Based on observation, interview, and record review, the facility failed to ensure a fall intervention was implemented timely after a fall event occurred and fall interventions were in place for 1 of 3 residents reviewed for accidents. (Resident D) Findings include: The clinical record for Resident D was reviewed on 4/16/25 at 11:30 a.m. The diagnoses included, but were not limited to, borderline personality disorder, bipolar disorder, schizoaffective disorder, generalized anxiety disorder, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 4/9/25, indicated Resident D was moderately cognitively impaired and had two or more falls since the last MDS assessment. A care plan, revised 4/14/25, indicated Resident D was at risk for falls related to incontinence and psychoactive drug use. The interventions included, but were not limited to, anti-roll backs to the wheelchair, initiated on 4/14/25, and encourage the resident to wear nonskid footwear and/or nonskid socks, initiated on 3/11/25. A progress note, dated 4/13/25 at 10:46 p.m., indicated Resident D was observed sitting on the floor facing her bed. Resident D stated she was trying to move herself from the wheelchair to the bed and lost her balance and slipped to the floor. An observation was conducted of Resident D, on 4/16/25 at 12:42 p.m., of her sitting in a wheelchair that didn't have anti-roll backs present. Resident D was interviewed, and she stated she was upset because the facility staff took the wheelchair she was previously using and provided her with another one that she didn't like. Resident D didn't understand why her wheelchair was switched out. The Assistant Director of Nursing (ADON) was present and indicated the maintenance staff came and took Resident D's wheelchair to apply the anti-roll backs to the wheelchair. Resident D remained upset and stated she didn't want to eat lunch and wanted to lay herself back in bed. The ADON attempted to assist Resident D while she was transferring herself from the wheelchair to the bed, but Resident D refused any assistance and stated she could transfer herself. Resident D was wearing fluffy socks that were not nonskid socks while she was transferring herself from the wheelchair to the bed. This citation relates to Complaint IN00457282. 3.1-45(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure narcotic medication was administered per the physician orders, narcotic medication was readily available for use, and intravenous (IV) antibiotics were obtained to be administered as ordered by the physician for 2 of 3 residents reviewed for medication use. (Resident C and Resident D) Findings include: 1a. The clinical record for Resident C was reviewed on 4/16/25 at 10:47 a.m. The diagnoses included, but were not limited to, osteomyelitis (infection of bone), pressure ulcer of sacral region, paraplegia, and muscle spasm. Resident C was admitted to the facility on [DATE]. A Quarterly Minimum Data Set (MDS) assessment, dated 3/6/25, indicated Resident C was cognitively intact, had one injection, utilized antianxiety medication, antibiotic medication, and opioid medication. A care plan for IV medications, revised 3/7/25, indicated Resident C was on IV antibiotics related to osteomyelitis. A physician order, dated 2/28/25, indicated to administer three grams of ceftolozane-tazobactam (antibiotic) IV; three times a day for infection until 3/7/25. The order was discontinued on 3/1/25. The February 2025 electronic medication administration record (EMAR) indicated Resident C did not receive the IV antibiotic for the three scheduled administrations on 2/28/25. A progress note, dated 2/28/25 at 9:17 a.m., indicated the IV antibiotic was unavailable for administration. A progress note, dated 2/28/25 at 2:38 p.m., indicated the IV antibiotic was unavailable for administration. A physician order, dated 3/1/25, indicated to administer three grams of ceftolozane-tazobactam IV; three times a day for infection until 3/8/25. The order was discontinued on 3/7/25. The March 2025 EMAR indicated Resident C did not receive the IV antibiotic on the following date(s)/time(s): - 3/1/25 at 9:00 a.m., - 3/1/25 at 1:00 p.m., - 3/5/25 at 9:00 a.m., - 3/5/25 at 1:00 p.m., and - 3/6/25 at 9:00 a.m. A progress note, dated 3/1/25 at 12:58 p.m., indicated the IV antibiotic was on order and not available for administration. A progress note, dated 3/5/25 at 12:22 p.m., indicated the IV antibiotic was on hold due to the IV site being infiltrated (complication of intravenous therapy, with the administered medication or fluid leaking into the surrounding tissues; that occurs when the IV catheter dislodged, punctures the vein, or is not secured properly). 1b. A care plan, dated 2/28/25, indicated Resident C was on psychoactive medications to treat anxiety. The interventions included, but were not limited to, administering psychoactive medications as ordered. A physician order, dated 2/28/25, indicated to administer pregabalin (drug used to treat epilepsy, nerve pain and anxiety) 75 milligrams (mg) two times a day for neuropathy pain (damage, disease, or dysfunction of one or more nerves). The February 2025 EMAR indicated Resident C was not administered the pregabalin 75 mg on 2/28/25. The March 2025 EMAR indicated Resident C was not administered the pregabalin 75 mg on the following date(s)/time(s): - 3/1/25 in the morning and evening, - 3/2/25 in the evening, - 3/3/25 in the evening, and - 3/4/25 in the morning and evening. A progress note, dated 3/1/25 at 12:21 p.m., indicated the pregabalin 75 mg was on order from the pharmacy. A progress note, dated 3/2/25 at 4:14 p.m., indicated the pregabalin 75 mg was not available and the pharmacy was notified. A progress note, dated 3/3/25 at 7:45 a.m., indicted the pregabalin 75 mg was not available. A progress note, dated 3/4/25 at 1:28 p.m., indicated the pregabalin 75 mg was not available. A controlled drug receipt/record/disposition form indicated Resident C's pregabalin 75 mg, quantity of 12, was received on 3/4/25. The first administration of the pregabalin 75 mg was on 3/5/25 at 9:00 a.m. An interview conducted with the Director of Nursing (DON), on 4/16/25 at 4:08 p.m., indicated there were no other narcotic sheets for Resident C's pregabalin medication prior to 3/4/25. The DON was unsure why the pregabalin medication did not arrive prior to 3/4/25. 2. The clinical record for Resident D was reviewed on 4/16/25 at 11:30 a.m. The diagnoses included, but were not limited to, borderline personality disorder, bipolar disorder, schizoaffective disorder, generalized anxiety disorder, and major depressive disorder. A care plan, revised 1/17/25, indicated Resident D was prescribed psychoactive medication to treat the diagnosis of anxiety. The interventions included, but were not limited to, administering psychoactive medications as ordered. A physician order, dated 12/5/24, was noted for clonazepam (benzodiazepine/antianxiety medication) 0.5 mg one time a day at bedtime for schizoaffective disorder. The controlled drug record forms were reviewed and indicated the following date(s) to where there was no controlled drug record form to resemble a lapse in medication administration for Resident D's clonazepam: 12/27/24 to 12/31/24, 1/16/25 to 1/18/25, and 2/5/24 to 2/11/25. The controlled drug record forms indicated the following instances where the clonazepam was not signed off, as administered, daily: - 3/25/25, - 3/30/25, and - 4/10/25. A policy entitled Medication Administration, dated March 2023, was provided by the DON on 4/16/25 at 2:05 p.m. The policy indicated if a medication was ordered but not present, to contact the pharmacy or supervisor to obtain the medication. This citation relates to Complaint IN00457282. 3.1-25(a) 3.1-25(g)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a gradual dose reduction (GDR) was conducted instead of abruptly discontinuing an antidepressant medication and antianxiety medication for 1 of 3 residents reviewed for unnecessary medications. (Resident B) Findings include: The clinical record for Resident B was reviewed on 4/16/25 at 9:30 a.m. The diagnoses included, but were not limited to, stroke, dementia, anxiety disorder, alcohol abuse, and depression. The resident was admitted on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 1/17/25, indicated Resident B was cognitively impaired. A long-term care facility discharge medication summary, date of discharge 1/7/25, indicated Resident B received the following psychotropic medications: Start date: 10/21/24 - 0.5 milligrams of lorazepam (antianxiety/benzodiazepine) twice a day, Start date: 8/3/24 - 5 milligrams of Zyprexa (antipsychotic) three times a day, and Start date: 12/16/24 - 100 milligrams of sertraline (antidepressant) once a day. A physician order, dated 1/7/25, indicated the resident was to receive 0.5 milligrams of lorazepam twice a day for anxiety disorder. The medication was discontinued on 2/11/25 per request. A physician order, dated 1/7/25, indicated the resident was to receive 5 milligrams of Zyprexa three times a day for cognitive and social deficit. A physician order, dated 1/8/25, indicated the resident was to receive 100 milligrams of sertraline daily for a mood disorder. The medication was discontinued on 2/11/25 per request. A psychiatric (psych) provider visit note, dated 2/6/25, indicated the resident suffered from alcohol use disorder. She reported feeling depressed and anxious. She does have behaviors of frequently crying. The resident was admitted on a lot of medications and currently planned to discontinue medications. The plan for care at that time was to start GDR on Zyprexa from three times a day to twice a day; start 20-10 milligrams of Nuedexta for seven days, then increase to twice a day, and next week plan to continue weaning medications. A physician order, dated 2/8/25, indicated the resident was to receive Nuedexta daily for Pseudobulbar affect (PBA) (a neurological condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying). A social service note written by the Social Services Director (SSD), dated 2/10/25, indicated SSD spoke with resident's [Representative] .stated per the neurologist Dr [doctor] resident is not to be prescribed anti-depressants or anti-anxiety medications due to hx [history] of serotonin syndrome, delusional and emotionally unstable on these drug class. Sertraline, hydroxyzine and lorazepam to be d/c'd [discontinued] at [Resident B's Representative] request. Special instructions added to resident's profile. Psych NP [Psychiatric Nurse Practitioner] notified for next visit. The resident's clinical record did not have documentation that the psych provider was aware of and agreed to the referral by the resident's representative to abruptly stop the lorazepam and sertraline prior to discontinuing the medications. The black box warnings for the usage of lorazepam and sertraline indicated abrupt discontinuation of those medications could lead to withdrawal reactions. It was recommended to avoid the risk of withdrawal reactions to reduce the dosage of those medications gradually. An interview was conducted with the SSD on 4/16/25 at 12:40 p.m. She indicated Resident B's Representative had notified her that Resident B did not do well on psychotropic medications. She wanted those medications discontinued. The SSD had reported to the Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator that the resident's representative wanted the medications discontinued. The SSD had notified the psych provider by phone, and she would see the resident on the next psych visit. An interview was conducted with the MDS Coordinator on 4/16/25 at 12:45 p.m. She indicated the SSD had reported Resident B's Representative wanted the resident's antidepressant and antianxiety medications immediately stopped. She believed she was involved in a text group message by phone with the psych provider that indicated the notification of the resident's representative wishes to abruptly stop the antidepressant and antianxiety medications. At that time, she indicated she was unable to locate the group text message with the psych provider. An interview was conducted with Resident B's Representative on 4/16/25 at 1:24 p.m. She indicated she had spoken to the SSD requesting Resident B's antianxiety medication and antidepressant medication to be discontinued, but it was to be done slowly. Resident B had a past history with serotonin syndrome, and she should not be on the medications per the resident's neurologist. She had not meant to abruptly stop those types of medications. The psych provider was not available for interview. The behavior management policy was provided by the DON on 4/16/25 at 2:05 p.m. It indicated Policy .The purpose is to review residents who have behaviors and who are being monitored for these behaviors. Further, to discuss and review residents who have newly developed behaviors to ensure that all appropriate interventions are in place to manage the behaviors with non-pharmacological interventions or the least dosage of psychoactive med(s) possible to promote and maintain the highest degree of psychosocial well-being and quality of life .Standards: 1) The facility will make every effort to comply with state and federal regulations related to the use of psychoactive medications, to include regular, structured review for continued need, appropriate dose, side effects, risks and benefits . 3) Should a psychoactive medication(s) be necessary, regular efforts to reduce or discontinue this medication(s) will be made ongoing as appropriate based on review and discussion of the behaviors amongst the behavior management team members. This will usually be done by a GDR (Gradual Dose Reduction) trial . 5)Psychoactive medications include anti-anxiety/hypnotic, anti-psychotic and anti-depressants . This citation relates to Complaint IN00457282. 3.1-48(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor a resident's right for dignity to 2 of 5 residents reviewed for timely response to call lights and 1 of 1 resident reviewed for incontinence care by offering an incontinence brief. (Resident C and Resident F) Findings include: 1. In an interview with Resident C on 3-31-25 at 1:46 p.m., she indicated the minimum amount of time it took to get her call light answered was typically 30 minutes and this reflected all shifts, but especially night shift. She indicated she had been a resident of the facility for over five years. The clinical record of Resident C was reviewed on 3-31-25 at 12:05 p.m. Her most recent Minimum Data Set assessment, dated 3-15-25, indicated she was cognitively intact. 2. In an interview with a family member of Resident F on 4-1-25 at 2:46 p.m., she indicated earlier in the day, the resident had activated the call light to request toileting assistance. She added the call light had been on for about 20 minutes when she (the family member) then went to the nurse's station and found several staff members present and requested they assist the resident with toileting. She indicated she left the area for approximately 10 minutes and upon return, was informed by the staff that the resident was on the toilet. She indicated when she returned to the resident's room, she found the resident still waiting for assistance. She indicated in the recent past, she had received phone calls from the resident that she had her call light on for 30 minutes or more without a staff response and had asked her to call the facility's main line to gain access for assistance for the resident. The family member indicated since Resident F was admitted over one month ago, the resident has been offered by staff to wear an incontinence brief. They kept offering her a diaper and we have refused it every time. After a week of being told this, we told them not to offer that anymore. That is humiliating for anyone, but someone as young as she is. The clinical record of Resident F was reviewed on 4-2-25 at 11:14 a.m. Her admission Minimum Data Set assessment, dated 2-19-25, indicated she was less than [AGE] years old, was cognitively intact, was non-ambulatory, required substantial assistance from staff for toileting and was occasionally incontinent of urine and frequently incontinent of stool. In an interview with the Director of Nursing (DON) on 4-2-25 at 10:05 a.m., he indicated it would be difficult to put a numeric value on how quickly he expected call lights to be answered, as it was dependent on time of day and what might be going on in the facility, but expected the staff to respond as quickly as possible to all call lights. On 4-1-25 at 2:30 p.m., the DON provided a copy of a policy entitled, Call Light, Use of, with a review date of 1-1-2020. This policy indicated its purpose as, To respond promptly to resident's call for assistance .All facility personnel must be aware of call lights at all times. Answer ALL call lights promptly whether or not you are assigned to the resident . On 4-2-25 at 4:35 p.m., the Corporate Nurse provided a copy of a policy entitled, Dignity, dated 8-9-2023. This policy indicated, Staff will be polite and respectful at all times .Residents will be allowed to wear what they choose if at all possible .Staff will honor the resident's preferences as much as possible .Should a resident have an episode of incontinence, staff will change them upon discovery of the episode. This citation relates to Complaint IN00451947. 3.1-3(t) 3.1-3(u)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on interview and record review, the facility failed to ensure the attending physician and family were notified in a timely manner of a significant weight loss in less than 30 days for 1 of 2 residents reviewed for gastric feedings. (Resident G) B. Based on interview and record review, the facility failed to ensure the attending physician and family were notified in a timely manner of a new open area to a resident's neck for 1 of 2 residents reviewed for notification of change in condition. (Resident D) Findings include: A. During an interview on 4-1-25 at 3:56 p.m., with a family member of Resident G, she indicated during the previous night, she had spent the night in Resident G's room, at his request. She explained Resident G had several strokes during 2024, resulting in significant paralysis and an inability to swallow safely, thus causing him to require a feeding tube. The clinical record of Resident G was reviewed on 4-2-25 at 1:46 p.m. His diagnoses included, but were not limited to, encephalopathy, cerebral infarction with hemiplegia and hemiparesis affecting the right side, general muscle weakness, diabetes, gastrostomy (feeding tube) status. His re-admission Minimum Data Set (MDS) assessment, dated 3-5-25, indicated he was severely cognitively impaired, did not receive oral nutrition, and received 51 or more percent (%) of his nutrition from enteral feedings and received over 500 milliliters of enteral nutrition daily. It indicated his most recent weight was 205 pounds but did not indicate if this was reflective of any weight gain or weight loss. A review of Resident G's physician orders, effective 2-17-25, indicated he was to receive an enteral feeding of (brand name of liquid nutrition) of 60 milliliters (2 tablespoons) per hour, for a total of 1,440 milliliters every 24 hours. It also indicated he was not to receive anything by mouth. An order dated, 1-7-25, indicated to obtain his weight upon admission, then weekly for four weeks, then to obtain his weight monthly on Mondays. Resident G's initial weight, on 1-7-25, was recorded as 220.6 pounds, followed by a weight on 2-17-25, of 236.0 pounds, then a weight on 3-4-25, of 205.3 pounds. This reflected a significant weight loss of 30.7 pounds or more than 10% in less than one month. His clinical record indicated Resident G had been hospitalized from [DATE] to 2-17-25, and from 2-20-25 to 2-28-25. An interdisciplinary notation, dated 3-5-25, indicated Resident G had been recently readmitted to the facility and received tube feedings. It reflected a weight of 205.0 pounds, but did not reflect any weight loss or gain. It indicated his Food Intakes, as Fair. and he received enteral feedings at 60 milliliters per hour. It did not indicate he was to be, NPO [nothing by mouth]. It indicated his physician, and family had been notified of this information. A second interdisciplinary notation, dated 3-12-25, with an updated weight of 206.0 pounds, on 3-11-25, provided the same information. The interdisciplinary team notations failed to identify the significant weight loss until a notation from dietary, on 2-19-25, indicated, triggering for sig wt [significant weight] gain 5% x 30 days- not of concern at this time, likely due to previous tube feed + [plus] oral intakes. Further wt gain not recommended. Cont [Continue] to monitor weekly on swat [interdisciplinary team]. Specific documentation failed to reflect the attending physician or family had been notified of the significant weight loss on the above dates. A notation, dated 3-26-25, from the Registered Dietitian (RD), indicated Resident G's current weight of 208.5 pounds was a significant weight loss of 5% in a 30 day period. It identified a concern of the accuracy of the documented weight obtained, on 2-17-25, as well as changes made to the resident's enteral feeding orders, which had been at a higher rate previously. The notation indicated the plan of action was to continue to monitor Resident G in the weekly interdisciplinary meetings, related to the enteral nutrition. This notation did not reflect the attending physician, or family had been notified of the significant weight loss on this date. In an interview with the Director of Nursing (DON) on 4-2-25 at 2:02 p.m., he indicated Resident G was followed by the interdisciplinary team on a weekly basis due to receiving tube feedings. He indicated the RD was aware of Resident G's weight loss. B. The clinical record of Resident D was reviewed on 4-1-25 at 11:01 a.m. It indicated his diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, metabolic encephalopathy, tracheostomy status and dysphagia. His most recent Minimum Data Set (MDS) assessment, dated 1-25-25, indicated he was severely cognitively impaired, was nonverbal, nonambulatory, and was dependent on staff for all activities of daily care. It indicated he had a feeding tube and a tracheostomy (trach), which required oxygen support and tracheostomy care, including suctioning. It indicated he did not have any pressure ulcers, but did have an open area to his feet and moisture associated skin damage. In an interview on 4-2-25 at 12:30 p.m., with a family member of Resident D, she indicated, I was in on 3-23-25 for a visit and I did not see any problems with his skin. The next day, at his radiology appointment, I saw there was something on his neck. He does lean his head to the left a lot of the time .My guess is the trach collar elastic may have contributed to the place on his neck. She indicated he was taken directly to the emergency room (ER) after his radiology appointment for further treatment and evaluation. The family member indicated she had not been made aware of any skin concerns prior to noticing the open area to his neck at the radiology appointment on 3-24-25. She estimated the time of the radiology appointment was mid to late morning. She indicated she did not see a dressing or steri-strips to the open area, but there was some bloody drainage present to the trach tube ties and to the linen around/under the neck area. A review of the clinical record indicated a Weekly Skin Check form, dated 3-24-25 at 8:39 a.m., indicated Resident D had a newly open area. An accompanying document, also dated 3-24-25 at 8:39 a.m., entitled, Weekly Wound Event, indicated a new laceration, had been identified on that date to the left side of his neck, measuring 5.1 centimeters (cm) by 0.1 cm with a depth of 0.2 cm. It indicated a small amount of serosanguinous (combination of clear fluid and blood) drainage. It listed only steri strips as the current treatment. It indicated, on 3-24-25, the attending physician was aware and the responsible party updated on wound status. The clinical record documentation failed to identify when the open area was initially identified and what treatment, if any, was conducted prior to the Weekly Skin Check being conducted. The nursing progress notes failed to identify any notifications to the facility administration of the new open area and the time of Resident D's departure from the facility to the radiology appointment. The DON indicated, on 4-1-25 at 11:35 a.m., he would provide a copy of the emergency room visit of 3-24-25, but did not provide the documentation prior to exit on 4-2-25. In an interview with the DON on 4-2-25 at 10:05 a.m., he indicated the nurse on duty for the night shift, of 3-23-25 until the morning of 3-24-25, had notified him, on 3-24-25, close to 7:00 a.m., that a new open area to the left side of Resident D's neck had been identified about an hour earlier and had cleaned it up and covered it with a dressing. I told them that was fine and that I would have the wound nurse look at it as soon as she got there that morning. I went in with the wound nurse myself and that's when we found the laceration. It looked like the elastic from the trach mask had kind of cut into his neck. We cleaned it up and tried to pad it good with gauze squares. The DON indicated he did not see any documentation from the nurse who originally identified the open area and had made him aware of the situation, but the wound nurse documented her findings shortly thereafter. On 4-2-25 at 4:18 p.m., the Corporate Nurse provided a copy of a policy entitled, Guidelines for Notification of Change in Resident's Condition/Status/Treatment, dated 6-29-2024. It indicated, It is the intent of the facility to ensure that the resident, their attending physician, and the resident's Responsible Party/POA are notified of changes in the resident's condition, status or treatment. This notification will be done promptly in order to obtain any orders needed for appropriate treatment and/or monitoring related to the change--as well as to promote the resident right related to make choices about treatment and care preferences .Notification is provided to the physician to facilitate continuity of care and to obtain input from the physician about appropriate interventions/changes which can include additions to, or discontinuation of, current care/treatments--related to the notification. Notification is provided to the resident and/or the resident's Responsible Party/POA in conjunction with the resident right to make choices about care and treatment and to keep them informed of the resident's current health status--related to the notification. This citation relates to Complaint IN00456622. 3.1-3(n)(2) 3.1-5(a)(3)

Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 of 5 residents reviewed for bathing and hygiene care needs. (Resident B) Findings include: The clinical record of Resident B was reviewed on 3-31-25 at 10:12 a.m. His diagnoses included, but were not limited to, pneumonia, unspecified cirrhosis of liver, unspecified abnormalities of gait and mobility, cognitive communication deficit and general muscle weakness. His admission Minimum Data Set (MDS) assessment, dated 12-12-24, indicated he was moderately cognitively impaired, required moderate assistance from staff for bathing or showering, and supervision from staff for hygiene care. In an interview with a family member of Resident B on 3-31-25 at 11:15 a.m., he indicated Resident B received very few showers while at the facility. A comprehensive care plan was not located in Resident B's clinical record for assistance with activities of daily living (ADL's) or specifically for bathing and hygiene care needs. In an interview on 4-1-25 at 9:40 a.m. with the Director of Nursing (DON), he indicated the facility did not have a care plan for this resident's ADL's. In an interview on 4-1-25 at 11:04 a.m. with the MDS Coordinator, she indicated, It looks like I overlooked doing a care plan for ADL's, based on the admission MDS and the baseline care plan .The baseline care plan is done by the admitting nurse, usually on the same day they are admitted . It's based on what that nurse sees and is told initially. The admission MDS is conducted within that first week or so while the nursing staff can actually see how well the new admission [resident] is doing and what I can assess while I am in the process of that first MDS assessment. On 4-1-25 at 12:01 p.m., the DON provided a copy of a policy entitled, Baseline Care Plan Assessment/Comprehensive Care Plans, updated on 9-18-2018. This policy indicated, It is the policy of the facility to ensure that every resident has a Baseline Care Plan completed and implemented within 48 hours of admission .The Baseline Care Plan will be discontinued upon the completion of the Comprehensive Care Plan. The Comprehensive Care Plan will further expand on the resident's risks, goals and interventions using the 'Person-Centered' Plan of Care approach for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs . This citation relates to Complaint IN00450054. 3.1-35(a) 3.1-35(b)(1)

Based on interview and record review, the facility failed to provide bathing and/or showering care for 1 of 5 residents reviewed for bathing and hygiene care needs. (Resident B) Findings include: The clinical record of Resident B was reviewed on 3-31-25 at 10:12 a.m. His diagnoses included, but were not limited to, pneumonia, unspecified cirrhosis of liver, unspecified abnormalities of gait and mobility, cognitive communication deficit, and general muscle weakness. His admission Minimum Data Set (MDS) assessment, dated 12-12-24, indicated he was moderately cognitively impaired, required moderate assistance from staff for bathing or showering and supervision from staff for hygiene care and it was very important, for him to be able to choose what manner of bathing he received, such as tub bath, shower, bed bath or sponge bath. In an interview with a family member of Resident B on 3-31-25 at 11:15 a.m., he indicated Resident B received very few showers while at the facility. In an interview on 4-1-25 at 11:04 a.m., with the MDS Coordinator, she indicated It looks like I overlooked doing a care plan for ADL's [activities of daily living], based on the admission MDS and the baseline care plan .The baseline care plan is done by the admitting nurse, usually on the same day they are admitted . It's based on what that nurse sees and is told initially. The admission MDS is conducted within that first week or so while the nursing staff can actually see how well the new admission [resident] is doing and what I can assess while I am in the process of that first MDS assessment. A review of Resident B's bathing records for 12/2024, indicated his Bathing Choice Provided was scheduled for Monday and Thursday evenings. It indicated he received three bed baths, one partial bath and no showers for the 25 days of December he was present in the facility. His bathing records for 1/2025, indicated his Bathing Choice Provided was scheduled for Monday and Thursday evenings. It indicated he received three partial baths and one shower in the 30 days of January he was present in the facility. The facility provided a copy of an I Would Like To Know form, also known as a grievance form. The form, dated 1-2-25, indicated the facility's Social Services Designee (SD) had documented on the form that Resident B had questions regarding what his shower schedule was. A response to this form, dated 1-2-25, indicated the concern was brought to the attention of the nursing department on the same date. It indicated the Action Taken included contacting the son of Resident B to inform him to explain, the shower schedule/protocol .explained to son and resident that [name of Resident B] can take showers at his preferred times due to his level of independence .Shower given same day. The bathing documentation for 1-2-25, did not reflect bathing of any type was provided to Resident B. This citation relates to Complaint IN00450054. 3.1-38(a)(2)(A) 3.1-38(a)(3)(B)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident receiving continuous enteral (gastric) feedings received feedings as ordered and a significant weight loss occurring in less than 30 days was identified and timely interventions related to the weight loss were conducted for 1 of 2 residents reviewed for gastric feedings. (Resident G) Findings include: During an interview on 4-1-25 at 3:56 p.m., with a family member of Resident G, she indicated during the previous night, she had spent the night in Resident G's room, at his request. She explained Resident G had several strokes during 2024, resulting in significant paralysis and an inability to swallow safely, thus causing him to require a feeding tube. She indicated sometime between 2:00 a.m. and 4:00 a.m., on 4-1-25, the continuous feeding had run out and it had not been resumed prior to her leaving the facility later that morning at 8:20 a.m. She indicated the nursing staff informed her the reason the feeding was not resumed was because the needed feeding solution was locked in an office in the facility and was not accessible to the nursing staff. In an interview with the Director of Nursing (DON) on 4-2-25 at 9:45 a.m., he indicated he had not been made aware of any issues regarding Resident G's feeding being unavailable during the night shift on Monday night. In an interview with the DON, one hour later, he indicated he had attempted to reach out to the nurse who had been on duty during that time but had to leave a message for the nurse to return his call. In an interview with the DON on 4-2-25 at 3:05 p.m., he indicated the nurse had called back and confirmed Resident G's feeding had run out at approximately 3:00 a.m., on 4-1-25, due to the feeding solution having been locked up and inaccessible to the staff. He indicated the feeding was resumed on 4-1-25 at 8:30 a.m. The clinical record of Resident G was reviewed on 4-2-25 at 1:46 p.m. His diagnoses included, but were not limited to, encephalopathy, cerebral infarction with hemiplegia and hemiparesis affecting the right side, general muscle weakness, diabetes, gastrostomy (feeding tube) status. His re-admission Minimum Data Set (MDS) assessment, dated 3-4-25, indicated he was severely cognitively impaired, did not receive oral nutrition, and received 51 or more percent (%) of his nutrition from enteral feedings and received over 500 milliliters of enteral nutrition daily. It indicated his most recent weight was 205 pounds, but did not indicate if this was reflective of any weight gain or weight loss. A review of Resident G's medication administration record, treatment administration record and the nursing progress notes did not indicate any interruptions of the enteral feeding had occurred on 4-1-25. A review of Resident G's physician orders, effective 2-17-25, indicated he was to receive an enteral feeding of (brand name of liquid nutrition) of 60 milliliters (2 tablespoons) per hour, for a total of 1,440 milliliters every 24 hours. It also indicated he was not to receive anything by mouth. An order dated, 1-7-25, indicated to obtain his weight upon admission, then weekly for four weeks, then to obtain his weight monthly on Mondays. Resident G's initial weight on 1-7-25, was recorded as 220.6 pounds, followed by a weight on 2-17-25, of 236.0 pounds, then a weight on 3-4-25, of 205.3 pounds. This reflected a significant weight loss of 30.7 pounds of more than 10% in less than one month. His clinical record indicated Resident G had been hospitalized from [DATE] to 2-17-25, and from 2-20-25 to 2-28-25. An interdisciplinary notation, dated 3-5-25, indicated Resident G had been recently readmitted to the facility and received tube feedings. It reflected a weight of 205.0 pounds, but did not reflect any weight loss or gain. It indicated his Food Intakes as Fair and that he received enteral feedings at 60 milliliters per hour. It did not indicate he was to be NPO [nothing by mouth]. It indicated his physician, and family had been notified of this information. A second interdisciplinary notation, dated 3-12-25, with an updated weight of 206.0 pounds, on 3-11-25, provided the same information. The interdisciplinary team notations failed to identify the significant weight loss until a notation from dietary, on 2-19-25, indicated triggering for sig wt [significant weight] gain 5% x 30 days- not of concern at this time, likely due to previous tube feed + [plus] oral intakes. Further wt gain not recommended. Cont [Continue] to monitor weekly on swat [interdisciplinary team]. Specific documentation failed to reflect the attending physician or family had been notified of the significant weight loss on the above dates. A notation, dated 3-26-25, from the Registered Dietitian (RD), indicated Resident G's current weight of 208.5 pounds was a significant weight loss of 5% in a 30 day period. It identified a concern of the accuracy of the documented weight obtained, on 2-17-25, as well as changes made to the resident's enteral feeding orders, which had been at a higher rate previously. The notation indicated the plan of action was to continue to monitor Resident G in the weekly interdisciplinary meetings, related to the enteral nutrition. This notation did not reflect the attending physician, or family had been notified of the significant weight loss on this date. In an interview with the Director of Nursing (DON) on 4-2-25 at 2:02 p.m., he indicated Resident G was followed by the interdisciplinary team on a weekly basis due to receiving tube feedings. He indicated the RD was aware of Resident G's weight loss. He indicated missing several hours of the enteral feeding, on 4-1-25, could possibly be of concern. On 4-2-25 at 3:54 p.m., the DON provided a copy of policy entitled, Guidelines for Enteral Feeding: Adult, dated 7-3-2023. This policy indicated its purpose was To provide guidance to qualified licensed clinical staff in hanging and maintaining and managing and administering Tube/Feedings and Enteral Nutrition to residents .The nurse will review the order for type of formula, rate and advancement instructions, all associated orders. The formula will be retrieved from where it is stored until use in a clean/dry area and at the proper temperature for stability .Weigh the resident 3x weekly or as ordered (usually M-W-F) and record in the medical record . On 4-2-25 at 4:18 p.m., the Corporate Nurse provided a copy of a policy entitled, Guidelines for Notification of Change in Resident's Condition/Status/Treatment, dated 6-29-2024. It indicated, It is the intent of the facility to ensure that the resident, their attending physician, and the resident's Responsible Party/POA are notified of changes in the resident's condition, status or treatment. This notification will be done promptly in order to obtain any orders needed for appropriate treatment and/or monitoring related to the change--as well as to promote the resident right related to make choices about treatment and care preferences .Notification is provided to the physician to facilitate continuity of care and to obtain input from the physician about appropriate interventions/changes which can include additions to, or discontinuation of, current care/treatments--related to the notification. Notification is provided to the resident and/or the resident's Responsible Party/POA in conjunction with the resident right to make choices about care and treatment and to keep them informed of the resident's current health status--related to the notification. 3.1-46(a)(1) 3.1-46(a)(2)

Based on interview and record review, the facility failed to thoroughly document information regarding the identification of a newly identified open area and information regarding notification of a change in condition to the family regarding the new open area for 1 of 2 residents reviewed for tracheostomies (trach). (Resident D) Findings include: The clinical record of Resident D was reviewed on 4-1-25 at 11:01 a.m. It indicated his diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, metabolic encephalopathy, tracheostomy status and dysphagia. His most recent Minimum Data Set (MDS) assessment, dated 1-25-25, indicated he was severely cognitively impaired, was nonverbal, nonambulatory, and was dependent on staff for all activities of daily care. It indicated he had a feeding tube and a tracheostomy, which required oxygen support and tracheostomy care, including suctioning. It indicated he did not have any pressure ulcers, but did have an open area to his feet and moisture associated skin damage. In an interview on 4-2-25 at 12:30 p.m. with a family member of Resident D, she indicated, I was in on 3-23-25 for a visit and I did not see any problems with his skin. The next day, at his radiology appointment, I saw there was something on his neck. He does lean his head to the left a lot of the time .My guess is the trach collar elastic may have contributed to the place on his neck. She indicated he was taken directly to the emergency room (ER) after his radiology appointment for further treatment and evaluation. The family member indicated she had not been made aware of any skin concerns prior to noticing the open area to his neck at the radiology appointment on 3-24-25. She estimated the time of the radiology appointment was mid to late morning. She indicated she did not see a dressing or steri-strips to the open area, but there was some bloody drainage present to the trach tube ties and to the linen around/under the neck area. A review of the clinical record indicated a Weekly Skin Check form, dated 3-24-25 at 8:39 a.m., indicated Resident D had a newly open area. An accompanying document, also dated 3-24-25 at 8:39 a.m., entitled Weekly Wound Event, indicated a new laceration had been identified on that date to the left side of his neck, measuring 5.1 centimeters (cm) by 0.1 cm with a depth of 0.2 cm. It indicated a small amount of serosanguinous (combination of clear and bloody fluid) drainage. It listed only steri strips as the current treatment. It indicated, on 3-24-25, the attending physician was aware and the responsible party updated on wound status. The clinical record documentation failed to identify when the open area was initially identified and what treatment, if any, was conducted prior to the Weekly Skin Check being conducted. The nursing progress notes failed to identify any notifications to the attending physician, family or facility administration of the new open area and the time of Resident D's departure from the facility to the radiology appointment. The Director of Nursing (DON) indicated, on 4-1-25 at 11:35 a.m., he would provide a copy of the emergency room visit of 3-24-25, but it was not provided prior to exit on 4-2-25. In an interview with the DON on 4-2-25 at 10:05 a.m., he indicated the nurse on duty for the night shift, of 3-23-25 until the morning of 3-24-25, had notified him on 3-24-25, close to 7:00 a.m., that a new open area to the left side of Resident D's neck had been identified about an hour earlier and they had cleaned it up and covered it with a dressing. I told them that was fine and that I would have the wound nurse go look at it as soon as she got there that morning. I went in with the wound nurse myself and that's when we found the laceration. It looked like the elastic from the trach mask had kind of cut into his neck. We cleaned it up and tried to pad it good with gauze squares. The DON indicated he did not see any documentation from the nurse who originally identified the open area and had made him aware of the situation, but the wound nurse documented her findings shortly thereafter. On 4-1-25 at 3:15 p.m., in an interview with the Corporate Nurse, she indicated the facility does not have a specific policy on documentation. This citation relates to Complaint IN00456622. 3.1-50(a)(1) 3.1-50(a)(2) 3.1-50(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident's dignity was maintained by not sitting down while assisting a resident with eating for 1 of 1 resident randomly observed during dining. (Resident 2) Findings include: The clinical record for Resident 2 was reviewed on 10/7/24 at 11:00 a.m. The diagnoses included, but were not limited to, dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 7/10/24, indicated cognitive impairment. An Activities of Daily Living (ADL) care plan, revised 12/22/23, indicated she needed assistance with eating. An observation was conducted of Resident 2 in the dining room on 10/7/24 at 12:35 p.m. The resident was observed sitting at a table in the dining room. Certified Nursing Assistant (CNA) 1 was standing next to the resident's table assisting the resident with eating her meal. An interview was conducted with the Nurse Consultant (NC) on 10/7/24 at 3:30 p.m. She indicated CNA 1 should have been sitting while assisting Resident 2 with her meal. A resident rights policy was provided by the NC on 10/8/24 at 10:14 a.m. It indicated, .7) It is important that staff be aware of the resident rights to include, but not limited to .A dignified existence - resident being treated with dignity in all situations .To achieve this --staff will .1) Treat each resident with respect and dignity. 2) Care for each resident in a manner and environment that promotes the maintenance of/or enhances the resident's quality of life . 3.1-3(t)

Based on interview and record review, the facility failed to timely address a resident's grievance for 1 of 1 resident reviewed for choices. (Resident 11) Findings include: The clinical record for Resident 11 was reviewed on 10/3/24 at 9:00 a.m. The diagnoses included, but were not limited to, stroke. A quarterly Minimum Data Set (MDS) Assessment, dated 9/12/24, indicated Resident 11 was cognitively intact. An interview was conducted with Resident 11 on 10/3/24 at 9:41 a.m. He indicated he had been storing a Tupperware container that contained his tea pot and tea bags in a cabinet in the dining room for years. He was told a couple of days ago; he no longer was allowed to do that anymore. He had to store the Tupperware container in his room and take it back-an-forth from his room to the dining room every meal. It made it difficult. He was never given a reason why he could no longer store the container in the dining room. The resident had told everyone he was not happy about it. He had worked really hard to be able to use his crutches, but now he had to get back in the wheelchair. He cannot take his Tupperware container to the dining room with his crutches. An interview was conducted with the Activities Director on 10/7/24 at 2:49 p.m. She indicated Resident 11 was unhappy he was unable to store his teapot and tea bags in the dining room. He had stored the Tupperware container in the dining room for years, but was told, either 9/30/24 or 10/1/24, he was no longer able to store it there. He would use an exercise band strapped to his wheelchair to take his Tupperware container back-an-forth to the dining room. She did not fill out a grievance form about the resident's concern. A grievance policy was provided by the Administrator on 10/8/24 at 10:24 a.m. It indicated, . Purpose: To provide a 'process' by which a resident or resident's representative can have their questions/concerns brought to the proper source to be answered/addressed and resolved as much as possible to the satisfaction of the resident or their representative and to have this activity documented including: A. Question and Details B. Action taken (and by whom) C. Dates/Times D. Response back to resident/representative E. Documentation complete F. Filing in 'I would Like to know' . binder. Procedure: 1. When a resident or a resident's representative presents a question/concern, a staff member obtains the 'I would like to know' . form. A staff member completes the form for the resident or the resident's representative. If possible, a leadership staff person should complete the form. The form is then deposited into a designated secure area .3. During the following morning meeting, the Administrator or designee reads the 'I would like to know' . form to the CQI [Continuous Quality Improvement] committee and logs the questions/concern on the tracking form. 4. The Department Head(s) who is designated by the Administrator/CQI Committee to be the appropriate person(s) to address the question/concern will be provided a copy of the 'I would like to know form' . 6. At the CQI meeting, the Administrator or designee will review the log and the status of the unanswered questions/concerns will be discussed. The objective being to answer all logged questions/concerns as soon as possible. 7. The assigned Department Head should be prepared to share what has been done to date to answer/resolve the question/concern .10. When the question/concern has been answered or has been resolved to the greatest degree possible, the assigned Department Head will contact the appropriate party to discuss what has been done. It is important that the resident or the resident's representative understands and agrees with or accepts the 'answer' as being to their satisfaction . 3.1-7(a)(2) 3.1-7(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medications and collect urine samples as ordered, to timely schedule a follow-up appointment for a resident who was admitted with a healing leg fracture, and timely implement dietary recommendations for a resident with a feeding tube for 1 of 1 resident reviewed for mobility, 1 of 1 resident reviewed for feeding tubes, and 3 of 5 residents reviewed for unnecessary medications. (Resident 11, Resident 29, Resident 30, Resident 42, and Resident 95) Findings include: 1. The clinical record for Resident 42 was reviewed on 10/3/24 at 1:18 p.m. The diagnoses included, but were not limited to, fracture of the lower femur (thighbone) and depression. She was admitted to the facility on [DATE]. A physician's progress note, dated 9/10/24, indicated Resident 42 had recently admitted to the facility. She had a previous stay at another rehabilitation facility following a right femur fracture on 7/26/24. An admission Minimum Data Set (MDS) assessment, dated 9/11/24, indicated Resident 42 had severe cognitive impairment and was dependent on staff for bed mobility and lower body dressing. A physician's order, dated 9/17/24, indicated the right leg brace was to be monitored each shift for damage and wetness. The skin under the brace was to be monitored for open areas, redness, swelling, or any trouble moving toes. A physician progress note, dated 9/18/24, indicated she had received non-surgical care for her right femur fracture and continued to use a knee immobilizer. An orthopedic follow-up appointment was needed. During an interview on 10/3/24 at 2:59 p.m., Licensed Practical Nurse (LPN) 3 indicated Resident 42 had worn the brace on her right leg since being admitted to the facility and she thought there was an orthopedic appointment coming up soon. On 10/7/24 at 9:33 a.m., LPN 4 was observed talking on the phone at the nurses' station, inquiring about making an appointment for Resident 42 to see an orthopedic doctor. During an interview on 10/7/24 at 9:37 a.m., LPN 4 indicated she had just made an appointment for Resident 42 to see the orthopedic doctor for a follow-up appointment. LPN 4 was unsure why the appointment had not been previously scheduled. During an interview on 10/7/24 at 2:14 p.m., the Director of Nursing (DON) indicated the facility should have attempted to make the follow-up orthopedic appointment for Resident 42 sooner. 2. The clinical record for Resident 30 was reviewed on 10/2/24 at 3:25 p.m. The diagnoses included, but were not limited to, epilepsy and dysphagia (inability to swallow). A care plan, last revised 11/8/23, indicated Resident 30 had a nutritional problem related to having a gastric tube (g-tube) provide all hydration and nutritional needs. The goal was for him to maintain his weight to within ten percent of his ideal body weight range. The interventions included, but were not limited to, the registered dietician to evaluate feedings and flushes as needed for weight changes and skin issues. The registered dietician would make recommendations as needed. Resident 30's weight, on 7/9/24, was 188.4 pounds. His weight, on 8/5/24, was 193.4 pounds. A Nutritional Assessment, dated 8/21/24, indicated he received Jevity (type of nutritional feeding) at 80 milliliter (ml) an hour continuously. He was dependent on tube feedings for nutrition and had a possible significant weight gain. The plan was to continue the tube feedings as ordered and to continue following weights and lower tube feeding if weight gain persisted. A SWAT (Skin Weight Assessment Team) note, dated 9/18/24, indicated his most recent weight, done on 8/5/24, was 193.4 pounds. He was to continue to be monitored, and the Registered Dietician (RD) had requested weekly weights. A SWAT note, dated 9/25/24, indicated his most recent weight, done 8/5/24, was 193.4 pounds. The RD had requested a weekly weight be completed. A SWAT note, dated 10/2/24, indicated his most recent weight, done 8/5/24, was 193.4 pounds. The RD had requested a monthly and weekly weights be completed. The clinical record did not contain a weight for September 2024. During an interview on 10/8/24 at 9:30 a.m., Nurse Consultant (NC) 1 indicated Resident 30's October monthly weight was 198.7 pounds. There was not a September weight recorded. During an interview on 10/8/24 at 10:49 a.m., NC 1 indicated weekly weights should have been completed as recommended by the RD. On 10/8/24 at 10:49 a.m., NC 1 provided the S-W-A-T Program Meeting Guidance, dated 10/9/23, which read .Intent: It is the intent of the facility to assess the nutritional status as well as the skin condition status of each resident and to timely address any issues or any potential for issues related to weight and /or skin . Procedure .5 Interventions decided upon by the team will be recorded on the individual resident monitoring record form. The appropriate disciplines will address interventions determined by the team . 3. The clinical record for Resident 11 was reviewed on 10/3/24 at 9:00 a.m. The diagnoses included, but were not limited to, stroke. A physician order, dated 9/3/24, indicated Collect urine for urine culture to be picked up on 9/16/24 lab day. The start date was 9/15/24. A physician order, dated 9/3/24, indicated Fax urine culture results to Urology of Indiana .every shift .for 4 days may dc [discontinue] this order when completed. The start date was 9/16/24. The September 2024 Medication/Treatment Administration Record indicated, on 9/18/24 and 9/19/24, Resident 11's urine was not collected. An interview was conducted with the Nurse Consultant on 10/7/24 at 3:00 p.m. She indicated Resident 11's urine was not collected as ordered. 4. The clinical record for Resident 29 was reviewed on 10/3/24 at 2:50 p.m. The diagnoses included, but were not limited to, diabetes mellitus and hypertension. A diabetes care plan, dated 11/27/23, indicated the resident was to receive diabetic medication as ordered. A hypertension care plan, dated 11/27/23, indicated the staff was to administer medications as ordered. A physician order, dated 4/10/24, indicated the resident was to receive 25 milligrams of metoprolol (blood pressure medication) once daily. A physician order, dated 4/10/24, indicated the resident was to receive six units of lispro insulin (fast acting insulin) with each meal. A physician order, dated 6/27/24, indicated the resident was to receive eight units of degludec insulin (long acting insulin) twice a day. A physician order, dated 8/23/24, indicated the resident was to receive 0.2 milligrams of clonidine every four hours, if the systolic blood pressure was greater than 160, as needed. The September 2024 Medication Administration Record for Resident 29 indicated the following: The resident's systolic blood pressure was greater than 160, and he did not receive the 0.2 milligrams of clonidine on the following days: - 9/2/24 - blood pressure reading 163/73, - 9/7/24 - blood pressure reading 173/72, - 9/9/24 - blood pressure reading 193/84, - 9/10/24 - blood pressure reading 188/86, - 9/15/24 - blood pressure reading 180/93, - 9/19/24 - blood pressure reading 161/72, - 9/26/24 - blood pressure reading 183/78, and - 9/28/24 - blood pressure reading 167/81, The following days the resident's degludec insulin was not administered as ordered: - 9/4/24 - a.m. dosage, - 9/6/24 - a.m. dosage, - 9/7/24 - a.m. dosage, - 9/13/24 - a.m. dosage, - 9/18/24 - a.m. dosage, - 9/20/24 - a.m. dosage, - 9/24/24 - a.m. dosage, - 9/26/24 - a.m. dosage, and - 9/30/24 - a.m. dosage. The following days the resident's lispro insulin was not administered as ordered: - 9/3/24 - 8:15 a.m. dosage, - 9/4/24 - 8:15 a.m. dosage, - 9/5/24 - 8:15 a.m. dosage, - 9/6/24 - 8:15 a.m. dosage, 12:30 p.m. dosage, 5:30 p.m. dosage, - 9/7/24 - 8:15 a.m. dosage, - 9/9/24 - 8:15 a.m. dosage, - 9/13/24 - 8:15 a.m. dosage, - 9/15/24 - 8:15 a.m. dosage, - 9/16/24 - 8:15 a.m. dosage, - 9/17/24 - 12:30 p.m. dosage, - 9/18/24 - 8:15 a.m. dosage, - 9/19/24 - 8:15 a.m. dosage, 5:30 p.m. dosage, - 9/20/24 - 8:15 a.m. dosage, - 9/21/24 - 12:30 p.m. dosage, - 9/22/24 - 8:15 a.m. dosage, - 9/23/24 - 8:15 a.m. dosage, - 9/24/24 - 8:15 a.m. dosage, 5:30 p.m. dosage, - 9/25/24 - 8:15 a.m. dosage, - 9/26/24 - 8:15 a.m. dosage, - 9/27/24 - 8:15 a.m. dosage, - 9/29/24 - 8:15 a.m. dosage, and - 9/30/24 - 8:15 a.m. dosage. Resident 29's clinical record did not include parameters when to hold the resident's insulin nor documentation the medical provider was notified with clarification to hold the resident's insulin. An interview was conducted with the Nurse Consultant on 10/7/24 at 9:00 a.m. She indicated the nursing staff should be notifying the medical provider to hold Resident 29's insulin due to low blood sugars and the 0.2 milligrams of clonidine should have been administered if the resident's blood pressure results were greater than 160. She will have the medical provider review the clonidine order. 5. The clinical record for Resident 95 was reviewed on 10/4/24 at 1:21 p.m. The diagnoses included, but were not limited to, chronic kidney disease and Alzheimer's disease. A progress note, dated 9/17/24, indicated the resident's representatives provided physician orders to obtain a urine albumin/creatinine ratio (a test that measures how much protein in urine) lab. The urine sample will be picked up on 9/20/24. A physician order, dated 9/17/24, indicated the staff was to collect urine for an albumin-creatine ratio. The urine sample would be picked up on 9/20/24. Resident's 95 medical record did not include documentation the urine sample was obtained. An interview was conducted with the Nurse Consultant on 10/7/24 at 3:00 p.m. She indicated Resident 95's urine sample was not collected as ordered. A following physician orders policy was provided by the Nurse Consultant on 10/8/24 at 10:14 a.m. It indicated, .Policy: It is the policy of the facility to follow the orders of the physician .Procedure .4. All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received. 3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 5 of 5 residents medical records included documentation that indicated the resident or resident representative was provided education regarding the benefits and potential risks associated with the 2023-2024 COVID-19 vaccine; whether the COVID-19 vaccine was administered to the resident; or whether the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal for 4 of 5 residents reviewed for COVID-19 immunization. (Residents 11, 18, 20, 24, and 30) Findings include: The clinical records for Residents 11, 18, 20, 24, and 30 were reviewed on 10/3/24 at 11:48 a.m. Resident 11 was admitted to the facility on [DATE]. Resident 11's clinical record indicated he was last administered the COVID-19 vaccine on 7/7/22. There was no information in his clinical record that indicated Resident 11 or Resident 11's representative was provided education regarding the benefits and potential risks associated with the 2023-2024 COVID-19 vaccine; whether the 2023-2024 COVID-19 vaccine was administered to Resident 11; or whether Resident 11 did not receive the 2023-2024 COVID-19 vaccine due to medical contraindications or refusal. Resident 18 was admitted to the facility on [DATE]. Resident 18's clinical record indicated she was last administered the COVID-19 vaccine on 7/6/22. There was no information in her clinical record that indicated Resident 18 or Resident 18's representative was provided education regarding the benefits and potential risks associated with the 2023-2024 COVID-19 vaccine; whether the 2023-2024 COVID-19 vaccine was administered to Resident 18; or whether Resident 18 did not receive the 2023-2024 COVID-19 vaccine due to medical contraindications or refusal. Resident 20 was admitted to the facility on [DATE]. Resident 20's clinical record indicated he was last administered the COVID-19 vaccine on 7/6/22. There was no information in his clinical record that indicated Resident 20 or Resident 20's representative was provided education regarding the benefits and potential risks associated with the 2023-2024 COVID-19 vaccine; whether the 2023-2024 COVID-19 vaccine was administered to Resident 20; or whether Resident 20 did not receive the 2023-2024 COVID-19 vaccine due to medical contraindications or refusal. Resident 24 was admitted to the facility on [DATE]. Resident 24's clinical record indicated she was last administered the COVID-19 vaccine on 7/6/22. There was no information in her clinical record that indicated Resident 24 or Resident 24's representative was provided education regarding the benefits and potential risks associated with the 2023-2024 COVID-19 vaccine; whether the 2023-2024 COVID-19 vaccine was administered to Resident 24; or whether Resident 24 did not receive the 2023-2024 COVID-19 vaccine due to medical contraindications or refusal. Resident 30 was admitted to the facility on [DATE]. There was no information in Resident 30's clinical record that indicated Resident 30 or Resident 30's representative was provided education regarding the benefits and potential risks associated with the 2023-2024 COVID-19 vaccine; whether the 2023-2024 COVID-19 vaccine was administered to Resident 30; or whether Resident 30 did not receive the 2023-2024 COVID-19 vaccine due to medical contraindications or refusal. An interview was conducted with the Nurse Consultant (NC) on 10/4/24 at 10:45 a.m. She indicated they had no verification the 2023-2024 COVID-19 vaccination was offered, refused, medically contraindicated, or that education regarding the 2023-2024 COVID-19 vaccination was provided to Residents 11, 18, 20, 24, and 30. The NC provided the Post Public Health Emergency -Standard and Guidelines policy on 10/4/24 at 10:45 a.m. It read, The facility will continue to encourage everyone to remain up to date with all recommended Covid-19 vaccine doses. Healthcare Personnel, residents and visitors will be offered resources and counseled as necessary about the importance of the Covid-19 vaccine. The facility will provide education and visual alerts (signs, posters) to ensure everyone is aware of recommended IPC [Infection Prevention and Control] practices in the facility. The policy did not reference documentation of a resident's clinical record regarding whether the resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine; whether the COVID-19 vaccine was administered to the resident; or whether the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal.

Based on interview and record review, the facility failed to have a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. This had the potential to affect 49 of 49 residents in the facility. Findings include: The Payroll Based Journal (PBJ) Staffing Data Report for the third quarter of the 2024 Federal Fiscal Year indicated the facility had no RN coverage hours on the following dates: 4/7/24, 4/20/24, 4/21/24, 5/4/24, 5/5/24, 5/18/24, 5/19/24, 5/27/24, 6/1/24, 6/2/24, 6/15/24, 6/16/24, and 6/30/24. On 10/3/24 at 10:20 a.m., the Administrator provided the Daily Nursing Schedule for the above dates. They, along with the time sheets for RN 9 provided by the Director of Nursing (DON), on 10/4/24 at 10:45 a.m., indicated there was no RN coverage on Saturday, 4/20/24, and Sunday, 4/21/24, but the schedule and time sheets did verify RN coverage for 4/7/24, 5/4/24, 5/5/24, 5/18/24, 5/19/24, 5/27/24, 6/1/24, 6/2/24, 6/15/24, 6/16/24, and 6/30/24. An interview was conducted with the Staffing Coordinator (SC) and the DON on 10/3/24 at 11:28 a.m. The SC indicated she'd been the staffing coordinator for almost three years. The facility did not have RN coverage on 4/20/24 and 4/21/24. RN 9 was the facility's RN weekend option nurse, but she did not work on those dates, and they hadn't used agency nursing staff since 4/1/24. The DON indicated he worked Monday through Friday, and only worked weekends sometimes. An interview was conducted with the Nurse Consultant (NC) on 10/4/24 at 11:55 a.m. She indicated they had no facility policy regarding RN coverage. This citation relates to Complaints IN00433065 and IN00428580. 3.1-17(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to hold food on a steam table at safe temperatures with the potential to affect 48 of 49 residents residing at the facility. Findings include: On 10/4/24 at 12:41 p.m., the lunch service was observed in the facility's main kitchen with Facility [NAME] (FC) 1. FC 1 indicated he was serving the room trays. The steam table contained a serving pan of mixed vegetables and a serving pan of [NAME] fish filets. The temperature of the mixed vegetables was obtained at 121.8 degrees Fahrenheit (F). The temperature of the [NAME] fish fillets was obtained at 107 degrees F. FC 1 indicated the temperature of the mixed vegetables, and the [NAME] fish filets should have been at least 135 degrees F. On 10/4/24 at 12:48 p.m., the lunch service was observed in the facility's upstairs kitchenette. FC 2 indicated he was finishing the upstairs dining room's food service. The steam table contained a serving pan of French fries. The temperature of the French fries was obtained at 120 degrees F. On 10/4/24 at 1:50 p.m., the Regional Director of Operations provided the Food Safety Handout, dated 9/28/2020, which read, . Foods should be stored at appropriate temperatures to maintain safety .Hot foods held at 135 degrees Fahrenheit to 170 degrees Fahrenheit . 3.1-21(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was correctly completed, related to falls for 1 of 3 residents reviewed for falls. (Resident B) Findings include: The clinical record of Resident B was reviewed on 1-25-24 at 12:12 p.m. It indicated she was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, unspecified encephalopathy, diabetes, rheumatoid arthritis, depression, high blood pressure, unspecified signs and symptoms of cognitive function, general muscle weakness and unspecified protein-calorie malnutrition. Her admission MDS assessment, dated 10-9-23, under section J, indicated the facility was unable to determine if she had any falls or fractures in the 6 month period prior to her admission to the facility. It indicated she had sustained no falls from the time of her admission through the assessment reference date (ARD) of 10-9-23. A review of the clinical record from the date of admission and through 10-9-23, indicated she had sustained two falls on 10-8-23, one at 2:00 a.m. and the second at 5:30 p.m. In an interview on 1-25-24 at 2:00 p.m., with the Corporate Nurse, she indicated around the date of the MDS assessment for Resident B, the regular MDS staff person was out on medical leave and the facility was using a corporate MDS person. During the exit conference on 1-25-24 at 3:40 p.m., the Corporate Nurse indicated it appeared the regular MDS staff had conducted this particular MDS assessment. In an interview on 1-25-24 at 3:30 p.m., with the Executive Director, he indicated the facility does not have a particular policy related to the MDS assessments, but utilizes the most current RAI (Resident Assessment Instrument) manual. The Centers for Medicare & Medicaid Services ' Long-Term Care Facility Resident Assessment Instrument (RAI) User ' s Manual, October 2023, For Use Effective October 1, 2023, Section J, indicates for the review period for falls for the first or admission assessment, review the medical record for the time period from the admission date to the ARD .Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. All relevant records received from acute and post-acute facilities where the resident was admitted during the look-back period should be reviewed for evidence of one or more falls. Review nursing home incident reports and medical record (physician, nursing, therapy, and nursing assistant notes) for falls and level of injury. Ask the resident, staff, and family about falls during the look-back period. Resident and family reports of falls should be captured here, whether or not these incidents are documented in the medical record. Review any follow-up medical information received pertaining to the fall, even if this information is received after the ARD (e.g., emergency room x-ray, MRI, CT scan results), and ensure that this information is used to code the assessment. This Federal deficiency relates to Complaint IN00419429. 3.1-31(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3a. The clinical record for Resident 45 was reviewed on 8/7/23 at 2:17 p.m. The resident's diagnoses included, but were not limited to, opioid dependence with intoxication, major depressive disorder, bipolar disorder, psychoative substance abuse, personality disorder, and stroke. The resident was admitted to the facility on [DATE]. An Admissions MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 45 was cognitively impaired. 3b. The clinical record for Resident 40 was reviewed on 8/7/23 at 2:00 p.m. The resident's diagnosis included, but was not limited to, major depressive disorder. A Significant change of condition MDS assessment dated [DATE] indicated Resident 40 was cognitively intact. Resident 40's care plans did not indicate she makes false allegations. A reportable incident dated 8/6/23 indicated .Brief Description of Incident .8/6/23 At approximately 5:30 p.m. [Resident 40] notified nursing staff that there was an alleged physical altercation with [Resident 45] An interview was conducted with License Practical Nurse (LPN) 42 on 8/8/23 at 10:39 a.m. She indicated she had work over the weekend. Resident 40 had reported to her in the evening of 8/6/23, Resident 45 had touched her inappropriately early morning of 8/6/23. Resident 40 was sleeping in her bed and was awoken by Resident 45 standing over her rubbing her left thigh. Resident 40 was startled and kicked Resident 45 in the chest. Resident 45 did not fall after her roommate kicked her. Resident 45 then returned back to her bed. Resident 40 was embarrassed about the incident. Resident 45 was removed out of the room she shared with Resident 40 and placed on 1 on 1 supervision. LPN 42 had immediately reported to the Executive Director Resident 40 alleged Resident 45 had inappropriately touched her. An interview was conducted with Resident 40 on 8/8/23 at 11:02 a.m. She indicated she was Resident 45's roommate. The staff recently moved Resident 45 to another room, because Resident 45 had inappropriately touched her early morning of 8/6/23. Resident 40 had just gotten to sleep, because Resident 45 had been yelling very loudly all day into the night wanting her drugs. She then was startled awake by Resident 45 standing over her with her hand under her covers rubbing on her thigh. She then kicked Resident 45 in the chest. Resident 45 did not say anything and walked back to her own bed. It was scary. She reported the incident to the nurse later that evening. Resident 45 was moved to another room. An interview was conducted with the Executive Director (ED) on 8/11/23 at 4:00 p.m. He indicated the reportable incident reported on 8/6/23, he had realized after he had submitted that he had a made a few errors on the report. The residents involved section should have had Resident 40 and Resident 45's name listed. He was unaware of the brief description needed to be more detailed of the allegation that was reported. 3c. An interview was conducted with Resident 40 on 8/8/23 at 11:02 a.m. She indicated Resident 45 had inappropriately touched her a couple weeks after Resident 45 was admitted to the facility. She had woke up and Resident 40 was standing over her with her hand under the covers rubbing her thigh. Resident 40 yelled what are you doing? Resident 40 returned back to her bed at that time. She had reported to a staff person, and the staff person had thought it was her imagination possibly dreaming. Resident 40 agreed with the staff person maybe she was dreaming, and it didn't happened. After this past weekend, Resident 40 did it again. She knows now she was not dreaming; it really happened. Resident 40 indicated she felt sexually abused. An interview was conducted with Activities Assistant (AA) 35 on 8/9/23 at 8:56 a.m. She indicated she had heard about the incident over the weekend between Resident 40 and Resident 45 with the inappropriate touching. She indicated it was not the first time. A 2nd incident had occurred a few weeks ago. AA 35 had taken Resident 40 to an appointment approximately a little over a week ago. Resident 40 had indicated she had reported to the nurse staff that day, Resident 45 had inappropriately touched her. Resident 40 had woke up and Resident 45 was standing over her touching her in a sexual manner. Resident 40 stated she said What are you doing? Resident 45 then returned to her bed. Resident 40 had indicated she was embarrassed about the incident. Resident 45 does not know any better due to her state of mind. AA 35 had not reported the incident due to Resident 40 had indicated she had reported to the nurse on the night of the incident. An interview was conducted with the Executive Director (ED) on 8/9/23 at 9:49 a.m. He indicated he was unaware of any other allegations of sexual inappropriate touching between Resident 45 and Resident 40 prior to 8/6/23. The staff should have reported the incident. The Abuse Prevention Program policy was provided by the ED on 8/7/23 at 9:00 a.m. It read, The facility will not tolerate resident abuse or treatment by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals The Administrator or person in charge of the facility will keep the resident or resident representative informed of the progress of the investigation All personnel must promptly report any incident or suspected incident of resident abuse, mistreatment or neglect, including injuries of unknown origin For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: 1. Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm. pain, mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being. 2. Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless off their age, ability to comprehend or disability 6. Mental Abuse: Each resident has the right to be free from all types of abuse, including mental abuse. Mental abuse includes, but not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate resident(s), harassment, threats of punishment, humiliation, or withholding of treatment or services .Any alleged violations involving mistreatment abuse, neglect, misappropriation of resident property and any injuries of an unknown origin MUST be reported to the Administrator and Director of Nursing. The Administrator is the Abuse Coordinator of the facility. Additionally, the person(s) observing an incident of resident abuse or suspecting resident abuse must IMMEDIATELY report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred. The Charge Nurse will immediately report the incident to the Administrator or to the individual in charge of the facility during the Administrator's absence. 3.1-28(c) Based on interview and record review, the facility failed to timely report an allegation of abuse to the Administrator; notify a resident's representative of the initiation and progress of an abuse investigation; and include pertinent information regarding an alleged victim of an abuse allegation and ensure accurate and detailed description in their state reporting for 3 of 5 residents reviewed for abuse. (Residents 20 and 37 and 40) Findings include: 1. The clinical record for Resident 37 was reviewed on 8/7/23 at 3:00 p.m. Her diagnoses included, but were not limited to, vascular dementia. She resided on the memory care unit of the facility until 6/29/23. The 5/26/23 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 5, indicating she was severely cognitively impaired. The 6/29/23, 7:18 p.m. nurses note, recorded as a late entry on 7/6/23, read, Writer notified sister [name of sister] and provider about the incident that occurred same day. Sister appreciative of the call and thanked us for taking care of [name of Resident 37.] On 8/8/23 at 11:17 a.m., the ED (Executive Director) provided the investigative file into the 6/29/23 incident referenced in the above note. It included a 7/6/23 follow up incident report. The incident report indicated on 6/29/23, the ED was notified at 5:15 p.m. that another employee overheard a CNA (Certified Nursing Assistant) [CNA 3] state to Resident 37 that you are disgusting, and I'm going to puke after having an accident in which the aide would have to clean up. The 7/6/23 follow up section of the incident report indicated after the investigation was completed, Abuse inservices were completed facility wide. The 6/30/23 Confidential Witness Statement of LA (Laundry Aide) 5 was included in the file. It was conducted as an interview by the ED. It read, I was passing 1st level, putting linen in room (name of Resident 37) when I overheard [name of CNA 3] say 'You are disgusting. This is nasty. You should be ashamed of yourself. I'm going to throw up. There was a 6/28/23 handwritten statement from LA 5 included in the file. It read, I overheard an aide, [name of CNA 3,] speaking bad to a resident. She told [name of Resident 37] that she was disgusting, nasty, and that she was going [sic] puke. [Name of CNA 3] was cleaning her up after a bathroom accident. An interview was conducted with LA 5 on 8/8/23 at 2:59 p.m. She indicated, earlier in the day, she knocked on the door to Resident 37's room, but no one answered, so she went in to deliver laundry. LA 5 did not realize CNA 3 and Resident 37 were in the restroom until LA 5 was already in the room. While hanging up clothing, she heard CNA 3 say to Resident 37 that Resident 37 was nasty, should be ashamed of herself, and it was going to make her [CNA 3] sick. CNA 3 then began making gagging noises. Resident 37 was pretty much nonverbal and doesn't speak, more like repeats. LA 5 did not see them come out of the restroom, as LA 5 just tried to get in and out of the room quickly. LA 5 informed the BOM (Business Office Manager) the following day of what she heard. LA 5's supervisor was not working that day, so she told the BOM. It was bothering me overnight. CNA 3 always had an attitude anyway and always talked nasty towards people. LA 5 never saw CNA 3 again after that. The 7/3/23 Confidential Witness Statement of QMA 4 was included in the file. It was conducted as an interview by a previous Director of Nursing. It read, [Name of Resident 37] had a bowel movement and heard CNA ask her why she does that. She told her that if she does it again she will make resident clean herself up. Resident began laughing and she heard the aide say this isn't funny. An interview was conducted with QMA 4 on 8/8/23 at 2:30 p.m. She indicated she was assisting Resident 37's roommate in the room after a meal, while CNA 3 and Resident 37 were in the restroom. Resident 37 had a mess, trail coming from the dining room. QMA 4 heard CNA 3 say something like the next time you go on yourself, I'm going to make you change yourself. The way CNA 3 was talking to Resident 37 in the restroom did not sound abusive to her, because it was in such a calm voice. Resident 37 began laughing. CNA 3 was like, It's not funny [name of Resident 37.] After QMA 4 finished assisting Resident 37's roommate with incontinent care, QMA 4 left the room. The next thing QMA 4 knew, she was getting asked questions. QMA 4 knew telling a resident they were going to have to clean themselves up and it wasn't funny was not okay. The 7/3/23 Confidential Witness Statement of CNA 6 was included in the file. It was conducted as an interview by a previous DON. It read, Was on Boulevard [previous memory care unit of the facility] and noted a horrible smell. I was in hallway with [name of CNA 3 and QMA 4.] You were informed that above resident was in the bathroom. Staff member made statement that it was so bad it made me want to throw up. An interview was conducted with the ED on 8/8/23 at 2:06 p.m. and 3:10 p.m. He indicated the occurrence happened on 6/28/23, but it was not reported to him until the following day, 6/29/23, verbally by LA 5. The file included a 7/10/23 Employee Teachable Moment Form for QMA 4 and a 7/10/23 Employee Teachable Moment Form for LA 5, both regarding reporting of potential abuse immediately. 2. The clinical record for Resident 20 was reviewed on 8/7/23 at 2:37 p.m. Her diagnoses included, but were not limited to, heart failure and chronic kidney disease. She resided on the memory care unit of the facility until 6/29/23 The 5/17/23 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 00, indicating she was severely cognitively impaired. The clinical record for Resident 37 was reviewed on 8/7/23 at 3:00 p.m. Her diagnoses included, but were not limited to, vascular dementia. She resided on the memory care unit of the facility until 6/29/23. The 5/26/23 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 5, indicating she was severely cognitively impaired. The investigative file into an allegation of abuse involving Resident 37, Resident 20, and CNA (Certified Nursing Assistant) 7 was provided by the ED (Executive Director) on 8/8/23 at 11:17 a.m. The file included the 7/14/23 follow up incident report. The report indicated on 7/9/23 the ED was notified at 12:00 p.m. that an aide transferred a resident, Resident 37, and the resident appeared upset afterwards and then spoke in an upset tone. It indicated physician and family were notified. The 7/14/23 follow up section of the report indicated the investigation was completed and the resident had no adverse effects noted related to the alleged incident. Psychosocial follow ups were completed for 72 hours. Staff interviews were completed, and it was determined that no fault was found, and CNA 7 returned to schedule. The 7/14/23 follow up incident report did not indicate Resident 20 was involved, or that their family/representative was notified of the investigation. The file included a 7/9/23 written statement by the MDSC (Minimum Data Set Coordinator.) It read, Writer returned to unit from break to witness [name of CNA 7] transferring [initials of Resident 37] to recliner. The resident sat down in recliner hard and started crying. The CNA was yelling at the resident telling her that she was not allowed into her room and that she wasn't going to be laid down, that she never lays down at this time of day. Writer saw CNA leave resident to complete another task, at that time a member of laundry and a member of activities approached writer about another resident [initials of Resident 20.] Activities stated that the [sic] took [initials of Resident 20] to her room to have CNA lay her down as she was requesting, they told writer that CNA then pushed resident back out of her room and then blocked the doorway so she couldn't wheel herself into her room. It was reported that CNA was yelling at [initials of Resident 20] prior to writer re-entering unit. Writer asked both residents what happened. Both residents were crying at this time. [Initials of Resident 20] stated she wouldn't let me lay down and I'm tired. [Initials of Resident 37] unable to report what happened. VS [vital signs] and head to toe completed on both [Initials of Resident 20] stated her left shoulder and arm was hurting upon palpation. [Initials of Resident 37] c/o [complained of] left hip pain on assessment. NP [Nurse Practitioner] was notified and orders for xrays for both residents obtained. Administrator notified and CNA was sent home, where she started yelling and cussing at writer and the other 2 staff members while getting close to their faces while pointing fingers. CNA finally left building. An interview was conducted with the MDSC on 8/9/23 at 3:42 p.m. She indicated she took a 10 minute break and when she came back to the unit, she caught the tail end of what was going on. CNA 7 was transferring Resident 37 from her wheel chair into the recliner in the television area of the unit. It looked like it could have been a hard transfer, like she landed hard into the recliner. Resident 37 also had a tendency to drop weight. Then CNA 7 started yelling at Resident 37, saying she couldn't go into her room. The MDSC immediately separated them and informed the ED. Then AA (Activity Assistant) 9 and LA (Laundry Aide) 8 came to her and said they heard CNA 7 yelling at both Resident 37 and Resident 20, and was physically blocking both of them from going in their room. The MDSC had AA 9 and LA 8 write statements. The MDSC indicated she considered what she saw abuse, like confining them from their room. An x-ray was done on Resident 37's left hip, because of how hard she landed in the recliner, and an x-ray was done on Resident 20's left arm and shoulder due to her complaints of arm pain. Neither residents had fractures, came back clean. She indicated she thought both residents were crying because they both wanted to lay down after bingo, but weren't allowed to do so. She thought Resident 37 was crying more out of anger than pain, and Resident 20 was crying, because she was mad. The file included a 7/9/23 written statement from LA 8 that read, I was in the activities room with residents when I heard [name of Resident 20] yelling. Me being curious I went to see what was happening The aide with [name of Resident 20] was yelling at her saying she wasn't allowed to take a nap and stopping [name of Resident 20] from getting to bed. She was causing [name of Resident 20] to cry from it. After getting told she was getting sent home, she yelled at me and [name of AA 9] saying that we don't know what we're talking about. An interview was conducted with LA 8 on 8/10/23 at 2:13 p.m. She indicated she was locked out of the laundry room, so she was helping AA 9 in the activity room. Resident 20 wanted to go back to her room, so AA 9 wheeled her to her room, while LA 8 remained in the activity room. After a couple minutes, she heard Resident 20 yell, so she knew she was agitated, because Resident 20 doesn't really yell. Resident 20 was yelling at CNA 7, saying she wanted to go back to bed, wanted to lay down, and didn't feel well. CNA 7 was yelling back at Resident 20, saying, You're not going back to bed. It wasn't time, because CNA 7 was not going to get her up later. CNA 7 pushed Resident 20 into the television area of the unit. Resident 20 was crying. Resident 20 was usually only out of bed short amounts of time and rested a lot during the day. If she was up, it was because she was having a good day. Resident 20 was crying, upset, and kept asking anyone to take her to bed. Resident 20 asked AA 9 if she would take her to bed, and CNA 7 said no. Both LA 8 and AA 9 informed the MDSC about what happened, so the MDSC want to talk to CNA 7. CNA 7 then came to her and AA 9, pointing her finger in their faces, saying to the other CNA, CNA 35, saying she had to go home. CNA 35 was upset that she would have to do the floor alone, saying this shouldn't be happening. CNA 7 was very mad. The 7/14/23 Confidential Witness Statement of CNA 35 was included in the file. It was conducted as an interview by a previous DON (Director of Nursing.) It read, Staff member states that she knew that an activity aide had told above CNA that resident wanted to lay down. This was close to 12:00 and lunch was being served in 30 minutes. CNA in question told resident we aren't laying down right now, lunch is soon. She then did place resident in recliner until lunch. She heard no yelling. The file included a 7/9/23 written statement from AA 9. It read, I took [name of Resident 20] into her room because that's where she wanted to go. [Name of CNA 7] the aide took [name of Resident 20] back out of her room and started yelling at [name of Resident 20,] saying she wasn't allowed to take a nap yet and blocked [name of Resident 37] from going into their room and yelled and told her that she would put her in the recliner to be more comfortable. Me and [name of LA 8] walked back to the activities room to clean when we heard [name of Resident 37] start to cry so we walked back out and [name of CNA 7] was still yelling at [names of Residents 20 and 37.] After we told [name of MDSC] all of it and she talked to [name of CNA 7] and she came out and started yelling at me and [name of LA 8] saying we don't know what we are talking about. AA 9 was unavailable for interview. The file included a 7/12/23 Confidential Witness Statement of CNA 7, conducted as an interview by a previous DON. It read, Both residents requested to lay them down. The residents made request to activities aide and the activities aide told her [name of CNA 7] this request. Told resident no you are going to stay up, put both in recliners D/T [due to] lunch being served @ 12:30. CNA 7 was unavailable for interview. An interview was conducted with the ED on 8/10/23 at 12:05 p.m. He indicated nursing should have followed up with both residents families/representatives in regards to x-ray results, but he did not personally follow up with them on the results of the investigation for either resident. He always notified resident's family/representative of the initial allegation, and would pretty much just say there was an incident and we're investigating. He did not follow up with Resident 37's family on the results of the investigation, and he did not inform Resident 20's family/representative at all, in the beginning or after completion of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely create a baseline care plan for 1 of 1 resident reviewed for care planning (Resident 200). Findings include: The clinical record for Resident 200 was reviewed on 8/7/23 at 10:07 a.m. The Resident's diagnosis included, but were not limited to, hypertension and anxiety. He was admitted to the facility on [DATE]. A Nursing Progress Note, dated 7/29/23 at 7:30 a.m., indicated Resident 200 was alert and oriented to person, place, and time and able to make all needs and wants known. During an interview on 8//7/23 at 10:07 a.m., Resident 200 indicated that no one had gone over his baseline care plan with him. On 8/8/23 at 11:30 a.m., the DON (Director of Nursing) provided Resident 200's Baseline Care Plan which indicated that sections 1 through 3 had been completed on 8/8/23. During an interview on 8/09/23 at 2:54 p.m., the MDSC (Minimum Data Set Coordinator) indicated that she tried to do the baseline care plan within the first 48 to 72 hours of a residents stay. On 8/9/23 at 2:39 p.m., the RNC (Regional Nurse Consultant) provided the current Baseline Care Plan Assessment/ Comprehensive Care Plans policy which read .It is the policy of the facility to ensure that every resident has a Baseline Care Plan completed and implemented within 48 hours of admission .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The clinical record for Resident 202 was reviewed on 8/7/23 at 9:37 a.m. The Resident's diagnosis included, but were not limited to, fracture of lower leg including the ankle. He was admitted to the facility on [DATE]. A Social Services Evaluation, dated 7/12/23, indicated that Resident 202 previously lived with his spouse and was the one who prepared the meals, did the grocery shopping and provided his own transportation. His desired plan at discharge was to go back home with his spouse. During an interview on 8/7/23 at 8:37 a.m., Resident 202 indicated he was wondering what would happen when it was time for him to leave the facility. He knew plans were being made, but he was unsure what they were. During an interview on 8/11/23 at 10:01 a.m., Resident 202 indicated that discharge plans had not been discussed with him. During an interview on 8/11/23 at 11:20 a.m., the DON (Director of Nursing) indicated there was no discharge care plan present in Resident 202's health record. On 8/9/23 at 2:39 p.m., the RNC (Regional Nurse Consultant) provided the current Baseline Care Plan Assessment/ Comprehensive Care Plans policy which read .The Comprehensive Care Plan will include discharge planning as related to the IMPACT Act . This Federal tag relates to complaint IN00411900. 3.1-35(a)(b)(1) Based on observation, interview and record review, the facility failed to create a discharge planning care plan for a resident with a goal of returning to the community at discharge for 1 of 3 residents reviewed for discharge, to develop care plans for refusal of bathing and shampooing and a resident high risk for dehydration for 1 of 3 residents reviewed for Activities of Daily Living and 1 of 1 residents reviewed of hydration. (Resident 14 and Resident 27 and Resident 202) Findings include: 1. The clinical record for Resident 27 was reviewed on 8/7/23 at 9:05 a.m. The resident's diagnosis included, but was not limited to, dementia. A dehydration risk assessment for Resident 27 dated 6/12/23 indicated a total score of above 8 represents high risk - prevention protocol should be initiated immediately and documented on the care plan. The resident's assessment indicated a score of 10. The assessment indicated the resident was bed bound, totally dependent, incontinent of urine, had predisposing factors and medications contributing to dehydration. The resident's clinical record did not include a developed care with interventions in place for hydration. An interview was conducted with the Director of Nursing on 8/11/23 at 11:19 a.m. She indicated she was unable to find a care plan for Resident 27 for hydration. She should have one due to her score of greater than 8 per the dehydration risk assessment. 2. The clinical record for Resident 14 was reviewed on 8/7/23 at 12:05 p.m. The resident's diagnosis included, but was not limited to, Alzheimer's Disease. A care plan dated 5/23/23 indicated Resident 14 was cognitively impaired. An Annual MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 14 was cognitively impaired. A care plan dated 9/19/22 indicated Resident 14 has a preference that it was important to her to choose bathing. The intervention for bathing was the resident preferred a tub bath twice a week. The clinical record did not include a developed care plan and interventions in place to address refusals of bathing and shampooing. An interview was conducted with Resident 35 on 8/7/23 at 12:05 p.m. He indicated he was Resident 14's roommate and significant other. Resident 14 was suppose to have showers on Tuesdays and Fridays in the morning. Resident 14 does not receive her showers. The staff alot of times do not come in here to provide. She does refuse often to have staff wash her hair. An interview was conducted with Resident 14's Representative on 8/7/23 at 5:02 p.m. She indicated the staff do not make Resident 14 take showers or wash her hair. She hasn't had her hair washed in months. She understands the resident refuses, but she has dementia. She would think the staff would have a plan in place to address her refusals. An interview was conducted with Certified Nursing Assistant (CNA) 30 and CNA 42 on 8/11/23 at 10:02 a.m. CNA 42 indicated she was Resident 14's CNA today. The resident was suppose to receive a shower today, but refused. She would like the shower that evening. CNA 30 and CNA 42 indicated Resident 14 refused her showers often. Bed baths are at times completed with assistance from Resident 35. They indicated Resident 14 always refuses hair shampooing. CNA 30 and CNA 42 have not ever washed Resident 14's hair. An interview was conducted with the Director of Nursing on 8/11/23 at 2:07 p.m. She indicated Resident 14 should have a developed care plan for her refusals for showers and hair shampooing.

Based on interview and record review, the facility failed to timely update toileting care plans for 1 of 1 resident reviewed for bladder and bowel incontinence (Resident 4). Findings include: The clinical record for Resident 4 was reviewed on 8/7/23 at 11:12 a.m. The Resident's diagnosis included, but were not limited to, generalized muscle weakness and constipation. A care plan, last revised on 12/13/22, indicated that Resident 4 needed extensive to total assist with transfers. The goal was for her to feel safe and secure with using mechanical lift for transfers and for her to feel secure with staff providing major support for transfers with some support. The interventions included, but were not limited to, assess for increase in mobility level and/or decrease in mobility level, initiated 6/10/2019, and to use mechanical lift for transfers, revised on 11/8/22. A care plan, last revised on 12/13/22, indicated Resident 4 needed extensive assistance with toileting, bed mobility, and eating. The goal was for her to be able to feed herself after set up and for her to feel safe and secure and not fearful of falling out of bed when being turned and repositioned. The interventions included, but were not limited to, assess degree of mobility and level of functioning at least quarterly, assist to toilet and/or check and change frequently, encourage her to participate in ADL (Activities of Daily Living) care as much as possible, keep physician and family updated with current ADL status through care plan meetings, and to refer to proper therapies as indicated, initiated 6/10/2019. A Quarterly MDS (Minimum Data Set) Assessment, completed 6/5/23, indicated she was cognitively intact and needed total assistance of 2 staff members with transfers. She required extensive assistance of 2 staff members for toileting. During an interview on 8/7/23 at 11:12 a.m., Resident 4 indicated she had been using a commode to have a bowel movement for years, referring to a blue, padded shower chair on wheel in her bathroom. The facility staff would put her on the shower chair and wheel the chair over the commode so that she could have a bowel movement. She had been told by the facility that she was no longer allowed to use the shower chair to go to the bathroom because it wasn't safe and would have to use a bed pan. Using the bed pan to have a bowel movement was beyond horrible. She did not understand why all the sudden using the shower chair over the toilet was not safe. During an interview on 8/10/23 at 11:34 a.m., CNA (Certified Nursing Assistant) 30 indicated Resident 4 knew when she needed to have a bowel movement and had been using the toilet in the past. For about the past month, Resident 4 had been using a bed pan to have a bowel movement. During an interview on 8/10/23 at 11:36 a.m., the ADON (Assistant Director of Nursing) indicated Resident 4 had used a mechanical lift to be transferred to a commode chair which was wheeled over the toilet. During an interview on 8/10/23 at 11:50 a.m., the Therapy Director indicated Resident 4 had been screened on 7/12/23 for toilet transfers. Therapy had recommended the use of a toileting sling with the mechanical lift to increase the safety of toileting transfers. The nursing staff had been made aware of the recommendation on 7/12/23. During an interview on 8/10/23 at 2:53 p.m., Resident 4 indicated a toileting sling had not been offered for her to use. She was able to empty her bowels and bladder more completely when she used the commode chair. Resident 4's care plans had not been updated to reflect her preference for using a shower chair over the commode to toilet or that she was to have a toileting sling used for toileting. On 8/9/23 at 2:39 p.m., the RNC (Regional Nurse Consultant) provided the current Baseline Care Plan Assessment/ Comprehensive Care Plans policy which read .The facility Interdisciplinary team in conjunction with the resident .will discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/ safety and overall well-being attainable for the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure discharge need for oxygen therapy was identified and to involve the interdisciplinary team to develop a plan of treatment for discharge for 1 of 3 residents reviewed for discharge (Resident B). Findings include: The clinical record for Resident B was reviewed on 8/8/23 at 9:38 a.m. The Resident's diagnosis included, but were not limited to, COVID-19 infection, hypothyroidism, and chronic respiratory failure. She was admitted to the facility on [DATE] and discharged from the facility on 5/29/23. A care plan, initiated 3/13/23, indicated Resident B planned to remain in the facility for long term placement. She understood the need for long term placement, however, would want to return home if given the option to return to the community. The goal was for her to have 24-hour care and supervision while she was in the facility. The intervention, dated 3/13/23, that Resident B's family and Resident B preferred to discuss a return to community unless mandated by the Minimum Data Set Assessment. A physician's order, dated 3/13/23, indicated Resident B was to receive oxygen at 3 liters/minute using a nasal canula continually. The oxygen may be removed for showers and beauty shop visits as needed. A General Progress Note, dated 3/13/23, indicated Resident B had been seen the physician for an initial assessment after her hospitalization. She had a history of chronic oxygen use prior to hospitalization. A care plan, initiated 3/17/23, indicated that Resident B had chronic respiratory disease with a potential for exacerbation (worsening). The goals were for her to be able to tolerate normal ADL (Acts of Daily Living) daily without increased shortness of breath and for her to have no respiratory distress. The approaches, initiated 3/17/23, included but were not limited to, administer oxygen as ordered, administer medications as ordered, monitor oxygen saturation as ordered, and to notify physician as needed. An admission MDS (Minimum Data Set) Assessment, completed 3/23/23, indicated Resident B was cognitively intact and received oxygen therapy. She also received Physical, Occupational, and Speech Therapies. A Physical Therapy Discharge summary, dated [DATE], indicated that Resident B had met her goal of walking on a level surface for 125 ft independently using an assistive device without shortness of breath. Resident B used a rollator walker and oxygen at all times while walking. A Practitioner Progress Note, dated 5/3/23, indicated Resident B was scheduled to discharge to another state on May 29, 2023. A Physician/Practitioner Progress Note, dated 5/23/23 at 1:13 p.m., indicated that Resident B was being seen to discuss discharge plans. Resident B had been using 3 liters of oxygen at the facility and when oxygen was removed her oxygen saturation was remaining in the mid 90's. Resident B had chronic hypoxemic respiratory failure with home supplemental oxygen. Resident B planned to discharge on [DATE], oxygen would be arranged, and that discharge paperwork was to be given to Resident B upon departure from the facility. A General Note, dated 5/24/23, indicated that Resident B's family member had come to visit and was updated with oxygen information for discharge. Resident B's family member had been informed that Resident B had done the appropriate oxygen testing and that she would not qualify for home oxygen. During an interview on 8/10/23 at 10:27 a.m., Family Member 32 indicated that Resident B had been on oxygen therapy for 12 years prior to becoming hospitalized for COVID-19 in March 2023. FM 32 had been shocked that Resident B no longer qualified for home oxygen therapy, especially given that upon discharge from the facility Resident B was relocating to South Carolina which involved a 12-hour drive. Family Member 32 had not received any discharge instructions from the facility on the day of discharge and that it seemed as if the facility staff were surprised that Resident B was leaving. During an interview on 8/10/23 at 4:28 p.m., the SSD (Social Services Director) indicated that the clinical record did not contain a Discharge Planning Meeting note. During an interview on 8/10/23 at 4:35 p.m., the ADON (Assistant Director of Nursing) indicated she had removed Resident B's oxygen and monitored her oxygen saturations every half hour to hour for 8 to 9 hours. Resident B's oxygen saturation had not dropped below 90 while she had monitored it. The ADON had walked Resident B to the bathroom and to the Activity room during that monitoring time frame, without using the oxygen. The outside oxygen provided had indicated that Resident B's oxygen saturation would have to drop below 88% to qualify for home oxygen therapy. Therapies had not been involved with the oxygen testing. During an interview on 8/11/23 at 9:46 a.m., PTA (Physical Therapy Assistant) 33 indicated that he thought Resident B had been discharged with home oxygen therapy. PTA 33 had not worked with Resident B to titrate down her oxygen while she was in therapy. If he had known that Resident B was to be discharged without oxygen, he would have taken it off while treating her to see how she tolerated activity without oxygen. Normally, there would have been a physician's order to titrate her oxygen with therapy and to monitor her oxygen levels with activities. PTA 33 had not been consulted about home oxygen therapy. On 8/9/23 at 2:39 p.m., the RNC (Regional Nurse Consultant) provided the current Transfer and Discharge Policy and Procedure which read . The facility will provide provisions for continuity of care an in non-emergency situations a care plan meeting will be held with the appropriate parties to determine a relocation plan. This Federal tag relates to complaint IN00411900. 3.1-12(19)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written discharge plan of care to a resident with a planned discharge for 1 of 3 residents reviewed for discharge (Resident B). Findings include: The clinical record for Resident B was reviewed on 8/8/23 at 9:38 a.m. The Resident's diagnosis included, but were not limited to, COVID-19 infection, hypothyroidism, and chronic respiratory failure. She was admitted to the facility on [DATE] and discharged from the facility on 5/29/23. A Practitioner Progress Note, dated 5/3/23, indicated Resident B was scheduled to discharge to another state on May 29, 2023. A Physician/Practitioner Progress Note, dated 5/23/23 at 1:13 p.m., indicated that Resident B was being seen to discuss discharge plans. Resident B planned to discharge on [DATE]. A 30-day supply of medications would be sent to a local pharmacy, seven days of controlled meds would be sent with the patient upon discharge, and that discharge paperwork was to be given to Resident B upon departure from the facility. A Discharge Summary assessment was started on 5/29/23 at 8:01 a.m. The Discharge Summary assessment was closed and signed as complete on 6/12/23. The clinical record did not contain a progress note for 5/29/23, the day of discharge. On 8/8/23 at 1:39 p.m., the DON (Director of Nursing) provided the Resident Discharge summary, dated [DATE], which did not contain a signature confirming it had been received and that the discharge instructions were understood. On 8/10/23 at 11:36 a.m., the ADON (Assistant Director of Nursing) provided Resident B's Personal Inventory sheet, which included a signature on 3/13/23 when it was completed upon admission. There was no signature present on discharge. During an interview on 8/10/23 at 10:27 a.m., Family Member 32 indicated that no discharge instructions had been received from the facility on the day of discharge and that it seemed as if the facility staff were surprised that Resident B was leaving. Neither Resident B nor Family Member 32 had signed any discharge paperwork. During an interview on 8/10/23 at 4:29 p.m., the SSD (Social Service Director) indicated that upon discharge the inventory sheet and discharge paperwork should be signed by the resident or responsible party and a copy should be made for the medical chart. On 8/9/23 at 2:39 p.m., the RNC (Regional Nurse Consultant) provided the current Transfer and Discharge Policy and Procedure which read .Discharge to Home or a lower level of care where resident or family will be administering the resident's medications .Include instructions for post discharge care and explain to the resident and/or representative .Have resident and / or representative or person responsible for care sign the Post Discharge Instruction form. This includes release of medications .Give the Signed original Post Discharge Instructions form to the resident and/or representative .Place a signed copy of the form in the health record .Check the Personal Belongings Inventory form- Have resident and/ or representative or responsible care giver sign for belongings. Place original in the health record . This Federal tag relates to complaint IN00411900. 3.1-36(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The clinical record for Resident 4 was reviewed on 8/7/23 at 11:12 a.m. The Resident's diagnosis included, but were not limited to, generalized muscle weakness and constipation. A care plan, last revised on 12/13/22, indicated that Resident 4 needed extensive to total assist with transfers. The goal was for her to feel safe and secure with using mechanical lift for transfers and for her to feel secure with staff providing major support for transfers with some support. The interventions included, but were not limited to, assess for increase in mobility level and/or decrease in mobility level, initiated 6/10/2019, and to use mechanical lift for transfers, revised on 11/8/22. A care plan, last revised on 12/13/22, indicated Resident 4 needed extensive assistance with toileting, bed mobility, and eating. The goal was for her to be able to feed herself after set up and for her to feel safe and secure and not fearful of falling out of bed when being turned and repositioned. The interventions included, but were not limited to, assist to toilet and/or check and change frequently, encourage her to participate in ADL (Activities of Daily Living) care as much as possible, and to refer to proper therapies as indicated, initiated 6/10/2019. A Quarterly MDS (Minimum Data Set) Assessment, completed 6/5/23, indicated she was cognitively intact and needed total assistance of 2 staff members with transfers. She required extensive assistance of 2 staff members for toileting. An Occupational Therapy Evaluation and Plan of Treatment, completed 7/12/23, indicated the reason for the referral was to determine potential for Resident 4 to complete sliding board transfers to a bedside commode. Resident 4 had reported using a mechanical lift to transfer to a shower chair for toileting for approximately 4 years. The assessment summary indicated therapy's recommendation was for a toilet specific mechanical lift sling be used so that the sling could remain in place while patient was on the shower chair/ bedside commode. During an interview on 8/7/23 at 11:12 a.m., Resident 4 indicated she had been using a commode to have a bowel movement for years, referring to a blue, padded shower chair on wheel in her bathroom. The facility staff would put her on the shower chair and wheel the chair over the commode so that she could have a bowel movement. She had been told by the facility that she was no longer allowed to use the shower chair to go to the bathroom because it wasn't safe and would have to use a bed pan. Using the bed pan to have a bowel movement was beyond horrible. She did not understand why all the sudden using the shower chair over the toilet was not safe. During an interview on 8/10/23 at 11:34 a.m., CNA (Certified Nursing Assistant) 30 indicated Resident 4 knew when she needed to have a bowel movement and had been using the toilet in the past. For about the past month, Resident 4 had been using a bed pan to have a bowel movement. During an interview on 8/10/23 at 11:36 a.m., the ADON (Assistant Director of Nursing) indicated Resident 4 had used a mechanical lift to be transferred to a commode chair which was wheeled over the toilet. Therapy had not felt it was safe. During an interview on 8/10/23 at 11:50 a.m., the Therapy Director indicated Resident 4 had been screened on 7/12/23 for toilet transfers. Therapy had recommended the use of a toileting sling with the mechanical lift to increase the safety of toileting transfers. The nursing staff had been made aware of the recommendation on 7/12/23. During an interview on 8/10/23 at 2:53 p.m., Resident 4 indicated a toileting sling had not been offered for her to use. She was able to empty her bowels and bladder more completely when she used the commode chair. During an interview on 8/10/23 at 3:05 p.m., the Environmental Director indicated there were no toileting slings present in the building. During an interview on 8/11/23 at 8:26 a.m., the DON (Director of Nursing) indicated that the toilet sling for the mechanical lift had not been order previously but was ordered that morning. This Federal Tag relates to complaint IN00411900. 3.1-38(A) 3.1-38(3) Based on observation, interview and record review, the facility failed to provide bathing and hair shampooing for 1 of 3 residents reviewed for Activities of Daily Living and to timely order a toileting sling to assist a resident with toileting for 1 of 1 resident reviewed for bladder and bowel incontinence (Resident 4 and Resident 14). 1. The clinical record for Resident 14 was reviewed on 8/7/23 at 12:05 p.m. The resident's diagnosis included, but was not limited to, Alzheimer's Disease. A care plan dated 5/23/23 indicated Resident 14 was cognitively impaired. An Annual MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 14 was cognitively impaired. A care plan dated 9/19/22 indicated Resident 14 has a preference that it was important to her to choose bathing. The intervention for bathing was the resident preferred a tub bath twice a week. The clinical record did not include a developed care plan and interventions in place to address refusals of bathing and shampooing. A July 2023 bath report indicated the following days resident did not receive a shower: 7/7/23, 7/11/23, 7/21/23, 7/25/23, - documented as partial bath was given, July 2023 shower sheets indicated the following days resident did not receive shampooing: 7/20/23 and 7/25/23. An August 2023 bathing report indicated the following days the resident had not received a shower: 8/1/23, 8/3/23, 8/8/23, 8/11/23 - documented as partial bath was given August 2023 Showers sheets indicated resident had not refused showers or shampooing twice weekly. Observations were made of Resident 14 on 8/7/23 at 12:05 p.m., 8/10/23 at 11:33 a.m., and 8/11/23 at 9:55 a.m. The resident was observed with dirty hair and not combed. An interview was conducted with Resident 35 on 8/7/23 at 12:05 p.m. He indicated he was Resident 14's roommate and significant other. Resident 14 does not received her showers. She refuses often to have staff wash her hair. She was suppose to have showers on Tuesdays and Fridays in the morning. An interview was conducted with Resident 14's Representative on 8/7/23 at 5:02 p.m. She indicated the staff do not make Resident 14 take showers or wash her hair. She hasn't had her hair washed in months. She would think the staff would have a plan in place to address her refusals. An interview was conducted with Resident 35 on 8/11/23 at 9:55 a.m. He indicated Resident 14 has not received a shower this week. An interview was conducted with Certified Nursing Assistant (CNA) 30 and CNA 42 on 8/11/23 at 10:02 a.m. CNA 42 indicated she was Resident 14's CNA today. The resident was suppose to receive a shower today, but refused. She would like her shower that evening. CNA 30 and CNA 42 indicated Resident 14 refused her showers often. Bed baths are at times completed with assistance from Resident 35; the resident's roommate. They indicated Resident 14 always refuses hair shampooing. CNA 30 and CNA 42 have not ever washed Resident 14's hair. If a resident refuses shampooing it should indicate on the shower sheets. An interview was conducted with Director of Nursing on 8/11/23 at 11:25 a.m. She was unsure why the the showers sheets and the bathing reports for July and August do not match with bathing provided and why resident was not getting her showers. An ADL policy was provided by the Director of Nursing on 8/11/23 at 12:56 p.m. It indicated .Policy: Residents are given routine daily care and HS [night care] by a CNA or a Nurse to promote hygiene, provide comfort and a homelike environment Assisting the resident in personal care such as bathing, showering, dressing, eating, hair care, oral car, nail care, appropriate skin care (as indicated as per care plan) as well as encouraging participation .Do all required ADL documentation as required per policy and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The clinical record for Resident B was reviewed on 8/8/23 at 9:38 a.m. The Resident's diagnosis included, but were not limited to, COVID-19 infection, hypothyroidism, and chronic respiratory failure. She was admitted to the facility on [DATE]. A physician's order, dated 3/10/23, indicated she was to receive levothyroxine (thyroid replacement) 75 mg tablet once daily for hypothyroidism. A physician's order dated 3/13/23indicated she was to receive two daridorexant hydrochloride (sleep aide) 25 mg tablet, to equal a dose of 50 mg, at bedtime daily for sleep disorder. The MAR (Medication Administration Record) for March, April, and May 2023, contained no documentation that the levothyroxine was administered on the following days: 3/15, 3/19, 3/23, 3/24, 4/19, 4,27, and 4/30/23. The clinical record contained nursing progress notes which indicated that the daridoxexant was unavailable to administer on the following days: 3/15, 3/16, 3/17, 3/19, and 3/20/23. During an interview on 8/10/23 at 10:27 a.m., Family Member 32 indicated that during Resident B's stay there were many times when her medications were not available for her to take. This Federal tag relates to complaint IN00411900. 3.1-37(a) 2. The clinical record for Resident 24 was reviewed on 8/7/23 at 10:05 a.m. The resident's diagnosis included, but was not limited to, dementia. A Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 24 was cognitively impaired. The assessment indicated the resident was total dependence with 1 staff person for bathing and extensive assistance by one staff person for personal hygiene. A care plan dated 7/13/23 indicated The resident presents with moderate to extreme anxiety. This problem/need is manifested by: frequent skin picking Interventions: Administer treatments as ordered .Monitor skin as needed . The weekly skin assessments for July 2023 indicated the resident did not have any skin issues. The weekly skin assessments indicated on 8/3/23 and 8/9/23 the resident did not have any skin issues. A psych visit note dated 7/26/23 indicated the resident in the last week has open areas on her nose and legs from picking. A psych visit note dated 8/2/23 indicated the resident's open areas on her nose and legs due to her picking are healing. Observations of Resident 24 on 8/7/23 at 10:16 a.m., and 8/10/23 at 11:36 a.m. The resident was observed with an open area on her nose approximately inch in length. An observation was made of Resident 24 with Certified Nursing Assistant (CNA) 42 on 8/11/23 at 10:06 a.m. The resident was observed with an open area inch in length on her nose. The resident's legs were observed with 2 small scabbed wounds on her left leg and 5 scabbed wound areas on her right leg. The resident's legs were dry and white and flaky. CNA 42 indicated at that time, the resident picks at her skin. She needed lotion on her lower extremities. An interview was conducted with the Director of Nursing on 8/11/23 at 10:20 a.m. She indicated Resident 24's open areas should be monitored. An ADL policy was provided by the Director of Nursing on 8/11/23 at 12:56 p.m. It indicated .Policy: Residents are given routine daily care and HS [night care] by a CNA or a Nurse to promote hygiene, provide comfort and a homelike environment Assisting the resident in personal care such as bathing, showering, dressing, eating, hair care, oral car, nail care, appropriate skin care (as indicated as per care plan) as well as encouraging participation .Do all required ADL documentation as required per policy and regulations. A skin policy was provided by the Director of Nursing on 8/11/23 at 12:56 p.m. It indicated .Note: Any skin changes should be documented immediately and reported to appropriate parties with treatment put into place by physician order .Based on observation, interview, and record review, the facility failed to administer a resident's medication, as ordered, for 1 of 1 resident reviewed for pain and 1 of 6 residents reviewed for unnecessary medications, and to ensure monitoring and addressing wounds and providing skin treatment to dry skin for 1 of 1 residents reviewed for wounds. (Residents' 24, 31 and B) Findings include: 1. The clinical record for Resident 31 was reviewed on 8/7/23 at 10:45 a.m. Her diagnoses included, but were not limited to, herpes viral vesicular dermatitis. The 5/29/23 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status score) of 15, indicating she was cognitively intact. The at risk for skin breakdown care plan, revised 9/21/22, indicated an intervention was to administer vitamins and minerals as ordered. The physician's orders indicated to administer one 1000 mg tablet of L-Lysine one time a day, starting 5/24/23. An observation of Resident 31 was made on 8/7/23 at 10:50 a.m. She was lying in bed, when LPN (Licensed Practical Nurse) 10 entered the room to administer her morning medications. While doing so, Resident 31 inquired about her Lysine supplement for the canker sore on her lip and why she hadn't received it since 8/2/23. LPN 10 looked at Resident 31's lip and informed her it looked raw. An interview and observation was conducted with Resident 31 on 8/7/23 at 10:50 a.m., after the above observation. She indicated she began getting canker sores in October, 2022, and the Lysine was supposed to take care of this crap, as she pointed to her mouth. Some of the food she ate, burns like h***. Nursing was telling her they were waiting on the pharmacy. The August, 2023 MAR (medication administration record) indicated she did not receive the Lysine on 8/5/23. The corresponding medication administration note read, Awaiting pharmacy. The MAR indicated she received the Lysine on 8/2/23, 8/3/23, 8/4/23, 8/6/23, and 8/7/23. An interview and observation of the medication cart was made with LPN 10 on 8/10/23 at 3:00 p.m. She indicated they did not have the Lysine in the facility to administer on 8/7/23, but it came in later, so she began receiving it again on 8/8/23.

Based on observation, interview, and record review, the facility failed to implement residents' fall interventions for 1 of 1 resident reviewed for accidents and 1 of 6 residents reviewed for unnecessary medication. (Resident 21 and Resident 37) 1. The clinical record for Resident 37 was reviewed on 8/7/23 at 3:00 p.m. Her diagnoses included, but were not limited to, vascular dementia. She resided on the memory care unit of the facility until 6/29/23, when she moved to the upstairs unit of the facility. The 5/26/23 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 5, indicating she was severely cognitively impaired. The fall risk care plan, revised 8/10/21, indicated an intervention was for her to be a 2 person assist with transfers, starting 5/11/23, and to wrap her call light in bright colored tape so it can be seen easily, starting 8/10/21. An observation of Resident 37's call light in her room was made on 8/10/23 at 10:50 a.m. Her call light was hanging on the wall above her bed. It did not have brightly colored tape on it. An interview and observation of Resident 37's call light was conducted with the ADON (Assistant Director of Nursing) on 8/10/23 at 10:54 a.m. There was no tape on her call light. The ADON indicated since she recently moved to the unit, the tape probably didn't get put on there. The investigative file into an allegation of abuse involving Resident 37 and CNA (Certified Nursing Assistant) 7 was provided by the ED (Executive Director) on 8/8/23 at 11:17 a.m. The file included the 7/14/23 follow up incident report. The report indicated on 7/9/23 the ED was notified at 12:00 p.m. that an aide transferred a resident and the resident appeared upset afterwards and then spoke in an upset tone. The 7/14/23 follow up section of the report indicated the investigation was completed and the resident had no adverse effects noted related to the alleged incident. Psychosocial follow ups were completed for 72 hours. Staff interviews were completed, and it was determined that no fault was found, and CNA 7 returned to schedule. The file included a 7/9/23 written statement by the MDSC (Minimum Data Set Coordinator.) It read, Writer returned to unit from break to witness [name of CNA 7] transferring [initials of Resident 37] to recliner. The resident sat down in recliner hard and started crying. The CNA was yelling at the resident telling her that she was not allowed into her room and that she wasn't going to be laid down, that she never lays down at this time of day Writer saw CNA leave resident to complete another task, at that time a member of laundry and a member of activities approached writer about another resident [initials of Resident 20.] Activities stated that the [sic] took [initials of Resident 20] to her room to have CNA lay her down as she was requesting, they told writer that CNA then pushed resident back out of her room and then blocked the doorway so she couldn't wheel herself into her room. It was reported that CNA was yelling at [initials of Resident 20] prior to writer re-entering unit. Writer asked both residents what happened. Both residents were crying at this time. [Initials of Resident 20] stated she wouldn't let me lay down and I'm tired. [Initials of Resident 37] unable to report what happened. VS [vital signs] and head to toe completed on both [Initials of Resident 20] stated her left shoulder and arm was hurting upon palpation. [Initials of Resident 37] c/o [complained of] left hip pain on assessment. NP [Nurse Practitioner] was notified and orders for xrays for both residents obtained. An interview was conducted with the MDSC on 8/9/23 at 3:42 p.m. She indicated she took a 10 minute break and when she came back to the unit, she caught the tail end of what was going on. CNA 7 was transferring Resident 37 from her wheel chair into the recliner in the television area of the unit. It looked like it could have been a hard transfer, like she landed hard into the recliner. Resident 37 also had a tendency to drop weight. An x-ray was done on Resident 37's left hip, because of how hard she landed in the recliner. There was no resulting fracture. The file included a 7/9/23 written statement from AA 9. It read, I took [name of Resident 20] into her room because that's where she wanted to go. [Name of CNA 7] the aide took [name of Resident 20] back out of her room and started yelling at [name of Resident 20,] saying she wasn't allowed to take a nap yet and blocked [name of Resident 37] from going into their room and yelled and told her that she would put her in the recliner to be more comfortable. Me and [name of LA 8] walked back to the activities room to clean when we heard [name of Resident 37] start to cry so we walked back out and [name of CNA 7] was still yelling at [names of Residents 20 and 37.] After we told [name of MDSC] all of it and she talked to [name of CNA 7] and she came out and started yelling at me and [name of LA 8] saying we don't know what we are talking about. AA 9 was unavailable for interview. The file included a 7/12/23 Confidential Witness Statement of CNA 7, conducted as an interview by a previous DON. It read, Both residents requested to lay them down. The residents made request to activities aide and the activities aide told her [name of CNA 7] this request. Told resident no you are going to stay up, put both in recliners D/T [due to] lunch being served @ 12:30. CNA 7 was unavailable for interview. An interview was conducted with the MDSC on 8/10 at 10:57a.m. She indicated there were not 2 staff transferring Resident 37 from her wheel chair into her recliner on 7/9/23. Only CNA 7 transferred her. Resident 37 was a 2 person transfer at the time due to a back fracture and her history of dropping her weight. 2. The clinical record for Resident 21 was reviewed on 8/8/23 at 11:10 a.m. Her diagnoses included, but were not limited to, dementia. The 7/29/23 nurse's note indicated a CNA (Certified Nursing Assistant) was headed to the linen cart and informed the writer of this note that Resident 21 was on the floor. The writer observed Resident 21 laying on the floor on her right side next to her bed. She had on her gown, gripper socks, with the bed in the lowest position. The 8/1/23 IDT (Interdisciplinary Team) Post Fall note read, This writer observed observed res [resident] laying on the floor on her right side next to the bed. Res had on her gown and gripper socks with the bed in the lowest position. IDT recommendation: Scoop mattress in bed. The risk of falls care plan indicated she had a history of falls. An intervention was to have a scoop mattress in the bed, initiated 8/1/23. An observation of Resident 21's mattress was made on 8/11/23 at 11:55 a.m. with QMA (Qualified Medication Aide) 37. She did not have a scoop mattress. QMA 37 indicated her mattress was just a regular mattress. An interview and observation of Resident 21's mattress was conducted with the DON (Director of Nursing) on 8/11/23 at 12:08 p.m. She indicated she was going to make sure Resident 21 was provided with a scoop mattress. The Accident and Incident Guidelines was provided by the DON on 8/11/23 at 12:20 p.m. It read, The DON and the IDT At-Risk team will review the incident/accident at the next CQI meeting Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to clarify oxygen services for 1 of 5 residents reviewed for unnecessary medications. (Resident 3) Findings include: The clinical record for Resident 3 was reviewed on 8/7/23 at 11:03 a.m. The resident's diagnosis included, but was not limited to, chronic obstructive pulmonary disease. A care plan dated 2/17/21 indicated Resident 3 requires oxygen. The interventions put in place indicated the staff was to administer oxygen as ordered. A physician order dated 1/20/23 indicated Resident 3 was to wear 2 liters of oxygen continuously. The staff may remove oxygen during showers and at the hair salon. An observation was made on 8/6/23 at 12:12 p.m. Resident 3 was observed sitting in her wheelchair in the common area. She was not wearing oxygen. An observation was made of Resident 3 on 8/10/23 at 1:30 p.m. Resident 3 was observed in her room sitting in her wheelchair. She was not wearing oxygen. An observation was made of Resident 3 with the Regional Nurse Consultant (RNC) on 8/12/23 at 2:02 p.m. Resident 3 was observed sitting in her wheelchair in the activities room. Social Services Director (SSD)was removing a nasal cannula out of the package. SSD indicated the resident's portable oxygen tank was being filled at that time. An interview was conducted with RNC on 8/10/23 at 2:15 p.m. She indicated she would clarify with the the Nurse Practitioner if the oxygen order could be changed to as needed. An oxygen policy was provided by the Director of Nursing on 8/12/23 at 3:00 p.m. It indicated .a. Evaluation .iii. Review order for oxygen administration to include the delivery methods, flow rate, and duration of oxygen therapy . This Federal Tag relates to complaint IN00411900. 3.1-47(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure psychoactive and narcotic medications were administered as ordered; review and implement a resident's individualized mental health safety plan post inpatient psychiatric stay; and adequately monitor and address a resident's ongoing behaviors resulting in increased behaviors, increased anxiety, and interference of peers' daily routine and environment for 1 of 3 residents reviewed for abuse. (Resident 45) Findings include: The clinical record for Resident 45 was reviewed on 8/7/23 at 2:17 p.m. The resident's diagnoses included, but were not limited to, opioid dependence with intoxication, major depressive disorder, bipolar disorder, psychoactive substance abuse, personality disorder, and stroke. The resident was admitted to the facility on [DATE]. An Admissions MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 45 was cognitively impaired. Individualized Mental Health Safety Plan created at Psychiatric Hospital dated 5/26/23 indicated .developed this plan with my support system, specific to my needs. I am at the greatest risk of harm to myself or someone else during the 1st month after a crisis. My safety plan is designed to help ensure safety and to minimize safety risks. I will review an revise the plan with my support system and provider(s). Step 1: My most important reason for living: is to be alive. Step 2: My early warning signs that a crisis may be developing (mood changes, surroundings, people, thoughts, behavior): I isolate; avoiding friends/social activities/work/school, Sleep/Appetite changes. Mood changes (swings, irritability, crying spells, outburst etc.), Active Substance Abuse, not tending to ADLS [Activities of Daily Living], Thoughts of Suicide or Self- Harm, and Change in Energy Level Step 5: Professionals or agencies I can contact during a crisis .Step 6: My environment will be made safe by myself through the completion of the following safety measures. These safety measures will be completed immediately .Alcohol/drugs removed . An Admissions Trauma Screening indicator assessment was conducted on Resident 45 dated 6/12/23. It indicated if the resident had indicators with a response of yes it should be incorporated in her care plan. The resident's indicator assessment was the following: .2. Exposure to any form of trauma including natural disaster, community violence/war, serious injury or illness, serious accident, assault with a weapon, impoverishment, homelessness, persistent bullying. The answer was marked as no. 3. Factors that increase the resident's vulnerability (e.g., dementia, confusion, disorientation, poor insight/poor judgment, poor communication skills, poor ambulation or inability to ambulate/propel wheelchair, frailty/weakness, history of being exploited, for example, giving away money persona items). The answer was marked as yes. 4. History of substance use/abuse (alcoholism, drug abuse including prescription drug abuse/narcotic seeking) and/or compulsive behavior (uncontrolled or poorly controlled gambling, overeating, exercise, obsessions). The answer to the question was marked as yes. 5. Psychiatric history and/or present mental health diagnosis, including psychotic symptoms (e.g., delusional thinking, hallucinations) and possible misinterpretation of events and the intentions of others. The answer was marked as no. 6. Denial and/or evasiveness when discussing mental health issues, minimizing significance of mental health/psychosocial issues. Including Anosognosia (complete lack of awareness of one's mental health issues). The answer to the question was marked as no. 7. Depressive illness and/or present signs/symptoms of depression/mood distress. Low self-esteem, isolation withdrawn behavior. Complaints of chronic pain, illness, fatigue and/or persistent anger, fear and/or anxiety. The answer was marked as yes. 8. History or presence of dysfunctional behavior (e.g., provoking, aggressive, manipulative, derogatory, disrespectful, abhorrent, insensitive, attention-seeking, criminal history and/or otherwise abrasive/inappropriate behavior), including roaming/wandering into peer's rooms/personal space. The answer was marked as no. The resident's risk measure for likelihood for psychiatric, behavioral and/or physical symptomology related to trauma was scored as minimal symptomology. A care plan dated 6/12/23 indicated the resident had potential for safety hazard and/or injury r/t [related to] smoking. The resident was provided the facility smoking policy. A Substance Use Disorder (SUD) care plan dated 6/12/23 indicated the following interventions assist to recognize problem exists by non-judgmental active listening, .Assist with arranging profession SUD services, .Discuss alternative solutions to substance use (hobbies, activities, exercises, meditation .), .Encourage and assist with selecting a treatment program and provider, .keep behavioral health specialist updated ., Monitor closely and frequently visits in-house or upon return to facility from leave of absence., Promote and encourage involvement in self help groups (AA [alcohol anonymous], narcotics anonymous), .Stress substance use is not acceptable while residing at the facility . A care plan dated 6/19/23 indicated Resident 45 was impaired cognitive function or impaired thought processes r/t [related to] difficulty making decisions. A care plan dated 6/19/23 indicated the resident had depression. The interventions were the following: approach in warm calm manner, .encourage family visits, encourage res [resident] to attend activities of choice, .encourage res to avoid feelings and concerns, .notify MD [medical provider] prn [as needed], .offer support and reassurance, .ongoing behavior monitoring, .re-approach when agitated . The resident's plan of care did not have developed care plans to include her individualized mental health safety plan provided on admission, or address her mental health disorders, and/or behaviors. A physician order for the resident dated 6/9/23 indicated behavior monitoring: monitor for behaviors such as anxiety, depression, change in mood, self isolation, false accusations etc. There must be a nurses note for any behavior with added documentation for non-pharmacological interventions and prn [as needed] medications administered every shift . A physician order dated 6/9/23 indicated the resident was to receive 60 milligrams of duloxetine daily for depression. Discontinued on 7/5/23. A physician order dated 6/12/23 indicated Resident 45 was to receive 2 milligrams of buprenorphine three times a day for opioid use disorder. The June 2023 Medication/Treatment Administration Record (MAR/TAR) and the narcotic controlled record form indicated the following days and times behavior monitoring was not conducted and buprenorphine medication was not administered as ordered: behaviors monitoring: 6/12/23 - evening shift, 6/13/23 - evening shift, 6/15/23 - evening shift, 6/16/23 - evening shift, and 6/28/23 - evening shift Buprenorphine medication: 6/10/23 - midday administration, 6/12/23 - evening administration, and 6/15/23 - midday administration A medical provider note dated 6/12/23 indicated Resident 45 had a history of chronic opioid dependence and multiple suicide attempts. She was discharged from a psychiatric hospital for neurocognitive disorder. On exam, she was oriented to self and location. The resident's thought and behavior was normal. The plan for the resident and her personality disorder would be followed by psych. An initial psych visit dated 7/5/23 indicated Resident 45's mood was depressed and not sleeping. The resident had made statements that day, wish I would not wake up, sometimes wish were dead. The resident's history included, drug abuse, depression, suicide attempts, homeless and incarcerated for more than 18 years. The plan at that time was to titrate duloxetine dosage from 60 milligrams to 30 milligrams for 3 days then discontinue. The new medication to start was 10 milligrams of zyprexa at night to treat bipolar and insomnia. A psych follow up would be conducted next week. A physician order dated 7/5/26 indicated the staff was to administer 10 milligrams of zyprexa at night. Discontinued on 7/26/23. A physician order dated 7/6/23 indicated for staff to administer 30 milligrams of duloxetine for 3 days. A physician order dated 7/18/23 indicated the resident was to receive 3 milligrams of melatonin nightly. A physician order dated 7/26/23 indicated the resident was to receive 15 milligrams of zyprexa at night. A physician order dated 7/27/23 indicated the resident to receive 50 milligrams of hydroxyzine twice a day for anxiety. The July 2023 MAR/TAR and the narcotic controlled record form indicated the following days and times behavior monitoring was not conducted and zyprexa, melatonin, hydroxyzine, and buprenorphine medications were not administered as ordered: Behavior monitoring: 7/7/23 - evening shift, 7/11/23 - evening shift, 7/12/23 - evening shift, 7/13/23 - evening shift, 7/20/23 - evening shift, 7/22/23 - day shift, 7/27/23 - evening shift, 7/29/23 - evening shift, and 7/31/32 - evening shift 2 milligrams of buprenorphine medications: 7/2/23 - day, midday, and evening dose, 7/3/23 - day, midday, and evening dose, 7/14/23 - day dose, 7/24/23 - evening dose, and 7/25/23 - day dose, 3 milligrams of melatonin medication: 7/20/23, 7/23/23, 7/27/23, 7/29/23 and 7/31/23 10 milligrams of zyprexa medication: 7/7/23, 7/11/23, 7/12/23, 7/13/23, and 7/20/23, 15 milligrams of zyprexa medication: 7/27/23, 7/29/23 and 7/31/23 50 milligrams of hydroxyzine medication: 7/27/23 - evening dose, 7/29/23 - evening dose, and 7/31/23 - evening dose A psych visit follow up dated 7/12/23 indicated the resident was having racing thoughts. She stated, I am going crazy. The plan was to continue current treatment and psych follow up next week. The July 2023 MAR indicated the resident had a behavior in the evening on 7/23/23. There was no nursing notes in the resident's clinical record on the evening of 7/23/23 with notation of what type of behavior the resident had nor non-pharmacological and/or medication interventions attempted to address the behavior as ordered. A Re-Admissions Trauma Screening indicator assessment was conducted on Resident 45 dated 7/25/23. It indicated if the resident had indicators with a response of yes it should be incorporated in her care plan. The resident had indicators in factors that increase the resident's vulnerability, history of substance use/abuse, and depressive illness. The resident score indicator assessment indicated with minimal symptomology. A social services note for Resident 45 dated 7/27/23 indicated it had been reported to the Social Services Director (SSD) Resident 45 had been overheard by Resident 40 making comments of having suicidal thoughts during a happy hour activity on 7/26/23. During an interview with the resident, SSD had asked the resident, how she was doing and how washappy hour yesterday? The resident stated, I've been better. She was unable to recall the happy hour activity. The resident had indicated to SSD if she had made comments about suicide she had been joking. SSD notified the psych provider. A social services note dated 7/27/23 indicated S. S. [Social Services Director] was called by ADON [Assistant Director of Nursing] to come and speak with resident. Resident is upset due to not being able to go on an outing. S.S. and ADON spoke with resident in regard to her wanderguard. S.S. educated resident on wanderguard and what they are used for. Resident has wanderguard for being a risk of elopement. Resident has also been drug seeking, making calls for sexual favors, and had alcohol on 7/26/23. Resident had OD'd [overdosed] on heroin 9 times prior to stay at facility. S.S. explained to resident that wanderguard is for her safety. Resident screaming and cussing at ADON and S.S. resident then threatened to leave facility and got on elevator and said she would leave out the front doors. S.S. followed resident downstairs to ensure safety and ensure there was no risk for elopement. Resident stated she wanted to discharge from facility. S.S. explained to resident that if she were to make that decision on her own than resident would not be able to return to facility. Resident stated she has nowhere to go and does not care. S.S. asked to speak with resident in private area to avoid disturbing other residents and guests as well as keep resident's general and medical private. Resident and S.S. spoke in small conference room downstairs and S.S. reeducated resident on safety, AMA [against medical advice] policies and wanderguard education. Resident left room and head back towards elevator when resident stopped housekeeper and asked do you know where my room is? Help me look for my room. Resident was guided by housekeeper to elevator and was instructed on where her room was located. S. S. gave resident space and reported incident to Administrator. S.S. would like to make a note that resident made two phone calls (unknown on who) and resident was asking people to come visit . A nursing progress note dated 7/30/23 indicated Resident 45 was observed using a vape while in her room. Education was provided to the resident vaping was not allowed inside the facility. The vape was removed from the resident's room and locked in the narcotic medication box. A medical provider noted dated 7/31/23 indicated the resident currently was severely manic. She was paranoid and delusional. The resident was described as anxious, uncooperative and agitated behavior with rapid, pressured and tangential [erratic] speech. The plan was to continue hydroxyzine and zyprexa for her diagnosis of bipolar disorder. The psych provider was notified. The August 2023 MAR/TAR and the narcotic controlled record form indicated the following days and times behavior monitoring was not conducted and zyprexa, melatonin, hydroxyzine, and buprenorphine medications were not administered as ordered: Behavior monitoring: 8/5/23 - evening 2 mg Buprenorphine: 8/4/23 - midday and evening shift, 8/5/23 - day, midday and evening shift, and 8/9/23 - day dose 15 mg Zyprexa: 8/5/23 and 8/6/23 50 mg hydroxyzine: 8/5/23 A psych visit dated 8/2/23 indicated .chief complaint. patient presents with 'can't sit still,' 'racing thoughts,' vaping in rm [room], bipolar symptoms .[Medical Nurse Practitioner (NP) 30] asked [Psych NP 31] to see as pt [patient] told her 'my mind not shut off.' .Mental Status Exam .Behavior Social, can't seem to sit still, motor restless, .mood she feels restless, anxious often, affect anxious .Plan .add akathesia [unable to remain still], inderal LA 60 mg [milligrams] am [a.m.] See 2 wks [weeks]. A physician order dated 8/3/23 indicated Resident 45 was to receive 60 mg of inderal for akathesia. A behavior monitoring note dated 8/3/23 indicated Res showing aggressive behavior towards staff r/t vape res noted throwing walker into wall. Writer, social services, ADON unable to redirect will update as needed and continuing to monitor. A nursing progress note dated 8/4/23 indicated Resident up walking around. Stopped by nurses station to ask for an inhaler. Resident talking normally, does not display any shortness of breath. Reminded resident that the order states she can take this medicine every 4 hours as needed. Resident started screaming and cursing and walked away, got on the elevator, went downstairs and came back up. Started screaming again demanding to know when she could have the inhaler. This writer responded that it was a least 2 hours before she could get the next dose. This writer attempted to redirect the resident to go lay down and relax to which resident replied 'F*** going to bed you go to bed!' Resident continued to walk through hallways with her walker, not showing any shortness of breath or labored breathing. A behavior progress note dated 8/5/23 at 10:04 a.m., indicated Resident yelling and cursing. Resident stated she wanted to leave this f'ing [f***ing] place. Resident stated she was an adult. Resident threw walker against elevator Interventions attempted: asked resident to calm down and have eat. Resident refused for writer to take vitals but allowed writer to get o2 [oxygen saturations] and it ranged between 94-96% .Effectiveness of the interventions: No effective resident has been walking the unit non stop going in out of the elevators. A nursing progress note dated 8/5/23 at 11:51 a.m., indicated Resident ask to go out to vape. CNA [Certified Nursing Assistant] took resident out, writer gave resident a purple and white vape. Resident came back in and gave writer green and back vape. Writer ask resident where was the vape that was given to her she first stated the one she handed the writer was the one. Writer then told resident she was given a purple and white vape and she needs to return it to me to be stored. Resident stated I'm not giving it back then proceeded down the hall. CNA and another nurse went with writer and explained that she has to give the vape pine back. After resident kept refusing she gave the vape back to writer. Writer don't know where the green and black vape came from because resident didn't receive it from writer. A nursing progress note dated 8/5/23 at 12:45 p.m., indicated Resident out of buprenorphine. Writer called pharmacy and they stated they needed script. NP came in this a.m. and writer spoke to her about sending a script for this med. NP stated script was sent on 7/31. Script wasn't filled due to NP never sign to complete the process. NP resent this a.m. A nursing progress note dated 8/5/23 at 1:54 p.m., indicated Writer has explained to resident several times in the last 20 minutes the order the NP wroter (sic) for her concerning anxiety. Writer explained that facility doesn't have medication on hand to be given at this time. Resident then went on to say she wants to leave facility and who does she talk to. Resident is very impulsive at this time. Writer tried to help resident with interventions to easy anxiety. Resident stated she needs medication. Writer explained as soon as it comes in or her next dose is due it will be given to her. Resident continued to come to nurses station and repeat behavior. Resident is going up and down elevator at this time. Resident is not easily redirected. A physician order dated 8/5/23 indicated Resident was to receive 25 mg of hydroxyzine every 24 hours as needed for anxiety and agitation. Resident 45 received at 3:11 p.m. A behavior note dated 8/5/23 at 7:50 p.m., indicated Res up at nurse's station several times during the shift, asking to use the phone and to go outside to vape, this writer took her out earlier in the shift and attempted to call the numbers that were listed but the appeared not to work. Res currently out in the common areas pacing up and down the hallways yelling. Res received her scheduled evening meds A behavior note dated 8/5/23 at 10:26 p.m., indicated Res continues to coming to nurse's station yelling out and res was informed that she could not receive another dose of PRN Tylenol until around 8:00 p.m. which was given per res request; res back out at nurse station demanding Tylenol on several occasion, res redirected to recliner in common area to watch tv and knocked her walker over. Res became aggressive and attempted to yank the med cup holder off the medication cart. This writer intervened and informed res that she needed to return to her room and that she was disturbing other peers on the unit. CNA present at the nurse station during intervention. On call notified concerning res behaviors; currently awaiting return call. Res currently present at the nurse station again. The August [DATE] indicated 8/6/23 at 1:45 a.m., Resident 45 received 25 mg of hydroxyzine as needed for anxiety/agitation and it was effective. A MAR note dated 8/6/23 at 3:11 p.m., indicated res stated she feels 'amped up and can't calm down', offered to provide an activity for resident which she declined, attempted to call two different recovery coaches for resident to speak with, left vm [voicemail] for [Recovery Coach 1] unable to leave vm for [Recovery Coach 2]. The nurse administered 25 mg hydroxyzine as needed for anxiety/agitation. The record did not indicate if the as needed medication was effective. A behavior note dated 8/6/23 at 6:20 p.m., indicated the resident's behavior was anxiety, yelling, attempting to open main facility doors, asking how to take wanderguard off, excessive pacing, ADON and NP on call notified. Resident has been exhibiting signs of anxiety all day according to shift report, during this shift, resident has been yelling hallway and attempting to open facility doors. resident states she feels 'amped up and can't calm down.' Resident has been pacing the hallways. when asked if resident knows what is causing the anxiety, resident stated she did not know. nurse administered prn hydroxyzine as ordered. nurse offered activities to help with anxiety but resident declined. nurse attempted to call recovery coaches to speak with resident to help calm her down. left vm with [Recovery Coach 1], unable to lvm [leave voicemail] with [Recovery Coach 2], anxiety uncontrolled even after prn hydroxyzine. ADON notified. Call put in to on call patient coordinator, .currently waiting on call back from on call provider. will continue to monitor resident. A physician order dated 8/7/23 at 12:34 a.m., indicated Resident was to receive 0.5 mg of Ativan twice a day as needed for anxiety/agitation. Resident 45 received as ordered at that time. A nursing note dated 8/7/23 at 4:35 a.m., indicated Resident remains with sitter due to having increased yelling this weekend, moved to room .and calm at this point, resting well . An observation was made of Resident 45 on 8/7/23 at 10:30 a.m. The resident was observed propelling self in wheelchair down hallway with staff person presence. Resident 45 indicated to staff person she was not trying to get in bed with another resident. A resident council meeting was conducted on 8/07/23 at 11:29 a.m. Resident 4, Resident 22, Resident 14, Resident 44, Resident 13, and Resident 35 attended the meeting. The council indicated Resident 45 was loud yelling out, cussing down the hallways day and night and smoking in her room. She was disruptive. Resident 45 had a drug addiction and trying to get off drugs. She was unpredictable. The council was fearful of what she might do. A SSD note dated 8/7/23 at 11:38 a.m., indicated .S.S. spoke with resident to check in and see how she was doing. Resident is currently on 1 on 1's with staff. Resident stated she still feels amped up and is adamant on getting something to help calm her down. S.S. stated she will let psych NP know and when she comes to visit Wednesday, pscyh will evaluate resident and see if there is anything they can do for her. Resident content with the psych NP coming to evaluate her. Resident stated she is doing okay other than having a lot of anxiety. When S.S. asked how long this has been going on, resident stated she has been experiencing anxiety for 3-4 days. S.S. will alert psych NP to come look at resident . The August 2023 Controlled Drug Record indicated Resident 45 was administered PRN ativan on 8/8/23 at 8:30 a.m. A behavior noted dated 8/8/2023 at 8:47 a.m., indicated .Therapy Director paged S.S.D. and stated resident was downstairs cussing, screaming, and calling staff names. S.S. and ADON went downstairs and found resident in the middle of the hallway in her w/c and resident stated to S.S. and ADON 'And here come the b****** S.S. and ADON tried to talk to resident and figure out what had resident upset. Resident stated she wants to go home. Resident has no home, no family and no address. Resident was homeless prior to stay at facility before she was taken to hospital. Resident and S.S. called resident's [family member] yesterday and resident's [family member] said she has nowhere to go, and she will not d/c [discharge] home with her. S.S. stated that if she would like to d/c she needs to have transportation, a pharmacy for meds, PCP, and an accurate and safe address for S.S. to d/c her too. Resident then replied 'I live in these streets and have lived in these streets my whole life' S.S. tried stating that if she were to d/c resident, all S.S. would be able to do since resident does not have an address would be to d/c her out the front door which is not safe. Resident did not comply and continued to cuss at S.S. and ADON. Resident then became very upset and angry and started yelling as resident got up out of w/c [wheelchair], resident did not lock wheelchair and she continued to push her wheelchair angrily behind her and storm off. This resulted in a resident [Resident 19] behind her getting hit with the w/c. ADON tried to explain to resident that she needs to think about actions and others before getting so angry. ADON gave resident her walker since that is what therapy provided for resident and took w/c to therapy since resident started using w/c unsafely. A behavior note dated 8/8/23 at 9:02 a.m., indicated Resident was in therapy room trying to take wheelchairs, walkers etc. from therapy stating, 'I want this d*** red walker, I don't want that ugly silver walker!' Director of Therapy stated that the walker resident was referring to is used only in therapy room by therapy staff. Resident began yelling and took a stool and sat down and began to refuse to get up until she got w/c. Resident's wheelchair was returned to her with education from nursing and therapy on how to safely use wheelchair . An interview was conducted with SSD on 8/8/23 at 9:46 a.m. She indicated Resident 45's behaviors has increased for approximately a week in half. The resident had participated in a happy hour activity on 7/26/23 and did drink a beer. The Psych NP was notified, and she indicated it was okay for the resident to consume alcohol. The therapy department had paged for staff assistance this morning, due to Resident 45 had become agitated in therapy. Resident 45 was observed in the hallway yelling and stating she wanted to be discharged . During that time, the resident had abruptly stood up and pushed back her wheelchair. It was not locked at that time, and it rolled into Resident 19 coming out of the dining room. Psych NP 31 was notified of the incident between Resident 40 and Resident 45 this past weekend. Resident 40 had awoken to Resident 45 at her bedside. Resident 40 had pushed Resident 45 in the chest at that time. Resident 45 then returned back to her bed. Resident 45 reported to SSD that she had awoken up standing next to Resident 40's bed. Resident 40 then pushed her. Resident 45 at that time, realized she was at the wrong bed. She then returned back to her own bed. Resident 45 can not recall why she was standing at Resident 40's bedside. Resident 40 had reported she no longer wanted to be roommates with Resident 45. Psych NP 31 will be out 8/9/23 to evaluate Resident 45. Resident 45 was currently 1 on 1 staff supervision. The resident's clinical record did not have a physician order that Resident 45 was able to consume alcohol. An interview was conducted with Qualified Medication Aide (QMA) 4 and Certified Nursing Assistant (CNA) 30 on 8/8/23 at 10:09 a.m. QMA 4 indicated she was Resident 45's sitter that day. She had taken Resident 45 that morning to the therapy department. The resident had complaints of her legs hurting. Physical Therapist (PT) 40 had suggested she come into therapy to use the bicycle and apply some heat on her legs. She agreed. PT 4 was instructed to bring Resident 45 back upstairs or call her to come back down to get her. CNA 30 had indicated Resident 45 had gotten upset downstairs in therapy, and staff had to go downstairs to assist. The resident's wheelchair had bumped Resident 19. He was not hurt. CNA 30 and QMA 4 indicated Resident 45 has had lots of outbursts. She does not sleep. She had inappropriately touched her roommate over the weekend, so she was moved to another room. Resident 45 was manipulative and lots of behaviors. The behaviors has been getting worse for about a week. An interview was conducted with PT 40 and Therapy Director on 8/8/23 at 10:16 a.m. PT 40 indicated resident was being evaluated today. The resident wanted to use the rollator machine, and he had told her she had to work up to that machine. The resident did not like that answer and got agitated with that response. She then walked away. Resident 45 then walked about 30 feet, and then returned for the wheelchair. After, she retrieved the wheelchair she left the therapy department. The Therapy Director called SSD and Executive Director to assist. She was always in eye sight of a staff member. The Therapy Director tried to calm her down and return back to the therapy department. PT 40 and the Therapy Director did not see Resident 19 get hit with the wheelchair, but they did observe ADON assess the resident. He was not hurt. Resident 45 was very agitated at that time. The Therapy Director indicated it has gotten worse in the last couple of weeks. It has been a hit or miss with her behaviors. An interview was conducted with License Practical Nurse (LPN) 42 on 8/8/23 at 10:39 a.m. She indicated Resident 45 was in the hallway yelling and therapy staff were in view. She did not observe any residents in the hallway with Resident 45. After ADON and SSD arrived she left the hallway. Resident 45's agitation in the past week has gotten worse. She did work the weekend. Resident 40 had reported to her Resident 45 had touched her inappropriately early morning of 8/6/23. Resident 40 was embarrassed about the incident. Resident 45 was removed out of the room she shared with Resident 40 and placed on 1 on 1 supervision. Resident 45 over the weekend had been loud, yelling, cussing and exit seeking. The PRN medications given were not working to calm her down. She had worked the evening shift of 8/6/23. She was given report by day shift nurse Resident 45 had been anxious all day long. An interview was conducted with Resident 40 on 8/8/23 at 11:02 a.m. She indicated she was Resident 45's roommate. The staff recently moved Resident 45 to another room, because Resident 45 had inappropriately touched her on 8/6/23. Resident 40 had just gotten to sleep, because Resident 45 had been yelling very loudly all day into the night wanting her drugs. She then was startled awake by Resident 45 standing over her with her hand under her covers rubbing on her thigh. She then kicked Resident 45 in the chest. Resident 45 did not say anything and walked back to her own bed. She reported to the nurse later that evening. This is the 2nd incident this has happened. The fist time, was shortly after Resident 45 was admitted . She had woke up and Resident 40 was standing over her with her hand under the covers rubbing her thigh. Resident 40 yelled what are you doing? Resident 40 returned back to her bed that time too. She had reported to the staff person, and the staff person had thought it was her imagination possibly dreaming. Resident 40 agreed with the staff person maybe she was dreaming, and it didn't happened. After this past weekend, and Resident 40 did it again. She knows now she was not dreaming; it really happened. At first, Resident 40 had tried to get along with Resident 45, but the last few weeks she has gotten worse to deal with. The drug counselors brought her[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent for 1 of 5 residents observed during medication pass. There were 25 opportunities with 2 errors resulting in an 8 % medications error rate. The errors involved 1 resident (Resident 45) in the sample of 5. Findings include: The clinical record for Resident 45 was reviewed on 8/7/23 at 2:17 p.m. The resident's diagnoses included, but were not limited to, opioid dependence with intoxication, major depressive disorder, bipolar disorder, personality disorder, and stroke. The resident was admitted to the facility on [DATE]. An Admissions MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 45 was cognitively impaired. A physician's order, dated 6/12/23, indicated Resident 45 was to receive Buprenorphine sublingual tablet 2 mg to be given three times a day. A physician's order, dated 6/9/23, indicated to give memantine hydrochloride (medication for memory) 10mg daily. The order was discontinued on 8/2/23. On 8/10/23 at 8:31 a.m., Resident 45 was randomly observed receiving medications from QMA (Qualified Medication Aide) 4. QMA 4 performed hand hygiene and prepared the medications to be given to Resident 45. QMA 4 opened an individual dose pack of memantine hydrochloride 10 mg and placed it in the medication cup to be given. QMA 4 then indicated that the Buprenorphine sublingual 2 mg tablet was unavailable to give because it had not come in from pharmacy. QMA 4 prepared the rest of Resident 45's medications and administered them, including the memantine, to Resident 45. On 8/10/23 at 3:55 p.m., the Director of Nursing provided the current Medication Administration Policy which read .To ensure that resident medications are administer in a timely manner and documentation is completed to substantiate administration Licensed professional nurses administer medications according to times documented on the Medication Administration Record . 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to store controlled medication under double lock in 1 of 2 medication rooms. Findings include: On 8/11/23 at 10:44 a.m., the 200-hall medication room was observed with QMA 4. The refrigerator in the medication room contained an unlocked metal lock box for the storage of refrigerated controlled substances. The metal lock box contained liquid lorazepam for 3 residents of the second floor. QMA 4 indicated that the box should have been locked while being stored in the refrigerator. During an interview on 8/11/23 at 11:51 a.m., the DON (Director of Nursing Services) indicated the lorazepam should have been stored in a locked container in the refrigerator. On 8/11/23 at 11:51 a.m., the DON provided the Medication Storage in The Facility policy, dated February 2017, which read .All drugs classified as Schedule II of the Controlled Substances Act will be stored under double locks . 3.1-25(n)

Based on interview and record review, the facility failed to implement a corrective plan of action that included monitoring, tracking, evaluating effectiveness for an identified concern area, abuse. This affected 3 of 5 residents reviewed for abuse. This had a potential to effect 48 of 48 residents resided in the facility. Findings include: An interview was conducted with the Executive Director (ED) on 8/7/23 at 10:00 a.m. The ED indicated the Quality Assurance and Performance Improvement (QAPI) committee met monthly regularly. One deficiency that was identified during this recertification and complaint survey on 8/6/23 through 8/11/23, was cited at harm level - F600 - G. Abuse: 1 resident was verbally abused by a staff person while providing incontinent care. 2 residents were verbally and mentally abused by a staff person that refused to honor residents' preference to return to their room and lay down. A fourth resident was sexually abused by her roommate that inappropriately touched her while she was sleeping. There was no evidence the facility had developed or implemented an appropriate action plan with measures to correct the deficiency that was cited. Cross reference F600 An interview was conducted with the ED on 8/11/23 at 4:14 p.m. The ED indicated in March 2023 the corporate office conducted a mock survey to identify areas that needed improvement to ensure compliance with regulations. Once of the areas was identify during that survey was abuse. The staff was unable to identify different types of abuse. He indicated there were other areas that needed to be corrected. That staff were in the process of correcting, but unable to fix everything all at once. The staff were unable to correct all areas. Education was provided to the staff regarding identification of different types of abuse. There were no audits, tracking or follow up to ensure the abuse concern recognized from that survey was corrected. In the July 2023 QAPI meeting, abuse was discussed related to the abuse incidents in June. Reeducation was provided to the staff on abuse and reporting. A QAPI program and plan was provided by the ED on 8/7/23 at 9:00 a.m. It indicated .Mission: It is the mission of Quality Assurance and Performance Improvement Program and Plan to develop, implement, and maintain an effective, comprehensive, and data driven QAPI Program in accordance with Federal Guidelines that focuses on indicators of outcomes of quality of care and quality of life for our residents The QAPI Program: .5. Identifies and prioritizes problems and opportunities based on performance indicator data, resident input, and other information 6. Implements actions aimed at performance improvement to address gaps in systems and the effectiveness of the corrective actions. 7. Evaluates implemented corrective actions and tracks performance to ensure improvements are realized and maintained D. The QAPI Plan includes the following components: 1. Tracking and measure performance .6. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed . 3.1-52

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure grievances reported were addressed that included resolutions. This had a potential to affect 6 of 6 resident council members and 1 of 1 residents reviewed for food. (Resident's 4, 13, 14, 22, 31, 35, 44) Findings include: 1. The May, June, and July 2023 Resident Council Minutes were provided by the Executive Director on 8/7/23 at 11:01 a.m. The May and June 2023 Resident Council Minutes indicated the council had concerns with alternative food choices that are not listed on the menu. The staff were not asking the residents what they would like to eat. The council minutes did not include resolutions to the concerns addressed in May or June. The July 2023 Resident Council Minutes did not include resolutions to the concerns addressed in May or June. A resident council meeting was conducted on 8/07/23 at 11:29 a.m. Resident 4, Resident 22, Resident 14, Resident 44, Resident 13, and Resident 35 attended the meeting. The council indicated some grievances are not addressed nor are they given resolutions to those concerns. The staff do not always ask what we want to eat. The residents receive whatever the meal was for that day. The alternative choices are not on the menus. An interview was conducted with the Social Service Director (SSD) on 8/11/23 at 8:55 a.m. She indicated she was the grievance official. She does not have any grievances that have been filed by resident council in May, June or July. 2. The clinical record for Resident 31 was reviewed on 8/7/23 at 1:17 p.m. The resident's diagnosis included, but was not limited to, anemia. A Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 31 was cognitively intact. An interview was conducted with Resident 31 on 8/7/23 at 10:50 a.m. She indicated she has requested meals when she was missed, and the staff bring her in a food tray with food she had not ordered. She had spoke to the Assistent Director of Nursing about the concern, and she indicated Resident 31 would start filling out her own menu. She doesn't always get to do that and when she does the food brought in at times was not what she ordered. An interview was conducted the Dietary Manager (DM) on 8/11/23 at 9:35 a.m. DM indicated he had been having trouble printing the options on the tickets. The alternative meal choices are burgers, chef salad, grilled cheese. When the staff go into the resident's room; at that time the resident can ask staff the alternative options. The residents are unable to circle on the meal ticket their alternative choice item. An observation was made of an 8/11/23 lunch meal ticket on 8/11/23 at 9:39 a.m. The meal ticket indicated the residents' lunch meal tray would include breaded fish, wheat bread, hashbrown casserole, creamy cole slaw, coconut cake and margarine butter. The ticket did not include alternative food choices. An interview was conducted with Certified Nursing Assistant (CNA) 30 on 8/11/23 at 10:00 a.m. She indicated she enters the resident's room with the meal ticket and tells the resident what will be served at that meal. If the resident wants something else, she tells them they can have grilled cheese, chef salad, soup, and burger. That was all the alternative food choices she new. When she first started working in the facility, the alternatives were included on the meal ticket. Now they are removed. Resident 31 fills out her meal ticket and signs it. If she would like an alternative she writes it on the ticket. An observation was made of a lunch meal tray on 8/11/23 at 12:52 p.m. The tray included the following food items: breaded fish, hashbrown casserole and creamy cole slaw. The meal tray did not include the wheat bread, the coconut cake or the margarine as per the meal ticket indicated. An interview was conducted with the Activities Director on 8/11/23 at 12:10 p.m. She indicated she writes down grievances the resident council have filed monthly and provide to the appropriate department management. The department management addresses the concern with resolutions and provides it back to her. She does not turn the grievances reported in from resident council to the grievance official. She has her own binder with only resident council grievances. She was new to this position and trying to get a system down. She does not document the resolutions that have been discussed with resident council after a grievance was filed. The meal tickets only include what was being served at that meal. She had looked into why the alternative food choices are not included on the meal tickets. The DM had indicated the food company program utilized to print the meal tickets do not allow for staff to add alternative food choices on the tickets. The residents were able to see them in the past on the ticket. She did not have documentation the information was provided to the resident council. A grievance policy was provided by the SSD on 8/11/23 at 8:50 a.m. It indicated .Procedure: 10. When the question. concern has been answered or has been resolved to the greatest degree possible, the assigned Dept. Head will contact the appropriate party to discuss what has been done. It is important that the resident or the resident's representative understands and agrees with or accepts the 'Answer' as being to their satisfaction. This exchange of information must end as positively as possible for the resident or their representative in order to define the effort as a successful answer . 3.1-7(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the residents were able to file a grievance anonymously. This had a potential to effect 48 of 48 residents that reside in the facility. Findings include: A resident council meeting was conducted on 8/07/23 at 11:29 a.m. Resident 4, Resident 22, Resident 14, Resident 44, Resident 13, and Resident 35 attended the meeting. The council indicated the residents have to report to a staff person to file a grievance or a concern. They are unable to file a grievance anonymously. An interview was conducted with the Activities Director on 8/11/23 at 8:43 a.m. She indicated the residents notify the staff when he or she has a grievance or a concern needed to be addressed. The staff fill out a paper and turn it in to Social Services Director (SSD). An observation was made with the SSD on 8/11/23 at 8:43 a.m. An observation was made of the copy room with the SSD on the 1st floor. The grievances forms were located in a folder on the wall. The SSD indicated the staff fill them out for the residents. A resident with a concern would fill the form out and turn it in to her to address. She was the grievance official in the facility. An interview was conducted with SSD on 8/11/23 at 12:36 p.m. She indicated she was unaware there should be a place residents can file grievances anonymously. A grievance policy was provided by the SSD on 8/11/23 at 8:50 a.m. It indicated .Procedure: 1. When a resident or a resident's representative presents a question/concern, a staff member obtains the 'I would like to know' form. A staff member completes the form for the resident or resident's representative. If possible, a leadership staff person should completed the form . 3.1-7(1)

Based on interview and record review, the facility failed to ensure a resident who was identified with a pressure ulcer received timely treatment and continued treatment for 2 of 3 residents reviewed for pressure ulcers. (Resident B and Resident G) Findings include: 1. The clinical record for Resident B was reviewed on 6/19/23 at 12:00 p.m. The diagnoses included, but was not limited to, quadriplegia, anxiety disorder, burns involving 30-39% of body surface, tracheostomy status, and weakness. An admission assessment, dated 5/18/23, did not indicate any pressure ulcer concerns to Resident B's buttocks, sacrum, and/or coccyx area. There were third degree burns that were noted throughout Resident B's body surface area. A care plan for wounds, dated 5/19/23 and revised on 6/15/23, indicated the following, .I was admitted with pressure injury: Right gluteal fold. surgical wound to my left foot requiring use of wound vac to promote wound healing .BURNS INVOLVING 30-39% OF BODY SURFACE .Interventions .Administer treatment (product specific) as ordered A Weekly Wound Evaluation, dated 5/30/23, indicated a stage 2 pressure ulcer was identified on 5/27/23 to Resident B's right gluteal fold. The area measured 3.5 x 3.2 centimeters and was 0.2 centimeters in depth. The area contained 20% slough tissue with yellow wound color. The comments were to cleanse with wound cleanser, apply calcium alginate, and cover with a foam dressing. There were no progress notes, dated 5/27/23, in regards to any skin impairment identified to Resident B. A physician order, dated 5/31/23 for a start date of 6/1/23, to cleanse right gluteal fold with wound cleanser, apply calcium alginate, and cover with foam dressing daily. The electronic treatment administration record (ETAR), for June of 2023, indicated the initial treatment on 6/1/23 was not signed off. It was documented as refused on 6/2/23 and initially signed off, as completed, on 6/3/23. The date(s) of 6/11/23, 6/16/23, and 6/17/23 were left blank. 2. The clinical record for Resident G was reviewed on 6/20/23 at 11:14 a.m. The diagnoses included, but were not limited to, streptococcal sepsis, pressure ulcer of sacral region, stage 4, weakness, osteomyelitis of multiple sites, paraplegia, and prediabetes. An admission assessment, dated 4/27/23, indicated the following skin concerns for Resident G: - Two stage 3 pressure ulcers to the right buttock, - Three stage 3 pressure ulcers to the right hip, - A stage 3 pressure ulcer to the coccyx, - A stage 3 pressure ulcer to the sacrum, & - A stage 3 pressure ulcer to the left thigh (rear). A progress note, dated 4/27/23 at 11:09 p.m., indicated Resident G was admitted to the facility that evening. He was noted with multiple wounds on his buttocks and hips. The pressure ulcers were measured and dressings applied per orders. A wound care plan, revised 5/4/23, indicated the following, .I [Resident G] was admitted with pressure injuries to right buttock, right thigh (Rear), left gluteal fold and sacrum .Interventions .Administer treatment (product specific) as ordered A physician order, dated 5/1/23, indicated to cleanse the wounds to right hip tracts and right sacral tracts with saline and gauze, flush wounds with rubber tipped catheter and saline, pack wounds with a strip of AquaCell AG, cover with absorbent secondary dressing. A physician order, dated 5/1/23, indicated to cleanse the wounds to bilateral ischium and sacral wound with saline and gauze, apply dakins solution to dry packing strips and pack wound, and cover with absorbent secondary dressing. There were no previous physician orders for Resident G's wounds prior to 5/1/23. The ETAR for May of 2023 indicated the treatments for Resident G's pressure ulcers were not signed off, as completed, on 5/1/23 and 5/2/23. The initial treatment was completed on 5/3/23. A policy titled Preventative Skin Care, undated, was provided by the Interim Director of Nursing (IDON) on 6/19/23 at 3:15 p.m. The policy indicated the following, .It is the intent of the facility that the facility provide skin care through careful washing, rinsing, and drying to keep residents clean, comfortable, well-groomed and free from pressure sores A policy titled S.W.A.T. - Skin Weight Assessment Team, undated, was provided by the IDON on 6/20/23 at 12:20 p.m. The policy indicated the following, .Policy .Further, that a resident who enters the facility with pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing A policy titled Physician Orders, undated, was provided by the IDON on 6/20/23 at 12:20 p.m. The policy indicated the following, .It is the policy of the facility to follow the orders of the physician. At the time of admission the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission This Federal tag relates to Complaint IN00410707. 3.1-40(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement follow up instructions to change a tracheostomy every 2 weeks for 1 of 2 residents reviewed for tracheostomy status. (Resident B) Findings include: The clinical record for Resident B was reviewed on 6/19/23 at 12:00 p.m. The diagnoses included, but were not limited to, anxiety disorder, burns involving 30-39% of body surface, tracheostomy status, and quadriplegia. Resident B was admitted to the facility on [DATE]. A respiratory care plan, dated 5/21/23, indicated Resident B had a tracheostomy that was a Shiley size 6.0. The interventions were to perform tracheostomy care daily and as needed along with keeping an additional tracheostomy tube (same size as the resident's) at bedside for an emergency situation. An After Visit Summary, dated 5/25/23, indicated the following, .1. Needs trach [tracheostomy] changed every 2 weeks. Last change 5/5/23 with 7.0 cuffed portex. Trach needs to stay in place until next surgery is completed Another After Visit Summary, dated 6/1/23, indicated the following, .1. Needs trach changed every 2 weeks. Last change 5/5/23 with 7.0 cuffed portex Another After Visit Summary, dated 6/8/23, indicated the following, .2. Needs trach changed every 2 weeks. Last change 5/5/23 with 7.0 cuffed portex The tracheostomy tube mentioned in Resident B's care plan did not match the type and size of the tracheostomy tube mentioned in the follow up visits with the Nurse Practitioner at the burn clinic on 5/25/23, 6/1/23, and 6/8/23. A physician order, dated 6/8/23, indicated to change the 7.0 cuffed portex tracheostomy every 2 weeks. There were no previous physician orders to change Resident B's tracheostomy prior to 6/8/23. An interview conducted with the Interim Director of Nursing (IDON), on 6/20/23 at 10:20 a.m., indicated a company comes out to conduct visits related to residents with a tracheostomy and she was reaching out for any notes/visits for Resident B. An interview conducted with the IDON, on 6/20/23 at 12:58 a.m., indicated the company that comes out to conduct visits regarding residents respiratory status has no record of seeing Resident B. A policy titled Tracheostomy Care Guidelines, undated, was provided by the IDON on 6/19/23 at 3:15 p.m. The policy indicated the following, .III. Procedure .a. Evaluation .4) Validate when tracheostomy care was last performed .b. Planning .1) Verify physician's order to provide tracheostomy care .d. Recording and reporting .1) Record respiratory evaluations before and after care; type and size of tracheostomy tube; frequency and extent of care; type, amount color, and odor of drainage; resident tolerance and understanding of procedure as applicable A policy titled Physician Orders, undated, was provided by the IDON on 6/20/23 at 12:20 p.m. The policy indicated the following, .It is the policy of the facility to follow the orders of the physician. At the time of admission the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission This Federal tag relates to Complaint IN00410707. 3.1-47(a)(4) 3.1-47(a)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure complete and accurate documentation of a resident's clinical record for 1 of 1 resident randomly reviewed for personal property. (Resident L) Findings include: The clinical record for Resident L was reviewed on 4/11/23 at 10:40 a.m. Her diagnoses included, but were not limited to, major depressive disorder. She was admitted to the facility on [DATE] from another facility. The 4/11/23 progress note for Resident L, written by the Activities Director, indicated Resident L informed her that her purse was missing. An interview and observation was conducted with Resident L in her room on 4/11/23 at 10:45 a.m. She indicated someone took her wallet that contained her debit card and social security card. It was brown with zippers and a shoulder strap. She subsequently canceled her debit card and contacted social security about getting a new social security card. She last saw the wallet on 4/9/23 and suspected it was taken while she was in the shower on 4/10/23. She did not fill out an inventory sheet upon admission to the facility, as they did not provide one for completion until a couple days after admission and needed help to complete it. There was a blank, unsigned inventory sheet folded in half on Resident L's bedside table at this time. An interview was conducted with the DON (Director of Nursing) on 4/11/23 at 12:46 p.m. She indicated inventory sheets should be completed the day of admission, so all personal belongings could be accounted for. The DON provided a copy of a blank inventory sheet on 4/12/23 at 12:10 p.m. It had a section for non-clothing items including a purse/wallet. There was a section at the bottom for the resident or responsible party to sign and date as well as a staff member on admission. The DON provided the Resident Personal Clothes and Belongings Handling policy on 4/11/23 at 3:13 p.m. It read, Purpose: To ensure that all clothing/personal belongings are identified/labeled/stored/laundered appropriately. Procedure: (Upon admission and annually the following will be done .) Personal belongings are to be listed as well, such as TV/Recliner/bookcase etc The CNA [Certified Nursing Assistant] submits the list of the resident's clothing/belongings to the charge nurse. This list becomes part of the chart. The CNA will inform the nurse as new articles of clothing/belongings are brought in or removed so that the inventory sheet can be updated. Items brought in will be labeled appropriately. 3.1-50(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' rooms were maintained in a cleanly manner regarding floor care for 2 of 5 residents reviewed for room cleanliness. (Residents B and K) Findings include: 1. The clinical record for Resident B was reviewed on 4/10/23 at 11:24 a.m. Her diagnoses included, but were not limited to, Covid-19, dementia, and Parkinson's disease. She was admitted to the facility on [DATE] after a hospitalization for worsening symptoms of Covid-19. She was discharged from the facility to home on 3/24/23. An interview was conducted with Family Member 2 on 4/11/23 at 11:59 a.m. She indicated Resident B was in transmission based precautions for Covid-19 the whole time she was at the facility. She visited twice a day and everyday she visited, the same trash was on the floor and under the bed. She asked staff about sweeping the room, but the following day, the same trash remained on the floor, so she retrieved a broom and swept the room herself. An interview was conducted with the HS (Housekeeping Supervisor) on 4/11/23 at 10:45 a.m. She indicated they didn't currently have any residents in transmission based precaution rooms, but most recently, Resident B resided in one. At the time, housekeeping did not clean transmission based precaution rooms daily, only upon request. Resident B's family requested her room be cleaned, so housekeeping obliged, but that was day 3 of her stay. The room was not cleaned by housekeeping her first 2 days at the facility. They relied on nursing to clean the room as needed. The HS was more recently informed transmission based precaution rooms needed cleaned daily. An interview was conducted with LPN (Licensed Practical Nurse) 3 on 4/11/23 at 11:46 a.m. She indicated when a resident was in transmission based precautions, nursing would wipe down frequently touched items like the bedside table and bed rails, but did not sweep or mop the floors. She knew housekeeping was having some staffing issues. 2. The clinical record for Resident K was reviewed on 4/12/23 at 9:40 a.m. Her diagnoses included, but were not limited to, heart failure. The 12/12/22 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 13, indicating she was cognitively intact. An interview and observation was conducted with Resident K in her room on 4/12/23 at 10:00 a.m. There was a significant amount of crumbs, debris, and food particles all over her floor, in the corner near her walker, on both sides of the recliner in which she was sitting, in the middle of the floor, and around her bed. Resident K indicated staff did not clean the floors regularly and it had been about 2 weeks since it was last swept and mopped. She would like for them to clean it more often. On 4/12/23 at 10:15 a.m., an interview was conducted with the HS (Housekeeping Supervisor) on the way to observe Resident K's room with her. The HS indicated one of the housekeepers was supposed to clean Resident K's room yesterday, and as far as she knew, it had been, but housekeeping staff were not currently required to document or sign off on cleaning of residents' rooms. The housekeeping department was currently down 3 staff members. An observation of Resident K's room was made with the HS on 4/12/23 at 10:17 a.m. The crumbs, debris, and food particles remained. The HS indicated it looked to her like the floors needed to be cleaned. Resident K informed the HS that no one came in and cleaned the floors yesterday. The General Cleaning Policies and Procedures Resident Room - Clean was provided by the RDO (Regional Director of Operations) on 4/11/23 at 2:37 p.m. It read, Purpose: To provide a clean, attractive and safe environment for residents, visitors and staff Materials required: .3. Wet Floor Caution Signs .16. Endless Twist Hospital Dust Mops 17. Dust Mop Holder 18. Broom. This Federal tag relates to Complaint IN00404639. 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to do a self-administration assessment for a resident who self-administers medications for 1 of 1 resident randomly observed for self-administration of medications (Resident 41). Findings include: The clinical record for Resident 41 was reviewed on 2/16/22 at 9:40 a.m. The Resident's diagnosis included, but were not limited to, hypertension and atrial fibrillation. A Quarterly MDS (Minimum Data Set) Assessment, completed 1/12/22, indicated she was cognitively intact. During a random observation on 2/16/22 at 9:44 a.m., Resident 41 was observed laying in her bed with her bedside table in front of her. On her bedside table was a plastic medication cup which contained 6 pills. She indicated that it was her morning medications. The nurse left them for her each morning so that she could take them after she eats her breakfast. On 2/16/22 at 11:07 a.m., the DON (Director of Nursing) indicated that there was no self-administration assessment was present in the clinical record. On 2/16/22 at 11:07 a.m., the DON provided the Medication Administration Procedure, dated 8/29/2016, which read .21. Remain with the resident until each medication is swallowed. Never leave medication with the resident . 3.1-11(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a transfer form, containing information for continuity of care, for 1 of 2 resident reviewed for hospitalization (Resident 29). Findings include: The clinical record for Resident 29 was reviewed on 2/21/22 at 9:22 a.m. The Resident's diagnosis included, but was not limited to, cerebral palsy and quadriplegia. She was discharged to the hospital on 2/2/22. An admission MDS (Minimum Data Set) Assessment, completed 1/3/22, indicated she did not speak and had severely impaired decision-making skills. A physician's progress note, dated 2/2/22, indicated she had a change in her condition and that she should be transferred to the hospital for further evaluation. A SBAR (change in condition communication form), dated 2/2/22 at 7:40 p.m., indicated she was being sent to the hospital and that her family had been notified. The clinical record did not contain a transfer to hospital assessment or a transfer and discharge report. During an interview on 2/21/22 at 11:57 a.m., the DON (Director of Nursing) indicated she could not locate a transfer form for her hospital discharge on [DATE] in the clinical record. On 2/21/22 at 11:00 a.m., the DON provided the Transfer to Hospital Policy, dated 8/13/2021, which read .1. Purpose: To ensure continuity of care between transferring facility and hospital or other health care facility. 2. Procedure: Transfer to hospital A. Complete and print the Transfer to Hospital assessment . B. Completed and Print an [sic] SBAR . C. Print a Transfer/ Discharge report . This report will include demographics and the medication list . 3.1-12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure showers and shaving were provided for 2 of 3 residents reviewed for Activities of Daily Living (ADL). (Resident 10 and 107) Finding include: 1. The clinical record for Resident 10 was reviewed on 2/15/22 at 12:15 p.m. The resident's diagnosis included, but was not limited to, dementia. A care plan dated 12/7/21, indicated Late loss ADL: I need limited extensive assist with toileting, bed mobility, and eating/drinking d/t [due to] weakness .Intervention .encourage to participate in ADL's as much as possible . Observations were made on the following days and times Resident 10 was observed with white facial hair on her chin: 2/15/22 at 12:06 p.m., 2/17/22 at 11:19 a.m., 2/18/22 at 10:00 a.m ., 2/18/22 at 1:00 p.m., and 2/21/22 at 10:40 a.m. Resident 10's February 2022 shower sheets were provided by the Director of Nursing on 2/18/22 at 2:05 p.m. They indicated the following days the resident had received a shower, but was not provided shaving: 2/1/22 - Tuesday, 2/4/22 -Thursday, 2/8/22 - Tuesday, 2/11/22 - Thursday, 2/15/22 - Tuesday An observation was made of Resident 10 with Certified Nursing (CNA) 6 on 2/21/22 at 11:04 a.m. Resident 10 had white facial hair observed on her chin. CNA 6 indicated at that time, residents are shaved on his or her shower days. Resident 10 did need to be shaved. 2. The clinical record for Resident 107 was reviewed on 2/15/22 at 3:00 p.m. The resident's diagnoses included, but were not limited to, gout and osteoarthritis. The resident was admitted on [DATE]. A care plan dated 2/8/22 indicated, I [Resident 10] need assist with all ADL's (including bed mobility, eating, toileting and transfers) since my recent medical event and I am in a weekend state .Interventions .Staff will assess and honor my preferences . A care plan dated 2/7/22 indicated, Preferences: I express, during the assessment process, that it is important to me to: chose what clothes to wear, choose between shower, tub, bed, or sponge bath, have snacks available between meals, choose my own bedtime, choose my time to get up, have family/friend involved in discussions re: care .Resident preference for bathing: Showers Frequency of bath: 2x [2 times] . The shower scheduled binder indicated Resident 107 received showers twice a week on Mondays and Thursdays. An interview was conducted with Resident 107 on 2/15/22 at 2:59 p.m. He indicated he had received only 1 shower since he was admitted . He had been in the facility for a couple of weeks. Resident 107's February 2022 shower sheets were provided by the Director of Nursing on 2/18/22 at 10:08 a.m. The resident had received 1 shower on Tuesday, 2/8/22. The following days Resident 107 had not received a shower: 2/10/22 - Thursday, 2/15/22 - Tuesday, and 2/17/22 - Thursday An interview was conducted with the Director of Nursing on 2/18/22 at 10:28 a.m. She indicated she was unable to provide additional shower sheets. She had spoken to the Certified Nursing Assistant, and the resident was agitated on 2/17/22, so she had not provided the shower to him. A bath Shower policy was provided by the Director of Nursing on 2/18/22 at 12:32 p.m. It indicated .To cleanse and refresh the resident's skin . 3.1-38(3) 3.1-38(3)(D)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer medications, as ordered by the physician, to 1 of 1 resident reviewed for pain management (Resident 258). Findings include: The clinical record for Resident 258 was reviewed on 2/15/22 at 3:47 p.m. The Resident's diagnosis included, but were not limited [NAME] osteoarthritis and dementia. He was admitted to the facility on [DATE]. A physician's order, dated 2/7/22, indicated he was to receive 1 tablet of Norco (narcotic pain medication) 5-325 mg (milligram) every 8 hours for pain until 2/10/22. The order was discontinued and rewritten on 2/8/22, with the same instructions for use. A care plan, initiated on 2/8/22, indicated he had the potential for pain and discomfort related to his diagnosis which included polyosteoarthritis. The goal was for his pain to be controlled to an acceptable level. An intervention, dated 2/8/22, was to administer pain medications as ordered by the physician. The February 2022 MAR (Medication Administration Record) did not indicate the medication had been administered on the following days and times: 2/7/22 at 10:00 p.m., 2/8/22 at 6:15 a.m., 2:00 p.m. and 10:00 p.m., 2/9/22 at 6:15 a.m., 2:00 p.m. and 10:00 p.m., and 2/10/22 at 6:15 a.m., 2:00 p.m., and 10:00 p.m. During an interview on 2/18/22 at 2:32 p.m., LPN (Licensed Practical Nurse) 4 indicated she had cared for him on 2/8/22 on the day shift. She had not administered the Norco as ordered due to it not being available from the pharmacy. She had called the pharmacy to have it delivered and had not attempted to administer it from the emergency drug supply at the facility. He had not appeared to be in pain while she was caring for him. During an interview on 2/18/22 at 2:44 p.m., Pharmacist 5 indicated that the pharmacy had not received a prescription to dispense Norco while Resident 258 had been residing at the facility. On 2/21/22 at 11:19 a.m., the DON (Director of Nursing) provided the Medication Administration General Guidelines Policy, dated 4/24/2019, which read .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions . 3.1-37(a)

Based on interview and record review, the facility failed to provide timely assessments of a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers (Resident 27). Findings include: The clinical record for Resident 27 was reviewed on 2/16/22 at 9:49 a.m. The Resident's diagnosis included, but were not limited to, adult failure to thrive and hemiparesis of right side. An admission MDS (Minimum Data Set) Assessment, completed 12/31/21, indicated she was severely cognitively impaired, required total assistance with activities of daily living, and was at risk for pressure ulcers. A care plan initiated 12/24/21 indicated she was at risk for skin breakdown due to decreased mobility, right hemiparesis, and a history of arterial ulcers. The goal was to provide preventative measures in an attempt to avoid skin breakdown. The interventions, initiated 12/24/21, included, but were not limited to, monitor skin daily during care and skin assessments at least weekly by a nurse. A Nursing- New Skin Alteration Assessment, dated 1/13/22, indicated she had developed a 4 cm (centimeter) x 3 cm non-blanching red area on her right trochanter (hip). A physician's order, dated 1/13/22, indicated she was to have Cavalon (skin protectant), or skin prep applied to her bilateral hips twice daily and a mepilix (foam) dressing applied to her right trochanter for protection twice daily for protection. The January and February 2022 TAR (Treatment Administration Records) indicate that the treatment was performed, as ordered, from 1/13/22 through 2/8/22. The clinical record did not contain a weekly pressure injury assessment for the right trochanter until 2/8/22. The weekly pressure injury assessment for the right trochanter, completed 2/8/22, indicated it was 1.4 cm x 1.8 cm and 100% dry eschar (black scab like tissue). The dressing was changed to Medi-honey (type of ointment) and a foam dressing. During an interview on 2/18/22 at 3:10 p.m., LPN (Licensed Practical Nurse) 2 indicated weekly skin assessments were routinely done on all residents. During an interview on 2/18/22 at 3:14 p.m., UM (Unit Manager) 3 indicated she was the nurse who had discovered the red area on her right trochanter and completed the initial new skin alteration assessment and that a weekly re-assessment and measurements should have been done weekly on the wound. She did not see any re-assessments in the clinical record until 2/8/22. On 2/18/22 at 9:43 a.m., the DON (Director of Nursing) provided the Skin Management Program Policy, dated 8/14/2014, which read .H. Documentation .II. The wound nurse will follow up weekly and prn[sic] for all pressure ulcers and document in the EMR [sic] on the 'Wound- Pressure ulcer assessment with Braden'. In addition, the wound nurse will follow up on all non-pressure wounds weekly and prn[sic] and document in the EMR [sic] on the 'Wound- non pressure assessment' . 3.1-40(a) 3.1-40(a)(1)

Based on interview and record review, the facility failed to timely evaluate a resident for Physical/Occupational Therapy per the plan of care for 1 of 1 residents reviewed for accidents. (Resident 34) Findings include: The clinical record for Resident 34 was reviewed on 2/15/22 at 1:15 p.m. The resident's diagnosis included, but was not limited to, Parkinson's Disease. A hospital discharge summary for Resident 34 dated 1/25/22 indicated .pt [patient] appears medically stable. OT [Occupational Therapy] recommends subacute rehab .hospital problem list .debility . A physician progress note dated 1/26/22 indicated .[Resident 34] .was recently hospitalized for intractable nausea and vomiting secondary to gastroparesis .new complaint: weakness .Plan: .debility. Fall precaution, supportive care, and PT/OT [Physical Therapy/Occupational Therapy]. A physical therapy evaluation dated 2/9/22 indicated Resident 34 was evaluated for her ability to transfer. An interview was conducted with Physical Therapist 9 on 2/18/22 at 2:58 p.m. She indicated the nursing staff inform the therapy department verbally or provide a physician's order for a resident to be evaluated. She was evaluated after her fall on 2/9/22, but had not been evaluated after her discharge from the hospital on 1/25/22. An interview was conducted with the Director of Nursing on 2/21/22 at 11:40 a.m. She indicated she was unable to provide a PT/OT evaluation that was completed per the physician's plan of care on 1/26/22. 3.1-23(a)(1)

Based on observation, interview, and record review, the facility failed to ensure the residents' rooms were clean and in good repair for 2 of 6 residents reviewed. (Resident 11 and 47) Findings include: 1. The clinical record for Resident 47 was reviewed on 2/15/22 at 1:15 p.m. The resident's diagnosis included, but was not limited to, An observation was made of Resident 47 in her room on 2/15/22 at 3:06 p.m. The resident's wall was observed with white drywall exposed on the back wall behind the bed. The flooring had white debris below the exposed drywall. 2. The clinical record for Resident 11 was reviewed on 2/16/22 at 9:15 a.m. The resident's diagnosis included, but was not limited to, Observations were made of Resident 11 in her room on 2/16/22 at 3:29 p.m., 2/17/22 at 11:31 a.m., 2/18/22 at 9:55 a.m. Resident 11 was lying in bed during those times. The resident's side and back walls were observed with quarter size gouges with drywall exposed. [NAME] debris was on the floor below the gouge on the back wall. During an environmental tour with the Maintenance Director (MD) and the Executive Director (ED) on 2/21/22 at 9:00 a.m., an observation was made of Resident 47's room. The resident's flooring behind her bed contained white debris. The MD indicated the wall had been repaired. An observation was made of Resident 11's room. There were two gouges observed on side and back wall the size of a quarter and white debris on back wall flooring. The MD indicated he was unaware of gouges on Resident 11's walls. The maintenance and housekeeping department was responsible for cleaning the floors to remove the white residue from the wall damage. A Resident Rooms maintenance policy was provided by the Executive Director on 2/21/22 at 9:39 a.m. It indicated .Procedure .(5). clean, repair, or replace floor tile, mopboards, and walls as needed . 3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure food was stored and prepared under sanitary conditions related to: foods not in original containers not clearly labeled for contents, dated, or stored with tight fitting lids; storing food at least 6 inches off floor; storing dish racks on ground; not labeling, dating, and/or covering items in coolers or freezer; and not ensuring foods are not expired, for 68 of 69 residents served meals from the kitchen. Findings include: A brief kitchen tour was conducted with DM (Dietary Manager) 2 on 2/15/22 at 10:27 a.m. During the kitchen tour, the following was observed: In the dry goods room: - A large plastic container containing a white substance was located on the floor. DM 2 identified it as sugar. The label on the container did not identify the contents and the preparation date was 8/2/21. An interview with DM 2 was conducted at the same time as the observation. DM 2 indicated, they go through sugar so fast that the date on the container was incorrect and had not been changed. She further stated, usually the container of sugar was stored on the wire shelf. -A large rolling bin with a clear lid, identified by DM 2 as oats, was not labeled with the contents and the preparation date was 7/21/21. The clear lid had crumbs and debris on the top. An interview with DM 2 was conducted at the same time as the observation. DM 2 indicated, the facility will go through a bin of oats in about a month and the date of preparation on the container was not up to date. In the reach-in cooler: - Five dishes of applesauce were on a shelf uncovered and undated. -Nine Styrofoam clam shells containing cookies were undated and unlabeled. -One slice of pie was left uncovered and unlabeled. -A large, clear pitcher of a yellow liquid was unlabeled and undated. - An undated cart contained six, undated fruit cups and eight, undated cups of cottage cheese. In the walk-in cooler: -Four, undated and unlabeled, Styrofoam clam shells containing salad. -Two, undated and unlabeled beverage dispensers, one containing a yellow liquid and the other containing an orange liquid. -An opened, undated bag of cheese cubes with an expiration date of 12/4/21. -A large, plastic, undated and unlabeled bag containing a pastry bag with whipped topping. In the freezer: -A tray with two cups of ice cream left uncovered and unlabeled. A Food Protection and Storage policy was received from DON (Director of Nursing) on 2/15/22 at 11:30 a.m. It indicated, .all foods shall be stored and protected under safe and sanitary conditions .The Dietary Manager will check the food storage area for: .Items stored 6 off the floor on shelves, racks, or dollies, which allow cleaning .Open boxes, containers of food are securely closed, labeled, and dated .Food not in original containers are clearly labeled for contents, dated, and stored in food rated container with tight fitting lids . 3.1-21(i)(3)