**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policy and procedures for abuse prevention by not reporting an allegation of abuse for a resident with a history of making abuse allegations. This failure applies to one of four residents (R1) reviewed for abuse.Findings include: R1 is a [AGE] year-old female with a diagnosis's history of Dementia with Behavioral Disturbance, Chronic Venous Hypertension with Ulcers of Right and Left Lower Extremities, Stage 3 Chronic Kidney Disease, Hypothyroidism, and Recurrent Severe Major Depressive Disorder who was admitted to the facility 05/04/2025. R1's Behavior Progress Note dated 5/21/2025 documents a CNA (Certified Nursing Assistant) informed that R1 went to the bathroom by herself, urine was all over the floor in the bathroom, R1 was then brought to common area and said, The lady abused me. I'm gonna call V7 (Family Member). The facility did not have an abuse investigation report for R1's abuse allegation from 05/21/2025. On 08/13/2025 at 1:34 PM V1 (Administrator) stated if she was aware of any abuse related concerns for R1 she would have addressed them, but she was not aware of these issues for R1. On 08/13/2025 1:53 PM V2 (Director of Nursing) stated R1 had a history of making allegations prior to admission towards caregivers and families, doesn't know if the documentation regarding R1 stating the lady abused me, would be considered an allegation, doesn't know what the writer meant. R1 has impaired cognition this would not change that an allegation was made but may affect V2's perception of what happened, this allegation would still have to be investigated if V2 were made aware of it, this should have been reported to the administrator, if the nurse would have informed V1 or V2 that R1 stated someone abused her V2 would have notified the administrator. If something is reported or seen in the community, we immediately report it to our administrator. The proper protocol would have been followed if she or V1 would have been notified about the allegations of abuse from R1. On 08/14/2025 from 10:26 AM - 11:30 AM V1 (Administrator) stated they spoke to the nurse and aide involved with caring for R1 on 05/21 and the nurse made the clinical decision to document the comment about being abused and wanting to call V7 (Family Member) from R1 to demonstrate her psychiatric behavior in conjunction with other behaviors displayed during that time, and quoted this because the nurse was just attempting to document paranoid and delusional behavior; what we have done for R1 is have multiple care plans in place based on three care plan meetings since she arrived to the facility and have been documenting on her behaviors of paranoia and delusions and consulted with psychiatry to coordinate her care. V1 stated V6 (Certified Nursing Assistant) was the staff being accused by R1 of abusing her on 05/21 and was the aide working with R1 during that time. V6 had informed the nurse that R1 went in the bathroom alone and when V6 went in there to monitor her, R1 didn't want her there and became upset when V6 stated she was there because she didn't want her to slip and fall. When V6 brought R1 out to the common area R1 made the abuse accusation and V6 told V4 (Registered Nurse) what happened and knew that R1 was upset with her for intervening in R1's care. V6 reported to the nurse that there was urine on the floor, and she was assisting R1 because she was engaging in behavior that wasn't safe. On 08/14/2025 12:52 PM V1 (Administrator) stated she followed up with V4 (Registered Nurse) and V4 doesn't recall or remember anyone else being in the room with V6 (Certified Nursing Assistant) on 05/21 when she was caring for R1. When asked by the surveyor how it can be determined R1's report of abuse by V6 occurred if there were no witnesses V1 replied by V6 coming forward and reporting what happened that's how V4 (Registered Nurse) made her judgment that R1's report of abuse was a psychiatric behavior not an allegation of abuse. The facility's Abuse, Neglect and Exploitation Policy received 08/14/2025 states: Franciscan Communities affirms that each resident has the right to be free from abuse. The community must adhere to policies and procedures that include the following components: reporting. Allegations shall be reported immediately to:The Executive Director/Administrator.State Survey and Certification agency through established procedures. The community will utilize of the following recommendations for prevention of abuse of residents:React to all allegations of abuse by residents. The community will consider factors indicating possible abuse including, but not limited to, the following possible indicators:Resident report of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policy and procedures for abuse prevention by not investigating an allegation of abuse for a resident with a history of making abuse allegations. This failure applies to one of four residents (R1) reviewed for abuse.Findings include: R1 is a [AGE] year-old female with a diagnosis's history of Dementia with Behavioral Disturbance, Chronic Venous Hypertension with Ulcers of Right and Left Lower Extremities, Stage 3 Chronic Kidney Disease, Hypothyroidism, and Recurrent Severe Major Depressive Disorder who was admitted to the facility 05/04/2025. R1's Behavior Progress Note dated 5/21/2025 documents a CNA (Certified Nursing Assistant) informed that R1 went to the bathroom by herself, urine was all over the floor in the bathroom. R1 was then brought to common area and said, The lady abused me. I'm gonna call V7 (Family Member). The facility did not have an abuse investigation report for R1's abuse allegation from 05/21/2025. On 08/13/2025 1:53 PM V2 (Director of Nursing) stated R1 had a history of making allegations prior to admission towards caregivers and families, doesn't know if the documentation regarding R1 stating the lady abused me, would be considered an allegation, doesn't know what the writer meant. R1 has impaired cognition this would not change that an allegation was made but may affect V2's perception of what happened. The allegation would still have to be investigated if V2 were made aware of it, this should have been reported to the administrator. If the nurse would have informed V1 or V2 that R1 stated someone abused her V2 would have notified the administrator. If something is reported or seen in the community, we immediately report it to our administrator. The proper protocol would have been followed if she or V1 would have been notified about the allegations of abuse from R1. On 08/14/2025 from 10:26 AM - 11:30 AM V1 (Administrator) stated they spoke to the nurse and aide involved with caring for R1 on 05/21 and the nurse made the clinical decision to document the comment about being abused and wanting to call V7 (Family Member) from R1 to demonstrate her psychiatric behavior in conjunction with other behaviors displayed during that time, and quoted this because the nurse was just attempting to document paranoid and delusional behavior. What we have done for R1 is have multiple care plans in place based on three care plan meetings since she arrived to the facility and have been documenting on her behaviors of paranoia and delusions and consulted with psychiatry to coordinate her care. V1 stated V6 (Certified Nursing Assistant) was the staff being accused by R1 of abusing her on 05/21 and was the aide working with R1 during that time. V6 had informed the nurse that R1 went in the bathroom alone and when V6 went in there to monitor her, R1 didn't want her there and became upset when V6 stated she was there because she didn't want her to slip and fall. When V6 brought R1 out to the common area R1 made the abuse accusation and V6 told V4 (Registered Nurse) what happened and knew that R1 was upset with her for intervening in R1's care. V6 reported to the nurse that there was urine on the floor, and she was assisting R1 because she was engaging in behavior that wasn't safe. When asked by the surveyor once the allegation of abuse was made to V4 what should have been done, V1 responded if someone makes an allegation of abuse the accused staff member is put on leave pending investigation for the safety of that resident and other residents. On 08/14/2025 at 11:42 AM V8 (Medical Director) stated the nurses are trained to quote the patient, the nurse that documented R1's allegation of abuse was quoting the patient not expressing an opinion, just because the patient uses the word abuse the nurse still can use clinical judgment to determine if it's a concern or not, this does not necessarily require investigation if the patient repeats things multiple times. V8 stated there is a certain amount of leeway the facility has and if we investigate every single thing a person is saying we'll be investigating everything, the nurse has the ability to use her clinical judgment to determine whether an investigation of what is being said needs to be done, if someone cries abuse because a band aid is ripped off or says someone was trying to poison them it doesn't necessarily require investigation, R1 has a history of complaining about every little thing and claiming someone quote on quote abused her. On 08/14/2025 at 11:47 AM V1 (Administrator) confirmed that no other staff was present with V6 (Certified Nursing Assistant) when she was monitoring R1 on 05/21 after being found in the bathroom by V6 standing in urine. When asked by the surveyor if there were any other witnesses present to confirm R1's allegation of abuse towards V6 (Certified Nursing Assistant) reported to V4 (Registered Nurse), V1 stated she had not yet had an opportunity to speak with anyone about this and she had not yet investigated this information. On 08/14/2025 12:52 PM V1 (Administrator) stated she followed up with V4 (Registered Nurse) and V4 doesn't recall or remember anyone else being in the room with V6 (Certified Nursing Assistant) on 05/21 when she was caring for R1. When asked by the surveyor how it can be determined R1's report of abuse by V6 occurred if there were no witnesses, V1 replied by V6 coming forward and reporting what happened that's how V4 (Registered Nurse) made her judgment that R1's report of abuse was a psychiatric behavior not an allegation of abuse. The facility's Abuse, Neglect and Exploitation Policy received 08/14/2025 states: Franciscan Communities affirms that each resident has the right to be free from abuse. The community must adhere to policies and procedures that include the following components: investigation and reporting. Allegations shall be reported immediately to:The Executive Director/Administrator.State Survey and Certification agency through established procedures. The community will utilize of the following recommendations for prevention of abuse of residents:React to all allegations of abuse by residents. The community will consider factors indicating possible abuse including, but not limited to, the following possible indicators:Resident report of abuse. When reports of abuse occur, an investigation is immediately warranted. Once the resident is cared for and the alleged abuser is removed from the community an initial reporting has occurred, an investigation should be conducted. The community must ensure to protect all residents after alleged abuse. This must include:Responding immediately to protect the alleged victim and the integrity of the investigation.Immediate removal of the alleged perpetrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to provide bed hold notifications to residents and/or family members when residents were discharged to a local hospital. This failure affected 5 residents (R5, R19, R37, R64 and R120) reviewed for bed hold notification in a total sample of 38. This failure had the potential to affect all residents in the facility. Findings include: R5 originally admitted on [DATE] with diagnosis that include and are not limited to: pneumonia, sepsis, dysphagia and acute kidney failure. Resident was transferred to a local hospital on 1/6/2025 per progress notes. Per record review no bed hold notification on record. R19 originally admitted on [DATE] with most recent readmission on [DATE] with diagnosis that include and are not limited to: pick's disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia and aphasia. Resident was transferred to a local hospital on [DATE] and 12/30/2024 per progress notes. Per record review no bed hold notification on record. R37 originally admitted on [DATE] with most recent readmission on [DATE] with diagnosis that include and are not limited to: calculus of bile duct with acute cholecystitis with obstruction, muscle weakness, difficulty in walking and cognitive communication deficit. Resident was transferred to a local hospital on [DATE], 12/16/2024 and 12/19/2024 per progress notes. Per record review no bed hold notification on record. R64 originally admitted on [DATE] with most recent readmission dated 11/5/2024 with diagnosis that include and are not limited to: Alzheimer's disease, cognitive communication deficit, anemia and generalized anxiety disorder. Resident was transferred to a local hospital on [DATE] per progress notes. Per record review no bed hold notification on record. R120 originally admitted on [DATE] with most recent readmission on [DATE] with diagnosis that include and are not limited to: displaced fracture of base of neck of left femur, hemiplegia and hemiparesis, muscle weakness and dysphagia. Resident was transferred to a local hospital on [DATE] per progress notes. Per record review no bed hold notification on record. On 01/15/25, at 2:41 PM, V1 (Administrator) was asked to provide surveyor the bed holds for the listed 18 discharges from hospital in the last three months. V1 stated, it has not been documented in the records. We are in the process of in-servicing the nursing staff on the proper procedure. On 1/15/2025, at 2:52 PM V2 DON (Director of Nursing) stated, regarding bed hold policy my expectation for the staff moving forward is communication with families and residents. I am not familiar with the bed hold policy. I remember from years ago I remember sending something with the patient when they discharged . The nurses are not aware of bed hold policy. We communicate with the families when they are discharged . We let them know what we are sending them out for, that we got the order. We call for follow up with the hospital. The hospital will usually ask us if they will come back to facility. We leave their belongings the same in their room unless family states that resident expires or are transferring elsewhere. Going forward I have started reviewing something that was given to me and started an in-service with the nurses on our bed hold policy. I am working on the verbiage so families and staff can understand it. Bed hold policy has not been being followed in the whole facility. On 1/15/2025, at 3:11 PM V1 stated, regarding the bed hold policy, it has not been being done in the whole facility. We are in the process of educating staff now. I do not know how this could have gotten overlooked. We do not charge any residents for any bed holds. For Medicare residents, we do not charge a bed hold. Private pay we do charge for the room whether they are here or not if belongings are in room. We do not kick residents out after the 10 days. The resident belongings stay in the room when they are discharged out to hospital. We do not move their belongings. Bed Hold Notices Policy with effective date of 5/1/2019 documents (in part): Policy: Franciscan Ministries supports the resident and/or resident's representative's right to be informed of the policy regarding holding a bed prior to and/or upon a resident's transfer to the hospital, therapeutic leave or discharge, including the duration of the bed hold. Purpose: To ensure a resident has the information regarding his/her rights regarding bed holds. Procedure: Notice Before Transfer 1. The following information is given to the resident and/or resident representative. a. The duration of the State bed-hold, if any during which the resident is permitted to return and resume residence in the nursing community. b. The reserve bed payment policy in the State plan, if any; and c. The community policy regarding bed hold periods to include permitting residents to return. 2. Policy Administration: 3. 2. The Executive Director/Administrator and Director of Nursing share responsibility for the implementation and communication of this policy. 4. 3. The Executive Director and [NAME] President of Clinical Services share responsibility for monitoring and reporting on implementation of this policy. This responsibility includes bringing to the attention of the Senior Management or the Board instances where this policy is not being applied.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to perform proper hand hygiene, failed to follow proper food storage practices, and failed to ensure dishwasher maintained proper temperature during final rinsing cycles to prevent the spread of food-borne illness and contamination. These failures have the potential to affect all 87 residents receiving meals from the kitchen. Findings include: On 01/13/25 at 09:25AM during the initial kitchen tour with V4 (Director of Dinning Services), surveyor observed three 50 pound bags of carrots on the floor, half full containers of: flour, salt, sugar, and navy beans without open and used by dates. V4 said, the carrots should not be placed directly on the floor and the flour, salt, sugar, and navy beans must be labeled with the open date and used by date. V4 said, he did not know what happened and that the staff are expected to follow the facility policy to label and date food when it is opened. On 01/14/25 at 09:25AM surveyor checked the temperature for the dishwasher with V4. Surveyor observed final rinse temperature of174 Fahrenheit (F) and repeat of final rinse at 175F. Surveyor requested for the high temperature dishwasher policy and specifications. V4 said, the dishwasher machine the facility uses, the final rinse is expected to be between 180F to 190F and V4 will be calling a local company to come and check the dishwasher machine. On 01/14/25 at 11:36 AM surveyor observed resident dining in [NAME] dining room on first floor. V12(Dietary Server) observed opening refrigerator with gloves on, removed saran wrap from plate of tomato and lettuce, touched the tomato and lettuce and added it to lunch plate for R40 with the same gloved hands. Surveyor did not observe V12 perform hand hygiene. Surveyor asked V12 if she should have washed her hands and changed gloves after touching refrigerator and prior to touching residents' food. V12 said, I think so. On 01/15/2025 at 11:50AM V8 (Local company Account Representative) said, when the dish washer machine final rise temperature was checked on 01/14/2025 at 12:09PM, the temperature of the final rinse was not holding up, and the dishwasher temperature was switched to low temperature with chemical rinse, because there were no parts available to fix the machine at that time and ordered the parts. V8 said that the machine requires 6 elements, and one element was not working. V8 showed pictures of exposed wires to the surveyor. and said, that is why the temperature is not holding up. On 01/15/2025 at 9:50AM V2 (Director of Nursing) said, the staff are expected to wash their hands or use hand sanitizer before and after care, after removing gloves and after touching a soiled or dirty surface. Staff in the dining room are required to wash their hands before putting gloves on and before serving meals, and when hands get soiled and when changing tasks. On 01/15/2025 at 9:55AM V3 (Infection Preventionist) said, staff are expected to wash hands or use hands sanitizers all the time, between patients, before and after using personal protective equipment, before and after serving food, before and after passing medications, and when hands get soiled. V3 said, vegetables or food should not be placed directly on the floor because it can cause cross contamination and cause infection. On 01/15/2025 at 11:04 AM V1 (Administrator) said, she was not aware of any concern with the dishwasher or with the final rinse temperatures and V1 works directly with V4 to fix any equipment that is not working properly. V4 usually makes sure that the kitchen equipment is fixed immediately. V1 said, the staff are expected to follow facility policy and not place food directly on the floor and practice hand washing to prevent infection and residents getting sick. Facility policy titled, Sanitation and Infection Prevention/Control Policy number F006 dated issued:5/95 and revised 1/2025 documents (in part): Policy: To prevent communication of food with infections microorganism, Food and Nutrition Services associate are expected to observe the following Infection Prevention and Control Practices. Procedure: Use a spatula or tongs or wear disposable gloves when handling food, do not touch food with bare hands, do not perform multiple activities while wearing gloves which will be used in food handling. Facility policy titled, Sanitation and infection Prevention/Control: Disposable glove use Policy number F021 dated revised: 1/24 documents (in part): Policies: Disposable, no-latex gloves must be worn at the following times, When handling read-to eat-foods, When handling clean utensils/dishes/equipment, When handling soiled dishware Procedure: Disposable gloves must be changed and handwashed when gloves are dirty or ripped and when moving from one task to another, such as moving from handling dirty dishes to handling clean dishes. Facility policy titled, Sanitation and Infection Prevention/Control Policy number F019 date reviewed (1/24) documents (in part): Policies: Dishmachine wash, and rinse water should be maintained at temperatures that meet the guidelines established by the food and drug administration. Single-tank conveyor, dual temperature machine: Wash temperature 160F. Final rinse temperature 180F-194F. Facility policy titled, Production, Purchasing, Storage; Food and Supply storage policy number B003 revised dated (1/25) documents (in part): Policies: All food, non-food items and supplies used in food preparation [NAME] be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures: Most but all but not all products contain an expiration date, the words sell by, best by, enjoyed by or used by should precede the date. Food past the used by date, sell by, best by, or enjoyed by date should be discarded. Cover, label, and date unused portion opened packages. Use the medadvantage/fresh date labeling system or complete all section on the [NAME] orange label. Refrigerator Storage: Store items 6 inches above the floor. The bottom shelf must be solid to prevent product from splash and dust.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident received her medications as ordered. This applies to 1 of 3 residents (R5) reviewed for medication administration in the sample of 11. The findings include: R5's EMR (Electronic Medical Record) shows that R5's admission Evaluation was created at 1:47 PM on 5/29/24. R5's Medication Administration Record for May 2024 shows that R5 was admitted to the facility on [DATE]. This same document shows that R5 was ordered to receive Allegra (Allergy) 24hr 1 tablet, Amlodipine (Antihypertensive) 2.5mg, Cefpodoxime Proxetil (Antibiotic) 200mg, Januvia (Antidiabetic) 25mg, Telmisartin (Antihypertensive) 80mg, Bisoprolol Fumarate (Antihypertensive) 10mg, and Preservision (Supplement) 1 tablet. None of these medications are signed out as given. A Pharmacy Manifest Document dated 5/30/24 shows that R5's medications were not delivered until 4:36 AM on 5/30/24. On 7/19/24 at 2:05 PM V23 (RN) stated, (V22) worked the PM shift on the day of admission. I get the orders from the hospital and clarified them with the doctor. Then I send the orders to the pharmacy, and they put them in the computer. Then I verify them again between the computer and the medication list to make sure they are right. On 7/19/24 at 2:15 PM V22 (RN) stated, The family had their own stock of medications. I remember I talked to the family and told them that the medications had not come in yet from the pharmacy. I don't know if the family gave her medications or not, but I didn't have them yet from the pharmacy and I told them that. The resident was very sarcastic, and it was hard for me to tell if she wanted to take medications or not. I had a difficult time with her because she was always sarcastic, and I couldn't tell if she was joking or not. The facility policy entitled Medication Administration dated 6/1/23 states, Medications are administered in accordance with written orders of the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to report an allegation of rough handling/mistreatment made by one resident (R38) regarding an employee (CNA/V6); failed to prevent further instances of rough handling/mistreatment initially reported to V9/RN on 2/6/24 who failed to recognize the alleged abuse, failed to report the alleged abuse; and failed to immediately remove alleged abuser from further contact with the resident. This failure affected one resident (R38) of 6 residents reviewed for abuse in the sample of 69. This failure resulted in R38 to experience severe pain to her left shoulder as a result of V6's rough treatment and continues to express feelings of pain, fear, anguish, and intimidation when V6 returns to roughly handle the resident even after repeated requests to be gentle in providing care. Findings include: R38 is an alert and oriented [AGE] year-old resident with diagnoses including chronic diastolic congestive heart failure, osteoarthritis, scoliosis, and spondylosis with radiculopathy. Care Plan dated 2/9/24 reads in part, The resident has limited physical mobility related to disease Process (arthritis, pain, and chronic wounds.) The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Interventions: Invite The resident to activity programs that encourage arm movement or gentle arm exercises as tolerated. Monitor/document/report any signs/symptoms of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Provide gentle range of motion as tolerated with daily care. There were no care plans related to R38's susceptibility to abuse and/or preventing abuse. On 03/18/24 at 11:55 AM, R38 stated that on 2/6/24 during care, V6/CNA was very rough with her, ignored her requests to be slow and gentle in moving her arm as it was painful if done too quickly. V6 ignored her requests to not be handled roughly and snapped back at the resident saying to her that she'd been a CNA for 11 years, knows what she is doing, and doesn't need to be told what to do. Resident indicated her shoulder was hurt due to V6's careless actions and caused her extreme pain after the incident of 2/6/24 so she informed V9 (RN) about what had happened to her between V6 and to call her doctor for x-rays. V9 called the doctor who ordered x-rays and pain medication but failed to alert the doctor or immediate supervisor about the incident. R38 indicated that she reported to V9 RN about V6 always wearing and talking on an earpiece and does not pay attention to her but is more focused on her phone calls. Resident said she is afraid if she complained further that they will get another rotating aide that does not know what they are doing and does not want to get on this cycle of aides that she has to orient to her particular care needs, so she tolerates V6 who continues to be rough to cause further pain during care. R28 said that this CNA V6 has been assigned to her numerous times after the 2/6/24 incident even after she reported it to the nurse (V9). R38 indicated she was also concerned about others who can't speak up like the residents on the second floor who she knows V6 floats to. On 3/19/24 at 2:45 PM, V9 (RN) stated, I know (R38), and she is mostly on her bed. She is alert times 4 (cognitively intact with no confusion). Surveyor asked if he recalled R38 complaining about arm/shoulder pain, V9 stated, She complained her shoulder was hurt by V6 CNA because she was rough with her. Surveyor asked to recall the incident of 2/6/24, V9 stated, I recall her shoulder was in a lot of pain, so I asked what happened and she told me that the CNA was rough with her arm and hurt her shoulder. I then asked if she wanted any pain medication, so I called the doctor who ordered x-ray and told him that the resident was in extreme pain. Surveyor asked what he did when R38 told him that V6 was rough and hurt the resident's shoulder, V9 stated, I asked the resident first what happened, if V6 was rough and how it happened whether it was when she was turned in bed or whatever and she said it was during a bed bath I think is what she said. I also talked to (V6) about what happened, and she didn't say anything that the resident was in pain, I just remember that I documented that the CNA told me to see her because she claimed the resident was in pain. Surveyor asked if he informed anyone else about the incident, V9 stated, I can't recall but I think I told V2 (DON), but I did not document that in the notes, just that I called the doctor. Surveyor asked if an incident such as what R38 described and what steps or procedures he should do? V9 stated that if a resident had a problem with a CNA assigned to them, they would just swap out that CNA with another one the resident liked. Surveyor asked if this was what he did in this situation that occurred on 2/6/24, V9 stated, No I didn't do that. Surveyor asked if he perceived this rough handling by V6 as potential abuse, V9 stated, I didn't think that at the time but if the resident told me V6 hurt her, then I guess it was. Surveyor asked when he received any abuse training, V9 indicated that he had a refresher this month. Surveyor asked what the facility's procedures were of any suspected or reported abuse, V9 stated, We do an abuse assessment on the resident and report what happened to the DON. We are to report any abuse incident, assess and interview the resident and report it but I missed the reporting part of it, I'm sorry. Surveyor clarified if V6 finished her shift taking care of R38 or if he reassigned V6, V9 stated, No sir, she finished her shift with R38. After the interview with V9 (RN), Surveyor showed V9 the progress notes he entered pertaining to the incident and to confirm whether he wrote the entry, V9 stated, Yes I wrote that. V9's nursing notes read in part, 2/7/2024 at 21:45 Health Status Note. Note Text: Late entry: Around 4PM yesterday, CNA called NOD (nurse on duty) to report that resident is in pain. Checked resident, noted facial grimace and was holding her shoulder, reporting of pain. When asked what happened, she said that CNA lifted her shoulder when asked to adjust her blouse on the back. Resident requested to have her shoulder massaged, provided relief. Resident informed both NOD and CNA that her both shoulders has limited ROM, especially the left one. Offered pain pill, resident declined. CNA kept resident comfortable. At bedtime, checked resident, she reported that pain is tolerable but still there. She added that she will inform MD about in on Thursday. Surveyor asked if there was anywhere in the documentation, he wrote informing either the DON or any supervisor of the incident involving V6 and the resident R38, V9 stated, No sir. I did not do that, so I didn't put that in there. On 3/19/24 at 2:55 PM, V6/CNA stated to surveyors during interview, I've worked here since September and applied for an open position. Surveyor asked if she used to work as an agency CNA prior to her hire, V6 stated No I haven't. V6's statement however did not align with her personnel file showing her previous position was an agency CNA. Surveyor asked about R38 and if she recalled the incident of 2/6/24 where the resident complained of shoulder pain, V6 stated, Yes I know (R38) and I remember her complaining about her shoulder, so I told the nurse, but I'm not frequent on her floor. I generally work the second floor. Surveyor asked the type of floor the second floor was, V6 stated, It's dementia mostly. Surveyor asked if there was anything she could recall of the incident of 2/6/24 other than the resident complaining of shoulder pain, V6 stated, (R38) is very particular about her care and she verbally tells me how she wants things all the time, she likes her phone to be near her. She's also particular about her sheets going up close to her neck when she's in bed, and she needs her gown changed and clean. Surveyor asked if these were unreasonable requests, V6 indicated they were not. Surveyor asked if she could recall during the incident of 2/6/24 if there was any discussion about slowing down or being gentle with her, V6 stated, I'm always gentle with my residents. Surveyor clarified that the question was if there was any discussion by the resident for her to be gentle when moving her arm or any other body part, V6 stated, Yes I think she mentioned something like that. Surveyor asked when she was told to slow down and be gentle what she did, V6 stated, I don't remember. Surveyor asked if she could recall if the nurse V9 asked her what happened, V6 stated, Yes he just asked me what happened, and I told him she was in pain. Surveyor asked if there was any argument on 2/6/24 with R38 or if the resident asked her not to be too rough with her in any manner, V6 stated, No I never argued with her and like I said she (R38) is very particular with how she wants things. Surveyor asked how long she'd been a CNA, V6 stated, I've been a CNA 11-12 years. Surveyor asked if she ever mentioned this fact to the resident, V6 stated, No, I don't have conversations with residents, I just do my job. Surveyor asked if there was anything out of the ordinary that may have occurred on 2/6/24 during her care of R38 or during anytime she'd been assigned to R38 V6 stated, No, she's not a difficult resident, she's just particular but (R38) has a way she talks to other people in a condescending manner. Surveyor asked how that made her feel, V6 stated, I just try to ignore it. Surveyor asked if she'd had any other issues with any other residents she'd care for, V6 paused and then stated, No but earlier this year one of the resident's family complained about my care so the administrator suspended me and when I got back the DON V2 gave me a 1:1 about general care and respecting patients. Surveyor asked if she knew what the specific complaint was that the family alleged, V6 stated, I don't know. Surveyor asked the rationale for her being provided 1:1 training about general care and respecting residents as she mentioned, V6 stated, I can't answer that. Surveyor asked if she'd been trained on the topic of abuse, V6 stated that she received one upon hire and she did an online training in the past November. On 3/19/24 at 3:35 PM, surveyors asked V2/ DON if she knew about the incident of 2/6/24, V2 stated, I don't recall V9 tell me anything about R38 or I do not recall it. I believe I was not in the building, but it may have been my previous assistant, but she no longer works here but I don't know who he spoke to. Surveyor asked if she knew about R38's shoulder/arm pain, V2 stated, I am not aware of anything about her shoulder. (R38) is very alert x 4 and she's able to make her needs known. She's particular and has particular preferences. There's certain staff she gravitates to and likes the normal CNA's or the regular CNA's and does not like any of the agency CNA's we had. She likes CNA's who are assigned to the unit that are the permanent on the unit because over time they have gotten to know her. Surveyor asked if these were reasonable requests, V2 indicated that they were. Surveyor asked about V6 and her work record with residents, V2 stated, I've never had any issues with (V6). Surveyor asked if V6 had any history with any other residents that resulted in any disciplinary action, V2 hesitated and stated, I've never had any issues with her except one time recently I think in January there was something about another resident and their care from V6, so we ended up putting her on administrative leave. Surveyor asked what the administrative leave was about, V2 stated, It was about some customer service issue some family had with V6. Surveyor clarified if that administrative leave was a suspension or personal leave, V2 stated, She was suspended. Surveyor asked what specific customer service issue V6 was suspended for, V2 stated, I think the family alleged that their mom was left cold and wet (urine) and wasn't given a blanket or something like that. Surveyor asked how leaving a resident wet and cold was a customer service issue, V2 stated, Well it was also a care issue. Surveyor asked what units V6 normally worked on, V2 stated that V6 worked all throughout the facility including the dementia unit. Surveyor asked if any of the residents on the dementia unit were interviewable or could voice any concerns to anyone, V2 stated, No most of them are confused. V2 paused and stated, Oh I see what you mean. I gave V6 in-service training, and she's been a CNA for a while, and I trust her. On 3/19/24. 2:00 PM. V13 (Director of Resident Services) stated, I'm responsible for the abuse in service training portion in our skills fair and we had our latest one in November. We try to capture all the staff for the campus in these skills fairs that touch on various subjects, one is abuse which I do. I make it a point during training that anything you hear or see, you have to report immediately to your immediate supervisor, who will then report it to V1(Administrator). I tell them about the 8 types of abuse, and anyone can report abuse including family, the resident themselves, and any staff. I tell staff that even idle gossip staff may hear about regarding residents being mistreated should be reported right away to their supervisor. I know we don't like to gossip but a lot of that gossip may include clues about some staff member that may be abusing a resident. Staff shouldn't determine themselves whether it's just a customer service issue because they should report it and let the supervisor and administrator determine this with their investigation whether it is actual abuse or just a service failure. Surveyor asked V13 a hypothetical question about if a CNA was being rough with a resident and that was reported to the nurse what the next step would be, V13 stated, They should immediately remove that person from the resident, and let their immediate supervisor know and also the administrator so they can investigate. It's not up to that individual to do this, they just need to separate the resident from that individual and report it right away. On 3/19/24 at 2:35 PM, V11 RN stated, I know R38 very well because she is on my unit and it's my permanent floor. Sometimes she said she likes mostly the morning people. Sometimes if she doesn't like somebody, I try to change CNA. She mostly complains about them talking on the phone when they're working with the resident, but they should not be talking on the phone. I talked to CNA's at once if they talk on the phone. Surveyor asked if she heard about the incident that occurred on 2/6/24 involving R38 and V6, V11 stated, I hear someone was rough with her (R38) but it's not on my shift. I hear that from the CNA amongst themselves too. The CNA's talk that somebody was rough with her and not nice with her. It was a few months ago, I think. I know for example who it was generally, and I try to figure out who, so I try to ask CNA's. Sometimes you know when she's not happy, so I tell V12/Administrative assistant not to schedule a particular CNA (V6). Surveyor asked if she informed the Administrator or DON about what she heard, V11 stated, I don't tell Administrator or anyone, just V12. If there's any problem with any CNA, I Usually I tell V12. Surveyor asked if V12 was her immediate supervisor who she reported problems to, V11 stated, No. Surveyor asked if she discovered who the CNA was, she heard about involved with R38's rough treatment, V11 stated, What I hear was about (V6). I hear that she (R38) doesn't like her because the resident told me herself that (V6) was always rough with her. She tells me V6 doesn't know too much what to do and how to care for her. I heard this again today, but I was busy. Surveyor asked V11 if she told anyone else other than V12, V11 stated, No I don't tell anybody, I'm sorry. On 3/19/24 at 11: 00 am V12, stated. I'm a scheduler for nurses and CNA's but my title is administrative assistant. I recall talking to R38 because I followed up with the resident because of (V6). I try to see residents twice a week but I remember that I followed up with her I think last month about V6 because the resident said that the CNA wasn't familiar with her routines so the resident herself walked through it with the CNA so she can follow the steps. She has a routine that she likes. Surveyor asked if the resident or any other residents complained about the CNA, V12 stated, I'm not sure. I come in at 7 AM and I usually go on the floor and make sure the CNAs are there and then I go in to say hello to most of the residents. I see (R38) because she likes to give me feedback. The only thing she told me about V6 was that she wasn't aware of her routine and that was all she told me. Surveyor asked if R38 requested a different CNA, V12 stated, No but we try not to put (V6) with the resident and she works mostly the second floor or wherever we need her. On 3/20/24 at 11:45 AM, V1 (Administrator) and V2 (DON) presented information to survey team indicating that they had met with R38 last night to address the resident's concerns voiced on 2/6/24. This type-written response reads in part (V1) and (V2) met with (R38) at 6:35 PM on 3/19/24. V1 said to R38, I heard you need to report to me about someone hurting you. R38 went on to relay that V6 had given her a bed bath and after the bath she asked V6 to boost her up so she could pull her nightgown down in back. R38 reported that V6 wears earbuds a lot and was not sure how much she heard her. V6 proceeded to grab R38's left arm and pulled it to the side and R38 called out telling V6 she was in pain. R38 reported it to my nurse (V9) and waited until Thursday for V39 (attending physician) to come and examine the resident and then ordered an x-ray. The interview goes on to state that (V6) tends to have an unpleasant attitude with R38. The written report goes on to conclude that R38 stated that V6's actions were unintentional and received education regarding being fully engaged with residents during care with no external distractions such as cell phones and ear buds and to engage with residents verbally during care regardless of ability to reciprocate. This report fails to indicate any re-in-service education on abuse prevention. On 3/20/24 at 1:30 PM, surveyors re-interviewed R38 to verify the meeting the resident had with V1 and V2. R38 stated to surveyors that V1 Administrator and V2 DON came to see her abruptly after dinner when she was already in bed last night around 7 PM and asked her about V6. R38 indicated that V1 asked if V6 was rough with her, and she told her that she was. R38 stated, the Administrator did most of the talking and I felt pressured to say that the CNA's (V6) actions were not willful because she kept emphasizing and repeating the word willful and that V6's intentions were not willful. R38 indicated to surveyors that she didn't agree with this but in order to pacify administration, R38 stated that she gave in and agreed with them even though she felt V6 intentionally and repeatedly ignored her and was rough each time she came. R38 informed surveyors that she still felt pain in her arm and shoulders after the incident and also every time when V6 returned on numerous occasions. R38 added that yesterday (3/19/24) V6 was assigned to her but was abruptly removed from her assignment which she was relieved to find out. R38 indicated that prior to yesterday, V6 continued to ignore her and provided rough care which caused her more pain. R38 stated that she brought concerns to the administrator on numerous occasions about the quality of staff in general, but the administrator's response would be to pass the buck as a corporate issue. R38 stated that she felt even more vulnerable now with administration by complaining stating, When the Administrator came in the room, she had this look on her face that she was annoyed with me and that Oh it's her complaining again, but R38 didn't expect any real changes to come as she'd been dealing with the same issues for a while with no improvement. On 3/21/24 at 4:30 PM V39 (Attending Physician) stated to surveyors, (R38) is a very fragile patient and she has to be handled in a very delicate manner as she is brittle and has a complete rotator cuff tear and underlying severe arthritis that would worsen if it were exacerbated in any way. This was the reason I had ordered X-rays for that day when I got a call from a nurse telling me there was some incident that happened that caused the patient severe pain, so I suspected further injury to her shoulders. Surveyor asked if it was about the 2/6/24 incident, V39 stated, I don't know the exact date, I just know it happened a month ago. Surveyor asked if how he was informed of the incident involving his patient (R38) and V6, V39 stated, I found out from the resident that some staff person was careless and rough with her, but the nurse made no mention of any incident with R38's CNA being rough, it was the resident herself who informed when I came to see her. Facility policy dated, 3/7/2018 titled Abuse, Neglect, and Exploitation reads in part but not limited to, Facility affirms that each resident has the right to be free from abuse and neglect. Residents must not be subjected to abuse by anyone, including but not limited to community staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Abuse means the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse. Prevention of Abuse: Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents. Recognize signs of burnout, frustration and stress in associates that may lead to abuse. Provide education on what constitutes abuse, and neglect. React to all allegations or questions of abuse by residents, family members, associates or visitors. Take appropriate actions when abuse is suspected. Provide instructions to staff on care needs of residents. Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling, or ignoring residents while giving care. Identification of alleged abuse, neglect and exploitation: The community will consider factors indicating possible abuse, neglect following possible indicators: Resident, staff or family report of abuse, physical injury of a resident, Verbal abuse of a resident overheard. Physical abuse of a resident observed. Psychological abuse of a resident observed. Failure to provide care needs such as, bathing, dressing, turning and positioning. Response and reporting of abuse, neglect: Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect is suspected, the licensed nurse should: Respond to the needs of the resident and protect them from further incident and document response. Notify the director of nursing and executive director/administrator immediately and document notification. Initiate an investigation immediately. Notify attending physician, resident's family/legal representative and Medical Director and document notification. Prohibit and prevent retaliation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions to promote wound healing for one of three Residents (R18) reviewed for pressure ulcer and pressure ulcer interventions, in a total sample of 69 residents. Findings include: R18 is a cognitively impaired [AGE] year-old resident with diagnoses listed in part, but not limited to, hemiplegia and hemiparesis, gastrostomy, heart failure, and a stage four pressure ulcer of the sacral region. A wound evaluation and management summary report dated 03/19/2024 showed R18 with a wound described as stage four with a duration greater than 1,049 days and measuring 3.0 x 1.8 x 0.3 cm. The facility pressure injury report dated 01/06/2024 states the wound was acquired, In House. Three skin observation tool forms found in R18's Electronic Health Record, dated 03/02/2024, 03/09/2024, and 03/16/2024 lack any describable wound documentation, such as wound site, type, measurement, and stage; instead containing the words, No new area, No new area noted, and no new skin issue noted. R18's nursing care plan dated 03/15/2024, R18 is to be turned and repositioned, as needed to aid in comfort and provide off-loading. R18's nursing care plan dated 03/15/2024, documents it is the staff's responsibility to keep R18's skin free of moisture. On 03/18/2024 at 10:09am, surveyor observed R18 lying in bed on her air mattress, asleep, her torso raised, and backside facing the wall. After over two hours of continuous observation, at 12:20pm, surveyor observed R18 laying on the air mattress with her backside facing the wall, torso raised, asleep, with no change in position. During continuous observation, surveyor observed R18 with perspiration on her face, and two blankets covering her body. On 3/19/2024 continuous observation from 10:05am to 12:20pm surveyor observed R18 asleep in bed, laying on air mattress, on her back with several blankets atop her body. V10 (CNA) said R18 is a total assist and V10 repositions her every two hours. V10 also said she provides clean sheets for R18 at the start of all her shifts, showers R18 once per week, and gives R18 a bed bath once per week, or as needed. On 03/19/24 at 11:50am V33 (Family Member) said, R18 needs round-the-clock nursing care, being bathed, brushed, and sanitary needs. V33 said R18 struggles in the past at the facility led to bed sores. V33 said bed sores were acquired at the facility five years ago and never closed and R18 uses an air mattress around-the-clock. On 03/20/24 11:45am, V1 (Administrator) said there was an MDS on file that said R18's chronic stage four pressure ulcer was originally a stage one pressure ulcer that R18 had upon arrival at the facility in 2013. V1 did not recall when R18's pressure ulcer changed from a stage one to a four, adding she would have to look through ten years' worth of documentation. On 03/20/2024 at 1:40pm, V11 (RN) said she was performing afternoon wound care, along with V10, for R18, who was laying on her back on her air mattress bed. Surveyor asked to observe R18's wound. V11 and V10 proceeded to move R18 onto her left side to expose the stage four wound site of the sacral region, which was covered with a dressing. As V10 held R18 to the side, V11 took the dressing off, revealing a hole slightly smaller than a golf ball. When asked to describe the area, V11 hesitated and paused, saying it looked a little green. A few seconds later, fluid began to leak from R18's urinary catheter, running vertically down the left buttocks area, near the wound site. The area around R18's wound site was visibly moist. R18 had a linen sheet on top of her air mattress, folded over four times under her back. Surveyor also observed the air mattress pump on static mode. When asked V11 about the air mattress pump, V11 said she did not change the pump's settings at all, preferring to leave it as is. On 03/21/24 at 10:18am, V2 (Director of Nursing) said she was not sure if the wound nurse or the facility's environmental services sets the settings of the air mattress pump, adding the pump has a locking mechanism in place. On 03/21/2024 at 1:46pm, V38 (Medical Director) said R18's wound is not new and has been ongoing for a while. V38 said he discusses only newly acquired wounds with the facility, and that stage three wounds and above are discussed in detail. V38 said he does not usually discuss wounds with the wound doctor, unless it is his patient. V38 said repositioning, offloading, and turning every two hours are considered general principles for pressure wound care. On 03/21/2024 at 3:54pm, V29 (Wound Doctor) said he started seeing R18 in March of 2021 for the wound. V29 said repositioning every two hours, offloading, providing incontinence care, keeping the wound area clean, and following with daily dressing changes is the typical recommendation. V29 also said from his experience, individual repositioning was important to the healing process of pressure wounds, adding some of the aides at long term care facilities won't turn the individual, thinking that the air mattress is doing the turning and the mattress does it on its own. V29 said, standard air mattress bed preparation includes not utilizing fitted sheets, not placing too many pads and diapers, minimal would be advisable. Lastly, V29 said he described R18's stage four pressure wound as, unavoidable based on the lab results from R18's hospitalization in February instead of R18's long term care facility lab results January 11, 2024, which included a pre-albumin result of 23.8, within normal range. V29 said he was referring to what the hospital's admission lab results said to designate R18's wound, unavoidable. Surveyors clarified with V29 if the wound was avoidable or not, V29 affirmed that it was avoidable since R18 was able to heal other wounds. Facility policy with an effective date 06/01/2023, and titled, Management and Treatment of Pressure Ulcers-SNF reads in part, In order to heal any wound, including pressure ulcers, some basic principles need to be followed. These are: Protect the wound from infection, trauma, and cold. Protecting the wound from trauma includes the proper support surface. The air mattresses' owner's manual states in part, it is designed to assist in the prevention and treatment of pressure ulcers. The same manual also indicates there are two modes, alternate and static. Static mode turns off Alternating Pressure Therapy. Multiple layering of linens or under pads beneath the resident can negatively affect the mattresses' pressure management capabilities and should be avoided unless recommended by a caregiver.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain consent prior to administering a psychotropic medication to one resident (R42) of three residents reviewed for unnecessary medications in a sample of sixty-nine. Findings include: According to electronic medical records, R42 is an [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses that include but are not limited to: Alzheimer's disease, major depressive disorder, psychotic disorder with delusions, vascular dementia - unspecified severity- with agitation, generalized anxiety disorder and unspecified psychosis. Medication order dated 05/24/2022 Lorazepam 0.5 mg give one tablet by mouth three times a day related to psychotic disorder with delusions due to known physiological condition. Consent for this medication has an effective date of 11/04/2022 that was electronically signed by the nurse on 12/01/2022 and signed by resident's representative on 3/12/2024. Medication was initiated prior to having consent to give medication per medication administration record for June 2022. On 03/21/2024 at 10:16 am, V2 (DON) stated the consents she provided for R42 were all the consents she had on file for the resident regarding psychotropic medications. V2 stated, the policy states consent should be obtained prior to administration if not we would be out of practice. V2 stated, that some things that could happen to a resident if given a psychotropic medication prior to obtaining consent would be adverse reactions and mental status changes. On 03/21/2024 at 11:32 am V3 (Infection Preventionist/Psychotropic Nurse) stated, he took over the psychotropic medications about three months ago. He started doing an audit at that time and provided in-service education to staff regarding psychotropic medications. V3 stated, facility should always obtain consent prior to giving psychotropic medications and he has not seen any instances in the facility where psychotropic medications were given before consent even after his audit. When presented with the preceding information, V3 stated that happened prior to him (V3) starting and he (V3) was unaware of the situation of the medication being given prior to consent being obtained. Psychotropic Medication Policy with an effective date of 09/01/2022. The policy states 2. All psychotropic medications prior to administration must have a signed consent completed by the resident and or representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review, the facility failed to ensure stock medications were labeled with open and expiration date, failed to ensure opened vaccine vial, nasal sprays, inhalers, and insulins were labeled with open and discard dates, and failed to store an inhaler with a pharmacy label. These failures affected six (R6, R7, R12, R25, R42, R50) residents reviewed for medication storage and labeling and have the potential to affect residents receiving medications from the second-floor east side medication cart and first-floor rosewood medication cart. On [DATE] at 1:00pm, Surveyor and V40 RN (Registered Nurse) inspected the second-floor medication cart for rooms 201 through 228. The following observations were made: V40 stated, Floor Stock meds should be labeled with open date and manufacturers expiration date. Surveyor asked V40 do you use the manufacturers expiration date if the medication has been opened. V40 stated, yes (referring to the manufactures stamped expiration date). R6, Ipratropium Bromide Nasal Solution, open date [DATE] no expiration date. V40 stated, I go by the manufacturers expiration date which is 12/25. R6 open Nasal Saline Bottle with no expiration date Opened Arnuity Ellipta 200 mcg (30 dose) inhaler with no expiration date and without the name of resident on inhaler. R42 opened vial of Genteal Tears mod liq drops no expiration date. R12 Lantus Solostar 100u/ml inj opened [DATE] expiration date [DATE]. V40 stated, I do not give that on my shift, that should not be on the cart. Surveyor asked V40 if medication has expired. V40 stated, yes it should not be on the cart. We put expired medication in a different place. R7 eye drops Brimonidine Tart 0.2% 5ml opened [DATE] expiration date [DATE]. Proheal Critical Care Liq protein 30 fl ounce opened [DATE], no expiration date. V40 stated, it is good until [DATE] (manufacturers date). Surveyor reviewed instructions on back of bottle which shows, discard within 60 days after opening. Medication Room Refrigerator: Tuberculin purified protein derivative, diluted aplisol opened [DATE] no expiration date. V40 stated, it should have an expiration date. On [DATE] at approximately 2:00pm surveyor and V2 (DON) reviewed 1st floor Rosewood 1 HCC medication cart for rooms 101-109. Surveyor asked V2 how medication stored on the med cart should be labeled. V2 stated, all meds should be labeled with open date and expiration date. Nurses are expected to put open date and expiration date on all meds. The following observations were made: R25, Fluticasone Propionate 50mcg nasal spray opened. Bottle with date of [DATE]. Surveyor asked V2 does the date of [DATE] refer to open date or expiration date. V2 stated, I am not sure what the date means. R50 Fluticasone 50mcg nasal spray dated [DATE]. V2 stated, I am not sure if that is the open date or the expiration date. Proheal Critical Care Liq protein 30 fl ounce opened 2/28/ no year noted, no expiration date. V2 stated, it is good until [DATE] (manufacturers date). Surveyor reviewed instructions on back of bottle which shows, discard within 60 days after opening. V2 stated, nurses should put an open date and expiration date. Facility Policy Medication Labeling and Storage revised February 2023 Policy Interpretation and Implementation Medication Storage in part documents 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Medication Labeling 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. d. expiration date, when applicable; e. resident's name; 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility administration failed to take appropriate action to ensure the safety of 2 (R38, R55) of 3 residents reviewed for abuse in the sample of 69. The facility administration failed to protect residents from harmful actions inflicted by staff, failed to conduct a thorough investigation of allegations of abuse, and failed to honor the requests of the resident(s) to remain safe and free from harm. This failure has the potential to affect all 69 residents currently residing in the facility. Findings include: On 3/18/24 at 9:50 AM, V1 (administrator) presented survey team with a census roster showing 69 total residents. 1. R38 is an alert and oriented [AGE] year old resident with diagnoses including chronic diastolic congestive heart failure, osteoarthritis, scoliosis, and spondylosis with radiculopathy. On 3/18//2024 at 11:55 AM, R38 stated that on 2/6/24 V6/CNA, while giving her a bed bath, was very rough and caused her arm/shoulder pain and possible injury. R38 stated that V6 is usually talking on her earpiece and does not pay attention or focus on her but instead on her phone calls. The resident also asked V6 not to wear them but V6 ignores her repeatedly. R38 stated that she asked V6 to be gentle in moving her body and arms while conducting any care but V6 disregarded her requests with repeated responses of I've been a CNA for 11 years and I don't need you to tell me what to do. V6 continued pulling her clothes off over her shoulder in a rushed and rough manner as she screamed in pain during the process, yet V6 continued on. R38 stated she informed her nurse V9 (RN) about the incident after several days of experiencing extreme pain and expected the nurse to report it to her doctor and to administration, but she did not hear anything back from anyone. R38 was expecting that she would get some resolution to the conflict. R38 stated V6 was never removed from her care and continued to care for her numerous times after the incident and that this CNA continued to be careless and rough in her care. R38 stated that she saw herself as an advocate not only for herself, but for others who couldn't speak up for themselves. She worried that V6 acted in the same manner with other residents on the dementia unit where she knew V6 had worked. On 3/19/24 at 2:45 PM, V9 (RN) stated, I know (R38), and she is mostly in her bed. She is alert times 4 (cognitively intact with no confusion). She would complain about care especially if it's someone who doesn't know her routine, if her food is delivered late, she will complain, and if she does not get a bath from certain CNA's. Surveyor asked if the resident's requests seemed reasonable, V9 stated, Yes. Surveyor asked if he recalled R38 complaining about arm/shoulder pain, V9 stated, She complained about her shoulder and that a CNA was rough with her. It was V6 and she's on this floor now if you want to talk with her. Surveyor asked V9 to recall the incident, I recall her shoulder was in a lot of pain and so I asked her what happened, and she told me about it. I asked if she wanted any pain medication for that, so I called the doctor who ordered an x-ray. Surveyor asked what else he did when told of the incident with the CNA, V9 stated, I asked the resident first what happened, if it happened when the CNA turned her and I asked her which CNA and she told me V6, so I also talked to the CNA about what happened. Surveyor asked if he informed anyone else about the incident, V9 stated, I think I told V2 (DON), but I did not document that in the notes, just that I called the doctor. Surveyor asked if any incident like what R38 described what he was supposed to do? V9 stated that if a resident had a problem with a CNA assigned to them, they would just swap out that CNA with another one the resident liked. Surveyor asked when the last time he received abuse training, V9 indicated that he had a refresher this month. Surveyor asked what the facility's procedures were of any suspected or reported abuse, V9 stated, We do an abuse assessment on the resident and report what happened to the DON. We are to report any abuse incident, assess and interview the resident and report it. I missed the reporting part. Surveyor asked if he separated V6 from the resident and V9 stated, No. On 3/19/24 at 2:55 PM, V6/CNA stated to surveyors during interview, I've worked here since September and applied for an open position. Surveyor asked if she used to work as an agency CNA prior to her hire? V6 stated No I haven't. V6's statement however did not align with her personnel file showing her previous position was an agency CNA. Surveyor asked about R38 and if she recalled the incident of 2/6/24 where the resident complained of shoulder pain? V6 stated, Yes I know (R38) and I remember her complaining about her shoulder, so I told the nurse, but I'm not frequent on her floor. I generally work the second floor. Surveyor asked the type of floor the second floor was? V6 stated, It's dementia mostly. Surveyor asked if there was anything she could recall of the incident of 2/6/24 other than the resident complaining of shoulder pain? V6 stated, (R38) is very particular about her care and she verbally tells me how she wants things all the time, she likes her phone to be near her. She's also particular about her sheets going up close to her neck when she's in bed, and she needs her gown changed and clean. Surveyor asked if these were unreasonable requests, V6 indicated they were not. Surveyor asked if she could recall during the incident of 2/6/24 if there was any discussion about slowing down or being gentle with her? V6 stated, I'm always gentle with my residents. Surveyor clarified that the question was if there was any discussion by the resident for her to be gentle when moving her arm or any other body part, V6 stated, Yes I think she mentioned something like that. Surveyor asked when she was told to slow down and be gentle what she did, V6 stated, I don't remember. Surveyor asked if she could recall if the nurse V9 asked her what happened? V6 stated, Yes he just asked me what happened, and I told him she was in pain. Surveyor asked if there was any argument on 2/6/24 with R38 or if the resident asked her not to be too rough with her in any manner, V6 stated, No I never argued with her and like I said she (R38) is very particular with how she wants things. Surveyor asked how long she'd been a CNA, V6 stated, I've been a CNA 11-12 years. Surveyor asked if she ever mentioned this fact to the resident, V6 stated, No, I don't have conversations with residents, I just do my job. Surveyor asked if there was anything out of the ordinary that may have occurred on 2/6/24 during her care of R38 or during anytime she'd been assigned to R38? V6 stated, No, she's not a difficult resident, she's just particular but (R38) has a way she talks to other people in a condescending manner. Surveyor asked how that made her feel, V6 stated, I just try to ignore it. Surveyor asked if she'd had any other issues with any other residents she'd care for, V6 paused and then stated, No but earlier this year one of the resident's family complained about my care so the administrator suspended me and when I got back the DON V2 gave me a 1:1 about general care and respecting patients. Surveyor asked if she knew what the specific complaint was that the family alleged, V6 stated, I don't know. Surveyor asked the rationale for her being provided 1:1 training about general care and respecting residents as she mentioned, V6 stated, I can't answer that. Surveyor asked if she'd been trained on the topic of abuse, V6 stated that she received one upon hire and she did an online training in the past November. On 3/19/24 at 3:35 PM, surveyors asked V2/ DON if she knew about the incident of 2/6/24? V2 stated, I don't recall V9 telling me anything about R38 or I do not recall it. I believe I was not in the building and it may have been my previous assistant; but she no longer works here and I don't know who he spoke to. Surveyor asked if she knew about R38's shoulder/arm pain? V2 stated, I am not aware of anything about her shoulder. (R38) is very alert x 4 and she's able to make her needs known. She's particular and has particular preferences. There's certain staff she gravitates to and likes the normal CNA's or the regular CNA's and does not like any of the agency CNA's we had. She likes CNA's who are assigned to the unit that are the permanent on the unit because over time they have gotten to know her. Surveyor asked if these were reasonable requests, V2 indicated that they were. Surveyor asked about V6 and her work record with residents, V2 stated, I've never had any issues with (V6). Surveyor asked if V6 had any history with any other residents that resulted in any disciplinary action, V2 hesitated and stated, I've never had any issues with her except one time recently I think in January there was something about another resident and their care from V6, so we ended up putting her on administrative leave. Surveyor asked what the administrative leave was about, V2 stated, It was about some customer service issue some family had with V6. Surveyor clarified if that administrative leave was a suspension or personal leave, V2 stated, She was suspended. Surveyor asked what specific customer service issue V6 was suspended for, V2 stated, I think the family alleged that their mom was left cold and wet (urine) and wasn't given a blanket or something like that. Surveyor asked how leaving a resident wet and cold was a customer service issue, V2 stated, Well it was also a care issue. Surveyor asked what units V6 normally worked on, V2 stated that V6 worked all throughout the facility including the dementia unit. Surveyor asked if any of the residents on the dementia unit were interviewable or could voice any concerns to anyone, V2 stated, No most of them are confused. V2 paused and stated, Oh I see what you mean. I gave V6 in-service training, and she's been a CNA for a while, and I trust her. On 3/19/24. 2:00 PM. V13 (Director of Resident Services) stated, I'm responsible for the abuse in service training portion in our skills fair and we had our latest one in November. We try to capture all the staff for the campus in these skills fairs that touch on various subjects, one is abuse which I do. I make it a point during training that anything you hear or see, you have to report immediately to your immediate supervisor, who will then report it to V1(Administrator). I tell them about the 8 types of abuse, and anyone can report abuse including family, the resident themselves, and any staff. I tell staff that even idle gossip staff may hear about regarding residents being mistreated should be reported right away to their supervisor. I know we don't like to gossip but a lot of that gossip may include clues about some staff member that may be abusing a resident. Staff shouldn't determine themselves whether it's just a customer service issue because they should report it and let the supervisor and administrator determine this with their investigation whether it is actual abuse or just a service failure. Surveyor asked V13 a hypothetical question about if a CNA was being rough with a resident and that was reported to the nurse what the next step would be, V13 stated, They should immediately remove that person from the resident, and let their immediate supervisor know and also the administrator so they can investigate. It's not up to that individual to do this, they just need to separate the resident from that individual and report it right away. On 3/19/24 at 2:35 PM, V11 RN stated, I know R38 very well because she is on my unit and it's my permanent floor. Sometime she said she likes mostly the morning people. Sometimes she doesn't like somebody, I try to change CNAs. She mostly complains about them talking on the phone when they are working with the resident. They should not be talking on the phone. I talk to CNA at once if they talk on the phone. Sometimes I hear someone being rough with her (R38) but it's not on my shift. I hear that from the CNA amongst themselves. The CNA's talk that somebody was rough with her and not nice with her. It was a few months ago I think, I heard someone was not nice to her. I know for example who it was generally, and I try to figure out who, so I try to ask CNA's. Sometimes you know when she's not happy, so I tell V12/Administrative Assistant not to schedule a particular CNA (V6). Surveyor asked if she informed the administrator or DON about what she heard, V11 stated, I don't tell administrator or anyone, just V12. If there's any problem with any CNA, I Usually I tell V12. That CNA I hear about is (V6). I hear that she (R38) doesn't like her because the resident told me herself. She tells me V6 doesn't know too much what to do, how to care for her. I heard this again today, but I was busy. Surveyor asked V11 if she told anyone else other than V12, V11 stated, No I don't tell anybody. I don't tell anybody. I'm sorry. V1 (Administrator) and V2 (DON) presented information to survey team indicating that they had met with R38 last night to address the resident's concerns voiced on 2/6/24. This type-written response reads in part (V1) and (V2) met with (R38) at 6:35 PM on 3/19/24. V1 said to R38, I heard you need to report to me about someone hurting you. R38 went on to relay that V6 had given her a bed bath and after the bath she asked V6 to boost her up so she could pull her nightgown down in back. R38 reported that V6 wears earbuds a lot and was not sure how much she heard her. V6 proceeded to grab R38's left arm and pulled it to the side and R38 called out telling V6 she was in pain. R38 reported it to my nurse (V9) and waited until Thursday for V39 (attending physician) to come and examine the resident and then ordered an x-ray. The interview goes on to state that (V6) tends to have an unpleasant attitude with R38. The written report goes on to conclude that R38 stated that she felt V6's actions were unintentional and (V9) received education regarding being fully engaged with residents during care with no external distractions such as cell phones and ear buds and to engage with residents verbally during care regardless of ability to reciprocate. This report fails to indicate any re-inservice education on abuse prevention. On 3/20/24 at 1:30 PM, surveyors re-interviewed R38 to verify the meeting the resident had with V1 and V2. R38 stated to surveyors that V1 Administrator and V2 DON came to see her abruptly after dinner when she was already in bed last night around 7 PM and asked her about V6. R38 indicated that V1 asked if V6 was rough with her, and she told her that she was. R38 stated, the Administrator did most of the talking and I felt pressured to say that the CNA's (V6) actions were not willful because she kept emphasizing and repeating the word willful and that V6's intentions were not willful. R38 indicated to surveyors that she didn't agree with this but in order to pacify administration, R38 stated that she gave in and agreed with them even though she felt V6 intentionally and repeatedly ignored her and was rough each time she came. R38 informed surveyors that she still felt pain in her arm and shoulders after the incident and also every time when V6 returned on numerous occasions. R38 added that yesterday (3/19/24) V6 was assigned to her but was abruptly removed from her assignment which she was relieved to find out. R38 indicated that prior to yesterday, V6 continued to ignore her and provided rough care which caused her more pain. R38 stated that she brought concerns to the administrator on numerous occasions about the quality of staff in general, but the administrator's response would be to pass the buck as a corporate issue. R38 stated that she felt even more vulnerable now with administration by complaining stating, When the administrator came in the room, she had this look on her face that she was annoyed with me and that Oh it's her complaining again, but R38 didn't expect any real changes to come as she'd been dealing with the same issues for a while with no improvement. On 3/21/24 at 4:30 PM V39 (Attending Physician) stated to surveyors, (R38) is a very fragile patient and she has to be handled in a very delicate manner as she is brittle and has a complete rotator cuff tear and underlying severe arthritis that would worsen if it is exacerbated in any way. This was the reason I had ordered X-rays for that day when I got a call from a nurse telling me there was some incident that happened that caused the patient severe pain, so I suspected further injury to her shoulders. Surveyor asked if it was about the 2/6/24 incident? V39 stated, I don't know the exact date, I just know it happened a month ago. Surveyor asked if how he was informed of the incident involving his patient (R38) and V6, V39 stated, I found out from the resident that some staff person was careless and rough with her, but the nurse made no mention of any incident with R38's CNA being rough, it was the resident herself who informed me when I came to see her. 2. R55 is a [AGE] year-old female who has resided at the facility since 6/1/2022 with past medical history including, but not limited to ataxia, age-related osteoporosis, thoracogenic scoliosis, thoracic region, overactive bladder, pain in right leg, pain in left hip. On 3/9/2024 at 11:10 AM, R55 was observed in her room, awake, alert and oriented and stated that she is doing okay. Surveyor asked the resident about the incident that happened with a staff in December of 2023, and she said, you mean the guy? Surveyor said yes and resident said that staff will pat her on her bottom after changing her incontinence brief, she does not think that he should be doing that. Surveyor asked resident how that makes her feel and she said it makes her angry, it is not appropriate for him to be doing that. R55 also said that the staff member identified as V8 (former aide) called her a fat ass and that was wrong of him, no one should be addressed like that. R55 reported the incident to a nurse because it makes her feel uncomfortable. R55 added that she has not seen the staff recently, she thinks he got another job, she has not had any issues with any other resident or staff. Minimum Data Set (MDS) assessment dated [DATE], section C (Cognitive) documented that R55 has a BIMs (Brief Interview for mental Status) score of 13, section GG (functional abilities and goals) of the same assessment indicated that R55 requires substantial/maximal assistance from staff for most activities of daily living (ADLS). Facility reported incident (initial) dated 12/11/2023 documented that R55 reported to her nurse and the administrator that a C.N.A made inappropriate comments to her and slapped her. She could not recall the exact times, but it was over the course of the last few months. The perpetrator put on administrative leave pending investigation. The final report documented that V1 (Administrator) interviewed R55 on 12/11/2023 and resident stated that V8 (C.N.A) hit her on her behind and called her a fat ass. Resident stated that the last time V8 hit her on the behind was last Thursday, he used to do it more often, it quit for a while and then started again. R55 added that when V8 called her a fat ass, she said to him, no I am not a fat ass. R55 also reported to V1 that one time she was coming out of the shower with V8, and he said, I was going to kiss you back there, and R55 said no, R55 added that V8 went on to make some kissing noises as they were walking down the hall. On 12/13/2023, V1 received an email from R55's sister indicating that she spoke to R55 last night and she reported that after drying her in the shower, V8 will touch her breast to make sure there was no soap left. V1 followed up with R55 the same day and she stated that while showering, V8 will put his bare hand under her armpit and under her breast to make sure the soap was all gone. R55 added that he made her feel uncomfortable. 03/20/24 12:04 PM, V1 (Administrator) said that she investigated the abuse allegation for R55, resident is alert and oriented X 3 and has never made any abuse allegation towards any staff or resident. V1 interviewed the resident who told her that staff (V8) called her a fat ass, pats her on her bottom after changing her incontinence brief and touched her breast during shower. V8 was suspended during the investigation, he did not return to the facility because he was terminated. V1 said that she did not substantiate abuse because the staff (V8) was able to explain the patting on resident's bottom, it is not the appropriate thing to do because it could be interpreted as uncomfortable for the resident, staff are not supposed to make residents uncomfortable. V1 said that she did not consider this an abuse, staff was terminated due to customer service, he could have used a better judgement when providing care, and she felt it was better to part ways. 03/20/24 02:10 PM, V4 (Executive Director) said that residents are screened for abuse risk upon admission and every 6 months, those at risk will be identified and referred to nursing and social worker for follow-up. Those identified at risk will have a care plan, at risk residents are those with psych issue, aggressive behavior, history of abuse and substance abuse. Dependent residents may potentially be at risk for abuse, but they don't have an abuse care plan, if there is an allegation of abuse and it is not substantiated, the resident will not have a care plan because no abuse occurred. The administrator will determine whether any abuse is willful and investigates all abuse and does a good job, if she said abuse did not occur, then there is no abuse.

Based on interview and record review, the facility failed to follow the their Abuse, Neglect, and Exploitation Policy by allowing staff to remain caring for a resident after an allegation of neglect. This affected 1 of 3 residents (R1) reviewed for Neglect. Findings include: On 7-11-23 at 11:23 AM, V3 (Scheduler) said on 7-10-23, V5 (CNA) worked 11:00 PM to 7:00 AM. V3 said V5 was not supposed to be working pending an investigation. V3 notified V5 on 7-7-23 that she was removed from the schedule pending a neglect investigation. V3 reached out to V5 this morning and per V1 (Administrator), V5 is removed from the schedule and will be notified when the investigation is over. On 7-11-23 at 1:12 PM, V5 (CNA) said the scheduler told V5 last Friday that she was suspended pending a Neglect Investigation. V5 said that she worked the nightshift (11:00 PM to 7:00 AM) of 7-10-23 because she saw her name on the schedule and she thought it was ok to return to work. V5 thought the investigation was over. On 7-12-23 at 8:35 AM, V2 (DON) said an employee is suspended to protect the resident during an abuse/neglect investigation. This was an oversight (human error) when the scheduler left V5 on the schedule for 7-10-23 and V5 should not have worked. On 7-13-23 at 1:30 PM, V1 (Administrator) said V5(CNA) was informed of the suspension pending Neglect investigation last Friday. R1 was removed from the schedule last Friday and was suspended. V1 said V5 was still suspended on Monday 7-10-23 and should not have worked. Daily Schedule dated 7-10-23 documents V5 listed on the schedule for the 1st Floor 10:30 PM to 6:45 AM. There is no indication of suspension or removal from the schedule. Midnight Census dated 7-10-23 documents 28 resident on the 1st floor. Abuse, Neglect, and Exploitation Policy (revised 3-7-18) documents: Policy Franciscan Ministries affirms that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Neglect means the failure of the community, its associates, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The community will make efforts to protect all residents after alleged abuse, neglect, and/or exploitation. Examples of ways to protect a resident from harm during an investigation of abuse, neglect, and exploitation may include, but are not limited to: reassignment of nursing staff duties, time off for nursing staff. Place the accused associate on Administrative Leave pending completion of the investigation and notify Human Resources designee. Remove the employee from resident care areas immediately. In response to allegations of abuse, neglect, exploitation or mistreatment, the community must: prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for 1 (R16) of 18 residents reviewed for care planning in the sample of 36. This failure did not meet the resident's preferences and goals that were consistent with the resident's medical, physical, mental and psychosocial needs. Findings include: R16 is a cognitively impaired [AGE] year old resident with a diagnoses listed in part with hemiplegia and hemiparesis, gastrostomy, heart failure, and pressure ulcer of sacral region stage 4. Care plan dated 8/4/22 reads in part, The resident has a stage 4 pressure injury on sacrum. Goal: Sacral pressure injury will not increase in size. Interventions: The resident requires the bed as flat as possible to reduce shear; Keep skin free of moisture; Monitor the area for any signs of infection; treat the area as ordered; Treat pain as per ordered prior to treatment/turning etc. to ensure the resident's comfort. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. On 2/14/23 at 10:40 AM, R16 was observed in bed asleep on her back with her torso raised up several inches and lying atop a blue-colored air mattress. There were numerous, white-colored sheets on the bed mattress and a tight fitted sheet appeared to wrap around the mattress compressing the sides of the air mattress. An air pump was dangling precariously with one hook at the foot of the bed and had tubes that were hitting the ground. At 2:20 PM, R16 was observed in the same position on her back with her torso and head slightly raised up as was previously observed at 10:40 AM. On 2/15/23 at 9:20 AM, R16 was observed asleep in bed on her back with her torso raised up several inches. A tightly fitted sheet remained wrapped around R16's air mattress compressing the sides of the air mattress and there were again multiple layers of sheets on the mattress over and under R16's body. The same mattress pump remained dangling at the foot of the bed with one hook and tubing hitting the floor. On all three separate observations R16 was not in bed as flat as possible to reduce shear as stated in R16's care plan. Care plan dated 7/5/22 (revised 10/5/22) reads in part, The resident has an ADL (Activities of Daily Living) self-care performance deficit related to CVA (Cardiovascular accident) with hemiplegia. Goal: The resident will maintain current level of function through the review dated. Interventions: Bed mobility: The resident needs total assist of 2 staff. Bathing/Showering: The resident needs 2 person assist; Personal hygiene: The resident needs total assist with minimum 2 person assist. Physician orders dated 5/24/2022 reads in part: Turn and Reposition every two hours every shift for prevent pressure injury. Review of records showed no evidence to demonstrate the plan of care and physician orders to turn and reposition R16 utilizing the required 2-persons were implemented. On 2/16/23 at 10:40 AM, interview with V3 (ADON/Assistant Director of Nursing and wound care nurse) stated, I am the wound nurse and ADON. (R16) she is nonverbal and stays in bed, NPO (nothing by mouth), and she has feeding tube. She requires minimum two people with all ADL's (Activities of Daily Living). She has stage 4 in the sacrum, and it was acquired here in the facility. The wound has remained a stage 4 for two years. We are changing her positions every two hours and the CNA's are repositioning her. Surveyor asked how she monitored compliance with these orders for turning and repositioning, V3 stated, I have seen them turning her. I work here 8-4:30 PM so I eyeball it. It takes two people to reposition her and they (CNAs) are doing pericare when she is soiled so they turn and reposition her then and as needed. Surveyor asked if it was important to reposition R16 and whether that had any impact on delayed healing if it was not being done, V3 stated, I don't know. Surveyor asked how many times in the day R16 would require repositioning, V3 stated, they reposition her every shift so 4 times a day she is turned. Care plan dated 7/5/22 (revised 11/30/22) reads in part, The resident has arthritis and chronic pain and is at risk for complications. Goal: The resident will be/remain free of complications related to arthritis related joint impairment. Interventions: Educate resident on joint conservation techniques. Encourage adequate nutrition and hydration. Give analgesics as ordered by physician. Monitor and document for side effects and effectiveness. Heat/cold applications as ordered and as tolerated. Monitor/document/report to MD as needed for signs and symptoms related to arthritis: joint pain, usually worse on wakening. Review of records show interventions to educate resident and encouragement to improve nutrition and hydration would be unlikely as R16 is severely cognitively impaired. MDS (minimum data set) dated 12/16/22 shows that R16 as rarely/never understood. Functional status of bed mobility as total dependence and requiring a minimum 2+ person to move from lying position, to turn side to side, and to position body while in bed. Section M on this same MDS assessment showed R16 with one stage 4 pressure ulcer and had 0 number of stage 4 pressure ulcers that were present upon admission/entry or reentry to the facility; Skin and ulcer/treatment interventions show R16 to have pressure reducing device for chair and bed but did not show that R16 was on a turning and repositioning program as ordered by the physician. Facility policy dated 8/26/2019 titled Care Planning-Resident participation reads in part, The facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). Procedure: The community informs the resident, in a language he or she can understand of his or her rights regarding planning and implementing care, including the right to be informed of his or her total health status. If the resident has impaired decision making ability or has been declared incompetent by a court, the community, to the extent practicable, consults with and keeps him or her informed. The care planning process includes an assessment of the resident's strengths and needs and incorporates the resident's personal and cultural preferences in developing goals of care.

Based on observation, interview, and record review, the facility failed to implement appropriate care plan interventions and provide adequate supervision for a cognitively impaired resident at risk for falls (R37); failed to prevent a fall by not providing appropriate transfer assistance for a cognitively impaired resident at risk for falls (R50); failed to follow their facility policy and procedure for fall management. This failure affected 2 residents from a sample of 26 but has the potential to affect all 73 residents who currently reside at the facility. Findings include: Reviewed facility matrix and fall list for last 6 months provided by facility. R37 had 6 documented falls and identified as a fall resident. R50 was not listed on the fall list nor documented on the matrix as a fall resident. R37 admitted to facility on 03/04/2022 and has a past medical history not limited to: Dementia with Other Behavioral Disturbance, Anxiety Disorder, Altered Mental Status, Unspecified Psychosis, Insomnia, and Depression. R37's Minimum Data Set (MDS) Section C Cognitive Patterns dated 12/08/2022 showed her Brief Interview for Mental Status (BIMS) score as 04 which indicates severe cognitive impairment. Section G Functional Status dated 12/08/2022 showed she requires limited assistance of 1-person physical assist for transfers. Section G also showed for balance during transitions and walking, R37 is not steady and is only able to stabilize with staff assistance. R37's care plan last revised on 11/21/2022 showed the following: 09/11/2022, 00:15 unwitnessed fall with care plan intervention of refer to physical/occupational therapy for evaluation and treatment; 10/05/2022, 04:00 witnessed fall with care plan intervention to provide non-skid socks to wear during the night; 11/06/2022, 13:35 witnessed fall with care plan intervention to remind resident to use walker for ambulation; 11/20/2022, 00:55 unwitnessed fall with care plan intervention to keep bathroom light on during night; 01/31/2023 unwitnessed fall x2 with care plan intervention to keep over-the-head light on during the night. On 02/15/2023 at 12:01 PM, observed R37's room with no safety features in place, and observed an oxygen concentrator in the room with an extra-long tubing tangled on the floor near her bed. R50 admitted to facility on 02/04/2019 and has a past medical history not limited to: Alzheimer's Disease, Hypertension, Traumatic Subarachnoid Hemorrhage, Major Depressive Disorder, Unspecified Visual Loss, Vascular Dementia, Anxiety Disorder, and Psychosis. R50's Minimum Data Set (MDS) Section C Cognitive Patterns dated 12/01/2022 showed his Brief Interview for Mental Status (BIMS) score as 02 which indicates severe cognitive impairment. Section G Functional Status dated 11/30/2022 showed he requires extensive assistance of 2+ person physical assist for transfer. R50's Care Plan last revised on 01/18/2023 showed he is at risk for falls due to impaired cognitive and safety skills, is on psychotropic medications, has a history of repeated falls with injury, and is non-compliant with safety measures. Care plan documents a fall on same date with intervention of staff education on proper transfer. R50's incident report dated 01/18/2023 showed Certified Nursing Assistant (CNA) said during transfer patient slid down to the floor. Report continued with staff unable to complete safe transfer and per report, assigned CNA failed to check with the nurse the transfer status of the resident (assist x2) and performed doing it alone. On 02/14/23 at 11:33 AM, R50 was not in his room. Observed bed in high position with 1 fall mat folded up against the wall near his bed. No other fall mat was observed in R50's room. On 02/16/2023 at 3:20 PM, V23 (MDS Coordinator) said care plan interventions should be updated after every fall, but that is done by V3 (Assistant Director of Nursing). On 02/16/2023 at 03:29 PM, V3 (Assistant Director of Nursing) said care plans and interventions should be updated after each fall. When asked why R37's 2 falls from 01/31/2023 were not listed on her care plan and was not care planned as a fall risk, V3 said after November 2022, corporate said to no longer date falls for residents, only update their interventions. V3 added that R37's falls occurred during the night because it was dark in the room so keeping an overhead light on would help to prevent R37 from falling. When asked if there was a more appropriate and effective intervention to prevent falls for a resident with severe cognitive impairment other than remind/educate or leave a light on, V3 said more frequent checks done every hour would be beneficial for these residents. When asked should the facility follow a resident's plan of care to prevent falls, V3 said yes, their plan of care should be followed. Reviewed facility's fall management policy that showed how to implement a post fall assessment. Policy show on page 4 of 6, complete a fall risk assessment and revise the care plan to include interventions to prevent future falls. Policy also indicated to document teaching provided to resident and their understanding of that teaching. No fall risk assessment and/or documentation of teaching provided for R50.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain consistent hospice communication for 5 of 7 (R12, R22, R27, R47, R60) residents reviewed for hospice care in the sample of 36 residents. Findings include: R12 is an [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Heart Failure, Lymphedema, Major Depressive Disorder, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Morbid Obesity. R12's Plan of Service dated 11/11/2022 reads in part, Admit to Xxxxxxx Care Hospice. R22 is an [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Dementia, Major Depressive Disorder, Anxiety Disorder, Aortic Aneurysm of Unspecified site, and Personal History of Other Malignant Neoplasm of Large Intestines. R22's Plan of Service dated 08/16/2022 reads in part, Admit to Hospice. R27 is an [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Diastolic Heart Failure, Unspecified Atrial Fibrillation, Essential Hypertension, Unspecified Osteoarthritis, and Vascular Dementia. R27's Plan of Service dated 01/13/2023 reads in part, Hospice Eval and Tx (by Xxxxxxxx). R47 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Major Depressive Disorder, Chronic Systolic Heart Failure, Alzheimer's Disease, Unspecified Osteoarthritis, Unspecified Atrial Fibrillation, and Benign Prostatic Hyperplasia. R47's Plan of Service dated 12/29/2022 reads in part, Xxxxxxxx Hospice evaluation. R60 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Dysphagia, Essential Hypertension, and Unspecified Dementia. R60's Plan of Service dated 06/15/2022 reads in part, Hospice eval and Tx. On 02/15/23 at 09:48 AM Surveyor inspected R47's and R27's hospice communication binder, blank patient care sheets noted, no charting noted. On 02/15/23 at 10:06 AM Surveyor inspected R12's hospice communication binder, last Certified Nursing Assistant hospice communication documented on 01/27/2023 and last hospice nurse communication documented on 11/28/2022. On 02/15/23 at 10:11 AM Surveyor inspected R60's hospice communication binder, last Certified Nursing Assistant hospice communication documented on 12/30/2022 and last hospice nurse communication documented on 01/13/2023. On 02/15/23 at 10:16 AM Surveyor inspected R22's hospice communication binder, last Certified Nursing Assistant hospice communication documented on 12/30/2022 and last hospice nurse communication documented on 01/12/2023. On 02/15/23 at 11:38 AM Surveyor interviewed V6 (Registered Nurse), V6 stated, Hospice nurse was visiting R47 this morning, around 8:30 AM. R47 had fever and low oxygen level during my morning rounds around 7:00 AM, I called the hospice nurse, and she came in shortly after. Surveyor further clarified that there is no notes in R47's hospice communication binder, R6 (RN) stated, Even though R47 is under hospice care, his patient care is provided by hospice staff and should be shared to our facility's staff for continuity of care. I saw the hospice nurse writing in her computer device, but the facility staff doesn't have access to that information. She usually gives us verbal updates. On 02/15/23 11:43 AM Surveyor interviewed V3 (Assistant Director of Nursing), V3 stated, Hospice communication binder is used to hold residents' information. The hospice nurse charts in the hospice communication binder when there are new orders or residents' change of condition; otherwise, the hospice nurse communicates patient care verbally and in her computer device. Our facility's staff doesn't have access to hospice nurse's notes. Surveyor asked what is a downfall of almost exclusively verbal communication between hospice and facility's staff, V3 (DON) stated, It's important to effectively communicate among interdisciplinary teams to avoid loss of pertinent information pertaining to hospice residents' care. Hospice -Skilled Facility Agreement executed on 12/24/2021 reads in part, Hospice shall designate a member of the Hospice Interdisciplinary Group who shall communicate with Nursing Home representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family. Hospice Services - Community Agreement policy dated 03/2019 reads in part, If hospice care is furnished in a community through an agreement, the community must meet the following requirements: A communication process, including how the communication will be documented between the community and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of quality by failing to prevent the development of a facility-acquired pressure injury, failed to follow the plan of care to heal the facility-developed pressure injury; and failed to train all facility nursing staff including contracted nurses on pressure ulcer prevention and care. This failure affects 1 (R16) of 3 residents reviewed in the sample of 36 residents and has the potential to affect all residents residing in the facility. Findings include: On 2/14/23, V1 (Administrator) presented the survey team with the current resident census total of 73 residents per facility matrix. R16 is a cognitively impaired [AGE] year old resident with diagnoses listed in part with hemiplegia and hemiparesis, gastrostomy, heart failure, and pressure ulcer of sacral region stage 4. Physician orders dated 5/24/2022 reads in part: Turn and Reposition every two hours every shift for prevent pressure injury. On 2/14/23 at 10:40 AM, R16 was observed in bed asleep on her back with her torso raised up several inches and lying atop a blue-colored air mattress. There were numerous, white-colored sheets on the bed mattress and a tight fitted sheet appeared to wrap around the mattress compressing the sides of the air mattress. An air pump was dangling precariously with one hook at the foot of the bed and had tubes that were hitting the ground. V7 (RN) was asked about R16 and stated, Yes she is my patient. She is always in bed. I have two Certified Nursing Assistants (CNA's) today but usually we have 3 on the floor. At 2:20 PM, R16 was observed in the same position on her back with her torso and head slightly raised up as was previously observed at 10:40 AM. On 2/15/23 at 9:20 AM, R16 was observed asleep in bed on her back with her torso raised up several inches. A tightly fitted sheet remained wrapped around R16's air mattress compressing the sides of the air mattress and there were again multiple layers of sheets on the mattress over and under R16's body. The same mattress pump remained dangling at the foot of the bed with one hook and tubing hitting the floor. On 2/15/23 at 11:10 AM, surveyor asked V7 (RN) to come and see R16 with the surveyor. R16 appeared to be in the same position and was observed in bed asleep on her back with her torso raised up several inches. Surveyor asked V7(RN) to describe to the surveyor R16's positioning, V7 stated, She is on her back, and we raise her head up a little bit for comfort. Surveyor asked to describe more about R16, V7 stated, (R16) has a G-tube (gastrostomy tube) and a urinary catheter because she has a pressure ulcer on her sacral area. I don't know if she got the pressure ulcer here or from the hospital, but I think I was told it was from here. The wound nurse (V3) comes every Friday and they do wound rounds with her and the wound doctor, but I don't know anything else about it. The nurses do the wound care every day except Friday when V3 (wound nurse) does it. Wound care is done on the PM shift mostly, so I don't normally do it because I am AM shift nurse. Surveyor asked how R16 appeared to her, V7 stated, She looks uncomfortable, but she looks that way a lot. This is a fitted sheet, and it should not be here, we are supposed to have flat sheet. Surveyor asked why a fitted sheet was not supposed to be used as she said, V7 stated, Because I think they told us it is not good for the air mattress to work. Surveyor asked about the green incontinence pads that were bunched up under R16's sacral area, V7 stated, The CNA's shouldn't be using that much under her I will let the CNA know. Surveyor asked about the dangling mattress pump at the foot of the bed, V7 stated, Oh, I saw that yesterday, I should have let maintenance know about it. I will call them now. Surveyor asked if the mattress pump was functioning properly, V7 stated, I don't know. I don't touch this. I think it's working but I don't know anything about this. Surveyor asked if anyone instructed her on how to operate the mattress pump for R16, V7 stated, No, maintenance takes care of this. At 11:20 AM, V7 (RN) called in V8 (CNA) and asked her about R16's bed, V8 stated, I didn't do her bed, that was the night shift that makes her bed. Surveyor asked how many incontinence pads were supposed to be under R16, V8 stated, Those pads shouldn't be under her like that. It was probably when she was turned or something. Surveyor asked when she last turned R16, V8 stated, I did it around 7:30 or 8, I don't remember. Surveyor asked if anyone helped her do this, V8 stated, No, I did it myself and I was going to do it again just now that's why I came in. On 2/15/23 at 2:40 PM, V15 (CNA) was observed in R16's room with the privacy curtain drawn. Surveyor entered the room, and V15 stated, patient care! to deter anyone from coming into the room. Surveyor came into the room, and V15 stated to surveyor, Come here and help me change her. Surveyor identified self and informed V15 that surveyor was unable to comply with her request. Surveyor asked V15 what she was doing, V15 stated, I was about to clean her (R16) up, should I stop? Surveyor answered and said to continue how she normally took care of R16 and left the room. At 2:45 PM, Surveyor approached V14 (RN) and requested to see if he could observe him conduct wound care for R16, V14 stated, Yes. I usually do her anyway on my shift. V14 proceeded to R16's room and saw V15 already in the room and informed her to clean R16 up because he was going to do wound care for R16. V15 was overheard saying, I'm almost done so I will wait for you to do her dressing change.V14 went to his cart and took several supplies with him and placed them in his hand and brought them to the room and placed the supplies onto a bedside table and went into the bathroom to wash his hands and put on gloves. Surveyor asked V14 to explain the procedure to surveyor as he conducted the wound care. V14 stated, (R16) is totally dependent and non-responsive resident. She has a pressure ulcer on the coccyx area, and she got it here in the facility, but it was here before I ever started working here which was about 6 months ago. V14 removed the soiled beige colored bandage/dressing cover that had no date or markings on the bandage to identify when the dressing was changed or who changed the dressing. V14 continued and removed the bandage to reveal the wound. V14 stated, It measures approximately 3 centimeters by 2 centimeters wide and 1 centimeter deep. Surveyor asked to describe the wound size further to the surveyor, V14 stated, I'd say it is smaller than a golf ball size but bigger than a marble. First, I clean it with normal saline solution and then I pack the wound with the silver alginate dressing, then cover it with the foam dressing (bandage cover). As V14 was cleaning R16's wound with the normal saline, R16 twitched her body forward and made a moaning sound. As V14 started packing R16's wound with the silver alginate dressing, R16 retracted her body again and moaned. Surveyor asked about the movements and sounds R16 made, V15 stated, She does that all the time when we change her dressing. V14 added, She has overall pain, but she gets regular scheduled pain medications later on. Surveyor asked if the movements and sounds R16 made were pain responses and whether he should have stopped the procedure or pre-medicated her before doing the wound care, V14 stated, I think she is like that, but I did it pretty quickly, so I don't think she was in pain. Surveyor asked to clarify what clinical stage R16's wound was, V14 stated, It is a stage 3 pressure sore. Surveyor asked to clarify the staging of the wound, V14 stated, Yes it's a stage 3 not a stage 4, that's what it looks like to me. Surveyor asked why there were no initials or date placed on the dressing cover to denote when the wound dressing was changed, V14 stated, We were told not to do that, but I knew it was changed because I changed it yesterday. Surveyor asked if this was considered best nursing practice to not date wound dressings when they are done, V14 stated, I guess it would be sir, but we never do that here. Surveyor asked whether R16 had any other wounds, V14 stated, Yes, it is on her right trochanter hip area, but it is almost healed. V15 turned R16 to her side to reveal another undated and un-initialed wound dressing on R16's right hip area. V15 proceeded to peel off the wound dressing to show surveyor until surveyor asked V15 to stop what she was doing. Surveyor asked V14 if V15 was a nurse and allowed to do wound care, V14 stated, No. She is not a nurse and should not be doing that because she is not licensed. A wound evaluation report provided to surveyor by V1 (Administrator) and submitted by V18 (Wound Doctor) dated 11/11/2022 shows in part, (R16) Focused wound Exam (site 1) Stage 4 press wound sacrum full thickness. Etiology (quality): Pressure; MDS 3.0 Stage 4; Wound size (Length x Width x Depth) 2.6 x 1.8 x 0.3 cm.; Surface area 4.68 centimeters squared. Wound progress: Deteriorated. A recent wound evaluation report also provided by V and submitted by V18 dated 2/10/2023 shows in part, (R16) Focused wound Exam (site 1) Stage 4 press wound sacrum full thickness. Etiology (quality): Pressure; MDS 3.0 Stage 4; Wound size (Length x Width x Depth) 2.7 x 1.6 x 0.3 cm.; Surface area 4.32 centimeters squared. Wound progress: No Change. Plan of care reviewed and addressed. Recommendations: Off-load wound; reposition per facility protocol. Care plan dated 8/4/22 reads in part, The resident has a stage 4 pressure injury on sacrum. Goal: Sacral pressure injury will not increase in size. Interventions: The resident requires the bed as flat as possible to reduce shear; Keep skin free of moisture; Monitor the area for any signs of infection; treat the area as ordered; Treat pain as per ordered prior to treatment/turning etc. to ensure the resident's comfort. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Another care plan dated 7/5/22 (revised 10/5/22) reads in part, The resident has an ADL (activities of Daily Living) self-care performance deficit related to CVA (Cardiovascular accident) with hemiplegia. Goal: The resident will maintain current level of function through the review dated. Interventions: Bed mobility: The resident needs total assist of 2 staff. Bathing/Showering: The resident needs 2 person assist; Personal hygiene: The resident needs total assist with minimum 2 person assist. On 2/16/23 at 10:40 AM, interview with V3 (ADON/Assistant Director of Nursing and wound care nurse) stated, I am the wound nurse and ADON. I've been the wound nurse since 2021. I am wound care certified. I do rounds with V18 every Friday. Mostly the nurse on the floor does the wound care. They do the wounds everyday except Friday when I do them. Surveyor asked about R16, V3 stated, (R16) she is nonverbal and stays in bed, NPO (nothing by mouth), and she has feeding tube. She requires minimum two people with all ADL's (Activities of daily living). She has stage 4 in the sacrum, and it was acquired here in the facility. The wound has remained a stage 4 for two years. It is a chronic wound, and it is not deteriorating, it is stable. Surveyor asked based on her training and clinical knowledge why the wound wasn't healing, V3 stated, She has multiple diagnosis she is anemic, diabetic, and hemiplegia. We are doing daily treatments and wound doctor is overseeing it. The treatment was changed multiple times. She is on air mattress, urinary catheter; We are changing her positions every two hours and the CNA's are repositioning her. Surveyor asked how she monitored compliance with these orders for turning and repositioning, V3 stated, I have seen them turning her. I work here 8-4:30 PM so I eyeball it. It takes two people to reposition her, and they (CNAs) are doing pericare when she is soiled so they turn and reposition her then and as needed. Surveyor asked if it was important to reposition R16 and whether that had any impact on delayed healing if it was not being done, V3 stated, I don't know. Surveyor asked how many times in the day R16 would require repositioning, V3 stated, they reposition her every shift so 4 times a day she is turned. Surveyor asked about dating and initialing of wound dressings when rendered, V3 stated, We don't date or initial wound dressings because our corporate say not to and it is in our policy. Surveyor asked about the training of the nurses since wound care is done 6 out of the 7 days by the floor nurses, V3 stated, I don't know about their training. I communicate to the nurses the type of wound. Surveyor asked if she directly trained the floor nurses about wound care, V3 stated, No I just tell them about the wound and a year ago in a job fair, I told them. Surveyor asked about the wound training of the agency nurses on the floor, V3 stated, I don't know but they should know. Surveyor asked since she was a certified wound nurse and based on her own wound training and clinical background whether the wound was an avoidable wound, V3 stated, I think that this wound was preventable because if she would not be on hard surface for a long time or if she could be more up from bed and from the wheelchair or sitting position and changing positions, it could have been prevented. Positioning is important and nutrition. Surveyor asked about pain management of wounds, V3 stated, When we do wound care for (R16), she is not pre-medicated for pain. She has scheduled medications, but we don't pre-medicate for pain but if she doesn't have any, but I will do that from now on. On 2/16/23 at 4:00 PM, Surveyor reminded V3 to provide the policy where it indicates to not initial or date the dressing when it is accomplished V3 stated, I thought the DON (V2) gave you that. Surveyor asked V3 if she considered it a best practice to initial and date when a dressing is done, V3 stated, I don't know. I can't answer that. On 2/16/23 at 4:10 PM, V2 (Director of nursing) was asked about dating and initializing when changing wound dressings, V2 stated, It is considered best practice to initial and date when a wound dressing has been changed. Efforts to reach V18 (Wound Doctor) were unsuccessful and was informed by V1 (Administrator) and V3 (ADON/wound nurse) that V18 was on vacation and was possibly unreachable because V18 was in the mountains. V1 offered surveyor contact information for R16's primary physician and for the facility's Medical Director. Efforts to reach the V19 (primary physician) were met with the answering service informing surveyor that only a covering doctor was available to be paged if there were orders needed by the nursing home facility. On 2/16/23 at 4:30 PM, interview with V24 (Medical Director) stated, I am informed of any acquired wounds as the Medical Director, and we go over this topic during our monthly quality assurance meetings. When it comes to pressure ulcers we talk about any facility-acquired pressure sores and especially anything above a stage 2 where we talk about root cause, and we develop interventions to prevent and heal these wounds. Surveyor asked that since they talk about wounds higher than a stage 2, what his feedback was about (R16). V24 stated, I do recall this resident being discussed but please refresh my memory. Surveyor provided brief information about R16 and asked the importance of turning and repositioning for R16 as ordered by the Primary Physician (V19). Turning and repositioning is an important preventative measure but once the wound develops however, it is crucial now for turning and repositioning to be done. Surveyor asked about the specialty air mattress and how the bed should be prepared, V24 stated, I really couldn't speak to that however I do know that the bed should be made minimally to prevent over padding of sheets, etc. to prevent pressure area and to attempt better healing. Surveyor asked if nurses should be indicating on the wound dressing who or when the dressing was changed, V24 stated, I am not that familiar with nursing practice however, I do consider it would be best practice to initial and date a wound. Surveyor asked whether, CNAs were allowed to do dressing changes, V24 stated, I would not think they are allowed to do so unless they are licensed nurses. Surveyor asked about pain management during wound care, V24 stated, From what I know about pain management, and assuming that the cognitive impaired resident is unable to ask for pain medications, it would be appropriate and good practice to administer pain medication approximately 30 to 45 minutes before dressing changes are done. If a patient shows signs of discomfort and retracts during wound care then pain medication should have been provided prior to this procedure and if there were signs of moaning or retracting when the procedure was being done, that procedure should have been immediately stopped.

Based on observation, interview, and record review, the facility failed to inform visitors of a current Covid outbreak status upon entering the facility and failed to implement correct use of personal protective equipment while in Covid outbreak status. This failure has the potential to affect all 73 residents who reside currently at the facility. Findings include: On 02/14/2023 at 09:30 AM, upon entering the facility, surveyor(s) did not observe any signage visible on the front doors indicating there was a positive Covid-19 case and/or the facility was in outbreak status. At 09:35 AM, V20 (Administrative Assistant) seated at reception desk directed surveyor(s) to sign in at kiosk but did not inform team of outbreak status or to apply an N95 mask upon entrance. Also, notification was not observed on kiosk upon signing in, indicating the facility was currently in outbreak status. During entrance conference, V1 (Administrator) informed surveyors of one positive Covid resident in the building, but did not inform surveyors that the facility was currently in outbreak status. On 02/14/2023 at 11:14 AM, R10's family member said during a phone interview that she was not aware of the facility having a Covid positive resident in building. On 02/14/2023 at 11:35 AM, V21 (Life Enrichment Associate) said they just had a Covid positive resident on the 2nd floor, now there's one on the first floor. V21 then said no alert is sent to her regarding positive cases and she is notified when she logs into the computer system. On 02/14/2023 at 12:10 PM, surveyor observed a visitor walk past multiple staff members and push a resident in a wheelchair into the 2nd floor dining room. Visitor was improperly wearing her N95 surgical, was wearing the mask sideways with the straps around her ears and not over her head. Observed no staff member direct visitor on how to properly wear her N95 mask. On 02/15/2023 at 10:37 AM, V1 (Administrator) said the facility sends an email initially when in outbreak status, then weekly updates until out of outbreak status. At 10:45 AM, when asked if the receptionist should inform visitors of being in outbreak status and how to apply and wear the proper face mask, V2 (Director of Nursing) initially said it's not required then said yes, they should inform visitors of such. On 02/15/2023 at 11:51 AM, V4 (Infection Preventionist) said the facility has been in outbreak status since 01/05/2023, then said signs have been posted at the front door since 01/27/2023 indicating the same. On 02/16/2023 at 1:53 PM, V20 (Administrative Assistant) said when visitors enter the facility she informs them of current outbreak status and ensures they apply an N95 mask due to outbreak status. She also instructs visitors to sign in on the kiosk and to be mindful about proper mask use, distancing and hand sanitizing. On 02/16/23 at 02:30 PM, V4 (Infection Preventionist) said families are informed of the facility's Covid status through an email sent by V1 (Administrator) initially with outbreak status, then weekly until out of outbreak status. V4 then said the facility informs all family with every Covid positive case. At 2:43 PM, V4 (Infection Preventionist) also said if staff or visitors are observed not properly wearing PPE, they are informed of proper use by a member of the management team. V4 then showed surveyor where the Covid outbreak status signs were located near the front doors. Observed signs to the right of inner doors of front entrance that were not clearly visible upon entrance to facility. At 04:25 PM, V4 (Infection Preventionist) provided corrective action documentation for infection control practices during Covid 19 outbreak including visible signs upon entrance, proper handwashing and N95 mask use, as well as communicating to all who enter regarding current outbreak status by the receptionist and on the kiosk when signing in. Reviewed infection prevention and control program policy last revised 12/22/2021 that documents it is facility policy to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. The policy also documents family members and visitors are provided information relative to the rationale for isolation precautions and behaviors required of them in observing these precautions.