**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policy review, the facility failed to immediately report an injury of unknown origin for one of 28 sampled residents (Resident (R) 97). This failure decreased the facility's potential to protect R97 from a possible allegation of abuse and ensure a safe environment during the investigation of the cause of injury. Findings include: A review of the facility's policy titled Abuse Prohibition reviewed 12/27/24 indicated, Injuries of unknown origin should be thoroughly investigated to determine the cause. Discussion should be held with the Governing Body or Division Nurse if the cause cannot be identified prior to reporting. Once an injury or event is identified as suspicious and may constitute abuse, the center will follow the investigation procedures. Review of R97's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses which included Alzheimer's, severe dementia with psychotic features, depression, and agitation. Review of R97's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/25 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the cognitive interview. The staff assessment indicated R97 was severely cognitively impaired. Review of R97's Care Plan, dated 03/21/24 and located in the Care Plan tab of the EMR, revealed R97 had a focus area of pain related to a left (lf) wrist fracture. A review of Nursing Notes, found under Notes tab of EMR, dated 02/26/25, revealed an acute radial fracture noted. There were no documented falls. A review of the Patient at Risk (PAR) review, provided by the facility, dated 02/27/25, revealed a full investigation into the etiology of the fracture. The investigation could not determine the cause of the fracture. There were no witnesses to the cause of the injury. A review of the X-Ray Report, provided by the facility, dated 02/26/25 revealed a subtle hairline fracture of the distal radius. During an interview conducted on 04/09/25 at 2:02 PM the Administrator stated she was the abuse coordinator. The Administrator stated that the incident was not witnessed, and she was notified when they received the report of the fracture. The Administrator stated that the incident should have been reported as an injury of unknown origin within the mandated timeframe. The Administrator stated that no report was made to the stated agency. During an interview conducted on 04/09/25 at 2:37 PM Licensed Practical Nurse (LPN) 2 stated that she was notified by staff about R97 swollen wrist. LPN2 stated that R97 is ambulatory and will often sit on the ground and get up by herself. LPN2 stated R97 did not show any signs of pain, and no accident or fall was witnessed by staff. LPN2 stated she did not remember the timeframe of the incident but reported the incident to the Director of Nursing (DON) as soon as she received the report of the fracture. LPN2 stated they are in-serviced monthly on abuse and immediately report all injuries or allegations of abuse to management, and they do the investigations and reporting.

Based on observations, staff interview, and reviews of the facility's policy and procedures, the facility failed to ensure that the medication error rate was not five percent or greater, the medication error rate was 7.69 percent. Findings include: Review of the facility's policy titled, Pharmacy Services Medication Administration-General dated 2024, indicated, The joint responsibility of the center and the pharmacy is to facilitate accurate medication administration. Prior to medication administration the Nurse or Certified Medication Aide: . Reads the administration directions on the MAR [Medication Administration Record] and verifies correct medication, dose and direction for use. On 04/09/25, three Licensed Practical Nurses and two Certified Medication Aides (CMA) were observed administering medications on three of three halls. A total of 25 medication opportunities were observed. Two medications errors were observed. On 04/09/25 at 8:40 AM, CMA2 was observed administering the following medication to resident (R) 80: 1. Aspirin 81 mg po (by mouth) daily 2. Vitamin D3 1 capsule po daily 3. Culturelle 15 billion cell sprinkle capsule 1 capsule sprinkle po bid (CMA handled capsule in hand without gloves) 4. Diltiazem 120 milligram (mg) 1 tab po daily 5. Iron 65 mg 1 tab po daily 6. Furosemide 20mg 1 tab po daily 7. Polyethylene Glycol 3350 (administered ½ cap with 8oz water) [ MD order 1 cap full by mouth 1 time a day mix with 4-8 ounces of liquid] 8. Senna Plus 8.6 mg-50mg 1 every 12 hours [MD order Senna Plus 8.6mg-50mg tab 2 tablets po every 12 hours] 9. Xarelto 10 mg 1 tab po daily Two (2) medication errors were observed by CMA2 while administering the medications to R80. CMA2 administered ½ cap Polyethylene Glycol 3350 with 8oz water and administered one tablet of the Senna Plus 8.6 mg -50mg. Review of R80's physician orders, dated 06/07/24, indicated, Polyethylene Glycol 3350 one capful by mouth one time per day. Mix with four to eight ounces of liquid. Diagnosis (DX): Constipation, unspecified and Senna Plus 8.6 mg -50mg 2 tabs by mouth every 12 hours, take with plenty of water. DX; constipation. Interview with CMA2 on 04/10/25 at 9:10 AM confirmed that the medication errors occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of facility policy, the facility failed to ensure staff adhered to the guidelines for Enhanced Barrier Precautions for two of sixteen residents (Resident (R)44 and R81). Additionally, the staff member failed to sanitize a stand to lift equipment after using it on R44. This failure has the potential cross-contamination. Findings include: Review of facility's policy titled, Transmission Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airborne) with a review date of 12/27/24, indicated, .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from patient to patient during high contact activities. Nursing home patients with wounds and indwelling medical devices are especially at high risk of both acquisition and colonization of MDROs. The use of a gown and gloves for high-contact patient care activities is indicated when Contact Precautions do not apply, for nursing home patients with wounds and/or indwelling medical devices, regardless of MDRO colonization as well as for patients with MDRO infection or colonization. Examples of high contact patient care activities requiring gown and glove use for Enhanced Barrier Precautions include: . Dressing. Bathing/showering. Transferring. Providing hygiene. Changing linens. Changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, and tracheostomy/ventilator . 1. R44's Face Sheet located in the resident's electronic medical record section (EMR) tab labeled admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that include cerebral vascular accident with hemiplegia, atrial fibrillation, diabetes mellitus, COPD, gastrostomy tube placement Review of R44's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/07/24 located in the resident's EMR section titled MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. The resident was assessed to have a gastrostomy tube. Observation on 04/08/25 at 9:30 AM revealed Certified Nursing Assistant (CNA)10 entering R44's room without donning a gown, carrying wash cloths and towels. At 9:55 AM, CNA 10 exited the resident's room carrying a bag with dirty items. The CNA was observed entering the resident's room again without donning a gown with a sit-to-stand lift. Ten minutes later, the CNA exited the room with the sit-to-stand lift and returned the lift to the storage area without sanitizing the equipment On 04/08/25 at 10:15 AM, an interview with CNA10 revealed that it was no longer required to wear a gown while providing care for the resident. CNA acknowledged that she did not sanitize the lift only when used on residents in contact isolation. An interview on 04/08/25 at 10:21 AM with Certified Medication Aide (CMT) 3 revealed R44 had a gastrostomy tube, but she no longer received nutrition through the tube. CMT3 also stated the resident on Enhanced Barrier Precautions (EBP), only providing care of the gastrostomy tube. The CNAs did not need to don a gown when providing care. A few minutes later, CMT3 returned and stated that it made sense for the CNAs to wear a gown while providing this resident's ADLs On 04/08/25 at 10:38 AM, an interview with Licensed Practical Nurse (LPN)2 confirmed R44 was on EBP for her gastrostomy tube; and the staff should don a gown and gloves when providing care to this resident. LPN2 also stated that CNA10 should have sanitized the sit-to-stand lift after using it on R44. 2. A review of R81's Face Sheet located in the resident's EMR section titled admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease with late onset and stage IV sacral pressure ulcer. A review of the R81's Quarterly MDS with an ARD 03/13/25 located in the resident's EMR section titled MDS revealed the resident had a Brief Interview for Mental Status score of three out of fifteen, indicating the resident had severely impaired cognition. The resident was assessed to have an unhealed sacral ulcer. Observation on 04/08/25 at 9:30 AM revealed the resident sitting in a recliner chair in the day room, dressed. No Personal Protective Equipment (PPE) cart was observed outside the resident's room. Observation 04/09/25 at 8:12 AM revealed R81 in a low bed with a specialty mattress, call light within reach. The PPE cart was located outside the resident's room, with signage for EBP. The cart contained a gown, gloves, and foot coverings. An observation on 04/09/25 at 8:15 AM revealed the Hospice CNA entered the room with towels and washcloths and did not don personal protective equipment (PPE) as indicated on the signage before entering the room. An interview on 04/09/25 at 8:40 AM with the Hospice CNA revealed that she had just finished providing the resident with a bath and changing the linen on her bed. The Hospice CNA stated the resident had a sacral ulcer that required a dressing change. The Hospice CNA stated that she was unaware that the resident was on Enhanced Barrier Precautions. The CNA further stated that the facility will usually send a communication informing Hospice staff of such issues, however, this information was not communicated. An interview on 04/09/25 at 9:08 AM with LPN2 revealed the resident was on EBP due to her sacral wounds, which required dressing changes. LPN2 stated there was supposed to be a PPE cart outside the resident's room and had noticed this morning the cart was not long there, so she replaced the cart. LPN 2 was informed that the PPE cart was not present on 04/07 and 04/08. An interview with the Infection Control Preventionist (ICP) on 04/10/25 at 9:00 AM revealed that any unnatural opening (such as wounds, gastrostomy tube, tracheostomy, or Foley catheters) in the body that puts residents at risk for infections. So those residents will be placed on EBP. The ICP stated R44 was placed on EBP for her gastrostomy tube even though it was not being used. The staff were expected to don gloves and gowns when providing any type of care to this resident. Also, it is an expectation that staff will sanitize the lifts after each resident lift. The ICP further stated that R81 was on EBP due to her open sacral wound and the Hospice CNA should have donned PPE when providing care to this resident. The ICP stated she would follow up with communicating to the Hospice Program that the resident was on EBP.

Based on record review and interviews, the facility failed to ensure five Certified Nurse Aides (CNA) of five CNAs reviewed received their annual performance evaluation. Failing to ensure CNAs received their annual performance evaluations potentially could cause CNAs to not meet the requirements of their job description and potentially lead to poor resident care. Findings Include: Review of the facility's policy titled, dated 2019, .3.1 HR (Human Resources) Conditions of Employment: Standard of Conduct: Performance Evaluations, revealed, It is the intent of this organization to evaluate its [sic] associates on the performance of essential job functions .The goal of ongoing performance management is to support the associate in understanding the essential functions and responsibilities of the position .Managers are accountable for failure to providing [sic] ongoing performance management for their direct reports in their personal evaluation. Review of CNA 3's personnel file revealed there had not been an annual performance evaluation completed since their date of hire. Review of CNA 4's personnel file revealed there had not been an annual performance evaluation completed since their date of hire. Review of CNA 5's personnel file revealed there had not been an annual performance evaluation completed since their date of hire. Review of CNA 6's personnel file revealed there had not been an annual performance evaluation completed since their date of hire. Review of CNA 7's personnel file revealed there had not been an annual performance evaluation completed since their date of hire. During an interview on 04/10/25 at 1:40 PM, the Assistant Director of Nursing (ADON) stated she was not aware that staff needed an annual performance review. During an interview on 04/10/25 at 1:44 PM, the Human Resources Director stated she prints the list of all employees every month that are scheduled to receive their annual performance review and provides the list to the department managers. She stated she rarely gets reviews returned. She stated for the CNAs; she will give the list to the ADON. She confirmed she did not have any performance evaluations for the five CNAs that had been reviewed. During an interview on 04/10/25 at 2:48 PM, the Director of Nursing (DON) stated the regulation should be followed and CNAs should have annual performance evaluations. During an interview on 04/10/25 at 2:59 PM, the Administrator stated that the regulation should be followed, and CNAs should receive their annual performance evaluations.

Based on staff interviews, record review, and review of facility policy titled, Abuse Prohibition, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime for resident to resident physical and verbal abuse in accordance with section 1150B of the Social Security Act. The facility failed to report one allegation of physical and verbal abuse to the State Survey Agency (SSA) for one of one resident (Resident (R) 35) reviewed for abuse. These failures had the potential to contribute to further physical and verbal abuse and possible psychosocial harm for R35. Findings include: Review of the facility's policy titled Abuse Prohibition, revised December 2022, revealed All allegations of abuse or allegations involving serious bodily injury must be reported immediately but no later than 2 hours . ln addition: The administrator or designee will take immediate action to prevent further potential occurrences while the alleged occurrence is being investigated. The Administrator or designee will notify the Complaint Investigation Intake and Referral Unit and the legal representative and/or responsible party of the incident and the pending investigation. The Ombudsman will also be notified as appropriate. The Administrator or designee will direct the investigation. Review of R35's Face Sheet from the electronic medical record (EMR) Data Collection; admission Data tab showed medical diagnoses that included Alzheimer's disease with late onset, dementia with other behavioral disturbances; delusional disorder; and insomnia. Review of R35's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/14/2023 showed a Brief Interview for Mental Status (BIMS) score of 99 indicative that the BIMS was not completed. The staff assessment for mental status indicated that R35 had short- and long-term memory problems and was severely cognitively impaired in daily decision making. Review of R35's EMR Nurses Notes revealed: 4/18/2023 06:00 [6:00 a.m.] Note Text: Observation Data: Reason for observation: Follow-up Incident/Fall - Pushed against the door by another res [resident] Pain location: Rt [right] Shoulder and Back Additional comments: This res [R35] was constantly following the res [R33] that pushed her causing the other res [R35] to become agitated at her pushing her against the door frame stating, 'R33 cursed' this res [R35] hit her rt shoulder and back during the incident, this nurse escorted this res [R35] back to her room away from the res [R33], when assessed no injuries were noted at the time. Review of the paper facility reported incident investigation, dated 4/18/2023 provided by the Administrator on 4/26/2023 revealed that During the course of the investigation, R33 proceeded to push R35 in the hallway. During an interview on 4/26/2023 at 10:09 a.m., the Administrator revealed that the incident on 4/18/2023 had not been reported to the SSA. The Administrator stated that there was not a separate report for the incident on 4/18/2023 because she included it in the ongoing investigation that was still active from the incident on 4/09/2023. Since it was the same two people, it was part of the same investigation. The Administrator stated she thought she could include the 4/18/2023 incident when she submitted the 5-day report because the final report was going to be the same.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and review of the facility's policy titled, ADL [Activities of Daily Living] Plan of Care, the facility failed to ensure residents received showers per the shower schedule for one of three residents (Resident (R) 58) reviewed for ADLs. Specifically, the facility failed to ensure that scheduled showers were completed for R58. Findings include: Review of the facility's policy titled, ADL Plan of Care, dated 12/30/2022, revealed . Guideline Resident's ADL needs are assessed on admission and are addressed on the baseline Care Plan and communicated to staff. Nursing develops the patient's ADL care plan and will communicate the level of assistance required for the patient. The ADL care plan will be updated in conjunction with the comprehensive care plan as required per regulatory and RAI [Resident Assessment Instrument] guidance and with changes in patient needs. Review of the admission Minimum Data Set [MDS] with an assessment reference date (ARD) of 3/20/2023, found in the electronic medical record [EMR] under the MDS tab, revealed R58 had a Brief Interview for Mental Status [BIMS] score of 11 out of 15 which indicated the resident was cognitively intact. The MDS indicated R58 required physical help in part from one staff member with bathing. Per this MDS, the resident had no refusals of care, and it was very important for the resident to make choices regarding bathing. Review of R58's Self-Care Deficit Care Plan, dated 3/28/2023 and found in the EMR under the Care Plan tab, indicated to assist with ADLs as needed. Review of R58's Nurses Note, dated 4/26/2023 and found in the EMR under the Nurses Notes tab revealed Resident refused his shower on night shift and this nurse was told in report that he refused it earlier today as well. His family member is in the room and said he had a tough time in therapy today and doesn't want the shower. She said he had a sponge bath last night as well. However, there were no further nurses' notes that documented that R58 had refused any showers since admission. Review of the facility's Shower Schedule, undated and provided by the facility, revealed showers were scheduled by room number. The document indicated R58 was to be showered weekly on Tuesdays and Fridays. Review of the facility's Shower Sheets provided by the facility revealed R58 did not receive a shower on nine of 13 shower opportunities. R58 did not receive a shower on the following dates after admission: [DATE], 3/31/2023, 4/04/2023, 4/07/2023, 4/11/2023, 4/14/2023, 4/18/2023, 4/21/2023, and 4/25/2023. There were no shower refusals documented on the shower sheets. Additionally, review of the shower sheet dated 3/29/2023 revealed a written note at the bottom of the sheet which stated [R58] must get a shower today. Has doctor apt [appointment] in a.m. During an interview and observation on 4/24/2023 at 12:52 p.m., R58 was sitting in a wheelchair next to the overbed table wearing shorts and a shirt. R58 stated he had a shower twice since he was admitted to the facility. R58 also stated he was in a car accident prior to admission and was in pain the first week so he understood why the staff did not give him a shower. R58 indicated that he had to request a shower before his ortho appointment which was on 3/29/2023. R58 indicated he had scheduled shower days but was not sure of the days. R58 revealed he preferred a shower rather than a bed bath twice a week and he had not refused any showers. During an interview on 4/26/2023 at 2:08 p.m., Certified Nursing Assistant (CNA) 4 stated she had given R58 two showers when he was admitted , and he had not refused showers when she was assigned to him. CNA4 stated showers were provided to residents twice a week and if the resident refused the shower, then the assigned nurse was notified, and the nurse would talk to the resident to encourage them to shower. CNA4 indicated the shower sheet was initialed by the assigned CNA after the shower was provided to the resident. CNA4 stated any shower refusals by the resident were supposed to be entered on the shower sheet too. CNA4 explained she was not aware that R58 had only received two showers and she was not aware of any reason that he could not have a shower. During an interview on 4/26/2023 at 2:29 p.m., CNA5 stated she had provided one shower to R58 the second week he had been at the facility. CNA5 stated she had not been assigned to provide a shower to R58 in a long time but was not aware that he had refused any showers. CNA5 indicated the shower sheet was initialed after a shower was provided to the resident. CNA5 indicated if the resident refused the shower, the nurse was notified, and the refusal was documented in the book. During an interview on 4/27/2023 at 3:46 p.m., the Director of Nursing (DON) stated she expected the CNAs to provide morning and evening cares on the residents which included washing their face and hands, round every two hours during the day to check and change the resident's briefs and provide showers twice a week which could be done by the day or night shift staff. The DON stated showers were not scheduled with the residents instead they were provided when the staff had time to give them. The DON indicated R58 was admitted after a car accident with broken bones and could not receive a shower because he was in pain. The DON indicated R58 had refused showers but only found one nurses note that documented his refusal on 4/26/2023.

Based on observation, staff interview, record review, and review of the facility's policy titled, Weight and Nutrition Management, the facility failed to implement a planned intervention to prevent weight loss for one of four residents (Resident (R) 32) reviewed for nutritional status. The facility failed to serve R32 a nutritional shake with meals as ordered by the resident's physician. The deficient practice had the potential to prevent the maintenance of adequate nutritional status, to the extent possible, to ensure R32 was able to maintain the highest practicable level of well-being. Findings include: Review of the facility's policy titled, Weight and Nutrition Management, dated 12/30/2022, revealed, It is the intent of this center to review and assess nutritional aspects related to significant weight changes. Guideline . The center should discuss and document the risk for significant weight changes, nutritional issues, needs, and goals in the context of the patient's overall condition and plan of care through a collaborative interdisciplinary team (IDT) environment. The center should consider possible interventions and monitor the effectiveness of the interventions, while adhering to patient preferences and plan of care. Review of R32's Face Sheet, provided by the facility, revealed R32 was admitted to the facility with diagnoses which included weight loss. Review of R32's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/06/2023, located in the resident's electronic medical record (EMR) under the MDS tab, specified the resident had experienced a significant weight loss and was independent with set up help only with eating. The resident had a Brief Interview for Mental Status (BIMS) score of 99, which meant the resident was unable to complete the interview. Review of R32's monthly weights located in the resident's EMR under the Weight tab revealed the resident weighed 162.9 pounds on 3/16/2023 and 156.8 pounds on 4/05/2023 which equates to a 6.1 pound weight loss during this time period. Review of R32's comprehensive care plan located in the resident's EMR under the Care Plan tab revealed a Care Area/Problem updated on 4/07/2023 that specified R32 was at Risk for altered nutritional status. A care plan intervention specified R32 was to receive a nutritional shake as ordered. Review of R32's Physician Orders, located in the resident's EMR under the Orders tab revealed a current order, that was originally written on 2/20/2023, for R32 to receive a carton of a nutritional shake with meals related to a risk of malnutrition. Observation on 4/25/2023 at 9:03 a.m. revealed R32 was in his room eating his breakfast meal. Review of the resident meal tray slip revealed the resident was to receive a nutritional shake with his meal. Observation of R32's breakfast meal tray revealed he was not served a nutritional shake with this meal. Observation on 4/25/2023 at 1:00 p.m. revealed R32 was in the dining room eating his lunch meal. Review of the resident meal tray slip revealed the resident was to receive a nutritional shake with his meal. Observation of R32's lunch meal tray revealed he was not served a nutritional shake with this meal. During an interview on 4/25/2023 at 1:00 p.m., Licensed Practical Nurse (LPN) 2 confirmed that R32 did not receive a nutritional shake on his lunch meal tray. Observation on 4/25/2023 at 1:05 p.m. revealed LPN2 obtained and provided R32 a nutritional shake and placed a straw in the shake for the resident. Observation on 4/25/2023 at 1:40 p.m. revealed LPN2 picked up R32's finished lunch meal tray in the dining room. LPN2 stated that R32 consumed 100 percent of the nutritional shake that she provided him during the lunch meal. During an interview on 4/27/2023 at 9:05 a.m., the facility's Medical Director, who was R32's Physician, stated that R32 had experienced a recent weight loss of six pounds and would benefit from receiving the nutritional shake at each of his meals as ordered. During an interview on 4/27/2023 at 10:20 a.m., the Dining and Nutrition Services Manager (DNSM) stated that the dietary department was responsible for providing R32 with the nutritional shake on his meal trays as noted on the resident's meal tray slip, but the kitchen staff failed to serve R32 the nutritional shake during the 4/25/2023 breakfast and lunch meals as ordered.

Based on observation, staff interviews, record review, and review of medication guidance titled, Instructions for Use Toujeo® Solostar® (insulin glargine injection) 1.5 mL single-patient-use prefilled pen, the facility failed to ensure proper injection technique was used for one of one sampled residenst (Resident (R) 14) reviewed for insulin during medication administration. This failure had the potential to result in the wrong dose of insulin being administered to the resident. Findings include: Review of the Toujeo guidance titled, Instructions for Use Toujeo® Solostar® (insulin glargine injection) 1.5 mL single-patient-use prefilled pen, undated, accessed on 4/27/2023 at https://www.toujeopro.com/dam/jcr:850417fb-a90f-4c51-84a0-897ea4831be8/Toujeo%20SoloStar%20Instructions%20for%20Use.pdf revealed. 2A Take a new needle and peel off the protective seal. 2B Keep the needle straight and screw it onto the pen until fixed. Do not overtighten. 2C Pull off the outer needle cap. Keep this for later. 2D Pull off the inner needle cap and throw away. Step 3: Do a safety test. Always do a safety test before each injection to: Check your pen and the needle to make sure they are working properly. make sure that you get the correct insulin dose. If the pen is new, you must perform safety tests before you use the pen for the first time until you see insulin coming out of the needle tip. If you see insulin coming out of the needle tip, the pen is ready to use. If you do not see insulin coming out before taking your dose, you could get an underdose or no insulin at all. This could cause high blood sugar. 3A Select 3 units by turning the dose selector until the dose pointer is at the mark between 2 and 4. 3B Press the injection button all the way in. When insulin comes out of the needle tip, your pen is working correctly . Review of R14's undated Face Sheet, under the admission Record tab in the electronic medical record (EMR), revealed R14 was admitted to the facility with diagnosis of type 2 diabetes mellitus [DM] with other diabetic kidney complication. Review of R14's quarterly Minimum Data Set [MDS] with an assessment reference date (ARD) of 1/05/2023, found in the electronic medical record (EMR) under the MDS tab, revealed R14 had a Brief Interview for Mental Status [BIMS] score of 11 out of 15, which indicated she was moderately cognitively intact. The MDS also indicated R14 had a diagnosis of DM and received seven insulin injections during the last seven days. Review of R14's Physician Orders, dated 4/06/2023, found in the EMR under the Orders tab, revealed an order for Toujeo Solostar U-300 Insulin 300 unit/ML [milliliters] (1.5 ML) subcutaneous pen 40 unit/units subcutaneous 1 [one] time per day for DM. Observation on 4/27/2302 at 7:54 a.m. revealed Licensed Practical Nurse (LPN) 3 retrieved R14's insulin pen (an insulin pen contains the vial of insulin inside the pen and has a mechanism where the dose to be administered is set on a dial at the top of the pen, and only that amount can then be injected) from the medication cart, wiped the top with an alcohol wipe and dialed the dose to 40 units. LPN3 attached a needle to the insulin pen then carried the pen to R14's room. LPN3 washed her hands, applied gloves, observed R14's abdomen to find a spot that was not bruised, cleansed the right lower quadrant with an alcohol wipe, gently inserted the pen needle into the flesh, injected the dose then removed the needle from the abdomen after slowly counting to five. LPN3 carried the pen to the medication cart, disposed of the needle, and performed hand hygiene. During an interview on 4/27/2023 at 7:59 a.m., LPN3 stated she had not received training on how to administer insulin using an insulin pen and she primed the pen prior to the first dose of insulin administered, not prior to every injection, per manufacturer's guidelines. During an interview on 4/27/2023 at 9:48 a.m., the Resident Care Coordinator (RCC) stated she trained staff during orientation on the administration of insulin but not on the use of the insulin pen. The RCC indicated she was not aware that the insulin pen had to be primed with three units prior to administering the insulin to the resident. The RCC stated the insulin pen should be primed to ensure the needle was functioning correctly to administer the correct dose of insulin. During an interview on 4/27/2023 at 9:52 a.m., the Director of Nursing (DON) stated that nurses were trained on how to administer insulin to residents but not how to use the insulin pens. The DON acknowledged she was not aware the insulin pen should be primed with three units prior to every injection to ensure the needle worked. The DON indicated she expected the nurses to follow the manufacturer's guidelines when using the insulin pens.

Based on observation, resident and staff interviews, tasting of foods served on a requested test tray, record review, review of Resident Council meeting minutes, and review of the facility's policy titled, Meal Service, the facility failed to serve food that was hot to three of 38 sampled residents (Resident (R) 61, R52, and R47) reviewed for food palatability. This had the potential to affect 64 residents who consumed food that was prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Meal Service, dated of 12/30/2022, revealed, It is the intent of the center to provide an enjoyable meal service in a safe, sanitary, and comfortable environment while focusing on patient centered care. Guideline . The center should provide meals and hydration that conserve nutritive value, flavor, and appearance, and that are palatable, attractive, and a safe and appetizing temperature. 1. Review of R61's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/04/2023, located in the resident's electronic medical record (EMR) under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated the resident was cognitively intact. During an interview on 4/24/2023 at 11:20 a.m., R61 stated she did not like the food the facility served at meals. The resident specified she was served cold food at meals, and this occurred at breakfast, lunch, and evening meals. Observation on 4/24/2023 at 1:03 p.m. revealed R61 was in her room eating her lunch meal which included a hamburger and tater tots. R61 stated the hamburger and tater tots she was served were cold. R61 also stated she did not receive any salt, pepper, mustard, or ketchup on her meal tray to help improve the taste of the food. R61 stated her lunch meal was not appetizing. 2. Review of R52's admission MDS with an ARD of 2/05/2023, located in the resident's EMR under the MDS tab revealed a BIMS score of eight of 15 which indicated the resident had moderate cognitive impairment. During an interview on 4/24/2023 at 10:14 a.m., family member (F) 52 stated that she visited daily, and the food served to residents at meals was not always hot. F52 specified that R52 ate meals in his room and about ninety percent of the time the food at meals was cold when served. Review of the Resident Council meeting minutes dated 3/29/2023, provided by the facility, revealed, eight residents attended the meeting and Residents c/o [complained of] coffee being cold and not always getting sugar on their tray. In response to resident and family complaints about food, a test tray was requested for the breakfast meal of 4/26/2023. Observations revealed that, before the tray cart left the kitchen at 7:58 a.m. food temperatures were at acceptable levels, greater than 140 degrees Fahrenheit The meal trays were placed on an enclosed cart with no heating element. The last breakfast tray was served on the 200 hall on 4/26/2023 at 8:28 a.m. At this time, the test tray was sampled in the presence of the facility's Infection Preventionist (IP). Observation and tasting of the food revealed the following: The sausage served on the test tray tasted cold. The IP also tasted the sausage and agreed that it tasted cold. The French toast served on the test tray tasted cold. The IP also tasted the French toast and agreed that it tasted cold. The scrambled eggs served on the test tray tasted slightly warm. The IP also tasted the scrambled eggs and agreed they tasted slightly warm. The grits served on the test tray tasted slightly warm. The IP also tasted the grits and agreed they tasted slightly warm. The coffee served on the test tray tasted barely warm. The IP opted to not taste the coffee that was served on the test tray. 3. During a Resident Council interview, that was conducted by the survey team on 4/26/2023 at 3:00 p.m., R47 voiced a concern that food was not always hot when served at meals. R47 specified that during the previous week he was served pizza that looked like it never even went into the oven. The resident stated the pizza was too cold and he did not eat it. During an interview on 4/27/2023 at 10:20 a.m., the Dining and Nutritional Services Manager (DNSM) stated food should be hot when served to residents at meals.

Based on staff interview, record review, and review of facility policy titled, Abuse Prohibition, the facility failed to ensure residents were free from physical abuse by another resident for one of one resident (R) 35 reviewed for resident-to-resident altercations and one supplemental resident R57. R35 was the victim of physical abuse perpetrated by R33 on three occasions and R57 was the victim of physical abuse perpetrated by R33 on one occasion. This deficient practice had the potential to affect the safety of all residents in the facility. Findings include: Review of the facility's policy titled, Abuse Prohibition, revised December 2022, revealed . It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse .This policy applies to anyone subjecting a patient to abuse including center staff, other patients .The center will identify, correct, and intervene in situations in which abuse .is more likely to occur. This will include an analysis of: The deployment of staff on each shift in sufficient numbers to meet the needs of the patients and assure that the staff assigned has knowledge of the individual patients' care needs. The assessment, care planning and monitoring of patients with specialty needs and behaviors which might lead to conflict, such as patients with a history of aggressive behaviors, patients who have behaviors such as entering other patients' room .Protect the residents from abuse by anyone including, but necessarily limited to: Facility staff, other residents .Patients who have displayed or attempted to display abusive behavior towards other patients. ii. From the assessment, intervention strategies will be developed on the care plan or behavior management plan to prevent occurrences including monitoring for factors that trigger abusive behavior for this patient iii. The care plan including interventions will be evaluated on a regular basis and revised as necessary. Allegations that do not involve abuse or allegations with serious bodily injury must be reported immediately but no later than 24 hours . At the discretion of the Administrative staff, room changes may be implemented, if necessary, to protect the resident(s) from the alleged perpetrator. 1. Review of R35's Face Sheet from the electronic medical record (EMR) Data Collection; admission Data tab showed medical diagnoses that included Alzheimer's disease with late onset, dementia with other behavioral disturbances; delusional disorder; and insomnia. Review of R35's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 1/14/2023 showed a Brief Interview for Mental Status (BIMS) score of 99 indicative that the BIMS was not completed. The staff assessment for mental status indicated R35 had short and long term memory problems and was severely cognitively impaired in daily decision making. Review of R35's EMR Nurses Notes revealed: 4/09/2023 23:58 [11:58 p.m.] Note Text: 19:15 p.m. [7:15 p.m.] Res [resident] [R35] was hit in the head and face per another resident [R33] with a small stuffed animal, no injuries were noted after assessing res [R35] but she is very anxious, the other res [R33] was separated from this resident [R35] and redirected to another area, this res [R35] was given prn [as needed] Ativan for anxiety. 4/18/2023 06:00 [6:00 a.m.] Note Text: Observation Data: Reason for observation: Follow-up Incident/Fall - Pushed against the door by another res. Pain location: Rt [right] Shoulder and Back Additional comments: This res [R35] was constantly following the res [R33] that pushed her causing the other res to become agitated at her pushing her against the door frame stating [R33 cursed R35] this res [R35] hit her right shoulder and back during the incident, this nurse escorted this res [R35] back to her room away from the res [R33], when assessed no injuries were noted at the time. 4/24/2023 06:37 [6:37 a.m.] Note Text: While coming around the corner into the nurse's station, this nurse obs [observed] another res [R33] slap this res [R35] on the left side of her face, I immediately went and separated the other res [R33] from this res [R35]. When I asked [R33] 'Why did you slap her?' She stated, 'I'm having a bad day.' A staff member assisted the other res [R35] to her room after I administered her meds, this res [R35] became a little anxious, mild redness noted to the left side of her face, res [R35] was given her meds and assisted to bed per staff. Review of R35's Care Plan from the EMR Care Plan tab showed: Care Area/Problem: Altercations/risk of altercation (4/09/2023: Onset). Goal: Patient will not injure self or others during the review period (4/09/2023: Onset) Interventions: Administer medications as ordered, encourage patient to express feelings, intervene as needed, Notify MD [medical doctor] as indicated, observe patient to patient interactions Review of the paper facility reported incident investigation, provided by the Administrator, included both the events on 4/09/2023 and 4/18/2023 (the investigation of the events of 4/23/2023 were still ongoing) showed the resident-to-resident abuse was unsubstantiated we were unable to substantiate abuse due to the cognition and intent of R33 during a paranoid state. The MD and responsible parties agree with the plan. Both residents will continue to be followed. An abuse in-service with associates was held today. During an interview on 4/25/23 at 4:44 p.m., regarding the incidents with R33, the charge nurse Licensed Practical Nurse (LPN) 2 stated, There was an incident last week with [R33] and [R35] during which [R35] was sitting and [R33] had a stuffed animal in her hand. LPN2 stated it occurred on the night shift and the interventions at that time were that they separated them. LPN2 stated that yesterday (4/24/2023) there was another incident, R33 came and slapped R35. LPN2 stated the staff intervened and separated them. LPN2 stated that at one point they were doing one on one with R33, but that there is always a nurse aide on the unit. There is one nurse aide on the unit for the twelve residents. 2. Review of R57's Face Sheet from the EMR Data Collection; admission Data tab showed diagnoses including Alzheimer's disease with late onset; dementia in other diseases classified elsewhere, moderate, without other behavioral disturbances; generalized anxiety disorder; and depression. Review of R57's admission MDS, with an ARD of 3/02/2023 showed a BIMS score of six out of 15, indicative that the resident was severely cognitively impaired in daily decision making. Review of R33's EMR Nurses Notes revealed: 4/23/2023 19:00 [09:00 p.m.] This nurse witnessed Resident [R33] wandering in hallway of secured unit, raise hand up in air then hit another resident [R57] on right upper arm causing redness immediately afterwards. During an interview on 4/25/2023 at 6:00 p.m. with the Administrator and the Director of Nursing (DON) it was revealed that R33 had a history of behaviors and that was why she was placed on Seroquel (an antipsychotic medication) originally. The physician did a Gradual Dose Reduction (GDR) with Seroquel, and it was discontinued in February 2023. They noticed the behaviors starting again. The first incident was 4/09/2023, R33 hit R35 with a stuffed animal. The DON revealed that R35 gets on R33's nerves, and R35 did turn around and hit R33 in the face. The DON stated staff redirected R33 and put her in an area where she could be visualized by the staff. The DON continued to state, on 4/17/2023, R33 shoved R35 into the bathroom door and there were no injuries; afterwards, both residents were put to bed, and a urinalysis was ordered for R33. Depakote was ordered for R33, and increased observations were provided by staff. The Administrator stated that an Administrative Assistant provided close observation of R33 from 1:00 p.m. to 2:45 p.m. on 4/18/2023 by sitting outside of her room in a chair. On 4/23/2023, R33 hit a different resident, R57, in the arm in the common area on the memory care unit. No injuries were noted. Interventions included separating the residents and increasing observations by the nursing staff. On 4/24/2023, R33 was sent to the emergency room (ER) where the psychiatrist made the recommendation to restart the antipsychotic medication. The Administrator indicated R33 was sent to the ER because the close supervision was not working. The Administrator stated she sent referrals to other facilities for placement of R33. The Administrator stated she considered moving R33 and R35 off the memory care unit, but they wander so they cannot be removed from the locked unit. The Administrator indicated she provided abuse education to all staff on 4/17/2023 and 4/18/2023. The Administrator stated the policy said to report it and intervene, notify the physician; it says they will make sure they are free from abuse. During an interview on 4/26/2023 at 5:31 a.m., Certified Nursing Assistant (CNA) 2 stated that R35 usually slept all night. CNA2 stated sometimes R33 wandered at night, sometimes into other residents' rooms and takes things. CNA2 stated she was told to keep an eye on her [R33]. Sometimes she sees R33 wandering in the hallway when she comes out of her room and watches her. When they go on break, another nurse covers the watching of residents. Often a CNA from another unit will come over. This evening R33 had a sitter. During an interview on 4/26/2023 at 5:38 a.m., the Environmental Services Aide stated she helped in other areas, though she was not a CNA. The Environmental Services Aide stated the first time she sat with R33 she was told to watch the resident and that if she got up to stick close to her. The Environmental Services aide stated she was not told that R33 had hit, shoved, or threw anything at anyone, but heard she was told keep an eye on R33 if she woke up and stay close to her and not let her go into other rooms. During an interview on 4/26/2023 at 5:56 a.m., LPN1, a staff nurse that covers both halls, stated that in the incident last week, R33 pushed R35 into the door frame, and called her a bitch, there was no injury. LPN1 stated the second incident occurred in hallway tv area next to nurses' station, R33 came around the corner and just walked up and slapped R35, R35 had a red area on the face. LPN1 stated around 6:40 a.m. that day the staff were told to watch R33, it was not a one on one though. LPN1 stated they were not able to provide close supervision, because there was only one CNA on each side and one nurse. Often a nurse is in a room and CNAs are in rooms and sometimes there was only one CNA for both units. LPN1 stated since the first incident, there had been only one CNA and since the second incident only one CNA. LPN1 stated on Sunday (4/23/2023), R33 hit another resident, R57, before she had slapped R35 and the incidents were reported to management. LPN1 stated the staff were told to watch, no additional staff were added. LPN1 stated other residents on the floor may not be safe without one-on-one supervision until R33's meds are adjusted. During an interview on 4/26/2023 at 7:26 a.m., the Administrator stated that for today R33 has had a one on one, they added one at 6:45 p.m. last night the day she hit R57. The Administrator stated, Things progressed and the doctor agreed to send her out [to the ER]. This was not her normal. We didn't expect that this would happen. At some point you run out of interventions.

Based on observation, resident and staff interviews, record review, and review of the facility's policy titled, Dialysis and Nutrition Management, the facility failed to make meal scheduling adjustments for the provision of meals during the mornings for one of two residents (Resident (R) 48) reviewed for dialysis and who left the facility to receive dialysis treatments. The deficient practice had the potential to prevent the maintenance of adequate nutritional status, to the extent possible, to ensure R48 was able to maintain the highest practicable level of well-being. Findings include: Review of the facility's policy titled, Dialysis and Nutrition Management, dated 12/30/2022, revealed, It is the intent of this center to review and assess the nutritional aspects related to patients receiving dialysis services. Guideline . The center should provide a nutritional snack during dialysis center visits, as needed and desired . The center should provide meal-scheduling adjustments as needed. Review of R48's Face Sheet, provided by the facility, revealed R48 was admitted to the facility with diagnoses which included end stage renal disease (ESRD) and type 2 diabetes mellitus with diabetic chronic kidney disease. Review of R48's comprehensive care plan located in the resident's electronic medical record (EMR) under the Care Plan tab revealed a Care Area/Problem updated on 3/29/2023 that specified R48 was at risk for altered nutritional status related to ESRD on Hemodialysis. An intervention specified Provide diet as prescribed. The care plan did not address how the facility was going to provide R48 with a breakfast meal prior to her being transported from the facility to the dialysis center three times per week. Review of R48's quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 4/04/2023, located in the resident's EMR under the MDS tab, specified the resident received dialysis. The resident had a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact. Review of R48's Physician Orders, located in the resident's EMR under the Orders tab, revealed a current order for the resident to receive dialysis on Monday, Wednesday, and Friday. During an interview on 4/24/2023 at 2:20 p.m., R48 stated she was transported to a dialysis center to receive dialysis treatments three times per week on Monday, Wednesday, and Friday. R48 explained she left the facility to go to the dialysis center at around 5:30 a.m. to 5:45 a.m. and did not receive a breakfast meal or any food to take with her prior to leaving the facility. R48 specified that after her dialysis treatments she returned to the facility between 10:30 a.m. to 11:00 a.m. and when she returned her uneaten breakfast meal tray would still be in her room. R48 stated she did not eat any food served on her breakfast tray because the food was cold and had been sitting in her room since earlier in the morning. R48 stated after she returned from dialysis, she was hungry and would ask staff for something to drink and eat. R48 explained that about a month ago her dialysis treatment schedule was changed to 6:00 a.m., so she had to leave the facility before her breakfast meal was served and no one had discussed with her a plan to receive her breakfast meal or food before she left for her dialysis treatment. During an additional interview on 4/26/2023 at 5:40 a.m., R48 was seated in her room, and she stated that she was ready to go to dialysis. R48 stated that she was not provided with a breakfast meal or any food to take with her to dialysis this morning. R48 stated earlier in the morning she requested the nursing staff to provide her with a nutritional supplemental beverage and she had consumed this beverage. Observation on 4/26/2023 at 6:02 a.m. revealed R48 exited the facility and was placed on a transport van. R48 was observed not to have any food provided by the facility to take with her to the dialysis center. Observation on 4/26/2023 at 10:00 a.m. revealed R48 was not in her room, but her uneaten breakfast tray was in her room. Observation on 4/26/2023 at 10:48 a.m. revealed that R48 had returned to the facility and was being assisted back to her room. Observation on 4/26/2023 at 11:02 a.m. revealed R48 was in her room and her uneaten breakfast tray remained in her room. During an interview on 4/26/2023 at 11:02 a.m., R48 stated that when she returned from dialysis her uneaten breakfast meal tray was left in her room. R48 stated she was hungry but did not eat any food from her breakfast tray. R48 stated that she would like something to eat and drink, but no one had offered her anything since she returned from her dialysis treatment. During an interview on 4/26/2023 at 11:15 a.m., Certified Nursing Assistant (CNA) 3 stated on the mornings that R48 received dialysis her breakfast meal tray was delivered from the kitchen to the hallway after the resident had left the facility for her dialysis treatment. CNA3 stated that staff would leave R48's breakfast meal in her room because she might eat something from her meal tray when she returned to the facility after her dialysis treatment. During an interview on 4/26/2023 at 11:22 a.m., the Dining and Nutritional Services Manager (DNSM) stated she was not aware that R48's scheduled dialysis treatments were changed to the early morning (6:00 a.m.) during the past month. The DNSM explained that no adjustments were made by the kitchen staff to prepare and serve R48's breakfast meal earlier on her dialysis days to ensure that she received it prior to being transported to dialysis.

Based on observation, resident and staff interviews, record review, and review of the facility's policy titled, ''Infection Control Recommendations,'' the facility failed to ensure infection control policies were followed for four of 22 sampled residents that included: the storage of a Yankaeur catheter used for suctioning for one resident (R1), the storage of nebulizer masks for two residents (Resident (R) 9 and R39), and the cleaning of a nebulizer mask after medication administration for one resident (R211). These deficient practices had the potential to spread infection. Findings Include: Review of a facility's policy titled, ''Infection Control Recommendations,'' updated June 2018, indicated, ''Nebulizers should be in a bag when not in use . Nebulizers should be rinsed with sterile water or sterile saline and air dried after each treatment . Suction Yankauers are to be discarded when soiled, and equipment should be bagged when not in use.'' 1. Review of R1's quarterly ''Minimum Data Set (MDS)'' assessment located in the resident's EMR under the ''Minimum Data Set'' tab with an Assessment Reference Date (ARD) of 3/06/2023, revealed R1 had severely impaired cognition. Review of the ''Physician Orders'' located in the R1's EMR under the ''Orders'' tab dated 7/20/2022 revealed ''oral suction as needed [prn] for excess secretions.'' Review of R1's April 2023 ''Medication Administration Record [MAR],'' located in the resident's EMR under the ''Med and Treat'' tab, revealed R1 was suctioned as needed. During an observation in R1's room on 4/24/2023 at 10:21 a.m., the Surveyor observed a clean Yankauer catheter without the original packaging, not bagged, lying in the top drawer of R1's bedside table. During an interview on 4/26/2023 at 6:25 a.m., the Director of Nursing (DON) stated clean Yankauer catheters were to be stored in a bag if opened and attached to the suction machine. During an interview on 4/24/2023 at 4:20 p.m., the Infection Preventionist (IP) Nurse stated sometimes there were agency staff during the night shift and there have been issues with the storage of respiratory equipment. The IP stated that on Mondays and a few other days, she made rounds and addressed any respiratory issues. The IP stated on 4/24/2023, she observed R1's Yankauer catheter open and uncovered, lying in her drawer. The IP stated Yankaeur catheters were to be kept in a bag when not in use to prevent infection issues. 2. Review of R9's undated ''Resident Face Sheet,'' located in the resident's EMR under the ''Resident'' tab, indicated R9 was admitted to the facility with diagnoses including emphysema. Review of R9's quarterly ''MDS,'' assessment located in the resident's EMR under the ''Minimum Data Set'' tab with an ARD of 1/12/20253, revealed R9 had severely impaired cognition. Review of the ''Physician Orders'' dated 3/28/2023 indicated: ipratropium 0.5 milligram (mg) -albuterol 3 mg (2.5mg base)/3 milliliters (ml) nebulization solution, one solution for nebulization inhalation three times per day, budesonide 0.25 mg/2ml suspension for nebulization, one suspension for nebulization inhalation twice per day for emphysema, and albuterol sulfate 2.5mg/3ml solution for nebulization, one solution for nebulization inhalation every six hours as needed (prn) shortness of breath/wheezing. Review of R9's April 2023 ''MAR,'' located in the resident's EMR under the ''Med and Treat'' tab, revealed R9 received the ipratropium-albuterol solution and budesonide via nebulization as ordered. During an observation in R9's room on 4/24/2023 at 10:30 a.m., the Surveyor observed R9's nebulizer mask lying directly on her bureau and the mask was not in a bag. 3. Review of R39's undated ''Resident Face Sheet,'' located in the resident's EMR under the ''Resident'' tab, revealed the resident was admitted to the facility with diagnoses including acute respiratory failure with hypoxia. Review of R39's annual ''MDS'' assessment, with an ''ARD'' of 2/05/2023, revealed R39 had a Brief Interview of Mental Status ''BIMS'' score of 13 out of 15, indicating intact cognition. Review of the ''Physician Orders'' dated 7/20/2022 revealed ''ipratropium 0.5 mg-albuterol 3mg (2.5 mg base) 3 ml nebulization solution, one vial for inhalation every 6 hours prn for shortness of breath/wheezing.'' During an observation in R39's room on 4/24/2023 at 10:38 a.m., the Surveyor observed R39's nebulizer mask sitting directly on her table and not in a bag. The nebulizer bag was observed on the floor. During an interview on 4/24/2023 at 10:37 a.m., R39 stated her nebulizer was usually on the table at the end of her bed and often was not in a bag. During an interview on 4/27/2023 at 7:50 a.m., Licensed Practical Nurse (LPN) 4 confirmed that nebulizer masks after being rinsed and dried were to be placed in a bag for storage. During an interview on 4/24/2023 at 4:20 p.m., the IP stated when she made rounds on 4/24/2023. R39's nebulizer mask was not in a bag on her table and the nebulizer bag was on the floor. She stated R9's nebulizer mask was on her bureau and was not stored in a bag. The IP Nurse stated she corrected these issues and other respiratory equipment storage issues she observed during her rounds on that day. She stated the staff were to ensure the equipment was clean, and in a bag when not in use. During an interview on 4/26/2023 at 6:25 a.m., the DON stated nebulizer masks were to be stored in a bag when not in use. 4. Review of R211's undated Face Sheet, under the admission Record tab in the electronic medical record (EMR), revealed R211 was admitted to the facility with diagnosis of chronic obstructive pulmonary disease (COPD) with acute exacerbation. Review of R211's quarterly MDS with an assessment reference date (ARD) of 1/05/2023, found in the electronic medical record (EMR) under the MDS tab, revealed R14 had a Brief Interview for Mental Status [BIMS] score of 11 out of 15, which indicated she was moderately cognitively impaired. Review of R211's Physician Orders, dated 4/14/2023, found in the EMR under the Orders tab, revealed an order for ipratropium 0.5 mg-albuterol 3 mg (2.5 mg base)/3 ml nebulization soln [solution] (Ipratropium Bromide/Albuterol Sulfate) 1vial inhalation 4 times per day. Observation on 4/26/2023 at 3:52 p.m. revealed LPN3 retrieved R211's vial of ipratropium bromide/albuterol from the medication cart, then carried the vial to R211's room. LPN3 placed the inhalation solution in the nebulizer cup on the machine. LPN3 connected the nebulizer to the face mask then applied it to R211's face. After the medicine was gone, LPN3 removed the mask then placed it in the bag next to the nebulizer. Interview on 4/26/2023 at 3:52 p.m., LPN3 stated she had not been trained to clean the mask after administration of the medication and prior to placing it in the bag. Interview on 4/26/2023 at 3:54 p.m., the DON indicated she expected the nurses to clean the nebulizer mask with normal saline after medication administration to remove the medication from the mask for infection control purposes. The DON stated LPN3 was trained on cleaning the nebulizer in February 2023. Interview on 4/26/2023 at 4:11 p.m., the IP stated that nebulizers should be rinsed with sterile water or sterile saline and air dried after each treatment to clean them. Review of LPN3's Nebulizer Treatment Skills Check, dated 9/08/2022, revealed she satisfactorily completed the return demonstration for nebulizer treatment which included rinsing the mask after administration of the treatment. Review of the facility's in-service titled Residents with Respiratory Symptoms, dated 2/20/2023 and signed by LPN3, revealed the nurses were instructed to rinse the nebulizer after each treatment with sterile water and air dry.

Based on observation, staff interviews, review of the facility's meal schedule, and review of the facility's policy titled, Meal Times, the facility failed to have sufficient dietary staff to assure food was prepared, served, and stored in a sanitary and safe manner. Kitchen cleaning schedules were not implemented due to a lack of sufficient staff to perform these duties, and food preparation, and service equipment was not cleaned and sanitized. Dietary staff failed to cover stored food and discard a stored food item with an expired use by date. Additionally, there was not sufficient dietary staff to ensure resident meals were served as scheduled. The lack of dietary staff had the potential to affect 64 of 64 residents who consumed food that was prepared from the kitchen. Findings include: Review of the facility's undated policy titled, Meal Times, revealed the resident's breakfast meal service was scheduled to begin at 7:15 a.m. and end at 8:15 a.m., resident lunch meal service was scheduled to begin at 12:15 p.m. and end at 1:15 p.m., and the resident evening meal service was to begin at 5:15 p.m. and end at 6:15 p.m. The facility's Meal Times policy did not provide specific times when meals were scheduled to be served to residents in the facility dining rooms or on facility hallways. Observation during the initial kitchen walk-through on 4/24/2023 from 9:10 a.m. to 9:40 a.m. revealed the kitchen was not clean. Kitchen food preparation and service equipment, including ovens, food preparation pans, manual can opener, shelves, knife rack, storage bin and kitchen carts were unclean with visible food debris. Opened food was not covered when stored and a food item with an expired use by date was not discarded. During an interview on 4/24/2023 at 9:40 a.m., the Dining and Nutritional Services Manager (DNSM) stated the kitchen had a daily cleaning schedule and a weekly deep cleaning schedule that staff were to initial when they completed their assigned cleaning duties. The DNSM explained the kitchen's equipment was observed unclean during the initial kitchen inspection on 4/24/2023 because there was not enough dietary staff available to perform scheduled cleaning duties. Observation of the resident meal service revealed the kitchen was serving meals later than scheduled at the following times: Observation on 4/24/2023 at 12:39 p.m. revealed resident lunch meals were delivered to the facility's independent dining room in an enclosed cart which was 24 minutes later than scheduled. During an interview on 4/27/2023 at 1:50 p.m., the Administrator confirmed the independent dining room lunch meal service is scheduled to begin at 12:15 p.m. Observation on 4/24/23 at 12:56 p.m. revealed resident lunch meals were delivered to the facility's 200 hall in an enclosed cart, which was 26 minutes later than scheduled. During an interview on 4/27/2023 at 1:50 p.m., the Administrator confirmed the 200-hall resident lunch meal service is scheduled to begin at 12:30 p.m. Observation on 4/26/2023 at 7:10 a.m. revealed the DNSM and another dietary employee were the only two employees working in the kitchen, and they were in the process of preparing the resident's breakfast meal and setting up the kitchen tray line. Observation on 4/26/2023 at 7:40 a.m. revealed the DNSM served the first resident breakfast meal from the kitchen's tray line. Observation on 4/26/2023 at 7:58 a.m. revealed the first resident breakfast meal cart left the kitchen and arrived on the 200 hallway at 8:00 a.m. which was 45 minutes later than scheduled. During an interview on 4/27/2023 at 10:20 a.m., the DNSM stated the reason the 4/26/2023 breakfast tray line started late, and resident meals were served later than scheduled was because there were only two employees working in the kitchen to prepare and serve this meal. The DNSM explained three dietary employees should be scheduled to work in the kitchen to prepare and serve the breakfast meal to ensure the meal is served as scheduled. The DNSM further explained that the dietary department had several vacant positions and she had to fill in and work positions in the kitchen on a continual basis because there was not sufficient staff. The DNSM stated the kitchen currently had three vacant cook positions and five vacant dietary aide positions. The DNSM further stated that the dietary department currently had only five employees who could work, including herself, which was not enough staff to keep the kitchen clean and to always get the resident meals prepared and served on time. During an interview on 4/27/2023 at 1:50 p.m., the Administrator confirmed that 200 hall resident breakfast meal service was scheduled to begin at 7:15 a.m. The Administrator stated the facility was trying to address the staffing shortages in the dietary department by having staff, including herself, be cross trained to work in the kitchen when needed to help cover vacant positions. The Administrator stated the facility was actively trying to recruit and hire dietary staff to fill the department's vacant positions. Cross-reference F812.

Based on observation, staff interviews, and review of the facility's policies titled, Cleaning and Sanitizing and Storage Areas, the facility failed to keep the kitchen's ovens, food preparation pans, manual can opener, shelves, knife rack, storage bin and kitchen carts clean and sanitized and failed to close stored food items and discard a bread product with an expired use by date. This had the potential to affect 64 residents who consumed food that was prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Cleaning and Sanitizing, dated 12/30/2022, revealed, It is the intent of this center to clean and sanitize utensils, dishware, pots and pans, workspace, and equipment to minimize the risk of food-borne illnesses. Guideline Cleaning schedules should be implemented and maintained for all areas of the kitchen. Work surfaces and equipment should be cleaned and sanitized as needed . Fixed equipment Items should be cleaned and sanitized appropriately. Review of the facility's policy titled, Storage Areas, dated 12/30/2022, revealed, It is the intent of this center to store food in a manner that maintains quality and safety. Guideline Items should be covered, sealed, labeled, and dated appropriately. 1. Observation during the initial kitchen inspection on 4/24/2023 from 9:10 a.m. to 9:40 a.m. with the Dining and Nutritional Services Manager (DNSM) present, revealed the following unclean equipment: a. The kitchen's convection oven was unclean with heavy buildup of accumulated blackened spills on its interior racks and bottom shelf. Also, the top of the convection oven was unclean with accumulated blackened and dried food debris. b. The kitchen's two conventional ovens were very unclean with heavy accumulated blackened and dried food spills on the interiors of both ovens. c. Seven of seven food preparation sheet pans, that were stored stacked tightly together and ready for use, were unclean with a heavy grease residue. d. The kitchen's large manual can opener, that was ready for use and attached to a food preparation table, was unclean with sticky residue on its blade and on its table base attachment. e. The food preparation table, that the manual can opener was attached to, had a bottom shelf that was unclean with accumulated sticky dried substances and loose food debris. f. The kitchen's knife rack, that contained 6 stored knives, was very unclean with dried sticky substances on the rack's top where knifes were inserted into the rack. g. A food preparation table, positioned near the kitchen's two conventional ovens, had a bottom shelf that was very unclean with rusted areas, dried and sticky substances, and loose food debris. Dry food goods were observed stored on this unclean shelf. h. A kitchen steam table, that was not operational, had a bottom shelf that was very unclean with dried and sticky food substances with loose food debris. Food service and food preparation pans were observed stored on this unclean shelf. i. A three shelf rolling utility cart, that was observed actively being utilized by kitchen staff to transport food within the kitchen, was unclean with accumulated dried food substances. j. A kitchen cart, observed with packages of cereal stored on it, was unclean with accumulated dried substances and loose food debris. k. A large rolling storage container, with plastic lids stored inside of it, was unclean with accumulated splatters of a dried and sticky brown substance on the container's exterior and interior. During an interview on 4/24/2023 at 9:40 a.m., the DNSM stated the kitchen had a daily cleaning schedule and a weekly deep cleaning schedule that staff were to initial when they completed their assigned cleaning duties. The DNSM explained the kitchen's equipment was observed unclean during the initial kitchen inspection on 4/24/2023 because there was not enough dietary staff available to perform scheduled cleaning duties. 2. Observation during the initial kitchen inspection on 4/24/2023 from 9:10 a.m. to 9:40 a.m., revealed the following concerns with food storage: a. Observation of bread products stored on the kitchen's bread racks revealed one package of rolls was stored opened and unprotected from possible contamination and one package of hot dog buns had an expired use by date of 4/20/2023. b. Observation of food stored in the kitchen's walk-in freezer revealed a 10-pound box of cod, a 20-pound box of cookie dough and a 15-pound box of ground beef patties were stored opened and unprotected from possible contamination. During an interview on 4/24/2023 at 9:40 a.m., the DNSM stated that stored food should be closed completely and food with an expired use by date should be discarded by staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff and police interviews, and review of the facility policy titled, Abuse Prohibition, the facility failed to protect the resident's right to be free from physical abuse by staff for one of three residents (R) (#1) reviewed for abuse. Specifically, on 7/8/2022, Certified Nurse Aide (CNA) #3 slapped R#1's leg, as witnessed by the Administrator. Findings include: Review of the facility policy titled, Abuse Prohibition, dated 10/11/2022, revealed It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy also indicated, Definitions: 'Physical Abuse' includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Review of a Face Sheet revealed R#1 had diagnoses that included Alzheimer's disease with early onset, dementia with behavioral disturbance, major depressive disorder, and adjustment disorder with mixed anxiety and depressed mood. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed R#1 had a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment. The MDS indicated R#1 had verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others on one to three days during the seven-day look-back period. According to the MDS, R#1 required limited assistance with bed mobility and extensive assistance with transfer and toilet use. The MDS indicated R#1 had no range of motion limitations. A review of a care plan dated as revised 10/25/2022, revealed R#1 had behaviors evidenced by high confusion, agitation, anxiety, delusions, paranoia, and rejecting care. Interventions included communicating face to face with simple descriptive statements; maintaining a tolerant, calm manner; simplifying activities and tasks to reduce frustration and dependence on others; and using a gentle, friendly tone of voice, with slow, deliberate gestures, and avoiding sudden movements. Review of a Facility Incident Report Form, dated 7/8/2022, revealed R#1 was combative with care, and a CNA swatted the resident's leg. The CNA was identified as CNA#3. The report indicated CNA#3 was removed from the facility, and a skin assessment was completed for R#1. Review of the skin assessment, dated 7/08/2022, revealed a bruise was noted to R#1's right upper arm and bilateral knees and a scab was noted to the left elbow area. There was no redness noted to R#1's leg. Review of a letter dated 7/15/2022 from the facility to the Georgia Department of Community Health's Complaint Intake Unit revealed the Administrator heard yelling from R#1's room on 7/8/2022 at approximately 6:30 p.m. The Administrator entered the room and observed CNA#3 attempting to change the resident's brief. R#1 was attempting to get up, and the Administrator witnessed CNA #3 swatting R#1's left thigh as she went to position R#1's legs onto the bed. The Administrator called out the CNA's name, and CNA#3 immediately apologized. R#1 was rambling and became angry, attempting to launch at CNA#3. CNA#3 was instructed to leave R#1's room. CNA#3 informed the Administrator that R#1 was scratching her up and she showed the Administrator her arms. The Administrator informed CNA#3 that it was never okay to hit any resident. The letter indicated the physician, responsible party, and police department were notified. CNA#3 was suspended pending an investigation. The charge nurse finished providing care to R#1, and the resident was assessed to have no marks on their leg. R#1 was noted to have old, yellowed bruising to the knees, right shoulder, and upper right arm. The letter indicated R#1 received anticoagulant (blood thinner) therapy. An officer from the police department arrived at the facility and spoke with the Administrator regarding the incident. A warrant was obtained for elder abuse and an Adult Protective Services (APS) referral was completed. The facility concluded the allegation did occur. Observation on 1/16/2023 at 11:40 a.m. revealed R#1 in bed napping with the blankets pulled up. Observation on 1/17/2023 at 10:30 a.m. revealed R#1 in bed, resting. An interview was attempted with R#1; however, R#1 was unable to appropriately respond to questions. CNA#3 was not available for interview during the survey. An interview on 1/16/2023 at 3:12 p.m. with the Administrator, she stated she witnessed the incident as she was making rounds on the memory care unit on 7/08/2022. She stated she had walked down the hall and headed back up the hall and heard someone yell. She knocked on the resident's door, opened it, and saw CNA#3 smack R#1 on the thigh. She stated she had the charge nurse go into the room and finish care and she spoke with CNA#3. CNA#3 was sent home pending an investigation. The Administrator stated the facility substantiated the allegation and dismissed the CNA. The physician, family, and police were notified. The two-hour report to the state survey agency (SSA) was completed, and the five-day investigation report was submitted. The Administrator stated this type of behavior could not be tolerated in the facility. The Administrator indicated residents needed to feel safe in the facility, and staff were to treat residents with dignity and respect. An interview on 1/16/2023 at 8:24 p.m. with the police, the police officer stated he was called to the facility on 7/08/2022 sometime around 7:30 p.m. and spoke with the Administrator regarding the event. The officer was informed by the Administrator that she witnessed CNA#3 smack R#1's leg. The officer indicated R#1's responsible party wanted to press charges and an arrest was made.