**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documents, policy review and staff interviews for 1 of 6 residents reviewed for abuse (Resident # 2), the facility failed to follow up on and report a potential allegation of abuse. The findings include: Resident #2's diagnoses included quadriplegia (paralysis of all four extremities), anxiety, and depression. The Medicare 5-day MDS assessment dated [DATE] identified Resident #2 was cognitively intact and had not exhibited behavioral symptoms towards self or others. The MDS assessment further indicated Resident #2 was dependent for toileting and bathing and always incontinent of bowel. A care plan dated 7/9/2025 identified Resident #2 required total assistance for activities of daily living (ADL). Interventions included the assistance of one staff member with incontinence care and using a hands-free system to use the call light. 0n 8/6/2025 at 3:20 PM during a screening interview, Resident #2 indicated that 3 to 4 months ago, a nursing aide whose name she/he did not recall came in during a morning shift around 11:00 AM to provide a bath. Resident #2 indicated he/she refused care, but the nursing aide proceeded to wash him/her anyway. Resident #2 indicated she/he complained to his/her nurse that day (LPN#1) and to the DNS at the time (RN#5). Resident #2 indicated she/he had not seen the nurse aide again since the incident and indicated she/he did not know what LPN#1 and RN#5 had done about the incident. On 8/11/2025 at 11:00 AM, an interview with LPN #2, who was taking care of Resident #2, indicated she had heard about the incident but could not recall from where. LPN # 2 further indicated she did not know any details. However, LPN#2 indicated she thought it had occurred on a weekend when she was off. On 8/11/2025 at 11:44 AM, an interview with LPN#1 identified that sometime in the end of March 2025 or April 2025 (LPN#1 could not recall the exact date), NA#8 came to her to inform her that Resident #2 was refusing care from NA#8. LPN#1 indicated she spoke to Resident #2, who indicated NA#8 was trying to change him/her against his/her will. Additionally, LPN#1 indicated Resident #1 had informed her that NA#8 had changed him/her against his/her will during the night therefore she/he want NA#8 taking care of him/her anymore. LPN#1 indicated she had the nursing aides switch assignments so NA#8 would not be assigned to Resident #2 and then informed RN#5 about the resident's concern. LPN#1 did not recall which nursing aide took over Resident #2's care. LPN#1 indicated that when there is an allegation of abuse, staff are supposed to contact the DNS, and the DNS handles things from there. LPN#1 further indicated that she did not follow up with the resident afterwards and did not recall if the DNS had spoken to Resident #2 after being informed. LPN#1 indicated she did not tell the supervisor of the shift because she had already told the DNS. On 8/11/2025 at 12:23 PM, an interview with the Administrator indicated he was not aware of an incident between NA#8 and Resident #2. The Administrator also identified RN#5's last day working as a DNS was on 6/30/2025 and the current DNS served as Assistant Director of Nursing Services (ADNS) from 5/15/2025 to 7/21/2025 and then assumed DNS role on 7/22/2025. On 8/11/2025 at 2:18 PM, an interview with RN#5 identified RN#5 did not recall an incident between NA#8 and Resident #2 and indicated that had there been an incident, she would have written an incident report. The written report would been left on her desk after she left the facility. RN#5 indicated that when there was an allegation of staff-to-resident abuse, the process included: staff write statements, notifying the social worker, and removing the staff member from the schedule pending investigation. A review of nursing notes and social work notes from 3/15/2025 to 5/30/2025 failed to identify an incident where Resident#2 refused care and complained of being provided peri care against his/her will. A review of facility accident and incident reports from 1/1/2025 to 8/6/2025 for Resident #2 failed to identify an incident between NA#8 and Resident #2 or any other incident of potential abuse. A review of the facility's state's reportable events data since the last recertification survey on 12/21/2023 failed to identify an allegation of abuse for Resident #2. On 8/13/2025 at 10:30 AM, an interview with the DNS indicated she was not aware of an incident between Resident #2 and NA#8, but indicated that if a resident refuses care, staff should document it and reapproach later. Additionally, the DNS indicated there were no other incident and accident reports for Resident #2 from 1/1/2025 to 8/6/2025 other than what was already provided. On 8/14/2025 at 9:13 AM, an interview with NA#8 identified NA#8 denied providing care to Resident #2 without his/her consent. NA#8 did indicate that there was an incident a few months prior (NA#8 could not recall the exact day or month) where she was providing incontinence care to Resident #2 after Resident #2 had agreed to be peri care, but Resident #2 complained that NA#8 was taking too long and yelled at her to stop and leave. NA#8 indicated she stopped and reported to LPN#1 the resident did not want her/him (NA #8) taking care of him/her anymore. NA#8 indicated she could not recall which nursing aide switched assignments with her that day. The facility policy for abuse notes any staff suspecting abuse should immediately report it to the supervisor, who would then report it to the DNS and the Administrator. An Accident and Incident report would be completed, and nursing staff would document a description of the incident in the resident's record. Additionally, the Abuse policy indicated the Administrator, DNS, or designee would initiate an investigation and submit an online report to the Facilities Licensing and Investigation Section.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documents, policy review and staff interviews for 1 of 6 residents reviewed for abuse (Resident # 2), the facility failed to conduct a thorough investigation regarding an allegation of mistreatment. The findings include: Resident #2's diagnoses included quadriplegia (paralysis of all four extremities), anxiety, and depression. The Medicare 5-day MDS assessment dated [DATE] identified Resident #2 was cognitively intact and had not exhibited behavioral symptoms towards self or others. The MDS assessment further indicated Resident #2 was dependent for toileting and bathing and always incontinent of bowel. A care plan dated 7/9/2025 identified Resident #2 required total assistance for activities of daily living (ADL). Interventions included the assistance of one staff member with incontinence care and using a hands-free system to use the call light. 0n 8/6/2025 at 3:20 PM during a screening interview, Resident #2 indicated that 3 to 4 months ago, a nursing aide whose name she/he did not recall came in during a morning shift around 11:00 AM to provide a bath. Resident #2 indicated he/she refused care, but the nursing aide proceeded to wash him/her anyway. Resident #2 indicated she/he complained to his/her nurse that day (LPN#1) and to the DNS at the time (RN#5). Resident #2 indicated she/he had not seen the nurse aide again since the incident and indicated she/he did not know what LPN#1 and RN#5 had done about the incident. On 8/11/2025 at 11:00 AM, an interview with LPN #2, who was taking care of Resident #2, indicated she had heard about the incident but could not recall from where. LPN # 2 further indicated she did not know any details. However, LPN#2 indicated she thought it had occurred on a weekend when she was off. On 8/11/2025 at 11:44 AM, an interview with LPN#1 identified that sometime in the end of March 2025 or April 2025 (LPN#1 could not recall the exact date), NA#8 came to her to inform her that Resident #2 was refusing care from NA#8. LPN#1 indicated she spoke to Resident #2, who indicated NA#8 was trying to change him/her against his/her will. Additionally, LPN#1 indicated Resident #1 had informed her that NA#8 had changed him/her against his/her will during the night therefore she/he want NA#8 taking care of him/her anymore. LPN#1 indicated she had the nursing aides switch assignments so NA#8 would not be assigned to Resident #2 and then informed RN#5 about the resident's concern. LPN#1 did not recall which nursing aide took over Resident #2's care. LPN#1 indicated that when there is an allegation of abuse, staff are supposed to contact the DNS, and the DNS handles things from there. LPN#1 further indicated that she did not follow up with the resident afterwards and did not recall if the DNS had spoken to Resident #2 after being informed. LPN#1 indicated she did not tell the supervisor of the shift because she had already told the DNS. On 8/11/2025 at 12:23 PM, an interview with the Administrator indicated he was not aware of an incident between NA#8 and Resident #2. The Administrator also identified RN#5's last day working as a DNS was on 6/30/2025 and the current DNS served as Assistant Director of Nursing Services (ADNS) from 5/15/2025 to 7/21/2025 and then assumed DNS role on 7/22/2025. On 8/11/2025 at 2:18 PM, an interview with RN#5 identified RN#5 did not recall an incident between NA#8 and Resident #2 and indicated that had there been an incident, she would have written an incident report. The written report would been left on her desk after she left the facility. RN#5 indicated that when there was an allegation of staff-to-resident abuse, the process included: staff write statements, notifying the social worker, and removing the staff member from the schedule pending investigation. On 8/13/2025 at 10:30 AM, an interview with the DNS indicated she was not aware of an incident between Resident #2 and NA#8, but indicated that if a resident refuses care, staff should document it and reapproach later. Additionally, the DNS indicated there were no other incident and accident reports for Resident #2 from 1/1/2025 to 8/6/2025 other than what was already provided. On 8/14/2025 at 9:13 AM, an interview with NA#8 identified NA#8 denied providing care to Resident #2 without his/her consent. NA#8 did indicate that there was an incident a few months prior (NA#8 could not recall the exact day or month) where she was providing incontinence care to Resident #2 after Resident #2 had agreed to peri care, but Resident #2 complained that NA#8 was taking too long and yelled at her to stop and leave. NA#8 indicated she stopped and reported to LPN#1 the resident did not want her/him (NA #8) taking care of him/her anymore. NA#8 indicated she could not recall which nursing aide switched assignments with her that day. The facility policy for Abuse notes any staff suspecting abuse should immediately report it to the supervisor, who would then report it to the DNS and the Administrator. Additionally, the policy directed the Administrator, DNS, or designee would initiate an investigation. The Abuse policy further indicated that an investigation would include interviews of all witnesses, including the accused, interviews with any individual with relevant information, signed and dated statements for all involved parties, and a review of the accused staff member's employment record.

Based on clinical record review and staff interviews for 1 of 3 employee files reviewed for Nurse Aide (NA # 8), the facility failed to conduct a thorough investigation on the history of prospective staff, including required background checks, prior to the hire date. The findings include: On 8/14/2025 at 12:55 PM, an interview and review of employee files with the Human Resources Director identified NA#8 was hired on 4/12/2024. She was certified as a nursing aide since 3/07/2023. Although NA#8's employee file contained signed employee consents for background checks, the file did not contain documentation of a completed state or federal background check, including fingerprint-based screening through the Applicant Background Check Management System (ABCMS). The Human Resources Director indicated she was unable to retrieve evidence of an ABCMS screening on the online portal. The Human Resource Director indicated background checks, including the ABCMS screening, are done by the facility prior to employing staff and could not identify a reason for NA#8 not having one. Furthermore, the Human Resource Director indicated NA#8 would be removed from the schedule until NA#8 completes an ABCMS screening. On an interview on 8/14/2025 at 1:35 PM, the Administrator could not explain why NA # 8 did not have a background check or an ABCMS screening prior to being hired. The Administrator indicated that when the Human Resource Director began working at the facility, she had been auditing employee records, and the facility would ensure employee records are audited for background checks. Although requested, the facility was unable to produce a policy for pre-employment screening. However, the facilities abuse policy given during the survey identified a section for pre-hire screening, which indicated the facility would ensure an active license or certification and would review regulatory action reports. The abuse policy did not identify a process for ensuring background checks and ABCMS screenings were completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who required emergency services and transfer to the hospital, the facility failed to conduct an complete and accurate assessment at the time the resident was noted to have a change in condition. The findings include: Resident #1's diagnoses included dementia, dysphagia (difficulty swallowing), and gastroesophageal reflux disease (GERD). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decision regarding tasks of daily life and was dependent on staff for all activities of daily living. The Resident Care Plan dated 1/3/25 identified Resident #1 had a potential for aspiration, asthma, and GERD. Interventions directed to assist with meals, check vital signs and lung sounds for any signs of aspiration, keep the resident in an upright position for thirty (30) minutes after meals, keep head of bed elevated, monitor for nausea, vomiting and signs of aspiration. The Situation Background Assessment Recommendation (SBAR) dated 2/9/25 at 6:42 AM identified Resident #1 was unresponsive and in respiratory distress, breathing with accessory muscles and had increased congestion. The documented assessment identified the following: blood pressure 124/78, pulse 78, respirations 18, pulse oximetry 88%, and temperature 98.3 obtained on 2/3/25 at 4:17 PM. The note identified, subsequent to physician notification, Resident #1 was transferred to the hospital. Upon further review, the clinical record failed to reflect vital signs were current and/or repeated The prehospital care report dated 2/9/25 identified Emergency Medical Services (EMS) was dispatched to the facility at 5:30 AM. Upon entering the room, EMS found Resident #1 lying in a semi-Fowler's position with rapid gurgling respiration, Resident #1 was not alert and responsive only to pain, and Resident #1 was on two (2) liters of oxygen. The staff stated Resident #1 had vomited twice, they did not know when Resident #1 had initially vomited, the mouth was noted to be full of sputum and vomit, Resident #1 was rolled onto the left side, the airway was cleared, and lung sounds had bilateral rhonchi and mild wheezing. Resident #1's oxygen saturation was 72% on the two (2) liters, the oxygen was increased to six (6) liters with a slow increase to the 80's, the resident's airway was suctioned to remove traces of vomit, placed on non-rebreather at fifteen (15) liters and the oxygen saturation level increased to the upper 90's. The report identified Resident #1's blood pressure was 169/76, pulse 124, and respirations 40. The hospital Discharge summary dated [DATE] identified Resident #1 was admitted to the hospital on [DATE] with diagnoses that included an altered mental status, influenza A infection, a urinary tract infection, and aspiration pneumonia of both lungs due to gastric secretions. Resident #1 was treated with antibiotics and improved rapidly with return to the facility on 2/16/24. Interview with one (1) of the paramedics, Person #1, on 2/26/25 at 10:35 AM identified on 2/9/25 EMS was dispatched to the facility for a report of Resident #1 having difficulty breathing. Person #1 stated when they arrived at Resident #1's bedside, Resident #1 was choking on his/her vomit, and there were no facility staff members in the room. Person #1 identified Resident #1 was found lying in a semi-Fowler's position (on back with head of bed at a 30-40 degree angle). Person #1 stated Resident #1 had oxygen at two (2) liters on, but it appeared no other interventions were being done. Person #1 identified although a staff member indicated Resident #1 vomited two (2) times, staff did not provide any vital signs or further reports, only the written transfer paperwork including DNR status was provided. Interview with the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #2, on 2/26/25 at 12:35 PM identified RN #1, the 11PM-7AM Nursing Supervisor called her to the floor to assist in preparing Resident #1 for transfer to the hospital and that RN #1 requested she complete the hospital transfer paperwork. RN #2 stated she did a brief assessment and although she obtained Resident #1's vital signs she did not enter them into the clinical record. Interview with the Director of Nursing (DON) on 2/26/25 at 2:00 PM identified when a resident had a change in condition the expectation was to check vital signs, complete an assessment and perform appropriate interventions and then document that information in the clinical record. The DON explained, for a resident that vomited, the expectation would have been for staff to ensure the head of bed was elevated, turn the resident on his/her side, and clean the resident's mouth. Attempts to interview RN #1 and NA #3 were unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who had a change in condition and required transfer to the hospital, the facility failed to monitor and implement interventions until Emergency Medical Services arrived and failed to give a thorough hand off report. The findings include: Resident #1's diagnoses included dementia, dysphagia (difficulty swallowing), and gastroesophageal reflux disease (GERD). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decision regarding tasks of daily life and was dependent on staff for all activities of daily living. The Resident Care Plan dated 1/3/25 identified Resident #1 had a potential for aspiration, asthma, and GERD. Interventions directed to assist with meals, check vital signs and lung sounds for any signs of aspiration, keep the resident in an upright position for thirty (30) minutes after meals, keep head of bed elevated, monitor for nausea, vomiting and signs of aspiration. The Situation Background Assessment Recommendation (SBAR) dated 2/9/25 at 6:42 AM identified Resident #1 was unresponsive and in respiratory distress, breathing with accessory muscles and had increased congestion. The note identified, subsequent to physician notification, Resident #1 was transferred to the hospital. The prehospital care report dated 2/9/25 identified Emergency Medical Services (EMS) was dispatched to the facility at 5:30 AM. Upon entering the room EMS found Resident #1 lying in a semi-Fowler's position with rapid gurgling respiration, Resident #1 was not alert and responsive only to pain, and Resident #1 was on two (2) liters of oxygen. The staff stated Resident #1 had vomited twice, they did not know when Resident #1 had initially vomited, the mouth was noted to be full of sputum and vomit, Resident #1 was rolled onto the left side, the airway was cleared, and lung sounds had bilateral rhonchi and mild wheezing. Resident #1's oxygen saturation was 72% on the two (2) liters, the oxygen was increased to six (6) liters with a slow increase to the 80's, the resident's airway was suctioned to remove traces of vomit, placed on non-rebreather at fifteen (15) liters and the oxygen saturation level increased to the upper 90's. Once on the stretcher Resident #1 was kept in a right recumbent position, lying on the side, the resident responsiveness improved. The report identified Resident #1's blood pressure was 169/76, pulse 124, and respirations 40. Resident #1 was transported to the hospital at 6:05 AM. The hospital Discharge summary dated [DATE] identified Resident #1 was admitted to the hospital on [DATE] with diagnoses that included an altered mental status, influenza A infection, a urinary tract infection, and aspiration pneumonia of both lungs due to gastric secretions. Resident #1 was treated with antibiotics and improved rapidly with return to the facility on 2/16/24. Interview with one (1) of the paramedics, Person #1, on 2/26/25 at 10:35 AM identified on 2/9/25 EMS was dispatched to the facility for a report of Resident #1 having difficulty breathing. Person #1 stated when they arrived at Resident #1's bedside, Resident #1 was choking on his/her vomit, and there were no facility staff members in the room. Person #1 identified Resident #1 was found lying in a semi-Fowler's position (on their back with the head of the bed at a 30-40 degree angle). Person #1 indicated he/she and the other EMS present heard Resident #1 gurgling, turned the resident onto a side, cleared the airway, and the resident's breathing began to improve. Person #1 stated Resident #1 had oxygen at two (2) liters on, but it appeared no other interventions were being done. Person #1 identified although a staff member indicated Resident #1 vomited two (2) times, staff did not provide any vital signs or further reports, only the written transfer paperwork including DNR status was provided. Interview with the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #2, on 2/26/25 at 12:35 PM identified the 11PM-7AM Nursing Supervisor, RN #1, called her to the floor to assist in preparing Resident #1 for transfer to the hospital. RN #2 identified she conducted a brief assessment. Interview with the Director of Nursing (DON) on 2/26/25 at 2:00 PM identified when a resident had a change in condition the expectation was to check vital signs, complete an assessment and perform appropriate interventions and then document that information in the clinical record. The DON explained, for a resident that vomited, the expectation would have been for staff to ensure the head of bed was elevated, turn the resident on his/her side, and clean the resident's mouth. The DON stated when a resident had a change in condition and EMS was called the expectation was that a licensed staff member would remain with the resident until EMS arrived and then provide report to EMS. Attempts to interview RN #1 and NA #3 were unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse and neglect, the facility failed ensure the resident was free from misappropriation. The findings include: Resident #1 was admitted with diagnoses that included cardiomyopathy and muscle weakness. A 5-day MDS dated [DATE] identified Resident #1 had moderately impaired cognition. A resident care plan (RCP) dated 7/7/2024 identified Resident #1 had impaired memory, recall and decision-making skills. RCP directed to offer gentle reminders, offer one step at a time directions and to support /reassure if anxious. A facility reportable event form dated 9/6/2024 identified that on 8/22/2024, Resident #1 was accompanied by NA #1 to an appointment and Resident #1's credit card was given to NA #1 to pay for transportation. The report indicated NA #1 used Resident #1's credit card to purchase her own personal items. The facility summary dated 9/11/2024 identified that on 8/22/2024, Resident #1 had a scheduled appointment that required a staff member to accompany him/her. NA#1 was entrusted with Resident #1's credit card to pay for the taxi cab ride since the taxi cab did not accept cash. NA #1 and Resident #1 returned to the facility without concerns and Resident #1 had the credit card in his/her possession. On 9/5/2024, Resident #1's emergency contact/Person #1, stated she/he had received Resident #1's credit card statement, and noted several fraudulent purchases and had notified the police. On 9/6/2024, the local police notified the facility that on 8/22/2024, NA #1 was seen on camera footage at a store where she purchased items on Resident #1's credit card without permission. NA # 1 was a no call, no show for scheduled shifts on 9/4 and 9/5/2024. The facility summary identified based on the information provided by the local police, observation of the camera footage at the store confirmed NA #1 used the card to make the purchases, several charges were made on the Resident #1's credit card statement through NA#1's personal cell phone, the facility substantiated the fraudulent charges made on Resident #1's credit card to NA #1. NA #1's employment was subsequently terminated. Interview with Person #1 on 9/30/2024 at 10:00 AM identified he/she provided Resident #1's credit card to the front desk receptionist to pay for the cab fare to transport Resident #1 to an appointment on 8/22/2024. Person #1 retrieved the credit card from the facility on 8/26/2024 after receiving a notification to complete a set up for an apple pay account that was linked to Resident #1's credit card, and Resident #1 was not able to set up such an account on his/her cell phone. The facility had determined that the supervisor on 8/22/2024 had secured Resident #1's credit card in a locked box until Person #1 had retrieved it on 8/26/2024. Person #1 thought that perhaps the apple pay notification was a fraud attempt and did not inform the facility of the apple pay notification. On 8/29/2024 the credit company notified Person #1 of possible fraudulent activity on Resident #1's credit card account and Person #1 closed the account. Upon receiving the credit card statement on 9/5/2025 with approximately $500.00 dollars of charges that Resident #1 did not make, Person #1 notified the local police. Person #1 stated the police retrieved camera footage of NA #1 using Resident #1's credit card to purchase items on 8/22/2024 while Resident #1 was at the appointment, and the police thought that NA #1 had taken a picture of Resident #1's credit card before she returned it to the facility supervisor on 8/22/2024. Person #1 indicated NA #1 continued to use Resident #1's credit card to make the additional purchases. Interview with the DON on 9/30/2024 at 10:55 AM identified on 9/6/2024 the local police brought video footage of a person using Resident #1's credit card and she was able to identify that the person in the footage was NA #1. Upon interview with Resident #1 on 9/5/2024, the DON indicated that although Resident #1 could not recall the event, he/she stated that only family members can use his/her credit card. NA #1 used Resident #1's credit card to purchase personal items and for personal activities totaling $539.06 dollars. Further, the DON stated NA #1's employment was terminated as the allegation of misappropriation was substantiated. The facility policy Abuse/Resident dated 7/23/2023, directed in part that any abuse or mistreatment of any kind towards a resident is strictly prohibited. The policy defines abuse as misappropriation of resident property by means of deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of two (2) sampled residents (Resident #2) who had indwelling urinary catheters, the facility failed to ensure the resident attended scheduled outpatient urology appointments and maintain accurate documentation in the clinical record of when the appointments were canceled, missed or rescheduled. The findings include: Resident #2's diagnoses included quadriplegia and neuromuscular dysfunction of the bladder. The admission record identified Resident #2 was responsible for him/herself. A physician's order dated 3/4/23 directed indwelling foley catheter #16Fr with 10cc balloon. The resident care plan dated 4/3/23 identified Resident #2 had an indwelling catheter and was at risk for urinary tract infections (UTI's). Interventions directed to conduct catheter care as ordered and as needed, medications as ordered, observe for sediment, cloudy, bloody, scant or foul-smelling urine and report to the physician, and to watch for signs and symptoms of UTI's. The care plan identified Resident #2 would intermittently refuse to take medications, participate in rehab therapy, get out of bed and accept care from staff. Interventions included documenting the care being resisted and discuss with the resident and family implications of not complying with therapeutic regimen. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had no memory recall deficits, did not exhibit rejection of care behaviors, had an indwelling catheter, was always incontinent of bowel and required assistance of one (1) staff for toilet use. The progress note dated 7/3/23 failed to identify why Resident #2 did not attend the urology appointment scheduled that day. The progress note dated 7/15/23 identified Resident #2 was re-admitted from the hospital, the note failed to identify Resident #2 did not attend the urology appointment on 7/15/23 and if the appointment was rescheduled. The nursing note dated 8/17/23 at 2:11 PM identified Resident #2's missed the urology appointment due to transportation not being rescheduled. The nursing note dated 9/12/23 identified Resident #2 had an appointment on 9/14/23. The nursing note dated 9/14/24 at 2:17 PM identified Resident #2's transportation did not show up, Resident #2 missed the urology appointment, and the appointment would be rescheduled. The note did not indicate what the next appointment date was. The nursing note dated 10/23/23 at 4:49 PM identified Resident #2 returned to the facility from the hospital around 1:40 PM. Review of the progress notes failed to identify if urology was contacted and if an appointment was rescheduled. The progress note dated 11/20/23 failed to identify why Resident #2 did not attend the urology appointment on 11/20/23 and if the appointment was rescheduled. The nursing note dated 11/28/23 at 6:51 PM identified Resident #2's urology appointment was cancelled related to his/her insurance not being active and Resident #2 refused to pay for transportation. The nursing notes failed to identify follow up about Resident #2's insurance lapse and if the appointment was rescheduled. The nursing note dated 1/26/24 at 11:34 AM identified Resident #2's urology appointment was cancelled due to a transportation issue and the urology appointment was rescheduled to March. The nursing note dated 3/21/24 at 2:15 PM identified Resident #2 refused to go to his/her urology appointment. Upon further review, the nursing notes failed to identify if Resident #2 was provided education on the importance of attending the appointment and if Resident #2 was offered another appointment. Review of the clinical record failed to identify any urology after visit summaries. Interview with the Advanced Practice Registered Nurse (APRN) #1 on 8/5/24 at 1:38 PM identified Resident #2 had a foley catheter due to neuromuscular dysfunction of the bladder and is at an increased risk of urinary tract infections (UTI's). APRN #1 identified Resident #2 goes to outpatient urology appointments for a more thorough assessment including looking for stenosis and blockages. Interview with the Administrator on 8/5/24 at 2:02 PM identified when a resident goes to an outpatient appointment, if they came back with a visit summary, it would go in the residents chart. The Administrator identified that sometimes residents do not return with them and the staff have to call the office. The Administrator was unable to provide documentation of appointment summaries and the last urology appointment Resident #2 attended. Review of the appointment book with the Administrator identified Resident #2 was scheduled for transportation on 3/19/24 that was changed to 3/21/24, Resident #2 was not in the appointment book for 1/26/24 and she could not provide the appointment book for 2023. The Administrator identified the nursing staff are responsible to schedule the appointments and then inform the receptionist who then schedules the transportation and a nurse aide if needed. The Administrator further identified when Resident #2 insurance lapsed, the funds in his/her account would have to be used to pay for transportation. The Administrator identified Resident #2 was responsible for his/her funds and insurance management. The Administrator identified if Resident #2 had no personal funds, then the facility would pay for the transportation. The Administrator identified Resident #2 would refuse to go to the appointments and should be re-educated on the importance of the visit and staff should offer another day with all being documented in the clinical record. Review of the MD appointments/offsite/transportation policy directed the that the facility will assist in booking transportation for medical appointments and may provide supervision when necessary. It identified when the appointment is booked, the nurse will inform the scheduler. It further identified the facility will use insurance covered transportation whenever possible and will receive approval from the resident if the resident will be charged for transportation. Review of the resident rights policy directed that residents have the right to participate in planning care and treatment, to be fully informed of the care to be provided and the caregivers who will be providing the care and to be informed in advance about changes in their care and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #2) who required social service assistance, the facility Social Worker failed to maintain the resident's dignity and respect during a verbal altercation with the resident. The findings include: Resident #2's diagnoses included post-traumatic stress disorder, anxiety disorder, depression, and history of alcohol dependence. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable and consistent decisions regarding tasks of daily living. The Resident Care Plan dated 11/16/23 identified Resident #2 had a diagnosis of depression, was impulsive and could direct anger at others. Interventions directed to encourage Resident #2 to seek staff assistance if having difficulty with another resident, re-direct him/her if a mood change was noted, offer clear and simple explanations, and minimize information overload, report changes in mental status, encourage group activities, encourage expression of feelings, offer emotional support, and provide psychiatric services as needed. The social service note dated 1/10/24 at 3:50 PM identified on 1/10/24 the former Social Worker (SW) #2, saw Resident #2 walk behind the nurse's station on the third floor. The note indicated SW #2 told Resident #2, residents are not allowed behind the nurse's station, Resident #2 said okay and left the nurse's station. The note identified about twenty (20) minutes later Resident #2 approached SW #2 at her office screaming at her, SW #2 reminded Resident #2 he/she could not go behind the nurse's station, Resident #2 told SW #2 to not tell him/her what he/she can do and cannot do, SW #2 again reminded Resident #2 he/she is not to go behind the nurse's station as he/she is a resident and not staff and Resident #2 continued to scream at SW #2. The concern form dated 1/11/24 identified Resident #2 was displeased with how SW #2 spoke to him/her regarding a matter. The form indicated when Resident #2 went to SW #2 to let SW #2 about the dissatisfaction there was a verbal altercation between the two (2). The form identified disciplinary action was taken against SW #2. The psychiatric note dated 1/17/24 identified Resident #2 was seen for follow up for mood and reported he/she continued to be upset about the altercation that occurred with SW #2. A physician's order directed to increase the Sertraline (for depression) from 100 milligrams (mg) daily to 150 mg daily. Interview and review of the social service notes dated 1/12/24 and 1/16/24 with Social Worker (SW) #1 on 4/26/24 at 1:10 PM identified she met with Resident #2 on both occasions to follow up on the interaction that occurred on 1/10/24 with SW #2. SW #1 provided reassurance and validation to Resident #2. Interview with Resident #2 on 4/26/24 at 12:00 PM identified on 1/10/24 he/she was on the third floor visiting another resident and SW #2 told him/her that he/she was not allowed to be on the third floor. Resident #2 stated he/she did not appreciate SW #2 picking on him/her and went to SW #2's office to tell her that. Resident #1 reported SW #2 told him/her not to tell her how to do her job. Resident #2 stated during the conversation he/she received a phone call from a family member and SW #2 made a comment about the family member and then SW #2 slammed her door. Resident #2 identified he/she wrote a statement and gave it to administration regarding this event. Interview with the Administrator on 4/26/24 at 1:45 PM identified she initiated an investigation regarding the complaint Resident #2 made about the interaction with SW #2 on 1/10/24. The Administrator stated she was not able to determine the exact words that were exchanged between the two (2) but did determine a verbal altercation occurred between Resident #2 and SW #2 that other staff could hear. The Administrator identified this was an infraction of resident rights because SW #2 should have de-escalated the situation or requested assistance if needed. The Administrator indicated Resident #2 had informed her SW #2 had made a comment about a family member. Review of the facility policy for Resident Rights, revision date July 2021, directed the resident has the right to be treated with consideration, respect and full recognition of their dignity and individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, and interviews for the 1 resident (Resident #53) reviewed for activities of daily living, the facility failed to promote dignity while dining. The findings include: Resident #53 was admitted to the facility on [DATE] with diagnoses that included sleep apnea, type 2 diabetes mellitus, anxiety disorder, morbid obesity, and spondylosis. A physician's order dated 7/3/23 directed Resident #53 to be assisted 1:1 for self-feeding of all meals due to decreased bilateral upper extremity function. Resident is to be provided built-up spoon and fork with curve. Hot drinks to be provided in [NAME] spill proof straw due to decreased grip strength, with meals. The quarterly MDS dated [DATE] identified Resident #53 had intact cognition, required supervision with eating, was dependent for bathing, personal hygiene, and was on a therapeutic diet. The care plan dated 11/1/23 identified Resident #53 required staff assistance with ADL's. Interventions included delivering meals and set-up as needed and keeping commonly used/needed articles within reach. The care plan failed to identify Resident #53 required adaptive feeding equipment or a 1:1 assist for self-feeding. Observation and interview with LPN #1 on 11/30/23 at 1:00 PM identified Resident #53 was in bed, with a spoon on his/her abdomen, a fork in the bed, and a piece of food on his/her neck. Resident #53 requested that LPN #1 assist with removing the piece food from his/her neck. A 1:1 assist for self-feeding and a built-up spoon and fork were not provided with lunch. LPN #1 identified that she was unaware that Resident #53 required a built-up spoon and fork with a curve or a 1:1 assist for self-feeding of all meals. Review of resident care card dated 12/6/23 failed to identify that a 1:1 assist for self-feeding and adaptive devices were required for dining. Interview with the DNS on 12/7/23 at 11:25 AM identified that if there is an order for adaptive feeding equipment or a 1:1 assist for self-feeding then it should be followed, additionally if the resident is refusing the interventions or no longer needs the assistance then nursing should have rehabilitation services reevaluate the resident and discontinue or maintain the order for a 1:1 and the built-up utensils. Review of the facility's resident bill of rights policy directs residents to have the right to be treated with consideration, respect and full recognition of their dignity and individuality. Residents have the right to receive quality care and services with reasonable accommodation of individual needs and preferences. Review of the facility's adaptive feeding equipment policy directs the provision of appropriate equipment for eating to residents, to promote optimal level of independence with meals. Incorporate recommendations for adaptive feeding equipment into the resident's care plan and nurse aide care card. If the adaptive equipment is not received with the meal, notify the kitchen before assisting the resident to eat.

**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 care planning, the facility failed to invite the resident to participate in the quarterly care plan meetings. The findings include: Resident #67 was admitted to the facility on [DATE] with diagnoses that included cirrhosis of the liver and abdominal distention. The admission MDS assessment dated [DATE] identified Resident #67 had intact cognition and required maximum assistance with care and was dependent on staff for transfers. Review of the resident care plan sign in sheets dated 4/14/22 - 9/28/23 identified the following. a. A care plan meeting was held 7/21/22, however, the resident care plan sign in sheet identified Resident #67 had not signed in as attending. Review of the nursing and social service notes dated 7/15/22 - 7/25/22 did not reflect Resident #67 was invited to participate in his/her resident care plan meeting or had refused to attend. b. The clinical record identified a quarterly care plan meeting was not held in October 2022. Review of the nursing and social service notes dated 10/15/22 - 10/30/22 did not reflect Resident #67 was invited to participate in his/her resident care plan meeting or had refused to attend. c. The clinical record identified a quarterly care plan meeting was not held in January 2023. Review of the nursing and social worker progress notes dated 1/30/23 - 1/31/23 did not reflect Resident #67 was invited to participate in his/her resident care plan meeting or had refused to attend. d. A care plan meeting was held 4/27/23. The resident signature area on the resident care plan sign in sheet identified Resident #67's name had been printed. Review of the nursing and social service notes dated 4/20/23 - 4/30/23 did not reflect Resident #67 attended the resident care plan meeting or had refused to attend. e. The clinical record identified a quarterly care plan meeting was not held in July 2023. Review of the nursing and social service notes dated 7/1/23 - 7/31/23 did not reflect Resident #67 was invited to participate in his/her resident care plan meeting or had refused to attend. Interview with Resident #67 on 11/28/23 at 11:57 AM indicated he/she had a care plan meeting when he/she first came to the facility but has not had any other meetings with the interdisciplinary team since then. Resident #67 indicated he/she would not refuse to attend a meeting that was about his/her care or plan for discharge either to another facility or home. Interview with Resident #67 on 11/29/23 at 7:00 AM indicated he/she did not go to any care plan meeting in April or September of this year. Resident #67 indicated he/she did not have any care plan meetings with the interdisciplinary team at all this year. Interview with SW #1 on 12/7/23 at 10:04 AM indicated she follows the schedule the MDS coordinator, LPN #4, gives her. SW #1 indicated all residents are to have a resident care plan meeting every 3 months. SW #1 indicated she did not recall if they had any meetings with Resident #67. SW #1 indicated she could not recall if Resident #67 was at any of the meetings and even though his/her name was printed on the sheet for 4/27/23, and 9/28/23, she could not confirm that Resident #67 had signed it or if he/she had attended. After reviewing the sign in form for the resident care conferences, SW #1 indicated she does not know why Resident #67 was not invited the meetings that should have been scheduled in October 2022, January 2023, and July 2023. SW #1 indicated she was responsible to write a progress note after every care plan meeting, but she does not have time to put notes in. After review of the clinical record, SW #1 indicated she had not written any progress notes related to Resident #67's care plan meetings from 4/14/22 - 9/29/23, over 16 months. Interview with the MDS Coordinator, (LPN #4) on 12/7/23 at 10:07 AM identified she sends the invite letters to the family and if resident has a BIMS of 15 (cognitively intact) she gives another letter to the resident approximately 2 weeks before their quarterly care plan meeting. LPN #4 indicated for Resident #67, she would have given a letter to the family and to Resident #67. LPN #4 indicated there would be no record or documentation of who and when letters were given out other than she follows her schedule. LPN #4 indicated that all residents were to have a quarterly care plan meeting and an annual meeting with the interdisciplinary team. LPN #4 indicated she did not know why Resident #67 did not have the quarterly care plan meeting in 2022 because she started in January 2023. LPN #4 indicated she did not know why Resident #67 did not have a meeting in January 2023 because for that month, she was in training. LPN #4 indicated she could not explain why Resident #67 did not have quarterly care plan meetings in January and July of 2023. LPN #4 indicated she could not recall if Resident #67 had attended any of the resident care plan meetings. LPN #4 indicated that SW #1 was responsible for writing the progress note for each meeting and who attended or refused to attend. Interview with the DNS on 12/7/23 at 10:10 AM indicated she was not involved with the care plan meetings that it was the responsibility of the MDS coordinator who was LPN #4. Review of the Residents [NAME] of Rights Policy identified that the resident has the right to participate in planning their care and treatment, to identify individuals to be included in the care planning process, to be fully informed of the care to be provided and the caregivers who will be providing the care, and to be informed in advance about changes in their care and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation and interview for 1 of 3 residents (Resident #22), who was discharged from the facility with Medicare A days remaining, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) to the resident upon his/her discharge. The findings include: Resident #22 was admitted to the facility on [DATE] on Medicare A. Facility documentation, provided to the survey team on 11/28/23, identified Resident #22 was discharged home on [DATE] with Medicare A benefit days remaining. Interview with the RN #1 on 11/29/23 at 11:00 AM identified facility staff have looked, and they cannot find the NOMNC that had been provided to Resident #22 upon his/her discharge. Although requested, the facility could not determine if a Notice of Medicare Non-Coverage (NOMNC) had been provided to Resident #22 upon his/her discharge from the facility.

**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 #20) reviewed for communication, the facility failed to follow up on the resident's complaint of lost hearing aids. The findings include: Resident #20 was admitted to the facility with diagnoses that included mild cognitive impairment and hard of hearing. The quarterly MDS dated [DATE] identified Resident #20 had moderately impaired cognition and had moderately impaired hearing and did not have hearing aids. Additionally, resident requires extensive assistance with care. The care plan dated 3/20/23 identified resident was hearing impaired. Interventions included to offer audiology consultation as needed and gain his/her attention before attempting to communicate to resident. Review of the April and May 2023 MAR's and TAR's identified staff was not signing that the residents hearing aids were being applied in the morning and removed in the evening. Review of the nurse's notes and physician progress notes dated 4/1/23 - 5/31/23 failed to reflect the residents hearing aids were lost. A consent form dated 9/7/23 identified the resident representative signed consent for audiology, eye, dental, and podiatry consultations. As of 12/6/23 Resident #20 had not been seen by the audiologist. Interview with Resident #20 on 11/28/23 at 7:51 AM identified to be able to communicate with the resident, the surveyor had to get close to the resident's left ear and speak very loud because the resident could not hear. Resident #20 indicated his/her hearing aides were missing because someone stole them. Resident #20 indicated she does crossword puzzle books all day because she cannot hear the television that was located at the foot of his/her bed. Further, the television was on without closed captions. Resident #20 indicated he/she has asked many times for hearing aids, but they have not been provided. Resident #20 indicated the facility has not given him/her any adaptive hearing equipment to assist him/her with hearing people and the television. Interview with the Resident Representative on 12/5/23 at 12:50 PM indicated that Resident #20 had bilateral hearing aids until NA #5 gave Resident #20 a shower in April 2023. The Resident Representative indicated while visiting, he/she had spoken to LPN #6, who had informed him/her that the hearing aids went missing during the shower. The Resident Representative indicated LPN #6 told him/her to inform the social worker and indicated he/she felt since the facility lost the hearing aids during the shower, that they should have to pay to replace the hearing aids. The Resident Representative indicated she tried to call the social worker many times but never received a call back and attempted to see the social worker while visiting the facility and was always told the social worker was not available, so he/she finally just gave up. The Resident representative indicated he/she was never informed there was a concern form for missing items that he/she could fill out. Interview with LPN #6 on 12/5/23 at 1:21 PM indicated she recalls it happened a while ago. LPN #6 recalls talking to NA #5 and NA #5 had given resident #20 a shower and he thought he took the hearing aids out of the resident's ears and placed them on a shelf. LPN #6 indicated Resident #20 was bed bound and was not ambulatory at the time. LPN #6 indicated she remembers telling the Resident Representative the hearing aids were missing and to speak with the social worker. LPN #6 indicated she had informed the social worker that Resident #20's Representative wanted to speak to her about the missing hearing aids and wanted the facility to pay for the hearing aids and wanted a resolution to the missing hearing aids. LPN #6 indicated she interviewed Resident #20 at that time who was sure the hearing aids were in his/her ears when he/she got in the shower. LPN #6 indicated the nurses do not put in and take out the hearing aids and they do not sign off in the MAR or TAR. LPN #6 indicated that the hearing aids were left in the nightstands and the nurse aides were responsible to put them in and take them out each day. LPN #6 indicated she did not follow up with the Resident's Representative about the hearing aids, she just assumed the Resident Representative would take care of it. Interview with SW #1 on 12/6/23 at 11:04 AM indicated she was not aware that Resident #20 was missing any hearing aids. SW #1 indicated she had not spoken with a charge nurse or Resident #20's representative regarding hearing aids. SW #1 indicated when the hearing aids are missing, the charge nurse is responsible for informing her and if she was notified that the hearing aides were missing, she would fill out a grievance/concern form, put a note in the progress notes and then look for them. SW #1 indicated if unable to find the hearing aids she would inform nursing. SW #1 indicated it would be the responsibility of the DNS to resolve the issue. SW #1 indicated she was responsible for all grievances, concerns, and missing items (they all go on the same form). SW #1 indicated there should have been a grievance form filled out in April 2023 for the hearing aids if they were lost in the shower and the facility probably would have paid to replace them. Review of the grievance/concern log from 1/1/23 - 11/30/23 by SW #1 identified there was not grievance or concern form for Resident #20's hearing aids. Interview with the DNS on 12/6/23 at 11:15 AM indicated the expectation was that the nurses would sign off that they put the hearing aids in each morning and sign off that they remove them at bedtime. After clinical record review, the DNS indicated there wasn't a physician order to put in or remove the hearing aids. The DNS indicated the reason for the nurses to sign off is if the hearing aids go missing, they can take further steps right away. The DNS indicated that without the documentation on the for the hearing aids she cannot tell exactly when they got lost. The DNS indicated she was not aware that Resident #20 was missing the hearing aids, and the nurse should update the supervisor and the facility should have been responsible to replace them. The DNS indicated the supervisor should have updated the Administrator to get them replaced. The DNS indicated she needed to review the missing item or hearing aid policy. Review of the missing item policy by the DNS indicated the nurse should have notified the family and appropriate department head which would be the social worker and document in the resident's medial record. After reviewing the hearing aid policy by the DNS she indicated the license staff were supposed to be responsible to make sure the hearing aides were in place and document on the TAR or MAR of the placement in the morning and removal. The DNS indicated she does not know why this was not done but will make sure moving forward that the nurses are signing off for the hearing aids. Interview with Administrator and Corporate RN #1on 12/6/23 at 11:50 AM indicated when the nurse is first aware that hearing aides are missing, she must notify the social worker and the nurse or social worker can fill out the grievance form. The Administrator indicated the staff will look for the hearing aids and if not found the facility would replace them. The Administrator indicated the grievance needs to have resolution within 72 hours. The Administrator indicated she was not aware until today that Resident #20 was missing the hearing aids since April 2023. Corporate RN #1 indicated that the facility will complete the grievance form now and offer the resident an amplifier with headphones so he/she could watch television. Interview with NA #5 on 12/6/23 at 2:52 PM indicated he recalls that he had brought Resident #20 into the shower back in April 2023 on a Friday during the 3:00 -11:00 PM shift. NA #5 indicated he had started giving the shower when Resident #20 informed him that he/she still had the bilateral hearing aids in. NA #5 indicated that he removed the hearing aids and placed them on a shelf in the shower room. NA #5 indicated later that Friday evening the resident requested his/her hearing aids back, so he went back to the shower room to retrieve them, and they were gone. NA #5 indicated that he did inform the charge nurse but does not recall who the charge nurse was. Review of the facility Concern Forms Procedure identified it was the right of the resident and/or representative to have prompt and reasonable resolution of a complaint/concern without any discrimination. The concern form should be completed as soon as possible. The social worker was responsible for ensuring that all concern forms were completed with appropriate follow up to ensure that a reasonable resolution has been made. A resolution from the appropriate department should be determined in a reasonable amount of time. The resolution should be documented in the medical record. The resident and/or resident representative should be informed of the resolution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #80) reviewed for preadmission screening and resident review (PASARR), the facility failed to ensure a Level 1 PASARR screening was completed prior to admission to the facility. The findings include: Resident #80 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, major depressive disorder, and vascular dementia. The annual MDS dated [DATE] identified Resident #80 had severely impaired cognition and delusions as a potential indicator of psychosis, in the last 7 days. The care plan dated 8/31/23 identified Resident #80 had a disruption in cognitive operations and activities, had exhibited compulsive/delusional behaviors, and could be accusatory, at times. Interventions included discussing with the resident alternative ways to express emotion and release physical tension, involve the resident in treatment planning and decision making, and consulting psychiatric services, as needed. The care plan further identified Resident #80 was at risk for potential adverse effects of psychotropic medication use for diagnoses of dementia, bipolar, and anxiety. Interventions included for staff to be aware of Resident #80's interactions with other residents, identify common behavioral expressions and expected responses to interventions, implement appropriate person-centered interventions, and document the responses. Review of the Notice of PASARR Level 1 Screen Outcome report dated 12/1/23 identified a PASARR Level 2 onsite evaluation must be conducted for Resident #80. The report further identified that this review was a compliance issue, due to Resident #80's admission to the nursing facility without a Level 1 PASARR screen. Resident #80 was admitted on [DATE] and no Level 1 PASARR was submitted until 11/19/23. Interview with SW #1 on 12/6/23 at 1:15 PM identified that Resident #80 was an out of state transfer so he/she did not come to the facility with a completed Level 1 PASARR. SW #1 further identified that she did not submit a Level 1 PASARR when Resident #80 was admitted because he/she was self-pay, and she did not think there was a requirement to complete a Level 1 PASARR for a resident that was self-pay. SW #1 indicated that Resident #80 now had Medicaid pending so she was told that a Level 1 PASARR needed to be completed, and a Level 1 PASARR screening was completed on 11/20/23. SW #1 further indicated that a Level 2 PASARR evaluation was recommended and a Level 2 PASARR onsite evaluation was scheduled. Interview with the Admissions Coordinator on 12/7/23 at 9:20 AM identified her responsibilities related to PASARR include requesting, from the hospital, a completed PASARR for any resident that receives a bed offer to this facility. Once the resident is admitted to the facility, the business office will admit the resident into the online portal, then the social worker will handle the process from there. The admissions coordinator further identified that she is unsure of the process if there is no Level 1 PASARR completed once the resident arrives at the facility. The admissions coordinator indicated that the business office manager that was in place at the time of Resident #80's admission to the facility, is no longer employed at the facility and not available on-site for an interview. Review of the facility's preadmission screening and resident review (PASARR) policy directs all admissions will have an approved PASARR. A level 1 (preliminary assessment) screen will be done to determine if there is mental illness or mental retardation. Those individuals who test positive for a level 1 will then be evaluated in depth with a level 2 PASARR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to form the individual's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #53) reviewed for rehabilitation and restorative services, the facility failed to develop a comprehensive care plan that included interventions for refusals of care and refusals of specialized rehabilitation services and for 1 of 3 residents (Resident #54) reviewed for pressure ulcers, the facility failed to develop a comprehensive care plan following the onset of a new pressure ulcer. The findings include: 1. Resident #54 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, hemiplegia, and gastrostomy status. The nursing admission assessment dated [DATE] identified Resident #54 had bilateral heel deep tissue injuries, an ulcer to the back of the head, and a stage 3 pressure ulcer to the coccyx. Special treatments included skin prep to the bilateral heels and daily dressing changes to the back of the head and coccyx. The nursing admission assessment further identified Resident #54 had a Braden score of 11 (high risk). The admission MDS dated [DATE] identified Resident #54 had moderately impaired cognition and the number of unhealed pressure ulcers/injuries present on admission included 1 stage 3 pressure ulcer and 2 unstageable pressure injuries presenting as deep tissue injuries. The care plan dated 10/9/23 identified Resident #54 was at risk for skin breakdown due to decreased mobility, incontinence, and other risk factors including poor nutrition, pronounced body prominences, poor circulation, altered sensation, and mechanical forces. Interventions included offloading heels while in bed and completing a Braden scale upon admission/readmission and as per facility policy. The nurse's note dated 11/21/23 at 1:34 PM identified that Resident #54's heel was cleansed with normal saline and the wound nurse was notified of opening. The wound physician's note dated 11/24/23 identified Resident #54 had a new open area on the right heel, was wearing offloading boots, and getting regular moisturizing. The right heel wound was a stage 2 pressure injury pressure ulcer with a status of not healed. Initial wound encounter measurements were 1.5cm length x 1cm width x 0cm depth. The peri-wound skin color, texture, and moisture were normal. Interview and clinical record review with the ADNS on 12/1/23 at 2:50 PM, failed to provide documentation to reflect that Resident #54's comprehensive care plan was updated to include goals and interventions for the new right heel pressure ulcer. The ADNS indicated that she would expect the care plan to be updated with information including the location and interventions for the new pressure ulcer. Interview and clinical record review with the DNS on 12/6/23 at 3:34 PM identified that she would expect the care plan to have been updated following the onset of a new pressure ulcer. The DNS further identified that she would expect to see details about the wound noted in the care plan such as interventions and goals; wound measurements and characteristics such as odor and drainage should be recorded in a progress note. The DNS indicated that she would expect the nurse that identified the wound and the wound nurse to be responsible for updating the care plan. Review of the facility's care planning policy directs a comprehensive and individualized plan of care will be developed for each resident. The care plan will guide caregivers to assist residents to achieve or maintain their highest practical level of well-being. The care plan is reviewed and updated at least quarterly and as necessary to reflect changes in the resident's status. Review of the facility's wound and skin care protocols directs the interdisciplinary team to address problems, goals, and interventions directed toward the prevention and/or treatment of impaired skin integrity/pressure ulcer, consistent with resident/family goals. The care plan including the admission/readmission care plan will address preventative and/or treatment of impaired skin integrity/pressure ulcer. 2. Resident #53 was admitted to the facility on [DATE] with diagnoses that included spondylosis, intervertebral disc displacement, and cervicalgia. The nurse's notes dated 8/1/23 through 12/6/23 identified Resident #53 had 32 documented refusals of care or refusals of specialized rehabilitation services. The concern form dated 9/11/23 identified Resident #53 indicated that he/she was not being taken out of bed and put into a chair on Monday, Wednesday, and Friday (MWF). The summary of findings identified that Resident #53 had been refusing to get out of bed when offered by staff and the staff failed to document it. Recommendations were to ensure Resident #53 gets out of bed, per the MWF schedule, and if he/she refuses multiple approaches are recommended, as well as documentation of the refusal. The quarterly MDS dated [DATE] identified Resident #53 had intact cognition, was dependent for bathing, personal hygiene, rolling left to right, and laying to sitting. The quarterly MDS further identified Resident #53 was administered 60 minutes of occupational therapy and 75 minutes of physical therapy over a 7 day look back period. The care plan dated 11/1/23 identified Resident # 53 required staff assistance with ADL's. Interventions included to deliver meals and set-up as needed, keep commonly used/needed articles within reach, PT and OT services as ordered, and at times Resident #53 may refuse a shower: attempt to redirect and provide a full bed bath should he/she continue to refuse. The care plan further identified Resident #53 was admitted to the facility for short term rehabilitation (STR) after being hospitalized for STR. Interventions included establishing a discharge plan with Resident #53 and his/her family, evaluate progress and make revisions as needed, encourage participation in scheduled therapy sessions, provide PT/OT/ST services per the physician's order, and evaluate/record strengths with appropriate parties, determine and address gaps in the resident's abilities that will affect discharge. The care plan failed to identify a focused plan of care and interventions for Resident #53's refusals of care and refusals of specialized rehabilitation services. A physician's order dated 11/23/23 directed for occupational therapy (OT) 3 times, weekly, for 4 weeks (recertification effective 11/23/23 through 12/22/23). The occupational therapy recertification and updated plan of treatment report dated 11/23/23 directed for Resident #53 to continue necessary OT services in order to facilitate sitting tolerance and postural control, provision of modalities and strengthening, increase functional actively tolerance, develop and instruct on compensatory strategies and maximize independence with ADLs in order to enhance quality of life by improving ability to perform ADLs with increased independence and safety, facilitate increased participation with functional daily activities, decrease risk for falls, improve functional use of upper extremities during ADLs and facility ability to live in environment with the least amount of supervision and assistance. Interview with Resident #53 on 11/28/23 at 12:10 PM identified that he/she was working with PT and OT, but progress was not being made so those services were canceled. Resident #53 further identified that he/she was scheduled to get out of bed to the chair with OT every Monday, Wednesday, and Friday, but that was not regularly occurring. Interview with Resident #53 on 11/29/23 at 2:45 PM identified that he/she did not get out of bed to the chair today due to abdominal discomfort after eating lunch. Interview with NA #4 on 12/1/23 at 1:17 PM identified that Resident #53 has refused care when it was offered indicating that he/she is in pain or does not want to be touched; Resident #53 is inconsistent with his/her reports. NA #4 indicated that the nurse aides will reproach Resident 3-4 times over a shift to offer care, and then they will report the refusals to the nurse or supervisor. Interview and clinical record review with the ANDS on 12/1/23 at 1:57 PM identified that Resident #53 has chronically refused care and rehabilitation services. The ADNS further identified that Resident #53's care plan reflects, at times, he/she will refuse showers, but there is no care plan for refusals to get out of bed or refusals for specialized rehabilitation services. Observation on 12/1/23 at 3:10 PM identified Resident #53 was transferred via a hoyer lift with an assist of 3 facility staff members to a customized wheelchair. Interview with Resident #53 on 12/5/23 at 11:00 AM identified that he/she did not get out of bed on Wednesday, 12/4/23, because he/she was not feeling well after starting a new diabetic medication. Interview with the Rehabilitation Therapy Director on 12/5/23 at 12:27 PM identified that Resident #53 is scheduled to get out of bed on Monday, Wednesday, and Fridays from 1:30 PM -4:30 PM. The Rehabilitation Therapy Director indicated that Resident #53 has refused the intervention approximately 50% of the time; Resident #53 will indicate that he/she isn't feeling well and is unable to get out of bed to the chair. The Rehabilitation Therapy Director identified that Resident #53 refused to get out of bed, the day prior, on 12/4/23, because he/she had been started on a new medication and was not feeling well; the therapy director indicated he would attempt to get Resident #53 out of bed into the chair, today. The Rehabilitation Therapy Director further identified that it is the responsibility of the unit nurses and nurse aides to get Resident #53 out of bed to a chair, but he makes himself available to assist staff. The Rehabilitation Therapy Director identified that when he puts Resident #53's knee-foot orthotic on he will encourage and discuss with him/her the plan to get out of bed to the chair; sometimes Resident #53 will refuse to get out of bed with OT and sometimes he/she will refuse with the nurse aides. The Rehabilitation Therapy Director indicated that Resident #53's representative was aware of his/her refusals to get out of bed and education has been provided to both parties. Interview with LPN #3 on 12/5/23 at 2:24 PM identified that Resident #53 will refuse to get out of bed, and that a reason for the refusal may not be provided other than he/she does not want to get out of bed. Interview with the Physiatrist (MD#1) on 12/6/23 at 1:21 PM identified that Resident #53 has refused care and treatment attempts to get out of bed. MD #1 further identified that multiple treatment modalities and medication regimens have been attempted. Interview and clinical record review with the DNS on 12/6/23 at 4:04 PM failed to identify a comprehensive care plan addressing refusals of care and therapeutic services such as PT and OT. The DNS further identified that she would expect to see a care plan for refusals of care and refusals to get out of bed for specialized rehabilitation services, as well as documentation in the progress note of the refusal. Review of the facility's care planning policy directs a comprehensive care plan based on the identified needs, strengths, and preferences of the resident will be developed no later than 7 days after the completion of the admission MDS. The care plan is developed by the interdisciplinary team (IDT) in collaboration with the resident and/or responsible party and the resident's physician. The IDT may include, but is not limited to, the resident care coordinator, charge nurse, nurse aide, dietary manager, dietitian, social worker, rehabilitation therapist, and activities director.

**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 #53 and 67) reviewed for activities of daily living, the facility failed to conduct quarterly resident care conferences and/or invite the resident to attend the meetings. The findings include: 1. Resident #53 was admitted to the facility on [DATE] with diagnoses that included sleep apnea, type 2 diabetes mellitus, anxiety disorder, morbid obesity, and spondylosis. Review of the resident care plan sign-in sheet identified a resident care conference was held on 3/22/23. The quarterly MDS dated [DATE] identified Resident #53 had intact cognition, was always incontinent of bowel and bladder, required supervision with eating, was dependent for bathing, personal hygiene, rolling left to right, laying to sitting, and was on a therapeutic diet. The care plan dated 11/1/23 identified Resident #53 was admitted to the facility for short term rehabilitation (STR) after being hospitalized for STR. Interventions included establishing a discharge plan with Resident #53 and his/her family, evaluate progress and make revisions as needed, social services will be available to the resident and family to answer any questions or concerns, and evaluate/record strengths with appropriate parties, determine and address gaps in the resident's abilities that will affect discharge. Review of the resident care plan sign-in sheet identified a resident care conference was held on 11/1/23. Interview with Resident #53 on 11/28/23 at 12:10 PM identified that he/she was unaware of the last resident care conference (RCC) meeting that he/she had participated in. Resident #53 further identified that last Thursday a two-minute meeting with two staff members took place in his/her room. Resident #53 called into question if that could have been the meeting this writer was referring to. Interview with SW #1 on 12/6/23 at 3:17 PM identified that she participated in a RCC for Resident #53 back in September or October. SW #1 further identified that the MDS coordinator schedules and retains documentation for the RCC meetings. Interview and clinical record review with the MDS coordinator (LPN #4) on 12/6/23 at 3:21 PM identified RCC meeting are completed quarterly; after the MDS is completed, an RCC should follow within 21 days. LPN #4 indicated that she is responsible for scheduling RCC meetings, and she was unsure why no RCC was completed for Resident #53 after the 3/22/23 RCC and before the 11/1/23 RCC. LPN #4 further indicated that the last care conference was held on 11/1/23, in the resident's room; attendees were Resident #53, SW #1, and herself. LPN #4 identified that during morning report she will notify the IDC team of all upcoming RCC meetings, to encourage attendance from other disciplines. LPN #4 further identified that when she gave Resident #53 the invitation for the November RCC, his/her resident representative was present and received the invitation, as well; the invitation was given with one month's notice to allow the opportunity to reschedule, if necessary. LPN #4 indicated that documentation in the resident's clinical record is usually completed by social services, and that she was told to document the RCC meeting on the resident care plan form and retain it in a binder. Interview with the DNS on 12/6/23 at 4:05 PM indicated that she was unable to confidently speak to the process related to RCC meetings, and she further indicated that the MDS coordinator completes these meetings. Review of the facility's care planning policy directs a care conference to discuss the plan of care to be held on or before day 21 from admission and then at least quarterly. The resident and/or family/responsible party will be invited to attend all care plan conferences. 2. Resident #67 was admitted to the facility on [DATE] with diagnoses that included cirrhosis of the liver and abdominal distention. The admission MDS dated [DATE] identified Resident #67 had intact cognition and required maximum assistance with care and dependent on staff for transfers. Review of the census report for Resident #67 there were no transfers out of facility for extended periods of time. Review of the Resident Care Plan sign in sheets dated 4/14/22 - 9/28/23 identified the following. a. 7/21/22 a meeting was held no signature of Resident #67. Review of the nursing and social worker progress notes dated 7/15/22 - 7/25/22 did not reflect Resident #67 was invited to participate in his/her resident care plan meeting or had refused to attend. b. 10/20/22 meeting was not held. Review of the nursing and social worker progress notes dated 10/15/22 - 10/30/22 did not reflect Resident #67 was invited to participate in his/her resident care plan meeting or had refused to attend. c. January 2023 meeting was not held. Review of the nursing and social worker progress notes dated 1/30/23 - 1/31/23 did not reflect Resident #67 was invited to participate in his/her resident care plan meeting or had refused to attend. d. 4/27/23 a meeting was held and Resident #67's name is printed on the form in the signature area. Review of the nursing and social worker progress notes dated 4/20/23 - 4/30/23 did not reflect Resident #67 attended the resident care plan meeting or had refused to attend. e. July 2023 meeting was not held. Review of the nursing and social worker progress notes dated 7/1/23 - 7/31/23 did not reflect Resident #67 was invited to participate in his/her resident care plan meeting or had refused to attend. Interview with Resident #67 on 11/28/23 at 11:57 AM indicated he/she had a care plan meeting when he/she first came to the facility but has not had any other meetings every 3 months with the interdisciplinary team since. Resident #67 indicated he/she would not refuse to attend a meeting that was about his/her care and plan for discharge either to another facility or home. Interview with Resident #67 on 11/29/23 at 7:00 AM indicated he/she did not go to any care plan meeting in April or September of this year. Resident #67 indicated he/she did not have any care plan meetings with the interdisciplinary team at all this year. Interview with SW #1 on 12/7/23 at 10:04 AM indicated she follows the schedule the MDS coordinator LPN #4 gives her. SW #1 indicated all residents are to have a resident care plan meeting every 3 months. SW #1 indicated she did not recall if they had any meetings with Resident #67. SW #1 indicated she could not recall if Resident #67 was at any of the meetings and even though the residents name was printed on the sheet for 4/27/23 and 9/28/23 she could not confirm that Resident #67 had signed it or that he/she had attended. Review of the sign in form for the resident care conferences, SW #1 indicated she does not know why Resident #67 was not invited or attend the meetings that should have been scheduled in October 2022, January 2023, and July 2023. SW #1 indicated she was responsible to write a progress note after every care plan meeting, but she does not have time to put notes in. After review of the clinical record, SW #1 indicated she had not put in any progress notes related to Resident #67's care plan meetings from 4/14/22 - 9/29/23. Interview with MDS Coordinator, (LPN #4) on 12/7/23 at 10:07 AM indicated she send the invite letters to the family and if resident has a BIMS of 15 (cognitively intact) she gives another letter to the resident approximately 2 weeks before their quarterly meeting. LPN #4 indicated for Resident #67 she would have given a letter to the family and to Resident #67. LPN #4 indicated there would be no record or documentation of who and when letters were given out other than she follows her schedule. LPN #4 indicated that all residents were to have a quarterly meeting and an annual meeting with the interdisciplinary team. LPN #4 indicated she did not know why Resident #67 did not have the quarterly meetings in 2022 because she started in January 2023. LPN #4 indicated she did not know why Resident #67 did not have a meeting in January 2023 because for that month she was in training. LPN #4 indicated she could not explain why Resident #67 did not have quarterly meetings in January and July of 2023. LPN #4 indicated she could not recall if Resident #67 had attended any of the resident care plan meetings. LPN #4 indicated that SW #1 was responsible for writing the progress note for each meeting and who attended or refused to attend. Interview with the DNS on 12/7/23 at 10:10 AM indicated she was not involved with the care plan meetings that it was the responsibility of the MDS coordinator who was LPN #4. Review of the facility Care Planning Policy identified it was to ensure a resident has a comprehensive and individualized plan of care. The care plan is developed by the Interdisciplinary team in collaboration with the resident and/or residents' representative and the resident's physician. The IDT may include but not limited to, the MDS coordinator, charge nurse, nursing assistant, dietary manager, dietitian, social worker, rehab therapists, and activities director. A care conference is to discuss the plan of care and will be held on or before day 21 from admission and then at least quarterly. The resident and/or resident representative will be invited to attend all care plan conferences.

**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 #451) reviewed for accidents, the facility failed to administer medications according to professional standards of practice to prevent a medication error, and as a result, a medication that the resident had an allergy to was administered. The findings include: Resident #451 was admitted to the facility on [DATE] with diagnoses that included Sjogren syndrome, anxiety disorder, chronic pain. Further, Resident #451 had an allergy to acetaminophen. The admission MDS dated [DATE] identified Resident # 451 had intact cognition, with supervision needed for bed mobility, transfers, locomotion and dressing. A physician's order dated 10/17/22 directed to administer Oxycodone 5mg daily for pain for 10 days as needed, expiring on 10/27/22. The nurse's note dated 10/28/22 at 6:16 AM by RN #5 identified Resident #451 was given Oxycodone-Acetaminophen (Percocet) about 12:10 AM instead of Oxycodone 5mg by the nurse on the 3rd floor. The APRN was notified who ordered Diphenhydramine to be given every 6 hours. Resident #451 reported itching and it was given Diphenhydramine at 2:00 AM with good effect. The nurse's note by LPN #10 dated 10/28/22 at 7:45 AM identified that Resident #451 complained of back pain around 12:30 AM and requested Oxycodone 5mg. Resident #451's narcotic medications were not available in the facility, and LPN #10 asked RN #5 (RN Supervisor) to access the e-Box to secure the facility's supply of narcotics. RN #5 unlocked the e-Box, looked through the locked e-Box, and handed the medications to LPN #10 who looked through the medications and took what she believed to be Oxycodone 5mg. LPN #10 indicated she handed the medication to RN #5 to verify the medication as correct and he handed it back to LPN #10 and started signing it out in the narcotic book as LPN #10 documents she went to administer the medication to the resident. LPN #10 indicated RN #5 advised her after the medication administration that the medication was not the correct medication. Resident #451 complained of itching around the face and chest area 30 minutes after the administration, the APRN was notified, and Diphenhydramine (an antihistamine) was ordered and given at 2:00 AM. The nurse's note further indicates that the Diphenhydramine was effective as Resident #451 stated the itching went away and was able to sleep. A review of Resident #451's status as documented in the nurse's notes is outlined as follows: 10/28/22 at 2:48 PM indicated Resident #451 complained of chest pain, and the APRN was notified ordering an antacid, and a proton pump inhibitor immediately, and if no effect send Resident #451 to the emergency room for evaluation, continued complaint of back itchiness. 10/29/22 at 7:23 AM identified Resident #451 identified vomiting and diarrhea for past 2 days, APRN ordered Zofran next shift noted to follow up. 10/29/22 1:33 PM identified Resident #451 complained of itchiness and vomited once this shift, resident was given Diphenhydramine and encouraged to consume some food, resident indicated unable to keep anything down last night. 10/29/23 at 2:52 PM identified Resident #251 indicated still has loose stools less frequent, and itchiness was diminished, resident has anxiety regarding situation. 10/30/22 at 11:32 AM indicates Resident #451 complained of shakes, tightness in chest and weakness and states subjectively I feel like my body is vibrating, I cannot keep anything down. A muscle relaxant, inhaler and Diphenhydramine administered, fluids encouraged, ate one banana, vitals BP 131/98, O2 100%, respirations 19 Heart rate 97 bpm. Pain rate 7-10. Resident refused Oxycodone 5mg. 10/30/22 at 5:01 PM identified Resident #451 continues to complain of heaviness in chest vitals 131/98, no changes in mental status, respiratory or GI observed. Resident #451 is allergic to acetaminophen and administered to resident on morning of 10/28/23 and resident started reacting to Percocet with generalized itching, especially on ears, progressed to heaviness on chest but resident denies having trouble breathing, feels like something was crushing chest but isn't having problems breathing. Physician notified, ordered Resident #451 to be transferred to hospital for evaluation. 10/31/22 at 1:47 AM Resident #451 returned from ED, while at ED was given EpiPen, IV fluid, chest x-ray and labs done negative. Sent back to facility when stabilized, resident states feeling better. Physician's order dated 10/30/22 indicated Resident #451 agrees to be evaluated by allergist at hospital ED because of med allergy to acetaminophen which was given on 10/26/22 and the resident felt itchy. Given Diphenhydramine and not continuing to have tightness of chest with breathing. Physician's note date 10/30/22 identified Resident #451 has allergy to acetaminophen and was given acetaminophen on 10/27/22, had a red hive, feeling itching in legs and thighs, requiring Diphenhydramine. Resident #451 has a history of allergy to acetaminophen, no complaints of tightness in the chest on deep breathing past 2 - 3 days. Chest has no wheezing but on left side of thighs and legs fees itch, has some tightness on deep breathing, previously refused ED evaluation now reconsiders and agrees to go to ED for evaluation by an allergist. Discharge summary from hospital 10/31/22 identified Resident #451 was asked to be seen by physician identified the itching resolved after EPI pen administration in the emergency room yesterday and Resident #451 continues to complain of chest tightness. Resident presents as improving clinically, Diphenhydramine to be given as needed. Facility document Disciplinary Action dated 11/11/22 identified LPN #10 received disciplinary action for the administration of an incorrect medication to Resident #451 causing an allergic reaction. Interview with the DNS on 12/7/23 at 2:20 PM identified both RN #5 and LPN #10 were disciplined. The facility's policy on accident reporting states all events involving any resident as defined by the public health code must be reported: Class D: an event which has caused or resulted in a serious injury or a significant change in a resident's condition; and event which involves a medication error of clinical significance. Clinical significance is defined as an event that adversely alters a resident's mental or physical condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for the 1 resident (Resident #53) reviewed for activities of daily living, the facility failed to provide a dependent resident with weekly showers. The findings include: Resident #53 was admitted to the facility on [DATE] with diagnoses that included sleep apnea, type 2 diabetes mellitus, anxiety disorder, morbid obesity, and spondylosis. A physician's order dated 3/7/23 directed staff to provide a shower every Saturday on the 7:00 AM - 3:00 PM shift. Review of the TAR's dated 9/1/23 through 12/6/23 failed to identify Resident #53 refused showers, the documentation identified showers were given weekly on the scheduled shower days, Saturday 7:00 AM - 3:00 PM. Review of the nurse's note dated 9/1/23 through 9/30/23 identified a progress note dated 9/2/23 indicating Resident #53 refused a shower/bed bath twice, this shift. Review of the nurse's notes dated 10/1/23 through 12/6/23 failed to identify Resident #53 refused scheduled showers or notification of the refusals made to the resident representative. The quarterly MDS dated [DATE] identified Resident #53 had intact cognition, was dependent for bathing, personal hygiene, rolling left to right, and laying to sitting. The facility assessment with a revision date of 10/21/23 identified special care needs provided at the facility included: hospice, ostomy care, bariatric care, palliative care, and end of life care. The care plan dated 11/1/23 identified Resident #53 required staff assistance with ADL's. Interventions included assist as needed to meet toileting needs, transfer per physician's orders, assist with ADL's as needed, and at times Resident #53 may refuse a shower: attempt to redirect and provide a full bed bath should he/she continue to refuse. Interview with Resident #53 on 11/28/23 at 12:10 PM identified he/she had not received a shower since prior to admission, and that the facility staff has only offered and provided bed baths. Resident #53 indicated that originally the facility did not have the appropriate bariatric equipment to provide a shower; and only recently had an appropriately sized shower chair been ordered. Resident #53 further indicated that staff members state that he/she refuses showers, but Resident #53 identified that he/she does not refuse showers but has requested to have care provided at a later time. Interview and clinical record review with the ADNS on 12/1/23 at 1:57 PM failed to identify Resident #53's shower refusals, in recent times, and documentation indicated that bed baths were being documented as showers. The ADNS indicated that Resident #53 was scheduled to receive a shower on Saturdays during the 7:00 AM - 3:00 PM shift, but he/she has not been receptive to showers; chronically refusing showers or requesting the shower to be provided at a later time with no specific reason for refusal. The ADNS identified that the facility had a bariatric shower gurney, and while it would accommodate Resident #53's weight it did not safely or comfortably accommodate his/her width, additionally two bariatric shower chairs were requested: one was received from a sister facility on 10/27/23 (which the facility staff believed would not accommodate Resident #53's width or allow for proper cleaning) and the other chair was received on Monday. Subsequent to surveyor inquiry on 12/2/23 Resident #53 was Hoyer-lifted into a bariatric shower chair and received a shower. Interview with LPN #3 on 12/5/23 at 2:24 PM identified that Resident #53's primary nurse was on vacation, but that she had provided care for Resident #53, and he/she has refused showers. LPN #3 indicated that there is no specific reason for refusal, that he/she does not want to have a shower. LPN #3 indicated that Resident #53 prefers bed baths, and his/her resident representative is aware of the refusals for showers. LPN #3 further indicated that Resident #53 was showered in a shower chair, on 12/2/23 and did well, with no refusal. Interview with NA #2 on 12/5/23 at 2:33 PM identified Resident #53 refuses showers without providing a specific reason for refusal, sometimes Resident #53 will identify pain as a reason for refusal. NA #2 indicated that she will offer Resident #53 a shower on Saturday mornings, and if he/she refuses she will reattempt after breakfast and if he/she refuses again then she will provide a bed bath. If Resident #53 refuses the shower or bed bath after the second attempt she will notify the nurse and the nurse will talk to the resident. NA #2 identified that 12/2/23 was the first time she brought Resident #53 into the shower room and used the new chair that was just received. The nurse's note dated 12/5/23 at 4:49 PM identified that the writer went to speak with Resident #53 about his/her recent shower and the experience. Resident #53 indicated that it went well and did not have any concerns, he/she further indicated that there were no issues sitting in the chair and is looking forward to the next shower. Interview and clinical record review with the DNS on 12/6/23 at 4:04 PM failed to identify that showers were provided on Resident #53's scheduled shower days during the month of November 2023; on 11/4/23 Resident #53 refused to get out of bed and was given a bed bath, but the documentation failed to identify why he/she refused a shower. The DNS further identified that there was no documentation for refusals of showers on 11/11, 11/18, or 11/25/23. The DNS indicated that Resident #53 has orders for a shower on the day shift on Saturdays and outside of a refusal she would expect that the shower is given; in the case of a refusal, she would expect documentation of the refusal to be recorded in the clinical record and notification of the refusal to the resident representative. The DNS indicated that bariatric equipment is ordered from an outside supplier, if the facility does not have it in the facility at the time of admission, and within the resident's first week of admission they would ensure the proper equipment is in place for the resident. The DNS indicated that she was unable to confirm if an appropriate bariatric shower chair was in place at the time of Resident #53's admission to the facility. Review of the facility's bathing/showering policy directs each resident will be offered a full bath/shower weekly.

**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 #20) reviewed for communication, the facility failed to assist the resident to replace hearing aids when they were lost. The findings. Resident #20 was admitted to the facility with diagnoses that included mild cognitive impairment and hearing impairment. The quarterly MDS dated [DATE] identified Resident #20 had moderately impaired cognition, moderately impaired hearing and did not have hearing aids Additionally, the resident required extensive assistance with care. The care plan dated 3/20/23 identified the resident was hearing impaired. Interventions included to offer audiology consultation as needed and gain his/her attention before attempting to communicate to resident. Review of the MAR and TAR's dated 4/1/23 - 5/31/23 identified nurses were not documenting if hearing aids were being applied or removed daily. Review of the nurse's notes and physician progress notes dated 4/1/23 - 5/31/23 did not identify that the residents hearing aids were missing and that the resident representative and physician had been notified. An audiology consultant consent form dated 9/7/23 identified the resident representative signed consent for audiology, eye, dental, and podiatry. In an interview with Resident #20 on 11/28/23 at 7:51 AM, the resident identified the surveyor would have to get close to his/her left ear and speak very loud because he/she could not hear. Resident #20 indicated his/her hearing aides were missing because someone stole them and identified he/she does crossword puzzle books all day because he/she cannot hear the television that was located at the foot of his/her bed. The television was observed to be on without closed captioning enabled. Resident #20 indicated he/she has asked many times for hearing aids but has had no response. Resident #20 indicated the facility did not give him/her anything else like an amplifier box to assist him/her with hearing people and the television. Interview with Person #1 on 12/5/23 at 12:50 PM indicated that Resident #20 had bilateral hearing aids until NA #5 gave Resident #20 a shower in April 2023. Person #1 indicated while visiting, he/she had spoken to LPN #6, who had informed him/her that the hearing aids went missing during the shower. Person #1 indicated LPN #6 told him/her to inform the social worker. Person #1 identified since the facility lost the hearing aids that they should have to pay to replace the hearing aids. Person #1 indicated she tried to call the social worker many times but never received a call back and attempted to see the social worker while visiting the facility and was always told the social worker was not available. Person #1 stated he/she finally just gave up and indicated he/she was never informed there was a concern form for missing items that he/she could fill out. Interview with LPN #6 on 12/5/23 at 1:21 PM indicated she recalls the hearing aides were lost a while ago maybe April or May 2023. LPN #6 recalls talking to NA #5 who had given the resident a shower and he thought he took them out of the resident's ears and placed them on a shelf. LPN #6 indicated Resident #20 was bed bound and was not ambulatory at the time. LPN #6 indicated she remembers telling Person #1 the hearing aids were missing and to speak with the social worker but was unable to find the documentation. LPN #6 indicated she had informed the social worker that Person #1 wanted to speak to her about the missing hearing aids and that Person #1 wanted the facility to pay for the hearing aids and wanted a resolution to the hearing aids. LPN #6 indicated she interviewed Resident #20 at that time who was sure they were in his/her ears when he/she went into the shower. LPN #6 indicated the nurses do not put in and take out the hearing aids and they do not sign off in the MAR or TAR. LPN #6 indicated that the hearing aids were left in the nightstands and the nurse's aides were responsible to put them in and take them out each day. LPN #6 indicated she did not follow up with the Person #1 about the hearing aids because she just assumed the Person #1 would take care of it. Interview with SW #1 on 12/6/23 at 11:04 AM indicated she was not aware that Resident #20 was missing any hearing aids. SW #1 indicated she had not spoken with a charge nurse or Person #1 regarding the hearing aids. SW #1 indicated when the hearing aids went missing, the charge nurse was responsible to notify her. SW #1 indicated if she was notified that the hearing aids were missing, she would have filled out a grievance/concern form, put a note in the progress notes and then look for them. SW #1 indicated if she was unable to find the hearing aids, she would inform nursing. SW #1 indicated it would be the responsibility of the DNS to resolve the issue. SW #1 indicated she was responsible for all grievances, concerns, and missing items (they all go on the same form). SW #1 indicated there should have been a grievance form filled out in April 2023 for the hearing aids if they were lost in the shower and the facility probably would have paid to replace them. Review of the grievance/concern log from 1/1/23 - 11/30/23 by SW #1 indicated Resident #20's name did not appear nor did the lost hearing aids. SW #1 indicated the DNS and Administrator would do the resolution and once completed would return to her as the social worker for the book with a receipt or education attached. Interview with the DNS on 12/6/23 at 11:15 AM identified that with hearing aids, it is her expectation that the nurses document daily that the hearing aids are put in and removed at bedtime. After clinical record review, the DNS indicated there was no physician's order to put in and remove the hearing aids. The DNS indicated the reason that the nurses are responsible for documenting every day that the hearing aids are put in and removed is if the hearing aids go missing, they can take further steps right away. The DNS indicated that without the documentation on the TAR for the hearing aid(s) she cannot tell exactly when they got lost. The DNS indicated she was not aware that Resident #20 was missing the hearing aids, and the nurse should update the supervisor and the facility should have been responsible to replace them. The DNS indicated the supervisor should have updated the Administrator to get them replaced. After reviewing the missing item policy, the DNS indicated the nurse should have notified the family and appropriate department head which would be the social worker and document in the resident's medial record. After review of the hearing aid policy, the DNS indicated the license staff were responsible to make sure the hearing aides were in place and document on the TAR or MAR of the placement in the morning and removal of the hearing aids at bedtime. The DNS indicated she does not know why this was not done. The DNS indicated she would have Resident #20 seen by the audiologist. Interview with Administrator and Corporate RN #1on 12/6/23 at 11:50 AM indicated when the nurse was first aware that the hearing aides were missing, she was responsible to notify the social worker and the nurse or social worker can fill out the grievance form. The Administrator indicated the staff will look for the hearing aids and if not found the facility would replace them. The Administrator indicated a written grievance should have a resolution within 72 hours. The Administrator indicated she was not aware until today that Resident #20 was missing hearing aids since April 2023. Corporate RN #1 indicated that the facility will complete the grievance form now and offer the resident an amplifier with headphones so she/he could watch television. Interview with NA #5 on 12/6/23 at 2:52 PM indicated he recalls that he had brought Resident #20 into the shower back in April 2023 on a Friday 3:00 - 11:00 PM shift. NA #5 indicated he had started giving the shower when Resident #20 informed him that he/she still had the bilateral hearing aids in. NA #5 indicated that he then removed the hearing aids and placed them on a shelf in the shower room. NA #5 indicated later that Friday evening the resident requested his/her hearing aids back, so he went back to the shower room to retrieve them, and they were gone. NA #5 indicated that he did inform the charge nurse but does not recall who the charge nurse was. Interview with the DNS on 12/6/23 at 3:45 PM indicated the facility had not attempted to get Resident #20 seen by the audiologist or provide alternate hearing devices. Review of the facility Hearing Aid Policy identified the purpose was to ensure residents who have hearing aid(s) are provided with assistance regarding the daily placement and removal of the hearing aid(s) and checking to make sure the aid(s) are properly functioning. The nurses will initial on the TAR or the MAR for the resident on the placement and removal of the hearing aid(s). Hearing aids will be kept in a secure area such as the medication cart or medication room. Hearing aid(s) will be on the resident's care plan and on the care card. The hearing aid will be removed from the resident's ear in the evening prior to sleep and wiped down gently with a tissue, open the battery door, and placed in a designated area for storage. The nurse will initial the [NAME] that the hearing aid was removed. If the hearing aid is missing the missing item policy will be initiated and the responsible party will be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #54 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, hemiplegia, and gastrostomy status. The nursing admission assessment dated [DATE] identified Resident #54 had bilateral heel deep tissue injuries, an ulcer to the back of the head, and a stage 3 pressure ulcer to the coccyx. Special treatments included skin prep to the bilateral heels and daily dressing changes to the back of the head and coccyx. The nursing admission assessment further identified Resident #54 had a Braden score of 11 (high risk for skin breakdown). The admission MDS dated [DATE] identified Resident #54 had moderately impaired cognition and the number of unhealed pressure ulcers/injuries present on admission included 1 stage 3 pressure ulcer and 2 unstageable pressure injuries presenting as deep tissue injuries. The wound physician's order dated 10/6/23 directed to offload Resident #54's heels per facility protocol. Review of the October 2023 order summary report and TAR failed to identify documentation of how and with what frequency Resident #54's heels were being offloaded. The care plan dated 10/9/23 identified Resident #54 was at risk for skin breakdown due to decreased mobility, incontinence, and other risk factors including poor nutrition, pronounced body prominences, poor circulation, altered sensation, and mechanical forces. Interventions included offloading heels while in bed and completing a Braden Scale upon admission/readmission and as per facility policy. Review of the November 2023 order summary report and TAR failed to identify documentation of how and with what frequency Resident #54's heels were being offloaded. The wound physician's note dated 11/24/23 at 10:20 AM identified Resident #54 had a new open area on the right heel, was wearing offloading boots, and getting regular moisturizing. The right heel wound was a stage 2 pressure injury pressure ulcer with a status of not healed. Wound orders directed the application of alginate and a dry wound dressing to the right heel and to offload heels, per the facility policy. Interview and clinical record review with the wound nurse (RN #2) on 12/1/23 at 9:53 AM indicated that the floor nurse identified a skin alteration on Resident #54's heel on 11/21/23 and the floor nurse verbally made her aware. RN #2 further identified that she assessed the heel on 11/21/23 and there was no opening on the skin, but she did note the skin was dry and there was a slight discoloration; at the time of RN #2's assessment, Resident #54 was in bed and his/her heels were not properly offloaded, RN #2 then offloaded Resident #54's heels and applied skin prep. RN #2 further identified that she would expect Resident #54's heels to be offloaded while in bed, it is protocol for all residents with limited mobility and in bed most of the time. RN#2 indicated that they had tried to offload Resident #54's heels using a pillow, but it was the same level as the bed and his/her heels were touching the bed. Interview with the wound physician (MD #2) on 12/1/23 at 11:30 AM identified that Resident #54 had offloading boots prior to the development of the right heel pressure ulcer, and that she would expect his/her heels to be offloaded, as Resident #54 is vulnerable. MD #2 indicated that during weekly rounds, she ensures Resident #54's heels are offloaded, and the skin is protected through the provision of good hygiene and keeping the skin well moisturized. Observation and interview with RN #3 on 12/6/23 at 12:15 PM failed to identify that Resident #54's heels were properly offloaded, while in bed. Resident #54's lower extremities were elevated on a pillow with the entire heel in contact with the pillow. RN #3 indicated that he would expect Resident #54's heels to be offloaded with a boot or a pillow utilizing proper placement to offload the heels from the pillow. Further observation with RN #3 failed to identify offloading boots were present in Resident #54's room. Interview and clinical record review with the DNS on 12/6/23 at 3:35 PM failed to identify there was direction in the order summary report or the TAR for offloading Resident #54's heels. The DNS further indicated that according to Resident #54's Braden Scale score, he/she is at risk for skin breakdown, and there should be an order and documentation ensuring Resident #54's heels were offloaded while in bed. The DNS identified that to properly offload heels using a pillow, the heels should not be touching the pillow or mattress. Review of the facility's heel ulcer management policy directs that the most effective intervention for heel ulcers is to eliminate pressure by suspending the heels off the surface of the bed. The preferred way to accomplish this is through the use of a pillow(s). Review of the wound prevention/interventions for all residents policy directs the use of pillows to elevate heels while in bed or other pressure reducing devices for feet in bed or the chair. 2. Resident #49 was admitted to the facility on [DATE] with diagnoses that included hemiplegia following a stroke, heart failure, and osteomyelitis. Review of the clinical record identified that Resident #49 was hospitalized for a surgical revision of a right total right knee replacement from 1/22/23 - 1/31/23. The Braden Scale, completed on 1/31/23, identified Resident #49 had a total score of 15 and was at mild risk for development for pressure ulcers. a. Review of the clinical record failed to identify any additional Braden Scale assessments had been completed after 1/31/23, over 10 months. Review of Braden Scale Policy identified the purpose of the protocol was to predict a resident's risk for pressure sore development by utilizing the Braden Scale Assessment Tool. All residents will have a Braden Scale completed weekly for 4 weeks on admission and readmission. Thereafter, a Braden Scale will be completed quarterly, annually, and upon a significant change of condition. b. The care plan dated 3/27/23 identified that Resident #49 had a history of wounds. Interventions included checking skin at least weekly on scheduled bath day and to monitor response to any treatments per policy. The care plan further identified Resident #49 was at risk for skin breakdown due to altered mobility and incontinence. Interventions included inspecting skin when giving care for signs and symptoms of breakdown. The quarterly MDS dated [DATE] identified Resident #49 was always incontinent of bowel and bladder and required the assistance of 2 or more staff with transfers, toileting, and bathing. The MDS also identified that Resident #49 was at risk for pressure ulcers. The nurse aide care card identified Resident #49 required turning and repositioning every 2 hours, offset bilateral heels, and barrier cream to the buttocks. A wound care physician's note dated 5/24/23 identified that Resident #49 was being treated for a surgical dehiscence of the right knee. Additionally, the note also directed to follow the facility pressure ulcer prevention protocol, and that the plan of care was discussed and coordinated with the IC/Wound treatment nurse. Review of the physician's order summary dated 6/1/23 directed Resident #49 to have weekly body audits every Sunday on the day shift, and a pressurized mattress in place to be checked every shift for placement and settings. The order report also identified Resident #49 received Amoxicillin (an antibiotic) 250 mg three times daily for chronic knee infection for lifetime. Review of the June 2023 MAR identified Resident #49 had orders for skin prep and offloading of the left heel every shift. The MAR also identified multiple treatments ordered to the right lateral thigh, middle buttock, right knee, and bilateral lower extremities. Although requested, the facility failed to provide signed physician's orders from June 2023. Although requested, the facility failed to provide documentation of the weekly body audit completed the week of 6/4/23. A wound care physician's note dated 6/7/23 identified that Resident #49 was seen for follow up of the right knee wound and report of new wounds on the buttocks. The exam identified the buttock with a moderate amount of fresh blood drainage and diffuse excoriation. The treatment plan for the buttock included applying alginate, a dry dressing, and change twice daily and as needed. The note also directed to follow the facility pressure ulcer prevention protocol, and that the plan of care was discussed and coordinated with the IC/Wound treatment nurse. A wound care physician's note dated 6/14/23 identified that Resident #49 was seen for follow up and had a new wound on the lateral right leg. The exam identified the buttock wound measured 5 cm x 0.5 cm x 0.1 cm with a moderate amount of fresh blood drainage and excoriation. The treatment plan for the buttock included applying alginate, a dry dressing, and change twice daily and as needed, and that no Triad paste was to be applied as barrier past to the wound. Although requested, the facility failed to provide documentation from a weekly body audit completed the week of 6/18/23. A weekly body audit completed on 6/25/23 identified that Resident #49 had intact skin. (This is in conflict with the wound care notes). Review of the clinical documentation failed to identify any wound care notes for visits within the facility after 6/28/23. Although requested, the facility failed to provide any documentation related to a 6/29/23 wound consult visit. A weekly body audit completed on 7/2/23 was blank. A wound note dated 7/5/23 by RN #2 (IC/Wound nurse) identified that Resident #49 was seen for wounds on the right lateral thigh, right knee and buttocks. The buttocks was noted to be excoriated and treated with medihoney followed by alginate and Allevyn. The note failed to identify any additional assessment information, including wound measurements or stage. Review of the clinical record failed to identify any complete wound assessments of Resident #49's wounds at the buttocks after 7/5/23. The weekly body audits completed on 7/9/23 and 7/23/23 identified that Resident #49 had intact skin (this is in conflict with the wound notes). A review of the July 2023 TAR identified treatment orders including a nursing measure to apply protective barrier cream for incontinence to the peri area and buttocks every shift. The TAR also identified a treatment order dated 7/11/23 for skin prep to the right and left heel every evening to prevent skin break down. Review of the clinical record failed to identify any complete wound assessments of Resident #49's wounds following the 7/27/23 wound consult visit. The 8/28/23 wound consult sheet identified Resident #49 had a newly identified right heel pressure area with recommendation to turn every 1 - 1.5 hours, offload heels at all times, use low air loss mattress, and use multipodus boots bilaterally. Review of the clinical record failed to identify any complete wound assessments of Resident #49's wounds following the 8/28/23 wound consult visit. The 10/2/23 wound consult sheet identified Resident #49 had a newly identified open sacral wound measuring 1.6 cm x 0.3 cm x 0.1 cm with a pink base and peri wound maceration. Review of the clinical record failed to identify any complete wound assessments of Resident #49's swounds following the 10/2/23 wound consult visit. The 11/29/23 nursing note by RN #2 identified Resident #49 had 2 stage 3 pressure ulcers on the coccyx with one area measuring 8.5 cm x 3.5 cm x 0, a second area measuring 2 cm x 2.5 cm x 0. The note further identified Resident #49 complained of pain at the area, and wound beds with slough and mild drainage and both areas were being treated with medihoney and cover with Alleyvn. The 11/30/23 nursing note by RN #2 identified that the facility contacted the wound care center and were directed to continue medihoney to sacral wound until follow up on 12/7/23, and that Resident #49's representative was notified. Interview with the DNS on 12/5/23 at 4:13 PM identified for residents of the facility who had newly identified skin issues or wounds, that the nurse caring for the resident should document the wound, the nurse would also notify the RN shift supervisor so that a RN assessment could be completed, then the physician or APRN should be notified. The DNS also identified that this was the process for any change in condition, and the resident representative should also be notified. Further, for residents of the facility who had newly identified skin issues or wounds, that the nurse caring for the resident should document the wound, the nurse would also notify the RN shift supervisor so that a RN assessment could be completed, then the physician or APRN should be notified. The DNS also identified that this was the process for any change in condition, and the resident representative should also be notified. Interview with RN #2 on 12/6/23 at 8:40 AM identified that Resident #49's representative requested treatment of Resident #49's knee wound not healing. RN #2 identified that once Resident #49 began treating at the wound center, she (RN #2) believed the wound center was addressing all of the residents wounds. RN #2 identified that she did not follow any of the wound tracking for Resident #49 following the initiation of treatment with the outside wound provider due to lack of wound healing, and the notes from the provider were given to the nurse assigned to her at the facility when she returned from the visits. RN #4 identified that she was not notified of Resident #49's sacral wound until 11/29/23 when she completed rounds with the wound care physician. RN #2 identified she was notified of skin issues for residents of the facility during daily morning report and by word of mouth. RN #2 identified that there was no formal reporting system or communication method set up to notify her if a resident had a newly identified wound or that a previously identified wound was worsening. RN #2 also identified she did not complete the RN assessment of any newly identified wounds and the assessment would be completed by the RN nursing supervisor, once a resident's nurse notified the supervisor it was needed. Subsequent to surveyor inquiry, the facility provided a 12/7/23 wound consult sheet which identified that Resident #49 had a sacral wound which was unstageable, full thickness with slough, and was debrided at the visit. The consult sheet also identified Resident #49 had a wound on the right foot at the 2nd toe with concern for bone exposure. Recommendations included cleansing with Vashe 10 minute soak, Aquacel Ag in wound and cover with foam, offload, use pressurized air mattress, turn every 1.5 hours, keep pressure off sacrum, and sit for one hour in custom wheel chair and then back to bed side to side. Although attempted, an interview with Resident #49's representative was not obtained. Although requested, the facility failed to provide any signed physician's orders from 6/2023 -12/2023. Although requested, the facility did not provide weekly body audits completed on the following dates: 7/30, 8/6, 8/13, 8/20, 8/30, 9/6, 9/13, 9/14, 9/20, 9/25, 9/27, 10/1, 10/11, 10/18, 10/26, 10/31, 11/1, 11/15, 11/22, and 11/29/23 The facility policy on body audits directed that the purpose of the policy was to assess, identify, and document any alterations in skin integrity in order to develop a plan of care for the treatment and prevention of skin problems. The policy further directed that all residents would have weekly body audits completed and documented by a licensed nurse and that any alterations in skin integrity would be documented on the body audit form. The policy also directed any alterations in skin integrity were identified, the physician and responsible part should be notified, and new treatment orders should be obtained, if applicable. The facility policy on Braden Scale directed that all residents would be assessed for risk of pressure sore development on admission, readmission, annually, quarterly, and upon a significant change of condition and that a licensed nurse was responsible for completion. The facility policy on wound and skin care protocols identified that all residents would be assessed by the nurse for risk of skin breakdown utilizing the Braden Scale on admission/readmission weekly for 4 weeks, upon a significant change of condition, and quarterly. The policy also directed weekly body audits would be completed on bath/shower days by a licensed nurse, and that identified skin areas would have weekly documentation until healed. The policy identified that wounds that required weekly documentation until healed included pressure wounds, skin tears, and surgical wounds, and that all wounds would be reviewed during the weekly at risk meeting utilizing the skin and pressure ulcer tracking sheets. The facility policy on wound prevention/interventions for all residents directed that interventions were be directed toward minimizing and/or eliminating any negative effects of contributing factors for resident of the facility. The policy also directed that prevention interventions for the facility included: Pressure redistribution mattresses, daily skin observations by the nurse aide, weekly body audits completed on bath/shower days by a licensed nurse, and turn and position every two hours or as needed based on the needs of the individual resident. The facility policy on documentation directed all residents would be assessed for risk of skin breakdown utilizing the Braden Scale on admission/readmission weekly for 4 weeks, upon a significant change of condition, and quarterly. The policy further directed that a weekly body audit would be completed on bath/shower day. The policy also directed that a complete wound assessment and documentation would be done weekly until each area was healed utilizing the skin/wound tracking record, and the documentation should include: site and location of the wound, stage (for pressure ulcers, including Stage I) with wound healing to be described by changes in the wound appearance and size (not by reverse/down staging), wound size including length, width, and depth in centimeters, appearance of the wound bed including color, drainage, odor, and periphery, any tunneling or undermining with depth of the area and clock orientation, surrounding skin condition (i.e intact, edematous, macerated, temperature if abnormal), drainage/exudate including amount, color, consistency, and odor. For Resident #49, the facility failed to complete Braden Scale assessments, weekly body audits, and weekly wound assessments by a registered nurse including wound documentation per policy. Further, the facility staff documented at least 3 times on a weekly body audit form that Resident #49 had intact skin when the resident did not. Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #26, 49 and 54) reviewed for pressure ulcer, the facility failed to follow the policy for Braden Scale assessments, failed to have treatments in place for a new pressure ulcer, failed to follow the air mattress manufacturer's recommendations, failed to complete weekly wound assessments by a registered nurse including wound documentation, failed to complete weekly body audits, failed to accurately complete weekly body audits, and failed to implement appropriate preventative measure. The findings include: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included failure to thrive and deep vein embolism and thrombosis. The physician's order dated 4/24/23 directed to complete a Braden Scale on admission and every week for 4 weeks, (5/1, 5/8, 5/15 and 5/22/23). The care plan dated 4/27/23 identified the Braden Scale was to be completed on admission and readmission and as per facility policy. The admission MDS dated [DATE] identified Resident #26 had moderately impaired cognition and required total assistance for personal hygiene, extensive assistance for bed mobility and was at risk for pressure ulcers but did not have any pressure ulcers on admission. a. Review of the clinical record identified although a Braden Scale was done on admission, 4/24/23, it had not been completed weekly for 4 weeks on (5/1, 5/8, 5/15 and 5/22/23). Further, the clinical record failed to identify a Braden Scale had been done quarterly, July 2023. Interview with the DNS on 12/5/23 at 10:20 AM indicated the Braden Scale was to be done on admission and readmission by the RN only. After clinical record review, the DNS indicated the Braden Scale was done on 4/24/23 and had not been done since and did not need to be completed. Review of Braden Scale Policy identified the purpose of the protocol was to predict a resident's risk for pressure sore development by utilizing the Braden Scale Assessment Tool. All residents will have a Braden Scale completed weekly for 4 weeks on admission and readmission. Thereafter, a Braden Scale will be completed quarterly, annually, and upon a significant change of condition. Review of the Skin and Wound Protocol Policy identified that to prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and develop appropriate interventions. All residents will be assessed by the nurse for risk of skin breakdown, utilizing the Braden Scale upon admission/readmission and weekly for the first 4 weeks, upon significant change in condition and quarterly thereafter. b. A nurses note, written by an LPN, dated 7/20/23 at 1:13 PM identified Resident #26 had 2 new open areas found on the buttocks, near the gluteal cleft. Wound #1 (left buttock) was approximately 1.0 cm by 2.0 cm and was red in color without discharge. Wound #2 (right buttock) was approximately 0.5cm x 1.0 cm, red in color, with no drainage. A nurses note, written by the Wound Nurse (RN #2), on 7/20/23 at 2:07 PM identified Resident #26 had open areas on buttocks, peri wound was red, no drainage or bleeding noted. Alginate applied on area followed by Allevyn, will notify wound doctor. The clinical record failed to reflect a thorough RN assessment of the wounds including measurements and stage had been completed at the time the wounds were found. Further, the clinical record failed to reflect a Braden Scale had been completed according to facility policy. Interview with the DNS on 12/1/23 at 9:50 AM indicated when a new pressure ulcer is identified, an RN assessment must be done, and include the measurements (length x width x depth), a description of the wound bed, the peri wound bed, and if there was any drainage. c. A physician's order (put in place by RN #2, as a nursing measure, without notifying the physician) dated 7/20/23 at 1:39 PM directed to cleanse the coccyx with normal saline and apply alginate and cover with Allevyn every day. (There was no treatment put into place for the right and left buttock wounds). Review of the clinical record from 7/20/23 - 11/30/23, 4 months, failed to reflect weekly wound documentation for the coccyx, left buttock or right buttock open areas. Review of the July 2023 TAR dated 7/21/23 - 7/30/23 identified the treatment to the coccyx (put in place by a RN without notifying the physician) had not been signed for as completed 2 times. Review of the August 2023 TAR identified the treatment to the coccyx (put in place by a RN without notifying the physician) had not been signed for as completed 16 times. Review of the September 2023 TAR identified the treatment to the coccyx (put in place by a RN without notifying the physician) had not been signed for as completed 11 times. Review of the October 2023 TAR identified the treatment to the coccyx (put in place by a RN without notifying the physician) had not been signed for as completed 4 times. Review of the November 2023 TAR identified the treatment to the coccyx (put in place by a RN without notifying the physician) had not been signed for as completed 8 times. Interview with RN #2 (wound nurse), with Corporate Regional RN #4 present, on 11/30/23 at 10:54 AM indicated Resident #26 developed 2 new pressure ulcers on the buttocks (a right and a left open area). RN #2 indicated she did put an order in place, as a nursing measure. After review of the clinical record, RN #2 indicated there was only a treatment for 1 area, the coccyx. RN #2 indicated there were 2 pressure areas, but she only put in one treatment order as a nursing measure because she did not notify the physician or APRN. RN #2 indicated that the treatment order she put in place probably was meant for the left buttock open area and she did not write a treatment order for the right buttock. RN #2 indicated she must have forgotten to write a treatment for the right open area. RN #2 indicated she does write treatment orders without notifying the APRN or physician for the residents until the resident is seen by the wound physician on Fridays. Interview with the DNS on 12/1/23 at 9:50 AM indicated when a new pressure ulcer is noted, after the assessment by a RN, the RN must notify the physician or APRN and the wound physician to get the appropriate treatment. The DNS indicated there should be a treatment for each open area or one treatment order identifying both open areas. The DNS indicated the nurse's, including RN #2, cannot write their own orders or nursing measures. The DNS indicated the nurse must notify the physician or APRN. Interview with Director of Clinical Services, (RN #1), on 12/1/23 at 1:28 PM indicated Resident #26 did not have any wound doctor documentation for the 2 pressure areas to the left and right buttocks that developed in July 2023. RN #1 indicated there was only wound documentation of a skin tear on the arm, but nothing for initial or weekly, including measurements on a coccyx or buttocks. RN #1 indicated she would contact the wound doctor for the only 1 time she saw the left and right buttock on 7/26/23, because they did not have it in the clinical record. d. The weight record dated 7/6/23 identified Resident #26 weighed 126 lbs. The quarterly MDS dated [DATE] identified Resident #26 had severely impaired cognition and was at risk of developing pressure ulcers. The weight record dated 11/6/23 identified Resident #26 weighed 134 lbs. The care plan dated 11/10/23 identified Resident #26 was at risk for skin breakdown. Interventions included pressure reducing mattress setting at 150 lbs. A physician's order dated 11/13/23 directed to check placement and function of air mattress every shift. Interview with Resident #26 on 11/28/23 at 11:25 AM indicated he/she prefers to be in bed all day because it hurts too much to get out of bed into a chair. Resident #26 indicated that his/her bed was hard, and he/she had a lump in his/her buttock. Resident #26 indicated that the bed was not comfortable. Observation on 11/28/23 at 11:27 AM identified Resident #26 was laying on an air mattress with setting at 250 lbs. Interview with LPN #5 on 11/28/23 at 11:30 AM indicated that there was a physician's order for the air mattress which included to check for placement of air mattress and that it was functioning. LPN #5 indicated she does not check the weight setting on the air mattress she just checks that it is on the bed and the pump is running. LPN #5 indicated an air mattress is set based on the resident's weight when it is first placed on the bed by maintenance or the rental company. Observation by LPN #5 indicated the air mattress was set at 250 lbs. LPN #5 indicated Resident #26 only weighs 134 lbs., so the machine should be set at either 100 lbs. or 150 lbs., and indicated it was too firm. LPN #5 indicated she did not know how to change the weight setting and would have to call maintenance. Interview with the Assistant Maintenance Director on 11/29/23 at 6:50 AM indicated he was called to unit yesterday on 11/28/23 for Resident #26's air mattress but he could not find the nurse. Assistant Maintenance Director indicated he asked the resident what he/she weighed and set the air mattress from 250 lbs. to 150 lbs. based on what the resident said he/she weighed. Interview with Resident #26 on 11/29/23 at 11:00 AM indicated the air mattress feels better now. Resident #26 indicated he/she does not feel that lump in his/her buttock anymore. Interview with the RN #2 on 11/30/23 at 10:54 AM indicated Resident #26 had an air mattress because she had developed 2 new pressure ulcers in July 2023. RN #2 indicated the expectation of the nurses was if the machine starts to beep to call the rental company. RN #2 indicated the nurse's responsibility was to check that the air mattress was on the bed and inflated. RN #2 indicated the nurses were not responsible to check the weight setting on the machine to make sure it matched the resident's weight. RN #2 indicated the weight was set when the air mattress was placed on the bed by the rental company or maintenance and that was the only time. RN #2 indicated she was not aware if there was a lock out setting on the different types of air mattresses at the facility. RN #2 indicated the nurses do not check the weight setting every shift or even daily. Interview with Director of Clinical Services, (RN #4), on 11/30/23 at 11:10 AM indicated her expectation of the nurses was to make sure the mattress was plugged in and inflated and that the machine is on. RN #4 indicated she would expect the nurse every shift to ask the resident if he/she was comfortable and not bottoming out. RN #4 indicated, if possible, the correct weight would be done when mattress was placed on the bed and then locked out so no one could change the setting. RN #4 indicated the setting for the weight should be checked at least monthly. RN #4 indicated if the mattress cannot be locked out, the nurses should check the weight setting every shift with the checking of the placement and function. Interview with the DNS on 12/5/23 at 10:13 AM indicated the air mattress should be set based on manufacturers recommendations and the policy. The DNS indicated based on Resident #26's physician order for the air mattress, the nurses were just checking the air mattress was on the bed and running. The DNS did not know if or when the nurses check the weight setting on the air mattress. Review of the Alternating Pressure Mattress Policy identified the purpose was to prevent pressure ulcers and treat those that have occurred and promote comfort. Review of the manufacturer recommendations for the air mattress identified to place the resident on the bed and adjust the mattress' internal pressure according to the residents' weight by using the weight button on the control panel. Simply press the weight button to adjust the patient's weight from 100 lbs. to 325 lbs.

**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 #46) reviewed for range of motion, the facility failed to complete nail care on a resident with contracted hands to keep nails short. The findings include: Resident #46's diagnoses included vascular dementia, cerebral infarction with right sided body paralysis. The quarterly MDS dated [DATE] identified Resident #46 had severely impaired cognition and was totally dependent with the assist of two for bed mobility, dressing and personal hygiene. The care plan dated 9/26/23, identified Resident #46 was dependent on staff for activities of daily living. Interventions included, assisting with skin care, mouth care and incontinent episodes. Observation on 11/30/23 at 12:34 PM identified Resident #46's hands appeared contracted, were closed fisted and the left hand pointer fingernail was long and jagged, with black debris under the nail. The surveyor was unable to visualize the other fingernails as both hands are closed in a fist. Interview on 11/30/23 at 1:20 PM with the DNS indicated she was not aware that any of Resident #46's nails were long and identified she will have staff cut and file the resident's fingernails. Interview on 12/6/23 at 8:57 AM with the Therapy Director identified that the resident has difficulty opening both hands and that therapy has requested Resident #46's fingernails be cut a few times. Interview with NA #1 on 12/6/23 at 10:47 AM identified she was assigned and familiar with Resident #46 and indicated the resident's nails were going to be cut and filed on 12/5/23 in the afternoon. NA #1 identified the residents nails are cut when the nails are long. Review of the morning/ADL care policy directed to provide fingernail care, including trimming nails if needed daily as part of am 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 7 of 7 residents (Resident #9, 27, 48, 50, 51, 61, and #66) reviewed for accidents, the facility failed to provide supervision of the residents during the fire drill, and for 1 of 9 residents (Resident #29) reviewed for accidents, the facility failed to ensure that 1:1 supervision was provided to a resident with an identified aspiration risk, and for the only sampled resident (Resident #53) reviewed for activities of daily living, the facility failed to ensure medications were not left unsecured in the resident's room. The findings include: 1a. Resident #9 was admitted to the facility with diagnoses that included stroke with hemiplegia, dementia, and anxiety. The quarterly MDS dated [DATE] identified Resident #9 had severely impaired cognition and required total assistance with care. The care plan dated 10/20/23 identified Resident #9 was at risk for falls. Interventions included having the call light in reach when in the chair. A physicians order, not dated, identified Resident #9 gets out of bed into a custom wheel chair with a roho cushion with a seat belt and a lap tray. b. Resident # 27 was admitted to the facility with diagnoses that included dementia and anxiety. The annual MDS dated [DATE] identified Resident #27 had severely impaired cognition. The care plan dated 10/3/23 identified had falls on 3/5/22, 5/9/22, 10/25/22, 11/9/22. Interventions included that Resident#27 uses a wheelchair for mobility and an assist of 2 stand pivot for transfers. The Nursing Annual Evaluation dated 9/20/23 identified Resident #27 was at risk for falls. c. Resident #48 was admitted to the facility with diagnoses that included dementia, difficulty in walking, and anxiety. The quarterly MDS dated [DATE] identified Resident #48 had severely impaired cognition. The care plan dated 8/3/23 identified Resident #48 was at risk for falls and has had multiple falls. Interventions directed to have call light in reach. A physicians order not dated indicated Resident #48 was a transfer and ambulation with a rolling walker and assist of 1 with wheelchair to follow. The Fall assessment dated [DATE] identified Resident had a fall in the hallway and had 2 falls prior in the last 30 days. d. Resident #50 was admitted to the facility with diagnoses that included dementia and anxiety. The Nursing Quarterly Evaluation dated 6/11/23 identified Resident #50 was at risk for falls and has had falls within the last 30 days. The quarterly MDS dated [DATE] identified Resident #50 had severely impaired cognition. The care plan dated 9/14/23 identified that Resident #50 had had recent falls. Interventions directed to follow fall prevention care plan. A physician's order, not dated, directed Resident #50 to stand pivot with assist of 1 with rolling walker and ambulate with rolling walker and assist of 2. e. Resident #51 was admitted to the facility with a diagnosis that included dementia and anxiety. The quarterly MDS dated [DATE] identified Resident #51 had severely impaired cognition and one recent fall. The care plan dated 9/26/23 identified Resident #51 was at risk for falls and had fallen. Interventions included to have call light within reach. A physicians order, not dated, directed that Resident #51 required assist of 1 for transfers with a rolling walker. The Nursing Quarterly Evaluation dated 10/6/23 identified Resident #51 was at risk for falls and had an unsteady gait. f. Resident #61 was admitted to the facility with diagnoses that included dementia and anxiety. The quarterly MDS dated [DATE] identified Resident #61 had severely impaired cognition. The care plan dated 11/16/23 identified Resident #61 was at risk for falls. Interventions directed to transfer per physician orders. A physician order, not dated, directed to transfer with a rolling walker and assist of 1. g. Resident #66 was admitted to the facility with diagnoses that included dementia and anxiety. The admission/annual/quarterly MDS dated [DATE] identified Resident #61 had severely impaired cognition. The Nursing Quarterly Evaluation dated 10/10/23 identified Resident #66 was at risk for falls and had an unsteady gait and decreased balance. The care plan dated 11/28/23 identified Resident #66 had falls. Interventions included have call light within reach. A physicians order not dated directed Resident #66 to stand pivot transfer with assist of 1. Observation on 11/28/23 at 10:32 AM identified that when the fire alarm sounded during the drill, NA #6 and NA #7 took the residents that were sitting in wheelchairs in the hallway and put them inside of the east lounge, and NA #6 closed the door. NA # 6 and NA #7 then went to the end of the hallway to remove a row of 15 wheelchairs out of the hallway. Although there were 7 residents left in the east lounge, there was not a staff member with the residents. At 10:39 AM, 7 minutes later, LPN #5 walked over the east lounge door and opened it peeked in and then closed the door. At 10:44 AM, 5 minutes later, the surveyor notified the DNS about the residents in the lounge unsupervised. Observation and interview with the DNS on 11/28/23 at 9:44 AM indicated that the 7 residents in the east lounge should not have been left alone with the door closed during a fire drill. The DNS indicated there was not a policy for who had to be in the room with the residents, but her expectation was that one of the nurse aides would be in there to ensure the residents safety. The DNS indicated that the 7 residents in the lounge were all at risk of falling, and for safety, should not have been left alone. Interview with LPN #5 on 11/28/23 at 9:49 AM identified during the fire drill it was her responsibility to account for all the residents on her unit. LPN #5 indicated that was why she just opened the east lounge door and quickly closed it. LPN #5 indicated during a fire drill she was not supposed to open any of the doors for safety, but she had to see which of her residents were in the room behind the closed door. LPN #5 indicated that there was no specific person assigned to the east lounge, but residents should not be in the lounge without a staff member present for safety. LPN #5 indicated some of the residents in the room were hers from the east side and some of the residents where from the west side. LPN #5 indicated that the residents from the east side were fall risks that was why a nurse aide should have been in the room. Interview with NA #6 on 11/28/23 at 10:46 AM indicated that during a fire drill she was responsible to remove all residents and wheelchairs from the hallways and place them inside a room behind a closed door. NA #6 indicated she was going to stay in the east lounge with the residents but as she was placing the last resident into the room, the Administrator told her to hurry up and help move the row of wheelchairs at the end of the hallway. NA #6 indicated she felt she had to follow the directive from the Administrator even though she knew the residents should not have been left alone. NA #6 indicated she was just doing wat she was told to do. Interview with LPN #8 on 11/28/23 at 10:49 AM indicated that during the fire drill she had to account for all residents on west unit. LPN #8 indicated that the residents in the east lounge were the responsibility of the nurse on the east side. LPN #8 indicated that it was the responsibility of the east nurse to make sure someone was assigned to stay with the residents in the east lounge behind the closed door. Review of the Fire Safety Policy identified that when the fire alarm sounds, staff will close all windows and doors. Staff will remove all obstructions from the corridors such as wheelchairs, laundry carts, medication carts, etc. The nurses will take a head count of all residents for their unit. The nurse's aides not on their assigned unit report back immediately. Move all residents into rooms and/or lounges. Do not block the residents into rooms. 2. Resident #29 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, dysphagia, and macular degeneration. The care plan dated 7/24/23 identified Resident #29 required assistance with ADLs. Interventions included delivering and setting up meals, and providing assistance with feeding as needed. The quarterly MDS dated [DATE] identified Resident #29 had moderately impaired cognition, was always incontinent of bowel and bladder and required the assistance of one staff member with dressing, transfers, and toilet use; and required set up for eating. A physician's order dated 11/6/23 directed that Resident #29 required an advanced dysphagia diet, level 3 texture. The orders further directed that Resident #29 required set up for all meals, 1:1 supervision/assistance during all meals and cueing for small bites/slow rate, sips of liquid between bites, and should be in an upright position during meals. Review of the clinical record identified the order had been in place since 7/21/22. A review of Resident #29's nurse aide care card on 11/28/23 identified that Resident #29 was able to feed his/herself but required meal set up and had precautions of small bites at a slow rate, sips of liquid between bits, and position upright during meals. Observation on 11/28/23 at 12:15 PM identified Resident #29 seated in a wheelchair with a meal plate and drink positioned on a bedside table placed directed in front of him/her while in his/her room. Resident #29 was observed to be sleeping slumped forward. No facility staff near or entering Resident #29 at any time during this observation. Observation, interview, and review of the clinical record with the DNS on 11/28/23 at 12:25 PM identified that Resident #29 had been feeding independently for an unknown period of time. The DNS identified that Resident #29 did not require any supervision with meals. A review of Resident #29's active orders with the DNS identified that Resident #29 had an active order that directed the resident required set up for all meals, 1:1 supervision/assistance during all meals and cueing for small bites/slow rate, sips of liquid between bites, and should be in an upright position during meals. The DNS identified That's an old order, even though it's still there, the resident feeds him/herself, I am not sure why that's still there. The DNS was unable to identify when Resident #29 had a change in status from requiring supervision with meals to feeding independently. Subsequent to surveyor inquiry, on 11/28/23 at 12:28 PM, a female facility staff member was observed in Resident #29's room providing 1:1 supervision. Resident #29 was observed awake and eating during this observation. Interview with the Therapy Director on 12/6/23 at 8:55 AM identified that Resident #29 did not have any changes from therapy that recommended a change from 1:1 supervision to feeding independently. The Therapy Director identified that Resident #29 last had a speech therapy evaluation on 6/6/23 and at that time there were no changes were recommended to Resident #29's dysphagia diet and need for 1:1 supervision with meals. Review of the facility policy on feeding directed that residents should be assisted to an upright position as possible, and cueing should be provided as needed. The facility policy on resident rights directed that residents of the facility had the right to receive care and services with reasonable accommodation of the residents' individual needs. Although requested, the facility failed to provide a policy on 1:1 feeding and supervision with meals. 3. Resident #53 was admitted to the facility on [DATE] with diagnoses that included sleep apnea, type 2 diabetes mellitus, anxiety disorder, morbid obesity, and spondylosis. The quarterly MDS dated [DATE] identified Resident #53 had intact cognition, was always incontinent of bowel and bladder, required supervision with eating, was dependent for bathing, personal hygiene, rolling left to right, laying to sitting, and was on a therapeutic diet. The care plan dated 11/1/23 identified Resident # 53 required staff assistance with ADL's. Interventions included to deliver meals and set-up as needed and keep commonly used/needed articles within reach. Observation and interview with the ADNS on 12/1/23 at 2:50 PM identified a Fluticasone Propionate allergy relief nasal spray and a Ventolin HFA inhaler in a basin, on Resident #53's bedside table. Resident #53 identified that the medications had been there for a while but was unable to quantify a precise amount of time and was unsure the last time he used either medication. Resident #53 further identified that he/she believed they were medications brought in from home. The ADNS removed the medications from the bedside table and informed Resident #53 that the facility can order those medications, if he/she feels like they are needed, and licensed facility staff will assist with administration. The ADNS indicated that Resident #53 should not self-administer medications, and the inhaler and nasal spray should not be at the bedside. Interview with the DNS on 12/6/23 at 4:00 PM identified that the inhaler and nasal spray should not be left in the residents room on the bedside table because he/she does not have an evaluation or a physician's order to self-administer medication. The DNS further identified that proper medication storage, for residents that are allowed to self-administer, ensures that the medication is locked and not on the bedside table. Review of the facility's general dose preparation and medication administration policy directs facility staff should not leave medications or chemicals unattended. Review of the facility's self-administration of medications policy directs the facility, in conjunction with the interdisciplinary care team, should assess and determine, with respect to each resident, whether self-administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #53 was admitted to the facility on [DATE] with diagnoses that included sleep apnea, type 2 diabetes mellitus, anxiety disorder, morbid obesity, and spondylosis. A physician's order dated [DATE] directed Resident #53 to receive the following died; a carbohydrate-controlled diet regular texture, thin liquids consistency, double protein, small starch, prefers no muffins, pastries, or donuts. A physician's order dated [DATE] directed Resident #53 to be assisted 1:1 for self-feeding of all meals due to decreased bilateral upper extremity function. Further, Resident #53 is to be provided a built-up spoon and fork with curve, hot drinks to be provided in Kennedy cup, spill proof with straw due to decreased grip strength. Review of the dietitian's notes dated [DATE] and [DATE] identified Resident #53 receives a carbohydrate-controlled diet with double protein and small starches. The quarterly MDS dated [DATE] identified Resident #53 had intact cognition, required supervision with eating and was on a therapeutic diet. The care plan dated [DATE] identified Resident #53 required staff assistance with ADL's. Interventions included delivering meals and set-up as needed and keeping commonly used/needed articles within reach. The care plan further identified Resident #53 had the potential for a nutritional decline related to multiple medical problems and the need for a therapeutic diet. Interventions included encouraging diet compliance and provision of diet as ordered. Review of the dietitian's note dated [DATE] identified Resident #53 receives a carbohydrate-controlled diet with double protein and small starches. Interview with Resident #53 on [DATE] at 12:10 PM identified that he/she developed type 2 diabetes and is currently receiving meals that are heavy in carbohydrates. Resident #53 indicated that he/she has requested, multiple times, for meals to contain less carbohydrates and a double portion of protein, as well as no pastries or donuts, to assist with better blood sugar control. Interview with the Dietary Director on [DATE] at 1:20 PM indicated that she had started working at the facility on [DATE] and was unaware of Resident #53's order for double protein portions and the adaptive feeding equipment; she was only aware that his/her therapeutic diet was carbohydrate control. The Dietary Director further indicated that when a change is made to a resident's diet order or dietary preferences are modified the dietitian or nursing staff will leave a slip in her mailbox to notify the dietary staff of the change. The same process is used for rehabilitation services to notify the dietary staff of a change involving adaptive feeding equipment. The Dietary Director indicated that the facility does not use individual meal slips at each meal, but a master roster for all residents that identifies each resident's diet, liquid, need for adaptive equipment, allergies, and special accommodations. Review of the facility's resident dietary roster dated [DATE] failed to identify Resident #53's orders for adaptive feeding equipment and double protein. Subsequent to surveyor inquiry the dietary roster was updated to reflect Resident #53's dietary orders. Interview and review of the clinical record with the Dietitian on [DATE] at 11:20 AM identified that she could not recall if Resident #53 indicated to her that he/she was not receiving double protein during meals, however, Resident #53 did continue to reinforce that he/she liked the double protein and less starch. The Dietitian indicated that she surmised that Resident #53 was currently receiving double protein portions and less starch because it was in the order and was listed on the [DATE] dietary roster. The Dietitian further indicated that when she writes a dietary note or completes a quarterly or annual assessment, she reconciles her orders with the dietary roster. The Dietitian identified that the dietary roster format had recently been updated and potentially the order could have fallen off the roster when the update was made. The Dietitian indicated that the process for communicating diet order changes or dietary preferences would be for her to update the order in point click care and then print a copy of any dietary modifications and place a copy in the dietary director's mailbox. Review of the facility's resident's bill of rights policy directs a resident has the right to choose activities, schedules, and health care consistent with their interests, assessment, and plan of care. Review of the facility's simplified guideline for standard carbohydrate-controlled diet directs whenever possible the carbohydrate-controlled diet should be created by a registered or licensed dietitian to assure optimal variety, client satisfaction, and therapeutic benefit. The guideline further identified the importance of proper diet in the treatment and control of diabetes. Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #52 and 53) reviewed for nutrition, for Resident #52, the facility failed to do weights per policy and physician order and for Resident #53 the facility failed to ensure the meals received were in accordance with the ordered therapeutic diet. The findings include: 1. Resident #52 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, and quadriplegia. Review of the weight record dated [DATE] identified Resident #52 weighed 128 lbs. A physician's order dated [DATE] directed to provide 1:1 assistance with feeding. The admission MDS dated [DATE] identified Resident #52 had severely impaired cognition and required maximum assistance with eating. Review of the weight record dated [DATE] identified Resident #52 weighed 133.8 lbs., (a 5.8 lbs. increase from the previous weight dated [DATE]). Review of the weight record dated [DATE] identified Resident #52 weighed 131.8 lbs. Review of the weight record dated [DATE] identified Resident #52 weighed 132.2 lbs. The quarterly MDS dated [DATE] identified Resident #52 had severely impaired cognition, was on a mechanically altered diet and required assistance with eating. Additionally, Resident #52 had a weight loss of 5% or more in the last month or 10% in the last 6 months that was not prescribed by a physician for weight loss. Review of the weight record dated [DATE] identified Resident #52 weighed 121.7 lbs., a 10.5 lbs. loss from the previous weight dated [DATE]). A physician's order dated [DATE] directed to provide 1:1 assistance with feeding. The care plan dated [DATE] identified Resident #52 had a nutritional decline with a significant weight loss. Interventions included weights as ordered and per facility policy. The dietitian progress note dated [DATE] at 3:51 PM identified Resident #52 had a significant weight loss. Team, APRN, and psychiatry were updated and a reweight was needed. The APRN progress note dated [DATE] at 2:07 PM identified she was asked to see Resident #52 by the dietitian for a significant weight loss. Resident #52 had triggered for a 10 lb. weight loss in 30 days or 7% in 30 days. Plan to increased house supplement, order weekly weights and labs. A physician's order dated [DATE] directed to get weekly weights. Review of the weight record dated [DATE] identified Resident #52 weighed 117.8 lbs., a 3.9 lbs. loss from the previous weight dated [DATE]). Review of the weight record dated [DATE] identified Resident #52 weighed 107 lbs., a 10.8 lbs. loss since previous weight dated [DATE]. Review of the weight record dated [DATE] identified Resident #52 weighed 112 lbs., a 5.8 lbs. loss since weight of [DATE]. Interview with the Dietitian on [DATE] at 1:39 PM indicated when a weight loss is identified at the time a weight is done, nursing is to notify her within that week. The Dietitian indicated that notification does not usually occur, but she finds significant weight losses each week when she runs a report in the electronic medical record system. The Dietitian indicated she is in the facility twice a week and that every week she pulls a weight report. The Dietitian indicated all residents are to be weighed on admission within 24 hours, then weekly for 4 weeks, and then monthly unless directed by the physician, or if a resident has a weight loss, the resident will be weighed weekly. The Dietitian indicated when a resident has a weight loss, she will do an assessment and make recommendations to the APRN or physician. The Dietitian indicated nursing must get the order and note the order. The Dietitian indicated when Resident #52 was admitted , the hospital documentation identified Resident #52 weighed 150 lbs., however, when the resident was first weighed at the facility, he/she weighed 128 lbs. The Dietitian indicated her expectation was that the weights are done weekly, but they were not done weekly for Resident #52. The Dietitian indicated she noticed the admission weekly weights for 4 weeks had not been done on [DATE] and she requested a weight from nursing, and it was done. The Dietitian indicated she did not see Resident #52 until the quarterly review in [DATE] and identified she did not see Resident #52 on [DATE] when nursing obtained the weight that identified weight loss because she was not notified until she ran the report on [DATE] the next week. The Dietitian indicated she has a heavy caseload in this facility and if someone does not trigger a significant weight loss she does not go back. The Dietitian indicated she had first seen and reviewed the weight loss for Resident #52 on [DATE] and had requested a reweight because her weight triggered as a significant weight loss, and she wanted a reweight to confirm the weight loss and would expect the reweight within 24 hours. The Dietitian identified she notified the team (Administrator, DNS, ADNS, MDS Nurse, and the Dietary Supervisor) via email on [DATE] and at the weekly at risk meeting that Resident #52 had a significant weight loss and needed the reweight. The Dietitian identified that although the requested reweight should have been done within 24 hours, it was not done until [DATE], 3 weeks later. The dietitian indicated she did not recommend weekly weights at that time but did tell the APRN and expected she would order labs and weekly weights. The dietitian noted the APRN ordered weekly weight on [DATE]. The Dietitian noted on [DATE] Resident #52 had lost 10 lbs., an 8% weight loss in 30 days and she requested a reweight. The Dietitian noted if the reweight was accurate, Resident #52 would have had a significant weight loss of 12% in 6 months. The Dietitian noted the weekly weights ordered on [DATE] had not been done. The Dietitian noted that getting weights done by nursing was a problem. The Dietitian indicated she does not follow up to make sure the weekly weights are being done. Additionally, the Dietitian indicated she does not look at the weekly weights after a weight loss unless it triggers on the report as significant. After clinical record review, the Dietitian identified the admission weight was not done for 4 days, the weekly weights for 4 weeks from admission were not completed, after the significant weight loss the APRN ordered weekly weights not done, and the requested reweights were not done. Interview with the DNS on [DATE] at 2:21 PM indicated that all residents were weighed on admission within 24 hours and then weekly for 4 weeks on the residents scheduled shower day, and then monthly. The DNS noted the nurses sign off on the [NAME] for the weekly weights but the nurse's aides get the weights. The DNS indicated that the physician could order weekly weights and nursing was responsible to get the weights. The DNS noted when the nurse places the weight in the MAR or TAR it will automatically transfer the weight onto the vital sign weight section. After review of the clinical record, the DNS indicated Resident #52 admission weight wasn't obtained for 4 days, the weekly weights for 4 weeks after admission were not done, and the reweight requested on [DATE] was not done. The DNS noted there was an APRN order on [DATE] for weekly weights and that was not done except once a month for September, October, and [DATE]. The DNS indicated the order for weekly weights was noted, but she did not see it in the MAR, TAR, or weight log and identified it may have been a transcription error. The DNS indicated she did not know why the weights were not done per the policy and the physicians orders. Interview and review of the clinical record with the DNS on [DATE] failed to provide documentation that the resident was weighed according to facility policy and physician's order. Review of the Weight Monitoring Policy identified accurate and timely measurement of weight changes in all residents as an important tool in assessing their nutritional status. Resident's will be weighed weekly for 4 weeks on admission and readmission then monthly within the first 7 days, unless otherwise indicated in the physician order or recommended by the dietitian. It is the responsibility of the charge nurse to assure the weights are taken. Weights will be taken and recorded in the electronic medical record. If there was a 5 lbs. weight discrepancy (plus or minus) a reweight should be obtained. The charge nurse should then review the weight and compare this to the previous weights to determine a 5% weight change in 30 days or 10% change in 180 days. Significant weight changes will be reported to the Physician/APRN, residents' representative. Dietitian, DNS and ADNS, and MDS nurse. The facility failed to obtain weekly weights for 4 weeks after admission and failed to obtain weekly weights as per the physician's order dated [DATE].

**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 resident (Resident #69) reviewed for enteral feeding, the facility failed to ensure the resident received care and services to prevent complications (infection). The findings include: Resident # 69 was admitted to the facility on [DATE] with diagnoses that included Glucose-6-Phosphate Dehydrogenase (G6PD), right leg below knee amputee, and hypotension (low blood pressure). Resident #69 also had a court appointed conservator. The admission MDS dated [DATE] identified Resident #69 had moderately impaired cognition, required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #69 receives nutrition via feeding tube. The care plan dated 7/24/23 identified a concern with enteral feeding with interventions that include to care for insertion site as ordered and to watch for sign and symptoms of intolerance such as abdominal pain, nausea, diarrhea, constipation, bloating belching and retching. Observation on 11/28/23 at 10:20 AM identified the enteral feeding fluid (water) was hung and undated, and the syringe and container had a date of 11/22/23, 6 days prior. Interview with LPN #8 on 11/28/23 02:15 PM identified the tubing and syringe is to be changed on the 11:00 PM - 7:00 AM shift and she did not know why it was not done. Interview with the DNS and ADNS 12/7/23 at 9:00 AM identified that tubing and enteral feeding solutions should be labeled, and syringe and container used to assist with medication administration should be changed daily. The policy for enteral feeding indicated the process for assembling equipment for tube feed is to label the tube feeding bag to include the resident's name, date, time, contents rate of flow and nurse's initials, as well as to change the gastrostomy tube set-up and irrigation syringe every 24 hours for open bag system, and every 48 hours for a closed prefilled bag system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, and interviews, the facility failed to ensure that the DNS did not serve as the RN supervisor. The findings include: Review of DNS job description dated 9/25/23 identified he/she was to plan, organize, develop, and direct the overall operations of the nursing services department in accordance with current federal, state, and local standards and regulations and as directed by the Administrator. Interview with the DNS on 12/7/23 at 8:20 AM indicated that she was required to act as the day supervisor on 11/20/23 from 7:00 AM - 4:00 PM and was responsible to do any RN assessments as needed. The DNS indicated there are times when she has had to supervise, and other times the ADNS will supervise. Review of the schedules dated 11/15/23 - 12/2/23 identified the DNS acted in the capacity of the day supervisor on 11/16, 11/20, 11/24, 11/27, 11/29, 11/30, and 12/1/23 for the 7:00 AM - 3:00 PM shift, and she leaves the facility each day about 4:00 PM, even if she was the supervisor for the day. The DNS identified on 11/18/23, a Saturday, she was required to act in the capacity of the RN Supervisor on a double shift, 7:00 AM until 11:00 PM. Interview with Nursing Scheduler on 12/7/23 at 8:34 AM indicated she does the nursing schedule 3 weeks in advance and asks staff to pick up any empty spots needed. The Nursing Scheduler indicated the day before, she gives the next day schedule to the DNS, and on Fridays, she gives the DNS the weekend schedule and the DNS gives it to the supervisors to post from the red book. The Nursing Scheduler indicated that she meets with the Administrator, DNS, ADNS, and HR weekly to review the prior week schedule with call outs and notifies them of the days they did not meet the minimal staffing nursing ratio's, and the next weeks schedules and any empty slots that still need to be filled with staff. The nursing scheduler indicated if no one will pick up empty shifts, the DNS, ADNS or RN #2 will have to supervise. Interview with the Administrator on 12/7/23 at 9:03 AM indicated she was aware that the facility had some staffing challenges and was aware that the DNS fills in as the supervisor for the day at times. Review of the Facility assessment dated [DATE] identified that 90% of the residents were dependent on staff for mobility. Additionally, the acuity of each resident is considered when determining staffing and resource needs. Staffing for nursing: DNS/ADNS- full time and available 24/7 Additionally: 7:00 AM - 3:00 PM -1 RN supervisor and 3 LPN's, 3:00 PM - 11:00 PM -1 RN supervisor and 3 LPN's, 11:00 PM - 7:00 AM -1 RN supervisor and 2 LPN's.

**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 of 5 residents (Resident #80) reviewed for unnecessary medications, the facility failed to identify and monitor target behaviors for a resident receiving an antipsychotic medication since admission, over 8 months. The findings include: Resident #80 was admitted to the facility on [DATE] on an antipsychotic medication with diagnoses that included dementia with psychotic disturbance, major depressive disorder, anxiety and bipolar disorder. Physician's order dated 4/6/23 directed to administer Olanzapine (antipsychotic medication) 5mg daily for behaviors. Physician's order dated 4/18/23 directed to discontinue Olanzapine (antipsychotic medication) 5mg daily for behaviors. Physician's order dated 4/20/23 directed to administer Depakote (medication used to treat some psychiatric conditions) 500mg every evening for mania. Physician's order dated 4/21/23 directed to administer Depakote 250mg daily for mania, and Seroquel (antipsychotic medication) 50mg daily for behavior/psychosis. Physician's order dated 5/8/23 directed to administer Seroquel XR 24 hour release, 150mg at bedtime for psychosis. A psychiatric note dated 6/6/23 identified Resident #80 was being seen for a follow up for anxiety, psychotic symptoms, yelling and medication review. Behaviors of concerns included resistant, attention seeking, yelling out and delusions. Associated signs and symptoms included a history of delusions and behavioral disturbances. The plan identified Resident #80 will continue on current treatment plan, continue to monitor for medication side effects and worsening of mood, anxiety, behaviors and cognitive skills. The significant change MDS dated [DATE] identified Resident #80 had severely impaired cognition. The care plan dated 8/21/23 identified Resident #80 has disruption in cognitive operations and activities, can be impulsive and not always able to control behavior, can direct anger towards others, and is at risk for potential adverse effects of psychotropic drug use. Interventions included to obtain psychiatric consultations as needed, if you see mood changing, offer to assist to another area, spend a few minutes with the resident, be aware of mood state and behavior, and identify common behavioral expressions and expected responses to intervention. Further, the care plan indicated to identify target behaviors and ongoing monitoring of these behaviors. Review of the clinical record, including the MAR's from April 2023 - December 2023 failed to reflect that target behaviors had been identified and monitored every shift for Resident #80 who was receiving antipsychotic medication since admission 3/30/23. Interview with RN #1 on 12/6/23 at 1:00 PM identified the target behaviors should be on the MAR and be monitored every shift. RN #1 could not find target behavior monitoring. Review of the behavior monitoring/antipsychotic medication policy identified the purpose to ensure antipsychotic medications are administered and monitored for OBRA guidelines. Residents receiving antipsychotic medication will have specific target behaviors identified and monitored every shift. Anytime a resident is started on an antipsychotic medication a behavior flow sheet will be initiated and the target behaviors will be recorded where indicated on the flow sheet. Each shift will record, where indicated, the number of episodes for each behavior, interventions, outcomes and side effects. Nursing documentation/charting will be done by exception. Although Resident #80 was admitted on antipsychotic medications and medications for bipolar disorder, the facility failed to identify target behaviors, and monitor those target behaviors, every shift, according to the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 5 residents (Resident #26, 45, 46, and 80) reviewed for immunizations, the facility failed to ensure that the resident and/or resident representative was educated on, or offered influenza and/or pneumococcal vaccinations. The findings include: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included iron deficiency anemia, adjustment disorder, and failure to thrive. The quarterly MDS dated [DATE] identified Resident #26 had moderately impaired cognition and required the assistance of one to two staff members with transfers, eating, and toilet use. A review of Resident #26's clinical record on 12/1/23 failed to identify any documentation that the facility reviewed pneumococcal immunization status with Resident #26. The clinical record review identified that Resident #26 had a consent status of to be determined for the Pneumovax 23 vaccine. Further review of Resident #26's clinical record identified the facility form Pneumococcal Consent, was labeled with Resident #26's name but failed to identify that the form had been reviewed or education provided about the vaccine. 2. Resident #45 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, neuromuscular dysfunction of the bladder, and peripheral vascular disease. The quarterly MDS dated [DATE] identified Resident #45 had intact cognition and required the assistance of two staff members with transfers, dressing, and eating. A review of Resident #45's clinical record on 12/1/23 failed to identify any documentation related to pneumococcal immunizations and/or education related to the vaccine. 3. Resident #46 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, hemiplegia, and chronic respiratory failure. The quarterly MDS dated [DATE] identified Resident #46 had severely impaired cognition and required the assistance of two staff members with transfers, dressing, and bathing. A review of Resident #46's clinical record on 12/1/23 failed to identify any documentation that the facility reviewed pneumococcal immunization status with Resident #46's representative. Review of the electronic clinical record identified that Resident #46's representative refused the pneumococcal immunization on 2/13/23 but failed to identify that any education was provided to the resident representative regarding risks and benefits of immunization. 4. Resident #80 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, bipolar disorder, and anxiety. The 5-day MDS dated [DATE] identified Resident #80 had severely impaired cognition and required the assistance of one to two staff members with transfers, dressing, and toilet use. A review of Resident #80's clinical record identified an Influenza Consent form dated 10/5/23 for 2022 - 2023. The form identified that the facility would be administering the influenza vaccine from 10/2022 - 3/2023. The form was further identified to have a notation at signature portion of the form for consent of the immunization with the following: Permission given by along with Resident #80's resident representative. The form failed to identify the facility staff member who completed the form, provided the education and obtained consent. A review of Resident #80's clinical record on 12/1/23 failed to identify any documentation related to pneumococcal immunizations and/or education provided related to the vaccine. Interview with RN #2 (IP nurse) on 12/1/23 at 3:00 PM identified that she was unable locate any pneumococcal education or immunization documentation for Resident #26, 45, 46 and 80. RN #2 further identified that she was in charge of the immunizations for residents of the facility for the current flu season, which she initially began administering on 9/28/23. RN #2 identified that she offered the vaccines to the residents of the facility who did not require a resident representative to provide consent or refusal for vaccinations. RN #2 further identified that due to the number of residents she needed to vaccinate, the Administrator obtained the phone consent from the resident representatives' to assist RN #2. RN #2 identified that she was unsure why the Administrator did not sign as a witness to the phone consents, but her understanding was that the Administrator reviewed the information on the consent forms, and if the resident representative gave consent, the Administrator made a note of the date and the name on the resident's consent form and then returned the completed forms to RN #2 to allow her to administer the influenza immunizations. Interview with the Administrator on 12/7/23 at 7:29 AM identified that she did not obtain phone consents from resident representatives for influenza immunizations. The Administrator identified that she did not have a clinical background, and that RN #2 had completed the calls to the resident representatives to obtain consent for the influenza vaccines. The Administrator identified that Resident #80's representative returned a call from RN #2 regarding the influenza vaccine, and that she notified RN #2 verbally about the call back, but she did not review any information or sign any documentation regarding any immunizations. Interview with RN #2 on 12/7/23 at 8:20 AM identified that the Administrator did not obtain phone consents from the resident representatives' as she previously reported to this surveyor on 12/1/23. RN #2 identified that the Administrator only obtained a phone consent from Resident #80's representative. RN #2 further identified that despite her previous interview, she obtained the phone consents for the influenza immunizations, not the Administrator. The facility policy on pneumococcal vaccines directed that the vaccine would be offered to residents upon admission to the facility. The policy further directed that the IP nurse would obtain a history of the resident's vaccination history and determine the need for the vaccine. The policy also directed that the resident or resident representative would be given a copy of the pneumococcal vaccine fact sheet and the opportunity to ask questions, and the documentation of the education would be included in the educational log of the resident's chart. The facility policy on influenza vaccines directed that the vaccine would be offered to residents during October/November and throughout the flu season. The policy directed that the resident or resident representative would be given a copy of the influenza vaccine fact sheet, educated on risks and benefits of the vaccine, the opportunity to ask questions, and the documentation of the education would be included in the educational log or in the narrative nurses notes of the resident's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #49 was admitted to the facility on [DATE] with diagnoses that included hemiplegia following a stroke, heart failure, and osteomyelitis. The physician's order dated 2/1/23 directed to administer Ceftriaxone (an antibiotic) 1 gram daily via IV at 5:00 PM daily. The physician's order dated 2/11/23 at 8:39 PM directed to discontinue Ceftriaxone (an antibiotic) 1 gram daily via IV at 5:00 PM daily. The order directed to administer Ceftriaxone 1 gram daily at 9:00 PM. Review of the February 2023 MAR identified that 1 gram Ceftriaxone was administered on 2/11/23 at 5:00 PM, and again at 9:00 PM. A reportable event form, completed by the DNS on 2/15/23 identified Resident #49 was on an IV antibiotic daily, in the evening, and on 2/11/23 was offered the medication on the 7:00 AM - 3:00 PM shift, and again on the 3:00 PM - 11:00 PM shift, which resulting in the medication being administered twice. The reportable event form also identified that the medication error occurred at 10:00 AM on 2/11/23. The report identified that the DNS notified the APRN of the medication error on 2/15/23 and resident representative on 2/16/23. The report failed to identify the facility staff member who administered the medication in error. (The APRN was notified of the medication error on 2/15/23, 4 days after the error occurred, and the resident representative was notified on 2/16/23 5 days after the medication error occurred). A nurse's note dated 2/16/23 at 4:34 PM, written by the DNS, identified that Resident #49 was on Ceftriaxone 1 gram every shift for an infection at the right knee and it was administered twice, and that the APRN and family were notified. Review of the clinical record failed to identify any additional documentation related to the medication error on 2/11/23. The annual MDS dated [DATE] identified Resident #49 was frequently incontinent of bowel and bladder and required the assistance of 2 or more staff with transfers, toileting, and bathing. The care plan dated 10/11/23 identified that Resident #49 had received an IV medication at the wrong time, resulting in the wrong dose of medication (2 doses). Interventions included reporting the error to the physician and family. Interview with the DNS on 12/5/23 at 10:13 AM identified she completed the investigation and reportable event form on 2/15/23 for the medication error that occurred 2/11/23. Upon reviewing the reportable event form she completed, the DNS identified that she was notified of the medication error, but could not remember if she was notified prior to 2/15/23. The DNS further identified that she believed the medication was administered once on the day shift and again on evening shift which constituted the error. The DNS identified she would have to check her notes to confirm the staff members involved and how she was notified of the error. The DNS was unable to identify why the investigation occurred 4 days after the medication error occurred, why the APRN was not notified for 4 days, or why the resident representative was not notified for 5 days. Although requested, the facility failed to provide any additional clarification or documentation regarding discovery of the medication error that occurred on 2/11/23. The facility policy on medication errors directed that when a medication error is identified, the licensed nurse would determine the nature of the error and notify the physician, and that all medication errors would be reported to the resident's physician and family. The facility policy on change in a resident's condition/family/MD notification directed that when there was a significant change of the resident's physical, mental or emotional status, the resident's attending physician (or if not available, covering physician or medical associate) and family or resident representative should be notified. The policy further directed that the nurse would document in the nurse's notes regarding the notifications. 7. Resident #80 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, bipolar disorder, and anxiety. The physician's orders dated 3/30/23 directed to complete weekly body audits on admission and every week on Wednesday during the 7:00 AM - 3:00 PM shift by a licensed nurse, and that the body audit be documented on the body audit form. Review of the clinical record failed to identify any Braden scale (an assessment tool to assess and document a patient's risk for developing pressure injuries) assessments were completed after 4/13/23. The care plan dated 7/24/23 identified that Resident #80 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included completing a Braden scale on admission/readmission and per facility policy, inspect skin when providing care for signs and symptoms of skin breakdown, and consult with a wound care nurse specialist as needed/ordered. A significant change MDS dated [DATE] identified Resident #80 had severely impaired cognition, was always incontinent of bowel and bladder, and required the assistance of one to two staff members with transfers, dressing, and toilet use. The MDS also identified Resident #80 was at risk for pressure ulcer development, had no current pressure ulcers or other skins issues and interventions included pressure reducing device for bed and chair. The clinical record identified skin assessments were not done on 9/6/23 and 9/13/23. A wound tracking note dated 9/16/23 at 10:38 PM by LPN #9 identified Resident #80 had open areas over the center of the buttocks at the sacrum and right buttock. A nurse's note dated 9/16/23 at 10:44 PM by LPN #9 identified Resident #80 had 2 new open areas and the wound nurse had been made aware. Review of the clinical record failed to identify any additional documentation on the new open areas, including an RN assessment, follow up assessments, notification to the wound nurse, to the physician, or to the resident representative following the initial documentation of the newly identified wounds by LPN #9 on 9/16/23. Further, a treatment was not initiated between 9/16/23 - 10/6/23, 3 weeks. A nurse's note dated 10/6/23 at 1:00 PM by the Wound Nurse (RN #2) identified that Resident #80 was seen by the wound team for moisture associated skin damage (MASD) on the gluteal cleft measuring 2.0 cm x 0.5 cm x 0.2 cm. The note further identified that the wound had no signs of infection or drainage noted and was treated with alginate twice daily. A wound physician's note dated 10/6/23 identified Resident #80 was seen for an initial evaluation for a wound on the gluteal cleft measuring 2 cm length x 0.5 cm width x 0.2 cm in depth with a moderate amount of serosanguineous drainage noted. The treatment plan included applying alginate with a dry dressing and changing twice daily and as needed if soiled, saturated, or accidentally removed. Interview with the DNS on 12/5/23 at 10:13 AM identified residents should have a body audit on admission and then weekly. The DNS indicated the weekly body audit is to be completed by the charge nurse to see any changes with the skin and is done on the shower schedule. The DNS further identified that if body audits were not documented that would indicate that they were not done. The DNS also identified that the Braden scales were to be completed only on admission or readmission to the facility. Interview with the DNS on 12/5/23 at 4:13 PM identified for residents of the facility who had newly identified skin issues or wounds, the nurse caring for the resident should document the wound, the nurse would also notify the RN shift supervisor so that a RN assessment could be completed and notify the physician or APRN. The DNS also identified that this was the process for any change in condition, and the resident representative should also be notified. Although attempted, an interview with LPN #9 was not obtained. The facility policy on body audits directed that the purpose of the policy was to assess, identify, and document any alterations in skin integrity in order to develop a plan of care for the treatment and prevention of skin problems. The policy further directed that all residents would have weekly body audits completed and documented by a licensed nurse and that any alterations in skin integrity would be documented on the body audit form. The policy also directed if any alterations in skin integrity were identified, the physician and responsible part should be notified, and new treatment orders should be obtained, if applicable. The facility policy on change in a resident's condition/family/MD notification directed that when there was a significant change of the resident's physical, mental or emotional status, the resident's attending physician (or if not available, covering physician or medical associate) and family or resident representative should be notified. The policy further directed that the nurse would document in the nurse's notes regarding the notifications. Although on 9/16/23 Resident #80 was identified with new open areas over the center of the buttocks at the sacrum and right buttock, the physician was not notified until 10/6/23. Further, the clinical record lacked documentation that the resident representative had been notified of the new open areas. 4. Resident #42 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, psychophysical visual disturbances, and dementia. The quarterly MDS dated [DATE] identified Resident #42 had intact cognition , required extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Resident #42 required limited assistance with walking and supervision with eating and utilized a walker for mobility. The care plan dated 6/15/23 identified a concern with hallucinations, and interventions included to administer medications as ordered, and maintain safety in the environment. The care plan also identified the resident had visual impairment due to [NAME] Syndrome which at times caused visual hallucinations. Interventions included to arrange for visual exam, don't rearrange personal property, clutter free, orient to surroundings. The nurse's note dated 6/17/23 at 7:17 AM identified Resident #42 reported to the RN that the resident saw hallucinations. Resident #42 went to dialysis and was transferred to the hospital from the dialysis center with hallucinations. Resident #42 was readmitted to the facility on [DATE]. The Discharge summary dated [DATE] identified Resident #42 was admitted to the hospital 6/17/23 for hallucinations (seeing things that were not there) and believed the hallucinations were triggered by a bladder infection. Resident #42 was treated with antibiotics, and the hallucinations got better. Resident #42 was discharged back to the facility 6/21/23. Interview and review of the clinical record with APRN #1 on 11/30/23 at 11:50 AM identified Resident #42 had a diagnosis of [NAME] Syndrome and was subject to hallucinations. APRN #1's review of the clinical record for the date of 6/17/23 identified Resident #42 told the RN of his/her hallucinations, and there was no evidence of an RN assessment, or notification to physician or APRN of the hallucinations. Resident #42 was sent to dialysis and was sent to the hospital due to the continued hallucinations. APRN #1 identified had she or the physician known of the hallucinations an intervention could have been provided possibly eliminating the need for hospitalization. APRN #1 identified had she or the physician known of the hallucinations an intervention could have been provided possibly eliminating the need for hospitalization. Interview and clinical record review with the DNS and ADNS on 12/3/23 at 9:00 AM identified Resident #42's reporting of hallucinations to an RN, however failed to identify an RN assessment and notification to the physician or APRN or resident representative of the change in condition. The policy for change in condition/family/MD/notification identified all significant change in a resident's condition will be reported to physician and family and the nurse will document in the nurse's note that the physician and family or responsible party have been notified of the change in condition. 5. Resident #69 was admitted to the facility on [DATE] with a court appointed conservator and diagnoses that included Glucose-6-Phosphate Dehydrogenase (G6PD), right below the knee amputation, hemolysis and hypotension (low blood pressure). The admission MDS dated [DATE] identified Resident #69 had moderately impaired cognition, required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #69 receives nutrition via feeding tube. The care plan dated 7/24/23 identified a concern with possible complications associated with a recent right below the knee amputation. Interventions included monitoring vital signs as ordered per policy, watch surgical site for changes and report to the physician changes in color, width, depth, odor, drainage, bleeding, hematoma formation or increased edema. A focus was also identified for congestive heart failure with interventions which included to provide medications as per physician orders and vital signs and weights as ordered by the physician and report any vital signs or weights outside of acceptable parameters as set by the physician. a. A physician's order dated 7/24/23 directed to administer Metoprolol Tartrate 12.5 mg (an anti-hypertensive) twice daily at 9:00 AM and 6:00 PM and obtain vital signs on admission and for 3 days every shift starting 7/24/23 and ending 8/4/23 at 6:21 PM. Review of the clinical record for the time period ordered after admission identified vitals were recorded only once on 7/24/23 at 11:41 PM as follows. Temperature 97.3 F. Heart rate 90 beats per minute (bpm). Blood pressure 95/55 mmHg (120/80 is a normal reading). Oxygenation of 97% on room air. Review of blood pressure documentation identified the following: On 8/16/23 at 11:38 PM the resident's blood pressure was recorded at 97/58 mmHg. On 8/5/23 at 9:13 PM the resident's blood pressure was recorded at 104/47 mmHg. On 8/5/23 at 9:07 PM the resident's blood pressure was recorded at 104/47 mmHg. On 7/24/23 at 11:41 PM the resident's blood pressure was recorded at 95/55 mmHg. Interview and review of the clinical record review with APRN #1, DNS and ADNS on 12/7/23 at 9:00 AM identified when the vital signs were outside of normal parameters, the physician or APRN should have been notified. The policy for change in condition/family/MD/notification identified all significant change in a resident's condition will be reported to physician and family and the nurse will document in the nurse's note that the physician and family or responsible party have been notified of the change in condition. The vital signs policy identified blood pressure will be taken on admission and at least monthly. Vital signs will be taken on admission and at least monthly unless otherwise ordered by practitioner. Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #24) reviewed for non-pressure skin condition, the facility failed to notify the physician and the resident representative when significant changes occurred, and for 1 of 2 residents (Resident #26) reviewed for pressure ulcers, the facility failed to notify the physician and the resident representative when Resident #26 developed 2 new pressure ulcers, and for 1 residents (Resident #52) reviewed for nutrition, the facility failed to notify resident representative of a weight loss and new orders, and for 1 of 2 residents (Resident #42) reviewed for hospitalization, the facility failed to notify the physician when the resident began to have hallucinations, and for 1 of 12 residents (Resident #69) reviewed for quality of care, the facility failed to notify the physician or the resident representative when Resident #69's blood pressure was low, and for 1 of 2 residents (Resident #49) reviewed for hospitalizations, the facility failed to notify physician and resident representative of a medication error, and for 1 resident (Resident #80) reviewed for skin conditions, the facility failed to notify the physician and resident representative following a newly identified skin issue. The findings include: 1. Resident #24 was readmitted to the facility on [DATE] with a diagnosis that included diabetes, dementia, hypertension, and heart failure. The quarterly MDS dated [DATE] identified Resident #24 had severely impaired cognition and required total assistance with care. The care plan dated 10/5/23 identified the resident had congestive heart failure with interventions that included watching for and reporting increased edema. a. A physician's order dated 10/12/23 at 1:47 PM identified to obtain a weekly weight every 7 days on shower day. Review of the weigh reports dated 10/13/23 - 11/30/23 identified a weight done on 11/6/23 identified the resident weighed 134 lbs. Review of the nurse's notes dated 10/13/23 - 11/30/23 did not reflect that Resident #24 had refused to be weighed or that the physician or APRN had been notified that weights were not being done per the physician order. Interview and review of the clinical record with the DNS on 11/30/23 at 9:30 AM indicated Resident #24 had a physician order for weekly weights but she does not see that the weights had been completed each week or that the physician or APRN were notified that the weights were not done. The DNS indicated her expectation was the nurses would follow the physician orders and if they were not able to for some reason to notify the physician or APRN. b. A physician's order dated 11/17/23 directed to give extra Lasix 20 mg every day for 3 days, elevate bilateral lower extremities, apply ted stockings to bilateral lower extremities every morning and remove at bedtime. Review of the nurse's notes dated 11/17/23 - 11/20/23 did not reflect the resident's representative was notified of the new order for extra Lasix 20 mg daily for 3 days, elevate bilateral lower extremities, apply ted stockings to bilateral lower extremities every morning and remove at bedtime. c. Observation on 11/28/23 at 8:00 AM and 11:00 AM identified Resident #24 was sitting in a standard wheelchair at the bedside with nonskid socks on his/her feet touching the floor. Resident #24 did not have on ted stockings. Observation and interview with NA #9 on 11/28/23 at 11:00 AM indicated she was Resident #24's full time regular aide. NA #9 indicated Resident #24 had on non-skid socks because he/she was a fall risk. NA #9 indicated Resident #24 had never worn ted stockings and she had not seen the nurse, or anyone try to put them on Resident #24. NA #9 indicated if Resident #24 was to wear ted stockings it would be on the resident care card in the closet. NA #9 removed the care card from closet and indicated there was nothing about ted stocking on there. NA #9 indicated Resident #24 never refuses and does not believe Resident #24 would refuse to wear the ted stockings if she had to wear them. Interview with LPN #5 on 11/28/23 at 12:20 PM indicated she was not aware that Resident #24 needed to wear ted stockings and had never attempted to put ted stockings on Resident #24, ever. After clinical record review, LPN #5 indicated there was a physician's order in place for Resident #24 to wear ted stockings. LPN #5 indicated she documented twice in the kardex that she had put the ted stocking on the resident, but did not recall putting ted stocking on the resident since 11/18/23. LPN #5 indicated what might have happened was at the end of the shift things come up in the electronic medical record as not done and she just clicks off on them to complete assignment. Observation and interview with NA #9 on 11/29/23 at 9:45 AM indicated she had washed and dressed Resident #24 before breakfast and had put the ted stocking on Resident #24's right leg but because of a new skin tear, she did not put the ted stocking on the left leg. NA #9 indicated she had not informed the charge nurse, LPN #7, because she made a judgement call. NA #9 indicated she thought trying to put the ted stocking on the left leg over the skin tear would hurt Resident #24, so she decided not to put the ted stocking on as long as Resident #24 had a dressing on the left shin. Resident #24 indicated at that time, this was the first time wearing the ted stocking pointing to the right leg and stated, it was good. Interview with LPN #7 on 11/29/23 at 9:50 AM indicated she was not aware that Resident #24 needed ted stockings. LPN #7 indicated that NA #9 had not informed her that Resident #24 did not have the ted stocking on the left leg. LPN #7 indicated she had never seen Resident #24 wear ted stockings before. Interview with LPN #5 on 11/29/23 at 10:00 AM indicated she had caused a skin tear with her fingernail on Resident #24's left shin when trying to apply the ted stocking when Resident #24 was sitting in the wheelchair. LPN #5 indicated she had informed RN #2 about the skin tear. LPN #5 indicated she had not measured it but estimated it was about 0.5 cm with a flap of skin that was still attached. LPN #5 indicated she did not notify the APRN, physician or resident representative at that time. LPN #5 indicated she did not do the reportable event form because she knew how Resident #24 had gotten a skin tear. LPN #5 indicated she only had to do the reportable event form when the cause was not known, and they had to get statements from all the staff. LPN #5 indicated she did not notify the day supervisor, RN #3, because she had informed RN #2 the wound nurse. Interview with LPN # 6 on 12/5/23 at 2:06 PM indicated she worked the 11/17/23 as the charge nurse and she was responsible to note the new APRN order. LPN #6 indicated that if resident had refused the ted stocking, she would write a progress note and in the TAR click that it was refused. After review of the clinical record, LPN #6 indicated she signed off 5 out of 10 times on the MAR that she had applied the ted stockings, but she never applied them because she indicated I just know the resident would refuse them. LPN #6 indicated she should have gone back to the TAR and put that Resident #24 had refused to have the ted stockings applied and the notify the APRN, but she did not do that. LPN #6 indicated on the MAR she should have not put a check mark and that she should have put a number 2 for refused or 3 for hold and write a progress note. Review of the clinical record with the DNS on 12/5/23 at 2:10 PM indicated her expectation was the nurses would follow the physician orders and if they were not able to for some reason to notify the APRN or physician. The DNS indicated that the nurses should have documented accurately that the ted stocking were not being applied and if the resident refused that the APRN or physician and resident representative would be notified. d. The nurse's note dated 11/27/23 at 1:41 PM identified that Resident #24 was seen today by the APRN ordered extra Lasix 20 mg daily for 7 days in addition to the Lasix 80 mg daily. Resident #24 was encouraged to elevate his/her legs for the edema. A physician's order dated 11/27/23 directed to give extra Lasix 20 mg daily for 7 days. Review of the notes dated 11/27/23 - 11/30/23 did not reflect the resident's representative was notified of the increased edema, or new order for extra Lasix 20 mg daily for 7 days. Interview with the DNS on 12/5/23 at 2:10 PM indicated her expectation was the nurses would notify the resident representative of any new orders that day. Review of the clinical record, the DNS indicated she did not see the resident representative had been notified of the new order. e. Interview with LPN #5 on 11/29/23 at 10:00 AM indicated she had caused a skin tear with her fingernail on Resident #24's left shin when trying to apply the ted stocking when Resident #24 was sitting in the wheelchair. LPN #5 indicated she had informed RN #2 about the skin tear. LPN #5 indicated she had not measured it but estimated it was about 0.5 cm with a flap of skin that was still attached. LPN #5 indicated she did not notify the APRN, physician or resident representative at that time. LPN #5 indicated she did not do the reportable event form because she knew how Resident #24 had gotten a skin tear. LPN #5 indicated she only had to do the reportable event form when the cause was not known, and they had to get statements from all the staff. LPN #5 indicated she did not notify the day supervisor RN #3 because she had informed RN #2 the wound nurse. Review of a nurse's note, as a late entry dated 11/29/23 at 10:02 AM, identified that Resident #24 obtained a skin tear on 11/28/23 to the left shin while ted stockings were being applied. The wound nurse was made aware. Skin tear was cleansed with normal saline and covered with a dry clean dressing. Interview with RN #2 on 11/30/23 at 1:13 PM indicated that she did go and look at Resident #24's skin tear to the left shin but did not document anything. RN #2 indicated she informed the charge nurse to clean it with normal saline and put a dry clean dressing on it. RN #2 indicated that LPN #5 was responsible to start the accident and incident report, notify the APRN and the residents representative. RN #2 indicated it was her responsibility to notify the wound physician. After surveyor inquiry, the nurse's note dated 11/30/23 at 4:41 PM identified that Resident #24 was seen for skin tear to left lateral leg with sanguineous drainage noted on the dressing. The dressing was removed, and wound bed was pink, no signs or symptoms of infection, peri wound was dry and intact, with +2 pitting edema to the leg. The open area measured 1.5 cm by 1.0 cm by 0 with flap in place. APRN and family made aware of skin tear. No new orders at this time. The nurse's note dated 11/30/23 at 5:44 PM identified that the wound physician was notified of skin tear and ordered to apply Medi honey followed by alginate, cover with Allevyn. Interview with the DNS on 11/30/23 at 9:00 AM identified she was not aware of the skin tear for Resident #24 on 11/28/23. The DNS indicated the resident representative and the APRN or physician should have been notified right away. After clinical record review the DNS indicated there was no documentation about the skin tear or that the resident representative or physician had been notified. Review of the Change in Resident Condition Family and Physician Notification Policy identified was to make the residents physician and resident representative aware of any significant change in condition. When there is a change in condition of a resident's physical, mental or emotional status, or in the event of an accident involving the resident: the residents attending physician shall be notified and if not available the covering physician will be notified, the residents' representative shall be notified. The nurse will document in the nurse's notes that the physician and resident representative have been notified of the change in condition. Review of the facility Elastic Stockings Policy identified to improve circulation in the lower legs to prevent pooling of blood in the lower extremities. Elastic stockings are applied with a physician order. To measure and order, measure residents calf circumference and leg length from heel to back of knee of each leg with a tape measure. Review of the facility Accident and Incident Reportable Events identified it was to accurately document a resident incident or accident. All areas of the form will be completed accurately. The completed report is viewed by the DNS or designee for completeness and given a classification. Class E is an event that has caused or resulted in minor injury, distress, or discomfort to the resident. Document the physician and resident representative were notified. 2. Resident #26 was admitted to the facility on [DATE] with diagnoses that included failure to thrive and deep vein embolism and thrombosis. The admission MDS dated [DATE] identified Resident #26 had moderately impaired cognition and required total assistance for personal hygiene and extensive assistance for bed mobility. Resident #26 was at risk for pressure ulcers but did not have any pressure ulcers on admission. The care plan dated 6/20/23 identified Resident #26 was at risk for skin breakdown. Interventions included to apply a pressure reducing mattress set at 150 lbs. and nutritional supplements as ordered. A nurses note, written by an LPN, dated 7/20/23 at 1:13 PM identified 2 new open areas were found on the residents buttocks, near the gluteal cleft. Wound #1 (left buttock) was approximately 1.0 cm by 2.0 cm and was red in color without discharge. Wound #2 (right buttock) measured 0.5cm x 1.0 cm, was red in color, and no drainage was noted. Resident #26 denies pain in these areas. A nurses note written by the Wound Nurse (RN #2), on 7/20/23 at 2:07 PM identified Resident #26 has open area on the buttocks, peri wound was red, no drainage or bleeding noted. Alginate applied followed by Allevyn, will notify wound doctor. Review of the nurses notes 7/20/23 - 7/23/23 failed to reflect documentation that the resident representative and the physician/APRN were notified of the 2 new pressure areas on the right and left buttocks. Interview with RN #2 with Corporate Regional RN #4 present on 11/30/23 at 10:54 AM identified Resident #26 developed 2 new pressure areas on 7/20/23. RN #2 indicated she was notified by the LPN charge nurse of the areas, and she assessed the areas. After review of the clinical record, RN #2 indicated she knew both new pressure areas were open, but she was not able to identify what stages they were. RN #2 indicated that she put in a treatment order as a nursing measure but had only put in a treatment for 1 area and must have forgotten to put in a treatment for the second area. RN #2 indicated she did not notify the physician or APRN at that time. After review of the clinical record, RN #2 indicated when she wrote in her progress note she would notify the wound physician, she planned on notifying the wound physician on her next weekly visit. RN #2 indicated that the resident representative was not notified of the new pressure areas, or of the treatment, and the wound physician was not notified until 7/26/23 (6 days later) when she came in for the weekly wound rounds. RN #4 indicated although the physician or APRN and the resident representative should have been notified of the new open areas and treatment when first identified, it was not done. Interview with the DNS on 12/1/23 at 9:50 AM indicated when a new pressure ulcer was noted and assessed, RN #2 should have notified the physician or APRN and the wound physician to get the appropriate treatment and the resident representative should also be notified of the new pressure areas and the new treatment orders that day. The DNS indicated the notifications must be documented in the resident's clinical record. After clinical record review, the DNS indicated she did not see that the resident representative was ever notified, and the wound physician was notified on 7/26/23, 6 days after the wound's identification. Review of the Change in Resident Condition; Family and Physician Notification Policy identified the purpose was to make the residents physician and resident representative aware of any significant change in condition. When there is a change in condition of a resident's physical, mental or emotional status, or in the event of an accident involving the resident: the residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a home like environment. The findings include: a. Random Observation on 12/6/23 identified the following: 3rd floor center ceiling air condition units soiled in appearance. 3rd floor corridor ceiling fans (2 identified) dust covered and visibly soiled. room [ROOM NUMBER] - radiator near door dented, air mattress placed on bed - not hanging on bed, tape on bureau door, one side of shared bureau missing its lock, plate lopsided on wall-hole exposed, hole near baseboard, baseboard in disrepair. room [ROOM NUMBER] - baseboard in disrepair, door stop hole near baseboard, floor unclean, bureau drawer in disrepair. room [ROOM NUMBER] - perimeter around baseboard soiled with discoloration, wire hanging loosely from wall, wooden block approximately 12 x 3 on floor, various residual holes in wall possible previous wall hangings. room [ROOM NUMBER] - baseboard behind bed B is detached, venetian blind wand to expose room to natural light was on the floor detached and out of reach. room [ROOM NUMBER] - baseboard in disrepair, yellowing on floor near door, bathroom paint on baseboard, mirror soiled, floor radiator dented, bathroom pull cord out of reach. room [ROOM NUMBER] - bed frame soiled, floor yellowing at baseboard. room [ROOM NUMBER] - peeling paint on radiator, soiled baseboard behind toilet seat, brown particles in toilet above the water line, no bathroom sink backsplash, no caulking near bathroom sink, residue noted under faucet. room [ROOM NUMBER] - floor soiled near baseboard perimeter. room [ROOM NUMBER] - peeling paint on wall near door frame, floor near baseboard perimeter soiled, radiator soiled and peeling paint, ceiling chipped tile. room [ROOM NUMBER] - peeling paint, baseboard soiled. room [ROOM NUMBER] - bleached bedside tabletops. 3rd floor Lounge #1-multiple holes in walls visible from previous wall hangings, soiled light switch near air conditioning, soiled air conditioner, bleached out tabletops. 3rd floor Lounge #2 - soiled walls, areas unpainted, soiled light switch, scuffing on walls, plastered walls unpainted, bleached tabletops, scuffed door frame, soiled air condition unit, rails scuffed areas unpainted. On 12/7/23 at 1:15 PM the Administrator indicated she was aware of the areas of disrepair and would reach out to Corporate for information regarding outstanding bids. The Administrator failed to provide any information regarding the status of the outstanding bids and had no additional information regarding the areas. b. Random observations and interview on 12/7/23 at 10:20 AM with the Maintenance Director on the second floor identified the following: 2nd floor elevator area-soiled debris on floor, door frame 1/3 from floor scuffed-missing paint. 2nd floor lounge #1 - missing ceiling tile pieces, baseboard separated at corner, peeling paint, windows sills not painted/soiled. 2nd floor lounge #2 - floors soiled, peeling paint plastered areas unpainted, broken venetian blinds (2), thin paint in areas/blue green (former color) visible, door frame paint peeling. 2nd floor corridor-carpeting heavily stained, soiled. room [ROOM NUMBER] - areas on walls unpainted, fading paint on bureau, the electrical outlet cover and sockets a different unmatching color, baseboard has peeling paint throughout room. 2nd floor ceiling vent - plastic exterior grates are soiled, filters viewed and clean. The Maintenance Director identified he is aware of the concerns identified as they are consistent throughout the facility, and the Administrator currently has work orders out to bid for many of the repairs identified on both the 2nd and 3rd floors. He is awaiting information regarding contractors from the Administrator. Although requested, the facility failed to provide a policy on a homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. Resident #53 was admitted to the facility on [DATE] with diagnoses that included sleep apnea, type 2 diabetes mellitus, anxiety disorder, morbid obesity, and spondylosis. A physician's order dated 3/7/23 directed a licensed nurse to complete a body audit every Saturday, on the 7:00 AM through 3:00 PM shift. a. Review of the weekly body audit documentation identified that weekly body audits were not completed during the following weeks: 4/1/23 4/15/23 4/22/23 4/29/23 5/6/23 5/27/23 6/10/23 6/17/23 7/1/23 7/8/23 7/15/23 7/22/23 8/5/23 8/12/23 8/26/23 9/2/23 9/16/23 9/23/23 10/14/23 10/21/23 10/28/23 11/11/23 11/18/23 11/25/23 The quarterly MDS dated [DATE] identified Resident #53 had intact cognition, was dependent for bathing, personal hygiene, rolling left to right, and laying to sitting. The quarterly MDS further identified that Resident #53 was at risk for developing pressure ulcers. The care plan dated 11/1/23 identified Resident #53 was at risk for skin breakdown due to decreased mobility, and incontinence. Interventions included completing a Braden scale assessment per facility policy, inspecting skin when providing care, and turning and repositioning per standards of nursing practice. Interview and clinical record review with the Infection Control/Wound Nurse (RN #2) on 12/1/23 at 9:53 AM identified that it is the expectation that weekly skin audits are performed weekly on the resident's scheduled shower day, by the unit charge nurse. Interview and clinical record review with the DNS on 12/6/23 at 3:34 PM identified that she would expect weekly body audits to be completed weekly by the licensed nurse or charge nurse. The DNS further identified that she would expect the nurse to document in the resident's clinical record that the body audit was completed and record any alterations in the condition of the skin. Review of the facility's body audit policy directs a licensed nurse will conduct a weekly body audit on the resident, preferably on the bath/shower day, to identify any alterations in skin integrity. The body audit will be signed off by the nurse completing the audit on the treatment Kardex and the weekly body audit form. If there are no alterations in skin integrity identified, the nurse will indicate as such on the body audit form. Any alterations in skin integrity will be noted by marking the location on the body audit form, the physician and resident representative will be notified, and new treatment orders obtained, if applicable. A wound tracking sheet will be initiated, and the plan of care updated. b. A physician's order dated 3/7/23 directed for the administration of CPAP at bedtime, for sleep apnea. The quarterly MDS dated [DATE] identified Resident #53 had intact cognition, was dependent for bathing, personal hygiene, rolling left to right, and laying to sitting. The quarterly MDS further identified that Resident #53 required oxygen therapy via a non-invasive mechanical ventilator. The care plan dated 11/1/23 identified Resident #53 had obstructive sleep apnea (OSA) requiring a non-invasive mechanical ventilator/CPAP. Interventions included the application of a non-invasive mechanical ventilator per the physician's order and respiratory modalities per the physician's order. Observation and interview with Resident #53 on 12/1/23 at 10:30 AM identified that the clear connective tubing on Resident #53's CPAP machine was discolored and visibly soiled. Resident #53 indicated that it had been longer than a month since anyone at the facility had cleaned or changed the CPAP tubing. Resident #53 further indicated that his/her significant other usually cleaned or replaced the CPAP tubing, as needed. Interview and clinical record review with the ADNS on 12/1/23 at 1:57 PM failed to identify that there was a physician's order or documentation in Resident #53's TAR for cleaning, disinfecting, or replacing the CPAP connective tubing or mask. The ADNS further identified that she would have to refer to the facility's policy for CPAP tubing changes and cleaning guidelines, but she believed the connective tubing should be changed weekly. The ADNS identified that changing the tubing is the responsibility of the overnight nurse or supervisor. Subsequent to surveyor inquiry a physician's order was placed on 12/1/23 directing the CPAP-BIPAP tubing to be changed weekly and Resident #53's CPAP tubing was replaced. Interview with the DNS on 12/6/23 at 4:04 PM indicated that CPAP tubing should be changed weekly, on the night shift by the charge nurse. Review of the facility's BIPAP/CPAP care instructions/cleaning policy directs licensed nursing staff will care for the BIPAP/CPAP units to ensure they are clean and functioning. Care instructions included: disposable tubing to be changed every 2 weeks and non-disposable tubing to be cleaned daily with warm water and soap. Nasal and full masks need to be cleaned daily with warm water and soap and masks need to be disinfected one a week. Headgear for masks are washed monthly and as needed. 11. Resident #54 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, hemiplegia, and gastrostomy status. A physician's order dated 10/5/23 directed to administer Glucerna 1.2 at 70ml/hour around the clock no changes to flush, every shift. The admission MDS dated [DATE] identified Resident #54 had moderately impaired cognition and nutritional approaches that included a feeding tube with 51% or more total calories received through the feeding tube and 501cc/day or more fluid intake through the feeding tube. The care plan dated 10/9/23 identified Resident #54 had an enteral feeding tube to assist with maintaining or improving nutritional status, and he/she was at risk for weight loss, dehydration, and aspiration. Interventions included checking tube placement as ordered, monitor gastric residuals as ordered, and provide nutrition via feeding tube and flushes as ordered. Observation on 11/28/23 at 12:35 PM identified Resident #54 was in bed connected to the tube feeding machine, which was shut off via an empty tube feed bottle, with empty tubing, dated 11/27/23 at 3:00 AM. Interview with LPN #3 on 11/28/23 at 12:40 PM identified that she was unaware that Resident #54 was connected to an empty tube feed and the machine was off. LPN #3 indicated that the machine was operating and there was still formula remaining in the tube feeding when she completed her morning medication pass, around 8:00 AM. LPN #3 indicated that it wasn't until this writer brought it to her attention that she was aware that the tube feeding had run out. LPN #3 further identified that nurse aides do not touch the pumps, but they will notify the nurse if the machine is beeping or if they observe a feeding is complete and Resident # 54 is unable to reach or operate the tube feed pump. Observation and interview with the nursing supervisor (RN #3) on 11/28/23 at 12:55 PM identified that it looked like Resident #54's tube feed was spiked on 11/27/23 at 3:00 AM and the machine was stopped. RN #3 further identified that he was unaware why the machine was stopped, but he would expect a new bottle of tube feeding to be administered upon completion of the first tube feeding or the resident to be disconnected and the feeding tube to be flushed, if not in use. Interview with the DNS on 12/6/23 at 3:35 PM identified that Resident #54 was ordered to be on a continuous tube feed, and that it should not be connected to him/her if the bottle and tubing are empty. The DNS further identified that once a resident's tube feeding was completed, the expectation would be for the nurse to check for a residual, flush the tube, and reconnect the resident to a new bottle to resume the continuous feedings. Review of the facility's enteral feeding via gastrostomy (continuous/intermittent) policy directs enteral feedings are performed by licensed nursing personnel per physician's order. All residents on tube feeding must be carefully monitored. Nursing must monitor intake and output and report any significant changes in fluid status to the physician and dietitian. b. The nursing admission assessment dated [DATE] identified Resident #54 had bilateral heel deep tissue injuries, an ulcer to the back of the head, and a stage 3 pressure ulcer to the coccyx. Special treatments included skin prep to the bilateral heels and daily dressing changes to the back of the head and coccyx. The nursing admission assessment further identified Resident #54 had a Braden score of 11 (high risk). A physician's order dated 10/1/23 directed a licensed nurse to complete a body audit every Thursday, on the 7:00 AM - 3:00 PM shift. The admission MDS dated [DATE] identified Resident #54 had moderately impaired cognition and the number of unhealed pressure ulcers/injuries present on admission included 1 stage 3 pressure ulcer and 2 unstageable pressure injuries presenting as deep tissue injuries. The care plan dated 10/9/23 identified Resident #54 was at risk for skin breakdown due to decreased mobility, incontinence, and other risk factors including poor nutrition, pronounced body prominences, poor circulation, altered sensation, and mechanical forces. Interventions included to off load heels while in bed and complete Braden scale upon admission/readmission and as per facility policy. Review of the weekly body audit documentation identified that weekly body audits were not completed the weeks of 10/26, 11/2, and 11/16. The nurse's note dated 11/21/23 at 1:34 PM identified that Resident #54's heel was cleansed with normal saline and the wound nurse was notified of opening. The wound physician's note dated 11/24/23 identified Resident #54 had a new open area on the right heel, was wearing offloading boots, and getting regular moisturizing. The right heel wound was a stage 2 pressure injury pressure ulcer with a status of not healed. Initial wound encounter measurements were 1.5cm length x 1cm width x 0cm depth. The peri-wound skin color, texture, and moisture were normal. Interview and clinical record review with the Infection Control/Wound Nurse (RN #2) on 12/1/23 at 9:53 AM identified that it is the expectation that weekly skin audits are performed weekly on the resident's scheduled shower day, by the unit charge nurse. RN #2 identified that on the 11/9 body audit, there was no breakdown identified on Resident #54's right heel, and a weekly body audit was not completed on 11/16/23 (prior to the identification of a stage 2 pressure ulcer to the right heel on 11/21/23). Wound care observation and interview with the wound physician (MD #2) on 12/1/23 at 11:30 AM identified that she would expect weekly nursing skin assessments to be completed, as Resident #54 is very vulnerable. Interview and clinical record review with the ADNS on 12/1/23 at 2:50 PM identified that prior to the onset of the right heel pressure ulcer, the last body audit was completed on 11/9/23 and there were no new areas of concern identified; this was almost 2 weeks prior to the onset of the pressure ulcer. The ADNS indicated that she would expect weekly body audits to be completed weekly. Interview and clinical record review with the DNS on 12/6/23 at 3:34 PM identified that she would expect weekly body audits to be completed weekly by the licensed nurse or charge nurse and she would expect the nurse to document in the resident's clinical record that the body audit was completed and record any alterations in the condition of the skin. Review of the facility's body audit policy directs a licensed nurse will conduct a weekly body audit on the resident, preferably on the bath/shower day, to identify any alterations in skin integrity. The body audit will be signed off by the nurse completing the audit on the treatment Kardex and the weekly body audit form. If there are no alterations in skin integrity identified, the nurse will indicate as such on the body audit form. Any alterations in skin integrity will be noted by marking the location on the body audit form, the physician and resident representative will be notified, and new treatment orders obtained, if applicable. A wound tracking sheet will be initiated, and the plan of care updated. 7. Resident #29 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, dysphagia, and macular degeneration. Review of the clinical record failed to identify any documentation related to blood pressure and pulse from 5/29/22 - 9/23/22, 11/6/22 - 4/23/23, and 4/24/23 - 9/27/23, and failed to identify any documentation related to respirations from 11/6/22 - 9/27/23. The care plan dated 7/24/23 identified Resident #29 required extensive assistance with most ADLs. Interventions included delivering and setting up meals and providing assistance with feeding as needed. The quarterly MDS dated [DATE] identified Resident #29 had moderately impaired cognition, was always incontinent of bowel and bladder and required the assistance of one staff member with dressing, transfers, and toilet use; and required set up for eating. A physician's order dated 11/6/23 directed to administer Norvasc 2.5 mg daily for high blood pressure, with perimeters to hold the medication if blood pressure was less than 90/60 or pulse was less than 60. The orders further directed that Resident #29 required an advanced dysphagia diet, level 3 texture with set up for all meals, 1:1 supervision/assistance during all meals and cueing for small bites/slow rate, sips of liquid between bites, and should be in an upright position during meals. The nurse aide care card, reviewed on 11/28/23, identified that Resident #29 was able to feed his/herself but required meal set up and had precautions of small bites at a slow rate, sips of liquid between bits, and position upright during meals. Observation on 11/28/23 at beginning at 12:15 PM identified Resident #29 seated in a wheelchair with a meal plate and drink positioned on a bedside table placed directly in front of the resident while in his/her room. Resident #29 was observed to be sleeping slumped forward. No facility staff near or entering Resident #29 at any time during this observation. Observation, interview, and review of the clinical record with the DNS on 11/28/23 at 12:25 PM identified that Resident #29 had been eating independently for an unknown period of time and did not require any supervision with meals. A review of Resident #29's active orders with the DNS identified that Resident #29 had an active order to set up for all meals, 1:1 supervision/assistance during all meals and cueing for small bites/slow rate, sips of liquid between bites, and should be in an upright position during meals. The DNS identified that's an old order, even though it's still there the resident feeds him/herself. I am not sure why that's still there. The DNS was unable to identify when Resident #29 had a change in status from requiring supervision with meals to feeding independently. Subsequent to surveyor inquiry, on 11/28/23 at 12:28 PM a female facility staff member was observed in Resident #29's room providing 1:1 supervision. Resident #29 was observed awake and eating during this observation. Interview with the DNS on 12/5/23 at 10:13 AM identified that vital signs should be done monthly or more frequently if the physician's orders directed, and the vital signs would be located within the electronic clinical record, if completed. Interview with the Therapy Director on 12/6/23 at 8:55 AM identified that Resident #29 did not have any changes from therapy that recommended a change from 1:1 supervision to feeding independently. The Therapy Director identified that Resident #29 last had a speech therapy evaluation on 6/6/23 and at that time there were no changes were recommended to Resident #29's dysphagia diet and need for 1:1 supervision with meals. The facility policy on blood pressure monitoring directed that blood pressures would be checked on admission and at least monthly. The facility policy on pulse monitoring directed that a pulse would be taken on admission, monthly, as ordered by a physician, and as needed. The facility policy on respiratory rate monitoring directed that a respiratory rate would be taken on admission, monthly, as ordered by a physician, and as needed. Review of the facility policy on feeding directed that residents should be assisted to an upright position as possible, and cueing should be provided as needed. The facility policy on resident rights directed that residents of the facility had the right to receive care and services with reasonable accommodation for the residents' individual needs. Although requested, the facility failed to provide a policy on 1:1 feeding and supervision with meals. 8. Resident #49 was admitted to the facility on [DATE] with diagnoses that included hemiplegia following a stroke, heart failure, and osteomyelitis. Review of the clinical record identified that Resident #49 was hospitalized for a surgical revision of a right total right knee replacement from 1/22/23 - 1/31/23. The Braden scale completed on 1/31/23 identified Resident #49 had a total score of 15 and was at mild risk for development for pressure ulcers. Review of the clinical record failed to identify any additional Braden scale assessments were completed after 1/31/23. The care plan dated 3/27/23 identified that Resident #49 was at risk for hypoxemia due to a history of respiratory failure. The interventions included obtaining vital signs as ordered and per policy. The care plan also identified that Resident #49 had a history of wounds. Interventions included checking skin at least weekly on scheduled bath day and to monitor response to any treatments per policy. The care plan further identified Resident #49 at risk for skin breakdown due to altered mobility and incontinence. Interventions included inspecting skin when giving care for signs and symptoms of breakdown. The quarterly MDS dated [DATE] identified Resident #49 was always incontinent of bowel and bladder and required the assistance of 2 or more staff with transfers, toileting, and bathing. The MDS also identified that Resident #49 was at risk for pressure ulcers. Review of the June 2023 MAR identified Resident #49 had orders for skin prep and offloading of the left heel every shift. The MAR also identified multiple treatments ordered to the right lateral thigh, middle buttock, right knee, and bilateral lower extremities. Review of the physician's order summary dated 6/1/23 directed Resident #49 have a weekly body audit every Sunday on the day shift and have a pressurized mattress in place to be checked every shift for placement and settings. The order report also identified Resident #49 received Furosemide (a diuretic for fluid retention) 20 mg daily, Losartan (a blood pressure medication) 25 mg daily, Rivaroxaban (an anticoagulant) 15 mg daily for atrial fibrillation, Amoxicillin (an antibiotic) 250 mg three times daily for chronic knee infection for lifetime. Review of the clinical record failed to identify any documentation related to vital sign monitoring including blood pressure, pulse, respiration, or temperature monitoring for Resident #49 from 2/19/23 - 9/18/23. Interview with the DNS on 12/5/23 at 10:13 AM identified that vital signs should be done monthly or more frequently if the physician's orders directed, and the vital signs would be located within the electronic clinical record, if completed. The DNS also identified that Braden scales were completed on admission or readmission to the facility only. The facility policy on blood pressure monitoring directed that blood pressures would be checked on admission and at least monthly. The facility policy on pulse monitoring directed that a pulse would be taken on admission, monthly, as ordered by a physician, and as needed. The facility policy on respiratory rate monitoring directed that a respiratory rate would be taken on admission, monthly, as ordered by a physician, and as needed. The facility policy on Braden Scale directed that all residents would be assessed for risk of pressure sore development on admission, readmission, annually, quarterly, and upon a significant change of condition and that a licensed nurse was responsible for completion. The facility policy on wound and skin care protocols identified that all residents would be assessed by the nurse for risk of skin breakdown utilizing the Braden Scale on admission/readmission weekly for 4 weeks, upon a significant change of condition, and quarterly. 9. Resident #80 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, bipolar disorder, and anxiety. The physician's orders dated 3/30/23 directed that Resident #80 required weekly body audits on admission and every week on Wednesday during the day shift by a licensed nurse, and that the body audit be documented on the body audit form. Review of the clinical record failed to identify any Braden scale assessments were completed after 4/13/23. The care plan dated 7/24/23 identified that Resident #80 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included completing a Braden scale on admission/readmission and per facility policy, inspect skin when providing care for signs and symptoms of skin breakdown, and consult with a wound care nurse specialist as needed/ordered. The significant change MDS dated [DATE] identified Resident #80 had severely impaired cognition, was always incontinent of bowel and bladder, and required the assistance of one to two staff members with transfers, dressing, and toilet use. a. The care plan dated 8/21/23 identified Resident #80 had impaired memory, recall and decision-making skills. Interventions included to allow time for the resident to respond when speaking to him/her, if confused or forgetful, offer gentle reminders, offer medications as ordered. Be aware of effectiveness and side effects and make adjustments as needed/ordered. Physician's order dated 9/20/23 directed to obtain a blood pressure on shower day, (Wednesday in the morning). Review of the clinical record, including the MAR's identified staff did not obtain the residents blood pressure weekly on shower days on 10/18, 10/25, 11/1, 11/8, 11/15 or 11/22/23 as ordered. Interview with RN #1 on 12/6/23 at 1:00 PM identified after her review of the record, the blood pressures were not done. b. Review of the clinical record identified that Resident #80 had weekly body audits completed on the following dates following admission to the facility: 3/30, 4/13, 4/20, 5/17, 5/24, 6/29, 7/13, 7/27, 10/12, 11/23 and 11/29/23. A wound tracking note dated 9/16/23 at 10:38 PM by LPN #9 identified Resident #80 had open areas over the center of the buttocks at the sacrum and right buttock. A nurse's note dated 9/16/23 AT 10:44 PM by LPN #9 identified Resident #80 had 2 new open areas and the wound nurse had been made aware. Review of the clinical record failed to identify any additional documentation, including any RN assessments, follow up assessments of the open areas, notification to the wound nurse, physician notification, resident representative notification following the initial documentation by LPN #9 on 9/16/23. A nurse's note dated 10/6/23 at 1:00 PM by RN #2 (IP/wound nurse) identified that Resident #80 was seen by the wound team for moisture associated skin damage (MASD) on gluteal cleft measuring 2x0.5x0.2 The note further identified that the wound had no signs of infection or drainage noted and was treated with alginate twice daily. A wound physician's note dated 10/6/23 identified Resident #80 was seen for an initial evaluation for a wound on the gluteal cleft measuring 2 cm length x 0.5 cm width x 0.2 cm in depth with a moderate amount of serosanguineous drainage noted. The treatment plan included to apply alginate with a dry dressing and change twice daily and as needed if soiled, saturated, or accidently removed. Interview with the DNS on 12/5/23 at 10:13 AM identified residents should have body audit on admission and then weekly. The DNS indicated the weekly body audit was completed to see if any changes on skin weekly with the shower schedule and the charge nurse was responsible to do the weekly body audit. The DNS further identified that if body audits were not documented that would indicate that they were not done. The DNS also identified that Braden scales were completed on admission or readmission to the facility only. Interview with RN #2 on 12/5/23 at 10:34 AM identified that she was not notified of Resident #80's wound until 10/6/23, when she completed rounds with the wound care physician. RN #2 identified she was notified of skin issues for residents of the facility during daily morning report and by word of mouth. RN #2 identified that there was no formal reporting system or communication method set up to notify her a resident had a newly identified wound or that a previously identified wound was worsening. RN #2 also identified she did not complete the RN assessment of a newly identified wound and the assessment would be completed by the RN nursing supervisor, once a resident's nurse notified the supervisor it was needed. Interview with the DNS on 12/5/23 at 4:13 PM identified for residents of the facility who had newly identified skin issues or wounds, that the nurse caring for the resident should document the wound, the nurse would also notify the RN shift supervisor so that a RN assessment could be completed, then the physician or APRN should be notified. The DNS also identified that this was the process for any change in condition, and the resident representative should also be notified. Although attempted, an interview with LPN #9 was not obtained. The facility policy on Braden Scale directed that all residents would be assessed for risk of pressure sore development on admission, readmission, annually, quarterly, and upon a significant change of condition and that a licensed nurse was responsible for completion. The facility policy on body audits directed that the purpose of the policy was to assess, identify, and document any alterations in skin integrity in order to develop a plan of care for the treatment and prevention of skin problems. The policy further directed that all residents would have weekly body audits completed and documented by a licensed nurse and that any alterations in skin integrity would be documented on the body audit form. The policy also directed any alterations in skin integrity were identified, the physician and responsible part should be notified, and new treatment orders should be obtained, if applicable. The facility policy on wound and skin care protocols identified that all residents would be assessed by the nurse for risk of skin breakdown utilizing the Braden Scale on admission/readmission weekly for 4 weeks, upon a significant change of condition, and quarterly. The policy also directed weekly body audits would be completed on bath/shower days by a licensed nurse, and that identified skin areas would have weekly documentation until healed. The facility policy on wound prevention/interventions for all residents directed that weekly body audits would be completed on bath/shower days by a licensed nurse. 3. Resident #24 was readmitted to the facility with a diagnosis that included diabetes, dementia, hypertension, and heart failure. The quarterly MDS dated [DATE] identified Resident #24 had severely impaired cognition and required total assistance with care. The care plan dated 10/5/23 identified congestive heart failure with interventions to watch for increased edema and report to physician. a. A physician's order dated 11/17/23 directed to give extra Lasix 20 mg every day for 3 days, elevate bilateral lower extremities, apply ted stockings to bilateral lower extremities every morning and remove at bedtime. Observation on 11/28/23 at 8:00 AM, 10:00 AM and 11:00 AM identified Resident #24 was sitting in his/her standard wheelchair next to the bed with non-skid socks on without the benefit of the ted stockings. Observation and interview with NA #9 on 11/28/23 at 11:00 AM indicated she did morning care for Resident #24 before breakfast this morning. NA #9 indicated she works full-time and has Resident #24 on her assignment daily. NA #9 indicated Resident #24 has never had ted stockings. NA #9 indicated the care card in the closet does not state Resident #24 needed ted stockings. Review of the care card with NA #9 indicated if it was on the care card, she would be responsible for putting the ted stockings on Resident #24 every morning when she gets washed and dressed. NA #9 indicated she has not seen or put ted stockings on Resident #24 in the last 2 weeks. NA #9 indicated no one had verbally informed her that Resident #24 now needed ted stockings. NA #9 indicated Resident #24 only wears nonskid socks because he/she is a fall risk. NA #9 indicated she does not think Resident #24 would refuse the ted stockings if she had to put them on him/her. Interview with LPN #5 on 11/28/23 at 12:45 PM indicated she was not aware that Resident #24 needed ted stockings but would check the physician's orders. After clinical record review, LPN #5 indicated there was an order for ted stockings to be applied in the morning. LPN #5 indicated that the nurse aide or she as the charge nurse would be responsible to put the ted stockings on each morning before the resident gets out of bed. LPN #5 indicated Resident #24 would not refuse to allow the staff to put on the ted stockings in the mornings. LPN #5 indicated she had not applied the ted stockings before to Resident #24. LPN #5 indicated she had signed off that she had applied for them but did not recall ever putting them on Resident #24. LPN #5 verified Resident #24 did not have ted stockings on today because she did not know there was an order for them but had sign off that they were applied. LPN #5 indicated while she was doing a room search that she would not find any pairs of ted stockings in the Residents drawers because she knows she has not used them. LPN #5 indicated the ted stocks were available and that she would have to measure the resident's legs to know which size to use. After review of the Kardex, LPN #5 indicated she had signed off as applying the ted stockings on Resident #24 twice, but she did not apply them. LPN #5 indicated she did not know why she signed off as applying them it was a mistake. LPN #5 indicated what might have happened was at the end of the shift things come up in the electronic medical record as not done and she just clicks off on them as completed to complete her assignment. Interview with the DNS on 11/30/23 at 9:00 AM identified the nurse aide or the charge nurse can apply the ted stocking's every morning, but the nurse was responsible to make sure and check that the ted stockings were on before signing off in the Kardex. The DNS indicated that the nurse aide would be aware that Resident #24 needed the ted stocking from the resident care card. Review of the 2 resident care cards, the DNS indicated that the ted stocking was not on there. The DNS indicated the expectation was that the nurses would make sure the ted stockings were applied daily per the physician's order. Interview with LPN # 6 with the DNS present on 12/5/23 at 2:06 PM indicated she worked on 11/17/23 as the charge nurse and she was responsible to transcribe the new APRN order for the ted stockings. LPN #6 indicated that if the resident had refused the ted stocking, she would

Based on observation, review of facility policy and interviews, the facility failed to maintain a clean and sanitary kitchen environment. The findings include: a. During the brief initial kitchen tour, with the Food Service Director on 11/28/23 at 10:52 AM the following was identified. Dirt, grime, and debris were observed on the floors and walls. Two floor fans observed in the kitchen were covered with dust and debris, as lunch was being prepared by the dietary staff. b. During the kitchen tour with the Food Service Director on 11/29/2023 at 1:35 PM the following was identified. The entryway to the kitchen on the dining room side was observed with heavy black/brown/white debris in both corners of the door on the floor. Dietary Aide #2's hair was sticking out in the front and on the sides of his head covering. Paper-like products on the floor with debris, along with a blue glove and other debris under the food prep area tables (packages of cups, lids, dust, and grime). Personal lunch box and drink tumbler on a food prep station, along with covid test cards and masks. Black grime and mold like substance behind the dishwasher on the wall and on the chemical dispenser cover. Two flour bins, cookie crumbs, a bag of poultry type cubes and frozen stuffed shells in a blue bag all found with no labels or dates. Egg salad dated 11/25/23. Kitchen ice machine observed with 2 black colored particles on the ice. Dirt and debris on top of the dishwasher in front of the gauges. JBL speaker on the food storage shelf near the grill. Storage of steam table pans covered with dust and food like particles. Dirt and grime on the floor and side of stove. A piece of parchment paper left on grill top stove. Grease/grime on stove top burners and pan bottoms. Black spots and debris on walls next to and around both stoves. Black debris and dust on floor under wall vent coverings. Entries missing on the sanitizer bottle/bucket log, dishwasher temperature log and Prep, and cook refrigerator temperature logs for the month of November 2023. Spoiled moldy sweet potato in refrigerator #2. Dirty ladder and open garbage can near food prep area. Rusty dirty vents. Wall fan covered in dust/dirt. c. During the kitchen tour with the FSD on 11/29/23 at 1:35 PM, tin foil was covering the top shelf above the grill and had what appeared to be a yellow-like substance underneath the foil. The FSD indicated the shelf would be cleaned. d. The second-floor nourishment room tour on 11/30/23 at 12:36 PM with LPN #1 identified the following: Med pass 2.0 nutritional shake dated 9/26/2023. Missing entries for refrigerator temperatures month of November 2023. Interview with LPN #1 on 11/30/23 at 12:36 PM identified the Med pass supplement was expired and should have been discarded. LPN #1 thought the night shift was responsible for monitoring refrigerator temperatures. Subsequent to this tour, the Med pass 2.0 was removed and discarded by LPN #1.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews the facility stored clean supplies on the dirty linen carts, failed to ensure that the staff maintained appropriate infection control precautions related to Covid 19 antigen testing, failed to ensure infection surveillance monitoring was completed per facility policy, failed to ensure that environmental rounds were completed at least quarterly per facility policy, failed to have an established infection control committee, failed to report Covid 19 outbreaks to the state agency, and failed to maintain mechanisms of tracking Covid-19 outbreaks reported to the state agency. The findings include: 1. Observation on 11/29/23 at 6:30 AM on the third floor east side identified a 2-bin dirty linen cart in the hallway with a partially opened bag of briefs on the bottom shelve under the dirty linen bag, a stack of clean disposable wash cloth on top of the dirty linen hamper lid, and a new box of large gloves that was opened. The lid was missing on the hamper side with the dirty briefs in it. The observation identified NA #8 get clean items off dirty cart and enter room a resident room. Interview with NA #8 on 11/29/23 at 6:40 AM identified she had just provided incontinent care and was discarding the items. NA #8 indicated that she could put her clean items on her dirty cart because at the start of her shift at 11:00 PM, she wiped the cart down with bleach wipes. Observation on 11/29/23 on the third floor west side at 6:45 AM identified a 2 bin dirty linen cart with a bag of garbage in the top of the cart and another one hanging from the back of the cart dragging on the floor. Additionally, there was a tube of protective ointment on top of the dirty lid of the cart. Observation and interview with the Infection Control Nurse (RN #2) on 11/29/23 at 6:50 AM identified that staff cannot put any of the clean supplies for the residents on the dirty linen/garbage containers. RN #2 indicated that the east unit 2 bin cart was missing a lid on the dirty brief side and all carts must have lids on all of them. RN #2 indicated the nurse aides were to distribute all the clean linen and supplies needed to every resident room at the beginning of the shift so that they would not need to put clean items on a dirty cart. RN #2 indicated the west unit cart should not have a bag for garbage hanging off the back sitting on the floor and should not have another bag of garbage on the top of it. RN #2 indicated as soon as the bag was full it should have been brought to the dirty utility room on the unit. RN #2 indicated the protective ointment for residents cannot be on the top of the dirty linen cart. 2. Observation on 11/28/23 at 11:21 AM identified a staff Covid 19 testing station that included boxes of antigen tests, a large beige trash can with a step open lid, and an employee testing logbook, located on the reception counter directly inside the main entrance area of the facility. Interview with the Administrator and RN #1 (Director of Clinical Services) immediately following this observation identified that the facility staff had been instructed by the Administrator to complete antigen testing due to a Covid 19 outbreak in the facility. The Administrator identified that the staff had been instructed to complete the testing at the reception desk since the café was not available to use. RN #1 then identified that the facility staff should not be conducting any antigen testing at the reception desk. Subsequent to surveyor inquiry, RN #1 relocated the staff Covid 19 testing area to the business office of the facility. The facility policy on Covid 19 directed that the facility would utilize all outbreak procedures during a Covid 19 outbreak, including use of source control. The policy further directed that healthcare personnel in the facility may be tested at the discretion of the facility. The policy also directed to refer to the updated CMS guidance in QSO 20-38-NH revised. CMS memo QSO 20-38-NH revised directed that collecting and handling Covid 19 specimens correctly and safely was imperative to ensure the accuracy of test results and prevent any unnecessary exposures. The memo further directed that during specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment when collecting specimens. 3. A review of documentation provided by the facility on 12/1/23, as part of a review of the infection control program, failed to identify any infection surveillance monitoring for all of 2022 and from 1/1/23 - 4/2023. Interview with RN #2 (IP nurse) on 12/1/23 at 3:00 PM identified that she began in the IP nurse position in May 2023 and at that time she began to complete monthly infection reports for residents of the facility. RN #2 identified that she was unable to locate any monthly report documentation prior to her start in the IP position. Interview with the DNS on 12/7/23 at 8:28 AM identified that she was not involved in the infection control program for the facility and that it was the responsibility of the IP nurse to ensure that all areas of the program, including infection surveillance and environmental rounds, were completed. The facility policy on infection surveillance data collection directed that the purpose of the policy was to determine the presence or absence of infection in facility residents. The policy further directed that the IP nurse would complete an infection surveillance data form for each facility resident with an infection, and that the data collected would be analyzed monthly for trends and incorporated into the quarterly infection control report. The policy also directed that the infection control data forms for residents with identified infections would be maintained on file by the IP nurse for a period of no less than 3 years. The facility policy on quarterly infection reports directed that the IP nurse should gather monthly infection control reports for the quarter to review statistics, including rates of nosocomial infections and resolution rates, facility and community acquired pressure areas, and residents on IVs. The policy also directed that these records would be maintained for a period of no less than 3 years and that data would be presented to the infection control committee for review and recommendations. 4. A review of the infection control environmental round logs provided by the facility on 12/1/23 failed to identify any documentation that environmental rounding had been completed by the IP from 5/2022 - 12/2022. Interview with RN #2 on 12/1/23 at 3:00 PM identified that she was not the IP nurse during the timeframe in question. RN #2 further identified that the environmental rounds were to be completed at least quarterly, but she was unable to locate any documentation that any rounds were completed from 5/2022 - 12/2022. Interview with the DNS on 12/7/23 at 8:28 AM identified that she was not involved in the infection control program for the facility and that it was the responsibility of the IP nurse to ensure that all areas of the program, including infection surveillance and environmental rounds, were completed. The facility policy on infection control surveillance and safety rounds directed that surveillance rounds would be conducted on a quarterly basis by the IP nurse of his/her designee. The policy further directed that the data collected from the rounds would be compared and analyzed to formulate a quarterly report and training needs of the staff, and that the quarterly report would be presented at the quarterly medical staff meeting. 5. Interview with RN #2 on 12/5/23 at 10:34 AM identified that the facility did not have an infection control committee. RN #2 identified she assumed the role of the IP nurse in May 2023. RN #2 identified that there was no infection control committee in the facility, and she had not participated in any meetings related to infection control. RN #2 further identified that while she had completed monthly infection surveillance reports beginning in May 2023, she had not participated in or reviewed any of the report findings at any medical staff meetings. Interview with the DNS on 12/7/23 at 8:28 AM identified that she was not involved in the infection control program for the facility and that it was the responsibility of the IP nurse to ensure that all areas of the program, including infection surveillance and environmental rounds, were completed. The facility policy on the Infection Control Committee directed that the committee should be composed of the medical director, DNS, IP nurse, Administrator, and other facility staff as indicated. The policy further directed that the committee should meet at least quarterly in conjunction with medical staff meetings and as needed. The policy also directed that the IP nurse should prepare a quarterly report summarizing data collected for the prior 3 months and should include: the number and types of infections, infection rate, and resolution rate, review of infection surveillance rounds, and monitoring of adherence to infection control policies and procedures by staff. The facility policy on quarterly infection reports directed that the IP nurse should gather monthly infection control reports for the quarter to review statistics, including rates of nosocomial infections and resolution rates, facility and community acquired pressure areas, and residents on IVs. The policy also directed that these records would be maintained for a period of no less than 3 years and that data would be presented to the infection control committee for review and recommendations. 6. A review of facility Covid 19 outbreak line lists on 12/1/23 identified that multiple outbreaks were not reported to the state agency for 2022 and 2023. A review of the Covid 19 outbreak line lists for 2022 identified active Covid 10 outbreaks in the facility for the following months: 4/22, 5/22. 6/22, 7/22, and 9/22. A review of the DPH FLIS outbreak reportable event database for the facility identified one outbreak reported on 7/16/22. Review of the facility Covid 19 outbreak line list for 7/22 identified the outbreak began on 7/6/22, 10 days prior to the facility reporting the outbreak to the state agency. Review of the database failed to identify any Covid 19 outbreaks reported by the facility for 4/22, 5/22. 6/22, or 9/22. Interview with RN #2 (IP nurse) on 12/5/23 at 10:34 AM identified that the DNS was responsible to report all outbreaks in the facility to the state agency. Interview with the DNS on 12/7/23 at 8:28 AM identified that she was not involved in the infection control program for the facility and that it was the responsibility of the IP nurse to ensure that all areas of the program, including infection surveillance and environmental rounds, were completed. The DNS further identified that she was responsible to report all outbreaks to the state agency and she was unsure why she had failed to report the Covid 19 outbreaks in 2022. The facility policy on reporting an outbreak directed that the facility would provide immediate notice by phone to the state agency of an outbreak, and provide a written report within 72 hours, including outbreak data and a copy of the initial outbreak line list. The facility policy on reporting of communicable diseases identified the facility would follow the department of health services guidelines on notification of reportable communicable diseases by the IP Nurse or RN designee, within the timeframe outlined by local and state health departments. The policy further identified that the reporting, based on category, would be based on instructions from an annual list declared by the Commissioner of the Department of Health, and that list was updated annually. Review of the Connecticut DPH reportable diseases list for 2022 and 2023 identified Covid 19 as a category 2 disease. The reporting guidelines for a category 2 disease directed that reporting did require a phone call but must be reported electronically or by fax within 12 hours. 7. A review of facility Covid 19 outbreak line lists on 12/1/23 identified that multiple outbreaks reported to the state agency did not have a corresponding Covid 19 outbreak line list maintained by the facility. A review of the DPH FLIS outbreak reportable event database identified the facility reported Covid 19 outbreaks on the following dates: 12/21/22, 6/13/23, 8/7/23, and 10/21/23. The documentation provided by the facility failed to identify any line lists for the outbreak dates reported. Interview with RN #2 on 12/5/23 at 10:34 AM identified that the DNS was responsible to report all outbreaks in the facility to the state agency. RN #2 identified she was responsible for maintaining the outbreak line lists, and that she was unsure what happened to the missing line lists. Interview with the DNS on 12/7/23 at 8:28 AM identified that she was not involved in the infection control program for the facility and that it was the responsibility of the IP nurse to ensure that all areas of the program, including infection surveillance and environmental rounds, were completed. The DNS further identified that she was responsible for reporting all outbreaks to the state agency, but it was the IP nurse's responsibility to maintain the outbreak line lists. The facility policy on reporting an outbreak directed that the facility would provide immediate notice by phone to the state agency of an outbreak, and provide a written report within 72 hours, including outbreak data and a copy of the initial outbreak line list.

**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 5 residents (Resident #26, 46, and 80) reviewed for immunizations, the facility failed to ensure that the resident and/or resident representative was educated on and offered Covid 19 vaccinations. The findings include: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included iron deficiency anemia, adjustment disorder, and failure to thrive. The quarterly MDS dated [DATE] identified Resident #26 had moderately impaired cognition and required the assistance of one to two staff members with transfers, eating, and toilet use. A review of Resident #26's clinical record on 12/1/23 failed to identify any documentation that the facility reviewed Covid 19 immunization status with Resident #26. The clinical record review identified a blank Covid 19 vaccination consent form located in Resident #26's paper chart. 2. Resident #46 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, hemiplegia, and chronic respiratory failure. The quarterly MDS dated [DATE] identified Resident #46 had severely impaired cognition and required the assistance of two staff members with transfers, dressing, and bathing. A review of Resident #46's clinical record on 12/1/23 failed to identify any documentation that the facility reviewed Covid-19 immunization status with Resident #46's or the resident representative. Review of the electronic clinical record identified that Resident #46's representative refused the Covid 19 immunization on 2/13/23 but failed to identify that any education had been provided to the resident representative regarding risks and benefits of immunization. 3. Resident #80 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, bipolar disorder, and anxiety. The 5-day MDS dated [DATE] identified Resident # 80 had severely impaired cognition and required the assistance of one to two staff members with transfers, dressing, and toilet use. A review of Resident #80's clinical record on 12/1/23 failed to identify any documentation that the facility reviewed Covid-19 immunization status with Resident #80 or the resident representative. Interview with RN #2 (IP nurse) on 12/1/23 at 3:00 PM identified that she was unable locate any Covid 19 vaccine education or documentation for Resident #26, 46 and 80. The facility policy on Covid 19 vaccines directed that the vaccine would be offered and administered to residents of the facility. The policy also directed that the resident or resident representative would be given a copy of the Covid 19 vaccine fact sheet. The policy further directed that the facility would maintain a copy of the signed consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, and interviews the facility failed develop, implement, and maintain an effective training program for all staff. The findings include: Interview with the Staff Development Nurse, (RN #2) on [DATE] at 11:00 AM indicated she was responsible to do all the education and competencies at the facility for all the staff. RN #2 indicated she had not done any mandatory education in 2022 or 2023 for existing staff and she had not done any competencies with the existing nursing staff in 2022 or 2023. RN #2 indicated she could not find any documentation or records that education had been completed in 2022 and 2023 prior to her starting in that position. RN #2 indicated she had only done education and competencies with the new hire and did not do it with anyone else. Review of the Facility assessment dated [DATE] identified staff were assigned to units based on training, education, and competencies to best care for the residents. Staff training, education, and competencies: Annual education at hire and annually includes abuse, neglect, exploitation, misappropriation of resident's property, resident rights, communication, culture change (person centered and person directed care), infection control, identification of a resident change in condition, including how to identify medical issues, cultural care (ability to effectively deliver healthcare services that meet the social, cultural, and linguistic needs of the residents), CPR certification for all licensed staff required, IV certification required for all licensed staff, nursing licenses in good standing, and nurse's aide certification for all nurse's aides. Staff competencies at hire, annually, and as needed: communication, person-centered care, activities of daily living, disaster planning, infection control hand hygiene, infection control universal precautions and protective equipment, medication administration, vital signs and intake and output, resident assessment, caring for people with dementia, Alzheimer's and cognitive impairments, caring for mental and psychosocial disorders, non-pharmacological management of behaviors, and caring for a resident with trauma/PTSD.

**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 care was provided timely for a dependent resident. The findings include: Resident #1 was admitted with diagnoses that included chronic respiratory failure with tracheostomy, encephalopathy, stroke with right hemiplegia/hemiparesis (paralysis/weakness), atherosclerosis with gangrene of toes, and contractures. A Minimum Data Set assessment dated [DATE] identified Resident #1 had moderately impaired cognitive skills and required total assistance of tow (2) staff for bed mobility, toilet use and personal hygiene, was incontinent of urine and had a colostomy. The Resident Care Plan (RCP) dated 3/22/2023 identified Resident #1 required assistance with activities of daily living (ADLS) and was at risk for skin breakdown. Interventions directed to assist as needed with toileting, incontinent care as per policy, to keep skin clean/dry, apply barrier cream after incontinent care and to turn and repositioning frequently. A nursing note dated 6/20/2023 at 9:36 PM identified that on the day prior (on 6/19/2023) during the 7AM to 3 PM shift, no care was provided for Resident #1. A facility incident report dated 6/20/2023 identified based on review of camera recording, Resident #1 was neglected on 6/19/2023 when during the 7 AM to 3 PM shift NA #1 did not provide care to Resident #1 during the entire shift (8 hours). The facility investigation identified the facility substantiated the allegation of neglect, and NA #1's employment was terminated. Interview with the Administrator on 7/7/2023 at 10:20 AM identified that she routinely checks the facility hallway video recordings and on 6/20/2023 she reviewed the video for 6/19/2023 that recorded outside Resident #1's room. The Administrator indicated she reviewed the recording from 6:04 AM through 3 PM and identified NA #1 did not enter Resident #1's room during the shift (she observed NA #1 walk past the room two (2) times, but he did not enter the room during the shift) and she concluded that NA #1 had not provided any care to Resident #1 for the 8-hour shift. Surveyor review of the facility video identified no NAs were observed to enter Resident #1's room on 6/19/2023 between 6:04 AM to 3:16 PM; Resident #1 received no care for 9 hours and 12 minutes. Interview with NA #3 on 7/7/2023 at 9:30 AM identified although NA #3 worked on 6/19/2023, Resident #1 was not on her assignment, and she was not aware Resident #1 did not receive care during the 7 AM to 3 PM shift. Interview with NA #2 on 7/7/2023 at 12:30 PM identified Resident #1 was not on her assignment, and she was not aware Resident #1 did not receive care during the 7 AM to 3 PM shift. Interview with NA #1 on 7/7/2023 at 11:06 AM identified on 6/19/2023, the unit had three (3) NAs working instead of the usual four (4). NA #1 indicated he was aware Resident #1 was his patient to provide care to during the shift. NA #1 indicated he did not provide any care for Resident #1 during the shift, and further identified he was so busy, he forgot to provide the required care. He identified he looked in on Resident #1 twice but did not render any care, and he did not notify the nurse. Interview with LPN #1 on 7/7/2023 at 11:30 AM identified she was the charge nurse for Resident #1 on 6/19/2023 during the 7 AM to 3 PM shift, and she was not aware of any NA assignment issues or that Resident #1 did not receive care during the shift. LPN #1 indicated Resident #1 should have received care that would have included turning and positioning at least every two (2) to four (4) hours and checking for incontinence every two (2) hours as well as provide morning care. Interview with NA #5 on 7/10/2023 at 1:52 PM identified Resident #1 was her patient on 6/19/2023 during the 3 PM to 11 PM shift. NA #5 further indicated she provided incontinent care to Resident #1 at 4:15 PM and Resident #1's brief, bedding and clothing were saturated with urine. Interview with the DNS on 7/10/2023 at 11:00 AM identified Resident #1 was not provided care on 6/19/2023 by any staff between 6:15 AM to 4:15 PM (10 hours). The DNS further indicated the residents should be checked at least four (4) times during a shift for incontinence and repositioning, and that was not provided, and indicated NA #1 should have notified the nurse if care was not able to be provided timely. The facility Abuse Prohibition Policy dated 1/11/2023, directed in part, neglect was the deprivation of care necessary to maintain wellbeing. The facility Positioning Policy, directed in part, Residents who are unable to turn themselves will be positioned at least every two hours and as needed. The facility Incontinent Care Policy, directed in part, Residents are checked every two hours for incontinence and that incontinent care is provided.

**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 an accused staff member was removed from the schedule timely after an allegation of mistreatment. The findings include: Resident #1 was admitted with diagnoses that included chronic respiratory failure with tracheostomy, encephalopathy, stroke with right hemiplegia/hemiparesis (paralysis/weakness), atherosclerosis with gangrene of toes, and contractures. A Minimum Data Set assessment dated [DATE] identified Resident #1 had moderately impaired cognitive skills and required total assistance of tow (2) staff for bed mobility, toilet use and personal hygiene, was incontinent of urine and had a colostomy. The Resident Care Plan (RCP) dated 3/22/2023 identified Resident #1 required assistance with activities of daily living (ADLS) and was at risk for skin breakdown. Interventions directed to assist as needed with toileting, incontinent care as per policy, to keep skin clean/dry, apply barrier cream after incontinent care and to turn and repositioning frequently. A nursing note dated 6/20/2023 at 9:36 PM identified that on the day prior (on 6/19/2023) during the 7AM to 3 PM shift, no care was provided for Resident #1. A facility incident report dated 6/20/2023 identified based on review of camera recording, Resident #1 was neglected on 6/19/2023 when during the 7 AM to 3 PM shift NA #1 did not provide care to Resident #1 during the entire shift (8 hours). The facility investigation identified the facility substantiated the allegation of neglect, and NA #1's employment was terminated. Interview with the Administrator on 7/7/2023 at 10:20 AM identified that she routinely checks the facility hallway video recordings and on 6/20/2023 she reviewed the video for 6/19/2023 that recorded outside Resident #1's room. The Administrator indicated she reviewed the recording from 6:04 AM through 3 PM and identified NA #1 did not enter Resident #1's room during the shift (she observed NA #1 walk past the room two (2) times, but he did not enter the room during the shift) and she concluded that NA #1 had not provided any care to Resident #1 for the 8-hour shift. Interview with the DNS on 7/10/2023 at 11:00 AM identified Resident #1 was not provided care on 6/19/2023 by any staff between 6:15 AM to 4:15 PM (10 hours). The DNS further indicated the residents should be checked at least four (4) times during a shift for incontinence and repositioning, and that was not provided, and indicated NA #1 should have notified the nurse if care was not able to be provided timely. Interview, facility documentation review, and review of the reportable event system with the DNS and Administrator on 7/10/2023 at 11:30 AM identified on 6/19/2023 NA #1 worked during the 7 AM to 3 PM, and during the 3 PM to 11 PM shifts. Interview identified the DNS had initiated the entry of Resident #1's neglect allegation into the State Agency on-line reporting system on 6/20/2023 at 7:51 PM, and completed the entry at 8:18 PM. Review of NA #1's payroll punches for 6/20/2023 identified NA #1 punched out on 6/19/2023 at 10:51 PM (two hours after the report was initiated in the State Agency reporting system). The DNS indicated when she was notified that NA #1 had not provided Resident #1 any care during the 7 AM to 3 PM shift on 6/19/2023, she had directed the evening supervisor to send NA #1 home immediately pending the investigation. The DNS further indicated she did not know why NA #1 did not punch out until 10:51 PM, and indicated the NA should have punched out and left the facility immediately after the supervisor was directed. The facility failed to immediately suspend NA #1 upon identification that he was the staff member who failed to provide care for Resident #1 during the 7 AM to 3 PM shift on 6/19/2023. Although attempted, interview with the nursing supervisor was not obtained during the survey. The facility Abuse Prohibition Policy dated 1/11/2023 directed in part, neglect was the deprivation of care a caretaker of services necessary to maintain wellbeing, and that the individual accused will be immediately suspended pending the findings of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident # 6) reviewed for abuse, the facility failed to review and revise the resident's care plan after and allegation of abuse regarding staff to resident. The findings include: 1.Resident #6 was admitted on [DATE] with diagnoses that included personality disorder, adjustment disorder and type II diabetes mellitus. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was without cognitive impairment and was independent with locomotion on and off the unit with the utilization of a wheelchair. The Resident Care Plan (RCP) dated 7/30/21 identified Resident #6 could be physically and verbally aggressive with impulsiveness. Interventions included: to not express anger or impatience verbally or with physical movements which would likely increase confusion and agitation, to be cognizant of not approaching the resident's personal space and to do not make unrealistic demands. The nursing progress notes dated 9/27/21 at1:27 P.M. identified Registered Nurse (RN) met with the resident, secondary to allegation of staff causing injury to the resident's left thumb. Upon assessment the left thumb appeared to be swollen, no discoloration was noted at time. Resident # 6 stated that his/her left thumb was painful. The Advanced Practice Registered Nurse (APRN) was made aware of the incident and pain. Resident #6 was medicated for pain by the charge nurse and ice was applied to the left thumb. Resident #6 continued to self-propel in the hallway on the unit. All aspects of safety maintained. Additionally, the nursing progress note indicated staff would continue to assess the resident's pain level and swelling to left thumb. A Reportable Event Summary dated 9/30/21 identified on 9/27/2021 at approximately 1:00 P.M. Resident #6 alleged that a staff member whom s/he identified, caused injury to his/her left thumb after the staff member pulled his/her wheelchair backwards, hurting his/her left thumb. The alleged staff member was escorted from the unit, interviewed removed from the schedule pending investigation. An assessment was completed, APRN, conservator and police were notified, and an investigation was conducted. The facility was unable to substantiate the alleged allegation because it was determined to be unintentional, therefore the incident was deemed an accident. The nursing progress notes dated 9/27/21- through 10/5/21 noted x-rays the left hand was obtained for Resident #6 on 9/28/21 following complaints of discomfort which were negative for fractures. The left thumb presented with signs of discoloration and swelling with no increased pain. A second x-ray dated 10/4/21 of the left hand noted avulsion fracture to the left thumb with moderate displacement. An interview on 10/15/21 at 8:04 A.M. with the DNS and Administrator indicated that although the resident was wheeled backwards in the wheelchair and was trying to stop, the incident was viewed as an accident as the actual injury was not willful and instead happened by accident as a result of Resident #6 attempting to stop while being wheeled backwards. Staff were provided education on the proper way to transport a resident and the appropriate response to a resident who was resistive. Although, the DNS indicated she recalled having a conversation with Resident #65 who reported s/he witnessed the event, she was unable to produce a documented statement or notes from what was described as a 'soft file' related to the alleged incident. Resident #6 was admitted on [DATE] with diagnoses that included personality disorder, adjustment disorder and type II diabetes. The annual minimum data set (MDS) assessment dated [DATE] identified Resident #6 was without cognitive impairment and was independent with locomotion on and off the unit using a wheelchair. The resident care plan (RCP) dated 7/30/21 identified Resident #6 could be physically and verbally aggressive with impulsiveness. Interventions included not expressing anger or impatience verbally or with physical movements which would likely increase confusion and agitation, be cognizant of not approaching personal space and do not make unrealistic demands. Nursing Progress Notes 9/27/21 at1:27PM identified RN met with resident, secondary to allegation of staff causing injury to the left thumb. Upon assessment the left thumb appeared to be swollen, no discoloration was noted at that time. Resident stated that the left thumb was painful. APRN made aware. Resident was medicated for pain by charge nurse and ice applied to left thumb. Resident continued to self-propel in the hallway on the unit. All aspects of safety maintained. Would continue to assess pain level and swelling to left thumb. A Reportable Event summary dated 9/30/21 noted on 9/27/2021 at approximately 1:00 pm Resident #6 alleged that a staff member whom s/he identified, caused injury to the left thumb after the staff member pulled him/her wheelchair backwards, hurting his/her left thumb. The alleged staff member was escorted from the unit, interviewed removed from the schedule pending investigation. An assessment was completed, APRN, conservator and police notified, and investigation conducted. The facility was unable to substantiate the alleged allegation because it was determined that it was not intentional, therefore it was deemed an accident. Nursing Progress Notes dated 9/27/21- through 10/5/21 noted x-rays were obtained for Resident #6 in 9/28/21 following complaints of discomfort which were negative for fractures. The left thumb presented with signs of discoloration and swelling with no increased pain. A second x-ray dated 10/4/21 noted avulsion fracture to the left thumb with moderate displacement. An interview on 10/15/21 at 8:04 AM with the DNS and Administrator indicated that although the resident was wheeled backwards in the wheelchair and was trying to stop, the incident was viewed as an accident as the actual injury was not willful and instead happened by accident as a result of resident #6 attempting to stop while being wheeled backwards. Staff were provided education on the proper way to transport a resident and appropriate response to a resident who was resistive. A subsequent interview and care plan review on 10/18/21 at 10:08 A.M. with the DNS identified she did not understand the need to include revisions to the care plan following an alleged incident of physical mistreatment. An interview on 10/18/21 at 10:30 A.M. with RN #4 identified she revised the care plan effective 10/18/21 to reflect the alleged incident and explained to the DNS. The policy for Care Planning directs the care plan to be reviewed at least quarterly and as necessary to reflect changes in the resident status. The facility failed to review and revise the care plan following an alleged incident of staff to resident physical mistreatment in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, observations, review of facility policy and interviews for one of two residents (Resident #1) reviewed for vision and hearing, the facility failed to ensure the resident received and maintained assistive devices to maintain hearing abilities. The findings include: Resident #18's diagnoses included dementia with behavioral disturbances, depressive episodes, anxiety disorder and Parkinson's disease. The quarterly MDS assessment dated [DATE] identified Resident #18 had severe cognitive impairment and required extensive assistance of one-person physical support for dressing, difficulty hearing and noted the resident required hearing aids. The care plan identified the resident has a hearing deficit. Hearing aids are broken, and new mold ordered. See Audiology Consultation on 4/26/19 updated . Hearing device in place until new hearing aids in. Interventions include: to refer resident for an audiology evaluation as needed, to get resident's attention before speaking, face directly and speak clearly. Be patient with resident and offer reassurance as needed. Remove as much background noise as possible before speaking to resident. Use non-verbal communication as needed. Use short and direct phrases when talking to resident. Watch for any changes in cognitive status and report to Medical Doctor (MD). Interview with Person #1 on 10/13/21 at 9:40 A.M. identified Resident #18 has hearing aids but have been broken for some time. Person #1 identified the facility didn't seem to follow-up with this and noted during visitation, the resident continues to not have any devices for hearing. Observation of Resident #18 on 10/12, 10/13, 10/14 and 10/15/21 during the 7:00 A.M. to 3:00 P.M. shift identified the resident without benefit of any hearing devices being utilized. Review of facility documentation of the NA Care Card on 10/13/21 at 9:45 A.M. identified Resident #18 wears an amplifier set as hearing aids have been ordered but unavailable. The nursing progress notes dated 10/13/21 at 10:15 A.M. identified on 4/26/19 at 2:26 P.M., Resident #18 was given hearing apparatus by Health Drive. Hearing aid functions well and indicated the resident was very pleased to have his/her hearing improved. Noted to place head piece to back of head and microphone price set to #3. Review of facility documentation of the Health Drive Audiology Consultation on 10/13/21 at 10:30 A.M. identified on 5/21/19, Resident #18 was noted with BTE/[NAME] Sound Pocket Device. Providers clinical recommendations directed staff to supervise the resident while wearing ALD (Assisted Listening Device). Review of facility documentation of the Resident Care Conference on 10/13/21 at 10:45 A.M. identified on 11/21/19, NA worksheet noted for items needed as Hearing Aids Badly. Interview with NA #4 on 10/15/21 at 9:05 A.M. identified Resident #18 wears hearing aids but cannot identify why he/she does not have them currently. NA #4 was not able to identify how long Resident #18 has been without hearing aids or when they went missing. NA #4 identified nurse aides should follow the nurse aid care cards and care plans for guidance of care. Interview with LPN #3 on 10/15/21 at 9:20 A.M. identified Resident #18 does wear hearing aids but cannot verify where they are or when they became missing. Interview with DNS on 10/15/21 at 10:00 A.M. identified if a resident loses their hearing aids, they will notify Health Drive for Audiology, schedule an appointment and continue to monitor. The DNS was unable to identify when or how Resident #18's hearing aids or amplifier went missing. Subsequent to surveyor inquiry, the DNS on 10/15/21 at 10:10 A.M. was noted calling Health Drive to schedule an appointment for an audiology consultation. The DNS identified Resident #18 is not a candidate to be seen by audiology, however, she/he will be provided with an amplifier by Health Drive. Interview with NA #6 on 10/15/21 at 1:30 P.M. identified she currently has Resident #18 on her assignment. NA #6 identified she cannot remember when or how long the resident last used or had his/her hearing aids. NA #6 identified nurse aides should follow the resident's care card and care plans for guidance of care. Review of the Protecting Resident Personal Items/Missing Items Policy identified personal items will be identified on admission using personal inventory form. Resident/responsible party will be encouraged to notify staff when new items are brought into the facility in order to label when appropriate and update inventory list. The facility does not necessarily assume responsibility for missing item(s) depending on the individual circumstances surrounding the missing item.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interviews for one resident (Resident #46) reviewed for accidents, the facility failed to follow physician's order for the resident's transfer status to prevent a potential accident. The findings include: Resident #46 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, a history of falling, left sided homonymous bilateral field defects, neurologic neglect syndrome, left foot drop and obesity. The care plan dated 3/8/21 identified a need for staff assistance with Activities of Daily Living (ADL) and a risk for falls. Interventions directed to follow physician transfer orders and to encourage the resident to ask and wait for staff assistance for transfers. The quarterly MDS assessment dated [DATE] identified Resident #46 had intact cognition, was incontinent of bowel and bladder and required 2 persons physical assistance with transfers. The care plan dated 9/2/21 for transfers indicated that the transfer status on his/her care card listed the resident as an assist of 2 people and a mechanical lift. The nurse's note dated 9/17/21 at 8:57 P.M. identified that the nurse entered Resident #46's room where the resident was noted on the floor at bedside. NA #9 was with Resident #46 attempting to give the resident a shower when Resident #46 and NA #9 lost their balance during the transfer and Resident # 46 was guided to the floor by NA #9. Resident #46 reported pain to the occipital/back of the head area. The resident was then sent out to hospital, per APRN request. No injury was noted from the hospital. An interview with NA #9 on 10/18/21 at 12:02 P.M. indicated that she did not know the resident's assist status prior to attempting a transfer Resident #46 to the shower chair in resident's room. NA #9 further indicated she was a new employee to the facility and was the only aide in the room with the resident at the time of the incident. NA #9 further indicated that she did not check the care card prior to attempting to transfer the resident. An interview with DNS on 10/18/21 at 12:32 P.M. indicated that the expectation is for all nurse aides to look at the care card prior to attempting a transfer and providing care, especially if they are new.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, observations, facility policy, and interviews for one resident (Resident #272) reviewed for pain management, the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice related to pain management and in accordance with the physician's orders. The findings include: Resident #272 was admitted to the facility on [DATE] with diagnoses that included polyneuropathy, pain in right hip, bilateral osteoarthritis of knee, cervical disc degeneration, rheumatoid arthritis. The care plan dated 10/8/21 identified a risk for pain/discomfort. Interventions directed to provide pain medication as ordered and to observe the resident for signs/symptoms associated with pain. The admission MDS assessment dated [DATE] identified Resident #272 had intact cognition, was occasionally incontinent of bowel and bladder and required assist of 1 with transfers. A physician's order 2:45 P.M. dated 10/13/21 directed to give Ultram 25 Milligrams (MG) every 8 hours as needed for pain management for 14 days. Observations on 10/14/21 at 2:15 P.M. identified Resident #272 was up in his/her wheelchair leaning forward on the bedside table next to the bed. Resident #272 expressed that s/he was in pain and had already called for RN #5 to bring her/his pain medication about 20 minutes ago. Resident 272 further stated on a scale of 1- 10 his/her pain was a 6. Resident # 272 indicated s/he rang his/her call bell again to notify RN #5 to come to her/his room again. Resident # 272 further indicated s/he had not received his/her pain medication yet. Observations on 10/14/21 at 3:23 P.M. identified Resident #272 was walking with Physical Therapist (PT)#1 with a rolling walker. The resident was pale and diaphoretic and stated that s/he could not continue with therapy due to pain. Interview with PT #1 on 10/14/21 at 3:23 P.M. identified the nurse already knew of the resident's request for pain medication and that the nurse was coming with the medication. PT #1 further indicated s/he would go and inform the nurse again of the resident's pain and need for pain medication. Although a physician's order for Tylenol 325 MG three tablets by mouth every 8 hours for pain was not provided to the surveyor. The MAR for October 2021 directed Tylenol 325 MG three tablets by mouth every 8 hours for pain for 10 days. Additionally, the MAR October 2021 indicated the resident received the Tylenol 325 MG three tablets on 10/8, 9, 10, 11, 12, 13, 14, 2021. A review of the Medication Administration Record (MAR) for 10/2021 identified that Resident # 272 did not receive Ultram 25 Milligrams (MG) for pain on 10/13/21 and 10/14/21. However, the MAR for October 2021 did identify the first time Resident # 272 received Ultram 25 MG was on 10/15/21 at 920 A.M. (18 hours after being noted with pain of 6). Although an attempt was made to contact RN #5 for an interview the attempt was unsuccessful. The facility policy for pain directs in part that each resident will be evaluated for pain upon admission, annually, quarterly and upon significant change in condition by the licensed personnel. If a resident screen positive for pain, staff will develop interventions to be implemented as quickly as possible to promote maximum comfort.

Based on observation of the facility medication storage of the Emergency Medication Box (Ebox), review of facility policy and interviews, the facility failed to ensure medications were labeled in accordance with professional standards. The findings include: Observations on 10/15/21 at 10:15 A.M. identified 2 medications were found to be expired in the Emergency Medication Box (Ebox). A review of medications in the Ebox on the second floor indicated 19 pills in blister packs labeled Diazepam 5 MG, with an expiration date of 7/2021. Additionally, in the medication Ebox 13 pills in blister packs labeled Morphine 15 MG were noted to have an expiration date of 8/2021 and noted was a used vial of multiuse Tuberculosis vaccine with an expiration date of 7/6/2021. Interview with RN #2 at that time of the observation on 10/15/21 identified she did not check the expiration dates and indicated she was not aware of how often the medication Ebox should be check for expired medications. Interview with DNS at 10:23 A.M. identified the facility did not have a schedule for checking expired medication. The DNS further indicated that she was the person who would check medication dates for expiration dates in the facility and that she did would check whenever she had a chance. Although requested, a facility policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, observations, review of facility policy and interviews for one resident (Resident #18) reviewed for dental, the facility failed to provide emergency dental services. The findings include: Resident #18's diagnoses included dementia with behavioral disturbances, depressive episodes, anxiety disorder and Parkinson's disease. The care plan for ADL dated 11/11/20 identified Resident #18's dentures are chipped. Interventions included: to offer to assist the resident with placing and removing dentures each day. Offer to assist the resident with cleaning and soaking dentures overnight with nightly care. Dentist as ordered/needed. Additionally, the care noted resident wears dentures: to please provide good mouth care and make sure the residents dentures are given to him/her daily and assist with mouth care as needed. Please ensure the resident's dentures are cleaned daily and are available to me each day. Further review of the resident's care plan failed to identify a care for dental after 11/11/20. The quarterly MDS assessment dated [DATE] identified Resident #18 had severe cognitive impairment and required extensive assistance of one-person physical support for dressing. Observation of Resident #18 on 10/12, 10/13, 10/14 and 10/15/21 during the 7:00 A.M. to 3:00 P.M. shift identified resident without dentures being utilized. The NA Care Card on 10/13/21 at 9:45 A.M. identified Resident #18 wears dentures and noted the resident's dentures were being repaired on 4/23/20. The nursing progress notes dated 10/13/21 at 1:15 PM identified on 5/11/20 at 7:03 P.M., a speech therapist identified Resident #18 was missing his/her dentures. Room search was conducted, and staff was unable to find the dentures. The nursing progress notes dated 10/13/21 at 1:20 P.M. identified staff continued searches on 5/12, 5/13 and 5/14/20 for resident's dentures but the facility was unable to locate the dentures. The Health Drive Dental Consultation on 10/13/21 at 1:30 P.M. identified on 1/29/21 Resident #18 was seen for an annual examination. The examination identified Resident #18 had no teeth or dentures in place. Recommended treatment notes identified the resident does not have dentures but is able to eat regular consistency diet. No further recommendations made. Interview with NA #4 on 10/15/21 at 9:05 A.M. identified Resident #18 has dentures, but s/he could not identify why the resident does not have them currently. NA #4 was unable to identify how long Resident #18 had been without dentures or when they went missing. NA #4 identified nurse aides are directed to follow the NA care card and care plans for guidance of care. Interview with LPN #3 on 10/15/21 at 9:20 A.M. identified Resident #18 has dentures, but s/he could not identify where the dentures are or when they became missing. Interview with DNS on 10/15/21 at 10:00 A.M. identified if a resident has lost their dentures, the facility will notify Health Drive for a dental consultation, speech therapy and schedule an appointment and staff would continue to monitor. The DNS was unable to identify why the follow up for Resident #18's dental consultation was not conducted. Subsequent to inquiry, the DNS on 10/15/21 at 10:20 AM called Health Drive and scheduled an appointment for a dental consultation. The DNS further identified Resident #18 has been scheduled to see the dentist. Interview with NA #6 on 10/15/21 at 1:30 P.M. identified she currently has Resident #18 on her assignment. NA #6 identified she could not remember when or when the resident last used or had his/her dentures. NA #6 identified nurse aides are directed to follow the resident's care card and care plans for guidance of care. A review of the Health-Drive Dental Consultation dated 10/15/21 at 2:30 P.M. identified on 10/15/21, Resident #18 was seen for lost dentures. Treatment notes identified resident will be initiated for denture fabrication during process. Review of the Protecting Resident Personal Items/Missing Items Policy identified personal items will be identified on admission using personal inventory form. Resident/responsible party will be encouraged to notify staff when new items are brought into the facility to label when appropriate and update the inventory list. The facility does not necessarily assume responsibility for missing items depending on the individual circumstances surrounding the missing item.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation and interviews for one of three residents reviewed for mistreatment (Resident # 64), the facility failed to ensure care was provided in a dignified manner. The findings include: Resident # 64 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, ESRD, PVD, HTN, polyneuropathy, arthropathy, enterocolitis due to Clostridium Difficile ( C-Diff), not specified as recurrent, RBKA, arthritis and chronic left foot wound. The quarterly MDS assessment dated [DATE] identified Resident # 64 had intact cognition, was occasionally incontinent bladder, continent of bowel and required supervision with one person assist for bed mobility and toileting and independent with person hygiene with set up. The Reportable Event identified on 4/19/19 Resident # 64 had spoken with SW # 1 regarding a concern (approximately 10 days prior of 4/19/19). Resident# 64 indicated to SW #1 that he/she woke up on the 11:00 P.M. to 7:00 A.M. shift to RN # 1's hand in his/her brief checking to see if it was wet. Resident# 64 requested future care not to be provided by RN #1. The Reportable Event report additionally indicated education was provided to RN # 1 to first awake resident and then explain care that will be provided. The Corrective Action Plan (CAP) to prevent reoccurrence included RN # 1 not being assigned to care for Resident # 64 and if medications are needed and/ or required for Resident # 64, the medications are to be administered by another licensed nurse. RN # 1 received 1: 1 education on 4/19/19 to wake the resident first and explain the procedures to be done. The Reportable Event dated 5/12/19 at 4:40 P.M. identified Resident # 64 reported to a staff member he/she had been sodomized and/or was touched inappropriately by a staff member on the 11:00 P.M. to 7:00 A.M. shift. The care plan dated 5/13/19 identified an allegation of sexual assault. Interventions directed to watch for signs of mental distress, increased anxiety, and change in mood state and to report to the physician. Review of the summary report identified the Ombudsman had notified the facility administration on 5/13/19 that Resident # 64 had been sodomized by RN #1. The report identified although Resident # 64 did not recall the exact date of occurrence (approximately 10 days prior of 4/19/19), Resident # 64 verbalized he/she woke up and RN # 1 was playing on his/her tail and RN # 1's first knuckle was on his/her private area. An interview with SW # 1 at 5/22/19 3:15 P.M. identified Resident # 64 wheeled her/him self to my office 4/19/19 in the A.M., informed me that the 11:00 P.M. RN supervisor made him/her feel uncomfortable when the RN #1 (supervisor) went to check his/her brief before he/she could fully wake up. Resident # 64 requested 11:00 P.M. to 7:00 A.M.( supervisor) not provide care anymore to him/her. SW #1 on 5/22/19 also indicated she/he notified the ADNS and the administrator of Resident # 64's comment. An interview with SW # 1 on 5/22/19 at 3:15 P.M. identified social services should have conducted a follow up visit and/or visits with Resident # 64 status post the allegation of sexual inappropriate contact (5/13/19) and/ or status post the concern that had been brought to his/her attention on 4/19/19. Further indicating all concerns reported to social services are to be followed up with residents, especially if the concern is related to care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interview for one sampled resident (Resident # 1) reviewed for Advanced Directive, the facility failed to ensure a physician's order corresponded with the resident's advanced directive document. The findings include: Resident #1 was admitted on [DATE] with diagnoses that included end stage renal disease, spinal stenosis, diabetes mellitus, hyperlipidemia, hypertension, and Chronic Obstructive Pulmonary Disease (COPD). An Advanced Directive document dated 6/28/2018 directed do not administer 1. Cardiopulmonary Resuscitation 2. Artificial Respiration and 3. Artificially provide nutrition and hydration. The care plan dated 3/13/19 identified Advanced Directive choices. Interventions directed to implement the Advanced Directives as desired and as ordered. The quarterly MDS assessment dated [DATE] identified Resident #1 was mildly cognitive impairment, required limited assistance with transfer, mobility, dressing, and was totally dependent for bathing. A physician's order dated May 2019 did not specify a code status order for Resident # 1. Interview and clinical record review with RN #2 identified the code status order for Resident #1 on the May 2019 physician's orders was missing. RN #2 further identified the resident's code status should be present on all monthly physician's orders and indicated the facility staff is expected to ensure that the order is present. Review of facility Advanced Directive policy on 5/23/19 directs the Advance Directive plan of care will be documented on the residents Advance Directive consent form and physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation, review of policy and interview for one of three sampled residents for (Resident # 64), the facility failed to conducted an investigation immediately when the resident identified an allegation of abuse and/or in accordance to facility policy. The findings included: Resident # 64 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, ESRD, PVD, HTN, polyneuropathy, arthropathy, enterocolitis due to Clostridium Difficile, not specified as recurrent, RBKA, arthritis and chronic left foot wound. Review of the facility grievance log identified a concern dated 4/19/19 identified Resident # 64 had not been awakened prior to personal hygiene care being rendered. The quarterly MDS assessment dated [DATE] identified Resident # 64 had intact cognition, was occasionally incontinent bladder, continent of bowel and required supervision with one person assist for bed mobility and toileting and independent with person hygiene with set up. The Reportable Event identified on 4/19/19 Resident # 64 had spoken with SW # 1 regarding a concern (approximately 10 days prior of 4/19/19). Resident# 64 indicated to SW #1 that he/she woke up on the 11:00 P.M. to 7:00 A.M. shift to RN # 1's hand in his/her brief checking to see if it was wet. Resident# 64 requested future care not to be provided by RN #1. The Reportable Event report additionally indicated education was provided to RN # 1 to first awaken resident and then explain care that will be provided. The Corrective Action Plan (CAP) to prevent reoccurrence included RN # 1 not being assigned to care for Resident # 64 and if medications are needed and/ or required for Resident # 64, the medications are to be administered by another licensed nurse. RN # 1 received 1: 1 education on 4/19/19 to wake the resident first and explain the procedures to be done. The Reportable Event dated 5/12/19 at 4:40 P.M. identified Resident # 64 reported to a staff member that he/she had been sodomized and/or was touched inappropriately by a staff member on the 11:00 P.M. to 7:00 A.M. shift. The care plan dated 5/13/19 identified an allegation of sexual assault. Interventions directed to watch for signs of mental distress, increased anxiety, and change in mood state and to report to the physician. Review of the summary report identified the Ombudsman had notified the facility administration on 5/13/19 that Resident # 64 had been sodomized by RN #1. The report identified although Resident # 64 did not recall the exact date of occurrence (approximately 10 days prior of 4/19/19), Resident # 64 verbalized he/she woke up and RN # 1 was playing on his/her tail and RN # 1's first knuckle was on his/her private area. Further review of facility documentation on 5/22/19 failed to reflect that the facility had conducted an investigation regarding the allegation of sexual abuse on 4/19/19 within 2 hours of the resident's comment about RN #1 supervisor. An interview with SW # 1 at 5/22/19 3:15 P.M. identified Resident # 64 wheeled her/himself to my office 4/19/19 in the A.M., informed me that the 11:00 P.M. RN supervisor made him/her feel uncomfortable when the RN #1 supervisor went to check his/her brief before he/she could fully wake up. Resident # 64 requested 11:00 P.M. to 7:00 A.M. supervisor not provide care anymore to him/her. SW #1 on 5/22/19 also indicated she/he notified the ADNS and the administrator of Resident # 64's comment. An interview with SW # 1 on 5/22/19 at 3:15 P.M. identified social services should have conducted a follow up visit and/or visits with Resident # 64 status post the allegation of sexual inappropriate contact (5/13/19) and/ or status post the concern that had been brought to his/her attention on 4/19/19. Interview and review of facility documentation with the Administrator on 5/23/19 at 1:30 P.M. identified Resident # 64 had wheeled his/ her self into the Administrator's office on 5/13/19 (after therapy) with a complaint that an RN # 1 had been verbally abusive towards him/her and requested that the RN be fired. At the time of interview the Administrator identified he/she had received a text message notification from RN # 1 on 5/12/19 at 7:31 A.M. indicating Resident # 64 was aggressive to me this A.M. and called me a faggot. The Administrator indicated he/she already had been planning to come to the facility on 5/12/19 for Mother's Day and staff appreciation for Nursing Home Week to visit with staff and indicated he/she did visit the facility but did not have the opportunity to speak with Resident # 64. Review of the facility abuse policy in part notes all allegations of abuse are to be thoroughly investigated and acted upon, including concerns that have been expressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of facility documentation and interviews for one of three sampled residents (Resident #332) who was reviewed for accidents, the facility failed to ensure that the resident was transferred according to the current physician's order and/or failed to ensure appropriate supervision of the lower extremities during a transfer to prevent injuries and/or for one of three sampled residents (Resident #21) who was reviewed for an accident and had a history of spilling a hot beverage, the facility failed to ensure that lids on the cups were utilized when the resident was served a hot beverage. The findings include: 1. Resident #332's diagnoses included dementia without behavioral disturbances, osteoarthritis, deformity of the lower leg, and a history of repeated falls, a right knee replacement and a fracture of the left ankle. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #332 had some memory and cognitive impairments, required extensive two (2) person assistance with transfers in and/or out of the bed and chair, balance during transitions and walking was not steady, the resident was only able to stabilize with staff assistance, and the resident had no falls in the past ninety (90) days. The care plan dated through 4/30/18 identified Resident #332 was at risk for falls. Interventions included to ambulate with one (1) assist with a rolling walker, gait belt and wheelchair follow, transfer with the assist of one (1) and rolling walker, and physical and occupational therapies as ordered to help increase strength and endurance. A physician's order dated 4/30/18 identified Resident #332 would be discharged after the occupational therapy treatment on 4/26/18 and the order directed to transfer Resident #332 from the bed to the wheel chair with an assist of two (2). The nurse's note dated 5/8/18 identified the charge nurse was informed by a Nursing Instructor that during care while standing to ambulate Resident #332's right knee buckled and the student assisted the resident to a sitting positioning the bed. The note indicated Resident #332 complained of right knee pain at a level nine (9), the Advanced Practice Registered Nurse (APRN) was informed and the APRN ordered a two (2) view x-ray. The Reportable Event Form and facility investigation dated 5/8/19 identified Resident #332 fell while being transferred from the bed to a chair with an assist of one (1) person, Student #1. The x-ray report dated 5/8/18 identified an acute distal femur fracture. The nurse's note dated 5/9/18 at 1:00 AM identified Resident #332 was transferred to the hospital for an evaluation and was admitted for surgical intervention. The nurse's note dated 5/13/18 identified Resident #332 was readmitted to the long term care facility status post open reduction and internal fixation (ORIF) of the right femur. Interview with the Nursing Instructor, Instructor #1 on 5/22/19 at 11:30 AM, he indicated prior to the fall he reviewed the care card and care plan for Resident #332 and he identified the resident was an assist of one (1) with transfers on 5/8/18. Instructor #1 stated that he would not have permitted the student, Student #1, to assist Resident #332 without reviewing the plan of care. Interview with the charge nurse, Licensed Practical Nurse (LPN) #5 on 5/22/18 at 3:00 PM, she indicated that she could not recall the resident's level of care prior to the fall on 5/8/18. LPN #5 stated that the physician orders are part of the plan of care. LPN #5 identified that the nurses are responsible for noting the orders and updating the care plan, however LPN #5 could not determine why the orders were not noted and/or the care card revised to reflect the resident required two (2) for transfers. Interview with the Director of Nurses (DON) on 5/20/19 at 1:10 PM indicated that the nurses are responsible for verifying the orders and updating the resident's care plan. The DON could not determine why the orders were not noted and/or if the care card was revised to indicate the new order timely. Interview with the Corporate Clinical Nurse on 5/22/19 at 1:15 PM indicated that subsequent to the fall the practice was changed to include that an instructor has to be present with all transfers of the residents. An attempt to interview Student #1 was not successful. 2. Resident #21's diagnoses included dementia, anxiety disorder, bilateral age-related cataracts, nearsightedness, and a history of bilateral glaucoma. The annual Minimum Data Set assessment dated [DATE] identified Resident #21 had impaired vision, some difficulty with making decisions regarding tasks of daily life and required supervision and one (1) person assistance with eating. The resident care plan originated on 2/20/18 indicated Resident #21 accidentally spilled coffee on his/her lap and the resident sustained no injury. Interventions included to place the coffee cup on the table. The nurse's note dated 6/28/18 11:50 PM indicated that Resident #21 had spilled a cup of coffee onto the left thigh, the area was red and measured 6 centimeters (cm) x 30 cm, and a cold pack was applied to area. The note identified Resident #21 complained of discomfort and Tylenol 650 milligrams (mg) was given at 5:00 PM for discomfort with positive effect. An updated care plan dated 6/28/18 indicated Resident #21 had accidentally spilled coffee on the left thigh and had sustained blisters. Interventions directed to obtain an occupational therapy screen for the use of a special coffee cup with a lid and the kitchen to provide the dynex cup during meals. The Reportable Event Form dated 6/28/18 indicated that at 4:30 PM Resident #21 spilled a cup of hot coffee on the left thigh area and the area was noted to be red and tender. The report summary identified at approximately 10:00 PM three (3) blisters were noted to the left thigh area. Observations of Resident #21 on 5/20/19 during the noon meal identified the resident was seated with hot coffee in a cup without a lid/cover. Observations conducted on 5/21/19, Resident #21 was observed drinking coffee from a cup that did not have a lid. In an interview and observations with the 7AM-3PM nurse aide, Nurse Aide (NA) #2, on 5/21/19 at 12:15 PM she indicated that Resident #21 had previously burned himself/herself with hot coffee, however she was not aware that a cover/lid should be place on the coffee cup. During an interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #4 on 5/21/19 at 12:35 PM she indicated although she was one of the regular nurses on the unit, she was not aware that Resident #21 needed a lid on the coffee cup. LPN #4 stated she was unaware of Resident #21's needs regarding cover for coffee cup and would need to consult with nursing administration for direction. Subsequent to surveyor inquiry, LPN #4 indicated that lids were retrieved from the kitchen and placed on Resident #21 coffee cup. In an interview with dietary aide #1 on 5/21/19 at 12:20 PM she indicated that it was not communicated to the kitchen staff that Resident #21 needed a cover on the hot coffee cups. In an interview with the Assistant Director of Nursing (ADON) on 5/22/19 at 3:30 PM she indicated that Resident #21 sustained a burn after spilling coffee on 6/28/18 and the recommendation after the incident directed to place a cover/lid on cups with hot coffee. The ADON stated the nursing staff were responsible to ensure that lids are placed on the coffee cup before offering a hot liquid to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one of two residents (Resident # 73) reviewed for pressure ulcers, the facility failed to ensure interventions were in place to prevent the development of a pressure ulcer for a resident at risk for skin breakdown in accordance to facility policy and standards of care. The findings include: Resident # 73 was admitted to the facility on [DATE] with diagnoses that included COPD, type two diabetes mellitus and acute ischemic heart disease. The care plan dated 1/ 21/ 2019 identified Resident # 73 was at risk for skin breakdown. Interventions included : to encourage Resident #73 to reposition every 2 hours, to monitor skin for signs and symptoms of skin breakdown, to provide a pressure reduction cushion for Resident # 73's chair/ wheelchair and indicated to provide a pressure redistribution mattress. The re admission nursing note dated 4/30/19 identified that Resident #73 sustained a hip fracture requiring surgical intervention and returned to the nursing facility on 4/30/19. A Braden scale dated 5/7/19 identified low risk for skin breakdown. A body audit dated 5/9/19 identified no skin issues. The 14 day admission MDS assessment dated [DATE] identified Resident # 73 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene; was at risk for pressure ulcers and had a surgical wound. The care plan dated 5/15/19 identified Resident # 73 had a wound of the coccyx. Interventions directed to follow facility protocol / regime for treating breaks in skin integrity/ pressure ulcers, to take extra care when transferring Resident #73 , to provide incontinent care per policy, to provide a pressure reducing mattress in bed and the wheelchair, and directed to reposition Resident # 73 per standards of nursing practice. Review of facility Medication Administration Record ( MAR) and Treatment Administration Record ( TAR) for Resident # 73 from 4/30/19 through 5/14/19 failed to identify documentation of the utilization of a pressure reducing mattress, barrier creams, roho or gel cushion. A physician's order dated 5/15/19 directed daily cleansing of Resident #73's coccyx area wound with Normal Saline solution with application of skin prep to the peri wound, the application of santyl to the wound bed. Additionally, the order directed the application of Alginate and a dry clean dressing to Resident #73's coccyx area wound. The physician's order also directed that Resident # 73's dressing be checked each shift for placement and be changed as needed. A physical therapy screen for Resident # 73 for a roho cushion. Additionally, the physician's orders directed a specialized pressure reducing mattress bed (ma 6 s) to be obtained and that the settings be set according to Resident #73's weight and to check each shift. The nurse's note dated 5/15/19 at 8:37 A.M. identified a new open area to Resident #73's coccyx was observed and a new treatment plan was put into place. The wound was described as measuring 1.5 Centimeter (CM) x 2.0 CM and unstageable. The wound tracking notes dated 5/15/19 identified Resident # 73 had an unstageable coccyx wound measuring 1.5 CM x 1.0 CM with scant drainage. Resident #73's wound treatments included the application of santyl and alginate with a dry sterile dressing placed daily. A body audit dated 5/16/19 identified no issues. The wound tracking notes dated 5/20/19 identified unstageable coccyx wound measuring 1.2 CM x 1.0 CM with 100 % slough. The wound documentation of 5/20/19 identified Resident #73 had an unstageable pressure injury with full thickness skin and tissue loss. Initial wound measurements were 1.2 CM length x 1:0 CM width with an area of 1.2 square CM. There was no drainage observed and Resident #73 reported no pain. The wound bed has 25 to 50 percent slough, no granulation, no eschar and no epithelization was present. The plan of care included the application of alginate and santyl, cover wound with bordered foam and change daily. Interview and clinical record review with RN # 3 ( nursing supervisor) on 5/22/19 at 11:40 A.M. identified Resident # 73 did not have a specialized pressure reducing mattress, a roho cushion prior to observation of a new coccyx wound on 5/15/19. Furthermore, although the facility has some pressure reducing mattresses, RN # 3 could not identify if Resident # 73 had one prior to identification of a coccyx wound on 5/15/19 as no documentation was available. Interview and clinical record review with RN # 4 (Infection control and wound care nurse) on 5/22/19 at 12:00 P.M. identified Resident # 73 had a facility acquired pressure ulcer of the coccyx which was identified on 5/15/19. RN #4 identified Resident # 73 had sustained a hip fracture making him/ her at risk for skin breakdown. Additionally, RN #4 indicated that Resident # 73 wore a brief and was incontinent at times making him/ her at risk for skin breakdown. RN #4 further indicated the facility has a policy in place for prevention of wounds. RN # 4 identified that interventions for Resident # 73 following readmission to the facility following the hip fracture should have included the use of a pressure reducing mattress, use of a gel or roho cushion for sitting in chairs or a wheelchair and the application of barrier cream due to the resident has a history of incontinence. Although RN #4 identified nursing would document barrier cream application, specialty mattress or pressure reducing mattress checks, and the presence of roho or gel cushions on wheelchairs in the MAR/ TAR for Resident # 73, RN # 3 was unable to identify documentation in the 4/30/19 through 5/14/19 in the MAR/ TAR the interventions for Resident # 73. Although RN # 4 could not identify why no orders for Resident #73 were obtained for a pressure reducing mattress, or a gel/ roho cushion upon readmission to the facility following a hip fracture, she/he did identify that the current care card for Resident # 73 failed to identify incontinence as an issue thereby being a potential reason that no barrier cream application had been ordered or documented. Interview with APRN # 1 on 5/22/19 at 1:06 P.M. identified she/he was notified of Resident # 73's coccyx wound on 5/15/19 by the wound care nurse. APRN #1 identified that although she/he is not the wound care provider, she/he was aware that the facility has protocols in place for wound prevention and would expect the protocols would be followed. APRN #1 further indicated identified she/he would not expect a resident to develop a pressure ulcer in the facility if the wound care prevention protocols are followed. Review of facility policy for wound prevention/ interventions for all residents identified that interventions are directed toward minimizing any negative effects of the casual / contributing factors such as pressure, moisture, friction/ shear for all residents admitted to the facility. Interventions include pressure reducing mattresses, identification of residents at risk for incontinence, use of skin products as recommended, and use of pressure reducing devices in chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of facility documentation and interviews for one of three sampled residents (Resident #332) who was reviewed for accidents, the facility failed to ensure appropriate supervision of the lower extremities during a transfer to prevent injuries. The findings include: Resident #332's diagnoses included dementia, status post open reduction and internal fixation (ORIF) of the right distal femur on 5/9/18, osteoarthritis, and a history of a right knee replacement and a fracture of the left ankle. A physician's order dated 5/13/18 directed to administer the anticoagulant medication, Lovenox 40 milligrams/0.4 milliliters syringe, inject 0.4 milliliters (ml) subcutaneously daily and Aspirin 325 milligrams (mg) daily. A physician's order dated 5/15/18 directed to transfer from the bed to the wheelchair using a mechanical lift (Hoyer) and non-weight bearing right lower extremity. The significant change Minimum Data Set assessment dated [DATE] identified Resident #322 had some memory and cognitive impairments, required extensive two (2) person assistance with transfers in and/or out of the bed and chair, had functional range of motion impairment on one (1) side of a lower extremity, and was non-ambulatory. The nurse's note dated 6/14/19 at 2:21 PM identified the Nursing Supervisor was called to the hairdresser's room. The note indicated Resident #332 had a large hematoma to the right shin, black in color, the area measured 10.5 centimeters (cm) x 6 cm and the resident complained of pain. The note identified the Advanced Practice Registered Nurse (APRN) was informed and the APRN directed to cover the area with a high absorbency dressing that is required to handle heavy draining wounds or large wounds, followed by kerlix then wrap with Coban, a therapeutic elastic compression wrap, daily and as needed, ice pack to the area for fifteen (15) minutes four (4) times a day for twenty-four (24) hours, and bloodwork in the morning. The nurse's note date 6/14/18 at 9:59 PM identified a new order to hold the Lovenox. The Reportable Event Form dated 6/14/18 at 1:30 PM identified Resident #332 reported he/she bumped the Hoyer lift during the transfer. Review of the facility's investigation dated 6/14/18 indicated that the hematoma was identified by the Hairdresser just prior to Resident #332 being transferred from the unit to the hair dresser's salon that was located in the facility. The investigation identified that prior to the resident's transfer from the bed to the wheelchair there was no evidence of a hematoma. The investigation indicated Resident #332 reported that his/her lower right shin hit the base of the Hoyer during the transfer earlier that day on 6/14/18. A review of NA #6's statement indicated that she couldn't be sure if Resident #332 hit his/her leg during the transfer. The nurse's note dated 6/15/18 at 2:25 PM identified Resident #332's wound was evaluated by the APRN, who felt the wound had become hard around the borders, deeper, worsening and questioned the need for an Incision and Drainage (I&D). The note indicated Resident #332 was transferred to the hospital for an evaluation. The nurse's note dated 6/17/18 at 7:20 PM identified Resident #332 was readmitted to the facility status post I&D to the right shin. The note indicated the discharge instructions to cleanse the wound with Normal Saline, followed by Silvadene cream to the darkened skin along the wound edges, cover with Xeroform dressing, cover with dry gauze, and wrap with Kerlix twice a day, start in the morning, Keflex 500 mg four (4) times a day for three (3) days and to discontinue the Lovenox. Observations of Resident #332's room and interview with Director of Nurse (DON) on 5/21/19 at 1:40 PM identified that Resident #332's lower legs could have hit the Hoyer lift during the transfer without the knowledge of the staff based on the statements given for the investigation. Observations of the Hoyer lift identified the lift with a long pole at the center and a rectangular box that protruded inward. The pole and the box were noted to be covered with a soft foam. The DON stated subsequent to the incident on 5/8/18 she padded the Hoyer lift base to prevent additional injuries. Interview with NA #5 on 5/22/19 at 11:40 AM indicated that she transferred Resident #332 with NA #6 on 6/14/18. NA #5 stated Resident #332 was transferred from the bed (next to the door) via the Hoyer lift to the wheelchair that was in the door way of the room due to the lack of space, NA #5 indicated that it was a common practice. NA #5 identified that she was in back of the resident and guided Resident #332 body which was facing the base of the Hoyer and she felt she had sight of Resident #332's feet at all times. Interview with Hairdresser #1 on 5/22/19 at 11:50AM indicated that she recalled placing the foot rest to the wheelchair just prior to taking Resident #332 off the unit for a hair appointment. Hairdresser #1 stated that Resident #332 had Capri pants on and she identified a large discoloration to Resident #332's right shin. Hairdresser #1 indicated Resident #332 did not have any complaints of pain so she took Resident #332 to the hairdresser salon, however once she got to the salon she called the nurse to assess the discoloration. Interview with NA #6 on 5/22/19 at 2:00 PM indicated she was either behind or to the side of the Hoyer controlling the lift and did not see Resident #332's legs hit the Hoyer lift. Interview with the charge nurse, LPN #5, on 5/22/19 at 3:00 PM indicated that she was in the hallway when the two (2) nurse aides, Nurse Aide (NA) #5 and NA #6 transferred Resident #332 via the Hoyer lift into the wheelchair so she did not see if the resident's leg hit the Hoyer. LPN #5 indicated that she did not see any discoloration to Resident #332's lower limb until she was called to the hairdresser's salon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review for one of two residents (Resident # 64) reviewed for an allegation of abuse, the facility failed to ensure social services were provided status post an allegation of abuse and / or a grievance. The findings include: Resident # 64 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, ESRD, PVD, HTN, polyneuropathy, arthropathy, enterocolitis due to Clostridium Difficile, not specified as recurrent, RBKA, arthritis and chronic left foot wound. Review of the facility grievance log identified a concern dated 4/19/19 identified Resident # 64 had not been awakened prior to personal hygiene care being rendered. The quarterly MDS assessment dated [DATE] identified Resident # 64 had intact cognition, was occasionally incontinent bladder, continent of bowel and required supervision with one person assist for bed mobility and toileting and independent with person hygiene with set up. The Reportable Event identified on 4/19/19 Resident # 64 had spoken with SW # 1 regarding a concern (approximately 10 days prior of 4/19/19). Resident# 64 indicated to SW #1 that he/she woke up on the 11:00 P.M. to 7:00 A.M. shift to RN # 1's hand in his/her brief checking to see if it was wet. Resident# 64 requested future care not to be provided by RN #1. The Reportable Event report additionally indicated education was provided to RN # 1 to first awaken resident and then explain care that will be provided. The Corrective Action Plan (CAP) to prevent reoccurrence included RN # 1 not being assigned to care for Resident # 64 and if medications are needed and/ or required for Resident # 64, the medications are to be administered by another licensed nurse. RN # 1 received 1: 1 education on 4/19/19 to wake the resident first and explain the procedures to be done. The Reportable Event dated 5/12/19 at 4:40 P.M. identified Resident # 64 reported to a staff member that he/she had been sodomized and/or was touched inappropriately by a staff member on the 11:00 P.M. to 7:00 A.M. shift. The care plan dated 5/13/19 identified an allegation of sexual assault. Interventions directed to watch for signs of mental distress, increased anxiety, and change in mood state and to report to the physician. Review of the summary report identified the Ombudsman had notified the facility administration on 5/13/19 that Resident # 64 had been sodomized by RN #1. The report identified although Resident # 64 did not recall the exact date of occurrence (approximately 10 days prior of 4/19/19), Resident # 64 verbalized he/she woke up and RN # 1 was playing on his/her tail and RN # 1's first knuckle was on his/her private area. Further review of facility documentation on 5/22/19 failed to reflect that the facility had conducted an investigation regarding the allegation of sexual abuse on 4/19/19 within 2 hours of the resident's comment about RN #1 supervisor. An interview with SW # 1 at 5/22/19 3:15 P.M. identified Resident # 64 wheeled her/himself to my office 4/19/19 in the A.M., informed me that the 11:00 P.M. RN supervisor made him/her feel uncomfortable when the RN #1 supervisor went to check his/her brief before he/she could fully wake up. Resident # 64 requested 11:00 P.M. to 7:00 A.M. supervisor not provide care anymore to him/her. SW #1 on 5/22/19 also indicated she/he notified the ADNS and the administrator of Resident # 64's comment. An interview with SW # 1 on 5/22/19 at 3:15 P.M. identified social services should have conducted a follow up visit and/or visits with Resident # 64 status post the allegation of sexual inappropriate contact (5/13/19) and/ or status post the concern that had been brought to his/her attention on 4/19/19. Further indicating all concerns reported to social services are to be followed up with residents, especially if the concern is related to care and services. Interview and review of facility documentation with the Administrator on 5/23/19 at 1:30 P.M. identified Resident # 64 had wheeled his/ her self into the Administrator's office on 5/13/19 (after therapy) with a complaint that an RN # 1 had been verbally abusive towards him/her and requested that the RN be fired. At the time of interview the Administrator identified he/she had received a text message notification from RN # 1 on 5/12/19 at 7:31 A.M. indicating Resident # 64 was aggressive to me this A.M. and called me a faggot. The Administrator indicated he/she already had been planning to come to the facility on 5/12/19 for Mother's Day and staff appreciation for Nursing Home Week to visit with staff and indicated he/she did visit the facility but did not have the opportunity to speak with Resident # 64.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of policy and staff interviews for one of five residents (Resident #13) reviewed for unnecessary medication, the facility failed to administer insulin medication according to the physician's order. The finding include: Resident #13 was admitted to the facility on [DATE] with diagnosis that included insomnia, anxiety, heart failure, stroke, and diabetes. A care plan dated 12/6/17 and updated 12/3/18 indicated Resident #13 had diabetes and may experience signs and symptoms of hyper or hypoglycemia. Additionally, interventions included to provide medications per MD orders, perform finger sticks per orders and monitor for acute signs of hypoglycemia (heart palpitations, fatigue, shakiness, sweating, confusion, hunger, seizures, and loss of consciousness). The MDS assessment dated [DATE] identified Resident #18 was cognitively intact and required supervision of 2 staff for transfers and walked independently. Additionally, Resident #13 was independent with toileting, dressing and eating with set up help. The physician's order original order date ( 8/28/18) and current order dated 3/28/19 directed staff to administer Novolog Flex Pen insulin 100u/ml inject 18 units subcutaneously three times daily before meals. A Medication Error Report dated 4/16/19 identified on 4/8/19 Novolog 18 units SQ was administered at 10:00 A.M. and 1:30 P.M., however should the medication have been administered at 7:30 A.M. and 11:30A.M. Additionally, the report indicated Resident #13 reported that at approximately 4:00 P.M. Resident #13 felt shaky and weak. Further, the report identified that 1:1 education and a verbal warning was given to LPN # 6. A written statement from LPN # 6 on 4/17/19 identified LPN # 6 was a new nurse working for the first day at the facility and indicated LPN # 6 administered Resident # 13's insulin at 10:00 A.M. and 1:30PM. A written statement from LPN #7 on 4/17/19 identified on 4/8/19 at 4:50 P.M. LPN # 7 was asked by Resident #13 to check his/her blood sugar due to a feelings of shakiness. The statement further identified Resident # 13's blood sugar reading was 83 and apple juice was provided. A recheck of the resident's blood sugar at 5:45 P.M. was 110. Additionally LPN # 6 identified that Resident #13 stated his/her blood sugar reading was low due to the nurse combining his /her 7:30 A.M. and 11:30.A.M. insulin dose that morning. A care plan dated 4/17/19 identified Resident #13 did not receive his/her medication on time on 4/8/19. Interventions included: to be aware of side effects to watch for, specific to the medication error. An additional interventions include one on one education and progressive discipline was given to the employee. An in-service education form dated 4/17/19 identified education was provided to LPN # 6 on the 10 rights of medication administration and failure to adhere to this education would result in further disciplinary action. Interview with Resident # 18 on 5/20/19 2:03 P.M. identified on 4/8/19 a nurse administered the morning Novolog insulin 18 units at 11:10 A.M. and administered the noon dose at 12:53 P.M. (one hour and fifty three minutes apart). Additionally, Resident #13 indicated that he/she became shaky and sweaty and the nurse gave him/her apple juice and he/she felt better. Interview with DNS identified the Novolog Insulin 18 units was administered late and after meals for 2 doses on 4/8/19. The DNS also indicated LPN # 6 admitted to her/him Resident # 13's medication was not administered on time according to physician orders. Review of the facility policy for general dose preparation and Medication Administration notes that facility staff should verify each time a medication is administered to ensure the correct medication, dose, route, rate, time, and resident. Although the physician's orders directed to administer Novolog 18units three times a day before meals, the medication was administered late and after meals. Additionally, the time between medication doses was less than two hours apart per Resident #13 and 3.5 hours apart per medication error report. Further, Resident #13 reported signs of hypoglycemia (low blood sugar) and was treated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility documentation and interviews, the facility failed to maintain a clean, comfortable, homelike environment. The findings include: 1. During observations on 5/20, 5/21 and 5/22/19 of the second floor several dark colored stains were noted on the carpet throughout the unit. The areas included dark colored brown stains between rooms [ROOM NUMBERS], dark brown stain in front of room [ROOM NUMBER], in front of the fire door, between rooms [ROOM NUMBERS], a large dark brown stain between rooms [ROOM NUMBERS], dark brown stain in front of room [ROOM NUMBER], dark brown stain between rooms [ROOM NUMBERS], and in front of Rooms 235, 224, 225, and 231. On the third floor, the carpet was noted to be dirty with several discolored areas which included: the carpet outside of room [ROOM NUMBER] with approximately three (3) feet of a discolored area with white margins. The carpet outside room [ROOM NUMBER], 328, 331, 332 and 333 were noted to have a one (1) foot brown and white discolored circular area, the carpet between rooms [ROOM NUMBERS] was noted with an approximate five (5) feet circular darkened area of carpet, and the air conditioner unit was noted to be directly above the area and a small amount of water was dripping while the air conditioner was in use. The area outside room [ROOM NUMBER], 320, 321, 322 and 324 were also noted with brown discolored area with white margins. In an interview with the Director of Housekeeping on 5/22/19 at 9:30 AM he indicated that the staff spot cleans the carpet, however, the auto scrubber which extracts water from the carpet was broken and the facility only have a spot Bonnet which is utilized for cleaning stains. The Director of Housekeeping stated the entire carpet had not been extracted and/or cleaned and he borrowed a machine from another facility to do some extraction of the carpet. The Director of Housekeeping identified the carpet was spot cleaned monthly however the auto scrubber had been broken for about two (2) months. The Director of Housekeeping indicated that he does not have any cleaning schedule and/or documentation indicating when the carpets were cleaned. In an interview with [NAME] #1 on 5/22/19 at 9:35 AM he indicated that he has worked at the facility for five (5) years and they have never extracted the carpet and he only utilized the spot bonnet for cleaning spots. 2. Observations on 5/20/19 at 11:05 AM the shared bathroom sink counter in room [ROOM NUMBER] was noted with peeling and exposed particle board on front left corner with a black substance on particle board. The toilet bowl in room [ROOM NUMBER] was noted to be grossly stained with a brown substance and the toilet seat was missing. During an interview with the Director of Maintenance on 5/20/19 at 2:30 PM he indicated that the residents were not capable of using the toilet in room [ROOM NUMBER] and the toilet was only used by staff to flush waste. In an interview with the Director of Maintenance on 5/24/19 at 9:45 AM he indicated that the toilet was in disrepair for about three (3) months. Subsequent to surveyor inquiry, the toilet was replaced. 3. During observations on 5/20, 5/21 and again on 5/22/19 on the second floor a brown substance was observed on the bedside stand, back of the wall, and on the floor behind the bed in room [ROOM NUMBER]. In an interview with the Director of Housekeeping on 5/22/19 at 9:30AM he indicated that the substance on floor, wall and bedside stand was tube feeding. The Director of Housekeeping stated he usually utilized a scraper to clean area, however he was off for two (2) days and not sure why area was not cleaned. During an interview and observations with Housekeeper #1 5/22/19 at 9:40 AM he indicated that the resident rooms are cleaned daily however on 5/21/19 he went into room [ROOM NUMBER] and did not get to clean the floor because the staff were working with the resident and he never went back. Housekeeper #1 stated that the nursing staff should have informed him when they were finish with care, however he was not notified. The facility indicated that there are no policy and/or cleaning schedule for maintaining the carpet. 4. Observations of the resident units from 5/21-5/23/19 identified although the units were clutter free and essentially clean, the units were noted as odiferous. The second floor unit had carpets throughout the hallways which were identified as having stains throughout entire second floor. Interview with Person #2 on 5/21/19 at 10:40 AM indicated that he/she recalls the units smelling like urine. Person #2 stated that he/she reported the concerns to the Administrator and was told that the facility makes attempts to clean the carpet and deodorize areas identified as issues. Person #2 identified that he/she has not seen any improvement. Interview with the Director of Housekeeping on 5/22/19 at 11:00 AM indicated in the past five years the carpet has never been extracted. The Director of Housekeeping stated only spot cleaning is done to maintain the carpet and the staff makes attempts to deodorize the carpet on a routine basis. The Director of Housekeeping identified although there was no documentation to indicate when the carpet was cleaned, the staff try to clean the unit carpet monthly. Interview with the Administrator on 5/23/19 at 2:00 PM indicated that a purchase quote has been given to the corporate office for carpet replacement. The Administrator and Director of Housekeeping indicated that deodorization will continue until a better solution is in put into place by the corporate office.