**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 four (4) sampled residents (Resident #1) who were reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to complete a PASRR Level 2 screening when the initial screen expired causing a delay in Resident #1's transfer to another long term care facility. The findings include:Resident #1's diagnoses included congestive heart failure, chronic obstructive pulmonary disease, depression, post-traumatic stress disorder, and bipolar disorder. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory deficits and received anti-anxiety and anti-depressant medications. The PASRR Level 1 notice of action dated [DATE] identified Resident #1 received his/her approval for a period of seven (7) days and a Level 2 referral was not needed with this screening. The notice identified the admitting nursing facility was responsible for submitting the updated Level I/PASRR and LOC at admission so a Level 2 referral may be initiated. The social service note dated [DATE] at 10:28 AM identified Resident #1 was issued a Notice of Medicare Non-Coverage (NOMNC) on [DATE] and an appeal form was completed. The social service note dated [DATE] at 4:35 PM identified Resident #1 lost the appeal and was considered private pay. The note indicated the family was attempting to get Resident #1 into a facility that was Veteran Affairs (VA) connected. The PASRR Level 1 review dated [DATE] identified a previous PASRR short term approval for nursing facility stay is expiring or has expired, a PASRR Level 2 should have been conducted upon expiration of the PASSR Level 1 on [DATE]. The Grievance/Concern Form dated [DATE] identified Resident #1 and family members alleged social service was not assisting with transfers to another facility. The notice of the PASRR Level 2 dated [DATE] identified Resident #1 required the level of services provided in a nursing facility, did not need special services for serious mental health issues and was approved, therefore Resident #1 could choose the nursing facility. The social service note dated [DATE] at 10:19 AM identified Resident #1 was discharged to another long-term care facility. Interview with the Director of Social Services on [DATE] at 2:25 PM identified the process at the facility for PASRR screenings was, upon admission the Director of Social Services was responsible for looking at the PASSR Level 1 screening to determine if further screening was required. The Director of Social Services identified she failed to recognize Resident #1's PASRR Level 1 was approved for seven (7) days and due to Resident #1's psychiatric diagnoses a PASSR Level 2 screening was required. The Director of Social Services explained she did not discover this error until Resident #1's notice of Medicare non-coverage was issued and Resident #1's family requested to transfer Resident #1 to a facility with VA benefits. The Director of Social Services identified she contacted several VA facilities and one facility identified they were able to accept Resident #1 and requested a copy of the PASRR Level 2. The Director of Social Services explained the receiving facility was unable to accept Resident #1 until the PASRR Level 2 was completed, Resident #1 had to remain at the current facility as private pay from [DATE] to [DATE] for a total of fifteen (15) days until the process was completed. The Director of Social Services identified the facility failed to follow the requirements for filing a PASRR Level 2 when due. Interview with the Administrator on [DATE] at 2:55 PM identified the facility failed to follow the requirements for filing a PASRR Level 2 for Resident #1 which caused Resident #1 to have to pay privately until Resident #1 was able to be accepted at a VA facility. The facility Resident Rights policy identified residents have the right to a safe transfer or discharge through sufficient preparation by the nursing home.

**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 four (4) sampled residents (Resident #1) who were reviewed for coordination of the plan of care, the facility failed provide the baseline and comprehensive care plans to the resident or the resident's family within forty-eight hours of admission to promote continuity of care and communication with the staff. The findings include:Resident #1's diagnoses included congestive heart failure, chronic obstructive pulmonary disease, depression, and bipolar disorder. The baseline Resident Care Plan dated 5/28/25 identified Resident #1 had a colostomy, was incontinent of bladder, had bipolar disorder, and had a self-care deficit. Interventions directed to toilet the resident every two (2) hours, provide incontinent care, apply barrier protection after care, obtain lab work as ordered, administer medications as ordered, monitor behaviors, psychiatric consults as needed, and assist with daily living skills. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory deficits, required moderate assistance with personal hygiene and bed mobility, maximum assistance for dressing, was dependent on toileting, showers, transfers, and ambulation, had a colostomy, and was always incontinent of bladder. Review of the clinical record from 5/28/25 when the baseline care plan was developed through 7/28/25 failed to reflect documentation a meeting was held with Resident #1 and the family to discuss Resident #1's care or a copy of the care plans were provided until the 7/28/25 meeting. The Care Plan Meeting Invitation form identified the facility had a meeting with Resident #1 and family members on 7/28/25 and addressed concerns Resident #1 and his/her family had. Interview with the Director of Social Services on 8/18/25 at 2:25 PM identified she thought a meeting was held; however, she could not be sure because she did not document in the clinical record that a meeting occurred. The Director of Social Services checked further with the therapy department as they attended all care plan meetings, and the therapy department had no record of the meeting being held. Review of the facility Resident Rights policy identified the resident had the right to participate in their own care-planning and treatment. Review of the facility Care Plan policy identified the resident had the right to participate in the development and implementation of his/her plan of care.

**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 four (4) sampled residents (Resident #1) who was symptomatic for a urinary tract infection and had an order to collect a urine specimen, the facility failed to collect the urine at the time of the order or notify the physician of the delay with obtaining the specimen. The findings include:Resident #1's diagnoses included chronic kidney disease, congestive heart failure, and diabetes mellitus. The baseline Resident Care Plan dated 5/28/25 identified Resident #1 had a colostomy, was incontinent of bladder, and had a self-care deficit. Interventions directed to toilet the resident every two (2) hours, provide incontinent care, apply barrier protection after care, obtain lab work as ordered, and assist with daily living skills as needed. A physician's order dated 5/28/25 directed staff may straight catheterize Resident #1 if unable to obtain a urine specimen for urinalysis or culture and sensitivity as needed. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory deficits, required moderate assistance with personal hygiene, maximum assistance for dressing, was dependent on toileting, and was always incontinent of bladder. The nurse's note dated 6/4/25 at 9:19 PM identified the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, noted Resident #1 was very lethargic and hard to arouse around 9:00 PM during the medication pass. The note indicated when the nurse aide attempted to provide care Resident #1 became agitated and attempted to strike the nurse aide. The note identified Resident #1 was approached a second time and refused all medications. The plan was to continue to monitor Resident #1. The nurse's note dated 6/5/25 at 5:15 PM identified the 7AM-3PM charge nurse, LPN #2, noticed Resident #1 was listless throughout the day with a flat affect, responded appropriately to questions, complained of dysuria when being toileted in the morning, and was encouraged to increase fluid intake. The note identified the Advanced Practice Registered Nurse (APRN) was notified and directed labs and urine specimens to be done in the morning. The nurse's note dated 6/5/25 at 11:16 PM identified Resident #1 was lethargic during the shift and was found a couple of times with his/her feet dangling out of the bed. Review of the nurse's notes for 6/6/25 and 6/7/25 failed to identify attempts were made to collect a urine sample or there was notification to the APRN regarding the status. The nurse's note dated 6/8/25 at 2:24 PM by the 7AM-3PM floor nurse, LPN #4, identified a family member was in to visit and voiced concerns over Resident #1's increased confusion. The note indicated there was still the need to obtain a urine specimen. A physician's progress note dated 6/9/25 at 11:15 AM identified the urinalysis was positive for bacteria, and the culture and sensitivity were pending. The physician directed to continue to monitor and appropriate antibiotic treatment would be initiated once the culture and sensitivity results were back. The nurse's note dated 6/9/25 at 4:54 PM identified Resident #1 complained of dysuria and required extensive assistance for morning care. A urine specimen was obtained and sent to the lab, four (4) days after the initial order. The lab result dated 6/9/25 identified a positive urinary tract infection. The nurse's note dated 6/10/25 at 9:51 AM identified Resident #1's culture was rejected by the lab and the facility received an order to obtain another urine. The nurse's note dated 6/11/25 at 3:59 PM identified Resident #1 had periods of confusion during the shift and family member had also reported Resident #1 was having more confusion. A physician's progress note dated 6/12/25 at 8:30 AM identified the facility received the results of the urine culture and sensitivity and the APRN directed to administer Rocephin IM for four (4) days. The urine culture and sensitivity lab results dated 6/13/25 identified multiple gram-positive bacteria was noted in the urine. The Grievance/Concern Form dated 7/28/25 identified family members alleged when a urinalysis test was requested there was a delay in obtaining the specimen. Interview with LPN #2 on 8/18/25 at 1:40 PM identified the length of time from the urinalysis being ordered on 6/5/25 until treatment was ordered on 6/12/25 was longer than usual. Interview with LPN #1 on 8/18/25 at 2:00 PM identified she could not recall if she attempted to get a urine sample and noted if she had and was unsuccessful, she would have documented that in the clinical record. Interview with the Infection Control Nurse, Registered Nurse (RN) #1, on 8/18/25 at 2:18 PM identified the facility expectation to collect a urine sample once ordered was within twenty-four (24) hours. RN #1 indicated the physician should have been notified of the delay and inquire if the physician wanted Resident #1 to be straight cathed due to Resident #1's incontinence. RN #1 identified failure to follow proper protocol caused a delay in treating Resident #1. Review of the facility policy Resident Rights identified the resident had the right to receive adequate and appropriate care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, clinical record review, and review of facility policy for 1 of 2 sampled residents (Resident #37) reviewed for choices, the facility failed to ensure the resident's wheelchair of choice was able to be utilized. The findings include: Resident #37 diagnoses included abnormal posture, spinal instabilities, and pressure ulcer of the sacral region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was cognitively intact, required setup for eating and hygiene, and was dependent on staff for toileting and transfers. The Resident Care Plan dated 2/5/25 identified Resident #37 required modified wheelchair positioning for proper body alignment. Interventions included referral to therapy as needed for change in wheelchair positioning, monitor for complaints of pain or evidence for skin breakdown, and transfer out of bed into the modified wheelchair as ordered. A physician's order dated 4/14/25 directed Resident #37 was to be out of bed to the adapted tilt in space wheelchair up to 1 hour to facilitate quality of life. Interview with Resident #37 on 4/14/25 at 9:53 AM identified he/she received an electric wheelchair (currently in the room) from a family member about a year ago, but he/she was unable to use it as the facility prohibited its use. Interview with the Director of Rehabilitation on 4/15/25 at 1:13 PM identified she was aware of Resident #37's desire to use the electric wheelchair, and he/she was evaluated when they first received the electric wheelchair, but did he/she not need an electric wheelchair. Additionally, to maintain function, the decision was made by staff to keep Resident #37 in the customized wheelchair (CWC) to deconditioniong. Review of the summary of skilled services (rehabilitation therapy) dated 6/24/24 at 2:58 PM identified, in part, that Resident #37 had received the electric wheelchair from his/her family, utilized the wheelchair over that weekend but lacked therapy approval or knowledge. Resident #37 was provided educated on inspection, education, and training for any new equipment brought into the facility, as well as extensive education on safety risks associated with the use of an electric wheelchair within a skilled nursing facility due to other residents. Additionally, therapy had concerns that the resident would develop muscle atrophy of the bilateral upper extremities, and he/she had a high risk for impairments, risk for joint deformity, pain and injury due to a lack of positioning devices. Resident #37 was receptive to all education provided and was educated on the need for further assessments to determine if the device was safe for him/her and other residents as well as further education on risk for impairments and injury making the electric wheelchair inappropriate for that environment. (Although multiple requests were made, the facility was unable to provide a screen, evaluation, or assessment of Resident #37 in the electric wheelchair). Interview with Nursing Assistant (NA) #1 on 4/16/25 at 9:22 AM identified she took care of Resident #37 on a regular basis, and he/she used to bring up using the electric wheelchair all the time when the wheelchair was first received. She identified it was always in Resident #37's room, but she did not believe he/she was ever evaluated by therapy for its use and questioned if electric wheelchairs were even allowed in the facility. Follow up interview Director of Rehabilitation on 4/16/25 at 1:48 PM identified Resident #37 was currently receiving therapy for strengthening, and although she was aware of Resident #37's desire to use the electric wheelchair, the facility wanted him/her to keep his/her independence. Additionally, she identified for a resident receiving a muscle relaxant and pain medication might not be appropriate to use an electric wheelchair, because he/she might fall asleep, and the facility needed to think about the safety of other residents. The Director of Rehabilitation identified Resident #37 was highly motivated to be discharged and could use the electric wheelchair in the community. Observation of Resident #37 on 4/15/25 at 2:11 PM identified him/her alert and conversing with staff in the hallway utilizing the wall railing to self-propel in the non-electric wheelchair. Additional observations on 4/16/25 at 11:05 AM identified Resident #37 alert and oriented during a wound treatment change and on 4/16/25 at 2:10 PM he/she was self-propelling in the hallway in his/her non-electric wheelchair. Observations failed to identify Resident #37 dozing off or sleeping any point. Follow up interview with Resident #37 on 4/17/25 at 9:45 AM identified he/she got the electric wheelchair because it was more comfortable than the wheelchair the facility was providing. He/she also identified no one assessed him in the chair, just explained that it was not appropriate due to his leaning, but he/she did not understand that because both the current wheelchair and the electric wheelchair reclined. Review of occupational therapy summaries of daily skilled services notes failed to identify that Resident #37 was assessed in the electric wheelchair after the initial education provided on 6/24/24. Review of the Americans with Disabilities Act (ADA) Requirements: indicated that Wheelchairs, mobility aids, and other power-driven mobility devices directed, in part, that people with disabilities have the right to choose whatever mobility device best suits their needs. Review of the Resident's [NAME] of Rights directed, in part, that residents can store and use their personal possessions and have the right to receive quality care and services with reasonable accommodations of individual needs and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review for 1 of 3 residents, (Resident #19), sampled for advanced directives, the facility failed to identify a code status in the electronic health record. The findings included: Resident #19's diagnoses included chronic obstructive pulmonary disease, anemia and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was moderately cognitively impaired, and required substantial/ maximal assistance with dressing, eating and repositioning in bed. The Resident Care Plan dated 2/10/25 identified Resident #19's advance care planning code status was DNR/DNI/RNP (do not resuscitate, do not in tubate, Registered Nurse may pronounce). Interventions included a physician's order and documentation of the resident's code status and advance care planning in the resident's clinical record. The Resident Advance Directives form signed 3/7/24 identified Resident #19 had a code status of do not resuscitate (DNR). The physicians' orders failed to identify a code status. Interview and record review with Licensed Practical Nurse (LPN) #4 on 4/15/25 at 1:29 PM identified it is facility policy for advance directives to be in the electronic health record, entered by the charge nurse upon admission and passed on in report verbally. LPN #4 further identified in an emergency the protocol would be to check the electronic health record first. Resident #19's electronic record failed to identify code status. Interview and record review with the Director of Nursing (DNS) on 04/15/25 at 1:33 PM identified it is facility policy for advance directives to be in the chart and in the electronic health record, input by the RN supervisor within 24 hours of admission without exception. The DNS could not identify Resident #19's code status in the electronic health record, stating in an emergency, the nurse would have to check the physical chart. The Advance Directives Policy directed in part that an advance directive shall be displayed prominently in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documentation, facility policy, and interviews for 2 of 3 sampled residents, (Resident #28 and Resident #63), reviewed for abuse, for Resident #28, the facility failed to report an allegation of misappropriation of funds, and for Resident #63, the facility failed to report an allegation of neglect in a timely manner. The findings include: 1. Resident #28's diagnosis included depression, stroke, and spinal cord dysfunction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had a Brief Interview of Mental Status (BIMS) score of 14 indicating cognition was intact, was independent with eating after set up, was dependent on staff for dressing and transfers, and used a wheelchair for mobility. The Resident Care Plan dated 9/10/2024 identified Resident #28 had impaired Activities of Daily Living (ADL's) requiring assistance related to a history of a stroke. Interventions directed staff to assist with bathing, dressing, and personal hygiene. Interview with Resident #28 on 4/14/2025 at 11:07 AM identified that he/she had $40.00 missing from the bedside table that was going to be used to pay the hairdresser. Resident #28 indicated that due to the missing money, he/she was unable to attend the appointment. Further the missing money had been reported NA #5 approximately 6 months ago, but the facility had taken no action. Interview with Nurse Aide (NA) #5 on 4/16/2025 at 2:44 PM identified that Resident #28 requested her help to get his/her money from inside a cell phone case. When NA #5 opened the case, she explained to Resident #28 that there was no money inside. Resident #28 stated he/she was sure the money had been stored in the cell phone case. NA #5 indicated that she searched for the money in the resident's room, but no money was found. NA #5 stated she reported the incident to either the charge nurse or nursing supervisor, though she could not recall exactly to whom she reported the incident. Additionally, NA #5 stated that she had also completed a written statement and gave it to the nursing supervisor. Interview with LPN #7 on 4/16/2025 at 2:57 PM identified she did not recall being informed about the missing money. Interview with RN #1 on 4/16/2025 at 3:16 PM identified she did not recall NA #5 reporting the missing money. Re-interview with RN #1 on 4/17/2025 3:04 PM identified that the facility failed to provide any written documentation for the missing money being reported or investigated. An interview with the Administrator on 4/17/2025 at 3:08 PM identified that he was unaware of Resident #28's allegation of misappropriation so he would not have reported it to the state agency. Interview with the Director of Nursing Services (DNS) on 4/17/2025 at 5:51 PM identified that she could not explain why the policy for misappropriation [abuse] was not followed and the allegation was not immediately reported to the state agency. Subsequent to Surveyor inquiry, a reportable event was reported to the Department of Public Health (state agency) on 4/16/2025 and the police were notified. 2. Resident #63's diagnoses included dementia, adjustment disorder with anxiety, depressed mood and irritable bowel syndrome. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #63 had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impaired and required partial moderate assistance with transfers, substantial maximum assistance with bed mobility, and was totally dependent on staff for toileting. Additionally, Resident #63 was frequently incontinent of bowel and bladder. The elimination Resident Care Plan in effect on 9/26/2023 identified Resident #63 was incontinent of bowel and bladder related to impaired cognition and mobility. Interventions included toileting and incontinent care every 2 hours and as needed, disposable adult incontinence brief, and applying barrier skin protection following incontinent care. Review of the grievance concern form dated 10/6/2023 identified that on 9/26/2023 a family member had reported to LPN #3 (the day of the incident) that Resident #63 was neglected for many hours and lacked incontinence care, position changes, or hygiene. When Resident #63's brief was changed, it was noted to have a foul odor, was saturated through to his/her clothes and seat cushion, and a new irritation and open areas were noted. Further review of the grievance form identified that the incident had been reported to the Supervising Registered Nurse, (RN #1) on 9/29/23 (3 days after the initial allegation) and to the Director of Nursing (DNS) on 10/3/23 (7 days after the initial allegation). Review of the Reportable Event form dated 10/6/2023 identified a family member reported to the social worker that there was a delay in providing incontinence care to Resident #63 on 9/26/23. Further, the incident had already been reported to a staff member on 9/26/2023. The Reportable Event form indicated that although the incident had been reported on 9/26/2023, the allegation had not been reported to the state agency until 10/6/23 (3 days after the grievance form was completed on 10/6/2023 and 10 days following the initial allegation on 9/26/2023). An interview with the DNS on 4/17/25 at 10:28 AM identified she could not explain why the allegation of neglect had not been reported to the state agency, per the facility policy, within the requirement of 2 hours following when the neglect was first known by staff. Review of the abuse policy directed, in part, an allegation must be reported immediately to the administrator/DNS and will be entered into the DPH (state agency) reporting system (FLIS) within 2 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #28) reviewed for personal property, the facility failed to investigate an allegation of misappropriation of funds, and for the only sampled resident (Resident #63) reviewed for abuse, the facility failed to thoroughly investigate an allegation of neglect, investigate an allegation of neglect in a timely manner, and prevent access to the resident by the staff member following the allegation of neglect. The findings include: 1. Resident #28's diagnosis included depression, stroke, and spinal cord dysfunction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had a Brief Interview of Mental Status (BIMS) score of 14 indicating cognition was intact, was independent with eating after set up, was dependent on staff for dressing and transfers, and used a wheelchair for mobility. The Resident Care Plan dated 9/10/2024 identified Resident #28 had impaired Activities of Daily Living (ADL's) requiring assistance related to a history of a stroke. Interventions directed staff to assist with bathing, dressing, and personal hygiene. Interview with Resident #28 on 4/14/2025 at 11:07 AM identified that he/she had $40.00 missing from the bedside table that was going to be used to pay for a hairdresser appointment. Resident #28 indicated that due to the missing money, he/she was unable to attend the appointment. Further the missing money had been reported NA #5 approximately 6 months ago, but the facility had taken no action. Interview with Nurse Aide (NA) #5 on 4/16/2025 at 2:44 PM identified that Resident #28 requested her help to get his/her money from inside a cell phone case. When NA #5 opened the case, she explained to Resident #28 that there was no money inside. Resident #28 stated he/she was sure the money had been stored in the cell phone case. NA #5 indicated that she searched for the money in the resident's room, but no money was found. NA #5 stated she reported the incident to either the charge nurse or nursing supervisor, though she could not recall exactly to whom she reported the incident. Additionally, NA #5 stated that she had also completed a written statement and gave it to the nursing supervisor. Interview with LPN #7 on 4/16/2025 at 2:57 PM identified she did not recall being informed about the missing money. Interview with RN #1 on 4/16/2025 at 3:16 PM identified she did not recall NA #5 reporting the missing money. Re-interview with RN #1 on 4/17/2025 3:04 PM identified that the facility failed to have any written documentation for Resident #28's missing money being reported or investigated. An interview with the Administrator on 4/17/2025 at 3:08 PM identified that he was unaware of Resident #28's allegation of misappropriation so the facility would not have investigated the circumstances surrounding the missing money. Interview with the Director of Nursing Services (DNS) on 4/17/2025 at 5:51 PM identified that she could not explain why the policy was not followed and the allegation was not immediately investigated. Subsequent to Surveyor inquiry, a reportable event form was completed, and the facility began their investigation into the missing money. 2. Resident #63's diagnoses included dementia, adjustment disorder with anxiety, depressed mood and irritable bowel syndrome. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #63 had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impaired and required partial moderate assistance with transfers, substantial maximum assistance with bed mobility, and was totally dependent on staff for toileting. Additionally, Resident #63 was frequently incontinent of bowel and bladder. The elimination Resident Care Plan in effect on 9/26/23 identified Resident #63 was incontinent of bowel and bladder related to impaired cognition and mobility. Interventions included toileting and incontinent care every 2 hours and as needed, disposable adult incontinence brief, and applying barrier skin protection following incontinent care. Review of the grievance concern form dated 10/6/23 identified that on 9/26/23 a family member had reported to LPN #3 (the day of the incident) that Resident #63 was neglected for many hours and lacked incontinence care, position changes, or hygiene. When Resident #63's brief was changed, it was noted to have a foul odor, was saturated through to his/her clothes and seat cushion, and a new irritation and open areas were noted. Further review of the grievance form identified that the incident had been reported to the Supervising Registered Nurse, (RN #1) on 9/29/23 (3 days after the initial allegation) and to the Director of Nursing (DNS) on 10/3/23 (7 days after the initial allegation). Review of the Reportable Event form dated 10/6/23 identified a family member reported to the social worker that there was a delay in providing incontinence care to Resident #63 on 9/26/23. Further, the incident had already been reported to a staff member on 9/26/23. The Reportable Event form indicated that although the incident had been reported on 9/26/23, the allegation had not been reported to the state agency until 10/6/23 (3 days after the grievance form was completed and 10 days following the initial allegation). Review of the facility investigation attached with the Reportable Event, conducted by the DNS included written statements. Review of the written statements identified NA #6's statement was dated 10/4/25, LPN #3's statement was dated 10/4/25, RN #1's statement was dated 10/6/25, NA #7's statement was dated 10/10/25, and NA #8's statement was dated 10/10/25. None of the statements reviewed indicated that the investigation had been started until 8 days after the allegation had been reported to staff. RN #1's written statement dated 10/6/23 identified that on 9/26/23 Resident #63's family member mentioned a delay in care a day in the last week, a skin check was performed on 9/27/23, and an order was entered to treat redness of the skin. An interview with the DNS on 4/16/25 at 2:24 PM identified that NA #6 had not been immediately suspended at the time of the allegation, per the facility policy, and had subsequently been suspended on 10/7/23, 10/8/23, and 10/9/25 (10 days after the allegation was reported and allowing access to the resident prior to determining an outcome). The DNS further indicated that on 10/9/23 the family member of Resident #63 called the facility and stated they felt the NA involved could continue to work with Resident #63 and the incident was caused by a lack of communication. Resident #63's care plan was updated to include a toileting plan and rest time during the day. The DNS identified that the alleged neglect was unsubstantiated. Re-interview with the DNS on 4/17/25 at 10:28AM identified that the investigation consisted of incomplete investigation areas for a psychosocial service summary of interview with residents, summary of interviews with staff, summary of interview with resident's roommate, summary of interview with resident's family member, summary of interview with the alleged perpetrator, summary of interview with other resident's/family members care for by the alleged perpetrator and the conclusion of the event. Additionally, a summary of the investigation and the root cause/conclusion and corrective actions was missing on the investigation form. The DNS failed to identify a summary of the investigation or a conclusion that determined whether the allegation of neglect was or was not substantiated. The DNS indicated because the family member changed their mind about the allegation and felt comfortable with the alleged NA working with Resident #63 there was no neglect and no reason to continue the investigation. The DNS could not identify why care was not given. Review of the abuse policy directed, in part, all reports of abuse, neglect, misappropriations of resident's property and injuries of known or unknown source shall be promptly and thoroughly investigated by facility management. An incident of abuse neglect, misappropriation of resident's property or injury of known or unknown source, the Administrator or designee will appoint a member of management to investigate the alleged incident. Employees of this facility who have been accused of the alleged resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, facility policy, and interviews for the only sampled resident, (Resident #28), reviewed for urinary catheter care, the facility failed to perform weekly skin assessments; for the only sampled resident, (Resident #35), reviewed for positioning, the facility failed to ensure a positioning plan for a resident in a customized wheelchair was followed, for the only sampled resident, (Resident #42), reviewed for a non-pressure skin related condition, the facility failed to report a change in a resident's skin condition to a licensed nurse, and for 2 of 2 sampled residents, (Resident #28 and #63) reviewed for abuse, the facility failed to provide timely incontinent care. The findings included: 1. Resident #28's diagnosis included stroke, spinal cord dysfunction, and hemiplegia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The Resident required a wheelchair for mobility, was dependent with dressing and all transfers. The Resident Care Plan dated 1/15/2025 identified that Resident #28 was at risk for impaired skin integrity related to a history of skin tears and moisture-associated skin damage. Interventions included the use of a low air loss mattress, repositioning to meet the resident's needs, application of a pressure redistribution device, and staff were to report any new skin changes to the physician or nurse. A physician's order dated 3/17/2025 directed staff to perform weekly skin checks, complete the weekly skin evaluation form, and notify the Registered (RN) of any new findings. Review of clinical record from 3/19/2025 through 4/17/2025 identified staff did not complete weekly skin checks for Resident #28 on 3/26/2025 and 4/16/2025. The Treatment Administration Record (TAR) dated 4/1/2025 through 4/22/2025 identified that LPN #7 had signed that a skin check had been completed on 4/16/2025. Interview and review of clinical record on 4/17/2025 at 9:37 AM with RN #2 identified that the last fully documented weekly skin check for Resident #28 was performed on 4/9/2025 and that LPN #7 had not documented the completion of a Skin Check Evaluation form on 4/16/2025 as signed. Additionally, the skin check scheduled for 3/26/2025 had not been completed. RN #2 failed to identify why the weekly skin checks had not been completed per the physician order. RN #2 indicated that charge nurses were responsible for performing weekly skin assessments and if an assessment could not be completed on the day shift, communication through shift to shift handoff procedure was expected to ensure completion by the subsequent shift. An interview and review of the clinical record with LPN #7 on 4/17/2025 at 10:18 AM identified that she was responsible for the 4/16/2025 weekly skin check but did not complete the skin check. LPN #7 indicated that she had signed the skin check as complete on 4/16/25 but had not completed the skin check evaluation. She reported that she had intended to complete the skin check but was likely interrupted and failed to return to Resident #28 to complete the task. Interview on 4/17/2025 at 5:37 PM with the Director of Nursing (DNS) stated that weekly skin checks must be performed by the charge nurse and stated it was unacceptable to document a task as completed without performing the actual task. The DNS identified that a communication breakdown had occurred. Review of the facility's Weekly Skin Audit Policy dated 7/2020 directed, in part, that licensed nurses were required to perform weekly full-body skin audits. Nurses were instructed to initial the TAR to indicate task completion and to complete the Skin Evaluation Assessment. 2. Resident #35's diagnoses included abnormal posture, repeated falls, and end stage renal disease. A Wheeled Mobility Letter of Medical Necessity dated 12/13/24 identified a pelvic belt was provided to Resident #35 for pelvic stabilization and safety while in the wheelchair to reduce any risk of sliding. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #35 had a BIMS score of 3 indicating severe cognitive impairment and required substantial/maximal assistance from staff with transfers, set up clean up assistance with bed mobility, and was unable to walk. The Resident Care Plan dated 2/11/25 identified Resident #35 required modified wheelchair positioning for proper body alignment when out of bed. Interventions included out of bed to a modified wheelchair every morning, and referral to therapy as needed for changes in wheelchair positioning, complaints of pain, or evidence for skin breakdown. The Custom Wheelchair (CWC) Positioning Plan dated 3/21/25 directed the pelvic positioning belt be fastened snug across the resident's hips for proper skeletal alignment, leg rests on during periods of fatigue or being mobilized by a caregiver, and that leg rests could be removed during periods of alertness for wheelchair mobility and tilt the CWC as tolerated. The Nursing Assistant (NA) Care Card dated 3/24/25 identified Resident #35 was to be up out of bed to a CWC, pelvic positioning belt to be placed snug across the resident's hips at all times, and the positioning plan was to be followed. A physician's order dated 4/14/25 directed Resident #35 to be out of bed to a CWC according to the 24-hour positioning plan, head rest in place at all times, place a pelvic positioning belt fastened snug across the hips for proper pelvic positioning and alignment, provide leg rests during periods of fatigue/caregiver assistance for mobility, and remove leg rests during periods of alertness to facilitate use of bilateral lower extremities for wheelchair mobility every shift. Observation on 4/14/25 at 9:47 AM and 4/14/25 at 11:38 AM identified Resident #35 out of bed in the CWC, sitting on a transfer sling, self-propelling in the hallway without the benefit of the positioning belt being fastened and with both leg rests in place and not removed for independent wheelchair mobility. Observation on 4/14/25 at 12:03 PM identified Resident #35 self-propelling the CWC in the dining room, sitting on a transfer sling, with the trunk of his/her body in a slouched position, his/her head was approximately 2 inches below the headrest, and without the benefit of a seat belt worn. At 12:08 PM and 12:17 PM Nursing Assistant (NA) #2 approached Resident #35 and with the help of a second NA boosted him/her to a more upright position by utilizing the transfer sling, no belt was noted to be worn or removed for repositioning. Interview and observation with Person #1 on 4/16/25 at 9:50 AM identified Resident #35 in his/her room, out of bed to the CWC, the seatbelt was unbuckled and hanging on the outside of the wheelchair. Person #1 stated he/she pulled the belt out from under the transfer sling that was left under Resident #35 but was unable to fasten it him/herself, and now the seatbelt kept getting caught in the wheelchair wheels. Interview with Licensed Practical Nurse (LPN) #2 on 4/16/25 at 9:59 AM identified NA #2 was responsible for applying Resident #35's seatbelt per the NA Care Card located inside the closet, LPN #2 subsequently applied the seatbelt snugly across Resident #35's lap. Interview and review of the NA Care Card with NA #2 on 4/16/25 at 10:05 AM identified she worked at the facility for about a year, was the regular NA for Resident #35, and never applied Resident #35's seatbelt because it would be a restriction. Additionally, she identified that resident care information was inside the resident's closet. Review of Resident #35's NA Care Card with NA #2 identified a positing plan directing the resident be out of bed to the customized wheelchair, a pelvic positioning belt was to be placed snug across his/her hips at all times, and the positioning plan was to be followed. Additionally, a copy of the physician's order for the pelvic positioning belt was with the NA Care Cark. NA #2 could not identify why she did not follow the Care Card as instructed. Interview with the Director of Rehabilitation on 4/16/25 at 10:41 AM identified Resident #35 had a 24-hour positioning plan that included the belt to be on snug across the lap and failure to follow the plan of care would impede optimal body alignment. Additionally, nursing was responsible to ensure the application of the belt and education was still ongoing. The Customized Wheelchairs Policy directed, in part, the purpose of a CWC was to promote proper body alignment for resident's who are unable to be positioned in a standard wheelchair. 3. Resident #42's diagnosis included osteoporosis with a right arm humerus fracture, muscle weakness, and difficulty walking. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #42 had a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #42 was moderately cognitively impaired. The Resident required a wheelchair for mobility, was dependent with dressing, bathing, and toileting, and required maximal assistance with bed mobility including sit to stand and chair to bed transfers. The Resident Care plan dated 3/17/2025 identified Resident #42 was at risk for alteration in skin integrity. Interventions included the use of a pressure reduction cushion in the wheelchair, float heels off bed, apply moisture barrier per protocol, and perform a daily skin inspection during morning and evening care; staff were to report any changes in skin integrity. A physician's order currently in effect directed staff to perform weekly skin checks, complete the weekly skin evaluation, and notify the RN of any new findings. Observation and interview with Resident #42 on 4/14/2025 at 9:47 AM identified Resident #42 awake, in bed, and complaining of redness and inflammation to the buttocks and genital region. Resident #42 reported nursing staff had applied powder to the affected areas twice in one day a few weeks ago, but no further treatment had been provided. Resident #42 reported telling the nurse that the issue still remained, but nothing had been done. Interview with Licensed Practical Nurse (LPN) #7 on 4/16/2025 at 11:13 AM identified that LPN #7 was unaware Resident #42 was experiencing discomfort in the groin and buttocks region. LPN #7 stated she would follow up with Nursing Assistant (NA) #4, who had provided care to the resident earlier that morning. Interview with NA #4 on 4/16/2025 at 11:22 AM identified she had provided bathroom assistance to Resident #42 that morning. NA #4 stated she did not observe redness to the resident's genital area but noted the buttocks were red and raw. NA #4 did not report any skin integrity issues to the LPN or RN. Although NA #4 was aware of the requirement to escalate these types of findings to licensed nursing staff, NA #4 stated she forgot to do so in this instance. Subsequent to surveyor interview, a nurses note dated 4/21/2025, identified genital irritation requiring antifungal treatment and the left buttock wound would be followed by Wound primary care physician. Review of the Incontinent Care Policy dated 3/2021 directed, in part, that staff who are providing incontinent care were expected to immediately report any reddened, abraded, or broken skin areas to the nurse. 4. Resident #63's diagnoses included dementia, adjustment disorder with anxiety, depressed mood and irritable bowel syndrome. A physician's order dated 3/1/25 directed to apply Triad (protective) ointment to the sacral area every day and evening with skin care until seen by the wound nurse. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #63 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS score of 0) and required substantial maximum assistance for personal hygiene, dressing, toileting, bed mobility, and transfers. The Resident Care Plan (RCP) dated 4/5/23 identified Resident #63 had impaired Activities of Daily Living (ADL's). Interventions included to assist Resident #63 with bathing, dressing, hygiene, and transfers, Constant observations by the surveyors on 4/16/25 from 8:46 AM until 12:16 PM identified Resident #63 lying in bed, on his/her back, with the head of the bed raised approximately 90 degrees. Staff failed to provide incontinence care or turning and repositioning, and Resident #63 remained in the same position throughout the observation (3 and ½ hours). During an interview with LPN #3 on 4/16/25 at 12:16 PM she was informed that Resident #63 had not received incontinent care or turning and repositioning since the 8:46 AM constant surveyor's observations began. LPN #3 identified that NA #3 was assigned to Resident #63. Interview with NA #3 on 4/16/25 at 12:20 PM identified that she provided Resident #63 with morning care as soon as she came in at 7:00 AM and Resident # 63 was ready for breakfast. Although the surveyors had constant observations of Resident #63, NA #3 stated she had checked Resident #63 at 9:30 AM. During an observation of incontinence care being performed on Resident #63 by NA #3 on 4/16/25 at 12:22 PM an orange color could be seen through the outside of the resident's brief. When Resident #63's brief was removed, it was noted to be saturated and slight redness was noted to the resident's genitals and groin area. Re-interview with NA #3 on 4/16/25 at 2:00 PM identified that incontinent care should be provided to residents every 2-3 hours, but she did not have a chance to go back in to check Resident #63 after the initial incontinence care she had provided at 7:00 AM, and that this was an oversight on her part. NA #3 indicated that staffing was at a normal level as written on the schedule. Review of the Incontinence Care policy revised on 3/21 directed, in part, incontinence care will be provided at a minimum of every 2-3 hours and as soon as possible after episodes of incontinence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review for 1 of 3 sampled residents, (Resident #68), reviewed for accidents, the facility failed to follow a post fall care plan for safety interventions. The findings included: Resident # 68 diagnoses included dementia, lack of coordination, and Parkinsonism. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #68 was moderately cognitively impaired, and required partial/moderate assistance with transfers, toileting, and changing position in bed. The Resident Care Plan dated 3/15/25 identified that Resident #68 was a fall/safety risk. Interventions included keeping the bed at the lowest position and place floor pads to each side of bed. The Accident and Incident Reportable Event dated 12/21/24 identified Resident #68 was found on the floor next to the bed on 12/21/24 at 7:30 AM positioned on her/his right shoulder, stating she/he was getting out of bed and slipped due to a tissue that was on the floor. Observations on 4/15/25 at 9:14 AM and 4/16/25 at 5:45 AM identified Resident #68 in bed with a floor mat on the curtain side of the bed, but without the benefit of a floor mat by the window side of the bed. Interview with Registered Nurse (RN) Supervisor #1 on 4/16/25 at 9:33 AM identified the facility policy was for the supervisor to immediately put a post fall intervention in place. The interdisciplinary team would review the supervisors intervention and decide to implement that intervention or come up with a different permanent intervention. Additionally, following a fall, the new intervention was placed on the Nurse Aide (NA) Resident Care Card (inside the resident's closet) so the NA could implement the intervention. The charge nurse was also responsible for checking that interventions which had been put in place were being utilized. Subsequent to surveyor inquiry a second floor mat was placed in Resident #68's room, on the floor, at the bedside by the window. Interview and review of the clinical record on 4/16/25 at 12:23 PM with Licensed Practical Nurse (LPN) #2 identified that she was unaware of what the facility policy was regarding floor mats. On review of the clinical record, LPN #2 indicated she was unsure of what was in the Resident Care Plan but stated interventions were placed in the physicians order. During a record review of Resident #68's physicians orders LPN #2 indicated there was no order for floor mats. Follow up interview with RN #1 on 4/16/25 at 1:32 PM identified there should have been a physicians order for Resident #68's floor mats. Upon clinical record review RN #1 was unable to locate a physicians order. RN #1 indicated, that per the facility policy, a physicians order for floor mats for Resident #63 should have been in place to alert staff of the need to implement the fall intervention. Subsequent to surveyor inquiry a physician's order was put in place on 4/16/25 for bilateral floor mats on the floor next to the bed when the patient was in bed, every shift for safety. Review of the Assessing Falls and Their Cause policy directed, in part, documentation in the resident's medical record should include appropriate interventions taken to prevent future falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical record, facility policy and interviews for the only sampled resident (Resident #133) reviewed for respiratory care, the facility failed to obtain a physician's order for a resident who received oxygen. The findings include: Resident #133 was newly admitted , diagnosis included a fracture of the sacrum, muscle weakness and difficulty walking. The admission assessment dated [DATE] identified Resident #133 was cognitively alert, lungs were clear, denied shortness of breath, and was not on oxygen. The Resident Care Plan initiated on 4/11/2025 identified Resident #133 was at risk for cardiac issues related to hypertension. Interventions included administering oxygen as ordered, administering medications as ordered, and observing for signs and symptoms of cardiac/respiratory distress. Observation of Resident #133 on 4/14/2025 at 12:16 PM identified the administration of oxygen at 2 liters per minute via nasal cannula. Interview and review of the clinical record with LPN #7 identified that she did not know why the resident was receiving oxygen. LPN #7 identified that an order from the physician was required to administer oxygen but was unable to locate an order in the record or on the Medication/Treatment Administration Records. Subsequent to the surveyor inquiry, a physician's order dated 4/14/2024 at 4:42 PM directed staff to titrate Resident #133's oxygen to maintain an oxygen saturation equal to or greater than 90%. Interview with RN #1 on 4/16/2025 at 3:17 PM identified Resident #133's oxygen desaturated unexpectedly over the weekend and oxygen was placed on the resident. Following the placement of oxygen, the licensed nurse should have notified the provider to request an order, however, the weekend fill in RN Supervisor had failed to request an order. Interview with the Director of Nursing (DNS) on 4/17/2024 at 5:37 PM identified that the facility policy required that a nurse must have an order to administer oxygen. She stated it would have been the nurse's responsibility to inform the provider of the situation and request the appropriate order, which the staff would then place in the clinical record. The DNS indicated that moving forward, education would be provided to ensure all staff understand the importance of obtaining an order for administering oxygen. Review of the Oxygen Administration Policy dated 10/2010 directed, in part, staff to verify there is a physician's order and review the order before oxygen administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and review of facility policy for the only sampled Resident, (Resident #30), reviewed for dental services, the facility failed to accurately assess the residents oral status upon admission, failed to include a comprehensive Resident Care Plan (RCP) related to oral status, failed to code the Minimum Data Set (MDS) accurately related to dentition, and failed to ensure dental services were provided, as required, according to payor type. The findings include: Resident #30's diagnoses included epilepsy, left sided hemiplegia, and chronic obstructive pulmonary disease. A. The Nursing Clinical admission assessment dated [DATE] identified Resident #30 had all his/her own teeth, did not have dentures or partials, but failed to include an examination of Resident #30's oral/dental status. B. Review of the RCP in effect from 7/7/2023 through 4/17/2025 failed to address Resident #30's edentulous (without teeth) status. C. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #30 had a Brief Interview of Mental Status (BIMS) score of 13 indicating no cognitive impairment, required moderate assistance with oral hygiene, but failed to identify that Resident #30 was edentulous. All Subsequent MDS assessments failed to identify that Resident #30 was edentulous. D. Review of the clinical record failed to include that Resident #30 had seen by a dentist. An observation and interview with Resident #30 on 4/14/2025 at 12:15 PM identified the resident's oral status as edentulous with no tooth fragments visible in his/her mouth. Resident #30 identified he/she wanted dentures as his/her previous dentures had been thrown away prior to being admitted to the facility. Although the resident indicated he/she had requested assistance from the nurse to replace his/her dentures Resident #30 had never been seen by the dentist or been offered dental services An observation and interview on 4/17/2025 at 12:23 PM with Registered Nurse (RN) #1 and Resident #30, identified Resident #30 was edentulous and that RN #1 was unaware of his/her dental status. Resident #30 verbalized he/she has not had teeth at any point during his/her time at the facility. An interview with Register Nurse (RN) #1 on 4/17/2025 at 12:23 PM identified that both the MDS and Nursing admission Assessment indicated that Resident #30 had all his/her own natural teeth. Further, she identified that both the admitting Licensed Practical Nurse (LPN), and RN performed the admission nursing assessment together and were responsible for the accuracy of the assessment and that the information collected was inaccurate. RN #1 stated there was an in-house dentist within the facility and residents or their family member needed to request a dental visit to be seen. Subsequent to surveyor inquiry, RN #1 stated that she would place Resident #30 on the list to see a dentist. An interview and review of the clinical record with the Director of Nursing Services (DNS) and RN #6 on 4/17/2025 at 1:17 PM identified that nursing should complete an assessment of Resident #30's teeth and gums upon admission and before every MDS completion but was unable to explain why further assessments of Resident #30's teeth and gums were not performed. Further, it was the expectation for edentulous residents to receive a consultation with dental services. Review of the clinical record failed to identify that a comprehensive RCP had been developed for oral care since his/her admission, or that Resident #30 had received any dental services, routine or emergency. Subsequent to surveyor inquiry, the DNS stated she would speak with Resident #30 to ask his/her preference for an appointment with the in-house dentist or an outside dentist. Review of the Facility's admission Assessment and Follow Up Policy identified, in part, that a physical assessment should be performed by nurses, including the teeth and gums, for completion of the MDS. Attempts to interview the previous MDS Coordinator were unsuccessful, and the facility did not have a current in-house MDS Coordinator. The facility uses the Resident Assessment Instrument manual for MDS coding and assessments. Review of the Dental Services Policy identified in part that routine and emergency dental services are provided to Residents through a contract with a dentist that comes to the facility monthly. If dentures are damaged or lost, residents will be referred for dental services within 3 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and facility policy for 2 residents requiring precautions (Resident #15, #70), who were reviewed for infection control practices, the facility failed to ensure the appropriate precaution sign was placed outside the door for 2 residents with a history of a Multi Drug Resistant Organism (MDRO) and 1 resident with an indwelling medical device. The findings include: 1. Resident #15's diagnoses included hemiplegia and hemiparesis, chronic obstructive pulmonary disease, frequent urinary tract infections, and type 2 diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was dependent on upper and lower body dressing and toileting hygiene and required maximal assistance with rolling left and right. A Resident Care Plan (RCP) dated 2/17/2025 identified Resident #15 had a history of a MDRO, Extended Spectrum Beta-Lactamase (ESBL), bacteria in his/her urine. Interventions included monitoring urine color, odor, frequency, burning, intake and output as ordered, and medications as ordered. The RCP focus was marked resolved on 2/17/2025. The RCP lacked a current precautions problem for Enhanced Barrier Precautions for the history of ESBL. A review of physician orders failed to identify that Resident #15 was on any special precautions for the history of ESBL. 2. Resident #70's diagnoses included multiple sclerosis, urinary tract infection, and depression. The quarterly MDS assessment dated [DATE] identified Resident #70 had a BIMS score of 15 indicating no cognitive impairment, required substantial assistance with lower body dressing, required moderate assistance with chair/bed-to-chair transfers, and required partial assistance wheeling 150 feet with a manual wheelchair. A Resident Care Plan (RCP) dated 2/1/2025 identified Resident #70 had a history of Extended Spectrum Beta-Lactamase (ESBL) in his/her urine. Interventions included administering antibiotics, encouraging fluids, and monitoring vital signs. The RCP focus was marked resolved on 1/14/2025. Further, the RCP identified that the resident had an indwelling medical device. Interventions included indwelling medical device care per the facility protocol, and incontinent care every 2 hours and as needed. The RCP lacked a current precautions problem for Enhanced Barrier Precautions for the history of ESBL. A review of physician orders for November 2024 identified an order for ESBL contact precautions. A review physician orders from 3/1/2025 to 4/14/2025 failed to identify that the ESBL contact precautions were in place or that an order for Enhanced Barrier Precautions for Resident #70's indwelling medical device had been placed. 3. An observation on 4/14/2025 at 11:18 AM identified signage posted outside of Resident #15 and Resident #70's door (roommates), visible prior to entry which stated droplet and contact precautions for unknown Covid-19 with directions that providers and staff must wear a facemask, eye protection, gloves, and a gown for high-contact resident care activities. Further it was identified that LPN #8 was exiting the room wearing gloves and gown, without a mask or eye protection. An interview with LPN #8 on 4/14/2025 at 11:18 AM identified that the contact and droplet sign was placed outside Resident #15 and #70's door because a resident had an MDRO with ESBL. LPN #8 further identified she never wore a face mask or eye protection when entering the room because she knew that the sign incorrectly identified potential Covid-19. She indicated that eye protection might be included on the sign in the event staff were subjected to splashing of bodily fluid while changing the indwelling medical device but did not know why the incorrect signage was posted. A second observation on 4/14/2025 at 11:25 AM identified new signage posted outside of Resident #15 and Resident #70's door stating enteric contact precautions (for fecal infections) with directions that providers and staff must perform hand hygiene before entering the room and wash hands with soap and water after leaving the room, wear gloves whenever entering the room and whenever touching the patients intact skin, surfaces, or articles in close proximity to the resident, wear a gown when entering the room or cubicle and whenever anticipating that clothing will touch the patient or potentially contaminated environmental surfaces, and use patient-dedicated or single use disposable shared equipment or clean and disinfect shared equipment between patients. An interview with LPN #8 on 4/14/2025 at 11:25 AM identified the sign had been changed because the Resident did not have Covid-19. She further identified the precaution sign was being used for Resident #70 and not Resident #15 [although both residents had a history of ESBL]. LPN #8 indicated that precaution signs fall down frequently, and someone must have hung up an incorrect sign in error. LPN #8 failed to identify what the policy or procedure was for precaution signs and stated the only way to know what precaution a resident may be on was through communication during the shift handoff report. An interview with Registered Nurse (RN) #1 on 4/14/25 at 12:55 PM identified precautions for Residents were identified during report and the RN Supervisor and Infection Preventionist (IP) were responsible for alerting staff, bringing out the personal protective equipment (PPE) bin, and hanging the correct precautions sign according to the type of infection. She further identified the IP audited precaution signs to ensure the correct type of precautions required was being implemented. RN #1 indicated the nurse assigned to Resident #70 (LPN #8) should have been aware the sign was incorrect and although the IP was responsible to ensure correct signage was used, she should have alerted the IP he had hung the incorrect precaution sign for Resident #15 and Resident #70. An interview with the Infection Preventionist, RN #2, on 4/15/25 at 2:19 PM identified he was the responsible staff member for placing the correct precaution sign outside a resident's door. He further identified he received a report every morning indicating which residents should be on precautions and performed audits on precaution signs to ensure the correct signage had been placed. RN #2 stated he was made aware earlier by the nurses that an incorrect precaution sign was hanging outside Residents #15 and #70's door and he replaced it with the enteric contact precautions sign that was currently hung. He indicated the reason an incorrect sign was hung may have been because the correct sign fell down. RN #2 did not indicate why enteric precaution sign was used for Resident #15 and #70, but stated when droplet precautions were used the facility placed a report to nurse sign. An interview on 4/16/25 at 5:44 AM with RN #5 identified that there was no process to inform visitors when to use correct PPE [as nurses received during report] when visiting or which resident required the precautions. She further identified she instructed her staff to gown and glove for both residents in a shared room if they saw a precaution sign hung. An interview on 4/16/25 at 9:33 AM with RN #2 identified that visitors should don whatever PPE was listed on the precaution sign before entering a room and if a visitor has any questions they should ask a nurse. Although requested, the facility failed to provide a policy for Enhanced Barrier Precautions, Contact Precautions, or Droplet Precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy for 1 of 2 sampled residents (Resident #37) reviewed for choices, the facility failed to include a resident in the development and implementation of a person-centered Resident Care Plan. The findings included: Resident #37 diagnoses included abnormal posture, spinal instabilities, and pressure ulcer of the sacral region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was cognitively intact, required setup for eating and hygiene, and was dependent on staff for toileting and transfers. The Resident Care Plan (RCP) dated 2/4/25 failed to include resident discharge planning. Interview with the Director of Nurses (DNS) on 4/17/25 at 9:35 AM identified the facility does not currently have an MDS coordinator and the care planning and care plan schedules are created by the DNS, Rehabilitation Department, and social worker. Interview with Resident #37 on 4/17/25 at 9:45 AM identified staff had not discussed discharge home or invited him/her to a RCP meeting or discharge planning meeting even though he/she was ready to be discharged . The April 2025 and May 2025 RCP calendars provided identified care plan meetings scheduled on 4/24/25 and after but failed to identify prior calendars or care plan meeting dates. Interview and review of the Resident Care Conference attendance sheet with the DNS on 4/17/25 at 12:39 PM identified residents were involved in the care planning process by being invited to the quarterly care plan meetings. A review of the care conference signature sheet for Resident #37 failed to identify signatures or meetings after 10/24/24. During an interview with the Administrator on 4/22/25 at 10:33 AM he was unable to identify who was ultimately responsible for care plans and care plan meetings since there was no Director of Social Work and no MDS Coordinator in-house, stating it was a team effort. Interview and care conference calendar schedule review with the MDS coordinator, Licensed Practical Nurse (LPN) #5 on 4/22/25 at 11:47 AM identified his last day as the MDS coordinator was 3/16/25, and he had not trained anyone for the position. LPN #5 identified he was in charge of the care plan conference calendars but could not provide copies of calendars prior to 4/24/25 as there was an issue with the computer, and neither he nor the receptionist had hard copies. Additionally, LPN #5 identified residents had documentation in their progress notes reflecting the invitation to the resident care conference. A review of the progress note dated 10/24/24 at 12:04 PM identified a quarterly care plan meeting was held with Resident #37, Nursing Department and social services. The electronic health record failed to identify any progress notes reflecting Resident #37 had a RCP meeting after 10/24/24. The Comprehensive Person-Centered Care Plan Policy directed, in part, that each resident's care plan will be consistent with the residents right to participate in the development and implementation of the care plan.

Based on interview, review of facility documentation, and facility policy during a Resident Council meeting and review of Resident Council minutes, the facility failed to resolve ongoing issues with dietary, extended call bell wait times, locating staff for assistance, and inappropriate language used by staff. The findings include: Review of the Resident Council minutes for March 2024 through March 2025 identified that residents had dietary concerns in March 2024, May 2024, June 2024, July 2024, September 2024, October 2024, November 2024, December 2024, February 2025, and March 2025. Residents had concerns with staff using foul language in June 2024 and December 2024. Additionally, Residents had concerns with Nurse Aides for answering call bells, cell phone use on the units, breaks being taken at the same time, and the inability to locate staff when needed. During a Resident Council meeting conducted on 4/16/25 at 1:35 PM it was identified that the residents have been complaining about food issues for the past 2 years. Issues included taste, ability to get some items regularly (eggs), temperature, and liquid from vegetables not being drained and running into other items served on the same plate. Further residents identified that call bells were being answered timely while the surveyors were in the building, however 1 resident waited 20 minutes and almost fell, and several residents complained that the call bells were being shut off at the nurses stations. Residents indicated that staff members were using foul language, often could not be found, (indicating a staff member was found sleeping in a cubby) and that the noise level by staff was loud. Interview with the Administrator on 4/22/2025 at 2:48 PM identified that although in-services and monitoring occurred by staff management, he would possibly look into a food committee and that resident concerns should not occur on a continuing basis. Interview with the DNS on 4/22/2025 at 3:10 PM identified that she had conducted observations and had in-services, however, she would look into further measures to assist with resident satisfaction. Review of the Concern, Complaint and/or Grievance policy dated 11/25/2016, directed, in part, that it is the facility's intention to actively seek a resolution to a concern, complaint/grievance.

Based on review of the facility's Personal Funds Account, review of facility policy, and interviews, the facility failed to provide access to personal funds outside of the facilities posted banking hours. The findings include: Observation on 4/22/2025 at 11:00 AM identified a sign posted at the reception desk indicating banking hours were Monday through Friday from 8:00 AM to 7:00 PM, and Saturday and Sunday from 9:30 AM to 3:30 PM. Interview with the Business Office Manager on 4/22/2025 at 11:21 AM identified that residents had access to their personal bank account funds daily from 8:00 AM to 7:00 PM. The Business Office Manager reported that a petty cash lock box was kept at the reception desk to allow residents access to their funds when she was not available. She noted that, aside from herself, three facility receptionists had keys to the petty cash box. The Business Office Manager identified residents were unable to access their personal funds outside of the designated banking hours. Interview with Receptionist #1 on 4/22/2025 at 1:07 PM identified that the facility maintains a petty cash lock box for residents to access funds when the Business Office Manager was unavailable. She indicated that banking hours were Monday through Friday from 8:00 AM to 7:00 PM and Saturday and Sunday from 9:30 AM to 3:30 PM. Any resident requesting funds outside if this timeframe would have to wait until the following day when the receptionist or Business Office Manager were onsite. Interview with the Facility Administrator on 4/22/2025 at 2:57 PM identified that the only staff members who had access to the petty cash lock box were the receptionist and the Business Office Manager. Review of the Statement of Resident's Rights Regarding Personal Funds dated 7/2018 failed to indicate how residents get access to funds after their posted banking hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy for 5 of 5 residents, (Resident #26, #30, #50, and #70), reviewed for Resident Care Planning (RCP), the facility failed to provide documentation that quarterly Resident Care Conferences (RCCs) were held and failed to ensure revisions to the Resident Care Plan (RCP) within 7 days after completion of the resident's comprehensive assessment. The findings include: 1. Resident #26's diagnoses included Parkinson's Disease, dementia, and hypertensive heart disease with heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was dependent with personal hygiene, dressing, and rolling left and right. Review of the MDS assessment dated [DATE] identified Resident #25 required substantial assistance with personal hygiene and dressing, and moderate assistance with rolling left and right. a. The RCP in effect from 11/12/2024 through 4/17/2025 failed to reflect the changes in the amount of assistance Resident #26 required with Activities of Daily Living (ADL). b. A review of the RCC sign in sheet failed to identify that a Resident Care Conference (RCC) was held following the 1/29/25 MDS assessment. An interview with Social Worker #1 on 4/16/2025 at 10:43 AM identified Resident #26's RCP was last completed on 12/10/2024 and he/she should have received a quarterly RCP in March, 3 months from the 12/10/2024 date. She further identified that the MDS coordinator was responsible for scheduling RCP updates. Social Worker #1 failed to identify why an RCP was not completed for Resident #26 in 2025. Attempts to schedule an interview with the MDS coordinator were unsuccessful as the facility had only remote MDS Coordinators, and no permanent MDS Coordinator in the facility. An interview with the Director of Nursing Services (DNS) on 4/16/2025 at 1:56 PM identified that Resident #26's last care plan meeting was 11/12/2024 and his/her care plan meetings were not being held on a quarterly basis. The DNS further identified no care plan had been completed for Resident #26 after 12/10/2024. The DNS failed to identify why RCCs were not being held on a quarterly basis and why no RCP had been completed in 2025. 2. Resident #30's diagnoses included epilepsy, left sided hemiplegia, and chronic obstructive pulmonary disease. a. The admission MDS assessment dated [DATE] identified Resident #30 had a Brief Interview of Mental Status (BIMS) score of 13 indicating no cognitive impairment, required moderate assistance with upper body dressing and moving from a sitting to lying position, and was dependent with transfers. The quarterly MDS assessment dated [DATE] identified Resident #30 had a Brief Interview of Mental Status (BIMS) score of 13 indicating no cognitive impairment, required maximal assistance with upper body dressing and moving from a sitting to lying position, and was dependent with transfers. a. The RCP in effect from 7/7/2023 through 4/17/2025 failed to reflect the RCP had been revised to include the changes in the amount of assistance Resident #30 required with Activities of Daily Living (ADL). b. A review of the RCC sign in sheets failed to identify that although Resident #30 had MDS assessments on 12/20/2024 and 3/21/2025 that a meeting was held following the assessment or anytime during 2025. An interview with Social Worker #1 on 4/16/2025 at 10:43 AM identified Resident #30's did not have an RCP completed in 2025 and prior RCPs were not consistently completed within 7 days of his/her MDS submission. Further, she identified the MDS coordinator was responsible for scheduling RCP updates. Social Worker #1 failed to identify why an RCP was not completed for Resident #30 in 2025. 3. Resident #50's diagnoses included atherosclerotic heart disease with angina pectoris, chronic obstructive pulmonary disease, and major depressive disorder. a. The quarterly MDS assessment dated [DATE] identified Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was independent with upper and lower body dressing, moving from a sitting to lying position, and wheeling 150 feet in a manual wheelchair. The quarterly MDS assessment dated [DATE] identified Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required touching assistance with upper body dressing and moving from a sitting lying position, required moderate assistance with lower body dressing. The RCP in effect from 2/28/2023 through 4/17/2025 failed to reflect the RCP had been revised to include a review and revision to cardiac status and failed to include changes in the amount of assistance Resident #50 required with Activities of Daily Living (ADL). b. A review of the RCC sign in sheets for the time period of 1/1/2024 through 4/17/2025 identified RCP meetings for Resident #50 were held on 2/1/2024, 7/26/2024, 11/4/2024, and 2/20/2025. A review of MDS submissions for Resident #50 identified that MDSs were completed on 2/21/2024, 3/29/2024, 4/25/2024, 7/24/2024, 10/21/2024, and 1/27/2025. An interview on 4/22/2025 at 3:08 PM with Social Worker #2 identified that RCPs should be completed between 7 to 10 days after the MDS was completed. She further identified that although an RCP was completed on 5/9/24 (not within the allotted time), the facility failed to meet the requirement for RCP meetings for 6 out of 7 opportunities (2/21/2024, 03/29/2024, 4/25/2024, 7/24/2024, 10/21/2024, and 1/27/2025). 4. Resident #70's diagnoses included multiple sclerosis, depression, and chronic pain. a. The admission MDS assessment dated [DATE] identified Resident #70 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was dependent with lower body dressing, and was dependent on staff wheeling 150 feet in a manual wheelchair. The quarterly MDS assessment dated [DATE] identified Resident #70 had a BIMS score of 15 indicating no cognitive impairment, required substantial assistance with lower body dressing, and required partial assistance with wheeling 150 feet in a manual wheelchair. The RCP in effect from 4/9/2024 through 4/17/2025 failed to identify that a review and revision of the care plan related to multiple sclerosis and changes in the amount of ADL assistance required by Resident #70 had been completed since admission. b. A review of MDS submissions for Resident #70 identified that MDSs were completed on 6/6/2024, 9/12/2024, 10/3/2024, and 12/31/24. A review of social service progress notes for the time period of 4/1/2024 through 4/17/25 identified RCP meetings for Resident #70 were held on 7/17/2024, 9/12/2024, and 12/6/2024 but failed to meet the time requirement for RCP meetings. The RCC sign in sheets for the time period of 4/1/2024 through 4/17/2025 were requested, however, the facility failed to provide the requested sign-in sheets. An interview on 4/22/25 at 11:47 AM with the former MDS coordinator LPN #5 identified he was responsible for sending a list of Residents needing an RCC and RCP to the social worker and receptionist for scheduling off of a calendar he created. LPN #5 failed to produce a copy of any past calendar for RCC and RCP scheduling and indicated he erased the calendar from his computer at the end of every month. An interview with Social Worker #2 on 4/22/2024 at 3:08 PM identified that there was a facility expectation for RCPs to be revised the same day a resident has a RCC, although quarterly revisions instead are often made the same week, no later than 10 days, but should be completed between 7 to 10 days after a MDS was completed. She further identified RCPs were completed for Resident #70 on 4/9/2024, 7/19/2024, 10/16/2024, and 1/4/2025 and that the facility failed to meet 3 out of 4 opportunities (6/6/2024, 9/12/2024, 10/3/2024) for timely RCP completions. Review of the Facility's Comprehensive Person-Centered Care Plan Policy identified in part that care plans should incorporate identified problem areas, and aid in preventing or decline in a Resident's functional status and/or functional levels. The policy further identified that comprehensive person-centered care plans should be developed within 7 days of a Resident's completed MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy for 2 of 2 residents (Resident#37 and #50) reviewed for choices, the facility failed to provide medically related social services to facilitate discharge. The findings included: 1. Resident # 37 diagnoses included abnormal posture, spinal instabilities, and pressure ulcer of the sacral region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was cognitively intact, required setup for eating and hygiene and was dependent on staff for toileting, and transfers. Additionally, the MDS identified Resident #37's overall goal was to return to the community and active discharge planning already occurred. The Resident Care Plan dated 2/4/25 failed to identify a discharge plan. Interview with Resident #37 on 4/14/25 at 9:53 AM identified that he/she was waiting for a representative from Money Follows the Person (MFP), (a federal Medicaid program designed to help individuals transition out of nursing homes into home and community-based settings), to see him/her tomorrow so he/she could get back to the community. Interview with Social Worker #1 on 4/16/25 at 12:38 PM identified she was not versed in Money Follows the Person (MFP) because her supervisor oversaw that process. Social Worker #1 indicated that since her supervisor left, [the previous social workers last day was 3/28/25], the facility did not have a Director of Social Work. Additionally, she identified the Rehabilitation Department was helping with discharges since she was only in the facility for 8 hours a week. Social Worker #1 could not identify any discharge plans for Resident #37, or if he/she had MFP. Interview with the Administrator on 4/16/25 at 12:42 PM identified the facility policy for residents with MFP was to have the social worker follow them and assist with the process. Additionally, he identified the new social worker was starting 4/24/25 and until then the facility was pulling it together between the different departments, and he was not aware of any discharge plans for Resident #37. Interview with the Director of Rehabilitation on 4/16/25 at 1:48 PM identified Resident #37 was waiting for MFP, and was highly motivated to be discharged into the community but could not identify if a discharge plan was initiated since the facility did not have a social worker. Interview with Resident #37 on 4/17/25 at 9:45 AM identified no one had spoken to him/her about going home or invited him/her to meetings about discharge planning even though he/she was ready to go bacl to the community, and aside from setting up housing there was nothing keeping him/her in the facility. Additionally, Resident #37 identified that the case worker from MFP was supposed to come see him/her on 4/15/25 but never showed up for the meeting. Interview with the Community Care Case Manager for MFP on 4/17/25 at 12:19 PM identified Resident #37's application was started 3/9/25, a case worker was supposed to come out 4/15/25, for the initial assessment but rescheduled to 4/24/25 and a message had been left with the receptionist due to the facility's lack of a social worker. Interview with the DNS on 4/17/25 at 12:39 PM identified she was not aware Resident #37 was highly motivated to be discharged , not aware of any MFP visits set up or rescheduled visits, identifying it was the responsibility of the social worker to follow up and it was missed due to lack of communication. Interview with the Administrator on 4/22/25 at 10:33 AM identified that in the absence of a Director of Social Work he was stepping in, even though he had a bachelor's degree in business administration and not in social work. Additionally, he identified there was a social worker in the facility one day a week but residents with MFP were falling through the cracks. Follow up interview with Resident #37 on 4/22/25 at 12:06 PM identified that although the MFP case worker had notified the facility that Resident #37's meeting was to be rescheduled, he/she had never been notified about the rescheduled MFP appointment, and no one in the facility had been speaking to him/her regarding discharge. 2. Resident #50's diagnoses included atherosclerotic heart disease with angina, chronic obstructive pulmonary disease, and major depressive disorder. The Resident Care Plan (RCP) dated 7/15/2024 identified Resident #50's discharge planning included working with Money Follows the Person (MFP) to return to the community. Interventions included collaborating with the Interdisciplinary Team (IDT), resident, and family to collaborate on a plan, goals, and progress, and to set up home care as ordered. The quarterly MDS assessment dated [DATE] identified Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was independent with upper and lower body dressing and chair/bed to chair transfers and required touching assistance when walking 150 feet. An interview with Resident #50 on 4/14/2025 at 10:42 AM identified he/she wanted to discharge from the facility using the MFP program and was informed by the facility there was no one that could assist with his/her request. An interview on 4/16/2025 at 2:15 PM with the Director of Nursing Services identified she was not aware Resident #50 wanted to use the MFP program and stated she would look into Resident #50's request. Subsequent to surveyor inquiry, on 4/19/2025 at 11:56 AM, a facility representative spoke with Resident #50, and he/she relayed the location to where he/she wished to be discharged . An interview on 4/22/2025 at 1:43 PM with the Regional Clinical Registered Nurse (RN) #6 identified she was not aware of what the process was when a Resident had an MFP request but identified Social Work should be responsible for all MFP requests. RN #6 further indicated the facility had no MFP policy. An interview with the Administrator on 4/22/25 at 10:33 AM identified he was aware that staff was not assisting residents with MFP requests due to being short staffed, and stated it is falling through the gap. An interview with Social Worker #2 on 4/22/2025 at 1:45 PM confirmed there was no MFP policy and identified social workers would assist residents with identifying if they would benefit from MFP and assisting them with filling out the paperwork. Further she identified that once social work mailed a resident's paperwork to MFP a scheduler would call within a couple of days to arrange a meeting, after which the social worker met with the MFP Case Manager. Social Worker #2 identified the facility received notification in November of 2024 that Resident #50 needed to submit a voucher to MFP, but the facility failed to assist him/her in sending the voucher and instead informed the resident there was no housing manager at the facility to help him with MFP. Social Worker #2 failed to identify why social work had not assisted Resident #50 with his/her discharge request. The facility did not have a policy on Money Follows the Person discharges. The Process for Discharge policy directed, in part, that social services set up services and developed a discharge care plan (in the absence of social services, nursing, or MDS was to fill in). The social worker job description identified duties and responsibilities included in part, participating in discharge planning, development of social care plans and resident assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy for medication storage and labeling, the facility failed to ensure medication carts were locked when unattended and narcotics were secured properly. The findings include: 1. An observation on 4/14/2025 at 10:00 AM identified an unattended and unlocked medication cart outside the door of room [ROOM NUMBER] in the hallway. Two unsupervised residents were in the hallway, 1 resident rolled past the unlocked cart in his/her wheelchair. An interview with Licensed Practical Nurse (LPN) #1 on 4/14/25 at 10:13 AM identified that she forgot to lock the medication cart before entering a different room to provide routine care for a resident because she was rushing. She indicated she was aware of the facility policy to lock medication carts when not in use, not in view, and unattended. 2. An observation on 4/14/2025 at 11:22 AM identified an unattended and unlocked medication cart and an unattended and unlocked treatment cart in the Frog Lane hallway. An observation of the treatment cart with LPN #1 identified that multiple Resident prescription and non-prescription medications were in the unlocked treatment cart. An interview with LPN #1 on 4/14/2025 at 11:22 AM identified that she forgot to lock both carts after use. She further identified that she was aware of the facility policy to lock medication carts and treatment carts when not in use, not in view, and unattended. 3. An observation on 4/15/2025 at 8:04 AM identified the Frog Lane treatment cart was unlocked. One resident was present in the hallway. An inspection of the Frog Lane treatment cart drawers with LPN #2 identified nystatin and other resident medications present in the cart but there were no narcotics. An interview with LPN #2 on 4/15/2025 at 8:04 AM identified that she just got to the facility and should have locked the cart. She further identified that she was aware of the facility policy to lock medication carts and treatment carts when not in use, not in view, and unattended. 4. An observation on 4/16/2025 at 5:15 AM identified the Frog Lane medication cart was unlocked. One resident was watching tv in the activity room and there were no residents in the hallway. An interview with LPN #6 identified that she forgot to lock the cart. She further identified that she was aware of the facility policy to lock medication carts when not in use, not in view, and unattended. 5. An observation on 4/16/2025 at 5:23 AM identified the second floor [NAME] medication cart was unlocked. There were no residents in the hallway. An interview with Registered Nurse (RN) #5 identified that many nurses don't lock the carts and [although this was not observed by the surveyor], indicated nurses keep keys to the medication carts in the cart itself. She further stated that there had not been a recent in-service provided to nurses locking medication carts when leaving them unattended. She identified that she was aware of the facility policy to lock medication carts when not in use, not in view, and unattended. RN #5 failed to identify a reason why the second floor medication cart was left unattended and unlocked. 6. An observation on 4/16/2025 at 5:41 AM identified the [NAME] Road medication cart was unattended and unlocked. Four unidentified pills were on top of the cart in a white medication cup. No residents were near the [NAME] Road medication cart. An interview with RN #5 identified that the cart was unlocked and should be locked per policy. Subsequent to surveyor inquiry the medication cup with the unidentified medications was placed into the medication cart and locked. 7. An interview with the Director of Nursing Services (DNS) on 4/16/2025 at 2:18 PM identified that it was permissible for medication carts to be unlocked if a nurse has visual contact with the cart, but once a nurse walked away, the cart should have been locked. The DNS indicated that nurses do receive education on locking medication carts. Subsequent to surveyor inquiry the DNS stated she will add the issue of unlocked medication carts to a QAPI plan and perform audits. Review of the facility's Medication Administration Policy identified in part that keys to the medication carts should be in the possession of the nurse at all times, carts are never to be left unattended in resident care areas, and when not in full view and in control of the nurse the cart, must remain locked.

Based on review of facility documentation, facility policy and interviews for 4 of 5 employee files, the facility failed to ensure that the mandatory employee training/in-services were completed. The findings include: 1. LPN #1's date of hire was 11/11/2021. Review of facility documentation for LPN #1 identified that she worked in the facility between 11/11/2021 and 4/22/25. Review of the employee file for LPN #1 failed to identify that in-service training had been provided (Resident Rights, Communication and Behavioral Health) and included in the files from 2023 until present. 2. NA #1's date of hire was 8/8/2019. Review of facility documentation for NA #1 identified that she worked in the facility between 8/8/2019 and 4/22/25. Review of the employee file for NA #1 failed to identify that in-service training had been provided (Resident Rights, Communication and Behavioral Health) and included in the files from 2023 until present. 3. NA #3's date of hire was 10/11/2023. Review of facility documentation for NA #3 identified that she worked in the facility between 10/11/2023 and 4/22/25. Review of the employee file for NA #3 failed to identify that in-service training had been provided (Resident Rights, Communication and Behavioral Health) and included in the files from 2023 until present. 4. NA #4's date of hire was 11/23/2020. Review of facility documentation for NA #4 identified that she worked in the facility between 11/2020 and 4/22/25. Review of the employee file for NA #4 failed to identify that in-service training had been provided (Resident Rights, Communication and Behavioral Health) and included in the files from 2023 until present. Although requested, the facility could not provide documentation that current required trainings (mandatory inservices) had been completed for LPN#1, NA#1, NA#3 and NA#4. Interview and review of facility documentation with the Staff Development RN (RN #2) on 4/22/25 at 1:20 PM identified that required in-service trainings are provided upon hire and annually. RN#2 was unable to provide current documentation for the mandatoryt annual in-service training for LPN #1, NA #1, NA #3 and NA #4. RN #2 indicated that it was his responsibility to ensure the required in-service trainings were completed, documented, and placed in the employees' files for review. Interview and review of facility documentation with the Director of Nurses (DNS) on 4/22/25 at 2:30 PM identified that she was unable to locate the current mandatory annual in-service training documentation for LPN #1, NA#1, NA#3 and NA#4 and identified that RN#2 was responsible for ensuring that employees required in-service trainings were completed, documented, and placed in the employees' files. The DNS identified it is facility policy that staff complete the required in-service trainings upon hire and annually and that she and RN #2 would work on them. Although requested, facility's policy on employees' in-service trainings was not 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 #2) reviewed for abuse, the facility failed to ensure staff removed smoking paraphernalia in a resident's possession timely when a resident was found in possession of smoking paraphernalia including lighters. The findings include: Record review identified Resident #2 was admitted to the facility during 11/2023 and responsible for him/herself. Resident #2's diagnoses included anxiety, depression and nicotine dependence. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 2 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment, was supervision for ambulation, and independent with manual wheelchair use. The Resident Care Plan (RCP) dated 11/8/2024 identified Resident #2 was a recent smoker and declined use of a nicotine patch. Interventions directed facility smoking policy, smoking assessment as needed, and all smoking materials kept by nurse in secured cart. A nursing note dated 11/22/2024 at 10:22 PM by RN supervisor identified the resident was seen making his/her way towards the front door of the facility, a nurse's aide (NA) followed and found the resident outside smoking. Resident #2 put the cigarette out when he/she saw the NA and returned inside the building. The resident's LPN was informed of situation. Record review failed to identify that staff took possession of the cigarette and lighter device. A nurse's note dated 11/23/2024 at 5:47 PM identified Resident #2's family found two (2) lighters in the resident's room and the supervisor was notified. Interview, and record review with SW #1 on 12/2/2024 at 12:49 PM identified the facility was a non-smoking facility. Resident #2 had a history of going outside of the facility to smoke to look for cigarette butts, and of bringing smoking paraphernalia into the non-smoking facility. Interview and clinical record review with RN #1 on 12/2/2024 at 2:01 PM identified on 11/22/2024 she was the supervisor when Resident #2 was followed by nurse aide (NA) #5 who observed the resident outside the building smoking, she further indicated that she was not notified until later in the shift and she did not confiscate smoking paraphernalia from the resident. Interview failed to identify why she did not confiscate, or request the resident to give her the smoking paraphernalia. Interview with LPN #1 on 12/2/2024 at 2:31 PM identified she was the charge nurse on 11/22/2024 during the 3 to 11 PM shift and RN #1 supervisor notified her on 11/22/2024 that Resident #2 was found outside smoking by a NA. LPN #1 stated she was not directed to search for any smoking paraphilia. On 12/2/2024 at 2:43 PM interview with NA #5 identified that on 11/22/2024 she followed Resident #2 when she noticed he/she was headed outdoor. NA #5 stated she observed Resident #2 self-propelling out the door in his/her wheelchair, and she followed him/her outside. She observed Resident #2 light a cigarette as he/she was rolling in the wheelchair, and that the resident put it out when she approached him/her. Interview failed to identify what Resident #2 used to light the cigarette, or if he/she had any additional cigarettes. NA #5 stated she did not take away the smoking items and the resident returned inside the building, and she then notified the RN supervisor. Interview failed to identify why she did not request Resident #2 to give her the smoking paraphernalia. Interview, clinical record review, facility documentation review with DNS and Administrator on 12/2/2024 at 3:13 PM identified the facility was a smoke-free facility, and the State Agency was not notified when Resident #2 was found in possession of smoking paraphernalia, including two (2) lighters. Interview identified Resident #2 was observed smoking independently outside on 11/22/2024, and the resident's family found two lighters in the resident's room on 11/23/2024. The DNS stated she was not aware, and the staff should have conducted a room search when the resident was observed smoking on 11/22/2024. Interview identified staff should have confiscated the smoking paraphernalia on 11/22/2024 when they observed Resident #2 smoking. Review of facility documentation identified, as of 9/2023, the Facility was a smoke-free 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 one (1) of three (3) residents, (Resident #1), reviewed for falls, the facility failed to complete an assessment on a resident who had a fall with a subsequent injuries. The findings include: Resident #1's diagnoses included dementia without behavioral disturbances, anxiety, syncope and collapse, transient cerebral ischemic attack (stroke), atrial fibrillation (irregular heart rate) and unsteadiness in the feet. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and required supervision for bed mobility, moderate assistance for transfers and was dependent with toileting. Additionally, it identified that the resident had a history of falls prior to admission to the facility. The Resident Care Plan dated 12/12/23 identified that Resident #1 was a fall/safety risk with interventions that included keeping the call bell within reach, encouraging the use of the call bell, ensuring that appropriate footwear is worn, keeping the bed in the lowest position, observing for alterations in gait and maintaining a clutter free environment. A nurse's transfer form dated 12/13/23 at 2:56 PM identified that Resident #1 was transferred to the hospital due to a fall. Review of nurses' notes dated 12/13/23 failed to identify any documentation regarding a fall or a completed assessment post fall. Review of the post-fall evaluation dated 12/13/23 identified the form to be blank with no documentation. Review of the facility reportable event documentation dated 12/13/23 identified that the resident had a fall at 3:00 PM that day and was complaining of head and left hip pain. Statements were obtained from LPN #3, NA #3, NA #4, NA #5 and NA #6. A statement from RN #3 (Nursing Supervisor) were not available. Review of statement from NA #5 identified that the family requested that Resident #1 be put to bed towards the end of the 7:00 AM to 3:00 PM shift. She identified that she toileted the resident at 2:33 PM and he/she had a bowel movement, and then put him/her back to bed. Resident #1 then requested ice cream and she provided it to him/her with assistance. She stated that shortly after, she was charting, and NA #4 called her requesting assistance because Resident #1 was on the floor. She indicated that RN #3 came into the room and ordered them to get the resident off the floor and cleaned up and then put back to bed before emergency services arrived. She identified that it took 3 NA's to transfer the resident and that he/she was complaining of pain in his/her left hip. Interview with NA #4 on 7/30/24 at 2:06 PM identified that she was present in Resident #1's room after he/she fell and reported that when RN #3 came in, she chit chatted with him/her for only a minute or so and did not assess the resident for injuries, but told the staff (NA #3, NA #4, NA #5 and NA #6) to get the resident up to the toilet and cleaned up, stating that he had a bowel movement. She indicated that RN #3 then left the room to call the provider. She reported that they listened to RN #3 because she was in charge, but that the resident was very difficult to get off the floor and it took 3 or 4 people to get him up and into the wheelchair. She then identified that they put him on the toilet and when they went to get him off he wouldn't stand at all and was yelling in pain. Per the direction of RN #3, they then put the resident in bed to wait for emergency services to arrive. Interview with NA #3 on 7/30/24 at 2:08 PM identified that RN #3 did not assess Resident #1 after the fall on 12/13/23. She indicated that RN #3 came in the room and talked to the resident briefly and then told them (NA #3, NA #4, NA #5 and NA #6) to get him/her up off the floor and toileted. She indicated that when they first put the resident in the wheelchair it was difficult, but the resident seemed okay. When they got him/her on and off the toilet, he/she started yelling out and appeared to be in pain also grabbing their left side. She reported that as they were standing him/her, their body limped out and they struggled to get him/her back into the wheelchair and then in the bed, as it took 3 people to stand and transfer him/her. Interview with NA #6 on 7/30/24 at 2:16 PM identified that he was just coming on to his shift when the staff requested his assistance in Resident #1's room. He identified that Resident #1 was lying on the floor and RN #3 came in the room but was just there briefly and then they were told to just get him up and on the toilet. He identified that the resident had stooled all over and that he/she was dead weight and it required 3 people to get him/her up and transfer them to the wheelchair, then to the toilet, then back to the wheelchair, and then into bed. He stated he remembered the resident yelling and he/she appeared to be in excruciating pain every time they moved him, favoring one side. Interview with RN #3 on 7/30/24 at 1:18 PM identified that she directed the NA's to clean up Resident #1 post fall on 12/13/23 because he was soiled, but could not recall if she had directly told them to keep him/her on the floor or get them up. She reported that when she first walked in the resident's room, he/she was on their left side, and she remembered he/she had complained of back pain but that his/her cognition was off and could not remember if she had done a complete assessment. She indicated that the assessment should have been documented in the post fall assessment and a progress note and she was unsure why it was not done. Interview and clinical record review with the DNS on 7/30/23 at 12:56 PM identified that the clinical record failed to reflect documentation indicating that an assessment was completed on Resident #1 after the fall occurred on 12/13/23. She identified that after a fall, the RN is responsible for assessing the resident for any injuries or abnormalities and reporting off to the provider of their findings. She indicated that the resident should not be moved until the resident is assessed. If the resident is complaining of pain or any has any abnormalities, they should stay in that position until the provider gives direction and/or emergency services arrives. She identified that they are responsible for documenting their assessment in the post fall evaluation, which then triggers a progress note to be written. She identified that recently due to system changes, nurses can sign the evaluations without them being completed so they need to come up with a process to check the evaluations for completeness. She indicated that they currently review their Accident and Investigations (A & I) at the At-Risk meetings that are held weekly on Thursday ' s, as well as in morning report, but was unsure why the documentation and assessment on the 12/13/23 A & I for Resident #1 was incomplete. Although attempted, LPN #3 and NA #5 could not be reached for interview. Review of hospital documentation dated 12/13/23 identified that Resident #1 had sustained a left hip intertrochanteric fracture. Review of the Prehospital Care Report (ambulance run sheet) dated 12/22/23 identified that Resident #1 was found to have an intertrochanteric fracture of the left femur and underwent an Open Reduction and Internal Fixation (ORIF) surgery. It also reported that he/she has had a significant decline over the duration of the hospital admission and was discharged home with hospice services. Review of the Change in a Resident's Condition or Status policy dated 8/2017 directed, in part, that prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provide, including information prompted by the Interact SBAR Communication Form. The Charting and Documentation policy dated 3/2023 directed, in part, that documentation of procedures and treatments will include care-specific details, including: The date and time the procedure/treatment was provided, the name and title of the individual who provided the care, the assessment data and/or any unusual findings obtained during the procedure/treatment, how the resident tolerated the procedure/treatment, whether the resident refused the procedure/treatment, notification of family, physician or other staff, and the signature and title of the individual documenting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation and interviews for one (1) of three (3) residents reviewed for falls (Resident #2), the facility failed to supervise a resident in the bathroom who was cognitively impaired and required assistance, resulting in a fall with injury. The findings include: Resident #2's diagnoses included dementia without behavioral disturbances, a history of transient ischemic attack and cerebral infarction (stroke), muscle weakness and unsteadiness on feet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was moderately cognitively impaired and required extensive assistance of two (2) for bed mobility, transfers, toileting and personal hygiene. Additionally, it indicated that the resident had a history of falls, one of which resulted in a major injury in the facility. The Resident Care Plan dated 5/3/21 identified that Resident #2 was at risk for falls due to impaired mobility, incontinence and impaired safety awareness with interventions that included ensuring that appropriate footwear was worn, reminding and encouraging the use of the call bell, keeping frequently used items within reach, and a physical therapy screen as indicated. A physician's order dated 6/7/21 directed that Resident #2 was an assist of 1 with the grab bar or bed rail for all transfers. Review of the Resident Care Card (RCC) dated 4/19/21 identified that Resident #2 was a fall risk, had a low bed, and required a 1 person assist for transfers, ambulation, bathing, dressing, grooming and eating. Additionally, it identified that the resident had poor safety awareness. Review of the Fall Risk assessment dated [DATE] identified that Resident #2 was a high fall risk, indicating that the resident had intermittent confusion, had one (1) to two (2) falls in the past three (3) months, was chair bound and required assistance with elimination and required the use of an assistive device. A post fall evaluation note dated 6/19/21 at 2:07 AM identified that the nursing shift supervisor conducted a post fall assessment, that indicated that the resident continued to exhibit poor safety awareness. The Nurse Aide on duty left the resident in the bathroom and instructed the resident to use the call light or yell out for assistance when h/she was done. The NA heard a thump and found the resident on the bathroom floor. The resident sustained a laceration to the left side of his/her occipital lobe (the back of the head) and the resident was sent to the hospital by ambulance. A post fall progress note dated 6/19/21 at 2:53 PM identified that on 6/18/21 at 9:40 PM Resident #2 was observed by facility staff on his/her right side on the bathroom floor, the resident had self-transferred off the toilet resulting in the fall. Subsequent to the fall, the resident sustained a 2-centimeter laceration to the right occipital lobe, and the RN along with 3 other staff transferred the resident off of the floor with a gait belt. The note identified that the provider was notified, and staff received an order to transfer the resident to the hospital, where it was determined that the resident sustained an acute L1 fracture (first vertebra of the lumbar spine). Review of the facility reportable event documentation dated 6/18/21 identified that Resident #2 had a fall in his/her bathroom at approximately 9:40 PM. NA #1 toileted the resident and then proceeded to wait outside the resident's bathroom providing privacy. NA #2 heard a thump and then found the resident on the floor. Interventions tput into place after the fall included reminding the resident to call for assistance and staff education was provided on requiring a female NA to always be present within the bathroom when the resident is toileting. Review of the hospital discharge paperwork dated 6/19/21 identified that Resident #2 sustained an acute compression fracture of L1 and was transferred back to the nursing facility. Review of the facility schedule for 6/18/21 on the 3:00 PM to 11:00 PM shift when the fall occurred identified RN #2 was the nursing supervisor and the staff on the first floor (Resident #2's unit) included LPN #1, LPN #2, NA's #1, NA #2 and NA #7. Interview with NA #1 on 7/20/24 at 10:30 AM identified that he had brought Resident #2 to the bathroom and he/she had requested privacy so he stepped out into the bedroom leaving the bathroom door slightly ajar. He indicated that even though the resident required assistance with toileting, he/she had the right to privacy so he directed the resident to pull the bathroom alarm or call out when he/she was ready to get up and that he would stand outside and come assist. He identified that he checks the care card in the room prior to giving care but could not recall the details of this resident and if he/she had impaired cognition. He indicated that when the resident asked him to step out, he thought it was okay to do so because he was right outside the door. He reported that after the resident fell, he stayed with the resident and called out for help and the nurse came and then sent the supervisor and the other NA's for assistance. Interview with NA #2 on 7/30/24 at 11:13 AM identified that NA #1 had not requested any assistance with Resident #2 prior to the fall that she could recall. She indicated that if a resident is an assist of 1 she does not leave the resident alone in the bathroom. Although attempted RN #2, LPN #1, and LPN #2 could not be reached for an interview. Interview with the DNS on 7/30/24 at 11:27 AM identified that she was not the DNS at the time of the incident, but that NA #1 should have looked at the care card for the resident prior to providing any care on him/her. She indicated that if the resident requested privacy and he knew that he/she was an assist of 1, he should have called the nurse for assistance and notified her prior to leaving the resident in the bathroom unattended. Interview with COTA #1 (Rehab Director) on 7/30/24 at 1:14 PM identified that any resident requiring any level assistance should not be left attended and should be within arm's reach. She indicated that it was not appropriate for NA #1 to be outside of the bathroom door when Resident #2 was on the toilet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #3 and 62) reviewed for dignity, the facility failed to ensure dignified care related to dining and urinary catheters. The findings include: 1. Resident #3 was admitted to the facility with diagnoses that included dysphasia, Parkinson's disease, and dementia. Facility documentation dated 10/5/22 identified Resident #3 weighed 118.6 lbs. Facility documentation dated 1/1/23 identified Resident #3 weighed 108.2 lbs. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition and was totally dependent on staff for eating. The care plan dated 2/28/23 identified to provide the resident a nosey cup (adapted drinking cup) for all meals, 1:1 feeding assistance, encourage at least 50% intake of meal and offer substitute if the resident doesn't eat greater than 50%. Review of the nurse aide care card, undated, for Resident #3 identified the resident required a puree diet and to use a nosey cup for each meal. Observation on 3/6/23 at 12:15 PM identified the nurse aide delivered a meal tray to Resident #3 in his/her room and placed the meal on the overbed table near the window. The meal tray was in Styrofoam products. There was a square container with lid for the main meal, 2 Styrofoam cups with disposable plastic lids for drinks and a magic cup for dessert. Although the meal ticket identified the resident required a nosey cup, it was not on the meal tray. At 12:45 PM NA #2 entered the room without the benefit of hand sanitizing or washing her hands and moved the overbed table in front of the resident and opened the square container that had a scoop of puree meat, a scoop of puree vegetable, and a scoop of potatoes covered in gravy. NA #2 immediately mixed all 3 food items together without asking Resident #3 if that was his/her preference. NA #2 opened the cup of juice and instructed Resident #3 to open his/her mouth for a sip and held the cup for Resident #3. NA #2 began feeding Resident #3 a spoonful of the food mixture. The observation identified NA #2 did not get a nosey cup or heat up the food prior to feeding Resident #3. Interview with NA #2 on 3/6/23 at 12:54 PM indicated she always mixes all of Resident #2's food together so Resident #2 could get all the food in one bite. NA #2 indicated she wanted to make sure the resident received a little bit of each type of food in each bite. NA #2 indicated she did not know if Resident #3 wanted all the food mixed together because Resident #3 was not able to tell her. NA #2 noted no one had instructed her to mix all the food together to feed Resident #3. NA #2 indicated she did not want to feed Resident #2 all the meat then resident may not want anymore and would not get any of the vegetables or potatoes. NA #2 indicated she did not know what the policy was and did not recall if the facility had done education with her in the past regarding feeding of residents. Review of the meal ticket with NA #2 indicated she was not aware Resident #3 required a nosey cup. Upon surveyor request, the Dietary Supervisor took the temperature of the resident's food. Interview with Dietary Supervisor on 3/6/23 at 1:00 PM identified she took the temperature of Resident #3's mixed food, and it was almost 100 degrees F. Resident #3 had been provided 3 bites of the food prior to testing the temperature of the food. The Dietary Supervisor indicated the temperature should be approximately 120 degrees F when placed in front of resident to begin eating, it should not be 100 degrees. The Dietary Supervisor the Styrofoam does not hold the temperature that well and after sitting in the room for so long it was no longer hot. Interview with LPN #1 on 3/6/23 at 1:10 PM indicated the food should not be mixed together and NA #2 should have given separate spoonsful of food at a time to Resident #3. Interview with the Infection Control Nurse, (RN #2), on 3/13/23 at 10:39 AM indicated before feeding a resident, the nurse aide should complete hand hygiene. The nurse aide should feed slowly and give time to swallow, even with puree food, and for Resident #3 a drink in between each bite. RN #2 indicated the nurse aide should alternate the spoonful of food alternating each type of food between each drink for a variety of food. RN #2 indicated if the resident wanted the food mixed together it would be care planned and it was not care planned for Resident #3 so the expectation would be the nurse aide would alternate each bit of food. RN #2 indicated the foods should not be mixed all together. RN #2 indicated he did not recall the last time the nurse aide received education about feeding residents. Interview with the Director of Rehabilitation, (OTR #1) on 3/13/23 at 11:14 AM indicated residents that need to be fed should be given one spoonful at a time alternating with a sip of liquid. OTR #1 noted the food should never be mixed together unless a resident specifically asks for it that way. OTR #1 indicated Resident #3 should have received the nosey cup because Resident #3 can be independent or with a little assistance initially can be independent with liquids. Interview with the DNS on 3/13/23 at 2:10 PM indicated the tray should stay on the cart until the nurse aide is ready to feed Resident #3 keeping the food hot. The DNS noted Resident #3 could not inform the nurse aide whether or not he/she wanted all the food mixed together so the expectation was the nurse aide would give one bite of food at a time and not mix the food all together. The DNS indicated the nurse aide should be alternating a bite of food with liquids. The DNS indicated there had been an outbreak, and during the outbreak no one had discussed whether to use adaptive equipment. The DNS noted it would be a risk vs benefit when dealing with an outbreak, but you want the residents to be as independent as possible. Review of the Feeding a Resident Meals Policy identified trays are delivered in meal trucks to each unit. Residents unable to feed themselves are fed by all properly trained personnel. Residents are instructed by the nursing and occupational departments in the use of assistive devices. Nursing personnel check food for appropriate content, texture, and temperature. Trays are arranged to assist residents to feed themselves when possible. Residents' incapable of feeding themselves are fed. When feeding a resident, hands are to be washed for the resident and staff member. Feed resident slowly from tip of fork or spoon. Encourage resident to choose the order of food eaten, when possible. 2. Resident #62 was admitted to the facility with diagnoses that included obstructive and reflux uropathy, and neoplasm of the bladder. The care plan dated 10/27/22 identified the resident had a chronic urinary catheter related to obstructive uropathy with interventions that included to change the urinary catheter and bag per physician order. The significant change MDS dated [DATE] identified Resident #62 had severely impaired cognition and utilized a urinary catheter. Observations on 3/6/23 at 10:10 AM and 12:12 PM identified Resident #62 was lying in bed and the urinary catheter bag contained urine and was hanging on the bed frame visible from hallway. The urinary catheter drainage bag was without the benefit of a privacy cover. Interview with LPN #1 on 3/6/23 at 12:13 PM indicated the urinary drainage bag was visible from the hallway and should have been covered with privacy. LPN #1 indicated the nurse aide was responsible to make sure the drainage bag was covered and if it was not covered to go to the supply room and get a privacy bag. LPN #1 indicated as the charge nurse she was responsible to oversee and make sure the urinary drainage bag was covered. Interview with the DNS on 3/7/23 at 2:23 PM indicated Resident #62's urinary catheter drainage bag should be covered for vanity and dignity. The DNS indicated the nurse aides were educated to make sure the drainage bags were covered. Review of the Catheter Insertion and Indication Policy identified all catheter drainage bags will be placed in a covered bag to maintain the resident's dignity and privacy to the best of our ability. Review of the Quality of Life and Dignity Policy identified each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #65's diagnoses included acute kidney failure, dependence on hematologic treatments, and chronic kidney disease. The admission baseline resident care plan dated 12/26/22 identified R#65 required hematologic treatments on Monday, Wednesday, and Friday related to renal failure. R#65 was noted to have a right chest port for hematologic treatment access. Interventions included to check and change R#65's chest port dressing, and to monitor input and output. The admission Minimum Data Set (MDS) assessment dated [DATE] identified R#65 had intact cognition, and required one person physical assistance with dressing, eating, and was totally dependent on staff for toileting. Interview and review of the clinical record with Social Worker #1 (SW #1) on 3/7/23 at 10:35 AM failed to identify that a resident care plan meeting was scheduled or held following the admission MDS assessment dated [DATE]. SW #1 identified there was no requirement to conduct a care plan meeting following readmission of a resident. Interview and review of the facility care plan and the clinical record with Social Worker #1 (SW #1) on 3/7/23 at 10:35 AM failed to identify R65's care plan had been reviewed and revised following the admission MDS assessment dated [DATE]. Additionally, SW #1 could not find a resident care conference signature sheet indicating a care conference had been held which would have indicated that the care plan had been reviewed and revised. SW #1 identified that she was responsible to ensure resident care plan meetings are scheduled. Reinterview with SW #1 on 3/7/23 at 12:30 PM identified that a resident care plan meeting should be held with in 72 hours of admission, but that the meeting was overlooked. SW #1 indicated that it was her responsibility to schedule the meetings. Interview with the DNS on 3/8/23 at 11:44 AM indicated that there should have been a resident care plan meeting within 72 hours of admission. The DNS further identified that the care plan meeting is scheduled in conjunction with admission and the facility uses a checklist to ensure that the care plan meeting is completed. The DNS was unable to explain why the meeting was missed. Review of the Care Planning, Assessment policy revised 9/2017 directed that Social Services is responsible for notifying the resident/representative and for maintaining records to include date, time, and the location of the resident care conference. Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #62 and 65) reviewed for resident rights, the facility failed the ensure the resident or resident representative had the opportunity to participate in the process of care planning and making decisions about his or her care; and failed to complete a care plan meeting following admission. The findings included: 1. Resident #62 was admitted to the facility with diagnoses that included diabetes, cardiomyopathy, and chronic kidney disease. The care plan dated 10/27/22 identified essential support people for Resident #62 with interventions to have the essential support people review the plan of care with each care conference and staff to educate the essential support people. A care conference social worker quarterly note dated 10/27/22 at 11:24 indicated the care conference included the care plan nurse, social worker, and the family member. Resident #62 just had a re-admission from the hospital and on antibiotics. Code status was discussed with the family member. The significant change in condition MDS dated [DATE] identified Resident #62 had severely impaired cognition and required extensive assistance for dressing, personal hygiene, and transfers. Interview with SW #1 on 3/9/23 at 9:42 AM identified every resident is to have a care conferences every 90 days with the resident and their representative. SW #1 indicated the resident could have a care conference more often if there is a change in condition or a resident's request. SW #1 indicated the receptionist makes out the letter and recreation delivers the letters to the residents. SW #1 noted the MDS Coordinator, (RN #4) was responsible to schedule all the meetings and she follows the MDS schedule. SW #1 indicated Resident #62's last meeting was 10/27/22 and the next one was scheduled for 3/16/23. SW #1 indicated she was responsible to put the notes for the care conference in the resident's medical record. SW #1 indicated RN #4 did not realize that with a change of condition she was supposed to have a care conference meeting. SW #1 indicated Resident #62's representatives should have been invited when they did the change of condition to discuss the plan of care as part of the interdisciplinary team meeting. Interview with RN #4 on 3/9/23 at 9:49 AM indicated it was her responsibility to make the resident care conference schedule for every 90 days for all residents. RN #4 indicated every 90 days she does an MDS and then a care pan meeting will be done within a week after the MDS. RN #4 indicated it was her responsibility to update the care plan when she does the residents care plan meeting, and she runs the 90-day care plan meetings. RN #4 indicated Resident #62 had a significant change MDS in December 2022 and that resets the clock for when the quarterly MDS would be due next, which would be in March 2023. RN #4 indicated the last care conference Resident #62 and his/her representatives were invited to was on 10/27/22. RN #4 indicated the resident had a significant change in condition MDS on 11/2/22 and that resets the clock, and 12/17/22 another significant change in condition MDS when the resident was admitted to hospice. RN #4 indicated a care conference should have been done within a week of 12/17/22 but she did not schedule one or invite the resident or representatives to a meeting. Interview and clinical record review with RN #4 on 3/9/23 at 1:30 PM, failed to reflect that Resident #62 or his/her representative were invited to have a resident care conference in December 2022 or that a meeting was held. Review of Resident Rights Policy identified the resident had the right to participate in developing and implementing a person-centered plan of care that incorporates personal and cultural preferences. Review of Care Planning - Interdisciplinary Team Policy identified the interdisciplinary team was responsible for development of an individualized comprehensive person-centered plan for each resident. The resident, the resident's family and/or residents' legal representative are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. The resident and resident's representative have the right to participate in the development and implementation of his/her plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #20) reviewed for medication administration, the facility failed to notify the physician or APRN when medications were administered outside of the ordered time. The findings include: Resident #20 was admitted to the facility with diagnoses that included migraines, osteoarthritis and pain of both hips, polyneuropathy, bipolar disorder, and chronic obstructive pulmonary disease. The admission MDS dated [DATE] identified Resident #20 had intact cognition and had frequent pain limiting his/her day-to-day activities and sleep at night. The care plan dated 1/20/23 identified pain management for polyneuropathy and left shoulder pain. Interventions included to monitor pain, administer medications as ordered, and monitor and document effects of pain medications. An APRN #1 progress note dated 1/29/23 identified Resident #20 was seen for increased acute and chronic pain with history of osteoarthritis, and complaints of spasms. Recommendations included to start Flexeril for back spasms and consider Baclofen. An APRN #1 progress note dated 2/14/23 indicated Resident #20 had migraine headaches and Fioricet was helpful. Will continue order for Fioricet. An APRN #1 order dated 2/21/23 directed to not change medications unless approved by Physician or APRN after speaking with resident. A physician's order dated 2/23/23 directed to administer Tramadol 50 mg tablet every 12 hours for pain, Fioricet 50-300mg 2 tablets every 8 hours as needed for migraines, extra strength Tylenol 500 mg 2 tablets every 6 hours as needed for mild pain, and Flexeril 5mg every 8 hours as needed for muscle spasms. Additionally, administer Midodrine 5mg tablet 3 times a day for orthostasis and hold for systolic blood pressure greater than 130, Topamax 50 mg tablet give 2 tablets 2 times a day, Dicyclomine 20mg tablet 4 times a day, Gabapentin 600 mg tablet 3 times a day, and Hydroxyzine 25 mg tablet 2 times a day. Review of the March 2023 MAR identified on 3/4/23 the scheduled 9:00 AM medications were not signed out as given until 12:10 PM - 12:13 PM, 3 hours late, and the 12:00 PM - 1:00 PM scheduled medications were not signed out as given until 2:50 PM, 2 hours late. Review of the March 2023 MAR identified on 3/5/23 the scheduled 9:00 AM medications were not signed out as administered until 12:01 PM - 12:05 PM, 3 hours late. Additionally, the 12:00 PM - 1:00 PM scheduled medications were signed out as given 2:05 PM, and 10:25 PM. Interview with Resident #20 on 3/6/23 at 11:00 AM indicated she was upset that on 3/4/23 and 3/5/23 the same nurse was late with his/her 9:00 AM medications and that he/she did not receive them until after 12:00 PM. Resident #20 indicated she was had a medical background and has his/her medication regimen and if he/she does not receive his/her medications on time he/she becomes anxious and has physical symptoms. Resident #20 indicated when this specific nurse is on duty she gives the medications late. Resident #20 indicated he/she did report the late medications to LPN #1 on 3/6/23 that he/she was upset the medications were not given timely and this nurse had refused to give him/her the prn pain medications. Resident #20 indicated she was upset the 9:00 AM medications were so late and then the 1:00 PM medications were given at 2:00 PM and some of these medications were like getting a double dose. Additionally, Resident #20 indicated Saturday and Sunday evening at bedtime on 3/5/23 he/she had asked the same charge nurse for pain and migraine medication when the nurse came in to give the scheduled bedtime medications, but he/she never got the medication. Resident #20 indicated this nurse worked a double on Saturday and Sunday. Resident #20 indicated he/she did not receive the pain or migraine medication on Saturday or Sunday evening because it was this nurse's judgement. Resident #20 indicated the pool nurse informed Resident #20 to ask on the night shift. Resident #20 indicated he/she asked 2-3 times during the night and did not receive the prn Fioricet or the pain medication. Resident #20 indicated at 6:00 AM he/she asked for extra strength Tylenol and the day nurse must have come in early, and he/she received it. Interview with LPN #1 on 3/9/23 at 10:57 AM indicated Resident #20 reported Monday 3/6/23 in the morning that he/she had a horrible weekend because LPN #2 gave his/her medications over the weekend very late and refused to give Resident #20 his/her prn Flexeril for pain and Fioricet for his/her headaches. LPN #1 indicated Resident #20 was alert and oriented and had a medical background and knows his/her medications very well. LPN #1 indicated Resident #20 was never lethargic or drowsy when she requested prn medications and would not ask for them if not needed. LPN #1 noted Resident #20 reports that this happens every time LPN #2 works and she reports it to the supervisor every time. LPN #1 indicated on Monday when Resident #20 reported LPN #2 was late with the medications and refused to give the prn medications, LPN #1 reported it to the supervisor, RN #1. Interview with RN #1 on 3/9/23 at 11:15 AM indicated LPN #1 informed her that Resident #20 did not receive his/her medications in a timely manner over the weekend of 3/4 - 3/5/23 and the prn medications were not given when requested. RN #1 identified about noon on Saturday, LPN #2 approached RN #1 and stated she did not feel comfortable to give Resident #20 the medication for headache and pain. RN #2 indicated she had informed LPN #2 that there was a physician's order and if Resident #20 was requesting the prn medications she was to give it and monitor the resident. RN #1 indicated she was busy on Monday and Tuesday, so she did not speak to Resident #20 about the late medications and the nurse not giving the requested prn medications until Wednesday 3/8/23, which was when she notified the APRN. RN #2 indicated Resident #20 reported the medications were late both days over the weekend and Resident #20 stated he/she had to keep asking and doesn't get them which upset the resident and caused him/her to be anxious. RN #2 noted Resident #20 reported that he/she gets increased anxiety if medications are not given timely and his/her body will act in a negative way. RN #1 indicated she did not speak with Resident #20 on Monday when first informed because she thought it was addressed. RN #1 indicated there were no falls or emergencies on that unit for LPN #2 to be that late with the medications, but there were limited nurse aides. RN #1 indicated the scheduled medications were to be given within 1 hour of being scheduled and if they were late to notify the APRN. Interview with the DNS on 3/9/23 at 12:21 PM identified medications must be given 1 hour before or 1 hour after the scheduled times. The DNS indicated if medications were given late outside of the one-hour window, the nurse should notify the supervisor and the physician NS document that the physician was notified of the medications being given late and if there were any new orders regarding holding the next dose or changing the times for that day. The DNS noted the medications may need to be adjusted with the times by the APRN or MD. The DNS noted if the nurse was late with medications due being busy with other residents, she should ask the supervisor or another nurse for help, so the medications as still given within the timeframe. The DNS indicated the if a resident asks for a prn medication the nurse should give it if there is a physician's order. The DNS indicated she was aware LPN #2 was slower than other nurses and was not speedy. The DNS after review of the 3/4 and 3/5/23 medications that were scheduled at 9:00 AM indicated the medications were given at 12:11 PM. The DNS indicated after review of medical record LPN #2, nor the supervisors had notified the APRN or MD that the medications were over 3 hours late until 3/8/23. Interview with the DNS on 3/9/23 at 2:34 PM indicated she had spoken with Resident #20 on 3/9/23 after surveyor inquiry and clinical record review. The DNS indicated she interviewed RN #1 who informed the DNS that she was aware on 3/6/23 that Resident #20 had complained about LPN #2 but had not spoken to Resident #20 until 3/9/23 after surveyor inquiry. The DNS indicated RN #1 informed her that LPN #2 was late with her medications on Saturday and Sunday and that the resident stated it affects her body and mind. Additionally, that LPN #2 did not give him/her the prn medications when he/she had requested them. Interview with APRN #1 on 3/13/23 at 9:57 AM indicated she had spoken with Resident #20 about the pain/spasms and the migraines and had added the medications. APRN #1 indicated Resident #20 was alert and oriented and was a retired nurse that knew all of his/her medications very well. APRN #1 indicated she had no problem with Resident #20 requesting his/her prn medications. APRN #1 indicated she had heard there was a nurse that wouldn't give Resident #20 his/her prn medications so on 2/21/23 she put in the order for the medications not to be changed unless approved by her. APRN #1 indicated the medications had scheduled times based on how often they were to be given and must be given within a one-hour window from the scheduled time. APRN #1 indicated her expectation was if the nurse was going to give medications past the one-hour window she must call the APRN or physician and document in the clinical record. APRN #1 indicated after review of the clinical record that the 9:00 AM medications on 3/4/23 and 3/5/23 were not given until after 12:00 PM. APRN #1 identified if she were notified, she would have held the 12:00 -1:00 PM doses of medications especially for the Gabapentin 600mg and the Dicyclomine 20mg, and Midodrine 5mg. APRN #1 indicated she would have held all the three times, and four times daily medications, for the 12:00 PM and 1:00 PM doses, otherwise the resident would be getting a double dose. APRN #1 identified she would have instructed the nurse to give the 5:00 PM medications closer to the 4:00 PM side of the 1-hour window. APRN #1 indicated she would have expected a Nurses note indicating who the nurse spoke with and that that the physician or APRN was notified. Further, the APRN identified she had instructed the nursing staff if they call an on call APRN on weekends or evenings to put it in the communication book so she would be aware of any changes. APRN #1 indicated she was not aware or notified the medications were late on 3/4 and 3/5/23 and it was not in her communication book until today 3/13/23. Although attempted multiple times, an interview with LPN #2 was not obtained. Review of the Medication Administration Policy identified medications are prepared by a licensed nurse, follow the 5 rights right drug, right dose, right route, and right time are applied to each medication to be administered. Medications are to be administered within 60 minutes of the scheduled time. The nurse who administers the medication dose records the administration on the residents MAR directly after the medication is given. Review of Change in Condition and Change in Treatment and Services Policy identified when there is a change in condition the facility will inform the resident, residents' physician to ensure that every residents change in condition was assessed and documented properly and was reported to the physician and family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #3 and 36) reviewed for abuse, the facility failed to ensure the residents were free from abuse. The findings include: 1. Resident #3 was admitted to the facility in November 2020 with diagnoses that included Parkinson's disease, atrial fibrillation, and congestive heart failure. Facility documentation dated 4/21/21 identified the facility had contracted with a local nursing school to allow clinical site training by the LPN students in the program. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition and required extensive assistance with personal hygiene and eating. A reportable event form dated 5/26/21 identified the Registered Nurse Nursing Instructor, (Nursing Instructor #1) reported a student nurse, (Student Nurse #6) had been rough during care with Resident #3 and the incident had been witnessed by another student nurse on 5/18/21, 8 days earlier. Resident #3 was assessed by the APRN on 5/26/21, the day the allegation was reported to facility staff, with no injuries observed and psychiatry consultation was provided. Nursing Instructor #1 and Student Nurse #6 were removed from the facility. A care plan was initiated with intervention of no student nurses. Further, the reportable event form identified that Nursing Instructor #1 had removed Student Nurse #6 from her assignment on 5/18/21, 8 days prior. Review of the state agency reportable event forms dated 5/26/21 failed to reflect that the allegation of rough care to Resident #3 had been reported it to the state agency. Review of the weekly skin evaluation dated 5/26/21 at 12:51 PM identified a right forearm skin tear measuring length 1.3 cm x width 0.7 cm x depth 0.1 cm. Review of the psychiatry notes dated 5/26/21 identified Resident #3 was seen for an allegation of rough care with no report of abuse or signs and symptoms of abuse or change from baseline. The nurse's notes dated 5/26/21 through 5/29/21 failed to reflect documentation regarding the allegation of rough treatment by Student Nurse #6. A written statement from Student Nurse #2, dated 5/26/21 at 12:25 PM, identified she had witnessed Student Nurse #6 speaking in an aggressive tone to Resident #3 while providing personal care. Student Nurse #2 indicated Student Nurse #6 was physically aggressive while helping to move and dress Resident #3. Student Nurse #2 indicated Student Nurse #6 aggressively pulled Resident #3 towards. This occurred several times and eventually Resident #3 said ouch as Student Nurse #6 pulled Resident #3 towards her again. Student Nurse #2 indicated Student Nurse #6 was also making noises of disgust while performing the bed bath. Student Nurse #2 indicated at the end of care, Student Nurse #6 had left the room. Student Nurse #2 indicated Resident #3 expressed that he/she was upset and felt like he/she had been pulled, pushed, and punched. Student Nurse #2 indicated that she apologized to Resident #3 and indicated Resident #3 was concerned Student Nurse #6 was going to assist in putting him/her in the wheelchair. Student Nurse #2 indicated that is when she reported the incident to Nursing Instructor #1. Student Nurse #2 indicated that the Nursing Instructor #1 spoke to Resident #3, and Resident #3 told Nursing Instructor #1 that he/she was mishandled. 2. Resident #36 was admitted to the facility in December 2015 with diagnoses that included dementia with behavioral disturbance and hypothyroidism. The significant change MDS dated [DATE] identified Resident #36 had severely impaired cognition and required limited assistance with personal hygiene. The care plan dated 3/30/21 included interventions to assist with care. A reportable event form dated 5/26/21 at 9:30 AM identified it was reported to the DNS that a student nurse was rough with Resident #36. The Student Nurse was removed from the facility and the reportable event documented (Student Nurse to resident abuse without injury). Resident #36 was alert and pleasant, with confusion. Resident #36 required assistance with a rolling walker for transfers, ambulation, activities of daily living, and set up form meals. The physician was notified. Resident #36 was assessed, and psychiatry services were to be offered. Student Nurse involved and all other student nurses including Nursing Instructor #1 were removed from the facility. The nursing school director and interdisciplinary team updated. Review of the skin evaluation form dated 5/26/21 at 12:27 PM identified Resident #36 skin was intact. A nurse's note dated 5/26/21 at 1:26 PM identified RN #3 and the DNS notified the residents representative of the resident's status. Resident #36 in good spirits, no complaints at this time. A psychiatry physician note dated 5/26/21 identified Resident #36 was seen regarding an allegation of rough care. Limited history or exam available due to dementia. Resident #36 has memory impairment and is oriented to person only. Resident #36 recent and remote memory impaired. Resident #36 was calm, pleasant, and confused per baseline. A student nurse made an allegation that another student nurse was too rough with care. Open ended questions used for assessment. Resident #36 stated he/she is being treated well, no report of abuse or pain. No sign or symptoms of abuse at this time. Continue to monitor. A written statement from Student Nurse #4 dated 5/26/21 at 12:20 PM identified she had witnessed Student Nurse #6 talking on her cell phone using foul language in front of Resident #36 and denying Resident #36 care. Student Nurse #4 indicated she had heard a resident yelled at Student Nurse #6 to get the (explicative) out. A written statement dated 5/26/21 by Nursing Instructor #1 identified it was brought to her attention that on 5/18/21, Student Nurse #6 assisted Student Nurse #2 with Resident #3's care. Student Nurse #2 advised Nursing Instructor #1 that Student Nurse #6 was not gentle, or rough with resident care. Resident #3 was able to verbalize that he/she did not want students involved in his/her care. Nursing Instructor #1 indicated Resident #3 did not have any signs of emotional or physical distress observed and identified on 5/25/21 Student Nurse #6 was assisting Student Nurse #4 with resident care and Student Nurse #4 reported that Student Nurse #6 was talking inappropriate and loud on her cell phone in Resident #36's bathroom. Student Nurse #4 reported that Student Nurse #6 was impatient with the resident. Nursing Instructor #1 indicated she talked to Resident #36's roommate who stated that he/she would not want Student Nurse #6 taking care of his/her family. Nursing Instructor #1 indicated Resident #36's roommate referred to Student Nurse #6's tone of voice. Nursing Instructor #1 indicated she escorted Student Nurse #6 out of the facility on 5/26/21 at 9:30 AM and notified the DNS and the Administrator of the events the morning of 5/26/21. A written statement dated 5/27/21 by the Director of Human Resources identified on 5/4/21 she assisted LPN #4 in providing an orientation for the students of the nursing school. The Director of Human Resources and LPN #4 spoke to the student nurses and the nursing instructor at length regarding the expectations of the facility. The student nurses and the nursing instructor were oriented on multiple items, including but not limited to fire safety, sexual harassment, workplace accident/injury, infection control, resident right's, abuse and neglect (and the different types of each) and the chain of command used for reporting. The student nurses and the nursing instructor were provided information on how to contact the Director of Human Resources, LPN #4, the DNS, and the Administrator. The student nurses and Nursing Instructor #1 were also provided with print outs of the PowerPoint presentation, door codes, etc. A written statement dated 5/27/21 by LPN #4 identified general orientation was provided to the student nurses and Nursing Instructor #1. LPN #4 indicated she was assisted by the Director of Human Resources during that time to ensure facility general orientation was completed appropriately. The facility created and printed out of the PowerPoint and provided each student nurses and Nursing Instructor #1 with the material. The PowerPoint orientation material was discussed in detail, the expectations of the facility, nursing standards, the different types of abuse, the proper chain of command for reporting, and provided the contact information for the DNS, Administrator, Director of Human Resources, and LPN #4. Review of the summary report dated 6/2/21 at 4:58 PM identified an allegation of mistreatment nursing student to residents. Resident #3 and Resident #36 had poor cognition. The facility was a host site for student nurses from 5/4/21 until 5/26/21. On 5/26/21 Nursing Instructor #1 reported to the facility DNS that Student Nurse #6 had been asked to report to the school campus on 5/25/21 due to unprofessional conduct (foul language, talking on her cell phone at inappropriate times and places, and allegations of physical or verbal abuse from fellow students). Student Nurse #6 was directed by Nursing Instructor #1 not to report for clinical at the facility the following day (5/26/21). Student Nurse #6 reported to the facility on 5/26/21 without having gone to the school campus as requested and Nursing Instructor #1 escorted her out of the facility at 9:30 AM on 5/26/21 and advised the DNS of the situation at that time. The student nurses were asked to write a statement related to Student Nurse #6's unprofessionalism and based on preliminary statements, there may have been some verbal or physical mistreatment of a resident by Student Nurse #6 during the clinical rotation. The student nurses and Nursing Instructor #1 were asked to exit the building until a complete investigation could be conducted. Resident #3, and Resident #36 were interviewed by social service on 5/26/21. Neither residents expressed concern nor recalled an event in which they may have been mistreated. Additional alert and oriented residents were interviewed with no concerns related to their care or services. The facility staff were interviewed resulting in no concerns related to the care their residents received from the student nurses or Nursing Instructor #1. A facility wide skin audit was completed to ensure residents were free from signs and symptoms of physical abuse. The facility staff was re-educated on the abuse prevention, resident rights, and dignity protocols. A root cause analysis was completed determining Nursing Instructor #1 failed to report an allegation of abuse, neglect, or mistreatment timely to the facility leadership resulting in a delay with timely reporting and investigating an allegation of mistreatment toward a resident or residents to the state agency. In review of statements from the student nurses and Nursing Instructor #1 it is concluded Student Nurse #6 was unprofessional in her demeanor throughout her clinical rotation at the facility which was not shared with the facility leadership until 5/26/21. Although the facility is unable to substantiate physical abuse occurred, there is compelling testimony Student Nurse #6 had multiple events in which her conduct did not meet the facility philosophy and mission statement. The facility has put a systemic change in place for future student nurses to successfully complete a weekly quiz on reporting and recognizing signs and symptoms of abuse, neglect, or mistreatment. Additionally, the clinical instructor will meet daily with the DNS/Designee for an end of day report. Interview with the DNS on 3/9/23 at 10:27 AM identified on 5/26/21 Nursing Instructor #1 notified her Student Nurse #6 was rough with a resident (Resident #36) which she reported immediately to the state agency. The DNS indicated the student nurses, and Nursing Instructor #1 were escorted out of the facility. The DNS indicated she asked the student nurses and Nursing Instructor #1 for written statements. The DNS indicated RN #3 performed the investigation and another resident was identified, (Resident #3) which was added to the investigation. The DNS indicated RN #3 concluded the investigation and the summary report and added Resident #3 to the investigation. Interview with RN #3 on 3/13/23 at 1:06 PM identified she was employed by the facility for 2 years in 5/26/21. RN #3 indicated she worked in the capacity of the Infection Preventionist and Staff Development Coordinator. RN #3 indicated she was aware of the allegation of abuse on 5/26/21 and indicated she performed the investigation. RN #3 indicated during the investigation another resident was identified but she does not remember everything regarding the investigation because it was in 2021. RN #3 indicated Resident #3 and Resident #36 were involved in the investigation of mistreatment. RN #3 indicated she did not report Resident #3's allegation to the state agency, and she was unable to substantiate the allegation of mistreatment. Interview with RN #3 on 3/16/23 at 2:12 PM identified she reviewed the student nurses and Nursing Instructor #1's written statements. RN #3 indicated she did not interview the student nurses and Nursing Instructor #1 since they were not allowed to come back to the facility until the investigation was completed. RN #3 indicated the school was supposed to obtain an interview with the student nurses and Nursing Instructor #1. Although attempted, interviews with the Director of Human Resources, LPN #4, SW #1, Nursing Instructor #1 and Student Nurse #6 could not be obtained. Review of the facility abuse and neglect clinical protocol policy identified abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Mistreatment means inappropriate treatment or exploitation of a resident. Review of the facility abuse prevention program policy identified the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, [NAME], sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. As part of the resident abuse prevention, the administrator will: Protect the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals.

**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 #3) reviewed for abuse, the facility failed to report an allegation of abuse/mistreatment to the state agency. The findings include: Resident #3 was admitted to the facility in November 2020 with diagnoses that included Parkinson's disease, atrial fibrillation, and congestive heart failure. Facility documentation dated 4/21/21 identified the facility had contracted with a local nursing school to allow clinical site training by the LPN students in the program. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition and required extensive assistance with personal hygiene and eating. A reportable event form dated 5/26/21 identified the Registered Nurse Nursing Instructor, (Nursing Instructor #1) reported a student nurse, Student Nurse #6 was rough during care with Resident #3 and the incident had been witnessed by another student nurse on 5/18/21. Resident #3 was assessed by the APRN on 5/26/21, the day the allegation was reported, with no injuries observed. Psychiatry consultation was provided. Nursing Instructor #1 and Student Nurse #6 were removed from the facility. A care plan was initiated with intervention of no student nurses. Further, Nursing Instructor #1 removed Student Nurse #6 from assignment on 5/18/21, 8 days prior. The facility failed to report this allegation to the state agency. Review of the weekly skin evaluation dated 5/26/21 at 12:51 PM identified a right forearm skin tear measuring length 1.3 cm x width 0.7 cm x depth 0.1 cm. Review of the psychiatry notes dated 5/26/21 identified Resident #3 was seen for an allegation of rough care with no report of abuse or signs and symptoms of abuse or change from baseline. The nurse's note dated 5/26/21 through 5/29/21 failed to reflect documentation regarding the alleged allegation of abuse. A written statement from Student Nurse #2 dated 5/26/21 at 12:25 PM identified she had witnessed Student Nurse #6 speaking in an aggressive tone to Resident #3 while providing personal care. Student Nurse #2 indicated Student Nurse #6 was physically aggressive while helping to move and dress Resident #3. Student Nurse #2 indicated Student Nurse #6 aggressively pulled Resident #3 towards her disregarding Student Nurse #2 count. ??? This occurred several times and eventually Resident #3 said ouch as Student Nurse #6 pulled Resident #3 towards her again. Student Nurse #2 indicated Student Nurse #6 was also making noises of disgust while performing the bed bath. Student Nurse #2 indicated at the end of care Student Nurse #6 had left the room. Student Nurse #2 indicated Resident #3 expressed that he/she was upset and felt like he/she had been pulled, pushed, and punched. Student Nurse #2 indicated that she apologized to Resident #3 and indicated Resident #3 was concerned Student Nurse #6 was going to assist in putting him/her in the wheelchair. Student N Nurse #2 indicated that is when she reported her concerns to the Nursing Instructor #1. Student Nurse #2 indicated that the Nursing Instructor #1 spoke to Resident #3, and Resident #3 told Nursing Instructor #1 that he/she was mishandled. A reportable report form dated 6/2/21, 7 days later, identified Resident #3 was included in the investigation of an allegation of abuse/mistreatment. Review of the summary report dated 6/2/21 at 4:58 PM identified an allegation of mistreatment nursing student to residents. The facility was a host site for student nurses from 5/4/21 until 5/26/21. Resident #3 and Resident #36 had poor cognition. On 5/26/21 Nursing Instructor #1 reported to the facility DNS that Student Nurse #6 had been asked to report to the school campus on 5/25/21 due to unprofessional conduct (foul language, talking on her cell phone at inappropriate times and places, and allegations of physical or verbal abuse from fellow students). Student Nurse #6 was directed by Nursing Instructor #1 not to report for clinical at the facility the following day (5/26/21). Student Nurse #6 reported to the facility on 5/26/21 without having gone to the school campus as requested and Nursing Instructor #1 escorted her out of the facility at 9:30 AM on 5/26/21 and advised the DNS of the situation at that time. The student nurses were asked to write a statement related to Student Nurse #6's unprofessionalism and based on preliminary statements, there may have been some verbal or physical mistreatment of a resident by Student Nurse #6 during the clinical rotation. The student nurses and Nursing Instructor #1 were asked to exit the building until a complete investigation could be conducted. Resident #3, and Resident #36 were interviewed by social service on 5/26/21. Neither residents expressed concern nor recalled an event in which they may have been mistreated. Additional alert and oriented residents were interviewed with no concerns related to their care or services. The facility staff were interviewed resulting in no concerns related to the care their residents received from the student nurses or Nursing Instructor #1. A facility wide skin audit was completed to ensure residents were free from signs and symptoms of physical abuse. The facility staff was re-educated on the abuse prevention, resident rights, and dignity protocols. A root cause analysis was completed determining Nursing Instructor #1 failed to report an allegation of abuse, neglect, or mistreatment timely to the facility leadership resulting in a delay with timely reporting and investigating an allegation of mistreatment toward a resident or residents to the state agency. In review of statements from the student nurses and Nursing Instructor #1 it is concluded Student Nurse #6 was unprofessional in her demeanor throughout her clinical rotation at the facility which was not shared with the facility leadership until 5/26/21. Although the facility is unable to substantiate physical abuse occurred, there is compelling testimony Student Nurse #6 had multiple events in which her conduct did not meet the facility philosophy and mission statement. The facility has put a systemic change in place for future student nurses to successfully complete a weekly quiz on reporting and recognizing signs and symptoms of abuse, neglect, or mistreatment. Additionally, the clinical instructor will meet daily with the DNS/Designee for an end of day report. Interview with the DNS on 3/9/23 at 10:27 AM RN #3 performed the investigation and another resident, Resident #3 was added to the investigation. The DNS indicated RN #3 concluded the investigation and the summary report and added Resident #3 to the investigation. Interview and review of facility documentation with the DNS on 3/9/23 at 10:40 AM failed to reflect that the allegation of abuse for Resident #3 was immediately reported to the state agency. Interview with RN #3 on 3/13/23 at 1:06 PM identified she was employed by the facility for 2 years in 5/26/21. RN #3 indicated she worked in the capacity of the Infection Preventionist and Staff Development Coordinator. RN #3 indicated she was aware of the alleged allegation of abuse on 5/26/21. RN #3 indicated she performed the investigation. RN #3 indicated during the investigation another resident was added. RN #3 indicated she does not remember everything regarding the investigation because it was in 2021. RN #3 indicated Resident #3, and Resident #36 was involved in the investigation of mistreatment. RN #3 indicated Resident #3 indicated she did not want student nurses to care for her in the future. RN #3 indicated she did not report Resident #3 to the state agency. RN #3 indicated she was unable to substantiate the allegation of mistreatment. Review of the facility abuse investigation policy identified all reports of resident abuse, neglect, misappropriation of resident's property, injuries of known or unknown source, and exploitation shall be promptly reported and thoroughly investigated by facility management. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries unknown source and misappropriation of resident property, are reported to the state agency immediately, but not later than 2 hours after allegation is made. Review of in-service forms dated 5/26/21 and 5/29/21 identified the facility staff were in-serviced on resident rights, abuse, neglect and reporting.

Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 5 sampled residents (Resident #529) who was reviewed for Preadmission Screening and Resident Review 2 (PASSR 2), the facility failed to implement a PASSR 2 recommendation. Review of PASSR 2 identified the following rehabilitative service recommendations: Service or Support for socialization, leisure and recreation activities; mental health counseling; ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms; supportive counseling from NF staff; a guardian/conservator for decisions regarding health and safety, and training in ADL's. All recommendations care planned except for appointment of guardian/conservator for decisions related to health and safety. 3/7/2023 at 10:00 am: Interview with Social Worker identified nothing has been done regarding the PASSR recommendation for guardianship/conservatorship for Resident #529. Social Worker stated resident #529 was alert and oriented and would do well with a power of attorney appointment. Social Worker also indicated that she has a scheduled appointment with Resident #529's family on 3/9/23 at 10 AM to discuss appointment of power of attorney. Social work indicated hospital had power of attorney on hand but the facility has no paperwork on file.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #65's diagnoses included acute kidney failure, dependence on hematologic treatments, and chronic kidney disease. The admission baseline resident care plan dated 12/26/22 identified R#65 required hematologic treatments on Monday, Wednesday, and Friday related to renal failure. R#65 was noted to have a right chest port for hematologic treatment access. Interventions included to check and change R#65's chest port dressing, and to monitor input and output. The admission Minimum Data Set (MDS) assessment dated [DATE] identified R#65 had intact cognition, and required one person physical assistance with dressing, eating, and was totally dependent on staff for toileting. Interview and review of the facility care plan and the clinical record with Social Worker #1 (SW #1) on 3/7/23 at 10:35 AM failed to identify R# 65's care plan had been reviewed and revised following the admission MDS assessment dated [DATE]. Additionally, SW #1 could not find a resident care conference signature sheet indicating a care conference had been held which would have indicated that the care plan had been reviewed and revised. SW #1 identified that she was responsible to ensure resident care plan meetings are scheduled, but must have have missed scheduling the meeting. Interview with the (Director of Nursing) DNS on 3/8/23 at 11:44 AM identified a care plan meeting is held within 72 hours of admission. Review of the facility Care Planning policy Revised on 9/2017 directed that a comprehensive care plan for each resident is developed within seven (7) days of completion of the resident MDS assessment. Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #62 and 65) reviewed for care planning, the facility failed to revise and update the comprehensive care plan with a significant change of condition; and failed to complete a comprehensive care plan within seven days of completing a comprehensive assessment. The findings include: 1. Resident #62 was admitted to the facility with diagnoses that included diabetes, cardiomyopathy, and chronic kidney disease. The care plan dated 10/27/22 identified essential support people for Resident #62 with interventions to have the essential support people review the plan of care with each care conference and staff to educate the essential support people. A care conference social worker quarterly note dated 10/27/22 at 11:24 indicated the care conference included the care plan nurse, social worker, and the family member. Resident #62 just had a re-admission from the hospital and on antibiotics. Code status was discussed with the family member. The significant change in condition MDS dated [DATE] identified Resident #62 had severely impaired cognition and required extensive assistance for dressing, personal hygiene, and transfers. Interview with SW #1 on 3/9/23 at 9:42 AM indicated every resident was to have a care conference every 90 days with the resident and their representative. SW #1 indicated Resident #62's last meeting was 10/27/22 and the next one was scheduled for 3/16/23. SW #1 indicated she was responsible to put the notes for the care conference in the resident's medical record and RN #4 was responsible to update the comprehensive care plan. Interview with MDS coordinator RN #4 on 3/9/23 at 9:49 AM indicated it was her responsibility to make the resident care conference schedule every 90 days for all residents. RN #4 indicated every 90 days she does an MDS and then a care pan meeting will be done within a week after the MDS. RN #4 indicated it was her responsibility to update the care plan when she does the residents care plan meeting at least every 90 days. RN #4 indicated Resident #62 had a significant change MDS in December 2022 and that resets the clock for when the quarterly MDS would be due. RN #4 indicated the last care conference Resident #62 and his/her representatives were invited to was on 10/27/22, 5 months ago, and that was the last time the comprehensive care plan was updated. RN #4 indicated she updated the care plan when Resident #62 started on hospice by adding the hospice care plan. RN #4 indicated she did not do the comprehensive care plan in December 2022 because she did not have the resident care conference. RN #4 indicated she did not review or update the entire care plan at that time she just added in the hospice care plan in December 2022. Interview and clinical record review with RN #4 on 3/9/23 at 1:30 PM failed to reflect that Resident #62's comprehensive care plan was reviewed/revised or updated within a week of the 12/17/22 MDS. Review of the Care Planning - Interdisciplinary Team Policy identified the interdisciplinary team was responsible for development of an individualized comprehensive person-centered plan for each resident. The resident, the resident's family and/or residents' legal representative are encouraged to participate in the development of and revisions to the residents care plan. The resident and resident's representative have the right to participate in the development and implementation of his/her plan of care. A comprehensive care plan for each resident is developed within 7 days of completion of the resident assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #58) reviewed for unnecessary medications, the facility failed to ensure the Abnormal Involuntary Movement Scale (AIMS) was conducted when required and by qualified staff per facility policy. The findings include: Resident #58 was admitted to the facility with diagnoses that included gastro-esophageal reflux disease and dementia. A physician's order dated 9/23/22 directed to administer Reglan (medication for the stomach) 5 mg before meals. The annual MDS dated [DATE] identified Resident #58 had severely impaired cognition. The care plan dated 11/15/22 identified potential for gastro-intestinal distress. Interventions included to provide medications as ordered and to perform an AIMS as ordered. Review of the clinical record failed to reflect an AIMS test had been completed subsequent to the initiation of Reglan on 9/23/22. Interview with MD #1 on 3/8/23 at 7:00 AM identified he was not sure if an AIMS test was required if a resident was receiving Reglan. Interview with the DNS on 3/8/23 at 9:30 AM indicated although it was the facility policy to complete an AIMS test every 6 months for residents' on Reglan, the DNS could not find a written policy. The DNS indicated Resident #58 should have had an AIMS test done by a Physician, APRN, or RN because he/she was receiving Reglan. The DNS indicated Resident #58 last had an AIMS completed on 6/9/22 by the psychiatric APRN. Interview and review of the clinical record with LPN #1 on 3/8/23 at 9:55 AM indicated although she signed off as doing an AIMS test on 9/8/22 for Resident #58, she did not recall doing the AIMS. LPN #1 indicated per the documentation, she notified the psychiatric APRN verbally on 9/8/22 of the test results because that was the day the psychiatric APRN comes into the facility. Interview with RN #7 (Corporate Director of Clinical Services) on 3/8/23 at 11:40 AM indicated the AIMS test must be completed by a physician, APRN, RN, or a social worker. RN #7 indicated the last AIMS assessment completed by an APRN was dated 6/9/22 and was next due in December 2022. Interview with Pharmacist #1 on 3/8/23 at 12:10 PM identified the medication Reglan had a black box warning and required staff to complete an AIMS test every 6 months by a qualified nurse or APRN. Black Box Warning for Reglan 5 mg: Warning for Tardive Dyskinesia. Metoclopramide (Reglan) can cause tardive dyskinesia, a serious movement disorder that is often irreversible. There is no known treatment for tardive dyskinesia. The risk of developing tardive dyskinesia increases with duration of treatment and total cumulative dose. Discontinue metoclopramide in patients who develop signs of tardive dyskinesia. In some patients, symptoms lessen or resolve after metoclopramide is stopped. Avoid treatment with metoclopramide for longer than 12 weeks because of the increased risk of developing tardive dyskinesia with longer-term use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews for the only sampled resident reviewed for activities of daily living, the facility failed to ensure weekly showers or bed baths were given to a dependent resident. The findings included: Resident #479's diagnoses included heart failure, chronic obstructive pulmonary disease, and depression. Interview with Person #1 on 3/9/23 at 9:30 AM, indicated Resident #479 was not showered consistently, was not clean, and his/her skin had an odor. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #479 had intact cognition and was dependent for toileting, hygiene, and bathing. The Resident Care Plan dated 2/13/22 identified Resident #479 required assistance with activities of daily living (ADL's) related to his/her impaired mobility. Interventions directed facility staff to assist Resident #479 with bathing, dressing, and hygiene as ordered. Additional interventions directed facility staff to use a mechanical lift for transfers and a 2 person assist for bed mobility and ADLs. A physician's order dated 2/3/22 directed facility staff to complete weekly skin checks on bath/shower days, Tuesdays: 2/9/22, 2/16/22, and 2/23/22. Review of the Nurse Aide (NA) flow sheet for the month of February 2022 indicated Resident #479 received a bed bath on 2/5/22, shower on 2/9/22, and bed bath on 2/25/22 (a period of 15 days lapsed between Resident #479's last shower and bed bath). The nurse's note dated 3/17/22 at 6:27 PM identified the underlying cause of Resident #479's declining of his/her weekly showers was that s/he was too tired in the evenings. The facility changed Resident #479's shower schedule to day shift. Interview with the Director of Nursing (DNS) on 3/9/23 at 1:18 PM, indicated Resident #479 frequently refused showers due to the severity of Resident #479's illness, s/he had a difficult time tolerating a sitting position to be showered. The DNS indicated that Resident #479 and the resident representative were present at care plan meetings and the showering/bed bath schedules were discussed. Subsequently, accommodations for showering on day shift were made when Resident #479 would be less fatigued. Although requested, documentation that Resident #479 was offered, given, or refused a shower or bed bath from 2/10/22 through 2/24/22 was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #479's diagnoses included type 2 diabetes mellitus, chronic obstructive pulmonary disease, asthma, and obstructive and reflux uropathy. Interview with Person #1 on 3/9/23 at 9:30 AM indicated Resident #479 was regularly given medications late. The admission Minimum Data Set assessment dated [DATE] identified Resident #479 was cognitively intact, and received medications including insulin, an antidepressant, and a diuretic. The Resident Care Plan dated 2/13/22 identified pain and diabetes. Interventions directed facility staff to administer medications and monitor blood sugars as ordered. A physician's order dated 2/3/22 directed facility staff to administer 5 units of Tresiba Flex Touch Solution (a long-acting insulin for diabetes) every evening. A physician's order dated 2/4/22 directed Methenamine Hippurate 1 Gram (an antibiotic) to be given twice daily for chronic urinary tract infections. A physician's order dated 2/7/22 directed Ipratropium-Albuterol Solution 0.5-2.5mg/3ml (a bronchodilator) to be inhaled four times a day, for shortness of breath and wheezing. A physician's order dated 2/9/22 directed blood glucose monitoring twice daily. A physician's order dated 2/23/22 direct Tramadol (for pain) 50mg to be administered twice daily. Review of the March 2022 Medication Administration Audit Report identified the following: a. Tresiba Flex Touch Solution was scheduled to be administered once daily. The 5:00 PM dose on 3/5/22 was administered at 9:54 PM; on 3/10/22 at 9:26 PM, and on 3/20/22 the 5:00 PM administration time occurred on 3/21/22 at 1:05 AM. b. Methenamine Hippurate was scheduled to be administered twice daily. The 5:00 PM dose on 3/5/22 was administered at 9:53 PM; on 3/10/22 at 7:19 PM, and on 3/20/22 the 5:00 PM administration time occurred on 3/21/22 at 1:05 AM. c. Ipratropium-Albuterol Solution was scheduled to be administered four times daily. The 5:00 PM dose on 3/5/22 was administered at 9:53 PM; on 3/10/22 at 7:19 PM, and on 3/20/22 the 5:00 PM administration time occurred on 3/21/22 at 1:04 AM. d. Glucose monitoring was scheduled twice daily. The 4:30 PM monitoring occurred at 9:51 PM on 3/5/22; on 3/10/22 at 9:27 PM, and the 3/20/22 glucose monitoring scheduled at 4:30 PM was performed on 3/21/22 at 1:03 AM. e. Tramadol HCL was scheduled to be administered twice daily. The 5:00 PM dose on 3/5/22 occurred at 9:35 PM; on 3/10/22 at 9:26 PM, and the 3/20/22, 5:00 PM dose was administered on 3/21/22 at 1:03 AM. Interview with Licensed Practical Nurse (LPN) #3 on 3/9/23 at 3:15 PM identified that occasionally Resident #479 would be eating or visiting with family and would request his/her medications be administered later. LPN #3 indicated she would honor the request, lock the medications, and return at a later time. LPN #3 indicated that the late medication administration times documented in the clinical record were not accurate, sometimes she passed the medications a little late, but not 2-5 hours late. LPN #3 indicated that during some shifts she would give Resident #479 his/her medications and then move on to the next resident. Subsequently, she would not save the accurate medication administration time into the Resident #479's clinical record. LPN #3 identified that saving the accurate medication administration time in the clinical record is the facility's policy. However, in some instances she failed to record the correct time of administration. Interview with the Director of Nursing (DNS) on 3/13/23 at 1:00 PM indicated the expectation for medication administration is that medications should be given one hour before or after the ordered time, per facility policy. The DNS indicated that the facility staff try to adjust medications administration times to the resident's liking. If a resident refuses a medication, the facility staff should go back and reoffer. Documentation for medication administration should be saved at the time the medication is administered to the resident. Review of the medication administration policy directed medication administration times should be recorded on the Medication Administration Record (MAR) directly after the medication is given. At the end of each medication pass, the person administering the medication reviews the MAR to ensure necessary doses were administered and documented. Additionally, if a dose of regularly scheduled medications is withheld, refused, not available, or given at a time other than the scheduled time is noted electronically. An explanatory note is entered. Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 7 residents (Resident #20 and 479) reviewed for medication administration, the facility failed to ensure medications were given in a timely manner; and failed to ensure medications were given as ordered. The findings include: 1. Resident #20 was admitted to the facility with diagnoses that included migraines, osteoarthritis and pain of both hips, polyneuropathy, bipolar disorder, and chronic obstructive pulmonary disease. The admission MDS dated [DATE] identified Resident #20 had intact cognition and had frequent pain limiting his/her day-to-day activities and sleep at night. The care plan dated 1/20/23 identified pain management for polyneuropathy and left shoulder pain. Interventions included to monitor pain, administer medications as ordered, and monitor and document effects of pain medications. A physician's order dated 2/23/23 directed to administer Tramadol 50 mg tablet every 12 hours for pain, Fioricet 50-300mg 2 tablets every 8 hours as needed for migraines, extra strength Tylenol 500 mg 2 tablets every 6 hours as needed for mild pain, and Flexeril 5mg every 8 hours as needed for muscle spasms. Additionally, administer Midodrine 5mg tablet 3 times a day for orthostasis and hold for systolic blood pressure greater than 130, Topamax 50 mg tablet give 2 tablets 2 times a day, Dicyclomine 20mg tablet 4 times a day, Gabapentin 600 mg tablet 3 times a day, and Hydroxyzine 25 mg tablet 2 times a day. Review of the March 2023 MAR identified on 3/4/23 the scheduled 9:00 AM medications were not signed out as given until 12:10 PM - 12:13 PM, 3 hours late, and the 12:00 PM - 1:00 PM scheduled medications were not signed out as given until 2:50 PM, 2 hours late. Review of the March 2023 MAR identified on 3/5/23 the scheduled 9:00 AM medications were not signed out as administered until 12:01 PM - 12:05 PM, 3 hours late. Additionally, the 12:00 PM - 1:00 PM scheduled medications were signed out as given 2:05 PM, and 10:25 PM. Interview with Resident #20 on 3/6/23 at 11:00 AM indicated she was upset that on 3/4/23 and 3/5/23 the same nurse was late with his/her 9:00 AM medications and that he/she did not receive them until after 12:00 PM. Resident #20 indicated she was a retired nurse and has his/her medication regimen and if he/she does not receive his/her medications on time he/she becomes anxious and has physical symptoms. Resident #20 indicated when this specific nurse is on duty she gives the medications late. Resident #20 indicated he/she did report the late medications to LPN #1 on 3/6/23 that he/she was upset the medications were not given timely and this nurse had refused to give him/her the prn pain medications. Resident #20 indicated she was upset the 9:00 AM medications were so late and then the 1:00 PM medications were given at 2:00 PM and some of these medications were like getting a double dose. Additionally, Resident #20 indicated Saturday and Sunday evening at bedtime on 3/5/23 he/she had asked the same charge nurse for pain and migraine medication when the nurse came in to give the scheduled bedtime medications, but he/she never got the medication. Resident #20 indicated this nurse worked a double on Saturday and Sunday. Resident #20 indicated he/she did not receive the pain or migraine medication on Saturday or Sunday evening because it was this nurse's judgement. Resident #20 indicated the pool nurse informed Resident #20 to ask on the night shift. Resident #20 indicated he/she asked 2-3 times during the night and did not receive the prn Fioricet or the pain medication. Resident #20 indicated at 6:00 AM he/she asked for extra strength Tylenol and the day nurse must have come in early, and he/she received it. Interview with LPN #1 on 3/9/23 at 10:57 AM indicated Resident #20 reported Monday 3/6/23 in the morning that he/she had a horrible weekend because LPN #2 gave his/her medications over the weekend very late and refused to give Resident #20 his/her prn Flexeril for pain and Fioricet for his/her headaches. LPN #1 indicated Resident #20 was alert and oriented and had a medical background and knows his/her medications very well. LPN #1 indicated Resident #20 was never lethargic or drowsy when she requested prn medications and would not ask for them if not needed. LPN #1 noted Resident #20 reports that this happens every time LPN #2 works and she reports it to the supervisor every time. LPN #1 indicated on Monday when Resident #20 reported LPN #2 was late with the medications and refused to give the prn medications, LPN #1 reported it to the supervisor, RN #1. Interview with RN #1 on 3/9/23 at 11:15 AM indicated LPN #1 informed her that Resident #20 did not receive his/her medications in a timely manner over the weekend of 3/4 - 3/5/23 and the prn medications were not given when requested. RN #1 identified about noon on Saturday, LPN #2 approached RN #1 and stated she did not feel comfortable to give Resident #20 the medication for headache and pain. RN #2 indicated she had informed LPN #2 that there was a physician's order and if Resident #20 was requesting the prn medications she was to give it and monitor the resident. RN #1 indicated she was busy on Monday and Tuesday, so she did not speak to Resident #20 about the late medications and the nurse not giving the requested prn medications until Wednesday 3/8/23, which was when she notified the APRN. RN #2 indicated Resident #20 reported the medications were late both days over the weekend and Resident #20 stated he/she had to keep asking and doesn't get them which upset the resident and caused him/her to be anxious. RN #2 noted Resident #20 reported that he/she gets increased anxiety if medications are not given timely and his/her body will act in a negative way. RN #1 indicated she did not speak with Resident #20 on Monday when first informed because she thought it was addressed. RN #1 indicated there were no falls or emergencies on that unit for LPN #2 to be that late with the medications, but there were limited nurse aides. RN #1 indicated the scheduled medications were to be given within 1 hour of being scheduled and if they were late to notify the APRN. Interview with the DNS on 3/9/23 at 12:21 PM identified medications must be given 1 hour before or 1 hour after the scheduled times. The DNS indicated if medications were given late outside of the one-hour window, the nurse should notify the supervisor and the physician NS document that the physician was notified of the medications being given late and if there were any new orders regarding holding the next dose or changing the times for that day. The DNS noted the medications may need to be adjusted with the times by the APRN or MD. The DNS noted if the nurse was late with medications due being busy with other residents, she should ask the supervisor or another nurse for help, so the medications as still given within the timeframe. The DNS indicated the if a resident asks for a prn medication the nurse should give it if there is a physician's order. The DNS indicated she was aware LPN #2 was slower than other nurses and was not speedy. The DNS after review of the 3/4 and 3/5/23 medications that were scheduled at 9:00 AM indicated the medications were given at 12:11 PM. The DNS indicated after review of medical record LPN #2, nor the supervisors had notified the APRN or MD that the medications were over 3 hours late until 3/8/23. Interview with the DNS on 3/9/23 at 2:34 PM indicated she had spoken with Resident #20 on 3/9/23 after surveyor inquiry and clinical record review. The DNS indicated she interviewed RN #1 who informed the DNS that she was aware on 3/6/23 that Resident #20 had complained about LPN #2 but had not spoken to Resident #20 until 3/9/23 after surveyor inquiry. The DNS indicated RN #1 informed her that LPN #2 was late with her medications on Saturday and Sunday and that the resident stated it affects her body and mind. Additionally, that LPN #2 did not give him/her the prn medications when he/she had requested them. Interview with APRN #1 on 3/13/23 at 9:57 AM indicated she had spoken with Resident #20 about the pain/spasms and the migraines and had added the medications. APRN #1 indicated Resident #20 was alert and oriented and was a retired nurse that knew all of his/her medications very well. APRN #1 indicated she had no problem with Resident #20 requesting his/her prn medications. APRN #1 indicated she had heard there was a nurse that wouldn't give Resident #20 his/her prn medications so on 2/21/23 she put in the order for the medications not to be changed unless approved by her. APRN #1 indicated the medications had scheduled times based on how often they were to be given and must be given within a one-hour window from the scheduled time. APRN #1 indicated her expectation was if the nurse was going to give medications past the one-hour window she must call the APRN or physician and document in the clinical record. APRN #1 indicated after review of the clinical record that the 9:00 AM medications on 3/4/23 and 3/5/23 were not given until after 12:00 PM. APRN #1 identified if she were notified, she would have held the 12:00 -1:00 PM doses of medications especially for the Gabapentin 600mg and the Dicyclomine 20mg, and Midodrine 5mg. APRN #1 indicated she would have held all the three times, and four times daily medications, for the 12:00 PM and 1:00 PM doses, otherwise the resident would be getting a double dose. APRN #1 identified she would have instructed the nurse to give the 5:00 PM medications closer to the 4:00 PM side of the 1-hour window. APRN #1 indicated she would have expected a Nurses note indicating who the nurse spoke with and that that the physician or APRN was notified. Further, the APRN identified she had instructed the nursing staff if they call an on call APRN on weekends or evenings to put it in the communication book so she would be aware of any changes. APRN #1 indicated she was not aware or notified the medications were late on 3/4 and 3/5/23 and it was not in her communication book until today 3/13/23. Although attempted multiple times, an interview with LPN #2 was not obtained. Review of the Medication Administration Policy identified medications are prepared by a licensed nurse, follow the 5 rights right drug, right dose, right route, and right time are applied to each medication to be administered. Medications are to be administered within 60 minutes of the scheduled time. The nurse who administers the medication dose records the administration on the residents MAR directly after the medication is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews for 1 of 2 residents reviewed for pressure ulcer/injury, the facility failed to ensure an accurate pressure ulcer assessment and failed to conduct weekly wound measurements. The findings include: Resident #479 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus and chronic obstructive pulmonary disease. An admission nurse's note dated 2/3/22 at 1:30 PM identified an admission skin assessment that Resident #479 had 3 skin areas: a stage 2 sacral pressure ulcer that measured 13 centimeters (cm) by 7 cm, a right heel area (unspecified skin description) that measured 3 cm. by 3 cm., and a left heel area (unspecified skin description) lacking a measurement. Physician's orders dated 2/3/22 directed weekly skin checks and evaluations on bath/shower day, cleanse the Stage 2, coccyx pressure ulcer with normal saline, pat dry, apply TRIAD paste followed by a dry clean dressing once daily and as needed. The physician's order failed to address the bilateral heel skin alterations. The admission Minimum Data Set assessment dated [DATE] identified Resident #479 was cognitively intact and dependent for chair/bed transfers. Additionally, Resident #479 had one Stage 2 pressure ulcer on admission and no further documented pressure ulcer/skin injuries. The admission Resident Care Plan dated 2/3/22 identified a stage 2 coccyx pressure injury and left and right heel deep tissue injury (DTI). Interventions directed to record/report any new changes to the physician and nurse, off-loading boots (to relieve heel pressure) at all times, remove every shift for skin checks, and conduct weekly observations. A physician's order dated 2/15/22 directed skin prep to be applied to the right heel deep tissue injury once daily. A physician's order dated 2/21/22 directed skin prep to be applied to the left anterior heel blister, every evening at bedtime. Interview and clinical record review with Registered Nurse (RN #2) on 3/9/23 at 2:27 PM, identified that facility staff should have measured the right heel in addition to the coccyx and left heel. Although RN #2 identified that he was unsure why the right heel was not measured on admission, the charge nurse who completed the skin assessment would have been responsible for the measurement. Review of the Weekly Pressure Wound Rounds Tracking Sheet dated 2/8/22 failed to reflect that the left heel DTI had been measured or assessed since admission, or that the right heel DTI had been remeasured or assessed since the initial admission assessment. Review of the next Weekly Pressure Wound Rounds Tracking Sheet dated 2/15/22 failed to reflect a measurement or assessment of the left heel DTI. RN #2 indicated that both the 2/8/22 and 2/15/22 wound reports should have included measurements and assessments for both left and right heel DTI's per the facility practice. Interview with the Director of Nursing (DNS) on 3/13/23 at 1:00 PM indicated that documentation of the bilateral heel DTI's would have been expected to have occurred on admission and the subsequent weekly wound documentation including the assessment and tracking forms dated 2/8/22 and 2/15/22. Although requested, a copy of the pressure ulcer policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 8 residents (Resident #10) reviewed for nutrition, the facility failed to ensure the dietitian completed nutrition assessments after a change in condition and/or quarterly. The findings include: Resident #10 was admitted to the facility in October 2018 with diagnoses that included dementia with behavioral disturbance, depressive disorder, and delusional disorder. Reviewed of the weight summary dated 8/9/22 identified Resident #10 weighed 108.9 lbs. Reviewed of the weight summary dated 9/3/22 identified Resident #10 weighed 106.8 lbs. Reviewed of the weight summary for the month of October 2022 failed to reflect documentation of a weight Resident #10. The quarterly MDS dated [DATE] identified Resident #10 had severely impaired cognition and required supervision with eating. A nurse's note dated 10/12/22 at 2:42 PM identified Resident #10 was noted to have a fractured tooth on the lower left side of the mouth exposing a filling. Resident #10 denies pain, no redness or swelling noted. Resident #10 tolerating food and fluids without any difficulty. Resident representative made aware today and has signed the dental consent form. Resident #10 is to see in-house dental. Reviewed of the weight summary dated 11/1/22 identified Resident #10 weighed 103.4 lbs. A nurse's note dated 11/1/22 at 11:23 PM identified Resident #10 had a left gluteal stage 3 pressure injury measuring 1.5 cm length x 1.0 cm width x 0.3 cm depth. Wound bed 75% beefy red and 25% slough. Supervisor notified and requested Resident #10 to be seen by the wound physician. A social service note dated 11/3/22 at 10:55 AM identified a care conference with the Resident Representative, and the therapy department were in attendance. Resident #10 weight is gradually declining. The Resident Representative was not concerned as Resident #10 weighed less in the past. The Resident Representative often brings in meals and snacks. The Resident Representative has requested for resident's meat to be cut up. Resident #10 does not have bottom teeth and it is a struggle for he/she to chew meats. A nurse's note dated 11/6/22 at 1:23 PM identified Resident #10 complained of pain to left buttocks and left area. Medication Tramadol for pain was administered as ordered with minimum effect. The Resident Representative visiting expressing many concerns regarding the treatment for the open area, recent complained of pain, and awaiting dental services. Resident #10 had a dental visit on 10/27/22 and the Resident Representative was present during that visit. The dental service indicated they will return in two weeks. Will refer to nursing secretary regarding upcoming dental visit. APRN was notified to assess Resident #10 regarding pain. The wound physician to address open area on next visit. Resident #10 refused facility lunch and food brought in by family member despite encouragement. A nurse's note dated 11/7/22 at 2:29 PM identified Resident #10 was seen by the APRN for weight loss, and increase pain related to open area on left ischium. New order for Oxycodone and labs to be drawn. Resident Representative updated on new orders. Medical clearance received from the dental services for extraction of tooth placed in APRN book for review. The wound physician note dated 11/8/22 at 5:33 AM identified an initial visit for wound assessment to the left ischium. The left ischium has an acute unstageable pressure injury obscured full-thickness skin and tissue loss and has received a status of not healed. Measurement 1.2 cm length x 1.7 cm width x 0.3 cm depth. No tunneling has been noted. There is small amount of serous drainage noted with no odor. Resident #10 reported a wound pain of level 2/10. The wound bed has 51 - 75% slough, 1 - 25% granulation. Resident #10 has a diagnosis of pressure ulcer of left buttock, unstageable. Plan: Cleanse wound, apply Santyl, followed by dry clean dressing, change daily. Change as needed for soiling, saturation, or accidental removal. Optimize nutrition - registered dietician consultant. A nurse's note dated 11/11/22 at 10:46 PM identified Resident #10 status post tooth extraction, no swelling or sign and symptom of infection noted. Resident #10 food and fluid intake remains poor despite encouragement and offering alternative food. Review of the nurse's note dated 11/1/22 through 11/30/22 failed to reflect documentation that the dietitian has assessed Resident #10 regarding the left ischium pressure wound and weight loss. Reviewed of the weight summary dated 12/16/22 identified Resident #10 weighed 102.9 lbs. Reviewed of the weight summary dated 1/10/23 identified Resident #10 weighed was 99.3 lbs. The quarterly MDS dated [DATE] identified Resident #10 had severely impaired cognition and required supervision with eating. Review of the clinical record identified the last documented nutritional assessment by the Dietitian was completed on 8/1/22, 7 months ago. Interview and review of the clinical record with RN #7 on 3/8/23 at 1:00 PM identified he was not aware of the Dietitian had not assessed the resident since 8/1/22. RN #7 indicated he had spoken to the dietitian and the dietitian indicated it was an oversite that a nutritional assessment for the month of October 2022 and January 2023 was not completed. Interview with the DNS on 3/8/23 at 1:10 PM identified she was not aware the Dietitian had not assessed the resident since 8/1/22. Interview and review of the clinical record with the Dietitian on 3/9/23 at 1:10 PM identified she has been the only dietitian at the facility for approximately one year. The dietitian indicated she only works 2 days a week at the facility on Tuesdays, and Thursdays and indicated she did not complete the nutritional assessments due in October 2022 or January 2023. The dietitian indicated it was an oversite. The dietitian indicated she also works at another facility and identified if there is an issue with weight lost or a resident that needs to be seen, the license nurse will contact her. Review of the nutritional assessment policy identified as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition.

**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 pain management, the facility failed to ensure medications to treat pain were administered per physician's orders upon resident request. The findings include: Resident #20 was admitted to the facility with diagnoses that included migraines, osteoarthritis and pain of both hips, and polyneuropathy. The admission MDS dated [DATE] identified Resident #20 had intact cognition and had frequent pain limiting his/her day-to-day activities and sleep at night. The care plan dated 1/20/23 identified pain management for polyneuropathy and left shoulder pain. Interventions included to monitor pain, administer medications as ordered, monitor and document effects of pain medications. APRN #1 progress note dated 1/29/23 identified Resident #20 was seen for increased acute and chronic pain with history of osteoarthritis, and complaints of spasms. APRN added an order the medication Flexeril for back spasms and will consider baclofen. APRN #1 progress note dated 2/14/23 indicated Resident had migraine headaches and Floricet was helpful and will continue order for Floricet. APRN #1 order dated 2/21/23 directed to not change medications unless approved by APRN or MD after speaking with resident. A physician's order dated 2/23/23 directed to administer Tramadol 50 mg tablet every 12 hours for pain, Fioricet 50-300mg 2 tablets every 8 hours as needed for migraines, extra strength Tylenol 500 mg 2 tablets every 6 hours as needed for mild pain, and Flexeril 5mg every 8 hours as needed for muscle spasms. Interview with Resident #20 on 3/6/23 at 11:00 AM indicated on Saturday 3/4/23 and on Sunday 3/5/23 he/she requested the prn medications at bedtime for a migraine headache, but the same nurse stated it was her judgement whether to give the pain medication Flexeril and Fioricet for the resident's headaches. Resident #20 indicated this nurse worked a double on Saturday and Sunday and would not give him/her the prn medications for the migraine headache at bedtime. Resident #20 indicated he/she did not receive the pain medication because it was the nurse's judgement. Interview with LPN #1 on 3/9/23 at 10:57 AM indicated Resident #20 reported Monday morning 3/6/23 that he/she had a horrible weekend because LPN #2 refused to give the resident his/her prn medications Flexeril and Fiorect for headaches. LPN #1 indicated Resident #20 was alert and oriented and was had a medical background. LPN #1 indicated Resident #20 was never lethargic or drowsy when he/she requested prn medications and knows he/she can take them and does not get drowsy. LPN #1 indicated on Monday when Resident #20 reported LPN #2 refused to give the prn medications he/she reported it to RN #1 who was the supervisor on 3/6/23 in the morning. LPN #1 noted Resident #20 reports that this happens every time LPN #2 works on this unit, and the resident reports it to the supervisor every time. Interview with RN #1 on 3/9/23 at 11:15 AM indicated LPN #1 informed her that Resident #20 did not receive the prn medications upon request over the weekend because LPN #2 did not give it to Resident #20. RN #1 indicated LPN #2 had spoken to RN #1 on Saturday that she did not feel comfortable giving the resident the medication for headache and pain and RN #1 informed LPN #2 if there was an order to give the medications. LPN #2 was to give the medications requested and if she were worried giving the prn medication then monitor the resident. RN #1 indicated she had informed the other supervisor if a resident asks for a prn medication, we need to give it and the nurse can't hold a medication based on how the nurse feels about it. RN #1 indicated she informed the nurses if they did not feel comfortable giving a medication and there was a physician's order for the medication, to notify the supervisor and then the APRN/MD. Interview with the DNS on 3/9/23 at 12:21 PM identified if a resident asks for the prn medication for pain or migraines the nurse should evaluate the resident and if a resident asks for a physicians ordered medication, the nurse should give it. The DNS indicated if the nurse had a concern, he/she should discuss it with the supervisor and then the APRN. Upon review of the clinical record, the DNS indicated Resident #20 did not receive the Flexeril or the Fioricet in the evening or night of 3/4/23 and 3/5/23. Interview with the Corporate Director of Clinical Services (RN #7) on 3/9/23 at 2:01 PM indicated the charge nurse should have given the pain medications per the resident's request. RN #7 indicated since Resident #20 was alert and oriented she/she had a right to ask for and receive the medications per the physician's orders. Interview with APRN #1 on 3/13/23 at 9:57 AM indicated she had added the Flexeril and Fioricet, and she had discussed all the medications with the resident. APRN #1 indicated if there were orders for medications in place and the resident asks for the medications, they should be given upon request unless Resident #20 was lethargic. APRN #1 indicated she had heard of that a nurse was not giving Resident #20 his/her prn medications and that was why on 2/21/23 she wrote the order to not change the medications without calling her (APRN #1) first and that is why the order was put in place to not change the medications because that nurse called an on call and changed the orders. APRN #1 indicated she was not notified that the prn medications were not given as requested until today 3/13/23. APRN #1 indicated her expectation was the nurses would give an alert and oriented resident his/her prn medication upon request. Although attempted, an interview with LPN #2 was not obtained. Review of the Pain Assessment and Management Policy identified to provide guidelines for assessing the residents level of pain prior to administering analgesic pain medications. The pain management program is based on a facility wide commitment to resident comfort. Pain Management is defined as the process of alleviating the residents pain to a level that is acceptable to the resident and is based on his/her clinical condition and establish treatment goals. Administer the pain medication as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy, and interviews during a review of facility immunizations records for four of five Residents (Resident #'s 16, 18, 43 and 71), the facility failed to offer and provide influenza and pneumococcal immunizations as required. The findings include: Interview and review of facility immunization documentation with the Infection Control Nurse, RN#2, on 3/13/2023 at 8:52 AM identified the following: 1. Resident #16's diagnoses included unspecified dementia, cerebral infarction, and diabetes mellitus. Review of physician's order identified a standing order since 11/30/2022 to offer the flu vaccine. 2. Resident #18's diagnoses included hypertension, chronic kidney disease, and presence of a cardiac pacemaker. 3. Resident #43's diagnoses included unspecified dementia, cerebral infarction, and hypertensive heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #43 was cognitively intact. Interview with Resident #43 on 3/9/2023 at 3:20 PM indicated s/he had received her/his influenza vaccination at a pharmacy but was unable to recall the exact date. Additionally, Resident #43 indicated that s/he had received her/his pneumococcal vaccine from his/her primary care physician, did not recall the date, but the facility could contact the primary care physician for the information. Resident #43 indicated that s/he was not willing to take the COVID-19 vaccination. 4. Resident #71's diagnoses included traumatic subdural hemorrhage, encephalopathy, and myoneural disorder. Continued interview with RN #2 on 3/13/2023 at 8:52 AM identified that despite the standing physician's order, Resident #16 had never been offered the opportunity to accept or decline the influenza vaccine for the September 2022 to March 2023 flu season. RN #2 indicated that although it was the facility policy to offer the pneumococcal vaccine upon admission, Resident #18 and Resident #71 had never received an opportunity to accept or decline the pneumococcal vaccine. Additionally, RN #2 failed to identify that facility staff had attempted to obtain Resident #43's immunization administration history or that immunizations had been offered or declined. Review of the facility policy for Influenza Vaccination for Residents indicates all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually. Review of the facility policy for Pneumococcal Vaccination of Residents indicates if there is no established history or evidence of pneumococcal vaccination, the PCV13 vaccine will be offered to the resident upon admission followed by PPSV23 in one year unless there is a medical/clinical indication for sooner administration.

Based on observations, facility documentation, and interviews the facility failed to ensure that COVID-19 vaccination information was stored securely. The findings include: On 3/07/23 at 10:30 AM an observation of the Infection Control Office failed to ensure that staff and resident COVID-19 documents were secured from access by residents and staff. The office doors were unlocked and open and staff were not present in the office or outside in the adjacent hall. Interview with RN #2 on 3/07/23 at 10:49 AM indicated that the COVID-19 employee and patient records of vaccination status were kept locked in the Infection prevention office at all times due to HIPAA (to safeguard health information), however, RN#2 was unaware that the door needed to remain closed and locked if he was not in the office but in the building. A second observation on 3/09/23 at 3:17 PM identified that the Infection Prevention Office doors were left unlocked and open to the hall, without facility staff present, and that COVID-19 vaccination for both residents and staff was accessible and unprotected. Although requested, a facility health information safekeeping policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Interview with Person #1 on 3/9/23 at 9:30 AM indicated that s/he had reported to the facility that Resident #479's clothing was routinely lost. Person #1 indicated that s/he began to launder Resident #479's clothing at home after articles of clothing were reported missing. Interview with Social Worker (SW) #1 on 3/9/23 at 11:10 AM and review of the nurse's note dated 4/18/22 at 2:48 PM identified Social Services, Director of Nursing (DNS), and the Laundry Department were notified of Resident #479's missing clothing report. An additional nurse's note dated 4/19/22 at 1:39 PM indicated that laundry was notified of Resident #479's missing khakis. SW #1 indicated the process for reporting missing personal items is that a resident, resident representative, or facility staff member would notify the social worker of the missing item and then a grievance form should be filled out. Copies of the grievance form would be sent to the Director of Nursing (DNS), Administrator, appropriate department leadership, and reviewed during daily morning report. SW#1 indicated she had attended multiple meetings with facility staff, Resident # 479, and the resident representative. Initially, SW #1 did not recall facility staff, Resident #479, or representative notifying her of missing clothing items. After review of the nursing notes, she indicated that a grievance form should have been filed and if she had filed a grievance, it would have required a resolution for the missing clothing items. Interview with the DNS on 3/9/23 at 1:18 PM indicated that the procedure for lost clothing would be to first go to the laundry to see if the item(s) can be located, then there is an option for filing a grievance. The DNS did not recall if Resident #479 or a resident representative had reported missing clothing. Additionally, the DNS reported that Resident #479's significant other may have done his/her laundry, outside of the facility. Interview with the Director of Maintenance on 3/13/23 at 12:35 PM, indicated that the process for reporting missing clothing would be for a grievance form to be completed, the form would then be shared with housekeeping staff, subsequently a search for the missing item could be initiated. Additionally, all resident's clothing articles are labeled with the resident's name to facilitate locating missing personal items. The Director of Maintenance did not recall if Resident # 479's clothing was reported missing. Review of the Grievance log for 2022 indicated there was no grievance on file for Resident #479's missing clothing items. Review of the grievance/complaint reporting policy directed all complaint/grievances were to be recorded and filed in the facilities complaint/grievance log and maintained in the social service department. Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #20 and 479) reviewed for grievances, the facility failed to ensure the grievance policy was followed for a complaint regarding medications; and failed to ensure a grievance was completed when the resident reported missing personal items. The findings included: 1. Resident #20 was admitted to the facility with diagnoses that included migraines, osteoarthritis and pain of both hips, polyneuropathy, bipolar disorder, and chronic obstructive pulmonary disease. The admission MDS dated [DATE] identified Resident #20 had intact cognition and frequent pain limiting his/her day-to-day activities and sleep at night. The care plan dated 1/20/23 identified the resident had polyneuropathy and left shoulder pain. Interventions included to monitor pain, administer medications as ordered, monitor and document effects of pain medications. Interview with Resident #20 on 3/6/23 at 11:00 AM indicated she was upset that on 3/4/23 and 3/5/23 the same nurse was late with his/her 9:00 AM medications and that he/she did not receive them until after 12:00 PM. Resident #20 indicated she was a retired nurse and has his/her medication regimen and if he/she does not receive his/her medications on time he/she becomes anxious and has physical symptoms. Resident #20 indicated when this specific nurse is on duty, she gives the medications late. Resident #20 indicated he/she did report the late medications to LPN #1 on 3/6/23 that he/she was upset the medications were not given timely and this nurse had refused to give him/her the prn pain medications. Resident #20 indicated she was upset the 9:00 AM medications were so late and then the 1:00 PM medications were given at 2:00 PM and some of these medications were like getting a double dose. Additionally, Resident #20 indicated Saturday and Sunday evening at bedtime on 3/5/23 he/she had asked the same charge nurse for pain and migraine medication when the nurse came in to give the scheduled bedtime medications, but he/she never got the medication. Resident #20 indicated this nurse worked a double on Saturday and Sunday. Resident #20 indicated he/she did not receive the pain or migraine medication on Saturday or Sunday evening because it was this nurse's judgement. Resident #20 indicated the pool nurse informed Resident #20 to ask on the night shift. Resident #20 indicated he/she asked 2-3 times during the night and did not receive the prn Fioricet or the pain medication. Resident #20 indicated at 6:00 AM he/she asked for extra strength Tylenol and the day nurse must have come in early, and he/she received it. Interview with LPN #1 on 3/9/23 at 10:57 AM indicated Resident #20 reported Monday 3/6/23 in the morning that he/she had a horrible weekend because LPN #2 gave his/her medications over the weekend very late and refused to give Resident #20 his/her prn Flexeril for pain and Fioricet for his/her headaches. LPN #1 indicated Resident #20 was alert and oriented and had a medical background and knew his/her medications very well. LPN #1 indicated Resident #20 was never lethargic or drowsy when she requested prn medications and would not ask for them if not needed. LPN #1 noted Resident #20 reports that this happens every time LPN #2 works and she reports it to the supervisor every time. LPN #1 indicated on Monday when Resident #20 reported LPN #2 was late with the medications and refused to give the prn medications, LPN #1 reported it to the supervisor, RN #1. Interview with RN #1 on 3/9/23 at 11:15 AM indicated LPN #1 informed her that Resident #20 did not receive his/her medications in a timely manner over the weekend of 3/4 - 3/5/23 and the prn medications were not given when requested. RN #1 identified about noon on Saturday, LPN #2 approached RN #1 and stated she did not feel comfortable to give Resident #20 the medication for headache and pain. RN #2 indicated she had informed LPN #2 that there was a physician's order and if Resident #20 was requesting the prn medications she was to give it and monitor the resident. RN #1 indicated she was busy on Monday and Tuesday, so she did not speak to Resident #20 about the late medications and the nurse not giving the requested prn medications until Wednesday 3/8/23, which was when she notified the APRN. RN #2 indicated Resident #20 reported the medications were late both days over the weekend and Resident #20 stated he/she had to keep asking and doesn't get them which upset the resident and caused him/her to be anxious. RN #2 noted Resident #20 reported that he/she gets increased anxiety if medications are not given timely and his/her body will act in a negative way. RN #1 indicated she did not speak with Resident #20 on Monday when first informed because she thought it was addressed. RN #1 indicated there were no falls or emergencies on that unit for LPN #2 to be that late with the medications, but there were limited nurse aides. RN #1 indicated the scheduled medications were to be given within 1 hour of being scheduled and if they were late to notify the APRN. Interview the DNS on 3/9/23 at 12:21 PM indicated after review of medical record, LPN #2 nor the supervisors had notified the APRN or physician that the medications were over 3 hours late on 3/4 or and 3/5/23. The DNS indicated that RN #1 had informed her on 3/9/23 of Resident #20's complaint and the DNS indicated if she was notified on 3/6/23 she would have first interviewed the resident and would ask questions to see the scope and severity of the complaint and if ask the resident wanted to file a grievance. The DNS indicated she was not informed of the complaint from Resident #20 on Monday and the DNS indicated she would be filing a grievance now. Interview with the Corporate Director of Clinical Services (RN #7) on 3/9/23 at 2:01 PM indicated when she was informed the resident was upset that the medications were not given timely, and that nurse did not give the prn medications that were requested, RN #1 should have immediately notified the DNS and the DNS should have filled out a grievance and then started an investigation on Monday 3/6/23. RN #7 indicated the investigation should have started immediately to determine if this was a grievance or if it was a reportable for abuse depending on the outcome. Interview with the DNS on 3/9/23 at 2:34 PM indicated she had spoken with Resident #20 on 3/9/23 after surveyor inquiry and clinical record review. The DNS indicated she interviewed RN #1 who informed the DNS that she was aware on 3/6/23 that Resident #20 had complained about LPN #2 but had not spoken to Resident #20 until 3/9/23 after surveyor inquiry. The DNS indicated RN #1 informed her that LPN #2 was late with her medications on Saturday and Sunday and that the resident stated it affects his/her body and mind. Additionally, that LPN #2 did not give him/her the prn medications when he/she had requested them. Although attempted multiple times, an interview with LPN #2 was not obtained.

3. Review of facility outbreak documentation with the Infection Preventionist, RN #2, on 3/07/23 at 10:13 AM identified a COVID-19 outbreak had been declared on 4/11/22 and was still currently in effect. RN #2 indicated that he had been employed with the facility since 12/20/2022. Review of facility education, and competency records identified that although the COVID-19 outbreak had been declared on 4/11/22, the first infection control education for staff began on 5/2/22, 21 days following the first COVID-19 case. RN #2 identified that the facility employs approximately 127 facility staff. RN #2 provided documentation of education and competency for 2022 and 2023 as follows: a. In May 2022, 115 employees were educated; On 5/2/22 and 5/3/22, 47 staff were educated on COVID-19 increased positivity rates; 5/9 to 5/12/22, 5 were observed for proper PPE use, 5/20/22 to 5/21/22, 31 staff attended PPE use and unspecified COVID-19 training, and on 5/26/22 32 staff attended PPE and unspecified infection control education. b. In June 2022, 21 employees were educated on unspecified COVID-19 information. c. In July 2022, 3 housekeeping staff were observed for proper PPE use. d. In August of 2022 31 staff were educated, 6 on an unspecified COVID-19 update, 17 for an unspecified COVID-19 review, and 8 were educated on Antigen testing. RN #2 indicated that although the outbreak continued from August 2022 through 12/20/22 when his employment began, no additional educational or competency skill records were identified. RN #2 was unable to explain the lapse in education or competencies from 8/23/22 through 1/14/23 approximately 4.5 months during an active COVID-19 outbreak. Additionally, in the 3 months since RN #2 became employed at the facility, he had conducted 1 education/competency on 1/15/23 with 7 staff related to handwashing. RN #2 indicated that yearly education and competencies were required but that he was not aware of an education and competency policy. Interview with the DNS on 3/7/23 at 10:45 AM indicated that there have been several staff covering the Infection Preventionist role over the last year who would have coordinated education and competency training. The DNS identified that although she had felt that more education and competencies had been provided to staff, she failed to provide any further documentation. Subsequent to surveyor inquiry, the facility provided additional staff education as follows: a. On 3/7/23 the facility educated 20 employees on Norovirus and handwashing. b. On 3/9/23 and 3/10/23 COVID-19 testing, and guideline educations were held for 63 employees. c. On 3/10/23 the facility educated 37 employees on hand hygiene. Interview with RN#1 and the Administrator on 3/13/2023 at 3:32 PM indicated that there should have been more education and competencies during the COVID19 outbreak. The facility failed to provide adequate staff education, training records and competencies to demonstrate preventative measures during an extended COVID-19 outbreak. Although requested a facility policy for staff education and competencies was not provided. 2 a. Resident #21's diagnosis included diabetes mellitus. Review of the March 2023 Medication Administration Record (MAR) directed facility staff to obtain a blood glucose reading for Resident #21 daily at 6 AM. Observation on 3/8/23 at 6:25 AM with LPN #5 identified blood glucose testing supplies were obtained from the top drawer of the medication cart. LPN #5 placed gloves without the benefit of washing or sanitizing her hands. LPN #5 entered Resident #21's room, cleansed the resident's finger with an alcohol wipe without the benefit of allowing the alcohol to dry, pricked the residents finger with the lancet, and obtained the blood sample. LPN #5 again cleansed Resident #21's finger with the used alcohol wipe followed by wiping the finger with a clean gauze pad. LPN #5 discarded the lancet into the sharp container on the medication cart, and without the benefit of removing her gloves or sanitizing/washing her hands, opened the medication cart drawer, removed cleaning wipes, wiped the glucose testing device with one wipe and then wrapped the blood glucose testing device with 2 additional wipes leaving the wrapped meter on top of the medication cart and without allowing the device to dry. LPN #5 removed her gloves and without the benefit of washing her hands, used the computer on the medication cart and collected supplies for the next resident, Resident #22. Interview with LPN#5 on 3/8/23 at 6:28 AM indicated that she should have removed her gloves and sanitized her hands after leaving Resident #21's room. LPN #5 was then noted to sanitize her hands. Although LPN #5, acknowledged knowing she had not appropriately sanitized her hands after leaving Resident #21's room, she continued to utilize the equipment she had gathered for Resident #22 prior to appropriate hand washing/sanitization. b. Resident #22 diagnosis included diabetes mellitus, pneumonia, and depression. Review of the March 2023 Medication Administration Record (MAR) directed facility staff to obtain a blood glucose reading daily at 6:00 AM. Continued observation of LPN #5 on 3/8/23 at 6:32 AM identified LPN#5, after being questioned and washing her hands, placed on clean gloves, and picked up the supplies placed on top of the medication cart prior to hand washing or sanitizing and entered Resident #22's room. LPN #5 cleansed Resident #22's finger with the alcohol swab and without waiting for the alcohol to dry, immediately took the blood sample on the test strip. LPN#5 then wiped the finger with the same used alcohol swab followed by wiping the finger with a gauze pad. LPN#5 exited Resident #22's room with the used testing supplies. Without the benefit of removing her gloves, she discarded the lancet in the sharp container, opened the drawer of the medication cart and removed the cleaning wipes. LPN#5 cleaned the blood glucose meter with 1 wipe, wrapped the blood glucose monitor in 2 additional wipes, and set the glucometer aside on the top of the medication cart and without allowing the device to dry. LPN#5 removed her gloves and proceeded to use the computer without the benefit of washing/sanitizing her hands. Interview with LPN #5 on 3/8/23 at 6:32 AM indicated that although she knew from the previous interview that she should have removed her gloves and washed or sanitized her hands prior to conducting further tasks, she indicated she thought she had, and stated Oh well. LPN #5 identified that she had been taking blood sugar readings for a long time and was last educated 40 years ago. Additionally, LPN #5 indicated that a wait time of 5 minutes was required to clean the glucose meter and that she had wrapped the monitor and left it within the wipe to ensure it was clean. c. Resident #43's diagnoses included Diabetes mellitus, and UTI. During a third observation of LPN #5 on 3/8/23 at 6:39 AM, she used the still wrapped, first glucose monitoring device from on top of the cart and immediately entered Resident #43's room. LPN#5 wiped Resident #43's finger with alcohol and immediately took the blood sample. LPN#5 then wiped the finger again with the same used alcohol wipe and dried the finger with gauze. As LPN#5 was exiting Resident ##43's room, she was observed to remove one glove in the room to turn the light on and took the other glove off when exiting the room. LPN#5 discarded the lancet and gloves, opened the drawers of the cart and cleaned the glucometer with a wipe without wearing gloves and without the benefit of performing hand hygiene and wrapped the meter in 2 wipes leaving it on top of the cart and without allowing the device to dry. Interview with LPN#5 on 3/8/23 at 6:43 AM indicated that she had just returned from an extended absence and that she had not been educated on proper procedures for blood glucose testing and was unaware if she had completed the testing correctly. LPN #5 indicated that she was unable to recall facility protocol for re-using the same alcohol wipe to initially cleanse a resident's finger, and then cleanse the finger following the blood sampling, stating she used the other side of the alcohol wipe. LPN #5 was unaware of the facility policy to allow a resident's finger to dry prior to obtaining a blood sample, and indicated that the finger was not that wet. LPN #5 indicated that a wet finger was the equivalent to eating a cookie and having sugar to remain on the fingers, that it would not make a difference. Interview with the Infection Preventionist, RN#2, on 3/8/23 at 6:55 AM indicated that the procedure for obtaining a blood sugar was to wipe the selected finger and to let the finger dry completely before pricking the finger with the lancet. RN#2 indicated that first drop of blood should be wiped off with the gauze and the second drop used to take the sample. RN#2 indicated that gloves should be removed after removing the strip from the blood glucose device, in between tasks, with hand hygiene before and after glove placement and removal, and with every resident contact. RN#2 could not confirm when last glucometer education was completed with staff. Subsequent to surveyor inquiry 17 employees were educated on blood glucose monitoring use. Review of the Blood Glucose Level measuring policy indicated, in part, to wash the resident's hands with soap and warm water or use alcohol wipes. Clean the glucose monitoring device with a bleach product or germicidal disposable wipe (purple top) after each use. Allow meter dry times per manufacturer instructions. Review of the manufacturer's guidelines indicated that cleaning and disinfecting the glucose monitoring device directed the user to always wear the appropriate protective gear, including disposable gloves. Option 1 of cleaning indicated: Use a commercially available EPA-registered disinfectant detergent of germicide wipe. Open disinfectant package. Follow product label instructions to disinfect the meter. Use caution as to not allow moisture to enter the test strip port, data port or battery compartment, as it may damage the meter. Review of the Instructions for use on the Sani cloth germicidal disposable wipes (purple top) indicated that the special instructions for cleaning and decontamination indicated that disposable protective gloves when using this product. The manufacturers label indicated that all blood and other body fluids must be thoroughly cleaned from surfaces and objects before disinfection by the germicidal wipe. Use second germicidal wipe to thoroughly wet surface. Allow surface to remain wet two (2) minutes then let the cleaned surface air dry. 2. Interview and review of facility documentation with the Infection Control Nurse (RN#2) on 3/13/23 at 2:48 PM identified that he had been employed at the facility since December 2022. RN #2 indicated that he had not conducted any IV education or competencies since being employed at the facility. Additionally, RN #2 failed to exhibit any verification that licensed staff or Nurse Aids (NA) had received facility education, training or had demonstrated competency. Interview with the Director of Nursing (DON) on 3/13/23 at 3:00 PM identified that although she believed IV therapy education and competencies were required annually, education and competencies could be located in the facility. Review of the IV manual dated 4/1/2017 directed ongoing staff education, in-services and required a clinical competency program for Licensed Nurses was required at least annually and as deemed necessary by the facility management. Although requested, a facility policy for IV competencies, training, and education, one was not provided. Based on review of facility documentation, facility policy and interview, the facility failed to conduct nursing staff competencies for years 2021 and 2022. Further, based on facility documentation and interviews, the facility failed to ensure adequate staff education and competency skills during an 11 month COVID-19 outbreak and failed to ensure competency for glucose testing and handwashing. The findings include: 1. Interview and review of facility documentation with the DNS on 3/10/23 at 10:40 AM failed to reflect competencies for 2021 and 2022 had been completed. The DNS identified that multiple changes in the facility's staff development personnel, combined with the additional responsibilities associated with the Covid 19 pandemic as key factors in the facility's inability to complete clinical competencies. Although requested, the policy regarding staff competencies was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 10 residents (Resident #3) and 9 of 10 other residents who utilize adaptive equipment (Resident #14, 17, 35, 41, 48, 51, 54, 65, and 71) the facility failed to ensure adaptive equipment was provided during a GI outbreak (13 days). The findings include: Resident #3 was admitted to the facility with diagnoses that included dysphasia, Parkinson's disease, and dementia. Facility documentation dated 10/5/22 identified Resident #3 weighed 118.6 lbs. Facility documentation dated 1/1/23 identified Resident #3 weighed 108.2 lbs. Physician's monthly orders for February 2023 directed to provide a lactose reduced diet, puree texture, nectar thick liquids, no bread, and 1:1 feed for all meals. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition and was totally dependent on staff for eating. The care plan dated 2/28/23 identified the resident had weight loss and to provide the resident a nosey cup (adapted drinking cup) for all meals, 1:1 feeding assistance, encourage at least 50% intake of meal and offer substitute if the resident doesn't eat greater than 50%. Review of the nurse aide care card, undated, for Resident #3 identified the resident required a puree diet and to use a nosey cup for each meal. Observation on 3/6/23 at 12:15 PM identified the nurse aide delivered a meal tray to Resident #3 in his/her room and placed the meal on the overbed table near the window. The meal tray was in Styrofoam products. There was a square container with lid for the main meal, 2 Styrofoam cups with disposable plastic lids for drinks and a magic cup for dessert. Although the meal ticket identified the resident required a nosey cup, it was not on the meal tray. At 12:45 PM NA #2 opened the cup of juice and instructed Resident #3 to open his/her mouth for a sip and held the cup for Resident #3. NA #2 began feeding Resident #3 a spoonful of the food mixture. The observation identified NA #2 did not get a nosey cup. Interview with NA #2 on 3/6/23 at 12:54 PM indicated Resident #3 liked cranberry juice and she would provide it in the Styrofoam cup to Resident #3. NA #2 noted there was not a nosey cup on Resident #3's meal tray and was not sure if Resident #3 needed one. Review of the meal ticket, NA #2 indicated it said for Resident #3 to have a nosey cup, but she was not aware Resident #3 needed a nosey cup. Interview with Dietary Supervisor on 3/6/23 at 1:00 PM indicated because of the GI outbreak, the facility was using Styrofoam and paper and she was not giving out the adaptive equipment at meals for any of the residents that needed it including Resident #3. The Dietary Supervisor indicated dietary staff were responsible to put all adaptive equipment on the meal trays and indicated she had made the decision based on the local heath dept recommendation that the facility use paper products. The Dietary Supervisor indicated she made the decision not to give out the adaptive equipment to any of the residents on the list and identified she did not speak with the medical director, infection control nurse, director of nursing, or the rehabilitation director before she made the decision. Interview with the Medical Director (MD #1) on 3/8/23 at 6:45 AM indicated he was notified at the end of last week by the infection control nurse there was a GI outbreak but did not recall which day. MD #1 indicated he did not recall discussing the residents having to go on paper products for meals and indicated no one had asked him about whether or not to use the adaptive equipment for meals but he thinks therapy would be involved in the decision. MD #1 indicated he had not thought about that before and did not have a recommendation on whether or not the residents while using paper products for meals should still receive the adaptive equipment and he would have to think about it. MD #1 indicated his expectation was the infection control nurse, the dietary person, the DNS and the rehabilitation director would discuss it and he would agree with their recommendations. Interview with RN #2 on 3/13/23 at 10:45 AM indicated on 3/2/23 he had spoken with the local health department at the beginning of the GI outbreak who had given the recommendation to use paper products but he did not ask the local health department about the use of adaptive equipment. RN #2 indicated he informed the Dietary Supervisor of the recommendation to use paper products to help prevent the spread of infection. RN #2 indicated they did not discuss the adaptive equipment and indicated he did not discuss whether to use the adaptive equipment with the Medical Director MD #1, the DNS, the rehabilitation director. RN #2 indicated the GI outbreak started on 3/1/23 and ended today 3/13/23. RN #2 indicated he was aware that all residents that had adaptive equipment were not receive it during the outbreak (13 days). Interview with Director of Rehabilitation (OTR #1) on 3/13/23 at 11:14 AM indicated no one had asked her during the GI outbreak if residents should still receive the adaptive equipment. Director of Rehabilitation indicated the residents absolutely would still need the adaptive equipment for their independence and aid with meals and indicated she would have continued with the adaptive equipment during the outbreak even though the rest of the food and drinks were on paper. The Director of Rehabilitation indicated the adaptive equipment would go through the dishwasher that would kill the germs and indicated Resident #3 needs the nosey cup to be able to drink independently by him/herself. The Director of Rehabilitation indicated Resident #3 cannot feed him/herself but with the nosey cup can drink by him/herself and would benefit from the use of the nosey cup. Interview with the DNS on 3/13/23 at 2:10 PM indicated during the outbreak no one had discussed with her whether to use adaptive equipment or not. The DNS noted it would be a risk vs benefit when dealing with an outbreak, but you want the residents to be as independent as possible. Review of the Assistive Devices and Equipment Policy identified the facility provides, maintains, trains, and supervises the use of assistive devices and equipment for residents. Devices and equipment that assist with residents' mobility, safety, and independence are provided for residents. Review of the Feeding a Resident Meals Policy identified occupational therapy evaluations and adaptive self-help devices are provided as needed to promote and maintain independence in eating. Place utensils in hand of resident and guide hand from plate to mouth during feeding if indicated.

Based on observation, review of facility documentation, facility policy and staff interview, the facility failed to record the dishwashing temperature for 2 meals during a facility GI outbreak. The findings include: The facility was in an ongoing GI outbreak since 3/1/23, impacting 41 residents, with 20 residents having been resolved as of 3/4/23 and 4 resolved 3/6/23, as 17 residents continued to remain symptomatic with symptoms of nausea, vomiting and or diarrhea. Review of the dishwashing temperature log identified no documentation of food temperatures on 3/2/23 and 3/3/23 for dinner. Interview with the Dietary Supervisor on 3/6/23 at 10:10 AM identified the dishwashing temperatures for dinner on both for 3/2/23 and 3/3/23 were not documented on the dishwasher temperature log. The Dietary Supervisor identified it is the responsibility of dietary staff to log the temperature with each meal and he did not know why it wasn't documented. The facility policy indicates that dishwasher temperatures will be monitored and recorded 3 times a day by dietary aide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility documentation, facility policies, and interviews reviewed for infection control practices during multiple, concurrent outbreaks, the facility staff failed to redirect a visitor lacking Personal Protective Equipment (PPE) use, failed to implement appropriate environmental disinfecting following a lack of PPE use and lack of handwashing, failed to initiate timely contact tracing for a newly identified COVID-19 positive resident, failed to test COVID-19 symptomatic residents per CDC guidelines, failed to separate a COVID-19 symptomatic resident from a roommate, failed to maintain COVID-19 isolation protocols in accordance with standards, failed to appropriately cohort a resident with a multidrug resistant resident (MDRO) history, failed to perform appropriate hand hygiene with glove use, failed to follow appropriate blood glucose monitoring testing procedures, failed to follow the manufacturer's instructions for cleaning a glucose monitoring device. The findings include: Review of facility outbreak documentation with the Infection Preventionist, Registered Nurse (RN) #2, on 3/07/23 at 10:13 AM identified a COVID-19 outbreak had been declared on 4/11/22 and was still currently in effect. Additionally, RN #2 indicated that a gastrointestinal (GI) outbreak had been declared on 3/1/23. 1. Resident #41's diagnosis included Norovirus. Observations on 3/8/23 at 10:10 AM identified a facility visitor, Person #2, in Resident #41's isolation room without the benefit of wearing any Personal Protective Equipment (PPE). Person #2 was observed to exit the room, walk down the hall touching handrails and the bathroom doorknob. Person #2 did not sanitize or wash his/her hands prior to leaving Resident #41's room. Interview and review of facility policy with RN#1 on 3/8/23 at 9:55 AM identified that there was no facility policy for visitors to comply with infection control signage. After the surveyor reported the observation of Person #2's non-compliance to RN #1, indicated that RN supervisors could educate visitors, but most visitors did not listen. RN #1 added visitors did not need to comply with precautions and that it was just a suggestion. Further, RN #1 identified that visitor non-compliance could have been brought to the attention of the Director of Nurses (DNS), but that she had never done so. Interview with NA #4 on 3/8/23 at 10:20 AM identified that if she had observed Person #2's non-compliance, she would have notified the nurse to redirect them in the proper use of PPE. Interview with Person #2 on 3/8/23 at 10:20 AM identified that facility staff had educated him/her on one occasion, with an emphasis on handwashing but that s/he felt that handwashing was an effective infection control measure with no need to wear PPE to prevent the spread of illness. Interview with the Infection Preventionist, RN#2, on 3/9/23 at 10:00 AM identified that his expectation for facility staff, following report of visitor non-compliance would be to re-educate the visitor and request housekeeping disinfect the affected surfaces. RN #2 indicated that although there was no infection control facility policy requiring staff redirect visitor non-compliance, good infection control practices should have been maintained. RN #2 identified that he would be educating staff on appropriate infection control measures. Review of the facility policy for outbreaks identified, in part, that the facility would in-service all staff about the existence of an outbreak, their individual responsibilities, and the importance of compliance with isolation. Additionally, this information would be repeated as appropriate for residents and visitors as well as the importance of handwashing and proper PPE use for all. Review of the outbreak policy indicated that the facility would institute control and prevention measures to include cohorting residents, hand hygiene, isolation precautions, environmental cleaning indicating that high-touch surfaces should be cleaned frequently, and education of visitors concerning infection control and PPE usage. 2. a. Interview and review of Resident #42's clinical record with RN #2 on 3/9/23 at 9:48 AM identified that on 3/8/23 Resident #42 was hospitalized due to GI symptoms. While at the hospital Resident #42 was tested and received a diagnosis of COVID-19. RN #2 indicated that he was unsure how Resident #42 had contracted COVID-19 as he had not initiated contact tracing to determine the resident's potential exposure. Additionally, RN #2 was unable to indicate which staff had cared for Resident #42, if Resident #42 had been out of his/her room without the benefit of source control (a mask), or if any residents had entered Resident #42's room without appropriate source control. Subsequent to surveyor inquiry, contract tracing was initiated. Contract tracing showed a finding that Resident #42's roommate, Resident #56 had a visitor who tested positive for COVID-19 10 days earlier. b. Interview, review of facility outbreak information, and review of facility policy with RN #2 on 3/9/23 at 10:40 AM identified the facility had been in a COVID-19 outbreak since 4/11/22 and since 3/1/23 was experiencing a concurrent Gastrointestinal (GI) outbreak with 42 affected residents. RN #2 indicated that the facility used CDC guidance as their policy for COVID-19 testing. RN #2 stated that 1 resident had been tested and was positive for the Norovirus as of 3/7/23. RN #2 indicated that although 2 of the 42 residents had tested negative for COVID-19 (Resident #27 and Resident #56) since the onset of the GI outbreak, he assumed that all the subsequent GI symptomatic residents were the result of contracting the Norovirus. RN #2 indicated that COVID-19 signs and symptoms included nausea, vomiting, and diarrhea (GI symptoms). RN #2 was unable to explain why he was not following the CDC guidance for COVID-19 testing for residents with GI symptoms. RN #2 identified that there was no way to distinguish COVID-19 from Norovirus without appropriate testing. Subsequent to surveyor inquiry, the remaining 40 residents with GI symptoms were tested for COVID-19. Review of COVID-19 policy indicated that anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. c. Interview and review of the facility outbreak documentation with RN #2 on 3/9/23 at 10:40 AM identified that the facility had tested Resident #27 on 3/6/23 and Resident #56 on 3/7/23 for COVID-19 due to COVID-19 like symptoms. After negative results were identified, the facility did not isolate either resident from their roommate. Review of the facility COVID-19 policy related to patient placement indicated that a patient with suspected or confirmed SARS-Cov-2 infection should be placed in a single room and anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible. d. Interview and review of facility policy with RN #2 on 3/13/23 at 11:25 AM identified that Resident #42 returned from the hospital on 3/8/23 with a new diagnoses of COVID-19. Resident #42 was placed in a single room on droplet precautions for COVID-19. Resident #56, Resident #42's roommate remained on contact precautions for Norovirus but was never placed on droplet precautions for a COVID-19 exposure. RN #2 indicated that droplet precautions were eliminated for Resident #42 on 3/11/23 after Resident #42's antigen (in-house) test taken on 3/9/23 was negative and a PCR test (laboratory test for COVID-19) also taken on 3/9/23 with results obtained on 3/11/23 was negative. Interview with the Administrator, DNS, RN#2, and RN#7 on 3/13/23 at 2:10 PM indicated that Resident #42 had received both an antigen and PCR test on 3/9/23, both of which were negative. The Administrator indicated that he had made the decision to eliminate continued precautions for Resident #42. The Administrator identified that he failed to speak with a clinician to address the discontinuation of the COVID-19 precautions and failed to ensure further COVID-19 testing for Resident #42 was performed. RN #7 indicated that the facility followed CDC guidelines for discontinuing precautions. Review of CDC guidelines identified that COVID-19 positive residents should isolate for 5 days. For residents with exposure to a COVID-19 positive resident, COVID-19 testing should occur on days 1, 3, and 5, each test occurring 48 hours following the last. 2. Resident #62's diagnoses included an unhealed pressure ulcer. The significant change Minimum Data Set assessment dated [DATE] identified Resident #62 had malnutrition and an unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. Observation on 3/8/2020 at 10:10 AM identified Resident #62 shared a room with Resident #40, who was identified as having a history of MRSA. Interview with the Registered Nurse (RN) #7 on 3/13/2023 at 3:50 PM identified residents with a history of an MDRO should not be cohorted with a resident with an open wound. Although requested, a facility policy for MDRO cohorting was not provided. 3a. Resident #21's diagnosis included diabetes mellitus. Review of the March 2023 Medication Administration Record (MAR) directed facility staff to obtain a blood glucose reading at 6:00 AM daily. Observation on 3/8/23 at 6:25 AM with LPN #5 identified blood glucose testing supplies were obtained from the top drawer of the medication cart. LPN #5 placed gloves without the benefit of washing or sanitizing her hands. LPN #5 entered Resident #21's room, cleansed the resident's finger with an alcohol wipe without the benefit of allowing the alcohol to dry, pricked the residents finger with the lancet, and obtained the blood sample. LPN #5 again cleansed Resident #21's finger with the used alcohol wipe followed by wiping the finger with a clean gauze pad. LPN #5 discarded the lancet into the sharp container on the medication cart, and without the benefit of removing her gloves or sanitizing/washing her hands, opened the medication cart drawer, removed cleaning wipes, wiped the glucose testing device with one wipe and then wrapped the blood glucose testing device with 2 additional wipes leaving the wrapped meter on top of the medication cart. LPN #5 removed her gloves and without the benefit of washing her hands, used the computer on the medication cart and collected supplies for the next resident, Resident #22. Interview with LPN#5 on 3/8/23 at 6:28 AM indicated that she should have removed her gloves and sanitized her hands after leaving Resident #21's room. LPN #5 was then noted to sanitize her hands. Although LPN #5, acknowledged knowing she had not appropriately sanitized her hands after leaving Resident #21's room, she continued to utilize the equipment she had gathered for Resident #22 prior to appropriate hand washing/sanitization. b. Resident #22 diagnosis included diabetes mellitus, pneumonia, and depression. Review of the March 2023 Medication Administration Record (MAR) directed facility staff to obtain a blood glucose reading daily at 6:00 AM. Continued observation of LPN #5 on 3/8/23 at 6:32 AM identified LPN#5, after being questioned and washing her hands, placed on clean gloves, and picked up the supplies placed on top of the medication cart prior to hand washing or sanitizing and entered Resident #22's room. LPN #5 cleansed Resident #22's finger with the alcohol swab and without waiting for the alcohol to dry, immediately took the blood sample on the test strip. LPN#5 then wiped the finger with the same used alcohol swab followed by wiping the finger with a gauze pad. LPN#5 exited Resident #22's room with the used testing supplies. Without the benefit of removing her gloves, she discarded the lancet in the sharp container, opened the drawer of the medication cart and removed the cleaning wipes. LPN#5 cleaned the blood glucose meter with 1 wipe, wrapped the blood glucose monitor in 2 additional wipes, and set the glucometer aside on the top of the medication cart. LPN#5 removed her gloves and proceeded to use the computer without the benefit of washing/sanitizing her hands. Interview with LPN #5 on 3/8/23 at 6:32 AM indicated that although she knew from the previous interview that she should have removed her gloves and washed or sanitized her hands prior to conducting further tasks, she indicated she thought she had, and stated Oh well. LPN #5 identified that she had been taking blood sugar readings for a long time and was last educated 40 years ago. Additionally, LPN #5 indicated that a wait time of 5 minutes was required to clean the glucose meter and that she had wrapped the monitor and left it within the wipe to ensure it was clean. c. Resident #43's diagnoses included Diabetes mellitus, and UTI. During a third observation of LPN #5 on 3/8/23 at 6:39 AM, she used the still wrapped, first glucose monitoring device from on top of the cart and immediately entered Resident #43's room. LPN#5 wiped Resident #43's finger with alcohol and immediately took the blood sample. LPN#5 then wiped the finger again with the same used alcohol wipe and dried the finger with gauze. As LPN#5 was exiting Resident ##43's room, she was observed to remove one glove in the room to turn the light on and took the other glove off when exiting the room. LPN#5 discarded the lancet and gloves, opened the drawers of the cart and cleaned the glucometer with a wipe without wearing gloves and without the benefit of performing hand hygiene and wrapped the meter in 2 wipes leaving it on top of the cart. Interview with LPN#5 on 3/8/23 at 6:43 AM indicated that she had just returned from an extended absence and that she had not been educated on proper procedures for blood glucose testing and was unaware if she had completed the testing correctly. LPN #5 indicated that she was unable to recall facility protocol for re-using the same alcohol wipe to initially cleanse a resident's finger, and then cleanse the finger following the blood sampling, stating she used the other side of the alcohol wipe. LPN #5 was unaware of the facility policy to allow a resident's finger to dry prior to obtaining a blood sample, and indicated that the finger was not that wet. LPN #5 indicated that a wet finger was the equivalent to eating a cookie and having sugar to remain on the fingers, that it would not make a difference. Interview with the Infection Preventionist, RN#2, on 3/8/23 at 6:55 AM indicated that the procedure for obtaining a blood sugar was to wipe the selected finger and to let the finger dry completely before pricking the finger with the lancet. RN#2 indicated that first drop of blood should be wiped off with the gauze and the second drop used to take the sample. RN#2 indicated that gloves should be removed after removing the strip from the blood glucose device, in between tasks, with hand hygiene before and after glove placement and removal, and with every resident contact. RN#2 could not confirm when last glucometer education was completed with staff. Subsequent to surveyor inquiry 17 employees were educated on blood glucose monitoring use. Review of the Blood Glucose Level measuring policy indicated, in part, to wash the resident's hands with soap and warm water or use alcohol wipes. Clean the glucose monitoring device with a bleach product or germicidal disposable wipe (purple top) after each use. Allow meter dry times per manufacturer instructions. Review of the manufacturer's guidelines indicated that cleaning and disinfecting the glucose monitoring device directed the user to always wear the appropriate protective gear, including disposable gloves. Option 1 of cleaning indicated: Use a commercially available EPA-registered disinfectant detergent of germicide wipe. Open disinfectant package. Follow product label instructions to disinfect the meter. Use caution as to not allow moisture to enter the test strip port, data port or battery compartment, as it may damage the meter. Review of the Instructions for use on the Sani cloth germicidal disposable wipes (purple top) indicated that the special instructions for cleaning and decontamination indicated that disposable protective gloves when using this product. The manufacturers label indicated that all blood and other body fluids must be thoroughly cleaned from surfaces and objects before disinfection by the germicidal wipe. Use second germicidal wipe to thoroughly wet surface. Allow surface to remain wet two (2) minutes then let the cleaned surface air dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #71) reviewed for mistreatment, the facility failed to ensure the resident was free from verbal abuse. The findings include: Resident #71's diagnoses included, anxiety, chronic pain, vascular dementia without behavioral disturbances, congestive heart failure and abnormal posture. A quarterly MDS assessment dated [DATE] identified Resident #71 had moderately impaired cognition, required extensive assistance of two with bed mobility, transfers and personal hygiene. The assessment further noted the resident did not ambulate, and had a range of motion impairment to one side of the upper extremities. The Reportable Event summary report dated 01/06/20 identified that on 12/30/19 at 7:15 PM Resident #71 was being transferred to bed via a Hoyer lift (mechanical lift) by NA#4 and NA#5. During the transfer NA#5 and Resident #71 had a verbal altercation where both parties used profanity in addressing each other. The Reportable Event investigation included a statement from NA#4 dated 12/30/19 timed at 7:15 PM that identified, he/she had observed an argument between Resident #71 and NA#5 that occurred during a Hoyer transfer from the wheelchair to the bed. The statement identified that NA#5 was yelling and had stated to Resident #71 that she (NA#5) did not have to deal with Resident #71's shit. NA#5 continued arguing with the resident and the argument escalated. NA#5 further stated to Resident #71 that he/she was the most f-----g disrespectful person that she (NA#5) had met at any job. The facility investigation identified that the allegation could not be substantiated. The investigation further noted that NA#5 was terminated due to unsuccessful completion of her probationary period. Review of the clinical record identified an assessment for mental status (an assessment that determines the resident's cognitive status) dated 12/31/19 that determined that Resident #71 had intact cognition. An interview with Resident #71 on 02/02/20 at 09:28 AM identified that on the evening shift a female nurse aide had spoken all kinds of bad words to him/her like F-you and that he/she had been very upset by the way the nurse aide had spoken to her/him. Resident #71 further stated that the nurse aide had spoken that way to other residents and that the nurse aide did not work there anymore. An interview with NA #5 on 02/04/20 at 11:16 AM indicated that he/she provided assistance to NA#4 with the Hoyer transfer of Resident #71. NA #5 indicated that she was not Resident #71's primary nurse aide. NA #5 identified that during the transfer Resident #71 said things to her and that she responded to Resident #71 telling the resident to stop treating me like shit. NA #5 further stated that after the incident she had gone to the supervisor (RN#5) and told him what had occurred and remained in the facility on the same unit until the end of the shift. An interview with RN #5 on 02/04/20 at 11:50 AM indicated that he was the supervisor on duty on the evening of 12/30/19. RN #5 indicated that at approximately 9:30 PM, NA #5 had reported to him that she'd had an argument with Resident #71 during a transfer of the resident back to bed. RN#5 indicated that he did not assess or interview the resident after NA#5 reported to him about the argument, he thought the nurse aide swearing was just an off the cuff remark. An interview with NA #4 on 02/04/20 at 12:20 PM indicated that on the evening of 12/30/19 he was assigned to Resident #71. Nurse aide #4 indicated that after dinner (approximately 6:30 PM) Resident #71 wanted to go back to bed and that NA#5 had come to assist him with the transfer. NA#4 indicated that there were words between Resident #71 and NA#5 and that the argument continued. He indicated that NA#5 was upset and yelled at the resident that she did not have to put up with Resident #71's s--t. NA #4 further noted that NA #5 told the resident that she/he was f-----g disrespectful. NA#4 indicated that after transferring and settling the resident he immediately reported the incident to the charge nurse (LPN #5) and then directly to the supervisor (RN #5). NA #4 indicated that RN #5 told him to fill out a statement which he did when he went on break at approximately 8:45PM. An interview with LPN #5 on 02/05/20 at 11:32 AM indicated that he/she was the charge nurse on the evening of 12/30/19. LPN #5 indicated that after dinner at approximately 6:00 PM to 6:30 PM, NA #5 had reported that she had had an argument with Resident #71. LPN #5 indicated that right after speaking with NA #5, NA #4 then approached and reported that NA #5 had yelled profanity at the resident. LPN #5 indicated that she had immediately reported to the supervisor (RN #5) that NA #5 had argued and used profanity with Resident #71. An interview with the Director of Nursing (DNS) and the Corporate Nurse on 02/05/20 at 12:10 PM indicated that staff did not follow facility policy after an incident between staff and a resident. The DNS further indicated that it was facility expectation that the RN conduct an assessment of the resident after a reported incident. Review of the Facility Abuse Management policy and procedure identified in part, that it's the responsibility of employees, facility consultants, physicians, families, and visitors to promptly report any incident or suspected resident abuse. It further identified that abuse included verbal abuse and that while the investigation is being conducted, employees accused of an alleged resident abuse will be suspended from duty until the results of the investigation has been reviewed by the administrator. Subsequent to the incident all facility staff were provided education on 12/31/2019 related to resident rights, abuse and neglect. The facility failed to keep Resident #71 free from verbal abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, and interviews for one of three sampled residents (Resident #50), reviewed for mistreatment, the facility failed to report a potential misappropriation of funds to the state agency. The findings include: Resident #50's diagnoses included dementia and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #50 had severe cognitive impairment, required extensive assistance of one for transfers, dressing and toileting, had no behaviors, delusions or hallucinations. The care plan dated 4/5/19 identified the problem of dementia, impaired decision making and impaired memory with interventions that included, provide reality orientation and validation as needed. A grievance/concern form dated 5/7/19 identified Resident #50 stated he/she was missing a Christmas box that contained $35.00 and two to three Walmart gift cards for $20.00 each. The form further identified that the responsible party was refunded the money. A Grievance/Concern Form dated 6/18/19 identified Resident #50 was missing a Christmas lunch box that contained $35.00 and two to three Walmart gift cards for $25.00 each from top nightstand drawer. The form identified that $35.00 cash was provided for reimbursement; and the gift cards would be provided at a later date. Interview and review of grievance forms with the DNS on 2/3/20 at 1:06 PM identified that the grievance forms identified Resident #50 was missing $35.00 and gift cards and noted that the missing money and gift cards could potentially be considered misappropriation of resident funds/property, which would be considered a form of abuse. The DNS further identified that allegations of abuse are to be reported to the state agency within two hours. The DNS identified that reportable events for this year for Resident #50 did not include either of these incidents, and the DNS did not know if there were two separate incidents or if this was the same incident. The facility policy for Abuse Reporting identified allegations or incidents of misappropriation of funds are to be reported to the state agency within two hours of the allegation or occurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview for one of three sampled residents (Resident #71) reviewed for mistreatment, the facility failed to implement its policy to ensure the resident was protected after an allegation of verbal abuse was identified. The findings included: Resident #71's diagnoses included, anxiety, chronic pain, vascular dementia without behavioral disturbances, congestive heart failure abnormal posture. A quarterly MDS assessment dated [DATE] identified Resident #71 had moderately impaired cognition, required extensive assistance of two with bed mobility, transfers and personal hygiene. The assessment further noted the resident did not ambulate, had a range of motion impairment to one side of the upper extremities The Reportable Event summary report dated 01/06/20 identified that on 12/30/19 at 7:15 PM Resident #71 was being transferred to bed via a Hoyer lift (mechanical lift) by NA#4 and NA#5. During the transfer NA#5 and Resident #71 had a verbal altercation where both parties used profanity in addressing each other. The Reportable Event investigation included a statement from NA#4 dated 12/30/19 timed at 7:15 PM identified that evening he/she had observed an argument between Resident #71 and NA#5 that occurred during a Hoyer transfer from the wheelchair to the bed. The statement identified that NA#5 was yelling and had stated to Resident #71 that she (NA#5) did not have to deal with Resident #71's shit. NA#5 continued arguing with the resident and the argument escalated. NA#5 further stated to Resident #71 that he/she was the most f-----g disrespectful person that she (NA#5) had met at any job. The facility investigation identified that the allegation could not be substantiated. The investigation further noted that NA#5 was terminated due to unsuccessful completion of her probationary period. An interview with Resident #71 on 02/02/20 at 09:28 AM identified that on the evening shift a female nurse aide had spoken all kinds of bad words to him/her like F-you and that he/she had been very upset by the way the nurse aide had spoken to her/him. Resident #71 further stated that the nurse aide had spoken that way to other residents and that the nurse aide did not work there anymore. An interview with NA #5 on 02/04/20 at 11:16 AM indicated that he/she provided assistance to NA#4 with the Hoyer transfer of Resident #71. NA #5 indicated that she was not Resident #71's primary nurse aide. NA #5 identified that during the transfer Resident #71 said things to her and that she responded to Resident #71 telling the resident to stop treating me like s--t. NA #5 further stated that after the incident she had gone to the supervisor (RN#5) and told him what had happened and remained in the facility on the same unit until the end of the shift. An interview with RN #5 on 02/04/20 at 11:50 AM indicated that he was the supervisor on duty on the evening of 12/30/19. RN #5 indicated that at approximately 9:30 PM, NA #5 had reported to him that she had had an argument with Resident #71 during a transfer of the resident back to bed. RN#5 indicated that although he did not assess or interview the resident after NA#5 reported to him about the argument, he thought the nurse aide swearing was just an off the cuff remark. RN #5 further indicated that he did not think it was necessary to send NA#5 home because the facility's residents needed to be cared for to ensure the residents' safety and because he was not aware of what NA#4 had observed during the transfer until the end of the shift. An interview with NA #4 on 02/04/20 at 12:20 PM indicated that on the evening of 12/30/19 he was assigned to Resident #71. Nurse aide #4 indicated that after dinner (approximately 6:30 PM) Resident #71 wanted to go back to bed and that NA#5 had come to assist him with the transfer. NA#4 indicated that there were words between Resident #71 and NA#5 and that the argument continued. He indicated that NA#5 was upset and yelled at the resident that she did not have to put up with Resident #71's shit. NA #4 further noted that NA #5 told the resident that she/he was f-----g disrespectful. NA#4 indicated that after transferring and settling the resident he immediately reported the incident to the charge nurse (LPN #5) and then directly to the supervisor, RN#5. NA#4 indicated that RN #5 told him to fill out a statement which he did when he went on break at approximately 8:45PM. An interview with LPN #5 on 02/05/20 at 11:32 AM indicated that he/she was the charge nurse on that evening of 12/30/19. LPN #5 indicated that after dinner at approximately 6:00 PM to 6:30 PM, NA #5 had reported that she had had an argument with Resident #71. LPN #5 indicated that right after speaking with NA #5, NA#4 then approached and reported that NA #5 had yelled profanity at the resident. LPN #5 indicated that she had immediately reported to the supervisor RN #5 that NA #5 had argued and used profanity with Resident #71. LPN #5 further indicated that although she had kept her eyes on NA #5 she did not question RN #5 as to why NA #5 remained on the job caring for other residents. An interview with the Director of Nursing (DNS) and the Corporate Nurse on 02/05/20 at 12:10 PM indicated that staff did not follow facility policy after an incident between staff and a resident. The DNS further indicated that it was facility expectation that the RN conduct an assessment of the resident after a reported incident and that no matter the circumstances the alleged staff involved should be sent home to protect the resident as directed by facility policy. Review of the Facility Abuse Management policy and procedure identified in part, that it's the responsibility of employees, facility consultants, physicians, families, and visitors to promptly report any incident or suspected resident abuse. It further identified that abuse included verbal abuse and that while the investigation is being conducted, employees accused of an alleged resident abuse will be suspended from duty until the results of the investigation has been reviewed by the administrator. Subsequent to the incident all facility staff were provided education on 12/31/2019 related to resident rights, abuse and neglect. The facility failed to protect Resident #71 and other residents at risk for mistreatment by NA #4 by failing to implement the facility's policy by suspending NA #4 from the building, following an incident of mistreatment involving Resident #71.

Based on observation of the kitchen and dietary services and interviews, the facility failed to maintain the kitchen in a sanitary manner. The findings included: During initial tour of the kitchen on 02/02/20 at 9:17 AM, it was identified that three water bottles that belonged to the dietary staff were being stored in the walk-in refrigerator designated for facility food storage. During a subsequent observation of the kitchen on 02/05/20, it was identified that there was a water bottle and a lunch bag belonging to dietary staff being stored in the walk-in refrigerator designated for facility food storage. Observations on all days of survey 02/02/20, 02/03/20, 02/04/20 and 02/05/20 identified the dietary staff utilized Quat 64 to clean and sanitize the food preparation surfaces. The dietary staff identified the spray bottle being utilized as Quat 64. Interview with the Infection Preventionist (IP) on 02/05/20 identified that the dietary staff's personal food items should not be stored in the facility's walk-in refrigerator that stored the facility's food supply because it is a failure to maintain acceptable infection control practices. The IP further identified that the dietary department were supposed to utilize the Syn Quat 10 as a sanitizer and not the Quat 64 as the sanitizer for cleaning the food prep surfaces and the kitchen equipment. She noted that the Quat 64 is a disinfectant that is appropriate for use on hard surfaces like the floors and the restrooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of facility policy and staff interviews for 4 of 10 sampled residents (Residents #3, #31, #72, and #180) reviewed for immunizations, the facility failed to ensure that pneumococcal vaccination history was complete and pneumococcal vaccinations and education concerning the vaccinations were offered. Findings include: Interview on 2/4/2020 at approximately 12:00 PM with the Infection Preventionist (IP) during the time of the record reviews identified that she was in the process of updating all residents' pneumococcal immunization status' and noted that she had not completed the information gathering on all of the residents at that time. Further interview with the IP identified that the facility has a form that is completed by the resident or resident representative that provides information about the pneumococcal immunizations. She further noted that the form has an area where the resident or their representative can provide consent or decline consent. The IP also identified that the document is placed in the resident's physical chart and an entry made on the electronic medical record under the immunizations tab that indicates when the resident either received the immunization or when the resident declined the immunization. A. Review of Resident #3's clinical record identified that the resident was admitted to the facility on [DATE] with diagnoses that were inclusive of type 2 diabetes mellitus, atherosclerotic heart disease and chronic atrial fibrillation. An admission MDS assessment dated [DATE] identified the resident was [AGE] years of age and had moderate cognitive impairment, did not have an up to date pneumococcal vaccination and was not offered the vaccine. Further review of the clinical record and the facility vaccination tracking log failed to identify consents for the pneumococcal vaccines, education provided concerning the vaccines, historical information inclusive of vaccination history and documentation of administration of the Pneumovax 23 (PPSV23) or Prevnar 13 vaccines (PCV13). Interview with the Infection Preventionist (IP) on 02/05/20 at approximately 11:45 AM identified that the resident was eligible for a second pneumococcal immunization and was not offered the vaccine. Subsequent to surveyor inquiry, the IP provided information that the resident received a pneumococcal immunization on 03/28/18. B. Review of Resident #31's clinical record identified that the resident was admitted to the facility on [DATE] with diagnoses that were inclusive of sepsis due to E. Coli, benign neoplasm of the adrenal gland, type 2 diabetes mellitus and hypertension. An annual MDS assessment dated [DATE] identified the resident was [AGE] years of age, had severely impaired cognition, did not have an up to date pneumococcal vaccination and was not offered the vaccine. Further review of the clinical record and the facility vaccination tracking log failed to identify consents for the pneumococcal vaccines, education provided concerning the vaccines, historical information inclusive of vaccination history and documentation of administration of the Pneumovax 23 (PPSV23) or Prevnar 13 vaccines (PCV13). Interview on 02/05/20 at approximately 11:45 AM with the IP identified that although, there was no documentation in the facility vaccination tracking log or the resident's clinical record. She further noted that a pneumococcal vaccination had been administered to the resident on 10/07/2008; however, she identified that the resident was eligible for a second pneumococcal immunization but had not been offered the vaccine. C. Review of Resident #72's clinical record identified that the resident was admitted to the facility on [DATE] with diagnoses that were inclusive of congestive heart failure, abdominal aortic aneurysm without rupture and type 2 diabetes mellitus. A significant change MDS assessment dated [DATE] identified the resident was [AGE] years of age, was cognitively intact, did not have an up to date pneumococcal vaccination and was not offered the vaccine. Further review of the clinical record and the facility vaccination tracking log failed to identify consents for the pneumococcal vaccines, education provided concerning the vaccines, historical information inclusive of vaccination history and documentation of administration of the Pneumovax 23 (PPSV23) or Prevnar 13 vaccines (PCV13). Interview with the IP on 2/5/2020 at approximately 11:45 AM, the IP confirmed that the resident should have been offered the pneumococcal immunization but was not. D. Review of Resident #180's clinical record identified that the resident was admitted to the facility on [DATE] with diagnoses that were inclusive of congestive heart failure and acute kidney failure. An admission MDS assessment dated [DATE] identified the resident was [AGE] years of age and had moderately impaired cognition. The MDS failed to include information about the resident's vaccination history or if the facility had offered the pneumococcal vaccine to the resident. Further review of the clinical record and the facility vaccination tracking log failed to identify consents for the pneumococcal vaccines, education provided concerning the vaccines, historical information inclusive of vaccination history and documentation of administration of the Pneumovax 23 (PPSV23) or Prevnar 13 vaccines (PCV13). Interview with the IP on 2/5/2020 at approximately 11:45 AM, the IP identified that she had spoken with the resident concerning the pneumococcal immunizations but had not documented the conversation or any decision made or action takin in the clinical record or the facility vaccination tracking log. The facility policy entitled Policy for Pneumococcal Vaccination of Residents dated 7/20/2017 identified that the facility ascertains on admission the resident's immunization history. The policy also stated that residents who are eligible for the vaccination will be offered it and if given will be documented in the electronic medical record. In addition the policy noted that current residents 65 years and older will be offered the two types of pneumococcal vaccines and depending on the resident's history then the vaccines can be administered on a schedule of at least one year apart. The policy also noted that all of the information including education and vaccines not administered for any reason would be documented in the clinical record.