**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, staff interview, and resident interview, the facility failed to protect the resident's right to be free from abuse for three of three (Resident (R) 80, 359, 78) reviewed for abuse of 41 sampled residents. This failure to protect the residents increased the risk of further exposure to abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime, dated 01/03/25, revealed, Policy It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime. Cadia Healthcare adopts this policy to standardize procedures for employee screening, employee training, prevention, identification, investigation, protection, and reporting of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and reasonable suspicions of crime. Purpose: To ensure that all residents are protected from abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime . Guidelines . Prevention: The facility will; Provide residents and staff information on how to report concerns and incidents without fear of retribution. Provide training to ensure resident rights and safety are met. Monitor staffing patterns in relation to reported allegations or suspicions of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime . Protection: The facility will respond immediately to protect the alleged victim, the integrity of the investigation and provide protection from retaliation. Assessment of the alleged victim will be conducted for signs and symptoms of injury (physical and/ or psychosocial). Increased supervision, room changes, and staffing changes may be provided to the alleged victim and other residents. Psychological support will be offered during and after the investigation. The named person accused of the act will be immediately suspended pending outcome of the investigation. Reporting and Response: Witnessed or suspected incidents of abuse or reasonable suspicions of crime are to be reported immediately . The DON (Director of Nursing) or designee is responsible to conduct the abuse investigation. The NHA (Nursing Home Administrator) serves as the abuse coordinator. Allegations of resident abuse shall be reported to the appropriate state regulatory authority within 2 hours. Incidents involving reasonable suspicions of criminal conduct are reported to the applicable state agency and law enforcement within 8 hours or within 2 hours if the conduct causes serious bodily harm . 1. Review of R80's undated admission Record, located in R80's electronic medical record (EMR) under the Profile tab, revealed R80 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction, unspecified dementia with agitation, major depressive disorder. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/24, located under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated R80' was cognitively severely impaired. Review of the facility investigation, started 07/11/24, revealed the incident occurred on 07/07/24 when Certified Nursing Assistant (CNA) 1 stuck her tongue out and threw three wipes toward R80's head while in the process of changing the resident. R80 then attempted to throw spit at CNA1. CNA2 witnessed the incident and she and CNA1 left the room. CNA2 reported the incident to Licensed Practical Nurse (LPN)1 on 07/07/24. The incident was not reported to the Abuse Coordinator until 07/11/24. Failing to report the allegation of abuse allowed CNA1 to remain on schedule and she worked 07/08/24, 07/10/24, 07/11/24. Phone interview on 03/13/25 at 12:26 PM CNA2 stated, R80 was aggressive like normal when we went to change her. Then CNA1 threw three individual wipes at R80's face, R80 then spit in her hand and threw it at CNA1. After that we both walked out of the room, and I went to tell the nurse (LPN1) what happened. I went back to check on R80 and she was fine, she didn't say anything about it. During a phone interview on 03/13/25 at 1:20 PM, the former Administrator stated, The CNA was suspended during the investigation and later terminated. By terminating her we would have confirmed the abuse. The DON performed the investigation. 2. Record review of facility provided documentation and resident record review revealed one incident of resident-to-resident aggression with R17 as the assailant. On 06/12/24, R78 was revealed to have informed the facility that they had been struck by R17 on 06/11/24, the previous day. Review of R17's electronic medical record (EMR) Profile tab, revealed admission to the facility on [DATE] with diagnoses of syncope and collapse, undifferentiated schizophrenia, epilepsy, and major depressive disorder recurrent/moderate. Review of R17's quarterly MDS under the MDS tab of the EMR, with an ARD of 05/01/24, revealed a BIMS score of nine out of 15 which indicated moderate cognitive impairment. Further review revealed that R17 had no behaviors including physical and/or behavioral symptoms directed toward others. The incident of resident-to-resident behavior occurred 06/11/24. Review of R17's annual MDS under the MDS tab of the EMR, with an ARD of 01/29/25, revealed a BIMS score of twelve out of 15 which indicated moderate cognitive impairment. Further review revealed that R17 had no behaviors including physical and/or behavioral symptoms directed toward others. No recording of any physical and/or behavioral symptoms directed towards others since the 06/11/24 incident. Review of R17's Care Plan in the EMR under the Care Plan tab, initiated 02/17/23 and last revised 08/02/23, revealed R17 had the potential to have socially inappropriate behavior with the potential for physical resistiveness towards others as evidenced by scratching, swinging, kicking, pushing, and/or slapping. Interventions identified prior to the incidents below, to allow ten to 15 minutes for the resident to calm down then reapproach, approach calmly and unhurriedly, to avoid overstimulation, and to explain all care tasks prior to providing care. Review of R78's EMR Profile tab, revealed admission to the facility on [DATE] with diagnoses of Parkinson's disease, dementia, neurocognitive disorder with Lewy bodies, and anxiety disorder. Review of R78's annual MDS under the MDS tab of the EMR, with an ARD of 05/03/24, revealed a BIMS score of twelve out of 15 which indicated moderate cognitive impairment. Further review revealed R78 had no behaviors nor rejected care. The incident of resident-to-resident behavior occurred 06/11/24. Review of R78's quarterly MDS under the MDS tab of the EMR, with an ARD of 01/31/25, revealed a BIMS score of ten out of 15 which indicated moderate cognitive impairment. Further review revealed that R78 had no behaviors nor rejection of care. No recording of any physical and/or behavioral symptoms directed towards others since the 06/11/24 incident. Review of R78's Care Plan in the EMR under the Care Plan tab, initiated 09/29/23 and last revised 11/08/23, revealed R78 had the potential to be verbally aggressive (yelling and cursing) to staff and make false accusations of staff not providing care when all needs were met. Interventions identified prior to the incident below were to provide paired care for the resident, assess the resident's understanding of the situation and allow time for the resident to express self and feelings towards the situation, to assess and anticipate the resident's needs, and when the resident becomes agitated, to intervene before agitation escalates and guide away from source of distress. Review of the facility provided the Incident Report that documented on 06/12/24 at 1:30 PM, that there was a resident-to-resident abuse situation between R17 and R78. The incident was unwitnessed, and the resident representatives and the physician were notified timely. R78 stated that on 06/11/24, the day prior, R17 had stood over her and hit her in the face. She reported that the incident occurred during the night of 06/11/24 and that R17 had used her open hand and struck her in the forehead. She also stated that this was the first physical altercation with R17. The investigation of the 06/11/24 incident revealed no injuries to R17. R78 was sent to the hospital for a psychological evaluation on 06/12/24 and was readmitted on [DATE] with no new physician orders. R17 was readmitted to a different room. R78 was followed by psych services, with no deviation from baseline. Other facility residents were interviewed to determine if they had experienced any abuse, and there were no identified concerns. Staff were also interviewed with no identified concerns. The investigation revealed the interventions after the resident-to-resident included sending R17 to the hospital for psychiatric evaluation upon notification of the incident, a room change, and in-house psychiatric follow-up. No additional observations or reported incidents of resident-to-resident abuse have been documented between R17 and R78 since the event on 06/11/24. During an interview on 03/10/25 at 4:13 PM, R17 stated that she was not fearful of any residents or staff in the facility, including R78. She stated she was satisfied with her private room. She was unable to recall the resident-to-resident incident. During an interview on 03/11/25 at 11:18 AM, R78 stated she had a previous concern with a former roommate. She was unable to recall the resident's name, but stated she was not afraid of the other resident or anyone else. R78 said she was not bothered by the incident from 06/11/24 and had no concerns that she wished to discuss. During an interview on 03/14/25 at 11:25 AM, the Assistant Director of Nursing (ADON) said that she had completed the initial report for the resident-to-resident incident, but the former Director of Nursing had completed the investigation. She stated that staff would have told her what happened, reported the incident, and she would have informed the former Director of Nursing. She said she had two hours to report it and the investigation would have had to be done in five days. She stated that she would expect to see interviews with the residents involved, any witnesses, and staff. She said the facility would have gotten statements with other residents to see if they had any problems with the residents in the incident. She stated that there were no problems at all. She said the residents lived on separate hallways. The ADON said that R17 had her own room since the incident, and there had been no further issues. She said that R17 was able to be moved into a new room right away because there was open and available at the time of the incident. During an interview on 03/14/25 at 2:23 PM, the Director of Nursing (DON) stated she had not been in her current position during the time of the incident. She stated R17 did have behaviors, but the facility staff had been able to redirect her. The facility provides emotional support. Whenever they see the resident cycling or ramping up with behaviors, they have psych services see her again, to which she is usually agreeable. The resident was provided with her own room because she has had some roommate problems in the past, due to personality conflicts. She said R17 liked and did best in her own room. She does come out of her room, is social, circles around the nurse station, and sometimes goes to activities. The DON stated that staff have been trained to redirect her and provide her support because they want staff to deescalate the situation and makes sure all residents are safe. She stated dementia training was provided upon new hire and annually so they can handle difficult behaviors. She said that R78 has no ongoing behavioral issues and has done well with her new roommate. She said that if staff see abuse, she wants them to report it immediately so she can report it immediately and do the investigative process. The DON said she wants residents to be safe, and to separate them if there is a resident-to-resident behavior. She stated that if there is any incident they will begin behavior monitoring until psych services can see them. She said an investigation includes interviewing staff to complete the whole investigation process. She said psych services typically get involved with resident-to-resident incidents, and that they come in regularly so the residents can be assessed. During an interview on 03/14/25 at 3:44 PM, the Social Service Director (SSD) stated that R17 did have some paranoid behaviors and could get agitated. She said R17 had some history of agitation with other residents and staff, just yelling out. SSD said R17 was redirectable. SSD stated R17 was given her own room because she had believed that her former roommate had talked about her. SSD confirmed the resident did best in her own room. She stated that abuse training was completed by all staff upon hire and annually. During an interview on 03/14/25 at 6:45 PM, CNA13 stated that abuse training was completely on an ongoing basis. CNA13 said R17 moved rooms, to a different unit, and had not seen any behaviors since the original incident. She stated R78 had not been observed interacting with R17 since the room change. During an interview on 03/14/25 at 6:55 PM, Licensed Practical Nurse (LPN) 5 stated that the facility did abuse training a few times each year. He stated that he started last summer and had multiple abuse training since he had been at the facility, because the facility did not tolerate any types of abuse. LPN5 stated that if anyone saw anything that could be considered as potential abuse, anything on the body or that you notice is new, you had to report it immediately so it could be investigated. LPN5 said that there had been no identified concerns with R17 or R78 since working at the facility. 3. Review of R359's annual MDS, with an ARD of 10/08/24 and located in the EMR under the MDS tab, revealed R359 had an admission date of 10/01/24 and a BIMS score of 15 out of 15, which indicated R359's cognition was intact. The MDS assessment indicated R359 had diagnoses that included glaucoma, acquired absence of right leg above knee, and cerebrovascular disease. Review of R359's care plan, revised 10/29/24 located in the EMR under the Care Plan tab revealed The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] Activity Intolerance, RAKA [right above the knee amputation], Impaired balance, Limited Mobility, Musculoskeletal impairment/Acquired absence of right leg below the knee. An intervention included Assist with hygiene, grooming, toileting, dressing, oral care, and eating as needed. Review of the facility investigation dated 10/28/24, provided by the facility, revealed on October 28, 2024, at approximately 2pm, the resident and [family member] reported to his assigned nurse that they were upset about events that occurred over the weekend. The nurse then reported immediately to the social worker [name] and [name] ADON The social worker then met with the resident to perform a psychosocial visit. The resident stated that his 11-7 CNA (identified as CNA10) on Friday, October 25, 2024 treated him rudely and told him he needed to clean up his room because it was a mess. He also stated later on this past weekend (resident unsure of date/time) another CNA who he could not identify yanked up his brief causing him pain. Resident stated to the social worker to talk to his [family member] [name] as she knows everything that happened now it's not fresh in his mind. [name] ADON spoke to resident's [family member] [name] who stated that the resident called her on October 26, 2024, around 12:37pm and stated his new CNA on 11-7 told him Rudely to clean up his room, but he cannot see well so he couldn't do it. [Family member] also stated that she received a call from her husband on Sunday October 27, 2024, around 21:16 pm that he had put his call light on and an aide who he did not know came in and he asked for a diaper and the aide told him to put it on himself'. When he said he couldn't, she was very rough with him and pulled the tabs tight causing him pain to his penis and scrotum. A skin assessment was completed by nursing and no injury or skin abnormality was found on the resident. DON [Director of Nurses] and ADON were able to identify the 11-7 CNA who was involved in the October 25, 2024, incident as [CNA10] who was suspended immediately pending further investigation. Further investigation revealed [name] CNA10 did tell the resident to clean up his room because it was a mess. [CNA] was subsequently terminated on October 30, 2024, related to poor customer service. DON and ADON were unable to identify who the suspected CNA was involved in the alleged October 27, 2024, incident. All cognitively appropriate residents along the hallway where R359 resides were interviewed to determine if they experienced any care concerns. Full body skin checks were also completed on other residents who could not be interviewed, and no new skin abnormalities were identified. Staff members were also interviewed and denied having any knowledge of the- in question or any other incident involving the resident or any other residents, nor did they recall any concerns, issues, or complaints from R359 when providing care. Review of the facility's all staff training, conducted on 10/28/24, provided by the facility, revealed an abuse in-service was conducted by the staff developer in response to the abuse investigation that was substantiated for R359. The in-service included all types of abuse, reporting all suspected and alleged abuse immediately following the chain of command, writing statements, and monitoring residents involved in abuse. Review of CNA10's statement, dated 10/28/24, provided by the facility revealed I did a double 10/25 into 10/26 11-7 . On west [hall] I enter room [number] spoke with [bed number] R359 [resident's name]. Approx. [approximately] 12:25 when doing rounds I noticed his room had been cleaned w/ [with] things in it proper place. I mentioned that his room looked cleaned and that would be nice because he might receive a visitor. That comment came from a conversation [room and bed number] bed had with [room and bed number] bed to which they included me in saying that they were roommates at one point and that [room and bed number] would be visiting him [R359 room and bed number]. Later that morning [room and bed number] became bothered by the comment and reported some what of the truth to the RN [registered nurse] at the desk. I was informed not to enter that room. Review of the ADON's statement, dated 10/28/24, provided by the facility revealed I sat down with CNA10 to discuss the complaints from R359 and his [family member] [name]. I explained to her that they were very upset about way she talked to him, on October 26 at 12:37 in the morning. She [CNA10] stated to me that his room was a mess. that there were papers and trash on the floor and she did tell him that the room was disgusting and he needed to clean this mess up in case he had visitors. Review of CNA10's personnel file provided by the facility, revealed CNA10 was suspended pending the investigation on 10/28/24 and terminated on 10/30/24 due to poor customer service. During an interview on 03/12/25 at 2:13 PM, the ADON stated she became aware of the allegation by another staff member. The DON asked her to conduct skin assessments and interviews. The ADON stated she didn't remember specifics as it's been too long ago but she obtained a statement from CNA10. The ADON stated CNA10 admitted to her she told R359 his room was a mess; his room was disgusting and he needed to clean this mess up in case he had visitors. The ADON stated after further investigation they determined there was only one perpetrator. During an interview on 03/12/25 at 6:11 PM, the Administrator and DON stated safe surveys were completed on residents that had contact with CNA10 with questions about abuse and safety. The DON stated staff were also interviewed and statements were obtained from those who had worked with CNA10. During an interview on 03/13/25 at 6:26 PM, the SSD was asked about R359's investigation. SSD stated staff alerted her to R359's room as he had a complaint and was upset. SSD stated R359 told her his CNA pulled on his brief, and it was hurting him. SSD stated R359 didn't remember the details, but he had told his [family member] earlier. SSD stated she reported it immediately and the ADON called the [family member]. SSD stated she understood there was only one perpetrator identified and that it was CNA10. SSD stated R359 had no lasting pain from the brief. During a follow up interview on 03/13/25 at 6:30 PM, the ADON stated the timeframes helped substantiate that there was only one perpetrator, CNA10. ADON stated they compared the nursing schedule using a 72-hour timeframe and statements were taken from all nursing staff. R359 had no roommate, and there was not a second staff member present to witness care. During an interview on 03/13/25 at 7:00 PM, DON stated the ADON told her about R359's complaint and they started putting the pieces together by comparing schedules and assignment sheets. DON stated, just one person was identified, and a second person could not be substantiated. DON stated R359 wasn't certain CNAs by name and by process of elimination they figured it out. DON stated she didn't get the impression CNA10 meant any harm in her interactions with R359, and they couldn't prove his brief was pulled off abruptly as R359 had no injury or redness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure an injury of unknown origin was investigated for one out of 11 residents reviewed for abuse (Resident (R)2). R2's thumb was noted with a 1.5 centimeter (cm) by 1.5 cm purple area with swelling; once staff to resident abuse was ruled out as a potential cause, the facility failed to investigate further to determine how R2 sustained the injury. Findings include: Review of the facility's Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime policy dated 01/03/25 revealed, It is the policy of [facility name] to protect residents and prevent occurrences of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime . Injuries of unknown source are injuries where the source of the injury was not observed by any person; the source of the injury could not be explained by the resident; the injury is suspicious because of the extent of the injury or the location of the injury . All alleged incidents . including injuries of unknown source, shall be reported to the NHA [Nursing Home Administrator] or designee immediately. The NHA or designee shall investigate allegations . Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R2 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/19/25 in the EMR under the MDS tab revealed R2 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Incident Report for Web Intake #84519 (Initial Report) dated 03/18/24 and provided by the facility revealed R2 reported on 03/18/24 that on 03/17/24 at 1:30 PM Certified Nursing Assistant (CNA)2 pinched his thumb after he threw a soda can at her, causing an injury to his thumb. Review of the facility's Incident Report for Web Intake #84519 - Follow Up (Five Day Follow up Investigation file) provided by the facility dated 03/21/24 indicated on 03/17/24 at 2:00 PM, CNA2 was sitting at the computer on wheels in the long hallway and R2 approached and requested that she make his bed. CNA2 asked him to give her a minute as she was charting. R2 responded by pushing the computer on wheels into her knees and moving the computer screen side to side. CNA2 stated she was logging off the computer to leave when R2 threw a soda can at her. CNA7 came out of another resident's room and observed CNA2 charting and R2 sitting next to her. CNA7 witnessed R2 throw a can of soda at CNA2. CNA2 alerted 911 to file a police report against R2. R2 was transported to the emergency room [ER] for a psych evaluation on 3/17/24 at 3:00 PM and returned at 9:30 PM. The report indicated that review of the ER records revealed R2 stated he felt like staff was not cleaning him up after an accident or providing him with food so became frustrated and threw food. The investigation revealed on 03/18/24 R2 showed the Speech Therapist his right thumb and stated CNA2 hurt him on 03/17/24. R2's thumb was assessed and a 1.5 cm x 1.5 cm area of purple tone was noted. An X-ray was obtained on 03/18/24 and showed no acute fracture or dislocation but showed soft tissue swelling to the R2's thumb. CNA2 was suspended related to the allegation of abuse made on 03/18/24. CNA2 stated she did not touch R2. CNA7, who was a witness stated she did not see CNA2 touch R2. Video footage showed R2 pushed the computer into CNA2, shook the computer screen, and threw a soda at the CNA which hit her. The video footage in the hallway did not show CNA2 making contact with R2. The investigation revealed there was no documentation about the thumb injury in the emergency room documentation on 03/17/24. The allegation of CNA2 abusing R2 was unsubstantiated. There was no additional documentation showing further investigation into the injury of R2's thumb, which became an injury of unknown origin after the allegation of abuse by CNA2 towards R2 was ruled out as the cause. During an interview on 03/10/25 at 12:03 PM, R2 stated he remembered the incident with a CNA a year ago in which he was pinched. R2 stated a CNA wanted a soda from him and he stated no and threw the soda at her. During an interview on 03/13/25 at 02:37 PM, the Assistant Director of Nursing (ADON) stated the abuse incident dated 03/17/24 included an allegation of CNA2 grabbing R2 which was not substantiated. The ADON stated she did not remember an injury to R2's hand when the original investigation was completed; however, the next day he had a scratch on his hand and it would be considered an injury of unknown origin. The ADON stated any bruising or injury that was new and the staff did not know how it happened, was considered an injury of unknown origin. During an interview on 03/13/25 at 7:03 PM, the Administrator confirmed the investigation occurred prior to her employment at the facility; however, she would look to see if there was any further information about the injury to R2's hand. During an interview on 03/14/25 at 12:03 PM, the Director of Nursing (DON) stated the investigation into R2's injury to his hand should be part of the original investigation. The DON stated she would review the file to determine if there was any additional information to show how R2's hand was injured. During an interview on 03/14/25 at 2:19 PM, the DON stated the facility did not investigate the injury to R2's thumb after it had been ruled out that CNA2 did not abuse R2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to provide written notification of a facility-initiated transfer to the resident/responsible party (RP) for three (Resident (R)41, R30, and R258) of four residents reviewed for hospitalization. The failure had the potential to affect the residents and/or their representative concerning the resident's appeal rights. Findings include: Review of the facility's policy titled Resident and Ombudsman Notification of Transfer or Discharge, revised 11/28/27, provided by the facility, revealed It is the policy of [facility name] to provide residents/resident representatives and the ombudsman with a notice of transfer/discharge as required by Center for Medicare & Medicaid Services (CMS). CMS requires advance written notification of a resident transfer/ discharge and the reasons for the discharge. This policy did not address emergency transfers to the hospital. Review of the facility's Notice of Transfer/Discharge, undated, provided by the facility, revealed the notice included all the required elements for a facility-initiated transfer. This form was not utilized. 1. Review of R30's undated admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R30 was admitted to the facility on [DATE] and was re-admitted on [DATE]. Review of the EMR Progress Notes located under the Progress Notes tab, revealed a progress note, dated 12/19/24, R30 sustained unwitnessed fall in his room at approx. 1600 (4:00 PM), found face down next to bathroom door with wheelchair on top of his legs . R30 sustained lacerations to bridge of his nose and above left eyebrow and skin tear to LFA (left forearm) . Resident currently on Eliquis. Emergent transport initiated to Hospital for evaluation . Further review of the record revealed no documentation that written notification containing information as to the reason for the hospital transfer was provided to the resident, or the resident's representative. During an interview on 03/13/25 at 6:00 PM, the Administrator revealed, We did not provide any written transfer notice to the resident or the resident representative regarding the transfer to the hospital. 2. Review of admission Record, located under the Profile tab in the EMR, documented that R258 was re-admitted to the facility on [DATE] with a diagnosis of diabetes. Review of Nurses Note, located under the Notes tab in the EMR, indicated, R258 noted with decreased blood sugars after receiving Lantus insulin at bedtime. Blood sugar (BS) 94 .no signs or symptoms of hypoglycemia observed .R258 transferred to hospital. No documented evidence of a written transfer notice given to R258 upon transfer to the hospital. Review of the EMR under the tab Misc indicated no documented evidence of a transfer notice back in February 2024. Interview on 03/14/25 at 3:00 PM, the Administrator confirmed that there was no transfer notice for R258 when he went to the hospital on [DATE]. The Administrator confirmed that there should have been one. 3. Review of R41's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/24 and located in the EMR under the MDS tab, revealed R359 had an admission date of 09/22/22 and a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R41's cognition was intact. The MDS assessment indicated R41 had diagnoses that included stroke, hemiplegia and hemiparesis, and chronic obstructive pulmonary disease. Review of R41's care plan, revised 07/06/24 located in the EMR under the Progress Note tab revealed R41 has altered cardiovascular status r/t [related to] CAD [coronary artery disease], HTN [hypertension], HDL[hyperlipidemia]. Review of R41's nurse note, 07/02/24, located in the EMR under the Progress Note tab revealed Resident returned from outside the building smoking. Upong [sic] entering the building resident c/o [complaint of] not being able to move right arm, right arm cold to touch upon assessment and resident unable to move fingers and states he couldn't feel this nurse touching his skin. Dr. [doctor] [name] arrived to resident's room to assess and ordered to send resident out to ER [emergency room] for eval [evaluation]. [family member] [name] made aware. Review of R41's nurse note, 07/05/24, located in the EMR under the Progress Note tab revealed Resident returned from the hospital at approximately 1640 via stretcher. Received alert and stable with no c/o pain or discomfort. VSS [vital signs stable], Resident skin warm intact. Encouraged to use call light when need assistance. Safety in place. On 03/11/25 at 10:26 AM, R41 was awake in bed. R41 stated he had a stroke one day after smoking and went to the hospital. R41 was asked if he received any paperwork when going to the hospital. R41 stated he doesn't remember receiving any papers for a hospital transfer during that time. During an interview on 03/12/25 at 2:26 PM, the Chief Nursing Officer (CNO) was asked about transfer notices. The CNO stated a transfer form wasn't completed for R41 for 07/02/24. The CNO stated the nurse sending R41 out would have given the emergency medical service (EMS) a packet with the transfer form but there was no record of it. During an interview on 03/13/25 at 11:52 AM, the Director of Nursing (DON) was asked about the process when sending a resident to the hospital. The DON stated they sent an interagency transfer form that was filled out manually, the face sheet and a list of medications were sent in a packet that is given to the EMS. The DON asked if a transfer form that includes the regulation details such as date/location/reason/appeals rights. DON stated the unit manager give the bed hold to the resident. The transfer form was requested for R41's 07/02/24 transfer notice when he was sent to the hospital. None was provided as of exit, 03/14/25. During an interview on 03/13/25 at 1:43 PM, Licensed Practical Nurse Supervisor (LPNS)1 and LPNS2 were asked if they use the titled Notice of Transfer/Discharge Form, provided by the DON, when a resident was sent to the hospital. LPNS1 and LPNS2 reviewed the form and stated, No, they use another form and doesn't include appeal rights. LPNS1 and LPNS2 went on to say they gather the list of medications and face sheet and another hand-written transfer form that are given to EMS, but nothing was given to the resident. LPNS1 and LPNS2 were asked if R41 went to the hospital in July 2024 and they both stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 30) reviewed for hospital transfers was given a written copy of a bed hold notice prior to or within 24-hours of emergency transfer to the hospital. This failure created the potential for residents and/or responsible parties not to have the information needed to safeguard their return to the facility. Findings include: Review of the facility's policy titled, Bed Holds, dated 01/03/25, revealed Policy: Bed Hod Policy. Purpose: It is the policy of Cadia to implement bed holds in accordance with federal and state law, which require two written notices of a facility's Bed Hold Policy be provided to a resident and his/her family member or legal representative as outlined below. Procedure: . 2. Second Written Notice: (a) If the resident leaves the facility for emergency treatment at a hospital, a copy of the facility's Bed Hold Policy will be included in the documentation accompanying the resident to the hospital. In addition to the written notice included in the resident's paperwork, the admission Director/Designee will call the resident's family member or legal representative, explain the Bed Hold Policy, and advise the family member or legal representative that the written notice will be mailed to them for review. The admission Director/Designee will document this conversation, including the family member or legal representative's decision regarding the bed hold, in the resident's medical record . Review of R30's undated admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R30 was admitted to the facility on [DATE] and was re-admitted on [DATE]. Review of the EMR Progress Notes located under the Progress Notes tab, revealed a progress note, dated 12/19/24, R30 sustained unwitnessed fall in his room at approx. 1600 (4:00 PM), found face down next to bathroom door with wheelchair on top of his legs . R30 sustained lacerations to bridge of his nose and above left eyebrow and skin tear to LFA (left forearm) . Resident currently on Eliquis. Emergent transport initiated to [NAME] Hospital for evaluation . Further review of the resident EMR failed to reveal documentation of the resident and/or the resident's representative was given written notice that specified the duration of the facility's bed hold policy. During an interview on 03/13/25 at 6:00 PM, the Administrator revealed, We did not provide any written bed hold notice to the resident or the resident representative regarding the transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure that physician's orders were followed for one resident (Resident (R) 208) from a sample of 41 residents reviewed. This failure has the potential to negatively impact R208 and others that have similar orders that currently reside at the facility. Findings include: Review of R208's admission Record, located under the Profile in the Electronic medical record (EMR), indicated, that R208 was re-admitted to the facility on [DATE] for hypertension. Review of R208's Order Summary Report, dated 03/22/24, located under the Orders in the EMR, indicated Propranolol HCl Oral Tablet 40 milligrams (mg), give one tablet by mouth (PO) two times (BID) a day for hypertension, hold for heart rate (HR) less than 50. Review of Medication Administration Record (MAR), dated 03/01/24-03/30/24, under the tab Orders located in the EMR, indicated, .Propranolol HCL oral tablet 40 mg, give one tablet PO BID .hold for HR less than 50, starting 03/22/24. There is no documented HR taken on the following dates for the morning dose: 03/24/24 and there is no documented HR taken on the following dates for the bedtime dose: 03/22/24, 03/23/24, 03/25/24, and 03/26/24. Interview on 03/14/25 at 7:45 PM, the Director of Nursing (DON) confirmed that the HR was not taken on the dates listed above and should have been taken as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that fall interventions were followed for one resident (Resident (R) 82) out of five residents reviewed for falls, out of a sample of 41 residents. This failure had the potential to negatively impact R82 and other residents residing in the facility by not ensuring that staff consistently implemented fall interventions. Findings include: Review of R82's admission Record, located under the Profile tab in the Electronic Medical Record (EMR), indicated, that R82 was re-admitted to the facility on [DATE] was a diagnosis of fracture of the right pelvis and the right shoulder. Review of a significant change in status Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD), of 01/27/25, located under the MDS tab in the EMR, indicated, R82 had a Brief Interview for Mental Status (BIMS) of nine out 15, making R82 moderately impaired cognitively. Review of facility provided [name of state] Health and Social Services Division of Health Care Quality Incident Report, dated 09/20/24, .resident status post (s/p) fall complaint (c/o) pain .Sent to the hospital for further evaluation. Review of R82's Order Summary Report, under the Orders, tab dated 03/05/25, located in the EMR, indicated, Fall precautions: low bed, nonskid footwear every shift, no longer needs bolsters. Review of R82's Care Plan, revised on 10/16/24, located under the ''Care Plan tab in the EMR, indicated, R82 is at high risk for falls related to impaired cognition/confusion, deconditioning, gait/balance problems .history of community falls .actual facility fall. Interventions: .Bilateral fall mats (initiated: 07/10/24). There was no documented evidence that the care plan was revised to include a low bed as ordered by the physician on 03/05/25. During observation on 03/10/25 at 11:29 AM, R82 was sitting up in her bed with the television on. R82 was observed to be alert and confused. R82's bed was in a standard height with no bilateral floor mats. During this observation, R82 was attempted to be interviewed, but was confused. During observation on 03/11/25 at 11:00 AM and 6:00 PM, R82 was observed lying in bed. The bed was observed to be in standard height with no bilateral floor mats. During observations on 03/12/25 at 9:00 AM, 12:55 PM, and 5:13 PM, R82 was observed lying in bed. The bed was observed to be standard height with no bilateral floor mats. Interview on 03/13/25 at 3:25 PM, the ADON confirmed that R82 did not have bilateral floor mats, and that bed was in standard height.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to ensure that a resident with a urinary catheter bag was properly positioned in a manner to prevent potential urinary tract infections due to contamination for one of six residents (Resident (R)99) reviewed for urinary catheters and urinary tract infections out of a total sample of 41 residents. Findings include: Review of the facility's policy titled, Indwelling Urinary Catheter Management, revised 01/03/25, revealed It is the policy of [facility name] that residents with indwelling catheters are assessed for appropriate catheter use and that the resident's medical record reflects the supporting diagnosis .The medical record of residents admitted with an indwelling catheter is reviewed to determine the diagnosis and necessity of continued catheter use .The care plan is updated to reflect the resident's toileting needs .Residents with an indwelling catheter will receive daily/prn [as needed] catheter care. Catheters and drainage bags will be changed every 60 days or s needed. Review of R99's admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was originally admitted on [DATE], with diagnoses including retroperitoneal hematoma, urinary tract infection, and hydronephrosis. Review of R99's five day Minimum Data Set (MDS) assessment located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 02/08/25, revealed a Brief Interview for Mental Status (BIMS) assessment with a recorded score of six out of 15 which indicated severe cognitive impairment. R99 was documented to require a catheter and was administered antibiotic. R99 did not reject care. Review of the Physician Orders located in the EMR under the Orders tab revealed a 03/06/25 order for Urinary Catheter Type: indwelling Size 18 French balloon .10 ml (milliliters) one time a day every 28 day(s) . Interventions included to check tubing for kinks, to position the catheter bag and tubing below the level of the bladder, and to provide catheter are as ordered. Record review for R99 revealed there was no care plan initiated or revised for non-compliance with catheter care management. During an observation on 03/10/25 at 2:05 PM, R99 was observed sleeping in bed. The catheter bag was observed hanging from the right side of the bed, visible form the hallway. The bag was observed uncovered, skimming in contact along the floor. During an observation on 03/11/25 at 9:50 AM, R99 was again observed sleeping in bed. The catheter bag was hung from the right side of the bed, visible from the hallway. The uncovered bag was in contact with the floor. During an additional observation on 03/12/25 from 8:45 AM through 9:20 AM, R99 was observed in bed. The uncovered catheter bag, and tubing, was observed resting completely on the floor. During an interview on 03/12/25 at 8:47 AM, Certified Nursing Assistant (CNA) 5 said that the CNAs empty catheter bags once or twice in a shift. She said the bags should be hung below the resident's waist, off the ground when in a wheelchair or in bed. During an interview on 03/12/25 at 8:54 AM, CNA6 said that catheter bags were managed and handled by the nurses. She stated that the catheter bags were hung on the side of the bed, above the floor. During an interview on 03/12/25 at 9:05 AM, Licensed Practical Nurse (LPN)2 observed R99 sleeping in bed and confirmed the catheter bag as on the floor. LPN2 confirmed the catheter bag should be hanging from the side of the bed, off the floor. LPN2 stated that the resident constantly pulled the bag off the hook. CNA5 entered the resident's room and also confirmed the catheter bag was on the floor and should have been hanging on the side of the bed off the floor. CNA5 said the resident took the bag off the hook all the time. CNA5 rehung the catheter bag. During an interview on 03/13/25 at 11:56 AM, the Director of Nursing stated that catheter bags should be placed below the bladder and should be covered in a privacy bag. She stated that catheter bags should be monitored for no kinks and no backflow. She said that catheter bags should not be on the floor, and that there was a place for staff to hang them when the resident was in bed. The Director of Nursing stated that both CNAs and nurses should be aware of where to place the catheter bag. She said her expectation was that nurses and CNAs monitored R99's catheter when they went into his room. She stated that if the resident was doing something to keep putting the catheter bag on the floor, the facility would want to know so they could care plan for it. She said the staff should be telling her. She stated that she was not sure R99 was able to be reasoned with regarding catheter care management, so the facility would want to mitigate any issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to inform seven of seven residents in the resident council about the facility's grievance policy, the grievance official responsible for overseeing the grievance process was with their contact information and resolve grievances for three (Residents (R)158, R34, and R59) of three residents reviewed for grievances. This failure could prevent residents from addressing concerns and seeking resolution, leading to frustration and potentially impacting their well-being. Findings include: Review of the facility policy titled, Grievances, review date 01/03/25, provided by the facility revealed All grievances reported by a resident, responsible party, resident representative or family member will be promptly investigated and resolved. Follow up will be reported to the resident and/or reporting party. The facility will post guidance on how to file a grievance or complaint in prominent locations throughout the facility. a. All grievance decisions shall be documented on the Resident Concern Form. 1. Review of the resident council minutes for March 2024 through February 2025 did not include any discussion of the facility's grievance process. On 03/12/25 at 01:48 PM, the grievance policy was observed posted in the glass case in the front hallway at the second-floor main entrance. The posting was high above the standard height, making it difficult to read. On 03/11/25 at 2:29 PM, seven of seven residents in the resident council stated they were unaware of any formal complaint process the facility had. They were also unaware of any posting that would inform them. None of them knew of anyone designated to report complaints to, except the social worker. During an interview on 03/11/25 at 5:03 PM, the Social Service Director (SSD) was asked who the facility's grievance officer was. SSD stated it was the Administrator. SSD stated most complaints come through her department. SSD stated she writes out the concern and gives it to that department to be investigated and resolved. The Administrator then reviews it and signs off on them. SSD was asked how residents learned how to make a complaint. SSD stated they asked during resident council if anyone has a concern, and the policy was also posted. SSD was asked how residents that don't attend resident council find out about the grievance process. SSD stated she wasn't sure but going forward they will find a way to better educate. During an interview on 03/14/25 at 2:11 PM, the Administrator was informed during the resident council interview, seven of seven residents stated they were unaware of the facility's grievance process, how to make an anonymous complaint or who the grievance officer was. The Administrator stated there was a complaint box in front of the building residents could use and she has received complaints from residents from the box. 2. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R158 was admitted to the facility on [DATE] and was discharged on 11/08/24. R158's closed record was reviewed. During an interview on 03/11/25 at 3:47 PM, Family Member (FM)1, the responsible party for R158, stated there were multiple concerns occurring during R158's stay at the facility. FM1 stated she had filed grievances and talked with numerous staff including the SSD, Director of Nursing (DON), and the Administrator. FM1 stated one of her concerns was poor housekeeping services. FM1 stated the housekeeper assigned to R158's room did not clean the room and bathroom adequately. FM1 stated R158's toilet went five days one time without getting cleaned. FM1 stated public areas were also not cleaned and there were dirty floors, furniture etc. R158 stated staff did not address her concerns adequately and filed housekeeping grievance more than once. Review of a Resident Concern Form dated 09/03/24 and provided by the facility revealed FM1's grievance was taken by the SSD and included two concerns. One concern related to nursing and call bells and the other concern was about housekeeping. The housekeeping concern indicated there was a lack of housekeeping over the weekend, the garbage was full, and there were flies. The Resident Concern Form investigation was completed by the DON and addressed the nursing concern; however, did not address the housekeeping concerns. There was no response to the Resident Concern Form addressing the housekeeping issues. Review of a Resident Concern Form dated 10/11/24 revealed FM1 filed a grievance on this date with the SSD due to R158's room and bathroom not being cleaned for days at a time, feces on the bathroom floor and the dining room not getting cleaned from the previous day. The Resident Concern Form investigation was completed by the Housekeeping Director (HD) and FM1 was contacted on 10/18/24 with the results. Resolutions included inservicing housekeeping staff about the importance of cleaning rooms. During an interview on 03/12/25 at 3:10 PM, the SSD stated she did not remember FM1 expressing any concerns to her. The SSD stated when residents or family brought her concerns, she initiated the Resident Concern Form and then forwarded the form to the relevant department to do the investigation, document their response and contact the complainant once the investigation was completed. The SSD stated once the investigation was completed, the department head brought her the completed form, and she took it to the Administrator for signature. During an interview on 03/12/25 at 3:27 PM, the Housekeeping Director (HD) stated she remembered speaking to FM1 about housekeeping concerns and had responded to a Resident Concern Form. The HD stated when she received a Resident Concern Form she investigated the concern, documented the information on the form, and then contacted the complainant to discuss the results. The HD reviewed two Resident Concern Forms one dated 09/03/24 and one dated 10/11/24. The HD stated she completed the investigation and responded to the Resident Concern Form dated 10/11/24. The HD stated she personally checked R158's room for cleanliness after the grievance filed on 10/11/24. The HD reviewed the Resident Concern Form dated 09/1024 and verified she had not responded to that grievance and there was no response on the form related to the housekeeping concerns. The HD stated she did not remember responding to more than one Resident Concern Form from FM1. During an interview on 03/14/25 at 11:30 AM, the DON stated she met with FM1 several times about her concerns. The DON verified she responded to the nursing concerns on the Resident Concern Form dated 09/03/24. The DON stated when a grievance had concerns that addressed two departments such as nursing and housekeeping, two copies of the form were made with each copy going to the appropriate department head. The DON stated she did not investigate or respond to the housekeeping concerns on the Resident Concern Form dated 09/03/24. During an interview on 03/14/25 at 1:46 PM, the Administrator stated she was not employed when the grievance in September 2024 was filed by FM1. The Administrator stated the Administrator oversaw the grievance process and signed off on the grievance once completed. The Administrator stated if there were allegations for two different departments, each department should get a copy of the grievance and each department should respond. The Administrator stated the two responses should get combined for the total response. During an interview on 03/14/25 at 4:05 PM, the Administrator stated she could not find where the housekeeping part of the grievance dated 09/03/25 had been addressed. 3. Review of R34's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/10/24 and located in the EMR under the MDS tab, revealed R34 had an admission date of 02/13/17 and a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R34's cognition was intact. The MDS assessment indicated R34 had diagnoses that included depression, anxiety, and cerebrovascular disease. Review of R34's care plan, dated 03/20/20, located in the EMR under the Care Plan tab revealed an intervention R34 states that it is important to her to take care of her personal belongings and things. R34 prefers to use personal products she has purchased (dollar store/trips) but will also use facility issued personal products. She performs her own oral care and for hygiene requests that the staff keep her well groomed and nice. She prefers to have her personal items kept in order in her room. Review of R34's orders, dated 07/01/20, located in the EMR under the Order tab revealed Palliative Care . Review of the facility's grievances, dated 03/2024 to 03/2025, revealed no grievance addressing R34's personal property. During the resident council interview on 03/11/25 at 2:29 PM, R34 stated she had a small refrigerator for two or three years in her room and staff recently took it out of her room with no explanation. R34 stated the small refrigerator was currently at the nurse's station for her family to pick up. R34 went on to say it was only big enough to hold two or three cans of soda. During an interview on 03/11/25 at 3:48 PM, Licensed Practical Nurse Supervisor (LPNS)2 confirmed R34's small refrigerator was removed from her room and stored in a drawer at the nurses' station. LPNS2 opened the drawer, and the refrigerator was observed to be a mini box cooler only big enough to hold a few canned drinks. LPNS2 was asked why R34's refrigerator was removed from her room. LPNS2 stated because it's the facility's policy no personal refrigerators in resident rooms as they have a designated refrigerator for residents behind the nurses' station. On 03/12/25 at 9:24 AM, R34 was awake in bed watching television. R34 was asked in what manner was her refrigerator removed and how long ago. R34 stated two nurses came into her room sometime after Christmas saying they were conducting room checks. R34 stated the nurses walked around her bed and spotted her small refrigerator. They told her You can't have this and took it. They gave her no explanation. R34 stated she was so upset over the manner she called her granddaughter. Her granddaughter came in and the staff told her It's unsafe without further explanation. During an interview on 03/12/25 at 9:34 AM, the Social Service Director (SSD), was asked if she was aware R34's small refrigerator was removed earlier this year. SSD stated, Yes, it was an administrative decision. SSD stated the reason was because the refrigerator was a fire safety risk, she but she wasn't sure how it was a safety risk. SSD was asked if it was a new policy and SSD stated, No. SSD was asked why R34 wasn't given an explanation. SSD stated she didn't know. During an interview on 03/12/25 at 9:41 AM, the Administrator was asked if she was aware of R34's mini box cooler was removed sometime after Christmas. The Administrator stated, Yes for safety, as R34 was unable to maintain its cleanliness, ensured it was at the correct temperature and food was dated. The Administrator stated, the company doesn't allow it, and the reason was explained to R34's niece. The Administrator was asked for a personal property policy. The Administrator stated they didn't have a policy addressing personal property, just the grievance policy. The Administrator was asked if the admission packet included no small refrigerators allowed. The Administrator stated she wasn't sure. The Administrator was asked why the facility's outside food policy didn't mention the designated resident refrigerator at the nurses' station and only addressed perishable foods (time/temperature controlled foods). The Administrator was informed that R34's small refrigerator was a box cooler that only held soda cans which aren't perishable foods. The Administrator stated she would look at the policy and update it as indicated. The Administrator was asked if there was documentation of the staff's right to take R34's property. The Administrator stated, No after reviewing the EMR and finding no documentation. 4. Review of R59's quarterly MDS, with an ARD of 12/04/24 and located in the EMR under the MDS tab, revealed R34 had an admission date of 06/03/22 and a BIMS score of 15 out of 15, which indicated R59s cognition was intact. The MDS assessment indicated R59 had impairment on one side of this upper extremity, was dependent with transfers and had diagnoses that included other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting left non-dominant side, epilepsy, and muscle weakness. Review of R59's care plan, dated 06/13/22, located in the EMR under the Care Plan tab revealed an intervention R59 states that it is important to him to: take care of his personal belongings and things . Review of R59's social service note, dated 01/07/25, located in the EMR under the Progress Note tab revealed Met with resident about several issues today and called his [family member] to keep her in the loop. His electric razor is missing, but his [family member] doesn't want to buy another one and is just encouraging him to get used to disposable razors, which he used today. Also - per [family member], resident will need reminders about phone scams and to be more cautious. Nsg [nursing] already aware and SS [social services] discussed this with him today . On 03/14/25 at 11:10 AM, R59 was awake in bed holding his cell phone. R59 stated the facility does a good job with care, except his electric razor had been missing recently. R59 stated he ordered it off Amazon and it cost $60. R59 stated he asked Certified Nursing Aide (CNA)11 to plug it in to charge and that's when it was discovered gone. He reported it to the Unit Managers and maintenance looked around his bed for it and it was not found. R59 stated the electric razor kept him more independent as it's easier to do a good job shaving. R59 stated that other razors have been broken when the CNAs pushed his overbed table away during care very fast and his razor flies off, breaking it. During an interview on 03/14/25 on 11:15 AM, CNA11 was asked about R59's missing electric razor. CNA11 confirmed R59 had an electric razor, and he asked her a while ago to plug the razor in to charge and it wasn't there. CNA11 stated the razor was there the shift before her's. During an interview on 03/14/25 at 12:22 PM, the Director of Nurses (DON) asked about R59's missing razor on or around January 2025. The DON stated she thought she remembered something about this, and the social worker made a note. The DON asked if the missing razor should have been written as a grievance. The DON stated she thought so. During an interview on 03/14/25 at 1:41 PM, Licensed Practical Nurse Supervisor (LPNS)2 was asked if she was aware R59's electric razor was missing. LPNS2 stated, Yes, she was aware, but it was already reported to social services. LPNS2 stated his [family member] said she wasn't going to buy him any more razors as he keeps breaking them. LPNS2 was asked if R59 was his own representative and LPNS2 stated, Yes but it was the [family member's] Amazon account that he ordered the razors from. LPNS2 informed R59 stated the CNAs push his overbed table away during care very fast and his razor flies off it and they break. LPNS2 stated she was unaware of that. During a telephone interview on 03/14/25 at 6:38 PM, the Activity Assistant (AA) stated she assisted SSD and was asked if she was aware R59's electric razor was missing. AA stated, Yes she knew about it in January 2025 and R59's [family member] wanted R59 to use disposable razors because he's broken too many electric razors. AA was asked if R59 was his own representative and AA stated, Yes but R59 wants his [family member] in on his financial business. AA was asked if a written report was made about the missing razor. AA stated, No because R59's [family member] was not overly concerned about it. AA was asked could R59 had lost his electric razor since he was confined to the bed and required total assistance to get out of bed. AA stated, No. AA was asked if anyone looked for his razor beyond his room such as laundry in case it got caught in his bedding or if it fell in the trash or if it was stolen. AA stated she wasn't sure and would have to check with SSD. During an interview on 03/14/25 at 7:16 PM, the Administrator was asked why R59's missing electric razor wasn't written as a grievance per their policy. The Administrator stated R59 broke it and his [family member] said she wasn't going to get him anymore. The Administrator was informed the R59 reported it as missing and not broken. However, R59 reported the other electric razors had been broken when the CNAs pushed his overbed table aside quickly to give care. The Administrator stated she visits R59 regularly and he has never told her that.

Based on observations, record review, and interviews, the facility failed to ensure a medication error rate of less than five percent. During observation of medication pass, there were three errors observed out of 30 opportunities, resulting in a 10% error rate. This had the potential to place two residents (Residents (R) 36 and R93) at risk of not receiving the full benefit of their medication therapy. Findings include: 1.Review of R93's facility provided Order Summary Report revealed ritalin oral tablet 20 milligrams (mg) (Methylphenidate HCL), give one tablet by mouth (PO) two times (BID) a day for attention deficit disorder (ADD), starting 01/15/25. Review of R93's facility provided Order Summary Report revealed omeprazole oral capsule delayed release 40 mg, give one capsule PO one time a day for gastroesophageal reflux disease (GERD), starting 02/04/25. Review of facility provided Blister Package indicated omeprazole 40 mg capsule, one time a day for GERD .Take on empty stomach, before eating. Review of facility provided Blister Package indicated Methylphenidate 20 mg tablet twice daily for ADD. Preferably take 30-45 minutes before meals. Observation on 03/12/25 at 9:00 AM, Registered Nurse (RN) 1 prepared medications for R93, which included ritalin (hyperactivity medication) 20 mg one tablet, and omeprazole 40 mg one capsule, which she popped into a clear cup. After RN1 obtained all the medications needed for R93, she administered the medications. Interview on 03/12/25 at 9:05 AM, R93 said that she already had eaten breakfast. R93 said that she ate cereal this morning. Interview on 03/13/25 at 10:41 AM, RN1 confirmed that she was aware that these medications were to be given before meals; however, RN1 stated that she does her best to give them to the resident before breakfast but has other things to do prior to giving these medications. 2. Review of R36's facility provided Order Summary Report revealed glipizide 2.5 mg, give one tablet PO one time a day every Monday, Wednesday, Friday for diabetes. Give 30 minutes before meals, starting 12/03/24. Review of the facility provided Blister Package indicated, glipizide 2.5 mg one tablet PO one time a day every Monday, Wednesday, Friday for diabetes. Give 30 minutes before meals. Observation on 03/10/25 at 10:00 AM, Licensed Practical Nurse (LPN) 2 prepared medications for R36, which included glipizide (diabetes medication) 2.5 mg one tablet, which she popped into a clear cup. After LPN2 obtained all the medications needed for R36, she administered the medications. Interview on 03/10/25 at 10:15 AM, LPN2 confirmed that R36 already had her breakfast tray. Follow up interview on 03/13/25 at 12:05 PM, LPN2 said that R36's medication was held due to her blood sugar being low (blood sugar documented at 112) and said that she gave R36's medication around 9:00 AM; however, when the correct time for administration was discussed, LPN2 had nothing to say. Interview on 03/13/25 at 11:30 AM, the Director of Nursing (DON) said that she expects medications to be given as ordered, and according to blister package instructions.

Based on observation and interview, the facility failed to ensure the outdoor garbage/dumpster area was maintained in a manner to prevent pests from accessing garbage. A large dumpster contained garbage; there was no lid, and the bags were observed with holes and food. Findings include: During an observation on 03/10/25 at 9:45 AM with the Dietary Manager (DM), there was garbage on the ground around the garbage compactor including cigarette buts, paper, and pieces of cardboard. The DM verified the presence of the garbage on the ground and stated maintenance was responsible for keeping the area cleaned up. In addition, there was an extra-large dumpster that did not have a lid, and it could not be closed. This dumpster contained a lot of garbage, including large plastic bags of waste from the kitchen. There were five bags visible that had rips or torn areas with garbage such as food scraps/containers visible. The DM stated the compactor was gone for a while due to being repaired and that was why the large dumpster was present. The compactor had been repaired and returned to the premises; however, the large dumpster had not been removed. During an observation on 03/11/25 at 10:13 AM, the large dumpster was observed with the same garbage from 03/10/25 including the ripped garbage bags with food scraps/containers visible. During an observation on 03/11/25 at 7:05 PM, a large dumpster was observed with the same garbage noted at 10:13 AM with holes in the bags and food scraps/containers visible. During an observation on 03/12/25 at 10:01 AM, the DM and surveyor checked the dumpster area. The large dumpster continued to have ripped bags of garbage visible which was verified by the DM. The DM stated it was important to have a lid to cover the garbage so animals could not get into it. The DM stated the dumpster would be removed today. The garbage on the ground around the garbage compactor observed on 03/10/25 continued to be present (cigarette buts, paper, cardboard). During an interview on 02/12/25 at 10:18 AM, the Maintenance Director (MD) stated the large dumpster had been present for a couple of weeks while the compactor was repaired. The MD stated he had reached out to waste management to come and remove the dumpster. The MD stated waste management did not provide dumpsters that had lids. The MD stated the maintenance staff typically cleaned the garbage area twice a week on Mondays and Fridays. The MD stated the large dumpster was scheduled to be picked up on 02/13/25. During an interview on 03/13/25 at 10:29 AM, the Administrator stated there was no facility policy related to maintenance of the dumpster area. During an interview on 03/13/25 at 5:35 PM, the Registered Dietitian (RD) stated she completed sanitation inspections of the kitchen which included checking the dumpster area. The RD stated she looked to ensure the dumpster was not overfilled, that the lid was closed, and that there was no food/garbage on the ground. The RD stated the lid should be closed to ensure animals did not get into the garbage. During an interview on 03/13/25 at 6:59 PM, the Administrator stated the large dumpster was picked up today. She stated she was not sure how long the dumpster had been present at the facility. The Administrator stated the dumpster should have had a lid so the garbage would be enclosed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to follow Transmission Based Precautions, use proper hand hygiene, and change gloves during incontinent care. These breaches in infection control could cause a spread in disease and affect all the residents. Findings include: Review of the facility policy titled Infection Prevention and Control Program Policy, revised 04/14/21, provided by the facility revealed individuals with suspected or diagnosed communicable disease are placed on the appropriate precaution for that disease, as recommended by the Centers for Disease Control and Prevention (CDC) . Employees will follow hand hygiene practices consistent with standards of care . Review of facility provided poster titled, Stop: Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following high-contact resident care activities: .changing linen .changing briefs or assisting with toileting, device care or use: .feeding tube. Review of facility provided policy titled, Standard and Transmission Based Precautions, revised 01/02/25, indicated, .Policy: [name of the facility] institutes the following precautionary measures to help prevent the spread of Multi-Drug-Resistant Organisms (MDRO) and highly contagious infections/outbreaks. Our goal is to use these infection prevention principles to protect our residents and staff from spread of infections related to MDRO. The types of precautions and when to implement are defined below. Type of Precautions: 1. Standard Precautions-Applies to all residents. No room restrictions. Clean, non-sterile gloves when touching or coming into contact with blood, body fluids, secretions, or excretions. Remove gloves after use. Discard before touching non-contaminated items or environmental surfaces and before providing care to another resident. Hand Hygiene/alcohol-based hand gel/hand washing 2. Enhanced Barrier Precautions-Applies to all residents with wounds and/or indwelling medical devices (central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization as well as for residents with MDRO infection or colonization, when contact precautions do not otherwise apply. No room restrictions. Hand Hygiene/alcohol-based hand gel/hand washing Personal protective equipment (PPE)-gloves and gown and/or face protection during high- contact resident care activities: i.e.changing linens, changing briefs or assisting with toileting, device care or use. 3. Contact Precautions - Applies to all residents infected or colonized with a MDRO [multidrug-resistant bacteria] in the following situations: presence of acute diarrhea, draining wounds, or other sites of secretions or excretions that are unable to be covered or contained, . 1. Observation on 03/10/25 at 12:09 PM, Licensed Practical Nurse (LPN) 2 entered R68's enhanced barrier precaution (EBP) room with any person protective equipment (PPE) on and hung R68's tube feeding, removed the cap from the tube. LPN2 primed the line, dropped the tubbing on the floor, and picked the tubbing up off the floor. At the time of picking the tubbing off the floor, there was no observed cap at the end of the tubbing, and LPN2 flung it over the tube feed (TF) pole. LPN2 sat the two cups of liquid medications on the overbed table, then gave the medications. After incontinent care was completed, LPN2 went over to the TF pole, obtained the tubbing that was hung over the pole, and placed the tip of the tube into the g-tube without wiping it off. Observation on 03/10/25 at 12:24 PM, Certified Nursing Assistant (CNA) 12, entered R68's EBP room with PPE on. CNA12 had a gown, gloves, and mask. CNA12 brought another gown which she placed on R68's bed toward LPN2. LPN2 was on the right side of the bed that was closest to the window. CNA12 removed R68's wedges, and pillows. With the same gloves, CNA12 went to the bathroom got a gray basin, filled it with water, came back out and placed it onto the overbed table, and got R68's soap out of the top drawer of the nightstand. CNA12 removed R68's soiled brief tucking it under R68's bottom, then washing R68's perineal area. With the same gloves, CNA12 rinses and dries R68. CNA12 assists R68 in turning over to LPN2, and then CNA12 changed her. CNA12 removed fitted sheet, and bunched up brief which was soiled with bowel movement (BM) and washed, rinsed, and dried R68 all with the same gloves. CNA12 then placed a new brief on R68, and turned R68 towards her, while LPN2 removed linen, without LPN2 wearing PPE. After LPN2 removed the linen, LPN2 did not change gloves, but finished fixing R68's brief. CNA12 placed new linen on R68's bed with the same gloves. Review of Order Summary Report, dated 12/18/24, under the Orders tab, located in the Electronic Medical Record (EMR), indicated, EBP related to peg tube and history of extended-spectrum beta-lactamase (ESBL) in urine. Interview on 03/13/25 at 12:05 PM, LPN2 was unaware of EBP for tube feeding residents, stating that she has never worn a gown before giving tube feed. Indicated that the tube had a cap on it and that cap was present prior to her inserting the tip into the g-tube. Interview on 03/13/25 at 1:00 PM, CNA12 confirmed that she did not change her gloves when going from a dirty area to a clean area and indicated that she should have. 2. During observation on 03/11/25 at 10:06 AM, the Assistant Director of Nursing (ADON) went into R53's room without washing and/or sanitizing her hands prior to entering the room. R53 is on enhanced barrier precautions (EBP) and there was a sign on the door to let staff know what to do and a clear bin next to R53's door for personal protective equipment (PPE). Review of Order Summary Report, dated 12/02/24, under the Orders tab, located in the EMR, indicated, EBP related to gastrojejunostomy (GJ) tube. 3. During the medication observation pass on 03/11/25 at 10:39 AM, Registered Nurse (RN) 3 observed popping R74's seven medications into his left hand from the medication blister package followed by placing them into a clear medication cup on top of the medication cart. RN3 then gave R74 his medication. Interview on 03/13/25 at 10:53 AM, RN3 confirmed that he popped the medication into his hand; however, RN3 said that he sanitized his hands first and it was better than dropping the medication. Interview on 03/13/25 at 11:30 AM, the Director of Nursing (DON), she said that she expects nurses to pop medications directly into the medication cup, not into their hands. 4. Observation on 03/12/25 at 9:40 AM, the ADON entered R11's EBP room without washing her hands and/or sanitizing her hands; however, placed a gown on. Along with the ADON, Licensed Practical Nurse Supervisor (LPNS)2, entered the room at the same time, without putting on a gown, and did not wash hands and/or sanitize hands before entering the room but put on gloves. LPNS2 picked up linen off the floor near bed B and ADON left the room at 9:43 AM, removing her gown without sanitizing her hands or washing her hands, going down the hallway to get a hamper, and returned to the room. At 9:46 AM, ADON went back inside the room without washing hands and/or sanitizing hands and delivered hamper to LPNS2. LPNS2 finished gathering linen up off the floor and gathered linen off bed B, placing all linen in the hamper. Interview on 03/12/25 at 9:52 AM, the LPNS2 confirmed that she did not wear any PPE and should have. Confirmed that linen should not have been on the floor. 5. Observation on 03/13/25 at 3:25 PM, the ADON entered and exited R82's EBP room without washing and/or sanitizing her hands. Review of R82's Order Summary Report, dated 12/11/24, located under Orders tab in the EMR, documented, Enhanced Barrier Precautions related to history of Methicillin-resistant Staphylococcus aureus (MRSA). Interview on 03/14/25 at 2:00 PM, the ADON confirmed that she did not sanitize hands and/or wash her hands prior to and/or exiting EBP rooms as she should. Interview on 03/13/25 at 10:01 AM, the Infection Preventionist (IP) confirmed that medications should be popped directly into a medication cup, not into a nurse's hand. Said that when providing peri-care, gloves are to be changed when going from a dirty area to a clean area. She said that when giving medications through a gastrotomy tube (g-tube), if the tubing falls on the floor, that tubing is not to be used. If a resident is on EBP donning (putting on) is to occur prior to entering the room along with washing and/or sanitizing hands, and doffing (taking off) PPE prior to exiting the room, placing PPE in the bins provided in the room. After staff exit an EBP room, staff are to wash their hands and/or sanitize their hands. 6. Review of R15's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/05/25 and located in the electronic medical record (EMR) under the MDS tab, revealed R15 had an admission date of 01/30/25 and a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R15's cognition was intact. The MDS assessment indicated R15 had diagnoses of aftercare following joint replacement surgery, cancer, and disorder involving the immune mechanism, unspecified. Review of R15's nurses notes, dated 03/08/25, located in the EMR under the Progress Note tab revealed Received Urinalysis culture report. Urine positive for ESBL [extended-spectrum beta-lactamase (a bacteria resistant to many antibiotics)]. Notified on call nurse [name] and obtained order for 1gm [gram] of Ertapenem [antibiotic] daily x 7 days. Notified Infection Control Nurse. Awit [sic] further recommendations. Called Mr. [name] and informed of UA [urine analysis] Culture report and the start of the antibiotics. Review of R15's orders, dated 03/08/25, located in the EMR under the Order tab revealed Contact Precautions r/t [related to] ESBL in urine with ABT [antibiotic] tx [treatment] every shift for ESBL UTI [urinary tract infection] for 10 Days. On 03/10/25 at 2:12 PM, R15's room was noted to have a sign that read Stop, Contact Precautions everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. A supply of protective personnel equipment (PPE) that included gowns and gloves were hanging on the outside of the door. On 03/10/25 at 2:13 PM, Heavy Housekeeping (HH)1 was observed to knock on R15's closed door, enter the room without donning a gown and gloves and started sweeping the floor. R15 was sitting in the room dressed and groomed and talking on her phone as HH1 swept the floor around her. On 03/10/25 at 2:15 PM, HH1 came out of R15's room and briefly went across the hall to another room to sweep with the same broom and then back to his cart. HH1 was asked if he was supposed to wear a gown and gloves when cleaning R15's room. The contact precaution sign and the supply of PPE supplies were pointed to on the door. HH1 stated he wouldn't have known if he should use the gowns as no one told him. HH1 confirmed he didn't wear a gown and gloves into R15's room. On 03/12/25 at 12:22 PM, Licensed Practical Nurse (LPN)2 was observed entering R15's room without donning a gown to give R15's medications and stayed in the room for a few minutes talking with R15. LPN2 came out of R15's room and back to the medication cart. LPN2 was asked if R15 was still under contact precautions and LPN2 stated, No. LPN was asked if she should have used PPE to give medications and the supply of PPE and the contact precaution sign were pointed to on the door. LPN2 stated, No, only if she came in contact with R15's urine. During an interview on 03/13/25 at 10:30 AM, the Infection Preventionist (IP) was asked about R15. The IP stated R15 was currently taking an antibiotic for a urinary tract infection with ESBL. The IP stated R15 was complaining of burning upon urination and that's when a urinary analysis was conducted. The laboratory results came back with ESBL. The IP went on to say R15 was receiving treatment and contact precautions were started. The IP was asked if housekeeping should use PPE when cleaning R15's room since she has ESBL. The IP stated, Yes, housekeeping should use PPE. The IP was informed that HH1 didn't use PPE on 03/10/25. The DON was present and stated housekeeping were contract and they are responsible for their own training. The IP stated she will assist with additional training with housekeeping if she identifies a need. During an interview on 03/13/25 at 10:35 AM, the IP asked if LPN2 should wear PPE while passing medications to R15 while in her room. The IP stated, Yes. The IP was informed that LPN2 entered R15's room without donning PPE to give medications on 03/12/25. The IP was informed that LPN2 stated R15 wasn't under contact precautions and that she should only wear PPE if she encountered R15's urine. 7. Review of the COVID-19 policy dated 01/03/25 and provided by the facility revealed it was the policy of the facility, to prevent the spread of COVID-19 (Coronavirus) . When a resident meets the criteria to be a Person Under investigation (PUl) for symptoms identified or confirmed COVID, staff must contact the Provider and the Director of Nursing (DON). The resident will immediately be placed in isolation with contact/droplet precautions using Personal Protective Equipment (PPE) as described below . Personnel entering the room should use PPE, including gown, gloves, N95 respirator (or equivalent or higher level respirator), and eye protection. Facemasks can be used if N95 respirator (or equivalent or higher level respirator) is not available. For residents with suspected or confirmed COVID-19, an N95 (or equivalent or higher level respirator) mask, eye protection, gloves, and gown must be worn while performing any of the above procedures. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R158 was admitted to the facility on [DATE] and was discharged on 11/08/24. R158's closed record was reviewed. Review of a Physician's Order dated 10/13/24 and provided by the facility revealed the Physician ordered droplet and contact precautions for R158 from 10/13/24 through 10/21/24. During an interview on 03/11/25 at 3:47 PM, Family Member (FM)1 stated R158 was quarantined during her stay due to being exposed to someone in the facility with COVID in October 2024. During an interview on 03/13/25 at 10:12 AM with the IP and the DON, they stated if a resident was exposed to COVID, they were placed on quarantine with both contact and droplet precautions in place for eight days. All staff were required to don a gown, wear gloves, an N95 mask, eye protection, and a face shield to go into a COVID quarantine room. The IP and DON stated that the door to the room should remain closed. During an interview on 03/13/25 at 10:49 AM, LPN4 stated she remembered R158 being quarantined due to exposure to staff that tested positive for COVID. LPN4 stated R158 was under quarantine for seven days and there should have been a sign regarding isolation and PPE requirements posted outside the door. LPN4 stated contact isolation would have been in effect and nursing staff would have been required to wear full PPE if providing resident care: however, she did not think other staff such as housekeepers would have been required to wear PPE. LPN4 did not indicate that droplet precautions should also be in effect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record review, and policy review, the facility failed to ensure the responsible party (RP) for one of three residents (Resident(R)214) sampled for pressure ulcers, were made aware of the resident's change in condition. Findings include: Review of the facility's policy titled Provider Notification of Resident Change in Medical Condition dated 01/03/24, documented staff will notify the provider and applicable POA (power of attorney)/responsible parties of accident with injury, abnormal and critical diagnostic testing results, significant change in condition in physical, mental, or psychosocial status in either life-threatening or clinical components. Review of R214's undated admission Record located in the electronic medical record (EMR), under the Profile tab, indicated R214 was admitted on [DATE], and discharged on 10/26/23. R214's diagnoses included Parkinson's disease without dyskinesia, without mention of fluctuations, dementia, abnormal posture, muscle weakness, and acute embolism and thrombosis of left iliac vein. Review of R214's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 09/14/23, revealed the Brief Interview for Mental Status (BIMS), revealed a score of five out of 15, indicating R214 was severely cognitively impaired. Review of R214's Skin Alteration incident report, dated 10/13/23, provided by the facility, documented ulceration to left shoulder blade noted during care. Further review of the report revealed no documentation pertaining to the notification of R214's responsible party. Review of the Skin/Wound Note dated 10/16/23, located in the EMR under the Progress Notes tab, documented abrasion to left posterior shoulder, partial thickness. A physical therapy consult is recommended for the patient to evaluate for wheelchair evaluation-concern about round screws securing high back chair to frame being source of abrasion. Further review of R214's Progress Notes revealed there is no documentation related to notification of R214's responsible party. During an interview conducted with the Wound Care Nurse on 03/07/24 at 12:05 PM, the wound care nurse revealed after a new pressure ulcer was identified, an incident report would have been completed, and the family would be notified by the person completing the incident report. The wound was identified as resulting from a screw on the wheelchair and therapy was consulted for cover/pad for wheelchair. On 03/07/24 at 12:12 PM, the Wound Care Nurse confirmed the family was not notified of abrasion on shoulder. During an interview conducted with the Administrator on 03/07/24 at 3:37 PM, the Administrator confirmed the incident report was incomplete and that it was expected for the staff to complete the form and notify the responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of housekeeping procedures, and record review, the facility failed to ensure one (Resident (R)1) room out of 33 rooms observed was properly cleaned to ensure a homelike environment. Findings include: Review of R1's Profile in the electronic medical record (EMR) under the Clinical tab revealed R1 was admitted on [DATE] and had diagnoses that included acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease (COPD), and chronic diastolic heart failure. Review of R1's Quarterly Minimum Data Set (MDS) in the EMR under the MDS tab with an Assessment Reference Date (ARD) dated 02/19/24 revealed a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 indicating R1 was cognitively intact. During an observation and interview with R1 on 03/04/23 at 1:18 PM in the resident's room revealed the floor around R1's bed was observed with dirt and debris, the bed frame had a heavy buildup of dust on the headboard and footboard, and the frame holding the air mattress pump located at the end of the bed had a heavy buildup of dirt and debris. The bedside table was observed to have a buildup of dust on the top. In an interview, at the time of the observation, R1 stated, look at the wardrobe, look at the dust there, they never clean that, they never been taught how to clean. R1 stated, Why don't they clean my side of the room, just because I'm in bed? During an observation on 03/04/24 at 3:28 PM, R1's room remained in the same condition. During an observation and interview on 03/05/24 at 11:06 AM, R1 stated they swept the room, but didn't dust anything, the guy is new, he doesn't know anything. During an observation and interview on 03/06/24 at 10:21 AM, the Housekeeping Director (HKD) was observed dry mopping the hallway outside R1's room. The HKD was asked to describe the expectations of housekeeping staff when cleaning a resident room. HKD stated, we have a five step process, high dust, wipe high touch areas, empty trash, dry mop the floor, and then damp mop the floor. The HKD confirmed the heavy buildup of dust and dirt on R1's bed, dresser, wardrobe, and frame holding the air mattress pump. The HKD said he did have a new employee and would provide training today, (03/06/24), and would also clean R1's room appropriately. Review of the undated Procedure provided by the HKD, revealed step two of the five step cleaning process as Horizontal Surfaces - disinfected using a solution of properly diluted germicide, sanitize all horizontal surfaces. As you enter the room, work clockwise around the room hitting all surfaces. Use your high duster to dust hard to reach areas, such as the tops of closets, high lights, and ceilings areas as needed. Tabletops, headboards, windowsills, chairs, over bed lights, wall ledges, over bed tables, and the bases of over bed tables should all be done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, resident and staff interviews, the facility failed to ensure two Residents of six residents (Resident (R) 62 and R86) reviewed for abuse remained free from physical abuse. A total of 33 residents were reviewed in the sample. Findings include: Review of the facility's Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime Policy most recently reviewed 01/03/24 read, in pertinent part, It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime. 1.Review of R86's admission Record, found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted on [DATE] with diagnoses including dementia with mood and behavior disturbance. Review of R86's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/09/24, revealed a Brief Interview for Mental Status (BIMS) assessment could not be done due to the resident's poor cognition. The assessment indicated the resident had both short and long-term memory deficits. The assessment indicated R86 required substantial assistance from staff to complete his Activities of Daily Living (ADLs), including bed mobility and transfers. The resident did not exhibit any behaviors during the assessment reference period according to the assessment. Review of R86's Care Plan, dated 05/2023 and found in the EMR under the Care Plan Tab, indicated the resident was resistive to care at times, including refusing to take his medication, refusing to have his blood sugar checked, and refusing to get out of bed. Interventions included leaving the resident if he refused cares and reapproaching in 10 to 15 minutes and allowing the resident to make decisions about his own treatment to give him a sense of control. Review of an Incident Report related to R86, dated 06/21/23 and provided to the survey team, read, in pertinent part, at 1515 (3:15 PM) today, resident stated that he was picked up and swung into bed last night. Assigned CNA (Certified Nursing Assistant) suspended (during) investigation. Further review of the report revealed a staff member who was interviewed during the investigation stated she witnessed another staff member (CNA2) handling R86 roughly while helping him to sit down in his wheelchair. In addition, the report indicated a resident who was interviewed during the investigation of the incident reported she witnessed two staff members (CNA1 and CNA2) being rough with R86. Both CNA1 and CNA2 were suspended during the investigation and were terminated for rough handling of R86. The document indicated the allegation of CNA1 and CNA2 rough handling R86 was substantiated. During an interview with the Administrator and the Director of Nursing (DON) on 03/06/24 at 12:15 PM, both indicated they were not employed at the facility at the time of the investigation into R86's allegation of abuse. Both confirmed the investigation report revealed substantiated staff to resident abuse. Both stated their expectation was residents residing in the facility were to be free from all types of abuse. 2. Review of R62's undated Admissions Record located in the EMR under the Profile tab, indicated R62 was admitted to the facility initially on 08/06/20, with a readmission of 02/21/24, with diagnoses including functional quadriplegia, adjustment disorder with depressed mood, and cognitive communication deficit. Review of R62's quarterly MDS located in the EMR under the MDS tab, with an ARD of 12/06/23 revealed a BIMS score of 13 out of 15, indicating R62's cognition was intact. R62 was assessed as not displaying any behavioral indicators. Review of R62's Care Plan located in the EMR under Care Plan tab, revision date of 03/05/24, revealed R62 had an activities of daily living (ADLs) self-care performance due to deconditioning and impaired mobility-has history of decline from fractures, and most recently PNA (pneumonia). Interventions included R62 states that it is important to her to choose what type of bath she receives, she is scheduled for hair care/nail care and shower/bed bath weekly on Tuesday and Friday, 7-3 shift, avoid scrubbing & pat dry sensitive skin, provide a sponge bath when a full bath or shower cannot be tolerated. During an interview with R62 on 03/04/24 at 1:15 PM, R62 stated that she had been abused, and mistreated in the past. R62 stated that in the past year there was a CNA that had been rough with her while providing her care and turning her in the bed. R62 stated she had reported it to the Administration. Review of the Facility Reported Incident (FRI) provided by the facility, documented R62 was admitted to facility with rheumatoid arthritis, resident is an assist with all ADLs. On 11/08/23, R62 stated to social services that her assigned CNA (CNA7) for 7-3 [first shift] was rough with her during care. Resident has a BIMs of 11 .while speaking to the resident, the resident informed us (administration) that another CNA(CNA3) had overheard the accused CNA's interaction with the resident. Second CNA3 was interviewed, and resident's statements, and accusations were confirmed. CNA7 was terminated. Review of a Witness statement provided by the facility dated 11/13/23, documented by CNA3, revealed that on 11/08/23, around lunch time, (CNA3) witnessed (CNA7) storm out of (R62's) room. CNA3 went into R62's room to check on the resident. CNA3 observed that R62's bed was raised to about waist level, and the resident's lower body was exposed, R62 told CNA3 that CNA7 had been rough with her, pushing her around, and roughly turning her. R62 told CNA3 that she (R62) had told CNA7, can you be nice to me like you were this morning. CNA3 documented that she went to speak with CNA7, and CNA7 told CNA3 the same things as R62. Review of CNA7's written statement dated 11/13/23, CNA7 documented incident never occurred because the resident does not eat and only drinks coffee so she would not have to choose between the two. CNA7 refused to give further statements to Director of Nursing (DON) when requested by the DON on 11/14/23. During an interview on 03/05/24 at 1:57 PM with CNA3, CNA3 confirmed the witness statement she had written about the incident between CNA7 and R62. CNA3 reiterated that she had witnessed CNA7 storm out of R62's room, and she appeared mad. CNA3 stated she did not recall the verbal exchange between CNA7 and R62. However, R62 was visibly upset and crying when she went into the resident's room. During an interview with Unit Manager (UM)2 on 03/05/24 at 1:59 PM, the UM stated that CNA7 had told her she was not taking care of R62 anymore. UM2 went and spoke with R62, who informed her that CNA7 had been rough with her. During an interview with the DON on 03/05/24 at 2:04 PM, the DON stated she had spoken with R62, and both the CNAs (3 and 7) that were involved as part of her investigation. After interviewing both CNAs and the resident the DON substantiated the incident and terminated CNA7. During an interview with the Administrator on 03/05/24 at 2:12 PM, the Administrator was questioned about what she recalled about the incident. The Administrator stated she had spoken to R62 while doing rounds, resident reported to her she was very upset, that CNA7 had exposed her. The Administrator spoke with CNA3, who wrote her witness statement. After speaking with CNA7, CNA7 was terminated.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure that an allegation of staff to resident abuse was reported timely to the State Agency for one of six residents (Resident(R)62) sampled for allegations of abuse. This had the potential to place the resident at risk for further abuse. Findings include: Review of the facility's policy titled Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime review date 01/03/24, documented Reporting and Response: Witnessed or suspected incidents of abuse or reasonable suspicions of crime are to be reported immediately. A witness who fails to report abuse, neglect, mistreatment, misappropriation of resident property, exploitation, or suspicions of crime is considered to be as culpable as the accused. Their name will also be reported to the appropriate regulatory agency and/or law enforcement for further investigation. The Director of Nursing (DON) or designee is responsible for conducting the abuse investigation. The Nursing Home Administrator (NHA) serves as the abuse coordinator. Allegations of resident abuse shall be reported to the appropriate state regulatory within 2 hours. Review of R62's undated Admissions Record located in the electronic medical record (EMR) under the Profile tab, indicated R62 was admitted to the facility initially on 08/06/20, with a readmission of 02/21/24, with diagnoses including functional quadriplegia, adjustment disorder with depressed mood, and cognitive communication deficit. Review of R62's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab, with an assessment reference date (ARD) of 12/06/23,erevealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R62's cognition was intact. R62 was assessed as not displaying any behavioral indicators. During an interview conducted with R62 on 03/04/24 at 1:15 PM, R62 stated that she had been abused, and mistreated in the past. R62 stated that she couldn't remember the exact date, but in the past year there was a Certified Nursing Assistant (CNA) that had been rough with her while providing her care and turning her in the bed. R62 stated she had reported it to the Administration the same day it occurred. Review of the Facility Reported Incident (FRI) provided by the facility, revealed the FRI was submitted on 11/13/23 at 3:21 PM. The incident description was documented as resident stated CNA was ruff (sic) with her during care. Investigation on-going. Incident date/time: 11/13/23 at 12:00 PM. Upon further review of the FRI it was documented the incident occurred on 11/08/23, five days prior to the incident being reported. During an interview with the Administrator on 03/04/24 at 3:58 PM, the Administrator confirmed the incident was on 11/08/23, and the facility was aware of the allegations on 11/08/23. When questioned why the incident was not reported until 11/13/23, the Administrator stated the Director of Nursing (DON) thought it was more of a customer service issue at first.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, and resident and staff interviews, the facility failed to ensure a thorough investigation was completed related to allegations of potential abuse for two Residents of six residents (Resident (R)59 and R62) reviewed for abuse. A total of 33 residents were reviewed in the sample. Findings include: Review of the Abuse, Neglect, Mistreatment, Misappropriation, Exploitation, and Reasonable Suspicions of Crime Policy most recently reviewed 01/03/24 read, in pertinent part, It is the policy of Cadia Healthcare to protect residents and prevent occurrences of abuse, neglect, mistreatment, misappropriation of resident property, exploitation, and crime; and Investigation: The NHA (Nursing Home Administrator) or designee shall investigate allegations and report to appropriate regulatory agencies and/or law enforcement. All persons identified as involved in or with knowledge of the occurrence will be interviewed. 1.Review of R59's admission Record, found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted on [DATE] with diagnoses including rheumatoid arthritis and unsteadiness on her feet. Review of R59's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/16/24, revealed a Brief Interview for Mental Status (BIMS) assessment score of 10 out of 15, indicating the resident was moderately cognitively impaired. The assessment indicated R59 used a wheelchair for mobility. The resident did not exhibit any behaviors during the assessment reference period according to the assessment. Review of the Progress Notes located in the EMR under the Notes Tab, read, Resident (R59) reported that she had a wheelchair leg rest thrown on her right foot after resident (R51) was shouting at her. Right foot assessed, blanching erythema to 4th digit noted. Resident states it hurts just a little. Resident offered an ice pack and PRN (as needed) Tylenol (a medication used to control pain), resident refused both stating, it's not that bad it will be fine. This nurse told resident (R59) to let me know if she changed her mind and wanted any of those interventions offered or if the pain had gotten any worse at all, resident agreed. Resident (R59) asked this nurse what she should have done, resident educated that if she encounters an aggressive/angry resident to back away from them or the situation for her safety and to come find a staff member immediately and to never try to intervene herself. Resident shook her head in agreement. Resident returned to her room. This nurse will continue to monitor. Supervisor and Assistant Director of Nursing (ADON) aware. Review of R51's admission Record, found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted on [DATE] with diagnoses including congestive heart failure and dementia. Review of R51's Quarterly MDS with an ARD of 01/30/24, revealed a BIMS score of three out of 15, indicating the resident was severely cognitively impaired. The resident exhibited verbal behaviors toward others on one to three days during the assessment reference period according to the assessment. R51 did not exhibit any physical behaviors toward others during the assessment reference period. Review of an Incident Report related to R51 and R59, dated 01/08/24 and provided by the facility to the survey team, read, in pertinent part, Resident (R51) was in the hallway shouting at (R59) holding wheelchair leg. This nurse intervened. (R59) reports that (R51) hurt her foot with the wheelchair leg. Review of the facility's Investigation File related to the above incident report, dated 01/08/24 through 01/10/24 and provided by the facility to the survey team, revealed no interviews were conducted with statements by staff or residents, other than R51 and R59 related to the incident during the investigation. The allegation of potential abuse was not substantiated by the facility based solely on interviews with R51 and R59 and a physical assessment of R59 immediately after the incident (which was negative for any physical signs or symptoms of abuse). During an interview with the Administrator and the Director of Nursing (DON) on 03/06/24 at 11:33 AM, both confirmed no additional resident interviews were conducted and no staff interviews were conducted during the investigation into the above incident between R51 and R59. The DON indicated she had been responsible for conducting the investigation and stated, I spoke with the UM (Unit Manager) and she saw the episode. If there isn't a statement in the record I didn't get one. I did not talk to any other staff members or get any statements. I did not speak to any residents or get statements from them. The DON stated, In this situation I spoke to the UM who told me what happened, so I just went with that. The Administrator stated her expectation was staff and residents were to be interviewed during an investigation of potential abuse. 2. Review of R62's undated Admissions Record located in the EMR under the Profile tab, indicated R62 was admitted to the facility initially on 08/06/20, with a readmission of 02/21/24, with diagnoses including functional quadriplegia, adjustment disorder with depressed mood, and cognitive communication deficit. Review of R62's quarterly MDS located in the EMR under the MDS tab, with an ARD of 12/06/23, revealed a BIMS score of 13 out of 15, indicating R62's cognition was intact. Review of the Facility Reported Incident (FRI) provided by the facility, documented R62 was admitted to facility with rheumatoid arthritis, resident is an assist with all Activities of Daily Living (ADLs). On 11/08/23, R62 stated to social services that her assigned Certified Nursing Assistant (CNA)7 for was rough with her during care. Further review of the FRI indicated that additional residents and staff were not interviewed concerning the incident between CNA7 and R62. During an interview conducted with the Administrator on 03/05/24 at 4:14 PM, the Administrator revealed since the resident was alert and oriented, she didn't feel it was necessary to conduct official resident interviews. Upon further review of the FRI the Administrator confirmed the incident was incomplete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to complete a smoking assessment and secure smoking materials for one (Resident (R)61) out of one resident who the facility identified as a smokier out of a sample of 33 residents. This had the potential for an accident/hazard related to smoking. Findings include: Review of the facility's Smoking Policy, located in the admission Packet, dated 08/21, revealed Smoking and/or the use of tobacco, tobacco products or electronic cigarettes by residents or visitors is not permitted anywhere on facility property at any time. The definition of facility property for the purpose of this policy includes all land, buildings, structures, parking lots, sidewalks, and any vehicles owned or leased to the facility. Failure to maintain a smoke-free campus by residents and/or visitors could result in outcomes up to and including discharge. During the entrance conference on 03/04/24 the Administrator identified that the facility was a non-smoking facility and that there was only one resident (R61) who smoked. The expectation was that R61 was to smoke off the facility premises and all smoking materials were kept locked at the nurses' station. R61 was identified as a smoker and that numerous vapes had been repeatedly removed from R61's room. Review of R61's Profile located in the Clinical tab in the electronic medical record (EMR) revealed R61 was admitted on [DATE] and had diagnoses that included paralytic syndrome following nontraumatic intracerebral hemorrhage affecting left nondominant side, seizures, unspecified lack of coordination, and muscle spasm. Review of R61's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/08/23 revealed R61 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R61 was cognitively intact. There was no evidence of a smoking assessment in R61's EMR. During an interview on 03/05/24 at 2:30 PM, R61 said I smoke some. I buy them from my friend two doors down. We have to go to the church parking lot, smoke, and throw the butts in the dumpster. I have no idea if I'm supposed to tell anyone that I'm going outside to smoke or that they have to lock up my lighters. During the interview, R61 placed his cell phone over a lighter he had on top of his electric wheelchair. During an interview with the Administrator and the Director of Nursing (DON) on 03/06/24 at 9:40 AM, the Administrator and the DON each confirmed that they were unaware of R61 smoking or having smoking materials in his room. The DON stated, the expectation is that smoking materials are kept locked at the nurses' station. Review of the Nurses Progress Notes located in the EMR, dated 03/06/24 at 10:35 AM, revealed a notation by the DON that read, Met with resident who acknowledge that he understood the facility is smoke free. Discussed with resident the expectation is that we hold onto any smoking material such as cigarettes and lighters. Resident denied smoking daily and stated he only occasionally smoked and does not currently have any cigarette or lighters however 2 lighters were taken from resident's room. Also discussed with resident and offered smoking apron to which he refused. Offered smoking cessation program to resident who refused and stated he only smokes every once in a while, and has no cravings for cigarettes. This writer asked resident to inform me if/when he does obtain cigarettes so that a smoking assessment can be completed at that time. During an interview on 03/06/24 at 10:20 AM, Certified Nursing Assistant (CNA)4 stated, yes, I'm aware R61 smokes, at least since last summer, I thought everyone knew. During an interview with the Unit Manager (UM)1 on 03/07/24 at 9:51 AM, the UM1 stated, I know the social service staff have taken vapes out of R61's room before. The night shift gave me a lighter from his room this morning and I gave it to the social service staff. During an interview with the Social Service Director (SSD)1 and the SSD2on 03/07/24 at 12:19 PM, both the SSD1 and SSD2 confirmed they had been given lighters confiscated from R61.

Based on interview and record review the facility failed to allow 30 days for a resident or their responsible party to rescind the voluntary Attachment #3: Binding Arbitration Agreement after it was signed. This failure would take the right to rescind the agreement away. Findings include: Review of the facility Attachment #3: Binding Arbitration Agreement revealed it stated . (3) this Agreement may be rescinded by written notice sent to the other party via Certified Mail, return receipt requested, within twenty-one (21) days of the date upon which it is signed. Interview with the admission Coordinator on 03/07/24 at 10:33 AM confirmed the form allowed for only 21 days to rescind the Arbitration Agreement. She stated no one has pursued arbitration.

Based on interview and review of facility documentation, it was determined that for two (R74 and R255) out of three Medicare Part A discharges reviewed for the required notice for changes of coverage and services under Medicare, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to R74 who remained in the facility after the discontinuation of her Part A services. Additionally, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) to R255 who was discharged from Part A services and left the facility the day after his last covered day. Findings include: 1. R74's clinical record revealed: 10/20/22 - R74 started Medicare Part A skilled services. 2/24/23 - R74 was discharged from Medicare Part A skilled care services and remained living in the facility as a long-term care resident with 10 benefit days remaining. 3/23/23 9:50 AM - R74's SNF Beneficiary review revealed that a NOMNC form was provided, however, a SNFABN form was not given to the resident. Centers for Medicare and Medicaid Services, (CMS) form 20052, last revised 10/2022, documented the following: Resident has skilled benefit days remaining and is being discharged from Part A services and will continue living in the facility should receive both NOMNC and SNFABN forms. 3/23/23 10:38 AM - During an interview, E4 (Social Service Director), verified that R74 was still living in the facility and that a SNFABN form was not given to the resident. 2. R255's clinical record revealed: 11/8/22 - R255 started Medicare Part A skilled services. 11/20/22 - R255 was discharged from Medicare Part A skilled care services with 26 benefit days remaining. 11/21/22 - R255's discharge summary revealed that he was discharged to his home from the facility. 3/23/23 9:50 AM - R74's SNF Beneficiary review revealed that a NOMNC form was not provided to the resident. CMS form 20052 documented the following: Resident has skilled benefit days remaining and is being discharged from Part A services and is leaving the facility immediately following the last covered skilled day should receive a NOMNC form. 3/23/23 10:38 AM - During an interview, E4 confirmed that R255 was discharged from his Part A services on 11/20/22 and was discharged to his home from the facility on 11/21/22. 3/27/23 2:00 PM - Findings were reviewed with E1 (CNO), E2 (NHA), and E3 (DON) during the Exit Conference.

Based on interview and record review, it was determined that for one (R49) out of two residents reviewed for dental services, the facility failed to promptly assist a resident with follow up dental services after a consultation. Findings include: The facility policy for dental services available to residents, last updated 1/20/23, indicated, Lost /Damaged dentures. Residents with lost or damaged dentures are referred for dental services after consultation with resident and/or the next of kin. The resident is referred for dental services within three days. Review of R49's clinical record revealed: 4/1/22- An annual MDS assessment listed that R49 had no natural teeth or tooth fragment(s). 12/6/22 - During a dental exam for cleaning, E5 (Dentist) documented that R49 was in need of dentures, and that the resident stated, I lost my dentures that were made for me. Review of R49's clinical record lacked evidence of a facility response regarding the 12/6/22 dental visit that identified R49 lost his dentures. 1/6/23 - R49 was discharged home from the facility. Review of R49's discharge paperwork lacked evidence of any dental related consults, referrals, appointments or follow up care regarding R49's lost dentures. 3/9/23- An entry tracking MDS assessment showed that R49 was readmitted to the facility. The dental section was blank. 3/10/23 - R49 was readmitted to the facility with no dentures. During an interview on 3/20/23 at 1:15 PM, R49 reported to the Surveyor that he was in Need of a new set (dentures) and the loss was reported to the facility with no response. During an interview on 3/23/23 at 12:02 PM, R49 stated that since readmission he reported the missing dentures to E6 (RN). During an interview on 3/23/23 at 12:33 PM, E4 (SW) reported being unaware that R49 was in need of dentures. During an interview on 3/23/23 at 12:52 PM, E6 (RN) confirmed that she was aware R49 did not have dentures, but she did not report the loss to Social Work or other staff for a dental referral. During an interview on 3/24/23 at 10:18 AM, E4 (SW) confirmed the facility was unable to find any documentation of a response to R49's lost dentures, that was first reported in December 2022. E4 stated that she would be initiating a dental referral that day. During an interview on 3/24/23 at 10:58 AM, E1 (CNO) confirmed the facility had no evidence of response to R49's lost dentures. 3/27/2023 at 2:00 PM - Findings were reviewed during the Exit Conference with E1 (CNO), E2 (NHA) and E3 (DON).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined that for one (R1) out of one resident sampled for a change in condition, the facility failed to ensure accurate and complete records. Findings include: Review of R1's clinical record revealed: [DATE]- R1 was admitted to the facility. [DATE] 7:12 PM- A nurses note in the electronic medical record (EMR), documented by E4 (LPN Supervisor) stated, This nurse made aware by floor nurse that patient had emesis x (vomit times) 2 while CNA was performing care. Upon further assessment patient noted pale in color, with decreased o2 patient placed on facemask 6 liters (per minute- lpm). Auscultated lung sounds noted with bibasilar crackles. Notified On call of condition change in patient order to send out to ED, son aware and at bedside. EMT arrived pt condition deteriorated CPR initiated and once stable transferred by stretcher to (name of hospital) with EMT/paramedics. [DATE] 11:15 AM- During an interview, E4 (LPN Supervisor) stated that vital signs (measurements of respiratory rate, pulse, body temperature, pulse ox and blood pressure) were obtained on R1 during R1's [DATE] observed change in respiratory condition. E4 stated that the only vital sign that appeared abnormal was R1's pulse ox that measured 88%. E4 stated that R1 was then administered oxygen with a facemask at 2 lpm, and the oxygen was subsequently increased to 4 lpm. E4 further stated that R1's pulse ox reading did not rise above 91% during the administration of oxygen. [DATE] 11:45 AM- During an interview, E5 (RN) stated that she was alerted by the CNA caring for R1 at approximately 5:30 PM that R1 had vomited twice. E5 stated that she went to R1's room to check on her and E5 observed R1 to be pale in color, breathing rapidly and with difficulty. E5 raised the head of the bed to aid R1's breathing. E5 stated that vital signs were obtained and a face mask was applied to deliver oxygen at 2 lpm. Review of R1's EMR revealed incomplete documentation related to R1's [DATE] change in condition. The times of R1's observed change in condition, the nursing responses to R1's change in condition, including R1's vital signs, R1's response to oxygen placement, R1's height of bed adjustment and the time of the call placed to the on-call Physician were not documented in the EMR. Additionally, the times of the 911 calls placed by E4 (LPN Supervisor), what nursing report was given to 911, to the paramedics/ EMT and responses to their actions, were not documented in the EMR. These findings were reviewed during the exit conference on [DATE], beginning at 3:30 PM, with E1 (CNO), E2 (NHA), E3 (DON) and E5 (Corporate Nurse).