Based on interview, record review and review of the facility's policy and procedures, it was determined that for two (R49 and R90) out of six residents reviewed for abuse, the facility failed to report the allegations of abuse and injury of unknown origin within the two-hour requirement. Findings include:1. Review of R49's clinical record revealed: 7/18/25 3:27 PM - An x-ray report was received by the facility which stated that R49 had an acute hand fracture. 7/21/25 12:53 PM - Review of the State Agency's Incident Summary Report documented that the facility reported R49's injury of unknown origin, a hand fracture, approximately three days later. 8/28/25 2:40 PM - During an interview, surveyor reviewed finding with E2 (DON). E2 stated she wasn't aware of this and would look at it. 2. Review of R90's clinical record revealed: 6/4/25 10:00 AM - The facility's incident report documented an allegation of resident-to-resident abuse between R90 and R62. 6/4/25 1:59 PM - Review of the State Agency's Incident Summary Report documented that that the facility reported the incident approximately four hours after the altercation.

Based on observation and interview, it was determined for two out of two medication rooms reviewed for storage of controlled substances, the facility failed to ensure that the locked boxes were permanently affixed to medication room refrigerators.8/27/25 10:12 AM - During a tour of the second-floor medication room, the storage box for the controlled substances was observed on top of the refrigerator. The third-floor controlled substances box was observed in refrigerator, but it was not permanently affixed. 8/28/25 9:30 AM - The second-floor medication room, the storage box for the controlled substances continued to be on top of the refrigerator. The third-floor controlled substances box continued to be in the refrigerator, but it not permanently affixed. 8/28/25 10:00 AM - During an interview E14 (RN) stated, The controlled substances that have to be refrigerated are kept in the refrigerators and counted every shift. 8/29/25 2:30 PM - The findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E5 (ADON).

Based on interviews, record review, and facility policy review, the facility failed to notify the Resident Representative (RR) following a fall with injuries for one of three residents (Resident (R) 94) out of a total sample of 34 residents. The failure created a delay for R94 to have their RR to get to the hospital to see before R94's condition worsened. Findings include: Review of the facility's Fall Prevention/Post Fall Policy and procedure, last reviewed 08/25/24, revealed the following: A. On admission 1. The nurse completes Morse Fall Scale. 2. If it is determined that the resident is at risk for falls a care plan will be put in the record. B. Post-fall l. An Incident Report will be completed. 2. Nurse will document in the resident's progress note. 3. Morse Fall Scale will be completed. 4. Contact responsible party, physician, and Director of Nursing. This should be documented in progress notes as well as Action section of incident report. Closed record review of R94's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed the resident was admitted to the facility with diagnoses that included dementia, abnormalities of gait and mobility, unspecified convulsions, and seizures. Review of R94's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 12/24/23, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R94 had severe cognitive impairment. R94 was identified to be dependent on staff for all cares and was not walking at the time of the assessment. Review of R94's Care Plan, updated 1023/23 located under the Care Plan tab in the EMR noted R94 had a history of wandering and a history of falls. The resident attended the Safety Program, identified as the Cottage, from 9:00 AM to 8:00 PM. Safety interventions were identified as every 30 minute safety checks, safety helmet when out of bed, hipsters on at all times, followed by neurologist for seizures, non-slip footwear, wheelchair with anti tippers, and Physical Therapy evaluation and treatment dated 12/07/23. Review of a 12/24/23 Incident Report, provided by the Director of Nursing (DON), noted Resident witnessed by dietary staff getting up from wheelchair and falling to the floor. Dietary staff notified nursing staff. Resident assessed for injuries, noted W [with] facial laceration and bleeding from the mouth, upper/lower extrimities [extremities] assessed no limitations noted, VS [vital signs] assessed WNL [within normal limits], area noted with adequate lighting, wheelchair noted in lock position. PCP [primary care physician] notifled [notified], resident sent to hospital for further evaluation. Review of the Nurses Note, located under the Progress Notes tab in the EMR, dated 12/24/23 at 11:53 PM, read Resident witnessed by dietary staff getting up from wheelchair and falling to the floor. Dietary staff notified nursing staff. Resident assessed for injuries, noted w/ [with] facial laceration and bleeding from the mouth, upper/lower extrimities [extremities] assessed no limitations noted, VS [vital signs] assessed WNL [within normal limits], area noted with adequate lighting, free of clutter, wheelchair noted in lock position. PCP notified, resident sent to hospital for further evaluation. Attempted to notify POA, unsuccessful. The incident was identified to have occurred at 6:30 PM. Both the incident report and the nurses note were written by Licensed Practical Nurse (LPN)1. During an interview on 10/16/24 at 9:41 AM, R94's RR stated On Christmas eve, 12/24/23, her sister's friend who works at the hospital, notified her sister that [R94] was at the hospital. The sister called [R94's RR] who called the facility to ask what was going on. Neither the [R94's RR] or the sister had been notified by the facility. [R94] should not have been left alone. She was in a wheelchair next to the desk outside the nurse's station. She stood up and fell over the foot pedals. The facility never called me. R94's RR stated When I questioned nurse, the nurse [LPN1] said she called the resident's husband, she could not have, that number is disconnected, he passed on 11/01/23. Then the nurse said she had tried the next number, [RR's] cell, but couldn't get through. That's not true either. I did not receive any calls. By the time I got to the second hospital where she was transferred, [R94] was intubated, and I didn't get to speak to her. R94 was placed on Hospice (end of life) care and subsequently passed away. During an interview on 10/16/24 at 10:17 AM, LPN1 said I was on second floor, called when incident happened. I assessed the resident; she was bleeding from her head and lip. I called the ambulance, called the Power of Attorney [RR] home number, couldn't get through, tried both numbers but they didn't work. I remember that I talked to the daughter who had got wind of the incident, so I told her what happened and that I tried both numbers, they were busy or not working. [R94] was in the safety program, the Cottage, and had just come down from there. She was seated next to the desk, tried to get up and fell. Dietary saw it happen. During an interview on 10/18/24 at 11:55 AM, LPN5 stated I remember [R94], she walked all the time, we would have to encourage her to sit down or sit in the recliner to get her to rest, especially when she appeared tired. She did not always use a wheelchair, just sometimes. When you are sending someone to the hospital, you first take care of the resident, if bleeding put pressure, call doctor, get order to transmit, call ambulance, notify family. May not always check the box on the form, but always put it in the progress notes. The hospital transfer form for the 12/24/23 incident was not located in the EMR. The form had an area to check that the RR had been notified. The DON and Administrator were asked, on 10/18/24 at 12:19 PM, to locate the document. No documentation was provided as of exit on 10/18/24 at 4:00 PM. During an interview on 10/18/24 at 1:00 PM, the Administrator said she knew about the concern with notification because the RR had come in after the resident passed away. I thought [RR] had been notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to provide Form CMS-10055 (Centers for Medicaid and Medicare Services) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two of three residents (Resident (R) 10 and R77) reviewed for liability notices out of a total sample of 34 residents. This failure prevented the resident or responsible party the ability to make an informed decision related to the cost of continued therapy services. Findings include: Review of the CMS site, Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) OMB Approval Number: 0938-0566 accessed at https://www.cms.gov/medicare/medicare-general-information/bni/downloads/abn-form-instructions.pdf on 06/04/24 revealed, The beneficiary or his or her representative must choose only one of the three options listed in Blank (G). Unless otherwise instructed to do so according to the specific guidance provided in these instructions, the notifier must not decide for the beneficiary which of the 3 checkboxes to select . If the beneficiary cannot or will not make a choice, the notice should be annotated, for example: beneficiary refused to choose an option. 1. Review of R10's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of a document provided by the facility titled provided by the facility titled Notice of Medicare Non-Coverage indicated R10's skilled services ended on 10/12/24. Review of R10's EMR indicated the resident remained in the facility after the end of her skilled services. 2. Review of R77's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of a document provided by the facility titled provided by the facility titled Notice of Medicare Non-Coverage indicated R77's skilled services ended on 08/28/24. Review of R15's EMR indicated the resident remained in the facility after the end of her skilled services. During an interview conducted on 10/16/24 at 9:50 AM, the admission Coordinator confirmed she never provided the ABN letter along with the NOMNC notice. During an interview conducted on 10/18/24 at 11:07 AM, the Administrator stated they have never provided the ABN notice since there were residents who remained in their facility and Medicaid was their payment source and this would add to the confusion for the resident and/or family members, if the facility broke down the costs to provide continued skilled services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, and interviews, the facility failed to ensure their grievance procedures were followed for one resident (Resident (R) 79) of one resident reviewed for grievances out of a total sample of 34 residents. This failure increased the potential for resident grievances to go unresolved. Findings include: Review of a policy provided by the facility titled Grievance Procedure dated 03/11/22 indicated .The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.Notice on how to make a grievance is included in the Resident Handbook, and is also reviewed upon admission, is posted on each nursing floor.A copy of this procedure must be given to the resident upon request. Equipment and Supplies.Point Click Care Risk Management Incident report form (online).Grievance Form. Review of R79's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of a document provided by the facility titled Grievance Log dated 01/16/24 indicated a family member of R79 filed a grievance alleging the resident did not receive a dinner tray the night before. Under a heading titled Resolution it revealed there was a delay in staff delivery. During an interview conducted on 10/16/24 at 12:01 PM, the Administrator stated she was the staff member who handled all of the facility grievances and stated she had no additional information to provide on the meal tray issue and R79. A subsequent interview was conducted on 10/16/24 at 12:23 PM, and the Administrator confirmed she did not provide residents and/or family members with a written response of grievance(s) which included the resolution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, and interview, the facility failed to ensure three of three residents (Residents (R) 20, R67, and R95) allegations of physical/verbal abuse were fully investigated out of sample of six residents reviewed for abuse out of a total sample of 34 residents. This lack of investigation had the potential to lead to continued episodes physical and verbal abuse. Findings include: Review of a policy provided by the facility titled Resident Abuse Policy/Procedure dated 06/27/23, indicated .Investigation.Facility will thoroughly investigate any incidents reported regarding the identification if incident as listed above.The facility will investigate all incident reports based on information obtained from witness statements, caregiver statements, and interviews as available. 1. Review of R20'sFace Sheet, located in the EMR under the Profile tab revealed R 20 was admitted to the facility with diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Depression, Anxiety, and Acute Respiratory Failure. Review of the quarterly MDS located in the EMR under the MDS tab, dated 06/05/24 revealed the resident indicating the resident was cognitively intact and exhibited no mood or behaviors during the same assessment period. Review of the resident's Care Plan located in the EMR under the Care Plan tab revealed R20 had the potential for sad mood, tearfulness, withdrawn state secondary to history of depression, anxiety, and declining health. Review of the facility's investigation of a facility reported incident to the State Survey Agency (SSA) dated 04/01/24, revealed that in an interview with the DON and the Assistant Director of Nursing (ADON), Certified Nurse Aide (CNA) 7 stated she was giving aide to R20 with an orientee. They turned the resident on her side and the resident started to scream in pain. CNA7 described and re-enacted backing away from the resident with her hands up in the air and said, I'm not even touching you. CNA7 told the resident that her backside (used a derogatory term) was showing. She also told the resident that I guess that I will be in the DON's office on Tuesday. CNA7 described her relationship with the resident as friendly, and they often joked around. The investigation determined that under the care of CNA7, the resident felt humiliated, tearful, and manipulated. The resident was interviewed and indicated that she never felt comfortable with the aide, and she disagreed with the description of their relationship. CNA7 was initially suspended after the allegation was made and after the investigation, she was terminated from the facility. During an interview with the ADON on 10/16/24 at 3:36 PM, she stated that the DON spoke to the resident about the incident since the DON was responsible for investigating and reporting the incidents. During the investigation, the Quality Control Nurse was asked to speak to the resident to see if she thought CNA7 should return to work after suspension. R20 stated she did not think CNA7 should work at the facility. So, based on the statement from R20 and CNA7, the decision was made to terminate CNA7. When asked for documentation of other interviews conducted during the investigation, the ADON stated that she did not interview other residents during the investigation that may have had any interactions or care provided by CNA7. The ADON stated she had asked other staff about CNA7, and they did not have any problems with her. When asked if she documented the interviews with other staff members regarding CNA 7, she stated no, she did not have any written documentation. 2. Review of R67's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. 3. Review of R95's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of a document provided by the facility titled Physical dated 12/25/23 indicated R67 reported to staff he was punched in the eye by R95. R67 stated he attempted to intervene when R95 tried to open the dining room door. Continued review of the file failed to contain evidence of other potential staff and residents who may have witnessed the incident. During an interview on 10/17/24 at 12:29 PM, the Assistant Director of Nursing (ADON), with the Director of Nursing present, confirmed the investigative file did not contain evidence of interviews gathered from potential witnesses which would include staff and residents. During an interview on 10/18/24 at 11:10 AM, the Administrator stated the staff collect interviews from potential witnesses depending on the situation.

**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 four residents (Resident (R) 30) reviewed for accident hazards did not suffer a delay in treatment when the facility did not notify the physician of the delay in obtaining an x-ray as ordered. R30 experienced swelling to the right knee area and was administered non-narcotic pain medication for three days. The x-ray was obtained three days after being originally ordered and showed the resident had suffered an acute fracture to the distal femur. Findings include: Review of R30's electronic medical record (EMR) admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of Arthropathy (arthritis), Dementia, and Alzheimer's disease. Review of R30's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed the resident was cognitively impaired. The assessment indicated R30 was dependent on staff for transfer (movement from one surface to another) mobility and activities of daily living (ADL). Review of R30's EMR Nurse's Notes located under the Progress Notes tab, indicated that on 07/19/24 at 3:17 PM, R30 was noted to have swelling to her right knee. The physician was notified and ordered a 2-view x-ray of the right knee. On 07/19/24 at 10:02 PM Nurse's Notes indicated R30's right knee remained with swelling and awaiting x-ray to be completed. Further review of the Nurse's Notes for 07/19/24 indicated R30 was medicated for pain with Tylenol. On 07/20/24 at 2:23 PM Nurse's Notes indicated an ice pack was applied to the right knee. Tylenol 325mg two tablets administered for pain. waiting for x-ray to the R[right] knee. On 07/20/24 at 9:55 PM Nurse's Notes indicated affected leg supported with pillow, awaiting x-ray of right leg. On 07/21/24 at 3:19 PM Nurse's Notes indicated Tylenol administered for right knee pain. Attempted to reach Mobilex [x-ray] to know when staff was coming for x-ray no response. On 07/21/24 at 9:19 PM Nurse's Notes indicated resident continues with swelling to R knee, pain medication administered. Awaiting x-ray of the right knee. Review of R30's EMR Nurse's Notes and Orders revealed no documentation the physician was notified that the ordered x-ray had not been obtained. There was no documentation the facility attempted to contact another mobile x-ray company. There was no documentation the facility attempted to obtain physician guidance related to the resident's need for pain medication. Review of the Nurse's Notes revealed that the attending physician was called three days later on 07/22/24 at 9:51 AM and notified of the delay in completing the x-ray. On 07/22/24 at 9:51 AM nurse's notes indicated resident continued with right knee pain with movement, Tylenol administered as needed. [name of x-ray facility] contacted requesting estimated time of arrival for x-ray. The physician was notified [that the x-ray had yet to be completed], resident to remain on bedrest until x-ray is completed. Further review of the Nurse's Notes indicated that the x-ray to the right knee was completed on 07/22/24 at 10:41 PM, three days after the x-ray was ordered. On 07/23/24 at 7:28 AM nurse's notes indicated x-ray results received with following conclusion acute fracture of right distal femur [thigh bone are close to the knee] with modest displacement and angulation [fractured bone segments at an angle], old fracture of right mid patella [kneecap] with modest displacement without callus formation. Intact right knee Arthroplasty. MD [physician] made aware. On 07/23/24 at 10:14 AM nurse's notes indicated Oxycodone 1 tablet po Q 6H PRN for Pain . Oxycodone is a narcotic pain medication. In addition, the nurse's notes dated 07/23/24 indicated R30 was diagnosed with a fractured femur and sent to the Emergency Department for evaluation of the right knee and swelling, and her pain management was adjusted to better regulate her pain. While R30 had initially been receiving Tylenol for pain relief, a stronger medication, Morphine was prescribed upon her return to the facility to more effectively address the pain associated with the fractured femur. On 07/23/24 at 12:14 PM nurse's notes indicated R30 was sent to the Emergency Department for an Ortho consult and further evaluation and treatment. Interview on 10/19/24 at 12:30 PM, the Director of Nursing (DON) confirmed that obtaining the x-ray was delayed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the Face Sheet located in the Electronic Medical Record (EMR) under the Profile tab revealed R38 was admitted to the facility with diagnoses including Multiple Sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 09/25/24 revealed the resident was assessed with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R38 was cognitively intact. Further review of this MDS revealed R38 had no impairment of the upper extremities and was independent with eating. Review of the Care plan located in the EMR under the Care Plan tab revealed R38 was identified as being independent of dressing his upper extremity and with hygiene. Observation of the resident's room on 10/14/24 at 10:04 AM revealed R38 was in his room in his electric wheelchair, well dressed, alert and oriented. On the nightstand next to the bed, R38 had multiple bottles of water and a Keurig single use coffee maker. During an interview on 10/14/24 at 1:35 PM, R38 stated that he has had the Keurig for several years and he has never had a problem with it. He does not drink the water at the facility, which is used to make coffee, so that is why he has his own coffee maker. During an interview with the Assistant Director of Nursing (ADON) on 10/14/24 at approximately 2:30 PM, she stated she did not think the resident used the Keurig, but staff made it for him. She did not know if the resident had been assessed for the use of the Keurig. She stated that she would observe R38 using the Keurig coffee maker for safety. Further review of the EMR revealed no documentation of an assessment for the safe use of the Keurig coffee maker. Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 30) reviewed for accident hazards out of a total sample of 34 was transferred using the appropriate mechanical lift and number of staff as per the resident's plan of care. Findings include: Review of the EZ Lift Policy and Procedures revised date 08/01/24 indicated under Purpose . To prevent injury to the resident and staff when lifting and transferring . Key Procedural Points item 1. There will be (2) staff at all times when using the EZ way Lift or EZ Way stand up lift. Review of R30's electronic medical record (EMR) admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of Arthropathy (arthritis), Dementia, and Alzheimer's disease. Review of R30's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed the resident was cognitively impaired. The assessment indicated R30 was dependent on staff for transfers (movement from one surface to another) and activities of daily living (ADL-bathing, toileting, dressing). Review of R30's EMR Care Plan located under the Care Plan tab, revision date 02/06/20, indicated the resident had an ADL self-care performance deficit related to dementia and decreased mobility. The Intervention/Tasks revision, dated 01/09/24, under transfers indicated R30 was a Hoyer lift with two staff. Review of the facility's follow up report to the State Survey Agency (SSA), dated 07/26/24, indicated our investigation checked hours of video to check on who took care of resident on that particular day . we believe that CNA caring for the resident might have used incorrect mechanical lift . Review of documentation provided by the Director of Nursing (DON), dated 07/24/24, revealed video reviewed which indicated Certified Nursing Assistant (CNA) 9 took the stand-up lift into R30's room that morning and was later seen removing the stand-up lift from the room and placing it in the hallway. After lunch, the video showed CNA 9 taking the resident into the spa room alone and leaving the spa room two minutes later. CNA9 was then seen getting another CNA and the Hoyer lift and taking it into the resident's room. Review of a written statement by CNA9 dated 07/18/24 and 07/19/24 provided by the DON revealed: Question: Did you help transfer resident to wheelchair? - Response by CNA: Yes, transfer to wheelchair. Question: How did you transfer Resident? Who assisted you with transfer? Response by CNA: Mechanical Lift 2 person. Review of Employee Warning Record dated 7/19/24 indicated that the CNA was witnessed using the wrong lift on a resident and not having a second person assist. She failed to follow the resident's care plan and failed to follow the company policy of having a 2nd person with her while using the lift. She was previously made aware of this policy and signed a lift agreement that she knew if she would be terminated if she violated this policy . During an interview on 10/19/24 at 12:30 PM, the DON confirmed that she reviewed the videos for several days prior to the incident and observed CNA9 take the stand-up lift into R30's room and later removing the stand-up lift and placing it in the hallway. And then after lunch CNA 9 was seen in the video taking the resident into the spa room alone. The DON stated that two people are to be used when the stand-up and Hoyer lift are used. The DON further stated that patient care information provided to CNAs in Point Click Care (PCC) under the Tasks tab included patient care information under the Task Care Record, [NAME] and Task List. The DON confirmed CNA9 was aware of how the R30 was to be transferred by two staff using the Hoyer lift Review of the PCC patient care information under the Task Care Record, [NAME] and Task List revealed that the facility staff, including CNA9, had easy access to the resident's care activities information to include ADL's, safety, bed mobility, bathing, and transfers. Review of the PCC [NAME] documentation for R30 for the month of July 2024 indicated that R30 was assessed as a 4/3for the task of ADL-Transferring Hoyer Lift (2) staff members. The legend indicated 4 was Total assistance and 3 was Two plus person physical assist. CNA9 was aware that R30 was Total Dependence for transfer and required transfer support of 2 plus people when transferring with the use of the Hoyer Lift and not with the standup lift. Review of the Lift agreement signed and dated by CNA 7 on 07/12/23 revealed I verify that I have received training for the proper use of the EZ lift. I understand that there must always be two employees present while using the lifts .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to provide pain management that met professional standards for one of one resident (Resident (R) 30) reviewed for pain out of a total sample of 34 residents. R30 experienced swelling of the right knee area and received non-narcotic pain medication (Tylenol) while waiting three days for an x-ray. The facility failed to assess the resident's pain, failed to conduct pre and post pain medication assessments, and failed to indicate why Tylenol was administered to the resident. The x-ray revealed the resident had sustained a fracture to the right distal femur. Cross-Reference F684. Findings include: Review of the Pain Management Policy, reviewed date 11/15/23, under Key Procedural Point indicated Residents have a right to be free from pain. Review of R30's electronic medical record (EMR) admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of Arthropathy (arthritis), Dementia, and Alzheimer's disease. Review of R30's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed the resident was cognitively impaired. The assessment indicated R30 was dependent on staff for transfer (movement from one surface to another) mobility and activities of daily living (ADL). Review of R30's EMR Nurse's Notes located under the Progress Notes tab, indicated that on 07/19/24 at 3:17 PM, R30 was noted to have swelling to her right knee. The physician was notified and ordered a 2-view x-ray of the right knee. On 07/19/24 at 10:02 PM Nurse's Notes indicated R30's right knee remained with swelling and awaiting x-ray to be completed. Further review of the Nurse's Notes for 07/19/24 indicated R30 was medicated for pain with Tylenol. On 07/20/24 at 2:23 PM Nurse's Notes indicated an ice pack was applied to the right knee. Tylenol 325mg two tablets administered for pain. waiting for x-ray to the R[right] knee. On 07/20/24 at 9:55 PM Nurse's Notes indicated affected leg supported with pillow, awaiting x-ray of right leg. On 07/21/24 at 3:19 PM Nurse's Notes indicated Tylenol administered for right knee pain. Attempted to reach Mobilex [x-ray] to know when staff was coming for x-ray no response. On 07/21/24 at 9:19 PM Nurse's Notes indicated resident continues with swelling to R knee, pain medication administered. Awaiting x-ray of the right knee. On 07/22/24 at 9:51 AM nurse's notes indicated resident continued with right knee pain with movement, Tylenol administered as needed. [name of x-ray facility] contacted requesting estimated time of arrival for x-ray. The physician was notified [that the x-ray had yet to be completed], resident to remain on bedrest until x-ray is completed. Further review of the Nurse's Notes indicated that the x-ray to the right knee was completed on 07/22/24 at 10:41 PM, three days after the x-ray was ordered. Review of R30's Medication Administration Record (MAR) for the month of July 2024 revealed R30 received five doses of Tylenol 325mg II tablets from July 19, 2024 - July 23, 2024, for pain management prior to her visit to the Emergency Department on July 23, 2024. There was no documentation the resident's pain was assessed before the Tylenol was administered or afterwards to determine if relief had been obtained. On 07/23/24 at 7:28AM nurse's notes indicated x-ray results received with following conclusion acute fracture of right distal femur [thigh bone are close to the knee] with modest displacement and angulation [fractured bone segments at an angle], old fracture of right mid patella [kneecap] with modest displacement without callus formation. Intact right knee Arthroplasty. MD [physician] made aware. On 07/23/24 at 10:14AM nurse's notes indicated Oxycodone 1 tablet po Q 6H PRN for Pain . Oxycodone is a narcotic pain medication. In addition, the nurse's notes dated 07/23/24 indicated R30 was diagnosed with a fractured femur and sent to the Emergency Department for evaluation of the right knee and swelling, and her pain management was adjusted to better regulate her pain. While R30 had initially been receiving Tylenol for pain relief, a stronger medication, Morphine was prescribed upon her return to the facility to more effectively address the pain associated with the fractured femur. On 07/23/24 at 12:14 PM nurse's notes indicated R30 was sent to the Emergency Department for an Ortho consult and further evaluation and treatment. On 07/23/24 at 4:14 PM nurse's notes indicated R30 was to be discharged from the hospital and returned to the facility with an order for Morphine one tablet by mouth every six hours as needed for Moderate pain. Review of R30's Medication Administration Record (MAR) for the month of July 2024 revealed R30 received Morphine Sulfate 15mg for pain from July 24, 2024 - July 28, 2024, for a total of six doses after returning to the facility from the Emergency Department. Per the MAR July 2024 the resident had two orders: Morphine Sulfate 15mg one tablet every 6 hours: 07/24/24 Morphine 15mg one tablet administered at 9:26 AM for a pain level 6 and at 9:55 PM for a pain level 3 07/25/24 Morphine 15mg one tablet was administered at 2:19 PM for a pain level 7 Morphine Sulfate 15mg one tablet every 4 hours for Right femur fracture for moderate pain 1-5. 07/27/24 Morphine 15mg for a pain level of 5. 07/28/24 Morphine at 9:42 AM for a pain level 8 and at 8:00 PM for a pain level of 3 Interview on 10/19/24 at 12:30 PM, the Director of Nursing (DON) confirmed that obtaining the x-ray was delayed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. Review of R20'sFace Sheet, located in the EMR under the Profile tab revealed R20 was admitted to the facility with diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Depression, Anxiety and Acute Respiratory Failure. Review of the quarterly MDS located in the EMR under the MDS tab and dated 06/05/24, revealed the resident was assessed on the BIMS with a score of 14, indicating the resident was cognitively intact and exhibited no mood or behaviors during the same assessment period. Review of the resident's Care Plan located in the EMR under the Care Plan tab revealed the resident had the potential for sad mood, tearfulness, withdrawn state secondary to history of depression, anxiety and declining health. Review of a facility reported incident to the State Survey Agency (SSA) dated 04/01/24, indicated that the resident told the Director of Nursing (DON) that she wanted to talk to her privately about a particular aide. R20 said The evening aide screams at me. She verbalized that the aide makes her cry sometimes. Review of the facility's investigation revealed that in an interview with the DON and the Assistant Director of Nursing (ADON) it was revealed that Certified Nurse Aide (CNA) 7 was giving aide to R20 with an orientee. They turned the resident on her side and the resident started to scream in pain. CNA7 described and re-enacted backing away from the resident with her hands up in the air and saying, I'm not even touching you. CNA7 told the resident that her backside (used a derogatory term). She also told the resident that I guess that I will be in the DON's office on Tuesday. CNA7 described her relationship with the resident as friendly and they often joked around. The investigation determined that under the care of CNA7, the resident felt humiliated, tearful and manipulated. The resident was interviewed and indicated that she never felt comfortable with the aide, she disagreed with the description of their relationship. The CNA was initially suspended after the allegation was made and after the investigation, she was terminated from the facility. During an interview on 10/16/24 at 3:04 PM, R20 did not remember an incident with CNA7 and denied having any problems with staff. During an interview with the ADON on 10/16/24 at 3:36 PM, she stated that the resident about the incident. During the investigation, she asked the Quality Control Nurse to speak to the resident to see if she thinks the CNA should return to work. The resident stated she did not think the CNA should work at the facility. We decided to terminate her because of the resident's statement and what the CNA wrote up in her statement. The ADON also stated that she had not had any concerns about CNA7 before, she just would have a big mouth sometimes but she was a good worker. Review of the statement submitted by CNA7, dated 03/19/24 she stated, while changing R20, she was resistant to care, throwing her leg out of the bed at one point. I was not even touching her and she was screaming like I had my hands on her. I said to her, You sitting here yelling making it seem like I'm touching you and I'm leaning against the wall. The resident made the comment she would just leave or die. I stated you don't have to leave or die but please do not resist when someone is giving you care, you can do more harm to the aid than yourself. During an interview with the Quality Control Nurse on 10/17/24 at 9:52 AM, she stated she spoke to the resident about allowing CNA7 to return to work and the resident said no, she should not. She stated that she had not received any complaints regarding CNA7 in the past. In an interview with the DON, on 10/17/24 at 10:30 AM, she stated that she was involved with interviewing staff only when discipline was involved. The DON stated the way CNA7 described how she spoke to R20, just what she said to the resident, it was clear and concerning. After the interview with CNA7, I did not feel that she thought she had done anything wrong. We had to let her go. The ADON and I both thought she should not be here and was terminated. We did not feel like she was fixable. The DON stated she could not remember any complaints from other residents concerning CNA7's behavior. The DON stated that as soon as she found out about the incident, CNA7 was suspended and terminated. e. Review of R67's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R67's EMR titled annual MDS with an ARD of 08/29/23 indicated the resident had a BIMS score of six out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident had no behaviors. During an interview on 10/17/24 at 2:09 PM, R67 stated he did not remember the resident-to-resident which involved R95. The resident stated he was not fearful and stated he was fine. Review of R95's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R95's EMR titled quarterly MDS with an ARD of 10/23/23 indicated the clinical staff could not determine the resident's BIMS and revealed the resident had short-term and long-term memory problems. The assessment indicated the resident had physical/verbal behavior directed towards others. Review of R95's EMR titled administration Progress Notes located under the Prog (Progress) Note dated 12/25/23 indicated the resident was observed to punch R67 in the eye and the resident was then redirected from the area. Review of a document provided by the facility titled Physical indicated R67 reported to the facility that R95 punched him in the left eye. R67 said that R95 attempted to open the dining room door. R67 stated he tried to stop R95 from doing so and that was when R95 punched him in the eye. The clinical staff assessed the resident and there were no injuries. The resident's physician and responsible party were notified of the incident. c. Review of R89's admission Record, located under the Profile tab in the EMR noted the resident was admitted with diagnoses that included dementia with agitation. Review of the quarterly MDS, located under the MDS tab in the EMR with an ARD of 07/18/24 revealed a BIMS score of six out of 15 which indicated R89 had severe cognitive impairment. Review of the Care Plan, dated 07/24, located under the Care Plan tab in the EMR revealed a problem of Potential to be verbally aggressive, short tempered, displaying outbursts related to dementia and poor impulse control. Included in the interventions were Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Review of R87's admission Record, located under the Profile tab in the EMR noted the resident was initially admitted with diagnoses that included unspecified dementia, with mood disturbance, and cognitive communication deficit. Review of the admission MDS, located under the MDS tab in the EMR with an ARD of 09/12/24 revealed a BIMS score of seven out of 15 which indicated R87 had severe cognitive impairment. Review of the Care Plan, dated 07/24, located under the Care Plan tab in the EMR revealed no concerns related to behaviors, agitation, or aggression. Review of an incident report, dated 10/07/24, provided by the Assistant Director of Nurses (ADON), revealed Residents were sitting next to one another in common area. I was in hall talking with charge nurse and heard a commotion. I turned to look and saw [R87] standing up in front of [R89] holding her walker by the legs and trying to hit [R89]. Myself and the charge nurse immediately separated both residents. [R89] was ask what happened and she did not give me an answer. Just stated she did not do anything. She denied any pain and was assessed for injury. No inlury [injury] found. She was put on 15 min checks- [R87] was also assessed and visibly upset. He denied injury and stated he would be OK. Resident was noted with 2 small red scratches on his clavicle area. Both residents have a Hx [history] of dementia with anxiety. During an interview on 10/16/24 at 2:44 PM, the ADON, responsible for completing the investigation, stated [R89] was the aggressor. [R87] had his arm up talking with another resident, [R89] hit him on his arm. [R87] did not pay attention to her. [R89] then shook her hands at him. [R87] then stood up and pushed [R89]'s walker at her. The second time [R87] tried to hit [R89] with the walker, she held on and nothing occurred. Based on record review, interviews, and facility policy review, the facility failed to ensure: seven of 10 residents (Residents (R)69, R83, R89, R87, R20, and R67) reviewed for abuse were free from resident-to-resident abuse. These failures increased the risk of continued abuse towards the residents. Findings include: 1. Review of the Abuse Policy/Procedure, review date 06/27/23, under Identification indicated . abuse, neglect or mistreatment may be suspected in, but not limited to the following situations: ii. Physical Abuse: Intentionally and unnecessarily inflicting pain, injury, or degradation to a resident' This includes, but is not limited to hit, push, kick, slap, pinch, or sexually molest any resident'. iii. Verbal Abuse: ridiculing or demeaning a resident, cursing directed to a resident, threatening to inflict harm or verbal abuse to a resident . Under Protection . c. Residents will be protected from other residents in various ways depending on the level and type of abuse. Alternatives may include changing resident rooms, altering resident care plans or discharging a resident from the facility to protect the safety of other residents. d. Incidents involving resident to resident abuse will be reviewed by the clinical team. A care plan review will also be conducted to implement interventions to avoid further instances . a.Review of R69's EMR admission Record located under the Profile tab, indicated the resident was admitted to the facility with a diagnosis of Anxiety disorder, Dementia, and Major Depressive disorder, Review of R69's EMR quarterly MDS with an ARD of 08/26/24 indicated the resident had a BIMS score of three out of 15 which revealed the resident was cognitively impaired. Review of R69's EMR Care Plan located under the Care Plan tab, revision date 09/14/22, indicated the resident was at risk for elopement/wanderer, entering into other resident's rooms looking for family, car, related to impaired safety awareness and dementia. The Intervention/Tasks, revision date 12/22/21, indicated to distract resident from wandering, provide structured activities, visual safety checks every hour. Review of R69's EMR Nurse's Notes located under the Progress Notes tab, indicated that on 02/27/24 an altercation coming from R44's room was heard, R69 was observed placing his hand over his left eye. R69 was noted to have bloodshot and specks of blood within the orbital area. It was also documented in the same nurse's note that R69 stated he was hit in the eye by the other resident (R44) in the room. R69 was sent to the Emergency Department for further treatment and evaluation on 02/27/24 via ambulance services. Further review of the resident EMR indicated that R69 is on Xarelto, an anticoagulant medication, which can result in excessive bleeding and bruising. Review of the Emergency Department note, dated 02/27/24, indicated R69's sustained a Subconjunctival hemorrhage, and Corneal abrasion. R69 was discharged and returned to the nursing facility on 02/27/24 with a prescription for Erythromycin ophthalmic ointment. Review of the ER discharge instructions, dated [DATE], revealed the following prescription: Erythromycin ophthalmic (erythromycin 0.5% ophthalmic ointment) 0.5 inch in the eye four times a day. Review of the Medication Administration Record (MAR) of the months of February and March 2024, revealed that the resident was started on the Erythromycin ointment at 9:00 AM and with the last dose given on 03/04/24 at 12 noon. Review of the MAR for February 2024 revealed that on 02/27/24 the resident was medicated with Tylenol 325 mg ii tablets for pain. The pain was documented at a 5 out of 10 at 9:11 AM and 5:14 PM. During a telephone interview on 10/18/24 at 10:17AM, Registered Nurse (RN)1 stated R69 had wandered into resident R44's room and RN1 heard R44 say get out of my room, get out of my room. RN1 stated he went into the room and observed R69 covering his eye. RN1 stated he separated both residents and examined R69's eye and noted that R69's eye was bloodshot with blood specks. RN1 stated he notified the physician and transferred R69 to the Emergency Department for further treatment and evaluation. RN1 also stated that he talked to R44 and asked him to use the call light or call a staff member when someone enters his room. RN1 further stated R44 was in agreement with calling staff when someone entered his room. Review of R44's EMR admission Record located under the Profile tab, indicated the resident was admitted to the facility with diagnoses including Dementia and Alzheimer's disease. Review of R44's EMR annual MDS with an ARD of 08/16/24 indicated the resident had a BIMS score of five out of 15 which revealed the resident was cognitively impaired. Review of R44's EMR Care Plan located under the Care Plan tab, revision date 02/28/24, indicated the resident had the potential to become verbally and physically aggressive towards other residents that cause him to feel threatened or invade his personal space secondary to being impulsive, short tempered and territorial. The Intervention/Tasks revision dated 02/28/24 indicated the resident's behaviors was de-escalated by removing other persons from his space, . encourage seeking out of staff member when agitated before becoming physical . when the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress . Interview on 10/15/24 at 10:23AM, and 4:05 PM and on 10/18/24 at 8:15AM, R44 stated that R69 wanders into his room, and he tells him get out of my room but denied hitting R69. Interview on 10/18/24 at 5:20 PM, the Assistant Director of Nursing (ADON) stated R44 denied hitting resident R69. The ADON further stated that there have been no further altercations and or resident to resident abuse involving R44 and R69. b. Review of R83's EMR admission Record located under the Profile tab, indicated the resident was admitted to the facility diagnoses of Dementia, Personality Disorders, and Major Depressive disorder. Review of R83's EMR annual MDS with ARD of 11/20/23 indicated the resident had no BIMS score to determine the resident's was cognitive status. The assessment revealed the resident was dependent on staff for activities of daily living (ADL). Review of R83's EMR Care Plan located under the Care Plan tab, revision date 11/25/22, indicated the resident had an ADL self-care performance deficit related to Dementia, and had limited physical mobility related to being non-ambulatory. The Intervention/Tasks revision date 11/25/22 under locomotion indicated R83 was dependent on staff for locomotion using a Geri-chair. Further review of the Care Plan revealed R83 was at risk for emotional distress related to male resident rubbing her stomach and while she was seated in the lounge waiting for dinner. The Intervention/Tasks initiated date 07/18/24 indicated resident remains in common area for increased observation. Review of R83's EMR Nurse's Notes located under the Progress Notes tab, indicated a late entry note dated 07/21/24 indicated that on 07/20/24 a male resident was observed rubbing R83's groin area. R83 was sitting in a Geri-chair at the TV lounge. Interview with R83 was attempted during the survey without success. During an interview on 10/16/24 at 1:09 PM, Dietary Aide (DA) 1 stated that R83 was sitting in her Geri-chair near the nurses' station when R64 was observed rubbing R83's legs near the groin area, she stated I was breaking down the trays after lunch and I saw what he was doing and I told the nurse immediately. I separated them first, and then told the nurse, there were no nurses or staff around they were busy taking people to their rooms. He just rolled himself over to her, she doesn't talk so she did not tell him to get away or push him away. I rolled him to the opposite side of the room, locked his wheelchair and went to get and tell the nurse. Review of R64's EMR admission Record located under the Profile tab, indicated the resident was re-admitted into the facility with a diagnosis of Dementia. Review of 64's EMR quarterly MDS with an ARD of 08/21/24 indicated the resident had a BIMS of five out of 15 which revealed the resident was cognitively impaired. The assessment revealed the resident was dependent on staff for activities of daily living (ADL). Review of R64's EMR Care Plan located under the Care Plan tab, revision date 01/25/24, indicated the resident needed adequate supervision and observation as he had a behavior of becoming sexually inappropriate with female residents with dementia/cognitive impairment. The Intervention/Tasks revision date 07/22/24 indicated R64 was placed on 1:1 monitoring due to safety concerns when out of bed, 30-minute safety checks when in bed, re-direct resident if he displays any inappropriate behavior or verbalizations, visual safety checks put into place to monitor residents' location. Review of R64's EMR Nurse's Notes located under the Progress Notes tab, indicated a late entry note dated 07/24/24, revealed Currently, resident is being monitored by 1:1 supervision. Alternate placement on another floor is also being explored. However, it is the opinion of the clinical team that resident's behavior will continue as he identifies another target. Also discussed option to locate another facility that could better address needs. An interview with R64 was attempted during the survey process without success. Interview on 10/18/24 at 5:20 PM, the ADON stated that the dietary aide had stopped R64 if she had not stopped him, it could have gone a lot further. The ADON stated that no other incidences of touching other female residents have occurred to include resident R83. The ADON stated the dietary aide observed R64 touching the thighs of the resident near the groin area. R64 had wheel himself out of the Dining Room (DR) and approached the female resident who was sitting in her Geri chair outside the DR and near the nurses' station. R64 was immediately removed from the area and placed on 1:1 monitoring. The ADON further stated that the facility is trying to find more appropriate living arrangements for him. R64 remains on 1:1 monitoring until alternate placement is found for R64.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's policy titled, Dressing Change, dated 04/18/24, revealed, . Purpose to prevent contamination of wound, while restoring skin integrity and monitor healing process . create clean field with paper towels or drape . Open dressing pack . Put on first pair of disposable gloves . Remove soiled dressing and discard in plastic bag . Dispose of gloves in plastic bag . Wash hands . Put on second pair of disposable gloves . Pour prescribed solution onto gauze to be used for cleaning . Cleanse wound with prescribed solution . Apply prescribed medication if ordered . Apply dressings and secure with tape . Remove gloves and discard with all unused supplies in plastic bag . Wash hands . Review of R88's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed R88 was admitted on [DATE] with diagnosis of diabetes mellitus, muscle weakness, atrial fibrillation, malignant neoplasm of left kidney, peripheral vascular disease, and a stage III pressure sore. During an observation on 10/16/24 at 9:10 AM, LPN1, LPN2, and Certified Nursing Assistant (CNA) 3 were observed performing wound care for R88's stage III sacral pressure sore. LPN1 had placed her dressing change supplies on top of the overbed table. A protective barrier was not observed under the supplies. Prior to beginning the wound care, LPN2 suggested cleaning the resident before wound care to minimize the time she needed to be turned. A wash basin was placed on the same overbed table with the supplies and was used to wash the resident. After the bath was completed, the basin was removed from the overbed table which left a wet spot in the same area. Without cleaning the table, LPN1 proceeded to begin with the dressing change. She put on a pair of disposable gloves, removed the soiled dressing from the resident's sacral area and removed the gauze from the wound bed. LPN1 placed the soiled dressing in a plastic bag and removed her soiled gloves. Without performing hand hygiene, she put on a new pair of gloves and used a clean gauze and wound cleaner from the overbed table to clean the resident's wound. After cleaning the wound, LPN1 disposed of the gauze and gloves in the plastic bag and, without performing hand hygiene, she put on another pair of disposable gloves and placed a medicated ointment on top of a medicated gauze in the wound bed and covered the wound with a dressing. After completing the wound care, LPN1 removed her gloves and placed the remaining dressing supplies in the plastic bag and washed her hands. During an interview on 10/16/24 at 9:10 AM, LPN1 stated that she did not disinfect the top of the overbed table after CNA 3 removed the wash basin that left water on the table. LPN1 confirmed that she did not wash her hands between changing from soiled to clean gloves and stated she should have. During an interview with the Infection Preventionist (IP) on 10/16/24 at 3:14 PM, the IP stated that the nurse performing the wound care should have washed her hands between changing her soiled gloves to clean gloves and the overbed table should have been disinfected again after removing the wash basin. 3. Review of the facility's policy titled, Cleaning of Glucometers, dated 08/27/24, revealed, . The purpose of this procedure is to prevent the spread of infection . clean glucometers after every use . clean glucometer with approved product . allow appropriate amount of time for product to dry before using equipment on another resident . Review of the Clorox Healthcare Bleach Germicidal Wipes manufacturer's guidelines, located on the product's container, revealed the recommended drying times ranged from 30 seconds to kill bacteria to one minute to kill bloodborne pathogens. During an observation on 10/14/24 at 10:49 AM, Licensed Practical Nurse (LPN)4 prepared a blood glucose monitor to check the blood glucose level for RRe1. Using a disinfecting wipe, LPN4 wiped the monitor several times. Without allowing the disinfecting solution to dry, she used a tissue to wipe the monitor dry. LPN4 completed the blood glucose test for R1 and placed the monitor back on top of her medication cart. LPN4 used another disinfectant wipe on the same blood glucose monitor and approached R6 in the hallway. Before allowing enough time for the monitor to dry, LPN4 again used a tissue to dry the monitor before conducting the blood glucose test for R6. After obtaining the test, LPN4 placed the blood glucose monitor directly on top of the medication cart without a protective barrier underneath the monitor. During an interview on 10/15/24 at 2:34 PM, LPN4 was asked what process she followed for disinfecting the blood glucose monitor. She stated, I wiped the monitor, I was supposed to leave it for three minutes. I used the tissue because [the surveyor] was there. LPN4 stated, Usually, I would wait three minutes to air dry. She stated she had worked at the facility for four years and received training on blood glucose monitors when she was hired. During an interview on 10/15/24 at 1:42 PM, the Director of Nursing (DON) stated that the nurses are trained to allow three minutes for the disinfectant to dry on the blood glucose monitors when cleaning. She stated this was included in their policy. Based on observation, staff interviews, and review of the facility's policy, the facility failed to 1.) ensure staff changed gloves, performed hand hygiene, and followed proper cleaning techniques for one of one resident (Resident (R) 30) observed during incontinence care and one of one resident (R88) observed during wound care from a sample of 34 residents, and 2.) ensure staff followed recommended disinfectant drying times to disinfect a multi-use glucometer for two residents (R1 and R6) observed during medication pass. These failures increased the risk of cross contamination. Findings include: 1. Review of the facility's policy titled, Handwashing review date 02/28/24, revealed, Purpose To prevent or minimize the transfer of pathogens. 1. Hand washing is the most important procedure used to prevent the spread of pathogens. Review of the facility's policy titled, Peri Care of the Female Resident review date 01/03/24, revealed under Purpose To provide cleanliness and comfort while enhancing infection and irritation prevention . Cleaning is always done anterior to posterior (front to back) . Staff must change gloves after direct exposure to bodily fluids or fecal matter and clean/disinfect hands prior to completing resident care and touching other clean surfaces. Review of R30's admission Record located in the electronic medical record (EMR) under the Profile tab revealed she was admitted to the facility with diagnoses of Arthropathy (arthritis), Dementia, and Alzheimer's disease. Review of R30's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed the resident was cognitively impaired. The resident required maximum assistance for toileting and was frequently incontinent of bowel and bladder. Review of R30's Care Plan located in the EMR under the Care Plan tab indicated the resident had bladder and bowel incontinence related to dementia, and impaired mobility with interventions to provide peri care after each incontinent episode. During an observation on 10/16/24 at 1:55 PM, Certified Nursing Assistant (CNA) 4 and (CNA) 5 provided incontinence care to R30. CNA 4 and CNA5 each donned a pair of gloves, removed the resident's pants and adult brief. After removing the adult brief, R30 was turned on her right side and was observed to be incontinent of bowel with brown fecal material noted on the resident's right and left buttocks. Using the same gloves, CNA 4 cleaned the top of the resident's perineal area in a downward motion. CNA 4 did not separate R30's labia. CNA4 then discarded the soiled used wipes directly onto the floor. CNA 4 and CNA5 then turned R30 on her left side and CNA 5 cleaned the resident left and right buttock cheek and anal area in a back to front motion towards the labia with disposable wipes removing large amounts of fecal material. Resident R30 was then turned on her back, CNA 4 then repeated to clean the top of the peri area in a downward motion removing fecal material. After cleaning the resident, R30 was turned on her right side and a clean adult brief was applied. With the same soiled gloves, the resident's pants were pulled up and her white blouse was adjusted. CNA4 and CNA5 then adjusted the resident's pillows and pulled up the blue comforter, adjusted to call light within reach of the resident. CNA 4 then moved the resident's bed in place (against the wall) moving the bed by the footboard with the same soiled gloves. After picking up the soiled disposable wipes from the floor, CNA 4 removed and discarded her soiled gloves, CNA 4 was observed to leave R30's room without washing her hands. During an interview with CNA 4 and CNA5, immediately after the observation, CNA 4 and CNA5 confirmed they should have cleaned the peri area from top to bottom, separating the labia and cleaning the buttock and rectal area from front to back to avoid contamination of the vaginal/peri-area. The CNAs stated that they should have removed their soiled gloves after cleaning the resident's soiled body areas, and before putting on a clean brief and adjusting the resident's clothing and, pillow, comforter and before repositioning the call-light. During an interview with the Director of Nursing (DON) on 10/17/24 at 10:00 AM, she confirmed the CNAs should have changed her gloves and washed their hands.

Based on interview, record review, and policy review, the facility failed to ensure one resident (Resident (R) 32) out of the 36 sampled residents received their medication at the ordered time by the physician. Findings include: Review of R32's admission Record located in the Admission tab of the electronic medical record (EMR) revealed the latest admission date of 11/04/23 with diagnoses including Parkinsons and hypothyroidism. Record review of R32's quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/28/23 revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicated R32 was cognitively intact. Review of R32's Care Plan located in the Care Plan tab of the EMR, with a revised date of 02/20/20 revealed a problem was listed for hypothyroidism and an intervention was to administer medications as ordered. Review of R32's Physician orders, located in the Orders tab of the EMR revealed an order for levothyroxine (for thyroid), carbidopa-levodopa (for Parkinsons), and omeprazole (for GERD). Review of R32's Medication Administration Record (MAR) for October 2022 revealed R32 did receive her medications that were due at 6:00 AM at 2:30 AM on 10/26/23. During an interview with R32 on 12/11/23 at 1:52 PM, it was revealed that an agency nurse had given her morning medications to her in the middle of the night. R32 called the nursing supervisor and told her about the incident. R32 revealed an investigation was done and she has not had it happen again. During an interview on 12/12/23 at 1:30 PM with the Director of Nursing (DON) confirmed the Nursing Supervisor relayed to her R32 had gotten her morning medications, which were due at 6:00 AM, in the middle of the night. The DON revealed she started an investigation and found out the incident had occurred on 10/26/22 and confirmed the resident's levothyroxine, carbidopa-levodopa, and omeprazole were due at 6:00 AM and were given at 2:30 AM. The physician were notified. The DON revealed R32 had been assessed with no adverse reactions. Record review of the Medication Administration Procedure policy with a revised date of 09/24/23 revealed the purpose of the policy was to ensure all medications were administered according to a physician's order and given at the right time.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that one out of two residents (Resident (R) R24) observed during personal care were provided personal care in a manner that promoted infection control. Findings include: Review of R24's admission Record under the Admission tab located in the electronic medical record (EMR) revealed the facility admitted R24 on 10/01/21. During an observation on 12/12/23 at 10:24 AM, revealed CNA12 was going to provide personal care to R24. CNA12 applied gloves, raised the bed, and removed the tab holding R24's brief in place. Observation further revealed R24 had had a bowel movement. CNA12 used a different wipe each time she cleaned the peri area and the bowel movement from the back side. CNA12 did not remove her gloves after cleaning the bowel movements. Observation further revealed CNA applied a cream to R24's peri area with the same gloves that were used to clean bowel movement. CNA12 took a wipe and cleaned the small amount of bowel movement and cream off the gloves on her hands. CNA12 taped the brief, took the pants off R24, and pulled the linens over the resident. CNA12 still had not changed her dirty gloves, which had been used to clean bowel movement. CNA12 lowered the bed with the remote, put the lid back on the cream, and then removed her gloves as she was leaving the room. CNA walked down the hall and washed her hands. During an interview on 12/12/23 at 10:40 AM CNA12 revealed she would remove the gloves if they were soiled but would keep them on otherwise until she was done with care. CNA12 asked this surveyor should I change the gloves in between? During an interview on 12/12/23 at 10:49 AM with the Director of Nursing (DON) revealed once the resident was cleaned then staff should remove their gloves, wash their hands, and put on clean gloves to apply brief and clothes. The DON revealed that was her expectations. The DON further revealed, obviously it was an infection control issue if gloves were not changed from dirty to clean. The DON revealed if gloves were not changed it would contaminate clean things. The DON further revealed staff could wash their hands in each room since each room had a sink. Review of the facility policy titled, Perineal Care of the Female Resident' with a reviewed date of 07/26/23 revealed gloves were to be applied before contact with the resident. Staff were to use a clean washcloth or cleaning cloth to clean the peri-anal area. The policy further revealed staff were to remove gloves and wash their hands before applying an incontinent product under the resident. Staff should apply gloves before repositioning the resident and finally wash their hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure one Resident (R)83 was free from sexual abuse from R68. The facility also failed to ensure R47 was free from resident physical abuse from R143. Additionally, the facility failed to ensure R81 was free from sexual abuse from R73. Finally, the facility failed to ensure R51 was protected from verbal abuse by Certified Nursing Assistant (CNA) 5. Findings include: Review of a policy provided by the facility titled Resident Abuse Policy/Procedure, dated 2020, indicated . Physical Abuse: Intentionally and unnecessarily inflicting pain, injury or degradation to a resident. This includes, but is not limited to hit, push, kick, slap, pinch, or sexually molest any resident. 1. Review of R68's electronic medical record (EMR) titled admission Record, located under Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of a stroke. Review of R68's EMR titled annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/03/22 indicated the resident had a Brief Interview for Mental Status (BIMS) score of six out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident had behaviors not directed to others. The assessment indicated the resident had no impairments with upper and lower extremities and used a walker for ambulation. Review of R68's EMR titled Care Plan located under the Care Plan tab dated 10/15/23 indicated the resident had a behavior of becoming sexually inappropriate with female residents who were cognitively impaired. The goal was to redirect the resident if the resident displayed any inappropriate behaviors or verbalizations directed to other residents. Review of R68's EMR titled incident Progress Notes, located under the Prog (Progress) Notes dated 10/22/23 indicated the resident was found with his right hand touching R83's groin area. R68 was immediately removed from R83. R83 was assessed and no injuries. R68 was evaluated by the psychiatric nurse practitioner on 10/23/23 and ordered a medication adjustment. Review of R83's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia without behavioral disturbances. Review of R83's EMR titled quarterly MDS with an ARD of 08/21/23 indicated staff could not complete a BIMS score and determined the resident had short- and long-term memory problems. The assessment indicated the resident required extensive assistance of two staff for bed mobility and transfers. Review of R83's EMR titled incident Progress Notes located under the Prog Note tab, dated 10/22/23 indicated Licensed Practical Nurse (LPN) 2 observed R68 rubbing his right hand on R83's crotch and she immediately removed the female resident from R68. R83's Care Plan was updated on 10/23/23 which reflected the allegation of sexual abuse. The goal was for the resident not to suffer any emotional abuse from the incident. Review of a document provided by the facility titled Incident Report dated 10/23/23 indicated R68 was found by staff rubbing R83's groin area. The investigation revealed both residents were immediately separated. The physician and the residents' responsible parties were notified of the incident. The facility also reported the incident to the State Agency (SA). The police were notified but no action was taken. Review of a document provided by the facility titled Incident Report dated 10/27/23 The report indicated both R68 and R83 both had a diagnosis of dementia. According to the report, R68 spends most of his time in his room watching television and would ambulate to and from the dining room for meals. The report revealed R83 spends most of the day outside of the nursing station and in a wheelchair. The report indicated on 10/22/23, R68 entered the main dining room at approximately 4:00 PM, which was too early for the dinner meal. According to the report, the resident was escorted to the outside of the dining room, to sit and wait until dinner was scheduled at 5:00 PM. At approximately 4:00 PM, the nurse observed R68 with his hand rubbing the groin area of R83 and the nurse immediately told R68 to stop, and both were separated. The psychiatric nurse practitioner and the primary physician were notified along with residents' representative. The psychiatric nurse practitioner adjusted R68's antidepressant after this incident. There were no further incidents by R68 after this incident. During an interview on 12/12/23 at 10:55 AM, LPN 2 confirmed she was the staff member who observed R68 touching R83 and then separated. LPN 2 stated she observed R68 grabbing R83's crotch really hard and gripping his hand on her groin. LPN 2 stated she considered the actions of R68 against R83 as sexual abuse. During an interview on 12/12/23 at 11:12 AM, the Assistant Director of Nursing (ADON) was asked why a conclusion was not made at the end of her investigation of R68 and R83. ADON stated R68 had dementia and a head injury. The ADON stated R68 did not touch the groin of R83 but touched her legs and stomach. A request was made to observe the camera footage. The facility did not provide camera footage of this incident by the end of the survey. 2. Review of R47's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R47's EMR titled Care Plan located under the Care Plan tab dated 09/13/21 indicated the resident had impaired cognitive function. Review of R47's EMR titled quarterly MDS with an ARD of 05/20/22 indicated the resident had a BIMS score of six out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident required limited assistance of one staff for bed mobility and transfers. The assessment indicated the resident used both a walker, or a wheelchair for mobility. Review of R47's EMR titled incident Progress Note dated 07/25/22 indicated R47 received physical aggression from another resident. The progress note revealed the other resident (R143) lifted his walker and hit R47. R47 obtained two skin tears on both the left and right hands. The progress note revealed the resident sustained a skin tear on his right hand which measured 2 cm (centimeters) x 0.2 cm. The progress note indicated R47 had a skin tear on his left arm about 0.5 cm x 0.2 cm. Dressings were applied. The nurse notified the resident's responsible party and the physician. Review of R143's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility 05/26/22 with a diagnosis of unspecified dementia without behavioral disturbances. Review of R143's EMR titled admission MDS with an ARD of 06/01/22 indicated the resident had a BIMS score of six out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident had no behavior that placed others at risk of harm. Review of R143's EMR titled Care Plan located under the Care Plan dated 06/24/2022 indicated the resident had the potential to become physically aggressive as evidenced by poking his cane into other residents' chests. Review of a document provided by the facility titled Incident Report dated 07/24/22 indicated R47 received physical aggression from R143, when R143 hit R47 with a walker and caused skin tears. The residents' representative and physician were notified of the incident. The report indicated R47 was provided treatment after the incident. Review of a document provided by the facility titled Incident Report dated 07/28/22 indicated R143 became physically aggressive with R47, due to a hearing deficit. The report indicated R47 sustained bi-lateral skin tears after being hit with a walker held by R143. Both residents were evaluated. The physician and the residents' responsible parties were notified of the incident. The facility also reported the incident to the SA. The police were notified but no action was taken. During an interview on 12/13/23 at 2:24 PM, Certified Nursing Assistant (CNA) 9 stated she observed R143 hold his walker over R47 and hit him. CNA9 stated R47 attempted to defend himself and was yelling at R143. CNA 9 stated she remembered R47 was injured but could not remember if he bled after the altercation. CNA 9 stated she and a former CNA 14 separated the residents immediately. During an interview on 12/14/23 at 9:59 AM, the Administrator, Director of Nursing (DON) and ADON defined abuse as an allegation of mistreatment, physical and/or sexual abuse. The DON stated for R83, she was involved with inappropriate touching by R68. The DON stated for R47 and R143, stated both residents were involved in a resident to resident and the facility was required to report these allegations to the SA. 3. Review of R81's electronic medical record (EMR) titled admission Record, located under Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia and anxiety. Review of R81's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/23 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 99 indicative of severe cognitive impairment. Review of R81's EMR titled Care Plan located under the Care Plan tab indicated the resident has dementia and anxiety and is dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits. R81 has a history of wandering into different rooms and staff have to redirect her. R81 attends the safety program so she can be monitored more closely during the day and evening. Review of R73's EMR titled admission Record, located under Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia and major depressive disorder (MDD). Review of R73's EMR titled annual MDS with an ARD of 09/21/23, R73's BIMS score was four out of 15 indicating the resident was severely cognitively impaired. On 11/27/23 R73's BIMS score was 11 out of 15 indicating the resident was moderately cognitively impaired. Interview on 12/12/23 with the MDS Coordinator revealed that she felt the MDS was not accurate. The resident had become more cognitively impaired. She did not retest the resident. Interview on 12/12/23 with R73's daughter revealed that her father no longer can carry on a meaningful conversation. Review of R73's EMR titled Care Plan located under the Care Plan tab in the EMR indicated the resident had dementia and spent most of his time wheeling around the unit in his wheelchair. The resident was noted to have inappropriate sexual behaviors with staff during care. On 01/26/22, R73 grabbed the wrist of a therapist and wanted her to sit on his lap. R73 was referred to Psychiatric Services and the Psychiatric nurse practitioner increased his Zoloft (anti-depressant) from 50 milligrams (mg) to 75 mg. Review of a document provided by the facility titled Incident Report dated 08/24/23 indicated R81 was found by staff rubbing R73 in the groin area. The investigation revealed both residents were immediately separated. The physician and the residents' responsible parties were notified of the incident. The facility also reported the incident to the State Agency (SA). Review of a document provided by the facility titled Incident Report dated 08/24/23 indicated the facility's investigation. The report indicated that both residents have a diagnosis of dementia. Both residents are confused and were redirected after the incident. Both residents live on the same floor, but on a different wing. Video surveillance indicated that R73 wheeled up to R81 in the hallway and held her hand and then put her hand in his groin. R81 started rubbing R73's private parts. Interview on 12/11/23 at 11:06 AM with the husband of R81 revealed The gentleman next door to my wife had inappropriate behavior with her. The facility stated that the gentleman was seen on video to take his wife's hand and place it on his private area. My wife was moved to a different hall on the same floor. She is now in the safety program and can be monitored more closely. The safety program is on the first floor, and she is there until 8:00 PM. I am here every day from 7:00 AM until 2:00 PM. Interview on 12/12/23 at 1:24 PM with the Business Office Clerk (BOC) revealed I had to go to the second floor to visit a resident, and as I was walking down the hallway, I could see R81 and R73 sitting very close together. As I approached, I realized that R81 was rubbing R73 over his pants in a personal area. I was so shocked that I yelled to an aid to maybe move these two along. I went back downstairs and reported the incident to the staff development coordinator. When we went back upstairs, the two residents had been moved. During an interview on 12/14/23 at 9:59 AM, the Administrator, DON, and the ADON defined abuse as an allegation of mistreatment physical and/or sexual abuse. The DON stated R81and R73 were involved with inappropriate touching that was initiated by R73. The facility was required to report this incident to the SA. 4. Review of the EMR under the Profile tab revealed the Face Sheet indicated R51 was admitted to the facility on [DATE] with a diagnosis of dementia. Review of the MDS located in the EMR under the MDS tab with an ARD of 11/07/23 revealed a BIMS score of three out of 15 indicating R51 was severely impaired cognitively. Review of the Facility Reported Incident (FRI) dated 10/20/23 provided by the facility revealed the verbal abuse was substantiated by the facility. The investigation revealed it was not noted R51 had a response at the time of the incident but no reaction when asked again about how she felt about the incident and what she could recall. The facility interviewed staff and received witness statements. Per the FRI, CNA 5 was interviewed immediately after the incident by the Director of Nursing (DON) and was not allowed to come back to the facility after termination on 10/25/23. Interview on 12/12/23 at 12:00 PM with the AD stated she came into help with dinner and heard CNA 5 yell sit down then said, I said sit down. The AD stated she heard R51 ask why are you yelling at me and CNA5 said because you don't listen. The AD stated R51 seemed distraught. The AD stated another CNA came in and CNA5 stated for the CNA to take R51 out because she wasn't dealing with or couldn't handle this. The other aide removed R51, and the AD and nurse went to assess the resident. The AD stated she immediately reported the incident to DON. The AD stated R51 did not have any recollection of the event. Interview on 12/12/23 at 12:05 PM with the DON stated she went up to talk to R51 later in the afternoon and R51 didn't remember and did have some confusion due to diagnosis. The DON stated CNA 5 was interviewed immediately and sent home. The DON stated CNA 5 denied yelling at R51. The DON stated CNA 5 was terminated immediately for verbal abuse after the investigation was complete. Interview attempt on 12/12/23 at 1:08 PM with R51 confirmed the resident was severely impaired and could recall the event. Interview on 12/14/23 at 11:56 AM with the Administrator revealed her expectations were for the staff to speak to the residents in a gentle tone. She stated abuse of any kind is not tolerated. The Administrator confirmed all staff, including agency staff were educated annually on abuse, and as needed.

Based on record reviews and interviews, it was determined that for two (R73 and R25) out of 44 sampled residents for Care Plan Review, the facility failed to ensure that the care plan was prepared by an IDT (Interdisciplinary Team) that included the attending physician or his/her designee, the nurse's aide with responsibility for the resident and a staff member from nutrition/food services. Findings include: 1. Review of R73's clinical records revealed the following: 1/21/21 - The admission MDS (Minimum Data Set) Assessment was completed. 2/3/21 2:37 PM - E17's (RNAC) Plan of Care Note documented, .Son requested to speak with dietitian regarding resident's menu and food choices; dietitican made aware via email . 2/4/21 - Review of the resident record lacked evidence that R73's attending physician or designee, the nurse's aid responsible for the resident and a staff member from nutrition/food services participated in the care planning process. 6/24/21 12:44 PM - Meeting via phone conference before MDS Assessment was completed. E17's (RNAC) Plan of Care Note documented, .Son is requesting resident be scheduled for eye appointment for glaucoma and complaints of eye pain to the son .scheduler notified via email . 6/24/21 - Review of the resident record lacked evidence that R73's attending physician or designee, the nurse's aid responsible for the resident and a staff member from nutrition/food services participated in the care planning process. 6/28/21 - The Quarterly MDS Assessment was completed. 7/19/21 11:32 AM - In an interview, R73 stated that she wanted her son and son's wife to come up to her room when they visit her again. When asked if resident visitation was brought up during the careplan meeting discussions with any of the members of the interdisciplinary team, the resident replied that she was never invited to a care plan meeting. R73 stated, I don't know, I have not been to any meetings. 7/22/21 2:10 PM - In an interview, E17 confirmed that the facility lacked written evidence that the above IDT members participated in the care planning process. 8/3/21 2:32 PM - During an interview, E19 (CNA) stated, .Way before the pandemic started, the nurse's aids used to get invited to participate in meetings to talk about the residents condition. For now, I think they stopped asking. 2. Review of R25's clinical records revealed the following: 2/25/21- The Quarterly MDS Assessment was completed. 2/25/21 - Review of the resident record lacked evidence that R25's attending physician or designee, the nurse's aid responsible for the resident and a staff member from nutrition/food services participated in the care planning process. 5/17/21 - The Annual MDS Assessment was completed. 7/21/21 10:17 AM - In a telephone interview with a family member during the survey screening process, F1 (Family Member) stated that the nurse's aid, staff from food and nutrition services and the attending physician did not attend the care plan meetings. In addition, F1 had to pull a CNA to join the care plan meeting. 7/22/21 2:10 PM - In an interview, E17 (RNAC) confirmed that the facility lacked written evidence that the above IDT members participated in the care planning process. 8/3/21 2:26 PM - During an interview, E18 (CNA) stated that she knows her residents well and she always updates the nurses with any changes in resident status or any known preferences. E18 added, Before they asked the nurse's aids to come to meetings, but it stopped. I go to the nurses more often than they come out to ask me questions about a resident. Findings were reviewed with E1 (NHA) and E2 (DON) on 8/3/2021 during the Exit Conference, beginning at 5:30 PM.

Based on observation, record review and staff interview, it was determined that the facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (R38) out of three (3) residents investigated for ROM. Findings include: Review of R38's clinical record revealed: 9/10/20 - R38 was admitted to the facility with left hand and wrist contractures. 11/19/20 - A signed Physician's Order located in R38's medical records stated, .1) RNP Restorative NP [Nursing Program] left wrist/hand orthotic device (black splint) on daily in AM - skin check before and after donning [putting on splint]/doffing [removing splint]. 2) FMP [Functional Maintenance Program] - green splint on when in bed . 12/8/20 (Last Revision Date) - A care plan was developed for limited physical mobility related to muscle weakness and left hand/wrist contractures. Interventions included a splint to the left hand/wrist as ordered and referrals to Physical and Occupational Therapy as ordered. 4/30/21 - A quarterly MDS assessment indicated R38 was cognitively intact for daily decision making and had an upper extremity ROM limitation on one side of the body. 7/1/21 through 7/31/21 - A review of R38's Active Physician's Orders included an original order dated 6/7/21 which stated, .Rehab (rehabilitation): Occupational Therapy Eval (evaluation) and Treat as Indicated . There was no current order for the use of a left hand and/or wrist splint in the facility's Electronic Medical Records System, the source for all of the current Physician's Orders to be recorded. 7/1/21 through 7/20/21 - CNA documentation indicated that the black splint was removed at bedtime and a green splint was applied at night. There was lack of evidence that the green splint was removed in the AM [morning] and a black splint was applied as ordered for this same period of time. 7/21/21 11:52 AM to 7/23/21 9:46 AM - The following observations were made of R38: - 7/21/21 11:52 AM: R38's left hand/wrist was without a splint. The Surveyor asked R38 Do you wear a splint to the left hand and/or wrist? R38 was unable to tell the Surveyor when the splint was worn. The Surveyor observed a green splint on top of the table in R38's room and R38 stated she wore the splint at night when she was sleeping. - 7/22/21 10:33 AM: R38 was in bed and her left hand and/or wrist lacked a splint. - 7/23/21 9:46 AM: R38 was observed sitting up in chair with a tan left wrist splint. 7/23/21 10:50 AM - A telephone interview with E12 (COTA) revealed that the tan left hand splint was discontinued in October 2020 and E12 confirmed that it should not have been applied to R38. 7/23/21 11:05 AM - A joint observation with E12 (COTA) was conducted in which R38 was observed with a tan hand splint. E12 confirmed that R38 was wearing a splint that was discontinued in October 2020 and stated that she should be wearing a neutral thumb resting hand splint which was black in color. E12 proceeded to attempt to locate the black splint in R38's room, however, it could not be found. 7/26/21 12:14 PM - An interview with R38 confirmed that she puts on and takes off the tan splint as the facility does not put on the required splint. There was lack of evidence of an order for R38 to self apply the tan left hand/wrist splint, despite the fact that the facility was aware that the tan splint was being worn by R38. 7/26/21 12:35 PM - The Surveyor informed E3 (ADON) that R38 uses the tan splint since she has not been provided the appropriate splint during the day hours. 7/27/21 10:03 AM - An interview with E3 revealed that the facility was unable to locate the black splint, thus, an order was placed to obtain the ordered splint. 8/3/21 12:10 PM - An interview with E2 (DON) confirmed the above findings and stated that the facility failed to transcribe the 11/19/20 orders for the left hand/wrist splint into the facility's EMR system, resulting in failure to implement and provide the services to apply and remove the black splint. 8/3/21 5:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2).

Based on observation, interview, and review of the facility's policy and procedure, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as possible. Findings include: The facility's policy titled Oxygen Use with the last review date of 8/25/20, stated, .Steps in Procedure 2. Plug in O2 Concentrator or set up O2 tank in a storage container for safety . 7/20/21 11:00 AM - A random observation of R68's room revealed an oxygen tank located at the right side of the head of the bed and not secured in a storage container. A joint observation immediately with E5 (RN Supervisor) confirmed that the oxygen tank was not secured and E5 proceeded to remove the tank out of R68's room and placed it in a storage container. 8/3/21 5:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

Based on observation, record review, and interview, it was determined that the facility failed to offer a therapeutic diet for one (R38) out of two sampled residents reviewed for nutrition. Findings include: Review of R38's clinical record revealed: 3/31/21 - A Physician's Order was written for a mechanical soft sandwich at lunch daily in addition to the lunch meal. 7/20/21 1:02 PM - An observation of R38's lunch revealed that the meal ticket stated, mechanical soft sandwich daily @ [at] lunch in addition to meal per resident preference. Observation of R38's lunch tray lacked evidence of a sandwich. 7/20/21 1:30 PM - An interview with E11 (Dietary Aide) confirmed that she did not put a sandwich on R38's lunch tray and E11 proceeded to prepare a peanut butter and jelly (PBJ) sandwich for R38. 7/20/21 1:45 PM - A repeat observation of R38's lunch meal tray revealed a PBJ sandwich wrapped in plastic and R38 stated that I am going to have this (sandwich) later. 8/3/21 5:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

Based on observation, interview, and record review, it was determined that for two (R66 and R68) out of two sampled residents reviewed for respiratory care services, the facility failed to provide appropriate respiratory care as per the physician's orders. In addition, for R68, the facility failed to ensure the oxygen concentrator filter was maintained for cleanliness and the facility failed to ensure R66's oxygen tubing and the humidifier were changed weekly. Findings include: 1. Review of R68's clinical records revealed the following: 11/15/18 - R68 was admitted to the facility with diagnoses including COPD. 12/6/19 (revision date) - Review of the care plan for oxygen therapy related to COPD was initiated on 11/30/18 which included approaches to administer oxygen as ordered and to monitor and report signs and symptoms of respiratory distress to the attending physician. 12/1/20 - A Physician's Order was obtained by the facility for oxygen at 2 liters per minute (LPM) via nasal cannula (NC; a tube placed into nostrils to deliver oxygen) as needed for shortness of breath (SOB; difficulty breathing) and to titrate (adjust) to maintain an oxygen saturation of 92%. 7/1/21 through 7/18/21 - Review of the facility's electronic Medication Administration and Treatment Administration Records revealed that R68's oxygen saturation ranged between 93% to 100%. 7/19/21 11 AM - A random observation of R68's room revealed R68 in bed in no acute distress and R68 denied being short of breath. R68 had the oxygen via NC infusing at 3 LPM. The Surveyor asked R68 Do you know how many liters of oxygen you are ordered? and R68 replied No. A joint observation with E5 (RN Supervisor) confirmed that R68 did not have an order to administer oxygen at 3 LPM and proceeded to decrease the liters to 2 and E5 stated she would review R68's oxygen order. In addition, E5 confirmed that the oxygen concentrator filter was dusty and that it would be addressed. Although R68 was observed on 7/19/21 at 11 AM with oxygen being administered at 3 LPM (incorrect amount of oxygen), record review lacked evidence of a respiratory assessment, including an oxygen saturation level prior to initiating the oxygen, as well as the liters of oxygen being administered and a post administration respiratory assessment, including a repeat oxygen saturation level. 7/20/21 10:59 AM - A repeat observation of R68's room revealed R68 in bed with no SOB and without oxygen. The oxygen concentrator filter remained dusty. A joint observation with E5 (RN Supervisor) revealed that it was unclear if it was the responsibility of nursing staff to ensure the filter was kept clean or not, however, E5 stated that she will address the issue. 7/21/21 9:45 AM - A subsequent observation of R68's room revealed R68 sitting up in a chair with no SOB and no oxygen. The Surveyor observed the oxygen concentrator filter was clean without debris or dust. 7/29/21 10 AM - An interview with E3 (ADON) confirmed that R68's current order for oxygen was to be administered as needed for SOB and to titrate to 2 LPM via nasal cannula. In addition, prior to administering oxygen, staff must obtain oxygen saturation level and complete a respiratory assessment. Upon starting the oxygen, the staff must obtain a repeat oxygen saturation and document the outcome of this intervention. 8/3/21 12:10 PM - An interview with E2 (DON) confirmed the above findings. 2. Review of R66's clinical records revealed the following: a. 12/27/18 - R66 was admitted to the facility with dependence on supplemental O2 (oxygen). 11/24/20 - R66 had an active physician's order to change the oxygen tubing and canister weekly. 7/20/21 9:00 AM - R66 was observed in the 2nd floor dining room with oxygen (tank) in use via nasal cannula (NC) at 3 liters per minute (LPM)). No date was observed on the tubing. 7/21/21 9:35 AM - R66 was observed in her room with oxygen (tank) in use via nasal cannula at 2.5 LPM. No date was observed on the tubing. 7/22/21 11:00 AM - R66 was observed resting in bed with oxygen (concentrator) in use via NC at 4 LPM. No date was observed on the tubing or humidifier bottle. 7/22/21 12:15 PM - In an interview, E21 (LPN Charge Nurse) confirmed that the nasal oxygen tubing that R66 was using was not dated and further stated that the NC tubing should be changed weekly and dated by the 11-7 shift. b. 7/22/21 11:10 AM - Review of R66's July 2021 MAR (Medication Administration Record) revealed that the licensed nursing staff have been signing off R66's order for O2 at 4 LPM via nasal cannula (NC) every shift for hypoxemia (low level of oxygen in the blood) from July 1 - 22, 2021. 7/22/21 12:15 PM - R66 was observed in the hallway with O2 in use at 2 LPM via NC. 7/22/21 12:20 PM - Further review of R66's records revealed that R66 had an active physician's order, dated 1/7/21, for oxygen at 4 LPM via NC every shift for hypoxemia. 7/22/21 12:25 PM - In an interview, E21 (LPN Charge Nurse) stated that R66 was care planned for oxygen therapy that included oxygen via NC as ordered. E21 further stated that R66 should be getting O2 at 2 LPM and to maintain PO2 (oxygen saturation) level above 92%. 7/22/21 12:40 PM - In a follow up interview, E21 confirmed that R66's oxygen therapy flow rate order of 4 LPM was clarified after the surveyor inquiry and discontinued immediately. A new physician's order, dated 7/22/21, stated O2 at 2 LPM via NC continuously, may titrate to maintain PO2 greater than 92% for hypoxemia. The facility failed to ensure that R66 was provided respiratory care consistent with her physician's order and comprehensive person - centered care plan. Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on 8/3/21 at approximately 5:30 PM.

Based on record review, interview, and review of the facility's policy and procedure, it was determined that the facility failed to develop policies and procedures (P & P) for the monthly Medication Regimen Review (MRR) that included the time frames for different steps in the MRR process. In addition, the facility failed to ensure that the April 2021 MRR by the Consultant Pharmacist was obtained timely for one (69) out of five sampled residents for unnecessary medication review. Findings include: 1. Review of the facility's policy and procedure titled Consultant Pharmacist Reports, IIIA1: Medication Regimen Review, with an effective date of 12/20/20, failed to include the time frames for different steps in the MRR process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. 7/30/21 12:45 PM - An interview with E2 (DON) revealed that the above P & P was from the new Consultant Pharmacist and confirmed that the P & P lacked the time frames for different steps in the MRR process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. 2. Review of R69's clinical record revealed the following: There was lack of evidence that the monthly review was conducted by the Consultant Pharmacist for April 2021. 7/30/21 12:50 PM - An interview with E2 (DON) revealed that while requesting the June 2021 MRR from the Consultant Pharmacist during the survey on 7/21/21, E2 identified that the facility did not receive the April 2021 MRR and requested the same. Subsequently, the April 2021 MRR was provided to the facility during the survey. E2 confirmed that the facility failed to ensure the April 2021 MRR was obtained timely and E2 stated that the facility has contracted with a different Consultant Pharmacy organization as a result of this issue. 8/3/21 5:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

Based on record review and staff interviews, it was determined that the facility failed to ensure one (R40) out of five residents reviewed for unnecessary medications received adequate monitoring for insulin. Findings include: 11/26/20 - Review of electronic MAR/TAR Physician orders for R40 stated that a Hgba1c level was to be drawn every three months. 7/2021 - Review of MAR/TAR physician orders for R40 under Medications documented R40 was ordered to be given insulin daily at 8 PM. 8/2/21 1:50 PM - Interview with E21 (LPN) Supervisor confirmed one Hgba1c level was drawn for R40 on 4/6/21. 8/3/21 at 5:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

Based on record review and interview the facility failed to ensure that two (R32 and R38) out of five sampled residents reviewed for influenza and pneumococcal immunization received or were offered the PPSV23 pneumococcal vaccine. Findings include: 1. 10/1/18 - R32 was admitted to the facility. 8/2021 - Review of R32's admission consent documentation reflected that the resident/resident POA declined the vaccines stating received previously 2-2-19, however, there was no indication which vaccine R32 received. 11/17/18 - R32's record indicated the resident received PCV13. The facility's records lacked evidence to support that R32 received or did not receive the PPSV23 vaccine. 2. 9/18/20 - R38 was admitted to the facility. 8/2021 - Review of R38's admission consent documentation reflected the resident/resident POA consented to receive PCV13 in addition to PPSV23. 12/6/18 - R38's record indicated the resident received PCV13. The facility's records lacked evidence to support that R38 received or did not receive the PPSV23 vaccine. 8/3/21 5:30 PM - All findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

Based on observations, interviews, reviews of facility information and other resources as indicated, it was determined that the facility failed to ensure that proper infection control procedures were followed by nursing staff, including proper cleaning and disinfection of glucometers that are used to check residents' blood sugars, the lack of handwashing/sanitizing after contamination of clean gloved hands and storage/handling of oxygen tubing. Findings include: According to the Healthcare Professional Operator's Manual (2017) for the Evencare G3 glucometer, alcohol wipes were not included in the list of approved cleaning agents. 1. An observation on 8/3/21 at 7:54 AM during medication administration revealed that E43 (LPN) used two alcohol wipes simultaneously to clean and disinfect the glucometer before using it on R9. The facility practice of using alcohol wipes contradicts the manufacturer's instructions on cleaning and disinfecting the EVENCARE G3 glucometer between resident uses. 2. An observation on 8/2/21 at 12:10 PM, E15 (LPN), after R42 refused to have FSBS (finger stick blood sugar) performed, cleaned the glucometer using an alcohol pad. An interview immediately after the observation with E15 confirmed that she only uses alcohol pads to clean the glucometer between resident uses. 8/3/21 1:50 PM - An interview with E2 (DON) confirmed that the facility's practice was to use alcohol pads which contradicted the manufacturer's instructions. 3. An observation on 8/3/2021 at 9:57 AM revealed that after E4 (RN) washed her hands and applied cleaned gloves, E4 touched the front of her facemask to readjust it with her clean gloved hand, proceeded to R7's room opening R7's screen door and entered the room with her contaminated gloved hand and performed a COVID-19 nasal swab test on the resident. E4 failed to wash or sanitize her hands immediately after she touched the front of her facemask. The finding was immediately confirmed with E4. 4. 8/3/21 9:00 AM - Observed oxygen concentrator with uncovered oxygen tubing attached resting on a community table in the hallway on the third floor beside the exit for the patio/porch. 8/3/21 9:05 AM - Interview with E20 (LPN) stated they would find out which resident the concentrator belonged to. E20 took the concentrator with tubing attached away in the direction of the oxygen storage room. 8/3/21 9:26 AM - Observed E44 (CNA) brought an oxygen concentrator with tubing out from the oxygen storage room. 8/3/21 9:27 AM - Observed E44 (CNA) state to E20 (LPN) that the oxygen concentrator belonged to R9. 8/3/21 9:27 AM - Interview with E20 (LPN) confirmed that the concentrator was the same concentrator previously identified. 8/3/21 9:28 AM - Observed E20 (LPN) take the concentrator with the tubing from E44 (CNA) and place the nasal cannula on R9. 8/3/21 9:30 AM - Interview with E20 (LPN) confirmed the oxygen tubing was not changed after it was removed from the hallway table. E20 stated that the tubing was placed inside of a bag inside the oxygen storage room, however, it was not witnessed. 8/3/21 5:30 PM - All findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

2. Review of E7's (CNA's) personnel and educational transcript records revealed the following: 9/5/17 - E7's initial date of hire. 1/20 through 7/27/21 - There was lack of evidence of abuse prohibition and dementia trainings in E7's educational transcript records. 7/27/21 1 PM - An interview with E4 (Staff Educator) confirmed the above findings. 3. Review of E9's (LPN's) personnel and educational transcript records revealed the following: 7/17/06- E9's initial date of hire. 1/20 through 7/27/21 - There was lack of evidence of abuse prohibition and dementia trainings in E9's educational transcripts records. 7/27/21 1 PM - An interview with E4 (Staff Educator) confirmed the above findings. 8/3/21 5:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON). Based on interview and review of facility documentation as indicated, it was determined that the facility failed to ensure that required training on abuse, neglect, exploitation and misappropriation of resident property was completed for three (E7, E9 and E27) out of 17 randomly sampled staff members. Findings include: The facility policy entitled .Resident Abuse Policy/Procedure, last reviewed in 11/2006, stated, .Steps in Procedure 2. Training .2a All new employees will undergo initial orientation, during which time definitions of abuse and neglect and mistreatment are discussed and identified by Administrator or designee during orientation . 1. Review of E27's personnel records revealed: 11/24/20 - The first day of assignment at the facility for E27 (CNA). 8/3/21 at 1:30 PM - During an interview with E1 (NHA), no further evidence of training was provided.

Based on observations and interview, it was determined that the facility failed to provide qualified dietary managerial staff to oversee food safety practices during all times of the kitchen operation. Findings include: During the initial kitchen tour on 7/19/21 from 8:00 AM to 9:45 AM, it was revealed that there were no individuals on premise with current Certified Food Protection Manager training. Finding was reviewed and confirmed with E1 (NHA) on 7/21/2021 at approximately 11:30 AM.

Based on observations and interview it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: The following findings were made during the observation of the initial kitchen tour on 7/19/21 from 8:00 AM to 9:45 AM: - A spoon was left in the hand washing sink next to the dish washing station; - Non-Cleanable surfaces such as paper were used as shelving in the walk-in refrigerator. The usage of non-cleanable material traps moisture and microbes; - Observed expired yogurt in the walk-in refrigerator; - There were unlabeled foods (pork and eggs) left uncovered in the reach in refrigerator; - Observed dead insect parts lodged in the fume hood. Findings were reviewed and confirmed with E49 (Food Service Director) on 7/19/21 at approximately 10:00 AM. Findings were reviewed with E1 (NHA) on 7/19/21 at approximately 11:45 AM.