Based on observations, staff interviews, and review of the facility policy titled Promoting/Maintaining Resident Dignity During Mealtimes, the facility failed to promote dignity during dining for four of 36 sampled residents (R) (R16, R45, R42, and R250) related to staff referring to residents as feeders and not serving resident meals at the same time for residents who were dining together. These failures had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings included: A review of the facility's undated policy titled Promoting/Maintaining Resident Dignity During Mealtimes, revealed the Policy of It is the practice of the facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. The Policy Explanation and Compliance Guidelines section included 1. All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes. During a breakfast dining observation on 10/28/2024 at 8:00 am, the staff was observed passing out meal trays in the main dining room to approximately 32 residents. Certified Nursing Assistant (CNA) EE came into the dining room and was told by CNA GG that all the trays had not arrived. CNA EE confirmed that 11 residents did not have meal trays, including the dependent residents. CNA GG stated loudly, The feeder's trays ain't [sic] here? She was observed to reference the dependent residents as feeders multiple times during the meal observation in the direct area of the dependent residents (R16, R45, and R42). During a breakfast dining observation on 10/28/2024 at 8:00 am, four residents (R250, R8, R41, and R17) were observed sitting at the table together awaiting their meals. Three of the four residents (R8, R41, and R17) were served at 8:00 am. R250 was not served a tray and was observed watching the other three residents eat. During an interview with R250 at 8:10 am, he was asked if he was ready for breakfast, and he stated he wanted coffee and breakfast. During this observation, R17 finished breakfast and left the dining room at 8:15 am, and R8 finished his meal at 8:19 am and left the table. R41 stayed at the table with R250. She motioned for the Director of Nursing (DON) to come to the table at 8:26 am and stated that R250 had not received a breakfast tray. The DON asked Licensed Practical Nurse (LPN) HH if there was a tray for R250. LPN HH stated, What? He didn't eat? The DON said to R250, We got you a tray coming. Thank you (R41) for letting me know. R250's received a meal tray at 8:28 am. During an interview with LPN HH on 10/28/2024 at 8:31 am, she stated R250 was new to her, and she did not know he had not eaten until the DON informed her. She stated she would fill out a diet slip just in case they didn't have one. During an interview on 10/28/2024 at 10:49 am, CNA EE stated that she had received in-services related to dining, and stated All residents at the same table should be served at the same time. She explained that the situation with R250 not getting a tray was because he was new and must have come in over the weekend, so LPN HH had to go to the kitchen to get his tray. She was asked about the dependent residents and stated, Feeders come in last. We like to get the feeders out of bed. The feeders sit at the round table. She was asked if any of the dependent residents were alert, and she confirmed that R45 and R42 were alert. She was asked if she had received education related to labeling residents as feeders being a dignity concern, and she stated that she had always called them feeders. During an interview on 10/28/2024 at 11:00 am, LPN HH stated that she had not noticed if the staff referred to dependent residents as feeders, but if they had, that would be a dignity concern, especially if they were doing so in front of the residents. She stated if she was made aware of this or observed this behavior, she would pull the staff to the side and correct them. She confirmed that R45 and R42 were alert, dependent on staff for dining assistance, and sat in the dining room at the round table with R16.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and a review of the facility policy titled Residents' Rights and Treatment Regarding Advance Directives, the facility failed to ensure there were no discrepancies related to Advanced Directives for one of 38 sampled residents (R) (R3). The deficient practice had the potential to result in R3's Advance Directives not being followed. Findings included: A review of the facility policy titled Residents' Rights and Treatment Regarding Advance Directives, dated [DATE], revealed that it is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. Decisions regarding advanced directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions, and whether the resident wishes to change these instructions. Any decision-making regarding the resident's choice will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. A review of the Electronic Medical Record (EMR) for R3 revealed an admission date of [DATE]. A review of the care plan, last updated on [DATE], revealed that R3 had an advanced directive for Do Not Resuscitate (DNR) and that the resident DNR wishes wound be followed by staff through the next review. In the event that R3's heart stops beating, the facility staff were instructed not to perform Cardiopulmonary Resuscitation (CPR). It was noted that the facility would maintain the DNR form under Advance Directives in the resident's medical record. A review of the EMR revealed that R3 was documented as being a Full Code. However, a review of the physical medical chart revealed that R3 had a Physician Orders for Life-Sustaining Treatment (POLST) Georgia form dated [DATE] noting an order for DNR and a POLST Georgia form dated [DATE] noting an order for full code. During an interview on [DATE] at 9:40 am, Registered Nurse (RN) KK confirmed that the facility used a hybrid system of the EMR and the physical medical record. RN KK stated that she would use the EMR to identify the code status of a resident who was found unresponsive. She confirmed that the EMR noted that R3 was full code and that she would provide resuscitation efforts if R3 was found unresponsive. She was asked about the POLST Georgia form dated [DATE] noting an order for DNR in the physical record and she acknowledged that this was a discrepancy and needed to be reviewed. During an interview on [DATE] at 9:48 am, the Minimum Data Set (MDS) Coordinator stated that the POLST Georgia form dated [DATE], noting that R3 had an active order for full code, should have been removed due to the date. She stated that the nurse should have put the order in the EMR when the new POLST Form was signed by the physician. During an interview on [DATE] at 10:09 am, the Director of Nursing (DON) stated that the nurses are supposed to look at the EMR to determine resident code status. She was asked to verify R3's status. She stated that he was full code and that they would start CPR if he was found unresponsive. During an interview on [DATE] at 10:12 am, the Administrator stated there was a discrepancy in the EMR and the physical medical record for R3. She confirmed that she was the acting Social Worker and that it was between her and the DON to ensure that the EMR was updated. She confirmed that R3's current code status was DNR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to provide ADL care to three of 38 sampled residents (R) (R3, R10, and R22) related to facial shaving and nail trimming/cleaning. This failure had the potential to cause R3, R10, and R22 to have unmet needs and to feel self-conscious of their appearance. Findings included: A review of the facility policy titled Activities of Daily Living (ADLs), dated 2/12/2022, revealed the Policy was, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care. The Policy Explanation and Compliance Guidelines section included . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. A review of R3's electronic medical record (EMR) revealed diagnoses of, but not limited to, dementia with behavioral disturbance, restlessness and agitation, delusional disorders, and hallucinations. A review of R3's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of three (indicating severe cognitive impairment), Section E (Behavior) documented that rejection of care behaviors was not exhibited, and Section GG (Functional Abilities and Goals) documented R3 required partial/moderate assistance with personal hygiene. Observations of R3 on 10/26/2024 at 1:19 pm, 10/27/2024 at 8:36 am, 10/27/2024 at 12:00 pm, and 10/27/2024 at 4:51 pm revealed his face was not shaved. During an interview on 10/28/2024 at 9:47 am, Certified Nursing Assistant (CNA) GG stated that she assisted R3 with a shower on 10/26/2024. She stated that she did not ask the resident if he wanted to be shaved because the men usually refused. She stated that they do not do shower sheets or document anywhere if the residents had their faces shaved. 2. A review of R10's EMR revealed diagnoses of, but not limited to, cerebral infarction (CVA), muscle weakness (generalized), unsteadiness on feet, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. A review of R10's Quarterly MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a BIMS score of 12 (indicating moderate cognitive impairment), Section E (Behavior) documented that rejection of care behaviors was not exhibited, and Section GG (Functional Abilities and Goals) documented R10 required partial/moderate assistance with personal hygiene. An observation on 10/26/2024 at 9:44 am revealed R10 had a full beard, and his nails were long and sharp and needed to be trimmed. When asked about cutting his nails, R10 stated, No one does that. He stated no one had asked him if he wanted his nails cut. An observation on 10/27/2024 at 12:00 pm revealed R10's face was not shaved, and his nails had not been trimmed. An observation on 10/27/2024 at 2:09 pm revealed R10's face had been shaven, and he had a goatee, but his nails were still long and not trimmed. During an interview on 10/27/2024 at 12:07 pm, CNA JJ stated that she does assist the residents with shaving and nail care on their shower days. 3. A review of R22's EMR revealed diagnoses included, but not limited to, schizophrenia, bipolar disorder, and muscle weakness. A review of R22's Quarterly MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a BIMS score of 10 (indicating moderate cognitive impairment), Section E (Behavior) documented that rejection of care behaviors was not exhibited, and Section GG (Functional Abilities and Goals) documented R10 required supervision with personal hygiene. An observation on 10/26/2024 at 1:19 pm revealed R22's face was unshaven and his nails were long and jagged with a dark substance under them. An observation on 10/27/2024 at 2:15 pm revealed R22's face was unshaven and his nails were long and with a dark substance under them. In an interview with R22, he stated, All I need is a good shave. During an interview on 10/27/2024 at 2:15 pm, the Wound Care Nurse stated that she helped with shaving, haircuts, and trimming nails, but the residents refused care at times. She confirmed there was no documentation of ADL care being offered or refusals of ADL care. During an interview on 10/27/2024 at 12:02 pm, CNA JJ stated that she showered R22 recently but didn't clip or clean his nails and did not shave him. She stated she did not have a reason why those tasks were not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the facility's undated policy titled Elopements and Wandering Residents revealed the Policy Statement was This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. A review of R6's clinical record revealed diagnoses including, but not limited to, dementia with behaviors, paranoia with schizophrenia, cognitive communication deficit, intellectual disability, and extrapyramidal movement disorders. A review of R6's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 8 (indicating moderate cognitive impairment), Section E (Behaviors) documented no behaviors exhibited, Section GG (Functional Abilities and Goals) documented R6 was independent with mobility, and Section P (Restraints) documented a wander/elopement alarm was not used. A review of the clinical record revealed no assessment for elopement was completed before R6 eloped from the facility on 9/11/2024. During an interview on 10/26/24 at 11:32 am, R6 stated he recalled leaving the facility a few weeks ago. R6 stated he left the facility because he was tired of living there. During an interview on 10/27/2024 at 10:05 am, the Administrator revealed she recalled getting a telephone call that R6 was found outside the facility ambulating about a block from the facility. She further stated she directed Staff Member MM to escort the resident back to the facility. She stated R6 was escorted back to the facility, was assessed, and responsible parties were notified. Based on observations, staff interviews, record review, facility document review, and review of the facility policies titled Fall Risk Assessment and Elopements and Wandering Residents, the facility failed to ensure a complete post-fall assessment was performed for one of 13 residents (R) (R23) who sustained a fall. The facility also failed to complete an elopement assessment for one of 38 sampled R (R6). This deficient practice created a potential risk to the safety and well-being of R23 and R6. Findings include: 1. Review of the facility policy titled Fall Risk Assessment, dated 2023, revealed the Policy was It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. Review of the blank facility-provided document titled Fall/Incident Documentation & Reporting indicated When a resident has a fall/incident do the following: 1. Complete the fall/incident packet. 2. Then go to the electronic medical record (EMR). 3. Trigger UDA (User Defined Assessment). Record review revealed R23's diagnoses included, but not limited to, generalized muscle weakness, difficulty walking, insomnia, and unspecified dementia. Review of R23's EMR Progress Notes revealed a fall documented on 10/11/2024. The note documented that R23 was transferred to the hospital after the fall and returned with a cast to the left lower arm due to a fractured wrist. Observation on 10/26/2024 at 9:00 am revealed R23 with a cast on her left arm. During an interview and review of the EMR on 10/27/2024 at 2:25 pm, the Interim Director of Nursing (DON) confirmed a post-fall assessment dated [DATE] was triggered but not fully completed and further confirmed the UDA section was not completed. The Interim DON reported that she was unsure why this portion of the assessment was not completed. In an interview on 10/27/2024 at 4:28 pm, Licensed Practical Nurse (LPN) VV reported if a resident had an unwitnessed fall, the resident should be assessed for injury and neurological status. She further reported that an incident report should be completed after every fall. LPN VV was unsure if the triggered UDA should be completed after every fall event. In an interview on 10/27/2024 at 4:54 pm, the Administrator reported after a fall, an incident report and assessment of the resident should be completed, and all components of the incident report/assessment should be completed including the UDA. She stated she was unsure why the UDA was not triggered and completed for R23's fall on 10/11/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility policy titled Dental Services, the facility failed to provide routine and emergency dental services for three of 38 sampled residents (R) (R3, R13, and R22). This failure placed R3, R13, and R22 at risk for unmet needs and a diminished quality of life. Findings included: A review of the facility's undated policy titled Dental Services revealed the Policy was, It is the intent of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. The Policy Explanation and Compliance Guidelines section included . 9. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record. 1. A review of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE]. A review of the EMR revealed R3's funding source was documented as Medicaid Georgia (GA). A review of R3's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section L (Oral/Dental Status) documented R3 had no natural teeth or tooth fragments and was edentulous. A review of R3's EMR revealed that there was no dental assessment in the clinical record. Observations of R3 on 10/26/2024 at 1:19 pm, 10/27/2024 at 8:36 am, 10/27/2024 at 12:00 pm, and 10/27/2024 at 4:51 pm revealed he had no teeth or dentures. 2. A review of the EMR revealed that R13 was admitted to the facility on [DATE]. A review of the EMR revealed R13's funding source was documented as Medicaid GA. A review of the Quarterly MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a BIMS score of 10 (indicating moderate cognitive impairment), and Section J (Health Conditions) documented R13 frequently experienced moderate pain. There was nothing checked in Section L (Oral/Dental Status). A review of the Annual MDS assessment dated [DATE] revealed Section L (Oral/Dental Status) documented obvious or likely cavity or broken natural teeth. A review of the last dental exam documents dated 2/21/2024 revealed that R13 needed full mouth extractions under sedation due to R13 experiencing pain. He was ordered an antibiotic for an infection (clindamycin 150 milligrams (mg) every six hours until gone). The documentation further noted that there was a referral to an oral surgeon due to sedation and that the referral was sent to the facility. An observation of R13 on 10/26/2024 at 11:20 am revealed missing/broken/decayed teeth. In an interview, R13 stated that the dentist came three or four months ago and was going to do something for him, but they never came back. He stated he does have pain in his mouth and that he had told staff about his pain. 3. A review of the EMR revealed that R22 was admitted to the facility on [DATE]. A review of the EMR revealed R22's funding source was documented as Medicaid GA. A review of the Quarterly MDS assessment dated [DATE] revealed Section L (Oral/Dental Status) documented R22 had obvious or living cavities or broken natural teeth. A review of R22's EMR revealed that there was no dental assessment in the clinical record. An observation of R22 on 10/26/2024 at 1:19 pm revealed he had decayed/broken missing teeth. During an interview on 10/27/2024 at 12:12 pm, the Interim Director of Nursing (DON) stated that the Dental Provider last provided services in July 2024. She stated dental services were scheduled quarterly, by referral from staff, and on admission if they needed an assessment. She further stated R13 had stated that he had pain, but the location of the pain was not documented. She stated that the nurse should have documented the location of the pain. During an interview on 10/27/2024 at 12:26 pm, the Administrator confirmed that R13 went to the dental clinic twice due to pain and dental concerns. She stated, We have been working on his teeth for a while. Yes, he has mouth pain. She further stated the facility had changed dental providers in July 2024 and that she and the DON had been working to get residents on the list for the dental provider since then. During an interview on 10/28/2024 at 1:00 pm, the Administrator confirmed that R3 and R22 did not have any initial or routine dental assessment from a dental provider since admission to the facility. During an interview on 10/28/2024 at 1:00 pm, the Administrator confirmed that R13 had not received dental care from a dental provider since 2/21/2024 and that there was a referral to an oral surgeon due to sedation needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure that the Nursing Call System was functioning and operational for four of 26 resident rooms/bathrooms (Rooms 16, 17, 18, and 7). This failure placed the residents residing in the rooms at risk of accident, injury, or unmet needs related to an inability to call for staff assistance. Findings included: During an observation on 10/26/2024 at 9:44 am, the call light cord in room [ROOM NUMBER] was observed on the floor and not plugged into the Nursing Call Light Panel on the wall behind the resident bed. Certified Nursing Assistant (CNA) GG entered the room and verified the cord was on the floor and unplugged from the wall. When she tried to plug it back up, it was observed that the Nursing Call Light Panel only had one hole to accommodate one cord. There were two residents assigned to room [ROOM NUMBER]. CNA GG stated she would notify the nurse and the maintenance department. During an observation on 10/26/2024 at 9:48 am of the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], observation revealed no Nursing Call Light Panel was accessible in the bathroom. There was a gray panel with no accommodation for a call light cord. CNA GG confirmed this observation. During an observation on 10/26/2024 at 10:36 am in room [ROOM NUMBER], the call light cord was not functioning for the resident in Bed B. During observations and interview on 10/26/2024 at 10:53 am, the Interim Director of Nursing (DON) confirmed the Nursing Call Light Panel in room [ROOM NUMBER] only had one hole to accommodate one resident call light, even though two residents were assigned to that room. She further confirmed the resident's call light cord was not functioning to activate the Nursing Call System for the resident in room [ROOM NUMBER] Bed B. During an observation on 10/26/2024 at 10:57 am in room [ROOM NUMBER], the call light was pressed multiple times but wouldn't come on when the resident pressed the button to alert staff that they needed assistance. Registered Nurse (RN) KK was called into the room and confirmed that the Nursing Call System was not functioning. She stated that a new call light cord may be needed. During a second observation on 10/28/2024 at 11:47 am in room [ROOM NUMBER], the Nursing Call System had not been repaired and was not functional to accommodate both residents in the room. At this time, the Administrator and Regional Director of Environmental Services (RDES) stated staff had not informed the Administrator that the call lights were not functional in Rooms 16, 17,18, and 7 and in the shared bathroom of rooms [ROOM NUMBERS]. The RDES stated that he visited the facility twice a month and did rounds but was not aware of the Nursing Call System not functioning for all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure a clean, comfortable, and homelike environment for nine of 26 resident rooms (Rooms 15, 10, 11, 18, 20, 7, 16, 17, and 9) and one of two shower rooms (Ladies' Shower Room). These deficient practices had the potential to place the residents residing in and using the rooms at risk of living in an unsanitary and unsafe living environment and a potential for diminished quality of life. Findings included: During a resident room observation in room [ROOM NUMBER] on 10/26/2024 at 8:04 am, the following was observed: unlabeled and unbagged personal care products (skin and hair cleanser), unbagged and unclean graduate sitting on the back of the toilet, the paper towel dispenser was empty, the toilet was dirty, and the hand sanitizer dispenser was not working. A resident room observation in room [ROOM NUMBER] on 10/26/2024 at 9:19 am revealed thin linen sheets with stains, stains on the privacy curtain by Bed A, and writing on the walls by Bed A. A resident room observation in room [ROOM NUMBER] on 10/26/2024 at 10:36 am revealed a small indenture behind the door, missing paint from the door, rust on the vent in the room, faded spots in the privacy curtain, and there was no pull string for the overbed light. A resident room observation in room [ROOM NUMBER] on 10/26/2024 at 10:36 am revealed the floor tile was dirty and stained, broken window blinds, rust, dirt, and chipped paint in the room near the air unit, and the air unit was not sealed (the outside light was visible from the unit). An observation of the shared bathroom for rooms [ROOM NUMBERS] revealed the following: an empty soap dispenser, the floor vinyl peeling up, and plastic molding detaching from the wall. A resident room observation in room [ROOM NUMBER] on 10/26/2024 at 11:20 am revealed a broken toilet with the toilet tank cover sitting on the floor behind the toilet. The toilet flushing mechanism was observed to stick and continue to run when flushed. The sink was caked with a white and green thick build-up. There were unlabeled and unbagged personal care products (skin and hair cleanser), the floor vinyl peeling up, and the plastic molding was detaching from the wall. A resident room observation in room [ROOM NUMBER] on 10/26/2024 at 2:11 pm revealed a short privacy curtain between Bed A and Bed B. An observation in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] on 10/26/2024 at 9:45 am revealed the sink was dirty with hair, there were no paper towels in the dispenser, the toilet seat was observed with a dried brown substance on it, and hair was on the toilet. A resident room observation in room [ROOM NUMBER] on 10/27/2024 at 8:55 am revealed a strong urine smell in the room, missing paint from the wall, and short privacy curtains. A resident room observation in room [ROOM NUMBER] on 10/27/2024 at 8:58 am revealed a stained/bleached-out privacy curtain near Bed A. On 10/27/2024 at 4:30 pm, the Ladies' Shower Room was observed with a rusty chair and a black substance on the mesh shower chair. During an interview on 10/27/2024 at 4:26 pm, Housekeeper NN confirmed there was a strong urine smell in room [ROOM NUMBER] and stated it was a normal nursing home scent. She was unable to tell how often rooms were deep cleaned. During a comprehensive tour of the facility with the Administrator and the Regional Director of Environmental Services (RDES) on 10/28/2024 at 11:56 am, they confirmed all the areas of concern. The RDES stated that he visits the building twice a month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. A review of R3's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section E (Behavior) documented that rejection of care behaviors was not exhibited, and Section GG (Functional Abilities and Goals) documented R3 required partial/moderate assistance with personal hygiene. A review of the care plan, last updated 10/24/2024, revealed that R3 required set-up assistance from staff with personal hygiene. Observations of R3 on 10/26/2024 at 1:19 pm, 10/27/2024 at 8:36 am, 10/27/2024 at 12:00 pm, and 10/27/2024 at 4:51 pm revealed his face was not shaved. 6. A review of R10's Quarterly MDS assessment dated [DATE] revealed Section E (Behavior) documented that rejection of care behaviors was not exhibited, and Section GG (Functional Abilities and Goals) documented R10 required partial/moderate assistance with personal hygiene. A review of the care plan, last updated 7/17/2024, revealed that R10 required set-up, supervision, and limited assistance with ADL care related to a diagnosis of CVA (cerebrovascular accident) with left-side weakness. The Goal included assistance with ADLs will be provided. The Interventions included keeping the resident's nails clean and cut. Observations on 10/26/2024 at 9:44 am and 10/27/2024 at 12:00 pm revealed R10 had a full beard, and his nails were long and sharp and needed to be trimmed. An observation on 10/27/2024 at 2:09 pm revealed R10's face had been shaven, and he had a goatee, but his nails were still long and not trimmed. 7. A review of the Quarterly MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a BIMS score of 10 (indicating moderate cognitive impairment), and Section J (Health Conditions) documented R13 frequently experienced moderate pain. There was nothing checked in Section L (Oral/Dental Status). A review of the Annual MDS assessment dated [DATE] revealed Section L (Oral/Dental Status) documented obvious or likely cavity or broken natural teeth. A review of R13's care plan dated 10/18/2024 revealed that R13 had potential for oral/ dental health problems related to having broken teeth and dental caries. A Goal was that R13 would not develop any open area of the gums and would maintain adequate oral hygiene through the next review. Interventions included having dental consultants as needed, observing R13 for oral pain and ulceration, and observing/documenting/reporting to physicians any signs or symptoms of oral/dental problems needing attention. An observation of R13 on 10/26/2024 at 11:20 am revealed missing/broken/decayed teeth. In an interview, R13 stated that the dentist came three or four months ago and was going to do something for him, but they never came back. He stated he does have pain in his mouth and that he had told staff about his pain. During an interview on 10/28/2024 at 1:00 pm, the Administrator confirmed that R13 had not received dental care from a dental provider since 2/21/2024 8. A review of R22's Quarterly MDS assessment dated [DATE] revealed Section E (Behavior) documented that rejection of care behaviors was not exhibited, Section GG (Functional Abilities and Goals) documented R10 required supervision with personal hygiene, and Section L (Oral/Dental Status) documented R22 had obvious or living cavities or broken natural teeth. A review of the care plan, dated 10/24/2024, revealed R22 required supervision with ADL care related to impaired cognition from diagnoses of schizophrenia and bipolar disorder. Interventions included to keep resident's nails clean and cut. Further review of the care plan revealed that R22 had a potential for oral/dental health problems related to missing some natural teeth and had cavities. The Goal was the resident would not develop any open area of the gums and would maintain adequate oral hygiene. The Interventions included coordinating arrangements for dental care as needed/ordered and dental consults as needed. A review of R22's EMR revealed that there was no dental assessment in the clinical record. An observation of R22 on 10/26/2024 at 1:19 pm revealed he had decayed/broken missing teeth. Observations on 10/26/2024 at 1:19 pm and 10/27/2024 at 2:15 pm revealed R22's face was unshaven, and his nails were long and jagged with a dark substance under them. Cross-Reference F677 and F791 Based on staff interviews, record review, and review of the facility policy titled Comprehensive Care Plans, the facility failed to develop or implement comprehensive person-centered care plans for eight of 38 sampled residents (R) (R39, R42, R8, R19, R3, R10, R13, and R22). This failure increased the potential for R39, R42, R8, R19, R3, R10, R13, and R22 to not receive treatment and/or care according to their needs. Findings include: A review of the facility's undated policy titled Comprehensive Care Plans, revealed the care planning process would include an assessment of the resident's strengths and needs. The comprehensive care plan would be developed within seven days after completion of the comprehensive Minimum Data Set (MDS) assessment, and all Care Assessment Areas (CAAs) triggered by the MDS would be considered in developing the plan of care. Other factors would be determined by the interdisciplinary team (IDT) or as evidenced by the resident's clinical record. 1. A review of R39's medical record revealed diagnoses including dementia, weakness and unsteadiness on his feet, cognitive communication deficit, sexual dysfunction, and hypertension. A review of R39's MDS OBRA Annual Assessment, dated 2/14/2024, Section V (Care Assessment Area [CAA] Summary), revealed the assessment triggered cognitive loss/dementia, communication, activities of daily living (ADL) functional/rehabilitation potential, urinary incontinence, psychosocial wellbeing, behavioral symptoms, and pressure ulcer. A review of R39's medical record revealed physician's orders dated 2/8/2024 for amlodipine besylate, 5 milligrams (mg) one tablet by mouth (PO) one time a day (QD) for hypertension, 9/27/2024 Abilify 2 mg PO QD for dementia with behavioral disturbances, and 2/22/2024 Provera 5 mg PO QD morning for hypersexuality. A review of R39's care plan revealed that it did not include a plan for dementia, communication, ADL functional/rehabilitation potential, urinary incontinence, psychosocial well-being, behavioral symptoms, risk for pressure ulcer, and hypertension. 2. A review of R42's medical record revealed diagnoses including dementia, cognitive communication deficit, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, and major depressive disorder. A review of R42's MDS OBRA admission Assessment, dated 2/26/2024, Section V (CAA Summary), revealed the assessment triggered cognitive loss/dementia, communication, urinary incontinence, behavioral symptoms, pressure ulcer, and psychotropic drug use. A review of R42's medical record revealed physician's orders dated 3/13/2024 for lorazepam 1 mg PO three times a day (TID) for anxiety, 3/8/2024 trazodone hydrochloride (HCL) tablet 25 mg PO at bedtime (HS) for insomnia, 2/15/2024 amlodipine besylate 10 mg PO QD for hypertension, 2/15/2024 rosuvastatin calcium 10 mg PO QD for lipid control (hyperlipidemia), 2/15/2024 pantoprazole sodium 40 mg PO QD for GERD, 2/15/2024 quetiapine fumarate oral 50 mg PO QD for manic disorder, 2/14/2024 olanzapine 5 mg PO two times (BID) a day for manic disorder, and 2/14/2024 losartan potassium 50 mg PO BID for hypertension. A review of R42's care plan revealed the care plan did not include a plan for cognitive loss/dementia, communication, urinary incontinence, behavioral symptoms, pressure ulcer risk, psychotropic drug use, hypertension, anxiety, antipsychotic drug use, insomnia, GERD, hyperlipidemia, and manic disorder. 3. A review of R8's medical record revealed diagnoses including atrial fibrillation, chronic obstructive pulmonary disease (COPD), seizures, cerebral infarction, insomnia, hyperlipidemia, GERD, hypertension, and mental disorder. A review of R8's MDS OBRA admission Assessment, dated 9/9/2024, Section V (CAA) Summary, revealed the assessment triggered cognitive loss/dementia, communication, and dental care. A review of R8's medical record revealed physician's orders dated 10/17/2024 for olanzapine 5 mg PO TID for psychosis, 10/11/2024 Depakote 250 mg PO BID for dementia with behavioral disturbances, 8/30/2024 hydrocodone-acetaminophen 5-325 mg PO every 6 hours as needed for pain, 8/28/2024 Trelegy Ellipta inhalation aerosol 100-62.5-25 micrograms (MCG)/actuation (ACT) one puff via oral inhalation in the morning for COPD, 8/28/2024 donepezil HCl 5 mg PO at HS for dementia, 8/28/2024 atorvastatin calcium 20 mg at PO HS for hyperlipidemia, 8/28/2024 levetiracetam 1000 mg PO BID for seizures, 8/29/2024 diltiazem 120 mg PO in the morning for hypertension, 8/28/2024 metoprolol tartrate 25 mg give 0.5 tablet PO BID for hypertension, and 8/28/2024 pantoprazole sodium 40 mg, PO QD for GERD. A review of R8's care plan revealed the care plan did not include a plan for dementia, communication, dental care, antipsychotic drug use, pain, narcotic use, COPD, hyperlipidemia, seizures, hypertension, GERD, atrial fibrillation, cerebral infarction, mental disorder, and insomnia. 4. A review of R19's medical record revealed diagnoses of hyperlipidemia and GERD. A review of R19's medical record revealed physician's orders dated 8/16/2021 for omeprazole 40 mg PO QD for GERD and 8/16/2021 atorvastatin 20 mg PO QD for hyperlipidemia. A review of R19's care plan revealed that it did not include a plan for hyperlipidemia and GERD. During an interview with the MDS Coordinator on 10/27/2024 at 3:30 pm, the MDS Coordinator acknowledged that the MDS assessment triggered areas in R39, R42, and R8's CCA Summary that had not been care planned. She also acknowledged that R39, R42, R8, and R19's additional diagnoses and current medications had not been utilized in developing the residents' care plans. She stated the residents should have been care planned for areas related to clinical diagnoses, medications, and behavioral concerns. During an interview with the Interim Director of Nursing (DON) on 10/28/2024 at 7:47 am, she explained that all triggered CAAs identified during the MDS assessment should be included in a resident's current individualized care plan developed by the MDS Coordinator. She added that care plans should consist of clinical diagnoses and other areas of concern related to each resident's medical, emotional, behavioral, and psychosocial status. The DON acknowledged that R39, R42, R8, and R19 should have been care planned for the areas that were not in their care plans. During an interview with the Administrator on 10/28/2024 at 7:56 am, she stated her expectation was that the MDS Coordinator complete a thorough assessment for each resident, inclusive of the MDS CAAs, medical record, clinical diagnoses, medications, behavioral symptoms, psychosocial/mental status, and any other areas identified during the IDT meetings. The Administrator added that she expected the MDS Coordinator to include goals and interventions for each area identified in the resident's individualized comprehensive care plan. The Administrator acknowledged that the care plans for R39, R42, R8, and R19 did not reflect a comprehensive care plan.

Based on observations and staff interviews, the facility failed to label and date items in the freezer, failed to ensure items in dry food storage were not expired, failed to prevent cross-contamination hazards by storing scoops in the container, failed to wear hairnets, and failed to ensure routine cleaning and sanitation of the kitchen. This deficient practice had the potential to place 49 of 49 residents who received an oral diet from the kitchen at risk of foodborne illness. Findings Include: During the initial kitchen tour on 10/26/2024 at 7:47 am the following items were identified: 1. Dietary Aide AA and Dietary Aide BB were not wearing hairnets upon the surveyor's entry into the kitchen. 2. Items in the white standup freezer were not labeled or dated, including pancakes, cookies, biscuits, sausage, and fish nuggets. 3. In the dry storage pantry there were: a. Three bottles of expired thickened water with a use-by date of 8/24/2022. b. There were four plastic storage containers with sugar, rice, and flour with scoops on top and not in a bag. One scoop was in the container. During an interview on 10/26/2024 at 7:59 am with [NAME] FF, she confirmed the items in the standup freezer were not labeled or dated and reported that items in the freezer should have had a label on them. During an interview on 10/26/2024 at 8:07 am with Dietary Aide AA, he confirmed that scoops should be kept on top of the container and bagged. During an interview with the Dietary Manager (DM) on 10/27/2024 at 10:51 am, the DM acknowledged that storage bins did not have use by date, and she also confirmed that the scoops should not be kept in the containers with the rice, sugar, and flour. It was reported that the kitchen is deep cleaned monthly, and it was last deep clean was three weeks ago. The DM was unable to provide documentation of the cleaning. During a secondary tour of the kitchen on 10/27/2024 at 11:00 am, observation revealed there were four bags of unlabeled and dated meat in the walk-in freezer that were identified as beef stew by the DM. Observation on 10/27/2024 at 11:06 am revealed [NAME] CC who was observed to lick her gloved finger when sampling pureed sweet peas. [NAME] CC was not observed washing hands or changing gloves. During an interview and observation on 10/27/2024 at 12:00 pm, the DM reported an area on the floor with build-up was there because they were unable to move the table from the area to clean that area of the floor. The refrigerator was noted to have rusted, and the DM reported that it was due to the cleaning product that was used on the refrigerator. She reported that she has been out for a while, and the cleaning schedule may have gotten off track during her absence. An email from the Licensed Dietitian (LD) stated, The Nutritional Services Sanitation Inspection was completed by the LD on 9/20/2024 and identified concerns with items not being labeled and dated. In an interview on 10/27/2024 at 4:54 pm, the Administrator acknowledged that the items in the refrigerator and freezer should be labeled and dated. The Administrator stated she was not sure of the cleaning schedule but acknowledged that the kitchen should be cleaned daily. The Administrator further reported that hairnets should be worn by staff when in the kitchen. Lastly, the Administrator confirmed that [NAME] CC should not have sampled the sweet peas from her finger.

Based on observations and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner. This deficient practice had the potential to attract pests and rodents and transfer harmful microorganisms to food leading to food borne illness for the 49 residents residing in the facility. Findings include: During the initial observation of the dumpster area on 10/26/2024 at 8:30 am with Dietary Aide AA, there were two blue dumpsters observed with the door fully opened on one and partially opened on the other with a brief hanging out of the opening. During a second tour of the dumpster area on 10/27/2024 at 10:36 am with the Dietary Manager (DM), trash was on the ground to the right of one of the dumpsters and the door was opened on the other dumpster. The DM acknowledged the trash on the ground and that the dumpster doors should always be closed. During an interview with the Administrator on 10/27/2024 at 4:54 pm, it was acknowledged that the dumpsters should be kept closed on both the top and the sides. The Administrator went on to report that two dumpsters had been placed for nursing to put their items that would be separate from where dietary puts their trash.

2. Review of the facility's policy titled Infection Surveillance, revised 7/1/2024, revealed the Policy Statement was A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention practices in order to reduce infections and prevent the spread of infections. Review of the Infection Control Tracking Reports revealed the facility did not have documented evidence of infection control surveillance data for nine of ten months (January through September) for 2024. During an interview with the Interim Director of Nursing (DON)/ Infection Control Preventionist (ICP) on 10/27/2024 at 10:41 am, she stated she had taken the role of the facility's ICP in August of 2024 and was unable to locate any documentation for the monthly infection controls tracking system for 2024. Further interview revealed she did not know where the infection control tracking data for the past nine months (January through September) was and was only able to find infection control tracking data for 2021 and 2022. During an interview on 10/27/2024 at 2:40 pm, the Administrator stated she thought there was a more updated book with the 2024 monthly infection control surveillance data but could not locate it. Based on observations, staff interviews, record review, and review of the facility policies titled, Hand Hygiene and Infection Surveillance, the facility failed to maintain an effective infection prevention control program to ensure proper sanitation between resident interactions, failed to ensure beverages were covered before delivering on the hallway, failed to ensure hand sanitation when delivery meal trays, and failed to demonstrate ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. These deficient practices placed all 49 residents residing in the facility at risk of contracting avoidable infections. Findings include: 1. Review of the facility policy titled Hand Hygiene, dated 2023, indicated the following: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Observation on 10/26/2024 at 12:36 pm, in the dining room, revealed Registered Nurse (RN) UU with gloves on going from table to table cleaning multiple resident's hands with wipes. RN UU did not change gloves between residents. Observation on 10/26/2024 at 12:51 pm of a lunch food tray cart leaving the dining room and pushed to a resident hallway revealed there were seven trays on the cart, each with an uncovered beverage cup, during the meal delivery. Observation on 10/27/2024 at 1:09 pm of lunch meal tray delivery on a resident hallway by Certified Nursing Aide (CNA) TT revealed CNA TT delivering 12 meal trays to resident rooms. She was observed moving items on bedside tables and sometimes touching the residents in the rooms when delivering the trays. CNA TT did not use hand sanitizer or wash her hands between each delivery. During an interview with CNA TT on 10/27/2024 at 3:02 pm, it was reported that hand sanitizer was not used due to eczema. She reported typically she would use gloves but was informed that gloves could not be worn in the hallways with the surveyors in the building. CNA TT reported that the beverage cups were never covered when being delivered down the hallway, and she had not been directed to cover the cups. During an interview with the Administrator on 10/28/2024 at 2:43 pm, she stated staff should cover all drinks with a lid before distributing them down the hallways. She added that she did not know why the staff had not been covering the drinks, and she said it was the nursing staff's responsibility to ensure drinks were covered during transport. During further interview, she stated she expected staff to wash their hands and/or use hand sanitizer between resident contact and before and after entering and exiting a resident's room. She stated if the staff member had a skin condition that contraindicated the use of a hand sanitizer, she would expect the staff member to wash their hands when entering and exiting a resident's room and when assisting a resident. The Administrator indicated she had no problem or issues with the staff utilizing gloves to provide care. During an interview with the Interim Director of Nursing (DON) on 10/28/2024 at 2:51 pm, she stated that she expected staff to cover all drinks with lids before transporting them outside the dining room. The Interim DON stated it was the nursing staff's responsibility to ensure the drinks were covered.

Based on record review, family interview, staff interviews, and review of the facility policy titled, Accounting and Records of Resident Funds, the facility failed to provide a quarterly financial statement of a resident trust fund account for one of 40 residents (R) (#3). The deficient practice had the potential to affect the 40 residents with trust fund accounts managed by the facility. Findings include: Review of the facility policy titled, Accounting and Records of Resident Funds with revision date of April 2021 revealed under Policy Interpretation and Implementation 5. Individual accounting records are made available to the resident through quarterly statements and upon request. Record review for R#3 revealed a Quarterly Minimum Data Set (MDS) assessment which documented a Brief Interview for Mental Status (BIMS) summary score of 11, indicating moderate impairment. Interview with family of R#3 on 6/8/2023 at 12:35 p.m. revealed family member stated that the facility changes business office managers as often as she changes her underwear. She stated that she used to receive quarterly statements regularly, but she has not received a statement since December 2022. She stated that she does not believe that the statements are given to R #3. Review of the Trial Balance as of 6/8/2023 revealed R#3 to have an open Resident Trust Fund Account. No documentation was available to indicate that quarterly statements had been issued to R#3 or his responsible party. Interview on 6/7/2023 at 4:28 p.m. with Business Office Manager (BOM) II revealed she started working at the facility on May 26, 2023. She stated that she has a process for delivering quarterly statements to residents and their family/responsible parties. She stated that she does not know what the former BOM process was. Interview with Registered Nurse (RN) JJ on 6/8/2023 at 1:45 p.m. revealed R#3 finances are handled by his responsible party, brother and sister-in law. She stated that the family receives quarterly statements. A phone interview with former Business Office Manager HH on 6/8/2023 at 1:01 p.m. revealed she was employed at the facility from November 2022 to June 2023. She stated that she mailed statements out to residents quarterly. She stated that she does not remember if she mailed quarterly statements to R# 3s' family or not. She also stated that she does not remember if she gave the statements to him or not. She stated that she does not have any proof that R #3 or his family received quarterly statements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Change in a Resident's Condition or Status, the facility failed to notify the physician of a change in residents' behavioral status for 0ne of one residents (R#243). Specifically, the facility failed to inform the physician of the noted behavioral changes of R#243 which resulted in an resident -to resident altercation. Findings include: Review of facility's policy titled, Change in a Resident's Condition or Status revised February 2021 revealed: 1. The Nurse will notify the resident's attending physician or on-call physician when there has been: d. A significant change in the resident's physical/emotional/mental condition. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the Entry Tracking Record Minimum Data Set (MDS) dated [DATE] revealed R#243 was admitted to the facility on [DATE] and discharged [DATE]. Record review revealed R#243 had a diagnosis which included but not limited to Schizoaffective Disorder, Bipolar type, Insomnia and Anxiety Disorder, unspecified. Resident had physician orders which included monitoring every shift for behaviors to include: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusing care. Medication review for R#243 revealed the following medications : Trileptal Oral Tablet 300 Milligram (MG) (Oxcarbazepine) Give 1 tablet by mouth two times a day for mood stabilization, Temazepam Oral Capsule 30 MG Give 1 capsule by mouth at bedtime for insomnia, Risperdal Oral Tablet 1 MG (Risperidone) Give 1 tablet by mouth two times a day for mood stabilization, Risperdal Consta Intramuscular Suspension Reconstituted ER 12.5 MG (Risperidone Microspheres) Inject 12.5 mg intramuscularly one time a day every 14 day(s) for mood stability, Ativan Oral Tablet 0.5 MG (Lorazepam) Give 0.25 mg by mouth two times a day for anxiety, Diphenhydramine HCl Injection Solution 50 MG/ML Inject 50 mg intramuscularly one time a day every 14 day(s) for mood stabilizer and Buspirone HCl Oral Tablet 10 MG (Buspirone HCl) Give 1 tablet by mouth two times a day for anxiety. Review of R#243's Electronic Medical Record (EMR) under Health Status Note revealed a progress note dated 5/30/2023 at 4:51 p.m. that reads: Resident admitted to facility at 12:30 pm and admitted to room [ROOM NUMBER]-1. Transported via private car from SNF in ., Georgia. Alert and oriented to self but unable to assess orientation level as resident will not speak to this nurse or answer questions. Review of the Medication Administration Record (MAR) dated 5/31/2023 at 9:35 a.m. that reads: Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every shift Was a behavior observed? YES. Refusing medications. Review of the EMR revealed a Health status note dated 5/31/2023 at 10:20 a.m. that reads: Resident refused to take all morning medications. Attempted several times. States NO, I already took my medicine. Review of the EMR revealed a Health status note 6/1/2023 at 6:04 a.m. that reads: Resident refused pm medication this shift. Resident refused lab draw this shift. Resident continues to be nonverbal with writer only shaking his head no. Review of the EMR revealed a Health status note dated 6/1/2023 at 8:13 a.m. that reads: Refusing all morning medications. Pacing hallways. Restless and unable to sit still. Won't speak to this nurse or answer any questions. When passing this nurse in hallway he kicks foot in the air as if to kick this nurse. Review of EMR revealed a Health status note dated 6/1/2023 at 9:44 p.m. that reads: Resident reported to writer that he broke the patio door glass. When asked what happened resident just offered a blank stare. Resident visually observed for any obvious injury none noted. Patio door glass noted broken and still in windowpane in door. Resident noted calm pacing facility at times. Resident refused all pm medications this shift. Resident presently in bed. Review of EMR revealed an Incident Note dated 6/2/2023 at 9:45 a.m. that reads: Administrator called to facility for resident-to-resident physical altercation. Resident assaulted his roommate causing serious injury to roommate. Physician notified. Police notified. Family notified. State reportable completed. Resident sustained no injuries. Resident taken into custody by Tybee Island Police for aggravated assault at the request of his roommate. Family notified of transfer to Tybee Island Police station, and they are enroute for follow-up and pick up. Will continue to monitor. Review of EMR record revealed a Health status note dated 6/2/2023 at 2:07 p.m. that reads: Resident observed sitting in the TV room without any notable injuries. Resident questioned on whether or not he hit the injured patient that was sitting on the floor, and he responded, yes, but he hit me too. Writer unable to obtain any vital signs due to physical aggression. Communication conducted between brother and administrator, contact information Physician aware of incident. Patient was removed from facility in stable condition by Police Department. Interview on 6/7/2023 at 12:18 p.m. with Social Service Director (SSD) revealed R#243 was a new admission to the facility. Social Worker stated that on 6/1/2023 R#243 was refusing to take his medications and he gestured to kick Registered Nurse (RN) AA. SSD stated that he spoke with the Nurse at the behavior center for placement for R#243. SSD stated he called to follow up with the placement prior to leaving the facility for the day but he had no clue as to why the resident did not leave to go to the behavior center. Further interview revealed that social worker did not return to work until 6/5/23 and at the time he was informed of the incident and that R#243 had been arrested. After calling the Police department he was told resident would be sent to another jail where there was an outstanding warrant issued. Continued interview also revealed that the Administrator reported the incident to the state office and conducted the investigation on the incident, the Ombudsman and Adult Protective Services were notified on 6/5/2023. Interview on 6/7/2023 at 12:57 p.m. with RN AA revealed that she was at the facility on 6/2/2023 when the altercation between the two residents occurred. She stated that she was in the office when she heard a noise in the hall and when she came out, she observed the two residents in the hallway. She further stated there was no one else in the area. She further stated she observed R#29 on the floor in the front hall with his walker flipped over and he had blood coming down his face R#29 pointed at R#243 and said, he hit me. RN AA stated R#243 was in the hallway standing looking at R#29 and did not acknowledge anything about incident. Telephone interview on 6/7/2023 at 1:34 p.m. with Social Worker from the Behavior Unit revealed that she spoke with the Social Worker and the Director of Nursing (DON) from the facility regarding R#243 needing placement and the 1013 on 6/1/2023. She further stated that the team at their facility were still in the process of reviewing the financial and clinical notes to make a decision regarding admitting R#243 for services and this was communicated to the staff at the facility on 6/1/2023 that the final decision had not been made to admit R#243. Interview on 6/8/2023 at 9:30 a.m. with Certified Nurse Aide (CNA) CC revealed that she has worked at the facility for 13 years. She stated that she had received training on Abuse and how to deal with residents with dementia and aggressive residents. CNA CC further stated R#243 had not been in the facility long but recalled an incident when he was sitting in the dining room and suddenly jumped up and aggressively demanded coffee and she ran to get the coffee for him then he calmed down. Follow-up interview on 6/8/2023 at 9:35 a.m. with RN AA revealed she worked until 11 p.m. on 6/1/2023 and upon her departure, resident remained in the facility. RN AA further stated she was aware resident had broken the window on the door leading out to the patio. RN AA further stated that she did not call the physician to inform him of resident behavior because she was still waiting for resident to go to Behavior Health Center. She stated that the SSD and the Administrator are the only ones who had contact information to the behavior unit, so she did not have a way to contact the center regarding resident. She further stated she did not feel a need to call the physician to inform them of the resident's aggressive behavior and get further orders or instruction for care of the resident. Interview on 6/8/2023 at 9:45 a.m. with Administrator revealed that the Nurse at the facility called her to inform her R#243 had broken the window and she instructed her to call the physician and place resident on ever15-minutete checks until he went to bed. Administrator further stated SSD informed her on 6/1/2023 of the 1013 which was initiated due to R#243 being out of control and unmanageable. She stated that she left the faciity on 6/1/2023 at 4:30 p.m. and was aware that the behavior unit had not made a final decision regarding residents' admission to the facility. She further stated that she did not communicate that information to the staff. Administrator stated she is not sure why the nurse did not notify the physician of R#243's behavior, only the nurse can answer that question. Telephone interview on 6/8/2023 at 10:11 a.m. with Licensed Practical Nurse (LPN) DD revealed she worked 6/1/2023 on the 7 pm to 7 am shift and was informed in shift report that R#243 was awaiting transport to be sent to Behavior Health. She stated that around 8:30 p.m. R#243 informed her he had broken the window on the door. She further stated she did not notice any injury to resident, but observation of the door revealed the window was broken. LPN DD stated she contacted the Administrator and was advised to monitor resident, and place 1 staff member at each exit and 1 on the hall to monitor resident until he went to bed. LPN DD stated that she did not call the physician about resident behaviors. Telephone interview on 6/8/2023 at 10:18 a.m. with CNA EE revealed that she was not in the facility when the altercation between the 2 residents occurred. CNA EE further stated that she came to work on 6/1/23 and worked the 11 p.m. - 7 a.m. shift. CNA EE stated all night R#243 was pacing up and down the hallway from his room to the dining room looking at the front door. CNA EE further stated resident was not aggressive but had a strange look on his face and was pacing with both hands clenched in a fist. Telephone interview on 6/8/2023 at 10:25 a.m. with Nurse Practitioner (NP) FF from Behavioral Health Services revealed that she attempted to see R#243 while at the facility on 6/1/2023 but he refused services. NP FF stated R#243 was her client prior to admitting to this facility so she was aware R#243 had a history of refusing treatment and schizoaffective disorder. She further stated she asked R#2 if he would take his medications and he responded no. NP stated at this point she informed RN AA resident needed to be sent out on a 1013 if he continued to refuse is medications.

Based on record review, staff interviews, and review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, the facility failed to report abuse timely related to an employee-to-resident incident involving Resident (R) #292, for one of nine (9) facility reported incidents reviewed. Findings Include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating (Revised September 2022), revealed: Policy Interpretation and Implementation- Reporting Allegations to the Administrator and Authorities 1. If resident abuse or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. e. Law enforcement officials. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or resulting in serious bodily injury. Record review for R#292 revealed resident was admitted to the facility with diagnoses that include, but not limited to, Dementia with behavioral disturbance, schizophrenia, restlessness and agitation, other conduct disorders, diabetes mellitus II without complications. Review of electronic Nurse note did not show notes of this incident. Review of Facility Reported Incident Report dated 6/6/2022 indicated an abuse incident between two staff and R#292 took place on 6/2/2022 at or around 9:00 a.m. which consisted of physical aggression that resulted in injury. Review of the medical record dated 6/2/2022 indicated R#292 had an injury to the left side of their face and it was unknown how the injury occurred. Interview on 6/7/2023 at 3:47 p.m. with the Director of Nursing (DON) who reported she did not work on the day of the incident she remembered she notified Law enforcement and the corporate nurse after seeing R#292 eye was swollen/blackened. Interview on 6/8/2023 at 9:12 a.m. with Licensed Practical Nurse (LPN) LL who reported that she remembered the incident that occurred on 6/2/2022 with R#292. LPN LL reported that when she entered the shower room R#292 was seated in the wheelchair, and there was a big injury to R#292's eye she reported the incident to the Registered Nurse (RN). Interview on 6/8/2023 at 4:00 p.m. with the Administrator reported she did not work the day the incident occurred on 6/2/2022 with R#292 she was informed of the incident when she returned to work on 6/3/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Investigating Allegations: the facility failed to ensure that abuse allegations, including staff to resident altercations were thoroughly investigated for one resident (R#292). Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation, Investigating Allegations, with revision date of September 2022. The Investigation Allegations policy section included all allegations would be initiated and thoroughly investigated by the administrator. The Policy Statement indicated all reports of abuse (including injuries of unknown origin), are reported to local, state, and federal agencies (as required by current regulations), and thoroughly investigated by facility management. The policy further documented that the individual conducting the investigation at a minimum: c. observes the alleged victim, to include interactions with staff and other residents. h. interviews staff members (on all shifts) who had contact with the resident during the period of the alleged incident. I. interviews the resident's roommate, family members, and visitors. j. interviews other residents to whom the accused employee(s) provide care or services. L. documents the investigation completely and thoroughly. Review of the facility's investigation report indicated the above items were not conducted during the facility's investigation, as well as, not reported to the State Survey Agency within two hours of incident occurrence. Record review for R#292 revealed resident resided in the facility from [DATE] through 6/28/2022, on the [NAME] Hall, and had diagnoses that included dementia with behavioral disturbance, schizophrenia, restlessness and agitation, other conduct disorders, and diabetes mellitus type II. A review of the significant change Minimum Data Set (MDS) assessment revealed that R#292 was dependent on staff and required two-person extensive assistance with transfer. Interview on 6/8/2023 at 4:00 p.m. with the Administrator revealed she initiated the allegation of staff to resident abuse on her next day back to work which was more than 24 hours after the incident occurred. The Administrator reported that one of the staff involved did not return to the facility, and the other accused staff was placed in another building to work with other residents and was later terminated.

Based on record review, staff interview, and review of the facility's policy titled, Transfer Agreement the facility failed to comply with the requirements for an involuntary discharge for one of three residents (R) (#142). Specifically, the facility failed to ensure that R#142 was provided with proper notification of discharge from the facility. Additionally, the facility also failed to comply with the requirements for an involuntary discharge in accordance with their policy. Findings include: Review of facility policy titled Transfer Agreement reviewed and revised on 3/2017 revealed the following: Policy Interpretation and Implementation: 2. Our transfer agreement: b. Ensures that residents are transferred from the facility to the hospital and admitted in a timely manner when medically appropriate (as determined by the attending physician). e. Facilitates the exchange of medical and other information necessary or useful in the care and treatment of residents transferred between the institutions. i. Grants priority in admissions or readmission of residents from the health care facility to our facility. Review of the clinical record for R#142 revealed admission to the facility with diagnosis of Schizoaffective Disorder, Bipolar Type. Review of the Baseline Care plan (Target date: 11/29/2022) revealed R#142 was not a candidate to discharge home and is a long-term care resident per resident's family. Interview on 6/7/2023 at 2:57 p.m. with Officer MM of the local Police Department revealed that they responded to the facility on 3/29/2022 to conduct a well-check on R #142 after receiving a call from residents' family member who stated that R #142 called her and said someone had urinated in his bed. The family member also stated that she could hear a nurse yelling at R#142 during the call. Officer MM also revealed that upon arrival he saw R #142 talking with nurses and was free from any hurt, harm, or danger. R# 142 had no signs of trauma but admitted to the nursing home nurses that he had assaulted R# 27 because he felt that R# 27 had urinated in his bed. At that time, R #142 was placed under arrest and taken into custody. Officer MM also revealed he didn't see any signs of resident neglect, but he later filed a complaint as it was department protocol at the time of this event. Interview on 6/8/2023 at 12:49 p.m. with the Administrator revealed that on March 29, 2022, a family member of Resident # 142 called the local Police Department to the facility to conduct a well-check for R# 142. The family member stated that someone had urinated in the residents' bed. Because of this, R#142 attacked R# 27 because he felt that R #27 was the person who urinated in his bed. R# 142 admitted to assaulting R #27. As a result of the assault, R#27 had to be hospitalized . Upon hearing the admission of assault from Resident # 142, the police arrested R #142. R #142 was later released from jail. When R #142 arrived back at the facility, the Administrator had him sent to the local ER to be assessed for psychiatric reasons. The ER sent R #142 back to the nursing home stating he did not have any psychiatric or medical reasons that warranted a reason to be at the ER, so they were sending him back to the nursing home. When R #142 arrived at the nursing home, the Administrator confirmed that she did not allow EMS to leave R # 142 at her facility or at the neighboring facility. EMS then transported R#142 back to the ER. The Administrator revealed that she was not going to allow R#142 to return to this facility because the resident assaulted another resident who had to be hospitalized . Continued interview revealed she had tried to work with R #142, but when Resident assaulted R#27, that drew the line for her, and she decided at that time R#142 could no longer be a resident at this facility. During the interview, the Administrator confirmed that resident was not allowed to return to the facility, and she did not give R#142 proper notification for dismissal from the facility.

Based on observation, staff interviews, and review of the facility policy titled, Food Receiving and Storage, the facility failed to ensure that items were labeled/dated and used before the expiration date in the main kitchen. The facility also, failed to ensure that items in the dry storage area in the main kitchen were dated when received and were labeled and dated with a use by date. The deficient practice had the potential to affect 40 of 40 residents receiving an oral diet. Findings include: Review of the Policy titled, Food Receiving and Storage, with a revised date November 2022 revealed under policy statement : Foods shall be received and stored in a manner that complies with safe food handling practices. Under, Dry food and Storage: number 2. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. Further review of the Policy indicated under,Refrigerated /Frozen Storage number 1. foods are covered, labeled and dated (use by date). number 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. During the initial tour of the kitchen on 6/6/2023 at 11:40 a.m. with the Dietary manager (DM) revealed the following: 1. The reach in refrigerator on the right side of the kitchen at the entrance had four one-quart Grade-A Ultra-Pasteurized 40% Milkfat Heavy Cream cartons with an expiration date of 3/7/2023. 2. Two 15 oz. cans ultra pasteurized-sweetened whipped non-dairy topping with a best by date of 11/30/2022. 3. The second reach in refrigerator towards the rear of the kitchen had a 5 five-pound (2.26 kg) bucket of Chicken salad with a handwritten date it was opened on 5/27/2023, and a use by date of 6/1/2023. (Review of the weekly menu reported chicken salad sandwiches were served frequently) 4. Inside the white reach in freezer there was one large pan covered with foil with no label or use-by date on it. 5. The white freezer also had two bags of previously cooked stuffed baked potatoes without a label or use by date written on the bags. 6. The walk-in freezer had a very large piece of ice frozen on top of food boxes that contained food that was not identifiable. During a tour of the dry storage area 0n 6/6/2023 at 12:00 p.m. the following was revealed: 1. There were two large bags of opened spaghetti noodles wrapped in plastic wrap and there was no label or use-by date. 2. There were eight one1-liter bottles of Pedialyte Electrolyte Solution with no date and a black substance was on the top of the bottles, and as well as, on the bottles. Interview on 6/6/2023 from 11:40 a.m. until 12:24 p.m. with the DM revealed that when the freezer defrosts, the water drips onto the food boxes causing it to freeze on top of the food boxes making it difficult to tell what is in the boxes and to separate the boxes. The DM confirmed the expired dairy products in the refrigerator, and that the chicken salad was past the use-by date. The DM reported the large pan in the white freezer was a pan of cornbread dressing that was placed in there a month ago, and it was not labeled or dated along with the stuffed seafood baked potatoes; she reported that the spaghetti noodles were recently opened but were not labeled and dated. The DM reported the Pedialyte was purchased when the COVID stay-in-place was first initiated, and they kept the Pedialyte in case a resident needed extra electrolytes.

Based on observations, staff interviews, and review of the facility's policy titled, Homelike Enviornment, the facility failed to ensure a personalized and homelike setting was provided for the residents that resided in the facility. Specifically, the facility failed ensure that the residents name and room number was posted outside of the residents door. Findings include: Review of the facility's policy titled; Homelike Environment dated February 2021 revealed under Policy Interpretation and Implementaion the following: number 2. The facility, staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: d. personalized furniture and room arrangements. A tour of the facility on 6/5/2023 at 10:20 a.m. the following observations were made: Observation on 6/5/2023 at 10:23 a.m. revealed resident's room doors did not have resident's name on them. This was true for all residents in the building. Observation on 6/6/2023 at 10:08 a.m. revealed resident's room doors did not have resident's name on them. This was true for all residents in the building. Observation on 6/6/2023 at 10:08 a.m. revealed resident's room doors now have name tags and alternate forms of name tags on their doors. Interview on 6/6/2023 at 10:06 a.m. with the family member of R# 20 revealed the resident had been at the facility for the past three weeks and she has visited him almost every day since he was admitted . She revealed the doors have been without the resident's name on them since last week (5/28/2023 - 6/3/2023). Family member revealed she hasn't seen her father's name on the room since he has been at this facility. Interview on 6/6/2023 at 10:17 a.m. with Housekeeper GG revealed this was her third day on the job and she has not seen names on the doors since starting this job. Housekeeper GG revealed they have been painting the doors since I've been here, and no names have been on the doors. Interview on 6/6/2023 at 10:23 a.m. with the Maintenance Director revealed they began painting the doors on last week (5/28/2023). Each door was ready for new signage to be placed on them approximately twenty-four hours after the door has been painted. The Maintenance Director went on to explain that it was not his responsibility to replace the name tags and this responsibility was the responsibility of the administrative staff. The Maintenance Director also acknowledged that an alternative plan should have been put into action. Interview on 6/6/2023 at 10:36 a.m. with the Administrator acknowledged that there were no names and room numbers on the resident doors. Further interview revealed that the names and numbers were taken off the doors so that they may be painted, and they have only been off for a day or so. The Administrator confirmed that names and room numbers should be on the residnets doors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility policy titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures and Isolation - Categories of Transmission-Based Precautions the facility failed to allow one of one (R#36) readmitted residents that was fully vaccinated, symptom free, and COVID-19 negative to be readmitted to the general population and allowed visitation and the opportunity to interact with other residents. Findings include: Review of the undated facility policy titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures Policy statement: This facility follows recommended standard and transmission-based precautions, environmental cleaning, and social distancing practices to prevent the transmission of COVID-19 within the facility. COVID-19 Updates: New Admits: Unvaccinated- Quarantine for 10 days. Vaccinated for seven days. Review of the undated facility policy titled, Isolation - Categories of Transmission-Based Precautions Policy Statement: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection, arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. 4. The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission -based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. Record review revealed that R#36 was readmitted to the facility on [DATE]. The resident was admitted with diagnoses that included paranoid schizophrenia, cognitive communication deficit, and dementia. Review of the Quarterly Minimum Data Set (MDS), for R#36, dated 1/5/2022 revealed a Brief Interview for Mental Status score of one indicating the resident was severely cognitively impaired. Review of the resident's functional status revealed the resident required supervision and/or oversight from staff for walking in room or corridor but did not require staff assistance. Interview on 1/19/2022 at 12:09 p.m. with the Infection Preventionist (IP) revealed there is currently one resident on quarantine. The IP stated that R#36 was sent out to a Behavioral Health hospital for one week related to behaviors and was readmitted to the facility last night. The IP stated the resident was currently on isolation in room [ROOM NUMBER]. Further interview with the IP revealed the resident was fully vaccinated and boosted and that he had been tested when he was readmitted to the facility and was negative for COVID-19. In addition, the IP stated R#36 was symptom free when he was readmitted , and he has continued to remain symptom free since he was readmitted . Observations on 1/19/2022 at 12:15 p.m., 1/19/2022 at 4:58 p.m., and 1/20/2022 at 6:33 a.m. revealed R#36 in the isolation unit. The resident was observed each time walking around in the hallway on the isolation unit back and forth looking out of the windows in the double doors out toward the residents and staff on the hallway for the general population. Further observation revealed R#36 was the only resident on the isolation unit. A three-drawer cabinet was outside of the resident's door. Personal Protective Equipment observed in the drawers. Interview on 1/20/2022 at 3:17 p.m. with the IP revealed that R#36 had not had any visitors and that visitors can only visit in the front area through plexiglass. Interview on 1/20/2022 at 6:48 a.m. with the Administrator revealed that R#36 was on quarantine because he was recently readmitted from the hospital. The Administrator stated that when residents are readmitted to the facility, they are placed on quarantine and remain on quarantine for seven days. The Administrator stated this is the process even for residents who are fully vaccinated and don't have any symptoms. The Administrator stated that R#36 was tested for COVID-19 when he was readmitted to the facility and the test was negative and that R#36 has not had any symptoms since he was readmitted to the facility. The Administrator stated that she was aware of the new guidance that if a resident was fully vaccinated and did not have any symptoms that the resident could be admitted to the general population. The Administrator stated that although the resident was fully vaccinated and able to be admitted to the general population it was a corporate decision to place fully vaccinated and symptom free residents who are readmitted on quarantine for seven days (without visitation).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of facility document titled Position Summary, the facility failed to maintain a safe and homelike environment related to dust buildup on ceiling vents in five of 26 residents' rooms and/or bathrooms (3, 6, 9, 16, and 17), one hall and one women's shower room; and disrepair of one women's shower room related to missing tiles and broken light fixture. Findings include: 1. Observation during the initial tour of the facility on 1/18/2021 at 11:00 a.m. revealed room [ROOM NUMBER] and 17 had a dirty ceiling vent in the shared bathroom. This was confirmed during observation and interview with the Maintenance Director and Regional Facilities Director on 1/19/2022 at 3:30 p.m. 2. Observation of facility environment on 1/19/2022 starting at 11:30 a.m. revealed the following concerns: the women's shower room vent grates over the toilet were covered in dust and debris. There were missing tiles noted on the dividing wall between the toilet and shower area, and the light fixture in the ceiling was loose from the supporting structure. Observation of vent in the middle of the hall just off from the dining room in front of the women's shower room was covered in thick dust particles. room [ROOM NUMBER], 6, and 9 air intake vents were covered in dust and debris. Environmental rounds with the Administrator, Regional Maintenance Director, and facility Maintenance Director on 1/19/2022 at 3:15 p.m. confirmed all observations of vents, missing tile, and light fixture in the women's shower room as well as confirmation for vents covered in dust and debris in resident rooms 3, 6 and 9. Interview with Administrator on 1/19/2022 at 3:19 p.m. revealed that maintenance is responsible for ensuring that the vents are kept in good repair, and it is the responsibility of the housekeeping department to maintain them daily by dusting. Interview with Housekeeper LL on 1/20/2022 at 11:03 a.m. revealed that when residents room is cleaned the first thing that is done is the trash is taken out, all the furniture is dusted and wiped down with disinfectant, the bathroom is cleaned, and the resident's floor is swept and mopped. Continued interview revealed that he has never dusted any vents in the resident's rooms and had never been told to do so. Review of undated facility document titled Position Summary revealed under Position responsibilities and standards: Cleans (dust, dry mop, sanitize, scrub) assigned resident apartments and common areas daily according to facility procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, the facility failed to ensure that one resident (R) (#34) was free from misappropriation of resident's property of 25 sampled residents. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April 2021 revealed a Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Policy Interpretation and Implementation: The residents abuse, neglect, exploitation, and misappropriation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect resident from abuse, neglect, exploitation, and misappropriation of property by anyone but not necessarily limited to: a. facility staff, b. other residents, c. consultants . 8. Identify and investigate all possible incidents of abuse, neglect, exploitation, and misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. Review of the facility's Face Sheet revealed that R#34 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, hypertension, paraplegia, cognitive communication deficit, and major depressive disorder. Review of the admission Minimum Data Set (MDS) for R#34 dated 1/2/2022 revealed that the residents Brief Interview for Mental Status (BIMS) score was 15 indicating resident's cognition was intact. Review of the resident's behaviors revealed the resident had verbal behavioral symptoms directed toward others one to three days during the assessment period. The resident was totally dependent on staff for dressing, toileting, and personal hygiene. Review of a Health Status Note for R#34 dated 1/14/2022 documented at 7:15 p.m. resident was being given a shower by two CNA's when she was instructed to take out her money that was at her breast and to put the money in her wallet. After the shower they (staff) put the resident on the bed and the resident started counting her money and stated that somebody stole $200. I got $600 and now I only have $400. The resident kept saying there was a thief in the building. The resident was asked to count out her money and she counted out $420. When staff member returned to the resident's room at 8:30 p.m., the resident did not mention any more about her money. Signed by RN (Registered Nurse) Nurse Manager (sic) Interview on 1/19/2022 at 12:00 p.m. with R#34 revealed that when she was admitted to the facility that she had $600. The resident stated that last week on 1/14/2022 when she went to get a shower, she had her money in her bra and that staff told her to take the money and put it in her wallet. The resident pulled out her phone and showed that her phone case also included a wallet area. The resident stated when the CNA's told her that she needed to put her money in her wallet, she put her money in the wallet in her phone case. R#34 stated that after her shower when she was put to bed, she counted her money and that $200 was missing. R#34 stated she immediately told staff that her money was missing. R#34 stated she also told the RN Nurse Manager that same night. R#34 stated she also told Social Services and was told that she would not get her money back. Interview on 1/20/2022 at 1:45 p.m. with the RN AA (nurse manager) revealed that R#34 told her on 1/14/2022 that she had $200 stolen from her. The RN AA stated she talked with the resident and the resident showed her, at that time, that she had $400. RN AA stated that she searched the resident's room but did not find the missing money. RN AA stated she notified the Administrator of the missing money when the incident occurred. RN AA stated when she went back into the resident's room later that same night that the resident didn't mention anything about her money. RN AA stated she remembered seeing the resident eating food and thought the resident had spent the money on shopping and food. Review of the resident's medical chart revealed a form titled, Inventory Form that was blank. Interview on 1/20/2022 at 7:00 a.m. with the Administrator revealed that she had spoken to the resident about her money being taken and that the resident had been shopping and had spent $200. The Administrator stated she had the receipts showing the money had been spent and she had the facility incident report. Record review of the Facility Incident Report provided by the Administrator revealed it was incorrectly dated for 11/9/2020 (prior to the resident being admitted to the facility). Further review revealed that the Incident Report documented the report served as the Investigative Report and the five-day summary of the report of alleged financial misappropriation of R#34 reported to the State Survey Agency (SSA) on 1/18/2022. Documentation included that the resident (R#34) reported that she had $600 when she entered [NAME] Beach and now, she had $400. The investigation also included that staff reported that R#34 had given the Activity Assistant $200 for personal shopping and those receipts were being accumulated to substantiate personal shopping. In addition, the floor tech stated that the resident asked him to buy food. Review of the documents revealed only one receipt was present and it was noted to have $7.99 circled. There was a handwritten statement from the floor tech that documented R#34 gave him money and he spent the following: $27 on perfume, $17 on burgers, $18.90 on chips and cookies for a total of $62.90. The Facility Incident Report documented that the RN Supervisor did a thorough search of the resident's room and closet and no money was found. Further review of the Facility's Incident Report revealed that although the facility's investigation report to the State Survey Agency documented that the RN Nurse Manager did not find any money in the resident's room, the Health Status Note dated 1/14/2022 by the RN Nurse Manager documented that the resident counted out $420 in front of the RN Nurse Manager. The Facility Incident Report documented that the resident had given the Activity Assistant $200 for personal shopping; however, review revealed there were not any receipts to reflect this nor was there a written statement from the Activity Assistant stating that R#34 had given her $200 for personal shopping. Further review revealed there was a receipt signed by the resident that was dated 1/20/2022 showing the facility had given the resident $200 on 1/20/2022, after surveyor inquiry. Interview on 1/20/2022 at 1:35 p.m. with R#34 revealed that the Administrator gave her back the missing money. The resident stated she was so thankful because she had already been told, by staff, that the facility would not give her money back to her. Interview on 1/21/2022 at 5:02 p.m. with the Administrator revealed that she did not know what happened with the $200. The Administrator stated it would have been helpful to the resident and to the staff if an inventory had been made of the residents' personal property when the resident was admitted .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, and staff interviews, the facility failed to report physical abuse within two hours for resident (R) (#140) and failed to report an allegation of misappropriation of resident property within 24 hours for R#34, of a sampled of seven residents reviewed for reporting alleged violations. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised April 2021, stated the following: Reporting Allegations to the Administrator and Authorities -If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. -The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. -Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 1. Record review revealed R#6 was admitted to the facility on [DATE] with diagnoses including, dysphagia, cognitive communication deficit, generalized muscle weakness, schizoaffective disorder, paranoid schizophrenia, anxiety disorder, extrapyramidal and movement disorder, and major depressive disorder. Record review revealed R#140 was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbances, altered mental status, cognitive communication deficit, generalized muscle weakness, unsteadiness on feet, and essential hypertension. Review of facility Heath Status Note dated 12/14/2021 at 7:35 a.m. revealed writer heard the CNA (certified nursing assistant) yelling stop, stop. Writer noted R#140 on floor outside of room [ROOM NUMBER] with the resident in room [ROOM NUMBER]-1 (R#6) standing up out of his wheelchair bent over R#140 holding him by the legs. Resident noted with blood on right ear with two small lacerations noted on earlobe and bruising noted to right side of face. Review of Facility Incident Report form dated 12/17/2021 documented the type of incident which was resident to resident abuse. Details of incident were as follows; R#6 physically abused R#140 for entering his personal space. Interview on 1/20/2022 at 3:04 p.m. with Administrator in reference to altercation between R#6 and R#140 revealed the incident occurred on 12/14/2021 and was not reported to State officials until 12/17/2021 at 6:03 p.m. because that is when the incident was reported to her. Further interview also revealed the staff are supposed to report any abuse to her when it occurs, but this did not happen. 2. Review of the facility's Face Sheet revealed that R#34 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, hypertension, paraplegia, cognitive communication deficit, major depressive disorder. Review of the admission Minimum Data Set (MDS) for R#34 dated 1/2/2022 revealed that the residents Brief Interview for Mental Status (BIMS) score was 15 indicating resident's cognition was intact. Review of a Health Status Note for R#34 dated 1/14/2022 documented at 7:15 p.m. resident was being given a shower by two CNA's when she was instructed to take out her money that was at her breast and to put the money in her wallet. After the shower they (staff) put the resident on the bed and the resident started counting her money and stated that somebody stole $200. I got $600 and now I only have $400. Record review of the Facility Incident Report revealed it was incorrectly dated for 11/9/2020 (prior to the resident being admitted to the facility). Further review revealed that the Incident Report documented the report served as the Investigative Report and the five-day summary of the report of alleged financial misappropriation of R#34 reported to the State Survey Agency (SSA) on 1/18/2022. The SSA revealed that although the resident reported the missing money on 1/14/2022, the initial report was not received until 1/18/2022. The Final Report was received on 1/20/2022. Interview on 1/20/2022 at 1:45 p.m. with the (Registered Nurse) RN AA revealed that she reported the missing money to the Administrator on 1/14/2022 and that the Administrator was the Abuse Coordinator and is responsible for reporting the missing money. Interview on 1/21/2022 at 5:02 p.m. with the Administrator revealed that she did not know what happened with the $200. The Administrator stated the missing $200 should have been reported within 24 hours of being reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to ensure the environment was free from potential accident hazards by not ensuring that chemicals were kept secure and out of the reach of cognitively impaired, wandering residents. The facility had four wandering residents of a total census of 38. Findings include: Review of the Safety Data Sheet for Clorox Disinfecting Bleach (Sodium hypochlorite) last revised 3/6/2020 documented the following: 1. Emergency Overview: Hazard Statements: Causes severe skin burns and eye damage . Asphyxia from glottal edema may occur. Marked decrease in blood pressure may occur with moist rales, frothy sputum, and high blood pressure. 7. Storage: Keep containers tightly closed in a dry, cool, and well-ventilated place. Protect from moisture. Store locked up. Keep out of the reach of children. 11. Toxicological Information: Inhalation: May cause irritation of respiratory tract. May cause Pulmonary Edema, Eye Contact: Corrosive to the eyes and may cause severe damage including blindness. Causes serious eye damage. Skin contact: Avoid contact with skin. Corrosive. Causes burns. Ingestion: Ingestion causes burns of the upper digestive and respiratory tracts. Ingestion may cause gastrointestinal irritation, nausea, vomiting, and diarrhea. Review of the facility's admission Record revealed that R#8 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, altered mental status, and hypertension. Review of the admission Minimum Data Set (MDS) for R#8 dated 10/22/2021 revealed that the residents Brief Interview for Mental Status (BIMS) score was seven indicating severe cognitive impairment. The resident required supervision and/or oversight from staff for walking in room or corridor but did not require staff assistance. Review of the resident's behaviors revealed the resident did not exhibit any behavioral symptoms during the assessment period. Review of a Health Status Note dated 1/14/2022 revealed that while the nurse was sitting at the nurse's station, she was called by a Certified Nursing Assistant (CNA) and the nurse observed R#8 with a bottle of spray. The resident took a bottle of bleach from a housekeeping cart and went after staff with it. Chemicals were taken from resident and put away. Resident was informed this was very dangerous behavior. MD (Physician) and responsible party notified. Psych NP (nurse practitioner) notified. Interview on 1/20/2022 at 3:17 p.m. with the Registered Nurse (RN) AA revealed that after this incident occurred that she didn't have an in-service with the staff to ensure that chemicals were kept out of the reach of residents. RN AA stated that she did have a talk with some of the staff. Observation on 1/21/2022 at 2:20 p.m. with Housekeeping (HK) LL, while at the housekeeping cart, revealed that he could not shut the door on the cart completely because the lock was broken. HK LL stated that he didn't know how long the lock on the door had been broken, but maybe since the beginning of the week. HK LL stated that he did not report the broken lock to anyone. Interview on 1/21/2022 at 5:02 p.m. with the Administrator revealed that she did not know why there were not in-services conducted with the staff after the 1/14/2022 incident when the resident got the chemicals off the cart and sprayed staff. The Administrator stated in-service education should have been provided to staff when the incident occurred with R#8. Interview and observation with the Administrator, at this time, revealed that both housekeeping cleaning carts had been removed from use. No other residents were identified as having access or obtaining chemicals from a housekeeping cart.

Based on record review, staff interviews, and review of the facility policy titled, Test Results, the facility failed to ensure that abnormal laboratory test results were reported in a timely manner to the physician for one of 25 sampled residents (R) (#11). Findings include: Review of the facility policy titled, Test Results revised December 2009 documented, Policy Statement: The resident's Attending Physician will be notified of the results of diagnostic tests. Policy Interpretation and Implementation: 2. Should the test results be provided to the facility; the Attending Physician shall be promptly notified of the results. 3. The Director of Nursing Services, or Charge Nurse receiving the test results shall be responsible for notifying the Physician of such test results. 4. Signed and dated reports of all diagnostic services shall be made a part of the resident's medical record. Record review of the facility's Face Sheet revealed that R#11 was admitted to the facility 3/6/2017 with diagnoses that included cerebral infarction, hypertension, type 2 diabetes, and seizures. Review of the Quarterly Minimum Data Set (MDS) for R#11 dated 11/2/2021 revealed that the residents Brief Interview for Mental Status (BIMS) score was 10 indicating moderate cognitive impairment. Review of the Lab Results Report, for R#11, dated 1/18/2022 documented that the lab collection (blood was drawn) occurred on 1/18/2022 at 3:09 a.m. and the results of the lab work was reported to the facility on 1/18/2022 at 4:44 p.m. The test results were as follows: CBC (complete blood count): Hgb (hemoglobin) 10.1 (normal 12.0 - 15.5), Valproic Acid less than 10.0 (normal 50.0-100.0), Creatinine: 1.69 (normal 0.60 -1.20), Total protein: 6.0 (normal 6.2-8.2), Albumin: 3.2 (normal 3.5 - 5.7). Interview on 1/21/2022 at 10:37 a.m. with the Registered Nurse (RN) AA revealed that she is the only one that receives the labs and communicates the lab results to the Physician. Review of the Lab Result Report dated 1/18/2022, the Progress Notes, and the Clinical Risk Notes with the RN AA revealed that the 1/18/2022 lab results for R#11 had not been communicated to the Physician. RN AA stated she had been busy and didn't realize the resident had labs. RN AA stated she called the Physician last night, 1/20/2022, and relayed the lab results to him at that time and that she should have documented that she contacted the Physician last night but did not. Interview on 1/21/2021 at 12:30 p.m. with the Physician revealed that what he considered critical and what the lab considered to be critical were two different things and that he didn't necessarily expect abnormal labs that were normal for the resident to be communicated to him emergently. However, if results were abnormal and not the norm for the resident then he would expect to be notified as soon as they (staff) were aware and that he would respond quickly. Interview on 1/21/2022 at 5:23 p.m. with the Administrator revealed that she expected lab results to be communicated with the Physician and Responsible Party. The Administrator stated labs, especially critical labs, should be communicated with the Physician right away and shouldn't wait two to three days to be communicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility's policy titled, Charting and Documentation, the facility failed to document that lab results were communicated to the Physician for two of 25 sampled residents (R) (#34 and #10). Findings include: Review of the facility's undated policy titled, Charting and Documentation documented the following, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. Findings include: 1. Review of the facility's Face Sheet revealed that R#34 was newly admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, hypertension, paraplegia, cognitive communication deficit, and major depressive disorder. Review of the admission Minimum Data Set (MDS) for R#34 dated 1/2/2022 revealed that the residents Brief Interview for Mental Status (BIMS) score was 15 indicating resident's cognition was intact. The resident was completely dependent on staff for dressing, toileting, and personal hygiene. Review of a Lab Results Report for R#34 dated 1/3/2022 revealed that labs were received (obtained) from the resident on 1/3/2022 at 6:55 a.m. and the lab reported the results to the facility on 1/3/2022 at 6:03 p.m. Review of the report revealed that the following blood tests were received: CBC with Diff (complete blood count), a Comprehensive Metabolic Panel, and Hemoglobin A1C (HgbA1C). Further review revealed that the residents WBC (white blood count) was elevated at 12.6 (normal 3.5 - 10.5), Neutrophils 78.4 (normal 45.0-75.0), Lymphocytes 18 (normal 19.0 - 46.0), Potassium 3.3 (normal 3.5 - 5.1), Hgb A1C 9.6 (non-diabetic less than 5.7). Further review of the medical record revealed there was not any evidence of documentation that the labs had been communicated with the Physician. 2. Review of the clinical record for R#10 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: abscess of liver, chronic viral hepatitis, anemia, and pleural effusion. Review of the Quarterly MDS dated [DATE] documented that the residents BIMS score was 11 indicating moderate cognitive impairment. Review of a Lab Results Report for R#10 dated 1/10/2022 revealed that labs were obtained on 1/13/2022 at 4:32 a.m. and the lab reported the results to the facility on 1/13/2022 at 4:42 p.m. Review of the report revealed that the residents RBC (red blood count) was 4.11 (normal 4.32 - 5.72), Hgb (hemoglobin) was 11.8 (normal 13.5 - 17.5), Creatinine 1.44 (normal 0.70 - 1.30). Interview on 1/21/2022 at 10:37 a.m. with the Registered Nurse (RN) AA revealed that she is the only one that receives the labs and communicates the lab results to the Physician. Review of the Lab Results for R#34 and R#10, and review of the Progress Notes, the Clinical Risk Notes with the RN AA revealed there was not any evidence that the lab results had been communicated to the Physician. However, RN AA stated that she had faxed a copy of the results to the Physician but that she had failed to document this communication. Interview on 1/21/2021 at 12:30 p.m. with the Physician revealed that he would expect communication regarding labs to be documented. During an interview on 1/21/2022 at 5:23 p.m., the Administrator stated that all communication with the Physician should be documented.

Based on observations, staff interviews, and review of facility's policy titled, Infection Prevention and Control Program staff failed to wear Personal Protective Equipment (PPE) in accordance with CDC (Centers for Disease Control) recommendations to decrease potential exposure and spread of COVID-19. The facility census was 38 residents. Findings include: Review of the facility's undated policy titled, Infection Prevention and Control Program #11a. Prevention of Infection: 8. following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). Review of CDC Guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 9/10/21 revealed to Implement Source Control Measures. Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) Observation on 1/19/2022 from 11:38 a.m. until 12:00 p.m. revealed Housekeeper (HK) LL was observed cleaning rooms on the hallway. HK LL was observed to go from the hallway to resident room multiple times. HK LL was observed to wear a surgical mask below the level of his nose for 22 minutes while cleaning going in and out of a resident's room with multiple residents on the hall. Interview on 1/19/2022 at 12:00 with HK LL revealed that he was aware that his surgical mask was below his nose. HK LL stated that when he gets busy cleaning, he can't breathe that well with the surgical mask on and he must pull it down below his nose so that he can breathe. HK LL stated that he had not spoken with the Administrator or Infection Preventionist to explain that he had difficulty wearing the surgical mask while working. Observation on 1/19/2022 from 12:01 p.m. until 12:10 p.m. revealed that four residents were lined up to talk with the Activity Assistant (AA) at the Activity office. Observation revealed that while AA interacted with each of the residents for a variety of reasons including discussing money and giving snacks, AA's surgical mask was observed to be below her nose. Interview, at this time, with AA revealed that she did not realize that her mask had slipped below the level of her nose. Observation on 1/19/2022 at 12:43 p.m. with the Infection Preventionist (IP) revealed that Licensed Practical Nurse (LPN) FF was at a medication cart at the nurse's station. Continued observation revealed that LPN FF continued to work at the computer on wheels (COW) at the nurse's station for approximately five minutes with her surgical mask below her nose. LPN FF was observed to walk away from the computer down the adjoining hall with her mask below the level of her nose. Interview with the IP, at this time, revealed that she had spoken with LPN FF multiples times about wearing her mask appropriately, but she continued to wear it below her nose. IP stated that although the facility provided KN95 masks that staff were not compliant with wearing them. As of 1/21/22, the facility had no residents positive for COVID-19.