**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to administer medications per physician's orders for 4 of 4 residents (R1, R2, R3, R5) reviewed for pharmacy services in the sample of 15. Findings include: 1. R1's Face Sheet undated documents R1's admitting diagnoses as Paraplegia, Secondary Malignant Neoplasm of Bone, Unspecified Severe Protein-Calorie Malnutrition, Malignant Neoplasm of Prostate and Chronic Pain Syndrome. R1's Physician Order Summary (POS) dated February 2025 documents medications as Fentanyl Transdermal Patch 72 hours, 25 micrograms (mcg) /hr (Pain), Thiamine 100 milligrams (mg) Daily (low B1), Magnesium 400 milligrams Daily (supplement), Vitamin B6 Daily (supplement), Vitamin K2 100 mcg Daily (supplement), Vitamin B12 500 mcg Daily (vitamin), Oxycodone 10 mg every 6 hours as needed (pain), Potassium 10 Milliequivalent Daily (diuretic use), Senna Plus 50-8.6 mg twice a day (constipation), Lasix 20 mg Daily (edema), Eliquis 5 mg twice day (Deep Vein Thrombosis), Vitamin D3 50000 Units once a week (Vitamin D deficiency), Juven Daily (wound healing) and Baclofen 10 mg Daily (muscle spasms). R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact, rates pain 2/10, receives scheduled, PRN (as needed) pain medications and non-medication interventions, experiences pain occasionally and pain interferes with daily activities occasionally. R1's electronic medication administration (eMAR) dated 02/01/2025- 02/26/2025 documents several of R1's medications were administered 2 hours or more past scheduled times. On 2/6/2025 10 milligrams Oxycodone was scheduled 12:00 PM but was administered at 4:06 PM. On 2/7/2025 20 milligrams Lasix, 10 Milliequivalent Potassium, 100 Milligram Thiamine, 50000 Units Vitamin D3, 500 Micrograms Vitamin B12, 5 Milligram Eliquis, 400 Milligram (mg) Magnesium, and 50 Milligram (mg), Vitamin B6 was scheduled for 8:00 AM was administered at 10:03 AM. On 2/7/2025 10 Milligram (mg) Oxycodone was scheduled for 12:00 PM was administered at 2:37 PM. On 2/11/2025 Fentanyl Transdermal Patch 72 hour 25 Micrograms (mcg/hr.) was scheduled for 8:00 PM was administered 10:36 PM. On 2/12/2025 500 Micrograms (mcg) Vitamin B12, 100 Milligram (mg) Thiamine, Multivitamin with Minerals, 10 Micrograms (mEq) Potassium, 20 Milligram (mg) Lasix 50 Milligram (mg) Vitamin B6, 5 Milligram (mg) Eliquis was scheduled for 8:00 AM but was administered at 11:11 AM. On 2/12/202 100 Microgram (mcg) Vitamin K2 and 400 Milligram (mg) Magnesium was scheduled for 9:00 AM but was administered at 11:11 AM. On 2/22/2025 400 Milligram (mg) Magnesium, 100 Microgram (mcg) Vitamin K2, 500 Microgram (mcg) Vitamin B12, 100 Milligram (mg) Thiamine, 10 Milliequivalent (mEq) Potassium and 20 Milligram (mg) Lasix was scheduled for 8:00 AM but was administered at 11:19 AM. On 2/25/2025 Juven for wound healing was scheduled for 8:00 AM but was not administered until 2:48 PM. On 2/28/25 at 12:07 PM V8, Licensed Practical Nurse, LPN, stated R1's medications are late because sometimes he (R1) requests them to be given later. R1 was either talking on the telephone, outside smoking or taking a shower. She had not notified the doctor that the meds were being administered later than the scheduled time. R1's Nurse Progress notes dated 2/4/25 at 9:19 AM documents Late Entry: Resident yelled at this nurse due to was late coming in with medication. Tried to explain to resident that it was a few minutes, and we had an emergency. He stated, what was the emergency? Explained to resident that we could not let resident know other residents' information. Resident yelled at this nurse and said, I just want you to do your damn job! Explained to resident that I was and unfortunately things happen. Resident continued to yell at this nurse and stated he was reporting me. This nurse left his room. R1's Nurse Progress Notes dated 2/12/25 at 11:56 AM documents Med taken to resident at 7am and didn't want them until he ate his breakfast. I approached him at 8am and he did take them then as I stood there and watched him, I did not get meds signed off until later due to an emergency at that time. On 2/27/25 at 12:00 PM R1 stated he does argue with them about his medication because it's always an ordeal. He knows what medications he takes and when they short him on his medications. The vitamins are important to his well-being and his dealing with the cancer. Rather than saying they made a mistake the staff want to argue with him. On 2/27/2025 at 3:45 PM, V6 LPN stated she had not had to call the doctor because her meds are not late. R1 has accused her of messing with his meds and asked that she not be assigned to him anymore. 2. R2's Face Sheet undated documents R2's admitting diagnoses Disruption of External Operation (surgical) wound, not elsewhere, Classified, subsequent encounter, Acquired absence of other Genital Organ (s), Unilateral Primary Osteoarthritis, left hip, Lymphedema, not elsewhere classified, Neurocognitive Disorder with Lewy Bodies and Secondary Parkinson, unspecified. R2's Physician Order Summary (POS) dated February 2025 documents medications as 24 Microgram (mcg) Amitiza twice a day (Irritable Bowel Syndrome), 15 Milliliters (ml) Mouth/Throat solution 12%, 25-100 Milligram (mg) Carbidopa-Levodopa twice a day (Hypothyroidism), 850 Milligram (mg) Metformin (Type 2 Diabetes Mellitus), 500 Milligram (mg) Levetiracetam (tremors), 2.5 Milligram (mg) Eliquis (atrial fibrillation), 25 Milligram (mg) Metoprolol twice a day (primary hypertension) and Refresh Plus Ophthalmic Solution 0.5% (dry eyes). R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact and has medical conditions of coronary heart disease, hypertension, neurogenic bladder, diabetes mellitus, hyperlipidemia, Non-Alzheimer dementia. R2's electronic medication administration (eMAR) dated 02/01/2025- 02/26/2025 documents the following R2's medications were administered 2 hours or more past scheduled times: On 2/4/2025 40 Milligram (mg) Furosemide, 500 Microgram (mcg) Cyanocobalamin, Peridex Mouth/Throat Solution 0.12%, 25-100 Milligram (mg) Carbidopa-Levodopa twice a day, 850 Milligram (mg) Metformin, 500 Milligram (mg) Levetiracetam, 2.5 Milligram (mg) Eliquis twice a day, 25 Milligram (mg) Metoprolol twice a day and Refresh Plus Opthalmic Solution 0.5 %, 40 Milligram (mg) Lisinopril, 40 Milligram (mg) Protonix, 400 Microgram (mcg) Folic Acid were scheduled for 7:45 AM but were administered at 11:59 AM; on 2/4/2025 600 Milligram (mg) Guaifenesin ER, 10 Milliequivalent (mEq) Potassium Chloride Extended Release, 10 Milligram (mg) Zyrtec, Aspirin Enteric Coated (EC) Low Strength and 10 Milligram (mg) Amlodipine was scheduled for 8:00 AM but was administered at 11:59 AM; on 2/4/2025 Peridex Mouth/Throat Solution 0.12%, 25-100 Milligrams (mg) Carbidopa-Levodopa twice a day, 850 Milligram (mg) Metformin, 500 Milligram (mg) Levetiracetam, 2.5 Milligram (mg) Eliquis twice a day, 25 Milligram (mg) Metoprolol twice a day and Refresh Plus Opthalmic Solution 0.5 % were scheduled for 5:00 PM but was administered at 9:05 PM; on 2/18/2025 600 Milligram (mg) Guaifenesin Extended Release, 40 Milligram (mg) Atorvastatin were scheduled for 8:00 PM but were administered at 10:02 PM; on 2/21/2025 Peridex Mouth/Throat Solution 0.12%, 25-100 Milligram (mg) Carbidopa-Levodopa twice a day, 850 Milligram (mg) Metformin, 500 Milligram (mg) Levetiracetam, 2.5 Milligram (mg) Eliquis twice a day, 25 Milligram (mg) Metoprolol twice a day and Refresh Plus Opthalmic Solution 0.5 % were scheduled for 5:00 PM but was administered at 7:52 PM. 3. R3's Face Sheet undated documents R3's admitting diagnoses Non-pressure Chronic Ulcer of Other Part of Left Foot with Unspecified Severity, Diabetes Mellitus due to Underlying Condition with Foot Ulcer, Vascular Dementia, Unspecified Severity, with other Behavioral Disturbances, Encephalopathy, Unspecified, Hyperlipidemia, Unspecified. R3's Physician Order Summary (POS) dated February 2025 documents R3's medications as 40 Unit Lantus (Diabetes), 500 Milligram (mg) Metformin (Diabetes), 5 Milligram (mg) Lisinopril (hypertension), 50 Milligram (mg) Diclofenac (arthritis), 100 Milligram (mg) Gabapentin (pain), 325 Milligram (mg) Ferrous Sulfate (65 Fe), 81 Milligram (mg) Aspirin (supplement), 40 Milligram (mg) Omeprazole (Gastro-Esophageal Reflux Disease) and 100 Milligram (mg) Docusate (constipation) R3's electronic medication administration (eMAR) dated 02/01/2025- 02/26/2025 documents the following R2's medications were administered 2 hours or more before or after scheduled times; On 2/01/2025 100 Milligram (mg) Gabapentin was scheduled for 12:00 PM but was given at 2:04 PM; on 2/02/2025 100 Milligram (mg) Gabapentin was scheduled for 12:00 PM but was given at 3:43 PM; On 2/05/2025 100 Milligram (mg) Gabapentin was scheduled for 12:00 PM but was given at 4:09 PM ; on 2/06/2025 100 Milligram (mg) Gabapentin was scheduled for 7:00 AM but was given at 9:22 AM ; On 2/06/2025 500 Milligram (mg) Metformin was scheduled for 4:00 PM but was given at 6:17 PM; On 2/06/2025 50 Milligram (mg) Diclofenac and 100 Milligram (mg) Docusate was scheduled for 9:00 AM but was given at 11:24 AM ; On 2/06/2025 500 Milligram (mg) Metformin was scheduled for 4:00 PM but was given at 6:17 PM; On 2/12/2025 25 Milligram (mg) Quetiapine was scheduled for 2:00 PM but was given at 12:14 PM; On 2/13/2025 100 Milligram (mg) Gabapentin was scheduled for 7:00 AM but was given at 9:02 AM ; On 2/22/2025 100 Milligram (mg) Metformin was scheduled for 7:00 AM but was given at 9:10 AM ; On 2/23/2025 100 Milligram (mg) Docusate was scheduled for 9:00 AM but was given at 11:12 AM ; On 2/06/2025 50 Milligram (mg) Diclofenac was scheduled for 9:00 AM but was given at 11:11 AM. 4. R5's Face Sheet undated documents R5's admitting diagnosis Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Unspecified Asthma, Uncomplicated, Type 2 Diabetes Mellitus without Complications, Morbid (Severe) Obesity due to Excess Calories, Neuromuscular Dysfunction of Bladder, Unspecified, Fibromyalgia and Hypokalemia. R5's Physician Order Summary (POS) dated February 2025 documents medications as Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3)Milligram/3 Milliliters (short of breath),80 mg Simethicone (gas) , 5 Milligram (mg) Oxycodone (pain) , 5 Milligram (mg) Diazepam (anxiety), 24 Microgram (mcg) Amitiza (Irritable Bowel Syndrome), 1.25 Milligram (mg) Ergocalciferol (supplement), 50 Microgram/ACT Fluticasone Propionate Nasal Suspension (allergies), 300 mg Bupropion, 325 mg Ferrous Sulfate (65 Fe), 40 Microgram (mg) Furosemide, 20 mg Furosemide (edema), 20 Milliequivalent (mEq) Potassium Chloride (supplement), 20 Milligram (mg) Prednisone (Pneumonia), 25 Milligram (mg) Lamictal (seizure), 25 Milligram (mg) Metoprolol (hypertension), 175 Microgram (mcg) Levothyroxine (low thyroid hormone) and 360 Milligram (mg) Cardizem (hypertension), 300 Milligram (mg) Bupropion Extended Release (depression) and 200 - 5 Microgram (mcg)/ ACT Milligram (mg) Dulera Inhalation Aerosol. R5's electronic medication administration (eMAR) dated 02/01/2025- 02/26/2025 documents the following of R5's medications were administered 2 hours or more before or after scheduled times ; On 2/3/2025 24 Microgram (mcg) Amitiza was scheduled for 6:00 AM but was given at 8:23 AM; On 2/3/2025 360 Milligram (mg) Cardizem, 200-5 Microgram (mcg)/ACT Dulera Inhalation, 40 Milligram (mg) Pepcid, 175 Microgram (mcg) Levothyroxine and 25 Milligram (mg) Metoprolol was scheduled for 8:00 AM but were administered between 5:39 and 5:41 AM ; On 2/3/2025 80 Milligram (mg) Simethicone and 0.5-2.5 (3) Milligram (mg)/3 Milliliter Ipratropium-Albuterol was scheduled for 12:00 PM but was given at 8:23 AM; On 2/5/2025 3 Milligram (mg)/3 Milliliter (ml) Ipratropium-Albuterol Inhalation Solution 0.5-2.5 was scheduled for 6:00 PM but was given at 10:43 PM; On 2/6/2025 3 Milligram (mg)/3 Millimeter (ml) Ipratropium-Albuterol Inhalation Solution 0.5-2.5 was scheduled for 12:00 AM but was given at 2:51 AM; On 2/7/2025 3 Milligram (mg)/3 Milliliter (ml) Ipratropium-Albuterol Inhalation Solution 0.5-2.5 was scheduled for 12:00 PM but was given at 2:01 PM; On 2/8/2025 40 mg Pepcid, 500 Microgram (mcg)Milligram (mg) Cyanocobalamin, 325 Milligram (mg) Ferrous Sulfate (65 Fe), 5 Milligram (mg) Apixaban, 25 Milligram (mg) Metoprolol, Multivitamin, 25 Milligram (mg) Lamictal, 10 Milligram (mg) Escitalopram, 25 Milligram (mg) Diphenhydramine, 360 Milligram (mg) Cardizem, 20 Milligram (mg) Prednisone, 20 Milliequivalent (mEq) Potassium Chloride, Lactobacillus, 20 Milligram (mg) Furosemide, 50 Milligram/ACT Nasal Suspension, 40 Milligram (mg) Furosemide, 100 Milligram (mg) Docusate, 200-5 Microgram (mcg)/ACT Dulera Inhalation Aerosol, and 300 Milligram (mg) Bupropion Extended Release was scheduled for 8:00 AM but was administered at 12:50 PM; On 2/10/2025 1.25 Milligram (mg) (50000 Unit) Ergocalciferol was scheduled for 7:45 AM but was administered at 12:32 PM ; On 2/10/2025 40 Milligram (mg) Pepcid, 500 Microgram (mcg) Cyanocobalamin, 325 Milligram (mg) Ferrous Sulfate (65 Fe), 5 Milligram (mg) Apixaban, 25 Milligram (mg) Metoprolol, Multivitamin, 25 Milligram (mg) Lamictal, 10 Milligram (mg) Escitalopram, 25 Milligram (mg) Diphenhydramine, 360 Milligram (mg) Cardizem, 20 Milligram (mg) Prednisone, 20 Milliequivalent (mEq) Potassium Chloride, Lactobacillus, 20 Milligram (mg) Furosemide, 50 Microgram (mcg)/ACT Nasal Suspension, 40 mg Furosemide, 100 mg Docusate, 200-5 mcg/ACT Dulera Inhalation Aerosol, and 300 mg Bupropion ER was scheduled for 8:00 AM but was administered at 12:32 PM; on 2/11/2025 80 mg Simethicone, 3 mg/3 ml Ipratropium-Albuterol Inhalation Solution 0.5-2.5 were scheduled for 12:00 PM but were administered at 2:12 PM ; On 2/12/2025 325 mg Ferrous Sulfate (65 Fe) and 40 mg Pepcid was scheduled for 8:00 AM but was administered 10:09, 10:12 AM, respectfully; On 2/12/2025 5 Milligram (mg) Apixaban, 500 Microgram (mcg) Cyanocobalamin, 25 Milligram (mg) Diphenhydramine, 360 Milligram (mg) Cardizem and 300 Milligram (mg) Bupropion, 200-5 Microgram (mcg)/ACT Dulera Inhalation Solution, 100 Milligram (mg) Docusate Sodium, 50 Microgram (mcg)/ACT Fluticasone Propionate Nasal Suspension and 10 Milligram (mg) Escitalopram, 40 Milligram (mg) Furosemide, 20 Milligram (mg) Furosemide , Lactobacillus and 25 Milligram (mg) Lamictal, 25 Milligram (mg) Metoprolol, Multivitamin, 20 Milliequivalent (mEq) Potassium Chloride Extended Release, 20 Milligram (mg) Prednisone and Lidocaine Patch 4% were scheduled for 8:00 AM but were administered between 10:06 AM and 10:16 AM; On 2/14/2025 5 Milligram (mg) Baclofen 1 Milligram (mg) Mirapex, 3 Milligram (mg) Melatonin and 80 Milligram (mg) Simethicone Lidocaine External Patch 4 % were scheduled for 8:00 PM but were administered at 10:38 PM and 10:46 PM ; On 2/22/2025 40 mg Pepcid, 500 Microgram (mcg) Cyanocobalamin, 325 milligram (mg) Ferrous Sulfate (65 Fe), 5 Milligram (mg) Apixaban, 25 milligram (mg) Metoprolol, Multivitamin, 25 Milligram (mg) Lamictal, 10 Milligram (mg) Escitalopram, 25 Milligram (mg) Diphenhydramine, 360 Milligram (mg) Cardizem, 20 Milligram (mg) Prednisone, 20 Milliequivalent (mEq) Potassium Chloride, Lactobacillus, 20 Milligram (mg) Furosemide, 50 Microgram (mcg)/ACT Nasal Suspension, 40 Milligram (mg) Furosemide, 100 Milligram (mg) Docusate, 200-5 Microgram (mcg)/ACT Dulera Inhalation Aerosol, and 300 Milligram (mg) Bupropion Extended Release was scheduled for 8:00 AM but was administered between 11:25 and 11:26 AM; On 2/24/2025 80 mg Simethicone, Lidocaine External Patch 4%, 5 mg Baclofen and 3 Milligram (mg) Melatonin was scheduled for 8:00 PM but was administered between 9:58 and 10:00 PM; On 2/26/2025 Clobatesol Propionate External Cream 0.05% was scheduled for 6:00 AM but was not administered to 10:09 AM; On 2/26/2025 Clobatesol Propionate External Cream 0.05% was scheduled for 6:00 PM but was not administered to 10:07 PM. On 3/1/2025 at 12:17 PM V8, LPN stated she has not contacted the doctor when she is late with med administration. It was inevitable because you have to address a resident's need if they come to you while you are passing medications. It does cause a delay. On 3/3/2025 at 12:53 PM V9 Wound Care Nurse Practitioner stated she might have been contacted about late medications once, but she was uncertain. The staff are pretty good about notifying her or the medical director if there is a problem. V9 could not say there was any harm in the delay of administering medications. They would like for the orders to be followed as prescribed. On 3/3/2025 at 1:52 PM V10 LPN stated neither she or any nurses in the building contacted the nurse practitioner or doctor when the medications were administered after the scheduled time. V10 LPN stated the medication rounds are too heavy, most of the residents' medications were shifted from the night shift to days and evenings therefore the medications cannot be administered in the allotted time frame. They have complained to the administration about the medication passes being too heavy, but nothing is being done about it. The Facility's Policy Administering Medications revised April 2019 documents medications are administered in accordance with prescribed orders, including any time frames. Medications are administered within 1 hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise to prevent injury while smoking and elopement for 2 of 17 residents (R46, R47) reviewed for supervision in the sample of 41. Finding include: 1. R46's admission Profile, dated 12/8/23, documents that R46 was admitted on [DATE] with a diagnosis of Dementia. R46's Minimum Data Set, (MDS), dated [DATE], documents that R46 is moderately cognitively impaired and independent with ambulation. R46's Elopement Assessment, dated 9/8/23, documents that R46 is a risk for elopement. R46's Health Status Note, dated 10/20/2023 at 3:36 PM, documents, resident was found walking on street near stop sign by property. resident was able to be redirected and brought back into facility by staff. (Resident monitoring device) bracelet replaced to ensure proper function. notified regional nurse of incident. On 12/7/23 at 1:20 PM, V1, Administrator, stated that R46 did not get to the stop sign on the side of the property. V1 said she made it to the one at the end of the drive. (There is no stop sign at the end of drive). V1 stated that she is not sure what happened or if the door alarm went off. V1 stated that there were people outside. V1 stated that she had the staff replace the (resident monitoring device) just in case it was faulty. On 12/7/23 at 1:25 PM, V1 stated that at that time there was not clear documentation that (resident monitoring device) were checked to see if they were working. The policy Wandering and Elopement policy, dated 3/2019, documents, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 2. R47's admission Profile, print date of 12/8/23, documents that R47 was admitted on [DATE] and has diagnoses of Bipolar Disorder, Major Depressive Disorder, Anxiety and Vascular Dementia. R47's MDS, dated [DATE], documents that R47 is cognitively intact and is independent with ambulation. R47's Care Plan, dated 7/10/23, documents, The resident is a smoker. Interventions: Resident is supervised while smoking. Smoking materials are kept secured by staff. Smoking per facility protocol. R47's Smoking Evaluation, dated 7/10/2023, documents that R47 is to be supervised while smoking. (There is no other Smoking Evaluation available for review). On 12/4/23 at 10:10 AM, R47 stated, I smoke 3 times a day. I take myself outside and smoke behind the building. I keep my cigarettes and lighter. On 12/06/23 at 12:05 PM, V2, Registered Nurse, stated that R47 does go out to smoke by himself. On 12/06/23 at 12:05 PM, V1, Administrator, stated that R47 needs be evaluated to see if he is safe to smoke by himself. The Smoking Policy - Residents, dated 8/2022, documents, 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. it continues, 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

Based on interview and record review, the facility failed to ensure that residents maintain current level of urinary continency and receive timely treatment for urinary tract infections (UTI) for 2 of 3 residents (R44, R101) reviewed for continency and urinary tract infections in the sample of 41. Findings include: 1. On 12/11/23 at 1:50 PM, V2, Infection Preventionist, stated that R44 did not receive an order for antibiotics to treat a urinary tract infection for 3 days. V2 stated that 3 days to receive an antibiotic is too long. V2, stated, The nurses should have followed up with (V10) for orders. R44's Health Status Note, dated 12/2/2023 10:15 AM, documents, UA (urinalysis) culture results available--e. coli (Escherichia coli), faxed to (V10's) office. R44's Physician Orders, dated December 2023, documents, Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro). Give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 5 Days. Start Date of 12/5/2023 09:00 AM. On 12/11/23 at 3:00 PM, V6, Director of Nurses, stated that the nurses should continue to reach out to the Doctor for orders until they receive one. The policy Change in a Resident's Condition or Status, dated 2/2021, fails to document what to do if Physician fails to answer notice of change of condition. 2. R101's Face Sheet dated 12/11/2023 documents in part that R101 has a diagnosis of Cerebral infarction with hemiplegia and hemiparesis affecting the dominant right side and aphasia following the cerebral infarction. R101's care plan dated 11/13/2023 documents R101 has an Activity of Daily Living (ADL) self-care performance deficit. R101's care plan documents that R101 is totally dependent on staff for toilet use. On 12/04/23 at 10:31AM, V15, R101's daughter, stated R101 was admitted to the facility from the hospital last Tuesday. V15 stated that R101 had a stroke. V15 stated R101 was not incontinent prior to her admission and R101 is wearing an adult diaper and is being told to go in the diaper. On 12/11/23 at 10:57 AM, V15 stated that she had spoken to the facility about her concern and was told the problem is the mechanical lift will not fit in the bathroom. On 12/11/23 at 11:04 AM, V2, Infection Preventionist/ Nurse Manager stated the expectation for a resident admitted to the facility who is incontinent of urine if the mechanical lift will not fit in the bathroom, a bedside commode should be offered instead of just having resident go in adult diaper. On 12/11/23 at 11:22 AM, V16, Certified Nursing Assistant (CNA) stated (R101) is a (full body mechanical lift) and all (full body mechanical lifts) use a bedpan because the (full body mechanical lift) won't fit in bathroom. When asked by surveyor if a bedside commode had been utilized, V16 stated she had not thought of using a bedside commode. The facility policy Activities of Daily Living (ADL), supporting dated, revised March 2018 documents residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADL. The policy documents residents will be provided care, treatment, and services to ensure their ADL's do not diminish. The facility policy Behavior programs and toileting plans for urinary incontinence dated, revised October 2010 documents to review the resident's care plan to assess for any special needs of the resident and to provide treatment and services to address factors that are potentially modifiable. For example, providing adaptive equipment for residents with mobility problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide sufficient staffing to meet the needs of the residents at the facility by providing care and assistance for Activities of Daily Living. This failure has the potential to affect all 52 residents at the facility. Findings include: 1. On 12/4/23 at 10:30 AM, R29 had a very shaky voice and tears coming down her face during an interview related to staff On 12/04/23 10:27 AM, R29 stated, Our girls are good. It might take them a bit, but they are good. Agency staffing is horrible. They just don't care about us. They are here for a paycheck. Last week I had my light on and he came in and asked what I needed. I told him I had to go to the bathroom. He told me that I had an (incontinent brief) on and to just go in my brief. It will take agency staff over 30 minutes to answer a light. They just make me feel worthless. R29 stated that she did tell the nurses and they told her that she is ok. R29 stated that they walk around and talk on their phones with those things they put in their ears instead of working. R29's admission Profile, print date of 12/8/23, documents that R29 was admitted on [DATE] and has diagnoses Hemiplegia and hemiparesis following a stroke and Heart Failure. 2. On 12/04/23 at 09:48 AM, R45 stated, I don't think they have enough staff. They bring in agency and it takes them forever to get things done. I have waited for a half an hour for my call light. I get one shower a week and I don't think that is enough. I took a shower every other day at home, and they just don't have enough staff to do that here. 3. On 12/04/23 at 10:10 AM, R25 stated that he doesn't think there is enough staff. It takes about 30 minutes or more for them to come and answer the light. Over the weekend it took them an hour and a half to come and put me in my recliner from my wheelchair. I only get one shower a week and that is not enough my hair starts itching. I have talked to the Care Plan person in our meeting about this, but they don't have enough staff. R25's admission Profile, print date of 12/11/23, documents that R25 was admitted on [DATE] with diagnoses of Dementia and Type 2 Diabetes. R25's Care Plan, dated 10/2/20, documents, I enjoy participating in scheduled activities. Interventions: I prefer a shower 2 times per week at morning time of day. 4. On 12/04/23 at 9:36 AM, R42's call light was on. R42 stated that she has had her light on for awhile. R42 stated, You can't judge them on the one here today. It always takes her a long time. I want to get up and get out of bed. 5. During Resident Council Meeting on 12/5/2023 at 10:24AM, R35, R24, R37 and R27 all stated the facility does not have enough staff to provide care. R35, R24, R37, and R27 all stated it takes too long for call lights to be answered due to lack of staff. R24's Minimum Data Set (MDS) dated [DATE] documents that R24 is cognitively intact. R24's Care plan dated 10/16/2019 documents R24 requires supervision and set up for bathing. R27's MDS dated [DATE] documents R27 is cognitively intact. R35's MDS dated [DATE] documents R35 has moderate cognitive impairment. The facility's Resident Council Minutes dated 11/28/2023 documents under old business kids are brought to work. New business documents not enough staff to serve meals. Call lights are taking too long 30 minutes. Resident council minutes dated August 2023 documents it takes a long time to get call lights answered because there is not enough staff. On 12/11/23 at 03:51 PM V6, Director of Nursing (DON) stated the facility has 2 nurses on days and 2 nurses on nights as the nurse's work 12-hour shifts. 4 CNAs on days 3 on nights with an additional CNA coming in from 6-10PM. V6 stated the facility has enough staff if they are being utilized right. V6 stated she would expect that call lights be answered in 15-20 minutes. V6 stated she expects call lights to be answered timely and residents to get their showers. The facility did not provide a staffing policy. The Facility's CMS 671, Long Facility Application For Medicare and Medicaid, dated 12/5/2023, documents facility census at 52.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/4/23 at 10:25 AM, R24 was standing next to her dresser in her room, and she had two 1-ounce medication cups sitting on her bedside table. One of the medication cups contained one tablet that R24 identified as her Tums, and the other cup contained several tablets and capsules. R24 stated, That is my morning medication that (V4, LPN) gave me a little while ago. I will take it sometime before I go to lunch pretty soon. R24 stated she has a good roommate but stated she, (R17) is not in her right mind and can't remember what she did or said five minutes after it happens. R24's Minimum Data Set (MDS) dated [DATE] documents she is alert and oriented. R17 propelled herself out of the bathroom in her and R24's room and rolled past R24's bedside table that still had R24's medications unsecured in medication cups. R17 sat in her chair for a couple minutes listening to R24 talk. R24's medications were within easy reach for R17. R17's MDS dated [DATE] documents R17 is severely cognitively impaired. On 12/4/23 at 10:30 AM, V4, was standing by her medication cart in the hall a few doors down from R24's and R17's room. V4 stated, I thought (R24) was going to take her medications right away after I left them sit there for her. She already had breakfast which is what she usually waits for before taking her medications. I will go in right away and make sure she takes her medicine now. I know I am supposed to stay with the resident until they actually take their medications. I screwed up there. The facility's policy, Administering Medications, revised, April 2019, documents, Medications are administered in a safe and timely manner and as prescribed. Under Policy Interpretation and Implementation the policy documents: #4. Medications are administered in accordance with prescriber orders, including any required time frame. #20. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR (Medication Administration Record) may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medications. Based on observation and record review, the facility failed to ensure medications are under direct supervision of nurse for 2 of 24 residents (R24, R45) reviewed for medication storage in the sample of 41. Findings include: 1. On 12/04/23 at 09:43 AM, V3, Licensed Practical Nurse (LPN) took a full medication up into R45's room. At 09:45 AM, V3 was observed leaving the room. On 12/04/23 at 09:48 AM, R45's room was entered. R45's bedside table had a medication cup full of pills on it. On 12/04/23 at 09:48 AM, R45 was questioned what pills those in the cup were. R45 stated, Well I woke up late. So, she (V3) just got them to me.

Based on observation, interview and record review, the facility failed to securely seal, date and label refrigerated and frozen food. This failure has the ability to affect all 52 residents residing in the facility. Finding include: On 12/4/23 at 8:40 AM, the kitchen was entered. 1. The freezer had a pan covered in aluminum foil. The foil had holes in it, it was not labeled or dated as to what food and when the food was prepared. 2. The refrigerator had a pan of left-over roast beef that was dated 11/19/23, unknown if made date or expiration date. 3. The refrigerator had a large stainless pan that was covered with aluminum foil that was not labeled of what it was, when made or when it expires. On 12/4/23 at 9:00 AM, V11, Dietary Manager, stated that all foods should be labeled with expiration date, the date prepared, name of the food and all foods should be sealed tightly. At the time of exit the facility was unable to provide a facility policy on how to store refrigerated or frozen food items. The Long-Term Care Facility Application for Medicare and Medicaid dated 12/5/23, documents that 52 residents reside in the facility.

Based on interview, observation and record review, the facility failed to have a system in place to assess for efficacy of antibiotic use. This failure has the potential to affect all 52 residents living in the facility. Findings include: 1.On 12/11/23 at 2:00 PM, V2, Infection Preventionist, stated that she does not have enough time to devote to the infection control program as she once did so there are pieces missing in her infection control tracking. V2 stated, I really don't understand all of the infection control stuff. I used to have an infection control program on the computer that would generate all my tracking and infections but apparently it is not here anymore. On 12/11/23 at 3:10 PM, V6, Director of Nurses, was questioned if the facility has updated infection control and antibiotic stewardship policies, V6 stated, I just pulled off the policies from Medpass. 2. On 12/11/23 at 1:35 PM, V2 stated that if the nurse enters the antibiotic correctly when it is ordered the computer system will automatically generate a McGreer's report for a suspected urinary tract infection. V2 was questioned if R23 had a McGreer's report available for review. V2 stated that R23 did not. V2 stated V10, Nurse Practitioner, started R23 on Keflex (an antibiotic) before the urine culture report was available for review and then the antibiotic was changed to Fosfomycin. R23's Health Status Note, dated 12/3/2023 2:27 PM, documents, N.O. (new order) received on 11/28/23 from (V10) 1. Notify office if bleeding continues 2. Collect Straight cath (catheter) UA (urinalysis) - send to(Lab) Dx (diagnosis): Hematuria, suprapubic tenderness. 3. Follow-up 1 week. R23's Health Status Note, dated 12/7/2023 11:33 AM , documents, Progress note from (V10). Stop Keflex. urine culture grew e coli ESBL (Escherichia coli extended spectrum beta-lactamase), contact isolation. treat with Fosfomycin 3 G packet (mixed with 4 oz (ounce) cold water) x1 dose. repeat urine culture (only) 7 days after receiving Fosfomycin. R23's Medication Administration Record (MAR), dated December 2023, documents that R23 received 1 dose of Fosfomycin on 12/7/23 and 5 doses of Keflex from 12/5/23 until 12/6/23. The facility is unable to provide the urine culture at this time. 3. On 12/11/23 at 1:40 PM, V2 stated that R6 does not have a McGreer's report for a suspected upper respiratory infection and that R6 did not receive a chest Xray. V2 stated, (R6) started with upper respiratory symptoms and was put on an Azithromycin. R6's MAR, dated November 2023, documents R6 received Azithromycin from 11/18/23 until 11/22/23. 4. On 12/11/23 at 1:50 PM, V2 stated that R44 did not have a McGreer's report completed for a suspected urinary tract infection and that 3 days to receive an antibiotic is too long. V2, stated, The nurses should have followed up with (V10) for orders. R44's Health Status Note, dated 12/2/2023 10:15 AM, documents, UA culture results available--e. coli, faxed to (V10's) office. R44's Physician Orders, dated December 2023, documents, Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro). Give 1 capsule by mouth two times a day for uti for 5 Days. Start Date of 12/5/2023 09:00 AM. The facility is unable to provide the urine culture at this time. The policy Surveillance for Infections, dated 9/2017, documents, The infection preventionist will conduct ongoing surveillance for healthcare - associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission - based precautions and other preventative interventions. The Antibiotic Stewardship Order for Antibiotics, dated 12/2016, documents, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program and in conjunction with the facility's general policy for medication utilization and prescribing. This policy fails to document what clinical criteria are met for a clinical definition of an active infection or suspected sepsis.' The Antibiotic Stewardship - Orders for Antibiotics, dated 12/2016, documents, Antibiotic usage and outcome date will be collected and documented using a facility approved antibiotic surveillance tracking form. This data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. The Long - Term Care Facility Application for Medicare and Medicaid, dated 12/5/23, documents that 52 residents reside in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to honor a resident's rights in 1 of 7 residents (R5) reviewed for resident rights in the sample of 12. Findings include: On 9/20/23 at 10:15 AM, R5 was observed in bed and was tearful. R5 stated, she must wait 45-50 minutes for her call light to be answered. R5 stated, this happens on day shift all the time. R5 stated, she is continent of her bladder & bowels but because she must wait, she goes on herself. R5 stated, now she has resorted to screaming out for help, so that someone will help her. R5 stated, she uses the bed pan and needs help getting on it. R5 stated, she feels humiliated and angry when she goes on herself. R5 stated, she has asked to talk to V1, Administrator, about her concerns. R5 stated, V1 came to her room this morning and told her she needed to talk with her this morning, because she would be out of the building this afternoon, and then she stated she would be back to talk with her. R5 stated, V1 has not returned to her room. R5 stated, she is here due to Terminal Cancer, and she has been to the facility before and wanted to come back here, because it was home. R5 stated, the Doctors gave her 2 months to 1 year to live, and she wants to have a good quality of life. R5 stated, she talked to V3, Registered Nurse, (RN), Infection Control Preventionist, (ICP), and V6, Minimum Data Set, (MDS), Nurse and V6 told her she had a Care Plan meeting on 11/3/23 and she needed to notify the person in charge of what issues she is having. R5 stated, she talked with V7, Social Services Director, (SSD), that she was having issues getting staff to put her on the bed pan and a lack of communication with V1. R5 stated, this is her home, she was welcomed by the prior Administrator, Director of Nurse, (DON), and staff, but they don't have enough staff now. R5 stated, the staff are wonderful to her and it's not their fault, they need more help. R5's Face Sheet, undated, documents, R5 has a diagnosis of Malignant Neoplasm of the Pancreas. R5's MDS, dated [DATE], documents, R5 is cognitively intact and is occasionally incontinent of urine and bowels. R5's Care Plan, dated 8/8/23, documents, R5 has bladder incontinence and utilizes incontinence briefs and to change as needed. The Resident Rights Policy, undated, documents, it is the policy of the facility that all residents have the right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility. On 9/21/23 at 1:15 PM, V2, DON, stated, she would expect staff to respect the resident's rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to identify, continued weight loss in 2 of 4 residents (R6, R8) reviewed for weight loss in the sample of 12. Findings include: 1. R6's Face Sheet, undated, documents, R6 has an admitting diagnosis of Chronic Obstructive Pulmonary Disease. R6's Minimum Data Set, (MDS), dated [DATE], documents, R6 is cognitively intact and is independent with eating. R6's weights document the following: 3/21/23 - 174 lbs., (pounds), 6/21/23 - 152.4 lbs.; 8/23/23 - 149.3 lbs.; 9/20/23 - 140.6 lbs. - significant loss in 6 months, 3 months, and 30 days. R6's Physician Order Sheet, (POS), documents, an order dated 7/18/23 for a Regular Diet. R6's Progress Note, dated 7/6/23, documents, R6 is at 149 lbs. and is stable for 2 months after unusual loss. Med pass supplement was discontinued, due to resident refusal. Recommend to remove no concentrated sweets restriction from diet order and will continue to monitor for stable weight pattern or gain. There is no other documentation identified in R6's Progress Notes of R6's continued weight loss. On 9/21/23 at 8:50 AM, R6 stated, he started losing weight before he came to the facility, because he couldn't cook for himself any longer, so he started eating microwave food. R6 stated, since he's been at the facility, he's been eating better, but is still losing weight. 2. R8's Face Sheet, undated, documents, R8 has a diagnosis of Dementia. R8's MDS, dated [DATE], documents, R8 has severe cognitive impairment and is independent with eating. R8's weights document the following: 3/7/23 - 120 lbs.; 6/7/23 - 116 lbs.; 8/1/23 - 111.4 lbs.; 9/1/23 - 105.3 lbs. - Significant weight loss in 6 months, 3 months, and 30 days. R8's POS, documents, an order dated, 3/31/21 for a no added salt, Mechanical Soft Diet and 9/16/22 Med pass 60 milliliters, (ml), every morning and at bedtime for weight loss. R8's Progress Note, dated 7/6/2023, documents, R8 is at 111.8 lbs. with 5 lb. loss over 6 months. Recommended weight is 95-115 lbs. Diet is Mechanical Soft no added salt with 60 ml Med Pass Supplement twice daily. Would change supplement to 90 ml BID. Will monitor for stable weight pattern and adequate intake. There is no other documentation identified in R8's Progress Notes of R8's continued weight loss. On 9/21/23 at 1:00 PM, V11, Licensed Practical Nurse, (LPN), stated, the Nurses are the ones that put the weights in the computer, so they know if a resident has a weight loss or gain, and if so, they notify their Doctor and document it in the Nurse's Notes. On 9/21/23 at 1:10 PM, V12, Dietary Manager, stated, they get the information for the diet cards from the Physician Orders. V12 stated, they have Care Plan Meetings every week and she is notified if a resident has a weight loss in those meetings. Stated if they've had a weight loss, they have Nutritional Drinks they can give them to help them gain weight. V12 stated, she just recently took over the Dietary Manager position and has not met the Dietician yet. V12 stated, she is not sure if they review the residents monthly or quarterly or if they are notified of weight losses/gains. On 9/21/23 at 1:15 PM, V2, Director of Nurses, (DON), stated, she hasn't received any Dietary recommendations from the Dietician yet. V2 stated, the Dietician does not come to the building, she reviews the resident's information remotely and she isn't sure who they review monthly or quarterly. The Weighing and Measure the Resident Policy, dated 3/2011, documents, the purpose of this procedure is to determine the resident's weight to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide a Therapeutic Diet as ordered by the Physician in 1 of 4 residents (R11) reviewed for Therapeutic Diets in the sample of 12. Findings include: On 9/20/23 at 12:05 PM, R11 was observed in the dining room eating lunch. R11 was eating a Regular cheese sandwich and cheese puffs, the meal was not Pureed as per orders. R11's drinks were Regular Consistency and not Nectar Thick as ordered. On 9/21/23 at 12:15 PM, R11 was observed in the dining room. R11 was served and was eating a cheese sandwich, mashed potatoes with gravy and pumpkin pie. R11's drinks were regular consistency. R11 was not served a Pureed Diet or nectar thick liquids as ordered. R11's Face Sheet, undated, documents, R11 has a diagnosis of Dysphagia, Oropharyngeal Phase. R11's Minimum Data Set, (MDS), dated [DATE], documents, R11 has severe cognitive impairment, is independent with eating and is on a Mechanically Altered Diet. R11's Care Plan, dated 3/22/21, documents, R11 is at risk of choking. R11's Physician Order Sheet, (POS), documents, an order dated 8/4/22, for a Regular Diet, Pureed Texture, and Nectar Consistency Liquids. On 9/21/23 at 1:15 PM, V2, Director of Nurses, (DON), stated, she would expect the residents to be served the Diet Ordered by the Physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to supply a sufficient number of staff, Certified Nursing Assistants, (CNA), to care for the residents. This failure has the potential to affect all 53 residents residing in the facility. Findings include: On 9/20/23 at 10:15 AM, R5 stated, she must wait 45-50 minutes for her call light to be answered. R5 stated, this happens on day shift all the time. R5 stated, she is continent of her bladder & bowels, but because she must wait, she goes on herself. R5 stated, now she has resorted to screaming out for help so that someone will help her. R5 stated, she uses the bed pan and needs help getting on it. R5 stated, she feels humiliated and angry when she goes on herself. R5 stated, they need more CNAs. R5 stated, she doesn't blame the CNAs or Nurses, because they cut the number of staff due to census. R5 stated, they only have 1 CNA on the 100-hall, 2 on the 300-hall and a floater. R5 stated, the floater is assigned to help on all the halls and go to the 200-hall as needed. R5 stated, 9 times out of 10, that CNA is busy on the 300-hall. R5 stated, she is here due to Terminal Cancer, and she has been to the facility before and wanted to come back here, because it was home. R5 stated, the CNAs are willing to help, but there's just not enough to care for her in a timely manner. R5's Minimum Data Set, (MDS), dated [DATE], documents, R5 is cognitively intact. On 9/21/23 at 8:45 AM, R9 stated, they need more CNAs on 1st and 2nd shift. R9 stated, occasionally it takes longer to get care, because they need more help. R9's MDS, dated , 9/18/23, documents, R9 is cognitively intact. On 9/21/23 at 8:50 AM, R6 stated, they need more CNAs, when they're short staffed it takes more time to get help and it takes longer for his call light to be answered. R6's MDS, dated [DATE], documents, R6 is cognitively intact. On 9/21/23 at 9:15 AM, V8, CNA, they started this morning with only 3 CNAs and then pulled a CNA that works in Dietary to come and work the floor. V8 stated, they need more CNAs on all shifts. V8 stated, the residents aren't getting the care they should, because they have too many residents and not enough CNAs. V8 stated, she believes they have applications and hired one that started on nights last night and she trained one on days for 2 days, she was off and when she came back, the new CNA had a circle around her name on the schedule, so she is not sure if she called off or quit. V8 stated, staff have voiced to Management about the need for more CNAs, but it hasn't happened. On 9/21/23 at 1:00 PM, V11, Licensed Practical Nurse, (LPN), stated, they need more CNAs on all shifts. V11 stated, they can't give the proper care that is needed due to staffing. On 9/21/23 at 1:15 PM, V2, Director of Nurses, (DON), stated, staffing hasn't been bad, but she hopes it gets better. V2 stated, they are recruiting and V1, Administrator, has went to different hiring events. V2 stated, they just placed open positions on a hiring website and had around 15 applicants that they have called. On 9/21/23 at 2:25 PM, V13, Registered Nurse, (RN), stated, they need more CNAs, and because of this they are slower to answer the call lights. On 9/21/23 at 2:35 PM, V14, CNA, stated, there isn't enough staff, but that is all around, and they do the best they can to make sure the residents are taken care of. On 9/21/23 at 2:40 PM, V15, CNA, stated, they need more CNAs. V15 stated, this evening they only have 2 CNAs, and the DON is supposed to be staying over to help. V15 stated, this happens all the time so it's hard to give quality care to the residents. V15 stated, she's not sure what the facility is doing to get more staff. On 9/22/23 at 8:40 AM, V9, CNA, stated, they need more CNAs, it makes it harder to get showers done. On 9/22/23 at 8:45 AM, V16, LPN, stated, they need more CNAs, because of the staffing it makes it harder to give showers, timely care, and answer call lights. On 9/20/23 at 1:00 PM, there were 4 CNAs observed in the building working, 1 on 100-hall, 2 on 300-hall and 1 mainly on 300-hall but going over to 200-hall to answer call lights. On 9/21/23 at 9:10 AM, there were 4 CNAs observed working in the facility, 2 on 300-hall, 1 on 100-hall and 1 on 200-hall. On 9/21/23 at 2:30 PM, there were 2 CNAs observed working in the facility. V2, DON, was observed in the dining room assisting with the ice cream social. The Reporting Direct Care Staffing Information Policy, dated 8/2022, documents, direct care staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The Resident Census and Conditions of Residents form dated 9/20/23, documents, there are 53 residents residing in the facility.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 2 of 13 residents (R41 and R206) reviewed for abuse investigations in the sample of 23. Findings include: R41's Progress Note dated 5/31/2022 10:45 PM documents Walked around nurses' station to find male resident fondling res. breast. Male res. redirected and sent to room. Will inform Day shift nurse to inform proper persons. R206's Progress Notes dated 5/31/2022 at 10:45 PM documents Walked around nurses station found res. with his hand inside a female residents shirt fondling her breast, res. redirected and sent to his room. R41's and R206's Resident Abuse Investigation Report, with date of investigation completed as 6/6/22, contains documentation of interview with V4, Licensed Practical Nurse who witnessed R206 fondling R41's breast. The Investigation Report contains no documentation that R206 was interviewed regarding this incident although R206 is cognitively intact and the perpetrator. There are no documentation other residents were interviewed, or other staff were interviewed regarding this incident. On 12/14/22 at 9:39 AM V2, Director of Nursing (DON) states on 5/31/2022 at 10:45 PM there was an abuse situation which occurred between R41 and R206, and she was notified at 6:30 AM on 6/1/2022 of abuse allegation. V2 states that V4 was the employee who witnessed the occurrence on 5/31/2022 at 10:45 PM between R41 and R206, and that V4 was educated on notifying V1 and V2 immediately of abuse allegation. V2 states all employees were re-in serviced on immediate notification of abuse allegations. V2 states that an interview was conducted with R206 by the Social Service director who is no longer employed at the facility, and they do not have documentation of that interview with R206. V2 states she is not aware of what R206 stated to R41. V2 states she did not ask V4 what R206 said to R41. V2 states she does not have any documentation that she spoke to other residents. V2 states she does not have any documentation that she spoke to other staff members working during the occurrence on 5/31/2022. V2 states she does not have any documented interviews with R206 and R41 is not interviewable. Facility abuse prevention and prohibitions policy, Revision date November 2018, page 3 titled investigation documents Every employee will be interviewed who was working on the specific hall/wing the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will complete a questionnaire and complete as statement if indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pressure ulcer treatments per physician's orders and provide pressure ulcer treatment in a manner to promote healing and prevent contamination for 1 of 1 resident (R22) reviewed for pressure ulcers in the sample of 23. Findings include: R22's admission Profile, print date of 12/19/22, documents, that R22 was admitted on [DATE] and had diagnoses of left and right pressure ulcers of the heels, Peripheral Vascular Disease, Heart Failure and Edema. R22's Physician's Order (PO), dated 11/3/22, documents Wound Care: Cleanse left heel with wound cleanser, apply calcium alginate with Silver to wound bed, cover with dry gauze, wrap with Kling. Change daily, every day shift. R22's PO, dated 11/30/22, documents, Wound Care: Apply betadine paint to right heel. Leave open to air. No outer dressing required. On 12/13/22 at 1:15 PM, V9, Assistant Director of Nurses, stated, Upon (R22's) admission his legs have looked like this. He has no circulation in the left leg at all and the NP is trying to get him to agree to go to the vascular surgeon to see if there is anything that can be done. The open areas on the top of his feet, his shins and the back of his left leg were all caused because he gets large blisters and then they burst. His legs constantly weep because of all the edema. He refuses to put his feet up because he states that it causes him pain. He also has heel pressure ulcers. He was admitted with the one on the right heel and acquired the one on the left while here at the facility. On 12/13/22 at 1:15 PM, V9 provided wound and pressure ulcer care for R22. V9 placed a disposable waterproof bed pad under R22's feet. V9 removed the old dressings from R22's bilateral lower legs and feet. Some of the old bandages needed to be sprayed with wound cleanser to get the bandages wet so tissue wound not be pulled from R22's wounds. The disposable waterproof bed pad became soiled by wound cleanser and debris when R9 removed the old bandages. V9 did not remove the soiled disposable waterproof bed pad after it became contaminated. R22's heels were laying directly on this contaminated cloth. R22's had an unstageable right heel pressure ulcer the approximate size of a half dollar. The wound bed was 30% eschar tissue and a small amount of necrotic tissue. The rest of the wound bed was moist yellow tissue. R22 had an unstageable left heel pressure ulcer the size of quarter. This wound bed had a small amount of necrotic tissue, and the rest of the wound bed was moist and bright red. V9 cleansed the leg wounds and pressure ulcers with a spray wound cleanser. After V9 cleansed R22's heels, R22 placed his feet back onto the soiled disposable waterproof pad. V9 placed calcium alginate with silver on all open areas and on both heel pressure ulcers. V9 wrapped both feet and lower legs with gauze and then cover that with ace bandages. V9 did not paint R22's right heel with Betadine and leave open to air. During this procedure V9 changed gloves 7 times without hand hygiene in between. On 12/15/22 at 10:30 AM, V2, Director of Nurses, stated that a new clean disposable plastic lined cloth should have been put down after R22's heels were cleansed. The policy Pressure Ulcer Injury Prevention, dated4/2018, did not address/document that pressure ulcers should be treated per physician's orders or address staff should maintain a clean environment to prevent cross contamination during pressure ulcer treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R38's Face Sheet, undated, documents R38 has a diagnoses of Vascular Dementia, Major Depressive Disorder and Anxiety Disorder. R38's Care Plan, dated 3/30/33, documents R38 has anxiety with an intervention to monitor/document side effects and effectiveness. The care plan goes on to state that R38 has Depression with an intervention to monitor/document as needed any ongoing signs or symptoms of depression: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. R38's Medication Administration Record (MAR), documents orders for the following: 9/2/22 - Alprazolam 0.5mg at bedtime; 9/2/22 - Alprazolam 0.25mg every 24 hours as needed for anxiety and 8/17/22 - Lexapro 10mg daily for Major Depressive Disorder. R38's MAR has no documentation that the facility is monitoring the side effects, effectiveness or signs or symptoms of depression. R38's Electronic Medical Record does not document how the facility is documenting/monitoring R38's specific resident-centered behaviors to provide justification for the use of the psychotropic medications and their effectiveness. On 12/19/22 at 11:10 AM, V2, Director of Nurses, stated that she was unaware the residents that are on psychotropics need behavior tracking for the medications and their specific behaviors. The Facility's Psychotropic Medication Use Policy, reviewed 2/2021, documents The staff will observe, document, regarding the effectiveness of any interventions, including psychotropic medications. Based on interview and record review, the facility failed to provide resident centered medical management including monitoring and evaluation of residents' responses to psychotropic medications and failed to limit use of as needed (PRN) psychotropic medications without physician justification to 14 days for 4 of 5 residents (R13, R35, R38, R47) reviewed for psychotropic medications in the sample of 23. Finding include: R47's admission Profile, print date of 12/14/22, documents that R47 was admitted on [DATE] with diagnoses of Alzheimer's Disease with Late Onset, Psychotic Disorder with Delusions, Anxiety, Major Depressive Disorder and Dementia. R47's Care Plan Focus, created on 9/16/21, documents The resident has a behavior problem. The Care Plan Focus does not document what the behaviors R47 specifically displays. The Care Plan Interventions documented Administer antipsychotic mediations as ordered. Monitor/document for side effects and effectiveness. The Intervention, initiated date of 9/16/21, documented Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons, involved and situation. Document behavior and potential causes. R47's Care Plan Focus, with revisions on 6/22/21, documents I have dx of depression. I reported feeling down and having trouble sleeping. The Interventions document Bupropion as ordered. Caregivers to closely observe for increased suicidal thinking and behavior as well as hostility, agitation, and depressed mood and to contact health care provider immediately should these occur. The Interventions continued to Monitor/document/report to MD prn ongoing s/sx (signs/symptoms) of depression, unaltered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg (negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/ appetite, fear of being alone or with other, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. The Care Plan documents Administered medications as ordered, monitor/document for side effects and effectiveness. R47's Order Summary Report, print date of 12/14/22, documents, Escitalopram Oxalate Tablet 10 MG (milligram). Give 1 tablet by mouth one time a day for Depression with start date of 6/23/22. The Report documents Seroquel Tablet 50 MG. Give 100 mg by mouth at bedtime for dementia with psychosis with start date of 5/18/22. The Report documents Wellbutrin XL Tablet Extended Release 24 Hour 300 MG. Give 1 tablet by mouth one time a day related to Anxiety Disorder, Major Depressive Disorder with start date of 10/1/21. The Report documents Xanax Tablet 0.25 mg by mouth every 8 hours as needed for anxiety. Start date of 1/3/22. R47's Medication Administration Record (MAR), dated 12/2022, documents that R47 has been given 8 doses of the as needed Xanax from 12/1 through 12/12/22. R47's Electronic Medical Record does not document how the facility is documenting/monitoring R47's specific resident-centered behaviors to provide justification for the use of the psychotropic medications and their effectiveness. On 12/14/22 at 2:25 PM, V2, Director of Nurses (DON), stated, We do not have resident or drug specific behavior tracking. 2. R13's admission Record, print date of 12/14/22, documents that R13 was admitted on [DATE] and has diagnoses of Dementia with other behavioral disturbance, anxiety, Depression and Anxiety. R13's Order Summary Report, dated 12/14/22, documents, Alprazolam Tablet. Give 0.25 mg by mouth in the afternoon for anxiety with start date of 7/13/22. R13's Order Summary Report, dated 12/14/22, documents, Alprazolam Tablet. Give 0.25 mg by mouth in the morning for anxiety with start dated of 7/1/22. R13's Order Summary Report, dated 12/14/22, documents, Alprazolam Tablet. Give 1mg by mouth in the evening related to Unspecified Dementia with behavioral disturbance with start date of 11/22/22. R13's Order Summary Report, dated 12/14/22, documents, Amitriptyline HCL Tablet 50 MG. Give 1 tablet by mouth at bedtime related to Depression with start date of 1/28/22. R13's Order Summary Report, dated 12/14/22, documents, Bupropion HCL ER (XL) Tablet Extended Release 24-hour 300 mg. Give 1 tablet by mouth in the morning related to Depression with start date of 1/29/22. R13's Order Summary Report, dated 12/14/22, documents, Duloxetine HCL Capsule Delayed Release Sprinkle 60 mg with start date of 1/29/22. R13's Order Summary Report, dated 12/14/22, documents, Quetiapine Fumarate Tablet 50 mg. Give 50 mg by mouth two times a day for increased agitation with start date of 7/6/22. R13's Care Plan Focus, initiation date of 2/4/22, documents that R13 has actual/potential for verbally and physically aggressive behavior problem related to dementia with behavior disturbances. The Focus documents R13 has diagnoses of anxiety and depression. The Care Plan focus documents that R13 has been noted to be verbally and physically aggressive with others. R13's Care Plan Intervention, initiated on 11/25/22, document Administer medications as ordered. Monitor/document for side effects and effectiveness.' R13's Care Plan Intervention, initiated on 11/25/22 documents Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, person involved, and situations, document behavior and potential causes. R13's Electronic Medical Record does not document how the facility is documenting/monitoring R13's specific resident-centered behaviors to provide justification for the use of the psychotropic medications and their effectiveness. 3. R35's admission Record, print date of 12/14/22, documents that R35 was admitted on [DATE] with a diagnosis of Major Depressive Disorder. R35's Order Summary Report, dated 12/14/22, documents, Lexapro Tablet 10 MG (milligram) (Escitalopram Oxalate). Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE with start date of 4/2/21. R35's Care Plan Focus, initiated on 10/6/20, documents I have a dx (diagnosis) of depression. The Care Plan Intervention, initiated on 10/6/20, documented Care Management Committee will review my medication quarterly and sooner as needed to address effectiveness and possible GDR (gradual dose reduction). R35's Care Plan Intervention, initiated on 10/6/20, documents Administer Lexapro as ordered. Monitor/document for side effects and effectiveness. Black Box Warning. R35's Electronic Medical Record does not document how the facility is documenting/monitoring R35's specific resident-centered behaviors to provide justification for the use of the psychotropic medications and their effectiveness.

On 11/15/2021 at 8:20AM, entrance to facility, staff are observed to be wearing surgical masks and no eye protection. The COVID-19 data tracker documents the community transmission rate for Pike county, where the facility is located, is high. On 11/16/2021 at 2:10PM, V20, Regional Director, stated the facility is not wearing face shields/goggles as the county positivity rate identifies Pike county in the green. On 11/16/2021 at 3:00PM, V1, Administrator, stated she was providing training on face shields/goggles. 4. On 11/17/21 at 08:35 AM, R26 was in bed. V6, housekeeper, came out of R26's room with mask, shield, and gloves on. V6 was not wearing a gown. V6 doffed her gloves, did not sanitize her hands or don new set of gloves and entered R26's room with cleaning spray. V6 exited R26's room, took box of gloves in room without sanitizing hands or donning gloves and entering room. V6 exited R26's room, got a mop and entered R26's room. A sign posted on wall outside R26's room documents contact precautions, wash hands, gown, mask and gloves. On 11/17/21 at 01:11 PM, V15, LPN, donned gloves at medication cart at the nurse's station. V15 did not sanitize her hands prior to donning gloves. V15 picked up treatment supplies and proceded down hall with supplies in hand. V15 donned isolation gown, and changed gloves, but did not sanitize hands between glove change. V15 removed the dressing from R26's heel, cleansed with wound cleanser, and applied ointment and dressing. V15 exited the room, doffed gloves, and sanitized hands. The Resident Census and Conditions of Residents, CMS 672, dated 11/15/2021, documents a census of 49. Based on observation, interview and record review, the facility failed to wear required Personal Protective Equipment (PPE) to prevent the spread of COVID-19 and failed to perform hand hygiene to prevent the spread of infection. This has the potential to affect all 49 residents residing in the facility. Finding include: 1 On 11/15/21 at 12:08 PM, During the dining room observation, none of the staff wore protective eyewear. V11, Registered Nurse (RN), came into dining room to pass masks out to the residents to wear in the hallway. V11 was not wearing protective eyewear. V7, Certified Nurse Aide (CNA), V13, Dietary staff, V9, Licensed Practical Nurse (LPN), V10, CNA, V12, RN, were all in the dining room with no protective eyewear. At 12:59 PM, V3, LPN, was feeding a resident, was not wearingvprotective eyewear, and facemask was below her nose. V7, CNA, was feeding a resident and facemask was below her nose. 2. On 11/17/21 at 10:40 AM, V4, CNA and V8, CNA, were providing toileting for R3. V4 cleansed and rinsed R3's front perineal area then rectal area. V4 then removed her gloves, put new gloves on, no hand hygiene done between glove changes. V4 dried the areas, pulled up resdient's brief and pants. V4 removed gloves and put new gloves on, with no hand hygiene between glove changes. 3. On 11/17/21 at 1:30 PM, V14, LPN, brought the treatment cart into R3's room. V14 put gloves on without performing hand hygiene. V14 removed R3's dressings to abdomen and right upper leg, The dressings all had a small amount yellowish drainage on them. V14 removed gloves and put new gloves on, no hand hygiene between glove changes. V14 cleansed the 2 wounds to right abdomen and the wound to right upper leg with wound cleanser and a 4 x 4 gauze. V14 removed gloves, washed her hands, donned new gloves and applied Silvadene cream to the wound on her upper abdomen, and leg wounds, then to lower abdominal wound, non adherent dressings applied to wounds. V14 then removed gloves, no hand hygiene, with bare hands taped the non adherent dressings and dated them. V14 then put supplies away in the treatment cart, put gloves on, transferred R3 back to her wheelchair and washed her hands. On 11/18/21 at 10:16 AM, V12, RN, stated, I would expect hand hygiene between glove changes. On 11/18/21 at 10:16 AM, V12 stated, she would expect masks to cover both nose and mouth. The Centers for Disease Control and Prevention Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic: Summary of Recent Changes, 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic: Implement Universal Use of Personal Protective Equipment. If SARS-CoV-2 Infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below: Eye protection (i.e , goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. The facility Policy and Procedure for Infection Prevention and Control Manual dated 2019, documents, Standard Precautions Hand Hygiene, Appropriate hand hygiene is essential in preventing transmission of infectious agents. Purpose: To cleanse hands to prevent the spread of potentially deadly infections. To provide a clean and healthy environment for residents, staff and visitors. To reduce the risk to the healthcare provider of colonization or infections acquired from a resident. Gloves or the use of baby wipes are not a substitute for hand hygiene.