**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide needed care and services in accordance with resident's plan of care as ordered by physician, facility's protocol, and professional standard of practice. This deficiency affects two (R2 and R4) of three residents reviewed for Quality of care. Findings include:R2On 9/2/25 at 10:21AM, Observed R2 up in wheelchair. She is alert with cognitive and communication impairment due to intellectual disability. She needs assistance with ADLs (Activity of daily living) and transfers. Assessed skin condition of R2's bilateral under the breast with V8 LPN (Licensed Practical Nurse) and V9 CNA (Certified Nurse Assistant). Observed redness under both breasts. V9 CNA said that she applied this morning Vitamin D ointment. V8 LPN said that R2 has fungal rash, and she has an order of Nystatin powder twice daily, but she has not applied it yet. On 9/3/25 at 10:41AM, Reviewed R2's medical records with V4 Wound Care Nurse. V4 said that R2 ‘s Braden scale upon admission on [DATE] indicated score of 19 at high risk for skin impairment. She developed fungal rash under the breast as reported by nursing staff due to complaint of family member. She said that she observed the skin impairment under R2's bilateral breast but did not do the assessment but initiated the treatment order on 8/25/25. She also said she did not update care plan. She said that their protocol requires written assessment of skin impairment to be documented in wound assessment or progress notes, notify the physician for appropriate treatment order and update the care plan. She said that she just updated the care plan yesterday 9/2/25 when surveyor asked for it. She is not aware that group home case manager came in for complaint on 8/20/25 based on grievance report completed by V2 DON. V4 said that she did not update R2's family member of the treatment obtained for the redness under the breast. V4 said that Vitamin D ointment is not an appropriate treatment for fungal rash under the breast. R2 is admitted on [DATE] with diagnosis listed in part but not limited to Displaced fracture of olecranon process with intraarticular extension of right ulna, Cognitive communication deficit, Genetic related intellectual disability, Disorder of psychological development, Need for assistance with personal care, Difficulty walking, unsteadiness of feet. Physician order sheet indicated Nystatin external powder 100,000 unit/gm apply under both breasts topically every day and evening shift for fungal rash. Cleanse under the breast area with soap and water then apply powder under breast on affected areas ordered 8/25/25. No care plan formulated for under the breast fungal rash until 9/2/25. No documentation of under the breast fungal rash skin assessment and identification in R2's medical record. R2's admission Braden skin assessment indicated at high risk for skin impairment. R2's grievance form completed by V2 DON dated 8/20/25 indicated that R2's home care case manager presented concern about R2's redness under the breast. No documentation of assessment done. Treatment order not obtained until 8/25/25. R4On 9/2/25 at 11:02AM, Observed R4 lying in bed with low air loss mattress. He is alert and responsive to simple questions. He needs maximum to total care assistance with ADLs and transfers. V8 LPN said that R4 has sacral and right hip wound dressing. On 9/2/25 at 11:15Am, V2 DON (Director of Nursing) said that V4, Wound care nurse, is not yet in the building but will come later. She said that the floor nurse does the wound treatment in absence of wound care nurse. Informed V2 that surveyor will observe V8 LPN for R4's wound care. On 9/2/25 at 11:24AM, V8 LPN and V6 LPN reviewed R4's treatment orders and prepared for wound treatment. R4 has left AKA (Above the knee amputation). R4 repositioned to his right side. Observed no sacral wound dressing. R4 has moderate amount of soft brown bowel movement in his adult disposable brief. Observed redness with 100% epithelization tissue. V8 cleansed with NSS. Applied Nystatin powder 100,000 unit/gram to the sacral, applied gauze and covered with bordered gauze dressing. V8 also applied nystatin powder to perineal area. Then R4 repositioned to his left side. V8 removed the wound dressing saturated with moderate serosanguinous drainage. V8 cleansed with NSS. R4 has red wound tissue 50% granulation with 50% yellowish slough attached to the wound base. V8 applied calcium alginate and medical grade honey, gauze and covered with bordered gauze dressing. On 9/3/25 at 10:41AM, Reviewed R4's medical records with V4 Wound Care Nurse. V4 said that R4's re-admission Braden scale assessment dated [DATE] indicated high risk for skin impairment. He has DTI on sacrum and unstageable pressure ulcer on right hip. He has daily dressing and PRN to both sacral and right hip. She said that it's their protocol to follow physician orders in providing wound treatment. The floor nurses are knowledgeable to perform wound care as indicated in treatment record /Physician order. Informed above observation made during wound care with V8 LPN and V6 LPN. R4 is re-admitted on [DATE] with diagnosis listed in part but not limited to Acquired absence of left leg below the knee, Cognitive communication deficit, Dysphagia, Lack of coordination, Difficulty walking, Dermatitis, Type 2 Diabetes Mellitus, Parkinson's disease. Physician order sheet indicated: Right hip: Cleanse with normal saline, apply medical grade honey to wound bed, cover with calcium alginate and secure with bordered foam dressing daily and as needed. Sacrum: cleanse with normal saline, apply skin prep to site and cover with bordered foam dressing daily and as needed. Nystatin external powder 100,000 unit/gm apply to perineal area topically every day and evening shift for redness and itching. Comprehensive care plan indicated: R4 has an actual impairment to skin integrity related to contractures, Braden score and medical diagnosis. Left AKA- surgical wound, Sacrum- DTI (Deep tissue injury), Right hip- unstageable, and perineal fungal infection. He has an ADL self-care performance and impaired mobility. R4's wound /skin assessment report completed by V14 Wound care Nurse Practitioner dated 8/27/25 indicated: Sacrum Pressure ulcer, DTI, 2cm x 2cm x 0cm, 100% epithelial. Right hip Pressure ulcer, Unstageable, 2.8cm x 3cm x0.3cm, 40% slough, 60% granulation, peri wound-erythema, moderate amount of serosanguineous exudate. re-admission Braden scale assessment completed on 8/5/25 indicated at high risk for skin impairment. On 9/3/25 at 12:01PM, Informed V3 ADON of above observation made and concerns identified to R2 and R4. V3 said that V4 Wound nurse or floor nurse should document newly identified skin impairment to resident's wound assessment or progress notes, call physician for appropriate treatment order, update care plan and notify family member. The nurses should follow the physician orders when providing wound care. On 9/3/25 at 2:18PM, Informed V1 Administrator, V2 DON and V15 Nurse Consultant of concerns identified to R2 and R4. Facility's policy on Skin Care Regimen and Treatment Formulary reviewed 7/3/25 indicated: Policy Statement: it is the policy of the facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Procedures: 1. Charge nurse must document in the electronic health record any skin breakdown upon assessment and identification. Furthermore, treatment must be obtained from the patient's physician. 2. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee unless otherwise indicated by patient's attending physician.a) Pressure injuriesc) Other skin conditions5. Refer any skin breakdown to the skin care team and physician including wound physician/NP for further review and management as indicated.7. Notify the patient family/next of kin or POA for any new skin alteration that is identified during stay at the facility. 11. Treatment protocol: III. Stage 3 and Stage 4: Calcium alginate, Thera Honey, Deep tissue Injury (DTI): Foam dressinge) Rashes associated with allergy, dermatitis:*Incontinent rash with yeast infection: Antifungal: Triamcinolone/NystatinFacility's policy on Wound Care Guidelines reviewed 1/24/24 indicated: Procedures: 9. Documentation: c. The care plan shall be evaluated and revised based on resident's response to treatment, treatment, goals, and outcomes.d. The resident's skin alteration/breakdown shall be documented in the resident's clinical records in accordance with the facility's policy and in compliance with current regulatory standards. 12. Wound assessment for non-pressure skin alterations: non-pressure skin alterations documentation shall include but are not limited to perineal dermatitis, excoriation, skin tears, cuts, abrasions, surgical wounds, burns, rashes and abrasions and wound related pain. Facility's policy on Physician orders revised 7/3/5 indicated: Policy statement: It is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS. 9. Provision of care, treatment and services administered by the facility to the patient must be approved by the attending physician unless these treatment and services are governed by the facility's clinical policy and procedures as approved by the medical director. Facility's policy on Care plan revised 6/30/25 indicated: Policy statement: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. Procedures: 5. These will be periodically reviewed and revised by a team of qualified person after each assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess pressure ulcer for 1 (R105) of 4 residents reviewed for pressure ulcers in a sample of 50. Findings include: R105 is an [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: congested heart failure, atrial fibrillation, and osteomyelitis of the vertebral, sacral, and sacrococcygeal region. On the (MDS) Minimal Data Set assessment of 4/4/2025, section C, the BIMS (Brief Interviewed Mental Status) score was 11/15 and indicates moderate cognitive impairment. On MDS of 4/4/2025, GG section R105 requires partial/moderate assistance - Helper does less than half the effort. The helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort. Behavior Section E dated 1/24/205 and 2/10/2025 showed no refusal care behavior. On 5/5/2025 at 10:36 AM, R105 was observed in his room, upset because staff members just told him that he had to go to the hospital to treat his buttocks wound and did not want to talk about his care and just said, I don't feel good. Record review of wound treatment of the sacrum for April 2025 and May 2025, R105 only refused treatment on one day, dated 4/5/2025. Record review of 5/5/2025 hospital records read: R105 feels 'lousy and stated he is in pain and the sacrum wound is painful, moving around makes the pain worse. V19 (Hospital Physician) assessment described the sacrum wound as unstageable but I can see muscle, it is foul smelling with purulent discharge. On 05/05/25 at 2:32 PM, V7(Registered Nurse) said, R105 was transferred to the hospital because of losing weight and refusing care, wound worsening, and pain. I did not do the dressing today, but the DON (V2) and V14 (Certified Nursing Assistant) changed the dressing, and V18 (NP) called and gave the order to send the resident to the Emergency Department. When questioned, V7 (RN), what R105's weight-loss was and how the wound appeared, the nurse indicated she didn't know how much the resident lost and could not describe the wound because she had not seen it. The surveyor asked if R105 was her resident. V7 said it was, but she had received directives from the DON and followed V18's NP orders. The surveyor asked how much the resident ate today, but V7 was not able to provide the information either. On 5/6/2025 at 8:57 AM, requested skin assessment of R105's coccyx area to V6 (Wound Care Nurse) for the month of January 2025, and no skin assessment was provided upon request. V6 said, R105 did not have a current coccyx wound, and the 1/15/2025 wound assessment is a new stage 4 facility-acquired coccyx wound. V6 said that CNAs (Certified Nursing Assistants) assess the residents twice a week during showers and incontinence care and will notify the nurses and me if there is a skin impairment noted during care. I am not sure how long R105's wound was present before I was notified. 05/6/2025 at 11:30 AM, V2 (Director of Nursing) said, nurses are not expected to complete skin assessment, and the facility no longer enters skin assessment as an order. Certified nursing assistants will notify nurses or the wound care nurse if there is any skin impairment. The surveyor requested facility provide shower sheets from January to the current, and skin assessment, but only one skin evaluation dated 4/8/2025 was provided. Coccyx wound assessment dated [DATE] described the initial assessment as a Coccyx stage 4, and V2 was not able to discuss why treatment and assessment were not done sooner. The surveyor asked V2 if the resident came in with an existing pressure ulcer. V2 stated, No, it is facility-acquired. On 5/6/2025 at 12:40 PM, V12 (Licensed Practical Nurse) said that V14 (Certified Nursing Assistant Supervisor) called her to assist with R1's wound around 9:00 AM on 5/5/2025. V12 said, I am assigned to R105 sometimes, but the floor nurse was not available, so I went in the room to help. The wound looked big, and with a lot of drainage that looked like pus, and with an odor. On 5/6/2025 at 4:57 PM, V13(Family Member) said, I received a phone call on Monday from the facility that (R105) was going to the hospital because of the wound worsening, pain, and failure to thrive. I know that (R105) did not want to turn and move because of the pain. I spoke with the physician from the hospital today and indicated that the buttocks wound will never heal. That is what my uncle will have to live with. On 5/7/2025 at 1:45 PM, V18 (Nursing Practitioner) said her company recently started to provide services to the facility starting April 2025 and had to debride the wound a couple of times for non-viable tissue necrotic (dead) tissue. On 04/30/2025, V18 provided a description of the sacrum wound to have exposed tissue and be able to see Bone, Muscle,/Fascia after the debridement. V18 said, I used lidocaine numbing medication during the wound procedure and believes that R105 has other pain medication ordered, but could not provide which pain medication to the surveyor. When questioned on how long a wound would take to get to a stage 4, V18 said that it is not an easy question to answer because R105 had some comorbidities to take in consideration. On record review of the May TAR (Treatment Administration Record), V7 entered NN on the electronic treatment record for 5/5/2025, which means see nurses' notes, but no wound nurses' notes were recorded or provided to the surveyor when requested. On the electronic medication record, pain medication was ordered until 5/2/2025. Physician orders read: Acetaminophen Tablet 325 MG. Give 2 tablets by mouth every shift for pain (give 1 hour before treatment). There were no pain medications provided as needed for pain for the month of April 2025. R105's wound of the Coccyx initial assessment dated [DATE], and there are no weights completed since 4/9/2025 to determine percentage weight loss. When a pressure ulcer list was requested by the survey team on 5/5/25, R105 was not included on the pressure ulcer list until requested again by the survey team to provide a more precise list. Surveyors asked V6 about the discrepancy, but only indicated that it was because the resident was being discharged the same day as the start of the annual survey. On 5/06/2025 at 4:11 AM, V1(Administrator) provided the policy title, Skin Care Regimen and Treatment Formulary, reviewed dated 1/24/2024. Which reads in part (but not limited to), Policy Statement It is the policy of this facility to ensure prompt identification, documentation, and to obtain appropriate treatment for residents with skin breakdown. Procedures 1. Charge nurses must document in the Electronic Health Record any skin breakdown upon assessment and identification. Furthermore, treatment must be obtained from the patient's physician. 2. Routine daily wound care treatment/ dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician. Pressure Injuries: III. Stage 3 and Stage 4: Clean Wound Bed: Calcium Alginate, Thera Honey, Hydrocolloid, Xeroform Gauze

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a PASARR (pre-admission screening and resident review) for residents in the facility for a mental disorder or related condition prior to being admitted and failed to ensure residents identified with a mental disorder or related condition were evaluated and provided care in the most appropriate setting for 4 (R2, R4, R7, and R25) of 6 residents reviewed for PASARR screening. Findings include: R2 is [AGE] years of age. R2's medical diagnoses include but are not limited to Dementia diagnosed 6/14/24, Schizoaffective disorder upon admission, Major Depressive Disorder upon admission, and Anxiety upon admission. R2's comprehensive assessment dated [DATE] section C cognitive patterns documents a brief interview for mental status with a score of 11 out of 15. A score of 8-12 indicates R2 has moderate cognitive impairment. On 05/07/25 at 1:14 PM, V10 Admissions Director was inquired of R2's PASARR screening. V10 said, I just started a year ago. I know the PASARR screening was started in 2022 or 2023. I didn't know R2 was supposed to be screened. V10 did not provide a PASARR screening for R2. V10 provided R2's OBRA (Federal Omnibus Budget Reconciliation Act) pre-admission screening from June 1996. On 05/07/25 at 01:21 PM, review of R2's census indicates he was admitted to the facility on [DATE]. Upon review of R2's medical record, there was no documentation of a PASARR (preadmission screening resident review) upon admission. R2's current physician orders document the following medications- Ativan Oral Tablet 1 MG (Lorazepam) *Controlled Drug* Give 1 tablet by mouth two times a day. (Antianxiety medication) and Risperidone Oral Tablet 4 MG Give 1 tablet by mouth two times a day for schizophrenia, bipolar. (Antipsychotic medication). R4 is [AGE] years of age. R4 was admitted to the facility on [DATE]. R4's medical diagnoses include but are not limited to Dementia and Schizophrenia diagnosed on admission. Review of R4's electronic medical records does not document a PASARR screening upon admission. R4's comprehensive assessment dated [DATE] section C cognitive patterns documents a brief interview for mental status with a score of 3 out of 15. A score of 0-7 indicates R4 has severe cognitive impairment. On 05/07/25 at 11:56 AM, V10 provided R4's preadmission screening and resident review submitted on 5/7/25 at 10:51 AM. V10 Admissions Director was inquired of the newly submitted information. V10 said, R4 never had one so I ran it today. V10 submitted a level 1 screening to the state appointed agency on 5/7/25 when inquired of R4's screening. R4's current physician orders document the following - Behavior Monitoring for Schizophrenia: Monitor for the following: Delusion, Hallucinations, Disorganized speech, Grossly disorganized or catatonic behavior and Negative Symptoms (e.g. reduced emotional expression). There are no current medications related to her diagnoses. R7 is [AGE] years of age. R7 was admitted to the facility on [DATE]. R7's medical diagnoses include but are not limited to Epilepsy, Major Depressive Disorder, and Schizophrenia diagnosed on admission. Dementia was diagnosed on [DATE]. Review of R7's electronic medical records does not document a PASARR screening upon admission. R7's comprehensive assessment dated [DATE] section C cognitive patterns documents a brief interview for mental status with a score of 13 out of 15. A score of 13-15 indicates R7 is cognitively intact. On 05/07/25 at 11:00 AM, V10 provided R7's preadmission screening and resident review submitted on 5/7/25 at 10:42 AM. V10 Admissions Director was inquired of the newly submitted information. V10 said, R7 never had one so I ran it today too. V10 submitted a level 1 screening to the state appointed agency on 5/7/25 when inquired of R7's PASARR screening upon admission. R7's current physician orders document the following medications- Haloperidol Tablet 2 MG Give 1 tablet by mouth two times a day for Anxiety Disorder (Antipsychotic medication), Zoloft Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for depression (Antidepressant medication), and Ativan Oral Tablet 1 MG (Lorazepam) *Controlled Drug* Give 1 tablet by mouth three times a day for Anxiety. R25 is [AGE] years of age. R25's medical diagnoses include but are not limited to Dementia diagnosed 10/1/22, Schizoaffective Disorder, Major Depressive Disorder, and Visual Hallucinations diagnosed upon admission. R25's comprehensive assessment dated [DATE] section C cognitive patterns documents a brief interview for mental status with a score of 3 out of 15. A score of 0-7 indicates R25 has severe cognitive impairment. On 05/06/25 at 01:43 PM, V1 Administrator was inquired of R25's PASARR screening. V1 said, R25 did not have a PASARR assessment done. On 05/07/25 at 11:19 AM, review of R25's electronic medical record, no assessment was found. V10 Admissions Director initiated R25's PASARR screening upon surveyor request on 05/06/2025. R25 was admitted to the facility on [DATE]. Upon review of R2's medical record, there was no documentation of a PASARR (preadmission screening resident review) upon admission. Upon review of R25's electronic medical record, there was no documentation of a PASARR (preadmission screening resident review) upon admission. R25's current physician orders document the following medications- Olanzapine Oral Tablet 5 MG Give 1 tablet by mouth at bedtime. (Antipsychotic medication) and Mirtazapine Oral Tablet 30 MG Give 1 tablet by mouth at bedtime for depression, anxiety. (Antidepressant medication). The facility did not provide a policy regarding PASARR screening. Resident #25 PASARR 05/06/25 01:43 PM V1 said, R25 did not have a PASARR assessment done. 05/07/25 11:19 AM No assessment, initiated upon surveyor request on 05/06/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure soiled linens were handled in a manner to prevent cross contamination, and failed to ensure incontinence care was completed in a manner to prevent contamination for 1 of 3 residents (R1) reviewed for infection control in the sample of 3. The findings include: R1's admission sheet shows he was admitted to the facility on [DATE] with multiple diagnoses. His 7/24/24 facility assessment and care screening documents him to be cognitively intact. The same document shows R1 has a colostomy and to always be incontinent of urine. The functional assessment shows R1 requires substantial to maximal assistance to roll side to side, sit up, and to transfer between surfaces. On 10/12/24 at 9:30 AM, R1 was observed lying in bed wearing a hospital gown, and an incontinence brief. V4 CNA (Certified Nursing Assistant) entered the room and removed the top sheet. V4 removed R1's incontinence brief, and V5 CNA assisted her with positioning. R1's scrotum and groin area were bright red after the removal of the soiled brief. V4 and V5 rolled R1 over to his right side. The pad and sheet under him were visibly soiled from the buttocks area and up his back. After the brief was removed, V4, using a disposable wipe, did not open the wipe, and blotted parts of R1's buttocks. She did not wash his buttocks or his backside. V4 then wiped the buttocks with ointment. V4 and V5 rolled R1 over to his left side to remove the soiled linens. Once the linens were removed from under R1, V5 threw them on the floor. Without cleaning up the groin and scrotum from urine, V4 placed ointment across the area and placed the clean incontinence brief. On 10/12/24 at 1:00 PM, V2 DON (Director of Nursing) said R1 should be changed every 2 hours. When he is changed, the CNA should be using soap and water and cleaning wherever the skin has been soiled. The areas should include the groin and scrotum. V2 said if the urine is not cleaned off it could cause skin breakdown. The disposable wipes should have soap on them, and opened up to use. V2 said the soiled linens are to be placed in a bag and should not be thrown on the floor, that is an infection control issue. The facility's 7/31/24 policy for Incontinent and Perineal Care documents it is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident to prevent infection and skin irritation, and to observe the resident's skin condition. Procedures: 6. Wash the perineal area and gently dry after the procedure. 7. Discard disposable items into designated container/plastic bag.

Based on observation, interview, and record review the facility failed to follow the Statement of Resident Rights when a resident was left exposed showing his bare chest and legs visible from the hallway. This failure affected one resident (R86) reviewed for privacy in a total sample of 26. Findings include: On 06/04/24 at 05:56 AM, R86 was observed with his bare chest and legs exposed in his wheelchair from the hallway while V12 (Certified Nurse Aide) was observed changing the linen on R86's bed. On 06/04/24 at 05:59 AM, R86 said he prefers his door closed when changing and does not want to be exposed to the public. On 06/05/24 at 01:07 PM, V2 (Director of Nursing) stated staff should use the privacy curtain or close the door for privacy. On 06/04/24 at 06:00 AM, V12 (Certified Nursing Assistant) said staff should close the door or use the privacy curtain when changing a resident to ensure privacy. On 06/04/24 at 06:22 AM, R60 said R86 was exposed and visible from across the hallway. On 06/06/24 at 02:32 PM, V14 (Social Service Director) said she was told by V1 (Administrator) R86 has a preference to be in his brief and does not want to use the privacy curtain or his door closed. V14 said she added the behavior care plan today. V14 said she was unaware of R86 having these behaviors/preferences and did not see any of these behaviors charted in R86's medical record. Statement of Resident Rights documents: Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on observation, interview, and record review the facility failed to follow the Kitchen Policy by not labeling and dating a package of pita bread and a bulk bag of Indian (Baking) Flour. This failure has the capacity to affect 131 residents with an oral diet. The facility also failed to follow Sanitizer Manufacturer Instructions and Procedures for 3 Compartment Sinks by not immersing blender items for one minute. This failure has the capacity to affect 13 residents on a puree diet. Findings include: On 6-4-24 at 8:00 AM, surveyor observed walk-in refrigerator and noted pita bread wrapped in foil. The pita had no label with open/made date and expiration date. On 6-4-24 at 8:08 AM, surveyor observed dry food storage and noted an (opened) bag of Indian flour with no label with open date or expiration date. On 6-4-24 at 8:08 AM, V11 (Dietary Manager) said all food should be dated with open date and expiration date. V11 said the open date determines how long the food can be used. V11 said he will remove the pita bread and the Indian flour. Kitchen Policy dated 7-23-23 documents: e. Refrigerated food should be covered, dated, and labeled, and shelved to allow air circulation. i. Dry Storage: iv. large bulk items rice, flour, etc, are labeled. On 6-4-24 at 9:40 AM, surveyor observed V13 (Cook) sanitize blender items for less than 30 seconds in the 3 compartment sink. Manufacturer's Instructions documents: 3. Sanitize equipment and utensils by immersion in a use-solution of 1-2 ounces of this product per 4 gallons of water (or equivalent dilution) for at least 60 seconds at a temperature of 75 degrees. Procedures For 3 Compartment Sinks documents: Immerse utensils in Sanitizer Sink for a full minute. On 6-6-24 at 11:45 AM, V13 (Cook) said items are sanitized for 2 minutes to ensure all the bacteria is removed. On 6-4-24 at 9:45 AM, V11 (Dietary Manager) said staff should sanitize items for 30 seconds. Facility Roster dated 6-4-24 documents: 13 residents on puree diet. Facility Roster dated 6-4-24 documents: 131 residents on oral diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to keep a resident free from being physically abused by another resident. This failure applied to two (R3 and R4) of three residents reviewed for abuse. Findings include: R3 is a [AGE] year-old female with a diagnoses history of Bipolar Disorder, Schizophrenia, Schizoaffective Disorder, Paranoid Personality Disorder, Unspecified Psychosis not due to a Substance or Known Physiological Condition who was admitted to the facility 01/31/23. R3's admission's hospital report dated 01/20/23 documents R3 was sent to the hospital with a petition form nursing facility due to increasing agitation, paranoid, aggressive and bizarre behavior. R3 was petitioned from a healthcare facility related to delusional, paranoid, and physically aggressive behaviors towards co peers. R3's current care plan for abuse revised 05/11/23 documents she has a history of medical and mental health comorbidities, denies being a victim or perpetrator of abuse, has trouble with personal boundaries, may have some risk of engaging in untoward or conflictual behavior and evoking responses from others due to decline in cognitive functioning; she was involved in an altercation with a peer, the situation was instigated by a peer and involved inappropriate language; R3's current care plan for behavior initiated 03/29/23 documents she has trouble regulating personal behavior, demonstrates behavioral distress (such as physical aggression) with interventions including monitor and assess for mood/behaviors and provide redirection; R3's current care plan for history of aggressive/inappropriate behavior initiated 02/05/23 documents she has a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior, verbal or physical aggression with interventions including intervene when any inappropriate behavior is observed. R3's progress note dated 5/11/2023 05:18 PM documents writer was made aware by staff that resident was physically aggressive towards another resident. Resident remains on 1:1 monitoring. R3's abuse investigation report dated 05/17/23 documents on 05/11/23 at approximately 5 PM V10 (Licensed Practical Nurse) reported to V2 (Director of Nursing) that R3 became aggressive with R4 when they were attempting to pass each other in the hallway. R4 was interviewed and reported while ambulating in the hallway by wheelchair she was suddenly attacked by R3 who when passing by suddenly got up and tried to grab R4's arm. R4's arm was observed with three small scratch marks with no bleeding. V10 was interviewed and reported he observed R3 get up from her wheelchair and walk towards R4 in the hall and R3 reported while passing R4 in the hallway R4 was rude to her which R4 denied; V10 reported R3 immediately got up from her wheelchair and aggressively went towards R4 and tried to grab her arm. A total of five staff members were interviewed and reported they have never witnessed R3 physically abuse R4. The report did not include any information that any other staff witnessed the incident or were present during the incident. R4's progress note dated 05/11/2023 5:59 PM documents resident was sent out after she got in physical fight with another resident and was admitted to the hospital for right upper arm contusion. R4's progress note dated 05/13/2023 documents the resident readmitted from the hospital with diagnosis of shoulder pain post altercation. R4's hospital report dated 05/13/23 documents her chief complaint as right shoulder pain after altercation; she presented to the hospital with right shoulder pain after being hit by another resident and reported feeling a bone on her shoulder that isn't usually there. She was admitted by the emergency room after concern for safety at nursing home. R4 reported taking Tylenol and tramadol with relief for chronic arthritis. For shoulder pain after altercation with chronic osteoarthritis, increased tramadol to QID (four times daily) as needed. R4's current physician orders document an active order effective 05/13/23 for 50mg of Tramadol tablet by mouth every 12 hours as needed for pain. On 05/31/22 from 11:47 AM - 12:10 PM V13 (Social Services Worker) reported R3's mood fluctuates from being joyous and happy to delusional. V13 stated R3 can lash out at a resident for no reason if they are talking to themselves and she believes they are talking to her. V5 (Social Services Director) stated she did observe in R3's admission paperwork that while in the hospital she was noted with exhibiting auditory hallucinations, aggravated aggression, and paranoia. V5 stated prior to being in the hospital before admission to the facility R3 had been noted to be at of halfway house. V5 stated per R3's admission paperwork while she was at the halfway house, she exhibited delusional, paranoid, and physically aggressive behaviors to her co peers. V5 stated typically when residents exhibit these behaviors they are monitored. V5 stated R3's triggers involve her delusions. On 05/31/23 from 12:30 PM - 12:45 PM R4 stated during the incident with R3 as she was heading to her room R3 suddenly lunged at her. R4 stated she raised her arm to protect herself and R3 grabbed down on her arm. R4 stated her right shoulder still hurts and they tell her it's ok but she feels its probably dislocated. R4 reported her pain in her right shoulder at a level 10. R4 stated she needs to use her hands and arms daily and it is difficult because of her shoulder pain. R4 stated although she has arthritis her pain seems worse after the incident where she was attacked by R3. R4 stated she is terrified of being at the facility because of the attack by R3 and is only remaining at the facility for the sake of her R7 (Family Member) On 05/31/23 from 12:51 PM - 1:00 PM V10 (Licensed Practical Nurse) stated he was R3's nurse on 05/11/23. V10 stated before the incident R3 was talking with him while he was working behind the nurses station. V10 stated R3 left the nurses station and began walking down the hallway towards the beverage cart. V10 stated he assumed R3 was going to get some tea from the cart. V10 stated he suddenly heard R3 yell from the hallway and upon responding to the yelling he then found R3 standing with her feet caught under R4's wheelchair and holding R4's arm. V10 stated R4 reported to him that R3 attacked her and R3 reported to him that while she was getting tea R4 called her profane names. V10 stated he did not see the interaction between R3 and R4 before or during the incident. V10 stated he only recalled a male dietary staff present during the incident and he did not witness any part of the situation because his back was turned towards the residents. On 05/31/23 from 2:00 PM - 2:33 PM V1 (Administrator) would not specify the level of supervision needed for R3 due to her delusional behavior and history of physical aggression with others as reported by social services. V1 stated the residents are monitored at all times by all staff and includes frequent rounding and staff assigned for frequent rounding, however it is not possible to observe them at every moment. V1 stated an incident can occur if a staff member looks away for even a second. V1 stated it is possible to adequately monitor residents while performing other duties by alternately observing the residents whereabouts and activity between performing work duties such as reviewing health records or passing medication. V1 stated the facility cannot provide one to one supervision for residents on a consistent basis. V1 stated she had not received any information that there were any dietary staff present during R3's incident of being physically aggressive with R4 on 05/11/23. V1 stated all the staff who were interviewed regarding the incident reported that they did not witness the incident. V1 stated due to R3 being delusional it's possible that her report of being verbally attacked by R4 did not occur. V1 agreed if there was a verbal altercation between R3 and R4 prior to the physical altercation as reported by V10 (Licensed Practical Nurse) that any staff present should have been alerted to the situation and intervened to prevent escalation. The facility's abuse policy reviewed 06/01/23 states: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse. Abuse is willful infliction of mistreatment or injury. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Physical abuse includes but not limited to infliction of injury that occurs other than by accidental means and requires medical attention. Examples include grabbing and roughly handling. Prevention includes identify, correct and intervene in situations in which abuse is more likely to occur; deployment of sufficient staff to deal with behaviors in the units; monitoring of residents with needs and behaviors that might lead to conflicts.

Based on observation, interview and record review, the facility failed to follow pharmacy medication storage and labeling policy and facility medication pass policy by not noting and implementing open date labels and failing to refrigerate new medication requiring refrigeration before opening. This applies to 6 of 85 (R22, R27, R61, R70, R76, and R121) residents' medications in three of five medication carts and one of one medication storage rooms during the medication storage and labeling task. Findings Include: On 05/16/23 at 10:10 AM Surveyor conducted inspection of the facility medication storage room. Surveyor observed opened and undated medication for: R61 - Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous Solution Pen-injector 2 MG/3ML (Semaglutide) - no open date On 05/16/23 at 10:19 AM Surveyor conducted inspection of Unit C medication cart. Surveyor observed opened and undated medications for: R22 - Breo Ellipta Aerosol Powder Breath Activated 100-25 MCG/INH (Fluticasone Furoate-Vilanterol) - no open date R61 - HumaLOG Solution 100 UNIT/ML (Insulin Lispro) - no open date R76 - Lantus SoloStar Solution Pen-injector 100 UNIT/ML (Insulin Glargine)- no open date On 05/16/23 at 10:56 AM Surveyor conducted inspection of Unit D medication cart. Surveyor observed opened and undated medications for: R70 - Trelegy Ellipta Aerosol Powder Breath Activated 100-62.5-25 MCG/INH (Fluticasone-Umeclidin-Vilant) - no open date R121- HumaLOG Subcutaneous Solution 100 UNIT/ML (Insulin Lispro) - no open date On 05/16/23 at 11:47 AM Surveyor conducted inspection of Unit B medication cart. Surveyor observed unopened and inappropriately stored medication for: R27 - Latanoprost Solution 0.005 % eye drops - new, unopened, should be refrigerated when new and unopened On 5/17/2023 at 10:13 AM Surveyor interviewed V2 (Director of Nursing), V2 (DON) stated, You need to know the expiration date because medications like insulin are good for only 27 days. It is because of the effectivity of the medication. Other medications than insulin may also be no longer effective, that's why it's important to document expiration date upon opening. Facility Medication Pass policy dated 03/28/2023 reads in part, It is the policy of the facility to adhere to all federal and state regulations with medication pass procedures. Insulin vials are to be discarded within 28 days after opening. Pharmscript Medication Label policy dated 11/19/2018 reads in part, Each prescription medication label includes Beyond Use (or expiration) date of mediation.

Based on observation, interview and record review the facility failed to follow controlled medications count policy by failing to maintain an accurate count of schedule II controlled pain medication for 1 of 85 (R129) residents during the medication storage and labeling task. This failure has a potential to affect all 133 residents residing at the facility. Findings include: On 5/15/23 at 9:45 AM, V1 (Administrator) presented survey team with facility matrix showing 133 current residents. On 05/16/23 at 10:19 AM Surveyor conducted inspection of Unit C medication cart. R129's oxyCODONE HCl Oral Solution 5 MG/5ML (Oxycodone HCl) bottle - surveyor observed about half an inch of medication at the bottom of the bottle. Per R129's controlled drug administration record for schedule II controlled medication, last signed out amount on 05/07/2023 by V18 (Licensed Practical Nurse) was 165.5 milliliters. Surveyor requested V18 (LPN) to measure remaining schedule II controlled medication in the bottle; measured amount of remaining medication in the bottle was 16 milliliters; 149.5 milliliters discrepancy noticed. R129's Physician Order Sheet dated 03/01/2023 reads in part, Oxycodone HCL Oral Solution 5mg/5ml *Controlled Drug* Give 2.5ml by mouth every 6 hours as needed for moderate to severe pain. On 5/17/2023 at 9:54 AM Surveyor interviewed V2 (Director of Nursing), V2 (DON) stated, We're still doing the investigation. I talked to several nurses. Sometimes nurses miss to sign medical administration record and controlled drug administration sheet. I work every weekend and at least every other weekend I do spot checks in medication carts. There was no discrepancy noticed. Appropriate in-services are already started. Moving forward, Assistant Director of Nursing, MDS nurses, EMAR nurse, restorative nurse, and psychotropic nurse, will do narcotic count at least on the daily basis to check for any discrepancies. We never had issues like this before. V18 (Licensed Practical Nurse) mistook R129's medication for another liquid medication. V2 (DON) further indicated that V18's (LPN) mistake created the discrepancy in R129's schedule II controlled medication. On 5/17/2023 at 10:23 AM Surveyor interviewed V17 (Registered Nurse/ Clinical Care Coordinator), V17 (RN/CCC) stated, R129's schedule II controlled medication was at the appropriate line on the bottle when I signed it out on both 04/17/2023 and 04/30/2023. There was no discrepancy at the time. Surveyor asked V17 (RN/CCC) to clarify controlled medication administration process, V17 (RN/CCC) stated, If controlled medication is scheduled, it's scheduled, when it is to be given as needed, we assess pain and then we administer it. I look at the order, dose, last time was given, and I administer controlled medication to the appropriate resident, I then, sign it out on controlled drug administration sheet and in the Medication Administration Record. Surveyor asked how does V17 (RN/CCC) know the process of controlled medication administration, V17 (RN/CCC) said that nurses receive training upon hire and as needed during in-services. She does not remember when the last controlled medication administration in-service was, but she was hired in November of 2020. On 5/17/2023 at 11:01 AM Surveyor interviewed V18 (Licensed Practical Nurse), V18 (LPN) said that on the morning of 05/07/2023 R129 was yelling, and V18 (LPN) had to give her schedule II controlled pain medication. After V18 (LPN) gave R129 2.5 milliliters of medication, she recorded 23.5 milliliters on the first page of controlled drug administration sheet based on the mark on the bottle. Around 3:00 PM V18 (LPN) gave another dose of 2.5 milliliters to R129, and at that point, she discovered the second page of controlled drug administration sheet for R129's schedule II controlled medication. V18 (LPN) thought it was the second bottle and that's how she confused it with another liquid medication. Quantity values on the two bottles somewhat matched. When V18 (LPN) wanted to record the given amount of 2.5 milliliters, she realized remaining amount recorded on the controlled drug administration sheet was completely different, so she tried to match the number from previous sign out even though V18 (LPN) saw that there was less medication in the bottle than recorded. Surveyor asked what should V18 (LPN) have done when she noticed the discrepancy, V18 (LPN) said that when she saw the discrepancy, she should have checked the bottle to verify the difference. V18 (LPN) also said that she was trained pertaining to controlled medication administration upon hiring, which was in January 2021 and most recent in-service regarding nursing skills was in March 2023. On 5/17/2023 at 12:27 PM Surveyor interviewed V19 (Licensed Practical Nurse), V19 (LPN) stated, I don't know what happened. I always give R129 2.5ml of the schedule II controlled pain medication each morning. I don't remember how much was left in the bottle when I gave it last time (on 05/06/2023) but there are other nurses working on the floor. Surveyor asked what should be done if controlled medication discrepancy is discovered, V19 (LPN) said that if there is a discrepancy, the nurse should call another nurse or Director of Nursing to verify and then both have to count and sign. Pharmscript Controlled Substance Storage policy reads in part, Any discrepancy in controlled substance counts is reported to the Director of Nursing immediately. If a major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, Director of Nursing notifies the administrator and consultant pharmacist immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident was free from physical abuse. This applies to 1 of 5 residents (R2) reviewed for abuse in the sample of 10. The findings include: The facility's Final Abuse Report dated 11/3/2022 documents on 10/31/22 V5 (LPN) reported to V1 (Administrator) R1 hit R2 on the back. V5 said he was in the hallway passing medications when he heard a commotion. He saw R1 walking down the hallway speaking loudly so he went to address the situation, before he could get to R1, R1 hit R2 on the back The local police interviewed R1 regarding the allegation of physical abuse toward R2. R1 stated she did hit R2 because she was mad at her because R2 told her to be quiet. On 11/18/22 at 9:10 AM, R2 was sitting in the hallway. She was observed interacting with staff in a pleasant manner. R2 said there was a woman who hit me. There was an argument she was talking about my family then she hit me a few times all over. It hurt and made me feel like sh-t. R2 said she better not come near me again. On 11/18/22 at 9:47 AM, V5 (Licensed Practical Nurse-LPN) said he was the nurse the day of the incident with R1 and R2. He heard both yelling and screaming in the hallway and he saw R1 hit R2 in the back. On 11/18/22 at 12:07 PM, R1 was observed in her room upset and crying. She said someone is following her. V12 (CNA supervisor) in the room. R1 stated I'm irritated and can't take it. She's following me referring to another resident. When V12 asked who is following her she said the person with the walker and white sweater. V12 said she's referring to R12 she likes to walk the halls. On 11/18/22 at 12:08 PM, V12 said R1 has behaviors she can get verbal and easily irritated. On 11/18/22 at 10:50 AM, V4 (Social Services) said R1 has verbal outburst and disorganized thinking. She was sent out after the incident for behaviors. If she hears loud noises, she can get agitated. It's abuse if another resident hits another resident. On 11/18/22 at 11:54 AM, V1 (Administrator) confirmed R1 made physical contact with R2. R1's face sheet shows she is a [AGE] year-old female with diagnoses including encephalopathy, schizoaffective disorder, major depressive disorder, anxiety, and bipolar. R1's Minimum Data Set assessment dated [DATE] shows she's cognitively intact. R1's care plan dated through 2/2/23 shows she has verbally aggressive behaviors related to infective coping skills, mental/emotional illness, poor impulse control using profanity and racial slurs. R1 also has physically aggressive behaviors when agitated, attempting to push, shove, scratch, hit, slap, grab or otherwise harm another person with interventions to ask her calmly what is causing this upset behavior and assess her coping skills and support system. The facility's Abuse and Neglect Policy reviewed 10/24/22 states, It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimation, or punishment. Abuse assumes intent to harm .Physical Abuse includes but not limited to infliction of injury .examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting and rough handling .