Based on review of the facility's surveillance video, staff interview, record review, and review of the facility's policy titled, Prevention of Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure one (Resident (R)62) was free from sexual abuse by R50 out of a sample of 32 residents. This had the potential for further sexual abuse for the resident and other residents by R50. Findings include: Review of the facility's policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, reviewed 12/07/22, indicated, It is the policy . to actively preserve each patient's right to be free from . sexual.abuse.Sexual abuse is non-consensual sexual contact of any type with a resident Review of the Resident Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed R62 was admitted to the facility with a diagnosis of dementia and Alzheimer's. Review of R62's quarterly Minimum Data Set (MDS) located under the RAI tab of the EMR with an Assessment Reference Date (ARD) of 03/19/24 indicated a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was not cognitively intact. Review of the Resident Face Sheet revealed R50 was admitted to the facility with a diagnosis of dementia, psychotic disturbance, and high-risk heterosexual behavior. Review of R62's quarterly MDS located under the RAI tab of the EMR with an ARD of 05/13/24 indicated a BIMS score of five out of 15, which indicated the resident had severe cognitive impairment. Review of R50's Care Plan located under the RAI tab of the EMR initiated on 03/02/20 revealed R50 had his hand inside a female resident's shirt as well as staff reported he had been entering female resident rooms without permission from residents initiated on 01/09/23. Interventions include . Observe for sexually inappropriate behavior, remove from situation and report as indicated. (Initiated on 04/12/21) Redirect him from other resident's room. (Initiated on 02/05/21) Remove from situation when the attention is unwanted. Psych consult. Redirect when he is sexually inappropriate with other staff/residents. (Initiated on 03/16/20). Approach: R50 has been approved for psych services. R50 sees the psych NP and the psychotherapist. (Initiated on 03/03/20) Provide a room when he requests private time. Redirect when he is inappropriate with others. Chart behaviors each shift and as needed (Initiated on 03/02/20). Further review of R50's Care Plan revealed on 06/14/24 a Care Plan was initiated for R50 having had inappropriate sexual behaviors toward female residents. The interventions included observe for effectiveness of medication, report any misconduct to administrator immediately, redirect him from female company when being inappropriate, and medication as ordered. Review of the facility's 5-Day Follow-up Investigation Report, provided by the facility, dated 06/14/24, revealed Licensed Practical Nurse (LPN)1 notified the Administrator on 06/10/24 at 5:48 PM that R50 was groping R62. Further review of the facility's investigation revealed no residents or additional staff members were interviewed following the review of the surveillance cameras. Record review of R50's Social Services Note, located under the Progress Notes tab of the EMR, dated 06/13/24, that stated R50 was seen by psych services. There was no documentation that the resident received psych services until 07/01/24. Further documentation located under the Progress Notes tab revealed on 06/13/24 the Interdisciplinary Team (IDT) held a behavior management meeting, and the resident was prescribed medication to reduce sexual desires. Review of an additional facility's 5-Day Follow-up Investigation Report, dated 07/03/24, provided by the facility, revealed on 07/01/24 at 10:30 AM Certified Nursing Assistant (CNA)1 informed the Administrator that she witnessed resident R50 grabbing R62's breast. Further review of the facility's investigation revealed additional staff members were interviewed following the review of the surveillance cameras. Review of the facility's surveillance video along with the Administrator on 09/11/24 at 10:28 AM revealed on 06/10/24 both residents were sitting in front of the nursing station. R50 was seen reaching over and touching R62's legs and thigh area. During the surveillance two family members walked by and then two staff (identified as LPNs) witnessed the incident and brought R50 back to his room while allowing R62 to bring themselves back to their room. During the 07/01/24 incident, R50 and R62 were seen rolling in their wheelchair in front of the nursing station. R50 is then seen rubbing on R62's chest area. There were two staff members approximately two doors down from the residents. After approximately three minutes, CNA1 is then observed approaching the residents, saying something to the residents and proceeded to leave the residents and goes into another resident's room. The residents then rolled down the hallway and the video stopped. During an interview with Administrator on 09/11/24 at 10:28 AM, the Administrator stated during the 06/10/24 and 07/01/24 incidents staff should have removed both residents from the area as well. The Administrator confirmed staff did not follow the abuse policy as well as the resident care plan to separate the residents to ensure the residents were safe. The Administrator also confirmed they did not interview any additional staff to ensure they were not a victim of inappropriate touch. There have been no further incidents with R50 and R62, or any other resident.

Based on observation, staff interview, record review, and review of the facility's policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to complete a thorough investigation for two incidents of resident to resident sexual abuse for one (Resident (R) 62) by R50 out of three residents reviewed for abuse out of 32 residents reviewed in the sample. This failure had the potential for unknown other incidents of sexual abuse for R62 or any other residents. Findings include: Review of the facility's policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, reviewed 12/07/22, indicated, 1. The Administrator of the provider is responsible for assuring that an accurate and timely investigation is completed. If there is an occurrence of or allegation involving patient abuse (including injuries of unknown source), neglect, exploitation, mistreatment or misappropriation of patient property, the following investigation and reporting procedures will be followed: . Documentation of the investigation should include, but not be limited to, the following: Details of the alleged incident and injury. Signed statements from pertinent parties; Cognitive status of victim(s) and patient(s) who are witnesses (e.g., whether they are alert, oriented, and able to answer questions appropriately, which could help in determining whether the witness is credible and able to testify). Review of the facility's 5-Day Follow-up Investigation Report, provided by the facility, dated 06/14/24, revealed Licensed Practical Nurse (LPN)1 notified the Administrator on 06/10/24 at 5:48 PM that R50 was groping R62. Further review of the facility's investigation revealed no residents or additional staff members were interviewed following the review of the surveillance cameras. Review of the facility's 5-Day Follow-up Investigation Report, dated 07/03/24, provided by the facility, revealed on 07/01/24 at 10:30 AM CNA1 informed the Administrator that she witnessed resident R50 grabbing R62's breast. Further review of the facility's investigation revealed additional staff members were interviewed following the review of the surveillance cameras. There was no evidence that any residents or R50's family was interviewed to ensure a thorough investigation had been completed. Interview with Administrator on 09/11/24 at 10:28 AM stated during the 06/10/24 and 07/01/24 incidents between R62 and R50, they did not interview any additional staff, residents, or the family that was present in the video to ensure they were not a victim of inappropriate touch or to obtain additional witness statements. (Cross Reference F600)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R73's Face Sheet from the (EMR) Face Sheet tab showed a facility admission date of 03/02/22. Review of R73's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/09/24 showed a Brief Interview for Mental Status (BIMS) score of 99, indicative of being cognitively impaired. Review of R73's EMR Progress Notes tab showed a late entry note on 07/06/24 at 2:30 AM for 07/05/24 at 3:30 AM that revealed R73 was observed lying on his left side beside his bed, and appeared to have slid out of bed. There was no apparent injury, and he was assisted back to bed. Resident left the facility at 8:40 AM with emergency medical services, (EMS) due to seizure like activities. Review of R73's Progress Notes did not show evidence of the provision of a written notice of transfer provided to R73 and his RP. Upon request for evidence of the written notice of transfer provision, the facility was unable to provide a transfer notice from the facility to the emergency room. 2. Review of the Resident Face Sheet located in the EMR under the Face Sheet tab documented R32 was admitted to the facility on [DATE] and had a diagnosis of chronic kidney disease and unspecified fracture of the end of left femur. Review of the Progress Note found in the EMR under the Progress Note tab dated 07/12/24 documented the physician was notified that R32 had experienced a fall with a head laceration. and received orders for the resident to be transferred to the hospital. There was no documentation in the EMR indicating R32 and/or the RP were notified of the transfer to the hospital in writing. During an interview with R32 on 09/11/24 at 10:49 AM revealed she was sent to the emergency room with a packet of papers, but she was not sure what was in the packet, and she was never required to sign any paperwork regarding transfer/discharge. During an interview with the DHS on 09/11/24 at 1:30 PM, she indicated the resident was sent to the emergency room with a packet which included information regarding the bed hold policy, but nothing was sent related to a written notice to the family regarding transfer/discharge. She also verified the facility did not have a policy regarding a requirement for the RP to be notified via a written notice regarding the reason and date of a resident's transfer to the hospital. Based on resident and staff interviews and record review, the facility failed to provide a written notice of a transfer to the resident and/or resident's Responsible Party (RP) for three of three residents (Resident (R) 80, R32, and R73) reviewed for hospitalization out of a sample of 32 residents. This had the potential for the resident and or RP not knowing where and why a resident was transferred. Findings include: 1. Review of the Resident Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab documented R80 was admitted to the facility on [DATE] and had a diagnosis of dementia. Review of the Progress Note found in the EMR under the Progress Note tab dated 05/16/24 documented the physician was notified that R80 had an elevated axillary temperature of 102.3 degrees Fahrenheit (F), his right elbow had increased swelling, was red, hot, very painful, and he was transferred to the hospital. There was no documentation in the EMR that R80 or the RP were notified of the transfer to the hospital in writing. During an interview on 09/10/24 at 6:55 AM, the Director of Health Services (DHS) said although R80's family member was notified by telephone of R80's transfer to the hospital, she was not aware she had to send written notices to families/RP related to a resident's transfer to the hospital and therefore, a written notice was not sent to R80's RP or other residents that have been transferred to the hospital. The DHS said the facility did not have a policy that addressed the requirement for the responsible person to be notified via a written notice regarding the reason and date of a resident's transfer to the hospital. The DHS said she confirmed with the corporate office that a written notice to a resident's responsible person or family member related to a resident's transfer to the hospital was required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to offer residents hand hygiene prior to meals for five of five residents observed (Residents (R)24, R68, R99, R105, and R37) out of a total sample of 32 residents. This had the potential for the risk of transmission of infections. Findings include: 1. Review of Resident Face Sheet found in the Electronic Medical Record (EMR) under the Face Sheet tab documented R24 was admitted to the facility on [DATE] with diagnosis of dementia. Review of the quarterly Minimum Data Set (MDS) found in the EMR under the RAI tab with an assessment reference date (ARD) of 08/05/24 documented R24 had a Brief Interview of Mental Status (BIMS) score of nine out of 15, which indicated moderately impaired cognition, required set up by staff for eating, and was dependent on staff for hygiene, which included hand washing. During an observation on 09/09/24, at 1:00 PM, revealed R24 was sitting in his chair in his room. A staff member assisted R24 with his tray, and did not offer to assist him with hand hygiene. During an interview with R24 on 09/09/24 at 1:02 PM, R24 said although he would like to wash his hands before meals, the staff never helped him with hand washing. 2. Review of the Resident Face Sheet found in the EMR under the Face Sheet tab documented R68 was admitted to the facility on [DATE] with diagnosis of type 2 diabetes. Review of the quarterly MDS found in the EMR under the RAI tab with an ARD of 06/19/24, documented R68 had a BIMS score of 14 out of 15, which indicated intact cognition, was independent with eating, and required moderate assistance with hygiene. During an observation on 09/09/24, at 1:09 PM, R68 was in his room sitting in his bed. A staff member set up R68's tray, and did not offer to assist him with hand hygiene. During an interview on 09/09/24 at 1:10 PM, R68 said he was bed bound and not able to get out of bed to wash his hands at the sink. He said although he would like to wash his hands before meals, the staff never offered to assist him with hand washing. 3. Review of the Resident Face Sheet found in the EMR under the Face Sheet tab documented R99 was admitted to the facility on [DATE]. Review of the quarterly MDS found in the EMR under the RAI tab with an ARD of 06/05/24 documented R99 had a BIMS score of five out of 15, which indicated severely impaired cognition, required set up for eating, and supervision/touch for hygiene. During an observation on 09/09/24, at 1:08 PM, R99 was sitting in her chair in her room. A staff member assisted R99 with her tray and did not offer to assist her with hand hygiene. 4. Review of the Resident Face Sheet found in the EMR under the Face Sheet tab documented R105 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes. Review of the quarterly MDS found in the EMR under the RAI tab with an ARD of 08/28/24, documented R105 had a BIMS score of 13 out of 15, which indicated intact cognition, required set up for eating, and maximum assistance with hygiene. During an observation on 09/09/24, at 1:04 PM, R105 was sitting in her chair in her room. A staff member set up R105's tray, and did not offer to assist her with hand hygiene. During an interview on 09/09/24 at 1:06 PM, R105 said the staff never offered to assist her to wash her hands before meals. 5. Review of the Resident Face Sheet found in the EMR under the Face Sheet tab documented R37 was admitted to the facility on [DATE] with a diagnosis of blindness. Review of the quarterly MDS found in the EMR under the RAI tab with an ARD of 06/24/24, documented R37 had a BIMS score of nine out of 15, which indicated moderately impaired cognition, required set up for eating, and moderate assistance with hygiene. During an observation on 09/10/24, at 1:01 PM, a staff member set up R37's meal tray and did not offer to assist her with hand hygiene. During an interview on 09/09/24 at 1:06 PM, R37 said the staff never helped her wash her hands before meals. During an interview on 09/10/24 at 1:22 PM, Licensed Practical Nurse (LPN) 4 said sometimes the staff assisted residents to clean their hands before meals with hand sanitizer or a wet face cloth with soap. LPN4 said on 09/10/24, she set up R37's lunch tray and did not assist her with washing her hands. During an interview on 09/10/24 at 1:25 PM, Certified Nurse Aide (CNA)7 said she never assisted residents who ate their meals on the unit with hand washing prior to assisting them with their meals, unless their hands were soiled. During an interview on 09/10/24 at 1:28 PM, CNA6 said she did not assist residents with hand sanitation prior to meals on 09/11/24 and on other days she was assigned to the facility. She said they did not have hand wipes and did not have enough time to clean each residents' hands with face cloths or bring them to the sink to wash their hands. During an interview on 09/11/24 at 1:05 PM, the Infection Control Preventionist (IP) said although the staff used wipes in the dining room to provide hand sanitation to the residents prior to meals, she said the wipes were not used for residents on the units. She said hand sanitation was to be provided to residents prior to meals to prevent the potential for residents developing infections. During an interview on 09/10/24 at 3:30 PM, the Director of Health Services (DHS) said although the facility did not have a specific policy related to resident hand hygiene prior to meals, the expectation was that the staff would ensure all residents had the opportunity to wash their hands or be assisted by the staff to wash their hands prior to each meal to prevent residents from potentially acquiring an infection.

Based on observations, staff interviews, and review of the facility's policies titled, Receiving and Storage of Food and Supplies and Hand Washing, the facility failed to ensure food stored in the kitchen was labeled, dated, and not expired. Additionally, staff failed to perform adequate hand hygiene when leaving and returning to food preparation area after touching the lid of trash can. This had the potential to increase the spread of foodborne illness and infection for 108 out of 109 residents that received meals from the kitchen. Findings include: Review of facility policy titled, Receiving and Storage of Food and Supplies dated September 2001. Under the section labeled Guidelines: 1. The DM or trained designee is accountable for receiving and storage of food .7. Supplies already on shelves shall be moved forward and the latest date supplies placed on the back of shelves . 12. Date all stock with current delivery date. Review of the facility policy titled, Hand Washing dated September 2001 revealed, To prevent spreading bacteria, the dietary staff must wash their hands properly .before and after handling food .after handling unclean items such as trash. Guidelines: 1 .6. Dry hands with paper towels. Discard the paper towels in a foot operated trash can . During the initial observation of the kitchen with the DM (Dietary Manager) on 09/09/24 at 8:40 AM, there were six unopened 16-ounce containers of poultry seasoning located on a shelf in the dry good storage area that had an expiration date of 3/24. A transparent plastic bag containing two frozen pizzas, without a received date, open date, or expiration date were located in the walk-in freezer. There was one opened case of sliced ham and one opened case of beef roast both showing a received date of 09/02/24 that had no open date, located in the walk-in cooler. During an observation and interview on 09/09/24, Cook1 removed the six unopened 16-ounce containers of poultry seasoning, stating these should have been thrown away a long time ago. During an interview on 09/12/24 at 7:30 AM, the DM stated that the expired items and those not dated when opened should be disposed of because they could cause residents to become sick. During an observation on 09/12/24 at 11:30 AM, Cook1 was observed preparing pureed beets and turkey pot pie. Cook1 placed the container on the table and performed hand hygiene. After performing hand hygiene Cook1 returned to the prep area, grabbed the lid to the trash can with a barehand and placed the paper towel into the trash can. [NAME] 1 then continued to prepare the pot pie without hand hygiene. Cook1 confirmed they touched the trash can when they threw away the paper towel and did not perform hand hygiene before preparing the pot pie. During an interview on 09/12/24 at 11:50 AM, the DM confirmed dietary staff should wash their hands.

Based on observations, staff interviews, record review, and review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to protect the resident's right to be free from sexual abuse by another resident by failing to report an alleged allegation of abuse to the state agency timely for one of 15 sampled residents (R) (R6). Specifically, R6 was allegedly sexually abused by R5. Findings include: Review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property last reviewed on 1/11/2024 revealed under the sub section Procedures 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the administrator the provider entity. 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state survey agency and the state agency for adult protective services should be notified in accordance with the state through established procedures of any allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknow source and misappropriation of patient property, within two (2) hours after the allegation is made if the events upon which the allegations based involve abuse ore result in serious bodily injury. Review of the Facility Reported Incident (FRI) dated 11/17/2023 revealed that the Administrator of the facility reported an allegation of Abuse (resident to resident). The date and time of the incident occurrence was documented as 11/16/2023 at 3:00 pm. Details included R5 was seen fondling R6 after she had wandered into his room. The report indicated the physician, police, and responsible parties were notified. Steps taken by the facility to prevent further incidents were documented as Residents were separated, R6 was placed on 1:1 observation, an investigation was initiated. The form was submitted on 11/17/2023 at 10:58 am. (19 hours after the incident). Review of the police report dated 11/17/2023 at 10:30 am revealed in the Primary Narrative of the police officer on 11/17/2023 at 12:55 revealed on 11/17/2023 at approximately 1033 hours (10:33 am), I (the police officer) was dispatched to 1067 Battlefield Parkway [facility address] in regard to an assault. He further describes meeting with the Administrator and another employee of the facility and was told that R6 entered the room of R5 and exposed her breast and R5 touched her. The Administrator also stated that R5 claimed to have tried to push R6 out of his room. The police officer documented the Administrator wanted a report for documentation purposes. Certified Nursing Assistant's (CNA FF) statement was attached to the report. Review of written statement dated 11/16/2023 provided by CNA FF revealed she observed R5 in his room looking at the television. R6 along with another female resident entered his room. R6 pulled up her shirt and R5 was touching R6. She documented she removed R6 and the other female resident from R5's room, told the nurse, and went back to work. She further documented another resident notified her that R6 and the same female resident were back in R5's room, she documented we removed them once again. Review of a second written statement dated 11/16/2023 by CNA FF revealed at around 2:47 pm she saw R5 with his hands on another resident. She removed the female resident and told the nurse, then she wrote in her statement that another resident notified her that the female resident was back in R5's room. Review of a written statement completed by Licensed Practical Nurse (LPN) JJ on 11/17/2023 at 8:43 am simply stated she reported R5 was fondling R6. Review of a written note created by the Administrator documenting a meeting with LPN KK dated 11/24/2023 at 9:57 am where she asked LPN KK if CNA FF notified her of R5 fondling R6, to which she documented No, she did not. I would have remembered something like that. The note was signed by the Administrator. 1. Review of the electronic medical record (EMR) revealed R6 was admitted to the facility with diagnoses including but were not limited to senile degeneration of the brain and dementia. Review of R6's significant change of condition Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/2024 revealed a score of 3 on her brief interview for mental status (BIMS) indicating severe cognitive impairment and impaired decision-making abilities. Section C - Cognitive Patterns indicated: fluctuating altered level of consciousness, cognitive skill for daily decision making was severely impaired. Evidence identified acute change in mental status. Review of R6's care plan dated 11/21/2023 indicated a problem of dementia with behavioral disturbance, diagnosis of vascular dementia and wandering, entering other residents' rooms, destroying property, and disrupting other residents. She has been seen disrobing and sexually inappropriate in the presence of others, she can be easily redirected but has a short attention span. Continues to disrobe as of 12/5/2023. Goals included but are not limited to positive experiences in daily routine without overly demanding tasks and without becoming overly stressed. R6 will not disrobe in public areas. Interventions included but not limited to providing cues and supervision as needed, respect her rights to make decisions but assist her in making safe decisions. Layer clothing to delay disrobing, find clothing she tolerates wearing, stuffed animal for cuddling, assist with redressing as needed, give routine medications as ordered, redirect when she enters other resident rooms or inappropriate areas, involve her with activities and group activities. 2. Review of the EMR revealed R5 was admitted with diagnoses for including but not limited to bipolar disorder, personal history of traumatic brain injury, anxiety, and cognitive communication deficit. Review of R5's quarterly MDS with an ARD of 12/28/2023 revealed a BIMS score of 13, indicating little to no cognitive impairment. Section E- Behaviors revealed no potential indicator of psychosis. Review of the care plan for R5 revealed the last care plan conference was held 1/22/2024. Problems listed but not limited to behavioral symptoms, R5 has episodes of verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). R5 has solicited sexual favors from another resident, with Start Date listed as 9/28/2022. Goals included but not limited to residents will have decreased episodes of threatening, screaming at, or cursing at other residents, visitors, and/or staff. Interventions included but not limited to Approach Start Date: 8/10/2023 remind and educate to respect and honor when another resident says no to sexual advances. Nursing Approach Start Date: 9/28/2022 administer psychotropic medications as ordered. Notify MD as indicated. Nursing Approach Start Date: 9/28/2022 Assess whether the behavior endangers the resident and/or others. Intervene if necessary. CNA, Nursing, Social Services. Interview on 2/8/2024 at 9:15 am with CNA FF, she stated she witnessed an incident on 11/16/2023 at approximately 2:00 pm. She stated she was walking out of a room directly across the hall from R5's room. She stated he was in his wheelchair and R6 was standing in front of him with her shirt open. She went on to state R5 had his hands up and appeared to be groping R6. She indicated she immediately reported this to the nurse working with her on the hall. She revealed normally when something was reported, someone from administration usually interviewed staff within a few minutes and this did not happen. She stated when she returned to work the next day, she asked why they had not talked with her yet, and then discovered that Administration did not know. She stated at that point they began the investigation, and she was told she waited too long to report this incident. Interview on 2/8/2024 at 10:45 am with the Director of Health Services (DHS) revealed that the incident between R5 and R6 occurred on 11/16/2023 and was reported to LPN EE on 11/17/2023 who reported the incident to the Administrator (the abuse coordinator) immediately. She revealed CNA FF stated she reported the incident to LPN KK, who is no longer employed at the facility, at the time of occurrence. She revealed that LPN KK stated that CNA FF did not report the incident to her. She revealed the incident was reported to the state agency on 11/17/2023. She revealed that she did write up CNA FF for not reporting the incident immediately to the abuse coordinator (the Administrator). She stated that her expectation of staff who witness or suspect abuse of any kind are to verify the safety of the residents involved, report the incident immediately to the nurse, unit manager, herself, and the Administrator who is the abuse coordinator. She stated she expected staff to follow the policies and procedures regarding abuse and reporting as they have been educated to do. A telephone interview on 2/8/2023 at 12:14 pm with the Administrator revealed that the alleged incident between R5 and R6 occurred on 11/16/2023 around approximately 2:00 - 3:00 pm per CNA FF's statement, who witnessed the incident. She stated the incident was reported to her the morning of 11/17/2023 after the incident was reported to the LPN Unit Manager EE who immediately reported the incident to the Administrator. She revealed the incident was reported late to the state agency on 11/17/2023. She revealed that her expectation of staff was that they immediately report any suspected or witnessed abuse and follow the policies which the facility has provided education. She stated her phone number was posted at the nurse's desk and staff know they can call her at any time of the day or night, seven days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to ensure that two of four residents (R) (R#19 and R#47) were treated in a dignified manner related to transportation assistance (R#19 and R#47) and addressing a resident by his preferred name (R#19). Findings included: A review of an undated facility policy titled, Compliance, revealed staff were to, Treat all residents with respect and dignity; promote and provide the highest quality of life possible for each resident. The policy also indicated staff should, Conform to applicable professional standards by exercising sound judgment during the fulfillment of your duties. 1. A review of a Face Sheet revealed R#19 had diagnoses that included rheumatoid arthritis, generalized muscle weakness, lack of coordination, and chronic obstructive pulmonary disease (COPD). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#19 scored seven out of 15 on a Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. The MDS indicated the resident required extensive assistance with transfer, locomotion, personal hygiene, and bathing. On 1/12/23 at 9:05 a.m., an observation was made of Certified Nursing Assistant (CNA)#7 pulling R#19 backward down the hall in a shower chair. As the two entered the shower room, CNA#7 called the resident by a generic nickname. During an interview with Unit Manager (UM)#1 on 1/12/23 at 10:38 a.m., they stated staff were taught not to pull residents backward in wheelchairs due to the risk of tripping or tipping the resident over. The UM added a resident being pulled backward would not be able to see who or what may be approaching. 2. A review of a Face Sheet, revealed R#47 had diagnoses that included Alzheimer's disease, bilateral cataracts, and generalized muscle weakness. The quarterly MDS assessment dated [DATE], revealed R#47 was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status. The MDS indicated the resident required extensive assistance with transfer, required supervision for locomotion, and was totally dependent on staff for bathing. A review of a Care Plan, dated as last reviewed on 12/12/22, revealed R#47 required assistance with all aspects of daily care. On 1/12/23 at 10:45 a.m., UM#1 and this writer observed CNA#7 pulling R#47 backward down the hall in a shower chair to the resident's room. The UM stated that was an opportunity for an in-service and added that CNA#7 should not be pulling the resident backward. During an interview with CNA#7 on 1/12/23 at 10:50 a.m., he stated the reason he had referred to R#19 by a nickname because he had only worked on the resident's hall for three days and did not know the resident's name. The CNA stated the shower chair would not roll forward, so he had to pull the resident backward to keep the chair from tipping over. He added that when a chair would not roll correctly, pulling a resident backward had to be done. CNA#7 stated he had not reported the problems with the chair rolling to anyone and acknowledged he had been taught not to pull residents backwards. The CNA stated the only solution to keep the residents from being pulled backward was a new chair. During an interview with the Director of Health Service (DHS) on 1/12/23 at 11:00 a.m., the DHS stated staff were taught to address residents by Mr./Mrs. or the resident's preferred name. She stated if care was provided, she expected staff to look at the nameplate by the door to see for whom they would provide care. The DHS stated a resident should only be addressed by a nickname if that was the resident's preference. The DHS stated residents were expected to be pushed forward in wheelchairs or shower chairs. During an interview with Registered Nurse (RN)#6 on 1/12/23 at 12:02 p.m., she stated she was responsible for in-services for staff and added the last in-service on dignity and respect was held in either October 2022 or November 2022. The RN stated staff were taught to address residents by their preferred name, and it was not okay to randomly address a resident whose name was not known by a nickname. RN#6 stated residents were expected to be transported in wheelchairs and/or shower chairs in a forward-facing position so the residents were oriented as they went down the hall. She added if a shower chair was not working properly, the staff was expected to remove the resident from the chair and place the resident in a working chair. RN#6 added staff were expected to report the nonfunctional chair to maintenance, and the chair should be taken out of service until repaired. During an interview with the Administrator on 1/12/23 at 1:27 p.m. he stated that he expected staff to address residents as they preferred to be addressed. He stated the nickname used by CNA#7 was not acceptable unless that was what the resident preferred. The Administrator stated wheelchairs/shower chairs should be pushed forward. He added if the resident had to be pulled backwards, it should only be a few feet, and the resident should be notified.

Based on interviews, record review, and facility policy review, the facility failed to thoroughly investigate and resolve grievances for two of two residents (R) (R#21 and R#48) reviewed for resident rights. Specifically: 1. R#21's grievance was filed on 11/23/22 regarding missing dentures and clothes without documentation or evidence of complete resolution or verbal or written notification of the resident regarding the summary of the grievance and resolution and; 2. R#48's grievance was filed on 12/27/22 regarding alleged interactions with a staff member on 12/25/22. There was no documentation of interviews with other residents regarding their interactions with the staff member. Additionally, there was no documentation of complete resolution or verbal, or written notification provided to the resident regarding the summary of the grievance and resolution. Findings included: A review of a facility policy titled, Grievances: Healthcare Centers, last revised 11/21/22, revealed, 3. Once the referral is made to the responsible discipline, the responsible discipline will make prompt efforts to resolve the grievance, in addition to taking immediate action to prevent further potential violation of and [sic] patients' rights while the alleged violation is being investigated. The action taken should be recorded on the Grievance/Complaint Form: Healthcare Centers, then signed and returned to the Administrator or designee once the Grievance/Complaint Form: Healthcare Centers is returned with the action taken, the form will be sent to the Administrator for final review. 4. The Administrator or designee will be responsible for follow-up with the patient, authorized individual or other representative to determine the grievance has been resolved and to ensure the grievance process is understood. A copy of the completed grievance form, if requested, may be given to the complainant. The Administrator or designee will complete the Grievance/Complaint Log Form: Healthcare Centers indicating whether the problem was resolved and document reactions to the resolution. 5. The Grievance/Complaint should be resolved within three business days. 1. A review of a Resident Face Sheet revealed R#21 had diagnoses including dysphagia (difficulty swallowing), hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, and speech/language deficits following cerebral infarction. A review of R#21's quarterly Minimum Data Set (MDS) assessment, dated 12/23/22, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Per the MDS, the resident required a mechanically altered diet (food specifically prepared to alter the consistency to facilitate oral intake for those who struggled to chew or swallow foods). During an interview about missing property on 1/9/23 at 12:16 p.m., R#21 stated they filed a grievance regarding missing dentures, a suitcase of clothing, and a pair of sneakers of a certain brand and description. It was noted during the interview that the resident lacked a top denture. According to R#21, the denture was inadvertently thrown away after a return from the hospital in September 2022. The resident identified that the missing top denture had been reported to the Social Worker (SW) and Administrator (ADM) but had not been replaced. A review of grievance forms for the timeframe from July 2022 to December 2022 revealed R#21 filed a grievance with the ADM on a Grievance/Complaint Form: Healthcare Centers document on 11/23/22 regarding, in part, missing teeth. Investigative steps consisted of speaking to the SW. The investigative summary indicated a dental consultation was scheduled, that imprints were being made, and We will replace dentures. The summary also noted the facility planned to replace any missing clothing. The form was signed as completed by the Investigating Partner on 11/23/22 and signed as reviewed by the ADM on 11/23/22. A section at the bottom of the form to indicate the person filing the grievance had been informed of the results was not checked, signed, or dated. An interview with the SW on 1/11/23 at 11:19 a.m. revealed the process for grievances regarding missing items involved looking for the items in the resident's room and laundry. According to the SW, if the missing items were not located, the facility filed a grievance and contacted the resident or responsible party to determine if item replacement or reimbursement was desired. Once resolved, staff placed a copy of the grievance into a grievance notebook located in the SW's office or the Nurse Navigator's (NN) office. During a follow-up interview on 1/11/23 around 3:30 p.m., the SW stated the facility was hiring a new dental provider who would be providing orientation to the facility on 1/16/23. The SW asserted that the previous dental provider had already made a mold for R#21's dentures, but she was not sure about the status beyond that. The SW stated there should be a note in the resident's chart regarding the mold being made, but noted she sometimes forgot to transcribe handwritten notes into resident charts. The SW was unable to find documentation of the mold being made and called the previous dental office, placing them on speakerphone. The interview with dental office staff revealed that, on 10/24/22, a dental hygienist performed a cleaning for R#21, at which time it was noted the upper denture was missing. As the hygienist was not qualified to make a mold for the resident, a clinic visit to make a mold was scheduled with the dentist for 12/19/22. When the dentist came out, the facility informed the dentist that 12/31/22 was the last day the dentist would be providing services to the facility. Based on this information, the dentist did not make any molds, as the molds took at least six weeks to be completed, which was beyond the 12/31/22 service ending date. The SW indicated surprise, stating she thought the resident's dentures were lost after an 11/19/22 hospital visit and that the denture mold had been done. A review of R#21's medical record was performed by the SW at that time, which confirmed the only other hospital visit occurred on 8/30/22, noting it had to be after that visit when the dentures went missing. During an interview with the ADM on 1/11/23 at approximately 3:00 p.m., he revealed that the process for missing property grievances consisted of, in part, a search for the missing property in the laundry and/or housekeeping department to determine if the items could be located. The ADM noted if the items were not located, the grievance was reported to the NN, who completed an investigation and grievance form. Once the investigation was complete, the NN provided a summary of the resolution to the ADM. Per the ADM, he and the NN then signed the grievance form to indicate resolution of the grievance. During an interview on 1/11/23 at 4:47 p.m., the NN confirmed that signatures on a grievance form indicated the grievance had been investigated and resolved. The NN stated she signed R#21's grievance because the ADM took the grievance, so she thought everything was resolved. During a follow-up interview with the SW on 1/11/23 at 5:11 p.m., she confirmed she followed up on R#21's grievance. Regarding the missing clothes, she noted she spoke to R#21 to determine what was missing and searched for the items. The SW stated she found two pairs of pants and a gown in the laundry and returned them to R#21, which she confirmed was not documented. The SW noted she was not responsible for signing the grievance form, as the NN handled grievances. During a follow-up interview on 1/12/23 at 9:18 a.m., R#21 reiterated that their missing property included a pair of sneakers and a suitcase full of clothes, which were moved while being quarantined for COVID-19. The resident also confirmed they informed the ADM and the SW about the missing items but had not been reimbursed for any of the items. 2. A review of a Resident Face Sheet revealed R#48 had diagnoses including progressive neurological disease, generalized anxiety, chronic pain, morbid obesity, and bilateral cataracts. A five-day MDS assessment, dated 11/10/22, indicated R#48 scored 15 on the BIMS, which indicated the resident was cognitively intact. The MDS did not indicate that R#48 exhibited any behavioral symptoms of rejection of care. According to the MDS, the resident was totally dependent on staff for transfer and required supervision with locomotion. A review of a Care Plan, dated as reviewed/revised 12/28/22, revealed that in 2020, R#48 was care planned for fabrication of stories regarding other residents with visitors. On 9/5/22, the care plan indicated there had been no recent behaviors. The care plan also indicated the resident was at risk for social isolation with an intervention for R#48 to attend activities. The care plan also indicated R#48 required assistance for completion of activities of daily living. During an interview with R#48 on 1/9/23 at 10:56 a.m. the resident stated that on Christmas Day (2022), a male Certified Nursing Assistant (CNA) came into the resident's room around 8:00 a.m. and told the resident if the resident chose to get up, he would not put the resident back to bed, adding that he was not going to break his back getting the resident up and then back to bed. The resident stated the CNA's behavior had been reported to Unit Manager (UM)#1. The resident stated later that day someone from corporate came in around 2:00 p.m., got the resident out of bed, showered the resident, and washed the resident's hair. A review of a Grievance/Complaint form completed on 12/27/22 by the Nurse Navigator (NN) on behalf of R#48 revealed that on 12/25/22, CNA#7 told R#7, I don't have time to get you up and dressed. If I do, you'll have to stay up until the next shift. The Summary section of the form indicated the Director of Health Service (DHS) had reported that CNA#7 stated the other CNAs would not help him transfer R#48, and per policy, there had to be two staff members to use a mechanical lift. The summary also indicated CNA#7 was to be educated on using a polite tone of voice and being respectful. The form had a lift policy attached. During an interview with the SW on 1/11/23 at 9:34 a.m., she stated R#48 was alert and oriented but not always reliable when telling a story. The SW was aware of the grievance filed by R#48 and knew the grievance was about an incident between the resident and CNA#7 that occurred on Christmas Day. The SW stated the resident wanted to get up, and the CNA told the resident he was not breaking his back. The SW stated she was unaware of the grievance outcome since the NN was responsible for grievances. The CNA finally got the resident out of bed after the DHS called the CNA and spoke to him. The SW stated she was unaware of any other residents having issues with CNA#7. The SW stated she was not asked to participate in an investigation in any other way, such as interviewing other residents about their relationship with the CNA. During an interview with CNA#7 on 1/11/23 at 10:27 a.m., CNA#7 acknowledged R#48 was alert and oriented but was not always truthful. The CNA stated that when he went into R#48's room he always had another staff member with him. CNA#7 stated that on Christmas Day, there had been call outs, so he was the only one on R#48's hall until other staff could arrive. He added that as soon as he clocked in around 7:00 a.m., he went to check on R#48 since the resident complained that night shift did not provide incontinence care. CNA#7 stated that between 10:00 a.m. and 10:30 a.m., he asked R#48 if they wanted to get out of bed, and the resident declined. He then stated there was someone from corporate there, and R#48 told the corporate representative that he would not get the resident out of bed. CNA#7 stated he was not aware R#48 had filed a grievance about the Christmas Day incident since no one from management, including the DHS or the Administrator, had spoken with him. The CNA stated he brought the incident to the DHS's attention and let her know what the resident had said. The CNA acknowledged he did tell the resident when the next shift got in or someone to help him arrived, he would put the resident back to bed. The CNA denied telling R#48 he was not getting the resident out of bed due to not breaking his back and denied saying to the resident they would not get along if the resident reported him. During an interview with UM#1 on 1/11/23 at 1:30 p.m., the UM described R#48 as alert and oriented and at times truthful and at times not. The UM acknowledged R#48 had complained about CNA#7 and indicated the CNA stated he did not have time to get the resident out of bed. The UM stated she had reported this, and she and the NN completed a grievance for R#48 and spoke to the resident. She added that after that it was the NN's responsibility to complete the grievance process. During an interview with NN on 1/11/23 at 3:13 p.m., the NN stated she found out about the incident between R#48 and CNA #7 on 12/26/22 or 12/27/22 from UM#1, adding that she and UM#1 spoke with R#48. The NN stated R#48 told them that on Christmas Day, CNA#7 went into the resident's room and told the resident he was not getting the resident up due to He was not going to break his back. The resident told the NN and the UM someone from corporate came in and talked with R#48. The resident stated they told the corporate representative they really wanted to get up and have a shower and shampoo. The NN stated R#48 told her and the UM that this person made it happen. The NN stated R#48 told her and the UM that sometimes CNA#7 came into the room and said things jokingly, and sometimes some people did not understand the CNA's tone. The resident was not sure if the comment about not breaking his back was a joke or not, but the CNA's tone of voice came across hurtfully. The NN stated R#48 just wanted administrative staff aware and hopefully talk with CNA#7 about his tone of voice. The NN stated she told the DHS what happened, and the DHS stated she would talk to CNA#7 but added she was not sure if that had occurred since the CNA had been out of work for a few days. The NN stated her part of the investigation included speaking to the resident and the DHS. The NN stated she showed R#48 a copy of the lift policy and discussed the lift policy with the resident. The NN stated the investigation had not included speaking with other residents about their relationship with CNA#7. The NN stated the resolution of the grievance occurred almost immediately, since the DHS planned on speaking with the CNA about his tone of voice and being more professional. During an interview with the DHS on 1/11/23 at 3:38 p.m., she stated R#48 was alert and oriented but tried to manipulate staff to get what they wanted. The DHS stated she found out about the Christmas Day incident between R#48 and CNA#7 from CNA#7 on Christmas Day. The DHS stated she had spoken to the CNA on the telephone, and CNA#7 told her that R#48 wanted to get up. The DHS stated she told CNA#7 if the resident wanted to get up then a way to get the resident up needed to be figured out. The DHS stated she reminded the CNA that two staff members were required to operate a mechanical lift that was needed to get the resident out of bed. The DHS stated she had not spoken to R#48 on the day she became aware of the issue. The DHS stated she arrived in the facility a little before 3:00 p.m. on Christmas Day and R#48 was up in the wheelchair. Later, on Monday, 12/26/22, the DHS stated she found out from the NN and the UM what CNA#7 allegedly said to R#48. The DHS stated she sent the NN down to talk to the resident, and the NN came back with the grievance completed. The DHS stated she did not personally investigate the grievance but directed the NN to follow up on R#48's concern, which included talking to the resident and getting the details of what happened, to find a resolution. The DHS stated she did not remember if she had spoken to the CNA about the incident since the CNA had been out sick. She stated she had not called him on the phone to discuss the issue. The DHS was unable to recall if the NN or the UM had spoken to other residents to determine if other residents had issues with CNA#7's treatment. The DHS stated that after reading the grievance and based on the statements presented, including the lack of interviews with other residents and no action taken with the CNA, she did not feel the investigation of R#48's concerns was very good. During an interview with NN on 1/12/23 at 11:22 a.m., she reviewed the grievance for R#48 dated 12/27/22. The NN stated the issue was the way CNA#7 had addressed R#48. The NN stated she had not heard CNA#7 address the resident, but the words were still not kind. The NN stated again that R#48 had told her they were unaware if the CNA was joking or serious, but the CNA's words had upset the resident. The NN stated the facility policy was to close an investigation and reach resolution in three days and acknowledged the resolution of R#48's concern was past three days. The NN acknowledged there was no documented follow-up with R#48. The NN stated she showed R#48 the policy on mechanical lifts to help the resident understand why CNA#7 had not transferred the resident by himself. The NN acknowledged R#48, who was the complainant, was not made aware verbally or in writing about the summary of the grievance and the resolution. During an interview with the Administrator on 1/12/23 at 12:58 p.m. the Administrator stated that when a grievance was received, the grievance was routed through the NN, who was responsible for assisting in completion of the written grievance that stated the problem. The Administrator stated the grievance received for R#48 was more of a customer service issue. The Administrator stated he became aware of the grievance either on Monday or Tuesday after Christmas. He added a complete investigation should have included the customer service aspect, and he would have assigned CNA#7 additional customer service training in the online education system. The Administrator stated that when he reviewed R#48's grievance, he saw it as R#48 being angry due to not having their way and added the resident had a history of fabricating stories. The Administrator stated it was his expectation that at least a verbal conversation be held notifying R#48 on how the issue would be resolved. The Administrator stated he felt the grievance for R#48 had been resolved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was conducted for one of three sampled residents (R) (R#51) reviewed for PASARR. Specifically, the facility failed to refer R#51 to the appropriate state-designated authority for a Level II evaluation following a new mental illness diagnosis. Findings included: On 1/12/23 at 10:12 a.m., the Director of Health Services (DHS) reported the facility did not have a policy for level two PASARR referrals. A review of a Face Sheet revealed R#51 had diagnoses that included hemiplegia and hemiparesis (weakness and paralysis on one side of the body), chronic obstructive pulmonary disease, and cerebral infarction (stroke). A review of a PASARR Level I assessment dated [DATE], revealed R#51 did not have a primary diagnosis of serious mental illness. A review of the Active Orders in R#51's electronic medical record revealed a physician's order dated 11/8/21 for Seroquel (an antipsychotic medication) 400 milligrams (mg) at bedtime. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed R#51 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident's active diagnoses included schizophrenia. The MDS items A1500, A1510, and A1550 regarding Level II PASARR screening and related conditions were unanswered. Review of Resident #51's Care Plan, updated 12/2/22, revealed the resident received a routine antipsychotic medication (Seroquel) and an as needed (PRN) antianxiety medication (Xanax) with risk for adverse consequences. On 1/10/23 at 12:30 p.m., the Director of Health Service (DHS) provided a document titled, ICD-10 [International Classification of Diseases, Tenth Revision] Diagnosis Report-Clinical, which included the dates of R#51's diagnoses. According to the report, R#51 was diagnosed with schizophrenia on 11/14/21 and bipolar II disorder on 12/2/22. During an interview on 1/10/23 at 3:33 p.m., the Social Worker (SW) stated R#51 did not receive a Level II PASARR referral for the 11/14/21 diagnosis of schizophrenia. The SW stated she was unaware of the PASARR process until recently and was trying to figure the process out. During an interview on 1/12/23 at 12:52 p.m., the DHS reported R#51 was not referred for a Level II PASARR after the diagnosis of schizophrenia on 11/14/21. The DHS stated she was unaware of the process for Level II PASARR for new mental illness diagnoses. During an interview on 1/12/23 at 1:40 p.m., the Administrator stated a Level II PASARR was required anytime there was an diagnosis of mental illness.

Based on observation, interview, and record review, it was determined the facility failed to ensure planned fall prevention interventions were promptly and consistently implemented to reduce the risk of further falls for one of one sampled resident (R) (R#94) reviewed for accidents. Findings included: A review of a Face Sheet revealed R#94 had diagnoses that included malignant neoplasm (cancer) of breast, acute respiratory failure with hypoxia (low oxygen level), and secondary malignant neoplasm of liver and bile duct. A significant change Minimum Data Set (MDS) assessment, dated 12/9/22, revealed R#94 had a Brief Interview for Mental Status (BIMS) score of one, which indicated severe cognitive impairment. The MDS indicated the resident was totally dependent on staff for bed mobility and that transfers did not occur during the seven-day assessment period. A review of a Care Plan, updated 11/10/22, revealed R#94 had a history of falls prior to admission and was at risk for falls related to requiring extensive to total assistance with activities of daily living (ADLs). A review of a Facility Event Investigation Form, dated 12/18/22 at 2:48 a.m., revealed R#94 rolled out of bed and was on the floor. The form indicated the resident was repositioning in bed and turned over too far. The bed was in the low position and the call light was within reach. The section of the form titled, Root Cause and Patient Centered Interventions added revealed the resident was unable to determine side of bed during repositioning and indicated a wedge was added and rotated every two hours and as needed. A review of an Event Report, dated 12/18/22, indicated after the fall on 12/18/22, a wedge was placed to help the resident determine where the edge of bed was and would be moved side to side every two hours or as needed until a fall mat was available to place on the floor on the right side of the bed. On 1/10/23 at 9:50 a.m., R#94 was observed lying on their right side in bed. The bed was in the low position. The call light was within reach. There was no fall mat next to the bed and no wedge in the bed. On 1/10/23 at 2:59 p.m., R#94 was observed lying on their left side in bed. The bed was in the low position. The call light was within reach. A fall mat was on the floor on the right side of the bed and there was no wedge in the bed. During an interview at this time, Licensed Practical Nurse (LPN)#4 stated the resident should have had the fall mat before now. During an interview on 1/11/23 at 1:41 p.m., Certified Nursing Assistant (CNA)#5 stated the resident was supposed to have a fall mat on the floor by the bed. CNA#5 reported the resident had not attempted to get out of bed and required assistance to be repositioned. CNA#5 stated the resident had used the call light in the past but not recently. During an interview on 1/12/23 at 11:34 a.m., Registered Nurse (RN)#6 stated she was present when the resident's fall occurred. RN#6 indicated there was no wedge in place to prevent the resident from rolling off the bed. RN#6 stated the resident was not cognitively aware enough to know how to use the call light if they needed assistance. During an interview on 1/12/23 at 1:50 p.m., the Director of Health Service (DHS) stated nursing had meetings to decide on interventions. During an interview on 1/12/23 at 1:50 p.m., the Administrator stated he would expect appropriate fall prevention interventions to be implemented.

Based on observation, interviews, record review, and facility policy review, it was determined the facility failed to promptly refer a resident with lost dentures for dental services for one of one sampled resident (R) (R#21) reviewed for dental services. This resulted in the resident being without dentures for approximately four months. Findings included: A review of a facility policy titled, Dental Services-Lost/Missing Dentures, dated 11/21/17, revealed, The facility will assist residents in obtaining dental services in the event of lost or missing dentures. Additionally, the policy indicated the following: - 1. All instances in which a resident's dentures are missing/lost or damaged should be reported to the Administrator (or designated partner) immediately. a. The Administrator, working with the Nurse Navigator and/or Social Worker will contact the patient and patient's family to inform them of the missing/lost/damaged dentures. 2. The Administrator will initiate an investigation as soon as possible to locate the resident's missing dentures or determine the cause of the damage. a. The investigation should include a thorough search of the facility for the dentures as well as interviews with partners, the patient, and family members. b. If the investigation determines that the loss or damage to the dentures was the responsibility of the facility and/or partners, the resident will not be charged to replace or repair of the dentures. - i. Per our Customer Service Recovery policy, we will provide the customer with appropriate restitution. So, if it cannot be determined who was responsible for the missing or damaged dentures, the facility should assume responsibility. 3. The resident with lost or damaged dentures must be promptly, within 3 days, be referred for dental services. a. The Unit Manager or designee, working with the patient's physician, will generate a consult for dental services to repair or replace the patient's dentures. b. The Nurse Navigator and/or Social Worker will schedule the appointment for dental services as soon as possible. c. If the referral cannot occur within 3 days, the facility must assess and document that the resident is able to eat and drink adequately while awaiting dental services as well as the reason for the delay. d. Partners will assist residents who are eligible and desire to apply for reimbursement of dental services as an incurred medical expense under the State plan. Review of a Resident Face Sheet revealed R#21 had diagnoses including dysphagia (difficulty swallowing), hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, and speech/language deficits following cerebral infarction. A quarterly Minimum Data Set (MDS) assessment, dated 12/23/22, revealed R#21 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident required extensive assistance for bed mobility and required only supervision and set-up assistance with eating. According to the MDS, the resident did not have signs/symptoms of a possible swallowing disorder but received a mechanically altered diet (diet with an altered texture to facilitate chewing/swallowing). During an observation and interview with R#21 on 1/9/23 at 12:16 p.m., the resident did not have any top dentures. R#21 stated the dentures had been missing since September 2022. The resident stated they went to the hospital to have a procedure done and, in the ambulance on the way back to the facility, R#21 threw up and their top dentures came out. According to R#21, the emergency medical technician (EMT) retrieved the dentures, rinsed them off, and placed them inside a blue glove. After placing R#21 back in bed at the facility, the EMT placed the glove containing the dentures on the bedside table and said he would let everyone know what was in the glove. R#21 stated when the night shift came in and cleaned off the bedside table, they threw the glove away, thinking it was trash. The resident stated this was reported to the Social Worker (SW) and the Administrator, but the dentures still had not been replaced. During an interview on 1/11/23 at approximately 3:30 p.m., the SW stated the facility was getting a new dental provider that would be providing orientation to the facility on 1/16/23. The SW stated the previous provider had already done a mold for R#21's dentures, but she was not sure about the status beyond that. The SW stated there should have been a note in the resident's chart regarding the mold being made. The SW stated she was bad about writing notes on paper with the intention of documenting in the chart later, but she forgot sometimes. When the SW was unable to find documentation of the mold being made, she asked if it was okay to give the previous dental office a call and place them on speaker phone. The interview with the dental office staff revealed that on 10/24/22, the dental hygienist saw R#21 and performed a cleaning. That was when it was noted that the upper dentures were missing. The hygienist was not qualified to make a mold for the resident, so the next clinic visit was scheduled for 12/19/22 for the dentist to come out and do the mold. When the dentist came out, the facility informed the dentist that 12/31/22 was the last day the dentist would be providing services to the facility. Based on this information, the dentist did not make molds on anyone because it took at least six weeks to be completed and this would go beyond the 12/31/22 service ending date. The SW indicated this was a surprise to her. She stated she thought the resident's dentures were lost after an 11/19/22 hospital visit and that the denture mold had been done. A review of R#21's medical record was performed by the SW at this time, and she confirmed that the only other hospital visit was 8/30/22, so it had to be after that visit when the dentures went missing. During an interview at 10:40 a.m. on 1/12/23, the SW stated she was not aware she needed to document anything in the progress notes for dental visits. She stated the process was that the dental records were scanned to the resident's file. The SW provided a copy of the record for R#21's 10/24/22 visit with the dental hygienist. When asked if there were any records for the 12/19/22 visit, the SW stated no. During an interview on 1/11/23 at approximately 3:00 p.m., the Administrator revealed when a resident's property was missing, a search would be done by housekeeping and laundry to determine if the property could be located. If the property was not located, the Nurse Navigator (NN) should complete a grievance report and follow up on the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a change in a resident's Physician Orders for Life Sustaining Treatment (POLST) status was communicated between the hospice provider and the facility for one of five sampled residents (R) (R#20) reviewed for POLST accuracy/communication. Findings included: On [DATE] at 2:06 p.m., the Director of Health Service (DHS) stated the facility did not have a policy regarding communication between hospice and the facility. A review of a Resident Face Sheet revealed R#20 had diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), anxiety disorder, and shortness of breath. The significant change in status Minimum Data Set (MDS), dated [DATE], revealed R#20 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. Review of R#20's Physician Order Report revealed a physician's order dated [DATE] for hospice to evaluate the resident and admit if indicated. Review of R#20's medical record revealed the resident had signed a new POLST form dated [DATE], which indicated R#20 desired to have cardiopulmonary resuscitation (CPR) performed should the resident's heart stop beating. This form was signed by R#20 and the hospice physician; however, as of [DATE] at 11:01 a.m., the resident's electronic medical record (EMR) indicated R#20's code status was DNR [do not resuscitate]. On [DATE] at 6:00 p.m., the discrepancy was brought to the attention of the facility's Administrator. On [DATE] at 10:55 a.m., R#20 was interviewed. R#20 stated they decided to go on hospice when they got tired of going to different doctor appointments every week. R#20 described that they had had CPR done before and knew what was involved. R#20 stated if their heart stopped beating, they wanted an effort to be made to bring them back, and if it was not meant to be, then it would not work. On [DATE] at 12:16 p.m., the Social Worker (SW) was interviewed. The SW revealed she met with R#20 on the evening of [DATE], and R#20 indicated they wanted CPR, so the EMR was updated. The SW stated the person who uploaded the updated POLST form into the EMR from the hospice company was strictly a clerical person and would not have known there was a change. The SW stated during a conversation with the hospice provider, it was decided that hospice staff would have to communicate with the facility staff any time a POLST form was completed. On [DATE] at 10:13 a.m., Unit Manager (UM)#1 and the restorative nurse, Licensed Practical Nurse (LPN)#2, were interviewed together. UM#1 stated that when the hospice team came in to complete an admission for hospice services, it was typical for them to have the resident/family fill out a new POLST form. LPN#2 stated the SW was usually the point person when there was a change to the POLST form, and the SW kept that piece of the medical record up to date. Both nurses indicated they had no idea why the hospice team did not communicate the change for R#20 to the staff directly. On [DATE] at 10:22 a.m., the hospice Registered Nurse (Hospice RN) was interviewed. The hospice RN confirmed she completed the admission paperwork with R#20, including the POLST form. The hospice RN stated she thoroughly explained CPR to R#20, and the resident understood and indicated they wanted staff to try CPR if their heart stopped. The hospice RN indicated she spoke with the hospice social worker, who confirmed with the resident the desire for CPR. The hospice RN stated she thought she had told LPN#3 about the change for R#20. The hospice RN stated R#20 had previously been on hospice services and at that time was a DNR. On [DATE] at 10:30 a.m., LPN#3 was interviewed in the presence of the hospice RN. LPN#3 stated the hospice RN had not informed her of the change in the POLST form for R#20. LPN#3 stated R#20 told her of the change, but she did not communicate it to anyone. LPN#3 stated that when a resident went into cardiac arrest, she referred to the EMR to see if that person wanted CPR or if they were a DNR. She stated she was lucky there was no change in condition for R#20 because the EMR did not currently reflect what the resident wanted. On [DATE] at 11:11 a.m., the Director of Health Service (DHS) was interviewed. The DHS stated the hospice nurses, and the facility nurses were very good about communicating and were in the facility daily. She indicated they were continuously swapping information about the residents on hospice services. The DHS stated code status was very important, and it was her expectation that any time hospice admitted someone to services, the hospice nurse should be communicating to the facility nurses what the resident chose on their POLST form. The DHS stated she wished the hospice nurse had said something, since they talked multiple times per day. During the interview, the SW approached and stated the hospice RN left admission documents for the facility in a designated box. The SW stated the new POLST form was not included in the paperwork that was left in the box. On [DATE] at 11:50 a.m., the Administrator was interviewed. The Administrator stated the initial solution to prevent this from happening again was to take the responsibility of completing the POLST away from hospice. It would only be completed by facility staff. The Administrator stated his expectation was if the hospice RN identified a change, she would bring it to the attention of the facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure oxygen tubing was covered and stored when not in use, to prevent potential infection for two of four sampled residents (R) (R#20 and R#65) reviewed for oxygen use. Findings included: A review of the facility policy titled, Procedure: Guidelines for Oxygen Safety, dated 2019, revealed, Follow infection control precautions when caring for residents using oxygen, such as keeping the tubing, mask, or cannula covered when not in use. Keep the tubing and delivery system off the floor. 1. A review of a Resident Face Sheet revealed R#20 had diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), anxiety disorder, and shortness of breath. The significant change in status Minimum Data Set (MDS), dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated resident was independent with bed mobility and required only supervision with transfer. According to the MDS, the resident received oxygen therapy while a resident. Review of a Physician Order Report revealed R#20 had a physician's order dated 4/26/21 for oxygen at two liters per minute (LPM) via nasal cannula as tolerated. On 1/9/23 at 8:31 a.m., R#20's oxygen tubing and nasal cannula were observed on the floor next to the bed. On 1/10/23 at 10:50 a.m., oxygen tubing was observed hanging over the side rail for R#20. It was not covered or stored in a bag. The resident was out of the room. On 1/10/23 at 11:10 a.m., R#20 stated they were not provided with a bag in which to store the oxygen tubing. On 1/11/23 at 8:51 a.m., the oxygen tubing was observed hanging over the side rail for R#20. It was not covered or stored in a bag. The resident was out of the room. On 1/12/23 at 8:40 a.m., the nasal cannula for R#20 was observed to be hanging over the side rail to the bed. It was not covered or stored in a bag. 2. A review of a Resident Face Sheet revealed R#65 had diagnoses that included atherosclerotic heart disease, congestive heart failure, atrial fibrillation, and chronic respiratory failure. The quarterly MDS, dated [DATE], revealed R#65 had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident was independent with bed mobility and required only supervision with transfer. The MDS did not indicate the resident received oxygen therapy. Review of a Care Plan, dated 8/10/20, revealed R#65 was to receive oxygen via a nasal cannula as needed, for diagnoses of chronic respiratory failure, congestive heart failure, and hypertension. A review of a Physician Order Report revealed R#65 had a physician's order, dated 4/21/21, for oxygen at two LPM via nasal cannula to keep the oxygen saturation above 90%. On 1/9/23 at 11:16 a.m., the oxygen tubing with nasal cannula for R#65 was observed to be hanging over the oxygen concentrator and touching the floor next to the resident's bed. It was not covered or in a plastic bag. On 1/10/23 at 11:10 a.m., the oxygen tubing was observed on the floor by R#65's bed. It was not covered or stored in a bag. R#65 was out of the room. On 1/11/23 at 4:30 p.m., the oxygen tubing was observed to be hanging over the oxygen concentrator and touching the floor next to R#65's bed. It was not covered or stored in a bag. On 1/12/23 at 8:40 a.m., oxygen tubing with nasal cannula was observed to be hanging over the oxygen concentrator and touching the floor next to R#65's bed. It was not covered or stored in a bag. On 1/12/23 at 10:53 a.m., Unit Manager (UM)#1 was interviewed. The UM stated her expectation was that oxygen tubing would be kept off the floor when not in use. She stated she was not sure if there was a policy on how to properly store the oxygen tubing, but she would expect it to be, Maybe wrapped up nicely and placed on the concentrator? At 11:00 a.m., UM#1 went into the rooms of R#65 and R#20. The UM observed the tubing and stated, It's not very sanitary, referring to the tubing for R#20 that was hanging over the side rail of the bed. For R#65, the UM thought the tubing on the floor was more of a tripping hazard before she noticed the nasal cannula was draped over the concentrator. She removed the tubing from the room and stated she was going to replace it with fresh tubing and nasal cannulas. On 1/12/23 at 11:08 a.m., the Director of Health Service (DHS) was interviewed. The DHS stated it was her expectation the oxygen tubing was secured and out of the way, in or out of a bag. She indicated whoever went in the room, a certified nursing assistant (CNA) or a nurse, should observe the tubing and be able to secure it. The DHS stated they needed to make sure it was not on the floor. On 1/12/23 at 11:18 a.m., the Infection Preventionist (IP Nurse) was interviewed. She indicated her expectation was that a bag would be near the concentrator so the tubing could be stored when not in use. The IP Nurse stated it was a concern when she had completed rounds of the facility and indicated she completed on-the-spot education; however, she was unable to provide any documentation of the education. She indicated it was everyone's responsibility to ensure the oxygen tubing was being stored properly when not in use. On 1/12/23 at 11:56 a.m., the Administrator was interviewed. When asked about his expectation for storing oxygen tubing, he stated, I'm not a clinician and I am not prepared to answer that question. I don't even know what a cannula is, since I'm not a clinician.

Based on observation, interview, review of Corporate Quantified Recipe Extension for ham and cabbage and record review the facility failed to follow established menus in preparing pureed diets for five residents receiving pureed diets. Findings include; Observation of the pureed meal preparation on 4/13/21 at 11:40 a.m. revealed a dietary aide took cooked ham which was cut up and that was already in a four inch pan and added it to blender. the dietary aide then added hot water from coffee pot and poured powdered thicker (not measured) into the blender from food container and blended the ingredients. The dietary aide then checked the mixture for consistency and added additional water and thickener until she felt it had reached a desired consistency. Further observation revealed when dietary aide prepared pureed cabbage using the same process which included taking cooked cabbage from a four inch pan and added it to the blender along with water from coffee pot then poured in powdered thickener (not measured) from food container and blended until the desired consistency was reached. The Dietary Manager (DM) on 4/13/21 at 2:40 p.m. supplied a recipe book which was reviewed and included the following: Corporate Quantified Recipe Extension #2020 for pureed ham (dated 3/31/05) for multiple serving sizes from 50 to 150. The 50 servings recipe requirements were: three pounds, two ounces of ham roast, one quart and one cup of broth from base, and thickener 15 tablespoons. Production Method: 1. Remove portions required from the regular prepared recipe. (weight meat only. Do not include cooking juice or gray. 2. Process until fine consistency. 3. Combine hot broth and thicken right and gradually add to meat while processing. All liquid may not be required. 4. Scrape down sides of processor with a rubber spatula and process for 30 seconds. 5. Serve hot (over 140 degrees F). 6. Portion using a #10 scoop for a two ounce (oz) portion or #8 scoop for three oz. portion. Review of the Corporate Quantified Recipe Extension #490 Pureed Cooked Cabbage (dated 08/26/04) for multiple serving sizes from 50 to 150. The 50 serving recipe requirements were: nine pounds, six oz cooked cabbage, one cup and 14 tablespoons of thickener (Thicken Right), 10 tablespoons of margarine. Production method: 1. Remove portions required from the regular prepared recipe. Drain and reserve cooking liquid. 2. Process until fine consistency. 3. Added thicken right, reserved cooking liquid, and margarine. Process until smooth. 4. Scrape down sides of processor with a rubber spatula and process for 30 seconds. 5. Heat to serving temperature. Use #16 scoop for 1/2 cup serving. Serve hot (140 degrees F). An interview with dietary aide on 4/13/21 at 11:50 a.m. revealed the facility currently has five residents who receive a pureed diet. The Dietary aide revealed that she does not follow a recipe and was unaware of the Corporate Quantified Recipe Extension and was not trained how to prepare the pureed diets. The dietary aide stated she is unsure if the correct amounts of each item because she eyeballs each amount she adds until she reaches the right consistency. The dietary aide revealed that the amount of meat or vegetables added are based on a four inch pan that is used because that amount is usually the right amount needed to feed all five residents. The dietary aide stated she usually always uses water as the liquid base and does not add margarine to the pureed food. The dietary aide is unsure if any nutritional value or taste is lost based on the way the pureed meals are prepared. An interview with DM on 4/13/21 at 2:40 p.m. revealed his process for preparing the pureed meal is to cook the protein, put it in a little pan, and add a little water and puree it. The DM Dietary manager stated he has never followed a recipe to prepare a pureed recipe and was unaware of the Corporate Quantified Recipe Extension. The DM revealed that he has never been trained or educated to follow a specific recipe for each pureed meal item. An interview with Registered Dietician (RD) on 4/14/21 at 4:05 p.m. revealed she is in the facility once a month. The RD stated all menus for all diet types are prepared at a Corporate level and signed electronically and are available on meal tracker. The RD further revealed that the DM has been trained on meal tracker and should know how to access them. The RD revealed that all pureed meal recipes have been updated in the last 6 months and that the facility should not be using recipes dated in 2004 and 2005. The RD stated she has never looked for or observed any printed pureed meal recipes in the facility and she has never observed staff preparing a pureed meal. The RD stated she assumed that staff were preparing them correctly according to the recipe and that staff should not be using water as the primary liquid base since it does diminish the nutritional value of the meal. Record Review of Corporate Health Menus dated July 2020 to December 2020 along with menus dated 2020 July 15 Update Diet Guide Sheet revealed menus were not being utilized by the facility. The menus utilized by the DM are not the approved menus by the Corporate RD. An interview with RD on 4/15/21 at 1:30 p.m. revealed that staff completed the food temperature log on 4/14/21 at lunch time incorrectly. The RD stated staff are checking food temperature when its done cooking and recording that temperature and not waiting to check the temperature once the food is on the steam table. Continued interview, at this time, with the RD revealed that menus for all of the Corporate facilities were updated July 2020 and were signed and approved by a Registered Dietician and confirmed these are not being utilized by the facility. The RD revealed that it is her responsibility to ensure menus in use by the facility are current and reflect at the changes and updates that were made and approved by a Registered Dietician. Record Review of Dietary Mandatory monthly meetings dated 3/4/2021, 1/9/21, 12/16/20, and 11/19/20 revealed food temperatures and pureed meal prep were not an agenda item that was reviewed and/or discussed. The facility did not provide any evidence that in-services on pureed diet preparation or how to perform proper food temperatures once the foods were on the steam table and before being served prior to the Recertification survey.

Based on observations, staff interviews, review of the facility policy titled Food Temperatures and record review revealed the facility staff failed to maintain several hot food items on the serving line at 135 degrees Fahrenheit (F) or above and one cold food item at 41 degrees Fahrenheit (F) or below, which had the potential to affect 82 of 82 residents receiving an oral diet. Findings include: Review of the policy titled Food Temperatures revised 3/24/2016 revealed: Procedure: 1. All hot foods served from the steam table must be held at or above 135 degrees. 2. All potentially hazardous cold foods must be held at 41 degress or less. 3. Food temperatures will be taken before and after serving, temperatures will be logged directly on the Food Temperature Log form. The recorded food temperatures should be kept in a file for six months. 7. If the food item is not at an acceptable temperature, the food item must be removved and heated/cooled to an appropriate temperature prior to serving. Food items must be reheated to a tempature of 165 degrees for 15 seconds. Observation of lunch tray line on 4/14/21 at 11:50 a.m. revealed food items uncovered at 11:58 a.m. and first tray prepared at 12:03 p.m. Staff were not observed checking temperatures for any food items prior to preparing the first tray. Further observation revealed after eighth plate of food were prepared and served, a temperature check of food items found the following observations: fried chicken at 133 degrees F, hamburger at 129 degrees F and cold mixed berries was 71 degrees F and the pimento sandwiches at 66 degrees F. An interview with dietary aide on 4/14/21 at 12:30 p.m. revealed she is currently in training for the tray line and she does not know what the appropriate temperature of the hot or cold food items should be. The dietary aide revealed that she was unaware the chicken, and hamburger were being held at an unsafe temperture. The dietary aide revealed that she is unsure why her trainer was not with her on the tray line while she was preparing food plates when she is not fully trained. The dietary aide stated that the cook will usually come over and take all the temperatures before she serves the food but that no staff has ever explained the process of checking the temperatures to her or explained what the appropriate food temperatures should be. The dietary aide stated she is also unsure of what the appropriate temperature should be for food items to be served after they are reheated. The dietary aide stated she has received training by another dietary aide although this did not include proper food temperatures. Record review of Food Temperature Log dated 4/11/2021 through 4/17/21 revealed that temperature logs were completed for all meals, breakfast, lunch and dinner for dates of 4/11/21, 4/12/21, 4/13/21, and 4/14/21. An interview with Registered Dietician on 4/15/21 at 1:30 p.m. revealed staff completed the food temperature log on 4/14/21 at lunch time incorrectly. The RD stated staff are temping foods when its done cooking and recording that temperature and not waiting until the food is placed on the steam tables and prior to plating the foods for serving. Further interview with RD revealed that menus for all of the Corporate facilities were updated last July 2020 and were signed and approved by a RD are not being used by the DM. The RD further revealed that the DM is using outdated menus that do not reflect the changes/updates made to menu items in July 2020. The RD revealed that it is her responsibility to ensure menus in use by the facility are current and reflect at the changes and updates that were made and approved by the Corporate RD. The RD revealed that she was taking the DM's word that he was keeping up with menu changes and using the most current RD approved meal plans. Record Review of Dietary Mandatory monthly meetings dated 3/4/2021, 1/9/21, 12/16/20, and 11/19/20 revealed that food temperatures were not an agenda item that was reviewed and/or discussed. The facility did not provide any evidence that in-services on how to perform proper food temperatures or the facility policy once the foods were on the steam table and before being served prior to the Recertification survey.