**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the effective date of discharge in the discharge notice for one Resident (R) 98 of three residents sampled for the transfer discharge process when he was transferred to a hospital. The deficient practice has the potential misinform the representative of the Residents date of transfer. Findings include:On 06/03/25 progress notes reviewed. Resident (R) 98 was admitted to the facility on [DATE] for Physical Therapy (PT) and Occupational Therapy (OT) with a primary diagnosis of Pneumonia and Parkinson's disease. R98 was transferred to an acute care hospital three days later on 06/06/25 for respiratory failure secondary to recurrent aspiration pneumonia. On 07/24/25 reviewed the discharge and transfer notice with email documentation that was sent to the Long-Term Care Ombudsman (LTCO). The notice that was provided to the resident's representative and the LTCO did not have the date of the transfer written on the notice. On 07/25/25 at 10:30 AM, interview with the Social Services Director (SSD). Confirmed the date of the effective discharge on the transfer/ discharge notice was left blank.

Based on observation, interviews, and record review, the facility failed to implement the care plan for one resident (Resident (R), R38) sampled for accidents and R92, who was sampled for respiratory care. The deficient practice puts R38 at risk for falls that could result in harm if the mechanical lift is not used appropriately with two staff and puts R92 at risk for respiratory infection who already has compromised health. Cross reference to F689 1) On 07/22/25 at 08:30 AM, observed Certified Nurses Aide (CNA) 41 transferring R38 from bed to wheelchair using a mechanical lift on her own. When CNA41 was asked if the facility policy allowed her to transfer a resident using the mechanical lift by herself, CNA41 stated that she was able to if she felt capable and that R38 trusted her to do it. On 07/24/25 at 08:15 AM, interview with Head Nurse (HN) 6 and confirmed that transfers using the mechanical lift should always be completed with two staff. HN6 noted that this is for the resident's safety. HN6 also confirmed that this is noted in R38's care plan, which is accessible to all staff and should be followed as it directs the care of the resident. On 07/25/25 at 11:09 AM, record review of R38’s care plan noted in the “intervention” section for “Activities of Daily Living (ADL)-Transfers using mechanical lift with two staff assist.” Review of the facility’s “Goals and Objectives, Care Plans” policy, in the Policy Interpretation and Implementation section, it states “4. Goals and objectives are entered on the resident’s care plan so that all disciplines have access to such information…are derived from information contained in the resident’s comprehensive assessment…care plan goals and objectives are defined as the desired outcome for a specific resident problem…” 2) On 07/22/25 at 09:04 AM observed R92's oxygen (O2) concentrator in her room near the wall. On 07/24/25 reviewed R92's Electronic Health Record (EHR) which revealed she is receiving hospice services and has an order for oxygen use prn (as needed). Requested and received facility policy titled Oxygen Administration from the Director of Nursing (DON). Review of this policy found the following: Purpose. The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation . 2. Review the resident's care plan to assess for any special needs of the resident. On 07/25/25 at 10:15 AM interviewed the Director of Nursing (DON) by phone regarding R92's care plan. Inquired if DON saw any care plan for R92's respiratory care that included oxygen as an intervention. DON reviewed R92's care plan and stated she could not find anything in the care plan for oxygen use, and confirmed the resident had an order for Titrate Oxygen per nasal cannula PRN.

Based on observation, interviews, and record review, the facility failed to ensure that one of one resident (Resident (R), R38) sampled for accidents was free from accident hazard when staff transferred R38 using a mechanical lift with only one person assist. This deficient practice has the potential to affect all residents requiring transfers using a mechanical lift.Findings Include:On 07/22/25 at 08:30 AM, observed Certified Nurse's Aide (CNA) 41 transferring R38 from bed to wheelchair using mechanical lift on her own. When CNA41 was asked if the facility policy allowed her to transfer a resident using the mechanical lift by herself, CNA41 stated that she was able to if she felt capable and that R38 trusted her to do it. On 07/22/25 at 09:00 AM, interview with Registered Nurse (RN) 9. RN9 said that transfers using the mechanical lift should be done with two staff for safety reasons.On 07/24/25 at 08:15 AM, interview with Head Nurse (HN) 6, and confirmed that transfers using the mechanical lift should always be completed with two staff. HN6 noted that this is for resident's safety.Record review of the facility's Using a Mechanical Lifting Machine policy, revised July 2017, the General Guidelines section, notes, 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.Review of the facility's Safe use of Mechanical Lifts training, in the Procedures and Safety section, 3. Determine if another person is needed to assist with the lift. Most lifts require two people: One person to operate the lift and one person to guide the sling. CNA41 completed the training on 04/09/22.

Based on observations and interviews the facility failed to label the oxygen tubing that was connected to the oxygen (O2) concentrator with the date if initiation for one of one resident (R) 92, sampled for respiratory care. This deficient practice put R92 at risk for infection. Findings Include: On 07/22/25 at 09:04 AM and on 07/23/2025 at 10:31 AM observed R92's oxygen (O2) concentrator in her room near the wall that had tubing connected to it which was not labeled with the date of first use. On 07/24/25 at 10:43 AM interviewed 4th floor Head Nurse (HN) 6 in R92's room. Inquired of HN6 if the O2 tubing, that was attached to the O2 concentrator, should have a date when it was initiated and she confirmed this.On 07/25/25 at 10:15 AM interviewed Director of Nursing (DON) by phone regarding R92's oxygen use. Inquired if R92 had an order for oxygen and the DON confirmed that the resident had an order for Titrate Oxygen per nasal cannula PRN . and confirmed the oxygen tubing has to be labeled with the date it was initiated (opened and attached).

Based on observation, interview, and review of the facility's Storage of Medication Policy, the facility failed to discard two vials of expired Influenza (flu) vaccine in Young 4's medication refrigerator. This deficient practice has the potential to affect all residents in the facility due for flu vaccination.Findings Include:On 07/24/25 at 08:15 AM, medication refrigerator was checked with Registered Nurse (RN) 9. Observed two vials of expired flu vaccine dated 06/2025 still in the refrigerator located on Young 4. RN9 said that it should have been discarded last month for safety purposes. On 07/25/25 at 08:30 AM, interview with Head Nurse (HN) 6 also noted that it should have been discarded and confirmed that discarding expired medications is for the safety of the residents and to ensure the efficacy of drugs given. Review of the facility's Storage of Medication policy dated 2007 on 07/25/25 at 11:00 AM, in the Procedures section, int notes, 14. Outdated, contaminated, discontinued or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medication disposal.

Based on observations, staff interviews and policy review, the facility failed to: 1) Discard an expired container of Lemon Juice that was stored the kitchen refrigerator and 2) Label a supplement drink stored in the resident's kitchen refrigerator with the opened-on date once it was opened. As a result of this deficiency, the facility put residents at risk for foodborne illness.Findings Include:1) During the initial tour of the kitchen, on 07/22/25 at 08:50 AM, a one-gallon container of Lemon Juice, in the refrigerator, was labeled with an expiration date of 07/19/25. The container was half full and was located on the middle shelf. Staff interview on 07/22/25 at 08:52 AM, Kitchen Manager (KM) acknowledged that the Lemon Juice container was expired and should have been discarded. KM removed the Lemon Juice container and said they would discard it immediately. Review of facility policy on Food Labeling read; Purpose, to ensure that all foods served at the facility are fresh. Outdated foods that are kept beyond their allowed shelf life are not to be used in food production or served to residents and customers. Policy, Food & Nutrition Services will monitor the shelf life of the foods purchased, prepared and served to its residents and customers. A facility Food Storage Reference Table will be maintained by Food & Nutrition that lists the dates of foods used in the facility. Foods prepared for service will be labeled with date of service… III D. Manufacturer “Used by” or Expired dates – “Use by” of Expired dates stamped or printed on the original food container by the manufacturer. Unopened products with dates that have exceeded the “Best Used” by dates will be discarded… 2) On 07/22/25 at 12:54 PM observation of the resident's refrigerator on the fourth floor contained a TWO Kal supplement drink that was opened and did not have an opened-on date. Inquired with Registered Nurse (RN) 158 if the opened TWO Kal supplement drink has to have an opened-on date. RN158 confirmed the TWO Kal supplement drink in the resident's refrigerator should have been labeled with a date when it was opened.

Based on record review, interview, and facility policy review, the facility failed to report abuse investigation results within five working days to the state survey agency for 2 (Resident #302 and Resident #28) of 6 residents reviewed for abuse. Findings included: A facility policy titled, Prevention of Resident Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property, dated 11/03/2021, revealed the section titled IV. Procedure included 6. Within two (2) hours, the DON [Director of Nursing]/Administrator/Nursing Supervisor on duty shall notify by email, phone or FAX [facsimile] the following State Agencies as required by State law through established procedures of the reported incident and findings within five (5) working days from the day the discovery. The policy revealed the State Agencies listed to report the incident to included Adult Protective Services (APS) and Office of Health Care Assurance (OHCA). 1. An admission Record indicated the facility admitted Resident #302 on 05/13/2022. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson's disease, multiple sclerosis, chronic obstructive pulmonary disease, and visual hallucinations. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/16/2023, revealed Resident #302 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for personal hygiene and chair/bed transfers. The MDS revealed the resident required substantial/maximal assistance from staff for bed mobility. Resident #302's care plan included a problem statement initiated on 05/30/2023 that indicated the resident used antipsychotic medications related to Parkinson's disease with psychosis and visual hallucinations. Interventions directed staff to administer psychotropic medications as ordered and to monitor for side effects and effectiveness every shift. Resident #302's Progress Notes, dated 11/03/2023 at 11:13 PM, revealed an entry that indicated Registered Nurse (RN) #6 had received a call from Resident #302's Power of Attorney (POA) during mealtime for RN #6 to call the spouse later from the resident's room regarding the resident's concern about day shift staff. The Progress Notes revealed RN #6 went to the resident's bedside, and Resident #302 stated that a day shift certified nurse aide (CNA) had been rough with them that afternoon. The Progress Notes revealed Resident #302 described that they were slapped on the right upper back by the shoulder blade about 15 times. The Progress Notes revealed RN #6 attempted to clarify with the resident if staff had been trying to help them to loosen their congestion, but the resident said they did not feel that way. The Progress Notes revealed Resident #302 indicated it happened around 2:00 PM but they did not report it to the day shift staff. The Progress Notes also revealed the DON was notified. A document titled, EVENT REPORT, contained an Initial Report of alleged abuse, dated 11/03/2023 at 6:50 PM. The document revealed a notation dated 11/07/2023 at 12:36 PM that indicated the final report of the incident would be forwarded once the result of the investigation was completed. An email dated 11/07/2023 at 12:55 PM sent from the DON to the state agency also indicated the final report would follow pending an investigation. A document titled, EVENT REPORT, contained a Completed Report, dated 01/03/2024 for the alleged abuse allegation dated 11/03/2023. An email from the DON to the state agency dated 01/03/2024 at 4:35 PM revealed the final report was sent to the state agency. During an interview on 07/31/2024 at 11:57 AM, the DON stated for an abuse investigation there was a two-hour window to report to the State agency, then the final was due within five days. The DON said the process was for her to complete the final report and if she was not at the facility, then it was the nurse supervisor's responsibility. During an interview on 07/31/2024 at 2:04 PM, RN #5 stated she assisted with the abuse investigation process by obtaining interviews and witness statements. RN #5 said the initial report was due to the state by two hours after the allegation. RN #5 stated the investigation started as soon as an allegation was reported. RN #5 said the DON was responsible for the final report. During an interview on 07/31/2024 at 2:52 PM, Social Worker (SW) #22 stated the DON was responsible for the two-hour initial report and the five-day final report. During an interview on 08/01/2024 at 8:44 AM, the DON stated the charge nurse called her that evening when Resident #302 reported that a CNA had done something to them. The DON said she went to the facility and started the investigation and completed the initial two-hour notification to the state. The DON said she was responsible for gathering the information for the investigation and the nurse manager helped with gathering statements from staff and the roommates and other residents. The DON said the CNAs were a part of a union, therefore; someone had to be brought in from the outside to investigate, and the facility had to wait for the union report. The DON stated the facility did not meet the required five-day timeframe because they were waiting for the final report from the other agencies. The DON stated her expectation was to have the five-day investigations completed and turned in timely. During an interview on 08/01/2024 at 9:26 AM, the Administrator stated that as soon as an allegation happened the facility reported to the state, then completed an investigation by the fifth day. The Administrator said if the facility had to call for an external investigation the state would be notified. The Administrator reviewed the provided documentation for Resident #302's internal investigation and stated the DON did not send the facility investigation on 11/07/2023 with the five-day notification. The Administrator stated she expected the internal investigation to be sent to the state by the fifth day, even if the facility was waiting for the external investigation. 2. An admission Record revealed the facility admitted Resident #28 on 04/07/2017. According to the admission Record, the resident had a medical history with diagnoses that included quadriplegia, anxiety disorder, adjustment disorder with disturbance of conduct, anoxic brain damage, hemiplegia and hemiparesis (one-sided paralysis and weakness) following cerebral infarction affecting right dominant side, and dysphasia (difficulty with speech). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2024, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that Resident #28 had no physical or verbal behaviors directed towards others. Resident #28's care plan, included a problem statement revised on 11/09/2022 that indicated the resident had socially inappropriate behavior of talking loudly. Interventions directed staff to continue with therapeutic limits setting and include resident input to identify what could be done in place of minding other residents' business. A Progress Note dated 09/08/2023 at 4:17 PM, by Social Worker (SW) #22 revealed SW #22 heard Resident #28 screaming at a certified nurse aide (CNA) and was told by the charge nurse that the resident was yelling profanity to the CNA. The Progress Note revealed Resident #28 was very angry and said the CNA was acting like a monkey and saying profanity to the resident. The Progress Note indicated the CNA stated the resident slammed the bathroom door and yelled expletives at the CNA. The Progress Note also indicated Registered Nurse (RN) #6 called the nursing supervisor to speak with the CNA. During an interview on 07/30/2024 at 2:21 PM, SW #22 stated staff who heard of an allegation of abuse were to ensure the resident's safety, then notify the nurse supervisor. SW #22 stated the nurse supervisor checked on the resident and then called the Director of Nursing (DON), who was the Abuse Prohibition Coordinator. SW #22 stated the DON was responsible for reporting to state and other authorities and was responsible for the investigation. During an interview on 07/30/2024 at 3:27 PM, RN #6 stated that an accusation of abuse from a resident required the resident and the accused to be separated and the resident assessed for safety. RN #6 said she reported to her supervisor if the supervisor was in the building; if not, she called the DON and reported the allegation. She stated the DON was responsible for reporting to authorities and investigating the incident. During an interview on 08/01/2024 at 1:45 PM, the DON stated SW #22 submitted the initial report on 09/12/2023, and she submitted one on 09/17/2023. There was no evidence provided to indicate a five-day investigation was submitted. During an interview on 08/01/2024 at 10:08 AM, the Administrator said the internal investigation was expected to be turned in by the fifth day.

Based on interview, record review, and facility document and policy review, the facility failed to provide evidence that an allegation of abuse was thoroughly investigated for 1 (Resident #302) of 6 residents reviewed for abuse. Findings included: A facility policy titled, Prevention of Resident Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property, dated 11/03/2021, revealed the section titled, I. Purpose included, B. To report and conduct a thorough investigation of all incidents within specified timelines and provide appropriate corrective actions and preventive measures. The policy also specified that when investigating allegations of abuse, investigators will, e. Conduct and document all necessary interviews with staff, witnesses, resident, and alleged perpetrator as deemed necessary. An admission Record indicated the facility admitted Resident #302 on 05/13/2022. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson's disease, multiple sclerosis, chronic obstructive pulmonary disease (COPD), and visual hallucinations. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/16/2023, revealed Resident #302 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for personal hygiene and chair/bed-to-chair transfers. The MDS revealed the resident required substantial/maximal assistance from staff for bed mobility. Resident #302's care plan included a problem area, initiated on 05/30/2023, that indicated the resident used antipsychotic medications related to Parkinson's disease with psychosis and visual hallucinations. Resident #302's Progress Notes revealed a communication note, dated 11/03/2023 at 11:13 PM, that indicated Registered Nurse (RN) #6 received a call from Resident #302's Power of Attorney (POA) during mealtime requesting RN #6 to call the POA later from the resident's room regarding a concern about day shift staff. The note indicated RN #6 went to the resident's bedside, and Resident #302 stated that the day shift certified nurse aide (CNA) had been rough that afternoon. The note indicated that Resident #302 described that they were slapped on their right upper back by their shoulder blade about 15 times. According to the note, the RN attempted to clarify with the resident if CNA was trying to help them loosen their congestion, and the resident said they did not feel that way. The note revealed Resident #302 reported the incident happened around 2:00 PM but they did not report it to day shift staff. A document titled, EVENT REPORT contained an Initial Report of alleged abuse, dated 11/03/2023 at 6:50 PM. The document indicated that Resident #302 alleged that CNA #8 was rough with them. The document indicated that the resident reported that CNA #8 slapped them on their right shoulder blade area 15 times on 11/03/2023 around 2:00 PM. The document indicated the final report of the incident would be forwarded once the result of the investigation was completed. A document titled, EVENT REPORT contained a Completed Report, dated 01/03/2024. The document indicated that, when asked, Resident #302 did not feel like the staff member was trying to help loosen their congestion. The document indicated that a complete head-to-toe assessment was completed, and no injury was noted. The document indicated that CNA #8 was suspended pending the investigation. The facility's Daily Nursing Assignment Sheet for the day shift on 11/03/2023 revealed four CNAs (including CNA #8), RN #7, and Licensed Practical Nurse (LPN) #10 were working at the time the incident allegedly occurred. The facility provided documentation of Employee/Resident Quality Assurance Reports and a Supervisor's Quality Assurance Report that reflected documentation of interviews and statements related to this allegation. These reports reflected that as part of the investigation into the allegation, the facility obtained information from CNA #8, RN #6, and RN #5. There was no evidence provided to indicate the facility interviewed or obtained statements from the other staff members working at the time of the alleged incident, including the remaining three CNAs, RN #7, and LPN #10. The facility also provided documentation of two resident questionnaires, dated 11/08/2023. The facility did not provide evidence of any additional resident interviews or evidence to indicate that residents who were not interviewable were assessed for signs or symptoms of abuse. During an interview on 07/31/2024 at 2:04 PM, RN #5 stated that the abuse investigation process included obtaining interviews and witness statements. RN #5 stated an investigation started as soon as an allegation was reported, and staff followed a checklist to not miss any steps. RN #5 stated they then gathered information from anyone who may have heard or witnessed anything. Per RN #5, residents, family, and staff members were asked to complete witness statements during the process. She stated witness statement were obtained from for Resident #302's roommate and another resident for whom the CNA had provided care that day. RN #5 read over her report and stated if she had not documented it, then there were no head-to-toe assessments performed on residents who were not interviewable. RN #5 indicated the DON was responsible for the final report. During an interview on 08/01/2024 at 8:44 AM, the DON stated the charge nurse called her when Resident #302 reported that the CNA had done something to them. The DON indicated she went to the facility and started the investigation. The DON indicated she was responsible for gathering information for the investigation, and the nurse manager helped with gathering statements from staff, the roommates, and other residents. The DON stated they did not talk to any other residents and did not assess residents who were not interviewable for signs or symptoms of abuse. The DON indicated it was the facility policy to do those things for a thorough investigation. During an interview on 08/01/2024 at 9:26 AM, the Administrator indicated the investigation for Resident #302 had been completed. The Administrator stated that as soon as an allegation was made, the facility reported to the state survey agency, then completed an investigation by the fifth day. The Administrator indicated a thorough investigation usually included speaking with the residents in the room of the alleged incident, if they were alert, and talking to any other residents who were in the area. The Administrator indicated they also usually talked with other staff working at the time. The Administrator stated she did not know if that occurred for this investigation.

Based on record review, interview, and facility policy review, the facility failed to refer residents with newly evident or possible serious mental disorder, intellectual disorder, or related condition, to the state-designated mental health or intellectual disability authority for review. The deficiency affected 2 (Resident #9 and Resident #39) of 2 residents reviewed for Pre-admission Screening and Resident Review (PASARR; PASRR) services. Findings included: A facility policy titled, Preadmission Screening Resident Review (PASRR), dated 06/07/2018, revealed the section titled II. Policy, included, E. Social Services will be contacted for assistance with Level II evaluations and for any significant mood or behavior changes that may necessitate a Level II evaluation at any time throughout the resident's stay at [the facility]. The policy revealed the section titled, IV. Procedure, included, C. Nursing Supervisor, Unit Manager and Social Worker will review PASRR for Part C exceptions for individuals with MI [mental illness] or ID [intellectual disability]/DD [developmental disability] (i.e. [id est; that is], physician certification for less than 30 day stay that is required for condition which they were hospitalized for); and will follow up within the accepted time frame if additional action is necessary, such as Level I re-evaluation and Level II evaluations and appropriate review by the state agencies. Further review revealed, I. When observing any significant decline in mood and behavior in a resident with SMI [serious mental illness], IDT [interdisciplinary team] will determine if a significant change minimum data set (MDS) assessment is warranted. Care plan(s) will be revised, if appropriate. If the resident does not stabilize within 21 days, Level II evaluation will be initiated and submitted to AMHD [Adult Mental Health Division] through the ePASRR [electronic PASRR] website. 1. An admission Record indicated the facility admitted Resident #9 on 06/15/2004. According to the admission Record, Resident #9 had a medical history that included a diagnosis of psychotic disorder (onset 10/03/2017). Resident #9's Preadmission Screening Resident Review (PASARR) Level I Screen, dated 05/15/2004, revealed the resident did not have a mental disorder, which included psychotic disorder. A quarterly MDS, with an Assessment Reference Date (ARD) of 07/02/2024, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #9 had an active diagnosis of psychotic disorder. Resident #9's medical record revealed no evidence that indicated a referral was made to the appropriate state-designated authority after the resident's diagnosis of psychotic disorder. 2. An admission Record indicated the facility admitted Resident #39 on 06/06/2017. According to the admission Record, Resident #39 had medical history that included diagnoses of delusional disorders (onset 08/09/2018) and paranoid personality disorder (onset 08/09/2018). Resident #39's Preadmission Screening Resident Review (PASARR) Level I Screen, signed by a physician on 06/06/2017, revealed the resident did not have a serious mental illness, such as psychotic disorder or delusional (paranoid) disorder. A quarterly MDS, with an Assessment Reference Date (ARD) of 07/02/2024, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #39 had active diagnoses of psychotic disorder other than schizophrenia and paranoid personality disorder. Resident #39's medical record revealed no evidence that indicated a referral was made to the appropriate state-designated authority after the resident's diagnosis of psychotic disorder. During an interview on 08/01/2024 at 8:10 AM, the Director of Nursing (DON) stated the facility did not update Level I PASARRs after the residents had been admitted to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to ensure medication carts were locked when not within the line of sight of facility staff for 2 of 6 medication carts. Findings included: A facility policy titled, MEDICATION: Unit Storage; Expiration Dating; Inspection, dated 03/02/2005, specified, All medications/medication storage areas are locked when not observed by nurses. During an observation on 07/30/2024 at 11:31 AM, upon entrance to unit Young 4, a medication cart (Team 2 cart) was located between room [ROOM NUMBER] and room [ROOM NUMBER] and was not locked. There was no staff in the hallway. At 11:32 AM, Registered Nurse (RN) #2 exited room [ROOM NUMBER] and stated the medication cart should have been locked because it was out of her line of sight. During a concurrent interview RN #2 said the medication cart should have been locked when she walked away for medication safety. Some of the medications observed in the cart included lisinopril (used to treat high blood pressure), metoprolol (used to treat high blood pressure), trazodone (an antidepressant), Remeron (an antidepressant), Coumadin (an anticoagulant), Buspar (anti-anxiety), and insulin syringes. During an observation on 07/30/2024 at 1:29 PM, upon entrance to unit Young 5, a medication cart (Team 2 cart) was between room [ROOM NUMBER] and room [ROOM NUMBER] and was not locked. RN #3 exited room [ROOM NUMBER] and stated the medication cart should always be locked. During a concurrent interview RN #3 stated she was in a rush to administer medications to a resident but should not have left the medication cart unlocked. RN #3 stated the medication cart should be locked because there were medications inside and if it was unattended then it should be locked. Some of the medications observed in the cart included citalopram (an antidepressant), Depakote (an anticonvulsant), Seroquel (an antipsychotic), metoprolol tartrate (used to treat high blood pressure), levetiracetam liquid (an anticonvulsant) and insulin syringes. During an interview on 07/30/2024 at 3:47 PM, the Director of Nursing (DON) stated if the nurse left the medication cart that it should be locked. During an interview on 07/31/2024 at 10:45 AM, RN #5 stated if a medication cart was not attended then it should be locked. During an interview on 07/31/2024 at 10:58 AM, RN #1 stated if the medication cart was not visible to the nurse, then it should be locked. During an interview on 08/01/2024 at 8:41 AM, the DON stated she expected for staff to lock the medication cart if the cart would be left unattended. During an interview on 08/01/2024 at 9:29 AM, the Administrator stated she expected for the medication cart to be locked at all times when the nurse was out of sight.

Based on interview, record review, facility document review and facility policy review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI). Specifically, the facility failed to ensure corrective action was implemented and maintained to ensure sustained compliance with reporting and investigating alleged allegations of abuse. This had the potential to affect all residents that resided in the facility. Findings included: The Department of Health and Human Services Center for Medicare and Medicaid Services [CMS] Form CMS-2567's, dated 09/20/2021, 09/30/2022, and 09/14/2023, revealed the facility received deficiencies for F609 and F610 each year. The facility's Quality Assurance & Performance Improvement (QAPI) Plan 2023-2024, reviewed by the facility on 07/21/2022, revealed, Decisions will be made to promote excellence in quality of care, resident choice, person directed care, and resident transitions. Focus area will include systems that affect resident and family satisfactions, quality of care, and services provided, and all areas that affect the quality of life for persons living and working in our organization. The plan also indicated, The QAPIC [Quality Assessment and Performance Improvement Committee] has the responsibility to -Review quality improvement reports on identified quality deficiencies, such as survey findings, develop appropriate plans of action to correct identified and confirmed quality concerns, implement the plans of action, monitor the effectiveness of action plans and make revisions as needed. The plan revealed Attachment G included a Performance Improvement Project (PIP) Inventory with dates of review of 11/01/2018, 02/07/2019, 03/2020, 07/2021, and 05/2023. Further review revealed the inventory did not indicate there was a PIP for the area of abuse reporting and investigating. The plan revealed Attachment H included a Performance Improvement Project (PIP) Inventory with a date of review of 05/12/2022. Further review revealed the inventory did not indicate there was a PIP for the area of abuse reporting and investigating. During an interview on 08/01/2024 at 1:16 PM, the Director of Nursing (DON) said that all abuse allegations were discussed during the QAPI meetings, but it was not discussed whether the investigations were completed per the facility's abuse policy. During an interview on 08/01/2024 at 2:31 PM, the Quality Assurance (QA) Coordinator stated the facility QAPI plan was not effective if the facility was being cited for the same concerns each survey.

Based on observation and interview, the facility failed to assure a safe, clean, and comfortable homelike environment for two of five sampled residents (Resident (R)37, and R43). Findings include: On initial tour of facility 09/11/23 at 09:56 AM, at the bedside of R43's, equipment was observed. Surveyor noted that the tube feeding pole and parts of the bed were splattered with spilled/spots of questionable formula which smelled like milk. Also noted were areas of the bed with black stain and/or questionable dirt. An observation on 09/11/23 at 12:18 PM, tube feeding was in progress for R 37. Noted fresh formula and a dried crusty substance was spilled on the pole where the formula bag hangs. On 09/12/23 at 08:44 AM, surveyor observed R43's bedside table, feeding machine, pole, and bed were splattered with a milky and crusty substance. Noted an odor that smelled like formula. On 09/13/23 at 09:44 AM, an interview with nursing supervisor (NS)1 was done. Surveyor and NS1concurrently observed the soiled equipment and the smell of milk. NS1 agreed that cleaning is needed for rooms of R37 and R43.

Based on observations, staff interview and review of policy procedure, the facility failed to post staffing information for one Nursing Unit, 4th floor Young, out of three Nursing Units sampled. As a result of this deficiency the facility failed to follow regulation to make nurse staffing data available to the public for review. Findings include: During observation of the 4th floor Young Nursing Unit on 09/11/23 at 10:15AM, the staffing information form posted at the nurse's station was not completed. There was no information to show the total number and actual hours worked by licensed and unlicensed nursing staff as required. During staff interview on 09/11/23 at 02:30PM, the Director of Nursing acknowledged that the staffing information was not completed as previously mentioned. Review of facility procedure on Revised Procedure for Staff Posting read the following: Effective immediately, units are required to complete the Daily Staff Posting sheet by 0700 hours and post in the designated area (white board). At the beginning of each shift, the Charge Nurse for the on-coming shift will verify the census and staffing, and make changes as needed on the Daily Staff Posting sheet. The sheet will be changed at 0700 hours daily and submitted to the Nursing Supervisor/Nursing Office for record keeping .

Based on observations, staff interview and review of policy, the facility failed to secure a padlock that was attached to the medication refrigerator door on the 3rd floor Young Nursing Unit. As a result of this deficiency, the facility failed to properly store the refrigerated medications. Findings include: During observation of the 3rd floor Young Nursing Unit, on 09/11/23 at 11:20AM, the medication refrigerator was not secured. There was a padlock there to secure the door, but the padlock was not locked. There was no staff in the immediate vicinity, and anyone could remove the padlock and have access to the medications in the refrigerator. Staff interview on 09/11/23 at 11:45AM with the 3rd floor Head Nurse acknowledged that the padlock should have been locked and always secured. Head Nurse then locked the padlock and secured the refrigerator. Review of policy on Storage of Medication read Policy; Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Procedures; In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medications carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access . Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to perform proper hand hygiene and follow infection control protocol. This deficient practice places the residents and visitors at risk for the development and transmission of communicable disease and infections. Findings include: 1) Observation was conducted on 09/11/23 at 07:54 AM on the first-floor visitor check-in station. A Health Screener (HS) was observed conducting self-swab Covid testing on three state surveyors. After the first surveyor performed self-swabbing, HS collected the test swab and placed it on the table. HS then removed his gloves and threw them in the trash can. HS proceeded to don new gloves without hand hygiene and assisted the second surveyor with self-swabbing. Once the second surveyor finished self-swabbing, HS collected the test swab and placed it on the table. HS then removed his gloves and placed it in the trash can. HS proceeded to perform tasks near the table containing the test kits. A couple minutes later HS walked away from the testing station. 2) Observation was conducted on 09/13/23 at 08:50 AM on the fourth-floor hallway. A Registered Nurse (RN) 1 was prepping medications at the medication cart with gloves on. RN1 entered room [ROOM NUMBER] with the same gloves and administered medication via gastrostomy tube to R34. Following medication administration, RN1 removed the gastrostomy tube dressing and threw it in the trash. RN1 also removed her gloves at the same time and walked out of the room. A minute later, RN1 returned to the room and donned new gloves to finish the dressing change. She applied ointment and new dressing on the gastrostomy tube site. Once dressing change was completed, RN1 proceeded with medication administration without removing and changing her gloves. Interview was conducted on 09/13/23 at 09:46 AM in the fourth-floor hallway. RN1 stated that facility staff are supposed to change their gloves when performing different tasks. Interview was conducted with the facility's Infection Preventionist (IP) on 09/13/23 at 10:17 AM via telephone. IP stated that facility staff should be performing hand hygiene in between glove changes and change gloves when performing different tasks. A review of the facility policy titled, Hand Hygiene, dated 02/03/23 was conducted. The policy indicated, Indications for Antiseptic Hand Rubbing or Antiseptic Handwashing .before putting on and after removing gloves (wearing gloves is not a substitute for hand hygiene) .before administering medications .Before performing sterile or clean procedures such as but not limited to urinary catheterizations, IV insertions, dressing changes .

Based on interviews and record reviews, the facility failed to ensure alleged verbal abuse and an injury of unknown source resulting in serious bodily harm, were reported immediately, but not later than 2 hours after the allegation was made to the administrator of the facility and other officials, including to the State Survey Agency (SA) and Adult Protective Services (APS) for two residents (Resident (R)82 and R31) sampled. As a result of this deficient practice, all residents are at a risk of harm, including psychosocial harm. Findings include: The facility's Policy, Prevention of Resident Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property, effective date: 11/03/21 was reviewed. Residents, et al. shall not be humiliated, harassed ., it is the facility's policy to report alleged complaints and/or violations involving abuse, neglect, involuntary seclusion, injury of unknown origin and misappropriation of property immediately to the Administrator and the DON of the facility and shall be reported to the State agencies within specified timelines. (Cross Reference to F610: Investigate/Prevent/Correct Alleged Violations) 1) Review of the State Agency's (SA) Aspen Complaints/Incidents Tracking System (ACTS) documented the Director of Nursing (DON) emailed an Event Report of an allegation of abuse injury of unknown origin to the SA on 07/16/23 at 03:32 AM. The initial Event Report documented on 07/15/23 at 03:05 PM, a Certified Nurse Aide (CNA)1 reported to Licensed Nurse (LN)56 that R82 was displaying symptoms of pain to the lower left abdominal area. Upon assessment, NS56 documented R82 was lying in bed guarding the left side. LN56 called and included an interpreter language service via telephone to communicate with the resident. The nurse instructed the interpreter to ask the resident where does it sore? The resident initially answered, The lady with pain went away. The resident was asked a second time, where does it sore? R82 answered, Someone kicked her. The resident refused to go to the hospital, LN56's head to toe physical assessment documented no redness, no swelling, and no ecchymosis (discoloration of the skin resulting in bleeding under the skin, typically caused by bruising). The physician was notified and ordered an x-ray of the left lower rib cage. On 09/13/23 at 2:58 PM, conducted a concurrent record review of R82's electronic health record (EHR) to include the facility's completed investigation of the allegation of abuse and interview with the Director of Nursing (DON). Review of R82's x-ray results documented R82 sustained acute lateral 7th and 8th rib fractures, the physician interpreting the x-ray findings signed the results on 07/15/23 at 08:34 PM and staff wrote Noted 07/15/23 which was initialed by staff acknowledging receipt of the x-ray results. During the interview, the DON stated she was not notified by Nursing Supervisor (NS)29 of the incident within 2 hours of the incident but could not recall or provide documentation of the exact time. The DON also confirmed there was no documentation of the time the Administrator was notified of the incident. Inquired why was there a delay in NS29 informing the Administrator and the DON. DON stated, NS29 did not identify the incident as an allegation of abuse because staff know the resident has cognitive deficits and did not believe that someone kicked the resident. The DON confirmed NS29, and the DON made an initial determination that R82's allegation was not credible prior to reporting the allegation and of have been treated as an allegation of abuse and/or injury of unknown origin. Thus, the event was not reported to SA with in the 2-hour period and confirmed the facility did not report the incident to APS as required by federal and state regulation. On 09/13/23 at 04:38 PM, conducted an interview with the Administrator. Inquired when did the Administrator first become aware of R82's allegation of abuse. The Administrator reviewed the investigation and phone records and confirmed she was not immediately notified of the incident, but once she became aware, she informed nursing staff and the DON that R82's incident is a reportable event, and the SA and APS should be notified, and a complete investigation should be conducted. The Administrator confirmed NS29 did not immediately notify the DON and Administrator as soon as the resident verbalized the allegation of physical abuse but did not. On 09/14/23 at 02:50 PM, conducted an interview with NS29 regarding R82's allegation of abuse. NS29 confirmed the resident has cognitive deficits and her assessment of the resident and what the resident was saying to the interpreter, in her opinion, did not constitute as a credible report of abuse. NS29 could not recall or provide documentation of when she notified the DON and the Administrator of the event. 2) On 09/11/23 at 08:58 AM, conducted an interview with R31 at the resident's bedside. R31 stated, Last week a male CNA (CNA23) was really mean to him and his roommates. and CNA23 called the resident a motherfucker and treated me like a dummy. R31 also reported that he was upset because CNA23 handled his roommate, who is totally dependent on staff, roughly and he did not like that. Inquired if R31 had reported the incident to staff. R31 confirmed the facility knows about the incident and that CNA23 continued to work on the same floor as the resident. R31 reported feeling extremely upset at just the sight of CNA23 and in addition to speaking to the resident. On 09/14/23 at 10:52 AM, conducted a concurrent record review of R31's EHR and interview with Nurse Manager (NM)5. Inquired about the incident R31 reported to this surveyor. NM confirmed she became aware of the situation on Monday, 09/11/23. LN56 documented the incident as R31 having a behavior of swearing at CNA23. NM5 stated R31 reported that CNA23 called him the name of an actor that does not have teeth or hair, which upset R31. R31 felt like CNA23 was teasing him. NM5 stated LN56 called NS29 to address the situation. On 09/14/23 at 10:14 AM, conducted a concurrent record review and interview with the DON regarding R31's allegation of abuse. The DON reviewed the facility's documentation and stated she was first informed of the incident on 09/12/23 when an event report was created and confirmed NS29 did not identify R31's reports of abuse by CNA23 as an allegation of abuse. The DON confirmed NS29 made an initial determination whether the allegation is credible before reporting the allegation. As a result of NS29 initial determination that the allegation of abuse was not credible, the DON and Administrator was not immediately made aware of the situation, CNA23 should have been sent home to protect the resident and/or other resident from the potential of abuse, and the SA and APS should have been notified within the 2-hour timeframe but was not. On 09/14/23 at 12:33 PM, conducted a concurrent record review and interview with Social Worker (SW)1 regarding R31's reported incident. SW1 stated on 09/08/23, SW1 heard a commotion in the hallway involving R31. SW1 took R31 into the solarium to calm the resident down and find out what was going on. SW1 recalled that she had not seen R31 this mad before and R31 informed SW1 that CNA23 told the resident Okininam, which means fuck you in Ilocano. While in the solarium with R31, SW1 reported CNA23 came into the room and began arguing with R31 about what happened, then CNA23 stormed off. SW1 stated she was concerned about CNA23's behavior and interaction with the resident. SW1 stated that she informed LN56 and NS29 that the incident between CNA23 and R31 was possibly abuse, that CNA23 should not be working on the floor until an investigation is completed, and the DON and the Administrator should be notified immediately. SW1 reported that CNA23 informed NS29 that he wanted to go home and did not want to work due the allegations of abuse, but NS29 informed CNA23 that if he went home, he would be fired for resident abandonment. CNA23 was reassigned to another part on the same floor and worked the rest of the shift. On 09/14/23 at 2:23 PM, conducted an interview with NS29 regarding R31's allegation of verbal abuse by CNA23. Inquired if NS29 identified the incident as an allegation of verbal abuse. NS29 stated she did not identify the incident involving R31 and CNA 23 an allegation of abuse because the resident is well known will harass staff. NS29 denied that SW1 had informed her that the incident could potentially be abuse and needed to be handled according to the the facility's policy and procedure for abuse. NS29 stated she handled it as a grievance, informed CNA23 he could not leave, and did not inform the Administrator or the DON of the incident. NS29 confirmed the incident should have been handled as an allegation of abuse but did not.

Based on observations and interviews, in response to an allegation of abuse the facility failed to ensure allegations of abuse were thoroughly investigated, prevent further abuse while the investigation was in progress. As a result of this deficient practice, residents are at risk of abuse and experiencing harm. Findings include: (Cross Reference to F609: Reporting of Alleged Violations) On 09/13/23 at 02:58 PM, conducted a concurrent record review of R82's electronic health record (EHR) of the facility's completed investigation of the allegation of abuse with the Director of Nursing (DON). Inquired with the DON about the details of the investigation related to R82's report that someone kicked her in response to Licensed Nursing Staff (LN)56 assessing the resident's lower left abdomen for pain. The DON confirmed as a result of Nursing Supervisor (NS)29's determination that R82's allegation of being kicked in response to questioning regarding lower left abdomen pain as not being a credible allegation, the incident was not thoroughly investigated, but should have been. DON stated R82's physician determined that the resident's fractured ribs was a result of Osteopenia and not from being kicked. Inquired if R82 had a known diagnosis of Osteopenia at the time the allegation was made. The DON confirmed R82 did not have a diagnosis of Osteopenia or sign/symptoms prior to the allegation of abuse. DON stated Certified Nurse Aide (CNA)1 identified R82's symptoms of pain in the lower left abdomen when the resident was lying in bed (the resident has three mattresses side by side which are placed on the floor for the resident's safety) and when LN56 assessed the resident there was no observable trauma. Inquired about the resident's cognition and the DON confirmed that although the resident does have cognitive deficits the resident is able to make needs known at the resident may have been able to discern if a person was the cause of the injury. Reviewed staff 's written statements and inquired about CNA34's statement that the resident had signs and symptoms of pain while assisting CNA1 with transferring the resident from the shower, prior to returning the resident to her bed. The DON confirmed she was not aware that CNA34's statement and did not investigate the resident's activities prior to LN56 assessing R82 in the bed. Inquired if the DON confirmed she had not interviewed the staff involved and used the completed witness statements and progress notes as the source of information for the investigation. After reassessing the details of the investigation, the DON confirmed a thorough investigation had not been conducted and it is possible that R82 could have sustained the fractured ribs during transfer or other means which were not investigated due to staff discrediting the resident's allegation before conducting a thorough investigation. Reviewed the facility's policy and procedure for investigating an allegation of abuse and the DON confirmed the procedure for investigating allegations was not implemented and should have been. On 09/14/23 at 02:50 PM, conducted an interview with NS29 regarding R82's allegation of abuse. NS29 confirmed the resident has cognitive deficits and her assessment of the resident and what the resident was saying to the interpreter, in her opinion, did not constitute as a credible report of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of policy, the facility failed to provide written notice of discharge for two Residents (R)R32 & R90) out of two residents sampled. As a result of this deficiency, there was a potential for miscommunication and/or misunderstanding of discharge. Findings include: 1) Review of the Electronic Health Record (EHR) indicated that R32 was admitted to the hospital on [DATE] with diagnosis including Stroke, Diabetes, High Blood Pressure and discharged from the hospital on [DATE]. Further review did not show any written notice of discharge to the resident and/or representative. During staff interview on 09/13/23 at 01:50 PM, Social Worker (SW1) acknowledged that the facility did not provide written notification of discharge to R32 and/or representative. The Discharge/Transfer Notice form for R32 showed the family, representative was verbally notified by phone of discharge but there was no written notification given. 2) On 09/12/23 at 10:19 AM, conducted a review of R90's EHR documented the resident was transferred to the hospital on [DATE] due to the potential of sepsis related to unstable vital signs and increased fever. The Discharge/Transfer Notice form was not documented in the resident's EHR. During staff interview on 09/13/23 at 01:50 PM, SW1 acknowledged that the facility did not provide written notification of discharge to R90 and/or representative. Review of facility policy titled Transfer/Discharge Requirements and Documentation read Purpose; to ensure transfer and discharge requirements are met and documented in the medical record, as well as written notice provided to the resident and resident's family and/or resident's representative for transfer or discharge from the facility. Policy; Residents will be transferred or discharged from the facility for the following reasons: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . A written notice will be given to the resident, resident's responsible party, and/or resident's legal representative at least 30 days or as soon as practicable prior to, or upon, transfer or discharge of the resident. The notice must be in a language and manner understandable to the resident, and will include the reason for transfer/discharge, the effective date of transfer or discharge, location to which the resident was transferred/discharged , right of appeal, and information on how to notify the Ombudsman and appropriate protection and advocacy agencies .