Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents were treated with respect and dignity for four of 10 residents (Resident (R) 59, R287, R10, and R86) and failed to ensure a resident (R36) needing assistance with meals was assisted by staff sitting down, and failed to ensure a resident (R18) had their choice honored to receive medications by gastrostomy tube (G-Tube) out of 32 residents reviewed in the sample. As a result of this deficient practice the residents may negatively respond emotionally or may be triggered by past experiences to staff yelling/swearing. Residents may not feel respected or honored by staff hovering over residents while assisting with eating and not feeling valued when medication administration choices were not honored. Findings include: Review of the facility policy titled Administering Medications, revised 04/18, revealed Medication administration times are determined by resident need and benefit, not staff convenience. Factors that were considered include: . honoring resident choices and preferences, consistent with his or her care plan. Review of the facility policy titled Resident Rights, revised 02/01, revealed the Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include resident's right to: a dignified existence; be treated with respect, kindness, and dignity; be free from [verbal] abuse and neglect . 1. Review of R86's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/21/25 located in the EMR under the MDS tab revealed a brief interview for mental status (BIMS) score of 13 out of 15, indicating R56 was cognitively intact. 2. Review of R10's quarterly MDS with an ARD of 01/17/25 located in the EMR under the MDS tab revealed no BIMS score due to the resident being rarely/never understood or severely cognitively impaired. During a phone interview on 05/20/25 at 9:50 AM, Registered Nurse (RN) 4 explained Licensed Practical Nurse (LPN) 1 had entered an isolation room for COVID with a treatment cart on 03/18/25. RN4 told LPN1 that it was a break in protocol to take the cart into a resident room and LPN1 began yelling and swearing at RN4 being belligerent in front of two residents, R86 and R10. During an interview on 05/20/25 at 11:01 AM, LPN 1 confirmed the argument on 03/18/25 with RN4 in front of R10 and R86 explaining there was an issue between LPN1and RN4 that included being disrespectful to each other. LPN1 admitted her behavior was unacceptable and was regretful. LPN1 allowed RN4 to push her buttons resulting in a screaming match and LPN1 admitted was unprofessional and disrespectful to the residents in the room. During an interview on 05/21/25 at 5:33 PM, the Director of Nursing (DON) verbalized the expectation for any type of care, not to take the treatment cart into any room, and proper customer service, was being respectful to staff and residents. The DON revealed counseling sessions with the staff about the incident and RN4 no longer works at the facility. 3. Review of R287's admission MDS located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/21/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R287 was cognitively intact. 4. Review of R59's quarterly MDS with an ARD of 02/17/25 revealed a BIMS score of 15/15 indicating R59 was cognitively intact. During an interview on 05/21/25 at 8:26 AM, R59 reported about two months ago there was an argument in the hallway in the middle of the day between two staff members. They were yelling and swearing at each other and R59 was upset because R59 does not like hearing swearing in R59's presence and since this was R59's home, swearing was unacceptable and disrespectful. The resident said once in the middle of the night while sleeping and a loud argument woke R59 up with swearing, screaming about knowing how to do my job. R59 was very concerned if the staff were fighting. They got very loud and R59 did not like it at all and for the next several nights, had difficulty falling asleep. During an interview on 05/21/25 at 7:30 AM, RN2 recounted an encounter on 11/11/24 with LPN6 at change of shift at 11:30 PM when there was a disagreement between RN2 and LPN6. RN2 was feeling threatened by LPN6 when LPN6 moved in very close to RN2, violating RN2's personal space, pointing fingers in RN2's face, yelling and being very rude. Feeling threatened RN2 with raised voice, called for support from the CNA staff on the floor, the argument went on for several minutes and then LPN6 backed down and left the unit. During an interview on 05/21/25 at 10:26 AM the Director of Nursing (DON) was aware of the explosive incident on 11/11/24 between RN2 and LPN6 and both nurses were suspended during the investigation of the incident. Written warnings were issued and LPN6 no longer worked at the facility. The DON confirmed the behaviors of both nurses was unacceptable and the expectation was the staff acted respectfully towards each other, especially on the nursing unit. The DON confirmed because of the incident, the investigation showed the residents were affected by the explosive incident between the staff and as a result the residents were not respected or treated with the dignity they deserve from the staff. 5. Review of R36's annual MDS with and ARD of 04/11/25 revealed R36 had a BIMS score of five out of 15 indicating severe cognitive impairment and needs substantial maximal assistance with eating, helper does more than half the effort. Review of R36's Care Plan under the Care Plan tab in the EMR revealed a focus for activities of daily living (ADL) with intervention set up assist with eating. monitor for adequate intake, assist as needed Date Initiated: 05/25/21. During an observation on 05/19/25 at 12:30 PM, during the lunch meal R36 was in a wheelchair at table with lunch set up in front them. R36 was attempting to feed himself. At 12:31 PM, Certified Medication Aide Tech (CMAT)1 stopped by the table, while standing, placed a bite of food into R36's mouth and walked away. At 12:37 PM, CMAT1 stopped by and placed a bite in R36's mouth while standing and walked away. This same action of walking by R36 and placing a bite of food in the resident's mouth and walking away occurred a total of seven times. During an interview on 05/19/25 at 12:52 PM, LPN2/Charge Nurse observed CMAT1 walking by and feeding R36 from a standing position and confirmed the staff were not to stand to assist residents when feeding, the staff were to sit at the same level as the resident, to respectfully assist in feeding. During an interview on 05/21/25 at 10:44 AM, the DON confirmed when residents were assisted with eating their meals, support staff who were feeding residents were to sit at the same level as the residents. 6. Review of R18's admission Record located in the EMR under the Profile tab, revealed an admission date of 04/16/25 with medical diagnosis including encounter for attention to gastrostomy (G-Tube). Review of R18's admission MDS with an ARD of 04/30/25 revealed a BIMS score of 13 out of 15, indicating R18 was cognitively intact. Review of R18's physician Orders dated 04/16/25 located in the EMR under the Orders tab revealed orders for enteral feeding through G-Tube and medications were to be administered through the G-Tube. During an interview on 05/21/25 at 9:19 AM, CMAT1 confirmed the role of the CMAT was to administer oral medications and not to administer by G-Tube. CMAT1 confirmed all the medications they administered to R18 were crushed and placed in pudding or applesauce and administered by mouth. The CMAT confirmed the resident had an order for the medications to be administered via the G-tube. During an interview on 05/21/25 at 7:45AM, R18 expressed a preference to have medications administered through the G-Tube and not by mouth, the medications tasted bitter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure risk versus benefits were provided to the resident and/or the resident representative for one of six residents (Resident (R) 336) reviewed for unnecessary medications of 32 sample residents. This failure had the potential to affect the residents and/or representative medication knowledge. Findings include: Review of R336's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] and readmitted on [DATE]. R336 had diagnoses which included dementia. The resident was documented as passing away 01/18/25. Review of R336's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/24 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) was not assessed and the resident was documented as having severely impaired cognition. Review of R336's Order Summary Report located under the Orders tab of the EMR revealed an order dated 01/31/23 of Trazodone [an antidepressant with an off label use for insomnia] HCL [hydrochloride] oral tablet 50 MG (milligrams). Give one tablet by mouth at bedtime for insomnia. The Trazodone was discontinued on 10/20/24. Review of R336's EMR revealed there was no documented evidence the risks and benefits were completed for the Trazodone medication ordered by the resident's physician. During an interview on 05/21/25 at 8:21 AM, the Director of Nursing (DON) and the Regional Director of Clinical Operations (RDCO) both confirmed they did not have documented evidence that the risks and benefits were explained to R136 and/or the resident's representative prior to the use of Trazadone. During an interview on 05/21/25 at 3:57 PM, the DON stated the facility did not have a policy related to risk versus benefit for medications. Cross Reference F605

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, facility policy review, and resident and staff interviews, the facility failed to ensure residents' call light was within reach for one of one resident (Resident (R)136) reviewed for accommodation of needs. This failure placed the resident at risk of functionality not being maintained due to severe physical limitations, dignity, and well-being in accordance with his own needs and preferences, the resident could potentially not be able to call for assistance when needed. Findings include: Review of the facility's policy titled, Accommodation of Needs, revised March 2021, indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The policy further indicated, The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. Review of the facility's policy titled, Call Light, Answering, dated April 2022 indicated, The purpose of this procedure is to respond to the resident's requests and needs. Key Procedural Points .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Review of R136's undated admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed R136 was admitted to the facility on [DATE] with diagnoses that included functional quadriplegia, displaced spiral fracture of shaft of humerus, right arm, posterior subluxation [incomplete or partial dislocation of a joint or organ] of right hip, contracture of muscle unspecified upper arm, contracture of muscle left upper arm, contracture of muscle right lower leg, contracture of muscle left lower leg, and complete lesion at C5 [cervical spinal vertebrae] level of cervical spinal cord. Review of R136's Nursing Initial 48-hour Care Plan, dated 10/31/24 and located under the Assessment tab of the EMR, indicated, Specialty Interventions Related to Resident's Health Condition. Intervention: Resident call light and bedside table on dominant side. Review of R136's Care Plan, dated 11/01/24 and located under the Care Plan tab of the EMR, indicated [name of R136] is (high) risk for falls r/t [related to] Paralysis, bilateral [affecting both sides] lower/upper extremity contractures. Interventions were Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of the R136's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/07/24 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also indicated R136 had impairments on both sides of the upper and lower extremities, and the resident was completely dependent on staff for Activities of Daily Living (ADLs). Review of R136's quarterly MDS with an ARD date of 05/02/25 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have BIMS score of 15 out of 15 which indicated the resident was cognitively intact. The MDS further indicated that R136 had impairments on both sides of the upper and lower extremities and was completely dependent on staff for ADLs. During an observation and interview on 05/19/25 at 10:30 AM, R136 was observed lying in bed on his right side. At this time, the flat round touch pad call light and cord was observed to be hanging over the mobility bar located behind the resident on the left side of the head of the bed and almost touching the floor. R136's call light touch pad device was completely behind R136 where he could not reach it. R136 was observed to have a red stylus pen in his mouth and only able to use his stylus to touch his cell phone and move his head up and down. R136 stated, I need help with everything. I cannot move my body. My legs and hands are contracted. I can only move my head a little. R136 then stated, When I need help, I have to get on my phone and call the nurses station by dialing the number with my pen that I hold in my mouth. When R136 was asked if he could use his touch pad call light to call for assistance, he stated, Yes, but only if they put the call light close to me where I can hit it with my chin. Yes, I would be able to use it, but half the time it's out of my reach. During an observation on 05/19/25 at 12:30 PM, R136 was lying in bed on his right side. The flat round touch pad call light and cord was again to be observed to be hanging over the mobility bar located behind the resident on the left side of the head of the bed and out of reach. During an observation on 05/19/25 at 3:00 PM, R136 was lying in bed on his left side. The flat round touch pad call light and cord was still observed to be located hanging over the mobility bar located on the left side of the head of the bed and almost touching the floor. At this time, it was not positioned where the resident could use it. During an observation on 05/20/25 at 12:11 PM, R136 was lying in bed on the right side. At this time, he was talking on the cell phone that was observed to be mounted to the mobility bar on the right side of the head of the bed. At this time, the flat round touch pad call light and cord were observed to not be within reach and hanging over the mobility bar located behind the resident on the left side of the bed and almost touching the floor. During an observation on 05/20/25 at 1:41 PM, R136 was lying in bed on the right side with his eyes closed. At this time, the flat round touch pad call light and cord were observed to not be within reach and hanging over the mobility bar and almost touching the floor as was before. During an interview on 05/20/25 at 1:45 PM, Licensed Practical Nurse (LPN) 4 was asked if R136 would be able to use the touch pad call light to call for assistance. LPN4 stated, Yes, he would be able to use it. He can move his head and chin to push it if he needed to. He is alert and oriented x4. During an interview on 05/20/25 at 1:47 PM, Registered Nurse (RN) 3 was asked if R136 would be able to use the touch pad call light to call for assistance. RN3 stated, Yes, he has a 'Pancake' touch pad 'that's what we call it,' that he can use. He can also use his stylus and push the call light. Yes, he can definitely use it. During an interview on 05/20/25 at 1:50 PM, LPN1 was asked if R136 would be able to use the touch pad call light to call for assistance. LPN1 stated, Yes, he is total care [completely dependent on staff]. He must have everything done for him. He can use the touch pad call light if it is close to him. He is able to move his head to touch it. During an observation on 05/20/25 at 2:55 PM, R136 was lying in bed on his back. At this time, the flat touch pad call light and cord was observed to not be within reach of the resident and was observed to be hanging over the mobility bar on the left side and almost touching the floor. During an observation on 05/20/25 at 3:05 PM, R136 was observed lying in bed on his back. At this time, the flat touch pad call light was now observed to be next to the resident's chin to where he could push it if needed. During an interview and observation on 05/21/25 at 10:12 AM, Certified Medication Aide Tech (CMAT) 2 was asked if R136 could use the flat touch pad call light to call for assistance if needed. CMAT2 stated, Yes [name of R136] can use his call light but only if you put it by his head or shoulder and position it to where he can use it. He can use his head to push it, but it needs to be positioned close by. At this time during an observation with CMAT2, R136 was lying on the left side of the bed. The call light was observed to be hanging over the mobility bar behind the resident and almost touching the floor. It was observed to be out of reach. At this time, CMAT2 stated, It shouldn't be like this and confirmed it was not within reach of R136. CMAT2 proceeded to pick it up from the mobility bar and place it near the resident's head to where he could reach it. During an observation and interview on 05/22/25 at 5:30 AM with LPN7, R136 was lying on his back in bed with his eyes closed. The flat touch pad call light was observed to be located near R136's chin to where he could tap it if needed. LPN7 was asked if R136 could use the flat touch pad call light to call for assistance, the LPN stated, Yes, he can use it. There have been times when I've come in and the call light is on the floor. He can also use his stylus to use his cell phone to call us if he needs anything. As his nurse, I would expect the call light [to] be within his reach. During an interview on 05/22/25 at 10:30 AM, regarding the use of call light being accessible for R136, and what the expectation would be, the Director of Nursing (DON) stated, The call light should be within reach at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility's policy, the facility failed to ensure their primary system for identifying a resident's code status accurately reflected the resident's end of life wishes for two of 46 sampled residents (Resident (R) 9 and R43) reviewed for code status. This failure placed the residents at risk for their wishes not to be honored, risk of there being a delay in treatment, and death. Findings include: 1. Review of R9's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of [DATE] and a readmission date of [DATE]. Review of R9's EMR header information revealed the resident's code status was identified as Full Code and Do Not Resuscitate (DNR). Review of R9's Physician's Orders for Life Sustaining Treatment (POLST) form dated [DATE] and located in the resident's EMR under the Misc tab revealed Do Not Resuscitate [DNR] was selected. The POLST form was signed by the resident's representative and the resident's physician. Review of R9's Progress Note, dated [DATE] and located in the resident's EMR under the Progress Notes tab revealed the Social Services Director (SSD) documented, A care plan meeting was held with the resident and his daughter today. Resident/family desire a full code status and wishes will be honored at this time. The resident will remain in this facility for LTC [long term care]. No questions or concerns. Review of R9's POLST form dated [DATE] and located in the resident's EMR under the Misc tab revealed Attempt Resuscitation (CPR [Cardiopulmonary Resuscitation]) was selected which indicated the resident's code status was Full Code. The POLST form was signed by the resident's representative and the resident's physician. Review of R9's Physician Order located in the resident's EMR under the Orders tab revealed an order dated [DATE] of Code Status: Do Not Resuscitate and an order dated [DATE] of Code Status: Full Code. During a record review and interview on [DATE] at 11:33 AM, Licensed Practical Nurse (LPN) 2 reviewed the header in R9's EMR for code status. LPN2 stated she was confused by the code status information that was displayed as the EMR header indicated the resident was both a Full Code and a DNR and it was not clear what action to take. During an interview on [DATE] at 3:51 PM, the SSD stated the process for when a resident and/or representative requested a code status change, an updated POLST form was completed (signed by resident/representative and a physician), then uploaded to the resident's EMR under the Misc tab, and then an email was sent to nursing to update the resident's physician's order and the resident's care plan in the EMR. The SSD also stated the change in code status was also communicated in the daily morning meeting for the facility staff. During an interview on [DATE] at 9:21 AM, the LPN3 confirmed the process for updating a resident's code status was once the SSD informed nursing of the need to update the code status in the EMR, an order would be added to the physician's orders, and if there was a previous order, that order would be discontinued. LPN3 also stated during the process of updating the code status for R9, she was interrupted and failed to delete the old code status order resulting in the resident's EMR indicating two different code status options. LPN3 further stated this was where the nurses referred to when they needed to know what a resident's code status was. LPN3 stated R9's EMR which reflected two different code statuses and two different physician orders would create confusion about what to do for the code status of R9. During an interview on [DATE] at 12:46 PM, the Director of Nursing (DON) confirmed there was usually an audit done for orders updated in the daily morning meeting to ensure two people were reviewing the orders. This was not done for R9 when the new POLST order was updated, and it should have been confirmed by a second nurse. 2. 2. Review of R43's admission Record located under the Profile tab of the EMR revealed the resident was admitted on [DATE]. Review of R43's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score was not assessed and the staff documented R43 as having severely impaired cognition. Review ofR43's Care Plan, located under the Care Plan tab of the EMR and initiated on [DATE], revealed the Resident/ family desires a DNR [Do Not Resuscitate] status. Review of R43's physician Order Summary Report located under the Orders tab of the EMR revealed an active order for code status: Full Code, order date [DATE]. Review of R43's Physician Orders for Life-Sustaining Treatment (POLST) located under the Misc tab of the EMR, dated [DATE] and signed by the physician on [DATE], revealed Allow Natural Death (AND)- Do Not Attempt Resuscitation. During an interview on [DATE] at 7:43 AM, the Licensed Practical Nurse (LPN) 1 stated they would look in the EMR for the correct code status. She stated it would have been a discrepancy in the medical record as described above, and the EMR physician order would trump it. During an interview on [DATE] at 8:04 AM, the Social Services Director (SSD) stated when a resident was admitted , she gave them the POLST to sign and asked if they had a Power of Attornaey (POA). She stated that the form then got sent to the business office and uploaded. She stated she audited for changes and would send an email to the Unit Manager and Director of Nursing (DON); along with mentioning it in the morning clinical meeting. The SSD confirmed R43's code status was a DNR after looking at the EMR. She verified the orders had not been changed to reflect it. She stated it should have been changed in the system on [DATE]. She stated she had sent an email on [DATE] to the Unit Manager and the DON, along with talking about it in the morning meeting. During an interview on [DATE] at 11:30 AM, the DON stated there was a miscommunication with the SSD and it should have been changed immediately. During an interview on [DATE] at 12:15 PM, the DON stated she had a lot going on that day and missed it. Review of the facility's policy titled Advanced Directives, revised 09/2022, revealed Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff.a

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policy review, the facility failed to ensure monitoring of psychotropic medication side effects was conducted for one of six residents (Resident (R) 336) reviewed for unnecessary medications of 46 sample residents. This failure had the potential to result in an excess of medication provided to the residents resulting in oversedation. Findings include: Review of the facility's undated policy titled, Alternatives to Antipsychotics for Mood Disorders and Behaviors in LTC [Long Term Care], revealed Trazodone was indicated for depression. Trazodone has been used in mood disorders associated with poor/diminished sleep .Monitor for efficacy .Monitor for increased falls risk and cumulative anticholinergic side effects. Review of R336's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] and readmitted on [DATE]. R336 had diagnoses which included dementia. The resident expired on [DATE]. Review of R336's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) was not assessed and the resident was documented as having severely impaired cognition. Review of R336's Care Plan located under the Care Plan tab of the EMR revealed the resident used antidepressant medication, resolved [DATE]. Interventions included reporting to nurses, signs and symptoms which included fatigue, change in normal behavior, and insomnia. Review of R336's Care Plan, located under the Care Plan tab of the EMR revealed the resident used psychotropic medications, resolved [DATE]. Interventions included monitoring, recording, and report to MD [Medical Doctor] prn [as needed] side effects and adverse reactions which included fatigue and insomnia. Review of R336's physician Order Summary Report located under the Orders tab of the EMR revealed an order, dated [DATE], of Trazodone HCL [hydrochloride] oral tablet 50 MG (milligrams). Give one tablet by mouth at bedtime for insomnia. The Trazodone was discontinued on [DATE]. There were no orders related to the monitoring of side effects for Trazodone use. Review of the facility's investigation dated [DATE]and provided by the facility revealed the resident was observed drowsy at the dining table. Head dropped to the plate. Staff quickly raised R336's head from the plate. Review of R336's Progress Note dated [DATE] and located under the Progress Notes tab of the EMR revealed Observed drowsy but able to awaken without difficulty. NP [Nurse Practitioner] made aware with orders for UA C&S [urinary analysis culture and sensitivity] and CMP [comprehensive metabolic panel] on Monday. Daughter made aware but preferred for resident to be sent to the emergency room for evaluation. During an interview on [DATE] at 8:21 AM, the Director of Nursing (DON) and the Regional Director of Clinical Operations (RDCO) both confirmed there should have been monitoring for the Trazodone. The DON stated R336 had been more drowsy than normal. She also stated he had been drowsy on and off. They stated this medication should have been monitored for side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure all allegations of abuse and neglect were reported immediately but not later than two hours after the allegation for two of eight residents reviewed for abuse and/or neglect (Resident (R) 136 and R188) out of 46 sampled residents. This failure placed all residents of the facility at risk for further abuse and/or neglect. Findings include: Review of the facility's policy titled, Abuse Prevention Policy, last revised 03/01/18, revealed The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion .The resident has the right to be free from mistreatment, neglect .Reports of allegations or suspected abuse, neglect or exploitation .will be reported immediately .When abuse, neglect or exploitation is suspected the Licensed Nurse should: .Notify the Director of Nursing and Administrator .When suspicion or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted .Ensure that all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made . 1.Review of a Facility Incident Report, dated 03/06/25 revealed Type of Incident-Neglect .Details of Incident- [name of R136] is alleging that Certified Nursing Assistant (CNA) 48 neglected him by not turning him timely. Review of R136's undated admission Record, located in the Electronic Medical Record (EMR) under the Profile tab revealed R136 was admitted to the facility on [DATE]. Review of the R136's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/07/24 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R136's quarterly MDS with an ARD date of 05/02/25 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have BIMS score of 15 out of 15, which indicated the resident was cognitively intact. During an observation and interview on 05/19/25 at 10:30 AM, R136 lying in bed. When R136 was asked about the incident regarding CNA48. he stated, This was unacceptable, and I felt like it was neglect. Review of a written statement from RN2 dated 03/10/25 and provided by the facility revealed I had asked the CNA [referring to CNA 48] who was the assigned CNA to be working with [name of R136] to go and turn him at 2:00 AM. She refused. I let the CNA know that refusing to do a patient that is assigned to you on a shift is a problem. She agreed with me but still refused. I told her I was going to report her to the DON [Director of Nursing] . During an interview on 05/21/25 at 7:13 AM, regarding the incident that occurred with R136 and CNA 48 on 03/06/25, RN2 stated that she was the nurse working that nightRN2 stated, He [referring to R136] called and said that he needed to be turned around 2:00 AM or 2:30 AM. I told him I would send someone to his room. I told [name of CNA48] since you have him on your assignments, and since you are his assigned CNA, you need to go and turn him. CNA48 refused to go into R136's room. I told her I was going to let the Director of Nursing [DON] know that you are refusing to turn him. RN2 stated that she waited until morning until the DON came into work to report the incident. During an interview on 05/21/25 at 12:30 PM, regarding the incident that occurred on 03/06/25, the DON stated that she was not notified during the night by any staff which included RN2 about any incident regarding R136. The DON also stated when she came into work around 7:30 AM (over five hours later from when R136 requested assistance) that morning, RN2 reported the incident to her. he DON further stated, . [RN2] should have called me or the Administrator immediately but that didn't happen. The DON then stated, I agree it was also a delay in reporting to me or the Administrator. The nurse [referring to RN2] waited many hours to report the CNA [referring to CNA48] not wanting to turn a resident. She waited to report anything until I came in to work at 7:30 AM. During an interview on 05/21/25 at 1:00 PM, the Administrator stated that he was not immediately notified by RN2 or CNA48 of the neglect incident during night shift. The Administrator also stated, Nobody called me. The Administrator stated, I was notified by the Social Worker that following morning that [name of R136] had a complaint about not being turned the previous night. The Administrator stated it was his expectation he would have been immediately notified of the neglect. 2. Review of R188's admission Record located in the EMR under the Profile tab revealed an admission date of 01/24/24. The resident was discharged on 12/06/24. Review of the Facility Incident Report form, dated 10/03/24, revealed that the resident representative for R188 reported to the police that Certified Nursing Assistant (CNA)50 allegedly slapped R188 twice to the right side of her face. The CNA was suspended pending the outcome of the allegation. Review of the Police Incident Report revealed that on 10/03/24 at approximately 1:52 AM, there was a reported allegation of staff-to-resident abuse between R188 and CNA50. The family member of R188 (FM) 2 was also documented in the facility at this time. Review of the Administrator email to the State agency revealed the incident was State reported as an allegation of potential abuse on 10/03/24 at 10:40 AM, about 8 hours later, which was a delay in reporting. 3. Review of R189's admission Record located in the EMR under the Profile tab revealed an admission date of 08/29/24. The resident discharged on 10/13/24. Review of R189's discharge MDS located in the MDS tab in the EMR, with an ARD of 10/13/24, revealed a BIMS assessment with a recorded score of 15 out of 15 which indicated no cognitive impairment. R189 had no delirium, no mood, and no behaviors. On 10/03/24 at approximately 1:52 AM, there was a reported allegation of staff-to-resident abuse between R188 and CNA50. The family member of R188 (FM) 2 was also documented in the facility at this time. Record review revealed a Progress Note in the Progress Note tab for R188, dated 10/03/24 at 7:52 AM, revealed, .(FM2) verbally abused resident roommate (R189), stated angry black woman .used profanity towards resident roommate (R189). Review of the Facility Incident Report form, dated 10/03/24, revealed that on 10/03/24 at approximately 10:32 AM, R188 was documented to have thrown a full bottle of Gatorade at R189 and call her names. The police, physician, responsible, and Ombudsman were notified. Review of the Administrator email to the State agency revealed the incident was State reported as an allegation of potential abuse on 10/03/24 at 8:34 PM, about 10 hours after the facility became aware of the incident. During an interview on 05/22/25 at 6:58 AM, the Administrator stated that he did not have documentation that the incident of potential verbal abuse between R188's family member and R189 had been reported. He confirmed that if FM2 had come in and was verbally abusive to R189 there should have been a reportable incident to the State agency for that, which there was not. He said he did not know why he was not informed of the potential allegation of staff-to-resident abuse between R188 and CNA50 by the staff at the time of the incident which was 1:52 AM. He confirmed he should have been informed timely. The Administrator stated that the nurse on duty also did not inform him timely and was also no longer working at the facility. During an interview on 05/22/25 at 7:10 AM, the Regional Director of Clinical Operations stated that if a police officer came to the facility, even after regular hours, the Administrator should be alerted and notified timely. Upon reviewing the witness statements from the incident between R189 and the resident representative of R188, she confirmed that the potential verbal abuse by FM2 against R189 should have been reported and investigated. During an additional interview on 05/22/25 at 3:14 PM, the Regional Director of Clinical Operations confirmed that the potential allegation of visitor-to-resident verbal abuse between R189 and FM2 was not reported. During an interview on 05/22/25 at 3:22 PM, the Director of Nursing (DON) stated that she wanted to see any allegations of abuse reported right away, any physical abuse, financial exploitation, misappropriation of funds, any abuse, as soon as possible. She confirmed it should be reported within a two-hour window. She stated she would have wanted to see the incident between the family member of R188 verbally yelling at R189 be reported to the State agency for investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to conduct a thorough investigation for incidents of potential abuse for three of nine residents (Resident (R) 136, R188, and R189) reviewed out of 28 sampled residents, for potential staff-to-resident abuse for R136 and R188, and visitor-to-resident abuse for R189. The failure to investigate potential allegations of abuse for facility residents placed all residents at risk of abuse. Findings include: Review of the facility's policy titled, Abuse Prevention Policy, last revised 03/01/18, revealed The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion .When abuse, neglect or exploitation is suspected the Licensed Nurse should: .Notify the Director of Nursing and Administrator .Complete an incident report and initiate an immediate investigation to prevent further potential abuse .Once the resident is cared for and the initial reporting has occurred, an investigation should be conducted. Components of an investigation may include interview with the involved resident, if possible, and document all responses .Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. Obtain witness statements, according to policy. All statements should be signed and dated by the person making the statement. Document the entire investigation chronologically. Ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made . 1. Review of the Facility Incident Report form, dated 10/03/24, revealed that the resident representative for R188 reported to the police that Certified Nursing Assistant (CNA)50 allegedly slapped R188 twice to the right side of her face. Police were present at the facility, the responsible party, and Ombudsman were notified of the allegation. The CNA was suspended pending the outcome of the allegation. Continued review of the investigation revealed a witness statement from the 10/03/24 incident with CNA50, dated 10/02/24 (sic), stated, R188 was receiving care and started to have behaviors in the middle of changing her .She started spitting, hitting, and screaming and disturbing her roommates. There was no evidence that a complete investigation was completed of the incident between R188 and CNA50. Witness statements were completed only for the roommates of R188, and two CNAs at the facility. No additional staff members were interviewed for the investigation to determine if there were any other potential staff-to-resident abuse situations from CNA50. Additional residents from the facility were not interviewed to determine if they felt safe residing on the same unit with R188, or if they had experienced any staff-to-resident abuse from CNA50. The failure to do a complete and thorough investigation of the 10/03/24 staff-to-resident abuse allegation between R188 and CNA50 additionally led to the failure to do a thorough investigation of the visitor-to-resident verbal abuse between R189 and Family Member (FM)2. This was documented in the resident record for R188 as verbal abuse of R189 but was not reported nor investigated. During an interview on 05/22/25 at 6:58 AM, the Administrator stated that he did not have documentation that the incident of potential verbal abuse between FM2 and R189 had been reported. He confirmed that if FM2 had come in and was verbally abusive to R189 there should have been a reportable incident to the State agency for that, which there was not. He stated that he had not been made aware that resident witness statements from R189 and R62 had stated that FM2 had been in the resident room and had been verbally abusive with R189. The Administrator said that he had interviewed other residents after the staff-to-resident abuse allegation between R188 and CNA50 but had not documented any of those additional interviews. He confirmed he was not aware if he should have documented more interviews during the alleged incident of abuse. During an interview on 05/22/25 at 7:10 AM, the Regional Director of Clinical Operations upon reviewing the witness statements from the incident between R189 and FM2, she confirmed that the potential verbal abuse by FM2 against R189 should have been reported and investigated. During an additional interview on 05/22/25 at 3:14 PM, the Regional Director of Clinical Operations confirmed the potential allegation of visitor-to-resident verbal abuse between R189 and FM2 was not thoroughly investigated. She stated that a complete abuse investigation should include speaking with all assigned staff at the time of the incident, and to get written statements. She said even if staff were not working on the same floor, the staff could still be interviewed to see what they were aware of. She said she expected residents to be interviewed from the same room, and in the area to see if they heard anything or saw anything. The Regional Director of Clinical Operations said that she would want all the information she could get from residents and staff. During an interview on 05/22/25 at 3:22 PM, the Director of Nursing (DON) stated that for a thorough abuse investigation it would definitely include to first ensure the patient was safe. She said the person suspected of possible abuse would be off work. She confirmed that the investigation would then be to get statements, follow-ups, and check equipment. She stated that they would do patient interviews, and see what the outcomes were, and to see if any other residents or staff were involved. The DON said she would want to make sure they had not left anything out. She stated she would have wanted to see the incident between FM2 verbally yelling at R189 be reported to the State agency for investigation. 2.Review of a Facility Incident Report, dated 03/06/25 revealed Type of Incident-Neglect .Details of Incident . [name of R136] is alleging that Certified Nursing Assistant (CNA) 48 neglected him by not turning him timely. Review of the facility's Facility Follow Up Investigation, dated 03/13/2025 revealed . [name of R136] alleged that [name of CNA48] neglected him by not turning him timely . [name of R136] said he called and requested assistance at 2:03 AM on March 6, 2025. He said the CNA did not come to his room until 6:30 AM. When [name of CNA 48] was interviewed, she said she did not go in until 6:30 AM as she felt the resident was rude . The facility conclusion revealed It was determined that the accusation of neglect was Substantiated . Further review of the facility's investigation revealed written statements were obtained from Registered Nurse (RN) 2, a phone interview with CNA48, and 11 additional resident interviews were conducted; however, there was no investigation conducted as to why RN2 did not assist R136 with turning at 2:00 AM, or anytime during the night. Review of R136's undated admission Record, located in the Electronic Medical Record (EMR) under the Profile tab revealed R136 was admitted to the facility on [DATE]. Review of the R136's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/07/24 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R136's quarterly MDS with an ARD date of 05/02/25 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have BIMS score of 15 out of 15 which indicated the resident was cognitively intact. During an interview on 05/21/25 at 12:30 PM, regarding the incident that occurred on 03/06/25, when asked why the facility did not consider neglect on part of RN2 or consider this as part of the facility investigation, the DON stated, I agree it would be neglect on part of the nurse [RN2] too. We did not focus on why the nurse did not go into the resident's room to turn him. We were more focused on why the CNA didn't go in. She as the nurse could have gone in his room to turn him. During an interview on 05/21/25 at 1:00 PM the Administrator stated I see where it was neglect on part of the nurse as well when this happened. She could have gone into his [referring to R136] room and turned him. When the Administrator was asked why the facility did not conduct a thorough investigation and investigate why RN2 did not go in R136's room to turn him during the night, he stated, We did not look into why the nurse did not go in and turn him. That was not part of our investigation. It should have been investigated, and it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policy review, the facility failed to ensure a complete discharge summary was provided to the resident and/ or resident representative (RP) for one of three residents (Resident (R) 338) reviewed for discharges of 46 sample residents. This failure had the potential to affect the residents and/or representatives' knowledge of the residents' discharge plan. Findings include: Review of the facility's policy titled, Transfer or Discharge, Facility-Initiated, dated 10/2022, revealed Orientation for Transfer or Discharge (Planned) 1. A post-discharge plan is developed for each resident prior to his or her discharge. This plan will be reviewed with the resident, and/or his or her family, at least 24 (24) hours before the resident's discharge or transfer from the facility. Review of R338's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted [DATE] and the date of discharge was 12/19/24. Review of R338's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/24 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R338 was cognitively intact. Review of R338's Discharge Summary and Instructions located under the Assessment tab of the EMR, dated 12/19/24, revealed the following missing components: -2A. Psychosocial Status of the Resident (Social Services) - Blank and unsigned. -2B. Preparation for Discharge and Post Discharge Care (Social Services) - Blank and unsigned. During an interview on 05/20/25 at 1:17 PM, Licensed Practical Nurse (LPN) 3 stated she did not know the resident, but she filled out her section of the discharge summary. LPN3 also stated the Social Service Director's (SSD) portion of the discharge summary was not completed. She stated she faxed it to the resident's daughter. She confirmed the summary was not complete. During an interview on 05/20/25 at 1:39 PM, the Social Services Director (SSD) stated the discharge summary needed to be completed and then provided to the resident and family. She stated she did not see that the resident received any home health services and did not see where a discharge date was picked. She stated she started in this position in early January 2025 and was not here during this time. She confirmed the discharge summary was not fully complete and she stated she was not able to find the recapitulation summary of the resident's stay.

Based on observation, record review, staff interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for two of 46 sampled residents (Resident (R) 9 and R18). Failure to code the MDS correctly regarding R18's feeding tube, and R9 for hospice care, could lead to inaccurate assessment and care planning of the resident. Findings include: Review of the RAI Manual, dated 10/01/19 indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment . 1. Review of R9's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 11/13/20 and a readmission date of 01/21/21, with medical diagnoses that included adult failure to thrive and unspecified dementia. Review of R9's Physician order, dated 12/04/24 and located under the Orders tab in the EMR revealed a hospice wound order Review of R9's annual MDS with an Assessment Reference Date (ARD) of 03/14/25 and located in the resident's EMR under the MDS tab revealed the facility failed to document R9 was receiving hospice services. 2. Review of R18's admission Record located in the EMR under the Profile tab revealed an admission date of 04/16/25 with medical diagnoses including encounter for attention to gastrostomy (G-Tube) and dysphasia following cerebral infarction. Review of R18's Physician order, dated 04/16/25 revealed orders for enteral feeding through G-Tube and medications were to be administered through the G-Tube. Review of R18's admission MDS with an ARD of 04/30/25 and located in the resident's EMR under the MDS tab revealed during the assessment, the facility failed to document R18 had a G-Tube and was receiving nutrition and medication through the G-Tube. During an interview on 05/20/25 at 2:01 PM, the MDS Coordinator (MDSC) reviewed R9's and R18's MDS and confirmed the MDS did not indicate R9 was receiving hospice services; and that R18's MDS was not accurate as it did indicate the resident had a G-Tube. During an interview on 05/22/25 at 5:04 PM, the Regional Director of Clinical Operations (RDCO) confirmed the facility using the RAI manual for accuracy of MDS assessments.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure care plans were comprehensively developed for two of 46 sampled residents (Resident (R) 18 and R52) reviewed for care plans. This deficient practice placed the residents at risk for unmet care needs. Findings include: Review of the facility policy titled Care Plan-Comprehensive, dated 01/23, revealed A Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. An Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a Comprehensive Care Plan for each resident. The Comprehensive Care Plan has been designed to: . identify the professional services that are responsible for each element of care; . Incorporate risk factors associated with identified problems. 1. Review of R18's admission Record located in the EMR under the Profile tab, revealed an admission date of 04/16/25 with medical diagnoses including encounter for attention to gastrostomy (G-Tube) and dysphasia following cerebral infarction. Review of R18's admission Minimum Data Set (MDS) with an ARD of 04/30/25 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R18 was cognitively intact. During an observation on 05/20/25 at 4:38 PM, R18 was lying in bed. Licensed Practical Nurse (LPN) 9 was in the resident's room administering medication via the resident's G-tube. During an interview on 05/21/25 at 7:45AM, R18 expressed a preference to have medications administered through the G-Tube and not by mouth because the medications tasted bitter. Review of R18's Care Plan under the Care Plan tab initiated 04/17/25 in the EMR lacked documentation of a focus for G-tube care. During an interview on 05/20/25 at 2:01 PM, the MDS Coordinator (MDSC) stated that there should have been a care plan developed related to R18's G-tube care, administration of medications, and nutrition. During an interview on 05/21/25 at 10:41 PM, the Director of Nursing (DON) confirmed residents with a g-tube should have a care plan for resident's plan of care. 2. Review of R52's admission Record located in the EMR under the Profile tab, revealed an admission date of 11/07/23 with medical diagnoses including unspecified dementia with psychotic disturbance, and delusional disorders. Review of R52's Physician Orders located in the resident's EMR under the Orders tab revealed physician orders dated 01/22/25 for Seroquel [an antipsychotic] Oral Tablet 25 MG (quetiapine fumarate) Give 1 tablet by mouth two times a day for Psychotic disorder due to known physiological condition and sertraline [an antidepressant] HCl Oral Tablet 50 MG (sertraline HCl) Give 1 tablet by mouth one time a day related to unspecified dementia with psychotic disturbance and delusional disorders. Review of R52's Care Plan under the Care Plan tab in the EMR lacked documentation of a plan of care for the resident's psychotropic medications to include antipsychotic and antidepressant medications. During an interview on 05/22/25 at 12:41 PM, the MDSC confirmed R52 did not have a care plan related to psychotropic medication and antipsychotic medications, including monitoring of behaviors and care needed. During an interview on 05/22/25 at 12:44 PM, the Director of Nursing (DON) confirmed residents on psychotropic medications should have a care plan focus when on the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and facility policy review, the facility failed to ensure timely medication administration for one of seven residents (Resident (R) 286) reviewed for medication administration of 46 sample residents. The facility further failed to ensure physician orders were followed for the administration of medications using the gastrostomy (G-Tube) for one of six residents (Resident (R) 18). This had the potential for creating anxiety to the resident and possible medication administration errors or choking. Findings include: Review of the facility's policy titled, Administering Medications, dated 04/19, revealed Medications are administered within one (1) hour of their prescribed time, unless otherwise specified. 1.Review of R286's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] and had a discharge date of 01/18/25 with diagnoses which included chronic obstructive pulmonary disease, asthma, hemiplegia (one sided paralysis) and hemiparesis (one-sided muscle weakness), and unspecified combined systolic (congestive) and diastolic (congestive) heart failure. Review of R286's five-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/25, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R286 was cognitively intact. Review of the Medication Admin Audit Report, provided by the facility and dated 01/01/25- 01/18/25, revealed the following: -01/08/25 for methocarbamol oral tablet 500 MG [milligram]: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/08/25 at 17:00 (5:00 PM) with the Administration Time: 01/08/25 at 19:58 (7:58 PM). -01/10/25 for Spiriva HandiHaler Inhalation Capsule 18 MCG [microgram]: 1-capsule inhale orally one time a day related to other asthma. Schedule date: 01/10/25 at 7:00 (7:00 AM) with the Administration Time: 01/10/25 at 10:38 AM. -01/11/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/11/25 at 9:00 AM with the Administration Time: 01/11/25 at 11:03 AM. -01/12/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/12/25 at 9:00 AM with the Administration Time: 01/12/25 at 13:09 (1:09 PM). -01/14/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/14/25 at 17:00 (5:00 PM) with the Administration Time: 01/14/25 at 19:04 (7:04 PM). -01/16/25 for ipratropium-albuterol inhalation solution 0.5-2.5 MG/3ML [milligram/milliliter]: 1-vial inhale orally every 6-hours related to chronic obstructive pulmonary disease with (acute) exacerbation. Schedule date: 01/16/25 at 00:00 with the Administration Time: 01/16/25 at 5:54 AM. -01/17/25 for ipratropium-albuterol inhalation solution 0.5-2.5 MG/3ML: 1-vial inhale orally every 6-hours related to chronic obstructive pulmonary disease with (acute) exacerbation. Schedule date: 01/17/25 at 00:00 with the Administration Time: 01/17/25 at 4:56 AM. -01/17/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/17/25 at 9:00 AM with the Administration Time: 01/17/25 at 13:32 (1:32 PM). -01/17/25 for aspirin EC low strength oral tablet delayed release 81 MG: Give 1-tablet by mouth one time a day related to cerebral infarction. Schedule date: 01/17/25 at 9:00 AM with the Administration Time: 01/17/25 at 13:26 (1:26 PM). -01/17/25 for hydrochlorothiazide oral tablet 15 MG: give 1-tablet by mouth one time a day related to unspecified combined systolic congestive and diastolic (congestive) heart failure. Schedule date: 01/17/25 at 9:00 AM with the Administration Time: 01/17/25 at 13:26 (1:26 PM). -01/17/25 for atorvastatin calcium oral tablet 40 MG: Give 1-tablet by mouth one time a day for hemiplegia and hemiparesis. Schedule date: 01/17/25 at 9:00 AM with the Administration Time: 01/17/25 at 13:27 (1:27 PM). -01/18/25 for methocarbamol oral tablet 500 MG: Give 1-tablet by mouth two times a day for pain. Schedule date: 01/18/25 at 17:00 (5:00 PM) with the Administration Time: 01/18/25 at 19:56 (7:56 PM). Review of the performance improvement plan worksheet (PIP) provided by the facility and dated 03/18/25, revealed medications not being administered on time by nurses/ CMAs [Certified Medication Aide Tech]. Identify root causes: 1. Lack of education .Design and implement changes.1. Inservice all nurses and CMA's regarding proper time management. Reviews of the Education In-service Attendance Record, provided by the facility and dated 03/18/25, revealed three out of the five staff (Activity Director/ Medication Aide Tech), Licensed Practical Nurse (LPN) 5, and LPN8, identified as administering medications late were not on the list as educated. During an interview on 05/21/25 at 1:47 PM, the Director of Nursing (DON) stated the medication administration should be one-hour before to one-hour after the time displayed. She confirmed the late medications were out of policy and unacceptable. 2. Review of R18's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 04/16/25 with medical diagnosis including encounter for attention to gastrostomy (G-Tube). Review of R18's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 04/05/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R18 was cognitively intact. Review of R18's physician Orders dated 04/16/25 located in the EMR under the Orders tab revealed medications were to be crushed and administered through the G-Tube. Review of the Medication Administration Record (MAR) located in the EMR for May 2025 documented medications were administered on 15-day shifts by Certified Medication Aide Tech (CMAT) 1. During an interview on 05/21/25 at 9:19 AM, CMAT confirmed the role of the CMAT was to administer oral medications and not to administer by G-Tube. The CMAT confirmed all the medications she had administered to R18 were by mouth and was not according to physician's orders. During an interview on 05/21/25 at 9:09 AM, the Licensed Practical Nurse (LPN)2/Charge Nurse confirmed the role of the CMAT was for oral medications only and not to administer by G-Tube. LPN2 confirmed CMAT1 had not requested LPN2 to administer medications for R18 by G-Tube as CMAT1 was administering the medications by mouth for R18. LPN2 confirmed the physician's order for medication administration for R18 was by G-Tube and not by mouth and CMAT1 was not following the physician's orders. During an interview on 05/21/25 at 7:45 AM, R18 expressed the desire to have all the medications delivered by the G-Tube and not by mouth due to the medication taste. During an interview on 05/22/25 at 4:50 PM, the Director of Nursing (DON) confirmed the physician's orders were to be followed, including medication orders, for the residents. Review of the facility policy titled Administering Medications, revised 04/19, revealed Medications were administered in accordance with prescriber orders .Medication administration times are determined by resident need and benefit, not staff convenience. Factors that were considered include: . honoring resident choices and preferences, consistent with his or her care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure residents with a urinary catheter bag were properly positioned in a manner to prevent potential urinary tract infections due to contamination for one of three residents (Resident (R)10) reviewed for urinary catheters out of a total sample of 46 residents. The failure to ensure catheter bags were properly positioned placed the resident at risk of infection. Findings include: Review of the facility's undated policy titled, Indwelling Urinary Catheter Use, revealed It is the policy of the facility to ensure the appropriate use of indwelling urinary catheters in accordance with State and Federal Regulations, and national guidelines .Indwelling urinary catheters and drainage bags should not be changed at routine or fixed intervals. Indwelling urinary catheters and drainage bags are changed when there is indication of infection, obstruction, or as clinically indicated. Review of R10's admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was originally admitted on [DATE] with diagnoses including multiple sclerosis, other sequelae of cerebral infarction, and pressure ulcer of sacral region. Review of R10's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/25and located in the MDS tab in the EMR revealed a Brief Interview for Mental Status (BIMS) assessment with no recorded score out of 15, which indicated severe cognitive impairment. R10 was documented to require a catheter. Review of R10's Physician Orders located in the EMR under the Orders tab revealed a order dated 04/16/25 for Change indwelling Foley Cath [Catheter] 16 F [French]/10 ml [milliliters] every month and PRN [as needed] every day shift every 28 day(s) . Review of R10's Care Plan, initiated 04/16/25 and located in the resident's EMR under the Care Plan tab revealed the resident had an indwelling foley catheter related to sacrum end stage skin failure. Interventions dated 04/16/25 revealed .position catheter bag and tubing below the level of the bladder and away from the entrance room door, and to monitor and document the intake and output as per facility policy. During an observation on 05/19/25 at 10:25 AM, R10 was lying in bed with her eyes closed. R10's uncovered indwelling catheter collection bag was hanging from the right side of the resident's bed, resting on the floor. During an observation on 05/19/25 at 12:12 PM, R10 was lying in bed with her eyes closed. The catheter bag was still in the same position, resting uncovered on the floor. During an observation on 05/20/25 at 8:12 AM, R10 was observed resting in bed. The catheter bag was again observed uncovered and resting on the floor. During an observation on 05/20/25 at 9:50 AM, R10 was lying in her bed resting. The catheter bag was observed uncovered and resting on the floor. During an observation and interview on 05/20/25 at 9:51 AM, Licensed Practical Nurse (LPN) 2 and LPN3 stated that catheter bags should be kept off the floor. LPN2 observed R10 in bed, and confirmed the catheter bag was resting on the floor. LPN3 stated that a staff member must have lowered the resident's bed and proceeded to raise the resident's bed. The urinary catheter tubing stretched, but the catheter bag did not rise off the floor because the bag was not hooked to the bed. During an interview on 05/20/25 at 10:18 AM, the Regional Director of Clinical Operations (RDCO) stated that she expected urinary catheter bags to be hung off the floor.

Based on observations, staff interviews, record review, and policy review, the facility failed to ensure a resident with side rails was assessed for entrapment, evaluated for need, informed of the risks/benefits, and failed to obtain a physician's order for side rail use for one of one residents (Resident (R) 20) reviewed for side rails out of a total sample of 46 residents in the sample. This had the potential for safety risks to the resident. Findings include: Review of the facility policy titled Bedrails, with no revision date, revealed, The facility shall provide adequate management of Bedrails to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. If a bed or side rail is used, the facility will ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. a. Assess the resident for risk of entrapment from bed rails prior to installation. b. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. When bed/side rails are deemed to be appropriate for the resident, upon completion of the Side Rail Evaluation, the . nurse will review risks and benefits, obtain informed consent and obtain an order to monitor the resident while in bed with side rails were in use. Review of R20's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 02/19/20. Review of R20's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/21/25, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R20 was moderately impaired in cognition. During an observation on 05/19/25 at 10:58 AM, R20 was in bed with side rails on each side of the bed in the up position. During an interview on 05/20/25 at 11:53 AM, Certified Nursing Assistant (CNA)15 said R20 used the rail to assist herself and the staff when sitting on the side of the bed. Review of R20's Bed Environment Assessment, located under the Assessments tab in the EMR, dated 08/19/24, revealed documentation that no bed rails were in use. Review of R20's Misc tab for scanned documents in the EMR, lacked documentation of a consent form for the use of side rails. During an interview on 05/20/25 at 11:59 AM, Unit Manager Licensed Practical Nurse (LPN)3 confirmed a resident with side rails was to have a side rail assessment for use, obtain consent from the resident or the representative, and obtain a physician's order for the side rail(s). LPN3 verified R20 did have side rails in place and the EMR lacked a current bed assessment, physician's order, or a consent for the use of side rails. During an interview on 05/21/25 at 10:14 AM, the Director of Nursing (DON) confirmed if a resident had side rails in place, there should be a bed rail assessment, physician's order and signed consent listing the risks and benefits for side rail use.

Based on staff interviews, record review, and review of facility policy, the facility failed to ensure residents reviewed for verbal and physical abuse had accurate documentation of the abuse incidents in the resident record for one of nine residents (Resident (R) 189) reviewed for abuse out of a total of 46 resident in the sample. The deficient practice had the potential for facility residents to not be identified for potential incidents of abuse, which could affect physical and psychosocial well-being. Findings include: Review of the facility's policy titled, Medical Records, dated 08/2022, revealed It is the policy of the facility to maintain Medical Records in accordance with State and Federal Regulations .The facility will maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, systematically organized. Review of R189's admission Record located in the EMR under the Profile tab revealed an admission date of 08/29/24. The resident discharged on 10/13/24. Review of R188's admission Record located in the EMR under the Profile tab revealed an admission date of 01/24/24. The resident was discharged on 12/06/24. Facility provided documentation, and resident record review, revealed two incidents of potential abuse with R189. -On 10/03/24 at approximately 1:52 AM, a resident representative (Family Member (FM)2) for R188 was noted to be in the facility due to an allegation of staff to resident abuse between R188 and Certified Nursing Assistant (CNA)50. During this incident, statements from R189 and R62, both roommates of R188, revealed verbal abuse and name calling from R188's resident representative against R189. -On 10/03/24 at approximately 10:32 AM, R188 was documented to have thrown a full bottle of Gatorade at R189 and call her names. Both incidents were documented and recorded in the Progress Notes tab in the EMR, but only in the resident record for R188, but not for R189. Neither incident was documented in R189's complete record review. During an interview on 05/22/25 at 6:58 AM, the Administrator confirmed that upon review of R189's record, there was no documentation of the abuse incidents in her resident record. During an interview on 05/22/25 at 7:10 AM, the Regional Director of Clinical Operations stated that she would expect to see documentation in R189's resident record regarding the verbal abuse incident on 10/03/24 at approximately 1:52 AM. She confirmed this would be a documentation failure in the resident's record. During an interview on 05/22/25 at 12:25 PM, the Director of Nursing (DON) stated that if there was any altercation or incident including residents, both resident records should be documenting the concern to ensure complete and accurate records. Cross reference to F600

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and resident, resident family, and staff interviews, the facility failed to ensure four of eight residents (Residents (R) 17, 43, 136, and 188) reviewed for abuse out of 46 sampled residents were free from abuse. This had the potential and/or physical harm to the residents. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 indicated, Residents have the right to be free from abuse, neglect . Protect residents from abuse, neglect .by anyone including but not necessarily limited to: a. facility staff; b. other residents .Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; neglect of residents .identify and investigate all possible incidents of abuse, neglect .protect residents from any further harm during investigations. Review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property dated 08/22/22 indicated, It is the policy of this center that each resident has the right to be free from mistreatment of any kind .Each resident will be treated with respect and dignity at all times. The center will foster an environment that recognizes the worth and uniqueness of all individuals with regards to person-centered care and to promote respect . Definitions .Neglect means the failure of the center .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . 1.Review of a Facility Incident Report dated 03/06/25 indicated Type of Incident-Neglect. Details of Incident- [name of R136] is alleging that Certified Nursing Assistant (CNA) [48] neglected him by not turning him timely. Review of the Facility Follow Up Investigation dated 03/13/25 indicated, [name of R136] alleged that [name of CNA 48] neglected him by not turning him timely. The investigation indicated [name of R136] said he called and requested assistance at 2:03 AM on March 6, 2025. He said the CNA did not come to his room until 6:30 AM. When [name of CNA 48] was interviewed, she said she did not go in until 6:30 AM as she felt the resident was rude. The facility concluded, It was determined that the accusation of neglect was Substantiated. Review of R136's undated admission Record located in the Electronic Medical Record (EMR) under the Profile tab, revealed R136 was admitted to the facility on [DATE]. Review of R136's Care Plan, dated 11/01/24 and located under the Care Plan tab of the EMR, indicated [name of R136] is (high) risk for falls r/t [related to] Paralysis, bilateral [affecting both sides] lower/upper extremity contractures. Interventions indicated, The resident needs prompt response to all requests for assistance. Review of R136's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/24 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also indicated R136 had impairments on both sides of the upper and lower extremities, and the resident was completely dependent on staff for Activities of Daily Living (ADLs). Review of R136's quarterly MDS with an ARD date of 05/02/25 and located in the resident's EMR under the MDS tab indicated the facility assessed the resident to have BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The MDS further indicated that R136 had impairments on both sides of the upper and lower extremities and was completely dependent on staff for ADLs. During an observation and interview on 05/19/25 at 10:30 AM, R136 was lying in bed. R136 was observed to have a red stylus pen in his mouth and only able to use his stylus pen to touch his cell phone which was mounted to the mobility bar. He was also observed to only be able to move his head up and down. During an interview, R136 stated, From what I remember this was on a Wednesday .I called the nurse who told me someone was coming. I called around 2:00 AM or so. The CNA [identified as CNA48] came into my room. I asked her who my aide was. She said she was. I told her nobody came into my room to turn me. She [referring to CNA48] told me that I would have to wait until the next shift. She told me she was busy and would not be able to help me. Then around 6:00 AM or 6:30 AM, or so she came to change my roommate then told me I can do you, but this will be the first and last time I do this. R136 stated, The nurse [identified as Registered Nurse (RN) 2] came in and told me, 'I asked [name of CNA48] to come in and turn you.' The resident stated that he was eventually turned, but it was around 6 or 6:30 AM. When this incident occurred, R136 stated This was unacceptable, and I felt like it was neglect. Review of a written statement from RN2 dated 03/10/25 and provided by the facility indicated, I had asked the CNA [referring to CNA48] who was the assigned CNA to be working with [name of R136] to go and turn him at 2:00 AM. She refused. I let the CNA know that refusing to do a patient that is assigned to you on a shift is a problem. She agreed with me but still refused. I told her I was going to report her to the DON [Director of Nursing], and she said, 'you can go right ahead.' .The CNA [referring to CNA 48] went into [name of R136] room around 5:00 AM or so to turn him. He was very upset about the whole situation. Review of a phone interview that was conducted with CNA48 on 03/03/25 revealed, [name of CNA48] stated that everything started on Monday March 3, 2025. [name of CNA48] said R136 wanted her to get him ready at 3am for a 7am Dr. appointment. She [CNA 48] told him that it was too early, and she would get him ready at 6:00 AM. He refused and she told him that the CNA coming in for the next shift would get him ready. He [R136] got upset. When asked about the incident that occurred Wednesday night [referring to March 6, 2025], she [CNA48] admitted that she did not go into [name of R136's] room to provide care for him until 6:30 AM. During an interview on 05/20/25 at 11:11 AM, regarding the incident that occurred on 03/06/25 involving R136, the Administrator stated, I was contacted by the Social Worker on March 6, 2025, that he [referring to R136] had concerns and since he used the word 'neglect' we reported it as an allegation of neglect. He then stated, The girl [referring to CNA48] confessed that she didn't go back into his room until 6:30 AM, so we substantiated it for neglect. During an interview on 05/21/25 at 7:13 AM, regarding the incident that occurred with R136 and CNA48 on 03/06/25, RN2 stated that she was the nurse working the night of March 6, 2025. RN2 stated, He [referring to R136] called and said that he needed to be turned around 2:00 AM or 2:30 AM. I told him I would send someone in his room. I told [name of CNA48] since you have him on your assignments, and since you are his assigned CNA, you need to go and turn him. She [referring to CNA48] started arguing that nobody told her she had him. She refused to go into his room and was saying she wasn't assigned to him. I told her since she was on the clock and was assigned to him that she needed to go into his room and turn him. She again said that she was not going to. I told her I was going to let the Director of Nursing know that you are refusing to turn him. RN2 stated Towards the end of the morning around 5:00 AM or 5:30 AM or so I went in the room with [name of CNA48] and apologized to him about the confusion as to who was assigned to him. He was very upset. At that time, we ended up turning him. He was not wet. He just needed to be turned. RN2 stated that she waited until morning until the DON came into work to report the incident. During a second interview on 05/21/25 at 2:53 PM regarding the incident that occurred with R136 and CNA48 on 03/06/25, when RN2 was asked why she did not assist R136 when he was requesting to be turned around 2:00 AM or 2:30 AM, RN2 stated, I was busy with my work. I asked [name of CNA48] and she told me she wasn't going to do it. I had my own work to do. I want to say we went into his room around 5:00 AM or 5:30 AM or so to turn him. An unsuccessful attempt to contact CNA48 via phone was made on 05/21/25 at 9:30 AM. During an interview on 05/21/25 at 12:30 PM, regarding the incident that occurred on 03/06/25, the DON stated she was not notified during the night by any staff which included RN2 about any incident regarding R136 until she came into work around 7:30 AM the next morning. The DON stated, I agree it would be neglect on part of the nurse and the CNA. She [regarding RN2] should have called me or the Administrator immediately. We did not focus on why the nurse did not go into the room to turn him. We were more focused on why the CNA didn't go in. She [referring to RN2] as the nurse could have gone in his room to turn him. During an interview on 05/21/25 at 1:00 PM, the Administrator stated he was not notified by RN2 or CNA48 of this incident anytime during the night. He stated, Nobody called me. The Administrator stated, I see where it was neglect on part of the nurse as well when this happened. She should have called me, and she also could have gone into his [referring to R136] room and turned him. 2. Review of R189's admission Record located in the EMR under the Profile tab revealed an admission date of 08/29/24. The resident discharged on 10/13/24. Review of R189's discharge Minimum Data Set (MDS) assessment located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 10/13/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. R189 had no delirium, no mood, and no behaviors. Review of R188's admission Record located in the EMR under the Profile tab revealed an admission date of 01/24/24. Review of R188's quarterly MDS located in the MDS tab in the EMR, with an ARD of 10/12/24, revealed a BIMS score of eight out of 15, which indicated moderate cognitive impairment. Review of R188's discharge MDS assessment located in the MDS tab in the EMR, with an ARD of 12/06/24, documented the resident had verbal behavioral symptoms directed toward others for one to three days during the assessment period. Review of R188's Care Plan, initiated 02/19/24, documented the resident displayed verbally/physically abusive behaviors and racial comments such as hitting and spitting at staff. Interventions included analyzing key times, places, circumstances, triggers, and what de-escalates behavior and document, and to assess the resident's understanding of the situation. The care plan was last revised on 08/21/24, prior to the 10/03/24 incident. Review of R188's Care Plan, located in the EMR under the Care Plan tab and initiated 04/18/24, revealed R188 was verbally abusive. Interventions included to provide one-to-one supervision as needed. Review of the Facility Incident Report form, dated 10/03/24, provided by the facility revealed that on 10/03/24 at approximately 10:32 AM, R188 was documented to have thrown a full bottle of Gatorade at R189 and call her names. The bottle did not make contact with R188.a skin assessment was conducted .no areas of redness or bruising were present .(R188) was immediately removed, and her room was changed .The police, physician, responsible, and Ombudsman were notified. Witness statement from R189, dated 10/03/24, stated, .(R188) was yelling and calling me out .throw (sic) a full drink at me and it hit the floor. Review of R188's Progress Note, located under the Progress Note tab in the EMR and dated 10/03/24 at 10:32 AM, indicated that .was made aware by the Activity Coordinator that the resident threw her unopened Gatorade bottle at her roommate (R189) .The resident was cursing at the roommate and told her to Get out .Went into the room along with the Director of Nursing (DON) and spoke with the resident .Made her aware that she cannot throw items at her roommate, other residents or staff. Review of the Facility Incident Report investigation revealed that staff members interviewed all stated that they heard (R188) call (R189) a Black B---- and then they heard the sound of the bottle hitting the floor .When the officer arrived at the facility, the officer interviewed both residents .The officer issued a citation to (R188) for disorderly conduct. During an interview on 05/22/25 at 6:58 AM, the Administrator stated that during his investigation of the 10/03/24 resident to-resident abuse between R188 and R189 he learned that R188 had thrown a bottle of Gatorade at R189, but it did not hit her. He stated that he moved R188 to a different room. The Administrator stated that this was why the police officer came back to the facility and issued R188 a citation for a warrant. 3. Review of R17's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] and readmitted on [DATE]. Review of R17's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/25/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) was not assessed and the staff documented R17 as having severely impaired cognition. Review of R17's Progress Note dated 03/25/25 and located under the Progress Notes tab of the EMR revealed Resident was observed in female room with hands in her diaper. Resident was removed from the room immediately and put one on one monitoring, female resident was assessed and unharmed at this time, resident's family notified of incident, DON [Director of Nursing] and administrator notified at this time. Resident was transferred to [name] hospital for a psych [psychiatric] evaluation. 3. Review of R43's admission Record located under the Profile tab of the EMR revealed the resident was admitted on [DATE]. Review of R43's quarterly MDS with an ARD of 03/28/25 and located under the MDS tab of the EMR revealed a BIMS score was not assessed and the staff documented R43 as having severely impaired cognition. Review of R43's Progress Note dated 03/25/25 and located under the Progress Notes tab of the EMR revealed Resident was assessed and remains unharmed, no bruising or redness noted to vaginal area, no injuries noted. Resident's family notified of incident. During an interview on 05/19/25 at 12:59 PM, Family Member (FM) 1 stated there was an incident that he was aware of with R43 and another resident. He stated she was fine, and nothing happened and that they (the staff) had stopped it before anything occurred. Review of the facility's investigation, pr ovided by the facility and dated 03/31/25, revealed The nurse on duty stated that the last time she saw [R17] was between 12:00 AM and 1:00 AM. She said he was lying in his bed .it was determined after a thorough investigation that it was substantiated .We will implement the following measures: 1. Staff education on identifying and reporting changes in behavior. 2. Staff education on handling changing residents. 3. Both residents received a trauma assessment. 4. Both residents' care plans were updated. 5. Resident will both be seen by psych services. 6. Medical Director/ NP [Nurse Practitioner] is reviewing and modifying [R17's] medication. Review of the police report provided by the facility, dated as first reported 03/25/25, revealed Once on the scene, I spoke to the call [Certified Nursing Assistant (CNA) 16] who explained that while she was working at the nursing home .she walked into the room of [R43]. When she walked into the room, she saw another patient in [R43's] room, sitting on her bed. [CNA16] said the male patient; [R17] had his hand in [R43's] underwear .I was told that [R43] is alert but cannot talk or move that much. As for [R17], he is on multiple psych medications .one on one with [R17] until was transported. During an interview on 05/20/25 at 10:40 AM, Registered Nurse (RN) 1 stated before the incident R17 had been staring at women, appeared drooling, and then he would start to laugh. She stated he was very aggressive before he was sent out for two weeks. She stated he was very calm now. She stated they had two CNAs on the floor since the incident and a lot of in-services. During an interview on 05/20/25 at 12:59 PM, the DON stated R17 had behaviors which was why he was in the memory care unit. She stated she was not aware of any sexual behaviors before the incident. During an interview on 05/21/25 at 10:29 AM, the Administrator stated R17 was fine before the incident, and he was not aware of any behavior prior to. He stated he got a call from a nurse, and he drove to the facility. He stated the police were already at the facility and that R17 was in the common area. He stated R17 left the facility using 1013 transport (legal document used to authorize the involuntary transportation and evaluation of an individual experiencing severe mental health crisis). He stated no other facility was willing to take him. He stated he was told [R17] tried to put his hand inside. He stated he had to complete his report before he received the police report. He stated to his understanding R17 touched R43's naval area and not inside her brief. He stated for safety; they increased staffing in the memory care unit. During an interview on 05/21/25 at 12:17 PM, CNA16 stated at around 3:00 AM, she had gone upstairs to the supply closet. She stated when she came back down, she passed R43's room and saw R17 sitting on her bed. She stated she asked him what he was doing, and he told her he was visiting a friend. She stated R17 had his hand physically down her brief. She stated she felt like he had just done that, and it had not been long. She stated as soon as R17 saw her, he withdrew his hand. She stated she had never seen that behavior from him. She stated he was sent out by 7:00 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review, the facility failed to ensure residents received proper treatment and services to maintain vision and hearing abilities for one of two residents reviewed for communication (Resident (R) 22) out of 46 sampled residents. The failure to ensure communication deficits were properly assessed and managed placed the facility residents at risk of social isolation. Findings include: Review of R22's admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was originally admitted on [DATE], with diagnoses including non-Hodgkin lymphoma, hypertension, and diabetes mellitus. Review of R22's quarterly Minimum Data Set (MDS) located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 03/01/25 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. The MDS also revealed R22 was documented to have minimal difficulty in hearing, which indicated some hearing difficulty in some environments. Review of R22's Care Plan, located in the EMR under the Care Plan tab, with an initiated date of 12/12/21, revealed a care plan for a communication problem related to hearing deficit. Approaches included .to ensure availability and functioning of adaptive communication equipment: message board .hearing aids .refer to Audiology for hearing consult as ordered . Review of R22's Audiology Assessment, dated 09/30/24 and located in the resident's EMR under the Misc tab documented, The patient was referred by the facility for decreased hearing. The patient complains of hearing loss .She had a hearing aide [sic] for the right ear .but reports it stopped working/helping .A pocket talker is going to be requested for this patient at this time. During an interview on 05/19/25 at 10:49 AM, R22 stated that she could not hear well. She stated that she used to have hearing aids, but they were lost a long time ago. R22 said that if she could hear better, it would be easier to understand what people say. She said that someone said they would look into it for her, but they never got back to her. During an interview on 05/21/25 at 7:35 AM, Certified Nursing Assistant (CNA) 9 stated she had not seen R22 use a hearing device and confirmed the resident was hard of hearing. Upon entrance to R22's room, CNA9 spoke loudly into R22's ear to ask if she had a hearing device. R22 asked CNA9 to look in her purse, where a single hearing aid was found. R22 said it did not work. CNA9 said she had not seen R22 use any hearing devices. During an interview on 05/21/25 at 7:38 AM, Licensed Practical Nurse (LPN) 3 stated that she had not seen R22 use any form of hearing device. During an interview on 05/21/25 at 7:44 AM, the Social Service Director (SSD) stated that ancillary service providers come to the facility approximately every quarter and see about 20 residents at a time since they could not see them all at once. The SSD also stated she kept a list but was not familiar with R22 having any hearing issues. Upon review of her list, she stated that R22 had not been seen the last time audiology had come to the facility. After reviewing the 09/30/24 audiology report for R22, the SSD stated she had not been familiar with the recommendation for a pocket talker and would look into it. During an interview on 05/21/25 at 11:00 AM, the Director of Nursing (DON) stated that the last SSD had left the facility in January 2025, before the current one had started. She confirmed that the last SSD had not always followed up on things, and that she would expect there to be better communication with ancillary services. During an interview on 05/21/25 at 12:55 PM, the SSD stated she had discovered that R22's invoice for the pocket talker had not been paid, and that it was why it had not been provided to the resident. During an interview on 05/21/25 at 1:47 PM, the DON stated that the facility did not have a policy regarding ancillary services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled, Fall Prevention Protocol Policy, the facility failed to adequately supervise, accurately evaluate and identify risk, analyze recurrent falls, and implement new interventions for one of three residents (R) (R2) reviewed for falls. Specifically, the facility failed to ensure fall interventions were implemented for R2 after having two documented fall incidents. Findings include: Review of the facility policy titled Fall Prevention Protocol Policy revised 10/18/2021 revealed under step 1. All residents/patients are screened for fall risk on admission, significant change of condition, quarterly and annually. 4. After an incident of a fall: a. Complete the Post Falls Assessment. d. Complete pain assessment after the fall. g. Referrals, interventions, care plan updates completed in the clinical meeting. h. Review fall incident during the clinical meeting with a root cause analysis. Review of the electronic medical record (EMR) for R2 revealed admission to the facility with diagnoses including but not limited to myasthenia gravis and spinal stenosis. Review of the admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. R2 is dependent on staff for all activities of daily living (ADLs). Mobility and transfers were via mechanical lift by 2 staff members and unable to stand or walk. Review of the Nursing Progress Notes on 8/1/2023 at 5:23 pm documented R2 was observed on her back on the floor with confusion listed as the predisposing factor. There was no documented evidence of a Post Fall Assessment, care plan, or interventions to prevent falls. Review of the Nursing Progress Notes on 9/16/2023 at 10:40 pm documented R2 was observed on floor in sitting position. There was no documented evidence of a Post Fall Assessment, care plan or interventions to prevent falls. Review of the Nursing Progress Notes on 10/14/2023 at 4:36 am documented R2 was observed on the floor next to her bed in a sitting position, with no apparent injury noted. There was no documented evidence of a Post Fall Assessment or interventions to prevent falls. Review of the Nursing Progress Notes on 10/21/2023 at 10:29 pm documented as follows: Resident heard calling from her room. Upon entering room, resident was observed sitting on the floor with her back rested [sic] against her bed. There was no documented evidence of a Post Fall Assessment, or additional interventions to prevent falls. During an interview on 9/4/2024 at 1:15 pm, the Director of Nursing (DON) revealed that after a fall, there should be a Patient at Risk (PAR) meeting to see why they fell and to have the MDS nurse update the care plan. The DON also confirmed that there was no documented evidence of a PAR meeting after R2 fell. The DON further confirmed R2 did not have a care plan for falls until after they sustained the third fall in a two-month period.

Based on staff interviews, record review, and review of the facility policy titled, Facility Abuse Prevention, the facility failed to prevent resident to resident abuse on 7/04/2023, 9/03/2023, and 10/19/2023 for four of four residents (Resident (R) 43, R58, R22, and R24) of 22 sample residents from R50 resulting in a minor scratch injury to R43's face on 9/06/2023 and a skin tear to R58's right hand on 10/19/2023. Findings include: Review of the facility's policy titled, Facility Abuse Prevention, last reviewed on 11/15/2022, revealed Standard: The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. During a resident group meeting on 1/16/2024 at 3:00 PM, R54, R20, and R47 verbalized fear of R50's continued abusive behavior. 1. Review of R50's Face Sheet found under the Profile tab of the electronic medical record (EMR) revealed an admission date of 10/09/21 with diagnoses of delusional disorders, major depressive disorder, vascular dementia, and human immunodeficiency virus (HIV). Review of R50's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/2023 revealed a Brief Interview for Mental Status (BIMS) score of two out of 15 which indicated severe cognitive impairment. Review of R50's Care Plan found under the Care Plan tab of the EMR with a completion date of 11/01/2023, revealed that R50 had a care plan for the potential to demonstrate physical behaviors related to a history of slapping other residents. Review of Psychiatric Notes, dated 5/03/2023 and found in the Progress Notes tab of the EMR, revealed Risperdal (an antipsychotic medication used to treat schizophrenia and bipolar disease) 0.25 mg (milligrams), one tablet by mouth at bedtime had been discontinued on 3/15/2023. The note narrative revealed R50 had been more anxious and exit seeking since discontinuation of the Risperdal medication. Review of R50's Progress Note, dated 7/04/2023 and found in the EMR under the Progress Note tab, revealed that R50 was very physical with residents and slapped R43, tried to fight R22, and kept hitting R24. Review of the facility investigation provided by the facility, dated 7/12/2023, revealed on 7/04/2023 at 11:47 PM, R50 became aggressive in the hallway and slapped R43, tried to fight with R22, and pushed R24 when wheelchairs became tangled and threatened to hit him. Facility staff redirected R50 and separated R50 from R43, R22, and R24. The nursing staff monitored R50 for aggressive behaviors and ordered a urinalysis. There were no physical injuries for R43, R22 and R24. Review of a Progress Note, dated 9/03/2023 and found in the EMR under the Progress Note tab, revealed that R50 became very combative with R43. R43 received a small scratch on his left hand without drainage. R50 did not remember the incident. Review of the Facility Reported Incident provided by the facility, dated 9/03/2023, revealed R43 received a scratch to his face. Review of a Psychiatric Note, dated 9/06/2023 and found in the Progress Notes tab of the EMR, revealed R50 had been calmer since starting Rexulti (an atypical antipsychotic used for treatment of agitation associated with dementia due to Alzheimer's disease) and only had one episode of aggression over the weekend when a resident was scratched (9/03/2023 incident). Review of the facility investigation provided by the facility, dated 9/11/2023, revealed on 9/03/2023 at 7:00 AM, R50 became aggressive in the dining room and hit R43 resulting in a scratch on R43's face. The facility staff removed R50 from the dining room and monitored R50 for further interactions towards other residents. The facility ordered a urinalysis to check for potential infection for R50 facility psychiatrist would follow up. Review of R50's Progress Notes found under the Progress Notes tab of the EMR revealed that R50 had not been seen by psychiatric services since September 2023. Review of the Progress Note located in the Progress Notes tab in the EMR, revealed on 10/19/2023 at 7:33 PM, R50 became aggressive in the dining room and hit R58 on the mouth and right hand resulting in a skin tear to the right hand. The facility staff removed R50 from the dining area and assisted her back to her room. The facility staff monitored R50 to prevent any further aggressive conflicts. Review of Progress Note, dated 10/19/2023 and found under the Progress Note tab in the EMR, revealed that Registered Nurse (RN) 1 heard voices and yelling at the end of the hall. Upon arrival at the second-floor dining area RN1 noted R50 and R58 yelling at each other. The facility staff present stated to RN1 that R50 lunged at R58, and staff lowered R50 to the floor for safety in an attempt to separate the two residents for safety. The facility staff assisted R50 back to her room. R50 hit R58's hand and mouth, resulting in a scratched hand. Review of R50's Progress Notes found under the Progress Notes tab of the EMR revealed that there were no documented incidents of aggressive behavior since October 2023. 2. Review of R43's Face Sheet found under the Profile tab of the EMR revealed an admission with diagnoses of cerebral infarction, dementia, and anxiety disorder. Review of R43's quarterly MDS with an ARD of 10/11/2023 revealed a BIMS score of eight out of 15 which indicated moderately impaired cognition. Review of R43's Care Plan, dated 10/05/2023 and found under the Care Plan tab of EMR, revealed a plan for impaired cognitive function related to dementia and a plan for safety related to being hit by another resident. The plan indicated interventions for R43's safety included monitoring for signs and symptoms of fear or discomfort, comfort as needed, monitoring for whereabouts, and to keep R43 away from other residents. 3. Review of R58's Face Sheet found under the Profile tab of the EMR revealed an admission dated 10/14/2022 with diagnoses of subdural hemorrhage, paranoid schizophrenia, and adjustment disorder. Review of R58's quarterly MDS with an ARD of 7/11/2023 revealed a BIMS score of twelve out of 15 which indicated moderately impaired cognition. Review of R58's Care Plan found under the Care Plan tab of the EMR, dated 1/03/2024, revealed a care plan for impaired cognitive function and potential to demonstrate verbally abusive behaviors related to paranoid schizophrenia and adjustment disorder. 4. Review of R22's Face Sheet found under the Profile tab of the EMR revealed an admission with a diagnosis of dementia. Review of R22's quarterly MDS found under the MDS tab of the EMR with an ARD of 12/21/2023, revealed a BIMS score of three out of 15 which indicated severe cognitive impairment. Review of R22's Care Plan found under the Care Plan tab of the EMR, dated 1/10/2024, revealed a plan for impaired cognitive function related to dementia and a plan for resistance to care related to dementia. 5. Review of R24's Face Sheet found under the Profile tab of the EMR revealed an admission with diagnoses of cerebral infarction, major depressive disorder, and dementia. Review of R24's quarterly MDS with an ARD of 10/31/2023 revealed a BIMS score of seven out of 15 which indicated severe cognitive impairment. Review of R24's Care Plan found under the Care Plan tab, dated 1/03/2024, revealed a plan for a history of touching other residents. During an interview on 1/17/2023 at 5:11 PM, Licensed Practical Nurse (LPN) 1, Unit Two Manager, stated that R50 became angry every now and then and the anger came from out of nowhere. LPN1 stated that interventions used for R50 included separation of residents, providing a time out in the resident's room, providing diversional activities such as watching a television program, and that these interventions usually worked well for R50. LPN1 stated that she would have consulted the Psychiatric Nurse Practitioner, checked for a urinary tract infection and that the Nurse Practitioner would have been notified and may have recommended medication adjustments. LPN1 stated that R50 experienced aggressive behaviors toward R43 for some unknown reason. LPN1 stated she did not work the weekend of 7/04/2023 but was informed of the incident later. LPN1 stated that she saw that the Social Worker (SW) started the investigation and she thought that R50 was sent out to the hospital. LPN1 stated she thought the facility had considered moving R50 to another care home but was not sure. LPN1 stated that facility staff implemented monitoring R50 at all times as a prevention measure. When asked what monitoring at all times meant, LPN1 stated that she asked the aides and nurses on the unit to assist with monitoring and positioned herself to observe R50. When asked how long R50 was monitored at all times after the incident on 7/04/2023, LPN1 stated she did not know and could not reference a time. When asked how as Unit Manager she tracked aggressive incidents, LPN1 stated if an incident occurred, she asked nurses and aides to document in the progress notes and or the skilled assessment notes. LPN1 further stated that she thought that medication adjustments had taken place and R50 was doing better. During an interview on 1/17/2024 at 5:30 PM, RN1 stated she knew R50 and remembered the incident on 10/19/2023. RN1 stated she did not witness the separation of R50 and R58. RN1 further stated R58's scratch to the hand was approximately 1/2 inch long, described it as a scrape, and the skin was broken but no bleeding. RN1 stated she provided care for R58's injury. When asked if there was a plan for R50 after this incident, RN1 stated that it was a risk management decision issue. When asked if she could recall R50's care plan interventions for aggression, she stated not off hand. During an interview on 1/18/2024 at 11:45 AM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON stated she was familiar with R50's behaviors. When asked what she was doing to protect other residents from R50's aggressive behavior the DON stated when there were residents in the dining area on Unit Two a staff member was supposed to be present. The DON further stated that the nurses often placed R50 at the nurses' station for monitoring. The ADON stated that there was no behavior monitoring for R50's aggression or side effect monitoring for psychotropic medications. During an interview on 1/18/2024 at 12:40 PM, the Interim Administrator stated he was not aware of R50's aggressive behavior. The Administrator stated investigative approaches of aggressive behavior would have included interventions such as an interdisciplinary meeting to discuss the details of an incident, other facts, environmental influences, and determine a new approach in consideration of the three facility reported incidents that were substantiated for abuse.

Based on staff interviews, record review, and review of the facility policy titled, Abuse Prevention Policy, the facility failed to report an allegation of abuse to the state agency for one of eight residents (Resident (R) 54) of 22 sample residents. Findings include: Review of the facility's policy titled, Abuse Prevention Policy, dated 11/15/2022, revealed .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made . Review of R54's undated admission Record under the Profile tab in the electronic medical record (EMR) revealed R54 admitted to the facility with diagnoses which included dementia, hypertensive heart disease with heart failure, and atrial fibrillation. Review of R54's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (AR) of 12/22/2023 coded the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R54 had intact cognition. During a resident group meeting on 1/16/2024 at 3:00 PM, R54 stated Certified Nursing Assistant (CNA)2 was rough with caring for me, pulling my neck getting me in the wheelchair one day and then she verbally abused me too. R54 could not remember the day or shift of when this incident occurred. Review of the grievance log provided by the facility for the month of December 2023, revealed an entry on 12/10/2023 for R54 regarding an incident of alleged abuse. During an interview on 1/16/2024 at 4:15 PM, the Administrator stated he could not find the paperwork, so he went ahead and filled out the report for alleged abuse that had occurred on 12/10/2023. The Administrator also stated he had reached out to the previous interim administrator to see if the report had been sent to the state agency. During an interview on 1/19/2024 at 10:36 AM, the Director of Human Resources (HR) stated, I was the only person in administration and a housekeeper came and told me that the resident wanted to talk with someone. I talked to [R54], and it was more like being too rough with her when providing care. It was more physical than verbal abuse. I think it was more of being rough with care than anything. I either texted or emailed the administrator about this at that time. During an interview on 1/19/2024 at 10:36 AM the [NAME] President of Clinical Operations (VP) stated, I have looked and remembered that I was the interim administrator until the present administrator could get here. The deal was to keep everyone in the loop. They got a grievance, and they emailed it to me. I have always reported things like this to the state agency, but I don't know what happened this time.

Based on staff interviews, record review, facility document review, and review of the facility policy titled, Abuse Prevention Policy, the facility failed to thoroughly investigate an allegation of abuse for one of eight residents (Resident (R) 54) reviewed for abuse of 22 sample residents. Findings include: Review of the facility's policy titled, Abuse Prevention Policy, dated 11/15/22, revealed .Components of an investigation may include a) interview with the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. b) interview all witnesses separately. include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. Obtain witness statements, according to policy. All statements should be signed and dated by the person making the statement. c) Document the entire investigation chronologically. d) Notify the Local Ombudsman office to report the alleged abuse. e) Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made .f) Report results of all investigations will be reported to the facility Administrator, State Survey Agency within (5) working days of incident, and if the alleged violation is verified appropriate corrective action must be taken. g) The Administrator should follow up with the governmental agencies during business hours to confirm the report was received and to report the results of the investigation when final, as required by state agencies . Review of the undated admission Record under the Profile tab in the electronic medical record (EMR) revealed R54 admitted to the facility with diagnoses which included dementia, hypertensive heart disease with heart failure, and atrial fibrillation. Review of R54's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/2023 coded the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R54 was cognitively intact. During a resident group meeting on 1/16/2024 at 3:00 PM, R54 stated Certified Nursing Assistant (CNA)2 was rough with caring for me, pulling my neck getting me in the wheelchair one day and then she verbally abused me too. R54 could not remember the day or shift of when this incident occurred. Review of the grievance log for the month of December 2023 revealed an entry on 12/10/2023 for R54 related to the incident of alleged abuse. Review of the Facility Reportable Incident (FRI), dated 12/10/2023 and provided by the facility, revealed documentation on the Grievance/Complaint Form, dated 12/15/2023, under the Findings section of the form Investigation was carried out and it was unsubstantiated. The Action taken to correct problem section of this form revealed Inservice/Relias training assigned and completed by [CNA2] on customer service and resident rights. Staff was [sic] suspended during the investigation. The facility did not provide details of an investigation including additional staff or additional resident interviews associated with the reported incident. During an interview on 1/19/2024 at 10:36 AM by phone, the [NAME] President of Clinical Operations (VP) stated, We had already reviewed it [grievance/complaint of alleged abuse], suspended the employee and we determined it was unsubstantiated. We met with the employee [CNA2] and explained about the allegation, counseling, and then reassigned trainings which she did. We took her [CNA2] off the schedule so she would not have to work with this resident so both parties could be comfortable. During an interview on 1/19/2024 at 12:16 PM by phone, CNA6 stated, All I know is that the door to the room opened and [CNA2] told the Supervisor that [R54] said [CNA2] was being abusive to her [R54] . During an interview on 1/19/2024 at 12:09 PM the Director of Nursing (DON) stated, I know there was an investigation completed on the allegation of abuse by the CNA to this resident back in December. I have the statement of the CNA. No other investigative details were provided.

Based on interview, record review, and review of the facility policy titled, Notice Before Discharge, and Transfer, the facility failed to notify the State Long-Term Care Ombudsman of the hospital transfers. for one of one resident (Resident (R) 81) of 22 sample residents. Findings include: Review of the facility's policy titled, Notice Before Discharge, and Transfer dated November 2022, revealed Standard of Practice .4. This facility shall send a copy of the notice to the representative to the Office of the State Long Team Care (LTC) Ombudsman for a facility-initiated transfers or discharge. Review of the undated admission Record located under the Profile tab of the electronic medical record (EMR) revealed R81 was admitted to the facility with diagnoses of calculus of gallbladder and hyperlipidemia. Review of the Progress Note located under the Prog [Progress] Note tab of the EMR, dated 12/02/2023, indicated Resident received in bed with labored breathing . writer was asked by DON [Director of Nursing] to transfer resident to the hospital, 911 was called, resident was transferred to hospital for further evaluation. Family was notified of transfer. A request was made for documentation that the LTC Ombudsman Office had been notified of the facility's-initiated discharges. During an interview 1/19/2024 at 11:28 AM the Social Services Director stated she did not send a monthly list to the Ombudsman as she was instructed by the Ombudsman not to.

Based on staff interviews, record review, and review of the facility policy titled, Care Plan Policy, the facility failed to develop a comprehensive person-centered care plan for two of two residents (Resident (R) 27 and R29) of 22 sample residents reviewed for care plans. Findings include: Review of the facility's policy titled, Care Plan Policy, approved November 2023, indicated Each resident will have a plan of care to identify problems, needs, strengths, that will identify how the facility staff will provide services to attain or maintain the residents highest practicable physical, mental, and psychosocial wellbeing. 1. Review of R27's undated admission Record found under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted to the facility with diagnoses of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the admission Minimum Data Set (MDS) found under the MDS tab of the EMR, revealed R27 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating he was cognitively intact. The resident had upper extremity impairment on one side and lower extremity impairment on both sides. R27 was coded as needing supervision with Activities of Daily Living (ADL). During an interview on 1/16/2024 at 10:31 AM, R27 stated he did not get the help he needed to get out of bed. He stated everyone else got help but he did not. Review of the resident care plan found under the Care Plan tab of the EMR revealed there was only a care plan for dietary services. During an interview on 1/19/2024 at 9:53 AM the MDS Coordinator (MDSC) stated she was the only MDS Coordinator for the facility. She confirmed R27 did not have a care plan. 2. Review of R29's Face Sheet found under the Profile tab of the EMR revealed an initial admission with diagnoses of dementia, cerebral infarction, diabetes, hypertensive heart, end state renal disease, hypoxemia, anemia, repeated falls, and insomnia. Review of Physician Orders, dated 1/01/2024 and found under the Orders tab of the EMR, revealed fluoxetine HCL (hydrochloride) (antidepressant used for depression) oral tablet 20 milligrams (mg) one tablet by mouth every day for depression with a start date of 4/03/2023. Review of a Note to Attending Physician, dated 9/18/2023 and found under the Miscellaneous tab of the EMR, revealed R29 was having a good response to the medication fluoxetine HCL. Review of R29's Care Plan, dated 1/17/2024 and found under the Care Plan tab of the EMR, revealed no care plan for the antidepressant fluoxetine HCL and side effect monitoring of psychotropic medications. During an interview on 1/19/2024 at 1:25 PM, the MDSC stated R29 did not have a Care Plan for the antidepressant fluoxetine HCL or for side effect monitoring of psychotropic medications. MDSC stated there should have been one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of the facility policy titled, Facility Care Plan Policy, the facility failed to review and revise care plan interventions for one of two residents (Resident (R) 60) reviewed for care plans of 22 sample residents. This failure had the potential to delay appropriate interventions for care needs and safety concerns. Findings include: Review of the facility's policy titled, Facility Care Plan Policy, with a review date of November 2023, revealed that the plan of care was to be reviewed and updated as necessary at the completion of every assessment by the interdisciplinary team and resident representative party if so desired. Review of R60's Face Sheet found under the Profile tab of the electronic medical record (EMR) revealed an admission with diagnoses of diabetes, pancreatic disease, iron deficiency anemia, dysphagia, pain, wrist drop, and repeated falls. Review of R60's Care Plan, dated 10/13/2023 and located under the Care Plan tab of the EMR, revealed that the resident was fairly independent with Activities of Daily Living (ADL)s. Interventions included: ambulates ad lib, independent with bed mobility, encourage to turn and reposition routinely, independent with toileting, encourage to allow assist with cleaning, independent with transfers, set up assist with eating, set up with dressing, may need assist at time, supervision- min (minimum) assist with showers. Activities of Daily Living and the Impaired Cognitive Function interventions had not been revised or updated since the significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/07/2023 was completed. During an observation on 1/15/2024 at 12:26 PM, R60 was sleeping in her bed. R60's body was drawn into a fetal position. During an interview on 1/17/2024 at 8:53 AM, the MDS Coordinator (MDSC) stated R60 had a significant decline before she went to the hospital on [DATE] and upon readmission on [DATE], R60's condition and mobility had declined. The MDSC stated that the Care Plan areas for the significant change were not all updated. The MDSC confirmed that the activities of daily living and impaired cognition concerns had not been updated to include her current status, since the most recent significant change MDS with an ARD of 12/07/2023.

Based on staff interviews, record review, and review of the facility policy titled, Administration of Medications, the facility failed to administer a physician ordered antibiotic medication for one of one resident (Resident (R) 79) of 22 sample residents. Findings include: Review of the facility's policy titled, Administration of Medications, dated 11/15/2022, revealed .Medications must be administered in accordance with the orders (physician orders) . Review of R79's undated admission Record located under the Profile tab in the electronic medical record (EMR) revealed the resident was admitted to the facility with diagnoses which included otitis media of the right ear, abscess of the external right ear, and mastoiditis of the right ear. Review of COMS-Clinical admission Evaluation V2 located under the Assessment tab in the EMR revealed the mental status of R79 was alert but experienced some forgetfulness. Review of the Physician Orders located under the Orders tab in the EMR, dated 12/20/2023, revealed Ampicillin-Sulbactam Sodium Injection Inject three grams intramuscularly every six hours until 1/20/2024. Review of the Medication Administration Record (MAR), dated 1/2024, located under the Orders tab in the EMR revealed on 1/05/2024, 1/06/2024, 1/07/2024, and 1/08/2024 for the times the medication was to be given it was documented as having a code of 13 which represented Not Administered/See Progress Notes. Review of the Progress Notes for the documented dates above, located in the EMR under the Progress Notes tab, revealed there was no documentation indicating why the antibiotic was not administered to R79 as ordered by the physician. However, the progress note, on 1/09/2024 at 11:46 AM, revealed Due to resident running out of his Antibiotic injections, his stop date will be extended till 1/24/2024 (sic). Spoke to the Pharmacist who will be sending out some more Antibiotics stat. During an interview on 1/18/2024 at 10:01 AM, Licensed Practical Nurse (LPN) 1 stated, I could have sworn I put where I called the nurse practitioner and received the order to extend it until 1/24/2024 due to him missing doses. During an interview on 1/19/2024 at 2:30 PM, the Director of Nursing (DON) stated, Anytime the medication is not given to the resident as the physician has ordered, the nurse is to call and notify the physician. This is to be documented in the progress notes.

Based on staff interviews, record review, facility document review, and review of the facility policy titled, Dialysis, Care of the Resident Receiving Dialysis Treatments, the facility failed to have ongoing communication and collaboration with the dialysis center for one of one resident (Resident (R) 3) reviewed for dialysis out of 22 sample residents. Findings include: Review of the Dialysis Contract, dated 6/21/2023 and provided by the facility, revealed .Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and ESRD [End Stage Renal Disease] Dialysis Center . Review of the facility's policy titled, Dialysis, Care of the Resident Receiving Dialysis Treatments, dated 10/20/2022, revealed .Arrange for dialysis as ordered. Send Dialysis Information Transfer Form with resident . Post dialysis Assessment to be completed. Review of R3's undated admission Record under the Profile tab in the electronic medical record (EMR) revealed R3 was admitted to the facility with diagnoses which included end stage renal disease, hypertensive heart, chronic kidney disease with heart failure, and hypotension of hemodialysis. Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2023 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R3's EMR revealed there were no pre/post dialysis weights documented. There was no communication documented in the EMR of verbal/written reports from the dialysis center to the facility after each dialysis treatment. During an interview on 1/18/2024 at 9:49 AM, the Licensed Practical Nurse (LPN) 1 stated, The nurse is to document that either the nurse here at the facility calls the dialysis center or the dialysis center calls the facility with any reports .The nurses here do not get the pre weights before she [R3] goes to dialysis. During an interview on 1/18/2024 at 5:50 PM, the Director of Nursing (DON) stated, If they [the nurses] have already closed the post evaluation note [Post Dialysis Communication Form] then the nurse will write a new progress note containing the information they have received by calling the dialysis center. If they haven't closed the note, then the nurse can add the documentation there in the post evaluation note. The DON confirmed there was missing information for R3.

Based on staff interview record review and, the facility failed to ensure the monthly review of drug regimens were completed by a licensed pharmacist for two of two residents (Resident (R) 29 and R50) reviewed for monthly regimen review of 22 sample residents. This failure has the potential to impact the residents' health and wellness. Findings include: 1.Review of R29's Face Sheet found under the Profile tab of the electronic medical record (EMR) revealed an initial admission date of 7/10/2021 with diagnoses of dementia, cerebral infarction, diabetes, hypertensive heart, end stage renal disease, hypoxemia, anemia, repeated falls, and insomnia. Review of R29's Consultant Pharmacist Note found under the Miscellaneous tab of the EMR revealed a documented pharmacy review dated 9/18/2023 recommending no changes. During an interview on 1/19/2023 at 3:30 PM the Director of Nursing (DON) stated that there were no additional monthly medication reviews found for R29. The DON further stated that she had been trying to develop a system for reviewing recommendations and documenting implementation of any recommendations made by the pharmacist. 2. Review of R50's Face Sheet found under the Profile tab of the EMR revealed an admission date of 10/09/2021 with diagnoses of delusional disorders, major depressive disorder, vascular dementia, cancer, hypokalemia, anemia, vitamin D deficiency, hypertension, glaucoma, cataract, venous thrombosis, anticoagulants, and human immunodeficiency virus (HIV). Review of Consultant Pharmacist Log dated 10/26/2024 and provided by the DON, revealed R50's last monthly medication review was 10/26/2024. During an interview on 01/19/2023 at 3:30 PM, the DON stated that there were no additional monthly medication reviews found for R50. The DON further stated she had been trying to develop a system for reviewing recommendations and documenting implementation of any recommendations made by the pharmacist.

Based on observation, staff interviews, record review, and review of the facility policy titled, Administration of Medication, the facility failed to ensure the medication error rate was less than five percent for two of seven residents (Resident (R) 41 and (R)235) resulting from eight errors out of 29 opportunities for a medication error rate of 27.59 percent. Findings include: Review of the facility's policy titled, Administration of Medications dated 11/15/2022 revealed . Medications must be administered in accordance with the orders [physician orders] . Review of the facility's policy titled, Administration of Medication, dated 11/15/2022, revealed .Licensed Nurse/CMT [Certified Medication Tech] giving medication must follow the six rights to ensure safe medication administration. Each time you administer a medication, you need to be sure to have the: 1. Right individual; 2. Right medication; 3. Right dose; 4. Right time; 5. Right route; 6. Right documentation . 1. Review of R41's undated admission Record under the Profile tab located in the electronic medical record (EMR) revealed R41 was admitted to the facility with diagnoses which included dementia, congestive heart failure, diabetes mellitus, and hypertension. During the medication administration observation on 1/17/2024 at 8:32 AM, Licensed Practical Nurse (LPN) 4 crushed metformin (medication to control high blood sugars) 500 mg (milligrams), amlodipine (a calcium channel blocker) five mg, memantine (medication for neurodegenerative disease) ten mg, and atorvastatin (medication for lowering cholesterol) 80 mg. LPN4 placed these medications in a small cup of pudding for R41 to take. Gabapentin (medication for seizure prevention) 100 mg capsule was taken apart by LPN4 and placed in the pudding with the other medications. LPN4 began to administer the pudding to R41 with one spoonful at a time so R41 would not become choked. LPN4 administered three small spoonful's to R41 and then the resident verbalized to LPN4 this is all I can take. The cup contained remaining powdered medication in the pudding, at the time the resident refused to take anymore medication. Review of R41's Medication Administration Record (MAR) under the Order tab located in the EMR revealed LPN4 had documented all the above medications as given for 1/17/2024. During an interview on 1/17/2024 at 11:19 AM, the Director of Nursing (DON) stated, The crushed meds either need to be crushed one at a time and given that way so you will know which medication the resident refused to take or crush them all together and if the resident refuses the medications, then you will have to make all of them as not given. 2. Review of R235's undated admission Record under the Profile tab located in the EMR revealed R235 was admitted to the facility with diagnoses which included pulmonary hypertension, chronic obstructive pulmonary disease (COPD), heart failure, and diabetes mellitus. During the medication administration observation on 1/17/2024 at 9:04 AM, LPN4 obtained R235's blood pressure which was 107/98. As LPN4 was preparing the medications to be administrated to R235, the medication labels documented the lisinopril (medication for blood pressure) ten mg (milligrams) po (by mouth) daily. Hold if SBP (systolic blood pressure) less than 110 or DBP (diastolic blood pressure) less than 60 and metoprolol (medication for blood pressure) ER (extended release) 25 mg po daily. Hold if SBP (systolic blood pressure) is less than 110 or DBP (diastolic blood pressure) less than 60. Continued observation revealed LPN4 administrated both blood pressure medications to R235. LPN4 also administrated bevespi inhaler (medication for COPD) which the inhaler's directions of administration on the label revealed, Rinse [resident's mouth] with water after administration. LPN4 administrated this inhaler to R235 and did not instruct the resident on rinsing his mouth as directed to on the medication's label on the inhaler. During an interview on 1/17/2024 at 11:10 AM, LPN4 stated, I was just so nervous I forgot about the blood pressure parameters. And I didn't see any special directions on the inhaler's label. During an interview on 1/17/2024 at 11:19 AM, the DON stated, . the blood pressure medicines should not have been given to the resident with those parameters and the nurse should had followed the directions on the inhaler.

Based on observation, interview and facility policy review, the facility failed to store physician ordered medications in a locked compartment for one of one resident (Resident (R)234), failed to discard medications that were not administrated for one of one resident (R10), and failed to discard expired medications located in the refrigerator on the Memory Care Unit. Findings include: Review of the facility's policy titled, Storage of Medications and Biologicals, dated 11/29/22, revealed . Facility should ensure that all medications and biologicals, including treatment items, are securely stored in locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. All Medication, Treatment carts must be secured/locked when not attended by licensed staff. 1. Review of the undated admission Record under the Profile tab in the electronic medical record (EMR) revealed R234 was admitted to the facility with diagnoses of diabetes mellitus, dementia, myocardial infarction, and hypertension. During the Medication Administration Observation on 1/17/2024 at 9:14 AM, Licensed Practical Nurse (LPN)7 prepared the medications for R234 and placed them in a medicine cup on top of the medication cart. LPN7 went into R234's room to get a cup of thicken liquids and then returned to the medication cart. While LPN7 was in R234's room, the nurse was unable to visualize the medication on top of the medication cart. During an interview on 1/17/2024 at 11:10 AM, LPN7 stated, I should have not left those medicines when I went into his [R234] room. 2. Review of the undated admission Record under the Profile tab located in the EMR revealed R10 was admitted to the facility with diagnoses of cerebral infarction, chronic kidney disease, and osteoarthritis. During the medication Storage observation on 01/19/2024 at 1:28 PM, it was noted that in the first drawer of the medication cart, on the Memory Care Unit, there was a medicine cup with medications in it. The following medications were noted in the medicine cup: one yellow capsule, one large round white pill, two medium white pills, one dark tan round pill, one peach round pill, and one round yellow pill. During an interview on 1/19/2024 at 1:30 PM, the Certified Medication Aide Tech (CMAT)1 stated, I went to give them [the medications] to R10, and she was asleep. I wasn't going to wake her up so I put them in here so I could give them to her when she wakes up. When CMAT1 was asked what time the medications were scheduled for, she stated, 11:00 AM. During an observation on 1/19/2024 at 1:50 PM, the medication refrigerator on the Memory Care Unit revealed there were two full boxes of Moderna COVID-19 vaccines with the expiration date of 12/06/2023 list on both boxes. During an interview on 1/19/2024 at 2:00 PM, the CMAT1 stated, Expired medications have to be discarded and reordered. CMAT1 confirmed both boxes of the Moderna COVID-19 vaccines were expired. During an interview on 1/19/2024 at 2:15 PM the Director of Nursing (DON) stated, No medications should be left on the medication carts when the nurse is not right there with them. The medicines in the memory care medication cart should have been discarded also if the medication tech did not give them to the resident. The DON also confirmed the two boxes of Moderna COVID-19 vaccines were indeed expired and should have been discarded as well by staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility's document review, the facility failed to implement the communication process, including how the communication would be documented between the facility and the hospice provider to ensure one of one resident (Resident (R) 49) needs were met and addressed of 22 sample residents. Findings include: Review of the undated Agreement for Hospice Care for Skilled Nursing Facility and Nursing Facility Residents, provided by the facility, revealed Section 1.6 Coordination of Services indicated, .d. Provide for an and ensure the ongoing sharing of information between all disciplines providing care and services in all setting, whether the care and services are provided directly or under arrangement. e. Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions Review of R49's admission Record located under the Profile tab of electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's and dementia. Review of the Physician Order located under the Order tab of the EMR revealed on 7/07/2022, R49 was admitted to hospice. Review of the quarterly Minimum Data Set (MDS) located under the MDS tab of EMR with an Assessment Reference Date (ARD) of 12/29/2023 assessed the resident as receiving hospice care. Review of the Care Plan located under the Care Plan tab of the EMR revealed, The resident has a terminal prognosis r/t [related to] Alzheimer's dementia. On [name of hospice company] hospice. Interventions included,.Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Review of the Hospice Communication Log provided by the nurse, dated 12/13/2022, revealed Resident is sitting at . table with head down sleeping. Responds to voice, alert to self. continue with confusion, ability to speak 1-5 [sic] words, no signs of distress noted, eating lunch during visit. No issues noted. No refills needed. No concerns reported by the facility. Advised to call hospice with changes. There was no other documentation in the resident logbook. During an interview on 1/17/2024 at 9:04 AM the Licensed Practical Nurse (LPN) 6 stated there was not much documentation in the hospice logbook. LPN6 stated when hospice came, they did not leave any paperwork with them. If there were any changes to communicate, the hospice nurse told the nurse on duty verbally and told us to contact them if we had any concerns. During an interview on 1/17/2024 at 4:49 PM the Director of Nursing (DON) revealed she was made aware today that the hospice facility was not leaving their notes when they visited the resident on a routine basis. The DON stated they should have the hospice notes just in case something happened. The DON stated the Charge Nurse, (LPN1) was reaching out to the hospice facility to obtain the notes. During an interview on 1/17/2024 at 5:08 PM LPN1 revealed the resident was admitted to the facility on hospice and the facility should have at least had their care plan in the logbook and it would then be uploaded into the medical record. LPN1 confirmed the care plan, and the hospice documentation was not in the medical record or in the facilities premises.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer or provide documentation of consent or refusal for three of five residents (Residents (R)3, R50, and R34) of 22 sample residents reviewed for pneumonia vaccinations and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. Findings include: Review of CDC website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, last reviewed 9/22/2023, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older. The tables below provide detailed information . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give one dose of PCV15 [pneumococcal conjugate vaccines] or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV23 [pneumococcal polysaccharide vaccine] at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 is used, a dose of PPSV23 is NOT indicated . For adults 65 years or older who have only received a PPSV23, CDC recommends you . May give one dose of PCV15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults 65 years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended. For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete . The CDC guidelines went into effect on 10/21/2021 per recommendations from the Advisory Committee on Immunization Practices (ACIP). 1. Review of R3's admission Record located under the Profile tab of the electronic medical record (EMR), R3 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease, heart failure and was dependent on dialysis. R3 was currently over [AGE] years old. Review of the Immunizations located in the Immunization tab of the EMR revealed R3's last dose of PPSV 23 was dated, 1/12/2017 and the Next scheduled dose 1/12/2018 was not administered or refused. 2. Review of R50's admission Record located under the Profile tab of the EMR revealed R50 was admitted to the facility on [DATE] with diagnoses that included dementia, and HIV. R50 was over [AGE] years old. Review of the Immunizations located in the Immunization tab of the EMR revealed R50's last dose of PPSV 23 was dated 10/05/2021 and the Next scheduled dose on 10/05/2022 was not administered or refused. 3. Review of R34's admission Record located under the Profile tab of the EMR revealed R34 was admitted to the facility on [DATE] with diagnoses that included. diabetes mellitus and schizophrenia. R34 was over [AGE] years old. Review of the Immunizations located in the Immunization tab of the EMR revealed R34's last dose of PCV 13 was dated 10/05/2017 and the Next scheduled dose on 10/05/2018 was not administered or refused. During an interview on 1/19/2024 at 4:35 PM, the Assistant Director of Nursing (ADON) stated, If the information is not documented on the Immunization page then it was not asked or given to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R#58 was admitted to the facility on [DATE] with diagnoses including but not limited to diabetes mellitus and chronic embolism and thrombosis of the left popliteal vein. Review of R#58's care plans revealed the resident was at risk for skin breakdown r/t (related to) impaired mobility, incontinence, history of stage 4 pressure ulcer to the left heel. Noted on 3/18/22, a deep tissue injury (DTI) of the right heel, and an unstageable left heel (reopened stage 4). Review of R#58's treatment administration record (TAR) for March 2022 revealed no documentation of wound care on 3/27/22. Review of R#58's TAR for April 2022 revealed no documentation of wound care on 4/9/22, 4/10/22, 4/13/22, 4/23/22, and 4/24/22. Review of R#58's TAR for May 2022 revealed no documentation of wound care on 5/7/22, 5/8/22, 5/15/22, 5/21/22, 5/22/22, 5/29/22, and 5/30/22. During interview on 6/2/22 at 9:44 a.m. with the Treatment Nurse revealed she has been doing the treatments full-time for approximately one week and that she was previously working part-time. She further stated charge nurses are responsible for treatments on the weekend and she does not feel the treatments are being done on the weekends as ordered. During interview on 6/2/22 at 10:03 a.m. with the Administrator revealed the charge nurses are responsible for doing treatments for residents assigned to them on the weekends. States her expectation is for the nurses to do the treatments as ordered. Based on observations, interviews, record reviews and reviews of the facility policy titled Documentation Policy the facility failed to ensure licensed nursing staff accurately documented daily wound care for two (2) of six (6) residents (R) (R#50 and R#58) reviewed for pressure related wounds. Findings include: Review of the policy titled Documentation Policy reviewed 10/2018, indicated: A designated staff member will chart on all residents to maintain a complete and accurate medical record. 1. R#50's was admitted to the facility on [DATE] with diagnoses that included but not limited to fractured ribs, falls, dementia, osteoporosis, and hypertension. Review of R#50's significant change Minimum Data Set (MDS) dated [DATE] revealed Section G-Functional Status: resident required extensive assistance with bed mobility, dressing, was total dependent for transfers, locomotion, eating, toileting, and personal hygiene; Section M-Skin: resident had one (1) pressure ulcer not present on admission and 2 unstageable deep tissue injuries (DTI) not present on admission. Review of R#50's care plans revealed: Resident at risk for skin breakdown related to impaired mobility, incontinence, poor intake. 4/12/22: stage three (3) to sacrum. 4/14/22: DTI to bilateral heels. Review of R#50's Physician wound care orders revealed: Apply Santyl ointment 250 UNIT/GM (Collagenase) Apply to sacrum topically daily for wound care, cleanse open wound to sacral region with wound cleaner/normal saline. Pat dry. Layer with calcium alginate. Cover with silicone/dry dressing. Skin prep to left heel daily for unstageable DTI Skin prep to right heel daily for unstageable DTI Review of R#50's Treatment Administration Record (TAR) for April and May of 2022 revealed no documentation of wound care on the weekends for April and May of 2022. An interview held on 6/01/22 at 9:16 a.m. with the Licensed Practical Nurse (LPN) Wound Care Nurse revealed resident acquired the wound in the facility. She indicated the resident has very poor intake and has declined. She is on an air mattress, and the Wound Care Physician sees the resident weekly. The Physician indicated the wound was unavoidable related to malnutrition. She does all the wounds in the facility Monday through Friday. The nurses are responsible for doing the treatments on the weekend. She has been doing the wound care full time for just over a week. She verified the missing documentation for wound care for April and May of 2022. An interview held on 6/02/22 at 9:02 a.m. with the Administrator revealed they have 1 wound care nurse who works Monday through Friday. They used to have a weekend wound care nurse but not at this time. The weekend nurses are responsible for doing the treatments when there is not a wound care nurse scheduled. She verified the missing documentation of wound care for April and May of 2022, and she would expect the nurses to follow the Physicians orders.

Based on record review, staff interview, and review of facility policy titled, Infection Prevention and Control Program Overview, the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. The facility census was 72 residents. Findings include: A review of the facility policy titled Infection Prevention and Control Program Overview Issued November 28,2016 and last reviewed October 2021 revealed the following (not all inclusive) Goals The goals of the infection prevention program are to: A. Decrease the risk of infection to residents and personnel. B. Monitor for occurrence of infection and implement appropriate control measures C. Identify and correct problems relating to the infection prevention practices. D. Maintain compliance with state and federal regulations relating to infection prevention. Scope of The Infection Prevention and Control Program The infection prevention program is comp A. Surveillance of infections with implementation of control measures and prevention of infections There is on-going monitoring for infections among residents and personnel and subsequent documentation of infections that occur. B. Outbreak investigation Systems are in place to facilitate recognition of increases in infections as well as clusters and outbreaks. Division of Responsibilities for infection Prevention And Control Activities The Administrator/ Chief Executive Officer is ultimately responsible for the infection prevention program. A. Infection Preventionist Responsibility is delegated to the Infection Preventions (IP) to carry out the daily functions of the infection prevention program. Those functions are described in the IP job description. The IP has knowledge, competence, interest in infection prevention and appropriate qualifications. Reporting Mechanisms for Infection Prevention A. Resident infection cases are monitored by the IP. The IP completes the line listing of infections and monthly report forms and: 1. Reports to the Infection Prevention Committee 2. Reports to the Director of Nursing / Designee and others as directed 3. Provides feedback to staff as needed B. Employee infections and exposures to bloodborne pathogens or communicable diseases are reported by the employee to the employee supervisor, then to the IP. The IP completes the infection report form and reports a summary to the Infection Prevention Committee and Quality Assurance and Performance Improvement (QAPI)Committee. C. Compliance with infection prevention practices is monitored and documented by: Staff evaluation And observation of practices. D. The IP Administrator/ Designee and appropriate department managers review the compliance monitoring and initiate appropriate actions. There was no evidence the facility was following the Infection Prevention and Control Program policy by the lack of documentation made available during the three-day survey. The facility was unable to provide any infection prevention and control surveillance data during the survey process. During the entrance conference on 5/31/22, the team leader requested all infection control books and materials. An interview on 5/31/22 at 3:30p.m. with the Director of Nursing (DON) revealed she was responsible for the infection prevention program. The vaccine matrix, infection control books, including Antibiotic Stewardship and Covid testing logs were requested, and the DON stated she was working on getting the materials together. None of the requested infection control materials were provided on the day of entrance. An interview with the Administrator on 6/1/22 at 8:45a.m. revealed the DON is responsible for the infection control program and is out sick today and she isn't sure if the DON will return this week. Continued interview revealed the books are with the DON at home and she (the Administrator) does not have access to the Antibiotic Stewardship book or Covid-19 testing logs. Further interview revealed the DON has not been certified as an Infection Control Preventionist however she (the Administrator) is certified, and her Nursing Home Infection Preventionist Training Course certificate of completion was presented. During an interview on 6/1/22 at 12:00 p.m. with the Administrator the infection control books were requested, and she stated they were working on it. The Administrator revealed that the DON, who is the Infection control Preventionist (ICP), took the books home with her when she left the building yesterday to freshen them up for the survey team. The Administrator confirmed she was aware the infection control books had been removed from the facility by the DON and were not available. An interview 6/1/22 at 1:09 p.m. with the Administrator revealed they are still unable to produce requested infection control materials and testing logs and stated that she and the Regional Nurse was going to look in the DON office for the requested materials. Further interview confirmed no one has left the facility to obtain the materials from the DON and the DON was not answering calls or messages from the Facility. An interview with the Administrator and Regional Nurse 6/2/22 at 3:00 p.m. revealed the facility had no additional information to provide regarding the Infection Control Program or Antibiotic Stewardship Program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, and review of the facility policy titled, Antibiotic Stewardship, the facility failed to ensure it developed and implemented an Antibiotic Stewardship Program to include antibiotic use protocols and a system to monitor antibiotic use. This had the potential to affect all 72 residents who reside in the facility. Findings include: During a review of the facility policy titled Antibiotic Stewardship Issued November 2016 and last reviewed November 2019 revealed a policy statement: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Standards of Practice: 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. The policy explains the orientation, training and education, prescriber information to be provided, and other pertinent information related to monitoring antibiotics. During the entrance conference on 5/31/22, the team leader requested all infection control books and materials. An interview on 5/31/22 at 3:30 p.m. with the Director of Nursing (DON) revealed she was responsible for the infection prevention program. The vaccine matrix, infection control books, including Antibiotic Stewardship and Covid testing logs were requested and she stated she is working on getting the materials together. However, none of the requested infection control materials were provided the day of entrance to the survey. An interview with the Administrator 6/1/22 at 8:45 a.m. revealed the DON is responsible for the infection control program is out sick today and she isn't sure if she will return this week. Continued interview revealed the books are with her at home and she (the Administrator) does not have access to the Antibiotic Stewardship book or Covid-19 testing logs. During an interview on 6/1/22 at 12:00 p.m. with the Administrator, the infection control books were requested, and she stated they were working on it. The Administrator revealed that the DON, who is the Infection control Preventionist (ICP), took the books home with her when she left the building yesterday to freshen them up for the survey team. The Administrator confirmed she was aware the infection control books had been removed from the facility by the DON and were not available. An interview 6/1/22 at 1:09 p.m. with the Administrator revealed they are still unable to produce requested infection control materials and testing logs and stated that she and the Regional Nurse was going to look in the DON's office for the requested materials. Further interview confirmed no one has left the facility to obtain the materials from the DON and the DON was not answering calls or messages from the Facility. On 6/1/22 at 1:16 p.m. the Administrator provided a notebook labeled Nursing Facility Antibiotic Stewardship (ABX) Program which contained a training for implementing an Antibiotic Stewardship program in nursing facilities. There was no information regarding this facility contained in the notebook and no Infection Prevention [NAME] was presented. An interview with the Administrator and Regional Nurse 6/2/22 at 3:00 p.m. revealed the facility had no additional information to provide regarding the Infection Control Program or Antibiotic Stewardship Program.

Based on observations, interviews, record reviews, and facility policy titled, Facility Testing requirements for Staff and Residents. The facility failed to produce evidence of testing of residents and staff for the COVID-19 virus based on recommendations from the Centers of Disease Control (CDC), the Centers for Medicare and Medicaid (CMS) and the level of community transmission rates. The facility did not maintain testing logs or line listing forms for the residents or staff. The facility census was 72 residents. Findings include: A review of facility policy titled Facility Testing Requirements for Staff and Residents revised CMS: QSO -20-38-NH Testing of Staff and Residents Regulations issued September 4, 2020, revised September 24,2021 revealed the following: Policy statement: To enhance efforts to keep Coronavirus COVID-19 from spreading throughout this facility, the facility shall provide on-site testing. Staff and residents will be tested in adherence to Centers of Medicare and Medicaid Services guidance. Outbreak Trigger testing: Test all staff and residents in response to an outbreak (defined any single new infection in staff or any nursing home onset infection in a resident) Continue to test all staff and residents that tested negative every three days to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. Standards of Practice revealed the following steps of action include: Step 4. Document that the faculty staff's test was completed with results maintained on a line listing form. Step 15 Routine testing for unvaccinated staff will be conducted based on the community COVID-19 transmission level rates. Fully vaccinated staff do not have to be routinely tested. Step 17. Unvaccinated and Vaccinated residents who leave the facility for Leave of Absences or medical treatments (e.g., dialysis, chemotherapy) shall be tested based on the County Community level transmission rates (refer to Table 2 Routine Intervals by County Covid-19 Level of Community Transmission). An interview on 5/31/22 at 3:30 p.m. with the Director of Nursing (DON) revealed she was responsible for the infection prevention program. The vaccine matrix, infection control books, including Antibiotic Stewardship and Covid testing logs were requested and she stated she is working on getting the materials together. None of the requested infection control materials were provided the day of entrance to the survey. An interview with the Administrator 6/1/22 at 8:45 a.m. revealed the DON is responsible for the infection control program and is out sick today and she isn't sure if she will return this week. Continued interview revealed the books are with her at home and she does not have access to the Antibiotic Stewardship book or Covid-19 testing logs. During an interview on 6/1/22 at 12:00 p.m. with the Administrator, the infection control books were requested, and she stated they were working on it. The Administrator revealed that the DON, who is the Infection control Preventionist (ICP), took the books home with her when she left the building yesterday to freshen them up for the survey team. The Administrator confirmed she was aware the infection control books had been removed from the facility by the DON and were not available. An interview 6/1/22 at 1:09 p.m. with the Administrator revealed they are still unable to produce requested infection control materials and testing logs and stated that she and the Regional Nurse was going to look in the DON's office for the requested materials. Further interview confirmed no one has left the facility to obtain the materials from the DON and the DON was not answering calls or messages from the Facility. During interview on 6/1/22 at 3:27 p.m. with the Administrator she confirmed there was no evidence the sampled residents and staff were not tested appropriately. The Administrator further revealed no testing logs had been kept but sheets with the staff results were in the employee files and the Resident results had been placed in the Resident's Electronic Medical Records (EMR). The Administrator could not reveal the manner used to determine when the staff or Residents were due to be retested. An interview on 6/1/22 at 3:30 p.m. with the Regional Nurse Consultant confirmed the facility staff was unable to produce any testing logs or line listings. The method used to determine the need for testing or how the results are managed could not be ascertained. During the 3-day survey process the facility was unable to provide line listing forms required per the facility policy standard of practice.