality disorder, and psychosis. The care plan dated 9/28/23 identified Resident #123 had previously hit and kicked other residents. Interventions included safeguarding the safety of the resident, or other residents, and others in the area. Help the resident manage their emotions by asking and offering a drink. The quarterly MDS dated [DATE] identified Resident #123 had severely impaired cognition and was independent with transfer and locomotion off/on unit. Additionally, Resident #123 had exhibited physical and verbal behaviors toward others. The nurse's note dated 1/10/24 at 4:45 PM by RN #3 identified at 4:00 PM she was informed by the Director of Recreation that Resident #123 slapped Resident #116 on the face during smoke break. Both residents were separated immediately and placed on 1:1 monitoring. Resident #123 indicated Resident #116 swore at him/her, so he/she slapped him/her. Resident #123 was transferred to the hospital for psychiatric evaluation at 4:30 PM. The care plan dated 1/10/24 identified Resident #123 had hit another resident during smoking break. Interventions included keep Resident #123 at a designated chair away from the other resident during smoking break. The reportable event form dated 1/10/24 at 4:00 PM identified Resident #123 slapped Resident #116 in the face during smoking break. Resident #123 indicated Resident #116 swore at him/her. A written statement by the Director of Recreation dated 1/10/24 at 4:00 PM identified during smoking break Resident #123 got mad at Resident #116 and hit him/her in the face. The Director of Recreation indicated Resident #123 then left the courtyard. The Director of Recreation indicated both residents were immediately separated, and the supervisor was notified. The summary form dated 1/18/24 identified Resident #116 indicated Resident #123 sat next to him/her during smoke break. Resident #116 indicated he/she asked Resident #123 to move away because he/she attracts bad things. Resident #116 hit him/her in the face. No altercation or disagreement had occurred between the two residents prior to this incident. Resident #123 was currently in an inpatient psychiatric hospital, for medication review and treatment. Resident #123 will receive continued support from psychiatric and social services upon return. Resident #116 had received psychiatric and social services support. Each resident has a designated seat away from each other during smoking breaks.Although attempted, an interview with Administrator #1, and DNS #1 were not obtained. Review of the facility abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation policy identified the policy of the facility is to ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation. Physical abuse: the intentional infliction of physical pain, bodily harm, or physical coercion. 4a. Resident #43 was admitted to the facility in January 2020 with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety disorder, and depressive disorder.The quarterly MDS dated [DATE] identified Resident #43 had severely impaired cognition and was independent with bed mobility, transfer, and ambulation. Additionally, Resident #43 had no physical and verbal behaviors directed toward others. The nurse's note dated 2/2/24 at 3:38 PM by LPN #8 identified at 2:30 PM she observed Resident #43 leaning against the wall. Resident #43 indicated his/her roommate (Resident #123) punched him/her in the face. Resident #43 appeared to be confused. The DNS and the ADNS were notified. Resident #43 was placed on 1:1 and neurological assessment initiated. Resident #43 was transferred to the hospital for further evaluation at 2:30 PM. The nurse's note dated 2/2/24 at 5:06 PM by the ADNS identified Resident #43 reported to a nurse aide that he/she was punched in the face by another resident. Resident #43 was observed with a red mark on the center of his/her face, Resident #43 complained of headache, noted of increased confusion, no bleeding or loss of conscious, neurological assessment started. RN assessment was performed. Resident #43 was separated immediately and placed on 1:1 monitoring. The DNS, Administrator, police, APRN, and the power of attorney were notified. The care plan dated 2/2/24 identified Resident #43 was involved in an altercation where he/she was hit by roommate. Interventions included providing psychiatric and social services support. Allow the resident to talk through stressors and provide reassurance. b. Resident #123 was admitted to the facility in July 2020 with diagnoses that included major depressive disorder, anxiety disorder, schizophrenia, paranoid personality disorder, and psychosis. The quarterly MDS dated [DATE] identified Resident #123 had severely impaired cognition and was independent with transfer and locomotion off/on unit. Additionally, Resident #123 had exhibited physical and verbal behaviors toward others. The care plan dated 1/10/24 identified Resident #123 had hit another resident during smoking break. Interventions included keep Resident #123 at a designated chair away from the other resident during smoking break. The nurse's note dated 2/2/24 at 5:22 PM by the ADNS identified the DNS reported Resident #123 had a physical altercation with Resident #43. Resident #123 hit/punched Resident #43 in the face. Resident #123 believed Resident #43 took his/her bag. Resident #123 was observed with increased agitation and verbally abusive with the DNS. Resident #123 was placed on 1:1 monitoring. Resident #123 was transferred to the hospital for further evaluation. The APRN, police, and Resident #123's power of attorney were notified. The care plan dated 2/2/24 identified Resident #123 hit his/her roommate. Interventions included to remove other residents when Resident #123 is observed to be in an agitated state. If unable to deescalate the situation call 911.The reportable event form dated 2/2/24 at 2:00 PM identified Resident #123 hit Resident #43 in the face. Resident #123 alleges that Resident #43 took his/her bookbag and hid it in his/her purse. Resident #43 reported that he/she was hit in the face by Resident #123. Both residents were separated immediately, placed on 1:1 monitoring, and taken to the hospital for evaluation. The Administrator, police, APRN, and the resident representative were notified.The summary form dated 2/12/24 at 8:15 PM identified Resident #43 has been relocated to another unit. Both residents are receiving psychiatric and social services support. A search has underway to get Resident #123 into a psychiatric long term facility.Resident #123 was discharged to another facility on 3/18/24.Although attempted, an interview with the previous Administrator (Administrator #1), and the previous DNS (DNS #1) were not obtained. Review of the facility abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation policy identified the policy of the facility is to ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation. Physical abuse: the intentional infliction of physical pain, bodily harm, or physical coercion.

**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 2 of 8 residents (Resident #7 and 79) reviewed for range of motion and/or behaviors, the facility failed to develop and implement a comprehensive care plan for a resident with a contracture and a resident exhibiting disruptive behaviors. The findings include: Resident #7 was admitted to the facility in January 2025 with diagnoses that included dementia, cerebral infarction, and adult failure to thrive. The admission observation dated 1/3/25 identified Resident #7’s hand grasp strength was stronger on one side than the other side due to a right-hand contracture: Resident #7 presented with a contracture of the right hand and wrist joint. The care plan dated 7/15/25 failed to address Resident #7’s right-hand contracture and failed to identify therapeutic and nursing interventions and functional goals/outcomes. The quarterly MDS dated [DATE] identified Resident #7 had severely impaired cognition and had no upper extremity impairment. (The MDS failed to identify the right-hand contracture). Interview with the MDS Coordinator (LPN #14) on 7/30/25 at 5:38 PM identified that Resident #7 was not coded as having a contracture, and therefore she was unaware of the contracture. The ICD code for the diagnoses would have prompted her to document the contracture in the MDS and to create a care plan with appropriate interventions and therapy recommendations, as needed. Interview with the DNS on 7/30/25 at 6:00 PM identified that she would expect a comprehensive, interdisciplinary care plan for Resident #7’s contracture to have been developed. The DNS indicated that it would be the primary responsibility of the MDS Coordinator to develop the care plan, but any nurse could initiate a care plan. The facility’s Nursing Services policy directs that a consistent and interdisciplinary approach to the prevention, identification, treatment, and monitoring of contractures among residents is established. Thereby promoting functional independence, optimizing range of motion, and enhancing quality of life. The policy further directs that for residents at risk or with existing contractures, an individualized care plan shall be developed by the interdisciplinary team and collaboration with the resident and or responsible party. Care plans must address specific joints affected, therapy interventions (e.g., PT/OT), use of splints, positioning aids or orthotics, nursing interventions (e.g., ROM exercises, turning/repositioning schedule), functional goals, and expected outcomes. 2. Resident #79 had diagnoses that included schizoaffective disorder and post-traumatic stress disorder (PTSD). The quarterly MDS dated [DATE] identified Resident #79 required 1 person assist with transfers and toileting and had not exhibited any recent behavior symptoms. The care plan dated 6/5/25 identified Resident #79 had a diagnosis of PTSD and was an active smoker. Interventions included to assess the resident for anxiety and mood swings, identify triggers while addressing resident needs, and ensure the resident abides by the smoking policy. Physician’s order dated 7/10/25 directed to administer Nicotine Lozenge 4mg every 2 hours as needed for nicotine dependence. The July 2025 MAR identified a Nicotine Lozenge was last administered on 7/27/25 at 6:51 PM. Observation on 7/28/25 at 7:40 AM identified Resident #79 self-propelling to the nurse’s station where LPN #12 was inside the medication room visible through a half glass door. Resident #79 requested a lozenge. LPN #12 opened the medication door and informed Resident #79 that he/she would need to take a shower first. In response, Resident #79 began yelling, stating, “I don’t want to shower first, I want my lozenge now.” The nurse continued to repeat the instruction for the resident to shower first while Resident #79 was observed becoming increasingly agitated, yelling and screaming profanities at the nurse and stated “I am not feeling well.” An interview with LPN #12 on 7/28/25 at 7:40 AM identified she was the assigned nurse for the 11:00 PM to 7:00 AM shift 7/27/25 overnight to 7/28/25 and was counting controlled medications with the oncoming nurse. LPN #12 identified she had previously notified the nursing supervisor regarding Resident #79’s behavior but was unable to provide information on interventions to be implemented to address Resident #79’s escalating behaviors. Further observation identified LPN #12 closed the medication room door without any further intervention or redirection in response to Resident #79’s escalating behavior. Resident #79 self-propelled back down the hall, continually yelling and screaming profanities. An interview with RN #1 on 7/28/25 at 7:48 AM identified she was the assigned nursing supervisor for the 11:00 PM to 7:00 AM shift 7/27/25 overnight to 7/28/25. RN #1 identified she had not previously been notified of any concerning behaviors related to Resident #79 during the shift. RN #1 identified Resident #79 could occasionally get loud, disruptive and accusatory, sometimes requiring hospital transfer. RN #1 identified sitting with and allowing Resident #79 to talk about events would help to redirect the residents behaviors. RN #1 further identified Resident #79 should have received the lozenge when requested to prevent the escalating behavior. An interview with LPN #12 on 7/28/25 at 7:55 AM identified she was in the process of counting controlled medications with the oncoming nurse when Resident #79 approached her at the nurse’s station. LPN #12 indicated she put up her finger to gesture she was busy; however, Resident #79 continued to yell and scream profanities. According to LPN #12, she continued to put up her finger towards Resident #79 who should have known to wait. LPN #12 was unable to articulate what interventions should have been implemented to prevent or to de-escalate behaviors during the incident. An interview with the DNS on 7/28/25 at 8:02 AM identified Resident #79 had been known to hallucinate, make accusatory statements, and could become agitated, at times requiring a hospital transfer for evaluation. The DNS identified Resident #79 responded well to redirection through changes in activity or engaging in active listening. The DNS further identified LPN #12 should have paused the task, determined whether the medication could be administered, and notified the nursing supervisor. A subsequent interview with the DNS on 7/30/25 at 2:30 PM identified she would expect staff to follow the care plan regarding Resident #79’s escalating behavior. Although requested a policy for implementing the plan of care was not provided.

**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 4 residents (Resident #7, 10, 17 and 100) the facility failed to provide care according to professional standards.For 1 of 2 residents (Resident #7) reviewed for range of motion, the facility failed to provide treatment and care in accordance with professional standards, for a resident with a contracture.For 1 of 5 residents (Resident #10) reviewed for unnecessary medications, the facility failed to ensure that a resident with a history of hyperglycemia was assessed by a Registered Nurse following an elevated blood sugar.For 1 of 4 residents (Resident 17) reviewed for medication administration, the facility failed to ensure a self-administration assessment was completed for safety prior to leaving medication at the bedside.For 1 of 3 residents (Resident #100) reviewed for non-pressure ulcer, the facility failed to ensure the physician's orders were followed related to applying ace wraps and weekly skin checks. The findings include: 1. Resident #7 was admitted to the facility in January 2025 with diagnoses that included dementia, cerebral infarction, and adult failure to thrive. The admission observation dated 1/3/25 identified Resident #7’s hand grasp strength was stronger on one side than the other side due to a right-hand contracture: Resident #7 presented with a contracture of the right hand and wrist joint. The admission MDS dated [DATE] identified Resident #7 had severely impaired cognition and had no upper extremity impairment. (The MDS failed to identify a right-hand contracture). The physician’s order dated 3/11/25 directed for skin checks every shift, days, evening, and nights. The care plan dated 7/15/25 identified Resident #7 was at risk for pain. Interventions included observing for non-verbal signs of pain, positioning for comfort, providing medical management for underlying cause of pain, and PT/OT referral as indicated. The care plan failed to address Resident #7’s contracture and failed to identify therapeutic and nursing interventions and functional goals/outcomes. The quarterly MDS dated [DATE] identified Resident #7 had severely impaired cognition and had no upper extremity impairment. (The MDS failed to identify a right-hand contracture). Review of the physician’s orders failed to identify an interdisciplinary approach to monitor, manage, and treat Resident #7’s contracture. The nurse’s note dated 1/3/25 through 7/29/25 failed to identify documentation of on-going assessments specific to the contracture, monitoring skin integrity of the area of the contracture, or nursing interventions for the care Resident #7’s contracture. Interview with LPN #3 on 7/27/25 at 11:11 AM identified that she had worked for the facility for 6 months. LPN #3 indicated Resident #7’s right hand was contracted and that the resident goes to therapy, but she was not sure if an orthotic or splint had ever been ordered for the resident. Intermittent observations between 7/27/25 and 7/29/25 identified Resident #7’s right hand and wrist are contracted. Digits #2 and 3 are closed tightly with light yellow crust in between. Digit #1 is set under digits #2 and 3. The top portion of digit #1 was exposed in between digit #3 and 4. Digits #4 and #5 were closed tightly with digit #4 slightly laying on top of digit #5 and light-yellow crust in between the digits. Resident #7 exhibited facial grimacing when staff members attempted to gently move any of the digits. Interview and observation with NA #5 on 7/29/25 at 1:55 PM identified that she was not Resident #7’s regular nurse aide; she was a float and worked on this unit about once a week. NA #5 indicated that it was hard to get in between Resident #7’s fingers and palm of the contracted hand because it was so tight and painful. NA #5 identified that the yellow crust between the contracted fingers was not present when she last provided care for the resident approximately 2 weeks ago. NA #5 indicated she had cleaned the area earlier in the morning but could not remove all the crust because it was painful for the resident. NA #2 indicated that she did not notify the nurse of Resident #5’s pain during care because the pain was not new. Interview and observation with LPN #4 on 7/29/25 at 2:06 PM identified that she was not aware of the crust between Resident #7’s contracted fingers, and that usually there is a little piece of gauze in between the fingers and palm; she was unaware of any specific orders for the care of the contracture, but would notify OT that there was crust in the area of the contracture to find out how to best manage the area. Interview and observation with APRN #1 on 7/30/25 at 10:40 AM identified that Resident #7’s contracture was present on admission to the facility. APRN #1 further identified that she has observed some redness and dryness on the skin around the contracture, in the past, but was not aware of the yellow crust between his/her fingers. APRN #1 indicated that she would discuss recommendations with OT to protect the skin from experiencing any breakdown and refer Resident #7 to be seen by the Wound Specialist. APRN #1 further indicated that she was unaware that Resident #7 was having pain during care in the area of the contracture, and she would put in an order for Tylenol for pain management. Interview with the DNS on 7/30/25 at 5:10 PM identified that after OT assessed the contracture, an interdisciplinary plan should have been put in place, then orders would need to be put into the system to prevent further contracture and skin breakdown, based on the OT’s recommendations. The DNS indicated that on-going monitoring of Resident #7’s skin for breakdown in the area of the contracture should be completed every shift and as needed. The DNS indicated that she would sit with OT and the APRN to put appropriate orders in place to prevent skin breakdown and further contracture. Interview with the Medical Director (MD #1) on 7/31/25 at 11:40 AM identified that he would expect a plan between OT and nursing services to be put into motion to ensure Resident #7 had documented interventions in place to maintain skin integrity and to prevent further decline of the contracture. The facility’s Nursing Services policy directs that a consistent and interdisciplinary approach to the prevention, identification, treatment, and monitoring of contractures among residents is established. Thereby promoting functional independence, optimizing range of motion, and enhancing quality of life. The policy further directs that upon admission, nursing and therapy staff shall conduct a comprehensive functional mobility and muscular skeleton assessment. Risk factors for contracture development shall be identified and range of motion shall be evaluated and documented by therapy at admission, quarterly, and with significant change in condition. Therapy services interventions include evaluating for and implementing therapeutic exercises, manual stretching, positioning, and splinting, and training nursing staff and caregivers in techniques for safe range of motion exercises and positioning. Nursing interventions include performing passive/active range of motion exercises per the care plan, at least daily or as ordered, ensuring proper application and monitoring of splints/positioning devices, and maintaining correct body alignment during bed rest and wheelchair use. Monitoring and reassessment interventions should include monitoring skin integrity under devices at least once per shift and monitoring for any signs of pain, skin breakdown, or decline in function and reporting changes immediately to the charge nurse and therapy. All assessments, interventions, and resident responses must be documented and the clinical record. 2. Resident #100 was admitted to the facility in April 2023 with diagnoses that included lymphedema, acute kidney injury, and hypertension. The annual MDS dated [DATE] identified Resident #100 had intact cognition, required maximum assistance for dressing, putting on footwear, and personal hygiene and had 2 venous or atrial ulcers present. The care plan dated 5/20/25 identified Resident #100 has venous ulcers to the bilateral lower extremities. Interventions included providing wound treatments as ordered and wrapping both legs with compression socks. a. A vascular consultation dated 6/17/25 identified Resident #100 needs compression stockings or ace wraps to both legs from the ankle to the knee every morning and remove at bedtime. A wound note, written by MD #2 dated 6/18/25 identified Resident #100 has venous statis dermatitis to both lower extremities and venous statis ulcers to the left lateral leg, right superior leg, right inferior leg, and left inferior leg. Resident #100 was seen by vascular yesterday and recommendations included wrapping legs with compression stockings or ace wraps from the feet to the knees every morning and remove at bedtime. A physician’s order dated 6/19/25 directed to cleanse bilateral lower extremities with soap and water, rinse and dry well. Apply ammonium lactate 12% lotion to intact skin. Apply calcium alginate with silver to open areas, gauze to open wound, and xeroform to any blister and cover with a dry clean dressing twice daily and as needed. Apply ace wraps to bilateral lower extremities from the toes to the base of the knees. Ace wraps on in the morning and off at bedtime. Observation of Resident #100 on 7/27/25 at 10:21 AM identified the resident was seated in his/her wheelchair in the recreation room wearing shorts with feet dependent on the floor. Resident #100 has bilateral lower extremities wrapped with kerlix which is not dated. Resident #100 was without the benefit of ace wraps per the physician’s order. Observation on 7/27/25 at 1:15 PM identified Resident #100 was sitting in his/her wheelchair in the dining room wearing shorts with feet on the floor. The bilateral lower extremities are wrapped with kerlix, and the resident is without the benefit of the ace wraps. Observation on 7/28/25 at 10:00 AM identified Resident #100 was sitting in the unit dining room in the wheelchair wearing shorts with his/her feet on the floor. The bilateral lower extremities are wrapped with kerlix dated 7/27/25 3:00 PM to 11:00 PM, and the resident is without the benefit of the ace wraps. Observation of Resident #100 on 7/28/25 at 12:00 PM, 1:00 PM, and 1:50 PM identified the resident was sitting in the unit dining room in the wheelchair in a pair of shorts with his/her legs dependent wrapped in kerlix, feet on the floor. Resident #100 was without the benefit of ace wraps. Interview with LPN #2 on 7/28/25 at 1:52 PM indicated that the nurse aides got Resident #100 up this morning before she got to do the treatments today because she was busy doing the medication pass this morning and did not have time to do the treatments. LPN #2 indicated that she did not inform the supervisor or ask for assistance. LPN #2 indicated that sometimes she does the treatments in the mornings and sometimes in the afternoons, depending on the day. LPN #2 indicated the physician’s order says to put the ace wraps on in the morning, but the nurse aides sometimes get Resident #100 up out of bed before she can get to do the treatments with the ace wraps. After surveyor inquiry, LPN #2 indicated that she plans on doing Resident #100’s treatments now including putting on the ace wraps. Interview with MD #2 (wound physician) on 7/30/25 at 7:54 AM identified he had spoken with the vascular physician regarding wanting to continue to apply ace wraps versus the compression stockings. MD #1 indicated they decided the ace wraps were better for Resident #100’s edema and vascular wounds. MD #2 indicated the ace wraps must be applied to both legs before Resident #100 gets out of bed to give some compression to reduce edema and help with the venous return and circulation. MD #2 identified without the ace wraps the edema will increase. Interview with the DNS on 7/30/25 at 10:09 AM indicated the charge nurse was responsible to do the treatments on the unit and sometimes the supervisor will help the charge nurse with their treatments if the nurse notifies the supervisor they need assistance. The DNS indicated the ace wraps per the physician’s order should have been applied before Resident #100 gets out of bed daily and removed at bedtime. Review of the Compliance with and Implementation of Physician Orders Policy identified to ensure that all physicians orders are implemented accurately, timely, and in accordance with federal and state regulations. The IDT team, under the direction of the DNS, is responsible for verifying that services ordered by a physician or authorized provider are provided as prescribed. b. A physician’s order dated 4/29/25 directed to perform weekly body audits on shower days scheduled Thursday 7:00 AM to 3:00 PM. Review of the weekly skin checks dated 5/1/25 - 7/30/25 identified 3 out of 13 were completed. Interview with the DNS on 7/30/25 at 10:00 AM indicated that charge nurses were responsible to perform a weekly body audit on every resident based on the physician order. The DNS indicated the nurses must fill out the weekly skin check after inspecting the resident from head to toe. After clinical record review, the DNS indicated that the only completed weekly skin checks completed were done on 5/8, 6/12, and 6/19/25. The DNS indicated the skin checks are done and documented to identify if there are any new skin concerns or breakdown. Interview with APRN #1 on 7/30/25 at 11:01 AM identified the expectation is that nurses follow the physician’s orders. APRN #1 indicated the nurse is responsible to do a weekly head to toe assessment of the residents skin when the resident has a shower. APRN #1 indicated the nurses must document their assessment. Review of the Weekly Skin Check Policy identified this was to ensure residents’ skin is observed and the assessment is documented. Skin checks are completed by the nurse on the resident’s shower day and entered into matrix observation forms. Document all areas of concern on the skin sheet. Notify the wound nurse and physician of all areas of concern. Document in the medical record on the weekly skin check form. 3. Resident #17 was admitted to the facility in June 2024 with diagnoses that included aspiration pneumonia, poor vision, blindness in one eye, cataracts, visual hallucinations, and nicotine dependance. The self-administration assessment dated [DATE] at 11:28 AM identified Resident #17 did not want to self-administer medications. The self-administration assessment for a quarterly evaluation dated 12/16/24 at 10:16 PM identified Resident #17 did not want to self-administer medications. A physician’s order dated 6/14/25 directed to administer Budesonide-Formoterol HFA aerosol inhaler 160-4.5 mcg/actuation give 2 puffs twice a day. The care plan dated 6/24/25 identified at Resident #17 had decreased mobility and poor vision. Interventions included to orient Resident #17 to environment and placement of items. The July 2025 MAR identified Budesonide-Formoterol HFA aerosol inhaler 160-4.5 mcg/actuation was given late 32 out of 61 times and on 7/31/25 at 9:00 AM the medication was not available. The quarterly MDS dated [DATE] identified Resident #17 had intact cognition and required touching assistance with dressing and personal hygiene. The physician’s note dated 7/21/25 identified Resident #17 has acute chronic cough with increased phlegm, dark colored sputum, no blood in sputum. Medication observation on 7/31/25 at 10:20 AM identified RN #1 prepared medication for Resident #17. After RN #1 gave Resident #17 his/her medications, RN #1 informed Resident #17 she did not have the Budesonide-Formoterol Inhaler. Resident #17 indicated he/she was aware because it has been at his/her bedside for about 2 months. Resident #17 reached for the Budesonide-Formoterol Inhaler, which was on the top of the nightstand at the bedside. RN #1 indicated the Budesonide-Formoterol Inhaler was not dated when opened and must be discarded. RN #1 identified she would order a new Budesonide-Formoterol Inhaler from the pharmacy. RN #1 asked Resident #1 which nurse had provided him/her with the Budesonide-Formoterol Inhaler and Resident #17 indicated that he/she did not recall because it has been a couple of months now. Resident #17 indicated he has not used the Budesonide-Formoterol Inhaler for at least a month. Interview with Resident #17 on 7/31/25 12:20 PM indicated that the nurses were not giving him/her the Budesonide-Formoterol Inhaler when he/she needed it so about 2 months ago the nurse left it with him/her to use as needed. Resident #17 indicated that he/she was using the Budesonide-Formoterol Inhaler multiple times a day because when he/she laid down, he/she would get short of breath so he/she would sit up and use the inhaler during the day and at night. Resident #17 indicated that recently his/her physician had made some medication changes, and he/she has not used the Budesonide-Formoterol Inhaler in at least the last month because he/she does not need it any longer. Resident #17 did not know the name of the Budesonide-Formoterol Inhaler or how many times a day it should be taken. Interview with the DNS on 7/31/25 at 10:54 AM identified residents cannot self-administer medications or inhalers with a nurse doing a self-administration assessment first. The DNS indicated if the resident was able to self-administer any inhalers or medications it would be specific on the assessment and the nurse would get a physician order for the medication or inhaler. After clinical record review, the DNS indicated that Resident #17 does not have a self-administration assessment for the Budesonide-Formoterol Inhaler. The DNS indicated if Resident #17 was able to self-administer the Budesonide-Formoterol Inhaler, the charge nurse would be responsible to hand the Budesonide-Formoterol Inhaler to the resident for use only and keep the Budesonide-Formoterol Inhaler in the medication cart when not in use. Review of the facility Self-Administration of Medications Policy identified residents of the facility may self-administer medications if the interdisciplinary team, including a licensed nurse and a prescribing practitioner, determines that it is safe for them to do so. The procedure includes a licensed nurse who will conduct a self-administration assessment to evaluate the resident’s cognitive status, physical ability to handle and take medication, understanding of medication regimen, and willingness to self-administer. A physician’s order or other prescriber must write an order approving self-administration and the order will be specific which medication the resident is allowed to self-administer. The medications must be stored in the nursing medication cart. Each time the resident has a scheduled medication or is requesting medication the nurse is responsible to deliver that medication to the resident for use and then the nurse will place it back into the cart. Residents will be reassessed at least quarterly, upon change in condition, or if concerns about self-administration arise. 4. Resident #10 was admitted to the facility in August 2023 with diagnoses that included traumatic brain injury, dysphagia, and diabetes with hypoglycemia. A physician’s order dated 12/11/24 directed to check blood sugars 4 times daily before meals (6:00 AM, 12:00 PM, 6:00 PM, 12:00 AM) and notify the physician for blood sugars less than 70 and/or greater than 400. A physician's order dated 1/25/25 directed may check blood sugars as needed. A physician’s order dated 2/6/25 directed for Glyxambi (an oral medication used to treat diabetes) 25-5 milligram tablet daily at 9:00 AM. A physician’s order dated 3/13/25 directed a no concentrated sweets/low carb diet to include 1/2 portion of starch with all meals. A physician’s order dated 3/17/25 directed to administer Lantus Insulin (a long-acting Insulin) 38 units nightly at 9:00 PM. The quarterly MDS dated [DATE] identified Resident #10 had severely impaired cognition and received daily Insulin. The care plan dated 7/11/25 identified Resident #10 was at risk for abnormal blood sugar levels including hypoglycemia and hyperglycemia due to diabetes. Interventions included to obtain finger sticks as ordered and report abnormal findings to the physician. Interventions also included to monitor the resident for signs and symptoms of hyperglycemia. Review of the clinical record dated 7/24/25 at 1:44 PM identified the residents blood sugar, obtained by LPN #4, was 436. Further, the clinical record failed to identify any additional documentation including a RN assessment of Resident #10’s condition at that time. Interview with APRN #1 on 7/30/25 at 12:07 PM Resident #10 was routinely non-compliant with diet orders and often purchased snacks and sodas from the facility vending machine. APRN #1 identified that Resident #10 had a recent history of large fluctuations between hypoglycemia and hyperglycemia and had been seen by an endocrinologist outside the facility but was discharged from his care 6/9/25 due to continued dietary noncompliance. APRN #1 also identified that no adjustments would be made to Resident #10’s current diabetic management due to the large fluctuations in blood sugar levels and the dietary noncompliance. APRN #1 identified that the order in place regarding Resident #10’s blood sugar levels was for nursing staff to notify her or the physician of any blood sugar levels less than 70 and greater than 400, especially given the large fluctuations in blood sugar levels. APRN #1 identified that LPN #4 was not the regular nurse assigned to care for Resident #10, and she had not been notified by LPN #4 regarding the high blood sugar on 7/24/25. APRN #1 also identified that if she had been notified of the elevated blood sugar on 7/24/25 it would have been documented in her notes in the clinical record. Interview with LPN #4 on 7/30/25 at 1:14 PM identified she was a float nurse at the facility and did not typically provide care for Resident #10. LPN #4 identified she could not recall if she notified the RN Supervisor of the resident’s high blood sugar but indicated she did notify APRN #1 on 7/24/25. LPN #4 was unable to identify if she notified APRN #1 in person or via phone, and identified she recalled APRN #1 discussing the possibility of additional Insulin for the resident. LPN #4 identified that before the end of her shift at 3:00 PM, she rechecked Resident #10’s blood sugar level without discussion with APRN #1 and identified the blood sugar was somewhere around the lower 300’s but could not identify the number. Review of the clinical record failed to identify documentation by LPN #4 related to a recheck of Resident #10's blood sugar level on 7/24/25 or that the resident had been assessed by a Registered Nurse. Interview with the DNS on 7/31/25 at 11:01 AM identified that the licensed nursing staff was expected to follow the physician’s orders including when to notify for abnormal findings. The DNS identified LPN #4 should have notified the APRN and the RN Supervisor regarding the elevated blood sugar. The facility policy on hyperglycemia management directed that the facility would promptly identify, monitor, and treat hyperglycemia in accordance with the physician's orders and identified hyperglycemia was a blood sugar greater than 180 (persistent or acute); and severe hyperglycemia, a blood sugar greater than 300 or symptomatic (i.e. polyuria, polydipsia, confusion) The policy further directed that residents with diabetes would have blood sugar monitoring per the physicians orders and staff would recognize signs and symptoms of hyperglycemia, which included: increased thirst (polydipsia), frequent urination (polyuria), fatigue, weakness, blurred vision, nausea and vomiting, confusion, or altered mental state. The policy further directed for blood sugar levels greater than 400 with altered mental status, vomiting Kussmaul respirations, or fruity breath odor, staff would call 911, follow facility emergency response protocol, monitor vital signs and initiate oxygen if indicated, and document interventions and notify family/POA. The policy also directed to record all blood sugar readings, symptoms, interventions, and provider notifications in the clinical record.

**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 2 of 4 residents (Resident #77 and 82) reviewed for pressure ulcers, the facility failed to ensure weekly skin audits were completed and documented per the facility policy, and a specialty air mattress was set to the resident's weight per the physician's order. The findings include: Resident #77 was admitted to the facility in September 2021 with diagnoses that included peripheral vascular disease (PVD), obesity, and type 2 diabetes mellitus (DM). The quarterly MDS dated [DATE] identified Resident #77 had intact cognition, was dependent for toileting hygiene and bathing, required supervision for rolling left to right and sitting to lying, refused toilet transfers. Resident #77 had an indwelling catheter, was frequently incontinent of bowel, was at risk for developing pressure ulcers/injuries, and had one unstageable pressure ulcer. The care plan dated 7/20/25 identified Resident #77 was at risk for injury, impaired skin integrity and impaired tissue perfusion related to PVD. Interventions included reporting issues to the physician as needed and providing treatment, care, and lotion as needed for prevention. The care plan further identified Resident #77 had an unstageable pressure ulcer to the left buttock. Interventions included assessing the pressure ulcer first stage, size, and condition of the surrounding skin weekly. Review of the physician’s orders dated 2/1/25 through 7/27/25 failed to identify an order directing weekly skin checks. Subsequent to surveyor inquiry, a physician’s order dated 7/28/25 directed to complete weekly skin checks on shower days; once a day on Tuesdays 3:00-11:00 PM. Review of the clinical record dated 2/1/25 through 7/30/25 failed to identify documentation that weekly skin checks were being completed. Interview with APRN #1 on 7/30/25 at 11:02 AM identified that she would expect nurses to complete and document skin checks weekly and as needed, if a skin concern was identified by a nurse aide. APRN #1 indicated that weekly skin checks were important to monitor for changes occurring week to week. Interview and review of the clinical record with the DNS on 7/30/25 at 6:00 PM failed to identify a physician’s order for weekly skin checks, per the facility policy, and failed to identify documentation that weekly skin checks were being completed. The DNS indicated that she would expect weekly skin check documentation to be completed by nursing on the weekly skin check form; if Resident #77 refused the skin check she would expect to see a progress note documenting the refusal, education provided to the resident on the importance of a skin check, and notification of the refusal made to the nursing supervisor, APRN, and the resident representative, if applicable. Interview with the Medical Director (MD #1) on 7/31/25 identified that a resident with a history of PVD and DM would create a set up for skin issues, further Resident #77 refuses to move. MD #1 indicated Resident #77 should have weekly skin checks ordered The facility’s Weekly Skin Checks policy directs that a resident’s skin is observed by the nurse on shower days and observations documented in the electronic health record: document all areas of concern on the skin sheets, notify the Wound Care Nurse/MD of all areas of concern, document on the 24-hour report to alert the team to areas of concern, and document in the medical record on the weekly skin check form. 2. Resident #82 was admitted to the facility in December 2023 with diagnoses that included spina bifida, hearing loss, and kidney disease. The clinical record identified Resident #82 had a stage 4 facility acquired pressure ulcer on the right ischium first identified on 5/12/24. The quarterly MDS dated [DATE] identified Resident # 82 had intact cognition, was always incontinent of bowel and bladder, required substantial assistance with toileting, partial assistance with bathing and set up for transfers. A physician's order dated 1/6/25 directed staff to complete body audits weekly on Saturdays (shower day). Review of the clinical record for January 2025 identified only 2 weekly body audits had been completed; 1/11/25 and 1/25/25. A physician’s order dated 2/1/25 directed to provide a low air loss mattress with a setting of 150. The order further directed to check placement and function every shift and coordinate with the maintenance department if there was a noticeable malfunction. Review of the clinical record identified weekly body audits were not completed twice in February 2025 and once in March 2025. A care plan dated 4/15/25 directed that Resident #82 had actual skin impairment related to a stage 4 right ischium pressure ulcer. Interventions included weekly skin checks, use of a pressure-relieving mattress if appropriate, and reporting any skin changes to the physician or APRN as necessary. Review of the clinical record identified weekly body audits were not completed once in May 2025, 3 times in June 2025 and twice in July 2025. Review of the clinical record identified Resident #82 had a weight of 111.4 lbs. on 7/9/25. Observation and interview with Resident #82 on 7/27/25 at 10:00 AM identified he/she had a pressure ulcer located on the right buttock that was almost healed, and the facility had provided him/her with an air mattress that would only function intermittently at times. Resident #82 identified he/she had a communication barrier and that staff in the facility could not communicate effectively with him/her. Resident #82 reported during the observation that the air mattress was currently working, and he/she had not reported the issue to facility staff. Observation of the low air loss mattress weight settings identified the mattress was set at 220 lbs. Observation of Resident #82 on 7/29/25 at 11:58 AM identified that the low air loss mattress was set to 60 lbs. During this observation Resident #82 was observed to be sleeping. Observation with MD #2 (wound MD) and the ADNS on 7/30/25 at 7:20 AM identified Resident #82’s pressure ulcer had resolved. Observation with the ADNS immediately following the visit with MD #2 identified the low air loss mattress was set to 60 lbs. The ADNS identified the setting was not correct for Resident #82's weight but identified Resident #82 routinely changed the mattress setting. Observation and interview with Resident #82 on 7/30/25 at 7:30 AM identified the low air loss mattress did not appear to be operating. Resident #82 identified that the mattress had completely stopped working but the resident was unable to indicate the exact time frame. Resident #82 identified he/she was unsure if the facility staff ever checked the mattress. Resident #82 also identified he/she was unsure how to adjust the mattress setting. Observation and interview with RN #1 on 7/30/25 7:40 AM identified Resident #82’s low air loss mattress was not functioning and she would contact maintenance to replace the mattress. Observation on 7/30/25 at 8:45 AM identified Resident #82’s low air loss mattress had been replaced by maintenance. Observation of the replacement mattress settings identified the low air loss mattress was set to 660 lbs. Observation on 7/30/25 at 2:15 PM identify resident #82 low air loss mattress remained set at 660 lbs. Observation and interview on 7/30/25 at 2:25 PM with LPN #8 identified that she had not been notified Resident #82’s low air loss mattress had been changed. LPN #2 initially identified that she checked Resident #82’s mattress at least once during her shift and also identified Resident #82 changed the settings on the mattress regularly. LPN #8 was unable to identify when she had last checked on Resident #82 or observed his/her air mattress during her shift and further identified that while she signed off that she checked the settings daily, sometimes she did not always verify what the actual settings were compared to the physician's order. Subsequent to surveyor inquiry, LPN #8 changed the mattress setting for Resident #82 from 660 lbs. to 150 lbs. Review of the clinical record and care plans failed to identify documentation or a care plan related to Resident #82 changing the mattress settings and/or measures to address such. Review of the clinical record and interview with the ADNS on 7/31/25 at 9:07 AM identified that she was the wound nurse for the facility and identified that Resident #82 should have had weekly skin checks done and documented. The ADNS identified that the documentation related to skin checks required 2 steps. The steps included a sign off on the TAR for the weekly body audits and documentation under the weekly skin check assessments in the clinical record that would include the actual observations made by the nurse. The DNS identified that simply signing the TAR that the body audit was done did not mean that the skin check had been completed. Interview with the DNS on 7/31/25 at 11:01 AM identified that skin checks should be done weekly on the resident’s scheduled shower day and as needed if the nurse aide or licensed nurse identified an issue with the resident’s skin. The DNS identified that the licensed nurse assigned to the resident was expected to complete and document the skin check under the weekly skin assessment check area in the observations section of the clinical record which included the ability to document any changes related to the resident’s skin. The DNS identified the purpose was to ensure that any changes in the resident’s skin were documented week to week. The DNS identified she had been made aware there was an issue related to the nurses completing assessment documentation for the weekly skin checks during the survey and she had planned on providing education to the nursing staff to ensure complete skin assessments were documented in all residents’ clinical records. The DNS also identified that Resident #82’s low air loss mattress should have been set per the physician's order. The DNS identified she and other nursing staff in the facility had completed spot checks of the low air loss mattresses for residents but identified that Resident #82 had been reported by staff to change the settings of his/her air mattress. The DNS was unable to identify any specific incidents related to this or any documentation in the clinical record. The DNS identified that staff should be checking the mattress settings and function of the mattress at least once a shift and report any issues to maintenance per the physician's order. The facility policy on weekly skin checks directed that the policy was to ensure the resident skin was observed and documented on. The policy also directed that skin checks were completed by the nurse on shower days and entered under observations in the clinical record. The facility policy on air mattress overlays directed that an air mattress was used to prevent skin breakdown in accordance with the physician's order. The policy further directed that clinical staff were to verify the physician’s order and after placing the mattress, staff were to evaluate the inflation of the mattress within 20 minutes by performing a hand check and evaluate the mattress's function and proper inflation every shift. The facility policy on skin and wound management directed that the purpose of the policy was to provide guidelines for the structured assessment and identification of residents at risk for developing pressure ulcers/injuries. The policy directed at risk factors that could increase a residents susceptibility to develop or to not heal of pressure ulcers included the resident’s refusal related to some aspects of care and treatment. The policy also directed information that should be recorded in the resident’s medical record should include the type of assessment conducted; the condition of the resident’s skin; if the resident refused treatment including the reason for refusal; observations of anything unusual exhibited by the resident; and documentation in the medical record addressing physician notification if any new skin alterations were noted with a change in the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #7) reviewed for range of motion, the facility failed to provide appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for a resident with a hand contracture. The findings include:Resident #7 was admitted to the facility in January 2025 with diagnoses that included dementia, cerebral infarction, and adult failure to thrive. The admission observation dated 1/3/25 identified Resident #7's hand grasp strength was stronger on one side than the other side due to a right-hand contracture: Resident #7 presented with a contracture of the right hand and wrist joint. The Occupational Therapy Discharge Summary dates of service 1/6/25 through 1/29/25 identified a short-term goal was for Resident #7 to tolerate gentle passive range of motion (PROM) to the right hand to open hand slightly for placing of a hand towel/splint to prevent skin breakdown and prevent further contracture. Discharge reason: discharged to the hospital.The Occupational Therapy Discharge Summary dates of service 2/11/25 through 2/26/25 identified a short-term goal was for Resident #7 to tolerate gentle passive range of motion (PROM) to right hand to open hand slightly for placing of a hand towel/splint to prevent skin breakdown and prevent further contracture. Discharge reason: discharged to the hospital.The Occupational Therapy Discharge Summary dates of service 3/11/25 through 4/24/25 failed to identify short-term or long-term goals related to Resident #7's right-hand contracture. Discharge reason: highest practical level achieved.The Occupational Therapy Discharge Summary dates of service 7/10/25 through 7/23/25 failed to identify short-term or long-term goals related to Resident #7's right-hand contracture. Discharge reason: highest practical level achieved.The quarterly MDS dated [DATE] identified Resident #7 had severely impaired cognition and had no upper extremity impairment. (The MDS failed to identify a right-hand contracture). The care plan dated 7/15/25 failed to identify Resident #7's contracture and failed to identify therapeutic and nursing interventions and functional goals/outcomes.Intermittent observations between 7/27/25 and 7/29/25 identified Resident #7's right hand and wrist are contracted. Digits #2 and 3 are closed tightly with light yellow crust in between. Digit #1 is set under digits #2 and 3. The top portion of digit #1 was exposed in between digit #3 and 4. Digits #4 and #5 were closed tightly with digit #4 slightly laying on top of digit #5 and light-yellow crust in between the digits. Resident #7 exhibited facial grimacing when staff members attempted to gently move any of the digits. Interview and review of the clinical record with the Rehabilitation (Rehab) Services Director on 7/29/25 at 9:40 AM identified that Resident #7's right-hand contracture was chronic, and it was present on admission. The Rehab Director further identified it was the expectation that passive range of motion (PROM) would be completed daily by the nurse aides on the unit, in order for the resident to maintain functional ability, and Resident #7 was previously evaluated for a splint but there was no splint that could accommodate his/her deformity. The Rehab Director identified that she did not see interventions in the physician's orders or in the care plan, but she would expect nursing staff to be performing hand hygiene, ensuring proper positioning of the arm and hand, monitoring to ensure no new contractures develop on the upper arm, and reporting any changes in the condition or decline of the contracture. The Rehab Director indicated that there were limited interventions for OT to implement because Resident #7 would not regain function of the contracted hand; the goal would be to avoid skin breakdown and worsening of the contracture. Interview with OT #1 on 7/29/25 at 9:55 AM identified that she recently added Resident #7's name on a list to be seen by Physiatry for an evaluation due to pain when opening his/her hand or when completing range of motion (ROM) with the elbow and upper arm. OT #1 further indicated that she had encouraged the nurse aides to notify the rehab staff if they had trouble completing daily ADL care so that they could provide assistance, and she also encouraged the nurse aides to soak Resident #7's hand in warm water, as heat can help loosen it up.Interview with the Rehab Director on 7/31/25 at 8:25 AM identified that, subsequent to surveyor inquiry, she notified APRN #1 that Resident #7 had pain in the contracted hand, and he/she will need something for pain management. The Rehab Director indicated that Resident #7 would be seen by the Physiatrist on 8/6/25 to see if there are other interventions that can be attempted. Interview with the Medical Director (MD #1) on 7/31/25 at 11:40 AM identified that he would expect PT/OT to have followed up on Resident #7's right-hand contracture, weekly to start then every other week, and if the contracture remained stable, he would expect it to be seen monthly and as needed. MD #1 indicated that he would expect a plan between OT and nursing services to be put into motion to ensure Resident #7 had documented interventions in place to maintain skin integrity and to prevent further decline of the contracture. The facility's Nursing Services policy directs that a consistent and interdisciplinary approach to the prevention, identification, treatment, and monitoring of contractures among residents is established. Thereby promoting functional independence, optimizing range of motion, and enhancing quality of life. The policy further directs that upon admission, nursing and therapy staff shall conduct a comprehensive functional mobility and muscular skeleton assessment. Risk factors for contracture development shall be identified and range of motion shall be evaluated and documented by therapy at admission, quarterly, and with significant change in condition. Therapy services interventions include evaluating for and implementing therapeutic exercises, manual stretching, positioning, and splinting, and training nursing staff and caregivers in techniques for safe range of motion exercises and positioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #77) reviewed for indwelling catheter, the facility failed to ensure care according to professional standards for a resident who refused removal of an indwelling catheter over 5 months, that was ordered to be removed after 7 days. The findings include: Resident #77 was admitted to the facility in September 2021 with diagnoses that included urinary tract infection, chronic kidney disease, and acute candidiasis of the vulva and vagina.The quarterly MDS dated [DATE] identified Resident #77 had intact cognition, required maximal assistance for toileting hygiene, was dependent for bathing, required supervision for toilet transfers. Resident #77 was occasionally incontinent of urine, was frequently incontinent of bowel, was at risk for developing pressure ulcers/injuries, and had no pressure ulcer.The care plan dated 1/5/25 identified Resident #77 refused showers and bedding changes, contributing to persistent itchiness; he/she declined hygiene assistance and personal care interventions. The APRN Note dated 2/6/25 at 11:45 AM identified Resident #77 reported a history of nighttime incontinence and requested a foley catheter. However, the resident was able to stand and knowingly urinate on him/herself while in bed. Educate patient on proper toileting habits and the importance of using the restroom when able. Will defer foley at this time.The APRN note dated 2/7/25 at 8:45 AM identified Resident #77 reported a moisture related rash on buttocks and an open wound on left buttocks due to incontinence. The patient requested a foley catheter to help the rash improve, discussed with interdisciplinary team and the decision was made to insert a foley to help the rash and wounds quicker.A physician's order dated 2/7/25 with an end date of 2/14/25 directed foley catheter related to diagnosis of: chronic wound, provide foley catheter care every shift, days, evenings, nights. Review of the nurse's notes dated 2/14/25 failed to identify removal of the foley catheter was attempted, per the APRN's order with an end date of 2/14/25.The nurse's note dated 2/21/25 at 4:47 AM identified that Resident #77's foley catheter was patent and draining yellow urine to gravity.The nurse's note dated 3/19/25 at 1:26 PM identified that Resident #77's foley catheter was in place and patent.The APRN note date 4/9/25 at 9:15 AM identified Resident #77 had an indwelling foley catheter in place to prevent worsening of skin condition. Patient reluctant to have foley catheter removed today, will reevaluate the need for foley catheter in one to two weeks.The nurse's note dated 4/30/25 at 12:48 PM identified that Resident #77's complained to the writer of burning and discomfort around the foley catheter, stated there was a leak when I urinate. Foley catheter removed, clear amber colored urine noted, peri care provided. APRN made aware, waiting for further instructions.The nurse's note dated 4/30/25 at 2:37 PM identified that an order was obtained from the APRN for urinalysis/culture and sensitivity (UA/C&S), reinsert foley, keep it in until final results of urine. Foley catheter in place draining well, resident educated on the importance of perineal care/catheter. Writer informed resident was at risk at keeping foley catheter in place long-term, The foley put the resident at more risk for urinary infection. Resident voiced understanding.The APRN note dated 4/30/25 at 10:45 AM identified Resident #77 was seen today for evaluation of urethral burning and discomfort, as well as for wound care management. Patient reports experiencing increasing discomfort and burning sensation around the urethra where the foley catheter was inserted. The foley catheter was removed and clear amber colored urine was noted. Foley was reinserted and will be kept in place until urine culture results are available. Patient educated on the importance of perineal care, catheter maintenance and risks of long-term catheter use including increased UTI risk.The nurse's note dated 5/22/25 at 6:53 AM identified that Resident #77's foley catheter was draining yellow urine, 1 liter.Review of the Wound Care Specialist progress notes dated 6/11/25 through 7/30/25 identified under the History of Present Illness that Resident #77 had been refusing to get out of bed, the foley spout drain was opened to drain freely into a basin on the floor. Patient was not medically incontinent, however cannot or will not get out of bed to toilet (observation date unknown).The APRN note dated 7/24/25 at 8:58 PM identified Resident #77 reported new onset of right-sided kidney pain and has noticed his/her urine has become foul smelling. The urine in the foley bag was noted to be yellow and cloudy, he/she was also experiencing discomfort in the upper left quadrant of his/her abdomen.A physician's order dated 7/24/25 directed for a UA/C&S-one time. Special instructions: remove foley and replace foley and collect urine for UAC&S.The APRN note dated 7/28/25 at 8:12 PM identified Resident #77 was evaluated 4 days ago, for right kidney pain, foul smelling urine, and left upper quadrant discomfort at that time, his/her urine in the foley bag was noted to be yellow and cloudy. A urinalysis and urine culture were ordered after replacing the foley catheter and results today are indicative of a UTI, will monitor for improvement and adjust treatment based on available options as antibiotics selection is challenging due to multiple allergies and lack of sensitivity testing. Educated patient that indwelling catheters make him/her at higher risk for UTIs.The care plan (with a creation date of 7/30/25, subsequent to surveyor inquiry) identified Resident #77 had a foley catheter. Interventions included monitoring intake and output, providing foley care per facility policy, encouraging fluids, monitoring urine for color, odors, sediment and clogging, keeping foley bag below bladder level, and monitoring for signs and symptoms of infection.A physician's order dated 7/30/25 directed for an abdominal and retroperitoneal ultrasound.Interview and review of the clinical record with the DNS on 7/30/25 at 6:00 PM identified that Resident #77's foley was originally placed to promote wound healing, due to a Stage 3 pressure ulcer on his/her coccyx; now Resident #77 has refused to have it removed. The DNS indicated that the foley was removed on 7/24/25 because the balloon deflated, and Resident #77 began screaming that the nursing staff were violating his/her rights. The DNS further indicated that Resident #77 threatened to call the police if anyone attempted to remove the foley. The DNS identified that Resident #77 refused to see the psychiatric provider, and both the Medical APRN and Wound Specialist have educated him/her about the risks of leaving an indwelling foley catheter in place, over time. The DNS identified that there was no care plan in place for the long-term use of foley catheter, but she would expect there to be a care plan, in particular because Resident #77 refused to have it removed. The DNS identified that there were notes written by nursing and the Medical APRN that Resident #77 was educated on the risks of keeping a foley catheter in place, but she did not see detailed documentation of all of Resident #77's refusals to have the catheter removal.Interview with the Medical Director (MD #1) on 7/31/25 at 11:40 AM identified that he would endorse foley catheter placement in the setting of a significant moisture-associated skin damage (MASD) rash, to prevent further skin breakdown or the onset of a pressure ulcer. MD #1 indicated that keeping an indwelling foley catheter in place for 6 months was problematic and could lead to bigger problems, including a urinary tract infection. MD #1 further identified that he would expect to see documentation in the clinical record of Resident #77's refusals to have the foley catheter removed. MD #1 indicated that a Urology Consult for additional interventions would have been appropriate given Resident #77's refusals for the catheter removal.Interview with APRN #1 on 7/31/25 at 12:10 PM identified that Resident #77's foley catheter was placed in February 2025 related to MASD with incontinence. APRN #1 indicated that there had been several interdisciplinary team meetings to discuss discontinuing the foley, but Resident #77 refused to have it removed, despite education on the risks of long-term use of a foley catheter. APRN #1 identified that there was no medical reason for Resident #77 to still have the indwelling foley catheter; Resident #77 has elective incontinence and does not wasn't to get out of bed and put weight on his/her lower extremities. APRN #1 indicated that she has not sent Resident #77 for a Urology Consult, yet, but has referred him/her for Gastrointestinal (GI) and Gynecology (GYN) consults.The facility's Urinary Catheterization policy directs urinary catheterization to facilitate urinary drainage when medical necessary. Urinary catheters should be evaluated for need and removed promptly when no longer necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #100) reviewed for non-pressure ulcers, the facility failed to ensure hand hygiene was performed when required during the treatment of wounds. The findings include: Resident #100 was admitted to the facility in April 2023 with diagnoses that included lymphedema and acute kidney injury, and hypertension.The annual MDS dated [DATE] identified Resident #100 had intact cognition, required maximum assistance for dressing, putting on footwear, and personal hygiene. Additionally, Resident #100 has 2 venous or atrial ulcers present.The care plan dated 5/20/25 identified Resident #100 has venous ulcers to his/her bilateral lower extremities. Interventions included providing wound treatments as ordered and wrapping bilateral legs with compression socks.A vascular consult dated 6/17/25 directed compression stockings and a venous ultrasound. The physician identified the resident is wheelchair bound and has long standing bilateral lower extremity edema with weeping blisters on legs. Currently there are no signs of cellulitis. Resident #100 needs compression stockings or ace wraps to legs from ankle to knee every morning and take off at bedtime. A physician's order dated 6/19/25 directed to cleanse the bilateral lower extremities with soap and water, rinse and dry well and apply ammonium lactate 12% lotion to intact skin. Apply Calcium Alginate with silver to open wounds, xeroform to any blisters, cover with a dry clean dressing and secure with cling twice a day and as needed. Apply ace wraps every morning from the base of the toes to the base of the knees and remove at bedtime. Monitor for signs and symptoms of infection.Observation of Resident #100 treatment being done on 7/28/25 at 2:05 PM by LPN #2. LPN #2 assisted Resident #100 from the wheelchair to the bed. After washing her hands, LPN #2 put on a new pair of gloves on and removed the dressing on the right leg. With the same gloves on, LPN #2 removed the dressing on the right leg which had visible drainage. With the same gloves, LPN #2 placed a garbage bag in the bedside garbage can and discarded all the old dressings. LPN #2 removed her gloves and without the benefit of hand washing put on a clean disposable gown without tying it around her neck or waist and put on a new pair of gloves. LPN #2 opened treatment supplies onto a clean surface on the overbed table. LPN #2 did not wash the legs with soap and water per the physician order. LPN #2 sprayed the left leg dressing with wound cleanser because it was adhered to the wound and removed the dressing discarding it in the garbage. LPN #2's gown fell forward leaving her upper half exposed. LPN #2 sprayed wound cleaner on the open left leg area and patted it dry 4 x 4 then she sprayed the old dressing on the right lower leg wound cleaner to remove it. LPN #2 removed the dirty gloves and yelled in the hallway for a nurse aide to bring more clean gloves. LPN #2 put on a clean pair of gloves without the benefit of handwashing. LPN #2 placed the Calcium Alginate on left leg followed by an ABD pad and kerlix wrap. LPN #2 placed Calcium Alginate to the left leg followed by an ABD and kerlix wrap. LPN #2 applied the ace wrap to the right and left foot leaving toes exposed bringing the ace wrap to just below the knee. LPN #2 placed Resident #100's grippy socks and shoes on over the ace wraps. LPN #2 removed the supplies off the overbed table, discarded them in the garbage and removed her gloves and gown. LPN #2 left the resident's room with the garbage bag and walked to the utility room. LPN #2 returned to the resident's room, went into the bathroom and washed her hands. Interview with the DNS on 7/30/25 at 10:25 AM indicated the nurse doing a wound treatment is expected to wash his/her hands every time he/she removes their gloves. The DNS indicated that the nurse is expected to wash her hands and apply new gloves prior to removing the old dressing. The DNS indicated after removing the old dressing the nurse is required to remove her gloves, wash her hands and put on a new pair of gloves. The DNS indicated after doing the treatment to one leg the nurse is required to remove gloves, wash hands and put on a new pair of gloves before doing the other treatment and remove gloves and wash her hands again when done. The DNS indicated that if the nurse wanted to wear a gown, she must wear it the right way, tied, and have it cover her front and shoulders. Review of the handwashing policy identified all staff, contractors, volunteers, and visitors must adhere to hand hygiene protocols before and after resident contact, after contact with potentially contaminated surfaces, and as otherwise indicated. The purpose is to prevent the spread of infections by ensuring all healthcare personnel follow proper hand hygiene practices in accordance with CDC and CMS guidelines. Hand hygiene must be performed before and after direct resident contact, before performing aseptic tasks like wound dressing, after exposure to body fluids, before donning and after removing gloves. Review of the wound treatment process policy identified to prepare by gathering treatment supplies per wound order, perform hand hygiene and put on appropriate personal protective equipment. Position the resident for comfort and explain the procedure. Remove the old dressing and assess area. Cleanse wound per order using aseptic technique. Apply ordered dressing. Infection control; utilize standard and transmission precautions. Proper disposal of contaminated dressings in biohazard bags. Hand hygiene before and after all dressing changes.

Based on review of facility documentation, facility policy, and interview, the facility failed to ensure that a nurse aide was provided at least 12 hours annual in-service education, and competency evaluations were completed at least annually. The findings include: A review of education and in-service documentation for 2023, 2024, and 2025 failed to identify education and competencies had been completed for NA #14, who began employment at the facility on 12/5/22.Interview with LPN #1 on 7/30/25 at 7:15 AM identified she worked in a dual role as the staff development and infection control nurse. LPN #1 identified that the DNS and ADNS provided assistance to help her with staff development as they were able, but education was done as time allowed. LPN #1 identified that other than the actual in-service sign-in-sheets and competency packets, she did not have any tracking mechanisms to determine which staff required updated annual competencies or in services, or if all nurse aides in the facility had completed the required 12 hours of in-service training annually.Interview with the ADNS on 7/30/25 at 2:41 PM identified that she had provided some assistance to LPN #1 regarding in service and annual competencies for the facility nursing staff, however she was helping as time allowed. The ADNS identified that she was required to fill multiple roles at the facility which included the ADNS role, RN supervisor, wound care nurse, and had recently been tasked with tracking documentation for outside consultations including ophthalmology and dental visits due to issues that had been identified during the survey.Interview with the DNS on 7/31/25 at 9:27 AM identified she was not aware of any issues related to in services and education. The DNS identified she had notified LPN #1 several times that if she needed assistance to please notify the DNS and that the ADNS was also available to assist with education. The DNS identified that all clinical staff should have required education, in-services, and competencies following hire and then annually.The facility assessment tool directed that the facility would provide annual in-servicing, training, and competencies and the staff development nurse would be responsible to maintain competencies. The assessment tool also directed that staff education would be provided upon hire, annually, and as needed.

**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 3 residents (Resident #10, 76 and 122) the facility failed to notify the physician and/or resident representative when required.For 1 of 5 residents (Resident #10) reviewed for unnecessary medications, the facility failed to notify the physician and resident representative of elevated blood sugars and change in condition. For 1 of 4 residents (Resident #76) reviewed for dental services, the facility failed to notify the physician when a dental provider observed moderate inflammation with a possible abscess of the resident's tooth. For 1 of 3 residents (Resident #122) reviewed for closed record, the facility failed to notify the physician when the resident left the facility AMA. The findings include: 1.The hospital Discharge summary dated [DATE] identified Resident #122 was admitted to the hospital on [DATE] with symptoms of generalized weakness with acute on chronic bilateral knee pain, left greater than right, abdominal pain, and diarrhea. Resident #122’s last use of alcohol beverage was the day of admission early in the morning. Resident #122 was unfortunately unhoused. Resident #122 was evaluated and discharged on 6/19/25 to a nursing facility with diagnoses of diarrhea, and alcohol withdrawal. Resident #122 was admitted to the facility on [DATE] with diagnoses that included acute embolism and thrombosis of left popliteal vein, alcohol abuse, opioid use, and pain. The physician’s order dated 6/19/25 directed to transfer out of bed to any surface with limited assist for safety. Apply oxygen via nasal cannula at 2 liters to maintain oxygen saturation at or greater than 90% as needed. Special instructions: (If unable to maintain saturation equal to or greater than 90%, administer oxygen via non-rebreather mask at a minimum of 10 liters). Call the physician for status update and further recommendations. The care plan dated 6/20/25 identified Resident #122 was at risk for falls related to gait difficulty, left knee pain, and alcohol withdrawal. Interventions included for medication review by the pharmacist, assess for pain and rehabilitation screen. Review of a discharge AMA form dated 6/23/25 at 10:15 AM identified Resident #122 signed the form along with SW #1 to leave AMA. Review of the clinical record failed to reflect a physician’s order that directed to discharge the resident against medical advice (AMA). Additionally, the nurse’s note failed to reflect documentation on 6/23/25 regarding Resident #122 leaving the facility AMA and failed to reflect documentation that the physician was notified when Resident #122 left the facility AMA. The social service note dated 6/23/25 at 10:25 AM identified SW #1 spoke with Resident #122 after she was updated that Resident #122 wanted to leave AMA. SW #1 indicated she asked Resident #122 to reconsider staying at the facility for health reasons. SW #1 indicated she spoke in length with Resident #122 about not leaving but Resident #122 indicated he/she had things to do and would like to leave. SW #1 indicated she updated Resident #122 regarding the weather and heat advisory. SW #1 indicated Resident #122 updated SW #1 that his/her ride would be here soon. SW #1 indicated she provided Resident #122 with a bottle of water for his/her trip. Interview with SW #1 on 7/30/25 at 9:10 AM identified she met with Resident #122 and asked the resident to allow the facility couple of days to prepare for a safe discharge back to the community. SW #1 indicated she performed a cognition assessment and failed to document the result. Interview with the DNS on 7/30/25 at 8:00 AM identified she was aware Resident #122 was leaving the facility AMA. The DNS indicated she was not aware that RN #1, and LPN #3 did not notify the physician/APRN that Resident #122 left the facility AMA. The DNS indicated it was the responsibility of the RN Supervisor and the charge nurse to notify the physician/APRN that Resident #122 was leaving or left the facility AMA, and document that information in the clinical record. Although attempted, an interview with RN #1, and LPN #3 were not obtained. Review of the facility discharge against medical advice (AMA) policy identified it is the policy of the facility to respect a resident’s right to self-determination, including the right leave the facility against medical advice (AMA). The facility will take all reasonable measures to inform the resident (or their legal representative) of the risks, document informed refusal, and ensure compliance with federal and state regulations governing safe discharge and resident rights. The policy applies to all nursing, medical, administrative, and social services staff involved in resident discharge planning. Any resident who expresses intent to leave AMA will be assessed immediately by a Registered Nurse (RN) for decision-making capacity. Notification to the attending physician or on-call provider immediately. Evaluated safety risks (e.g. cognitive impairment, mobility limitations). The attending physician/APRN is contacted promptly to discuss the clinical risks of leaving AMA with the resident/legal representative. Provide written medical advice regarding the risks associated with discharge. Document recommendations in the electronic health record (EHR). The resident or legal representative must sign an “AMA Discharge Form”. 2. Resident #10 was admitted to the facility in August 2023 with diagnoses that included traumatic brain injury, dysphagia, and diabetes with hypoglycemia. A physician's order dated 12/11/24 directed to check blood sugars 4 times daily before meals (6:00 AM, 12:00 PM, 6:00 PM, 12:00 AM) and notify the physician when blood sugars are less than 70 or greater than 400. The quarterly MDS dated [DATE] identified Resident #10 had severely impaired cognition, was always continent of bowel and bladder and required supervision with toileting, dressing, and eating. The care plan dated 7/11/25 identified Resident #10 was at risk for abnormal blood sugar levels including hypoglycemia and hyperglycemia due to diabetes. Interventions included to obtain finger sticks as ordered and report abnormal findings to the physician. Interventions also included to monitor the resident for signs and symptoms of hyperglycemia. A nurse’s note dated 7/15/25 at 7:20 PM by RN #3 identified that at 4:30 PM she was informed by the charge nurse that Resident #10 had a blood sugar of 54, was nonverbal and sweating. The note further identified following treatments that included supplementation and Glucagon (a medication used to treat low blood glucose), Resident #10 had a blood sugar of 74 and became more responsive and alert. The note identified that by 7:00 PM, Resident #10’s blood glucose was 267 after dinner. The note also identified the APRN was notified, and the charge nurse was to notify Resident #10's resident representative. A nurse's note dated 7/15/25 at 10:04 PM by LPN #9, the unit charge nurse, identified that Resident #10 had a hypoglycemic reaction during the shift. Further review of the documentation failed to identify that Resident #10's resident representative had been notified of the hypoglycemic episode with need for treatment. Review of the clinical record identified Resident #10’s blood sugar, obtained by LPN #4 on 7/24/25, was 436. Further, the clinical record failed to identify additional documentation including notification of the physician. Interview with APRN #1 on 7/30/25 at 12:07 PM identified that she was not notified of the residents elevated blood sugar of 436 by LPN #4 on 7/24/25. APRN #1 identified that LPN #4 was not the regular nurse assigned to care for Resident #10. APRN #1 also identified that if she had been notified of the elevated blood sugar on 7/24/25 it would have been documented in her notes. APRN #1 also identified that the order in place regarding directed staff to notify her or the physician of any blood glucose levels less than 70 and greater than 400. Interview with LPN #4 on 7/30/25 at 1:14 PM identified she was a float nurse at the facility and did not typically provide care for Resident #10. LPN #4 identified she could not recall if she notified the RN Supervisor on 7/24/25 of the elevated blood sugar but indicated she did notify APRN #1. LPN #4 was unable to identify if she notified APRN #1 in person or via phone and was unable to identify any orders from APRN #1. LPN #4 identified that sometime before the end of her shift at 3:00 PM she rechecked Resident #10’s blood sugar. LPN #4 identified that she took it upon herself to recheck the blood sugar without discussing it with APRN #1 and identified the blood sugar was somewhere around the lower 300’s but could not identify the actual number and was not sure if it was documented. Review of the clinical record failed to identify documentation by LPN #4 related to a recheck of Resident #10's blood sugar level on 7/24/25. Interview with RN #3 on 7/30/25 at 4:55 PM identified she directed LPN #9 to contact and notify Resident #10’s resident representative of the hypoglycemic episode and altered mental status that occurred 7/15/25. RN #3 identified that she did not follow up or speak with LPN #9 any further regarding if she made contact or attempted to notify Resident #10’s resident representative but if it was done LPN #9 would typically document any attempts to contact in her progress note. Interview with the DNS on 7/31/25 at 11:01 AM identified that licensed nurses were responsible to notify the resident representative and document the notification or attempts in the resident’s clinical record. The DNS also identified that the licensed nursing staff was expected to follow the physicians orders including when to notify the physician for abnormal findings. The DNS identified LPN #4 should have notified the RN Supervisor of the elevated blood sugar. The DNS further identified LPN #4 should have also notified the APRN and documented the notification in the clinical record, and it would not have been appropriate for LPN #4 to obtain a blood sugar level without direction from APRN #1. Although multiple attempts were made, an interview with LPN #9 was not obtained. The facility policy on hyperglycemia management directed that the facility would promptly identify, monitor, and treat hyperglycemia in accordance with the physician's orders. The policy further directed that residents with diabetes would have blood sugar monitoring per the physicians orders and staff would recognize signs and symptoms of hyperglycemia. The policy further directed for blood sugar levels greater than 400 with altered mental status, vomiting, small respirations or fruity breath odor, staff would call 911, follow facility emergency response protocol, monitor vital signs and initiate oxygen if indicated, and document interventions and notify family/POA. The policy also directed to record all blood sugar readings, symptoms, interventions, and provider notifications in the clinical record. The facility policy on change of condition directed it was the policy of the facility to ensure that changes in the resident’s conditions were reported to providers and families. The policy further directed that the facility must immediately consult with the residents physician and notify the residents legal representative or interested family member if there was a significant change in the resident’s physical, mental, or psychosocial status or a need to alter treatment significantly. The policy further directed that any resident with the change of condition would receive timely and appropriate intervention. The policy further directed that the LPN was to collect data and administer provider ordered treatments or medications as indicated and that the RN Supervisor would also be notified accordingly, and the RN would assess and determine if a change of condition had occurred. The policy also directed that repeated attempts would be made to reach the attending physician and/or medical director and family until successful. The nurse would document attempts, noting the date and time. 3. Resident #76 had diagnoses that included stroke and hemiplegia (paralysis) of the left side. The care plan dated 12/6/22 identified Resident #76 was at risk for pain related to physical condition. Interventions included encouraging the resident to report pain and provide medical management of underlying causes. The admission MDS dated [DATE] identified Resident #76 had moderately impaired cognition, was independent with eating and had no dental related concerns. A dental consultation dated 7/14/25 identified Resident #76 was seen for an exam, prophylaxis and fluoride. Soft tissues were noted to have generalized moderate inflammation with a possible abscess of the #18 buccal (side of molar) #18 root tip, and the resident had not yet been to an oral surgeon. Recommendations for an oral surgeon to extract #18 tooth. Review of the clinical record dated 7/14/25 through 7/25/25 failed to identify the physician had been notified about the possible abscess of the #18 tooth root tip. Interview with Dental Hygienist #1 on 7/28/25 at 1:34 PM identified she last saw Resident #76 on 7/14/25 for prophylaxis. Dental Hygienist #1 identified she observed inflammation at the gumline and a fistula at the #18 tooth site consistent with signs of infection. The dentist was not onsite to further evaluate, however, previous recommendations for extraction of #18 were documented during earlier visits. Interview with Dentist #1 on 7/28/25 at 1:33 PM identified he provided dental services to Resident #76 in the past but had not evaluated the resident recently. Dentist #1 identified based on review of the clinical findings, Resident #76 had a chronic infection of the area that had exacerbated. Dentist #1 identified the #18 tooth required removal for some time and likely required antibiotics. Dentist #1 would have expected the facility provider to consider an antibiotic after reviewing the consultation. Interview with NP #1 on 7/29/25 at 11:50 AM identified she began providing services in March of 2024 and had not previously been notified of any dental related concerns related to Resident #76. NP #1 further identified she was not notified of the possible abscess noted on the dental consultation of 7/14/25. Based on the clinical findings, NP #1 would have instructed nursing to contact the dental provider to see if they would like treatment with antibiotics or wait to see the oral surgeon prior to extraction. Interview with the DNS on 7/28/25 at 2:30 PM identified she would expect the nurse who received the consultation form back from the dental provider to notify the physician of the changes which included moderate inflammation with a possible abscess. The change of condition policy directed any change in a resident’s baseline is considered a change in condition. All changes in condition will be reported to providers and families and the residents will receive a timely and appropriate intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 5 residents (Resident #3, 8, 21 and 79) reviewed for pre-admission screening and resident review (PASARR), for Residents #3, 8 and 21 the facility failed to notify the State-designated authority when the residents were identified with a new mental health diagnosis and for Resident #79 who had a history of attempted self-harm and physically violent behavior directed as others, the facility failed to incorporate PASARR recommendations that included a crisis/safety plan in the resident's plan of care. The findings include: Resident #79 was admitted to the facility in September 2024 with diagnoses that included schizoaffective disorder and bipolar disorder. The PASARR dated 4/8/25 identified Resident #79 received short term approval without specialized services with an approval period of 120 days. The Connecticut Summary of Findings PASARR dated 4/8/25 identified important symptoms, diagnoses, behaviors, other needs, and history that a provider should know about Resident #79 included: having thoughts that people are out to get him/her, attempted self-harm in the past, physically violent behavior directed towards his/her sibling 5 years ago, and physically violent behavior directed toward his/her parent 20 years ago. It is important staff can recognize the presence of depressive symptoms, thoughts of self-harm, sensations that appear real but are not or changes in behaviors as the early signs of possible need for psychiatric or behavioral intervention. Services and supports the nursing facility staff are required to provide Resident #79 included: supportive counseling from nursing facility staff and a crisis intervention plan/safety plan due to his/her history of self-harm and a history of physically violent behaviors; this plan should include looking for an increase in symptoms or changes in behaviors as well as steps to take for the staff to take when this happens. The care plan dated 6/5/25 identified Resident #79 has been determined a positive Level 2 and has the potential for altered thought process and difficulty adjusting to situations. Interventions failed to identify that a crisis intervention plan/safety plan was in place. The quarterly MDS dated [DATE] identified Resident #79 had intact cognition, had no physical or verbal behavioral symptoms directed towards others over the last 2 weeks, and required supervision while wheeling 50 - 150 feet in a manual wheelchair. Interview with Resident #105 on 7/27/25 at 8:40 AM identified that Resident #79 sings, yells, and screams in the hallway all day long and it drives everyone crazy. Interview with Resident #12 on 7/27/25 at 10:20 AM identified that Resident #79 shouts all night and all day that people are stealing and she shouts indiscriminately that she will (explicative) people up. Resident #12 indicated listening to the behavior was tiring and that he/she has voiced concerns to the DNS and other staff members, but nothing had been done. Interview and review of the clinical record with the Director of Social Services (SW #1) on 7/28/25 at 9:41 AM failed to identify a crisis/safety plan in Resident #79’s clinical record, and she was not aware that the PASARR recommendations included developing a crisis intervention plan/safety plan. SW #1 indicated that it was her responsibility to review PASARR recommendations, but this was an oversight on her part. SW #1 further indicated that she would collaborate with the interdisciplinary team, including nursing, the licensed clinical social worker, and the Psychiatric APRN, as well as Resident #79’s conservator to develop a crisis/safety plan, by tomorrow. The plan would include identifying Resident #79’s triggers and behavior and utilizing recreation, talk therapy, and non-pharmaceutical and pharmaceutical interventions. SW #1 identified that education would be provided to all department heads and the care team so direct care staff could identify early signs of behaviors, triggers, or escalation. Interview with the DNS on 7/30/25 at 5:10 PM identified that she was not aware that Resident 79 did not have a crisis/safety plan, but she would work with the interdisciplinary team in its development and ensure direct care nursing staff would be educated. Interview with the Psychiatric APRN (APRN #2) on 7/30/25 at 6:20 PM identified that prior to the survey process he was not aware of the PASARR recommendation to develop a crisis intervention plan/safety plan for Resident #79, but the plan had been developed, subsequent to surveyor inquiry. APRN #2 indicated that Resident #79 was alert and oriented and stable on his/her current medication regimen and continues to work with psychotherapy. APRN #2 identified that the team was aware of the importance of identifying early triggers and behaviors, and the need to place Resident #79 on a 1:1 or send him/her out for a higher level of psychiatric care, if needed, but currently he/she is stable and will remain on the current medication regimen. The facility’s PASARR policy directs that individuals with a serious mental illness, intellectual disability, or related condition will not be admitted without first undergoing the federally mandated PASARR screening process, consisting of Level 1 and, if applicable Level 2 screening. A Level 2 screening directs for the assessment of the need for specialized services and appropriateness of nursing facility placement. 2. Resident #3 was admitted to the facility in April 2012 with a diagnosis that included personality disorder and dementia. Notice of Level 1 screen dated 6/18/12 was negative and identified Resident #3 had a diagnosis of personality disorder. Additionally, Resident #3 had a diagnosis of dementia and required a comprehensive mental status exam. Resident #3 received long term care approval. The care plan dated 1/21/22 identified Resident #3 had increased risk for altered nutrition secondary to primary diagnosis of dementia, personality disorder, and mood disorder. Interventions included to encourage and monitor food intake. The quarterly MDS dated [DATE] identified Resident #3 had moderately impaired cognition and had a diagnosis of dementia, depression, and major depressive disorder, recurrent. The psychiatric evaluation and consultation dated 1/23/23 identified a diagnosis of mood disorder, severe to moderate, chronic illness and dementia. The psychiatric evaluation and consultation dated 2/4/23 identified a new diagnosis of major depressive disorder. The census report for Resident #3 identified he/she was readmitted from the hospital on 1/9/24 and 4/8/24. Review of the active diagnosis list dated 4/1/24 identified Resident #3 received a diagnosis of major depression disorder, recurrent. The psychosocial evaluation dated 4/1/24 identified Resident #3 has the cognitive ability and verbal capacity to participate and benefit from psychotherapy. The treatment plan and objective identified to treat confusion, depression and irritability. Resident #3 has a diagnosis of major depressive disorder, recurrent. Interview with SW #1 on 7/29/25 at 6:38 AM indicated the social worker was responsible to update the State-designated authority when a resident gets a new mental health diagnosis. SW #1 indicated that upon notification, the State-designated authority will determine if an onsite visit for a level 2 evaluation is needed, or if there are any specialized services the facility needs to provide to the residents. SW #1 indicated Resident #3 had a negative Level 1 screen dated 6/18/12 with a diagnosis listed as dementia and personality disorder. The Level 1 did not list the diagnosis of major depression disorder, recurrent. SW #1 indicated that she was not aware nor could find the comprehensive mental status exam that was recommended at that time. SW #1 indicated that review of the psychiatric notes identified the new diagnosis was given on 2/4/23. SW #1 indicated the prior social worker should have submitted a new Level 1 PASARR to the State-designated authority for review due to the new diagnosis in February 2023. SW #1 indicated when Resident #3 was readmitted on [DATE] or 4/8/25 the social worker should have caught that the major depressive disorder, recurrent was not listed on the PASARR and resubmitted at that time. SW #1 indicated that she will submit and update the State-designated authority today with the new diagnosis and documentation. 3. Resident #8 was admitted to the facility in May 2021 with diagnoses that included anxiety and major depressive disorder. A Notice of Level 1 PASARR determination dated 5/10/21 identified Resident #8 had a diagnosis of dementia with behavioral disturbances. Resident #8 received long-term care approval based on the information provided. A physician’s order dated 11/25/21 directed to administer Seroquel (antipsychotic medication) 50 mg daily at 9:00 AM for depression, and Seroquel 25 mg at bedtime for anxiety, agitation, and paranoia. Additionally, a psychological evaluation and consultation to treat as needed. The quarterly MDS dated [DATE] identified Resident #8 had intact cognition and had a diagnosis of anxiety and major depressive disorder. The Resident #8’s diagnosis list identified a new diagnosis on 5/1/22 of schizoaffective disorder, bipolar type. The annual MDS dated [DATE] identified Resident #8 had intact cognition and had a diagnosis of anxiety and major depressive disorder. Additionally, Resident #8 has a diagnosis of schizoaffective disorder, bipolar type. The psychiatric consultation dated 5/16/22 identified Resident #8 had a diagnosis of anxiety, dementia, and major depression disorder. The psychiatric consultation dated 7/7/22 identified Resident #8 had a new diagnosis schizoaffective disorder, bipolar type. The care plan dated 2/1/23 identified Resident #8 receives antidepressant and antipsychotic medications related to depression. Interventions included attempting gradual dose reduction to lowest dosage. A physician’s order dated 7/14/24 directed to administer Seroquel 50 mg daily and Seroquel 25 mg at bedtime for diagnosis of schizoaffective disorder, bipolar type. The census report identified Resident #8 had returned from the hospital on 7/14/24 and 12/21/24. Interview with SW #1 on 7/29/25 at 6:26 AM indicated Resident #8 only has a PASARR dated 5/10/21 which identified a diagnosis of dementia and anxiety but does not list the major depression or the diagnosis of schizoaffective disorder bipolar type. After clinical record review, SW #1 indicated Resident #8 received the diagnosis of schizoaffective disorder bipolar type on 7/7/22. SW #1 indicated that the social worker at that time should have submitted a notified the State-designated authority due to the new mental health diagnosis and update the care plan. SW #1 indicated that it was not picked up on 7/14/24 or 12/21/24 when the resident was readmitted . SW #1 identified she will be updating the State-designated authority with the new diagnosis of schizoaffective disorder and major depression. 4. Resident #21 was admitted to the facility in February 2021 with diagnoses that included violent behaviors and acute kidney injury. The care plan dated 1/3/22 identified Resident #21 was on antidepressant and antipsychotic medications. Interventions included attempting gradual dose reduction to the lowest therapeutic level. A physician’s order dated 1/4/22 directed to administer Risperidone (antipsychotic medication) 0.5 mg once a day. A physician’s order dated 3/24/22 directed to administer Risperidone 1 mg twice a day. Notice of Level 1 PASARR determination dated 4/4/22 identified Resident #8 had a diagnosis of dementia with behavioral disturbances and delusional disorder. Resident #8 received long-term care approval based on the information provided. There is no evidence of a PASARR condition or serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. The quarterly MDS dated [DATE] identified Resident #21 had moderately impaired cognition. The quarterly MDS dated [DATE] identified Resident #21 had moderately impaired cognition and a diagnosis of schizophrenia. The annual MDS dated [DATE] identified Resident #21 had moderately impaired cognition with a active diagnosis of depression and schizophrenia. A physician’s order dated 8/4/22 directed to administer Risperidone 2 mg twice a day for a diagnosis of schizoaffective disorder. A physician’s order dated 2/5/24 directed to Risperidone 1.5 mg twice a day for a diagnosis of schizoaffective disorder. A physician’s order dated 4/8/25 directed to monitor behaviors every shift for use of psychotropic medication. Monitor for paranoia, agitation, and hallucinations for a diagnosis of schizoaffective disorder depressive type. Interview with SW #1 on 7/29/25 at 6:43 AM identified after clinical record review Resident #21 had received the diagnosis of schizoaffective disorder on 4/11/22. SW #1 indicated that the social worker at that time should have updated the State-designated authority with the new diagnosis of schizoaffective disorder to determine if there were any specialized services needed. SW #1 indicated that when she started at the facility about 4 months ago she was informed there were only 2 residents that had a Level 2 positive PASARR. SW #1 indicated that she did not do any audits to check if it was accurate. SW #1 indicates that she was only reviewing the new admissions to the facility. Interview with the Administrator on 7/29/25 at 6:51 AM identified she has looked at the book that was there for the Level 2's in the facility but has not done an audit yet. The Administrator indicated the social worker is responsible for PASSAR’s. After reviewing the policy, the Administrator indicated that when a resident receives a new mental health diagnosis the social worker is responsible to update the State-designated authority at that time. Review of the PASARR policy identified individuals with a serious mental illness, intellectual disability, or related condition will not be admitted to the facility without first undergoing the federally mandated PASARR screening process, consisting of Level 1 and if applicable Level 2 screening. This is to ensure compliance with federal and state regulations by identifying individuals with serious mental illness, intellectual disabilities, or related conditions prior to admission to the facility and providing appropriate care and services. Level 2 screening is required if a Level 1 screening is positive. Mandatory PASARR Level 2 resubmission for any resident receiving a new diagnosis of mental illness or related condition, regardless of admission date will be communicated within the interdisciplinary team. Notify the PASARR authority if a current resident shows signs of MI or ID not previously identified. Re-screening is also required upon a significant change in condition.

**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 2 of 6 residents (Resident #6 and 125) reviewed for accidents, for Resident #6 the facility failed to provide adequate supervision to a resident who required aspiration precautions and supervision with intake and for Resident #125 the facility failed to provide adequate supervision and care planned interventions for a resident with a known history of substance abuse and a recent drug overdose to prevent a reoccurrence, and for 1 resident (Resident #10) reviewed for tube feeding and aspiration precautions, the facility failed to provide 1:1 feeding assistance and failed to ensure that mechanically altered diet orders were followed. The findings include:1a. Resident #125 was admitted to the facility in March 2024 with diagnoses that included osteomyelitis of vertebra, opioid abuse, anxiety disorder, and dorsalgia. The care plan dated 3/28/24 identified Resident #125 had a history or active diagnoses of substance abuse. Intervention included to offer resident the option of attending substance abuse group. Nursing and social services support as needed. The admission MDS dated [DATE] identified Resident #125 had intact cognition, required setup or clean up assistance with personal hygiene, and independent with eating. Additionally, Resident #125 had no physical and verbal behaviors directed toward others. The physician’s order dated 6/1/24 directed to monitor pain every shift and administer Oxycodone 10mg every 6 hours as needed for pain. The June 2024 identified Resident #125 received the medication Oxycodone 10mg on 6/3/24 at 4:55 PM for pain with good effect. The nurse’s note dated 6/3/24 at 7:00 PM by RN #3 identified around 6:25 PM there was a STAT call to the unit and Resident #125 was noted to be unresponsive to verbal/tactile command. Narcan was administered at 6:30 PM in left nostril times one with good effect. Resident #125 opened their eyes, vital signs were obtained, oxygen saturation was 97% on room air and EMS was called. Resident #125 was verbally responsive, and emergency responders arrived at 6:40 PM. Resident #125 left the facility at 6:50 PM. The APRN was notified, W-10, and the bed hold policy initiated. Message left for the resident representative. Consultation for pain management and mouth check with every medication pass every shift initiated. The reportable event form dated 6/3/24 at 6:25 PM identified Resident #125 became unresponsive and required the use of Narcan. Resident #125 was sent to the hospital for evaluation and monitoring. Resident #125 reported taking 2 doses of his/her pain medication. The Administrator was notified, and an investigation was initiated. The care plan dated 6/3/24 identified Resident #125 had a history or active diagnoses of substance abuse. On 6/3/24 Resident #125 had an unresponsive episode. Intervention included to check mouth with every medication pass on every shift. Pain management consultation. A written statement by LPN #10 dated 6/3/24 identified she was called to Resident #125’s room at around 6:30 PM by NA #17, stating it’s an emergency. Resident #125 was being assisted up in a sitting position by NA #17 who was calling the resident’s name over and over. Resident #125 did not respond. LPN #10 called RN #3 over immediately and Narcan was administered and 911 was called. The hospital discharge document dated 6/3/24 at 11:11 PM identified Resident #125 presented for an accidental overdose. Narcan revival from a nursing facility. Upon examination Resident #125 reported he/she possibly took two of his/her Oxycodone too close together. Resident #125 reported that he/she crushed up two of the Oxycodone today and snorted them. Resident #125 denies this was an intentional overdose. Resident #125 does not require admission or further hospitalization at this time, appropriate for discharge back to nursing home. The summary report dated 6/5/24 identified Resident #125 last received his dose Oxycodone 10mg as needed at 9:56 AM on 6/3/24. Resident #125 indicated he/she saved the earlier dose of medication, then requested a second dose of the day at 4:55 PM. Resident #125 indicated then he/she took both medication pills together. A room search was yielded with no results. This incident has not occurred with Resident #125 before. Resident #125 denies taking any other medications or recreational drug. Resident #125 returned from the hospital with no new orders, and no urinary toxicology screen had been done in the hospital. Resident #125 was seen by the Physiatrist who recommended a consultation with an addiction specialist. Mouth check with all medications administered. Although attempted, an interview with previous Administrator (Administrator #1), previous DNS (DNS #1), LPN #10, and NA #17 were not obtained. b. A physician’s order dated 6/1/24 directed to monitor pain every shift. A physician’s order dated 6/3/24 directed to check the resident’s mouth with every medication pass and obtain a pain medication consultation. The care plan dated 6/3/24 identified Resident #125 had a history or active diagnoses of substance abuse. On 6/3/24 Resident #125 had an unresponsive episode. Intervention included to check the resident’s mouth with every medication pass on every shift. Pain management consultation. A physician’s order dated 6/18/24 directed to administer Oxycodone 10mg every 12 hours for pain. The nurse’s note dated 6/19/24 at 9:50 PM by RN #3 identified at 8:30 PM she was notified by LPN #10 that Resident #125 was unresponsive to verbal and tactile stimulation with eyes closed. RN #3 indicated per Resident #250; Resident #125 was noted on his/her knees and Resident #250 called staff due to Resident #125 was not answering. Narcan was administered in left nostril at 8:37 PM, EMS was activated, and W-10 and bed hold policy initiated. Resident #125 slowly became responsive and alert. The ambulance arrived at 8:50 PM, and Resident #125 left at 9:00 PM for the hospital for evaluation. The physician and resident representative were notified. Room checked with no inappropriate contraband noted. The reportable event form dated 6/19/24 at 8:30 PM identified Resident #125 was observed unresponsive in Resident #250’s room. Narcan was administered time one and 911 was activated. Resident #125 became verbally responsive and alert. Resident #125 transferred to the hospital. The physician, Administrator, DNS, and resident representative were notified. The care plan dated 6/19/24 identified Resident #125 had a history or active diagnoses of substance abuse. On 6/19/24 Resident #125 had an unresponsive episode. Intervention included to check mouth with every medication pass on every shift. Supervised visits with Resident #250. Move resident to another unit. The summary report dated 6/24/24 at 11:22 AM identified at approximately 8:00 PM on 6/19/24, LPN #10 observed Resident #125 going down the hallway with Resident #250. At approximately 8:30 PM Resident #250 yelled down the hallway for help. LPN #10 observed Resident #125 unresponsive and Narcan was administered with positive effect. Investigation initiated. Resident #125 returned from the hospital with no new order, psychiatric and social service support to be provided. Upon the investigation, Resident #250 had gone out on leave of absence. Resident #125 last received his/her Oxycodone 10mg at 8:00 AM on 6/19/24 and did not receive the second dose due to incident. Mouth checks were maintained and care plan included recommendations for addictions services. Resident #125 indicated he/she “took two of the oxycodone’s together.” The previous Maintenance Director privately asked Resident #125 what happened. Resident #125 admitted to taking a Methadone pill but would not admit who gave him/her the pill. Resident #250 declined involvement and did not want to participate in the investigation process. Resident #250 was discharged home per his/her request on 6/20/24. Resident #125 had a planned discharge to home date of 6/21/24 with addiction and home care services. Interventions: Addiction services set up for Resident #125, mouth checks maintained, and last medication administration of Oxycodone schedule was assessed. Both residents were discharged home. Although attempted, an interview with the previous Administrator, (Administrator #1), previous DNS (DNS #1), LPN #10, and the Maintenance Director were not obtained. Review of the facility Narcan administration policy identified the facility will provide emergency treatment for residents who may demonstrate signs and symptoms of opiate overdose. 2. Resident #6 was admitted to the facility on [DATE] with diagnoses that included hemiplegia affecting the right side following a stroke, dysphagia, and dementia. The clinical record identified Resident #6 was hospitalized from [DATE] - 4/20/25 for Covid 19 infection. Review of the 4/20/25 hospital discharge documentation identified Resident #6 required speech therapy evaluation during hospitalization due to issues with swallowing. The documentation also identified Resident #6 had expressive aphasia and was unable to provide any information. The hospital documentation identified Resident #6 had a modified barium swallow and speech therapy evaluation which identified reduced airway closure and silent aspiration with swallowing. Recommendations included 1:1 supervision with intake, slow rate of feeding, single bites/sips, and pureed diet with nectar thickened liquids due to deficits with swallow safety and efficacy. The care plan dated 4/20/25 identified Resident #6 was at risk for aspiration due to noncompliance with diet. Interventions included to counsel and encouraged Resident #6 to be compliant with the plan of care. A physician’s order dated 4/21/25 directed a nectar thick pureed diet. Review of the physician’s orders and nurse aide care card failed to direct aspiration precautions or supervision with meals. The 5-day MDS dated [DATE] identified Resident #6 had moderately impaired cognition, was frequently incontinent of bowel and bladder, required set up for meals and substantial assistance with toileting and bathing. The MDS also identified Resident #6 had issues with swallowing that included coughing or choking during meals. A Speech Therapy discharge note dated 5/25/25 identified Resident #6 received skilled speech therapy services from 4/21/25 - 5/25/25 for dysphagia. The note identified Resident #6 had made gains with speech therapy and was consuming a pureed and nectar thickened liquid diet with no overt signs/symptoms of aspiration with cured strategy use. The note further identified discharge recommendations that included Resident #6 to continue with pureed consistency diet and nectar thick liquids, and close supervision with oral intake. The note also identified that Resident #6 had a good prognosis with consistent staff follow-up. Review of the care plan failed to identify the Speech therapy recommendations of 5/25/25. Observation on 7/27/25 at 8:27 AM identified Resident #6 was in bed, the bedside table located directly next to the left side of the bed with a meal tray on the table. Observation of the meal tray identified eggs and oatmeal were untouched while a small carton of milk and orange juice were empty. During this observation, Resident #6 was observed sleeping, lying flat, and no staff were observed within the vicinity of the room. Interview with LPN #13, an agency nurse, on 7/27/25 at 8:30 AM identified she was unsure of Resident #6’s diet order or supervision level with meals as it was her first shift working on Resident #6’s unit. Interview with NA #13 on 7/27/25 at 8:31 AM identified she was the regular nurse aide on the unit for Resident #6. NA #13 identified Resident #6 ate independently and did not require supervision with meals. Interview with APRN #1 on 7/29/25 at 12:07 PM identified that all residents on aspiration precautions or that required mechanically altered diets were addressed by the facility speech therapy department. APRN #1 identified she would receive emails and updates on these residents but did not write the orders or place the residents on aspiration precautions and this was the responsibility of the speech therapist. Interview with LPN #8 on 7/30/25 at 9:00 AM identified she was the nurse regularly assigned to care for Resident #6 and that the resident was to have supervision with meals and was usually brought to the dining room for all meals. Constant observation on 7/30/25 beginning at 12:20 PM identified Resident #6 seated in the wheelchair in the unit dining room. NA #4 was observed providing meal trays to other residents in the dining room and NA #13 was observed setting up Resident #6’s lunch meal tray and left the tray and table at 12:21 PM. Resident #6 was observed feeding him/herself without supervision beginning at 12:21 PM. NA #4 and NA #13 were observed exiting the dining room to the meal truck located in the hallway of the unit. Resident #6 was observed taking large spoonful’s of food, one after the other, and at 12:23 PM began coughing. At 12:24 PM, NA #4 reentered the dining room, came to Resident #6’s side as he/she was coughing, and directed Resident #6 to take smaller bites. At 12:25 PM, Resident #6 stopped coughing as NA #13 also reentered the dining room, and NA #4 continued to provide prompts to Resident #6 to take smaller bites and requested NA #13 find a smaller spoon because the spoon the resident was using was “too large.” Resident #6 began coughing again with NA #4 standing at his/her side. At 12:26 PM, NA #4 brought a chair next to Resident #6 as Resident #6 stopped coughing. At 12:29 PM NA #4 got up from the chair and began checking on other residents in the dining room. No other nurse aides were in the dining room from this point. At 12:30 PM, NA #4 provided verbal prompts to Resident #4 while circulating the dining room, and at 12:32 PM sat back down at Resident #6’s side and provided prompts to take small sips while drinking his/her milk. NA #4 was observed at Resident #6’s side until 12:36 PM, when the observation ended after Resident #6 declined the remainder of his/her meal. Constant observation on 7/30/25 beginning at 4:56 PM identified Resident #6 seated in the wheelchair in the unit dining room. At 5:00 PM, NA #11 was observed setting up Resident #6’s dinner meal tray and leaving the dining room. Resident #6 was then observed eating his/her meal unsupervised beginning at 5:01 PM. At 5:02 PM, LPN #11 was observed standing in one of 2 entryways of the dining room next to a medication cart also positioned at and blocking the entryway. LPN #11 was positioned opposite Resident 6’s table and seat position. Between LPN #11 and Resident #6 was a residential refrigerator. Observation directly behind Resident #6 failed to visualize LPN #11 due to obstruction by the refrigerator, and LPN #11 was only visible after moving approximately 3 feet to the left of Resident #6’s table to be able to see LPN #11 around the refrigerator and at the entryway. Resident #6 was observed continuing eating unsupervised taking large spoonful’s of food and had multiple coughing episodes at 5:04 PM, 5:07 PM, 5:11 PM, 5:14 PM, and 5:15 PM. During these episodes, LPN #11 continued to remain at the entryway on the opposite side of the refrigerator and did not attempt to observe or check on Resident #6 and was instead observed speaking with other residents regarding medications. At 5:18 PM, Resident #6 had another episode at which time LPN #11 stepped back from the side of refrigerator and into the dining room. LPN #11 asked Resident #6 if he/she was okay. Resident #6 had stopped coughing but did not provide a response. At 5:19 PM LPN #11 stepped back the medication cart at the dining room entryway, again obstructed by the refrigerator. At 5:20 PM, Resident #6 began coughing again after taking in half (2 oz) of thickened apple juice with one attempt. At 5:21 PM, while Resident #6 continued coughing, LPN #11 again stepped from the side of the refrigerator and again asked Resident #6 if he/she was okay. Resident #6 nodded yes and stopped coughing, and at 5:22 PM LPN #11 again stepped back to the medication cart at the dining room entryway. Resident #6 stopped eating and drinking and slightly pushed his/her meal tray away. Observation of the tray identified Resident #6 ate approximately 75% of the meal, which included pureed teriyaki chicken breast, rice, and stir-fried vegetables and 100 % of the thickened liquids, which included 4 oz of apple juice, 4 oz of skim milk, and 4 oz of coffee. No other staff were observed in the vicinity of Resident #6 or in the dining room area during Resident #6’s meal. Interview with LPN #11 on 7/30/25 at 5:22 PM identified she was aware Resident #6 was on aspiration precautions and required supervision with meals, and felt she was providing supervision of Resident #6 due to being in the dining room entryway. LPN #11 did not identify how she provided supervision while passing medications to other residents and being positioned on the opposite side of large appliance. Interview with the DNS on 7/30/25 at 5:24 PM identified Resident #6 should have direct supervision with all meals due to aspiration precautions, and that would include having a facility nurse or nurse aide in the dining room with eyes on Resident #6 for the entirety of his/her meals. The DNS identified Resident #6 was impulsive with eating and drinking and often took large bites and sips but did well if supervised and prompted by staff to take smaller bites and sips. The DNS identified that she would immediately in-service the nursing staff regarding the need to provide supervision to any residents who required aspiration precautions. Interview with SLP #1 on 7/31/25 at 8:03 AM identified that Resident #6 is to have close supervision with all meals due to dysphagia and aspiration risks. SLP #1 identified if Resident #6 opted to eat in his/her room, then the resident would need 1:1 supervision, but if in the dining room, close supervision was sufficient. SLP #1 identified that Resident #6 was impulsive with meals and when he/she ate or drank too fast, he/she would often cough which was a sign of aspiration. SLP #1 also identified that Resident #6 had a history of noncompliance with liquids and would often hang out by the facility vending machine. SLP #1 identified that while Resident #6 was unable to verbalize due to aphasia, other residents would often help and purchase sodas and other liquids from the facility vending machine. SLP #1 identified that she had observed intermittent issues regarding supervision of Resident #6 related to meals and had also observed meal trays in Resident #6’s room without any staff present. SLP #1 identified that she had not placed a specific order for Resident #6 related to aspiration precautions along with Resident #6’s diet order and identified that there may have been some confusion regarding this with some of the staff. Review of the clinical record failed to identify documentation related to Resident #6’s noncompliance related to vending machine items. The facility policy on aspiration precautions directed that the purpose of the policy was to establish standardized procedures for preventing aspiration and residents at risk due to dysphasia, altered mental status, or other conditions ensuring safe feeding practices and maintaining airway integrity. The policy directed that upon admission, quarterly, and with a significant change of condition, residents would be assessed for swallowing ability and aspiration risk including a referral to the speech language pathologist and findings and recommendations would be documented in the resident care plan. The policy also directed that residents identified as high risk for aspiration precautions would receive supervision during meals and snacks along with documentation of the supervision level including 1:1 feeding assistance or close observation, residents would be maintained at a 90° angle during meals and remain upright for at least 30 minutes after a meal, and would be observed for signs of aspiration which included coughing, choking, or respiratory distress. The policy also directed the speech and language pathologist would provide evaluations care plan input and staff training related to aspiration precautions; and nursing and dietary would implement interventions and monitor compliance. The facility policy on therapeutic diets directed that modified diet texture were altered inconsistency including pureed diets for residents with chewing or swallowing difficulties the policy also directed special considerations for dysphagia and aspiration risk included texture modified diets would follow speech language pathology recommendations and thickened liquids would only be used when ordered and proper consistency of the liquid would be verified prior to service the policy also directed that residents may decline therapeutic diet after being informed of potential risks per resident rights and refusals would be documented. The facility policy on a hazard free environment directed that the facility would identify, correct, and prevent environmental hazards to ensure resident safety and regulatory compliance. The policy further directed that all employees shared the responsibility of recognizing, reporting, and removing hazards promptly. The policy further directed that nursing staff would visually inspect resident rooms, hallways, and areas for hazards during routine care. 3. Resident #10 was admitted to the facility in August 2023 with diagnoses that included traumatic brain injury, dysphagia, and diabetes with hypoglycemia. Review of the clinical record identified Resident #10 had a g-tube in place upon admission but had fully transitioned to nutritional intake by mouth in March 2025. A physician’s order dated 3/13/25 directed diet orders that included ground solids and nectar thick liquids with single sips only, 1:1 feeding assistance, aspiration precautions, and encourage use of double swallow. The quarterly MDS dated [DATE] identified Resident #10 had severely impaired cognition, was always continent of bowel and bladder and required supervision with toileting, dressing, and eating. Review of a speech therapy evaluation by SLP #1 dated 7/12/25 identified Resident #10 had a history of dysphasia and aspiration pneumonia. Resident #10 was noted to have coughing with thin liquids, (a clinical sign and symptom of dysphasia), had behaviors impacting safety with meals including uncontrolled talking while eating, impulsive rate, unsafe intake amounts with decreased self-correction, decreased safety awareness, and poor self-monitoring skills. The report recommended to continue baseline diet of ground consistency with nectar thickened liquids, 1:1 supervision with all oral intake, small bites and sips, double swallow, throat clearance, and re-swallow. The note also identified due to documented physical impairments and associated functional deficits, Resident #10 was at risk for aspiration, behavioral outburst, weight loss, pneumonia, and further decline in function. An APRN note dated 7/21/25 at 4:46 PM identified Resident #10 was receiving 100% of caloric intake and medications by mouth and was only receiving g-tube flushes. The note identified a three-day caloric count scheduled from 7/22/25 - 7/24/25 to determine if Resident #10’s oral intake was adequate to establish the removal of the g-tube. Observation on 7/30/25 at 8:05 AM identified Resident #10 was seated in the dining room with several other residents. Resident #10 was observed to consume 100% of the meal by 8:10 AM. During the observation Resident #10 was observed taking large spoonful’s by mouth. Clinical staff were not present and did not provide 1:1 supervision at any time during the meal. Observation on 7/30/25 at 12:21 PM identified Resident #10 was seated in the unit dining room with several other residents. At 12:29 PM, NA #13 was observed setting up Resident #10’s meal tray and exiting the dining room. NA #4, who was assisting other residents in the dining room was present but was not observed providing any supervision to Resident #10. Resident #10 was observed eating his/her meal unsupervised, taking large spoonful’s of food by mouth and began coughing at 12:37 PM for approximately one minute. Resident #10 consumed 75 % of the meal and stopped eating at 12:39 PM and was observed coughing multiple times until 12:40 PM, when NA #4 came to Resident #10’s table. NA #4 left the table and Resident #10 exited the dining room at 12:41 PM while continuing to cough intermittently. Observation on 7/30/25 beginning at 4:56 PM identified Resident #10 seated in his/her wheelchair in the unit dining room with NA #11 who was observed setting up Resident #10’s dinner meal tray and leaving the dining room. Resident #10 was observed eating his/her meal unsupervised beginning 4:57 PM and taking in large spoonful’s of his/her meal. At 5:02 PM, LPN #11 was observed standing in one of the 2 entryways of the dining room next to a medication cart also positioned at and blocking the entryway, directly across from Resident #10. At this time, Resident #10 was observed to have consumed approximately 75 % of his/her meal. At the same time, NA #11 was also observed retrieving 2 clear plastic cups of a red colored liquid from an insulated beverage dispenser located in the dining room. Observation of the liquid identified it was regular thin liquid consistency. NA #11 handed one plastic cup of liquid to another resident and the second cup of liquid to Resident #10 while speaking to LPN #11 requesting medication to treat a headache. Resident #10 drank the entirety of the cup directly in front of LPN #11 in one attempt. At 5:05 PM, Resident #10 was observed to have completed 100% of his/her meal. Interview with LPN #11 on 7/30/25 at 5:22 PM identified she was aware Resident #10 required supervision with meals. LPN #11 was unable to identify if she visualized Resident #10 consuming the thin liquid or if he/she required 1:1 supervision during meals. Interview with the DNS on 7/30/25 at 5:24 PM identified Resident #10 is required to have 1:1 supervision with all meals due to aspiration precautions, was impulsive with eating and drinking, and often took large bites and sips. The DNS identified that Resident #10 also had a history of aspiration pneumonia and non-compliance with his/her diet orders due to often going to the facility vending machines. The DNS also identified even with prompts and 1:1 supervision, Resident #10 was often impulsive and took in large amounts of food and liquids too quickly. The DNS identified that she would immediately in-service the nursing staff regarding the need to provide supervision to any residents with aspiration precautions. Interview with SLP #1 on 7/31/25 at 8:03 AM identified that Resident #10 had multiple issues related to oral intake including behaviors with meals that included impulsivity, inability to self-regulate intake of large amounts of food at one time, poor safety awareness, along with functional and cognitive issues. SLP #1 identified that she had provided therapy to Resident #10 multiple times since his/her admission to the facility in 2023 and Resident #10 had reached his/her baseline in terms of swallowing function. SLP #1 identified that Resident #1 would always need 1:1 supervision with any oral intake due to his/her high risk for aspiration. SLP #1 identified Resident #10 was only to have nectar thickened liquids and should not have any thin liquids due to aspiration risk. The facility policy on aspiration precautions directed that the purpose of the policy was to establish standardized procedures for preventing aspiration and residents at risk due to dysphasia, altered mental status, or other conditions ensuring safe feeding practices and maintaining airway integrity. The policy directed that upon admission, quarterly, and with a significant change of condition, residents would be assessed for swallowing ability and aspiration risk including a referral to the speech language pathologist and findings and recommendations would be documented in the resident care plan. The policy also directed that residents identified as high risk for aspiration precautions would receive supervision during meals and snacks along with documentation of the supervision level including 1:1 feeding assistance or close observation, residents would be maintained at a 90° angle during meals and remain upright for at least 30 minutes after a meal, and would be observed for signs of aspiration which included coughing, choking, or respiratory distress. The policy also directed the speech and language pathologist would provide evaluations care plan input and staff training related to aspiration precautions; and nursing and dietary would implement interventions and monitor compliance. The facility policy on therapeutic diets directed that modified diet texture were altered inconsistency including pureed diets for residents with chewing or swallowing difficulties the policy also directed special considerations for dysphagia and aspiration risk included texture modified diets would follow speech language pathology recommendations and thickened liquids would only be used when ordered and proper consistency of the liquid would be verified prior to service the policy also directed that residents may decline therapeutic diet after being informed of potential risks per resident rights and refusals would be documented.

Based on observation, review of facility documentation, facility policy, manufacturer guidelines and interviews, the facility failed to ensure the level of sanitizing solution in the dishwasher was tested and maintained at an adequate level according to manufacturer guidelines to ensure tableware was sanitized. The findings include: A kitchen service report dated 7/22/25 identified ware washing results for glassware, plates, pots and pans were satisfactory with the sanitizer concentration measured 75 ppm (parts per million) falling within the acceptable range of 50 - 100 ppm.An observation during a test run of the low temperature dishwasher on 7/27/27 at 7:02 AM identified the sanitation strip had a recorded measurement of 0 - 10 ppm.A review of the dishwasher temperature log date 7/1/25 through 7/26/25 identified the wash cycle was recorded at 120. The rinse cycle was recorded at 50.An interview and facility documentation review with the Regional Food Service Director on 7/27/25 at 7:15 AM identified the number recorded under the wash cycle represented the temperature in degrees, while the number under rinse cycle reflected the sanitation concentration in ppm. Although not specifically labeled, staff were expected to understand that rinse reading represented ppm, obtained by submerging a sanitizer test strip in a reservoir of water flowing through the dishwasher to the clean side.An interview with Dietary Staff #1 on 7/27/25 at 7:22 AM identified she routinely operated the dishwasher and documented required readings onto the dishwasher temperature log as part of her assigned duties. Dietary Staff #1 identified she recorded both wash and rinse information based only on the dishwasher gauge (temperature readings) and never used test strips to measure sanitation.An interview with Dietary Staff #3 on 7/27/25 at 7:40 AM identified he routinely operated the dishwasher and documented required readings onto the dishwasher temperature log as part of his assigned duties. Dietary Staff #3 identified he recorded both wash and rinse information based only on the dishwasher gauge (temperature readings) and never used test strips to measure sanitation.An interview with the FSD on 7/27/25 at 7:42 AM identified the dishwasher was last serviced on 7/22/25 and was functioning properly with the appropriate sanitation levels. The FSD further identified she last checked the sanitation the previous morning, with a recorded reading of 50 ppm. The FSD further identified she was responsible to educate dietary staff on dishwasher sanitation procedure; however, was unable to provide any documentation of any prior training.An interview and sanitation strip manufacturer guideline review with Dietary Staff #4 on 7/27/25 at 8:24 AM identified he last checked the dishwasher sanitation at 1:00 PM following lunch the previous day. Dietary Staff #4 identified the reading at the time was within normal range. However, when asked to identify the corresponding range on the test strip. Dietary Staff #4 indicated the range fell between 0 - 10 ppm, despite the manufacturer's guidelines indicating the normal sanitizer range of 50 - 100 ppm.An interview with Dishwasher Technician #2 on 7/27/25 at 1:50 PM identified that a mechanism in the machine was not aligned properly, preventing the sanitizing solution to dispense. Without that mechanism functioning, the plates and utensils were not sanitized. The issue was addressed and subsequently the dishwasher was functioning properly.An interview with Dishwasher Technician #1 on 7/28/2025 at 6:57 AM identified he last provided routine service to the dishwasher on 7/22/25 and there were no identified concerns. Dishwasher Technician #1 identified the wash and rinse cycle gauge measured in degrees only and should be maintained between 115 - 120 degrees F. Sanitation should be measured using strips with a recorded reading of 50 - 100ppm. Any reading outside of those ranges would not offer effective sanitizing.An interview with the FSD on 7/31/2025 at 2:17 PM identified she would expect dietary staff to perform sanitation procedures in accordance with infection control practices.A review of the manufacturer guidelines for the dishwasher identified sanitizer should be maintained at 50 ppm.A review of the manufacturer guidelines for the sanitation strips identified sanitizer should be maintained between 50 -100 ppm.Although requested. A policy for ensuring clean and sanitary plates and utensils was not provided.

Based on review of facility documentation, facility policy, and interview, the facility failed to ensure ongoing tracking and surveillance of antibiotic usage from 1/1/23 to 12/31/24 and failed to ensure staff education on antibiotic stewardship. The findings include: Interview with the Infection Control Nurse (LPN #1) on 7/29/25 at 7:40 AM indicated that she started at the facility in March 2025. LPN #1 identified she was responsible for monitoring and tracking all antibiotic usage and infections based on McGeer's criteria on a daily to weekly basis and consulting with the provider about if the antibiotic was appropriate or not at the time the infection started. LPN #1 indicated when she started working at the facility there were not any monthly surveillance reports of antibiotic use from 1/1/23 through 12/31/24. There were no statistics or monthly infection control meeting minutes to identify that antibiotic usage had been reviewed, reported, or determined to have been appropriately used or not. LPN #1 indicated her position was responsible to educate the residents and staff at least annually on the ongoing stewardship program and if there were concerns with over antibiotic use. LPN #1 indicated there was no documentation regarding antibiotic stewardship education with the residents or staff that she could find. Interview with the DNS on 7/31/25 at 8:20 AM indicated the infection control nurse was responsible to do a daily but at least a weekly review of all antibiotic use and speak with the providers to determine if the appropriate antibiotic was being used for the resident's infection. The DNS indicated the infection control nurse would determine if a resident met the McGeer's criteria for an infection to be eligible to receive the antibiotic. The DNS indicated if the resident did not meet requirements the infection control nurse was expected to contact the provide and document the outcome. The DNS indicated her expectation was the infection control nurse would have a monthly infection control committee meeting to review the antibiotic use and data collected. The DNS indicated the infection control nurse was responsible to present the data quarterly for number of infections, comparisons to other months, and analyzing the data to present with a report at the QAA and medical staff meeting. The DNS indicated she did not have an antibiotic line lists or education for 2023 or 2024. Interview with the Administrator on 7/31/25 at 8:25 AM indicated QAA and QAPI meet quarterly with the medical staff meeting. The Administrator indicated that it was the infection control nurse or DNS's responsibility to present the ongoing infection rates, comparisons to other months or quarters, any outbreaks since prior quarter, and statistics or over prescribing of an antibiotic with the providers. After review from 1/1/23 to 12/31/24 the Administrator could not provide documentation of any infection control report or that the infection control nurse verbally had presented during the meeting based on the minutes from the meetings. The Administrator indicated that the infection control nurse was responsible to present a quarterly report based on her daily, weekly, and monthly surveillance of antibiotic usage and analyzing the data for any trends in infections or antibiotic usage by providers for the antibiotic stewardship program. The Administrator indicated that the infection control nurse did sign in to some of the quarterly QAA meetings, but she did not present any information related to the antibiotic stewardship statistics to the committee. Review of the Antibiotic Stewardship Policy identified the facility shall work to ensure the safe, effective use of antibiotics, and shall actively seek to minimize the inappropriate use of antibiotics through ongoing assessment, education, and leadership activities as part of the facility infection prevention and control program. The facility medical director, in conjunction with the infection preventionist, director of nursing, and consultant pharmacist shall assume the leadership roles in antibiotic stewardship. Antibiotic stewardship activities will be coordinated through the pharmacy committee and the infection control committee. Antibiotic stewardship activities shall include: regular review of antibiotic utilization patterns and sensitivity patterns at the committee meetings, reports from the laboratory on sensitivity and resistant patterns over time (quarterly, yearly, and past years), review of antibiotic utilization over the past (quarter, year, and past years), distribution of educational materials to staff and clinicians on improving safe, effective use of antibiotics as well as material on prevention of overprescribing on a regular basis in conjunction and coordination with annual in-service education. Additionally, reports back to the provider on potential mis-prescribing or over-prescribing as identified by the infection control committee. Review of the Infection Prevention Program Policy identified the infection prevention program will identify, protect, and control infections. The infection prevention and control must maintain and document an infection control program which has its goal the prevention and control of infection and communicable diseases. The facility must maintain surveillance, identification, prevention, control, and investigation of infections and communicable diseases. The facility must provide infection control education to staff, residents, and caregivers. Surveillance data will be collected using the infection prevention report to determine any changes in the trends of infections. Additionally, it will identify the types of infections among its population and staff. If a problem is identified with an outbreak or infection cluster, control measures will be developed, and surveillance continues to determine whether the problem is being controlled. Reporting and analyzing infections will be conducted as required by state law and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure staff followed up with a consulting physician office timely in accordance with hospital discharge directions. The findings include: Resident #1 had a diagnosis of malignant neoplasm of the left breast. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview of Mental Status (BIMS) score of five (5) indicating severely impaired cognition and required assistance with Activities of Daily Living (ADLs). The Resident Care Plan (RCP) dated 2/26/2025 identified a diagnosis of cancer. Interventions directed to monitor for adverse effects if receiving chemotherapy or radiation. Hospital Discharge summary dated [DATE] directed to contact Resident #1's oncology office two (2) weeks post discharge for Stage 4 left breast cancer. No appointments were listed on the discharge summary. The nursing admission note dated 7/30/2024 at 10:44 PM identified to follow up with Resident #1's oncology office within two (2) weeks related to Stage 4 left breast cancer. Record review failed to identify Resident #1's oncology office was contacted two (2) weeks after he/she was discharged from the hospital. Interview with oncology office RN #1 on 4/9/2025 at 10:59 AM identified the office did not receive a call from the facility within two (2) weeks after the resident was discharged from the hospital. Interview and record review with the DNS and Administrator on 4/9/2025 at 11:42 AM identified they were unable to locate documentation that the facility contacted Resident #1's oncology office two (2) weeks after hospital discharge, in accordance with the hospital directions. The interview identified the facility should have followed up with the oncology office, and the DNS and Administrator did not know why the facility did not follow up. Facility follow up appointment policy dated 3/4/2025 directed in part, upon admission the admitting RN will review the resident's chart and identify any follow up appointments needed based on hospital discharge instructions and schedule in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from physical mistreatment. The findings include: Resident #1's diagnoses included schizoaffective disorder, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition and was maximal assistance with all ADLs. The Resident Care Plan (RCP) dated 5/31/2024 identified Resident #1 exhibited behaviors as evidenced by being verbally/physically abusive, refusal of care, and aggression related to psychiatric conditions. Interventions directed approach resident in a calm and consistent manner, monitor for changes in mood/behavior and report to the physician, and to provide resident with the opportunity to express feelings through one-to-one and group visits. The facility incident report identified on 7/10/2024 at 6:00 PM identified Resident #2 reported to the DON that he/she witnessed NA #1 kick Resident #1 in the leg. Resident #1 confirmed that NA #1 kicked him/her in the leg. The report did not indicate any injury was noted, indicated NA #1 was sent home pending the investigation, and the local police, physician and family were notified. Record review for Resident #2 identified a quarterly MDS dated [DATE] indicated Resident #2 was alert and oriented. A nursing progress note dated 7/10/2024 at 10:02 PM by DON identified at approximately at 6:00 PM, Resident #1 reported to the Administrator that he/she was kicked in the legs by a staff member. Body assessment showed no signs of bruising, denied pain to his/her legs and was able to move legs within baseline. APRN #1 notified of the incident with orders received to monitor for pain and follow facility protocol. Resident #1's conservator was notified of the event. Facility incident summary dated 7/16/2024 identified the allegation of staff to resident abuse without injury was substantiated; Resident #1 confirmed the allegation that was witnessed by Resident #2. NA #1's employment was terminated. Interview with Resident #1 on 7/30/2024 at 10:25 AM identified NA #1 did kick him/her in the left leg. Interview with Resident #2 on 7/30/2024 at 10:40 AM identified he/she was across the hall from Resident #1 on 7/10/2024 and observed NA #1 assisting Resident #1 and NA #1 kicked Resident #1 in the leg. Resident #2 indicated the kick was not a gentle kick but was indicated it was meant to cause injury or harm. Resident #1 began to scream as per his/her normal baseline behaviors, but Resident #2 felt the kick was to intentional get more of a response out of Resident #1. Resident #2 indicated he/she immediately went to the Administrator and DON to report the incident. Interview with NA #1 on 7/30/2024 at 12:00 AM identified on 7/10/2024 at 5:30 PM, he denied the allegation. Interview with the DON and Administrator on 7/31/2024 at 10:15 AM identified on 7/10/2024, Resident #2 alleged he/she observed NA #1 kick Resident #1. Resident #1 was immediately interviewed, and he/she confirmed what Resident #2 had alleged. The results of the investigation identified the allegation was substantiated, and NA #1's employment was terminated. Review of the Resident Abuse, Mistreatment, Neglect, Exploitation, Misappropriation of Resident Property, and Retaliation Policy dated 9/16/2018 identified the facility will ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation of property, and retaliation as per state and federal guidelines. Physical abuse is defined as the intentional infliction of physical pain, bodily harm, or physical coercion. Facility documentation review identified staff education was initiated on 7/10/2024 regarding the facility resident abuse (prevention) policy. Audits were initiated on 7/11/2024, and a QAPI meeting was held on 7/11/2024. Based on review of facility documentation, past non-compliance was identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 6 residents (Resident #3, #7, #8) reviewed for resident to resident altercations, the facility failed to create and implement interventions for residents after resident to resident abuse allegations. The findings include: 1. Resident #3 was admitted to the facility with diagnoses that included dementia with behavioral disturbance and anxiety. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition, had verbal behavioral symptoms directed towards others, and required supervision with set up help on for activities of daily living (ADL's). The care plan dated 8/17/23 identified Resident #3 had behavioral symptoms with interventions included to encourage the resident to seek the assistance of staff when in challenging situations, social service to help deescalate upsurging behavior and to create a behavior modification plan through psychiatric services. Review of the accident and incident report (A & I) dated 10/17/23 identified Resident #3 was observed by the receptionist throwing juice in Resident #4's face and calling his/her racial slurs and names. Resident #3 was placed on 1:1 observation and sent to the hospital for an evaluation and was deemed not a danger to self or others by psychiatry. Review of Resident #3's behavioral care plan identified it was updated on 10/17/23 to include on 10/17/23 Resident #3 threw juice onto another resident in the lobby. However, the care plan failed to include new interventions subsequent to the event. 2. Resident #7 was admitted to the facility with diagnoses that included obstructive hydrocephalus (fluid on the brain) and bipolar disorder. The care plan dated 8/17/23 identified Resident #7 had a history of depression, anxiety and bipolar with interventions included behavior monitoring as indicated and monitor for changes in mood/behavior and report to the physician. The quarterly MDS dated [DATE] identified Resident #7 had severely impaired cognition, had verbal behavioral symptoms directed towards others, had delusions, and required supervision with set up help on for activities of daily living (ADL's). Review of the accident and incident report (A & I) dated 12/5/23 identified Resident #8 was observed grabbing Resident #7's jacket and calling him/her derogatory names. Resident #8 sustained a skin tear to the top of his/her lip. Both residents were placed on 1:1 and transferred to the hospital. Review of Resident #7's care plan failed to include a new care plan and interventions subsequent to the event on 12/5/23. 3. Resident #8 was admitted to the facility with diagnoses that included schizoaffective disorder and delusional disorders. The care plan dated 11/7/23 identified Resident #8 exhibited behaviors as evidenced by verbal/physical abuse, refusal of care, aggression and psychiatric concerns with interventions that included to approach the resident in a calm manner and monitor any changes in mood/behavior and report to the physician. The quarterly MDS dated [DATE] identified Resident #8 had moderately impaired cognition, had verbal behavioral symptoms directed towards others, and required assist of one staff for transfers and ambulated with walker/wheelchair with supervision. Review of the accident and incident report (A & I) dated 12/5/23 identified Resident #8 was observed grabbing Resident #7's jacket and calling him/her derogatory names. Resident #8 sustained a skin tear to the top of his/her lip. Both residents were placed on 1:1 and transferred to the hospital. Review of Resident #8's care plan failed to include a new care plan and interventions subsequent to the event on 12/5/23. An Interview with the DNS and Administrator on 12/20/23 at 4:00 PM identified the expectation is for the nursing supervisor to update the residents' care plans. She identified she would expect a new care plan with intervention to prevent re-occurrence. Review of the resident to resident altercation policy directed if two residents are involved in an altercation, staff will make any necessary changes in the care plan approaches to any or all of the involved individuals and consult psychiatric services as needed for assistance in assessing the resident, identify the causes and developing a care plan for intervention and management as necessary or as may be recommended by the physician or interdisciplinary care team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for four (4) of six (6)residents, (Resident #3, #4, #7, #8), reviewed for resident to resident altercations, the facility failed to document social services visits for residents after resident to resident altercations. The findings include: 1. Resident #3 was admitted to the facility with diagnoses that included dementia with behavioral disturbance and anxiety. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition, had verbal behavioral symptoms directed towards others, and required supervision with set up help on for activities of daily living (ADL's). The care plan dated 8/17/23 identified Resident #3 had behavioral symptoms with interventions that included to encourage the resident to seek the assistance of staff when in challenging situations, social service to help deescalate upsurging behavior and to create a behavior modification plan through psychiatric services. Review of the accident and incident report (A & I) dated 10/17/23 identified Resident #3 was observed by the receptionist throwing juice in Resident #4's face and calling his/her racial slurs and names. Resident #3 was placed on 1:1 observation and sent to the hospital for an evaluation and was cleared by psychiatry. The interventions to prevent reoccurrence were to provide psychiatry and social service support and to keep both residents away from each other. Review of Resident #3's progress notes subsequent to the event on 10/17/23 failed to identify documentation of a visit(s) from the social services department. 2. Resident #4 was admitted to the facility with diagnoses that included stroke, hemiplegia affecting right dominant side and mood disorder. The annual MDS dated [DATE] identified Resident #4 had no impairments in cognition, had no behavioral symptoms and required extensive assistance of two staff for bed mobility and transfers and supervision with set up help for ambulation with a wheelchair daily living (ADL's). The care plan dated 9/11/23 identified Resident #4 had a history of anxiety. Interventions included to monitor changes in mood/behavior and report to the physician and monitor for side effects of medication. Review of the accident and incident report (A & I) dated 10/17/23 identified Resident #3 was observed by the receptionist throwing juice in Resident #4's face and calling his/her racial slurs and names. Resident #3 was placed on 1:1 observation and sent to the hospital for an evaluation and was cleared by psychiatry. The interventions to prevent reoccurrence were to provide psychiatry and social service support and to keep both residents away from each other. Review of Resident #4's progress notes subsequent to the event on 10/17/23 failed to identify documentation of a visit(s) from the social services department. 3. Resident #7 was admitted to the facility with diagnoses that included obstructive hydrocephalus (fluid on the brain) and bipolar disorder. The care plan dated 8/17/23 identified Resident #7 had a history of depression, anxiety and bipolar. Interventions included behavior monitoring as indicated and monitor for changes in mood/behavior and report to the physician. The quarterly MDS dated [DATE] identified Resident #7 had severely impaired cognition, had verbal behavioral symptoms directed towards others, had delusions, and required supervision with set up help on for activities of daily living (ADL's). Review of the accident and incident report (A & I) dated 12/5/23 identified Resident #8 was observed grabbing Resident #7's jacket and calling him/her derogatory names. Resident #8 sustained a skin tear to the top of his/her lip. Both residents were placed on 1:1 and transferred to the hospital. Review of Resident #7's progress notes subsequent to the event on 12/15/23 failed to identify documentation of a visit(s) from the social services department. 4. Resident #8 was admitted to the facility with diagnoses that included schizoaffective disorder and delusional disorders. The care plan dated 11/7/23 identified Resident #8 exhibited behaviors as evidenced by verbal/physical abuse, refusal of care, aggression and psychiatric concerns with interventions that included to approach the resident in a calm manner and monitor any changes in mood/behavior and report to the physician. The quarterly MDS dated [DATE] identified Resident #8 had moderately impaired cognition, had verbal behavioral symptoms directed towards others, and required assist of one staff for transfers and ambulated with walker/wheelchair with supervision. Review of the accident and incident report (A & I) dated 12/5/23 identified Resident #8 was observed grabbing Resident #7's jacket and calling him/her derogatory names. Resident #8 sustained a skin tear to the top of his/her lip. Both residents were placed on 1:1 and transferred to the hospital. Review of Resident #8's progress notes subsequent to the event on 12/15/23 failed to identify documentation of a visit(s) from the social services department. Interview with SW #1 on 12/20/23 at 1:55 PM identified he spoke with Residents' #3, #4, #7 and #8 after the events that occurred. SW #1 identified he writes his visits in a word document then inputs the notes into the medical record. At 3:00 PM SW #1 provided a word document to the surveyor with notes that contained conversations he had with Resident #3 on 10/18/23, 10/19/23 and 10/20/23, Resident #4 on 10/17/23, 10/18/23 and 10/19/23, Resident #7 on 12/6/23, 12/7/23 and 12/8/23 and Resident #8 on 12/7/23, 12/8/23 and 12/11/23. He identified the word document notes were not in the medical records and should have been put in as soon as they were done. Interview with the DNS and Administrator on 12/20/23 at 4:00 PM identified SW #1 writes his notes in a word document. She further identified the notes should be imputed into the residents' medical record. Review of SW #1 job description identified his job functions include preparing and completing social service documentation in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for fifteen (15) of nineteen (19) residents (Resident #7, #8, #9, #11 , #12. #13,#14, #16, #18, #19, #20, #22, #23, #24 and #25) who have a history of substance abuse disorder and receive methadone treatment, the facility failed to ensure the residents had orders for Narcan (an opiate overdose reversal medication) administration. The findings include: 1. Resident #7 was admitted to the facility with diagnoses that included metabolic encephalopathy and opioid dependence. The care plan dated 9/21/23 identified Resident #7 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request, nursing support as needed and monitor for signs and symptoms of opioid overdose. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #7 had moderately impaired cognition and was independent with activities of daily living (ADL's). A physician's order dated 12/1/23 directed methadone 22 mg (an opioid agonist, used to treat opioid dependence) once a day. 2. Resident #8 was admitted to the facility with diagnoses that included COPD and opioid dependance. A physician's order dated 11/1/23 directed methadone 50 mg once a day. The quarterly MDS dated [DATE] identified Resident #8 had no impairments in cognition and was independent with ADL's. The care plan dated 10/19/23 identified Resident #8 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request, nursing support as needed and monitor for signs and symptoms of opioid overdose. A physician's order dated 12/1/23 directed methadone 50 mg once a day. 3. Resident #9 was admitted to the facility with diagnoses that included hypertension and opioid dependance. The quarterly MDS dated [DATE] identified Resident #9 had severely impaired cognition and was independent with ADL's. The care plan dated 10/17/23 identified Resident #9 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request, nursing support as needed and monitor for signs and symptoms of opioid overdose. A physician's order dated 12/1/23 directed methadone 75 mg once a day. 4. Resident #11 was admitted to the facility with diagnoses that included cellulitis and opioid dependence. The care plan dated 8/2/23 identified Resident #11 received methadone maintenance treatment. Interventions included to assist the resident with substance abuse counseling, monitor the resident for changes and provide resident with daily dose of methadone. The MDS dated [DATE] identified Resident #11 had moderately impaired cognition and required extensive assistance of one staff for ADL's. A physician's order dated 12/1/23 directed methadone 128 mg once a day. 5. Resident #12 was admitted to the facility with diagnoses that included pneumonia and psychoactive substance abuse disorder. The care plan dated 7/22/23 identified Resident #12 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. The quarterly MDS dated [DATE] identified Resident #12 had moderately impaired cognition and was independent with ADL's. A physician's order dated 12/1/23 directed methadone 75 mg once a day. 6. Resident #13 was admitted to the facility with diagnoses that included fracture of lumbar vertebra and opioid dependence. The quarterly MDS dated [DATE] identified Resident #13 had no impairments in cognition and required limited assistance with ADL's. The care plan dated 10/10/23 identified Resident #13 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. A physician's order dated 12/1/23 directed methadone 80 mg once a day. 7. Resident #14 was admitted to the facility with diagnoses that included hydrocephalus and opioid dependence. The quarterly MDS dated [DATE] identified Resident #14 had severely impaired cognition and required supervision with ADL's. The care plan dated 11/21/23 identified Resident #14 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. A physician's order dated 12/1/23 directed methadone 85 mg once a day. 8. Resident #16 was admitted to the facility with diagnoses that included urinary tract infection and psychoactive substance abuse disorder. The care plan dated 6/21/23 identified Resident #16 received methadone maintenance treatment. Interventions included to assist the resident with substance abuse counseling, monitor the resident for changes and provide resident with daily dose of methadone. The quarterly MDS dated [DATE] identified Resident #16's cognition was not assessed and was independent with ADL's. A physician's order dated 12/1/23 directed methadone 10 mg once a day. 9. Resident #18 was admitted to the facility with diagnoses that included epilepsy and anxiety. The quarterly MDS dated [DATE] identified Resident #18 had no impairments in cognition and required maximum assistance of one staff for ADL's. The care plan dated 12/21/23 identified Resident #18 had a history of substance abuse with interventions included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. A physician's order dated 12/1/23 directed methadone 120 mg once a day. 10. Resident #19 was admitted to the facility with diagnoses that included fracture of the left lower leg and opioid abuse. The care plan dated 9/22/23 identified Resident #19 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. The quarterly MDS dated [DATE] identified Resident #19 had no impairments in cognition and required supervision of one staff for ADL's. A physician's order dated 12/1/23 directed methadone 40 mg once a day. 11. Resident #20 was admitted to the facility with diagnoses that included pneumonia and opioid dependence. The care plan dated 10/18/23 identified Resident #20 received methadone maintenance treatment with interventions that included to assist the resident with substance abuse counseling, monitor the resident for changes and provide resident with daily dose of methadone. The quarterly MDS dated [DATE] identified Resident #20 had no impairments in cognition and was independent with ADL's. A physician's order dated 12/1/23 directed methadone 100 mg once a day. 12. Resident #22 was admitted to the facility with diagnoses that included COPD and psychoactive substance abuse disorder. The MDS dated [DATE] identified Resident #22 had no impairments in cognition and required limited assistance of one staff for ADL's. The care plan dated 11/14/23 identified Resident #22 had a history of substance abuse. Interventions included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. A physician's order dated 12/1/23 directed methadone 80 mg once a day. 13. Resident #23 was admitted to the facility with diagnoses that included fracture of foot and opioid dependence. The care plan dated 11/13/23 identified Resident #23 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. The quarterly MDS dated [DATE] identified Resident #23 had no impairments in cognition and required one staff assistance for ADL's. A physician's order dated 12/1/23 directed methadone 120 mg once a day. 14. Resident #24 was admitted to the facility with diagnoses that included COPD and opioid dependence. The quarterly MDS dated [DATE] identified Resident #24 had no impairments in cognition and was independent with ADL's. The care plan dated 11/28/23 identified Resident #24 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request, and nursing support as needed. A physician's order dated 12/1/23 directed methadone 80 mg once a day. 15. Resident #25 was admitted to the facility with diagnoses that included fracture of right lower leg, cocaine abuse and psychoactive substance abuse disorder. The quarterly MDS dated [DATE] identified Resident #25 had moderately impaired cognition and was independent with ADL's. The care plan dated 11/13/23 identified Resident #25 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. A physician's order dated 12/1/23 directed methadone 115 mg once a day. Review of Residents' #7, #8, #9, #11 #12,#13, #14, #16, #18, #19, #20 and #22, #23, #24 and #25's clinical record failed to identify an order for Narcan administration. Interview with LPN #2 (in charge of the methadone program at the facility) on 12/20/23 at 3:00 PM identified there was a house blanket order for Narcan for residents in the facility. Interview with Medical Director on 12/20/23 at 3:30 PM identified there should be an order for Narcan for any resident's who is on the methadone program. The Medical Director was unaware that Narcan was not in the order set for each resident on Methadone. It is her expectation that each resident on the methadone program have a specific order for Narcan. Subsequent to surveyor inquiry, on 12/21/23 Narcan orders were added to the physician orders for Residents' #7, #8, #9, #11, #12, #13, #14, #16, #18, #19, #20 and #22, #23, #24 and #25. Review of the Narcan policy directed that facility is to provide emergency treatment for residents who may demonstrate signs and symptoms of opiate overdose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #66) reviewed for dignity, the facility failed to ensure resident was treated in a dignified manner. The findings include: Resident #66 was admitted to the facility in September 2022 with diagnoses that included pain in the right hip, chest pain, chronic gout, and diabetes. The admission MDS dated [DATE] identified Resident #66 had intact cognition and required total 2-person assistance with transfers, and personal hygiene. Physician's orders dated November 2022 directed to provide 2- person assistance with bed mobility and utilize a hoyer lift for transfers. Interview with Resident #66 on 11/8/22 at 12:27 PM identified that on Sunday 11/6/22, a special day for him/her, during the 3:00 PM - 11:00 PM shift he/she was on the phone having a conversation when a nurse aide told him/her to (get off the phone if he/she wanted to get in bed). The nurse aides name was not provided. Resident #66 indicated he/she did not like the way the nurse aide spoke to him/her and stated he/she is a person and should be treated with respect. Resident #66 indicated he/she reported the incident to the Administrator the next day. In another interview with Resident #66 on 11/15/22 at 9:30 AM the resident's story remained consistent that on Sunday 11/6/22 a nurse aide told him/her to (get off the phone if you want to get in bed) and that the resident reported the incident, including the way the nurse aide spoke to him/her to the Administrator the next day. Resident #66 indicated that the Administrator does not follow through on reported complaints. Interview with the Administrator on 11/15/22 at 2:04 PM identified he was not aware of the allegation that on Sunday 11/6/22, a nurse aide told the resident to (get off the phone if you want to get in bed). The Administrator indicated he saw Resident #66 several times during the week of 11/7/22 - 11/11/22 and Resident #66 did not report that allegation to him. Although attempted, an interview with NA #8 and NA #9 was not obtained. Review of the facility resident rights policy directed to provide care and services in accordance with the Resident [NAME] of Rights as outlined by the Federal Nursing Home Reform Law. You have the right to be treated equally with other residents in receiving care and services, and regarding transfer and discharge, regardless of the source of payment for your care. You have the right to be treated with consideration, respect and full recognition of your dignity and individuality. You have the right to receive quality care and services with reasonable accommodation of your individual needs and preferences, except when your health or safety or the health or safety of others would be endangered by such accommodation. You have the right to make choices about aspects of your life that are significant to you. Although staff interviews failed to identify that they had been made aware of the incident, and that the nurse aide could not be identified, Resident #66's MDS indicated he/she has intact cognition and the resident's description of the events of 11/6/22 remained consistent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #72 and 81) reviewed for care planning, the facility failed to ensure that the residents were invited to the care plan conference. The findings include: 1. Resident #72 was admitted to the facility in December 2021 with diagnoses that included pneumonia, covid-19, and acute kidney failure. The annual MDS dated [DATE] identified Resident #72 had mildly impaired cognition and required assistance with transfers, dressing, and personal hygiene. The care plan dated 8/24/22 identified to initiate a person-centered care plan that includes objectives to meet the residents medical, nursing, mental, and psychosocial needs. The care plan meeting signature sheet dated 8/24/22 identified although the residents POA attended via phone, the resident did not attend the meeting. A social work progress note, written by SW #1 dated 11/7/22 at 8:48 PM identified a quarterly care plan meeting was held on 8/24/22 at 11:00 AM with the Social Worker, Dietitian, Charge Nurse, and POA. Discussion included resident's overall weights, oral intake, recent medical treatments, and diagnosis. Interview with Resident #72 on 11/8/22 at 12:30 PM indicated he/she had not attended a resident care plan conference with the IDT. Resident #72 indicated he/she was never invited to attend a care planning conference to discuss his/her plan of care and his/her goals. Resident #72 indicated if he/she were invited, he/she would attend. Interview with the RN #2 on 11/14/22 at 12:12 PM indicated Resident #72 and the POA would be invited to the meeting. RN #2 indicated SW #1 and the MDS coordinator were responsible together to run the admission, quarterly and annual resident care conferences. RN #2 indicated she did not know why Resident #72 was not invited. RN #2 indicated anyone that goes and participates at the resident care conference is responsible to sign in on the form to verify who attended. RN #2 indicated if the resident had refused to attend there would be a progress note indicating the resident refused to attend. Interview with SW #1 on 11/10/22 at 12:28 PM indicated she had been doing a virtual care plan conference with the POA's over the phone. SW #1 indicated she invites all the residents to attend whether they were alert and oriented or confused. SW #1 indicated everyone that attends is responsible to sign into the meeting, but sometimes people forget. SW #1 noted sometimes the resident signs and sometimes not. SW #1 indicated it was her responsibility to make sure everyone signed in. SW #1 indicated she did not know what happened or why the computer did not remind her to have a quarterly care conference for Resident #72 back in May 2022. SW #1 noted she did not believe Resident #72 would have refused to attend the care planning meeting if invited, but if he/she did it was her responsibility to write a progress note that the resident had refused. After clinical record review, SW #1 indicated there was not a progress not that Resident #72 had refused to attend a care plan meeting. SW #1 indicated it is complicated and a busy place with admissions and discharges that was why she did not put in the care plan meeting note from 8/24/22 until 11/7/22. SW #1 indicated she could not remember if Resident #72 was invited or had attended. Interview with SW #1 On 11/14/22 at 2:00 PM she identified that on the original resident care plan meeting sign in sheet for Resident #72, provided to the surveyor on 11/10/22 and dated 8/24/22 had the signature of SW #1 and the MDS coordinator. Subsequently, on 11/14/22, SW #1 provided a new signature sheet from 8/24/22 with an LPN signature added. SW #1 indicated she had the LPN sign it today 11/14/22, because she had recalled the LPN was at the meeting on 8/24/22. 2. Resident #81 was admitted to the facility in November 2021 with diagnoses that included schizophrenia and arthritis. The admission MDS dated [DATE] identified Resident #81 had intact cognition and required total assistance for dressing, toileting, personal hygiene, and transfers. The care plan dated 8/24/22 identified the resident was at risk for impaired decision making. Interventions included to encourage family, conservator, or POA to attend care planning and call with any changes. Additionally, Resident #81 was alert and oriented and able to make choices. Intervention included to invite and encourage resident to attend activities of choice as available. The resident care plan meeting signature form dated 8/24/22 identified only the signature of the social worker. The form indicated the social worker spoke with the resident's representative via the phone. Interview with Resident #81 on 11/8/22 at 12:58 PM indicated he/she was not invited to or attended any care planning meetings since admission. Resident #81 indicated he/she would have discussed needing to see a dentist to get all his/her bottom teeth removed and needing to see the eye doctor if he/she had been invited to attend. Interview with SW #1 on 11/14/22 at 11:30 AM identified Resident #81 should have had care plan meetings held on admission and quarterly in February 2022, May 2022, and August 2022, but she does not know why they were not done. SW #1 indicated the resident, and all departments should be present so if the resident or resident representative had any questions or wanted to change anything all departments would be available to answer the questions and participate. SW #1 indicated she was responsible to write a resident care progress note regarding the care plan meeting and who attended but was behind in writing progress notes. SW #1 indicated she had been at the facility for approximately a year, and it was her responsibility to make sure the admission, quarterly and annual resident care plan meetings took place with the interdisciplinary team. Interview with SW #1 on 11/14/22 at 12:28 PM indicated all residents on admission should have an interdisciplinary care plan meeting but it is difficult to get all the department heads together so the disciplines will see the new admissions on their own. SW #1 noted the facility has not been doing the 3-day admission care plan meetings, because it was too difficult to get the IDT team all together and those meetings had not occurred in at least the last year. SW #1 indicated she runs the meeting with MDS nurse. SW #1 noted if the charge nurse wasn't available, the MDS nurse could answer the nursing questions. SW #1 indicated since covid she has been doing a virtual meeting with the POA's over the phone. SW #1 indicated she invites all the residents to attend. SW #1 indicated everyone that attends was supposed to sign into the meeting, but sometimes people forget. SW #1 noted sometimes the resident signs and sometimes not. SW #1 indicated she depends on the computer to inform her of what residents were due for care conferences for her to schedule and run the resident care conferences. SW #1 indicated the computer did not inform her of the care conferences that were due for Resident #72 and Resident #81. SW #1 indicated there must be something wrong with the computer system. Interview with RN #2 on 11/16/22 at 9:12 AM indicated the expectation was the facility would do a 72-hour meeting as a meet and greet with the IDT on admission and they had day 14 - 21 to the compete the comprehensive care plan. RN #2 indicated then the IDT would have a quarterly meeting with the resident and resident representative, including SW #1, MDS nurse, dietitian, recreation, rehab if on case load or if needed. RN #2 indicated the expectation was everyone that attended including the resident would sign into the meeting. Interview and clinical record review with RN #2 on 11/16/22 at 2:10 PM, failed to reflect documentation that Resident #72 and Resident #82 were invited to or offered to participate in their resident care plan meetings. Review of facility Comprehensive Care Planning Policy identified the facility is to develop a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary (IDT) team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. Each resident's comprehensive person-centered care plan will be consistent with the residents' rights to participate in the development and implementation of his/her plan of care, including the right to participate in the planning process and participate in establishing the expected goals and outcomes of care. The resident will be informed of his/her right to participate in his/her treatment. The care planning process will facilitate the resident and the representative's involvement. The comprehensive care plan must be developed no later than day 21 days from admission. The IDT must review and update the care plan at least quarterly. The resident has the right to refuse to participate in the development of his/her care plan, but such refusals will be documented in the resident's clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #66) reviewed for choices, the facility failed to ensure resident choices were accommodated when the resident requested to go to bed and staff did not assist the resident for 4 hours. The findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included pain in the right hip, chest pain, chronic gout, and diabetes. The admission MDS dated [DATE] identified Resident #66 had intact cognition and required total 2-person assistance with transfers, and personal hygiene. Physician's orders dated November 2022 directed to provide 2- person assistance with bed mobility and utilize a hoyer lift for transfers. Interview with Resident #66 on 11/8/22 at 12:27 PM identified approximately 2 weeks ago, after he/she returned to his/her room from smoke break at 4:00 PM, he/she put the call light on and requested to go to bed. Resident #66 identified that a nurse aide told him/her they were short of staff and Resident #66 indicated he/she did not get assistance to go back to bed until 8:00 PM that night. Resident #66 indicated he/she was upset because his/her buttocks was hurting really bad. Resident #66 indicated he/she reported the incident to the Administrator. Interview with the Administrator on 11/15/22 at 2:04 PM identified he was not aware that Resident #66 requested to go to bed at 4:00 PM and the staff did not put Resident #66 to bed until 8:00 PM. The Administrator indicated if he knew about the issue, he would have investigated the issue and addressed the staff immediately. Interview with the DNS on 11/15/22 at 2:06 PM identified she was not aware approximately 2 weeks ago after the resident returned to his/her room from smoke break at 4:00 PM and requested to go to bed that staff told him/her they were short of staff and did not put the resident back to bed until 8:00 PM that night. The DNS indicated if she had known she would have in-service the staff immediately and investigated. The DNS indicated Resident #66 did not inform her of the issue. Interview with RN #5 on 11/18/22 at 4:15 PM identified she works as a supervisor on the 3:00 PM - 11:00 PM shift. RN #5 indicated she was not aware of the issue that Resident #66 had requested to go to bed at 4:00 PM and the staff did not put the resident to bed until 8:00 PM. RN #5 indicated she recalled one day that Resident #66 requested to go back to bed, and she assisted the nurse aide to put Resident #66 in bed because the resident transfers via hoyer lift. RN #5 indicated that evening the facility was short of staff. RN #5 indicated she does not remember the date and the time. RN #5 indicated Resident #66 was upset that night and she apologized to the resident. RN #5 indicated she did not document in the record that Resident #66 was upset. Review of the facility resident rights policy directed to provide care and services in accordance with the Resident [NAME] of Rights as outlined by the Federal Nursing Home Reform Law. You have the right to be treated equally with other residents in receiving care and services, and regarding transfer and discharge, regardless of the source of payment for your care. You have the right to be treated with consideration, respect and full recognition of your dignity and individuality. You have the right to receive quality care and services with reasonable accommodation of your individual needs and preferences, except when your health or safety or the health or safety of others would be endangered by such accommodation. You have the right to make choices about aspects of your life that are significant to you.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, facility policy and interviews for 2 residents (Resident #39 and 53) reviewed for personal funds, the facility failed to ensure the residents' had ready access to their personal funds managed by the facility. The findings included: 1. Resident # 39's diagnoses included chronic kidney disease and diabetes. The quarterly MDS 10/10/22 identified Resident #39 had a moderately impaired cognition, utilized a rolling walking. Interview on 11/9/22 at 9:53 AM with Resident #39 identified that he/she had no ability to access his/her funds the facility managed on the weekends. Review of the facility authorization and agreement to handle resident funds, signed by Resident #39 on 10/15/21, identified Resident #39 had a resident fund account managed by the facility with a $60.00 monthly allowance, and that Resident #39 would receive a statement at least quarterly. 2 Resident # 53's diagnoses included diabetes. The annual MDS dated [DATE] identified Resident #53 had intact cognition. Interview with Resident #53 on 11/8/22 at 11:44 AM identified that he/she has money in an account managed by the facility but is not able to access the money on the weekends, and that many times there was no money available during the limited banking hours the facility offered as many times the money would run out. Review of the facility authorization and agreement to handle resident funds, signed by Resident #53 on 7/13/22, identified that the resident had a resident fund account managed by the facility with a $75.00 monthly allowance and that Resident #53 would receive a statement at least quarterly. Interview with the Administrator on 11/10/22 at 11:37 AM identified that residents have access to banking hours which are handled by the front desk manager. The hours are posted. If residents want money on the weekend, they have to get money on Fridays when there are banking hours. The Administrator identified that the front desk would notify him if they ran out of money during the week and he would leave the facility to get additional money to dispense. The Administrator identified if residents wanted to access funds on the weekend, the facility staff would notify the nursing supervisor and the nursing supervisor would contact the Administrator to obtain funds for residents. The Administrator further identified the facility staff and supervisors were aware this was the facility process. Observation on 11/10/22 at 11:45 AM a sign posted at the facility front desk area located directly inside the main entrance read Attention: Resident Funds will be given from 10:30 AM - 11:30 AM and 2:00 PM - 3:00 PM. Interviews with LPN #4 and NA #2 on 11/10/22 at 11:50 AM identified they both work every other weekend, and that residents were not able to access funds at any time on the weekend. NA #2 further identified that residents were not able to access funds during the week as the front desk runs out of money all the time. LPN # 4 and NA #2 identified they had not ever heard that the Administrator could be contacted to allow residents to access funds. Interview with the Front Desk Manager on 11/10/22 at 12:50 PM identified she was the person in charge of dispensing funds during banking hours. The Front Desk Manager identified that the Administrator provide her a total of $750 per week and if the money ran out, she had to ask the Administrator to get additional money. The Front Desk Manager also identified that there was no availability for residents to get funds on the weekend, and that the residents were only able to access personal funds Monday through Friday, during the posted banking hours of 10:30 AM - 11:30 AM and 2:00 PM - 3:00 PM. Interview with LPN #3 on 11/10/22 at 12:59 PM identified she believed there was front desk staff over the weekend, but she was unsure if there were banking hours for residents to access personal funds. LPN #3 further identified that residents had reported to her that when they asked for money at the front desk, they were told they have to wait a day or 2 to be able to get it. Interview with NA #1 on 11/10/22 at 1:04 PM identified that banking hours for residents were only available Monday through Friday, and that residents were told if they wanted money over the weekend they would have to wait. NA #1 reported that she had never heard of any cash being available for the residents on the weekend and had also never heard that the nursing supervisor could notify the Administrator to get funds for the residents during the weekend. Although requested, the facility failed to provide a policy on access to personal funds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, facility policy and interviews for 1 residents (Resident 53) reviewed for personal funds, the facility failed to ensure the residents' received quarterly statements from their personal funds account managed by the facility. The findings include: Resident # 53's diagnoses included diabetes. The annual MDS dated [DATE] identified Resident #53 had intact cognition. Interview with Resident #53 on 11/8/22 at 11:44 AM identified that the facility has been managing his/her personal funds for the last 3 or 4 months but he/she had never gotten a statement. Review of the facility authorization and agreement to handle resident funds, signed by Resident #53 on 7/13/22, identified that the resident had a resident fund account managed by the facility with a $75.00 monthly allowance and that Resident #53 would receive a statement at least quarterly. Interview with the Administrator on 11/10/22 at 11:37 AM identified the facility only provides statements for resident funds account on request and that the facility did not provide statements to residents unless the residents asked for them. Review of the Resident Rights dated 7/13/21 identified that residents have the right to have the facility to manage their personal funds. Further, if the facility manages the residents personal funds, the residents have a right to a quarterly accounting of their funds, and that a separate statement about how the funds were managed by the facility would be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #600) reviewed for abuse, the facility failed to report an allegation of verbal abuse to the state agency in accordance with established timeframes and facility policy. The findings include: Resident #600 was admitted to the facility in April 2022 with diagnoses that included traumatic compartment syndrome of right upper extremity, chronic pain due to trauma, and asthma. The quarterly MDS dated [DATE] identified Resident #600 had intact cognition and required supervision with personal hygiene and eating. A grievance form dated 10/7/22 identified Resident #600 reported that he/she asked NA #6 to warm up his/her food, and NA #6 opened the container before placing it in the microwave. Resident #600 indicated an argument started between him/her and NA #6. Resident #600 reported that NA #6 started yelling at him/her and told him/her to shut up. The grievance form further identified the resolution was NA #6 was removed from the assignment and provided education. Resident #600 was given the opportunity to change room and the resident declined. A social service note dated 10/7/22 at 1:48 PM identified Resident #600 approached SW #1 and asked to file a grievance on NA #6. Resident #600 indicated he/she had spoken to RN #1 (previous DNS) regarding the incident and wanted to make sure the incident was documented. Interview and review of facility documentation with RN #2 on 11/15/22 at 10:22 AM identified she was not aware of the incident that took place on 10/7/22 with NA #6 and was not able to provide documentation that the incident that Resident #600 reported of being yelled at and told to shut up by NA #6 had been reported to the state agency. RN #2 indicated RN #1 (previous DNS) should have followed the facility policy, reported the allegation of verbal abuse to the state agency, and documented the incident. Interview with SW #1 on 11/16/22 at 11:43 AM identified Resident #600 reported to her on 10/7/22 that he/she asked NA #6 to warm up his/her food and she removed the cover despite the resident asking NA #6 to not open the food. Resident #600 indicated NA #6 walked by him/her in the hallway and said, shut up. Resident #600 indicated he told RN #1. SW #1 indicated RN #1 verbalized that she spoke to NA #6 and took care of the issue. SW #1 indicated NA #6 was not allowed to provide care to Resident #600. Although attempted, an interview with NA #6 was not obtained. Review of the facility resident abuse, mistreatment, neglect, exploitation, misappropriate of resident property, and retaliation policy directed to ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriate of resident property, and retaliation. Internal Reporting: All staff will report to their supervisor any allegations or incidents of all types of resident abuse, including injuries of unknown origin. Immediate Reporting Responsibilities: Any allegation or incident of abuse, mistreatment, neglect, exploitation, misappropriate of resident property, or retaliation will be reported to DPH online with the FLIS portal within two (2) hours. This report will be made by the DNS, ADNS, or Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #600) reviewed for abuse, the facility failed to thoroughly investigate an allegation of verbal abuse. The findings include: Resident #600 was admitted to the facility in April 2022 with diagnoses that included traumatic compartment syndrome of right upper extremity, chronic pain due to trauma, and asthma. The quarterly MDS dated [DATE] identified Resident #600 had intact cognition and required supervision with personal hygiene and eating. A grievance form dated 10/7/22 identified Resident #600 reported that he/she asked NA #6 to warm up his/her food, and NA #6 opened the container before placing it in the microwave. Resident #600 indicated an argument started between him/her and NA #6. Resident #600 reported that NA #6 started yelling at him/her and told him/her to shut up. The grievance form further identified the resolution was NA #6 was removed from the assignment and provided education. Resident #600 was given the opportunity to change room and the resident declined. A social service note dated 10/7/22 at 1:48 PM identified Resident #600 approached SW #1 and asked to file a grievance on NA #6. Resident #600 indicated he/she had spoken to RN #1 (previous DNS) regarding the incident and wanted to make sure the incident was documented. Interview and review of facility documentation with RN #2 on 11/15/22 at 10:22 AM identified she was not aware of the incident that took place on 10/7/22 with NA #6 and was not able to provide documentation that the incident that Resident #600 reported of being yelled at and told to shut up by NA #6 had been reported to the state agency. RN #2 indicated RN #1 (previous DNS) should have followed the facility policy, reported the allegation of verbal abuse to the state agency, and documented the incident. Interview with SW #1 on 11/16/22 at 11:43 AM identified Resident #600 reported to her on 10/7/22 that he/she asked NA #6 to warm up his/her food and she removed the cover despite the resident asking NA #6 to not open the food. Resident #600 indicated NA #6 walked by him/her in the hallway and said, shut up. Resident #600 indicated he told RN #1. SW #1 indicated RN #1 verbalized that she spoke to NA #6 and took care of the issue. SW #1 indicated NA #6 was not allowed to provide care to Resident #600. Although attempted, an interview with NA #6 was not obtained. Review of the facility resident abuse, mistreatment, neglect, exploitation, misappropriate of resident property, and retaliation policy directed to ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriate of resident property, and retaliation. Investigation and Response: An investigation will be immediately conducted of any allegation of abuse or injuries of unknown origin. The investigation will be documented and reported accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 3 of 4 residents (Resident #39, 72 and 75) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to ensure the resident was referred to the appropriate state-designated authority for Level II PASARR evaluation and determination after a newly evident or possible serious mental disorder was identified. The findings include: 1. A PASARR Level 1 screen dated 9/27/21 identified Resident #39 had a diagnosis of mild or situational depression and had no diagnosis of dementia. The Level I outcome was to refer for a Level II onsite. A level II evaluation must be conducted. A PASARR summary of findings dated 9/30/21 identified Resident #39 had a diagnosis of depression and poly substance abuse which requires routine follow up with a mental health professional and a psychiatric medication regimen including Bupropion, Zyprexa, and Trazodone. Effective 9/30/21, Resident #39 was Level II approved for long term care. Resident #39 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, diabetes and hyponatremia. The psychosocial evaluation dated 10/19/21 identified that Resident #39 had a diagnosis of adjustment disorder with mixed anxiety and depressed mood. The admission MDS dated [DATE] identified Resident #39 had intact cognition and a diagnosis of depressive disorder, no behaviors, delusions, or hallucinations. The psychosocial evaluation dated 11/17/21 identified Resident #39 had a diagnosis of major depressive disorder, opioid dependance, and other psychiatric disorder. A neurology consultation dated 12/9/21 identified Resident #39 had a significant history of schizoaffective disorder. A physician's order dated 12/30/21 directed to have a psychiatry evaluation as needed. The care plan dated 8/1/22 identified a psychosocial well-being care plan related to a positive Level II. Interventions included to a minimum of a yearly comprehensive psychiatric evaluation. The psychosocial evaluation dated 8/20/22 identified that Resident #39 had a new diagnosis of schizoaffective disorder and major depressive disorder. The quarterly MDS dated [DATE] identified Resident #39 had moderately impaired cognition, was independent with activities of daily living. Additionally, had a diagnosis of anxiety, depression, and schizoaffective disorder. The care plan dated 11/7/22 identified a psychosocial well-being care plan for schizoaffective disorder and depression. Interventions directed to have psychiatry and supportive care consult as ordered and a s needed, medications as ordered, and gradual dose reduction as ordered. Interview with SW #1 on 11/10/22 at 8:40 AM indicated Resident #39 had a Level II PASARR done on 3/30/22 but did not have the new diagnosis of schizoaffective disorder or major depression. SW #1 indicated Resident #39 was admitted with a diagnosis of depressive disorder and polysubstance abuse. SW #1 indicated Resident #39 on 8/20/22 received a new diagnosis of schizoaffective disorder and major depression she should have updated the contractor for another Level II evaluation and outcome. SW #1 indicated she was not sure at the time if the resident needed another Level II evaluation by the contractor because they already had done one prior to the new diagnosis. SW #1 indicated now looking at it she definitely should have notified the contractor of the new diagnosis and let them make a determination on the new diagnosis. Interview and clinical record review with RN #2 on 11/14/22 at 10:30 AM identified when Resident #39 was admitted to the facility in October 2021 there was not a diagnosis of schizoaffective disorder or major depression at that time. RN #2 indicated in review of the clinical record the neurology consult dated 12/9/21 identified Resident #39 had a history of schizoaffective disorder, but the psychiatric group that comes to the facility did not give the diagnosis of major depression or schizoaffective disorder until 7/12/22, over 7 months later. RN #2 indicated SW #1 should have updated the PASSAR in December 2021 and noted SW#1 informed her, she was not aware of the new diagnosis until July/August of 2022. RN #2 indicated SW #1 had 2 opportunities to update the contractor, once in December 2021 and again in July/August 2022. RN #1 indicated SW #1 would update the contractor of the new diagnosis. 2. Resident #72 was admitted to the facility on [DATE] with diagnoses that included covid-19 respiratory infection, pneumonia, and violent behaviors. A physician's order dated 12/30/21 directed to give Zyprexa 2.5mg daily and Trazadone 50 mg at bedtime. The admission MDS dated [DATE] identified Resident #72 had moderately impaired cognition. A Level I PASARR dated 4/4/22 identified Resident #72 had a diagnosis of delusional disorder and per the documents submitted, no Level II was required. A psychiatric evaluation dated 5/16/22 identified Resident #72 had a new diagnosis of schizoaffective disorder. The annual MDS dated [DATE] identified Resident #72 had a diagnosis of depression and schizoaffective disorder. A physician's order dated 8/4/22 directed to give Risperidone 2 mg at 8:00 AM and 8:00 PM. The care plan dated 8/24/22 identified Resident #72 received antipsychotic and antidepressant medications. Interventions included to attempt dosage reduction to lowest possible therapeutic level. An interview with SW #1 on 11/10/22 at 8:05 AM indicated Resident #72 was admitted on [DATE] with a 90-day approval, and on 12/30/21 was approved for long term care as a Level 1 PASARR with no Level 2 required for long term care on 4/4/22. SW #1 indicated Resident #72 was at a facility prior to being admitted to this facility with only a diagnosis of delusional disorder. SW #1 indicated she would only file for a Level 2 determination if there was a significant change in condition. SW #1 indicated when Resident #72 received a new diagnosis in May 2022 of personality disorder and schizoaffective disorder she should have submitted the new diagnosis to determine if Resident #72 required a Level 2 PASARR and if there were any recommendations. Interview with the Psychiatric APRN, APRN # 2C on 11/10/22 at 1:30 PM indicated she was the psychiatric APRN for the facility and the prior DNS had asked her to clarify the diagnosis on some residents. APRN #2 indicated for Resident #39 she had added the diagnosis of schizophrenia based the resident's presentation and symptoms. APRN #2 indicated she changed the diagnosis from the diagnosis of psychotic unspecified for both residents to a more specific diagnosis bases on presentation and getting to know the residents. APRN #2 indicated when she adds a new medication with a diagnosis for that medication or a new diagnosis, she adds the diagnosis in the chart and informs the charge nurse. Interview with RN #2 on 11/14/22 at 10:45 AM indicated that SW #1 was responsible to update the contractor to see if either Resident's #39 or 72 would require a Level II evaluation and any new outcome. RN #2 indicated when she was the DNS at the facility, she worked with the psychiatric group to clarify some of the general diagnoses. RN #2 indicated when Resident #39 and #72 had received the new psychiatric diagnosis, SW #1 should have right away submitted to for a new Level II evaluation and allow the contractor to determine if these residents were a Level II and if there were any recommendations that the facility would have to follow. RN #2 indicated she and SW #1 had missed updating the contractor with the new diagnosis and she was working on a system to identify when a resident gets a new psychiatric diagnosis that that information gets conveyed to the social worker right away so notifications could be made to the contractor. Review of the PASARR policy dated 11/1/21 identified all residents will have a completed PASAR level of care upon admission. All required documentation will be submitted to the contractor for a level of care determination. If resident was a Level 1 no further action required. If resident was a Level II the contractor will complete their evaluation either by phone or in person. The contractor will determine if the resident was a Level II, and the facility will implement recommendations into the residents plan of care. Social services will monitor for any new diagnosis or changes and report to the contractor as indicated. 3. Resident #75 was admitted to the facility on [DATE]. The annual MDS dated [DATE] identified Resident #75 was currently not considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition. The MDS also identified the resident had a diagnosis of depression. The resident had diagnoses that included stroke, schizoaffective disorder bipolar type, and diabetes. The Notice of Negative PASARR Level I Screen, date of determination 1/28/20 identified no level II condition - Level I negative. The quarterly MDS dated [DATE] identified Resident #75 has a diagnosis of schizophrenia (e.g., schizoaffective and schizophreniform disorder). Interview and review of Resident #75's diagnoses and PASARR documentation with the Social Worker on 11/10/22 at 10:15 AM identified Resident #75 only had a psychiatric diagnosis of depression on admission but must have received the diagnosis of schizoaffective disorder after a hospital stay. The Social Worker identified that the previous owner of the facility used a different computer system, and she was unsure how to check resident information in the previous system which was in place when resident was initially admitted . The Social Worker identified if a resident receives a new diagnosis of schizoaffective disorder, another PASARR assessment should be done. Interview and review of the clinical record with RN #2 on 11/10/22 at 11:00 AM identified that Resident #75 should have been referred for a Level II evaluation when the diagnosis of schizoaffective disorder was identified. RN #2 identified that although she had identified an issue with PASARR prior to surveyor inquiry, resolution was still in progress. Review of the facility's PASARR policy identified all residents will have a completed PASARR/Level of care upon admission. Social services will monitor for new diagnosis or changes and report to the contractor as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #67) reviewed for accidents, the facility failed to ensure the plan of care was updated after a fall. The findings include: Resident #67 was admitted to the facility with diagnoses that included diabetes and chronic pain. A reportable event form dated 7/31/22 at 9:40 AM identified Resident #67 fell forward while trying to transfer independently and hit his/her face on the overbed table and sustained a fracture of the right mandible. The quarterly MDS dated [DATE] identified Resident #67 had intact cognition and required supervision for dressing, eating, toilet use, personal hygiene, and transfers. Additionally, Resident #67 does not ambulate and uses the wheelchair for locomotion in room and on unit. Resident #67 required supervision (oversight and cueing) for transfers, had 1 fall with injury and 1 fall with major injury of a bone fracture. A reportable event form dated 10/13/22 (not timed) identified Resident #67 was observed on the floor at bedside. Resident #67 informed staff he/she was trying to self-transfer from the bed to the wheelchair and slid off. The care plan dated 11/8/22 identified Resident #67 had a history of falls. Interventions included to add dycem (2/27/22), check wheelchair brakes and instruct resident on proper use (4/30/22) and pharmacy to review medications (7/23/22). The care plan failed to include measures to address the residents falls that occurred on 7/31/22, 10/13/22 and 10/17/22. Interview with the RN #2 on 11/16/22 at 3:00 PM indicated each time the resident fell, there should be a new intervention put into place on the care plan to address the fall. RN #2 indicated she was not able to locate the new intervention for the 7/31/22 fall and she could not find any staff statements at the time of the fall as part of the investigation. RN #2 indicated there was not a new intervention for the 7/31/22 fall. RN #2 indicated although the 10/13/22 reportable event form listed an intervention to encourage the resident to lie down, it was not added to the care plan. Review of facility accident and incidents policy identified all accidents or incidents involving residents occurring on the premises shall be investigated and reported to the Administrator. The nurse supervisor and charge nurse or department head shall promptly initiate and document investigation of the accident or incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #67 was admitted to the facility with diagnoses that included diabetes and chronic pain. The quarterly MDS dated [DATE] identified Resident #67 had intact cognition and required supervision for dressing, eating, toilet use, personal hygiene, and transfers. Additionally, Resident #67 does not ambulate and uses the wheelchair for locomotion in room and on unit. Resident #67 required supervision (oversight and cueing) for transfers, had 1 fall with injury and 1 fall with major injury of a bone fracture. The care plan dated 11/8/22 identified a history of falls with interventions that included add dycem on wheelchair, check wheelchair brakes and instruct resident on proper use. Pharmacy medication review. The care plan failed to address the falls on 7/31/22, 10/13/22 and 10/17/22. Reportable event forms dated 7/23/22 at 4:25 AM, 7/31/22 at 9:40 AM and 10/13/22 identified Resident #67 had unwitnessed falls. On 7/23/22 at 4:25 AM and 7/31/22 the resident hit his/her head. Review of the clinical record failed to reflect neurological assessments had been competed on any of the 3 unwitnessed falls. Interview with the RN #2 on 11/16/22 at 3:00 PM indicated she was not able to locate any neurological assessments completed per the facility protocol for the 3 unwitnessed falls on 7/23/22, 7/31/22, and 10/13/22. RN #2 indicated she was the DNS at the times of the falls and the expectation was the nurses would have done the neurological assessments for any unwitnessed falls and if the resident went to the hospital and returned to continue the neurological assessments when the resident returned. Review of facility Neurological Assessment identified the purpose of this procedure was to provide guidelines for a neurological assessment when following an unwitnessed fall or subsequent to a fall with a head injury. Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #501) reviewed for abuse, the facility failed to ensure neurological assessments were completed after a resident was hit on the head and sustained a laceration, and for 1 resident (Resident #67) reviewed for accidents, the facility failed to ensure neurological assessments were completed after unwitnessed falls. The findings include: 1. Resident #501 was admitted to the facility on [DATE] with diagnoses that included chronic pain, anxiety, and major depressive disorder. The admission observation form dated 10/27/22 at 10:11 PM identified Resident #501 was oriented to person, place, and time. A physician's order dated 10/27/22 directed to administer Alprazolam (anti-anxiety medication) 0.5mg three times a day for anxiety disorder and Escitalopram (anti-depressant medication) 10mg once a day for major depressive disorder. The care plan dated 10/30/22 identified Resident #501 is new to the facility and requires a period of adjustment to the new environment. Interventions included to encourage socialization and positive effects/coping mechanisms. Review of a reportable event form dated 10/31/22 at 5:30 AM identified Resident #501 got into an argument with his/her roommate and the roommate allegedly hit Resident #501 with a cane. Resident #501 sustained a 1.0cm by 1.0cm superficial laceration to the forehead. Both residents were immediately separated, and Resident #501 was transferred to the hospital for evaluation. Upon return, Resident #501 was moved to another unit and would be evaluated by psychiatry. A nurse's note dated 10/31/22 at 7:57 AM identified observed Resident #501 with a 1.0cm by 1.0cm laceration to the right forehead. Both residents were immediately separated, and first aid was provided to Resident #501. EMS (911) called and responded. Resident #501 alleged his/her roommate hit him/her with a cane. The physician, and responsible party notified and Resident #501 was transferred to the hospital for evaluation. Review of the summary report dated 11/3/22 at 9:16 PM identified on 10/31/22 at 5:30 AM the staff heard screaming and went to Resident #501 and observed the roommate holding a cane and Resident #501 screaming to call 911. Resident #501 indicated the roommate hit him/her with the cane. Resident #501 was agitated an RN assessment identified 1.0cm by 1.0cm superficial laceration to the forehead. EMS (911) was called and the police arrived and Resident #501 was transferred to the hospital for evaluation. Resident #501 returned to the facility and did not require any closure of the wound as it was diagnosed as superficial skin tear. An investigation was immediately initiated. Resident #501 has been approached by several members of the staff, and the psychiatry team and refused to discuss what happened. The roommate indicated Resident #501 was looking for his/her television remote through the roommate belongings and when the roommate asked Resident #501 to stop Resident #501 started to use profanity. Resident #501's roommate admitted to hitting Resident #501 with a cane. According to staff, the residents had a good relationship prior. A written statement by RN #4 dated 10/31/22 identified Resident #501 alleged the roommate hit him/her in the head with a cane. A written statement by LPN #6 dated 10/31/22 identified at 5:45 AM a resident notified the nurse aide and herself that Resident #501 and his/her roommate were arguing. LPN #6 documented she went to the room and heard Resident #501 and the roommate arguing. LPN #6 documented she observed Resident #501 bleeding and the roommate standing by the bed. LPN #6 documented she immediately notified RN #4 who called the police, and RN #4 separated both residents. RN #4 placed Resident #501 in another room. LPN #6 documented the roommate stated that Resident #501 was going through his/her belonging and when he/she asked Resident #501 to stop Resident #501 spit at him/her, called him/her a (explicative) and threw urine at him/her. The roommate admitted that he/she hit Resident #501 with his/her cane. Review of the hospital Discharge summary dated [DATE] at 6:42 AM identified Resident #501 arrived at the hospital with bruising present. Resident #501 had a 2.0cm skin tear to the right forehead with dried blood located on the right face and a 4.0cm contusion to right forehead. Resident #501 was discharged from the hospital at 8:29 AM with diagnoses of head trauma, and assault. Interview with Resident #501 on 11/9/22 at 10:55 AM identified he/she got into an argument with his/her roommate. Resident #501 indicated he/she was looking for the television remote control and his/her roommate hit him/her with a cane on the head. Interview with RN #4 on 11/16/22 at 11:30 AM identified LPN #6 called him and upon arriving at the room, he observed Resident #501 lying in bed and there was blood on his/her head and the roommate was sitting on the side of his/her bed. Both residents were still arguing and were immediately separated. RN #4 indicated he place Resident #501 in the room across the hallway and did an assessment. RN #4 indicated he was trying to send Resident #501 to the hospital immediately due to the bleeding on his/her head. RN #4 indicated Resident #501 stated his/her roommate hit him/her with the cane. Review of the facility neurological assessment policy directed the purpose of this procedure is to provide guidelines for a neurological assessment: 1) upon physician order. 2) when following an unwitnessed fall. 3) subsequent to a fall with a suspected head injury. 4) when indicated by resident condition. Neurological assessments are indicated following a fall or other accident/injury involving head trauma.

**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 #81) who requested to be seen by the eye doctor, the facility failed to ensure the resident was seen by the eye doctor. The findings include: Resident #81 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, hypertension, and chronic pain. A physician's order dated 11/19/21 directed to have a visual acuity screening every 2 years for appropriate residents. The admission MDS dated [DATE] identified Resident #81 had intact cognition, had adequate vision and could see fine details such as regular print in newspapers or books. Resident #81 did not need corrective lenses. The care plan dated 8/24/22 identified Resident #81 had good vision with no glasses. The nurse's note dated 9/23/22 at 10:55 PM identified Resident #81 had requested to be seen by the eye doctor. The morning nurse to follow up with scheduling. Review of the vision form list dated 10/13/22 and 10/20/22 failed to reflect Resident #81 was not on the list and had not been seen. Interview with Resident #81 on 11/08/22 at 12:58 PM indicated he/she had told the charge nurse LPN #3 a few times that he/she needed to see the eye doctor. Resident #81 indicated he/she can't see well and had eye problems and identified he/she needs glasses and would like to see the eye doctor and had told staff. Interview with RN #2 on 11/9/22 at 1:06 PM indicated there was an eye doctor that comes to the facility to see the residents regularly. RN #2 indicated the full-time nurse on the unit was not aware that Resident #81 wanted to see the eye doctor. Interview with LPN #3 on 11/9/22 at 2:30 PM indicated she was not aware that Resident #81 wanted to see an eye doctor until after surveyor inquiry. Observation with RN #6 on 11/14/22 at 2:40 PM identified Resident #81 stated he/she would like to see the eye doctor and has been asking. RN #6 did not recall if Resident #81 had said anything about wanting to see an eye doctor prior. Interview with RN #2 on 11/16/22 at 9:09 AM indicated the vision provider was responsible to get consents based off the census sheets the facility provides. RN #2 indicated no one at the facility follows up to see if consent was obtained or not vision. RN #2 indicated she does not know how Resident #81 got missed for vision. RN #2 indicated Resident #81 may not have seen the eye doctor unless he/she requested to or had a problem and indicated she needs to add the consent for vision in the admission packet. Although attempted, an interview with the nursing scheduler was not obtained. Review of the Vision Services Policy identified all residents will be assessed to determine if there are any deficits related to vision. Assessments will be conducted on admission, quarterly, and as needed. The facility will offer this service at the facility. Decreased ability to see can limit the enjoyment of everyday activities and can contribute to social isolation and mood and behavior disorders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 of 3 residents, (Resident #65), who was at risk to develop pressure ulcers, the facility failed to ensure the air mattress (weight based air mattress) was set accurately to the residents weight. The findings include: Resident #65 was admitted to the facility in June 2022. Diagnoses included osteoporosis, diabetes and prostate cancer. The care plan provided, dated 6/8/22, identified Resident #65 had actual skin impairment and the potential for skin impairment. Interventions included pressure relieving mattress if appropriate. The quarterly MDS dated [DATE] identified Resident #65 had short and long term memory problems, severely impaired cognition, required total 2-person assistance with bed mobility, transfers, dressing toilet use, was always incontinent of bowel and bladder, was at risk to develop pressure ulcers and weighed 127 lbs. Intermittent observations during the survey on 11/8, 11/9 and 11/16/22 during the day shift identified Resident #65 was lying on an air mattress that was set to 350 lbs. Interview and observation with RN #2 on 11/16/22 at 11:00 AM identified Resident #65 was in bed on the air mattress set for someone who weighed 350 lbs. RN #2 identified that Resident #65 does not weigh 350 lbs., and the air mattress is a weight-based mattress and should be set to the resident's weight. RN #2 identified that Resident #65 weighed 160 lbs., and subsequently she set the air mattress to 160 lbs. Further, RN #2 obtained a physician ' s order for the air mattress setting of 160 lbs., and for the air mattress setting to be checked each shift. The Air Mattress Policy dated 1/19/2018 identified an air mattress overlay is used to prevent skin breakdown in accordance with physician's orders. Staff are to verify the physician's order, turn pump to inflate and adjust setting for comfort or as indicated in the physician ' s order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interview for 1 resident (Resident #43) reviewed for a specialized treatment and on a fluid restriction, the facility failed to ensure fluid intake was consistently monitored. The findings include: Resident #43's diagnoses included end stage renal disease, hypertension, heart failure and depression. The care plan dated 9/27/22 identified Resident #43 was at risk for complications related to alteration in renal function resulting from end stage renal disease. Interventions included to maintain fluid restriction as ordered by the physician and monitor intake and output (I & O). The quarterly MDS dated [DATE] identified Resident #43 had severely impaired cognition, required supervision with eating after set up and was receiving dialysis treatments. The physician's order dated 10/31/22 directed dialysis 3 days a week every Tuesday, Thursday and Saturday, and fluid restriction 1000 ml; nursing: 280mls per day; dietary: 720mls per day. Review of the I & O flow sheets and the intake documentation from the EMR dated 11/1/22 - 11/15/22 (15 days/45 shifts) identified I & O was not consistently documented on all 3 shifts, was not documented at all on 2 days, and consistently totaled for the 24-hour intake. Of the 15 days, there were only 2 days with documentation of the total 24 hour I & O. Interview and review of the I & O monitoring flow sheets with NA#3 and NA #4 on 11/16/22 at 10:00m AM identified although they were aware Resident #43 was on a fluid restriction and had a flow sheet for documenting the I & O, they were unable to explain why there were so many missing entries, indicating they are busy and sometimes forget. NA #3 identified that they were now supposed to document I & O in the computer however NA #4 indicated she was not in serviced on how to put I & O in the computer and that NA #3 only knows how to do it because she learned how when working at another facility. Interview and review of the I & O for Resident #43 with RN #2 on 11/16/22 at 12:50 PM identified that the staff have been documenting I & O in the computer since September and that everyone had been educated on the process. RN #2 identified that they have been auditing the I & O and were unaware that Resident #43's I & O was not being consistently monitored. RN #2 identified that any resident, especially those with diagnoses of end stage renal disease and on dialysis, who have orders for fluid restrictions should be monitored closely. Additionally, each shift the nurses should be documenting the total amount of intake on their shift and, per their policy, the 3:00 PM - 11:00 PM shift nurse should be totaling the fluid amounts for the 24-hour period to ensure the resident does not exceed the restriction amount and also to identify if residents are not meeting their prescribed fluid goals. Review of the Fluid Restriction Policy identified residents may require fluid restrictions for several reasons including renal failure and cardiac issues. Residents requiring a fluid restriction will have a provider order entered into the electronic medical record (EMR). Staff caring for such residents will be advised of the fluid restriction (this includes nursing and dietary). Intake and output from all sources will be monitored and documented accordingly. Review of the Hydration Policy identified nursing staff are responsible for documenting intake and output. The unit nurse is responsible for completing the intake and output record that becomes part of the medical record. The evening unit nurse will calculate the 24-hour total. Additionally, intake and output monitoring is indicated for, but not limited to, residents on dialysis/fluid restriction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record and facility policy for 1 unit, the facility failed to ensure the medication room was locked when unattended. The findings include. Observation on 11/10/22 at 6:00 AM, on C unit, identified LPN #2 was in the hallway by room [ROOM NUMBER] at the medication cart with an ear bud in her right ear. The C unit medication room, approximately 30 - 40 feet away from LPN #2 behind the nurse's station and around the corner was unattended and unlocked with over-the-counter medications on the counter. There were no licensed nurses near the nurse's station or unlocked medication room. Surveyor was unable to see LPN #2 from the medication room door. A resident was across from the nurse's station in the dining room. Interview with LPN #2 on 11/10/22 at 6:24 AM indicated she was passing medications when earlier a nursing assistant had asked for a colostomy bag so she had gone into the medication room and must have forgotten to lock it when she exited. LPN #2 indicated she was aware the medication room should be locked at all times. Interview with RN #3 the night supervisor on 11/10/22 at 6:06 AM indicated her expectation and the policy was the nurses would lock the medication room at all times even if sitting at the nurses' station. RN #3 indicated she does not know why LPN #2 would have left the medication room unlocked but LPN #2 had been educated to lock the medication room door while she was out passing her medications. Interview with RN #2 on 11/10/22 at 8:00 AM indicated her expectation was the medication room would be locked at all times especially when the nurse was out passing medications. Review of the Medication Administration policy dated 3/23/22 directed medications must be stored safely and out of reach from residents, either in a locked medication room or a locked medication/treatment cart. The licensed nurse is responsible for managing the security of medications on his/her unit and is expected to keep medication storage locked at all times. The licensed nurse is expected to carry on his/her person the keys for such medication storage.

**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 2 of 3 residents (Resident #39 and 81) reviewed for dental services, the facility failed to ensure a dental referral was made timely when dentures were identified as missing and failed to provide dental services to a resident who had complaints of dental pain. The findings include: 1. Resident #39 had diagnoses that included chronic kidney disease, diabetes and depression. A Consent for Dental Services in a Nursing Home form identified verbal consent by resident was given on 1/19/22 and the form signed on 7/14/22. A clinical notes document dated 1/19/22 identified Resident #39 requested to be seen for loose dentures. Has full upper dentures (FUD), and full lower dentures (FLD) that were about 1 year old and were very loose. A dental note dated 2/18/22 identified resident complaining of sore spot on lower full denture. FLD adjusted, and resident says it feels better. Resident complains that dentures are loose. This is due to bone loss and resident was told that they cannot do anything for looseness of dentures. Resident given some adhesive to use. A note dated 7/14/22 (written by the dental hygienist) identified resident complaining of sore spot on lower right from denture. Resident is edentulous. Resident wears FUD/FLD. Resident wants to see dentist for FLD pain on the lower right. Dentist to see for possible FLD adjustment. The annual MDS dated [DATE] identified Resident #39 had intact cognition, required supervision with all activities of daily living and had no natural teeth or tooth fragments. The physician's order dated 10/22/22 directed no concentrated sweets diet and consult for yearly dental evaluation. Interview with Resident #39 on 11/9/22 at 9:59 AM identified the resident was missing his/her lower denture which had been accidentally thrown in the garbage a few weeks ago. The resident indicated the facility was aware the denture was thrown away. Resident #39 identified needing them because he/she couldn't completely bite into a grinder. A second interview with Resident #39 on 11/15/22 at 11:30 AM identified he/she had informed the Social Worker last week about the lower dentures being missing but had not heard what was being done about it. Interview with Social Worker on 11/16/22 at 9:40 AM identified that Resident #39 had informed her about missing lower dentures and indicated she had informed the resident's charge nurse, however, could not recall which nurse. The Social Worker indicated she had not added the resident to the dentist list, but indicated the nurse she reported it to, should have. Interview and review of the dentist list with the Scheduler on 11/16/22 at 10:00 AM identified that Resident #39 had not been added to the list and the dental hygienist had been in the facility yesterday, 11/15/22. The Scheduler identified when nurses let her know that a resident is having dental issues and needs to be seen, she adds them to the list with whatever the issue is and when the dentist is due to come in, she sends the full resident list to the dentist. The Scheduler identified that sometimes the nurses will write the residents name down on the appointment book on the unit, so she will check that too, to see if there were any additional names added. The Scheduler identified she was not aware that Resident #39's lower dentures were missing and that the resident needed to see the dentist. Subsequent to surveyor inquiry, the Scheduler contacted the dentist and informed him about resident's dental issue and indicated he would research to find out when resident received dentures to see if the resident was eligible for a new pair. Further, the Scheduler added the resident to the dentist list to be seen. Interview with RN #2 on 11/16/22 at 10:15 AM identified that although they do have a system in place for addressing dental concerns, some residents have fallen through the cracks because of incomplete communication and staff forgetting to follow through by informing the supervisor or scheduler when dental issues are first identified. RN #2 identified that had she been aware of Resident #39's missing lower denture she would have had the resident assessed by the Speech Therapist to see if there were any chewing/swallowing issues indicated the resident's diet consistency may need to be modified temporarily until the dental issue was resolved. RN #2 identified an assessment should have been done last week when the Social Worker was informed. Additionally, whether the resident was eligible for new dentures was irrelevant because if the resident needed them, the facility would absorb the cost to replace them. Per facility policy, resident should have been referred to the dentist within 3 days of finding out. RN #2 identified she will have the resident assessed by the speech therapist today during lunch meal. Review of the Dental Services policy identified that routine and emergency dental services are available to meet the resident ' s oral health services in accordance with the resident ' s assessment and plan of care. Lost or damaged dentures will be replaced at the resident ' s expense unless an employee or contractor of the facility is responsible for accidentally or intentionally damaging the dentures. If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services and the reason for the delay. 2. Resident #81 was admitted to the facility in November 2021 with diagnoses that included osteoarthritis, hypertension, and chronic pain. A physician's order dated 11/19/21 directed to have a dental evaluation yearly. The admission MDS dated [DATE] identified Resident # 81 had intact cognition, required total assistance for personal hygiene and the oral status identified the resident had no natural teeth or tooth fragments. The quarterly MDS dated [DATE] identified the oral status did not indicate if there was broken or loosely fitting dentures or mouth or facial pain, discomfort or difficulty chewing. The annual MDS dated [DATE] (6 months after admission) identified Resident #81 did not have any broken or loosely fitting dentures, no natural teeth or tooth fragments, obvious or likely cavities or broken natural teeth, mouth or facial pain, or was unable to examine the mouth. The care plan dated 8/24/22 identified Resident #81 had no teeth. The nurse's note dated 9/23/22 at 10:55 PM identified Resident #81 had requested to be seen by the dentist. The morning nurse to follow up with scheduling. Review of the long-term care dental list dated 10/13/22 failed to reflect Resident #81 was on the list or had been seen by the dentist. Interview with Resident #81 on 11/08/22 at 12:58 PM indicated he/she had told the charge nurse, LPN #3, a few times that he/she needed his/her teeth extracted and has had mouth pain. Resident #81 indicated he/she had not seen a dentist since admission (a year ago) to this facility and needed the teeth pulled and dentures made. Resident #81 opened his/her mouth for surveyor to view the teeth. Resident #81 had no upper teeth and a full set of lower teeth, with a few broken teeth. Resident #81 had stated that the tooth in the left back had a crown and that was the tooth that hurts at times and must still have roots. Interview with RN #2 on 11/9/22 at 1:06 PM indicated there was a hygienist and a dentist that comes to the facility to see the residents regularly. RN #2 indicated the full-time nurse on the unit was not aware that Resident #81 was having mouth pain and wanted his/her teeth pulled out. RN #2 indicated she had Resident #81 added to the dental list for 11/14/22. RN #2 indicated the nursing scheduler was responsible to put residents on the dental list. RN #2 noted Resident #81 had not been seen by the dentist or a hygienist. RN #2 provided a form noting Resident #81 was added on the list for the dentist on 11/14/22 and the eye physician on 11/17/22 after surveyor inquiry. RN #2 indicated the process was for the nursing supervisor or MDS coordinator quarterly to look into the resident's mouth and if any issues to in for the nursing scheduler so the resident would be added to the list to be seen the next visit. Interview with LPN #3 on 11/9/22 at 2:30 PM indicated she was not aware that Resident #81 was having dental pain and wanted to see a dentist or wanted to see an eye doctor until after surveyor inquiry. Interview with MDS nurse RN #6 on 11/14/22 at 2:30PM indicated she started at the facility in January 2022 was responsible to do all the resident's assessments to complete the MDS's. RN #6 indicated for Resident #81 she did the annual assessment on 5/26/22 and indicated Resident #81 had no natural teeth or tooth fragments, and only had gums. RN #6 indicated for the new admissions, quarterly and annual MDS's she physically goes and looks into the residents' mouth and charts only in the MDS what she had seen. RN #6 indicated she does not write a progress note as to what she sees and will ask the resident if he/she has any pain. RN #6 indicated she does not discuss the dental or vision services at the resident care conference. Observation with RN #6 on 11/14/22 at 2:40 PM identified Resident #81 indicated he/she does have teeth on the bottom from the back of one side completely around to the other side with a couple chipped teeth, but nothing on top. Resident #81 indicated she has pain and discomfort at times from the left back tooth on the bottom where he/she had a crown and noted there must still be roots in there. RN #6 indicated the MDS's were done in error but could not recall what she had seen in Resident #81 's mouth in April of 2022 and there was no documentation other than the MDS which was wrong. Additionally, RN #6 did not recall if Resident #81 had said anything about wanting to see an eye doctor. The dental hygienist note dated 11/15/22 indicated Resident #81 was seen by the hygienist. Maxillary edentulous. Resident #81 had full upper denture but had lost it. Has a crown on tooth #19 that bothers resident occasionally but not right now. Heavy calculus present on lower anterior teeth and needs cavitron prophy. Resident #81 isn't brushing regularly. Dentist to follow up with exam and treatment plan if needed. Dental consent form dated 11/16/22 indicated Resident #81 wanted dental services. Interview with RN #2 on 11/16/22 at 9:09 AM indicated the dental and vision companies were responsible to get consents based off the census sheets the facility provides them. RN #2 indicated no one at the facility follows up to see if consent was obtained or not. RN #2 indicated she does not know how Resident #81 got missed for dental. RN #2 indicated Resident #81 should have at least been seen by the dental hygienist. Although attempted to interview the nursing scheduler she was not available. Review of facility Dental Examination and Assessment Policy identified each resident shall undergo a dental assessment prior to or within 90 days of admission. Residents will be offered dental services as needed. Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. Review of Dental Services Policy identified to provide routine and emergency dental services to meet residents' oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services are provided to our residents though a contract with a licensed dentist that comes to the facility monthly, or a referral to a community dentist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 of 2 residents (Resident #16) reviewed for hydration, the facility failed to provide fluids/drinks, consistent with the resident requests. The findings include: Resident #16 was admitted to the facility in May 2015. Diagnoses included history of urinary tract infections and urinary retention with the use of an indwelling catheter. The annual MDS dated [DATE] identified Resident #16 had intact cognition, required total assistance with transfers and toilet use, was independent with eating after set up and had an indwelling catheter. The care plan dated 9/14/22 identified Resident #16 was at risk for dehydration due to dementia, history of dysphagia or thickened fluids and dietary restrictions. Interventions included the resident would be monitored for signs and symptoms of dehydration, (thirst), staff would encourage food/fluid intake as applicable, monitor bloodwork, and monitor for changes in output. Additionally, the care plan identified the resident was non-complaint with fluid restriction with a goal that the resident will be educated by staff on the risks vs benefits of non-compliance for 3 months. Interventions included to counsel the resident and encourage the resident to be compliant with care. The clinical record failed to reflect a physician ' s order for the fluid restriction including what the restriction was. Further, the care plan identified Resident #16 had an indwelling catheter with interventions to monitor intake and output and encourage fluids. Physician's orders dated November 2022 directed to provide a low-fat low cholesterol diet. There was no order for a fluid restriction. Intermittent observations during the survey on 11/8, 11/9 and 11/16/22 during the day shift identified Resident #16 did not have a Styrofoam cup of water at the bedside. Interview with Resident #16 on 11/16/22 10:30 AM identified he/she is thirsty but does not get a water pitcher or cup of water because the staff said he/she was on a fluid restriction. The resident indicated he/she only gets fluids with medications and meals. Interview with RN #2 on 11/16/22 at 11:00 AM identified Resident #16 is not on a fluid restriction and he/she should be getting a big Styrofoam cup of water to drink. Interview with NA #11 on 11/16/22 at 11:10 AM identified she thought that Resident #16 was on a fluid restriction so she was not providing the big Styrofoam cup of water to the resident. Subsequent to surveyor inquiry, a big Styrofoam cup of water was provided to Resident #16. The Hydration Policy dated 2/21/17 identified residents will be provided with sufficient fluid intake to maintain proper hydration. Although requested, a policy on the provision of fluids was not provided.

**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 #10) reviewed for nutrition, the facility failed to ensure the resident received the diet per physician's order. The findings include: Resident #10 was admitted to the facility with diagnoses that included partial loss of teeth, anxiety, and dysphasia. A speech therapy evaluation and plan of treatment dated 10/18/22 identified swallowing evaluation done after Resident #10 demonstrated poor use of compensatory strategies for safe swallowing with soft diet during quarterly screen. Swallow evaluation is warranted to determine safest strategies and least restrictive diet in order to minimize the risk of aspiration, train and implement compensatory strategies. Treatment for dysphasia oropharyngeal phase. Goal was to have resident and caregiver utilize safe swallowing compensatory strategies in 5 out of 5 opportunities given minimal verbal and visual cueing in order to support safe swallowing and minimize risk of aspiration. Clinical bedside assessment Resident #10 had mild signs and symptoms of dysphasia with oral residue, lack of mastication, and residue on tongue base. Behaviors impacting safety were impulsive rate and large bites and sips taken. Recommendation was to facilitate safe and efficiency and use the following strategies and/or maneuvers during oral intake: alternate of solids and liquids, rate modification, bolus size modification, effortful swallow, second dry swallow and general swallow techniques and precautions. A speech therapy note dated 10/18/22 identified assisted Resident #10 with meal set up. Resident #10 given moderate verbal and visual cueing. Mild oral residue noted, dry cough noted immediately after swallowing of soft bolus declined alternating liquid with solid. A speech therapy note dated 10/21/22 identified skilled dysphagia services provided to Resident #10 whom had decreased mastication, mild oral residue, dry cough noted 3 times. Resident #10 was given moderate verbal and visual cueing of slow and safe rate of intake, small bites, and sips. The quarterly MDS dated [DATE] identified Resident #10 had moderately impaired cognition, and required supervision or touching assistance for eating, and had a mechanically altered diet. The care plan dated 10/27/22 identified to provide a mechanically altered diet consisting of a chopped consistency with puree vegetables. Monitor for difficulty with chewing and swallowing and need for modified consistency. Encourage resident to eat slowly and monitor for signs and symptoms of aspiration. A physician's order dated 10/31/22 directed to give a low sodium chopped diet with puree vegetables. Additionally, speech therapy 1 - 5 times a week for 2 - 8 weeks in order to train and implement safe swallowing strategies, ensure diet tolerance, decrease the risk of aspiration, enhance lingual, pharyngeal, and mandibular strength and range of motion. A speech therapy note dated 11/2/22 identified skilled dysphagia services provided to Resident #10. Therapist set up meal and provided verbal and visual cueing. Resident #10 had delayed anterior to posterior transit, delayed mastication, and adequate oral clearance. Observations on 11/9/22 at 12:55 PM identified Resident #10 was sitting on the edge of the bed with the lunch tray in front of him/her. Resident #10 was eating a whole turkey burger patty on a sandwich bun cut into 4 large squares with whole steak fries with puree carrots. Interview with Resident #10 on 11/9/22 at 12:56 PM indicated he/she only had 2 teeth in the front on the bottom and had a few stumps of chipped off teeth on top and did not have any dentures. Resident #10 indicated he/she was not sure if he/she should have received the whole turkey burger on the bun. Interview with the Regional Dietitian on 11/9/22 at 1:05 PM, who also observed Resident #10's meal tray with the turkey burger and indicated Resident #10 should have chopped meat and should not have received the whole turkey burger cut in large pieces. The Regional Dietitian indicated the turkey burger should have been cut up in ¼ inch size pieces, no larger than a quarter and indicated the steak fries were okay if they were soft, but the meal ticket indicated Resident #10 was supposed to get mashed potatoes. The Regional Dietitian indicated the head cook was responsible to make sure Resident #10 received the correct meal that matched the meal ticket and indicated from the manual on the unit, Resident #10's diet was the NDD3 diet dysphasia advanced and per the manual, Resident #10 should not have received any dry breads including the sandwich bun and could only have wet breads. Additionally, the Regional Dietitian noted Resident #10 should have ground meats per the manual. Interview with [NAME] #1 on 11/9/22 at 1:17 PM indicated Resident #10 was on a chopped diet with puree vegetables. [NAME] #1 indicated Resident #10 was supposed to get the meat that was the consistency of a sloppy joe chopped up and mashed potatoes. [NAME] #1 indicated he did not know how Resident #10 received the whole turkey burger on a bun and the steak fries. Interview with the Director of Dietary on 11/9/22 at 1:20 PM indicated he would have given Resident #10 the turkey burger on the bun but would have cut it up to nickel size pieces but would not have given the steak fries but instead would have given the mashed potatoes. Interview with the Speech Therapist/Rehab Director on 11/16/22 at 10:16 AM indicated Resident #10 has always been on that diet due to the missing teeth since before he started at the facility. Speech Therapist #1 noted Resident #10 only has 2 teeth one on top and one on bottom in front. Speech Therapist #1 indicated he had discharged Resident #10 from speech on 11/8/22. Speech Therapist #1 indicated he was asked to see Resident #10 to be remind the resident to eat slower and alternate liquids with solids. ST #1 indicated Resident #10 has oral dysphagia due to his/her teeth missing and he/she eats too fast and needs to slow down. ST #1 indicated Resident #10 needs nursing monitors which means during mealtime that nursing reports to him any unsafe eating. ST #1 noted Resident #10 prefers to eat in his/her room and nursing observes when passing out trays or if they hear him/her cough. ST #1 noted there was a potential risk of aspiration from Resident #10 eating too fast on a mechanical soft diet with thin liquids. ST #1 indicated Resident #10 was to receive chopped meats and puree vegetables. ST #1 indicated he did not have any documentation of education provided to nursing staff of the recommendations of reminding resident to eat slowly and alternating bites of solid with liquids and monitor for aspiration. ST #1 indicated he had not completed the discharge summary yet fom 11/8/22 as of 11/16/22. Review of facility Dysphasia Advanced diet identified breads to avoid were dry breads and recommended any well moistened breads. Meats; avoid tough or dry meats and poultry but recommended ground meats and poultry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Interview with the IP, (LPN #1) on 11/8/22 at 9:00 AM identified Resident #64 had tested Covid positive and was being moved to an isolation room and had been placed on transmission-based precautions. Observations with LPN #1 on 11/8/22 at 10:12 AM identified that Resident #64's room had been changed and the new room was observed to have 3 sets of signage to the immediate left of the door entryway including a droplet precautions sign, a how to complete hand hygiene sign, and a sign with instructions on how to don and doff PPE, including gown, mask/respirator, goggles/face shield and gloves. LPN #1 was also observed refilling PPE supplies in a PPE cart located to the direct right of the door entryway. Observed in the cart were multiple face shields, white gowns and boxes of gloves. Observation on 11/8/22 at 10:23 AM identified Housekeeper #1 was observed in Resident #64's room, bringing personal belongings from the resident's previous room on a cart. Housekeeper #1 was observed to be approximately 2 to 3 feet from Resident #64, who had a surgical mask on and was observed to be coughing intermittently. Housekeeper #1 was wearing a disposable gown, gloves, an N-95 mask, and prescription eyeglasses. Housekeeper #1 was not wearing a face shield or goggles. LPN #1 was also observed at this time directly outside the room, restocking the PPE cart. At approximately 10:25 AM, with LPN #1 still outside the room, Housekeeper #1 was interviewed regarding his lack of eye protection. Housekeeper #1 identified that no one ever told him that a face shield was required, and he indicated he didn't read the posted signs, he just does what they tell him to do, and he was not told to wear a face shield. Interview with LPN #1 on 11/8/22 at 10:28 AM identified that Housekeeper #1 should have been wearing eye protection in Resident #64's room. LPN #1 identified that Housekeeper #1 had annual competency signed off on Covid 19 and infection control in May 2022. Although requested, the facility failed to provide a policy on Covid 19 PPE requirements. Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #16) reviewed for indwelling catheters, the facility failed to implement measures, including resident education, to ensure the drainage bag was secured off the floor to maintain infection control, and for 1 resident (Resident #64) reviewed for transmission-based precautions, the facility failed to ensure staff in a covid positive room wore the appropriate PPE. The findings include: 1. Resident #16 was admitted to the facility in May 2015. Diagnoses included history of urinary tract infections and urinary retention with the use of an indwelling catheter. The annual MDS dated [DATE] identified Resident #16 had intact cognition, required total assistance with transfers and toilet use, and had an indwelling catheter. The care plan dated 9/14/22 identified Resident #16 had an indwelling catheter with interventions to monitor intake and output, provide foley care per policy, encourage fluids, keep foley bag below bladder level, and irrigate prn. Intermittent observations on 11/9/22 identified Resident #16 was in bed and the indwelling catheter drainage bag was on the floor. Observations on 11/16/22 at 10:30 AM identified Resident #16 was in bed and the indwelling catheter drainage bag was on the floor. Interview with Resident #16 on 11/16/22 10:30 AM identified the bag is usually on the floor. Interview with RN #2 on 11/16/22 at 11:00 AM identified the drainage bag should not be on the floor. Subsequent to surveyor inquiry, the drainage bag was secured to the bed off the floor by RN #2 The policy on urinary catheterization identified indwelling catheters should be properly secured after insertion to prevent movement and urethral trauma. Standard precautions; use gloves when manipulating the catheter site and drainage system and practice hand hygiene before and after. Urine drainage bags should be emptied at least once each shift using a container designated for that resident only. Care must be taken to keep the outlet valve from becoming contaminated. Use gloves and practice hand hygiene before and after handling the drainage device. The policy failed to direct that urinary drainage bags should not be left on the floor.

Based on review of facility documentation, facility policy and interview the facility failed to ensure the resident council was provided responses, actions and rationale regarding their concerns. The findings include: Review of the resident council meeting minutes from April 2022 through November 2022 identified repeated concerns related to the food taste/quality, temperature, menus, and variety for 5 consecutive months (April, May, June, July, and August 2022). The October and November 2022 resident council minutes indicated residents expressed housekeeping concerns, and in July, August, and September 2022 the residents voiced missing belongings and laundry concerns. The resident council minutes and facility documentation failed to reflect attempts or steps by the facility staff to address and resolve the resident's concerns related to food taste/quality, temperature, menus, and variety, housekeeping, missing belongings and laundry concerns. During the resident council interview on 11/10/22 at 10:30AM with 12 residents who regularly attend and participate in the monthly resident council meeting, residents continued to voice concerns about the food quality, variety and temperatures as well as feeling that administration does not respond to their concerns. Interview with the Director of Recreation on 11/10/22 at 11:45AM identified she started in the position in April 2022. The Director of Recreation indicated that she was responsible for attending and running the monthly resident council meetings and for writing up the monthly minutes. Although the Director of Recreation identified she would inform the appropriate departments regarding concerns raised in the meetings, she indicated she had no documentation to support who was informed and what if anything was done to address the residents' concerns. Director of Recreation indicated did not keep written documentation to support notifications and actions taken. The Director of Recreation identified they had a new Food Services Director (FSD) who started a few weeks ago and was hopeful that improvements would be made, because food complaints was an ongoing concern at the meetings. The Director of Recreation could not provide information regarding what steps were taken by the FSD since April 2022 to address resident food concerns other than the addition of hot plates. Going forward, Director of Recreation indicated she would take more detailed notes about issues raised, which residents voiced the concerns and will document who was informed, what was done to address the concerns and what the outcome was. Interview with RN #2, the Corporate Nurse on 11/16/22 at 10:30 AM identified that there should absolutely be documentation specific to resident concerns discussed in the resident council meetings, who was informed, what was done and what the outcome was. Review of the facility's Resident Council policy identified the staff member assigned to the council will be responsible for responding to any recommendations or grievances brought to him/her by the council. Upon receiving such recommendations or grievances, the staff member will promptly: document the recommendation or grievance; determine, in consultation with such other persons as may be appropriate, steps to address such recommendations or grievances where appropriate; communicate the facility's response and rationale for the response to the council and document same.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews the facility failed to ensure resident rooms and other living areas were clean and well maintained and for Resident #67, the facility failed to ensure the wheelchair arm rests were in good repair. The findings include: 1. Observations on 11/8/22 at 11:50 AM through 12:42 PM, and on 11/10/22 at 1:00 PM through 2:05 PM, and on 11/15/22 at 2:34 through 2:51 PM with the Administrator identified the following: a. Damaged, chipped and/or marred bedroom walls on A wing in rooms 102, 103, 106, 109, 110, 111, 112, 113, 114, 117, 118, dining room, nurses station, and the hallway, on B wing in rooms 222, 230, 236, 237, 238, clean utility room, and the hallway, on C wing in rooms 339, 340, 341, 343, 344, 345, 346, 347, 348, 349, 350, 351, 352, 355, 356, 357, the nursing station, and the hallway, on D wing in rooms 401, 405, 407, 408, 410, 411, 412, 414, 415, 416, shower room, and the dining room. b. Damaged, rusty, chipped, marred bedroom radiators on A wing in rooms 104, 107, 108, 112, 114, 117, shower room, and the dining room, on B wing in rooms 222, 227, 228, 229, 230, 232, 236, and 237, on C wing in rooms 341, 343, 347, 348, 349, 350, 355, 357, and the shower room. Recreation room. c. Damaged, rusty, chipped, marred bathroom radiators on A wing in rooms 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 114, 117, and 118, on B wing in rooms 221, 225, 236, and 237, on C wing in rooms 340, 341, 344, 345, 346, 347, 349, 350, and 357. d. Damaged, broken and/or missing nightstand, closet, and dresser drawer knobs on A wing in rooms [ROOM NUMBER], on B wing in rooms 223, 225, 226, 231, 232, and 236, on C wing in rooms 339, 345, 346, 348, and 356, on D wing in room [ROOM NUMBER]. e. Damaged and/or broken window blind on A wing in rooms [ROOM NUMBER], on B wing in dining room, on C wing in rooms 341, 343, 350, dining room, 355, and 357, and on D wing in room [ROOM NUMBER]. f. Damaged, stained, and/or dirty window shades and/or curtains on A wing in rooms 107, 110, and dining room, and on C wing in room [ROOM NUMBER]. g. Stains, debris and/or off-track privacy curtains on A wing in rooms 102, and 109, on B wing in room [ROOM NUMBER], and on C wing in rooms 343, 344, 351, and 357. h. Damaged, stained, rusty, dirty and/or debris on bedside tray table on A wing in rooms [ROOM NUMBER], on B wing in rooms 229, and 237, and on C wing in rooms 345, 346, 348, 349, 350, 351, and 357. i. Damaged, chipped and/or marred hallway wall on A wing, A wing nurse's station, and D wing hallway. j. Damaged, chipped and/or marred bathroom and bedroom door on A wing in rooms 103, 104, 105, 108, 110, 114, 117, shower room, and 118, on B wing in rooms 220, 221, 223, 227, and 232, on C wing in rooms [ROOM NUMBER], and on D wing in room [ROOM NUMBER], 405, 407, 408, 410, 411, 412, 414, 415, 416, and the shower room. k. Damaged, chipped and/or marred bed headboard and/or footboard on A wing in room [ROOM NUMBER], on B wing in room [ROOM NUMBER], on C wing in rooms 347, and 349, and on D wing in rooms 401, 405, 407, 408, 410, 411, 412, 413, 414, 415, and 416. l. Damaged, dirty, and/or peeling wall paper on B wing, and C wing dining room, on D wing in the hallway, and the shower room. m. Stains, discoloration, dirt, and debris on floors and in crevices, and corners in bedroom and bathroom on A wing in rooms [ROOM NUMBER], on B wing in rooms 223, 224, 226, 227, and 230, and on C wing in rooms [ROOM NUMBER]. n. Damaged and/or peeling cove base on A wing in room [ROOM NUMBER], and on C wing in the hallway. o. Damaged, stain, chipped and/or marred bathroom walls on A wing in rooms 106, 107, 110, 112, 117, and 118, on B wing in room [ROOM NUMBER], on C wing in rooms [ROOM NUMBER], and on D wing in the shower room. p. Damaged, broken, missing, and rusty bathroom shelf, rack, and paper towel holder on A wing in the shower room, on B wing in room [ROOM NUMBER], and on C wing in rooms [ROOM NUMBER]. q. Damaged, broken, and/or cracked floor tile in bedroom and/or bathroom on A wing shower room, on C wing in room [ROOM NUMBER], on D wing in room [ROOM NUMBER]. r. Damaged and/or torn arm rest on chairs at nurses station on A wing, and on C wing in room [ROOM NUMBER]. s. Damaged, broken, and/or missing toilet paper holder in bathroom on A wing in rooms 106, on B wing in the bathroom, and on C wing in rooms 345, 347, 349. t. Damaged, broken, crooked, and off the wall sink in bathroom on A wing in room [ROOM NUMBER], and on C wing in room [ROOM NUMBER]. u. Damaged and/or missing white foam pipe cover in bathroom on A wing in room [ROOM NUMBER], and on C wing in room [ROOM NUMBER]. v. Damaged and/or chipped toilet tank cover and/or discolored toilet bowl in bathroom on C wing in room [ROOM NUMBER]. 2. Observation on 11/15/22 at 2:34 PM with the Administrator identified the following: a. Three clean linen carts on the B wing with covers that were damaged, torn, worn, and/or stained on the B wing hallway. b. Two clean linen carts on the C wing with blue covers that were damaged, torn, worn, and/or stained on the C wing hallway. Review of the repair log A, B and D wings dated 8/8/22 - 11/10/22 failed to reflect the environmental concerns identified. Unable to review the repair log for C-wing as it was not able to be located. Interview with the Administrator on 11/15/22 at 2:52 PM identified the facility does not have a housekeeping director or maintenance director at this time and he is overseeing the housekeeping department. The Administrator indicated he was not aware of the damaged, torn, and stained linen cart covers. The Administrator indicated he was aware of the issues identified for the environment. The Administrator indicated there are modification and renovation plans that are in place, but he was unaware of the start date. The Administrator indicated right now the facility is just fixing the smaller issues. The Administrator indicated the facility has hired a new Maintenance Director/Housekeeping Director/Laundry who will start on 11/17/22. Review of the housekeeper job description directed to performs simple, repetitive cleaning tasks to maintain assigned areas of the nursing facility in a clean, orderly and attractive condition according to written and/or verbal instructions and standard housekeeping. Dusts furniture, floors, windowsills, ceiling, corners, etc., as assigned. Washed beds, furnishings, nursing stations, resident rooms, showers, pantries, equipment, etc., with prescribed cleaning solutions and disinfectants to prevent spread of disease. Review of the maintenance supervisor job description identified to performs a wide variety of general maintenance duties to include maintenance and repair of basic electrical equipment, refrigerator units, air conditioning, plumbing, grounds, painting, etc, according to written and/or verbal instructions and standard maintenance procedure. Constructs, repairs, and maintains building equipment and grounds in accordance with maintenance orders, plan diagrams, manufacture's specifications, construction blueprints, etc. Performs a wide variety of general maintenance duties including simple maintenance, carpentry, painting, electrical, plumbing, etc., as required. Services and maintains equipment such as resident beds, resident chairs, etc. Review of the maintenance assistant job description identified to performs a wide variety of general maintenance duties to include maintenance and repair of basic electrical equipment, refrigerator units, air conditioning, plumbing, grounds, painting, etc, according to written and/or verbal instructions and standard maintenance procedure. Constructs, repairs, and maintains building equipment and grounds in accordance with maintenance orders, plan diagrams, manufacture's specifications, construction blueprints, etc. Performs a wide variety of general maintenance duties including simple maintenance, carpentry, painting, electrical, plumbing, etc., as required. Services and maintains equipment such as resident beds, resident chairs, etc. 3. Resident #67 was admitted to the facility with diagnoses that included diabetes with diabetic neuropathy and chronic pain. The quarterly MDS dated [DATE] identified Resident #67 had intact cognition and required supervision for dressing, eating, toilet use, personal hygiene, and transfers. Additionally, Resident #67 did not ambulate and used the wheelchair for locomotion in room and on unit. The care plan dated 11/8/22 identified the resident was at risk for falls. Interventions included to place dycem on the wheelchair. Observation on 11/8/22 at 11:32 AM identified Resident #67 was sitting in the wheelchair and the left arm rest was completely covered with white nursing tape. Interview with Resident #67 on 11/8 /22 at 11:33 AM indicated the arm of the wheelchair has been taped for a few months and staff where aware and have not repaired it yet. Interview with NA#12 on 11/16/22 at 10:08 AM indicated she was the full-time nursing assistant for Resident #67. NA #12 indicated Resident #67's left arm rest has been tapped up with the white nursing tape for a few months and in September 2022 she recalls the resident telling her that therapy was supposed to replace the arm rest or the wheelchair. Interview with the Director of Rehabilitation on 11/16/22 at 10:13 AM indicated maintenance was responsible to replace worn or torn wheelchair arm rests. The Director of Rehabilitation indicated he put in an order 2 weeks ago for new arm rests, but Resident #67 was not on the list. The Director of Rehabilitation indicated he does quarterly audits of the wheelchairs and he gives recommendations for the sizes to maintenance to order new arm rests. Interview with the Administrator on 11/16/22 at 2:23 PM indicated he was covering for Maintenance since there was not a maintenance director for over a month and the new person has not started. The Administrator indicated that rehabilitation is responsible to make a list of who needed new arm rests and then he would order them. The Administrator indicated a couple of weeks ago he ordered 20 new arm rests but does not know for which residents. The Administrator indicated if the nursing staff and rehabilitation were aware in September it should have been changed by now. Review of the Assistive Devices and Equipment policy identified the facility provides wheelchairs, walkers, and canes. The devices and equipment will be maintained on schedule and according to manufacturer's instructions. Defective or worn devices will be discarded or repaired. Review of facility Resident Rights identified residents have the right to be treated with consideration, respect and full recognition of your dignity and individuality.

Based on observation, review of facility documentation, facility policy, and interviews the facility failed to ensure the walk-in refrigerator and freezer were maintained at the proper temperatures. The findings include: 1. Observation with the Director of Dietary on 11/8/22 at 10:20 AM identified some items in the freezer were noted to have chucks of ice oh them and there were chunks of ice on the floor. Three boxes on the bottom shelf had water lines halfway up the boxes. The Director of Dietary indicated that would occur when items defrost and then freeze again. A box was partially torn open and the item inside was covered with ice. The Director of Dietary indicated that item would have to be discarded and indicated he was aware the freezer door did not close properly. The freezer temperature was noted to be negative 4 degrees. Interview with the Director of Dietary on 11/10/22 indicated the freezer door was adjusted and now it is closing until they get the new part. 2a. Observation with the Director of Dietary of the Residents Nourishment refrigerator on Unit A on 11/10/22 at 10:45 AM noted the thermometer read 22 F on one thermometer and 26 degrees on another thermometer. There was disposable Tupperware container with cabbage and carrots not labeled or dated, a bottle of chucky salsa mild 20 ounces with less than a tablespoon in it not labeled or dated and a jar of salsa 15-ounce jar less than ¼ full not labeled or dated. The Director of Dietary on 11/10/22 at 10:50 AM indicated he would shut the refrigerator down and empty it into another refrigerator. The Director of Dietary indicated the items that were labeled or dated may have been staffs and discarded the items. b. Observation of the Residents Nourishment refrigerator on Unit D identified a lunch bag and a 1-quart glass water bottle with lemons, neither were labeled or dated. The Director of Dietary on 11/10/22 at 11:00 AM indicated the glass water bottle in the refrigerator door and the lunch bag on the shelve may have been staff food, not residents and indicated staff should not to use the resident's refrigerators and any items in the refrigerator had to be labeled and dated. The Director of Dietary indicated all items in the refrigerator had to be discarded after 3 days. Interview with NA #13 on 11/10/22 at 11:05 AM indicated the water bottle was hers and she was not aware that she could not keep her personal food or drinks in the resident's refrigerator. Interview with LPN #9 on 11/10/22 at 11:06 AM indicated that was her lunch on the shelve in the resident's refrigerator and she had placed her lunch in there this morning. Interview with Director of Dietary on 11/10/22 at 11:15 AM indicated the resident's nourishment refrigerators were being replaced and indicated he would educate staff that the refrigerators on each unit dining room are for residents only. The Director of Dietary indicated staff were to use the refrigerator in the staff breakroom. The Director of Dietary indicated all food items in the refrigerators must be labeled with the resident's name and the date when placed in the refrigerator and identified nursing and housekeeping were responsible to make sure all items were labeled and dated and discarded after 3 days. Although requested, a facility policy for nourishment room refrigerators, labeling and dating food items, refrigerator and freezer tempers it was not provided.

Based on observations, review of facility documentation and interview the facility failed to maintain an adequate pest control program. The findings include: Tour of the facility on 11/8/22 at 11:30 AM - 1:00 PM, and 11/10/22 at 12:55 PM - 2:15 PM identified numerous winged flying black insects were observed. Additionally, on 11/15/22 at 2:34 PM - 2:51 PM with the Administrator and RN #11 identified numerous winged flying black insects were observed. Winged flying black insects were noted in the following areas on bedroom walls, bathrooms, hallways, shower rooms, and the nourishment rooms. A wing in resident rooms, hallway, dining room, and the nourishment room. B wing in resident rooms, hallway, shower room, dining room, and the nourishment room. C wing in resident rooms, hallway, shower room, dining room, and the nourishment room. D wing in resident rooms, hallway, and the nourishment room. Review of the pest control invoice dated 11/2/22 at 7:24 AM identified (this was an add on trouble call ticket to check the B wing for fruit flies). Services was performed and a number of problem areas were found. Inspection of the kitchen identified fruit flies and treatment was provided throughout all areas in the kitchen. Inspection of B wing and all rooms identified fruit flies throughout the B wing. Treatment was provided to B wing to the adult fruit flies and a liquid treatment to cracks, crevices, under the sinks, behind toilets and all bathrooms, including the shower and dining room for eggs and larvae. Interview with the Administrator on 11/15/20 at 2:52 PM identified he was aware of the fruit fly issue on the B wing the last week of October 2022. The Administrator indicated he placed a call to the pest control company and notified them of the issue, and a follow up visit was done on 11/2/22. The Administrator indicated the facility does have a pest control program and the facility has educated the residents to discard or place any food items in a plastic container. The Administrator indicated the facility does not have a maintenance director at this time and he is overseeing the maintenance department. Review of the facility pest control policy dated 11/1/22 identified pest control services will be provided at the facility regularly as indicated. The facility will contract with a pest control company to perform these services.

**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 #22) reviewed for an allegation of mistreatment, the facility failed to ensure the resident was treated in a dignified manner. The findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included chronic viral hepatitis C, type 2 diabetes and hypertension. The admission MDS dated [DATE] identified Resident #22 required extensive assistance with personal care. The care plan dated 3/6/20 identified Resident #22 was alert and oriented, forgetful at times and had a behavior problem of being accusatory towards staff. Interventions included to provide opportunities for positive interaction and attention and to stop and talk while passing by. A Reportable Event Form dated 5/23/20 identified Resident #22 reported a nurse aide (NA #1) slammed his/her right hand in the bedroom door. Resident #22 was transferred to the hospital for further evaluation of the injury sustained to the right hand, and NA #1 was removed from the schedule pending investigation. A statement by Resident #71 (Resident #22's roommate) identified during the time of the alleged incident on 5/23/20, NA #1 slammed the door three times as Resident #22 attempted to keep the door open, and on the third occasion, inadvertently slammed the door onto Resident #22's hand causing an injury. Resident #71 reported NA #1 always had an attitude and stated to Resident #22, (you can call whoever you want, call the police if you want). Resident #71 also indicated the entire event could have been avoided if NA #1 approached Resident #22 the right way. NA #1 did not ask to close the door and did not explain why the door needed to be closed. Interview with NA #1 on 9/22/20 identified that while she was disciplined and reeducated regarding treating residents in a dignified many, she felt her verbal exchange with Resident #22 was not undignified. Review of NA #1's employee file identified she was in serviced on the resident's right to be addressed in a respectful manner when spoken to, and directed to find a more appropriate way to manage situations with sensitivity and respect. The facility policy directed that all residents be treated in a dignified manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #22) reviewed for mistreatment, the facility failed to ensure an allegation of neglect was reported to the State Agency per established requirements. The findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included chronic viral hepatitis C, type 2 diabetes and hypertension. The quarterly MDS dated [DATE] identified Resident #22 had intact cognition and required extensive assistance with bed mobility, transfers, dressing and hygiene, and required total assistance with toilet use. The corresponding care plan identified Resident #22 had a self-care deficit with interventions that included for staff to provide assistance with all ADL's. A Grievance Form dated 6/16/20 identified Resident #22's responsible representative called the facility and informed the ADNS that Resident #22 reported he/she had not been provided care during the weekend of 6/13/20 and 6/14/20. The Grievance Form identified statements were obtained from staff, resident and responsible representative. Additionally, the report indicated Resident #22 has a history of accusatory behavior. The resolution indicated Resident #22 would have assistance of 2 with all care due to accusatory behavior. Interview with the ADNS on 9/23/20 at 10:00 AM identified because Resident #22 was vague in his/her description about not receiving care, could not specifically the name of the staff who did not provide care and because the resident had a history of accusatory behaviors, she did not identify the incident as an allegation of neglect. Additionally, the ADNS indicated she was unable to substantiate the allegation therefore didn't classify it as neglect. Interview with RN #2 on 9/23/20 at 10:30AM identified the ADNS did not report the incident to the State Agency as an abuse/neglect allegation because she was unable to substantiate neglect very quickly and also because of the residents history of accusatory behaviors. Review of the facility's Resident Abuse Policy identified abuse is defined as: Neglect means the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, cause of physical ham, or pain or mental anguish. Additionally, the Department of Public Health shall be notified as required by law. The local police shall be notified when required. Incident report to have a case number noted. According to CMS, all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #73) reviewed for wounds, the facility failed to ensure a nutritional assessment was completed when the resident was identified with impaired skin integrity. The findings include: Resident #73 was re-admitted to the facility on [DATE] with diagnoses that included diabetes and multiple sclerosis. The 5-day MDS dated [DATE] identified Resident #73 had intact cognition, required extensive assistance with bed mobility, personal care and total assist with transfers. The MDS further identified Resident #73 had no pressure ulcers and was at risk for the development of pressure ulcers. A Wound Consultation dated 6/2/20 identified a dermatologic rash noted on the coccygeal region that measured 0.6cm x 0.3cm and that the plan of care was discussed with the wound treatment nurse. A Wound Consultation dated 6/9/20 noted the dermatologic rash on the coccyx region was resolved. The care plan dated 6/11/20 identified Resident #73 had a pressure ulcer on the coccyx related to immobility, diabetes and, thyroid dysfunction. Interventions included avoiding placing the resident on his/her back, measure weekly and report loose dressings to the treatment nurse. A Wound Consultation dated 7/28/20 noted an abrasion to the right lower extremity that measured 5.2cm x1.8cm with a new treatment plan for bacitracin followed by Xeroform dressing and ABD (protective) dressing to be changed daily. A Nutritional Progress note dated 7/29/20 identified a new wound on the right Achilles heel area with new recommendations for Prosource liquid protein 30ml daily for 30 days to assist with wound healing. A Wound Consultation dated 8/11/20 identified a newly identified area of cellulitis on the left buttock that measured 2.5 x 2.0cm with no granulation, slough eschar nor epithelialization. The plan of care was amended to include sitz baths twice daily. A review of the Nutritional Assessments and progress notes failed to reflect documentation or nutritional assessments regarding the presence of Resident #73's newly identified skin integrity issue (except for the Achilles heel area) or any new recommendations. An interview on 9/23/20 at 11:50 AM with Dietician #1 identified he did not document or follow up with Resident #73's skin integrity issues as a matter of oversight. An interview on 9/23/20 at 1:08 PM with the DNS identified all skin assessments be completed on admission and at least quarterly according to policy. The policy for Wound Care directed all wound/care treatments and services based on evidence-based standards of care under the direction of a physician. Standard of care recognized a nutritional assessment as an important aspect in wound management as skin condition reflects overall body function. Therefore, the presence of skin breakdown may be the most visible evidence of a health issue. The policy for Nutritional Assessments directed all Nutritional Assessments be conducted on admission and reviewed quarterly or as indicated. The policy for Pressure Ulcer Prevention directed pressure ulcer risk factors and interventions be implemented during review of the resident care plan.

**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 #6) reviewed for Intravenous Therapy (IVT), the facility failed to ensure a documented assessment of the insertion site every shift, and failed to ensure the physician's order included the rate of infusion for a IV medication. Additionally, the facility failed to ensure policies and procedures were updated annually, and that training and competencies were completed annually. The findings include: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included acute osteomyelitis of the left ankle, diabetes and peripheral vascular disease. The admission MDS dated [DATE] identified Resident #6 had intact cognition and required extensive assist with personal care. Physician's order dated 9/18/20 directed to administer IV Cefepine (antibiotic medication) 2gm/100ml via IV every 8 hours. The order lacked the infusion rate. Review of Nurse's Notes dated 9/18/20 through 9/24/20 failed to reflect consistent documentation of the IV site. Interview and review of the clinical record with the DNS on 9/23/20 at 1:00 PM identified staff should assess and document on the IV site every shift, and the physician ' s order should include the rate of infusion for an IV medication. Review of the IV Peripheral Therapy policy directed nursing documentation be completed each shift, including a site assessment. Although a policy relating to the transcription of physician's orders related to IV therapy was requested, none was provided. 2. Review of the Infusion Policy and Procedure Manual identified it was last reviewed and/or updated on 4/25/19, 17 months ago. Interview with the DNS on 9/23/20 at 1:20 PM identified she was responsible to ensure the IV Therapy program policies were updated annually, however, she had not as an oversight due to the Covid pandemic. 3. Review of facility documentation identified annual training competencies were not completed for all 32 nurses certified in IVT. Interview with the DNS on 9/23/20 at 1:20 PM identified she was responsible to ensure the IV competencies were completed annually, however she had not as an oversight due to the Covid pandemic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, facility policy, and interviews the facility failed to ensure resident rooms and other living areas were well maintained. The findings include: Observations on 9/21/20 at 11:50 AM through 1:00 PM, and on 9/23/20 at 10:00 AM, and on 9/24/20 at 8:23 AM with the Director of Environmental Services identified the following: a. Damaged, chipped and/or marred bedroom walls on A wing in rooms [ROOM NUMBER], on B wing in rooms [ROOM NUMBER], on C wing in room [ROOM NUMBER], 351, and 355 and on D wing in rooms 404, and 407. b. Damaged, rusty, chipped, marred bedroom radiators on A wing in rooms [ROOM NUMBERS], on B wing in rooms [ROOM NUMBER], and on C wing in rooms 350, and 357. c. Damaged, broken and/or missing dresser drawer knobs on A wing in rooms 106, 109, 110, 112, and 113, and on B wing in rooms 221, 222, 224, and 228. d. Damaged and/or broken window blind on A wing in rooms 105, 108, 111, 112, 117, and 118, on B wing in rooms 233, and 237, and on C wing in rooms 346, on 355. e. Missing window screens on A wing in rooms 102, 103, 104, 105, 106, 107, 108, 109, 110, 112, 113, 114, 117, 118 and the dining room. On B wing in rooms 220, 221, 223, 224, 225, 226, 227, 228, 229, 230, 231, 232, 233, 237, and 238. On C wing in rooms 350, 351, and the dining room. On D wing in rooms 402, 403, 407, 408, 409, 412, 413, 414, 415 and the dining room. f. Stains, debris and/or off-track privacy curtains on A wing in room [ROOM NUMBER]. g. Stains and/or debris in ceiling light cover on A wing in the clean utility room. h. Damaged, chipped and/or marred hallway wall on A wing, A wing nurse's station, and D wing hallway. i. Damaged, chipped and/or marred bathroom door on A wing in room [ROOM NUMBER] and on B wing in room [ROOM NUMBER]. j. [NAME] stains on ceiling tiles on A wing hallways, and recreation room. k. Damaged and/or peeling wall paper on A wing dining room C & D hallway and D wing nurse's station. Review of the maintenance repair log for A wing dated 7/27/20 through 9/23/20 failed to reflect the environmental concerns listed above. Review of the maintenance repair log for B wing dated 8/5/20 through 9/24/20 failed to reflect the environmental concerns listed above. Review of the maintenance repair log for C wing dated 7/23/20 through 9/23/20 failed to reflect the environmental concerns listed above. Review of the maintenance repair log for D wing dated 7/12/20 through 9/21/20 failed to reflect the environmental concerns listed above. Interview on 9/24/20 at 9:45 AM with the Director of Environmental Services indicated he was aware of some of the issues identified during the tour and identified that maintenance of the facility is ongoing and staff are responsible to fill out the maintenance log on each wing with any maintenance problems/issue that require repair and if there is an emergency or safety related concern, the staff members are responsible for calling the maintenance department immediately. Interview on 9/24/20 at 10:45 AM with the Administrator identified he was not aware of all the issues identify during tour. The Administrator indicated that the facility had recently completed an audit for bedroom window blinds. The Administrator indicated there is a maintenance repair log on each unit and any staff members can document any repair or issues. The Administrator indicated it is the responsibility of the maintenance department to oversee the repairs of the facility. Review of the Maintenance Work Order policy identified maintenance logs shall be filled out in order to establish a priority of maintenance service. In order to establish a priority of maintenance service, maintenance logs will be kept on a book on each unit. It shall be the responsibility of the maintenance department directors to prioritize the work to be completed. Work order requests should be placed in the log book at the nurse's station. The logs are reviewed daily by maintenance department. Emergency requests will be given priority in making necessary repairs. Review of the Director of Environmental Services Job Description identified the primary purpose of your position is to develop and implement facility maintenance, laundry, and housekeeper policies and procedures in an efficient, cost-effective manner to safely meet residents needs in compliance with Federal, State and Local requirements. Review of the Maintenance Assistance Job Description identified the primary purpose of this position is to implement facility maintenance policies and procedures in an efficient, cost-effective manner to safely meet residents needs in compliance with Federal, State and Local requirements. The facility failed to ensure resident rooms and other living areas were well maintained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 2 of 3 residents (Resident #46 and #73) reviewed for pressure ulcers, the facility failed to ensure nutritional assessments and skin risk assessments were completed according to standards of practice. The findings include: 1. Resident #46's diagnoses included morbid obesity, type II diabetes mellitus and anemia. The annual MDS dated [DATE] identified Resident #46 had intact cognition, required total assistance with bathing, transfers and toilet use, extensive assistance with bed mobility and supervision with eating. Additionally, the MDS identified Resident was 70 inches tall and weighed 298 lbs., was at risk for developing pressure ulcers, had a skin tear and moisture associated skin damage. Physician's order dated 8/26/20 directed to provide a carbohydrate consistent diet and diabetic evening snack, and apply triad hydrophilic wound dress paste topically to groin and buttocks every shift for wound prevention for 30 days. The care plan dated 9/1/20 identified Resident #46 had the potential for pressure ulcer development related to immobility, incontinence, refusal of turning and repositioning and recent history of pressure ulcers. Interventions included to educate resident/family/caregivers as to causes of skin breakdown including transfer/positioning requirements, good nutrition and frequent repositioning. The care plan also identified Resident #46 nutritional problem related to obesity, diabetes mellitus and risk for pressure ulcers. Interventions included registered dietitian (RD) to make diet change recommendations as needed, and staff to encourage resident to comply with diet, adequate nutrition. The Wound Specialist's progress note dated 9/8/20 identified Resident #46 had an unhealed dermatologic/rash of the bilateral buttocks that measured 3.0cm by 1.2cm and the wound was deteriorating. Further review identified the date acquired as 2/25/20, 7 months ago. Review of the Weekly Wound/Skin Condition Report dated 9/15/20 identified Resident #46 had a left buttock rash measuring 3.0cm by 1.2cm. Review of the Dietitian's Progress Notes from 4/22/20 through 9/3/20 failed to reflect Resident #46's impaired skin integrity. Although Comprehensive Nutritional Assessments were requested, none were found in the clinical record after October 2019, 1 year ago. Interview and review of the clinical record with the Dietitian on 9/23/20 at 12:00 PM identified when he comes to the facility, 2 days per week, he is provided with the updated Weekly Wound/Skin Condition Report from the wound nurse which he reviews. Although the Dietitian was able to identify documentation of Resident #46's left buttock rash on the report, he could not explain why he had not documented anything related to skin impairment in his progress notes. Although the Dietitian indicated he usually completed a Comprehensive Nutritional Assessment every 90 days, he could not explain why there were none found in Resident #46's clinical record since October 2019, indicating it was an oversight and should have been done. Review of the facility's Nutritional Assessment policy identified nutritional assessments will be completed prior to developing the resident's MDS assessment and care plan. Nutritional assessments will be reviewed quarterly and revised as necessary. 2. Resident #73 was re-admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus and multiple sclerosis. The 5-day MDS dated [DATE] identified Resident #73 had intact cognition, required extensive assistance with bed mobility, and personal care and total assistance with transfers. The MDS further identified Resident #73 had no pressure ulcers and was at risk for the development of pressure ulcers. The care plan dated 6/11/20 identified Resident #73 had a pressure ulcer on the coccyx related to immobility, diabetes and thyroid dysfunction. Interventions included avoiding placing the resident on his/her back, measure the wounds weekly and report loose dressings to the treatment nurse. a. A Wound Consultation dated 8/25/20 identified a new deep tissue injury (DTI) to the left heel. Review of Nutritional Assessments and progress notes subsequent to 8/25/20 failed to reflect Resident #73's impaired skin integrity or nutritional recommendations to address the impaired skin integrity. Interview with Dietician #1 on 9/23/20 at 11:50 AM identified he usually followed up on all skin integrity issues to determine if further nutritional intervention would be indicated. All skin integrity issues are documented, and all concerns followed up. Dietician #1 indicated he did not document or follow up with Resident #73's skin issues as a matter of oversight. Subsequent to surveyor inquiry, a nutritional progress note dated 9/23/20 noted a DTI to the left heel with new recommendations to for Prosource (protein supplement) 3ml twice daily. b. Review of the clinical record identified the only Braden Risk Assessments done between 5/20/20 through 9/9/20, (4 months) was on 9/20/20, which identified Resident #73 was at risk for the development of further pressure ulcers. Interview with the DNS on 9/23/20 at 1:08 PM identified all skin assessments be completed on admission and at least quarterly according to policy. Review of the policy for Wound Care directed all wound/care treatments and services are based on evidence-based standards of care under the direction of a physician. Standard of care recognized a nutritional assessment as an important aspect in wound management as skin condition reflects overall body function. Therefore, the presence of skin breakdown may be the most visible evidence of a health issue. Review of the Nutritional Assessment policy directed all Nutritional Assessments be conducted on admission and reviewed quarterly or as indicated. The policy for Pressure Ulcer Prevention direct pressure ulcer risk factors and interventions be implemented during review of the resident care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident's #24 and 66), reviewed for accidents, the facility failed to implement the necessary interventions to ensure residents were free from smoking materials on their person, and were supervised when smoking. The findings include: 1. Resident #24 was admitted to the facility with diagnoses that included dementia and chronic pain syndrome. The Smoking assessment dated [DATE] identified Resident #24 was forgetful and was taking psychotropic and narcotic medications. The Smoking Safety Screen dated 7/16, 7/23 and 7/30/20, identified Resident #24 agreed with the facility smoking policy and was safe to smoke with supervision. The admission MDS dated [DATE] identified Resident #24 had intact cognition and required limited assistance for bed mobility, transfers, walking in his/her room, walking in the corridor, locomotion of the unit, dressing, toileting and personal hygiene. The Smoking Agreement form, signed by Resident #24 on 7/30/20, identified the resident had a diagnosis of dementia and had a conservator. A Nursing Progress note dated 8/17/20 at 3:38 PM identified Resident #24 was observed smoking, and sharing a cigarette with another resident unsupervised in the courtyard. Resident #24 was educated on the smoking policy, his/her room was searched with no smoking materials found, and the APRN was notified. A Nursing Progress Note dated 9/11/20 at 8:25 PM identified Resident #24 was observed smoking unsupervised in the A/B courtyard. The resident continued to be non-complaint with the smoking policy despite education provided. The resident was re-educated about the smoking policy and his/her conservator was notified. Review of a Reportable Event Forms dated 8/17/20 and 9/11/20 identified Resident #24's unsupervised smoking occurrences were investigated. Re-education was provided to the resident and room searches were conducted every shift for 72 hours after the incidents. The care plan dated 9/14/20 identified Resident #24 was a smoker and was found smoking unsupervised in the courtyard on 9/11/20. The interventions included to instruct the resident about smoking risks, the smoking policy, notify the charge nurse immediately if the resident had violated the smoking policy and the resident required supervision while smoking. Review of Social Services progress notes dated July 2020 failed to reflect further documentation that addressed Resident #24's unsupervised smoking occurrences and not following the smoking policy. Review of the Psychiatric Service Progress Note dated 9/14/20, identified Resident #24 was found smoking unsupervised in the courtyard outside of the designated smoking times. Re-education was provided to the resident on the smoking policy. A Nursing Progress Note dated 9/21/20 identified at 6:45 PM the nurse overheard Resident #24 yelling at the receptionist about his/her cigarettes. Resident #24 identified to the nurse that someone stole cigarettes from his/her room. The nurse re-educated the resident on the smoking policy. Resident #24 continued to become verbally aggressive toward staff and was sent to the hospital. Interview with the DNS on 9/24/20 at 1:30 PM identified the facility should have implemented the smoking policy and care team meetings should have occurred to address the issues. Additionally, Resident #24 and 66 should have had care plan interventions reassessed to determine appropriateness. 2 Resident #66 was admitted to the facility with diagnosis of high blood pressure, urine retention, anxiety and depression. The Smoking Agreement, Smoking Assessment and Smoking Safety Screening dated 10/16/19 identified the resident understood and agreed to the smoking contract, designated smoking areas, times and consequences should the smoking agreement contract not be followed. The care plan dated 10/23/19 identified Resident #66 was a smoker. The care plan further identified the following dates when the resident was found smoking unsupervised in the courtyard outside of the designated smoking times and was in possession of smoking materials; 12/25/19, 2/1/20, 3/25, 5/5, 5/7, 5/11, 5/12, 5/26, 6/4, 6/16, 7/23, 8/17 and 9/14/20. The intervention after each incident included to educate the resident, encourage compliance with the smoking policy for safety, and complete room checks every shift for 72 hours. Review of facility documentation, identified Reportable Events Forms were completed after Resident #66 was found smoking unsupervised on the following dates; 12/25/19, 2/1/20, 5/5, 5/7, 5/11, 5/12, 5/26, 6/4, 6/16, 7/23, 8/17 and 9/14/20. Actions taken were to re-educate the resident on the smoking policy and perform room searches every shift for 72 hours. A Smoking assessment dated [DATE] and 3/26/20, identified Resident #66 was safe to smoke with supervision and a subsequent screening dated 7/23/20 identified the resident was safe to smoke without supervision. A Nursing Progress note dated 5/6/20 at 11:50 AM identified the DNS was called to Resident #66's room for the smell of smoke. Upon entering the room, a smoke smell was noted, and the resident was noted to be lying in bed. The resident admitted to smoking in his/her room and a cigarette was found in his/her bedside draw along with two (2) empty cigarette boxes. The resident would not identify where he/she obtained the smoking materials. Staff notified Resident #66's conservator, and the APRN. Additionally, education on smoking policy was provided to Resident #66. A Psychiatric Progress note dated 5/13/20 identified the resident was seen for smoking in the courtyard unsupervised and was educated on smoking safety. The resident refused the nicotine patch and refused to increase his/her antidepressant. The quarterly MDS dated [DATE] identified Resident #66 had intact cognition, required supervision and set up assistance for bed mobility, transfers, walking in his/her room and corridor, dressing, eating, toileting and self-propels in his/her wheelchair. A Psychiatric Progress note dated 8/19/20 identified the resident was seen per staff request as Resident #66 was seen smoking unsupervised outside of approved smoking guidelines and the resident was re-educated on the safety guidelines for smoking. A further review of the Psychiatric Service progress notes failed to address additional occurrences of the resident smoking unsupervised outside of the designated facility smoking times. Review of Social Service Progress Notes from January 2020 through September 2020 failed to reflect Resident #66's unsupervised smoking occurrences outside of the approved smoking times had been addressed by social services. Nursing Progress Note dated 9/14/20 at 1:38 PM identified the resident was observed by staff unsupervised smoking a cigarette in the A/B courtyard outside of the designated smoking times, and the conservator was notified. The resident was re-educated on the smoking policy and the Administrator was notified of the resident's frequent episodes of smoking in the A/B courtyard. Interview with the Administrator on 9/23/20 at 11:45 AM identified Resident #66 had occurrences from December 2019 to September 2020 of unsupervised smoking in the courtyard outside of the designated facility smoking times and was in possession of smoking materials. The Administrator was unable to identify where the resident had obtained his/her smoking materials. The Administrator further identified the facility should have reassessed the effectiveness of the interventions in place according to the facility's smoking policy and should have scheduled a care team meeting to address the frequency of the occurrences. Interview with the Director of Recreation on 9/23/20 at 12:50 PM identified he/she was unable to identify how Resident #66 had obtained smoking materials as the resident has had no window or outside visits. Resident #66's packages received at the facility are searched. The Director of Recreation further identified only 2 residents that smoke (Resident #23 and 24) received outside visits which were supervised. Review of the Smoking policy identified all residents who smoke will be assessed upon admission, quarterly and with a change in condition which would determine the resident's ability to smoke safely. Assessments would have included the resident's cognitive status, ability to understand smoking rules, judgment, manual dexterity and mobility. At the completion of the smoking assessment, a care plan would have been developed which would have included interventions to reflect the resident's needs, if any, and ability to smoke safely. Smoking is not permitted inside the facility; smoking is only allowed outside in designated areas and at designated times. All residents must be supervised while smoking by designated staff. Residents are not allowed to have cigarettes in their possession. All smoking materials will always be secured by the front desk receptionist in the smoking cart so as not be accessible to residents. If a resident was found to have or suspected to have smoking materials or sources of flame in their possession, they would have been asked to surrender the items. Repeat offenders of the smoking policy present a high-risk situation. The Administrator and DNS, along with the Care Team should consider interventions such as routine and random searches of room, belongings and or person as deemed necessary, as well as close observation. The facility failed to implement measures to ensure the environment was as free of accident hazards as possible when Resident #24 and 66 were repeatedly found smoking unsupervised, inside and outside the building, and had smoking material on their persons.

Based on observation, review of facility policy and interviews, the facility failed to maintain 2 of 4 medication carts in a clean and sanitary manner. The findings include: a. Observation of the medication cart on D wing with LPN #1 on 9/21/20 at 11:10 AM identified an accumulation of loose medication (pills) and/or blister pack back covers in the bottom of the first drawer, and/or stains and spilled liquids on the bottom of second drawer. Interview on 9/21/20 at 11:12 AM with LPN #1 indicated she was not aware of the loose pills and/or blister pack back covers and/or stains and/or spilled liquids at bottom of medication drawers. LPN #1 indicated it is the responsibility of the nurses to keep the medication cart clean. b. Observation of the medication cart on B wing with RN #1 and LPN #2 on 9/21/20 at 12:05 PM identified an accumulation of loose medication (pills) and/or blister pack back covers at the bottom of first drawer and/or stains and spilled liquids at the bottom of second drawer. Interview with LPN #2 on 9/21/20 at 12:06 PM indicated she was not aware the loose pills and/or blister pack back covers and/or stains and/or spilled liquids at bottom of medication drawer. LPN #2 indicated it is the responsibility of the nurses to keep the medication cart clean. Interview with RN #1 on 9/21/20 at 12:07 PM indicated she was not aware of the issues with the cleanliness of the medication carts and indicated it is the responsibility of the nurses to keep the medication carts clean at all times. Interview with the ADNS on 9/23/20 at 9:00 AM indicated she was not aware the medication carts were not cleaned. The ADNS indicated the expectation was that the nurse cleans the medication cart at the end of their shift and that the medication carts are clean at all times. Review of the Medication Storage policy identified the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, review of facility documentation, facility policy and interview, the facility failed to consistently maintain food temperature logs according to established criteria. The findings include: Review of the facility's food temperature logs for August and September 2020 on 9/21/20 at 10:12 AM failed to reflect consistent monitoring. Food temperatures were not documented during the dinner service on the following dates; 8/8, 8/9, 8/14, 8/15, 8/22, 8/23, 8/28, 8/29, 9/2, 9/4, 9/13 and 9/14/20. Food temperatures were not documented during the breakfast and lunch service on the following dates; 8/23, 9/5 and 9/20/20. Interview with the Food Service Director on 9/21/20 at 10:12 AM identified he would expect the kitchen staff to document all temperatures for hot and potentially hazardous foods ensure food safety and the prevention of food borne illness. Review of the policy for Food Safety identified hot foods or potentially hazardous foods would leave the kitchen or steam table at 140 degrees Fahrenheit or above. The Food Service Director would maintain records of such information. The facility failed to consistently maintain food temperature logs for hot and potentially hazardous foods during the months of August and September 20.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, facility policy and interviews, the facility failed to ensure foods were prepared under sanitary conditions. The findings include: 1. Observation on 9/21/20 at 10:22 AM during the tour of the kitchen and interview with the Food Service Director identified a large fan covered in a dirt like substance had been blowing directly on clean plates and plate covers that had been removed from the dishwasher. The Food Service Director identified the fan covered in a dirt like substance should not have been blowing on the clean plates and plate covers and kitchen staff was responsible to ensure the fan was clean. Subsequent to surveyor inquiry a staff member from housekeeping cleaned the fan. 2. Intermittent observations on 9/21/20 from 9:45 AM to 10:40 AM, 55 minutes, identified a large metal pan that contained the lunch meal of pasta [NAME] with ham was left opened to air. A rubbish barrel had been placed against the countertop near where the pasta [NAME] was left opened to air. The observation identified there were small insects flying in the kitchen from the rubbish barrel, flying near the pasta [NAME], and over food preparation areas. Interview with the Food Service Director on 9/21/20 at 10:32 AM identified prepared foods should be tightly sealed with a plastic film covering and not be left opened to air to prevent food borne illness, and the rubbish barrel should have been covered with a lid and not placed near the food preparation area. Subsequent to surveyor's inquiry a kitchen staff member covered the pan with a plastic film. 3. Review of the kitchens daily cleaning list (which required the staff to initial and date after each cleaning task was completed) with the Food Service Director on 9/23/20 at 10:40 AM identified the forms were incomplete (staff had not consistently dated or initialed the lists to indicated the tasks had been completed). The Food Service Director indicated staff should have initialed and dated the daily cleaning lists after each task was completed to ensure the kitchen was being maintained in a sanitary manner. Review of the policies for Food Storage, Food Safety and Food Preparation areas directed the facility to maintain a clean, sanitary and safe food preparation area, all kitchen machines and equipment are required to be cleaned after use to assure a sanitary environment was maintained, prepared foods were to be tightly sealed with a plastic film, foil or a lid prior to food service. Review of the Food Preparation Areas and Food Related Garbage policy directed the facility would maintain a clean, sanitary and safe food preparation area, all rubbish containers would be provided with tight-fitting lids and would be covered when not in continuous use.

Based on observation, review of facility policy, and interviews the facility failed to maintain the dumpster and compactor area in a sanitary manner. The findings include: Observation on 9/21/20 at 10:45 AM with the Food Service Director of the outside dumpster area identified the dumpster was uncovered with waste noted on the ground around the receptacle and trash compactor. Items included greater than 10 pairs of gloves, surgical masks, soiled cleansing wipes, old food, plastic utensils and paper cups which were scattered around the dumpster, compactor, parking lot and into the wood line behind the dumpster. Furthermore, a porcelain toilet was observed behind the dumpster. Interview with the Director of Maintenance on 9/21/20 at 10:45 AM identified maintenance staff are responsible to clean around the dumpster and compactor throughout the week and weekends. The Director of Maintenance was unable to identify why the cleaning did not occur. Review of the Rubbish Disposal policy identified food-related garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters and outside dumpsters provided by waste pick up services will be kept closed and free of surrounding litter.